Cardiovascular Disease Risk Factors in Chronic Kidney Disease in Children

An exploratory analysis on diastolic function in the intensive compared with less intensive blood pressure control to prevent adverse cardiac remodelling in children with chronic kidney disease (HOT-KID): a parallel-group, open-label, multicentre, randomised, controlled trial

BACKGROUND

Relationship between blood pressure (BP) control and left ventricular (LV) diastolic function in children with chronic kidney disease (CKD) is uncertain. The aim of this study is to investigate whether achieving lower BP yields a favourable impact on diastolic function.

METHODS

We performed an exploratory analysis in the HOT-KID, a parallel group, open-label, multicentre, randomised, controlled trial (ISRCTN25006406). Children with CKD were randomised to standard (50th-75th percentile) or intensive (<40th percentile) standardised office systolic BP targets. Echocardiograms were performed at baseline and at follow-up visits. Diastolic function was assessed by early (E) and late mitral inflow (A) E/A ratio, mitral annular motion of myocardial relaxation (e') and atrial contraction (a') velocity, LV compliance of E/e' and e'/a' ratio, and left atrial volume index (LAVi) by a blinded observer.

FINDINGS

There was a difference in the average annual rate of change in E/A ratio (difference in means -0·07 per year, 95% CI: -0·14 to -0·01), septal e' (difference in means -0·003 m/s per year, 95% CI: -0·005 to 0·001), and LAVi (difference in means 0·82 ml/m2 per year, 95% CI: 0·22-1·42) in the standard (n = 60) compared to the intensive treatment arm (n = 64). However, the average annual changes in all other diastolic function measures were similar between standard and intensive treatment groups. There was no difference for overall adverse events or serious adverse events between the two treatment groups.

INTERPRETATION

Our exploratory analysis in a small, open label RCT suggests that achieving lower blood pressure may favourably impact some measures of LV diastolic function in children with CKD.

FUNDING

British Heart Foundation (PG/11/90/28,994); The authors MDS, PJC acknowledge financial support from the Department of Health via the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre and Clinical Research Facilities awards to Guy's and St Thomas' NHS Foundation Trust in partnership with King's College London and King's College Hospital NHS Foundation Trust. There are no relationships with industry.

Framework for Kidney Health Follow-Up Among Neonates With Critical Cardiac Disease: A Report From the Neonatal Kidney Health Consensus Workshop

Acute kidney injury is common among neonates with critical cardiac disease. Risk factors and associations with kidney-related outcomes are heterogeneous and distinct from other neonates. As survival of children with critical cardiac disease increases to adulthood, the burden of chronic kidney disease is increasing. Thirty percent to 50% of adults with congenital heart disease have impaired kidney function, even in the absence of prior kidney injury episodes. This may be related to the current standardized acute kidney injury criteria, which may not fully capture clinically meaningful kidney injury and long-term kidney health risks. An improved understanding of which neonates with critical cardiac disease should undergo kidney health follow-up is imperative. During the National Institutes of Health-supported Neonatal Kidney Health Consensus Workshop to Address Kidney Health meeting conducted in February 2024, a panel of 51 neonatal nephrology experts focused on at-risk groups: (1) preterm infants, (2) critically ill infants with acute kidney injury, and (3) infants with critical cardiac disease. The critical cardiac disease subgroup, comprising multidisciplinary experts, used a modified Delphi process to achieve consensus on recommendations for kidney health follow-up. In this report, we review available data on kidney health follow-up in critical cardiac disease and summarize the 2 consensus-based recommendations. We introduce novel diagnostic and risk-stratification tools for acute kidney injury diagnosis in neonates with cardiac disease to guide follow-up recommendations. Finally, we identify important knowledge gaps, representing areas of focus for future research. These should be prioritized to understand and improve long-term kidney health in critical cardiac disease.

