Department of Health Library Services ePublications - Historical Collection
Please Note: Aboriginal and Torres Strait Islander people should be aware that this publication may contain images, voices or names of deceased persons in photographs, film, audio recordings or printed material.
Purpose
To apply preservation treatments, including digitisation, to a high value and vulnerable Historical collection of items held in the Darwin and Alice Springs libraries so that the items may be accessed without causing further damage to the original items and provide accessibility for stakeholders.
Reference and Research Disclaimer
Please note: this document is part of the Historical Collection and the information contained within may be out of date.
This copy is a reproduction of an original record. Please note that the quality of the original record may be poor and cannot be enhanced with the scanning process.
Northern Territory Department of Health Library Services Historical Collection
)
)
)
)
)
)
J
)
'.
. -.~ , ,:.
DL Hl51
~(~. c..
PAX
c...
A Prospective Survey of Aboriginal Children for Urinary Disease While Hospital Inpatients.
DL HIST 616.6
PAX
1989
by Dr J H Paxton
Advanced Trainee Paediatrics Royal Darwin Hospital
October 1989
'
)
)
)
)
)
J
.)
)
J
A Prospective Survey of Aboriginal Children for Urinary Disease While Hospital Inpatients.
J t ' ll"r J I!~ •.
Patients
All Aboriginal patients over 3 months of age, admitted under medical care to the Paediatric Unit at the Royal Darwin Hospital (ROH) from April to September 1989 were screened for urinary disease. The number of patients was 245, this consisting of 138 males and 1 07 females. 82 were under 1 year of age, 106 between 1 and 3 years and 57 over 3 years of age. The majority of patients (89%) came from remote Aboriginal settlements and the others from the Darwin urban area.
The most common admission diagnoses were diarrhoeal disease ( 49%) and acute respiratory illness ( 36%), with only ( 6%)
presenting with urinary or renal problems alone.
Undernutrition (< 80% of Standard Weight for Age) was evident in 57% of patients, and was most marked in the group between 1 and 3 years of age ( Table 1, p < 0. 001), reflecting the typical pattern of weanling malnutrition. Marasmus (<60% of Standard Weight For Age) was present in 7% of patients. Urban patients were better nourished than their counterparts from rural settlements (Table 2) .
Other common health problems in this group were iron
deficiency anaemia, scabies with secondary infection, oti tis media and intestinal infestation with parasites.
Table 1 - Nutritional Status by Age
<60% SH'FA4 60-80% SH'FA >80% SH'FA
---,
I---
< 1 year
1-3 years
>3 years All Ages
9% ( 7) 7% ( 7) 4% ( 2)
7% (16)
35% ( 28) 72% ( 76) 38% ( 20)
52% (124)
4Actual patient numbers in parentheses.
b5 patients Here not weighed chi-squared = 34. 2, p<O. 001
57% ( 46) 22% ( 23) 58% ( 31)
42% (100)
81 106
53
'
)
)
)
)
)
J
J
J
.)
Table 2 - Nutritional Status by Place of Residence
i) Patients< 3 years of age Number
,.
'.,. .
Urban Non-Urban
1 9 169
87.0 +/- 17.2 76. 1 +/- 13. 9
92.8 +/- 15.8 83. 9 +/- 10. 7
aAverage %SHFA +/- bAverage %SRFH +/-
standard deviation; t = 2. 07, p <O. 05 standard deviation; t = 2. 39, p <O. 02
ii) Patients > 3 years of age
Urban Non-urban
Number
5 52
107. 8 +/- 22. 2 83. 0 +/- 13. 5
a Average %SRFA +/- 1 standard deviation; t = 2. 45, p <O. 02
Methods
Height, weight and ·head circumference were recorded soon after admission, and demographic data collected. Data relating to patient weight were recorded as percentage of Standard Weight for Age
( SWFA) and percentage of Standard we·ight for Height C SWFH> 1• The initial screen consisted of ward urinalysis for blood, protein, glucose and nitrites, urine microscopy and culture, and blood urea and creatinine. Haematuria and proteinuria on urinalysis were
common on admission in the presence of acute infection, dehydration and fever. Most of these changes resolved quickly and were not
f~rther pursued. If persistent abnormalities were detected then -more detailed investigation followed.
