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Schaefer F, Montini G, Kang HG, Walle JV, Zaritsky J, Schreuder MF, Litwin M, Scalise A, Scott H, Potts J, Iveli P, Breitenstein S, Warady BA. Investigating the use of finerenone in children with chronic kidney disease and proteinuria: design of the FIONA and open-label extension studies. Trials 2024; 25:203. [PMID: 38509517 PMCID: PMC10956186 DOI: 10.1186/s13063-024-08021-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION Proteinuria is a modifiable risk factor for chronic kidney disease (CKD) progression in children. Finerenone, a selective, non-steroidal, mineralocorticoid receptor antagonist (MRA) has been approved to treat adults with CKD associated with type 2 diabetes mellitus (T2DM) following results from the phase III clinical trials FIDELIO-DKD (NCT02540993) and FIGARO-DKD (NCT02545049). In a pre-specified pooled analysis of both studies (N = 13,026), finerenone was shown to have an acceptable safety profile and was efficacious in decreasing the risk of adverse kidney and cardiovascular outcomes and of proteinuria. OBJECTIVE FIONA and the associated open-label extension (OLE) study aim to demonstrate that combining finerenone with an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) is safe, well-tolerated, and effective in sustainably reducing urinary protein excretion in children with CKD and proteinuria. DESIGN FIONA (NCT05196035; Eudra-CT: 2021-002071-19) is a randomized (2:1), double-blind, placebo-controlled, multicenter, phase III study of 6 months' duration in approximately 219 pediatric patients. Patients must have a clinical diagnosis of CKD (an eGFR ≥ 30 mL/min/1.73 m2 if ≥ 1 to < 18 years or a serum creatinine level ≤ 0.40 mg/dL for infants 6 months to < 1 year) with significant proteinuria despite ACEi or ARB usage. The primary objective is to demonstrate that finerenone, added to an ACEi or ARB, is superior to placebo in reducing urinary protein excretion. FIONA OLE (NCT05457283; Eudra-CT: 2021-002905-89) is a single-arm, open-label study, enrolling participants who have completed FIONA. The primary objective of FIONA OLE is to provide long-term safety data. FIONA has two primary endpoints: urinary protein-to-creatinine ratio (UPCR) reduction of ≥ 30% from baseline to day 180 and percent change in UPCR from baseline to day 180. A sample size of 198 participants (aged 2 to < 18 years) in FIONA will provide at least 80% power to reject the null hypothesis of either of the two primary endpoints. CONCLUSION FIONA is evaluating the use of finerenone in children with CKD and proteinuria. Should safety, tolerability, and efficacy be demonstrated, finerenone could become a useful additional therapeutic agent in managing proteinuria and improving kidney outcomes in children with CKD. TRIAL REGISTRATION ClinicalTrials.gov NCT05196035. Registered on 19 January 2022.
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Affiliation(s)
- Franz Schaefer
- Pediatric Nephrology Division, Heidelberg University Hospital, Heidelberg, Germany.
| | - Giovanni Montini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Erknet Center, C4C, Ghent, Belgium
| | - Joshua Zaritsky
- Department of Nephrology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Mieczyslaw Litwin
- Department of Nephrology and Arterial Hypertension, Children's Memorial Health Institute, Warsaw, Poland
| | | | - Helen Scott
- Bayer U.S Pharmaceuticals, Whippany, NJ, USA
| | - James Potts
- Bayer U.S Pharmaceuticals, Whippany, NJ, USA
| | | | | | - Bradley A Warady
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
- Children's Mercy Kansas City, Kansas City, MO, USA
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Aly R, Dogan YE, Bala N, Lugo C, Darwish S, Shoemaker L, Alli AA. Dysregulation of kidney proteases in the pathogenesis of hypertension following unilateral nephrectomy in juvenile mice. Am J Transl Res 2024; 16:544-556. [PMID: 38463588 PMCID: PMC10918144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/12/2023] [Indexed: 03/12/2024]
Abstract
BACKGROUND Unliteral nephrectomy (UNX) results in the reduction of kidney mass. The remaining kidney undergoes compensatory renal growth via hypertrophy of the glomeruli and renal tubules to maintain a normal glomerular filtration rate (GFR). These compensatory mechanisms result in increased capillary pressure and glomerular hyperfiltration to increase single nephron GFR. Over time, hyperfiltration may lead to kidney scarring and the development of hypertension. OBJECTIVES The first objective of this study was to test the hypothesis that a 50% reduction in functioning nephrons in juvenile mice leads to increased blood pressure over a 24-hour phase. The second objective was to test the hypothesis that UNX leads to changes in the expression and activity of kidney proteases in juvenile mice. METHODS Eight male C57B6 juvenile wild-type mice were subject to UNX and an equal number of mice were subject to sham (SH) surgery. Metabolic cage studies were performed for 5 weeks to collect urine produced during the inactive and active phases. Blood pressure was measured using the tail cuff method twice weekly and tail blood was collected on different days during the inactive or active phase of each animal. The mice were euthanized at the age of 9 weeks. Western blotting and immunohistochemistry were performed to investigate changes in renal protein expression of various cathepsins and renal kallikrein 1 (KLK1) between the two groups. Protease activity assays were performed using kidney lysates and urine samples from each group. RESULTS Compared to the SH group, UNX mice showed a persistent increase in blood pressure at week 3 which progressed toward the end of the study at week 5 of age. Cathepsin B, D, and S expression and activity were up-regulated in kidney cortex lysates from UNX mice compared to the SH control group. KLK1 protein expression was down-regulated and urinary nitric oxide excretion was decreased in UNX mice compared to the SH control group. CONCLUSION UNX results in the development of persistent and progressive hypertension. Down-regulation of KLK1 and up-regulation of various cathepsins may contribute to the development of hypertension via multiple mechanisms including a decrease in nitric oxide (NO) production.
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Affiliation(s)
- Rasha Aly
- Department of Pediatrics, Division of Pediatric Nephrology, University of Florida College of MedicineGainesville, FL, USA
| | - Yunus E Dogan
- Department of Physiology and Aging, University of Florida College of MedicineGainesville, FL, USA
- Department of Pediatrics, Faculty of Medicine, Erciyes UniversityKayseri, Turkey
| | - Niharika Bala
- Department of Physiology and Aging, University of Florida College of MedicineGainesville, FL, USA
| | - Carlos Lugo
- Department of Physiology and Aging, University of Florida College of MedicineGainesville, FL, USA
| | - Seena Darwish
- Department of Physiology and Aging, University of Florida College of MedicineGainesville, FL, USA
| | - Lawrence Shoemaker
- Department of Pediatrics, Division of Pediatric Nephrology, University of Florida College of MedicineGainesville, FL, USA
| | - Abdel A Alli
- Department of Pediatrics, Division of Pediatric Nephrology, University of Florida College of MedicineGainesville, FL, USA
- Department of Physiology and Aging, University of Florida College of MedicineGainesville, FL, USA
- Department of Medicine, Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of MedicineGainesville, FL, USA
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Carboni J, Thomas E, Gipson DS, Brady TM, Srivastava T, Selewski DT, Greenbaum LA, Wang CS, Dell KM, Kaskel F, Massengill S, Reidy K, Tran CL, Trachtman H, Lafayette R, Almaani S, Hingorani S, Gbadegesin R, Gibson KL, Sethna CB. Longitudinal analysis of blood pressure and lipids in childhood nephrotic syndrome. Pediatr Nephrol 2024:10.1007/s00467-024-06301-z. [PMID: 38319465 DOI: 10.1007/s00467-024-06301-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND In the current study, longitudinal BP and lipid measurements were examined in a NEPTUNE cohort of children with newly diagnosed nephrotic syndrome (cNEPTUNE). We hypothesized that hypertensive BP and dyslipidemia would persist in children with nephrotic syndrome, regardless of steroid treatment response. METHODS A multi-center longitudinal observational analysis of data obtained from children < 19 years of age with new onset nephrotic syndrome enrolled in the Nephrotic Syndrome Study Network (cNEPTUNE) was conducted. BP and lipid data were examined over time stratified by disease activity and steroid exposure. Generalized estimating equation regressions were used to find determinants of hypertensive BP and dyslipidemia. RESULTS Among 122 children, the prevalence of hypertensive BP at any visit ranged from 17.4% to 57.4%, while dyslipidemia prevalence ranged from 40.0% to 96.2% over a median of 30 months of follow-up. Hypertensive BP was found in 46.2% (116/251) of study visits during active disease compared with 31.0% (84/271) of visits while in remission. Dyslipidemia was present in 88.2% (120/136) of study visits during active disease and in 66.0% (101/153) while in remission. Neither dyslipidemia nor hypertensive BP were significantly different with/without medication exposure (steroids and/or CNI). In regression analysis, male sex and urine protein:creatinine ratio (UPC) were significant determinants of hypertensive BP over time, while eGFR was found to be a determinant of dyslipidemia over time. CONCLUSIONS Results demonstrate persistent hypertensive BPs and unfavorable lipid profiles in the cNEPTUNE cohort regardless of remission status or concurrent steroid or calcineurin inhibitor treatment.
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Affiliation(s)
- Johnathon Carboni
- Division of Nephrology, Department of Pediatrics, Cohen Children's Medical Center of NY, New Hyde Park, NY, USA
| | - Elizabeth Thomas
- Division of Nephrology, Department of Pediatrics, Dell Children's Medical Center, University of Texas, Austin, TX, USA
| | - Debbie S Gipson
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Tammy M Brady
- Division of Nephrology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tarak Srivastava
- Section of Nephrology, Children's Mercy Hospital and University of Missouri, Kansas City, MO, USA
| | - David T Selewski
- Division of Pediatric Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Larry A Greenbaum
- Division of Nephrology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Chia-Shi Wang
- Division of Nephrology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Katherine M Dell
- Center for Pediatric Nephrology and Hypertension, Cleveland Clinic Children's, Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
| | - Frederick Kaskel
- Division of Nephrology, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Susan Massengill
- Division of Nephrology, Department of Pediatrics, Levine Children's Hospital, Charlotte, NC, USA
| | - Kimberly Reidy
- Division of Nephrology, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Cheryl L Tran
- Division of Pediatric Nephrology, Department of Pediatrics and Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Howard Trachtman
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Richard Lafayette
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Salem Almaani
- Division of Nephrology, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sangeeta Hingorani
- Division of Nephrology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Rasheed Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, NC, USA
| | - Keisha L Gibson
- Division of Pediatric Nephrology, UNC Kidney Center, Chapel Hill, North Carolina, USA
| | - Christine B Sethna
- Division of Nephrology, Department of Pediatrics, Cohen Children's Medical Center of NY, New Hyde Park, NY, USA.
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Byfield RL, Xiao R, Shimbo D, Kronish IM, Furth SL, Amaral S, Cohen JB. Antihypertensive medication nonadherence and target organ damage in children with chronic kidney disease. Pediatr Nephrol 2024; 39:221-231. [PMID: 37442816 PMCID: PMC10790151 DOI: 10.1007/s00467-023-06059-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Nonadherence is common in children with chronic kidney disease (CKD). This may contribute to inadequate blood pressure control and adverse outcomes. This study examined associations between antihypertensive medication nonadherence, ambulatory blood pressure monitoring (ABPM) parameters, kidney function, and cardiac structure among children with CKD. METHODS We performed secondary analyses of data from the CKD in Children (CKiD) study, including participants with treated hypertension who underwent ABPM, laboratory testing, and echocardiography biannually. Nonadherence was defined by self-report of any missed antihypertensive medication 7 days prior to the study visit. Linear regression and mixed-effects models were used to assess the association of nonadherence with baseline and time-updated ABPM profiles, estimated glomerular filtration rate (eGFR), urine protein to creatinine ratio (UPCR), and left ventricular mass index (LVMI). RESULTS Five-hundred and eight participants met inclusion criteria, followed for a median of 2.9 years; 212 (42%) were female, with median age 13 years (IQR 10-16), median baseline eGFR 49 (33-64) ml/min/1.73 m2 and median UPCR 0.4 (0.1-1.0) g/g. Nonadherence occurred in 71 (14%) participants. Baseline nonadherence was not significantly associated with baseline 24-h ABPM parameters (for example, mean 24-h SBP [β - 0.1, 95% CI - 2.7, 2.5]), eGFR (β 1.0, 95% CI - 0.9, 1.2), UCPR (β 1.1, 95% CI - 0.8, 1.5), or LVMI (β 0.6, 95% CI - 1.6, 2.9). Similarly, there were no associations between baseline nonadherence and time-updated outcome measures. CONCLUSIONS Self-reported antihypertensive medication nonadherence occurred in 1 in 7 children with CKD. We found no associations between nonadherence and kidney function or cardiac structure over time. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Rushelle L Byfield
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH17-102E, NY, 10032, New York, USA.
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daichi Shimbo
- Columbia Hypertension Center, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Ian M Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, NY, USA
| | - Susan L Furth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sandra Amaral
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jordana B Cohen
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Kusumi K, Raina R, Samuels J, Tibrewal A, Furth S, Mitsnefes M, Devineni S, Warady BA. Evidence of increased vascular stiffness and left ventricular hypertrophy in children with cystic kidney disease. Pediatr Nephrol 2023; 38:4093-4100. [PMID: 37428222 DOI: 10.1007/s00467-023-06081-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the most common cause of mortality in chronic kidney disease (CKD). Children with early-onset CKD arguably experience the greatest lifetime CVD burden. We utilized data from the Chronic Kidney Disease in Children Cohort Study (CKiD) to evaluate two pediatric CKD cohorts: congenital anomalies of the kidney and urinary tract (CAKUT) and cystic kidney disease for CVD risks and outcomes. METHODS CVD risk factors and outcomes including blood pressures, left ventricular hypertrophy (LVH), left ventricular mass index (LVMI), and ambulatory arterial stiffness index (AASI) scores were evaluated. RESULTS Forty-one patients in the cystic kidney disease group were compared to 294 patients in the CAKUT group. Cystic kidney disease patients had higher cystatin-C levels, despite similar iGFR. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) indexes were higher in the CAKUT group, but a significantly higher proportion of cystic kidney disease patients was on anti-hypertensive medications. Cystic kidney disease patients had increased AASI scores and a higher incidence of LVH. CONCLUSIONS This study provides a nuanced analysis of CVD risk factors and outcomes including AASI and LVH in two pediatric CKD cohorts. Cystic kidney disease patients had increased AASI scores, higher incidence of LVH, and higher rates of anti-hypertensive medication use which could imply a greater burden of CVD despite similar GFR. Our work suggests that additional mechanisms may contribute to vascular dysfunction in cystic kidney disease, and that these patients may need additional interventions to prevent the development of CVD. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Kirsten Kusumi
- Division of Nephrology, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Rupesh Raina
- Division of Nephrology, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA.