Evaluation of salusin-β in paediatric patients with chronic kidney disease or hypertension

PURPOSE

Salusins are newly identified endogenous peptides implicated in the atherosclerotic process. Salusin-β, in particular, is recognized for its proatherogenic role. Given that atherosclerosis can commence in childhood, salusin-β holds promise as a potential biomarker for cardiovascular risk assessment. The objective of our study was to investigate salusin-β levels in children with early stages of chronic kidney disease (CKD) or hypertension (HTN), and compare them to healthy controls. Furthermore, we aimed to evaluate its association with obesity and pulse wave velocity (PWV), the latter being a well-established marker for determining arterial elasticity.

MATERIALS AND METHODS

This cross-sectional study involved 96 paediatric patients, including 46 with CKD and 50 with HTN, as well as 33 healthy controls. Anthropometric measurements, PWV assessments, serum salusin-β values, and basic laboratory investigations were conducted for all participants.

RESULTS

Salusin-β levels were found to be elevated in patients with CKD (p ​= ​0.014), but not in patients with HTN when compared to healthy controls. When correlating salusin-β levels with PWV, a significant but weak correlation was observed (r ​= ​0.211, p ​= ​0.020).

CONCLUSIONS

Salusin-β levels were elevated in paediatric patients with CKD. Additionally, salusin-β levels correlated significantly with PWV. Obesity played a smaller role in these correlations, with significant correlations observed only after combining cardiovascular risk factors revealing certain associations between salusin-β levels and some cardiovascular variables, but with inconclusive findings and, in some instances, even contrary to anticipated outcomes.

Efficacy and late kidney effects of nephron-sparing surgery in the management of unilateral Wilms tumor: a systematic review and meta-analysis

To evaluate the efficiency and long-term renal function of nephron sparing surgery (NSS) in unilateral WT patients compared with radical nephrectomy (RN). The review was performed following Cochrane Handbook guidelines and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched five databases (Pubmed, Embase, Scopus, Web of Science and Cochrane) for studies reporting the efficiency and late renal function of NSS and/or RN on February 10, 2023. Comparative studies were evaluated by Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) and RoB 2.0. Assessed outcomes included survival rate, relapse rate, eGFR, renal dysfunction and hypertension. 26 studies involving 10322 unilateral WT cases underwent RN and 657 unilateral WT cases underwent NSS were enrolled. Overall effect estimates demonstrated that NSS significantly increased eGFR at follow-up (SMD, 0.38; 95% CI 0.05-0.72; p = 0.025) compared to that at diagnosis, and RN did not significantly decrease eGFR at follow-up (SMD, - 0.33; 95% CI - 0.77-0.11; p = 0.142) compared to that at diagnosis. Moreover, no significant difference was found in outcomes of survivability (OR, 1.38; 95% CI 0.82-2.32; p = 0.226), recurrence (OR, 0.62; 95% CI 0.34-1.12; p = 0.114), eGFR at follow-up (SMD, 0.16; 95% CI - 0.36-0.69; p = 0.538), renal dysfunction (OR, 0.36; 95% CI 0.07-1.73; p = 0.200) and hypertension (OR, 0.17; 95% CI 0.03-1.10; p = 0.063). Current evidence suggests that NSS is safe and effective for unilateral WT patients, because it causes better renal function and similar oncological outcomes compared with RN. Future efforts to conduct more high-quality studies and explore sources of heterogeneity is recommended.

Chronic kidney disease-induced muscle atrophy: Molecular mechanisms and promising therapies

Chronic kidney disease (CKD) is a high-risk chronic catabolic disease due to its high morbidity and mortality. CKD is accompanied by many complications, leading to a poor quality of life, and serious complications may even threaten the life of CKD patients. Muscle atrophy is a common complication of CKD. Muscle atrophy and sarcopenia in CKD patients have complex pathways that are related to multiple mechanisms and related factors. This review not only discusses the mechanisms by which inflammation, oxidative stress, mitochondrial dysfunction promote CKD-induced muscle atrophy but also explores other CKD-related complications, such as metabolic acidosis, vitamin D deficiency, anorexia, and excess angiotensin II, as well as other related factors that play a role in CKD muscle atrophy, such as insulin resistance, hormones, hemodialysis, uremic toxins, intestinal flora imbalance, and miRNA. We highlight potential treatments and drugs that can effectively treat CKD-induced muscle atrophy in terms of complication treatment, nutritional supplementation, physical exercise, and drug intervention, thereby helping to improve the prognosis and quality of life of CKD patients.