Urine was obtained by suprapubic bladder aspiration (SPA) i f results obtained from bag urine samples were equivocal. If urine was not obtained after 2 or 3 attempts at SPA, a catheter specimen was obtained. Phase contrast microscopy on fresh urine was
performed i f persistent haematuria was found. Urinary calcium and protein excretion were measured where relevant using the
calcium/creatinine ratio21 ' 22
or protein/creatinine ratio23 ' 24 ' 25
on a spot urine sample.
Anti-streptococcal serology C ASOT, anti-DNAse B) and complement studies CC3, C4) were performed in children with persistent haematuria or suspected acute nephritis.
Radiological studies performed with clinical indication were renal ultrasound C U/S), micturating cystourethography ( MCU) and intravenous pyelography. Nuclear Medicine facilities are not available at RDH .
)
)
J
.)
U/S and MCU were performed in i l l children with urinary tract
.
infections (UTI). The criteria for diagnosis of a UTI were any bacterial growth on a urine obtained by SPA; a pure growth of a likely pathogen on catheter sampie with pyuria and a suggestive urinalysis; a bag urine sample with a pure growth of a likely
pathogen, pyuria and positive nitrites on urinalysis'.' ' Mariy-patti.ents received antibiotic therapy before arrival at RDH. In these cases pyuria on a SPA or catheter specimen, and strongly positive
nitrites on urinalyBis were required fur diagnosis of a UTI.
Results
Frequency of Urinary Disease
A remarkably high incidence of urinary abnormality was revealed, with 28% of patients displaying definite markers of
urinary disease. These consisted of urinary tract infections (14%), idiopathic glomerular haematuria ( 5%), renal calculi ( 4%), and anatomical abnormalities ( 5%). 4 ( 2%) patients presented with marked elevation of urea and creatinine from pre-renal renal
failure secondary to dehydration. Some patients displayed more than one pathology. These findings are described in more detail below.
Urinary Tract Infection
35 ( 14%) pati·ents had a UTI on admission. The distribution of these infections by age and sex is shown in Table 3. While the
incidence of UTI falls steadily with age, this observation fails to reach statistical significance ( Table 3, chi-squared = 3. 31, p <
0. 1). No change in incidence with nutritional status was
demonstrated ( Table 6, chi-squared = 0. 47, p> 0. 5). Si mi larly, no significant difference in incidence between the sexes after the age of 1 year was seen ( Table· 3, chi-squared = 3. 12, p < 0. 1), as would be expected in a Caucasian population. UTI was more frequent in children presenting with diarrhoea but this was not significant ( Table 5, chi-squared = 2. 7, p < 0. 1). The frequency of UTI is similar in patients from all areas.
8 patients had bacilluria without pyuria - all but one of
these specimens was obtained by SPA or bladder catheterisation. The remaining patient had a renal calculus revealed on U/S and a pure growth of E. Coli was produced from the urine. 2 other patients in this group were shown to have renal calculi. Organisms isolated in this group were E. Coli C 3), Proteus ( 2), Klebsiella ( 2) and
Aci nobacter ( 1).
Urinary pathogens and antibiotic resistance patterns are displayed in Table 4. The 5 patients with sterile urine were treated with broad spectrum antibiotic therapy before a urine
sample was obtained, had pyuria on microscopy and positive nitrites on urinalysis .
1
)
)
)
)
J
J
Table 3 - Incidence of UTI by Age and Sex
1 Sex
J.t 1 ••• • !: •
~FUT I /
~F
P a ti en ts b< 1 year
I - -
l I I I
M F : All
21%
18%
20%
9/43 7/39 16/82
---' ---
11-3 years
I
M F All
11 % 16%
13%
7/61 7/45 14/106
---, ---
>3 years 1 I I I
M F All
0%
22%
9%
0/34 5/23 5/57
---: ---
All Ages 1 I I I
M F
: All
12%
17%
14%
16/138 18/107 35/245
aPercentage of patients in that grouping with a UTI.
bNumber of patients with UTI/Total Number in that grouping.