- Northeast Ohio Medical University, Rootstown, OH, USA.
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, USA.
| | - Joshua Samuels
- Division of Pediatric Nephrology and Hypertension, University of Texas Medical School at Houston, Houston, TX, USA
| | - Abhishek Tibrewal
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, USA
| | - Susan Furth
- Pediatrics, Division of Nephrology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania Philadelphia, Philadelphia, PA, USA
| | - Mark Mitsnefes
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Bradley A Warady
- Division of Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
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Mitsnefes MM, Wühl E. Role of hypertension in progression of pediatric CKD. Pediatr Nephrol 2023; 38:3519-3528. [PMID: 36732375 DOI: 10.1007/s00467-023-05894-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Abstract
Hypertension is frequent in children with chronic kidney disease (CKD). Its prevalence varies according to CKD stage and cause. It is relatively uncommon in children with congenital kidney disease, while acquired kidney disease is associated with a higher prevalence of hypertension. Studies in children with CKD utilizing ambulatory blood pressure monitoring also showed a high prevalence of masked hypertension. Uncontrolled and longstanding hypertension in children is associated with progression of CKD. Aggressive treatment of high blood pressure should be an essential part of care to delay CKD progression in children.
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Affiliation(s)
- Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
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Denburg MR, Razzaghi H, Goodwin Davies AJ, Dharnidharka V, Dixon BP, Flynn JT, Glenn D, Gluck CA, Harshman L, Jovanovska A, Katsoufis CP, Kratchman AL, Levondosky M, Levondosky R, McDonald J, Mitsnefes M, Modi ZJ, Musante J, Neu AM, Pan CG, Patel HP, Patterson LT, Schuchard J, Verghese PS, Wilson AC, Wong C, Forrest CB. The Preserving Kidney Function in Children With CKD (PRESERVE) Study: Rationale, Design, and Methods. Kidney Med 2023; 5:100722. [PMID: 37965485 PMCID: PMC10641283 DOI: 10.1016/j.xkme.2023.100722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
Rationale & Objective PRESERVE seeks to provide new knowledge to inform shared decision-making regarding blood pressure (BP) management for pediatric chronic kidney disease (CKD). PRESERVE will compare the effectiveness of alternative strategies for monitoring and treating hypertension on preserving kidney function; expand the National Patient-Centered Clinical Research Network (PCORnet) common data model by adding pediatric- and kidney-specific variables and linking electronic health record data to other kidney disease databases; and assess the lived experiences of patients related to BP management. Study Design Multicenter retrospective cohort study (clinical outcomes) and cross-sectional study (patient-reported outcomes [PROs]). Setting & Participants PRESERVE will include approximately 20,000 children between January 2009-December 2022 with mild-moderate CKD from 15 health care institutions that participate in 6 PCORnet Clinical Research Networks (PEDSnet, STAR, GPC, PaTH, CAPRiCORN, and OneFlorida+). The inclusion criteria were ≥1 nephrologist visit and ≥2 estimated glomerular filtration rate (eGFR) values in the range of 30 to <90 mL/min/1.73 m2 separated by ≥90 days without an intervening value ≥90 mL/min/1.73 m2 and no prior dialysis or kidney transplant. Exposures BP measurements (clinic-based and 24-hour ambulatory BP); urine protein; and antihypertensive treatment by therapeutic class. Outcomes The primary outcome is a composite event of a 50% reduction in eGFR, eGFR of <15 mL/min/1.73 m2, long-term dialysis or kidney transplant. Secondary outcomes include change in eGFR, adverse events, and PROs. Analytical Approach Longitudinal models for dichotomous (proportional hazards or accelerated failure time) and continuous (generalized linear mixed models) clinical outcomes; multivariable linear regression for PROs. We will evaluate heterogeneity of treatment effect by CKD etiology and degree of proteinuria and will examine variation in hypertension management and outcomes based on socio-demographics. Limitations Causal inference limited by observational analyses. Conclusions PRESERVE will leverage the PCORnet infrastructure to conduct large-scale observational studies that address BP management knowledge gaps for pediatric CKD, focusing on outcomes that are meaningful to patients. Plain-Language Summary Hypertension is a major modifiable contributor to loss of kidney function in chronic kidney disease (CKD). The purpose of PRESERVE is to provide evidence to inform shared decision-making regarding blood pressure management for children with CKD. PRESERVE is a consortium of 16 health care institutions in PCORnet, the National Patient-Centered Clinical Research Network, and includes electronic health record data for >19,000 children with CKD. PRESERVE will (1) expand the PCORnet infrastructure for research in pediatric CKD by adding kidney-specific variables and linking electronic health record data to other kidney disease databases; (2) compare the effectiveness of alternative strategies for monitoring and treating hypertension on preserving kidney function; and (3) assess the lived experiences of patients and caregivers related to blood pressure management.
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Affiliation(s)
- Michelle R. Denburg
- Children’s Hospital of Philadelphia, Philadelphia, PA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - Vikas Dharnidharka
- St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Bradley P. Dixon
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Joseph T. Flynn
- Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Dorey Glenn
- University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Lyndsay Harshman
- University of Iowa Stead Family Children’s Hospital, Iowa City, IA
| | | | | | | | | | | | - Jill McDonald
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Mark Mitsnefes
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Zubin J. Modi
- C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | | | - Alicia M. Neu
- Johns Hopkins Children’s Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Cynthia G. Pan
- Medical College of Wisconsin, Children’s Wisconsin, Milwaukee, WI
| | - Hiren P. Patel
- Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | | | | | - Priya S. Verghese
- Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Amy C. Wilson
- Riley Children’s Health, Indiana University School of Medicine, Indianapolis, IN
| | - Cynthia Wong
- Stanford Children’s Health, Stanford University School of Medicine, Palo Alto, CA
| | - Christopher B. Forrest
- Children’s Hospital of Philadelphia, Philadelphia, PA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Ng DK, Matheson MB, Schwartz GJ, Wang FM, Mendley SR, Furth SL, Warady BA. Development of an adaptive clinical web-based prediction tool for kidney replacement therapy in children with chronic kidney disease. Kidney Int 2023; 104:985-994. [PMID: 37391041 PMCID: PMC10592093 DOI: 10.1016/j.kint.2023.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 07/02/2023]
Abstract
Clinicians need improved prediction models to estimate time to kidney replacement therapy (KRT) for children with chronic kidney disease (CKD). Here, we aimed to develop and validate a prediction tool based on common clinical variables for time to KRT in children using statistical learning methods and design a corresponding online calculator for clinical use. Among 890 children with CKD in the Chronic Kidney Disease in Children (CKiD) study, 172 variables related to sociodemographics, kidney/cardiovascular health, and therapy use, including longitudinal changes over one year were evaluated as candidate predictors in a random survival forest for time to KRT. An elementary model was specified with diagnosis, estimated glomerular filtration rate and proteinuria as predictors and then random survival forest identified nine additional candidate predictors for further evaluation. Best subset selection using these nine additional candidate predictors yielded an enriched model additionally based on blood pressure, change in estimated glomerular filtration rate over one year, anemia, albumin, chloride and bicarbonate. Four additional partially enriched models were constructed for clinical situations with incomplete data. Models performed well in cross-validation, and the elementary model was then externally validated using data from a European pediatric CKD cohort. A corresponding user-friendly online tool was developed for clinicians. Thus, our clinical prediction tool for time to KRT in children was developed in a large, representative pediatric CKD cohort with an exhaustive evaluation of potential predictors and supervised statistical learning methods. While our models performed well internally and externally, further external validation of enriched models is needed.
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Affiliation(s)
- Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Matthew B Matheson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - George J Schwartz
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | - Frances M Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Susan R Mendley
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Susan L Furth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Division of Nephrology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri, USA
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Močnik M, Golob Jančič S, Marčun Varda N. Liver and kidney ultrasound elastography in children and young adults with hypertension or chronic kidney disease. Pediatr Nephrol 2023; 38:3379-3387. [PMID: 37154960 DOI: 10.1007/s00467-023-05984-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Ultrasound elastography is a research method increasingly used to measure tissue elasticity. The aim of the study was to assess its usability in pediatric patients with either chronic kidney disease (CKD) or hypertension. METHODS A total of 46 patients with CKD (group 1), 50 patients with hypertension (group 2), and 33 healthy participants as the control group were included. In all, we performed studies assessing their cardiovascular risk along with liver and kidney elastography. RESULTS Liver elastography parameters were increased compared to those in the control group (1.49 m/s, p = 0.007, in group 1 and 1.52 m/s, p < 0.001, in group 2, vs. 1.41 m/s among controls). Kidney elastography parameters were significantly higher in group 2 (1.9 m/s, p = 0.001, and 1.9 m/s, p = 0.003, in each kidney) when compared to group 1 (1.79 m/s and 1.81 m/s). Additionally, all participants were divided according to overweight/obesity and normal weight status, where both liver (1.53 m/s vs. 1.45 m/s, p < 0.001) and kidney parameters (1.96 m/s and 1.92 m/s vs. 1.81 m/s and 1.84 m/s, p = 0.002) were significantly higher in the group of overweight/obese subjects. CONCLUSIONS Ultrasound elastography of the liver and kidney is feasible in pediatric patients with either CKD or hypertension, showing increased liver stiffness parameters in both groups, further aggravated by obesity. In obese patients with CKD, kidney stiffness also increased indicating a negative effect of clustering cardiovascular risk factors leading to decreased kidney elasticity. Further research is warranted. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Mirjam Močnik
- Department of Pediatrics, University Medical Centre Maribor, Ljubljanska Ulica 5, 2000, Maribor, Slovenia.
| | - Sonja Golob Jančič
- Department of Pediatrics, University Medical Centre Maribor, Ljubljanska Ulica 5, 2000, Maribor, Slovenia
| | - Nataša Marčun Varda
- Department of Pediatrics, University Medical Centre Maribor, Ljubljanska Ulica 5, 2000, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Taborska 8, 2000, Maribor, Slovenia
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10
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Ng DK, Carroll MK, Furth SL, Warady BA, Flynn JT. Blood Pressure Classification Status in Children With CKD Following Adoption of the 2017 American Academy of Pediatrics Guideline. Am J Kidney Dis 2023; 81:545-553. [PMID: 36521780 PMCID: PMC10122698 DOI: 10.1053/j.ajkd.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/04/2022] [Indexed: 12/14/2022]
Abstract
RATIONALE & OBJECTIVE Accurate detection of hypertension is crucial for clinical management of pediatric chronic kidney disease (CKD). The 2017 American Academy of Pediatrics (AAP) clinical practice guideline for childhood hypertension included new normative blood pressure (BP) values and revised definitions of BP categories. In this study, we examined the effect of applying the AAP guideline's normative data and definitions to the Chronic Kidney Disease in Children (CKiD) cohort compared with use of normative data and definitions from the 2004 Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS Children and adolescents in the CKiD cohort. EXPOSURE Clinic BP measurements. OUTCOME BP percentiles and hypertension stages calculated using the 2017 AAP guideline and the Fourth Report from 2004. ANALYTICAL APPROACH Agreement analysis compared the estimated percentile and prevalence of high BP based on the 2017 guideline and 2004 report to clinic and combined ambulatory BP readings. RESULTS The proportion of children classified as having normal clinic BP was similar using the 2017 and 2004 systems, but the use of the 2017 normative data classified more participants as having stages 1-2 hypertension (22% vs 11%), with marginal reproducibility (κ=0.569 [95% CI, 0.538-0.599]). Those identified as having stage 2 hypertension by the 2017 guideline had higher levels of proteinuria compared with those identified using the 2004 report. Comparing use of the 2017 guideline and the 2004 report in terms of ambulatory BP monitoring categories, there were substantially more participants with white coat (3.5% vs 1.5%) and ambulatory (15.5% vs 7.9%) hypertension, but the proportion with masked hypertension was lower (40.2% vs 47.8%, respectively), and the percentage of participants who were normotensive was similar (40.9% vs 42.9%, respectively). Overall, there was good reproducibility (κ=0.799 [95% CI, 0.778-0.819]) of classification by ambulatory BP monitoring. LIMITATIONS Relationship with long-term progression and target organ damage was not assessed. CONCLUSIONS A greater percentage of children with CKD were identified as having hypertension based on both clinic and ambulatory BP when using the 2017 AAP guideline versus the Fourth Report from 2004, and the 2017 guideline better discriminated those with higher levels of proteinuria. The substantial differences in the classification of hypertension when using the 2017 guideline should inform clinical care.
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Affiliation(s)
- Derek K Ng
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Megan K Carroll
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Susan L Furth
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bradley A Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Joseph T Flynn
- Division of Nephrology, Seattle Children's Hospital; Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington.