Echocardiogram screening in pediatric dialysis and transplantation

Transthoracic echocardiography is commonly used to identify structural and functional cardiac abnormalities that can be prevalent in childhood chronic kidney failure (KF). Left ventricular mass (LVM) increase is most frequently reported and may persist post-kidney transplant especially with hypertension and obesity. While systolic dysfunction is infrequently seen in childhood chronic KF, systolic strain identified by speckle tracking echocardiography has been frequently identified in dialysis and it can also persist post-transplant. Echocardiogram association with long-term outcomes has not been studied in childhood KF but there are many adult studies demonstrating associations between increased LVM, systolic dysfunction, strain, diastolic dysfunction, and cardiovascular events and mortality. There has been limited study of interventions to improve echocardiogram status. In childhood, improved blood pressure has been associated with better LVM, and conversion from hemodialysis to hemodiafiltration has been associated with better diastolic and systolic function. Whether long-term cardiac outcomes are also improved with these interventions is unclear. Echocardiography is a well-established technique, and regular use in childhood chronic KF seems justified. A case can be made to extend screening to include speckle tracking echocardiography and intradialytic studies in high-risk populations. Further longitudinal studies including these newer echocardiogram modalities, interventions, and long-term outcomes would help clarify recommendations for optimal use as a screening tool.

Low dialysate sodium in children and young adults on maintenance hemodialysis: a prospective, randomized, crossover study

BACKGROUND

The optimal dialysate sodium concentration (dNa) in children on hemodialysis (HD) is unknown. The aim of this study was to compare the effect on interdialytic weight gain (IDWG) and blood pressure (BP) of a low (135 mmol/l) and standard dNa (138 mmol/l) in children and young adults on maintenance HD.

METHODS

This prospective single-blind randomized crossover study consisted of a randomized sequence of two phases: "standard dNa" of 138 mmol/L and "low dNa" of 135 mmol/L. Each phase lasted 4 weeks. Inclusion criteria were age < 25 years, hypertension, pre-HD serum Na (sNa) ≥ 130 mmol/L, and occurrence of symptoms in less than 25% of sessions. Primary outcomes were pre-HD systolic and diastolic BP and IDWG.

RESULTS

Fifteen patients were recruited, mean age 17.8 ± 4.4 years. Pre-HD SBP and DBP were not different between the two treatments. Mean IDWG was significantly lower with low dNa than with standard dNa: 2.12 ± 1.39% vs. 2.77 ± 1.53%, respectively (p = 0.008). The first-hour refill index (a volume index based on blood-volume monitoring) was significantly lower with dNa 135 mmol/L (p = 0.018). The mean Na gradient (dNa-sNa) was - 2.53 ± 2.4 mmol/L with dNa 135 mmol/L and 0.17 ± 2.8 mmol/L with dNa 138 mmol/L (p = 0.0001). The incidence of symptomatic sessions was similar (1.0% vs. 1.0%).

CONCLUSIONS

In a selected population of hypertensive pediatric and young adult HD patients, a dNa of 135 mmol/L was associated with a significant reduction of IDWG compared with a dNa of 138 mmol/L. Furthermore, long-term studies are needed to investigate the effect of lowering dNa on BP. A higher resolution version of the Graphical abstract is available as Supplementary information.

