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Filler G, Sharma AP, Díaz González de Ferris ME. The ongoing need to improve long-term patient survival of pediatric solid organ recipients. Pediatr Transplant 2023; 27:e14465. [PMID: 36591816 DOI: 10.1111/petr.14465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Guido Filler
- Department of Paediatrics, University of Western Ontario, London, Ontario, Canada.,Department of Medicine, University of Western Ontario, London, Ontario, Canada.,Department of Pathology & Laboratory Medicine, University of Western Ontario, London, Ontario, Canada.,Lilibeth Caberto Kidney Clinical Research Unit, London, Ontario, Canada
| | - Ajay Parkesh Sharma
- Department of Paediatrics, University of Western Ontario, London, Ontario, Canada
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Kalantar-Zadeh K, Bellizzi V, Piccoli GB, Shi Y, Lim SK, Riaz S, Arronte RU, Lau WP, Fouque D. Caring for Patients With Advanced Chronic Kidney Disease: Dietary Options and Conservative Care Instead of Maintenance Dialysis. J Ren Nutr 2023:S1051-2276(23)00022-5. [PMID: 36796502 DOI: 10.1053/j.jrn.2023.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 01/30/2023] [Accepted: 02/07/2023] [Indexed: 02/17/2023] Open
Abstract
An expert advisory board discussed the prevention and treatment of chronic kidney disease (CKD), with a focus on dietary options. This is timely, given the uptake of value based models for kidney care in the United States. Timing of dialysis start is influenced by patients' clinical status and complex patient-clinician interactions. Patients value personal freedom and quality of life and may want to delay dialysis, whilst physicians are sometimes more concerned with clinical outcomes. Kidney-preserving therapy can prolong the dialysis-free period and preserve residual kidney function, thus patients are asked to adjust their lifestyle and diet, to follow a low- or very low-protein diet, with or without ketoacid analogues. Multi-modal approaches include pharmacotherapies, management of symptoms, and a gradual, individualized dialysis transition. Patient empowerment is vital, including CKD education and involvement in decision making. These ideas may help patients, their families, and clinical teams to improve the management of CKD.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California, Orange County, California
| | - Vincenzo Bellizzi
- Nephrology and Dialysis Division, Department of Medical Sciences, Hospital Sant'Anna e San Sebastiano, Caserta, Italy
| | - Giorgina B Piccoli
- Service de Néphrologie, Department of Medicine, Centre Hospitalier Le Mans, Le Mans, France
| | - Yunying Shi
- Department of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Soo Kun Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sumira Riaz
- Royal National Orthopaedic Hospital, London, UK
| | | | - Wai Pooi Lau
- Department of Dietetics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Denis Fouque
- Department of Nephrology, Centre Hospitalier Lyon Sud, Université Claude Bernard Lyon 1, Cardiometabolism and Nutrition (CarMeN), Lyon, France.
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Wolfe KR, Hutaff-Lee C, Wilkening G. Neuropsychological Screening in Pediatric Multidisciplinary Clinics: Group Characteristics and Predictive Utility. Arch Clin Neuropsychol 2021; 37:789-797. [PMID: 34747436 DOI: 10.1093/arclin/acab090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the feasibility of administering caregiver-report neuropsychological screening measures in pediatric multidisciplinary clinics (MDCs) and investigate predictive utility for cognitive and academic difficulties on follow-up testing. METHOD The Pediatric Perceived Cognitive Functioning (Peds PCF) and Colorado Learning Difficulties Questionnaire (CLDQ) were administered to caregivers of youth with history of brain tumor (BT), non-central nervous system (CNS) cancer, or Fontan circulation as part of routine neuropsychological consultation in MDCs from 2017 to 2019. We examined cross-sectional differences on screening measures, and relationships between screening and intellectual and academic test performance in a subset who presented for follow-up neuropsychological evaluation. Receiver operating characteristic (ROC) curve analysis was used to identify suggested cut scores on screening measures for predicting who would most benefit from further evaluation. RESULTS Screening was completed with 192 families. Children with history of non-CNS cancer (n = 29) had fewer parent-reported cognitive and academic concerns compared with either BT (n = 88) or Fontan (n = 75) groups. Peds PCF and CLDQ scores were related to intellectual and academic test performance in the group presenting for neuropsychological evaluation (n = 68). ROC curve analysis identified cut scores across screening measures with maximal sensitivity and specificity for detecting neuropsychological difficulties. CONCLUSIONS It is feasible to utilize parent rating measures during neuropsychological consultation in pediatric MDCs. The Peds PCF and CLDQ demonstrated sensitivity to intellectual and academic difficulties in children with significant medical histories. Screening may be a helpful tool for pediatric neuropsychologists and other professionals during MDC consultation to inform clinical management.