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11
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Douglas CE, Roem J, Flynn JT, Furth SL, Warady BA, Halbach SM. Effect of Age on Hypertension Recognition in Children With Chronic Kidney Disease: A Report From the Chronic Kidney Disease in Children Study. Hypertension 2023; 80:1048-1056. [PMID: 36861464 PMCID: PMC10133176 DOI: 10.1161/hypertensionaha.122.20354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/20/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Young age has been associated with poorer control of hypertension in children with chronic kidney disease (CKD). Using data from the CKiD Study (Chronic Kidney Disease in Children), we examined the relationship between age, hypertensive blood pressure (BP) recognition, and pharmacologic BP control in children with nondialysis-dependent CKD. METHODS Participants included 902 CKiD Study participants with CKD stages 2 to 4. A total of 3550 annual study visits met inclusion criteria and participants were stratified by age (0 to <7, ≥7 to <13, ≥13 to ≤18 years). Generalized estimating equations to account for repeated measures were applied to logistic regression analyses to evaluate the association of age with unrecognized hypertensive BP and medication use. RESULTS Children <7 years of age had a higher prevalence of hypertensive BP and a lower prevalence of antihypertensive medication use compared with older children. At visits where participants <7 years of age had hypertensive BP readings, 46% had unrecognized, untreated hypertensive BP compared with 21% of visits for children ≥13 years of age. The youngest age group was associated with higher odds of unrecognized hypertensive BP (adjusted odds ratio, 2.11 [95% CI, 1.37-3.24]) and lower odds of antihypertensive medication use among those with unrecognized hypertensive BP (adjusted OR, 0.51 [95% CI, 0.27-0.996]). CONCLUSIONS Children younger than 7 years of age with CKD are more likely to have both undiagnosed and undertreated hypertensive BP. Efforts to improve BP control in young children with CKD are needed to minimize development of cardiovascular disease and slow CKD progression.
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Affiliation(s)
| | - Jennifer Roem
- Department of Epidemiology, Johns Hopkins Bloomberg School
of Public Health, Baltimore, MD
| | - Joseph T Flynn
- Division of Nephrology, Seattle Children’s Hospital,
WA
- Department of Pediatrics, University of Washington School
of Medicine, Seattle
| | - Susan L Furth
- Departments of Pediatrics and Epidemiology, Perelman School
of Medicine at the University of Pennsylvania, Division of Nephrology, Children's
Hospital of Philadelphia
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children’s Mercy
Kansas City, MO
| | - Susan M Halbach
- Division of Nephrology, Seattle Children’s Hospital,
WA
- Department of Pediatrics, University of Washington School
of Medicine, Seattle
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12
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Warady BA, Feldman DL, Bell LE, Bacchetta J, Denburg MR, Flynn JT, Haffner D, Johnson RJ, Mitsnefes MM, Schaefer F, Jaure A, Furth SL. Improving Clinical Care for Children With CKD: A Report From a National Kidney Foundation Scientific Workshop. Am J Kidney Dis 2023; 81:466-474. [PMID: 36410592 DOI: 10.1053/j.ajkd.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 09/14/2022] [Indexed: 11/22/2022]
Abstract
Development of clinical guidelines and recommendations to address the care of pediatric patients with chronic kidney disease (CKD) has rarely included the perspectives of providers from a variety of health care disciplines or the patients and parents themselves. Accordingly, the National Kidney Foundation hosted an in-person, one and a half-day workshop that convened a multidisciplinary group of physicians, allied health care professionals, and pediatric patients with CKD and their parents, with the goal of developing key clinical recommendations regarding best practices for the clinical management of pediatric patients living with CKD. The key clinical recommendations pertained to 5 broad topics: addressing the needs of patients and parents/caregivers; modifying the progression of CKD; clinical management of CKD-mineral and bone disorder and growth retardation; clinical management of anemia, cardiovascular disease, and hypertension; and transition and transfer of pediatric patients to adult nephrology care. This report describes the recommendations generated by the participants who attended the workshop.
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Affiliation(s)
- Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri.
| | | | - Lorraine E Bell
- Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
| | - Justine Bacchetta
- Department of Pediatric Nephrology Rheumatology and Dermatology, Reference Center for Rare Renal Diseases, INSERM 1033, Hospices Civils de Lyon, Lyon, France
| | - Michelle R Denburg
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover
| | - Rebecca J Johnson
- Division of Developmental and Behavioral Health, Children's Mercy Kansas City, Kansas City, Missouri
| | - Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Franz Schaefer
- Pediatric Nephrology Division, Heidelberg University Medical Center, Heidelberg, Germany
| | - Allison Jaure
- School of Public Health, University of Sydney and The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Susan L Furth
- Division Pediatric Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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13
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Low dialysate sodium in children and young adults on maintenance hemodialysis: a prospective, randomized, crossover study. Pediatr Nephrol 2022; 38:1599-1607. [PMID: 36315274 DOI: 10.1007/s00467-022-05792-y] [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: 08/31/2022] [Revised: 09/29/2022] [Accepted: 10/12/2022] [Indexed: 03/01/2023]
Abstract
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.
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14
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Tain YL, Hsu CN. Cardiovascular Risks of Hypertension: Lessons from Children with Chronic Kidney Disease. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1650. [PMID: 36360378 PMCID: PMC9688449 DOI: 10.3390/children9111650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 09/29/2023]
Abstract
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.
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Affiliation(s)
- You-Lin Tain
- Division of Pediatric Nephrology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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15
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Bakhoum CY, Matheson MB, Greenberg JH, Furth SL, Ix JH, Garimella PS. Urine Uromodulin Is Not Associated With Blood Pressure in the Chronic Kidney Disease in Children Cohort. Hypertension 2022; 79:2298-2304. [PMID: 35920156 PMCID: PMC9458625 DOI: 10.1161/hypertensionaha.122.19566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Uromodulin regulates activity of the sodium-potassium-two-chloride transporter in the loop of Henle. In adults, higher urine uromodulin levels are associated with greater rise in blood pressure (BP) in response to salt intake. We hypothesized that higher urine uromodulin levels would be associated with higher BP in children with chronic kidney disease, and that there would be an interaction of dietary sodium on this association. METHODS In the chronic kidney disease in children Cohort, we utilized univariable and multivariable linear regression models to evaluate the relationship between baseline spot urine uromodulin levels indexed to urine creatinine (Umod/Cr mg/g) and 24-hour mean systolic and diastolic BP, as well as baseline clinic BP. We also tested whether sodium intake (g/day) modified these relationships. RESULTS Among 436 participants, the median age was 12.4 years (8.9-15.2), median estimated glomerular filtration rate was 50 mL/min per 1.73 m2 (36-62), and median 24-hour mean systolic BP was 112 mm Hg (104-119). The etiology of chronic kidney disease was glomerular disease in 27%. In univariable models, each 2-fold higher Umod/Cr ratio was associated with a 1.66 mm Hg (95% CI, -2.31 to -1.00) lower 24-hour mean systolic and a 1.71 mm Hg (-2.45 to -0.97) lower clinic systolic BP. However, there was no statistically significant association between Umod/Cr and either 24-hour or clinic BP in multivariable models. We did not find a significant interaction between uromodulin and sodium intake in their effect on BP (P>0.05 in all models). CONCLUSIONS Urine uromodulin levels are not associated with BP in the chronic kidney disease in children cohort. Further studies are needed to confirm this finding in healthy pediatric cohorts.
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Affiliation(s)
- Christine Y Bakhoum
- Department of Pediatrics, Section of Pediatric Nephrology, Yale University, New Haven, CT (C.Y.B., J.H.G.)
| | - Matthew B Matheson
- Bloomberg School of Public Health, John Hopkins University, Baltimore, MD (M.B.M.)
| | - Jason H Greenberg
- Department of Pediatrics, Section of Pediatric Nephrology, Yale University, New Haven, CT (C.Y.B., J.H.G.)
| | - Susan L Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and Division of Nephrology, Children's Hospital of Philadelphia (S.L.F.)
| | - Joachim H Ix
- Nephrology Section, Medicine Service, Veterans Affairs San Diego Healthcare System, La Jolla, CA (J.H.I.)
| | - Pranav S Garimella
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla (J.H.I., P.S.G.)
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16
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de Verteuil I, Fitzpatrick J, Alvarez Elias AC, Banh T, Vasilevska-Ristovska J, Browne J, Bondi BC, Hui W, Slorach C, Wei Teoh C, Langlois V, Mertens L, Parekh RS. Longitudinal Changes in Cardiac Structure and Function in Pediatric Kidney Transplant Recipients. Hypertension 2022; 79:1680-1689. [PMID: 35652352 DOI: 10.1161/hypertensionaha.121.17483] [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] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cardiovascular disease results in increased morbidity and mortality in pediatric kidney transplant recipients. Longitudinal changes in cardiac structure and function and the association with blood pressure control over time in pediatric kidney transplant recipients are unknown. METHODS To determine the influence of blood pressure control on cardiac changes following pediatric kidney transplant, we conducted a retrospective cohort study of children who received their first kidney transplant at the Hospital for Sick Children from 2004 to 2015. Children were followed until transfer to adult care or censoring in July 2018. Cardiac structure and function parameters were collected from clinical echocardiograms and assessed using standardized scores. Blood pressure control was determined by systolic blood pressure Z scores (above or below the 90th percentile) in combination with antihypertensive medications. A segmented mixed-effects model assessed Z scores of interventricular septum thickness, left ventricular end-diastolic dimension, and left ventricular posterior wall dimension. RESULTS Of 142 children included, 58% were men, mean age at transplant was 11 (±4.5) years, and average follow-up time was 4 (±3) years. All cardiac structural Z scores improved during follow-up. Interventricular septum thickness normalized at 4.0 years post-transplant. Left ventricular end-diastolic dimension normalized at 1.5 years post-transplant. Left ventricular posterior wall dimension normalized at 6.3 years post-transplant. Left ventricular mass index showed sustained improvement up to 12 years post-transplant. Individuals with uncontrolled blood pressure had increased left ventricular mass (β=2.97 [95% CI, 0.77-5.16]). CONCLUSIONS Cardiac structural abnormalities improve following kidney transplantation and normalize within 7 years, especially with controlled blood pressure. Strict blood pressure control is critical after pediatric kidney transplantation.
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Affiliation(s)
- Isabel de Verteuil
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jessica Fitzpatrick
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ana Catalina Alvarez Elias
- Division of Nephrology, (A.C.A.E., C.W.T., V.L., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation (A.C.A.E.), Toronto, Ontario, Canada
| | - Tonny Banh
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jovanka Vasilevska-Ristovska
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jordan Browne
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bianca C Bondi
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wei Hui
- Labatt Family Heart Center (W.H., C.S., L.M.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cameron Slorach
- Labatt Family Heart Center (W.H., C.S., L.M.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chia Wei Teoh
- Division of Nephrology, (A.C.A.E., C.W.T., V.L., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Temerty School of Medicine (C.W.T., V.L., L.M., R.S.P.), Toronto, Ontario, Canada
| | - Valerie Langlois
- Division of Nephrology, (A.C.A.E., C.W.T., V.L., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Temerty School of Medicine (C.W.T., V.L., L.M., R.S.P.), Toronto, Ontario, Canada
| | - Luc Mertens
- Labatt Family Heart Center (W.H., C.S., L.M.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Temerty School of Medicine (C.W.T., V.L., L.M., R.S.P.), Toronto, Ontario, Canada
| | - Rulan S Parekh
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Nephrology, (A.C.A.E., C.W.T., V.L., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Temerty School of Medicine (C.W.T., V.L., L.M., R.S.P.), Toronto, Ontario, Canada.,Toronto, Ontario, Canada and Dalla Lana School of Public Health (R.S.P.), Toronto, Ontario, Canada.,University of Toronto. University Health Network (R.S.P.) Toronto, Ontario, Canada
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17
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Hsu CN, Chen WL, Liao WT, Chang-Chien GP, Lin S, Tain YL. Hydrogen Sulfide-to-Thiosulfate Ratio Associated with Blood Pressure Abnormalities in Pediatric CKD. J Pers Med 2022; 12:jpm12081241. [PMID: 36013190 PMCID: PMC9409977 DOI: 10.3390/jpm12081241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
Abstract
Identifying children with chronic kidney disease (CKD) at high risk of cardiovascular disease (CVD) and ensuring they receive appropriate treatment can prevent CVD events and mortality later in life. Hydrogen sulfide (H2S) is a gaseous signaling molecule participating in CVD and CKD. Thiosulfate is not only an oxidation product of H2S but is also a H2S donor. We examined whether H2S, thiosulfate, and their combined ratio have differential associations with CVD risk markers in 56 children and adolescents aged 6–18 years with CKD stages G1–G4. Up to two-thirds of CKD children showed higher BP load on 24 h ambulatory blood pressure monitoring (ABPM), even in the early stage. CKD children with ABPM abnormalities had a higher H2S-to-thiosulfate ratio, while H2S-related parameters were not affected by the severity of CKD. The H2S-to-thiosulfate ratio was positively correlated with 24 h systolic BP (SBP), nighttime SBP, and carotid artery intima-media thickness (cIMT). After adjusting for confounders, H2S was negatively associated with LV mass, thiosulfate was positively associated with 24-DBP, and the H2S-to-thiosulfate ratio was positively correlated with nighttime SBP and cIMT. Our data demonstrate differential associations in circulating H2S, thiosulfate, and their combined ratio with CVD risk in childhood CKD. Further studies are required to determine whether targeting the H2S signaling pathway can develop novel therapeutic strategies against CVD in this high-risk population.
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Affiliation(s)
- Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan, China;
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung 807, Taiwan, China
| | - Wei-Ling Chen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan, China; (W.-L.C.); (W.-T.L.)
| | - Wei-Ting Liao
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan, China; (W.-L.C.); (W.-T.L.)
| | - Guo-Ping Chang-Chien
- Center for Environmental Toxin and Emerging-Contaminant Research, Cheng Shiu University, Kaohsiung 833, Taiwan, China; (G.-P.C.-C.); (S.L.)
- Super Micro Mass Research and Technology Center, Cheng Shiu University, Kaohsiung 833, Taiwan, China
- Institute of Environmental Toxin and Emerging-Contaminant, Cheng Shiu University, Kaohsiung 833, Taiwan, China
| | - Sufan Lin
- Center for Environmental Toxin and Emerging-Contaminant Research, Cheng Shiu University, Kaohsiung 833, Taiwan, China; (G.-P.C.-C.); (S.L.)
- Super Micro Mass Research and Technology Center, Cheng Shiu University, Kaohsiung 833, Taiwan, China
- Institute of Environmental Toxin and Emerging-Contaminant, Cheng Shiu University, Kaohsiung 833, Taiwan, China
| | - You-Lin Tain
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan, China; (W.-L.C.); (W.-T.L.)
