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Raina R, Jothi S, Haffner D, Somers M, Filler G, Vasistha P, Chakraborty R, Shapiro R, Randhawa PS, Parekh R, Licht C, Bunchman T, Sethi S, Mangat G, Zaritsky J, Schaefer F, Warady B, Bartosh S, McCulloch M, Alhasan K, Swiatecka-Urban A, Smoyer WE, Chandraker A, Yap HK, Jha V, Bagga A, Radhakrishnan J. Post-transplant recurrence of focal segmental glomerular sclerosis: consensus statements. Kidney Int 2024; 105:450-463. [PMID: 38142038 DOI: 10.1016/j.kint.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 10/03/2023] [Accepted: 10/17/2023] [Indexed: 12/25/2023]
Abstract
Focal segmental glomerular sclerosis (FSGS) is 1 of the primary causes of nephrotic syndrome in both pediatric and adult patients, which can lead to end-stage kidney disease. Recurrence of FSGS after kidney transplantation significantly increases allograft loss, leading to morbidity and mortality. Currently, there are no consensus guidelines for identifying those patients who are at risk for recurrence or for the management of recurrent FSGS. Our work group performed a literature search on PubMed/Medline, Embase, and Cochrane, and recommendations were proposed and graded for strength of evidence. Of the 614 initially identified studies, 221 were found suitable to formulate consensus guidelines for recurrent FSGS. These guidelines focus on the definition, epidemiology, risk factors, pathogenesis, and management of recurrent FSGS. We conclude that additional studies are required to strengthen the recommendations proposed in this review.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA; Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Swathi Jothi
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Michael Somers
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Guido Filler
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Prabhav Vasistha
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Ronith Chakraborty
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA; Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Ron Shapiro
- Recanati/Miller Transplantation Institute, The Mount Sinai Medical Center, New York, New York, USA
| | - Parmjeet S Randhawa
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rulan Parekh
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christopher Licht
- Division of Pediatric Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Timothy Bunchman
- Pediatric Nephrology and Transplantation, Children's Hospital of Richmond at Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Guneive Mangat
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Joshua Zaritsky
- Division of Pediatric Nephrology, Nemours, A.I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Franz Schaefer
- Department of Pediatric Nephrology, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Bradley Warady
- Division of Nephrology, University of Missouri-Kansas City School of Medicine, Children's Mercy, Kansas City, Missouri, USA
| | - Sharon Bartosh
- Department of Pediatrics, University of Wisconsin Medical School, Madison, Wisconsin, USA
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Khalid Alhasan
- Nephrology Unit, Pediatrics Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Pediatric Kidney Transplant Division, Organ Transplant Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Agnieszka Swiatecka-Urban
- University of Virginia Children's Hospital, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - William E Smoyer
- Center for Clinical and Translational Research and Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Anil Chandraker
- Transplantation Research Center, Kidney and Pancreas Transplantation, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hui Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales (UNSW), New Delhi, India; School of Public Health, Imperial College, London, UK; Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Arvind Bagga
- Division of Pediatric Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Jai Radhakrishnan
- Department of Medicine (Nephrology), Columbia University Medical Center, New York, New York, USA.
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Kula AJ, Flynn JT, Prince DK, Furth SL, Warady B, Isakova T, Christenson R, Bansal N. Descriptions and Determinants of N-Terminal Pro-B-Type Natriuretic Peptide in Pediatric CKD: The Chronic Kidney Disease in Children (CKiD) Study. Am J Kidney Dis 2023; 82:776-778. [PMID: 37393051 PMCID: PMC10989192 DOI: 10.1053/j.ajkd.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/28/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Alexander J Kula
- Division of Pediatric Nephrology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Nephrology, Seattle Children's Hospital, Seattle, Washington
| | - David K Prince
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington
| | - Susan L Furth
- Division of Pediatric Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Tamara Isakova
- Division of Nephrology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Robert Christenson
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington
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Wasik HL, Keswani M, Munshi R, Neu A, Richardson T, Warady B. Assessment of potential peritonitis risk factors in pediatric patients receiving maintenance peritoneal dialysis. Pediatr Nephrol 2023; 38:4119-4125. [PMID: 37421469 DOI: 10.1007/s00467-023-06076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/18/2023] [Accepted: 06/26/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Many recommendations regarding peritonitis prevention in international consensus guidelines are opinion-based rather than evidence-based. The aim of this study was to examine the impact of peritoneal dialysis (PD) catheter insertion technique, timing of gastrostomy placement, and use of prophylactic antibiotics prior to dental, gastrointestinal, and genitourinary procedures on the risk of peritonitis in pediatric patients on PD. METHODS We conducted a retrospective cohort study of pediatric patients on maintenance PD using data from the SCOPE collaborative from 2011 to 2022. Data pertaining to laparoscopic PD catheter insertion (vs. open), gastrostomy placement after PD catheter insertion (vs. before/concurrent), and no prophylactic antibiotics (vs. yes) were obtained. Multivariable generalized linear mixed modeling was used to assess the relationship between each exposure and occurrence of peritonitis. RESULTS There was no significant association between PD catheter insertion technique and development of peritonitis (aOR = 2.50, 95% CI 0.64-9.80, p = 0.19). Patients who had a gastrostomy placed after PD catheter insertion had higher rates of peritonitis, but the difference was not statistically significant (aOR = 3.19, 95% CI 0.90-11.28, p = 0.07). Most patients received prophylactic antibiotics prior to procedures, but there was no significant association between prophylactic antibiotic use and peritonitis (aOR = 1.74, 95% CI 0.23-13.11, p = 0.59). CONCLUSIONS PD catheter insertion technique does not appear to have a significant impact on peritonitis risk. Timing of gastrostomy placement may have some impact on peritonitis risk. Further study must be done to clarify the effect of prophylactic antibiotics on peritonitis risk. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Heather L Wasik
- Division of Pediatric Nephrology, SUNY Upstate Medical University, Physicians' Office Building 805, 725 Irving Avenue, Syracuse, NY, 13210, USA.
| | - Mahima Keswani
- Division of Pediatric Nephrology, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Raj Munshi
- Division of Pediatric Nephrology, Seattle Children's Hospital, Seattle, WA, USA
| | - Alicia Neu
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
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Carlson J, Gerson AC, Matheson MB, Manne S, Lande M, Harshman L, Johnson RJ, Shinnar S, Kogon AJ, Warady B, Furth S, Hooper S. Longitudinal changes of health-related quality of life in childhood chronic kidney disease. Pediatr Nephrol 2023; 38:4127-4136. [PMID: 37428223 PMCID: PMC10591962 DOI: 10.1007/s00467-023-06069-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Few longitudinal studies have evaluated the impact of chronic kidney disease (CKD) duration on health-related quality of life (HRQOL). The study's aim was to determine how HRQOL changes over time in childhood CKD. METHODS Study participants were children in the chronic kidney disease in children (CKiD) cohort who completed the pediatric quality of life inventory (PedsQL) on three or more occasions over the course of two or more years. Generalized gamma (GG) mixed-effects models were applied to assess the effect of CKD duration on HRQOL while controlling for selected covariates. RESULTS A total of 692 children (median age = 11.2) with a median of 8.3 years duration of CKD were evaluated. All subjects had a GFR greater than 15 ml/min/1.73 m2. GG models with child self-report PedsQL data indicated that longer CKD duration was associated with improved total HRQOL and the 4 domains of HRQOL. GG models with parent-proxy PedsQL data indicated that longer duration was associated with better emotional but worse school HRQOL. Increasing trajectories of child self-report HRQOL were observed in the majority of subjects, while parents less frequently reported increasing trajectories of HRQOL. There was no significant relationship between total HRQOL and time-varying GFR. CONCLUSIONS Longer duration of the disease is associated with improved HRQOL on child self-report scales; however, parent-proxy results were less likely to demonstrate any significant change over time. This divergence could be due to greater optimism and accommodation of CKD in children. Clinicians can use these data to better understand the needs of pediatric CKD patients. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Joann Carlson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Arlene C Gerson
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Sharon Manne
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Marc Lande
- University of Rochester Medical Center, Rochester, NY, USA
| | - Lyndsay Harshman
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Rebecca J Johnson
- Children's Mercy Kansas City, UMKC School of Medicine, Kansas City, MO, USA
| | - Shlomo Shinnar
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Amy J Kogon
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bradley Warady
- Children's Mercy Kansas City, UMKC School of Medicine, Kansas City, MO, USA
| | - Susan Furth
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephen Hooper
- School of Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
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Hogan J, Divard G, Aubert O, Garro R, Boyer O, Donald Cooper LA, Farris AB, Fila M, Seifert M, Sellier-Leclerc AL, Smith J, Fichtner A, Tönshoff B, Twombley K, Warady B, Pearl M, Zahr RS, Lefaucheur C, Patzer R, Loupy A. Validation of a prediction system for risk of kidney allograft failure in pediatric kidney transplant recipients: An international observational study. Am J Transplant 2023; 23:1561-1569. [PMID: 37453485 DOI: 10.1016/j.ajt.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
Predicting long-term kidney allograft failure is an unmet need for clinical care and clinical trial optimization in children. We aimed to validate a kidney allograft failure risk prediction system in a large international cohort of pediatric kidney transplant recipients. Patients from 20 centers in Europe and the United States, transplanted between 2004 and 2017, were included. Allograft assessment included estimated glomerular filtration rate, urine protein-to-creatinine ratio, circulating antihuman leukocyte antigen donor-specific antibody, and kidney allograft histology. Individual predictions of allograft failure were calculated using the integrative box (iBox) system. Prediction performances were assessed using discrimination and calibration. The allograft evaluations were performed in 706 kidney transplant recipients at a median time of 9.1 (interquartile range, 3.3-19.2) months posttransplant; mean estimated glomerular filtration rate was 68.7 ± 28.1 mL/min/1.73 m2, and median urine protein-to-creatinine ratio was 0.1 (0.0-0.4) g/g, and 134 (19.0%) patients had antihuman leukocyte antigen donor-specific antibodies. The iBox exhibited accurate calibration and discrimination for predicting the outcomes up to 10 years after evaluation, with a C-index of 0.81 (95% confidence interval, 0.75-0.87). This study confirms the generalizability of the iBox to predict long-term kidney allograft failure in children, with performances similar to those reported in adults. These results support the use of the iBox to improve patient monitoring and facilitate clinical trials in children.