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Affiliation(s)
- Kelly R Wolfe
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Christa Hutaff-Lee
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Greta Wilkening
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
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Factors associated with the absence of pharmacological treatment for common modifiable complications in children with chronic kidney disease. Pediatr Nephrol 2021; 36:3181-3189. [PMID: 33959814 PMCID: PMC8981496 DOI: 10.1007/s00467-021-05087-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/30/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with many comorbidities requiring complex management. We described treatment patterns for common modifiable CKD complications (high blood pressure, anemia, hyperphosphatemia, and acidosis) according to severity of CKD and examined factors associated with the absence of drug therapy, among participants with a persistent comorbidity, for 1 year in children enrolled in the CKiD study. METHODS A total of 703 CKiD participants contributed 2849 person-visits over a median 3.5 years of follow-up. Using pairs of annual visits, we examined whether participants with abnormal biomarker levels at the first (index) visit persisted in the abnormal levels 1 year later according to CKD risk stage. Multivariate analyses identified demographic and clinical factors associated with the absence of drug therapy among those with persistent comorbid conditions for 1 year. RESULTS The overall proportions of person-visits prescribing therapy at 1-year follow-up for treating anemia, acidosis, hyperphosphatemia, and high blood pressure were 54%, 45%, 29%, and 81%, respectively. The frequency of therapy increased with advanced CKD risk stage for all comorbidities; however, 19-23% of participants with acidosis, 24-27% with anemia, and 30-39% with hyperphosphatemia at high-risk stages (E and F) were not prescribed appropriate therapy despite the persistence of abnormal levels of these biomarkers for at least 1 year. The resolution of comorbidities at advanced CKD stages without treatment was unlikely. CONCLUSIONS Many children with CKD in the CKiD cohort did not receive pharmacological treatment for common and persistent modifiable comorbidities, even in severe CKD risk stages.
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Neumiller JJ, Shubrook JH, Manley T, Alicic RZ, Tuttle KR. Optimizing use of SGLT2 inhibitors and other evidence-based therapies to improve outcomes in patients with type 2 diabetes and chronic kidney disease: An opportunity for pharmacists. Am J Health Syst Pharm 2021; 79:e65-e70. [PMID: 34185826 DOI: 10.1093/ajhp/zxab271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joshua J Neumiller
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Jay H Shubrook
- Primary Care Department, Touro University, Vallejo, CA, USA
| | - Tom Manley
- National Kidney Foundation, New York, NY, USA
| | - Radica Z Alicic
- Providence Medical Research Center, Providence Health Care, Spokane, WA, and Division of Medicine, University of Washington, Spokane and Seattle, WA, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, WA, and Division of Nephrology, Kidney Research Institute, and Institute of Translational Health Sciences, University of Washington, Spokane and Seattle, WA, USA
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House TR, Wightman A. Adding Life to Their Years: The Current State of Pediatric Palliative Care in CKD. KIDNEY360 2021; 2:1063-1071. [PMID: 35373080 PMCID: PMC8791371 DOI: 10.34067/kid.0000282021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/05/2021] [Indexed: 01/16/2023]
Abstract
AbstractDespite continued advances in medical treatment, pediatric CKD remains an unremitting, burdensome condition characterized by decreased quality of life and earlier death. These burdens underscore the need for integration of pediatric palliative care (PPC) into nephrology practice. PPC is an evolving field that strives to (1) relieve physical, psychologic, social, practical, and existential suffering; (2) improve quality of life; (3) facilitate decision making; and (4) assist with care coordination in children with life-threatening or life-shortening conditions. Integration of palliative care into routine care has already begun for adults with kidney disease and children with other chronic diseases; however, similar integration has not occurred in pediatric nephrology. This review serves to provide a comprehensive definition of PPC, highlight the unmet need in pediatric nephrology and current integration efforts, discuss the state of palliative care in adult nephrology and analogous chronic pediatric disease states, and introduce future opportunities for study.