- College of Medicine, Chang Gung University, Taoyuan 330, Taiwan, China
- Correspondence: ; Tel.: +886-975-056-995; Fax: +886-7733-8009
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Jacobson MH, Wu Y, Liu M, Kannan K, Lee S, Ma J, Warady BA, Furth S, Trachtman H, Trasande L. Urinary Polycyclic Aromatic Hydrocarbons in a Longitudinal Cohort of Children with CKD: A Case of Reverse Causation? KIDNEY360 2022; 3:1011-1020. [PMID: 35845343 PMCID: PMC9255870 DOI: 10.34067/kid.0000892022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/28/2022] [Indexed: 01/10/2023]
Abstract
Background Air pollution, which results in the formation of polycyclic aromatic hydrocarbons (PAHs), has been identified as a cause of renal function decline and a contributor to CKD. However, the results of cross-sectional studies investigating personal, integrated biomarkers of PAHs have been mixed. Longitudinal studies may be better suited to evaluate environmental drivers of kidney decline. The purpose of this study was to examine associations of serially measured urinary PAH metabolites with clinical and subclinical measures of kidney function over time among children with CKD. Methods This study was conducted among 618 participants in the Chronic Kidney Disease in Children study, a cohort study of pediatric patients with CKD from the United States and Canada, between 2005 and 2015. In serially collected urine samples over time, nine PAH metabolites were measured. Clinical outcomes measured annually included eGFR, proteinuria, and BP. Subclinical biomarkers of tubular injury (kidney injury molecule-1 [KIM-1] and neutrophil gelatinase-associated lipocalin [NGAL]) and oxidant stress (8-hydroxy-2'-deoxyguanosine [8-OHdG] and F2-isoprostane) were assayed in urine samples. Results Children were followed over an average (SD) of 3.0 (1.6) years and 2469 study visits (mean±SD, 4.0±1.6). Hydroxynaphthalene (NAP) or hydroxyphenanthrene (PHEN) metabolites were detected in >99% of samples and NAP concentrations were greater than PHEN concentrations. PHEN metabolites, driven by 3-PHEN, were associated with increased eGFR and reduced proteinuria, diastolic BP z-score, and NGAL concentrations over time. However, PAH metabolites were consistently associated with increased KIM-1 and 8-OHdG concentrations. Conclusions Among children with CKD, these findings provoke the potential explanation of reverse causation, where renal function affects measured biomarker concentrations, even in the setting of a longitudinal study. Additional work is needed to determine if elevated KIM-1 and 8-OHdG excretion reflects site-specific injury to the proximal tubule mediated by low-grade oxidant stress.
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Affiliation(s)
- Melanie H Jacobson
- Division of Environmental Pediatrics, Department of Pediatrics, New York University Langone Medical Center, New York, New York
| | - Yinxiang Wu
- Department of Population Health, New York University Langone Medical Center, New York, New York
| | - Mengling Liu
- Department of Population Health, New York University Langone Medical Center, New York, New York
- Department of Environmental Medicine, New York University Langone Medical Center, New York, New York
| | - Kurunthachalam Kannan
- Division of Environmental Pediatrics, Department of Pediatrics, New York University Langone Medical Center, New York, New York
- Wadsworth Center, New York State Department of Health, and Department of Environmental Health Sciences, School of Public Health, State University of New York at Albany, Albany, New York
| | - Sunmi Lee
- Division of Environmental Pediatrics, Department of Pediatrics, New York University Langone Medical Center, New York, New York
- Wadsworth Center, New York State Department of Health, and Department of Environmental Health Sciences, School of Public Health, State University of New York at Albany, Albany, New York
| | - Jing Ma
- Wadsworth Center, New York State Department of Health, and Department of Environmental Health Sciences, School of Public Health, State University of New York at Albany, Albany, New York
| | - Bradley A Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Susan Furth
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Howard Trachtman
- Department of Pediatrics, Division of Nephrology, New York University Langone Medical Center, New York, New York
- University of Michigan, Ann Arbor, Michigan
| | - Leonardo Trasande
- Division of Environmental Pediatrics, Department of Pediatrics, New York University Langone Medical Center, New York, New York
- Department of Population Health, New York University Langone Medical Center, New York, New York
- Department of Environmental Medicine, New York University Langone Medical Center, New York, New York
- New York University Wagner School of Public Service, New York, New York
- New York University College of Global Public Health, New York, New York
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Dweik H, Kaur J, Jaka S, Faruki F, Shah RP, Amuk Williams OC, Chalia A, Bachu A. Cardiometabolic Comorbidity Risk in Pediatric Patients With Psychiatric Illnesses: A Case-Control Inpatient Study. Cureus 2022; 14:e26326. [PMID: 35911267 PMCID: PMC9314267 DOI: 10.7759/cureus.26326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives To delineate the differences in the cardiometabolic comorbidities in pediatric patients with medical versus psychiatric illnesses and to determine the risk of association between the spectrum of cardiometabolic comorbidities in pediatric patients with a broad range of psychiatric illnesses. Methods We conducted a case-control study using the nationwide inpatient sample (NIS), the largest hospital database in the United States (US) and included 179,550 pediatric patients (age 10-18 years) that were hospitalized with a primary diagnosis of psychiatric illness (N = 89,775) and pediatric patients that were hospitalized with a primary diagnosis of medical illness (N = 89,775). We used descriptive statistics and Pearson’s chi-square test to delineate the differences between pediatric inpatients with medical versus psychiatric illnesses. Results The majority of pediatric patients with psychiatric illnesses were females (58%) and white (62%), with a mean age of 15 years. Cardiometabolic comorbidities were higher in patients admitted for psychiatric illness, with a higher prevalence of hypothyroidism (1.6%) and obesity (7.1%) than in those hospitalized for medical illnesses. Among all cardiometabolic comorbidities, obesity had the highest prevalence across all psychiatric illnesses, measuring eight percent in patients with disruptive behavior disorders, followed by seven percent each in anxiety, mood, and psychotic disorders. Diabetes had the lowest prevalence hovering between one and two percent for a spectrum of psychiatric illnesses. Conclusion The prevalence of cardiometabolic comorbidities is higher in pediatric inpatients with psychiatric illnesses. This calls for timely monitoring of the routine labs and early diagnosis and management of the cardiometabolic comorbidities in this at-risk population.
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20
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Amanullah F, Malik AA, Zaidi Z. Chronic kidney disease causes and outcomes in children: Perspective from a LMIC setting. PLoS One 2022; 17:e0269632. [PMID: 35675292 PMCID: PMC9176774 DOI: 10.1371/journal.pone.0269632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 05/24/2022] [Indexed: 01/10/2023] Open
Abstract
Background and objective Chronic kidney disease (CKD) constitutes a major public health challenge, with a global prevalence of 15–74.7 cases /million children. Preventing CKD in children, slowing its progression and management of complications are essential, especially in challenged health systems in low middle income countries (LMIC). We conducted a retrospective review to assess the underlying cause and stage of CKD at presentation and clinical outcomes in children and adolescents at the Indus Hospital and Health Network (IHHN) in Karachi, Pakistan. Methods Children 0–16 years with CKD stage 1 and/or higher at presentation were included. Data including demographics, clinical status and lab results at presentation and during follow-up, surgical intervention if any, kidney function at last visit and outcome at last follow-up was recorded. Results A total of 229 children diagnosed with CKD are included in our study. The median age at diagnosis was 10 years with male: female ratio of 1.8:1. Only 5% children presented in stage 1 CKD. The rate of adverse outcomes is 4.5 times higher in children with CKD stage 3–5 compared to early CKD. Congenital anomaly of kidney and urinary tract (CAKUT) was the underlying cause in 49% children. Children with glomerular disease had comparatively worse outcome. Proteinuria, hypertension, anemia and bone disease were associated with high morbidity and mortality. Conclusion The true epidemiology of childhood CKD is unknown in Pakistan. Our cohort showed better CKD outcomes in children diagnosed early with appropriate surgical and medical follow-up. Prompt diagnosis, treatment and prevention of progression can be life-saving in our setting. CKD registry data can inform policy changes that can prevent poor outcomes.
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Affiliation(s)
| | - Amyn A. Malik
- Interactive Research and Development (IRD) Global, Singapore, Singapore
- Yale Institute for Global Health, New Haven, Connecticut, United States of America
- * E-mail: ,
| | - Zafar Zaidi
- The Indus Hospital and Health Network, Karachi, Pakistan
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21
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The causes and consequences of paediatric kidney disease on adult nephrology care. Pediatr Nephrol 2022; 37:1245-1261. [PMID: 34389906 DOI: 10.1007/s00467-021-05182-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 05/29/2021] [Accepted: 06/01/2021] [Indexed: 10/20/2022]
Abstract
Adult nephrologists often look after patients who have been diagnosed with kidney disease in childhood. This does present unique challenges to the adult nephrologist, who may be unfamiliar with the underlying cause of kidney disease as well as the complications of chronic kidney disease (CKD) that may have accumulated during childhood. This review discusses common causes of childhood CKD, in particular congenital anomalies of the kidney and urinary tract (CAKUT), autosomal dominant tubulointerstitial kidney disease (ADTKD), polycystic kidney disease, hereditary stone disease, nephrotic syndrome and atypical haemolytic uraemic syndrome. The long-term consequences of childhood CKD, such as the cardiovascular consequences, cognition and education as well as bone health, nutrition and growth are also discussed.
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22
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High blood pressure in children and adolescents: current perspectives and strategies to improve future kidney and cardiovascular health. Kidney Int Rep 2022; 7:954-970. [PMID: 35570999 PMCID: PMC9091586 DOI: 10.1016/j.ekir.2022.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 02/08/2023] Open
Abstract
Hypertension is one of the most common causes of preventable death worldwide. The prevalence of pediatric hypertension has increased significantly in recent decades. The cause of this is likely multifactorial, related to increasing childhood obesity, high dietary sodium intake, sedentary lifestyles, perinatal factors, familial aggregation, socioeconomic factors, and ethnic blood pressure (BP) differences. Pediatric hypertension represents a major public health threat. Uncontrolled pediatric hypertension is associated with subclinical cardiovascular disease and adult-onset hypertension. In children with chronic kidney disease (CKD), hypertension is also a strong risk factor for progression to kidney failure. Despite these risks, current rates of pediatric BP screening, hypertension detection, treatment, and control remain suboptimal. Contributing to these shortcomings are the challenges of accurately measuring pediatric BP, limited access to validated pediatric equipment and hypertension specialists, complex interpretation of pediatric BP measurements, problematic normative BP data, and conflicting society guidelines for pediatric hypertension. To date, limited pediatric hypertension research has been conducted to help address these challenges. However, there are several promising signs in the field of pediatric hypertension. There is greater attention being drawn on the cardiovascular risks of pediatric hypertension, more emphasis on the need for childhood BP screening and management, new public health initiatives being implemented, and increasing research interest and funding. This article summarizes what is currently known about pediatric hypertension, the existing knowledge-practice gaps, and ongoing research aimed at improving future kidney and cardiovascular health.
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23
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Wyld MLR, Mata NLDL, Viecelli A, Swaminathan R, O'Sullivan KM, O'Lone E, Rowlandson M, Francis A, Wyburn K, Webster AC. Sex-Based Differences in Risk Factors and Complications of Chronic Kidney Disease. Semin Nephrol 2022; 42:153-169. [PMID: 35718363 DOI: 10.1016/j.semnephrol.2022.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Globally, females are ∼30% more likely to have pre-dialysis chronic kidney disease (CKD) than males for reasons that are not fully understood. CKD is associated with numerous adverse health outcomes which makes understanding and working to eradicating sex based disparities in CKD prevalence essential. This review maps both what is known, and what is unknown, about the way sex and gender impacts (1) the epidemiology and risk factors for CKD including age, diabetes, hypertension, obesity, smoking, and cerebrovascular disease, and (2) the complications from CKD including kidney disease progression, cardiovascular disease, CKD mineral and bone disorders, anaemia, quality-of-life, cancer and mortality. This mapping can be used to guide future research.
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Affiliation(s)
- Melanie L R Wyld
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Department of Renal and Transplant Medicine, Westmead Hospital, Sydney, Australia.
| | - Nicole L De La Mata
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Andrea Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Ramyasuda Swaminathan
- Department of Nephrology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Kim M O'Sullivan
- Department of Medicine, Centre for Inflammatory Diseases, Monash University, Clayton, Victoria, Australia
| | - Emma O'Lone
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Matthew Rowlandson
- Department of Renal and Transplant Medicine, Westmead Hospital, Sydney, Australia
| | - Anna Francis
- Child and Adolescent Renal Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Kate Wyburn
- Department of Renal Medicine,Royal Prince Alfred Hospital, Sydney, Australia
| | - Angela C Webster
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Department of Renal and Transplant Medicine, Westmead Hospital, Sydney, Australia
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Bakhoum CY, Katz R, Samuels JA, Al-Rousan T, Furth SL, Ix JH, Garimella PS. Nocturnal Dipping and Left Ventricular Mass Index in the Chronic Kidney Disease in Children Cohort. Clin J Am Soc Nephrol 2022; 17:75-82. [PMID: 34772729 PMCID: PMC8763165 DOI: 10.2215/cjn.09810721] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/01/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES The physiologic nocturnal BP decline is often blunted in patients with CKD; however, the consequences of BP nondipping in children are largely unknown. Our objective was to determine risk factors for nondipping and to investigate if nondipping is associated with higher left ventricular mass index in children with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a cross-sectional analysis of ambulatory BP monitoring and echocardiographic data in participants of the Chronic Kidney Disease in Children study. Multivariable linear and spline regression analyses were used to evaluate the relationship of risk factors with dipping and of dipping with left ventricular mass index. RESULTS Within 552 participants, mean age was 11 (±4) years, mean eGFR was 53 (±20) ml/min per 1.73 m2, and 41% were classified as nondippers. In participants with nonglomerular CKD, female sex and higher sodium intake were significantly associated with less systolic and diastolic dipping (P≤0.05). In those with glomerular CKD, Black race and greater proteinuria were significantly associated with less systolic and diastolic dipping (P≤0.05). Systolic dipping and diastolic dipping were not significantly associated with left ventricular mass index; however, in spline regression plots, diastolic dipping appeared to have a nonlinear relationship with left ventricular mass index. As compared with diastolic dipping of 20%-25%, dipping of <20% was associated with 1.41-g/m2.7-higher left ventricular mass index (95% confidence interval, -0.47 to 3.29), and dipping of >25% was associated with 1.98-g/m2.7-higher left ventricular mass index (95% confidence interval, -0.77 to 4.73), although these relationships did not achieve statistical significance. CONCLUSIONS Black race, female sex, and greater proteinuria and sodium intake were significantly associated with blunted dipping in children with CKD. We did not find a statistically significant association between dipping and left ventricular mass index. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_12_20_CJN09810721.mp3.
