Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents

Autosomal dominant polycystic kidney disease: an overview of recent genetic and clinical advances

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most common inherited kidney disease, characterized by the progressive development of multiple kidney cysts, leading to a gradual decline in kidney function. ADPKD is also the fourth leading cause of kidney failure (KF) in adults. In addition to kidney manifestations, ADPKD is associated with various extrarenal features, including liver cysts, cardiovascular abnormalities, intracranial aneurysms, and chronic pain with significant impact on patients' quality of life. While several disease-modifying agents have been tested in ADPKD, tolvaptan remains the only approved drug by the US Food and Drug Administration. The Mayo Imaging Classification is currently the most practical tool for predicting rate of kidney disease progression in ADPKD. This review provides a comprehensive overview of ADPKD, focusing on its genetics, pathophysiology, clinical presentation, management, and prognostic tools. Advances in diagnostic imaging and genetic testing have improved the early detection of ADPKD, allowing better classification of patients and prediction of KF. The review also discusses current therapeutic approaches to ADPKD, including tolvaptan, a vasopressin V2-receptor antagonist. Additionally, we address specific issues in children and pregnant individuals with ADPKD. Despite substantial progress in understanding ADPKD, there is a large need for additional effective treatments and prognostic markers to provide a more personalized care for these patients.

Impaired Myocardial Work in Children with Hypertrophic Cardiomyopathy and Left Ventricular Fibrosis on Cardiac Magnetic Resonance Imaging

Echocardiography is pivotal for diagnosis and monitoring of hypertrophic cardiomyopathy (HCM) and can evaluate myocardial function using myocardial work (MW) calculations. Echocardiography is often supplemented by cardiovascular magnetic resonance (CMR) imaging, which can detect myocardial fibrosis using late gadolinium enhancement (LGE). We sought to study the relationship between baseline LGE and MW at baseline and during follow-up in pediatric HCM patients. During the study period (2008-2023), 75 patients were followed up for HCM. In 14 patients (age 14.2 ± 2.8 years, 50.0% male, 6.4 ± 2.9 years follow-up), both LGE-CMR and echocardiography were performed. Global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency (GWE) were measured, and myocardial fibrosis was estimated by qualitative assessment of LGE. Patients with LGE (n = 7) exhibited significantly impaired baseline MW, including GWI (mean difference, MD - 487.4 mmHg %, 95% CI [- 866.8 mmHg % to - 108.3 mmHg %], p = 0.027), GCW (MD - 536.8 mmHg %, 95% CI [- 929.8 mmHg % to - 144.4 mmHg %], p = 0.020), and GWE (MD - 4.4%, 95% CI [- 8.1% to - 0.7%], p = 0.039). Regional analysis revealed impaired MW indices in segments with LGE, notably basal and mid septal segments. GWI demonstrated high diagnostic performance for LGE presence (sensitivity 93%, specificity 88%, and area under receiver operating characteristic curve 0.85). Baseline LGE presence had no significant impact on MW deterioration during follow-up. MW is significantly impaired in HCM patients with myocardial fibrosis, highlighting potential utility of echocardiography-derived MW analysis as a valuable tool.

Comparing adolescent glomerular disease clinical outcomes to the clinical outcomes in childhood, young adult, and adult-onset glomerular disease in the CureGN database

BACKGROUND

There is a lack of evidence to suggest that outcomes of adolescent and adult-onset glomerular disease differ. Still, most glomerular disease trials include adults but exclude adolescents.

METHODS

We designed a retrospective study using the CureGN database to compare individuals with adolescent-onset glomerular disease relative to individuals with older and younger age at onset. The two main outcomes were sustained proteinuria remission off immunosuppression treatment and composite eGFR decline.

RESULTS

Our data did not show a significant difference in sustained proteinuria remission off treatment or composite eGFR decline between adolescent onset glomerular disease and either childhood (age 5-12), young adult (age 20-29), or adult (age 30-39) onset glomerular disease. Having high-risk APOL1 alleles and hypertension at the time of study enrollment decreased the likelihood of achieving sustained proteinuria remission off treatment. While participants with minimal change disease and IgA nephropathy were similarly likely to achieve sustained proteinuria remission off treatment, participants with focal segmental glomerulosclerosis and membranous nephropathy were less likely to achieve sustained proteinuria remission off treatment compared to participants with minimal change disease. CKD stage, high-risk APOL1 alleles, hypertension stage, and education all significantly impacted the likelihood of progression to the composite eGFR decline outcome.

CONCLUSIONS

Approximately 25% of each age cohort reached the composite eGFR decline outcome within 5 years. As more glomerular disease clinical trials become available, we must consider opening these trials to people with childhood and adolescent onset disease since like adults they are at high risk of progressive kidney function decline.

Tuberous sclerosis complex-associated kidney disease in children

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder which can have manifestations in the kidneys, along with other organ systems. Children with TSC may develop kidney lesions at any point during childhood, and typically these are angiomyolipomata (AML) and/or kidney cysts. Children may also have hypertension associated with TSC-associated kidney disease, and rarely reduced kidney function. New guidelines for the management of TSC-associated kidney disease in children and adults were published in 2024. This educational review summarises the relevant clinical aspects of these guidelines for paediatric nephrologists through a series of four clinical cases. These cases cover management of hypertension, frequency of follow-up and frequency of kidney imaging. Difficult clinical scenarios are reviewed, such as the management of TSC2-PKD1 contiguous gene syndrome and the management of large AMLs in children with TSC.

Association between PFAS exposure and metabolic-related biomarkers in Spanish adolescents

BACKGROUND

Per- and polyfluoroalkyl substances (PFAS) exert endocrine disruptive effects on the endocrine-metabolic axis. Emerging knowledge suggests that kisspeptin may play a key role in these effects.

OBJECTIVE

To assess the cross-sectional association of blood PFAS concentrations with kisspeptin levels, KISS1 gene DNA methylation, and metabolic-related biomarkers in adolescent males from the Spanish INMA-Granada cohort.

METHODS

Seven PFAS and twelve biomarkers (glucose-GLU, total cholesterol-TC, triglycerides, LDL, HDL, ALP, AST, ALT, GGT, total bilirubin-BILT, direct bilirubin-BILD, and urea) were measured in plasma and serum, respectively, from 129 adolescent males (15-17 yrs). Systolic and diastolic blood pressure (SBP, DBP), pulse, z-scored body mass index, kisspeptin protein levels (n = 104) and whole blood KISS1 DNA methylation (n = 117) were determined. Linear regression models, weighted quantile sum (WQS), and Bayesian kernel machine (BKMR) were fit.

RESULTS

PFHpA was associated with lower GLU levels [% change per log-unit increase in plasma concentrations (95%CI) = -4.73 (-8.98;-0.28)], and PFUnDA with higher GLU, TC, and HDL levels. In models adjusted by kisspeptin level, PFOS was associated with higher SBP [3.42 (-0.12; 7.09)]. Additionally, PFNA and total PFAS concentrations were associated with higher kisspeptin levels [3.91 (0.55; 7.37) and 6.14 (0.47; 12.13), respectively]. Mixture models showed that combined PFAS exposure was associated with higher HDL, lower hepatic biomarkers (ALT, BILD) and higher kisspeptin levels.

CONCLUSION

Certain PFAS (e.g. PFUnDA) and their mixture were associated with metabolic-related biomarkers, mainly GLU, HDL, and SBP. These associations may be influenced by kisspeptin levels. More studies are needed to verify these observations.

Long-term kidney outcomes in survivors of Wilms tumor: a single-center retrospective cohort study

BACKGROUND

Several studies have investigated long-term kidney outcomes in survivors of Wilms tumor (WT). However, many have small sample sizes, and there is a wide variation in reported outcomes. The aim of this study is to investigate the long-term kidney outcomes in survivors of WT (S-WT), including those patients considered to be at high risk for poor kidney outcomes, and using updated estimated glomerular filtration rate (eGFR) equations.

METHODS

This was a retrospective chart review of 64 patients treated for WT at a single pediatric center. Patients were off treatment for 5 years or more at the time of analysis and were evaluated for decreased kidney function, hypertension, proteinuria, and compensatory hypertrophy of the contralateral kidney.

RESULTS

At a median follow-up time of 11.3 years off treatment (range 5-22.6) and average age of 16.7 years (range 6.5-30), 35 patients had a decreased eGFR (< 90 mL/min/1.73 m2), and 2 patients had progressed to chronic kidney disease stage 5. Compensatory hypertrophy was observed in 67% of cases. 41% of patients had elevated clinic blood pressures, with 2 patients on an anti-hypertensive medication. Three of 9 patients had evidence of hypertension on ambulatory blood pressure monitoring. Eight of 37 patients (22%) had proteinuria.

CONCLUSIONS

Kidney dysfunction is common in S-WT at a young age. This population should be carefully monitored for the development of decreased eGFR, hypertension, and proteinuria as part of their routine survivorship care. This is particularly true for modifiable risk factors of chronic kidney disease progression, such as hypertension and proteinuria.

Vanadium exposure and kidney markers in a pediatric population: a cross-sectional study

BACKGROUND

Anthropogenic vanadium (V) emissions and exposure in the general population have recently increased. Experimental studies have shown that V is a nephrotoxic agent, but little is known about its effects on human kidney health. This work evaluated the association between urinary V concentrations with early kidney damage biomarkers and function in a pediatric population without any disease diagnosed.

METHODS

A cross-sectional study was carried out and included 914 healthy subjects and determined urinary V concentrations, glomerular filtration rate (eGFR), albumin-creatinine ratio (ACR), and the presence of kidney injury molecule 1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) in urine. We evaluated the V effect using linear and logistic regression models adjusted by confounders.