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Filler G, McIntyre CW. More Realistic Estimation of Time to ESRD in Children. Am J Kidney Dis 2018; 71:766-768. [PMID: 29801550 DOI: 10.1053/j.ajkd.2018.02.356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 02/17/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Guido Filler
- Department of Paediatrics, Western University, London Health Sciences Centre, London, Canada; Department of Pathology and Laboratory Medicine, Western University, London, Canada; Nephrology Division, Department of Medicine, Western University, London Health Sciences Centre, London, Canada; The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, Canada.
| | - Christopher W McIntyre
- Department of Paediatrics, Western University, London Health Sciences Centre, London, Canada; Nephrology Division, Department of Medicine, Western University, London Health Sciences Centre, London, Canada; The Lilibeth Caberto Kidney Clinical Research Unit, Western University, London, Canada; Department of Medical Biophysics, Western University, London, Canada
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Hongsawong N, Khamdee P, Silvilairat S, Chartapisak W. Prevalence and associated factors of renal dysfunction and proteinuria in cyanotic congenital heart disease. Pediatr Nephrol 2018; 33:493-501. [PMID: 28971258 DOI: 10.1007/s00467-017-3804-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 09/02/2017] [Accepted: 09/04/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cyanotic nephropathy (CN), seen in 30-50% of patients with congenital cyanotic heart disease (CCHD), affects both tubular and glomerular function, resulting in proteinuria and azotemia. Microalbuminuria is an early marker for glomerular damage and an independent predictor of progressive renal disease. METHODS A cross-sectional study was conducted. A total of 116 patients aged 1 month to 15 years with CCHD at Chiang Mai University Hospital between 2015 and 2016 were assessed and 94 patients were enrolled. To determine the prevalence and associated factors of significant albuminuria in CCHD patients, baseline characteristics, oxygen saturation, surgery, hemoglobin (Hb), hematocrit (Hct), spot urine albumin, urine protein, and creatinine were obtained. Binary logistic-regression modeling was used to identify associated factors. RESULTS Prevalence of CN in children with CCHD was 58.51% and 92.55% according to albuminuria and proteinuria staging respectively. Prevalence of significant proteinuria, significant albuminuria, and decreased GFR was 88.30%, 41.49% and 31.91% respectively. Participants with significant albuminuria had fewer previous surgeries (p = 0.05), a longer waiting time for surgery (p = 0.02), enalapril usage (p = 0.04), pulmonary hypertension (p = 0.03), higher Hct z-score (p = 0.03) and lower platelet count (p = 0.001) compared with those without significant albuminuria. Using multivariate logistic regression analysis, waiting duration for surgery (p = 0.04), Hct >40% (p = 0.02), and platelet count <290,000/mm3 (p = 0.04) were predictive of microalbuminuria. CONCLUSIONS Cyanotic nephropathy can be detected in the first decade of life with the presentation of microalbuminuria. High Hct level and low platelet count were identified as a predictor of microalbuminuria, whereas early cardiac surgery decreased the risk of developing significant albuminuria.