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Affiliation(s)
- Christine Y. Bakhoum
- Department of Pediatrics, Section of Pediatric Nephrology, Yale University, New Haven, Connecticut
| | - Ronit Katz
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Joshua A. Samuels
- Division of Pediatric Nephrology & Hypertension, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Tala Al-Rousan
- Division of Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California
| | - Susan L. Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joachim H. Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, California,Nephrology Section, Medicine Service, Veterans Affairs San Diego Healthcare System, La Jolla, California,Kidney Research Innovation Hub of San Diego, La Jolla, California
| | - Pranav S. Garimella
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, California,Kidney Research Innovation Hub of San Diego, La Jolla, California
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Leader HE, Mambwe T. Elevated Blood Pressure in Hospitalized Children Predicts True Elevated Blood Pressure Outpatient. Hosp Pediatr 2021:e2021006314. [PMID: 34966944 DOI: 10.1542/hpeds.2021-006314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine if elevated blood pressure (EBP) in hospitalized children accurately predicts EBP outpatient. METHODS A multicenter retrospective chart review was conducted at a large hospital system in Northeastern United States. Mean blood pressures during hospitalizations were classified as elevated or not elevated, by using the American Academy of Pediatrics (AAP) 2017 parameters. Mean blood pressure was then compared with each patient's mean blood pressure measured 3 times postdischarge. The data were analyzed to determine if inpatient EBP is an accurate predictor of outpatient EBP. RESULTS Of 5367 hospitalized children, 656 (12.2%) had EBP inpatient. Inpatient EBP was highly predictive of outpatient EBP, with a positive predictive value of 96% and negative predictive value of 98%. CONCLUSIONS Diagnosing hospitalized children with EBP, as defined by the AAP 2017 guidelines, accurately predicts true EBP outpatient.
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Affiliation(s)
- Hadassa E Leader
- K Hovnanian Children's Hospital, Hackensack Meridian Health Network, Neptune City, New Jersey
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Leader Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Twiza Mambwe
- University of Texas Health San Antonio, San Antonio, Texas
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26
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Hsu CN, Hou CY, Chang CI, Tain YL. Resveratrol Butyrate Ester Protects Adenine-Treated Rats against Hypertension and Kidney Disease by Regulating the Gut–Kidney Axis. Antioxidants (Basel) 2021; 11:antiox11010083. [PMID: 35052587 PMCID: PMC8772985 DOI: 10.3390/antiox11010083] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/23/2021] [Accepted: 12/28/2021] [Indexed: 01/14/2023] Open
Abstract
Despite recent advances in pharma-nutritional management, chronic kidney disease (CKD) remains an increasingly prevalent disorder. Resveratrol, a pleiotropic phytochemical, has been found to reduce the risk for several chronic diseases. Considering the low bioavailability of resveratrol, we recently synthesized resveratrol butyrate ester (RBE) via the esterification of resveratrol with butyrate. The aim of this study was to examine the effectiveness of RBE as regards protection from hypertension and kidney damage and explore the underlying mechanisms using a young rat adenine-induced CKD model. Three-week-old male Sprague Dawley rats received regular or 0.5% adenine chow for three weeks. Three groups of adenine-fed CKD rats (N = 8/group) received resveratrol (50 mg/L), or a low dose (25 mg/L) or high dose (50 mg/L) of RBE in drinking water from week 6 to week 12. As compared with the controls, adenine-treated rats had markedly increased creatinine levels and blood pressure, which was associated with renal hypertrophy and decreased creatinine clearance. Treatment with resveratrol or a low or high dose of RBE, similarly protected adenine-fed rats against hypertension and kidney damage. CKD-induced hypertension is associated with an altered gut microbiota profile, dysregulated renal short chain fatty acid (SCFA) receptor expression, activation of the aryl hydrocarbon receptor (AhR) signaling pathway, and reduced nitric oxide bioavailability. We found gut microbiota compositions were shaped differentially by resveratrol and RBE treatment in adenine-treated CKD rats. The beneficial effect of high-dose RBE was associated with reduced renal expression of SCFA G protein-coupled receptor 41 (GPR41) and olfactory receptor 78 (Olfr78), antagonizing the AhR signaling pathway, and increased abundance of beneficial bacteria such as genera Akkermansia, Blautia, and Enterococcus. Our study provided the first evidence documenting RBE as a novel phytochemical supplement targeting the gut–kidney axis to protect against adenine-induced kidney damage and hypertension.
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Affiliation(s)
- Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung 80756, Taiwan
| | - Chih-Yao Hou
- Department of Seafood Science, National Kaohsiung University of Science and Technology, Kaohsiung 81157, Taiwan;
| | - Chi-I Chang
- Department of Biological Science and Technology, National Pingtung University of Science and Technology, Pingtung 91201, Taiwan
- Correspondence: (C.-I.C.); (Y.-L.T.); Tel.: +886-8-7703202 (ext. 5185) (C.-I.C.); +886-975-056-995 (Y.-L.T.)
| | - You-Lin Tain
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- Correspondence: (C.-I.C.); (Y.-L.T.); Tel.: +886-8-7703202 (ext. 5185) (C.-I.C.); +886-975-056-995 (Y.-L.T.)
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Abstract
Over the past 2 decades, cardiovascular (CV) disease has been recognized as one of the most important complications of chronic kidney disease (CKD) and one of the leading causes of death in children with advanced CKD and in young adults who developed CKD during childhood. CV abnormalities develop early and progress during the course of CKD in children. Characterization of the prevalence and evolution of CV disease risk factors in progressive CKD is one of the primary aims of the Chronic Kidney Disease in Children study. In this review, we summarize up-to-date findings from the Chronic Kidney Disease in Children study with a focus on traditional and CKD-related CV risk factors and early subclinical markers of cardiac and vascular structure and function. We also discuss the effect of CV risk factors on progression of CKD.
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Affiliation(s)
- Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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28
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Neurocognition in Pediatric Chronic Kidney Disease: A Review of Data From the Chronic Kidney Disease in Children (CKiD) Study. Semin Nephrol 2021; 41:446-454. [PMID: 34916006 DOI: 10.1016/j.semnephrol.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pediatric chronic kidney disease (CKD) is associated with deficits in neurocognitive functioning, ranging from mild to severe, and correlated with the severity of kidney disease. Clinical variables that are associated with neurocognitive deficits include lower kidney function, hypertension, proteinuria, and metabolic acidosis. Commonly reported neurocognitive difficulties include academic underachievement and deficits in attention regulation and executive function as well as somewhat lower intellectual abilities compared with peer and normative data. Although often mild, these neurocognitive deficits may have broad implications for quality of life and likely contribute to both poorer high school graduation rates and long-term underemployment in the adult CKD population. The presence of neurocognitive deficits in predialytic CKD has been well characterized, but further longitudinal research is warranted to describe cognitive changes as children progress from early stage CKD to kidney replacement therapy. Such studies should include both cognitive and neuroimaging evaluations to better inform the impact of CKD progression on neurocognitive outcomes.
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29
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Levy RV, Reidy KJ, Le TH, David V, Winkler C, Xu Y, Warady B, Furth S, Kaskel F, Melamed ML. Association of GSTM1 Deletion With Progression of CKD in Children: Findings From the Chronic Kidney Disease in Children (CKiD) Study. Am J Kidney Dis 2021; 80:79-86. [PMID: 34871703 PMCID: PMC9166174 DOI: 10.1053/j.ajkd.2021.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 10/14/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE Loss of function of the product of the GSTM1 gene has been implicated in rapid progression of adult CKD. Its role in pediatric CKD has not been previously described. STUDY DESIGN The study is a secondary analysis of a prospective observational cohort examining the association between deletions in GSTM1 and progression of CKD. SETTING AND PARTICIPANTS We used data and samples from the prospective Chronic Kidney Disease in Children (CKiD) cohort aged 1-16 years at enrollment with CKD. EXPOSURE We defined exposure fewer than two GSTM1 alleles on real-time polymerase chain reaction amplification. OUTCOME The primary outcome was a composite of 50% decrease in estimated glomerular filtration rate (eGFR) or start of kidney replacement therapy. Secondary outcomes included remission of proteinuria in children with glomerular disease and cardiovascular complications. ANALYTIC APPROACH The primary analysis was by Cox proportional hazards model. Analysis was adjusted for age, sex, race, ethnicity, BMI category, diagnosis category, and eGFR. RESULTS 674 children were included in the analysis. Mean age at most recent visit was 11.9 years; 61% were male and 20% were Black. There were 241 occurrences of the primary outcome at the time of analysis. After adjustment for baseline characteristics, the risk of progression of CKD for exposed children was 1.94 (1.27, 2.97). The effect size was similar with either one or two deletions (autosomal dominant inheritance). The relationships between number of functional GSTM1 alleles and prespecified secondary outcomes were not statistically significant after adjustment. LIMITATIONS Missing data, especially for secondary outcomes, and relatively small sample size compared to genetic studies in adults. CONCLUSIONS GSTM1 deletion is associated with more rapid progression of pediatric CKD after adjustment in this large prospective cohort. No statistically significant associations were seen with secondary outcomes. If replicated, these findings may inform development of interventions for CKD in children.
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Affiliation(s)
- Rebecca V Levy
- Department of Medicine, Division of Nephrology, University of Rochester School of Medicine and Dentistry.
| | - Kimberly J Reidy
- Department of Pediatrics, Division of Pediatric Nephrology, Montefiore Medical Center, Bronx, NY, United States
| | - Thu H Le
- Department of Medicine, Division of Nephrology, University of Rochester School of Medicine and Dentistry
| | - Victor David
- Basic Science Laboratory, Center for Cancer Research, Frederick National Laboratory, Frederick, MD, USA
| | - Cheryl Winkler
- Basic Science Laboratory, Center for Cancer Research, Frederick National Laboratory, Frederick, MD, USA
| | - Yunwen Xu
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Bradley Warady
- Department of Pediatrics, Division of Pediatric Nephrology, Children's Mercy Kansas City MO, USA
| | - Susan Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Frederick Kaskel
- Department of Pediatrics, Division of Pediatric Nephrology, Montefiore Medical Center, Bronx, NY, United States
| | - Michal L Melamed
- Department of Medicine, Division of Nephrology, Albert Einstein College of Medicine, Bronx, NY, United States
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Jankauskiene A, Drozdz D, Wasilewska A, de Paula-Bernardes R, Glazer R, Valentin M, Tan M, Chiang Y, Bapatla K. Efficacy and safety of valsartan in children aged 1-5 years with hypertension, with or without chronic kidney disease: a randomized, double-blind study followed by open-label phase. Curr Med Res Opin 2021; 37:2113-2122. [PMID: 34543161 DOI: 10.1080/03007995.2021.1982681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess the dose-response relationship for reduction in mean systolic blood pressure (MSBP) with valsartan solution, in young children with hypertension with or without chronic kidney disease (CKD). METHODS In this multicenter, randomized, double-blind, double-dummy study, 127 young children aged 1-5 years with hypertension (MSBP ≥95th percentile) were randomized (1:1) to receive valsartan 0.25 or 4 mg/kg/day for 6 weeks, followed by a 20 week open-label phase, where patients received valsartan 1 mg/kg/day for 4 weeks, and then optionally titrated to 2 mg/kg/day or up to 4 mg/kg/day. The primary endpoint was the change in MSBP from baseline at Week 6 during the double-blind phase. RESULTS Overall, 120 patients (94.5%) completed the study; 63 had CKD. A clinically and statistically significant reduction in MSBP from baseline to Week 6 was observed with the valsartan 4 mg/kg group compared with the valsartan 0.25 mg/kg group (8.5 vs 4.1 mmHg; p = .0157). A positive dose-response relationship for MSBP reduction was observed between the 0.25 mg/kg and 4 mg/kg groups (p = .0012). In the CKD subgroup, a significant reduction in MSBP was observed with 4 mg/kg (9.2 mmHg) versus 0.25 mg/kg (1.2 mmHg; p = .0096). In the non-CKD subgroup, a numerically greater decrease in MSBP was observed with 4 mg/kg (7.8 mmHg) versus 0.25 mg/kg (6.9 mmHg; p = .6531). Incidence of adverse events was lower with valsartan 4 mg/kg than 0.25 mg/kg (41.9% vs 51.6%) and similar between CKD and non-CKD subgroups (48.4% vs 45.3%) irrespective of dose. Increase in serum potassium (>20% compared to baseline) was observed more frequently in patients with CKD compared to non-CKD patients. CONCLUSION Valsartan was efficacious and well tolerated in children 1 to 5 years of age with hypertension, with or without CKD. Clinical trial registration: The study has been registered at ClinicalTrials.gov (Identifier: NCT01617681).