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Affiliation(s)
- Julien Hogan
- Université Paris Cité, INSERM, UMR-S970, PARCC, Paris Translational Research Center for Organ Transplantation, Paris, France; Pediatric nephrology department, Robert Debré Hospital, APHP, Paris, France; Emory Transplant Center, Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Gillian Divard
- Université Paris Cité, INSERM, UMR-S970, PARCC, Paris Translational Research Center for Organ Transplantation, Paris, France
| | - Olivier Aubert
- Université Paris Cité, INSERM, UMR-S970, PARCC, Paris Translational Research Center for Organ Transplantation, Paris, France
| | - Rouba Garro
- Pediatric Nephrology Department, Children Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Olivia Boyer
- Pediatric Nephrology, MARHEA Reference Center, INSERM U1163, Imagine Institute, Paris Cité University, Necker-Enfants Malades Hospital, APHP.Centre, Paris, France
| | - Lee Alex Donald Cooper
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alton Brad Farris
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marc Fila
- Pediatric Nephrology Department, Montpellier University Hospital, Montpellier, France
| | - Michael Seifert
- Pediatric Nephrology Department, University of Alabama, Birmingham, Alabama, USA
| | | | - Jody Smith
- Pediatric Nephrology Department, Seattle Children, Seattle, New York, USA
| | - Alexander Fichtner
- Department of Pediatrics I, University Childrens Hospital Heidelberg, Heidelberg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Childrens Hospital Heidelberg, Heidelberg, Germany
| | - Katherine Twombley
- Pediatric Nephrology Department, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bradley Warady
- Pediatric Nephrology Department, Children's Mercy, Kansas City, Michigan, USA
| | - Meghan Pearl
- Pediatric Nephrology Department, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rima S Zahr
- UTHSC Department of Pediatric Nephrology and Hypertension, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Carmen Lefaucheur
- Université Paris Cité, INSERM, UMR-S970, PARCC, Paris Translational Research Center for Organ Transplantation, Paris, France
| | - Rachel Patzer
- Emory Transplant Center, Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Alexandre Loupy
- Université Paris Cité, INSERM, UMR-S970, PARCC, Paris Translational Research Center for Organ Transplantation, Paris, France.
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Amaral S, Schuchard J, Claes D, Dart A, Greenbaum LA, Massengill SF, Atkinson MA, Flynn JT, Dharnidharka VR, Fathallah-Shaykh S, Yadin O, Modi ZJ, Al-Uzri A, Wilson AC, Dell KM, Patel HP, Bruno C, Warady B, Furth S, Forrest CB. Patient-Reported Outcomes Over 24 Months in Pediatric CKD: Findings From the MyKidneyHealth Cohort Study. Am J Kidney Dis 2023; 82:213-224.e1. [PMID: 36889426 PMCID: PMC10440290 DOI: 10.1053/j.ajkd.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 12/24/2022] [Indexed: 03/08/2023]
Abstract
RATIONALE & OBJECTIVE The lived experience of children with chronic kidney disease (CKD) is poorly characterized. We examined the associations between patient-reported outcome (PRO) scores measuring their fatigue, sleep health, psychological distress, family relationships, and global health with clinical outcomes over time in children, adolescents, and younger adults with CKD and investigated how the PRO scores of this group compare with those of other children, adolescents, and younger adults. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 212 children, adolescentss, and adults aged 8 to 21 years with CKD and their parents recruited from 16 nephrology programs across North America. PREDICTORS CKD stage, disease etiology, and sociodemographic and clinical variables. OUTCOME PRO scores over 2 years. ANALYTICAL APPROACH We compared PRO scores in the CKD sample with a nationally representative general pediatric population (ages 8 to 17 years). Change of PROs over time and association of sociodemographic and clinical variables with PROs were assessed using multivariable regression models. RESULTS For all time points, 84% of the parents and 77% of the children, adolescents, and younger adults completed PRO surveys . The baseline PRO scores for the participants with CKD revealed a higher burden of fatigue, sleep-related impairment, psychological distress, impaired global health, and poorer family relationships compared with the general pediatric population, with median score differences≥1 SD for fatigue and global health. The baseline PRO scores did not differ by CKD stage or glomerular versus nonglomerular etiology. Over 2 years, PROs were stable with a<1-point annual change on average on each measure and intraclass correlation coefficients ranging from 0.53 to 0.79, indicating high stability. Hospitalization and parent-reported sleep problems were associated with worse fatigue, psychological health, and global health scores (all P<0.04). LIMITATIONS We were unable to assess responsiveness to change with dialysis or transplant. CONCLUSIONS Children with CKD experience a high yet stable burden of impairment across numerous PRO measures, especially fatigue and global health, independent of disease severity. These findings underscore the importance of assessing PROs, including fatigue and sleep measures, in this vulnerable population. PLAIN-LANGUAGE SUMMARY Children with chronic kidney disease (CKD) have many treatment demands and experience many systemic effects. How CKD impacts the daily life of a child is poorly understood. We surveyed 212 children, adolescents, and younger adults with CKD and their parents over 24 months to assess the participants' well-being over time. Among children, adolescents, and younger adults with CKD we found a very high and persistent burden of psychological distress that did not differ by degree of CKD or type of kidney disease. The participants with CKD endorsed greater impairment in fatigue and global health compared with healthy children, adolescents, and younger adults, and parent-reported sleep problems were associated with poorer patient-reported outcome (PRO) scores across all domains. These findings emphasize the importance of including PRO measures, including fatigue and sleep measures, into routine clinical care to optimize the lived experience of children with CKD.
