Combined use of creatinine and cystatin C improves the detection of renal dysfunction in children undergoing home parenteral nutrition

Chronic kidney disease - Epidemiology collaboration equations even using cystatin C overestimate renal function in patients with chronic intestinal failure on long-term parenteral nutrition

BACKGROUND & AIMS

Accurate determination of renal function is of utmost importance in chronic intestinal failure (CIF) patients on parenteral nutrition (PN) and creatinine based glomerular filtration rate (GFR) estimating equation is used in clinical practice. The aim of the present study is to evaluate the reliability of 3 CKD-EPI GFR estimating equations (eGFR) (creatinine, cystatin C or combined creatinine/cystatin C) compared with the reference method which is Iohexol plasma clearance (mGFR) in patients on long-term PN (>6 months) owing to CIF.

METHODS

Forty-eight patients (25 F) with a median age of 58 years (Interquartile Range:15) presenting CIF on PN for a median duration of 93 months (75) were included in this retrospective study. Concordance studies were performed by Pearson correlation and Bland-Altman method (Mean bias-Confidence Interval). Accuracy of the formulas was estimated with P30 representing the proportion of eGFR within 30 % of mGFR (±30 %).

RESULTS

Median mGFR was 65 (29) ml/min/1.73 m2 and the median eGFR was 85 (43) ml/min/1.73 m2 with 2009 CKD-EPIcreatinine, 74 (47) ml/min/1.73 m2 with 2012 CKD-EPIcystatin and 75 (48) ml/min/1.73 m2 with 2012 CKD-EPIcombined Cystatin C/Creatinine based formulas. The agreements were not acceptable for clinical practice. Median bias as well as lower and upper confidence intervals were for mGFR vs. eGFR (2009 CKD-EPIcreat): +21,1 (16.7,25.3), for mGFR vs. eGFR (2012 CKD-EPIcyst): +14.4 (12.9,20.5) and for mGFR vs. eGFR (2012 CKD-EPIcomb): +9.3 (7.9,15.5). Accuracy of all formulas estimated by P30 was less than 80 %. With the 3 eGFR equations, more than 46 % of patients were poorly stratified according to the classification of chronic kidney disease (CKD) with an overall tendency towards underestimation of the disease severity. Forty-seven percent of the patients had mGFR<60 ml/min/1.73 m2 corresponding to CKD Stage III or worse.

CONCLUSIONS

The eGFR estimating CKD-EPI equations significantly miscalculate the true levels of renal function in patients with CIF on PN and should be used with caution in daily clinical practice.

Incidence, diagnostics, therapeutic management and outcomes of paediatric intestinal pseudo-obstruction in the Netherlands: A 20-year retrospective cohort study

OBJECTIVES

To describe incidence, clinical course, diagnostic and therapeutic management and long-term follow-up of paediatric intestinal pseudo-obstruction (PIPO) in the Netherlands between 2000 and 2020.

METHODS

Multicenter, national, retrospective, observational study including patients aged <18 years diagnosed with PIPO and treated between 2000 and 2020 in Dutch academic medical centres. Outcomes included demographics, incidence, symptoms, diagnostic- and treatment methods used during follow-up, number of hospital admissions and mortality.

RESULTS

Between 2000 and 2020, 43 children (median age 120 months, range 13-301, 54% female) were diagnosed with PIPO in the Netherlands. Mean incidence was 0.008/100,000/years (range 0/100 000-0.029/100 000). Twenty-six patients developed PIPO in the neonatal period. Initial symptoms were vomiting (n = 21/35, 60%) and abdominal distension (n = 14/35, 40%). Diagnostic strategies included imaging, manometry, histopathology, metabolic- and genetic screening, endoscopy and exploratory surgery. Treatment was divided in nutritional support, pharmacotherapy, colonic irrigation and surgical interventions, of which nutrition and surgery were the cornerstones for care. During the observed study period, the median number of hospital admissions was 22.5 (range 1-176) with a median of 157.5 days (range 3-840) during 20-year follow-up. Two patients (6%) died: one from sepsis and one due to a severe underlying neurological disease. Heterogeneity in diagnostic- en treatment methods existed between patients.

CONCLUSIONS

PIPO is a rare, long-lasting complex disease requiring a high number of diagnostic and therapeutic interventions and hospital admissions. However, mortality rate is relatively low. Based on our results, we recommend centralization and standardization of care for this complex rare disease.

Pediatric Chronic Intestinal Failure: Something Moving?