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Affiliation(s)
- Nattaphorn Hongsawong
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
| | - Prapimdaw Khamdee
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suchaya Silvilairat
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Wattana Chartapisak
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
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Holt T, Filler G. Is it time for a multi-specialty approach to cardio-renal dysfunction in children with cyanotic congenital heart disease? Pediatr Nephrol 2018; 33:359-360. [PMID: 28971263 DOI: 10.1007/s00467-017-3805-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/04/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Tanya Holt
- Division of Critical Care, Department of Paediatrics, University of Saskatchewan, Saskatoon, SK, Canada
| | - Guido Filler
- Division of Nephrology, Department of Paediatrics, University of Western Ontario, London, ON, Canada.
- Children's Hospital, London Health Sciences Centre, and University of Western Ontario, 800 Commissioners Road East, London, ON, N6A 5W9, Canada.
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10
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Filler G, Diaz-Gonzalez de Ferris M. We have to do more for former paediatric renal transplant recipients! Transpl Int 2017; 31:152-154. [PMID: 28865119 DOI: 10.1111/tri.13058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 08/30/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Guido Filler
- Division of Nephrology, Department of Paediatrics, University of Western Ontario, London, ON, Canada
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12
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Filler G, Webber SA, Tönshoff B. Practice recommendations: A new type of article in Pediatric Transplantation. Pediatr Transplant 2016; 20:348-9. [PMID: 27038299 DOI: 10.1111/petr.12684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Guido Filler
- Departments of Pediatrics, Children's Hospital at London Health Science Centre, Pathology & Laboratory Medicine and Medicine, University of Western Ontario, London, ON, Canada.
| | | | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
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Filler G, Melk A, Marks SD. Practice recommendations for the monitoring of renal function in pediatric non-renal organ transplant recipients. Pediatr Transplant 2016; 20:352-63. [PMID: 26917052 DOI: 10.1111/petr.12685] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2016] [Indexed: 02/04/2023]
Abstract
The management of non-renal pediatric solid organ transplant recipients has become complex over the last decade with innovations in immunosuppression and surgical techniques. Post-transplantation follow-up is essential to ensure that children have functioning allografts for as long as possible. CKD is highly prevalent in these patients, often under recognized, and has a profound impact on patient survival. These practice recommendations focus on the early detection and management of hypertension, proteinuria, and renal dysfunction in non-renal pediatric solid organ transplant recipients. We present seven practice recommendations. Renal function should be monitored regularly in organ transplant recipients, utilizing assessment of serum creatinine and cystatin C. GFR should be calculated using the new Schwartz formula. Transplant physicians should also monitor blood pressure using automated oscillometric devices and confirm repeated abnormal measures with manual blood pressure readings and ambulatory 24-h blood pressure monitoring. Proteinuria and microalbuminuria should also be assessed regularly. Referrals to a pediatric nephrologist should be made for non-renal organ transplant recipients with repeated blood pressures >95th percentile using the Fourth Task Force reference intervals, microalbumin/creatinine ratio >32.5 mg/g (3.7 mg/mmol) creatinine on repeated testing and/or GFR <90 mL/min/1.73 m(2) .
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Affiliation(s)
- Guido Filler
- Department of Paediatrics, Schulich School of Medicine & Dentistry, London, ON, Canada.,Department of Medicine, Schulich School of Medicine & Dentistry, London, ON, Canada.,Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Kaddourah A, Goldstein SL, Lipshultz SE, Wilkinson JD, Sleeper LA, Lu M, Colan SD, Towbin JA, Aydin SI, Rossano J, Everitt MD, Gossett JG, Rusconi P, Kantor PF, Singh RK, Jefferies JL. Prevalence, predictors, and outcomes of cardiorenal syndrome in children with dilated cardiomyopathy: a report from the Pediatric Cardiomyopathy Registry. Pediatr Nephrol 2015; 30. [PMID: 26210985 PMCID: PMC4626312 DOI: 10.1007/s00467-015-3165-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The association of cardiorenal syndrome (CRS) with mortality in children with dilated cardiomyopathy (DCM) is unknown. METHODS With a modified Schwartz formula, we estimated glomerular filtration rates (eGFR) for children ≥1 year of age with DCM enrolled in the Pediatric Cardiomyopathy Registry at the time of DCM diagnosis and annually thereafter. CRS was defined as an eGFR of <90 mL/min/1.73 m(2). Children with and without CRS were compared on survival and serum creatinine concentrations (SCr). The association between eGFR and echocardiographic measures was assessed with linear mixed-effects regression models. RESULTS Of 285 eligible children with DCM diagnosed at ≥1 year of age, 93 were evaluable. CRS was identified in 57 of these 93 children (61.3%). Mean (standard deviation) eGFR was 62.0 (22.6) mL/min/1.73 m(2) for children with CRS and 108.0 (14.0) for those without (P < 0.001); median SCr concentrations were 0.9 and 0.5 mg/dL, respectively (P < 0.001). The mortality hazard ratio of children with CRS versus those with no CRS was 2.4 (95% confidence interval 0.8-7.4). eGFR was positively correlated with measures of left ventricular function and negatively correlated with age. CONCLUSIONS CRS in children newly diagnosed with DCM may be associated with higher 5-year mortality. Children with DCM, especially those with impaired left ventricular function, should be monitored for renal disease.