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Affiliation(s)
- Sandra Amaral
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Julia Schuchard
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Donna Claes
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Allison Dart
- Department of Pediatrics and Child Health, The Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Larry A Greenbaum
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Susan F Massengill
- Department of Pediatrics, Levine Children's Hospital at Atrium, Charlotte, North Carolina
| | - Meredith A Atkinson
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Joseph T Flynn
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; Division of Nephrology, Seattle Children's Hospital, Seattle, Washington
| | - Vikas R Dharnidharka
- Department of Pediatrics, School of Medicine, Washington University, St. Louis, Missouri; St. Louis Children's Hospital, St. Louis, Missouri
| | | | - Ora Yadin
- Department of Pediatrics, UCLA Mattel Children's Hospital, University of California at Los Angeles, Los Angeles, California
| | - Zubin J Modi
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Amira Al-Uzri
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Amy C Wilson
- Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Katherine M Dell
- Department of Pediatrics, Cleveland Clinic Children's and Case Western Reserve University, Cleveland, Ohio
| | - Hiren P Patel
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Cortney Bruno
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bradley Warady
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Susan Furth
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher B Forrest
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Ranchin B, Schmitt CP, Warady B, Craig JC, Licht C, Hataya H, Vidal E, Walle JV, Shroff R. Devices for long-term hemodialysis in small children – a plea for action. Kidney Int 2023; 103:1038-1040. [PMID: 36990213 DOI: 10.1016/j.kint.2023.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 03/30/2023]
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8
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Durand A, Winkler CA, Vince N, Douillard V, Geffard E, Binns-Roemer E, Ng DK, Gourraud PA, Reidy K, Warady B, Furth S, Kopp JB, Kaskel FJ, Limou S. Identification of Novel Genetic Risk Factors for Focal Segmental Glomerulosclerosis in Children: Results From the Chronic Kidney Disease in Children (CKiD) Cohort. Am J Kidney Dis 2023; 81:635-646.e1. [PMID: 36623684 DOI: 10.1053/j.ajkd.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 11/02/2022] [Indexed: 01/09/2023]
Abstract
RATIONALE & OBJECTIVE Focal segmental glomerulosclerosis (FSGS) is a major cause of pediatric nephrotic syndrome, and African Americans exhibit an increased risk for developing FSGS compared with other populations. Predisposing genetic factors have previously been described in adults. Here we performed genomic screening of primary FSGS in a pediatric African American population. STUDY DESIGN Prospective cohort with case-control genetic association study design. SETTING & PARTICIPANTS 140 African American children with chronic kidney disease from the Chronic Kidney Disease in Children (CKiD) cohort, including 32 cases with FSGS. PREDICTORS Over 680,000 common single-nucleotide polymorphisms (SNPs) were tested for association. We also ran a pathway enrichment analysis and a human leucocyte antigen (HLA)-focused association study. OUTCOME Primary biopsy-proven pediatric FSGS. ANALYTICAL APPROACH Multivariate logistic regression models. RESULTS The genome-wide association study revealed 169 SNPs from 14 independent loci significantly associated with FSGS (false discovery rate [FDR]<5%). We observed notable signals for genetic variants within the APOL1 (P=8.6×10-7; OR, 25.8 [95% CI, 7.1-94.0]), ALMS1 (P=1.3×10-7; 13.0% in FSGS cases vs 0% in controls), and FGFR4 (P=4.3×10-6; OR, 24.8 [95% CI, 6.3-97.7]) genes, all of which had previously been associated with adult FSGS, kidney function, or chronic kidney disease. We also highlighted novel, functionally relevant genes, including GRB2 (which encodes a slit diaphragm protein promoting podocyte structure through actin polymerization) and ITGB1 (which is linked to renal injuries). Our results suggest a major role for immune responses and antigen presentation in pediatric FSGS through (1) associations with SNPs in PTPRJ (or CD148, P=3.5×10-7), which plays a role in T-cell receptor signaling, (2) HLA-DRB1∗11:01 association (P=6.1×10-3; OR, 4.5 [95% CI, 1.5-13.0]), and (3) signaling pathway enrichment (P=1.3×10-6). LIMITATIONS Sample size and no independent replication cohort with genomic data readily available. CONCLUSIONS Our genetic study has identified functionally relevant risk factors and the importance of immune regulation for pediatric primary FSGS, which contributes to a better description of its molecular pathophysiological mechanisms.
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Affiliation(s)
- Axelle Durand
- Center for Research in Transplantation and Translational Immunology (UMR 1064), Nantes Université, Ecole Centrale Nantes, CHU Nantes, INSERM, F-44000 Nantes, France
| | - Cheryl A Winkler
- Basic Research Laboratory, Center for Cancer Research, Frederick National Laboratory, National Cancer Institute, Frederick, Maryland
| | - Nicolas Vince
- Center for Research in Transplantation and Translational Immunology (UMR 1064), Nantes Université, Ecole Centrale Nantes, CHU Nantes, INSERM, F-44000 Nantes, France
| | - Venceslas Douillard
- Center for Research in Transplantation and Translational Immunology (UMR 1064), Nantes Université, Ecole Centrale Nantes, CHU Nantes, INSERM, F-44000 Nantes, France
| | - Estelle Geffard
- Center for Research in Transplantation and Translational Immunology (UMR 1064), Nantes Université, Ecole Centrale Nantes, CHU Nantes, INSERM, F-44000 Nantes, France
| | - Elizabeth Binns-Roemer
- Basic Research Laboratory, Center for Cancer Research, Frederick National Laboratory, National Cancer Institute, Frederick, Maryland
| | - Derek K Ng
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Pierre-Antoine Gourraud
- Center for Research in Transplantation and Translational Immunology (UMR 1064), Nantes Université, Ecole Centrale Nantes, CHU Nantes, INSERM, F-44000 Nantes, France
| | - Kimberley Reidy
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | | | - Susan Furth
- Children's Hospital of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey B Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Frederick J Kaskel
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Sophie Limou
- Center for Research in Transplantation and Translational Immunology (UMR 1064), Nantes Université, Ecole Centrale Nantes, CHU Nantes, INSERM, F-44000 Nantes, France.
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9
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Guzman-Limon ML, Jiang S, Ng D, Flynn JT, Warady B, Furth SL, Samuels JA. Nocturnal Hypertension in Children With Chronic Kidney Disease Is Common and Associated With Progression to Kidney Replacement Therapy. Hypertension 2022; 79:2288-2297. [PMID: 35979846 PMCID: PMC9458620 DOI: 10.1161/hypertensionaha.121.18101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 06/17/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nocturnal hypertension is a risk factor for chronic kidney disease (CKD) progression among adults. In children, effects of nocturnal hypertension on CKD progression is less studied. METHODS We investigated the relationships between nocturnal, daytime, or sustained hypertension and progression to kidney replacement therapy in children using Cox proportional hazards models. Nocturnal and diurnal hypertension respectively defined as: mean blood pressure >95th percentile and/or load >25% for either systolic or diastolic blood pressure within sleep or wake periods. RESULTS One thousand five hundred seventy-seven ambulatory blood pressure monitoring studies from 701 CKiD participants were reviewed. Nighttime, daytime, and both types of hypertension were 19%, 7%, and 33%, respectively. Participants with both daytime and nocturnal hypertension had the highest risk of kidney replacement therapy. Among children with CKD, compared with those who were normotensive, those with isolated nocturnal hypertension had a hazard ratio of 1.49 ([CI, 0.97-2.28]; P=0.068) while those with both daytime and nocturnal hypertension had a HR of 2.23 ([CI, 1.60-3.11]; P<0.001) when adjusted for age, race, sex, and baseline proteinuria and glomerular filtration. Estimates for risk were similar among glomerular and nonglomerular participants but not significant in glomerular due to smaller sample size. CONCLUSIONS The presence of both daytime and nocturnal hypertension is significantly associated with risk of kidney replacement therapy. Our study confirms the utility of ambulatory blood pressure monitoring in children with CKD. Identifying and controlling both daytime and nocturnal hypertension using ambulatory blood pressure monitoring may improve outcomes and delay CKD progression in this population.
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Affiliation(s)
- Monica L Guzman-Limon
- McGovern Medical School at UTHealth, Pediatric Nephrology & Hypertension, Houston, TX (M.L.G.-L., J.A.S.)
| | - Shuai Jiang
- Johns Hopkins University, Baltimore, MD (S.J., D.N.)
| | - Derek Ng
- Johns Hopkins University, Baltimore, MD (S.J., D.N.)
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington, and Division of Nephrology, Seattle Children's Hospital, WA (J.T.F.)
| | | | - Susan L Furth
- The Children's Hospital of Philadelphia, PA (S.L.F.)
| | - Joshua A Samuels
- McGovern Medical School at UTHealth, Pediatric Nephrology & Hypertension, Houston, TX (M.L.G.-L., J.A.S.)
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10
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Amaral S, McCulloch CE, Lin F, Grimes BA, Furth S, Warady B, Brunson C, Siyahian S, Ku E. Association Between Dialysis Facility Ownership and Access to the Waiting List and Transplant in Pediatric Patients With End-stage Kidney Disease in the US. JAMA 2022; 328:451-459. [PMID: 35916847 PMCID: PMC9346544 DOI: 10.1001/jama.2022.11231] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE Care of adults at profit vs nonprofit dialysis facilities has been associated with lower access to transplant. Whether profit status is associated with transplant access for pediatric patients with end-stage kidney disease is unknown. OBJECTIVE To determine whether profit status of dialysis facilities is associated with placement on the kidney transplant waiting list or receipt of kidney transplant among pediatric patients receiving maintenance dialysis. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study reviewed the US Renal Data System records of 13 333 patients younger than 18 years who started dialysis from 2000 through 2018 in US dialysis facilities (followed up through June 30, 2019). EXPOSURES Time-updated profit status of dialysis facilities. MAIN OUTCOMES AND MEASURES Cox models, adjusted for clinical and demographic factors, were used to examine time to wait-listing and receipt of kidney transplant by profit status of dialysis facilities. RESULTS A total of 13 333 pediatric patients who started receiving maintenance dialysis were included in the analysis (median age, 12 years [IQR, 3-15 years]; 6054 females [45%]; 3321 non-Hispanic Black patients [25%]; 3695 Hispanic patients [28%]). During a median follow-up of 0.87 years (IQR, 0.39-1.85 years), the incidence of wait-listing was lower at profit facilities than at nonprofit facilities, 36.2 vs 49.8 per 100 person-years, respectively (absolute risk difference, -13.6 (95% CI, -15.4 to -11.8 per 100 person-years; adjusted hazard ratio [HR] for wait-listing at profit vs nonprofit facilities, 0.79; 95% CI, 0.75-0.83). During a median follow-up of 1.52 years (IQR, 0.75-2.87 years), the incidence of kidney transplant (living or deceased donor) was also lower at profit facilities than at nonprofit facilities, 21.5 vs 31.3 per 100 person-years, respectively; absolute risk difference, -9.8 (95% CI, -10.9 to -8.6 per 100 person-years) adjusted HR for kidney transplant at profit vs nonprofit facilities, 0.71 (95% CI, 0.67-0.74). CONCLUSIONS AND RELEVANCE Among a cohort of pediatric patients receiving dialysis in the US from 2000 through 2018, profit facility status was associated with longer time to wait-listing and longer time to kidney transplant.