RESULTS

Subjects found in the second and third tertiles of V showed an increase in urinary log-NGAL levels (βT2 vs. T1 = 0.39; 95% CI 0.14, 0.64, and βT3 vs. T1 = 1.04; 95% CI 0.75, 1.34) and log-KIM-1(βT2 vs. T1 = 0.25; 95% CI 0.04, 0.45 and βT3 vs. T1 = 0.39; 95% CI 0.15, 0.63); in addition, subjects in the third tertile had a positive and significant association with ACR (ORT3 vs. T1 = 1.96; 95% CI 1.29, 2.97) and increased in eGFR (βT3 vs. T1 = 3.98, 95% CI 0.39, 7.58), compared with subjects in the first tertile.

CONCLUSIONS

Our study reports the effect of V on kidney markers in a healthy pediatric population. It could be related to tubulointerstitial lesions and function abnormalities.

Prolonged remission after cyclophosphamide or tacrolimus treatment in childhood nephrotic syndrome: a cohort study

BACKGROUND

Steroid-sparing immunosuppression is used in 50% of children with nephrotic syndrome, to prevent relapses and steroid-related toxicity. However, rates and predictors of prolonged remission after cyclophosphamide and tacrolimus are uncertain.

METHODS

Retrospective analysis of children (1-18 years) enrolled in a longitudinal cohort. We included children diagnosed with steroid-sensitive nephrotic syndrome between 1996-2019 from Toronto, Canada. The exposure was cyclophosphamide or tacrolimus initiation. The primary outcome was prolonged remission (no further relapse or steroid-sparing immunosuppression). We evaluated predictors of prolonged remission and calcineurin inhibitor nephrotoxicity by logistic regression.

RESULTS

Of 578 children with steroid-sensitive nephrotic syndrome, 252 received cyclophosphamide and 120 received tacrolimus. Over median 5.4-year (IQR 2.4-9.1) follow-up, prolonged remission occurred in 72 (28.6%) after cyclophosphamide and 17 (14.2%) after tacrolimus. Relapse frequency decreased after initiation of either medication. Lower prior relapse rate, more recent treatment era, and female sex were predictive of prolonged remission after cyclophosphamide treatment. Use of tacrolimus as the first steroid-sparing medication was the only factor predictive of calcineurin inhibitor nephrotoxicity.

CONCLUSIONS

Less than one-third of children achieve prolonged remission after initiating cyclophosphamide or tacrolimus, although both reduce short-term relapse rates. Few factors predict prolonged remission after cyclophosphamide or tacrolimus use, or calcineurin inhibitor nephrotoxicity.

Investigation of a targeted panel of gut microbiome-derived toxins in children with chronic kidney disease

BACKGROUND

The gut-kidney axis is implicated in chronic kidney disease (CKD) morbidity. We describe how a panel of gut microbiome-derived toxins relates to kidney function and neurocognitive outcomes in children with CKD, consisting of indoleacetate, 3-indoxylsulfate, p-cresol glucuronide, p-cresol sulfate, and phenylacetylglutamine.

METHODS

The Chronic Kidney Disease in Children (CKiD) cohort is a North American multicenter prospective cohort that enrolled children aged 6 months to 16 years with estimated glomerular filtration rate (eGFR) 30-89 ml/min/1.73 m2. Data from the 2-year study visit were used for this analysis. Toxin quantification (Metabolon Inc., Durham, NC) was performed with ultra-high performance liquid chromatography/tandem mass spectrometry. Executive function and echocardiograms were assessed. Regression analysis examined the association of toxin levels with eGFR, CKD etiology, and neurocognitive and cardiac assessments (adjusted for age, sex, and urine protein:creatinine [UPCR]).

RESULTS

There were 150 CKiD participants included in this study. All toxins levels were significantly inversely correlated with eGFR (Spearman's rho - 0.45 to - 0.69). Children with non-glomerular CKD had significantly higher levels of 3-indoxylsulfate, phenylacetylglutamine, and p-cresol glucuronide. The toxin levels did not associate with neurocognitive outcomes. P-cresol glucuronide and phenylacetylglutamine negatively associated with left ventricular mass index z score, but did not associate with left ventricular hypertrophy.

CONCLUSIONS

Children with CKD have high levels of circulating gut microbiome-derived toxins. The levels of these toxins are strongly correlated with eGFR. There appear to be differences in toxin level based on glomerular versus non-glomerular etiology, even when accounting for the differences in eGFR between these two subgroups. In this sample, we did not detect any associations between these toxin levels and neurocognitive or cardiac outcomes.

Impact of intensive blood pressure control on kidney outcomes

PURPOSE OF REVIEW

Hypertension has long been recognized as a modifiable risk factor for cardiovascular events. However, the role of intensive blood pressure (BP) control in preventing kidney disease progression continues to be debated. This review will provide a brief update on the evidence in support of or against the intensive control of BP on kidney outcomes in patient with chronic kidney disease (CKD), focusing particularly on trial-grade evidence.

RECENT FINDINGS

Recently, three large trials conducted in China compared the effects of intensive BP control in adults with cardiovascular risk factors. All three trials demonstrated that intensive BP control confers cardiovascular benefits, but mixed results were noted in terms of the risk of adverse kidney outcomes. In individual-level meta-analyses of six trials of different BP control strategies in patients with CKD, intensive BP control appeared to reduce the risk of kidney replacement therapy in those with CKD stage 4-5, but not in patients with CKD stage 3.

SUMMARY

Most guidelines continue to recommend a systolic BP target of 120-130 mmHg for patients with CKD given the cardiovascular benefits observed in trials of intensive BP control, though there are some signals of potential risks to the kidney with this BP treatment strategy.

Interplay of Weight Status and Sleep Autonomic Function in Mediating and Moderating the Link Between Disease Severity and Blood Pressure in Paediatric Obstructive Sleep Apnoea

INTRODUCTION

Obstructive sleep apnoea (OSA) in children is associated with numerous adverse outcomes, including elevated blood pressure. While the associations between OSA, obesity, and autonomic dysfunction are recognised, the precise mechanisms linking these factors and their relationship with elevated blood pressure in children remain unclear.

METHODS

This retrospective case series included 76 children with OSA. The relationships between night-time systolic and diastolic blood pressures, body mass index, and clinical, polysomnographic, and sleep heart rate variability variables were investigated. Mediation and moderation analyses were performed.

RESULTS

Correlation analyses revealed significant associations between both systolic and diastolic blood pressures with body mass index, age, sex, adenoidal-nasopharyngeal ratio, apnoea-hypopnoea index, and sleep low frequency/high frequency (LF/HF) ratio. In multivariable linear regression models, body mass index, adenoidal-nasopharyngeal ratio, and LF/HF ratio were independently associated with systolic blood pressure, while body mass index and adenoidal-nasopharyngeal ratio were independently associated with diastolic blood pressure. Mediation and moderation analyses identified a conceptual mediation with a moderated direct path model in which body mass index mediated, and the LF/HF ratio moderated, the relationship between apnoea-hypopnoea index and systolic blood pressure. Additionally, children with concomitant OSA and attention deficit hyperactivity disorder had a significantly higher LF/HF ratio than those with OSA alone.

CONCLUSION

In children with OSA, the relationship between apnoea-hypopnoea index and systolic blood pressure was mediated by weight status and modulated by sleep sympathovagal balance. Children with OSA and attention deficit hyperactivity disorder exhibited greater disturbances in sympathovagal balance. Further research is warranted to explore these associations.

Influence of excess weight on metabolic risk factors in Argentinian preschool children

OBJECTIVES

Evaluate the differences in metabolic risk factors in preschool children with normal weight (NWG) or with some degree of excess weight (OWG).

METHODS

Body mass index (BMI), umbilical waist circumference (WC), mid-upper arm circumference (MUAC) and total body fat (TBF) in children aged 1-5.9 years. The following metabolic risk factors were measured: blood pressure, fasting glycaemia, fasting serum insulin, HOMA IR Index, total cholesterol (TC), LDL cholesterol (LDL-C) HDL cholesterol (HDL-C) and triacylglycerol (TG).

RESULTS

In population evaluated (n=689) MUAC, WC, TBF, HOMA IR were higher in OWG compared to NWG and significantly higher in OWG girls compared to boys (two ways ANOVA). Positive associations were found between diastolic blood pressure, insulin and HOMA-IR and WC, MUAC, TBF, BMI z score in the adjusted and unadjusted model.

CONCLUSIONS

MUAC may emerge as an indicator with predictive power for metabolic risk and would be very useful to measure in many setting. There is a need for in-depth research into sex difference.

Within-visit blood pressure variability in children and adolescents in the National Health and Nutrition Examination Survey (2013-2020)

BACKGROUND

Blood pressure (BP) varies depending on several factors. The objective of our study was to describe within-visit BP variability (BPV) in healthy children and compare BPV between manual and automated BP readings.

METHODS

We included individuals aged 8-17 years with three BP readings from NHANES 2013-2020 cycles. From 2013 to 2016, BP was obtained using auscultation (manual protocol, MP) and, subsequently, using oscillometry (automated protocol, AP). We excluded individuals with DBP 'zero'.