Pediatric chronic intestinal failure (PIF) is a rare and heterogeneous condition characterized by the inability of the patient's intestine to adequately absorb the required fluids and/or nutrients for growth and homeostasis. As a result, patients will become dependent on home parenteral nutrition (HPN). A MEDLINE search was performed in May 2024 with keywords "intestinal failure", "parenteral nutrition" and "pediatric". Different underlying conditions which may result in PIF include short bowel syndrome, intestinal neuromuscular motility disorders and congenital enteropathies. Most common complications associated with HPN are catheter-related bloodstream infections, catheter-related thrombosis, intestinal failure-associated liver disease, small intestinal bacterial overgrowth, metabolic bone disease and renal impairment. Treatment for children with PIF has markedly improved with a great reduction in morbidity and mortality. Centralization of care in specialist centers and international collaboration between centers is paramount to further improve care for this vulnerable patient group. A recently promising medical therapy has become available for children with short bowel syndrome which includes glucagon-like peptide 2, a naturally occurring hormone which is known to delay gastric emptying and induce epithelial proliferation. Despite advances in curative and supportive treatment, further research is necessary to improve nutritional, pharmacological and surgical care and prevention of complications associated with parenteral nutrition use.

Evaluation of pediatric patients for intestinal transplantation in the modern era

OBJECTIVES

To review recent evaluations of pediatric patients with intestinal failure (IF) for intestinal transplantation (ITx), waiting list decisions, and outcomes of patients listed and not listed for ITx at our center.

METHODS

Retrospective chart review of 97 patients evaluated for ITx from January 2014 to December 2021 including data from referring institutions and protocol laboratory testing, body imaging, endoscopy, and liver biopsy in selected cases. Survival analysis used Kaplan-Meier estimates and Cox proportional hazards regression.

RESULTS

Patients were referred almost entirely from outside institutions, one-third because of intestinal failure-associated liver disease (IFALD), two-thirds because of repeated infective and non-IFALD complications under minimally successful intestinal rehabilitation, and a single patient because of lost central vein access. The majority had short bowel syndrome (SBS). Waiting list placement was offered to 67 (69%) patients, 40 of whom for IFALD. The IFALD group was generally younger and more likely to have SBS, have received more parenteral nutrition, have demonstrated more evidence of chronic inflammation and have inferior kidney function compared to those offered ITx for non-IFALD complications and those not listed. ITx was performed in 53 patients. Superior postevaluation survival was independently associated with higher serum creatinine (hazard ratio [HR] 15.410, p = 014), whereas inferior postevaluation survival was associated with ITx (HR 0.515, p = 0.035) and higher serum fibrinogen (HR 0.994, p = 0.005).

CONCLUSIONS

Despite recent improvements in IF management, IFALD remains a prominent reason for ITx referral. Complications of IF inherent to ITx candidacy influence postevaluation and post-ITx survival.

Teenagers and young adults with a past of allogenic hematopoietic stem cell transplantation are at significant risk of chronic kidney disease

BACKGROUND

Allogenic hematopoietic stem cell transplantation (aHSCT) remains the treatment of choice for some malignant hemopathies in children, albeit with the risk of long-term consequences, including chronic kidney disease (CKD).

METHODS

In our single tertiary referral center, we retrospectively assessed the long-term renal outcome in a cohort of children and adolescents who had undergone aHSCT for malignant hemopathies between 2003 and 2017. We distinguished glomerular and tubular dysfunctions and assessed the accuracy of the most common formula(s) to estimate glomerular filtration rate (GFR) during standard clinical follow-up.

RESULTS

Among the 166 patients who had received aHSCT, 61 underwent kidney functional assessment 1 to 10 years post-transplantation. Twenty-seven patients (44.3%) had a CKD with glomerular impairment, including 20 patients with a GFR < 90 mL/min/1.73 m², and among these, 5 patients < 60 mL/min/1.73 m². Patients with tubular signs had a significantly higher baseline GFR: 112 mL/min/1.73 m² [100; 120] versus 102 [99.0; 112.5] for patients without kidney involvement, and 76 [61; 86] for patients with CKD (p < 0.01). Schwartz, CKiDU25, and EKFC formulas significantly overestimated mGFR, with a P30% ≤ 30%, which could lead to overlooking CKD diagnosis in this population. No patient reached kidney failure.

CONCLUSIONS

In conclusion, our study shows that CKD represents an important long-term sequela for children and adolescents who undergo aHSCT for malignant hemopathies, either with glomerular dysfunction or with the more insidious tubular dysfunction which could potentially impact growth. These patients could benefit from specialized long-term nephrology follow-up. A higher resolution version of the Graphical abstract is available as Supplementary information.