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Affiliation(s)
- Sandra Amaral
- Children’s Hospital of Philadelphia, Division of Pediatric Nephrology, Department of Pediatrics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Feng Lin
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Barbara A. Grimes
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Susan Furth
- Children’s Hospital of Philadelphia, Division of Pediatric Nephrology, Department of Pediatrics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Bradley Warady
- Division of Pediatric Nephrology, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Celina Brunson
- Division of Pediatric Nephrology, Children’s National Health System, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Salpi Siyahian
- Division of Nephrology, Department of Medicine and Pediatrics, University of California, San Francisco
| | - Elaine Ku
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Division of Nephrology, Department of Medicine and Pediatrics, University of California, San Francisco
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11
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Hogan J, Divard G, Garro R, Boyer O, Seifert M, Smith J, Tönshoff B, Twombley K, Warady B, Weng P, Zhar R, Patzer R, Loupy A. FC031: Validation of a Prediction System for Risk of Allograft Loss (IBOX) in Pediatric Kidney Transplant Recipients. Nephrol Dial Transplant 2022. [DOI: 10.1093/ndt/gfac101.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND AND AIMS
Kidney allograft loss is a common cause of end-stage renal disease but accurate prediction models of kidney allograft loss are lacking in children. The iBOX system has been broadly validated among adults. We aimed to validate the iBOX system in a large international cohort of pediatric kTx recipients.
METHOD
In this observational study, we used data from pediatric (<21) patients transplanted between 2005 and 2017 from 20 institutions in Europe and the USA. Patients with functional parameters (eGFR and UPCR), donor specific antibody and biopsy results (Banff scores g, ptc, cg, i, t and IFTA) were included. Individual predictions of allograft loss were obtained by applying the iBOX score on our data. The prediction performances of the model in our population were assessed via discrimination (c-statistics) and calibration.
RESULTS
A total of 573 kTx recipients were included. Median time from transplantation to evaluation was 1.0 (0.5–2.0) year with a mean age at evaluation at 12.1 (5.5) years and mean follow-up after transplantation 5.1 (2.8) years. Five-year death-censored graft survival from evaluation was 95%. At the time of evaluation, mean eGFR and uPCR were 65.5 (29.6) mL/min/1.73 m2 and 0.25 (1.2) g/g, respectively. A total of 118 (20.6%) of the patients had DSA. The iBOX system showed good discrimination with a c-statistic of 0.81 and good calibration (Figure 1).
CONCLUSION
The iBOX system demonstrated high accuracy in predicting kidney allograft loss in children with performances similar to those reported in adults.
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Affiliation(s)
- Julien Hogan
- Pediatric Nephrology, Robert Debré Hospital, APHP, Paris, France
- Paris Transplant Group, University of Paris, PARCC, INSERM U970, Paris, France
- Emory Transplant Center, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Gillian Divard
- Paris Transplant Group, University of Paris, PARCC, INSERM U970, Paris, France
| | - Rouba Garro
- Pediatric Nephrology, Children Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Olivia Boyer
- Pediatric Nephrology, Necker Hospital, APHP, Paris, France
| | - Michael Seifert
- Pediatric Nephrology, University of Alabama, Birmingham, AL, USA
| | - Jodi Smith
- Pediatric Nephrology, Seattle Children, Seattle, NY, USA
| | | | - Katherine Twombley
- Pediatric Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Bradley Warady
- Pediatric Nephrology, Children's Mercy, Kansas City, MI, USA
| | - Patricia Weng
- Pediatric Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Rima Zhar
- Pediatric Nephrology, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Rachel Patzer
- Emory Transplant Center, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Alexandre Loupy
- Paris Transplant Group, University of Paris, PARCC, INSERM U970, Paris, France
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12
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Warady B, Meyer Reigner S, Tirodkar C, Drozdz D. FC037: A Study to Ascertain the Optimum Starting Dose of Subcutaneous (SC) C.E.R.A. for Maintenance Treatment of Anemia in Pediatric Patients with Chronic Kidney Disease (CKD) on Dialysis or not yet on Dialysis. Nephrol Dial Transplant 2022. [DOI: 10.1093/ndt/gfac103.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND AND AIMS
The Phase II study DOLPHIN (NH19707; NCT00717366) demonstrated that pediatric patients with chronic kidney disease (CKD) on hemodialysis can be safely and effectively switched from maintenance treatment with epoetin alfa/beta or darbepoetin alfa to intravenous continuous erythropoietin receptor activator (C.E.R.A.)—methoxy polyethylene glycol-epoetin beta, using defined conversion factors [1]. This study (NH19708; NCT03552393; SKIPPER) was conducted to ascertain the optimum starting dose of C.E.R.A. administered subcutaneously for maintenance treatment of anemia in pediatric patients with CKD on dialysis, or those not yet on dialysis, using the same conversion factors.
Methods
This Phase II, open-label, single-arm, multicentre study included a 3-week screening period, 16-week dose-titration period, 4-week evaluation period and 24-week optional safety extension (for patients who completed the 20 weeks of treatment with hemoglobin [Hb] within ± 1 g/dL of their baseline Hb and within the target range of 10–12 g/dL). Patients aged 3 months to 17 years with stable chronic renal anemia and a baseline Hb concentration of 10.0–12.0 g/dL were switched from epoetin alfa/beta or darbepoetin to subcutaneous (SC) C.E.R.A. every 4 weeks using the previously determined conversion factors. The primary endpoint was change in Hb concentration (g/dL) between baseline and the evaluation period. Secondary endpoints included the number of patients with a mean Hb concentration within a target range of 10.0–12.0 g/dL and/or ± 1 g/dL of baseline during the evaluation period and change in C.E.R.A. SC dose over time. Safety/tolerability and the pharmacokinetics/pharmacodynamics profile of C.E.R.A. SC were also assessed.
RESULTS
Forty patients were enrolled, with 38 completing the core study period and 25 entering the safety extension period. Six patients withdrew from the study, mainly due to kidney transplantation (5/6; 83.3%). The mean age of patients was 10 years; 12 (30%) aged <5 years, 11 (27.5%) aged 5–11 years and 17 (42.5%) aged 12–17 years. Eighteen patients (45.0%) were on peritoneal dialysis, 5 (12.5%) were on hemodialysis and 17 (42.5%) were not on dialysis. The mean Hb level at baseline was 11.02 g/dL (range: 10.1–12.2 g/dL). Mean change in Hb between baseline and the evaluation period was 0.48 g/dL (standard deviation: 1.03; 90% confidence interval 0.20–0.76). Results were consistent based on sub-analyses by age groups (<5, 5–11, 12–17 years), dialysis status (no dialysis, hemodialysis or peritoneal dialysis) and previous type of erythropoiesis-stimulating agent treatment. Mean Hb concentration levels were maintained within 10–12 g/dL and within ± 1 g/dL of baseline throughout the entire core period and safety extension period. During the evaluation period, 24/38 patients (63.2%) maintained Hb within 10–12 g/dL, 19 (50%) maintained Hb within 1 g/dL of baseline and 18 (47.4%) fulfilled both criteria. The median ratio of C.E.R.A. dose between Week 1 (median dose of 75 μg) and Week 17 (50 μg) was 1.44, indicating a decrease relative to the initial dose. Safety results were consistent with the known safety profile for C.E.R.A. in adults and pediatric patients aged 6–17 years on hemodialysis and IV administration of C.E.R.A [1], with no unexpected safety signals detected.
CONCLUSION
In this study, the primary endpoint was met and provided evidence that pediatric patients with CKD on dialysis, or those not yet on dialysis, can be safely and effectively switched from previous treatment with epoetin alfa/beta or darbepoetin to C.E.R.A. SC every 4 weeks for maintenance treatment of anemia.
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Affiliation(s)
- Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Sylvie Meyer Reigner
- Pharma Development Clinical Science, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Chitra Tirodkar
- Global Data Operations-Biostatistics, PAREXEL International Ltd, Navigation House, Sheffield, UK
| | - Dorota Drozdz
- Department of Pediatric Nephrology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
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13
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Sanderson K, Warady B, Carey W, Tolia V, Boynton MH, Benjamin DK, Jackson W, Laughon M, Clark RH, Greenberg RG. Mortality Risk Factors among Infants Receiving Dialysis in the Neonatal Intensive Care Unit. J Pediatr 2022; 242:159-165. [PMID: 34798078 PMCID: PMC8882152 DOI: 10.1016/j.jpeds.2021.11.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To identify risk factors associated with mortality for infants receiving dialysis in the neonatal intensive care unit (NICU). STUDY DESIGN In this retrospective cohort study, we extracted data from the Pediatrix Clinical Data Warehouse on all infants who received dialysis in the NICU from 1999 to 2018. Using a Cox proportional hazards model with robust SEs we estimated the mortality hazard ratios associated with demographics, birth details, medical complications, and treatment exposures. RESULTS We identified 273 infants who received dialysis. Median gestational age at birth was 35 weeks (interquartile values 33-37), median birth weight was 2570 g (2000-3084), 8% were small for gestational age, 41% white, and 72% male. Over one-half of the infants (59%) had a kidney anomaly; 71 (26%) infants died before NICU hospital discharge. Factors associated with increased risk of dying after dialysis initiation included lack of kidney anomalies, Black race, gestational age of <32 weeks, necrotizing enterocolitis, dialysis within 7 days of life, and receipt of paralytics or vasopressors (all P < .05). CONCLUSION In this cohort of infants who received dialysis in the NICU over 2 decades, more than 70% of infants survived. The probability of death was greater among infants without a history of a kidney anomaly and those with risk factors consistent with greater severity of illness at dialysis initiation.