RESULTS

In 5656 individuals [MP group: 3365 (59.5%); AP group: 2291 (40.5%]), a ΔBP (difference between highest and lowest of three BP readings) at least 5 mmHg was noted in 49.1 and 60.7% of individuals for SBP and DBP, respectively. ΔDBP at least 10 mmHg was twice as common in the MP group as in the AP group. ΔDBP at least 20 mmHg was observed in 4.4% individuals. A difference of at least 5 mmHg between the initial and averaged second and third BP readings was noted in 24.9 and 34.5% of individuals for SBP and DBP, respectively. The highest of three BP readings was the first, second, or third in 44.2, 30.5, and 25.4% of individuals, for SBP, and 42.4, 29.8, and 27.7%, for DBP respectively.

CONCLUSION

Less than half of individuals had three DBP readings within 5 mmHg and some had ΔBP at least 20 mmHg. Initial BP is not always the highest; inclusion of the second and third BP readings may be more representative of the individual's actual BP. DBPV was higher with manual than with automated BP measurement.

X-Linked Hypophosphatemia Management in Adults: An International Working Group Clinical Practice Guideline

PURPOSE

An international working group (IWG) consisting of experts in X-linked hypophosphatemia (XLH) developed global guidelines providing a comprehensive, evidence-based approach to XLH diagnosis, management, and monitoring.

METHODS

The IWG, consisting of 43 members as well as methodologists and a patient partner, conducted 2 systematic reviews (SRs) and narrative reviews to address key areas. The SRs addressed the impact of burosumab compared to conventional therapy (phosphate and active vitamin D) or no therapy on patient-important outcomes in adults. They also evaluated conventional therapy compared to no therapy. GRADE methodology was applied to evaluate the certainty of evidence. Non-GRADED recommendations were made in the presence of insufficient evidence to conduct SRs. These guidelines have been reviewed and endorsed by several medical and patient societies and organizations.

RESULTS

The diagnosis of XLH is based on integrating clinical evaluation, laboratory findings confirming renal phosphate wasting (following exclusion of conditions mimicking XLH), and skeletal imaging. Fibroblast growth factor 23 measurement and DNA analysis are of value in the diagnosis, if available. Pathogenic or likely pathogenic variants in the PHEX gene are confirmatory but not necessary for the diagnosis. Management requires a multidisciplinary team knowledgeable and experienced in XLH. Effective medical therapy with burosumab can improve fracture and pseudofracture healing.

MAIN CONCLUSION

In adults with XLH and fractures or pseudofractures, burosumab is recommended over no therapy (strong recommendation, GRADEd). Additionally, burosumab is suggested as the preferred treatment compared to conventional therapy (conditional recommendation, GRADEd) in the absence of fractures or pseudofractures. If burosumab is not available, symptomatic adults should be treated with conventional therapy (Non-GRADEd recommendation).

Ambulatory Blood Pressure Phenotype and Cardiovascular Risk in Youth: The SHIP-AHOY Study

OBJECTIVE

To determine whether a specific blood pressure (BP) phenotype, based on clinic and 24-hour ambulatory BP (ABP), is associated with markers of target organ damage in otherwise healthy youth.

STUDY DESIGN

In 373 adolescents enrolled in a cross-sectional study of the relationship of BP to cardiovascular risk, clinic BP was measured by auscultation and categorized using the 2017 American Academy of Pediatrics guideline. ABP was measured for 24 hours by an oscillometric device and analyzed using the adult ABP wake SBP cut-point (130 mmHg), creating 4 BP phenotype groups: normal BP (n=212), white coat hypertensive (n=55), ambulatory hypertensive (n=63) and masked hypertensive (n=43). Echocardiographic measures and carotid-femoral pulse wave velocity (cfPWV) were measured as surrogate markers of cardiovascular risk.

RESULTS

LV mass was lowest in the normal BP group, whereas cfPWV and multiple measures of cardiac function were worse in the masked and ambulatory hypertensive groups. General linear models were constructed to examine the associations between BP phenotype and the CV risk measures. BP phenotype was significantly associated with diastolic function (E/e', e'/a'), systolic function (ejection fraction, peak longitudinal strain), and increased arterial stiffness after adjustment for BMI percentile (all p<=0.05).

CONCLUSIONS

BP phenotype is independently associated with surrogate markers of increased cardiovascular risk in adolescents, including impaired cardiac function and increased vascular stiffness. ABP monitoring has an important role in cardiovascular risk assessment in youth.

Renal artery branch stenosis induced hypertension in children: a case series

PURPOSE

Renal artery branch stenosis induced hypertension (HTN) in children is rare and facing a great challenge in diagnosis and treatment. This study aimed to summarize the clinical features and experience in diagnosis and treatment of these children.

METHODS

Four children diagnosed with renal artery branch stenosis induced HTN in the Cardiovascular Department of Children's Hospital, Capital Institute of Pediatrics were retrospectively summarized with the clinical data, the process of diagnosis and treatment, and the prognosis.

RESULTS

All patients were male with the age of 8 ~ 9 years. All were diagnosed with stage 2 HTN and most had significant symptoms. Routine examinations showed no abnormalities. A slight perfusion defect in the kidney was observed on abdominal contrast-enhanced computed tomography (CECT) in all cases. Renal artery branch stenosis was clearly detected by selective renal artery angiography. One had stenosis in the interlobular artery of the kidney, and the remaining had secondary branches stenosis. In terms of treatment, two children underwent selective renal artery embolization (SRAE), one underwent dilation by microcatheter, and the other one did not undergo interventional therapy due to arterial segmental narrowing. More than one year after SRAE, the number of antihypertensive medications was cut down with the blood pressure (BP) level reduced to normal.

CONCLUSION

Renal artery branch stenosis should be considered in younger children with early onset of HTN and significantly elevated BP. Selective renal artery angiography is the gold standard for diagnosis. However, the treatment is challenging, and SRAE may be a better choice in some cases.

Obesity-fertility cohort study: protocol for the assessment of children aged 6-12 years and their mothers

INTRODUCTION

Maternal preconception obesity and adverse gestational metabolic health increase the risk of childhood obesity in offspring, but the preconception period may be an opportune time to intervene, given the motivation of the mother and the epigenetic changes that may be beneficial for the gametes during this period. However, there is a lack of studies evaluating children born to women who have had a preconception intervention. Our group has therefore designed an ancillary study to assess children born to women enrolled in the obesity-fertility randomised controlled trial (RCT), who were 6-12 years of age, with the objective of evaluating the effect of a lifestyle intervention delivered during preconception and pregnancy on adiposity and cardiometabolic parameters in the offspring. This manuscript details the study protocol.

METHODS AND ANALYSIS

This is an ancillary nested cohort study of the obesity-fertility RCT. Women with obesity and infertility were recruited at an academic fertility clinic and randomised to the control group, which followed usual care, or to the intervention group, which received a lifestyle intervention alone for the first 6 months and then in combination with fertility treatments for up to 18 months or until the end of pregnancy. Those who have given birth to a single child are invited to participate in this follow-up study with their child aged 6-12 years. This study started in November 2023 and is expected to end in May 2025. The primary outcome is age-adjusted and sex-adjusted body mass index z-scores in children. Secondary outcomes are anthropometry, body composition, lifestyle, physical fitness level and blood or saliva markers of cardiometabolic health in both mothers and children. Of the 130 women who participated in the obesity-fertility RCT, 52 mother-child dyads (24 in the control group; 28 in the intervention group) were potentially eligible for this follow-up study. Comparisons between groups will be performed using unpaired tests and adjusted for potential confounders using multivariable regression models. This study will provide important new data on the impact of a preconception lifestyle intervention, maintained throughout pregnancy, on the health trajectory of children and mothers 6-12 years after delivery.

ETHICS AND DISSEMINATION

The study has been approved by the institutional research ethics review boards of the Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke. The results will be widely disseminated to the scientific community, relevant health professionals and general public.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT06402825).

Expanded discussion of kidney health monitoring for critically ill term and late preterm infants after acute kidney injury: a report from the Neonatal Kidney Health Consensus Workshop

BACKGROUND

Acute kidney injury (AKI) is common in the neonatal intensive care unit (NICU) and is associated with increased morbidity and mortality. Mounting evidence suggests infants with AKI in the NICU have higher risks of long-term kidney dysfunction, such as chronic kidney disease. However, guidelines for outpatient kidney-focused follow-up practices are lacking.

METHODS

As part of the National Institutes of Health-sponsored Consensus Workshop to Address Kidney Health in Neonatal Intensive Care Unit Graduates, a multidisciplinary workgroup within the US performed an in-depth review of the medical literature on term and late preterm (i.e. ≥ 34 weeks gestation) neonates admitted to the NICU with AKI to inform consensus recommendations for outpatient kidney health monitoring for high-risk and at-risk infants.

RESULTS

In this modified Delphi consensus statement, the workgroup developed three consensus recommendations and identified priority research gaps and opportunities for future study. Specific recommendations include completing a NICU discharge kidney health evaluation followed by a comprehensive kidney health assessment six months after discharge for high-risk infants and at two years of age for high-risk and at-risk infants.

CONCLUSIONS

Critically ill term and late preterm infants with AKI have an increased risk of long-term kidney dysfunction and merit evaluation at NICU discharge with subsequent comprehensive kidney health assessments based on risk factors. Current research gaps and opportunities for improved care include identifying optimal pre-discharge planning approaches, examining the impacts of different etiologies and severity of AKI on long-term kidney and overall health, exploring modification to current AKI diagnosis standards, and development of high-yield educational tools for families and providers.

Predicting Progression of STEC-HUS: Use of Shiga Toxin Subtype and Routine Laboratory Screening

BACKGROUND

Hemolytic uremic syndrome (HUS) is life-threatening sequelae of Shiga toxin-producing Escherichia coli (STEC) enteric infection. To address ambiguity in medical literature, we aimed to identify which STEC toxin profiles and clinical variables were at the highest risk of HUS progression to inform evidence-based screening guidelines.