Table 4 - Urinary Pathogens
Organism Number Resistance(%) .!.m.Q• Sulph Trim Cef
E. Coli 20 60% 45% 25% 0%
Klebsiella 5 100% 80% 40% 0%
Proteus 3 67% 0% 0% 67%
Enterococcus 1
Acinobacter 1
No Growth 5
•Abbreviations: Amp= ampicillin, Sulph = sulphamethoxazole, Trim=
trimethoprim, Cef = cephalexin.
)
1
)
)
)
.)
J
Jable 5 - Association of UTI and Diarrhoeal Disease
Diarrhoea
No Diarrhoea . , I I
UTI present UTI absent 18% ( 22)
10% (13)
82% ( 97) 90%(113)
chi-squared= 2. 7, p< 0. 1, NS.
Table 6 - Incidence of UTI and Nutritional Status
< 80% SRFA
> 80% SHFA
UTI present UTI absent 18% (21)
13% (9)
82% ( 97)
87% ( 60)
chi-squared= 0. 42, p> 0. 5, NS
Renal Calculi
Jt I . . , . f f'.•
The 9 patients with renal calculi were recognized because of persistent upper tract microscopic haematuria on ward testing (4) or on further investigation of a UTI (4). 2 of the patients with UTI had neither red blood cells or pyuria on urine microscopy. 1 patient presented from a rural community with a history of
recurrent microscopic haematuria on routine testing. He were unable to demonstrate haematuria over several days as an inpatient and there was no UTI, but a renal ultrasound displayed calculi.
The stones were detected by ultrasonography and all were
radiolucent. Urinary calcium excretion was elevated in 3 patients.
No other metabolic studies were undertaken.
·A patient with bilateral hydronephrosis secondary to bilateral large calculi required pyelolithotomy and another was demonstrated to develop unilateral hydronephrosis after passage of a renaL
pelvic stone into his ureter. This stone was removed surgically from the lower ureter after a period of observation. Neither of these patients suffered from renal colic or other symptoms of upper urinary tract obstruction. 2 other patients had less severe
obstruction and are being followed closely. Qualitative analysis of the stones in the first patient revealed calcium oxalate, ammonium urate and uric acid. Unfortunately the calculus was not analysed in the second patient due to an oversight.
)
)
)
)
J
.J
J
4 of the 9 patients had urinary tract infection at
presentation, and one of these had an E. Coli septicaemia. All the patients with calculi we~e between the ages of 10 months and 4 years 8 months, a significant clustering of the condition in this age group ( p=O. 04, exact test). There were 4 males and 5 females.
Children with calculi had a higher mean SHFA and SHFH when compared with their fellows frqm rural communities in the identical age
group, but only the latter statistic was significanfr (Efab·le·:7,1 t = 2.76, p < 0.05).
Table 7 - Nutritional Status of Patients with Calculi Ages 10 months - 4 years 8 months
: Patient ~~
Calculi I I
No Calculi :
9 1 26
78. 5 +/- 10. 4 72. 4 +/- 10. 6
89. 8 +/- 5. 9 1. 8 +/- 1. 1 81. 6 +/1 9. 4 1. 8 +/- 0. 8
a Average %SHFA +/- one standard deviation; t = 1. 7, p < 0. 1, NS.
bAverage %SRFH +/- one standard deviation; t = 2. O, p < 0. 05 cAverage Age (years) +/- one standard deviation.