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Affiliation(s)
- Keia Sanderson
- Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, NC
| | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO
| | - William Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, MN
| | - Veeral Tolia
- The MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL,Division of Neonatology, Department of Pediatrics, Baylor University Medical Center, Dallas, TX
| | - Marcella H. Boynton
- Department of Medicine-Internal Medicine, University of North Carolina, Chapel Hill, NC,North Carolina Translational and Clinical Sciences Institute, Chapel Hill, NC
| | | | - Wesley Jackson
- Division of Neonatology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Matthew Laughon
- Division of Neonatology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Reese H. Clark
- The MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL,Greenville Health System, Greenville, SC
| | - Rachel G. Greenberg
- Division of Neonatology, Department of Pediatrics, Duke University, Durham, NC,Duke Clinical Research Institute, Durham, NC
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14
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Raina R, Davenport A, Warady B, Vasistha P, Sethi SK, Chakraborty R, Khooblall P, Agarwal N, Vij M, Schaefer F, Malhotra K, Misra M. Dialysis disequilibrium syndrome (DDS) in pediatric patients on dialysis: systematic review and clinical practice recommendations. Pediatr Nephrol 2022; 37:263-274. [PMID: 34609583 DOI: 10.1007/s00467-021-05242-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Dialysis disequilibrium syndrome (DDS) is a rare neurological complication, most commonly affecting patients undergoing new initiation of hemodialysis (HD), but can also be seen in patients receiving chronic dialysis who miss regular treatments, patients having acute kidney injury (AKI), and in those treated with continuous kidney replacement therapy (CKRT) or peritoneal dialysis (PD). Although the pathogenesis is not well understood, DDS is likely a result of multiple physiological abnormalities. In this systematic review, we provide a synopsis of the data available on DDS that allow for a clear picture of its pathogenesis, preventive measures, and focus on effective management strategies. METHODS We conducted a literature search on PubMed/Medline and Embase from January 1960 to January 2021. Studies were included if the patient developed DDS irrespective of age and gender. A summary table was used to summarize the data from individual studies and included study type, population group, age group, sample size, patient characteristics, blood and dialysate flow rate, and overall outcome. A descriptive analysis calculating the frequency of population size, symptoms, and various treatments was performed using R software version 3.1.0. RESULTS A total of 49 studies (321 samples) were identified and analyzed. Out of the included 49 studies, a total of 48 studies reported the presence of DSS among patients (1 study reported based on number of dialysis and therefore was not considered for analysis). Among these 48 studies, 74.3% (226/304) patients were reported to have DSS. The most common symptoms were nausea (25.2%), headache (24.8%), vomiting (23.9%), muscle cramps (18.1%), affected level of consciousness (8.8%), confusion (4.4%), and seizure (4.9%) among the 226 DDS patients. Furthermore, 12 studies decided to switch from HD to alternative dialysis modalities including continuous venovenous hemofiltration/hemodiafiltration (CVVH/CVVHDF) or PD which reported no DDS symptoms. CONCLUSION Early recognition and timely prevention are crucial for DDS patients. We have provided comprehensive clinical practice points for pediatric, adolescent, and young adult populations. However, it is essential to recognize that DDS was reported more frequently in the early dialysis era, as there was a lack of advanced dialysis technology and limited resources.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA. .,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA. .,School of Medicine Cleveland Ohio, Case Western Reserve University, Cleveland, OH, USA.
| | - Andrew Davenport
- University College London Centre for Nephrology, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK
| | - Bradley Warady
- Division of Nephrology, University of Missouri-Kansas City School of Medicine, Children's Mercy, Kansas City, MO, USA
| | - Prabhav Vasistha
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, MedantaThe Medicity Hospital, Gurgaon, India
| | - Ronith Chakraborty
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Prajit Khooblall
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Nirav Agarwal
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Manan Vij
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Franz Schaefer
- Department of Pediatric Nephrology, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Kunal Malhotra
- Division of Nephrology, University of Missouri School of Medicine, Columbia, MO, USA
| | - Madhukar Misra
- Division of Nephrology, University of Missouri School of Medicine, Columbia, MO, USA
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15
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Viteri B, Elsingergy M, Roem J, Ng D, Warady B, Furth S, Tasian G. Ultrasound-Based Renal Parenchymal Area and Kidney Function Decline in Infants With Congenital Anomalies of the Kidney and Urinary Tract. Semin Nephrol 2021; 41:427-433. [PMID: 34916003 DOI: 10.1016/j.semnephrol.2021.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Congenital anomalies of the kidney and urinary tract are the leading cause of chronic kidney disease in children. Noninvasive imaging biomarkers that predict chronic kidney disease progression in early infancy are needed. We performed a pilot study nested in the prospective Chronic Kidney Disease in Children cohort study to determine the association between renal parenchymal area (RPA) on first post-natal renal ultrasound and change in estimated glomerular filtration rate (eGFR) in children with congenital anomalies of the kidney and urinary tract. Among 14 participants, 78.6% were males, the median age at the time of the ultrasound was 3.4 months (interquartile range, 1.3-7.9 mo), and the median total RPA z-score at baseline was -1.01 (interquartile range, -2.39 to 0.52). After a median follow-up period of 7.4 years (interquartile range, 6.8-8.2 y), the eGFR decreased from a median of 49.4 mL/min per 1.73 m2 at baseline to 29.4 mL/min per 1.73 m2, an annual eGFR percentage decrease of -4.68%. Lower RPA z-scores were correlated weakly with a higher annual decrease in eGFR (Spearman correlation, 0.35; 95% confidence interval, -0.25 to 0.76). This pilot study shows the feasibility of obtaining RPA from a routine ultrasound and suggests that a lower baseline RPA may be associated with a greater decrease in eGFR over time. Further studies with larger patient cohorts are needed to confirm this association.
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Affiliation(s)
- Bernarda Viteri
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Division of Body Imaging, Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mohamed Elsingergy
- Division of Body Imaging, Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer Roem
- Division of General Epidemiology and Methodology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Derek Ng
- Division of General Epidemiology and Methodology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Bradley Warady
- Department of Paediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Susan Furth
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Gregory Tasian
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Pediatric Urology, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.
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16
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Wasik H, Chadha V, Galbiati S, Warady B, Atkinson M. Dialysis Outcomes for Children With Lupus Nephritis Compared to Children With Other Forms of Nephritis: A Retrospective Cohort Study. Am J Kidney Dis 2021; 79:626-634. [PMID: 34461164 DOI: 10.1053/j.ajkd.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/16/2021] [Indexed: 01/12/2023]
Abstract
RATIONALE & OBJECTIVE Children with lupus nephritis (LN) are at high risk of developing kidney failure requiring initiation of kidney replacement therapy. This study compared outcomes among children with LN on dialysis with children with non-lupus glomerular disease and investigated risk factors for adverse outcomes among children with LN on dialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Children and adolescents aged 6-20 years with LN (n = 231) and non-lupus glomerular disease (n = 1,726) who initiated maintenance dialysis 1991-2018 and were enrolled in the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry. EXPOSURE Lupus nephritis. OUTCOME Hospitalization, mortality, and time to transplant. ANALYTICAL APPROACH Contingency tables were used to compare hospitalizations, and multivariable cause-specific hazards models were used to compare rates of death and transplantation in children with LN compared with those with non-lupus glomerular disease. Using data from children with LN, multivariable logistic regression models were fit to evaluate the risk factors for hospitalization, and multivariable Cox regression models were fit to evaluate factors associated with kidney transplantation. RESULTS Children with LN were more likely to be hospitalized in the first year after dialysis initiation (63.3% vs 48.6%, P < 0.001) and were less likely to receive a kidney transplant in the first 3 years after dialysis initiation (year 0-1: adjusted hazard ratio [AHR], 0.36 [95% CI, 0.23-0.57], P < 0.001; year 1-3: AHR, 0.73 [95% CI, 0.54-0.98], P = 0.04). Anemia was associated with hospitalization after dialysis initiation (adjusted OR, 4.44 [95% CI, 1.44-13.66], P = 0.01). Non-White race was associated with a lower rate of kidney transplantation (AHR, 0.47 [95% CI, 0.27-0.82], P = 0.01). LN was not associated with death while on dialysis (AHR, 1.21 [95% CI, 0.47-3.11], P = 0.7). LIMITATIONS The NAPRTCS registry does not collect information on lupus disease activity or medication doses and has limited data on medication use. CONCLUSIONS Children and adolescents with LN on dialysis are at higher risk for adverse outcomes including hospitalization and lower rates of kidney transplantation compared with children with non-lupus glomerular disease receiving maintenance dialysis.