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Affiliation(s)
| | - Dorota Drozdz
- Department of Pediatric Nephrology and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Wasilewska
- Department of Pediatrics and Nephrology, Medical University of Białystok, Waszyngtona, Poland
| | | | - Robert Glazer
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Monique Tan
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Jacobson MH, Wu Y, Liu M, Kannan K, Li AJ, Robinson M, Warady BA, Furth S, Trachtman H, Trasande L. Organophosphate pesticides and progression of chronic kidney disease among children: A prospective cohort study. ENVIRONMENT INTERNATIONAL 2021; 155:106597. [PMID: 33951537 PMCID: PMC8292180 DOI: 10.1016/j.envint.2021.106597] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 04/13/2021] [Accepted: 04/21/2021] [Indexed: 05/03/2023]
Abstract
BACKGROUND Growing evidence suggests that exposure to environmental chemicals, such as pesticides, impacts renal function and chronic kidney disease (CKD). However, it is not clear if pesticides may affect CKD progression and no studies exist in children. OBJECTIVES The objective of this study was to examine associations between serially measured urinary OP pesticide metabolites and clinical and laboratory measures of kidney function over time among children with CKD. METHODS This study used data on 618 participants enrolled in the CKD in Children study (CKiD), a cohort study of pediatric CKD patients from the US and Canada. Children were followed over an average of 3.0 years (standard deviation (SD) = 1.6) between 2005 and 2015. In serially collected urine samples over time, six nonspecific dialkyl phosphate (DAP) metabolites of OP pesticides were measured. Biomarkers of tubular injury (kidney injury molecule-1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL)) and oxidant stress (8-hydroxy-2'-deoxyguanosine (8-OHdG) and F2-isoprostane) were determined in the same specimens. Estimated glomerular filtration rate (eGFR), proteinuria, and blood pressure were assessed annually. RESULTS DAPs were associated with increased KIM-1 and 8-OHdG throughout follow-up. A standard deviation increase in ∑diethyl metabolites was associated with increases of 11.9% (95% Confidence Interval (CI): 4.8%, 19.4%) and 13.2% (95% CI: 9.3%, 17.2%) in KIM-1 and 8-OHdG over time, respectively. DAPs were associated with lower eGFR at baseline and higher eGFR over subsequent years. CONCLUSIONS These findings provide preliminary evidence suggesting that urinary DAP metabolites are associated with subclinical kidney injury among children with CKD, which may signal the potential for clinical events to manifest in the future. The results from this study are significant from both a clinical and public health perspective, given that OP pesticide exposure is a modifiable risk factor.
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Affiliation(s)
- Melanie H Jacobson
- Department of Pediatrics, Division of Environmental Pediatrics, NYU Langone Medical Center, New York, NY, USA.
| | - Yinxiang Wu
- Department of Population Health, NYU Langone Medical Center, New York, NY, USA
| | - Mengling Liu
- Department of Pediatrics, Division of Environmental Pediatrics, NYU Langone Medical Center, New York, NY, USA; Department of Environmental Medicine, NYU Langone Medical Center, New York, NY
| | - Kurunthachalam Kannan
- Department of Pediatrics, Division of Environmental Pediatrics, NYU Langone Medical Center, New York, NY, USA
| | - Adela Jing Li
- Department of Pediatrics, Division of Environmental Pediatrics, NYU Langone Medical Center, New York, NY, USA
| | - Morgan Robinson
- Department of Pediatrics, Division of Environmental Pediatrics, NYU Langone Medical Center, New York, NY, USA
| | - Bradley A Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Susan Furth
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Howard Trachtman
- Department of Pediatrics, Division of Nephrology, NYU Langone Medical Center, New York, NY, USA
| | - Leonardo Trasande
- Department of Pediatrics, Division of Environmental Pediatrics, NYU Langone Medical Center, New York, NY, USA; Department of Population Health, NYU Langone Medical Center, New York, NY, USA; Department of Environmental Medicine, NYU Langone Medical Center, New York, NY; NYU Wagner School of Public Service, New York, NY, USA; NYU College of Global Public Health, New York, NY, USA
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Hemoglobin and hematocrit levels are positively associated with blood pressure in children and adolescents 10 to 18 years old. Sci Rep 2021; 11:19052. [PMID: 34561491 PMCID: PMC8463603 DOI: 10.1038/s41598-021-98472-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 09/08/2021] [Indexed: 02/08/2023] Open
Abstract
To investigate the associations between hemoglobin (Hb) concentration and hematocrit (Hct), and blood pressure (BP) in children and adolescents. The study population consisted of 7950 subjects total (4229 boys and 3721 girls) aged 10-18 years who participated in the Korea National Health and Nutrition Examination Surveys conducted between 2007 and 2017. The prevalence of hypertension was 19.19% (21.51% for boys and 16.5% for girls) among the study population, and the prevalence of obesity was 9.59% (10.5% for boys and 8.6% for girls). Hb count and Hct tended to increase with the degree of obesity and BP elevation. Systolic BP (SBP) and diastolic BP (DBP) positively correlated with Hb count and Hct in both sexes. Following multiple linear regression analysis, Hb count and Hct presented a positive association with SBP and DBP after adjusting for age, BMI SDS, alcohol consumption, smoking status, physical activity, rural residence, household income, diagnosis of T2DM, hypertension, and dyslipidemia. Hb count and Hct were positively associated with SBP and DBP in children and adolescents 10-18 years old.
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Myette RL, Burger D, Geier P, Feber J. Diastolic hypertension is associated with proteinuria in pediatric patients. Health Sci Rep 2021; 4:e346. [PMID: 34401524 PMCID: PMC8351612 DOI: 10.1002/hsr2.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND AND AIMS Blood pressure lability has been observed in certain cohorts of pediatric patients with variable degrees of proteinuria; however, the impact of proteinuria on blood pressure is not fully elucidated. The objective of our study was to analyze blood pressure and heart rate in pediatric patients with proteinuria. METHODS We performed a retrospective chart review of patients (age 1-18) diagnosed with idiopathic nephrotic syndrome, with varying degrees of proteinuria. Blood pressure and heart rate data were analyzed in relation to anthropometric and biochemical parameters. A total of 72 urine sample analyses, along with associated blood pressure measurements, were obtained from the charts of 33 children (males = 25). RESULTS Diastolic blood pressure Z-scores were significantly higher in proteinuric patients (urine protein/creatinine >0.02 g/mmol) compared to non-proteinuric patients (P = .006; Cohen-d 0.97 [0.41; 1.53]). Systolic blood pressure was also significantly higher in proteinuric patients (P = .04), but with a less significant effect size (Cohen-d 0.54 [-0.002; 1.08]). Proteinuria (>0.02 g/mmol) was the most significant predictor of diastolic (β = .79, P = .04), but not systolic blood pressure elevation on multivariate analysis. CONCLUSIONS We observed a disproportionate increase in diastolic blood pressure vs systolic blood pressure in patients with proteinuria.
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Affiliation(s)
- Robert L. Myette
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Eastern OntarioUniversity of OttawaOttawaOntarioCanada
- Kidney Research Center, Department of Cellular and Molecular Medicine, The Ottawa Hospital Research InstituteUniversity of OttawaOttawaOntarioCanada
| | - Dylan Burger
- Kidney Research Center, Department of Cellular and Molecular Medicine, The Ottawa Hospital Research InstituteUniversity of OttawaOttawaOntarioCanada
| | - Pavel Geier
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Eastern OntarioUniversity of OttawaOttawaOntarioCanada
| | - Janusz Feber
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Eastern OntarioUniversity of OttawaOttawaOntarioCanada
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Richardson KL, Weaver DJ, Ng DK, Carroll MK, Furth SL, Warady BA, Flynn JT. L-type calcium channel blocker use and proteinuria among children with chronic kidney diseases. Pediatr Nephrol 2021; 36:2411-2419. [PMID: 33590332 PMCID: PMC8985842 DOI: 10.1007/s00467-021-04967-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/11/2021] [Accepted: 01/22/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hypertension is common among children with chronic kidney disease (CKD), and dihydropyridine calcium channel blockers (dhCCBs) are frequently used as treatment. The impact of dhCCBs on proteinuria in children with CKD is unclear. METHODS Data from 722 participants in the Chronic Kidney Disease in Children (CKiD) longitudinal cohort with a median age of 12 years were used to assess the association between dhCCBs and log transformed urine protein/creatinine levels as well as blood pressure control measured at annual visits. Angiotensin-converting enzyme inhibitor (ACEi) and angiotensin receptor blocker (ARB) use was evaluated as an effect measure modifier. RESULTS Individuals using dhCCBs had 18.8% higher urine protein/creatinine levels compared to those with no history of dhCCB or ACEi and ARB use. Among individuals using ACEi and ARB therapy concomitantly, dhCCB use was not associated with an increase in proteinuria. Those using dhCCBs had higher systolic and diastolic blood pressures. CONCLUSIONS Use of dhCCBs in children with CKD and hypertension is associated with higher levels of proteinuria and was not found to be associated with improved blood pressure control.
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Affiliation(s)
- Kelsey L Richardson
- Division of Pediatric Nephrology, Oregon Health & Sciences University, Portland, OR, USA
| | - Donald J Weaver
- Pediatric Nephrology and Hypertension, Atrium Health Levine Children's, 1000 Blythe Blvd, Str 200, Charlotte, NC, 28232, USA.
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Megan K Carroll
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Susan L Furth
- Division of Pediatric Nephrology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington; Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA
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Hemodiafiltration maintains a sustained improvement in blood pressure compared to conventional hemodialysis in children-the HDF, heart and height (3H) study. Pediatr Nephrol 2021; 36:2393-2403. [PMID: 33629141 DOI: 10.1007/s00467-021-04930-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/08/2020] [Accepted: 01/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hypertension is prevalent in children on dialysis and associated with cardiovascular disease. We studied the blood pressure (BP) trends and the evolution of BP over 1 year in children on conventional hemodialysis (HD) vs. hemodiafiltration (HDF). METHODS This is a post hoc analysis of the "3H - HDF-Hearts-Height" dataset, a multicenter, parallel-arm observational study. Seventy-eight children on HD and 55 on HDF who had three 24-h ambulatory BP monitoring (ABPM) measures over 1 year were included. Mean arterial pressure (MAP) was calculated and hypertension defined as 24-h MAP standard deviation score (SDS) ≥95th percentile. RESULTS Poor agreement between pre-dialysis systolic BP-SDS and 24-h MAP was found (mean difference - 0.6; 95% limits of agreement -4.9-3.8). At baseline, 82% on HD and 44% on HDF were hypertensive, with uncontrolled hypertension in 88% vs. 25% respectively; p < 0.001. At 12 months, children on HDF had consistently lower MAP-SDS compared to those on HD (p < 0.001). Over 1-year follow-up, the HD group had mean MAP-SDS increase of +0.98 (95%CI 0.77-1.20; p < 0.0001), whereas the HDF group had a non-significant increase of +0.15 (95%CI -0.10-0.40; p = 0.23). Significant predictors of MAP-SDS were dialysis modality (β = +0.83 [95%CI +0.51 - +1.15] HD vs. HDF, p < 0.0001) and higher inter-dialytic-weight-gain (IDWG)% (β = 0.13 [95%CI 0.06-0.19]; p = 0.0003). CONCLUSIONS Children on HD had a significant and sustained increase in BP over 1 year compared to a stable BP in those on HDF, despite an equivalent dialysis dose. Higher IDWG% was associated with higher 24-h MAP-SDS in both groups.
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Cao D, Chen Y, Gao X, Zhu Y, Wu D, Liu G. Hypertension in 172 Chinese Children: An 8-Year Retrospective Study. J NIPPON MED SCH 2021; 88:178-188. [PMID: 34193741 DOI: 10.1272/jnms.jnms.2021_88-301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We evaluated children with hypertension and compared those with essential and secondary (including renal and non-renal) hypertension. METHODS This retrospective study analyzed data from hypertensive children (age, 0-18 years) referred for treatment between January 2008 and December 2015. Demographic factors, causative factors, and medical treatments were evaluated. Treatment failure was defined as a systolic or diastolic blood pressure ≥95th percentile for age, gender, and height on three separate occasions, despite treatment. All patients not meeting the failure criteria were considered to have controlled hypertension. The control rate was defined as the proportion of patients with controlled blood pressure. RESULTS Among 172 consecutive patients, 28% had essential hypertension and 72% had secondary hypertension. As compared with children with secondary hypertension, those with essential hypertension had a higher frequency of family history of hypertension (P<0.001), a higher body mass index (BMI) (P=0.001), lower frequency of proteinuria (P=0.003), lower uric acid (P=0.04), and lower triglyceride (P=0.048). The medications used in the controlled group were similar to those used in the uncontrolled group. Angiotensin-converting enzyme inhibitors (ACEIs) were only used in nephrogenic patients, and a higher rate of ACEI use seemed to increase control rates. Control rates did not significantly differ by age, number of drugs, or cause of hypertension. CONCLUSIONS As compared with children with secondary hypertension, those with essential hypertension were more likely to have a family history of hypertension and had a higher BMI, lower frequency of proteinuria, and lower uric acid and triglyceride concentrations. Treatment guidelines for essential and secondary hypertension should be established for children of all ages.
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Affiliation(s)
- Di Cao
- Medical Affairs Department, Children's Hospital of Fudan University
| | - Yewei Chen
- Department of Pharmacy, Children's Hospital of Fudan University
| | - Xuan Gao
- Department of Pharmacy, Children's Hospital of Fudan University
| | - Yiqing Zhu
- Department of Pharmacy, Children's Hospital of Fudan University
| | - Dan Wu
- Department of Pharmacy, Children's Hospital of Fudan University
| | - Gongbao Liu
- Medical Affairs Department, Children's Hospital of Fudan University
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When should we start and stop ACEi/ARB in paediatric chronic kidney disease? Pediatr Nephrol 2021; 36:1751-1764. [PMID: 33057769 DOI: 10.1007/s00467-020-04788-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/19/2020] [Accepted: 09/15/2020] [Indexed: 12/29/2022]
Abstract
Renin-angiotensin-aldosterone inhibitors (RAASi) are the mainstay therapy in both adult and paediatric chronic kidney disease (CKD). RAASi slow down the progression of kidney failure by optimization of blood pressure and reduction of proteinuria. Despite recommendations from published guidelines in adults, the evidence related to the use of RAASi is surprisingly scarce in children. Moreover, their role in advanced CKD remains controversial. Without much guidance from the literature, paediatric nephrologists may discontinue RAASi in patients with advanced CKD due to apparent worsening of kidney function, hyperkalaemia and hypotension. Current data suggest that this strategy may in fact lead to a more rapid decline in kidney function. The optimal approach in this clinical scenario is still not well defined and there are varying practices worldwide. We will in this review describe the existing evidence on the use of RAASi in CKD with particular focus on paediatric data. We will also address the use of RAASi in advanced CKD and discuss the potential benefits and harms. At the end, we will suggest a practical approach for the use of RAASi in children with CKD based on current state of knowledge.