Haematuria
42 patients with significant haematuria were recognized. 14 of these had UTI' sand 6 had renal calculi. One patient with marked hypercalciuria and hypocalcemia (presenting with severe tetany) also had glomerular haematuria. Other causes of persistent
haematuria are displayed in table 8 below. There were no cases of acute nephritis during the study, although epidemics have been well described in this population2 ' 3• 13 cases had dysmorphic RBC on urine microscopy suggesting haematuria of glomerular origin. These patients had normal complement studies and normal urinary calcium excretion but raised anti-streptococcal serology.
It is our anecdotal experience that virtually all paediatric aboriginal patients have raised anti-streptococcal serology,
probably indicative of chronic streptococcal skin sepsis. All
patients screened in this survey with ASOT and anti-DNAse B studies had moderate to marked elevation of titres. In general the anti- DNAse B t i t r e was higher than the ASOT.
The patients with idiopathic upper tract haematuria fell into 2 distinct age groups, with 7 patients being under 3 years 8 months of age and the remaining 6 patients being over 9 years of age. The latter group is of particular interest as there were only 13
patients over 9 years of age in the survey, giving an incidence of glomerular hematuria in .this age group of 46% (6/13). This is
highly significant when compared with the incidence of 4% (7/175) in those under 9 years of age. ( Chi-squared = 1 7. 6, p < 0. 001).
)
'
}
)
)
.)
Table 8 - Pathology/Abnormalities Associated Rith Haematuria
Proteinuria
Abnormality
Urinary Tract Infection Idiopathic Glomerular Renal Cal c·u1 i
Renal Scarring/Atrophy Hypercalciuria : Idiopathic Non-glomerular: · PUJ obstruction
l
Hydronephrosis ?cause : Total
Incidence
1 4 ( 3 3 %)
13 (31%) 6 ( 14%) 3 ( 7%) 2 ( 5%) 2 ( 5%) 1 ( 2%) 1 ( 2%) 4 2 ( 1 00%)
J, I .'p' J 1: _. .. •
Many patients had proteinuria of minor degree at presentation when acutely unwell. In all except one i t resolved quickly. This patient was an infant with bronchiolitis who had moderate
asymptomatic prot einuria for 3 weeks before spontaneous resolut ion.
No specific renal diagnosis was made and the problem has not recurred since.
Anatomical Abnormalities
16 patients were detected with anatomical abnormalities of the urinary tract. These are displayed in table 9 below. 4 patients already described had hydronephrosis secondary to renal calculi.
6/16 of these patients (38%) had a UTI at presentation.
Table 9 - Anatomical Abnormalities
Abnormality Number Number with UTI Calculi with obstruction 4 1
PUJ obstruction 4 2
Vesico-Ureteric Reflux 4 Renal Scarring/Atrophy 3
Hydronephrosis ?cause 1
Total 1 6 6
)
1
)
)
)
J
J
J
J
Biochemical Findings
Low blood urea was noticed i.n many patients, and was. most evident in children under 1 year of age. 20% ( 28/ 1 36) of patients under 3 years of age· had blood urea levels below 1. 4mmol/L, which is highly significant when compared with the normal population frequency of 5%11 ( P .< 0. 001).
J t 1
. i' ,
1: • •.Discussion
Renal disease is a major cause of morbidity and mortality in the Aboriginal population4 ' 5
' 6 ' 7
' 8 ' 9
' 10
• In some surveys of Aboriginal adults, 30-40% of those tested have abnormalities ·on urinalysis3 • In a survey of a South Australian Aboriginal
community, 16% of the population had renal disease, 19% were hypertensive, and 16% had diabetes mellitus. Half of those with diabetes had renal disease8• Anecdotal evidence also suggests that the incidence of end-stage renal disease in the Aboriginal
population is many times that seen in Caucasians.
The overall incidence of markers of urinary disease of 28% in this population is also remarkably high. This is particularly so when i t is considered that most patients surveyed presented with respiratory or gastrointestinal disease, and no symptoms directly ref erabl e to the urinary tract. The high incidence of malnutrition and poor hygiene in those surveyed is likely to be a major
contributing factor, although no relationship between percentage SHFA and incidence of urinary disease was observed. While this population has been selected by their requirement for hospital
admission, over 50% of ··the Aboriginal population in the area served by RDH will require admission to ROH before their second birthday.