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Affiliation(s)
- Heather Wasik
- Division of Pediatric Nephrology, SUNY Upstate Medical University, Syracuse, New York.
| | - Vimal Chadha
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | | | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Meredith Atkinson
- Division of Pediatric Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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18
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Warady B, Chadha V, Chin M, Gbadagesin RA, Gibson K, Gipson D, Goldsberry A, Lieberman K, Meyer C, Meyers K, Nozu K, O'Grady M, Rheault M, Kashtan C. FC 023SAFETY OF BARDOXOLONE METHYL IN PEDIATRIC PATIENTS WITH ALPORT SYNDROME IN CARDINAL PHASE 3 TRIAL. Nephrol Dial Transplant 2021. [DOI: 10.1093/ndt/gfab133.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background and Aims
Alport syndrome is a genetic disease accounting for an estimated 3% of children with end-stage kidney disease (ESKD) in the US (USRDS, 2014). Current management recommendations include the use of renin-angiotensin-aldosterone system inhibitors (RAASi) in patients with proteinuria, but no specific therapies have been approved for this disease. A Phase 3 study (CARDINAL; NCT03019185) assessed the safety and efficacy of bardoxolone methyl (Bard) in adult and adolescent patients with Alport syndrome.
Method
CARDINAL was an international, multicenter, double-blind, placebo-controlled, randomized trial. Eligible participants were 12 to 70 years old, had confirmed diagnosis of Alport syndrome, baseline eGFR 30-90 mL/min/1.73 m2 and urinary albumin to creatinine ratio (UACR) ≤ 3500 mg/g. For pediatric patients (12 to < 18 years of age), eGFR was calculated using the Bedside Schwartz equation. Patients were randomized 1:1 to Bard or placebo and were to be followed for up to 104 weeks (2 treatment periods of 48 weeks and 4 weeks off treatment between Weeks 48 and 52). The primary efficacy endpoints were changes from baseline in eGFR in patients randomized to Bard compared to placebo at Week 48 and Week 100. The key secondary endpoints were the off-treatment changes from baseline in eGFR in patients randomized to Bard compared to placebo at Week 52 and Week 104, 4 weeks after withdrawal.
Results
A total of 23 (15%) pediatric patients were randomized to Bard (n=11) or placebo (n=12). The average age was 15.3 years, mean (± SD) baseline eGFR was 69.9 ± 15.4 mL/min/1.73 m2 and geometric mean (± SE) baseline UACR was 230.9 ± 95.8 mg/g. A total of 19 of 23 (83%) pediatric patients were male, and 14 (61%) patients had X-linked Alport syndrome, while 6 (26%) patients had autosomal disease. Mean (± SD) baseline body weight was 65.5 ± 10.2 kg and 57.8 ± 16.0 kg and baseline height was 171.7 ± 5.9 cm and 166.3 ± 14.9 cm for Bard and placebo patients, respectively. Seventeen (74%) pediatric patients were on RAASi treatment.
Treatment of pediatric patients with Bard resulted in a significantly higher mean change from baseline in on-treatment eGFR relative to placebo at Week 100 (13.8 mL/min/1.73 m2; p = 0.017) and higher mean off-treatment eGFR relative to placebo at Week 104 (14.6 mL/min/1.73 m2; p = 0.0035).
In pediatric patients treated with Bard, UACR remained generally unchanged relative to baseline at Week 100 (geometric mean ± SE to baseline ratio: 0.7 ± 0.3), while placebo patients had an increase in UACR (geometric mean ± SE to baseline ratio: 2.1 ± 0.9).
Pediatric patients generally continued along their baseline growth curves for height and weight in both treatment groups. At Week 100, mean ± SD changes from baseline in body weight were 0.5 ± 3.9 kg and 3.2 ± 3.5 kg and those for height were 1.6 ± 1.4 cm and 4.3 ± 5.1 cm for Bard and placebo patients, respectively. Changes in blood pressure (BP) were similar across treatment groups.
As seen in the adult population, treatment with Bard resulted in transient increases in mean aminotransferase levels in pediatric patients that remained below 3 x ULN for a majority (8/11 [73%]) of patients and returned to baseline at Week 104, 4 weeks after drug withdrawal (mean ± SD change from baseline in ALT: 0.4 ± 3.7 U/L; AST: -0.9 ± 5.6 U/L). Increases in ALT did not coincide with increases in total bilirubin and no Hy’s law cases were reported.
No serious adverse events (AEs) were reported in pediatric patients treated with Bard and reported AEs were consistent with those observed in previous studies. One placebo-treated pediatric patient and no Bard patients developed ESKD during the trial.
Conclusion
In CARDINAL, the addition of Bard to RAASi in pediatric patients with chronic kidney disease due to Alport syndrome appeared to preserve kidney function and very importantly from a safety standpoint, was safe and well-tolerated.
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Affiliation(s)
- Bradley Warady
- Children’s Mercy Kansas City, Pediatric Nephrology, Kansas City, United States of America
| | - Vimal Chadha
- Children’s Mercy Kansas City, Nephrology, Kansas City, United States of America
| | - Melanie Chin
- Reata Pharmaceuticals, Product Development, Plano , United States of America
| | - Rasheed A Gbadagesin
- Duke University School of Medicine, Pediatrics, Durham, United States of America
| | - Keisha Gibson
- University of North Carolina at Chapel Hill, Medicine and Pediatrics, Chapel Hill, United States of America
| | - Debbie Gipson
- University of Michigan, Pediatric Nephrology, Ann Arbor, United States of America
| | - Angie Goldsberry
- Reata Pharmaceuticals, Product Development, Plano , United States of America
| | - Kenneth Lieberman
- Hackensack University Medical Center, Pediatrics, Hackensack, United States of America
| | - Colin Meyer
- Reata Pharmaceuticals, Product Development, Plano , United States of America
| | - Kevin Meyers
- CHOP and UPENN, Pediatric Nephrology, Philadelphia, United States of America
| | - Kandai Nozu
- Kobe University Graduate School of Medicine, Pediatrics, Hyogo, United States of America
| | - Megan O'Grady
- Reata Pharmaceuticals, Product Development, Plano , United States of America
| | - Michelle Rheault
- University of Minnesota, Pediatrics, Saint Louis Park, United States of America
| | - Clifford Kashtan
- University of Minnesota, Pediatrics, Saint Louis Park, United States of America
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19
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Bartosova M, Schaefer B, Zhang C, Herzog R, Ridinger D, Damgov I, Lévai E, Marinovic I, Eckert C, Romero P, Sallay P, Ujszaszi A, Unterwurzacher M, Wagner A, Hildenbrand G, Warady B, Schaefer F, Zarogiannis SG, Kratochwill K, Schmitt C. FC 109GLUCOSE DERIVATIVE INDUCED VASCULOPATHY IN CHILDREN ON PERITONEAL DIALYSIS. Nephrol Dial Transplant 2021. [DOI: 10.1093/ndt/gfab126.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and Aims
Patients with chronic kidney disease patients (CKD) have an exceedingly high cardiovascular risk. While vasculopathy is further accelerated during peritoneal dialysis (PD), the pathophysiological role of reactive metabolites such as glucose degradation products (GDP) is uncertain.
Method
Omental and parietal peritoneal tissues from 100 non-CKD individuals, 107 children with CKD5, 60 children treated with neutral pH, low GDP, and 30 children treated with acidic pH, high GDP PD fluids underwent standardized digital histomorphometry. Omental arterioles localized within the fat tissue, protected from direct PD fluid exposure were microdissected for multi-omics analysis. Key regulated pathways were validated by quantitative immunostaining, with localization microscopy in peritoneal tissues of matched cohorts and in vitro in human umbilical vein endothelial cells.
Results
Arterioles from children with CKD5 exhibited reduced lumen to vessel ratio (L/V) and reduced endothelial telomere length compared to non-CKD individuals; gene ontology analysis identified enrichment of arteriolar genes associated with nuclear telomere cap complex and focal adhesion. Pathway analysis of arteriolar cross-omics identified top canonical pathways including telomere extension by telomerase, actin cytoskeleton, integrin and tight junction signalling.
Peritoneal vasculopathy progressed with PD vintage and was more pronounced with high versus low GDP exposure (p<0.001). Compared to CKD5, low GDP-PD upregulated 145/110 and downregulated 38/34 arteriolar genes/proteins, high GDP-PD upregulated 684/137 and supressed 1560/55 genes/proteins (p<0.01). High GDP milieu induced upregulation of arteriolar genes involved in cell death/apoptosis and suppressed genes related to cell viability/survival, cytoskeleton organization and immune response biofunctions. Vasculopathy associated canonical pathways concordantly regulated on arteriolar gene and protein level with high GDP exposure included cell death/proliferation, apoptosis, cytoskeleton organization, metabolism and detoxification, cell junction signalling, and immune response.