METHODS

This was a 5-year retrospective study of children aged <18 years with E. coli O157, Shiga toxin 1 (stx1), or Shiga toxin 2 (stx2)-positive stool. Demographics, clinical symptoms, laboratory studies, and HUS progression were abstracted from the electronic health record. Univariate and multivariable logistic regression identified variables associated with HUS.

RESULTS

Of 1071 children with STEC, 55 were hospitalized with HUS (mean age 4.4 years [SD 3.7]). Predictors of HUS were age < 5 years and stool positive for E. coli O157 with stx2, or non-O157 stx2. No children of any age with O157 alone, O157 and stx1, or non-O157 stx1 and stx2 developed HUS. The prevalence of HUS with non-O157 stx1 alone was 0.2%. Vomiting, dehydration, abnormal blood counts, and chemistry were the only clinical variables associated with HUS.

CONCLUSION

We urge care management guidelines based on E. coli serotype and stx. All families of children with STEC should be counseled on the signs and symptoms of HUS and the steps to prevent dehydration; however, serial laboratory monitoring for HUS screening can be reserved for children at the highest risk for HUS. Given the substantial differences in HUS risk with stx2 as the main driver of HUS, we advocate that laboratories provide stx results to better inform anticipatory guidance.

Childhood obesity: The threatening apprentice of the adiposity empire

Childhood obesity is a global health problem, with its prevalence having tripled since 1975. The increase in its prevalence has been predominantly in developing countries, but also in those with high economic status. Nowadays, there are multiple obesity definitions, however, one of the most accurate is the one which defines obesity as the accumulation of excessive body adiposity and not as an body weight excess. Nevertheless, the body mass index (BMI) is the most frequently used tool for its classification, according to the cut-off points established by the Center for Disease Control and World Health Organization tables. In children and adolescents an adiposity excess is related to the appearance of cardiovascular disease in adulthood and with many comorbidities such as metabolic syndrome, insulin resistance, type 2 diabetes, hypertension and metabolic dysfunction-associated steatotic liver disease, among others. Currently, there is still controversy about which is the ideal indicator for measuring overweight and obesity. BMI is still used as a standardized measure but may miss cases in which body composition is pathological despite a BMI within the normal-weight category. An adequate knowledge of the impact on health of dysfunctional adiposity as well as its accurate diagnosis will allow health professionals to address this condition in a more precise and comprehensive manner, and substantially improve the associated cardiometabolic risk and prognosis.

Different risk factors for elevated blood pressure according to abdominal obesity in overweight children and adolescents

BACKGROUND

The increasing hypertension (HTN) prevalence in children, largely driven by obesity, highlights the need to investigate its risk factors, including the role of abdominal obesity.

METHODS

We analysed data from the Korea National Health and Nutrition Examination Survey (2007-2021) to assess the prevalence of overweight and obesity (OW-OB), elevated blood pressure (EBP), and HTN among 11,554 participants aged 10-18 years. EBP and HTN were defined according to the 2017 American Academy of Pediatrics guidelines, and abdominal obesity was defined as a waist-to-height ratio (WHtR) of ≥ 0.5. Secular trends in the prevalence of OW-OB and EBP-HTN were examined across five time periods, and risk factors for EBP-HTN were evaluated in OW-OB children stratified by abdominal obesity status.

RESULTS

The prevalence of EBP, HTN, and OW-OB was 8.22% (95% confidence interval [CI], 7.60-8.86), 10.46% (95% CI, 9.72-11.20), and 25.11% (95% CI, 24.17-26.05), respectively. Among the 3,015 participants with OW-OB, 13.53% (95% CI, 12.03-15.04) and 17.64% (95% CI, 15.98-19.31) were diagnosed with EBP and HTN, respectively. Although the prevalence of OW-OB and EBP-HTN had increasing trends from 2007 to 2009 to 2019-2021, these trends were not statistically significant. In the children with OW-OB, obesity severity, male sex, older age, and paternal HTN were associated with EBP-HTN. The HTN risk factors differed according to abdominal obesity status. In participants with abdominal obesity, male sex (OR 2.32, 95% CI 1.643-3.299; p < 0.0001), older age (OR 1.16, 95% CI 1.102-1.233; p < 0.0001), and severe obesity (OR 3.12, 95% CI 1.991-4.895; p < 0.0001) were significant risk factors; whereas, in those without abdominal obesity, paternal HTN (OR 1.66, 95% CI 1.207-2.303; p = 0.0025), hypercholesterolemia (OR 1.85, 95% CI 1.114-3.083; p = 0.0178), male sex (OR 1.83, 95% CI 1.329-2.530; p = 0.0002), and older age (OR 1.11, 95% CI 1.036-1.198; p = 0.0038) were significant risk factors.

CONCLUSIONS

In children with overweight or obesity, the risk factors for EBP-HTN vary depending on the presence of abdominal obesity. These findings highlight the need for differentiated surveillance and prevention strategies based on abdominal obesity status in this high-risk population.

CLINICAL TRIAL NUMBER

Not applicable.

Delayed-Onset Neurologic Changes Following Posterior Spinal Fusion: A Case Series

BACKGROUND

Delayed-onset neurologic changes (DONCs) following spinal deformity surgery are poorly understood and are often devastating.

METHODS

A retrospective review of cases from 12 hospitals was performed. The clinical and radiographic parameters of patients who experienced a new DONC after spinal deformity correction were evaluated.

RESULTS

Eighteen patients, with a mean preoperative major Cobb angle of 75° ± 24°, were included. The mean age at surgery was 13 ± 2 years, and 6 patients (33%) were male. Seven patients had temporary intraoperative neuromonitoring changes. Fourteen patients (78%) had neurologic changes within 24 hours postoperatively (range, 3 to 24 hours). Of 16 patients with blood pressure data, 8 (50%) had at least 1 documented episode of hypotension surrounding the change in neurologic status. No misaligned implants were seen on axial imaging. Fourteen patients (78%) were treated with vasopressors. Sixteen patients (89%) returned to the operating room, and 11 patients (61%) underwent implant removal. Seven patients (39%) sustained a spinal cord infarct, with only 1 (6%) experiencing recovery beyond an ASIA (American Spinal Injury Association Impairment Scale) score of B. Ten (91%) of the 11 patients without an infarct demonstrated recovery (5 patients with an ASIA score of D and 5 with a score of E).

CONCLUSIONS

A DONC is a rare complication of spinal deformity surgery. This study represents the largest documented series of DONCs and highlights the multifactorial and still poorly understood nature of this condition. The primary modifiable risk factor may be hypotension in the postoperative period: 50% of patients had a mean arterial pressure below the 5th percentile for their height, as documented around the time of the neurologic change. Eighty-six percent of patients with a spinal cord infarct had minimal neurologic recovery, whereas nearly all of the patients without an infarct did recover function. The management of this condition may include elevation of blood pressure with temporary implant removal.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Quality of Evidence and Strength of Recommendations in American Academy of Pediatrics' Guidelines

OBJECTIVE

Summarize the quality of the evidence and the strength of recommendations in the American Academy of Pediatrics' (AAP) current clinical practice guidelines.

METHODS

We identified the AAP's current clinical practice guidelines from its website. Three independent reviewers abstracted each recommendation, the quality of evidence supporting it, and its strength from every guideline. We resolved discrepancies by consensus and analyzed results using descriptive statistics.

RESULTS

We identified 14 current clinical practice guidelines. Individual guidelines make between 1 and 39 recommendations (mean 16.9, median 15), and the guidelines make a total of 236 recommendations. Twenty-five (10.6%) recommendations are based on Level A evidence (well-designed and -conducted trials, meta-analyses), 112 (47.5%) Level B (trials with minor limitations; consistent findings from multiple observational studies), 64 (27.1%) Level C (single or few observational studies or multiples studies with inconsistent findings or major limitations), 15 (6.4%) Level D (expert opinion, case reports, reasoning from first principles), and 20 (8.5%) Level X (exceptional situations in which validating studies cannot be performed and there is a clear preponderance of benefit or harm). Eighty-two (34.7%) recommendations are Strong, 117 (49.6%) Moderate, and 37 (15.7%) Weak. Fifty of the 117 (42.7%) Moderate Recommendations are based on Level C evidence, and 10 of the 80 (13%) Strong Recommendations are based on Level X evidence.

CONCLUSION

A minority of recommendations in the AAP's current clinical practice guidelines (10.6%) are based on the highest-quality evidence. Additional research is needed to improve the quality of evidence supporting pediatric clinical practice guidelines.

Role of Inflammatory Biomarkers in Mediating Causal Effect of Life Course Body Composition on Hypertension

BACKGROUND

The mediating role of inflammatory biomarkers in the causal relationship between body composition and hypertension remains unclear and requires further investigation.

METHODS

This study used a combination of retrospective observational analysis and Mendelian randomization approaches. Observational data were derived from 4717 Chinese children and adolescents aged 6 to 18 years who underwent dual-energy X-ray absorptiometry to assess body composition. Mendelian randomization analyses utilized summary statistics from large-scale data sets, including UK Biobank, deCODE2021, International Consortium of Blood Pressure, FinnGen, and other consortia. The inflammatory biomarkers included leptin, insulin, adiponectin, osteocalcin, FGF23 (fibroblast growth factor 23), and PTH (parathyroid hormone).