This suggests that the incidence of renal and urinary disease in Aboriginal children in the community is also very high.
Urinary Tract Infection
Urinary tract infection was the most frequent abnormality de t e c t e d w i t h an i n c i de n c e of· 1 4 % . · I n t he Ca u ca s i an pop u 1 at i on older than 1 year of age the incidence is approximately 10 times greater in females11 • This relationship was less evident here with 7. 4% ( 7/95) of males and 17. 6% ( 12/68) of females over 1 year
having UTis. This difference is significant C p < 0. 001), suggesting that additional aetiologic factors are working to produce UTI' s i n Aboriginal children.
Bacilluria without pyuria was found in 8 patients. 2 of these patients had renal calculi. All the urine samples except one were collected by SPA or bladder catheterisation. The clinical
significance of this finding is unclear, although bacilluria in the presence of anatomical abnormalities or calculi would seem
potentially dangerous.
As mentioned before, difference in epidemiology of UTI between Aboriginal children and other populations suggest that different aetiological factors are active in producing the infections.
1
)
)
J
)
.J
J
J
~ O G
/ JO
Renal Calculi
Urinary calculi have been described previously in Aboriginal children and are thought to be of the endemic type described in Indonesia, Thailand and other countries12 ' 13
' 14
' 1 5 1 1 6
• 17
• 18
' 1
' .
These stones are generally composed of uric acid anq, u,rat-es13•1
Their aetiology is unknown but proposed factors include low urine output, recurrent dehydration, diarrhoea _and UTI' s, hot environment and a low phosphate di et in which the main protein source is
cereal16• This type of disease is generally much more frequent in males than females and is associated with significant morbidity13 •
In this study renal calculi were present in 4% of patients.
This incidence is the highest described in Aboriginal patients, apart from an incidence of 6. 6% found in Aboriginal children
undergoing radiological investigation of the urinary tract in Alice Springs1 4 , which is obviously a highly selected sample. One patient in this current study was diagnosed without haematuria or UTI being found while and inpatient, suggesting that other patients with
calculi may have been missed. The only method for detecting all stones is to perform an ultrasound study on all patients, which is not currently a practical proposition.
In a study conducted in Derby, Western Australia, an incidence of 1 in 234 paediatric hospital admissions was found. This was
described as remarkably high12• Several features of the Derby study are likely to contribute to this lower incidence:
1) It was retrospective and therefore cases are likely to have been missed.
2) Diagnostic ultrasound was not used, lowering the pick-up rate of small stones.
3) Many of the . calculi were found in the bladder, suggesting diagnosis of calculi later in the evolution of the disease.
4) Most of the patients presented with urinary
sympt o~s (dysur.ia1 abdominal pain and urinary retention being the most common) also suggesting later diagnosis.
Renal calculi are probably much more frequent in Aboriginal children than previously suspected. This survey has detected calculi in an earlier stage of evolution than other studies. The absence of a marked male predominance may mean that progression of stone disease to advanced stages and therefore specific symptoms is less common in females, although patient numbers are too small at this stage to be confident of this. Passage of a renal pelvic stone into the ureter has been clearly documented and i t seems likely that passage into the bladder can occur, supporting suggestions that bladder stones originate in the upper urinary tract .
Patients with calculi are significantly better nourished than children in the same age and population group. There were similar findings in a study of bladder stones in Thailand, where the
incidence of calculi was higher in villages where food was more freely available and nutrition presumed to be better1' . Dietary factors may therefore play a role in aetiology of calculi.
~)
)
)
)
J
J
Haematuria
I, , • ,. , ,: .. ~
l
After UTI and calculi have been excluded, the largest group of patients with haematuria are older children with upper tract
haematuria and no aetiology demonstrated. Short of renal biopsy i t seems likely that this group will remain classified as idiopathic.