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Affiliation(s)
- Ahmad Kaddourah
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Steven E Lipshultz
- Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI, USA,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - James D Wilkinson
- Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit, MI, USA
| | | | - Minmin Lu
- New England Research Institutes, Watertown, MA, USA
| | | | - Jeffrey A Towbin
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Scott I Aydin
- Montefiore Medical Center, New York City, New York, USA
| | - Joseph Rossano
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Jeffrey G Gossett
- Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Paolo Rusconi
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Paul F Kantor
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Rakesh K Singh
- Columbia University Medical Center, New York City, New York, USA
| | - John L Jefferies
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. ML 2003, Cincinnati, OH, 45229, USA.
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Prevalence and predictors of aortic dilation as a novel cardiovascular complication in children with end-stage renal disease. Clin Nephrol 2015; 83:262-71. [PMID: 25816808 PMCID: PMC4535175 DOI: 10.5414/cn108489] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/18/2022] Open
Abstract
Background: Cardiovascular disease is the leading cause of death in children with end-stage renal disease (ESRD). Isolated aortic dilation (AD) is rare in children. We aimed to determine the prevalence and the risk factors for AD in children with ESRD. Methods and study design: We reviewed records of all ESRD patients followed at our institution from January 2007 to October 2012. AD was defined as Z-score > 2 in the dimension of at least one of the following echocardiographic aortic parameters: annulus, root at the sinus, sino-tubular junction, ,or ascending aorta. Results: The records of 78 patients on dialysis and 19 kidney transplant recipients were available. 30 patients (30.9%) had AD. Multivariate analysis revealed independent associations of AD with body mass index (BMI) Z-score (OR = 0.52, 95% confidence interval (CI): 0.35 – 0.78) and ESRD secondary to glomerular disease (OR = 4.58, 95% CI: 1.45 – 14.46). We developed a classification and regression tree (CART) model to identify patients at low vs. high AD risk. Our model classified 62 patients of the cohort (64%) to be high- or low-risk, with a positive predictive value of 89% and a negative predictive value of 100%. Conclusion: Our data suggest that AD, as a possible marker of aortopathy and early aneurysm formation, is a novel and prevalent cardiovascular complication in ESRD children. Glomerular disease and low BMI Z-score appear to be potent predictors. CART modeling helps identify high-risk children, potentially guiding decisions regarding targeted echocardiographic evaluations.