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Ceravolo G, Macchia TL, Cuppari C, Dipasquale V, Gambadauro A, Casto C, Ceravolo MD, Cutrupi M, Calabrò MP, Borgia P, Piccolo G, Mancuso A, Albiero R, Chimenz R. Update on the Classification and Pathophysiological Mechanisms of Pediatric Cardiorenal Syndromes. CHILDREN-BASEL 2021; 8:children8070528. [PMID: 34206173 PMCID: PMC8305733 DOI: 10.3390/children8070528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 11/16/2022]
Abstract
Cardiorenal syndrome (CRS) is defined as a disorder resulting from the abnormal interaction between the heart and kidney, in which acute or chronic dysfunction of one organ may lead to acute and/or chronic dysfunction of the other. The functional interplay between the heart and kidney is characterized by a complex bidirectional symbiotic interaction, regulated by a wide array of both genetic and environmental mechanisms. There are at least five known subtypes of CRS, based on the severity of clinical features and the degree of heart/renal failure. The fourth subtype (cardiorenal syndrome type 4 (CRS4)) is characterized by a primary chronic kidney disease (CKD), which in turn leads to a decreased cardiac function. Impairment of renal function is among the most important pathophysiological factors contributing to heart failure (HF) in the pediatric age group, and cardiovascular complications could be one of the most important causes of mortality in pediatric patients with advanced CKD. In this context, a loss of glomerular filtration rate directly correlates with both the progression of cardiovascular complications in CRS and the risk of HF. This review describes the interaction pathways between the heart and kidney and the recently identified pathophysiological mechanisms underlying pediatric CRS, with a special focus on CRS4, which encompasses both primary CKD and cardiovascular disease (CVD).
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Affiliation(s)
- Giorgia Ceravolo
- Unit of Emergency Pediatric, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, “G. Martino” Policlinic, 98124 Messina, Italy; (G.C.); (C.C.); (V.D.); (A.G.); (C.C.); (M.D.C.); (M.C.); (A.M.)
| | - Tommaso La Macchia
- Unit of Cardiology, Department of Clinical and Experimental Medicine, University of Messina, “G. Martino” Policlinic, 98124 Messina, Italy;
| | - Caterina Cuppari
- Unit of Emergency Pediatric, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, “G. Martino” Policlinic, 98124 Messina, Italy; (G.C.); (C.C.); (V.D.); (A.G.); (C.C.); (M.D.C.); (M.C.); (A.M.)
| | - Valeria Dipasquale
- Unit of Emergency Pediatric, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, “G. Martino” Policlinic, 98124 Messina, Italy; (G.C.); (C.C.); (V.D.); (A.G.); (C.C.); (M.D.C.); (M.C.); (A.M.)
| | - Antonella Gambadauro
- Unit of Emergency Pediatric, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, “G. Martino” Policlinic, 98124 Messina, Italy; (G.C.); (C.C.); (V.D.); (A.G.); (C.C.); (M.D.C.); (M.C.); (A.M.)
| | - Celeste Casto
- Unit of Emergency Pediatric, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, “G. Martino” Policlinic, 98124 Messina, Italy; (G.C.); (C.C.); (V.D.); (A.G.); (C.C.); (M.D.C.); (M.C.); (A.M.)
| | - Maria Domenica Ceravolo
- Unit of Emergency Pediatric, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, “G. Martino” Policlinic, 98124 Messina, Italy; (G.C.); (C.C.); (V.D.); (A.G.); (C.C.); (M.D.C.); (M.C.); (A.M.)
| | - Maricia Cutrupi
- Unit of Emergency Pediatric, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, “G. Martino” Policlinic, 98124 Messina, Italy; (G.C.); (C.C.); (V.D.); (A.G.); (C.C.); (M.D.C.); (M.C.); (A.M.)
| | - Maria Pia Calabrò
- Unit of Pediatric Cardiology, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, “G. Martino” Policlinic, 98124 Messina, Italy;
| | - Paola Borgia
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; (P.B.); (G.P.)
| | - Gianluca Piccolo
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; (P.B.); (G.P.)
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Alessio Mancuso
- Unit of Emergency Pediatric, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, “G. Martino” Policlinic, 98124 Messina, Italy; (G.C.); (C.C.); (V.D.); (A.G.); (C.C.); (M.D.C.); (M.C.); (A.M.)
| | - Remo Albiero
- Department of Cardiology, Sondrio General Hospital, 23100 Sondrio, Italy;
| | - Roberto Chimenz
- Unit of Pediatric Nephrology, and Rheumatology with Dialysis, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, “G. Martino” Policlinic, 98124 Messina, Italy
- Correspondence: ; Tel.: +39-3479962816
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Dionne JM, Jiang S, Ng DK, Flynn JT, Mitsnefes MM, Furth SL, Warady BA, Samuels JA. Mean Arterial Pressure and Chronic Kidney Disease Progression in the CKiD Cohort. Hypertension 2021; 78:65-73. [PMID: 34058856 DOI: 10.1161/hypertensionaha.120.16692] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia/BC Children's Hospital, Vancouver, Canada (J.M.D.)
| | - Shuai Jiang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (S.J., D.K.N.)
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (S.J., D.K.N.)
| | - Joseph T Flynn
- Division of Nephrology, Department of Pediatrics, Seattle Children's Hospital, WA (J.T.F.)
| | - Mark M Mitsnefes
- Division of Nephrology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, OH (M.M.M.)
| | - Susan L Furth
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, PA (S.L.F.)
| | - Bradley A Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, MO (B.A.W.)
| | - Joshua A Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School at the University of Texas, Houston (J.A.S.)
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Flynn JT, Carroll MK, Ng DK, Furth SL, Warady BA. Achieved clinic blood pressure level and chronic kidney disease progression in children: a report from the Chronic Kidney Disease in Children cohort. Pediatr Nephrol 2021; 36:1551-1559. [PMID: 33200315 PMCID: PMC8087620 DOI: 10.1007/s00467-020-04833-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/02/2020] [Accepted: 10/16/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Control of hypertension delays progression of pediatric chronic kidney disease (CKD), yet few data are available regarding what clinic blood pressure (BP) levels may slow progression. METHODS Longitudinal BP data from children in the Chronic Kidney Disease in Children cohort study who had hypertension or an auscultatory BP ≥ 90th percentile were studied. BP categories were defined as the maximum systolic or diastolic BP percentile (< 50th, 50th to 75th, 75th to 90th, and ≥ 90th percentile) with time-updated classifications corresponding to annual study visits. The primary outcome was time to kidney replacement therapy or a 30% decline in estimated glomerular filtration rate. Cox proportional hazard models described the effect of each BP category compared to BP ≥ 90th percentile. RESULTS Seven hundred fifty-four participants (median age 9.9 years at study entry) met inclusion criteria; 65% were male and 26% had glomerular CKD. Any BP < 90th percentile was associated with a decreased risk of progression for those with glomerular CKD (hazard ratio (HR), 0.63; 95% CI, 0.28-1.39 (< 50th); HR, 0.59; 95% CI, 0.28-1.26 (50th-75th); HR, 0.40; 95% CI, 0.18-0.93 (75th-90th)). Similar results were found for those with non-glomerular CKD: any BP < 90th percentile was associated with decreased risk of progression (HR, 0.78; 90% CI, 0.49-1.25 (< 50th); HR, 0.53; 95% CI, 0.33-0.84 (50th-75th); HR, 0.71; 95% CI, 0.46-1.08 (75th-90th)). CONCLUSIONS Achieved clinic BP < 90th percentile was associated with slower CKD progression in children with glomerular or non-glomerular CKD. These data provide guidance for management of children with CKD in the office setting. Graphical abstract.
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Affiliation(s)
- Joseph T. Flynn
- Division of Nephrology, Seattle Children’s Hospital; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Megan K. Carroll
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan L. Furth
- Division of Nephrology, Children’s Hospital of Philadelphia; Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Bradley A. Warady
- Division of Nephrology, Children’s Mercy Kansas City, Kansas City, MO
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Kupferman JC, Lande MB, Stabouli S, Zafeiriou DI, Pavlakis SG. Hypertension and childhood stroke. Pediatr Nephrol 2021; 36:809-823. [PMID: 32350664 DOI: 10.1007/s00467-020-04550-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 03/18/2020] [Accepted: 03/23/2020] [Indexed: 01/09/2023]
Abstract
Cerebrovascular disease (stroke) is one of the ten leading causes of death in children and adolescents. Multiple etiologies, from arteriopathies to prothrombic states, can cause stroke in youth. In adult stroke, hypertension has been shown to be the single most important modifiable risk factor. Although hypertension has not been strongly identified as a risk factor in childhood stroke to date, there is preliminary evidence that suggests that hypertension may also be associated with stroke in children. In this review, we summarize the literature that may link hypertension to stroke in the young. We have identified a series of barriers and limitations in the fields of pediatric hypertension and pediatric neurology that might explain why hypertension has been overlooked in childhood stroke. We suggest that hypertension may be a relevant risk factor that, alone or in combination with other multiple factors, contributes to the development of stroke in children. Currently, there are no consensus guidelines for the management of post-stroke hypertension in children. Thus, we recommend that blood pressure be assessed carefully in every child presenting with acute stroke in order to better understand the effects of hypertension in the development and the outcome of childhood stroke. We suggest a treatment algorithm to help practitioners manage hypertension after a stroke.
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Affiliation(s)
- Juan C Kupferman
- Department of Pediatrics, Maimonides Medical Center, Brooklyn, NY, USA.
| | - Marc B Lande
- Department of Pediatrics, University of Rochester, Rochester, NY, USA
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios I Zafeiriou
- 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Steven G Pavlakis
- Department of Pediatrics, Maimonides Medical Center, Brooklyn, NY, USA
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42
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Cheung AK, Chang TI, Cushman WC, Furth SL, Hou FF, Ix JH, Knoll GA, Muntner P, Pecoits-Filho R, Sarnak MJ, Tobe SW, Tomson CR, Mann JF. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int 2021; 99:S1-S87. [PMID: 33637192 DOI: 10.1016/j.kint.2020.11.003] [Citation(s) in RCA: 361] [Impact Index Per Article: 120.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
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43
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Atkinson MA, Ng DK, Warady BA, Furth SL, Flynn JT. The CKiD study: overview and summary of findings related to kidney disease progression. Pediatr Nephrol 2021; 36:527-538. [PMID: 32016626 PMCID: PMC7396280 DOI: 10.1007/s00467-019-04458-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/10/2019] [Accepted: 12/16/2019] [Indexed: 12/15/2022]
Abstract
The Chronic Kidney Disease in Children (CKiD) cohort study is a North American (USA and Canada) multicenter, prospective study of children with chronic kidney disease (CKD). The original aims of the study were (1) to identify novel risk factors for CKD progression; (2) to measure the impact of kidney function decline on growth, cognition, and behavior; and (3) to characterize the evolution of cardiovascular disease risk factors. CKiD has developed into a national and international resource for the investigation of a variety of factors related to CKD in children. This review highlights notable findings in the area of CKD progression and outlines ongoing opportunities to enhance understanding of CKD progression in children. CKiD's contributions to the clinical care of children with CKD include updated and more accurate glomerular filtration rate estimating equations for children and young adults, and resources designed to help estimate the CKD progression timeline. In addition, results from CKiD have strengthened the evidence that treatment of hypertension and proteinuria should continue as a primary strategy for slowing the rate of disease progression in children.
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Affiliation(s)
| | - Derek K. Ng
- Johns Hopkins Bloomberg School of Public Health
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44
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Hsu WF, Kao YW, Chen M, Chiang HC, Chen SY, Lu MC, Shia BC, Hsieh KS. A reappraisal of the prevalence of pediatric hypertension through a nationwide database in Taiwan. Sci Rep 2021; 11:4475. [PMID: 33627680 PMCID: PMC7904942 DOI: 10.1038/s41598-021-84001-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/05/2021] [Indexed: 01/31/2023] Open
Abstract
Hypertension in childhood and adolescence is associated with adult cardiovascular morbidity and mortality. However, the reported prevalence of pediatric hypertension varies considerably. We conducted a pioneer nationwide population-based study to investigate the prevalence of hypertension among children and adolescents. Pediatric patients who had been diagnosed with hypertension between 2000 and 2013 were selected from the National Health Insurance Research Database in Taiwan. Other metabolic syndrome-related diseases that would increase cardiovascular risk, including diabetes mellitus (DM), hyperlipidemia, and obesity, were also retrieved for further evaluation. In total, 10,364 children and adolescents diagnosed with hypertension were identified. The prevalence of pediatric hypertension in Taiwan ranged from 0.19 to 0.38 per 1000 children and adolescents between 2000 and 2013. Essential hypertension was most commonly coded (90.6%), which was much more than secondary hypertension (14.3%). Children and adolescents with hypertension were often associated with DM, hyperlipidemia, and obesity, with the odds ratios as 14.05 (95% confidence interval (CI) 11.74-16.81, p < 0.001), 10.65 (95% CI 9.48-11.97, p < 0.001), and 19.08 (95% CI 15.65-23.26, p < 0.001), respectively. To improve lifelong cardiovascular health, our results emphasize the importance of early proper recognition and suitable management of hypertension, as well as metabolic syndrome-related diseases, among children and adolescents.
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Affiliation(s)
- Wan-Fu Hsu
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Yi-Wei Kao
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
- Research Center of Big Data, College of Management, Taipei Medical University, Taipei, Taiwan, ROC
| | - Mingchih Chen
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
| | - Huei-Chen Chiang
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
| | - Shih-Yen Chen
- Department of Pediatrics, Shuangho Hospital, Taipei Medical University, New Taipei City, Taiwan, ROC
| | - Meng-Che Lu
- Department of Pediatrics, Shuangho Hospital, Taipei Medical University, New Taipei City, Taiwan, ROC
| | - Ben-Chang Shia
- Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, New Taipei City, Taiwan, ROC.
- Research Center of Big Data, College of Management, Taipei Medical University, Taipei, Taiwan, ROC.
| | - Kai-Sheng Hsieh
- Department of Pediatrics, Shuangho Hospital, Taipei Medical University, New Taipei City, Taiwan, ROC.
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC.