Post-streptococcal acute glomerulonephritis CPSAGN) is very common in rural Aboriginal communities2 ' 3 because of the high rate of skin infection with beta-hemolytic streptococci, and these findings may represent residuae of this illness. Whether chronic renal disease results from PSAGN26 ' 27 is controversial. If i t occurs malnourished populations may be at higher risk of this complication. A high
incidence of microscopic haematuria has been seen in the adult Aboriginal population, who also have a high incidence of chronic renal failure and these findings may represent the beginning of this phenomenon4•
Biochemical Findings
The high incidence of low blood urea in Aboriginal children in likely related to low dietary protein intake. The rise in mean
blood urea with age seen here is also observed in the Caucasian population. A low blood urea may be of clinical relevance as urea in the renal medullary interstitium is of prime importance in
concentrating urine in the Loop of Henle through the countercurrent exchange mechanism.
Any limitation of ability to concentrate urine must logically predispose to dehydration in arid environments and with acute
illness.
Summary
This prospective survey of Aboriginal children has revealed an enormous incidence of urinary abnormalities. The most common
pathology is urinary tract infection, found with similar incidence in all age groups. Renal calculi are prevalent in young children and idiopathic upper tract haematuria frequent in older children.
Much of this disease has the potential to cause long term morbidity and may have an impact on the high incidence -of chronic and end-stage renal disease in the adult Aboriginal population.
Further careful attention to renal disease in Aboriginal children is therefore of obvious importance.
)
)
)
)
J
J
8. 8% of patients from Port Keats (4/45) had renal calculi.
This is in contrast to the incidence of 1. 8% in patients from Man i n gr i d a ( 1 / 5 6 ) . P a t i e n t s a mp 1 e s f r om o t he r i n d i vi I
ci'u a
1 11 • •communities were not large enough to study separately. This trend is not statistically significant ( p = 0. 24, Exact t"E~st) but may become significant as further patients are incorporated into the study. The population from Port Keats is significantly better nourished, which correlates well with the above nutritional
observations, but the samples are otherwise compa~able (Table 10).
It has been suggested that the incidence of calculi is higher in desert than non-desert dwellers12• However, most of this group of patients come from non-desert regions. Perhaps disease becomes less advanced (ie smaller stones which are asymptomatic) and is therefore more difficult to detect in children from areas where water is more plentiful. Alternatively the incidence of similar subclinical disease in the desert dwellers may be enormous.
The clustering of patients in the 10 month to 4 year 8 month age group in this study is consistent with data from third world countries, where the maximum incidence of bladder stones occurs in the first 5 years of life17 • This finding is also consistent with the observed very low frequency of urinary stones in Aboriginal adults14 ' 20 •
Many of the patients with calculi had UTI' s a t presentation, so appropriate management in those with small stones not requiring surgical removal probably includes prophylaxis against UTI. This presents major logistical difficulties in patients from isolated communities. Our current practice is to administer 3mg/kg of gentamicin intramuscularly monthly.
Table 10 - Characteristics of Patients with Calculi from 2 Communities
Community Port Keats Maningrida
i
45 56
Calculi
4 2. 6 +/- 2. 8 77. 8 +/-15.1 85. 3 +/-11. 2 2. 3 +/- 2.1 71. 6 +/-12. 3 79. 6 +/-8. 2
aAverage age (years) +/- 1 standard deviation; t = 0.60, ;p ·>O. 5 bAverage percent of SRFA +/- 1 standard deviation; t= 2.22, p <0.05 cAverage percent of SRFA +/- 1 standard deviation; t = 2.55, p < 0.01
1
)
)
)
)
)
)
J
References
1. Stuart HC and Stevenson SS. Havard Standards. Nelson Textbook of Pediatrics 1 959; 7th edition, Philidelphia: Saunders.
2. Gogna NK, Nossar V, Walker AC. Epidemic of acute poststreptococcal glomerulonephritis in Aboriginal communities. MJA 1983, 1: 64-66.