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Saxena N, Rizk DV. The interdisciplinary team: the whole is larger than the parts. Adv Chronic Kidney Dis 2014; 21:333-7. [PMID: 24969383 DOI: 10.1053/j.ackd.2014.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 01/30/2014] [Accepted: 02/19/2014] [Indexed: 01/12/2023]
Abstract
Chronic kidney disease (CKD) is an emerging global health problem. Caring for CKD patients is a medical and financial challenge currently placing a significant burden on our health-care system. This creates an impetus to explore nontraditional models of care. In this article, we explore the role of interdisciplinary care clinics in managing the complex and multifaceted aspects of CKD. By having different providers work seamlessly in a synergistic and collaborative environment, there is less risk of fragmentation of care. In this patient-centered model of care, patients are empowered and engaged to achieve therapeutic targets, make lifestyle changes, and participate in decision-making. Timely referral and education delivered by advanced practitioners are 2 of the crucial elements central to the success of the interdisciplinary model. Further studies are needed to identify other key elements that would enhance the interdisciplinary approach to ensure that guideline-based therapeutic targets are reached and to define the subset of patients that would benefit the most. Innovative information technology solutions that could enhance the implementation of interdisciplinary clinics and expand their reach should be exploited. Lastly, for the paradigm shift to occur, the integrative approach should prove to be cost-effective.
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Yee J. Resolved: the case for CKD clinics. Adv Chronic Kidney Dis 2014; 21:327-30. [PMID: 24969381 DOI: 10.1053/j.ackd.2014.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 05/23/2014] [Indexed: 01/21/2023]
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Filler G. No association between cyclosporine levels and dyslipidemia? Nephrourol Mon 2014; 6:e14296. [PMID: 24719816 PMCID: PMC3968964 DOI: 10.5812/numonthly.14296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 12/01/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- Guido Filler
- Department of Pathology and Laboratory Medicine, University of Western Ontario, Ontario, Canada
- Department of Pediatrics, University of Western Ontario, Ontario, Canada
- Department of Medicine, University of Western Ontario, Ontario, Canada
- Corresponding author: Guido Filler, 800 Commissioners Road East, VH B1-436, Ontario, Canada. Tel: +1-5196858377, Fax: +1-5196858156, E-mail:
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Watson AR, Hayes WN, Vondrak K, Ariceta G, Schmitt CP, Ekim M, Fischbach M, Edefonti A, Shroff R, Holta T, Zurowska A, Klaus G, Bakkaloglu S, Stefanidis CJ, Van de Walle J. Factors influencing choice of renal replacement therapy in European paediatric nephrology units. Pediatr Nephrol 2013; 28:2361-8. [PMID: 23843162 DOI: 10.1007/s00467-013-2555-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 05/28/2013] [Accepted: 06/18/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many factors may impact upon choice of renal replacement therapy (RRT) for children and adolescents, including patient and family choice, patient size and distance from the renal centre as well as logistic issues such as facilities and staffing at the unit. We report a survey of factors influencing treatment choice in 14 European paediatric nephrology units. METHODS A questionnaire was developed by consensus and completed by 14 members of the European Paediatric Dialysis Working Group on facilities, staffing and family assessments impacting on choice of therapy as well as choice of therapy for 97 patients commencing initial RRT in 2011. RESULTS All units offered all modalities of RRT, but there were limitations for pre-emptive transplantation (PET) and largely adult surgical dependence for creation of arteriovenous fistulae and transplantation. The average waiting time for a deceased donor kidney was 18.5 (range 3-36) months. Full time dietetic support was available in six of the 14 units. There was no social worker, psychology, play therapy or teaching support in three, two, seven and four units, respectively. Assessment by other members of the multidisciplinary team and home visits before choice of therapy was carried out in 50 % of units, and although all patients were discussed at team meetings, the medical opinion predominated. In terms of types of RRT, 50 % of patients were commenced on chronic peritoneal dialysis (PD), 34 % on haemodialysis (HD) and 16 % underwent pre-emptive transplantation (PET). Chronic PD predominated in patients aged <5 years and HD predominated in those aged >10 years. Patient and family choice and age or size of patient were predominant factors in choice of therapy with a predictable decline in renal function favouring PET and social factors HD. CONCLUSIONS Chronic peritoneal dialysis predominated as primary choice of RRT, especially in younger children. The PET rates remain low. The influence of surgeons predominanted, and national transplant rules may be significant. Most units had insufficient multiprofessional support, which may impact upon initial choice of therapy as well as sustaining families through RRT.