Cardiovascular Risks of Hypertension: Lessons from Children with Chronic Kidney Disease

Hypertension is the most common complication of chronic kidney disease (CKD) in children, having a strong association with subsequential cardiovascular disease (CVD). In pediatric CKD, a considerable percentage of children with hypertension are undiagnosed or undertreated. Prior research has evaluated structural and functional markers of subclinical CVD and biomarkers in adults with CKD, while ideal biomarkers in pediatrics are still insufficiently studied. The ultimate goal of this review is to summarize what is currently known about state of hypertension, cardiovascular risk factors, and potential CVD markers/biomarkers in children with pre-dialysis CKD. We discuss omics-related biomarkers and the pathophysiologic processes of endothelial dysfunction, kidney injury, oxidative stress and inflammation that are classified by specific biomarkers. Moreover, we illustrate the existing challenges and highlight the paucity of pediatric CKD research to evaluate these CVD biomarkers for future clinical pediatric practice. Thus, achieving clinical utility of CVD biomarkers for use in pediatric CKD remains a significant challenge requiring additional efforts.

Analysis of the Effectiveness of the Nurse-Led "Outpatient-Ward-Home" Management Model in Chronic Kidney Patients

Objective

To investigate the application and effect of the nurse-led "outpatient-ward-home" management model in the care of patients with chronic kidney disease (CKD).

Methods

120 patients with CKD admitted to our hospital between April 2020 and April 2021 were selected as trial subjects. All patients were divided into experimental and control groups according to the random number table method, with 60 cases in each group. The patients in the experimental group implemented the nurse-led "outpatient-ward-home" management model; the patients in the control group were given routine care and telephone follow-up. The self-rating anxiety scale (SAS), self-rating depression scale (SDS), Pittsburgh Sleep Quality Index (PSQI) score, self-management scores, nutritional status, renal function indicators, and chronic renal failure quality of life scale (QLICD-CRF2.0) were compared between the two groups before and 6 months after the intervention.

Results

Before the intervention, there were no statistically significant differences between the control and experimental groups in SAS, SDS, PSQI scores, self-management scores, QLICD-CRF2.0 scores, body mass index (BMI), prealbumin (PAb), albumin (ALB), serum creatinine (Scr), blood urea nitrogen (BUN), and glomerular filtration rate (GFR) levels (P > 0.05). After 6 months of intervention, SAS, SDS, PSQI scores, Scr, BUN, and GFR levels were lower in the experimental group than in the control group; self-management scores, QLICD-CRF2.0 scores, BMI, PAb, and ALB levels were higher in the experimental group than in the control group (P < 0.05).

Conclusion

The nurse-led "outpatient-ward-family" intervention model can improve the negative emotions and sleep disorders of CKD patients, enhance patients' self-management ability, and to a certain extent, slow down the disease process and improve the quality of life.

Reduced Blood Pressure Dipping Is A Risk Factor for the Progression of Chronic Kidney Disease in Children

Background: Elevated blood pressure and proteinuria are well-established risk factors for chronic kidney disease (CKD) progression in children. This study aimed to analyze risk factors for CKD progress, emphasizing detailed ambulatory blood pressure (ABPM) data. Methods: In 55 children with CKD II−V, observed for ≥1 year or until initiation of kidney replacement therapy, we analyzed ABPM, clinical, and biochemical parameters. Results: At the beginning, the glomerular filtration rate (eGFR) was 66 (interquartile range—IQR: 42.8−75.3) mL/min/1.73 m2, and the observation period was 27 (16−36) months. The mean eGFR decline was 2.9 ± 5.7 mL/min/1.73 m2/year. eGFR decline correlated (p < 0.05) with age (r = 0.30), initial proteinuria (r = 0.31), nighttime systolic and mean blood pressure (r = 0.27, r = 0.29), and systolic and diastolic blood pressure dipping (r = −0.37, r = −0.29). There was no relation between mean arterial pressure during 24 h (MAP 24 h Z-score) and eGFR decline and no difference in eGFR decline between those with MAP 24 h < and ≥50 th percentile. In multivariate analysis, systolic blood pressure dipping (beta = −0.43), presence of proteinuria (beta = −0.35), and age (beta = 0.25) were predictors of eGFR decline. Conclusions: Systolic blood pressure dipping may be a valuable indicator of CKD progression in children.