RESULTS

The observational analysis revealed that increased fat mass positively influenced diastolic blood pressure through osteocalcin, while fat-free mass had an inverse effect. Insulin mediated the association between fat mass and systolic blood pressure, diastolic blood pressure, and hypertension, with additional indirect effects observed for PTH (all P<0.05). The Mendelian randomization analyses demonstrated a causal relationship between childhood body mass index and hypertension mediated by insulin (indirect effect: odds ratio, 0.87 [95% CI, 0.78-0.97]) and adiponectin (odds ratio, 1.13 [95% CI, 1.04-1.23]). Adiponectin mediated the effects of fat-free mass (odds ratio, 0.81 [95% CI, 0.71-0.93]) and fat mass (odds ratio, 1.30 [95% CI, 1.11-1.51]) on hypertension. Leptin, adiponectin, and insulin also mediated the causal effects of body composition on systolic blood pressure, diastolic blood pressure, and hypertension.

CONCLUSIONS

These findings indicate that body composition influences blood pressure through distinct inflammatory biomarkers. Targeting inflammatory biomarkers may provide tailored strategies for managing body composition and hypertension.

Reliability of Composite Autonomic Symptom Score (COMPASS)-31 in Congenital Central Hypoventilation Syndrome

RATIONALE

Congenital central hypoventilation syndrome (CCHS) is a rare disorder characterized by alveolar hypoventilation and variable autonomic nervous system (ANS) dysfunction (ANSD) due to mutations in PHOX2B, a gene crucial for ANS neural crest lineage differentiation.

OBJECTIVES AND METHODS

Our prospective study aims were twofold: to (1) assess the relationships between the subjective Composite Autonomic Symptom Score (COMPASS)-31 and objective indices of ANSD obtained from heart rate variability analyses, ambulatory blood pressure (BP) monitoring, and CO2 chemosensitivities and (2) describe the organ system ANSD, its relationship to PHOX2B genotype, and its consequences on quality of life (PedsQL) in children with CCHS.

RESULTS

Thirty-two PHOX2B mutation-confirmed subjects (median [range] age 9.2 years (4.4; 18.0), 15 girls) were enrolled. COMPASS-31 was assessed in 32 matched (sex and age, range: 4.3; 18.9 years) healthy controls. As compared to healthy controls, children with CCHS had increased vasomotor (p = 0.001), secretomotor (p = 0.021), gastrointestinal (p = 0.002) and pupillomotor (p = 0.028) scores and decreased orthostatic intolerance scores (p = 0.050). There was no difference in overall COMPASS-31 score between CCHS and controls (p = 0.083). However, in CCHS, overall COMPASS-31 scores correlated with high frequencies (HF) normalized (cardiac parasympathetic modulation: R = -0.53; p = 0.002), low frequencies (LF)/HF ratio (R = 0.56; p< 0.001), and both systolic and diastolic nighttime BP dipping (R = 0.45, p = 0.012 and R = 0.40, p = 0.028, respectively). No significant relationships between COMPASS-31 scores and chemosensitivity testing, PedsQL scores, or PHOX2B genotype were identified.

CONCLUSIONS

COMPASS-31 identified some aspects of CCHS-related ANSD, and scores correlate with objective ANS function measures, supporting the potential utility of COMPASS-31 in CCHS.

Accuracy of Electronic Health Record Phenotypes to Detect Recognition of Hypertension in Pediatric Primary Care

OBJECTIVE

To evaluate the accuracy of extractable electronic health record (EHR) data to define clinician recognition of hypertension in pediatric primary care.

METHODS

We used EHR data to perform a cross-sectional study of children aged 3 to 18 years at well-visits in Connecticut from 2018 to 2023 (n = 50,290) that had either 1) incident hypertension (hypertensive blood pressure [BP] at the well-visit and ≥2 prior hypertensive BPs without prior diagnosis of hypertension) or 2) isolated hypertensive BP at the well-visit without necessarily having prior hypertensive BPs. We tested the accuracy of EHR phenotypes to detect recognition of incident hypertension or hypertensive BP using structured elements, including diagnosis codes, problem list entries, number of BP measurements, orders, and follow-up information. The primary outcome of hypertension recognition was determined by chart review.

RESULTS

Among 239 children with incident hypertension and a random sample of 220 children with hypertensive BP, 13% in each sample had clinician recognition of hypertension and hypertensive BP, respectively. An algorithm using International Classification of Diseases, Tenth Revision (ICD-10) encounter diagnosis code, ICD-10 problem list, or multiple BPs during the visit had the highest area under the curve (AUC) for attention to incident hypertension (AUC, 0.84; sensitivity, 71.9%; specificity, 95.7%). Adding follow-up BP information to this algorithm had the highest AUC for attention to hypertensive BP (AUC, 0.85; sensitivity, 75.9%; specificity, 93.2%). For patients with hypertension recognition by chart review, ∼20% had only free text documentation of hypertension without any structured elements.

CONCLUSIONS

EHR phenotypes for hypertension recognition have high specificity and moderate sensitivity and may be used in clinician decision support to improve guideline-recommended care.

Development and validation of pFIB scores for exclusion of significant liver fibrosis in pediatric MASLD

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent pediatric liver disease, yet accurate risk scores for referral of children/adolescents with suspected clinically significant liver fibrosis are currently lacking.

APPROACH AND RESULTS

Clinical and biochemical variables were collected in a prospective cohort of 327 children and adolescents with severe obesity, in whom liver fibrosis was evaluated by transient elastography. Logistic regression was performed to establish continuous (pFIB-c) and simplified (pFIB-6) diagnostic scores that accurately exclude significant (≥F2) fibrosis. Performance for each was compared to established noninvve fibrosis scores. These scores were validated in elastography (n=504) and multiple biopsy-proven MASLD (n=261) cohorts. Patient sex, ethnicity, weight z-score, homeostatic model assessment of insulin resistance index, ALT, and presence of hypertension were included in the scores. The pFIB-c and pFIB-6 exhibited good discriminatory capacity (c-statistic of 0.839 and 0.826), outperforming existing indices. Negative predictive values were >90% for both scores in the derivation and elastography validation cohorts. Performance in the histological cohorts varied (AUROCs for the pFIB-c between 0.710 and 0.770), as the scores were less accurate when applied to populations in tertiary referral centers characterized by a high prevalence of significant fibrosis and high ALT levels.

CONCLUSIONS

Analyzing several cohorts totaling approximately 1100 children and adolescents, we developed novel risk scores incorporating readily available clinical variables. In accordance with the aim of excluding pediatric MASLD-associated fibrosis, the scores performed better in nonselected cohorts of children and adolescents living with obesity than in patients referred to tertiary liver units.

MicroRNAs in idiopathic childhood nephrotic syndrome

BACKGROUND

miRNAs are non-coding RNA that are recognized as biomarkers of kidney disorders. There is limited information on the differential expression of miRNA and their target genes in idiopathic nephrotic syndrome of childhood.

METHODS

We enrolled patients, 2-18 years old, with steroid-sensitive nephrotic syndrome, either at onset or during relapse, and steroid-resistant disease, at diagnosis of steroid-resistance. Patients with steroid-sensitive disease were off immunosuppressive medications, while those with steroid-resistance were on therapy with prednisolone at enrollment. Controls were healthy children attending the hospital for vaccinations or for minor non-infectious, non-kidney ailments. Following RNA extraction from whole blood, differential expression of 2549 miRNAs was examined to identify differentially expressed miRNA, defined as those with absolute log2 fold change > 2 and adjusted P < 0.05. Target genes, predicted using miRNet, were compared against the genes for nephrotic syndrome in the NCBI database, and the ontology of selected genes was examined using DAVID.

RESULTS

Comparison of miRNA expression in 36 patients and 12 controls led to the identification of 62 and 12 differentially expressed miRNA in patients with steroid-sensitive and steroid-resistant disease, respectively. Of 76 miRNAs that were differentially regulated between the two disease categories, 26 were unique to steroid-sensitive disease and 11 to steroid-resistance. Of 5955 and 2813 genes targeted by the miRNAs specific to steroid-sensitive and steroid-resistant nephrotic syndrome, respectively, 79 were relevant in context of the disease.

CONCLUSION

Steroid-sensitive and steroid-resistant nephrotic syndrome have distinct miRNA expression profiles, which can be examined as biomarkers and in pathogenetic pathways.

Kidney and blood pressure outcomes 11 years after pediatric critical illness and longitudinal impact of AKI: a prospective cohort study

BACKGROUND

Acute kidney injury (AKI) is common in critically ill children and associated with adverse short-term outcomes; however, long-term outcomes are not well described.

METHODS

This longitudinal prospective cohort study examined the prevalence of chronic kidney disease (CKD) and hypertension (HTN) 11 vs. 6 years after pediatric intensive care unit (PICU) admission and association with AKI. We examined children (age < 19 years) without pre-existing kidney disease 11 ± 1.5 years after PICU admission at a single center. AKI was defined using serum creatinine criteria. The primary outcome was a composite of CKD or HTN. CKD was defined as estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m2 or albuminuria. Multivariable analyses compared outcomes at 11- vs. 6-year follow-up and association with AKI during PICU admission.

RESULTS

Of 96 children evaluated 11 years after PICU admission, 16% had evidence of CKD or HTN (vs. 28% at 6 years, p < 0.05). Multivariable analysis did not show improvement in outcomes from 6- to 11-year follow-up. eGFR decreased from 6- to 11-year follow-up (adjusted coefficient - 11.7, 95% CI - 17.6 to - 5.9) and systolic and diastolic blood pressures improved. AKI was associated with composite outcome at 6-year (adjusted odds ratio (aOR) 12.7, 95% CI 3.2-51.2, p < 0.001), but not 11-year follow-up (p = 0.31). AKI was associated with CKD (aOR 10.4, 95% CI 3.1-34.7) at 11 years.