Quantitative validation in PD cohorts with similar PD vintage, dialytic glucose exposure and age (n=15 / group) verified increased proapoptotic activity and cytoskeleton disintegration with high-GDP exposure; single-molecule-localization microscopy demonstrated arteriolar endothelial zonula occludens-1 (ZO-1) disruption. Absolute and relative to endoluminal surface length, arteriolar endothelial cell counts were inversely correlated with GDP exposure, with apoptosis marker caspase-3, TGF-ß induced pSMAD2/3, interleukin-6, ZO-1 protein abundance and the degree of vasculopathy. In vitro, exposure to GDP 3,4-dideoxyglucosone-3-ene dose-dependently reduced nuclear endothelial lamin-A/C and membrane ZO-1 assembly. Transendothelial electrical resistance was decreased. ZO-1 and sealing tight junction claudin-5 protein abundance were decreased in cells after incubation with high GDP compared to low GDP PD fluid and culture media. On nanoscale level GDP reduced junction cluster formation in the membrane area.
Conclusion
Multi-omics analysis of omental arterioles from children without pre-existing vasculopathy and life-style related confounders identified key mechanisms of vascular aging in CKD5 and the major contribution of GDP to accelerated vasculopathy during PD, i.e. disruption of endothelial cell junctions and cytoskeleton and induction of apoptosis.
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Affiliation(s)
- Maria Bartosova
- University of Heidelberg, Center of Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Betti Schaefer
- University of Heidelberg, Center of Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Conghui Zhang
- University of Heidelberg, Center of Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Rebecca Herzog
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
| | - David Ridinger
- Heidelberg University, Kirchhoff Institute for Physics, Heidelberg, Germany
| | - Ivan Damgov
- University of Heidelberg, Center of Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Eszter Lévai
- University of Heidelberg, Center of Pediatric and Adolescent Medicine, Heidelberg, Germany
- Semmelweis University, 1st Department of Pediatrics, Budapest, Hungary
- MTA-SE, Pediatrics and Nephrology Research Group, Budapest, Hungary
| | - Iva Marinovic
- University of Heidelberg, Center of Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Christoph Eckert
- University of Heidelberg, Institute of Pathology, Heidelberg, Germany
| | - Philipp Romero
- University of Heidelberg, Department of General, Visceral and Transplantation Surgery, Heidelberg, Germany
| | - Peter Sallay
- Semmelweis University, 1st Department of Pediatrics, Budapest, Hungary
| | - Akos Ujszaszi
- University of Heidelberg, Division of Nephrology, Heidelberg, Germany
| | - Markus Unterwurzacher
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
| | - Anja Wagner
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
| | - Georg Hildenbrand
- Heidelberg University, Kirchhoff Institute for Physics, Heidelberg, Germany
| | - Bradley Warady
- Children´s Mercy Kansas City, Kansas City, United States of America
| | - Franz Schaefer
- University of Heidelberg, Center of Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Sotirios G Zarogiannis
- University of Heidelberg, Center of Pediatric and Adolescent Medicine, Heidelberg, Germany
- University of Thessaly, Department of Physiology, Larissa, Greece
| | - Klaus Kratochwill
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
| | - Claus Schmitt
- University of Heidelberg, Center of Pediatric and Adolescent Medicine, Heidelberg, Germany
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20
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Nourse P, Cullis B, Finkelstein F, Numanoglu A, Warady B, Antwi S, McCulloch M. ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 Update (paediatrics). Perit Dial Int 2021; 41:139-157. [PMID: 33523772 DOI: 10.1177/0896860820982120] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
SUMMARY OF RECOMMENDATIONS 1.1 Peritoneal dialysis is a suitable renal replacement therapy modality for treatment of acute kidney injury in children. (1C)2. Access and fluid delivery for acute PD in children.2.1 We recommend a Tenckhoff catheter inserted by a surgeon in the operating theatre as the optimal choice for PD access. (1B) (optimal)2.2 Insertion of a PD catheter with an insertion kit and using Seldinger technique is an acceptable alternative. (1C) (optimal)2.3 Interventional radiological placement of PD catheters combining ultrasound and fluoroscopy is an acceptable alternative. (1D) (optimal)2.4 Rigid catheters placed using a stylet should only be used when soft Seldinger catheters are not available, with the duration of use limited to <3 days to minimize the risk of complications. (1C) (minimum standard)2.5 Improvised PD catheters should only be used when no standard PD access is available. (practice point) (minimum standard)2.6 We recommend the use of prophylactic antibiotics prior to PD catheter insertion. (1B) (optimal)2.7 A closed delivery system with a Y connection should be used. (1A) (optimal) A system utilizing buretrols to measure fill and drainage volumes should be used when performing manual PD in small children. (practice point) (optimal)2.8 In resource limited settings, an open system with spiking of bags may be used; however, this should be designed to limit the number of potential sites for contamination and ensure precise measurement of fill and drainage volumes. (practice point) (minimum standard)2.9 Automated peritoneal dialysis is suitable for the management of paediatric AKI, except in neonates for whom fill volumes are too small for currently available machines. (1D)3. Peritoneal dialysis solutions for acute PD in children3.1 The composition of the acute peritoneal dialysis solution should include dextrose in a concentration designed to achieve the target ultrafiltration. (practice point)3.2 Once potassium levels in the serum fall below 4 mmol/l, potassium should be added to dialysate using sterile technique. (practice point) (optimal) If no facilities exist to measure the serum potassium, consideration should be given for the empiric addition of potassium to the dialysis solution after 12 h of continuous PD to achieve a dialysate concentration of 3-4 mmol/l. (practice point) (minimum standard)3.3 Serum concentrations of electrolytes should be measured 12 hourly for the first 24 h and daily once stable. (practice point) (optimal) In resource poor settings, sodium and potassium should be measured daily, if practical. (practice point) (minimum standard)3.4 In the setting of hepatic dysfunction, hemodynamic instability and persistent/worsening metabolic acidosis, it is preferable to use bicarbonate containing solutions. (1D) (optimal) Where these solutions are not available, the use of lactate containing solutions is an alternative. (2D) (minimum standard)3.5 Commercially prepared dialysis solutions should be used. (1C) (optimal) However, where resources do not permit this, locally prepared fluids may be used with careful observation of sterile preparation procedures and patient outcomes (e.g. rate of peritonitis). (1C) (minimum standard)4. Prescription of acute PD in paediatric patients4.1 The initial fill volume should be limited to 10-20 ml/kg to minimize the risk of dialysate leakage; a gradual increase in the volume to approximately 30-40 ml/kg (800-1100 ml/m2) may occur as tolerated by the patient. (practice point)4.2 The initial exchange duration, including inflow, dwell and drain times, should generally be every 60-90 min; gradual prolongation of the dwell time can occur as fluid and solute removal targets are achieved. In neonates and small infants, the cycle duration may need to be reduced to achieve adequate ultrafiltration. (practice point)4.3 Close monitoring of total fluid intake and output is mandatory with a goal to achieve and maintain normotension and euvolemia. (1B)4.4 Acute PD should be continuous throughout the full 24-h period for the initial 1-3 days of therapy. (1C)4.5 Close monitoring of drug dosages and levels, where available, should be conducted when providing acute PD. (practice point)5. Continuous flow peritoneal dialysis (CFPD)5.1 Continuous flow peritoneal dialysis can be considered as a PD treatment option when an increase in solute clearance and ultrafiltration is desired but cannot be achieved with standard acute PD. Therapy with this technique should be considered experimental since experience with the therapy is limited. (practice point) 5.2 Continuous flow peritoneal dialysis can be considered for dialysis therapy in children with AKI when the use of only very small fill volumes is preferred (e.g. children with high ventilator pressures). (practice point).