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Affiliation(s)
- Alan R Watson
- Children's Renal & Urology Unit, Nottingham Children's Hospital, QMC Campus, Derby Road, Nottingham, NG7 2UH, UK,
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St Peter WL, Wazny LD, Patel UD. New models of chronic kidney disease care including pharmacists: improving medication reconciliation and medication management. Curr Opin Nephrol Hypertens 2013; 22:656-62. [PMID: 24076556 PMCID: PMC4012859 DOI: 10.1097/mnh.0b013e328365b364] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Patients with chronic kidney disease (CKD) are complex, have many medication-related problems (MRPs) and high rates of medication nonadherence, and are less adherent to some medications than patients with higher levels of kidney function. Nonadherence in CKD patients increases the odds of uncontrolled hypertension, which can increase the risk of CKD progression. This review discusses reasons for gaps in medication-related care for CKD patients, pharmacy services to reduce these gaps and successful models that incorporate pharmacist care. RECENT FINDINGS Pharmacists are currently being trained to deliver patient-centred care, including identification and management of MRPs and helping patients overcome barriers to improve medication adherence. A growing body of evidence indicates that pharmacist services for CKD patients, including medication reconciliation and medication therapy management, positively affect clinical and cost outcomes, including lower rates of decline in glomerular filtration rates, reduced mortality and fewer hospitalizations and hospital days, but more robust research is needed. Team-based models including pharmacists exist today and are being studied in a wide range of innovative care and reimbursement models. SUMMARY Opportunities are growing to include pharmacists as integral members of CKD and dialysis healthcare teams to reduce MRPs, increase medication adherence and improve patient outcomes.
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Affiliation(s)
- Wendy L St Peter
- aChronic Disease Research Group, Minneapolis Medical Research Foundation bCollege of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA cManitoba Renal Program dWinnipeg Regional Health Authority Pharmacy Program, Winnipeg, Manitoba, Canada eDepartment of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Hooper DK, Kirby CL, Margolis PA, Goebel J. Reliable individualized monitoring improves cholesterol control in kidney transplant recipients. Pediatrics 2013; 131:e1271-9. [PMID: 23478865 PMCID: PMC4535026 DOI: 10.1542/peds.2012-2374] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To develop and evaluate a system for reliable and efficient individualized risk-based monitoring of cholesterol and 11 other tests after kidney transplantation in children. METHODS We identified system components that drive reliable individualized monitoring and used quality improvement methods to develop and implement interventions, including (1) monitoring schedules individualized by dyslipidemia risk assigned to each patient, (2) automated previsit decision support from our electronic medical record, (3) standardized work flow and responsibility, and (4) automated forwarding of results to providers. We measured the proportion of patients due for cholesterol testing who had it performed within 1 week of their clinic visit and the proportion of patients in our population who achieved low-density lipoprotein (LDL) cholesterol control at baseline and for 2 years after improved monitoring. RESULTS The proportion of visits in which cholesterol monitoring was completed when indicated improved from 80% to 98% within 8 months and was sustained for more than 1 year. The number of patients with controlled LDL (<130 mg/dL, 3.3 mmol/L) improved from 44 (71%) of 62 at the start of our project to 58 (94%) of 62 (P = .002) at an average follow-up of 24 months. CONCLUSIONS Using quality improvement and health information technology, we achieved sustained, reliable and efficient personalized monitoring of cholesterol and 11 other tests. This approach enabled substantial improvement in LDL cholesterol control. Structured methods of system redesign that leverage information technology systems hold promise for rapidly achieving reliable individualized care in other settings.
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Affiliation(s)
- David K. Hooper
- Division of Nephrology and Hypertension, and,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Peter A. Margolis
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jens Goebel
- Division of Nephrology and Hypertension, and,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Filler G, Huang SHS. High prevalence of renal dysfunction also after small bowel transplantation. Pediatr Transplant 2013. [PMID: 23198902 DOI: 10.1111/petr.12025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Shih-Han Susan Huang
- Department of Medicine; Schulich School of Medicine & Dentistry; London; ON; Canada
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