CONCLUSIONS

This study provides novel data showing that adverse kidney and blood pressure outcomes remain highly prevalent 10 years after critical illness in childhood. The association with AKI wanes over time.

Current status of elevated blood pressure and hypertension among adolescents in Asia: a systematic review

Background

Hypertension among adolescents in Asia is an emerging public health concern that is directly associated with early onset cardiovascular risks. As such, it can also lead to further health issues and challenges for health care in the future. As existing studies have predominantly focussed on adult populations, we sought to provide targeted insights into adolescent hypertension across Asia, elucidating the impact of rapid lifestyle and environmental changes on this younger population. Therefore, in this systematic review, we aimed to evaluate the prevalence and trends of elevated blood pressure (BP) and hypertension among adolescents aged 10-19 years across Asia, address gaps in region-specific data, and determine any demographic risk factors.

Methods

Following PRISMA guidelines, we searched PubMed, EMBASE, Science Direct, Web of Science, Google Scholar, and Scopus for cross-sectional studies on adolescent hypertension/elevated BP in Asia published from January 2019 to June 2024, after which we narratively synthesised their findings.

Results

Of the 2634 retrieved studies, 39 met the inclusion criteria, covering over 200 000 adolescents in Asia. The prevalence of hypertension ranges from 0.7% in urban Bangladesh to 24.5% in urban Malaysia, with urban areas generally showing higher rates than rural areas (e.g. India: 8.4% urban vs. 5.7% rural). By region, East Asia has the highest overall prevalence (14.25%), followed by West Asia (14.14%), South Asia (13.77%), Southeast Asia (13.16%), and Central Asia (12.37%). Males had higher prevalence rates (for example, 22.3% in Chinese males vs. 20% in females).

Conclusions

The increasing prevalence of adolescent hypertension in urban Asia is a significant public health concern. Although extensive research has been conducted in East and South Asia, there is a dearth of studies in Western, Southeast, and Central Asia, emphasising a need for future research. Standardised diagnostic criteria and targeted interventions are crucial for addressing regional disparities and reducing long-term cardiovascular risks.

Metabolic improvement after exercise training in children with obesity: Possible role of the six-minute walking test

The aims of this study are to evaluate the effectiveness of an online supervised training program in modulating lipid and glucose metabolism in children with obesity and to investigate the possible role of the 6-minute walking test (6MWT) as a predictor of metabolic improvement. A total of 35 Caucasian children with obesity (aged 8-13) were enrolled in the study and tested before (T0) and after (T1) a 12-week online supervised exercise training protocol: cardiovascular fitness (by means of 6MWT), metabolic biochemical profile, lifestyle (with ad hoc questionnaires focusing on physical activity, nutrition, sedentariness, sleep hours and quality, health perception) and Cardiac Autonomic Regulation (CAR) were assessed. Spearman correlations between the variations in the studied outcomes were explored. After intervention, the distance covered during 6MWT significantly increased (p < 0.001), and nutrition quality improved slightly but significantly (p = 0.03). The improvement in the 6MWT performance was shown to be significantly correlatee with the reduction of insulin levels (r = -0.455; p = 0.02), HOMA-IR Index (r = -0.452; p = 0.02), total cholesterol values (r = -0.549; p = 0.004) and Atherogenic Index of Plasma (AIP) (r = 0.422; p = 0.04). Moreover, there was a significant correlation between the improvement in 6MWT and health perception (r = 0.578; p = 0.002). We observed that the improvement in the 6MWT performance correlates with better metabolic profile after exercise training in children with obesity suggesting the goodness of this simple test on unveil changes in pathogenetic processes underlying obesity.

Aortic stiffness assessed by blood pressure and echocardiography in young and normotensive patients with isolated aortic coarctation versus those with aortic coarctation and ventricular septal defect

BACKGROUND

Aortic coarctation can occur isolated or associated with ventricular septal defect. This study evaluated aortic stiffness in normotensive patients surgically treated for aortic coarctation and ventricular septal defect and in those who underwent simple aortic coarctation repair. Both groups were compared with healthy controls. Again, the two pathological groups were compared with each other regarding aortic stiffness and left ventricular diastolic function. A possible relationship between aortic stiffness and left ventricular diastolic function was investigated.

METHODS

Twenty-two isolated aortic coarctation patients and 17 aortic coarctation and ventricular septal defect patients were enrolled. Aortic root distensibility and aortic stiffness index were calculated from echocardiography and blood pressure. E wave to A wave (E/A) ratio was measured from mitral valve inflow profile.

RESULTS

Aortic root distensibility and aortic stiffness index in simple aortic coarctation vs healthy controls: both p < 0.0001. Aortic root distensibility and aortic stiffness index in aortic coarctation/ventricular septal defect vs healthy controls: both p < 0.0001. Aortic root distensibility and aortic stiffness index were similar in the two pathological groups (both p = ns). No statistically significant difference was detected in relation to left ventricular diastolic function (p = ns). No correlation was detected between aortic stiffness and diastolic function in simple aortic coarctation and aortic coarctation/ventricular septal defect groups (both p = ns).

CONCLUSIONS

In both normotensive isolated aortic coarctation and aortic coarctation/ventricular septal defects subgroups, aortic stiffness is increased in a similar way in comparison with controls. Diastolic function was normal and similar in both groups. Aortic stiffness was not related to left ventricular diastolic function in this specific setting.

Cardiovascular Health in the Transition From Adolescence to Emerging Adulthood: A Scientific Statement From the American Heart Association

Cardiovascular disease remains a leading cause of death in the United States, with an alarming rise in the proportion of young adults experiencing cardiovascular events. Many adolescents enter adulthood with significant cardiovascular disease risk factors. This scientific statement addresses the critical need for cardiovascular health promotion during emerging adulthood, a transitional stage between the ages of 18 and 25 or 29 years of age. We discuss the significance of social determinants of health and the interplay between individual-level risk factors and developmental changes, including shifts in substance use, social connections, and emotional well-being. We conclude by outlining strategies for optimizing cardiovascular health promotion and disease prevention, underscoring the importance of primordial prevention, early intervention, and tailored approaches to address the unique needs of emerging adults. Addressing these multifaceted factors is crucial for mitigating the burden of cardiovascular disease risk factors among emerging adults and promoting long-term cardiovascular well-being.

Interval healthcare provider contact and blood pressure control in children with chronic kidney disease and hypertension

BACKGROUND

Prior studies in the CKiD (Chronic Kidney Disease in Children) cohort have shown poor blood pressure (BP) control over time. It is unclear whether the lack of BP control is associated with frequency of provider contact between annual study visits.

METHODS

Six hundred eighty-nine CKiD participants with elevated BP or self-reported history of hypertension contributed longitudinal annual data (2,916 total visits). Provider visits were categorized as any well or sick visit, excluding emergency department visits. Repeated measures logistic regression quantified the association between number of visits over the last year (categorized as 0, 1-2, 3-5, 6-10 or > 10 visits) and BP control (defined as non-elevated BP at an annual CKiD visit). Models were unadjusted, minimally adjusted (controlling for sociodemographic factors), and fully adjusted (additionally controlling for chronic kidney disease (CKD) severity).

RESULTS

Compared to those with no interval healthcare provider visits over the prior year, participants with 3-5 visits had significantly greater odds of BP control across all models (unadjusted, OR 1.45, 95% CI 1.10-1.89; minimally adjusted, OR 1.36, 95% CI 1.03-1.79; fully adjusted, OR 1.36, 95% CI 1.01-1.81); those with fewer or more frequent visits did not consistently have significant improvement in BP control.

CONCLUSIONS

In this cohort of youth with CKD and elevated BP, interval healthcare provider contact of 3-5 visits per year between annual CKiD visits was associated with improved BP control; less and more frequent contact was not, even after adjusting for CKD severity. Optimal frequency of health visits by CKD and comorbidity severity deserves further study.

Role of subclinical hypothyroidism on kidney damage in children with obesity

BACKGROUND/OBJECTIVES

The interplay of subclinical hypothyroidism (SH) with obesity has been well-documented, while an intriguing but still controversial association with kidney damage (KD) has recently emerged. Given the heightened cardiometabolic risk inherent to pediatric obesity, this might further impact on the overall health of children with obesity. Therefore, we aimed at evaluating the impact of SH on KD in children with obesity.

SUBJECTS/METHODS

We retrospectively examined 355 children with obesity stratified according to presence or absence of SH. KD was defined as reduced estimated glomerular filtration rate (eGFR<90 mL/min/1.73 m2) and/or hypertension, and/or albuminuria (≥30 mg/g urinary creatinine), while SH was defined by thyroid stimulating hormone (TSH) > 4.5μ UI/ml with normal free triiodothyronine and free thyroxine levels.

RESULTS

Children with SH showed a higher KD prevalence than those without SH (p = 0.004). They also had lower eGFR levels than their counterparts without SH (p = 0.001) and showed an adjusted OR to have KD of 2.04 (95% CI: 1.15-3.61; p = 0.015). A general linear model for eGFR variance showed an inverse association of eGFR with TSH levels (p < 0.0001).

CONCLUSIONS

Although preliminary, our data suggested an increased risk of KD in children with obesity and SH.