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45
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Charnaya O, Seifert M. Promoting cardiovascular health post-transplant through early diagnosis and adequate management of hypertension and dyslipidemia. Pediatr Transplant 2021; 25:e13811. [PMID: 32871051 DOI: 10.1111/petr.13811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/18/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
Abstract
Despite correction of underlying solid organ failure by transplantation, pediatric transplant recipients still have increased mortality rates compared to the general pediatric population, in part due to increased cardiovascular risk. In particular, pediatric kidney and non-kidney transplant recipients with chronic kidney disease have significant cardiovascular risk that worsens with declining kidney function. Biomarkers associated with future cardiovascular risk such as casual and ambulatory hypertension, dyslipidemia, vascular stiffness and calcification, and left ventricular hypertrophy can be detected throughout the post-transplant period and in patients with stable kidney function. Among these, hypertension and dyslipidemia are two potentially modifiable cardiovascular risk factors that are highly prevalent in kidney and non-kidney pediatric transplant recipients. Standardized approaches to appropriate BP measurement and lipid monitoring are needed to detect and address these risk factors in a timely fashion. To achieve sustained improvement in cardiovascular health, clinicians should partner with patients and their caregivers to address these and other risk factors with a combined approach that integrates pharmacologic with non-pharmacologic approaches. This review outlines the scope and impact of hypertension and dyslipidemia in pediatric transplant recipients, with a particular focus on pediatric kidney transplantation given the high burden of chronic kidney disease-associated cardiovascular risk. We also review the current published guidelines for monitoring and managing abnormalities in blood pressure and lipids, highlighting the important role of therapeutic lifestyle changes in concert with antihypertensive and lipid-lowering medications.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Seifert
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL, USA
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Roth CL, Perez FA, Whitlock KB, Elfers C, Yanovski JA, Shoemaker AH, Abuzzahab MJ. A phase 3 randomized clinical trial using a once-weekly glucagon-like peptide-1 receptor agonist in adolescents and young adults with hypothalamic obesity. Diabetes Obes Metab 2021; 23:363-373. [PMID: 33026160 PMCID: PMC7821019 DOI: 10.1111/dom.14224] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/24/2020] [Accepted: 10/04/2020] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the efficacy, safety and tolerability of a glucagon-like peptide-1 receptor agonist (GLP-1 RA) in patients with hypothalamic obesity (HO). MATERIALS AND METHODS A two-arm, randomized, multicentre, double-blind, placebo-controlled trial was conducted in 10- to 25-year-olds with hypothalamic injury following intracranial tumour and HO. Participants were randomized to once-weekly subcutaneous injections of a GLP-1 RA exenatide 2 mg (ExQW) or placebo for 36 weeks. The primary efficacy endpoint was 36-week % change in body mass index (BMI). Secondary outcomes included change in body composition (by dual energy x-ray absorptiometry). RESULTS Forty-two participants were randomized to ExQW (n = 23) or placebo (n = 19). Participants were 5 ± 2 years (mean ± SD) postdiagnosis and development of HO (BMI 37.3 ± 7.1 kg/m2 ). In intention-to-treat analysis, the effect of 36-week ExQW vs. placebo on % Δ BMI was not significant (estimated treatment difference -1.7 ± 1.8%, 95% CI -4.1 to 0.6%, P = .40); however, total body fat mass was reduced (estimated treatment difference -3.1 ± 1.4 kg, 95% CI -5.7 to -0.4 kg, P = .02). There was a significant reduction in waist circumference (estimated effect of treatment -3.5 [95% CI -5.5 to -1.6] cm, P = .004). All patients treated with placebo increased % of adipose tissue, while 50% treated with ExQW had reductions (P < .001). Mean HbA1c, glucose tolerance and serum lipids did not change significantly with therapy. ExQW was well tolerated. The most frequent adverse events were transient gastrointestinal disturbances (ExQW vs. placebo: nausea 6/23 vs. 3/18, vomiting 4/23 vs. 4/18 and diarrhoea 7/23 vs. 3/18). CONCLUSIONS GLP-1 RAs are a promising and safe treatment to improve or stabilize HO in children and young adults.
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Affiliation(s)
- Christian L. Roth
- Seattle Children's Research InstituteSeattleWashington
- Department of PediatricsUniversity of WashingtonSeattleWashington
| | - Francisco A. Perez
- Department of RadiologySeattle Children's and University of WashingtonSeattleWashington
| | | | | | - Jack A. Yanovski
- Section on Growth and Obesity, Division of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaMaryland
| | - Ashley H. Shoemaker
- Division of Pediatric EndocrinologyVanderbilt University Medical CenterNashvilleTennessee
| | - M. Jennifer Abuzzahab
- McNeely Pediatric Diabetes Center and Endocrinology ClinicChildren's MinnesotaSt. PaulMinnesota
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47
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Chen WL, Tain YL, Chen HE, Hsu CN. Cardiovascular Disease Risk in Children With Chronic Kidney Disease: Impact of Apolipoprotein C-II and Apolipoprotein C-III. Front Pediatr 2021; 9:706323. [PMID: 34458211 PMCID: PMC8397580 DOI: 10.3389/fped.2021.706323] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/08/2021] [Indexed: 01/28/2023] Open
Abstract
Cardiovascular disease (CVD) is an evolving process that begins in the early stages of chronic kidney disease (CKD) in children. Several surrogate markers, such as ambulatory blood pressure monitoring (ABPM), left ventricular (LV) mass, and arterial stiffness assessment, allow for the early detection of subclinical CVD in pediatric CKD. Four groups of plasma samples (n = 3/group) from congenital anomalies of the kidney and urinary tract (CAKUT), as well as non-CAKUT patients with or without BP abnormalities, were studied to screen differentially expressed proteins using isobaric tags for relative and absolute protein quantification (iTRAQ)-based proteomics. As a result, 20 differentially expressed proteins associated with hypertension in children with CKD were discovered. Among them, apolipoprotein C-II (apoC-II) was found to have the highest abundance among the CKD patients with hypertension. As such, we hypothesized that apoC-II and apolipoprotein C-III (apoC-III) levels were related to BP abnormalities and CVD in children suffering from mild-to-moderate CKD. We examined their associations with surrogate markers of CV risk in 88 pediatric patients with CKD stages G1-G4. Children with CKD stages G2-G4 had a higher plasma apoC-II level than G1 patients (6.35 vs. 5.05 mg/dl, p < 0.05). We observed that ABPM abnormalities, LV mass, and arterial stiffness parameters were greater in CKD children who had stages G2-G4 than in those who had stage G1 (all p < 0.05). Plasma levels of apoC-II and apoC-III were positively correlated with total cholesterol, triglyceride, and low-density lipoprotein (LDL) (all p < 0.001). In multivariate linear regression analyses, apoC-II was correlated with a high LV mass index and an abnormal ABPM profile, and apoC-III was correlated with 24-h hypertension (r = 0.303, p = 0.003) and asleep hypertension (r = 0.379, p < 0.001). Early evaluations of apoC-II and apoC-III, ABPM, and surrogate markers of CV risk will aid in early preventative interventions to reduce the risk of CV in youths suffering from CKD.
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Affiliation(s)
- Wei-Ling Chen
- Division of Pediatric Nephrology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - You-Lin Tain
- Division of Pediatric Nephrology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hung-En Chen
- Division of Pediatric Nephrology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
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48
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Simões e Silva AC, Lanza K, Palmeira VA, Costa LB, Flynn JT. 2020 update on the renin-angiotensin-aldosterone system in pediatric kidney disease and its interactions with coronavirus. Pediatr Nephrol 2021; 36:1407-1426. [PMID: 32995920 PMCID: PMC7524035 DOI: 10.1007/s00467-020-04759-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/12/2020] [Accepted: 09/03/2020] [Indexed: 12/16/2022]
Abstract
The last decade was crucial for our understanding of the renin-angiotensin-aldosterone system (RAAS) as a two-axis, counter-regulatory system, divided into the classical axis, formed by angiotensin-converting enzyme (ACE), angiotensin II (Ang II), and the angiotensin type 1 receptor (AT1R), and the alternative axis comprising angiotensin-converting enzyme 2 (ACE2), angiotensin-(1-7) (Ang-(1-7)), and the Mas receptor. Breakthrough discoveries also took place, with other RAAS endopeptides being described, including alamandine and angiotensin A. In this review, we characterize the two RAAS axes and the role of their components in pediatric kidney diseases, including childhood hypertension (HTN), pediatric glomerular diseases, congenital abnormalities of the kidney and urinary tract (CAKUT), and chronic kidney disease (CKD). We also present recent findings on potential interactions between the novel coronavirus, SARS-CoV-2, and components of the RAAS, as well as potential implications of coronavirus disease 2019 (COVID-19) for pediatric kidney diseases.
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Affiliation(s)
- Ana Cristina Simões e Silva
- grid.8430.f0000 0001 2181 4888Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Avenida Alfredo Balena, 190, 2nd floor, Room # 281, Belo Horizonte, MG 30130-100 Brazil ,grid.8430.f0000 0001 2181 4888Pediatric Nephrology Unit, Department of Pediatrics, Faculty of Medicine, UFMG, Belo Horizonte, Brazil
| | - Katharina Lanza
- grid.8430.f0000 0001 2181 4888Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Avenida Alfredo Balena, 190, 2nd floor, Room # 281, Belo Horizonte, MG 30130-100 Brazil
| | - Vitória Andrade Palmeira
- grid.8430.f0000 0001 2181 4888Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Avenida Alfredo Balena, 190, 2nd floor, Room # 281, Belo Horizonte, MG 30130-100 Brazil
| | - Larissa Braga Costa
- grid.8430.f0000 0001 2181 4888Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Avenida Alfredo Balena, 190, 2nd floor, Room # 281, Belo Horizonte, MG 30130-100 Brazil
| | - Joseph T. Flynn
- grid.34477.330000000122986657Pediatric Nephrology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA 98105 USA
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49
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Chrysaidou K, Chainoglou A, Karava V, Dotis J, Printza N, Stabouli S. Secondary Hypertension in Children and Adolescents: Novel Insights. Curr Hypertens Rev 2020; 16:37-44. [PMID: 31038068 DOI: 10.2174/1573402115666190416152820] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 12/25/2022]
Abstract
Hypertension is a significant risk factor for cardiovascular morbidity and mortality, not only in adults, but in youths also, as it is associated with long-term negative health effects. The predominant type of hypertension in children is the secondary hypertension, with the chronic kidney disease being the most common cause, however, nowadays, there is a rising incidence of primary hypertension due to the rising incidence of obesity in children. Although office blood pressure has guided patient management for many years, ambulatory blood pressure monitoring provides useful information, facilitates the diagnosis and management of hypertension in children and adolescents, by monitoring treatment and evaluation for secondary causes or specific phenotypes of hypertension. In the field of secondary hypertension, there are numerous studies, which have reported a strong association between different determinants of 24-hour blood pressure profile and the underlying cause. In addition, in children with secondary hypertension, ambulatory blood pressure monitoring parameters offer the unique advantage to identify pediatric low- and high-risk children for target organ damage. Novel insights in the pathogenesis of hypertension, including the role of perinatal factors or new cardiovascular biomarkers, such as fibroblast growth factor 23, need to be further evaluated in the near future.
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Affiliation(s)
- Katerina Chrysaidou
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Athanasia Chainoglou
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Vasiliki Karava
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - John Dotis
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Nikoleta Printza
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
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50
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Kim JY, Lee Y, Kang HG, Ha IS, Cheong HI, Choi HJ, Han KH, Kim SH, Cho MH, Shin JI, Lee JH, Park YS, Cho H. Left-ventricular diastolic dysfunction in Korean children with chronic kidney disease: data from the KNOW-Ped CKD study. BMC Nephrol 2020; 21:533. [PMID: 33297989 PMCID: PMC7724800 DOI: 10.1186/s12882-020-02152-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/04/2020] [Indexed: 12/29/2022] Open
Abstract
Background Cardiovascular disease (CVD) is the most common cause of mortality in pediatric chronic kidney disease (CKD) patients. Left ventricular (LV) hypertrophy (LVH) is associated with LV diastolic dysfunction (LVDD) development and is used as an early marker of CVD in pediatric CKD. This study aimed to assess the prevalence and risk factors of LVDD and the association between LVH and LVDD in Korean pediatric CKD patients. Methods Data were collected using the baseline data of the Korean cohort study for outcome in patients with pediatric chronic kidney disease, a nationwide, 10-year, prospective, observational cohort study of pediatric CKD. A total of 244 patients were included in the final analysis. Two-dimensional echocardiography and tissue Doppler images were used to evaluate LVH and LVDD. LVH was defined as an LV mass index (LVMI) ≥38 g/m2.7 and LV-wall thickness z-score > 1.64. LVDD was defined as a mitral peak velocity of early filling to early diastolic mitral annular velocity (E/E’) > 14. Univariate and multivariate logistic regression analyses were performed to evaluate risk factors of LVDD. Results In this study, the male-to-female ratio was 2.2 (168:76) and median age was 11.2 years. The average estimated glomerular filtration rate was 57.4 ml/min/1.73 m2, and no patients received renal replacement therapy. The mean value of LVMI and E/E’ was 37.0 g/m2.7 and 7.4, respectively. The prevalence of LVH was 40.1 and 17.4% by LVMI ≥38 g/m2.7 and LV-wall thickness z-score, respectively. The prevalence of LVDD was 4.5%, and patients with LVH showed greater risk of LVDD (odds ratio 7.3, p = 0.012). In the univariate analysis, young age, low hemoglobin level, higher LVMI, and higher LV-wall thickness z-score were associated with LVDD. In the multivariate analysis, young age, low hemoglobin level, and higher LV-wall thickness z-score were independently associated with LVDD. Conclusion This study shows that LVH patients have a greater risk of LVDD and that anemia is the only modifiable risk factor for LVDD in Korean pediatric CKD patients.
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Affiliation(s)
- Jeong Yeon Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Yeonhee Lee
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Hyun Jin Choi
- National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Chungcheongbuk-do, South Korea
| | - Kyoung Hee Han
- Department of Pediatrics, Jeju University Hospital, Jeju, South Korea
| | - Seong Heon Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, South Korea
| | - Min Hyun Cho
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Severance Children's Hospital, Seoul, South Korea
| | - Joo Hoon Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young Seo Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
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