J t ' ·- ' I'.•
3. Devanesen et al. Lessons from an outbreak of glomerulonephritis in an Aboriginal community. Annu Rep Menzies Sch Health Res 1987 Jul- 1988 Jun;
(3):86-89.
4. Pugsley D, Mathews J, Peach H, Devanesen D. Renal disease in Aboriginal Communities. Annu Rep Menzies Sch Health Res 1987 Jul - 1988 Jun; (3): 86.
5. Kamien M. The physical health of Aboriginal children in Bourke, New South Wales. MJ A 1 976, 1: 33-37.
· 6. Kamien M. The physical health of Aboriginal adults in Bourke, New South Wales.
MJA 1976, 1: 38-43.
7. Kamien M. Concealed Illnesses: Infections of the Urine and Kidneys. Ab Health Worker, 1 977; 1 (2): 8-1 0.
8. Grime B. Kidney Survey. Ab Health Worker, 1984; 8(3): 28-30.
9. Harris L, Knight J, Henderson R. Morbidity patterns in a general paediatric unit in rural Western Australia. MJA, 1986; 145: 441-443.
10. Assumpcao C. Some urinary tract disease in Australian Aboriginal inpatients in 1980. Aust NZ J Med 1988; 18: 17-20.
11. Vaughan VC, McKay RJ, Behrman RE. Nelson Textbook of Pediatrics, 13th Edition. Philidelphia:Saunders.
12. Adsett D. Urinary calculi in children of the Kimberly region of Western Australia. Aust Paediatr J 1982, 18: 283-285.
13. Jones TH, Henderson TR. Urinary calculi in children in Western Australia:
1972-86. Aust Paediatr J 1989, 25: 93-95.
14. Farago C. Urolithiasis in the Aboriginal and Non-Aboriginal children and adults of Central Australia. Australas Radiol 1987; 31: 300-303.
1 5. Wisniewski ZS, Brockis JG; Ryan GD. Urinary bladder stones in Aboriginal children. Aust NZ J Surg 1981; 51: 292-295.
16. Van Reen R. Idiopathic urinary bladder stones of childhood. Aust NZ J Surg, 1980; 50: 18-22.
17. Anderson DA. The nutritional significance of primary bladder stones. Br J Urol 1962; 48: 617-621.
18. Thalut K, Rizal A, Brockis R, Bowyer R, Taylor T, Wisniewski Z. The endemic bladder stones of Indonesia - epidemiology and clinical features. Br J Urol 1976;
48: 617-621.
,
19. Halstead SB, Valyasevi A. Studies of bladder stone disease in Thailand. III.Epidemiologic_ Studies in Ubol Province. Am J Clin Nutr 1967; 20(12): 1 329-1339.
20. Bateson EM. Do Australian Aborigines suffer from renal tract calculi? Aust NZ J Med 1977; 7: 380-381.
21. Stark H, Tieder M, Eistenstein B, Davidovits M, Litwin A. Hypercalciuria as a cause of persistent or recurrent haematuria. Arch Dis Child 1988j, 6~: ,312:-313i 22. Stapleton FB, Roy S, Noe HN, Jerkins G. Hypercalciuria in children with hematuria. NEJM 1984; 31 0: 1345-1348.
23. Houser M. Assessment of proteinuria using random urine samples. J Pediatrics 1984; 104: 845-848.
24. Ginsberg JM, Chang BS, Matarese RA, Garella S. Use of single voided urine samples to estimate quantitative proteinuria. NEJM 1983; 309: 1543-1546.
25. Shaw AB, Risdon P, Lewis-Jackson JD. Protein creatinine index and Albustix in ) assessment of proteinuria. BMJ 1983; 287: 929-932.
26. Editorial. Poststreptococcal Glomerulonephritis. BMJ Nov 1979; 1243-1244.
27. Schacht RG, Gluck MC, Gallo GR, Baldwin DS. Progression to uremia after remission of acute poststreptococcal glomerulonephritis. NEJM 1976; 295: 977-981.
) 25: 93-95.
)
)
J
J