A recent update on childhood obesity: aetiology, treatment and complications

Obesity is a complex, chronic condition characterised by excess adiposity. Rates of obesity in childhood and adolescence are increasing worldwide, with a corresponding increase in adulthood. The aetiology of obesity is multifactorial and results from a combination of endocrine, genetic, environmental and societal factors. Population level approaches to reduce the prevalence of childhood obesity worldwide are urgently needed. There are wide-ranging complications from excess weight affecting every system in the body, which lead to significant morbidity and reduced life expectancy. Treatment of obesity and its complications requires a multi-faceted, biopsychosocial approach incorporating dietary, exercise and psychological treatments. Pharmacological treatments for treating childhood obesity have recently become available, and there is further development of new anti-obesity medications in the pipeline. In addition, bariatric surgery is being increasingly recognised as a treatment option for obesity in adolescence providing the potential to reverse complications related to excess weight. In this review, we present an update on the prevalence, aetiology, complications and treatment of childhood obesity.

Food Insecurity and Its Cardiovascular Implications in Underresourced Communities

BACKGROUND

Food insecurity is linked to poorer cardiovascular health (CVH) outcomes, particularly in underresourced communities, where social determinants of health play a critical role. Despite the recognized connections, there remains a lack of empirical evidence delineating the implications of food insecurity on CVH. CVH, a broader concept than cardiovascular disease, encompasses the overall well-being of the cardiovascular system and is supported by favorable lifestyle choices and physiological metrics. Particularly in underresourced communities, the study of CVH could provide valuable insights for early intervention and targeted public health initiatives. This study aimed to fill this knowledge gap.

METHODS AND RESULTS

We conducted a cross-sectional analysis of baseline data from the E-DUCASS (Educational Strategy on a Vulnerable Population to Improve Cardiovascular Health and Food Insecurity) program (NCT05379842), a 24-month randomized study targeting participants at risk for food insecurity. CVH was assessed using the Life's Essential 8 score. The sample included 451 participants aged 12 to 80 years, stratified by age (30.6% children [aged 12-19 years], 35.9% young adults [aged 20-39 years], and 33.5% adults [aged 40-80 years]) and sex (42.1% men and 57.9% women). The mean CVH score was 65.1 (95% CI, 63.9-66.4), with diet, physical activity, nicotine exposure, and body mass index being the lowest-scoring metrics. Food insecurity significantly influenced CVH; those participants with severe food insecurity had lower CVH scores than those without (effect size, -2.83 [95% CI, -5.10 to -0.56]; P<0.05).

CONCLUSIONS

Our findings highlight the negative association between food insecurity and CVH in underresourced Mediterranean communities. These results underscore the need for strategies aimed at reducing cardiovascular risk, potentially through health literacy programs like E-DUCASS, that focus on improving lifestyle and alleviating food insecurity.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT05379842.

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

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

Phenylbutyrate Treatment in a Boy With MCT8 Deficiency: Improvement of Thyroid Function Tests and Possible Hepatotoxicity

CONTEXT

Monocarboxylate transporter 8 (MCT8) deficiency is a rare X-chromosomal inherited disease leading to severe cognitive impairment, muscular hypotonia, and symptoms of peripheral thyrotoxicosis. Experimental approaches aiming to functionally rescue mutant MCT8 activity by the chemical chaperone phenylbutyrate (PB) demonstrated promising effects in vitro for several MCT8 missense mutations.

OBJECTIVE

The objective was to evaluate biochemical and clinical effects of PB in doses equivalent to those approved for the treatment of urea cycle disorders in a boy with MCT8 deficiency due to a novel MCT8 missense mutation c.703G>T (p.V235L).

RESULTS

During a treatment period of 13 months, PB led to a significant decrease of elevated thyrotropin and triiodothyronine (T3) serum concentrations, while free thyroxine (fT4) increased. The weight z-score of the toddler remained remarkably stable during the treatment period. Neurodevelopmental assessments (BSID-III) revealed a slight increase of gross motor skills from developmental age 4 to 6 months. However, increasing liver enzyme serum activities and accumulation of phenylacetate in urine led to treatment interruptions and dose alterations. In vitro analyses in MDCK1 cells confirmed the pathogenicity of MCT8 p.V235L. However, while PB increased expression of the mutant protein, it did not rescue T3 transport, suggesting a PB effect on thyroid function tests independent of restoring MCT8 activity.

CONCLUSION

In a clinical attempt of PB treatment in MCT8 deficiency we observed a significant improvement of thyroid hormone function tests, tendencies toward body weight stabilization and slight neurodevelopmental improvement. Hepatotoxicity of PB may be a limiting factor in MCT8 deficiency and requires further investigation.

Home Blood Pressure Monitoring

The diagnosis and management of hypertension have been based primarily on blood pressure (BP) measurement in the office setting. Higher out-of-office BP is associated with an increased risk of cardiovascular disease, independent of office BP. Home BP monitoring (HBPM) consists of the measurement of BP by a person outside of the office at home and is a validated approach for out-of-office BP measurement. HBPM provides valuable data for diagnosing and managing hypertension. Another validated approach, ambulatory BP monitoring (ABPM), has been considered to be the reference standard of out-of-office BP measurement. However, HBPM offers potential advantages over ABPM including being a better measure of basal BP, wide availability to patients and clinicians, evidence supporting its use for better office BP control, and demonstrated efficacy when using telemonitoring along with HBPM. This state-of-the-art review examines the current state of HBPM and includes discussion of recent hypertension guidelines on HBPM, advantages of using telemonitoring with HBPM, use of self-titration of antihypertensive medication with HBPM, validation of HBPM devices, best practices for conducting HBPM in the clinical setting, how HBPM can be used as an implementation strategy approach to improve BP control in the United States, health equity in HBPM use, and HBPM use among specific populations. Finally, research gaps and future directions of HBPM are reviewed.

Multicenter Analysis of Cardiometabolic-Related Diagnoses in Youth With Congenital Adrenal Hyperplasia: A PEDSnet Study

CONTEXT

Small cohorts of youth with congenital adrenal hyperplasia (CAH) demonstrate increased risk of obesity and poor cardiometabolic health.

OBJECTIVE

To determine the odds of cardiometabolic-related diagnoses in youth with CAH compared with matched controls in a cross-sectional analysis in a large, multisite database (PEDSnet).

METHODS

Electronic health record data (2009-2019) from 6 PEDSnet sites were used to determine odds of cardiometabolic-related outcomes based on diagnosis, anthropometric, and laboratory data using logistic regression among youth with CAH vs controls. Youth with CAH and ≥1 outpatient visit in PEDSnet (n = 1647) were propensity score-matched on 8 variables to controls (n = 6588). A subset of youth with classic CAH (n = 547, with glucocorticoid and mineralocorticoid prescriptions) were matched to controls (n = 2188). Odds of having cardiometabolic-related diagnoses among youth over 2 years with CAH were compared with matched controls.

RESULTS

Outcomes were calculated for all individuals with CAH (median age at last visit 12.9 years [7.3, 17.6]) and a subset with classic CAH (median age at last visit 11.6 years [4.7, 17.5]) compared with their matched controls. All individuals with CAH had higher odds of overweight/obesity (odds ratio [95% CI] 3.63 [3.24,4.07]), hypertension (3.07 [2.60,3.64]), dysglycemia (1.95 [1.35,2.82], dyslipidemia (2.28 [1.79,2.91]), and liver dysfunction (2.30 [1.91,2.76]) than matched controls. Individuals with classic CAH had higher odds of overweight/obesity (3.21 [2.61,3.93]), hypertension (8.22 [6.71,10.08]), and liver dysfunction (2.11 [1.55,2.89]) than matched controls.

CONCLUSION

Overall, youth with CAH are at increased risk of diagnoses related to worse cardiometabolic health.

Body mass index modifies genetic susceptibility to high systolic blood pressure in adolescents and young adults: results from an 18-year longitudinal study

Genome-wide association studies (GWAS) in adults have identified single nucleotide polymorphisms (SNPs) associated with systolic blood pressure (SBP), but it is unclear whether the findings apply in youth. Further, the role of body mass index (BMI) in these associations is understudied. Our objective was to determine whether BMI modifies genetic susceptibility to high SBP in young people. The sample comprised 714 participants of European ancestry recruited in 1999-2000 from 10 Montreal-area high schools for a longitudinal study. SBP was measured at ages 12, 15, 17, 24, and 30. Blood and saliva samples were collected at ages 14, 20, and 25. Two evidence-based genetic risk scores (GRS) were constructed based on GWAS results in adults: GRS22 used 22 SNPs and GRS182 added 160 additional SNPs to GRS22. Sex-specific associations between each GRS and repeated measures of SBP were estimated using linear mixed models including BMI and a GRS*BMI product term. GRS182 explained a greater proportion of SBP variance than GRS22, and a greater proportion in females than males. The associations increased monotonically with BMI values between 22 kg/m2 and 35 kg/m2. Results indicate that BMI modifies the association between a GRS and SBP levels from adolescence to adulthood.

Hypertension in Childhood Cancer Survivors: Causes, Screening, and Management

PURPOSE OF REVIEW

Survivors of childhood cancer and hematopoietic cell transplant are at risk for developing chronic health conditions, including hypertension. Studies have identified hypertension as an influential risk factor for late kidney dysfunction and cardiovascular disease in childhood cancer survivors. The overall risk of hypertension depends on the specific cancer treatment, from chemotherapy to surgery to radiation. In this report, we aim to review the main causes of hypertension in childhood cancer survivors, with a focus on newer therapies, as well as the current recommendations for screening and management of hypertension in this patient population.

RECENT FINDINGS

Novel targeted therapies and immunotherapies are being increasingly used in pediatric cancer treatment, with unclear impact on long-term health. Screening guidelines for hypertension in the survivor population have been issued by various childhood cancer cooperative groups based on best available evidence and expert opinion. Newer studies have focused on individual risk prediction, which may help improve the diagnosis and management of hypertension, particularly in higher-risk individuals. Despite the importance of hypertension as one of the few modifiable risk factors for cardiovascular and renal health, studies have yet to define optimal blood pressure targets, screening parameters, or management strategies in childhood cancer survivors. Additionally, further studies are needed to demonstrate improvement in outcomes following interventions for hypertension specifically in this patient population.

Prevalence of Hypertension in Adolescents: Differences Between 2016 ESH and 2017 AAP Guidelines

Introduction: The American Academy of Pediatrics (AAP) published in 2017 new guidelines for the screening and management of hypertension in children containing different nomograms compared to the European guidelines, leading to a reclassification of blood pressure values, the consequences of which are still little investigated. The aim of our study was to evaluate the prevalence of high blood pressure values estimated with both the most recent American and European guidelines and to analyze the relationship of blood pressure increases with lifestyles and potentially risky behaviors in a school population in Western Sicily. Methods: On the occasion of the XV World Hypertension Day, blood pressure values of 1301 students aged between 13 and 18 were measured. Two questionnaires were administered, one relating to anamnestic data and anthropometric parameters and a second aimed at investigating lifestyle. For the diagnosis of increased blood pressure, both ESH and AAP criteria were considered. Results: The prevalence of elevated blood pressure was 7.5% according to ESH criteria and nearly twice as high using AAP criteria, with a more pronounced discrepancy in females. Individuals with elevated blood pressure were younger, exhibited higher body weight and BMI, and had an increased prevalence of overweight and obesity. Classification based on ESH criteria revealed higher alcohol and drug consumption among normotensive individuals. AAP criteria identified a higher proportion of males and greater height in the hypertensive group. Systolic blood pressure correlated significantly with height, weight, and BMI, with stronger associations in males, while diastolic pressure correlated with weight and BMI. Conclusions: To the best of our knowledge, our study is the only one to analyze the prevalence of increased blood pressure and its relationship with lifestyle factors and anthropometric data in adolescence in our region. Our study confirms that elevated blood pressure is common in adolescence, with higher prevalence using the 2017 AAP criteria than ESH guidelines.

Is Childhood IgA Nephropathy Different From Adult IgA Nephropathy? A Narrative Review

Purpose of the review

Immunoglobulin A (IgA) nephropathy (IgAN) is the most common primary glomerular kidney disease. Children and adults are presumed to have the same disease and are treated similarly. However, there are differences between childhood IgAN and adult IgAN that may require unique treatment considerations, even after transition to adult nephrology services. A narrative review was conducted to compare childhood and adult IgAN and to describe the distinct characteristics of childhood IgAN. Reframing childhood IgAN can inform guideline recommendations unique to childhood IgAN, the development of targeted therapies, and clinical trial design.

Sources of information

Medline and Embase were searched for reports on children and adults with IgAN published between January 2013 and December 2023 (updated May 2024). The search was not restricted by age group, outcomes reported, language, or study design. Randomized controlled trials (RCTs), observational studies, review articles, and nephrology conference abstracts were included. A total of 3104 reports were retrieved. Forty-seven reports (37 primary studies and 10 reviews) were included in the review. Two RCTs and 35 observational studies included a total of 45 085 participants (9223 children and 35 862 adults).

Method

Data were extracted for primary IgAN and not for IgA vasculitis-associated nephritis. Findings were described with no statistical comparisons due to variations in interventions and outcome definitions.

Key findings

Gross hematuria was the obvious clinical difference between childhood IgAN and adult (60-88% vs 15-20%). Nephrotic syndrome was more common in children, approaching up to 44%, while <18% of adults had nephrotic syndrome. Children were biopsied sooner (6 vs 15 months) and had more inflammatory kidney lesions (mesangial hypercellularity: 41-82% vs 38-64%; endocapillary hypercellularity: 39-58% vs 17-34%). Chronic kidney lesions were more prevalent in adults (segmental sclerosis: 62-77% vs 8-51%; interstitial fibrosis/tubular atrophy: 34-37% vs 1-18%). The use of immunosuppressive therapy was higher in children (46-84% vs 35-56%). Children were started on immunosuppressive therapy sooner than adults. Adults were more likely to be optimized with renin-angiotensin system inhibitors (87-94% vs 49-75%). Children had better kidney function than adults at diagnosis (estimated glomerular filtration rate of 90-128 vs 50-88 ml/min/1.73 m2), and children also had better kidney survival, with kidney failure of 3.1% vs 13.4% at 5 years. Children had more risk alleles for IgAN and higher levels of mannose-binding lectin than adults.

Limitations

Most studies were retrospective and observational, with limited data on children and disease mechanisms. Data were not pooled for analysis because of important differences in definitions and measurements of baseline characteristics and outcomes. Data from countries with established urine screening programs were different compared to countries without urine screening programs. Some observed differences may be due to practice variation and delayed diagnosis in adults (lead-time bias). Well-designed prospective studies and standardized measures for kidney function assessment and outcomes can reduce heterogeneity and improve results from reviews.

Conclusion

Inherent differences between childhood IgAN and adult IgAN may be due to distinct disease mechanisms. Approaching childhood IgAN as a separate condition could lead to the discovery of targeted therapies and improve management during childhood and after the transition to adult care.

Mapping variants in thyroid hormone transporter MCT8 to disease severity by genomic, phenotypic, functional, structural and deep learning integration

Predicting and quantifying phenotypic consequences of genetic variants in rare disorders is a major challenge, particularly pertinent for 'actionable' genes such as thyroid hormone transporter MCT8 (encoded by the X-linked SLC16A2 gene), where loss-of-function (LoF) variants cause a rare neurodevelopmental and (treatable) metabolic disorder in males. The combination of deep phenotyping data with functional and computational tests and with outcomes in population cohorts, enabled us to: (i) identify the genetic aetiology of divergent clinical phenotypes of MCT8 deficiency with genotype-phenotype relationships present across survival and 24 out of 32 disease features; (ii) demonstrate a mild phenocopy in ~400,000 individuals with common genetic variants in MCT8; (iii) assess therapeutic effectiveness, which did not differ among LoF-categories; (iv) advance structural insights in normal and mutated MCT8 by delineating seven critical functional domains; (v) create a pathogenicity-severity MCT8 variant classifier that accurately predicted pathogenicity (AUC:0.91) and severity (AUC:0.86) for 8151 variants. Our information-dense mapping provides a generalizable approach to advance multiple dimensions of rare genetic disorders.

Prediction of Hypertension in the Pediatric Population Using Machine Learning and Transfer Learning: A Multicentric Analysis of the SAYCARE Study

Objective

To develop a machine learning (ML) model utilizing transfer learning (TL) techniques to predict hypertension in children and adolescents across South America.

Methods

Data from two cohorts (children and adolescents) in seven South American cities were analyzed. A TL strategy was implemented by transferring knowledge from a CatBoost model trained on the children's sample and adapting it to the adolescent sample. Model performance was evaluated using standard metrics.

Results

Among children, the prevalence of normal blood pressure was 88.9% (301 participants), while 14.1% (50 participants) had elevated blood pressure (EBP). In the adolescent group, the prevalence of normal blood pressure was 92.5% (284 participants), with 7.5% (23 participants) presenting with EBP. Random Forest, XGBoost, and LightGBM achieved high accuracy (0.90) for children, with XGBoost and LightGBM demonstrating superior recall (0.50) and AUC-ROC (0.74). For adolescents, models without TL showed poor performance, with accuracy and recall values remaining low and AUC-ROC ranging from 0.46 to 0.56. After applying TL, model performance improved significantly, with CatBoost achieving an AUC-ROC of 0.82, accuracy of 1.0, and recall of 0.18.

Conclusion

Soft drinks, filled cookies, and chips were key dietary predictors of elevated blood pressure, with higher intake in adolescents. Machine learning with transfer learning effectively identified these risks, emphasizing the need for early dietary interventions to prevent hypertension and support cardiovascular health in pediatric populations.

Ultrasound Doppler renal pulsatility index is a predictive marker of arterial stiffness in children with solitary functioning kidney

INTRODUCTION

Patients with solitary functioning kidney (SFK) have glomerular hyperfiltration, hypertension, proteinuria and impaired renal function resulting in microvascular atherosclerotic abnormalities. This condition leads to an increase in arterial stiffness. In this study, we aimed to investigate the usefulness of non-invasive renal Doppler ultrasonography hemodynamic parameters in demonstrating arterial stiffness in pediatric patients with SFK.

METHODS

The study included 59 children aged 6-18 years who were diagnosed with SFK. Demographic, biochemical, anthropometric, and blood pressure data were recorded. The renal Doppler ultrasound hemodynamic parameters renal resistive index (RRI), renal pulsatility index (RPI), carotid-femoral pulse wave velocity (cfPWV), central augmentation index (cAIx) and carotid intima media thickness (cIMT) were evaluated.

RESULTS

Eighteen (30.5%) cases with acquired SFK and 41 (64.5%) cases with congenital SFK were detected. Central augmentation indices were higher in children with congenital SFK than in children with acquired SFK (p = 0.038). CkiD-eGFR-SCr-CysC was lower in patients with acquired SFK (p = 0.011). LDL cholesterol levels were higher in children with acquired SFK (p = 0.018). We found a significant correlation between RPI and cfPWV with a correlation coefficient (r) of 0.321 and a statistically significant p-value of 0.013.

CONCLUSIONS

Congenital SFK is associated with increased microvascular atherosclerotic burden. RPI assessment with renal Doppler ultrasound may be a non-invasive method to identify arterial stiffness.