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Affiliation(s)
- Peter Nourse
- Pediatric Nephrology Red Cross War Memorial Children's Hospital, 37716University of Cape Town, South Africa
| | - Brett Cullis
- Hilton Life Hospital, Renal and Intensive Care Units, Hilton, South Africa
| | | | - Alp Numanoglu
- Department of Surgery 63731Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Bradley Warady
- Division of Nephrology, University of Missouri-Kansas City School of Medicine, MO, USA
| | - Sampson Antwi
- Department of Child Health, Kwame Nkrumah University of Science & Technology/Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Mignon McCulloch
- Pediatric Nephrology Red Cross War Memorial Children's Hospital, 37716University of Cape Town, South Africa
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21
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Laster M, Denburg M, Okuda Y, Kumar J, Furth S, Warady B, Kalantar-Zadeh K, Norris K, Salusky IB. Race and Ethnicity Predict Bone Markers and Fracture in Pediatric Patients With Chronic Kidney Disease. J Bone Miner Res 2021; 36:298-304. [PMID: 32960469 PMCID: PMC8893169 DOI: 10.1002/jbmr.4182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 01/17/2023]
Abstract
Studies in healthy children have shown racial-ethnic differences in bone markers and bone outcomes including fractures. At present, limited studies have evaluated the impact of race and ethnicity on bone markers and fractures within the pediatric chronic kidney disease (CKD) population. In a cohort study of 762 children between the ages of 1.5 years and 18 years, with CKD stages 1 to 4 from the CKD in children (CKiD) cohort, the relationship between racial-ethnic group and bone markers (parathyroid hormone [PTH], 25-hydroxyvitamin D [25-OHD], 1,25-dihydroxyvitamin D [1,25(OH)2 D], and C-terminal fibroblast growth factor [FGF23]) was determined using linear mixed models. Additionally, logistic regression was used to evaluate racial-ethnic differences in prevalent fracture upon study entry. Black race was associated with 23% higher PTH levels (confidence interval [CI], 2.5% to 47.7%; p = .03), 33.1% lower 25-OHD levels (CI, -39.7% to -25.7%; p < .0001), and no difference in C-terminal FGF23 or 1,25(OH)2 D levels when compared to whites. Hispanic ethnicity was associated with 15.9% lower C-terminal FGF23 levels (CI, -28.3% to -1.5%; p = .03) and 13.8% lower 25-OHD levels (CI, -22.2% to -4.5%; p = .005) when compared to whites. Black and Hispanic children had 74% (odds ratio [OR] 0.26; CI, 0.14 to 0.49; p = .001) and 66% (OR 0.34; CI, 0.17 to 0.65; p < .0001) lower odds of any fracture than white children at study entry, respectively. Race and ethnicity are associated with differences in bone markers and despite lower 25-OHD levels, both black and Hispanic children with CKD reported a lower prevalent fracture history than white children. The current findings in the CKD population are similar to racial-ethnic differences described in healthy children. Additional studies are needed to better understand how these differences might impact the management of pediatric CKD-MBD. © 2020 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Marciana Laster
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
| | - Michelle Denburg
- The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Yusuke Okuda
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan.,Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension and Kidney Transplantation, University of California, Irvine, Irvine, CA, USA
| | - Juhi Kumar
- Weill Cornell Medical College, New York, NY, USA
| | - Susan Furth
- The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Bradley Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension and Kidney Transplantation, University of California, Irvine, Irvine, CA, USA
| | - Keith Norris
- Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
| | - Isidro B Salusky
- Department of Pediatrics, Division of Nephrology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
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22
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Rees L, Shaw V, Qizalbash L, Anderson C, Desloovere A, Greenbaum L, Haffner D, Nelms C, Oosterveld M, Paglialonga F, Polderman N, Renken-Terhaerdt J, Tuokkola J, Warady B, Walle JVD, Shroff R. Delivery of a nutritional prescription by enteral tube feeding in children with chronic kidney disease stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2021; 36:187-204. [PMID: 32728841 PMCID: PMC7701061 DOI: 10.1007/s00467-020-04623-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 12/14/2022]
Abstract
The nutritional prescription (whether in the form of food or liquid formulas) may be taken orally when a child has the capacity for spontaneous intake by mouth, but may need to be administered partially or completely by nasogastric tube or gastrostomy device ("enteral tube feeding"). The relative use of each of these methods varies both within and between countries. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPRs) based on evidence where available, or on the expert opinion of the Taskforce members, using a Delphi process to seek consensus from the wider community of experts in the field. We present CPRs for delivery of the nutritional prescription via enteral tube feeding to children with chronic kidney disease stages 2-5 and on dialysis. We address the types of enteral feeding tubes, when they should be used, placement techniques, recommendations and contraindications for their use, and evidence for their effects on growth parameters. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgement. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT.
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Affiliation(s)
- Lesley Rees
- The Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health, University College Londonfig, WC1N 3JH, London, UK.
| | - Vanessa Shaw
- grid.83440.3b0000000121901201The Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health, University College Londonfig, WC1N 3JH, London, UK ,grid.11201.330000 0001 2219 0747University of Plymouth, Plymouth, UK
| | - Leila Qizalbash
- Great Northern Children’s Hospital, Upon Tyne, Newcastle, UK
| | - Caroline Anderson
- grid.430506.4Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - An Desloovere
- grid.410566.00000 0004 0626 3303University Hospital Ghent, Ghent, Belgium
| | - Laurence Greenbaum
- grid.428158.20000 0004 0371 6071Emory University and Children’s Healthcare of Atlanta, Atlanta, USA
| | - Dieter Haffner
- grid.10423.340000 0000 9529 9877Children’s Hospital, Hannover Medical School, Hannover, Germany
| | - Christina Nelms
- grid.24434.350000 0004 1937 0060PedsFeeds LLC, University of Nebraska, Lincoln, USA
| | - Michiel Oosterveld
- grid.414503.70000 0004 0529 2508Emma Children’s Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Fabio Paglialonga
- grid.414818.00000 0004 1757 8749Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nonnie Polderman
- grid.414137.40000 0001 0684 7788British Columbia Children’s Hospital, Vancouver, Canada
| | - José Renken-Terhaerdt
- grid.7692.a0000000090126352Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jetta Tuokkola
- grid.7737.40000 0004 0410 2071Children’s Hospital and Clinical Nutrition Unit, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Bradley Warady
- grid.239559.10000 0004 0415 5050Children’s Mercy, Kansas City, USA
| | - Johan Van de Walle
- grid.410566.00000 0004 0626 3303University Hospital Ghent, Ghent, Belgium
| | - Rukshana Shroff
- grid.83440.3b0000000121901201The Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health, University College Londonfig, WC1N 3JH, London, UK
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23
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Devarajan P, Block G, Gibson K, McKay J, Meyer C, Robinson K, Warady B, Chang A. P0066KIDNEYCODE: A GENETIC TESTING PROGRAM FOR PATIENTS WITH CHRONIC KIDNEY DISEASE. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and Aims
Knowledge about genetic causes of chronic kidney disease (CKD) is one of the key gaps in global kidney research and recent International Society of Nephrology recommendations encourage the adoption of genetic testing to enable a goal of providing precision medicine based on individual risk (1). A recent whole-exome sequencing study showed that genetic inheritance may be responsible for up to 10% of CKD diagnoses, many of which may be previously undiagnosed or mis-diagnosed (2). Continued advances in DNA sequencing technology have made genetic testing, even whole-exome sequencing, applicable to routine clinical diagnoses. In order to test the hypothesis that genetic testing can provide valuable information to increase the accuracy and precision of diagnosis in CKD, we designed a gene panel to prospectively provide genetic testing in a subset of patients with CKD defined by a specific set of inclusion criteria.
Method
Reata Pharmaceuticals is partnering with Invitae on a program called KidneyCode, which provides no-charge genetic testing to enable diagnosis of three specific rare monogenic causes of CKD: Alport syndrome (AS), autosomal dominant polycystic kidney disease (ADPKD) due to PKD2 mutations, and focal segmental glomerulosclerosis (FSGS), as well as detection of variants in one of the autosomal recessive polycystic kidney disease gene, PKHD1. Invitae’s renal disease panel includes 17 genes (ACTN4, ANLN, CD2AP, COL4A3, COL4A4, COL4A5, CRB2, HNF1A, INF2, LMX1B, MYO1E, NPHS1, NPHS2, PAX2, PKD2, PKHD1, and TRPC6), and its assay includes both full-gene sequencing and intragenic deletion/duplication analysis using next-generation sequencing (NGS). The assay targets the coding exons and flanking 10bp of intronic sequences. Invitae’s method of variant classification uses a systematic process for assessing evidence based on guidelines published by the American College of Medical Genetics (3). Patients in the US at risk for hereditary CKD (eGFR ≤ 90 mL/min/1.73m2 plus hematuria or a family history of CKD) or with a known diagnosis of AS or FSGS are eligible. Family members of those with suspected or known AS or FSGS are also eligible. All participants in the KidneyCode program have access to genetic counseling follow-up at no additional charge.
Results
In the first five months of the KidneyCode program, 152 genetic tests have been completed. A genetic variant was reported in 87 patients. Of those 87 patients, 67 patients had 75 variants in COL4A3, 4, or 5 genes (34 Pathogenic/Likely Pathogenic (P/LP), 41 Variants of Uncertain Significance (VUS)), 20 patients had 24 variants in genes associated with FSGS (3 P/LP, 21 VUS), 15 patients had 20 variants in PKHD1 (1 P/LP, 19 VUS), and 2 patients had variants in PKD2 (1 P/LP, 1 VUS).
Of the 34 patients with Pathogenic or Likely Pathogenic COL4A variants, 19 reported a previous diagnosis of Alport syndrome. Other diagnoses in patients with COL4A mutations included FSGS, thin basement membrane disease, and familial hematuria. Extra-renal manifestations such as hearing loss and eye disease were reported in 7 of the 34 patients with COL4A variants.
Conclusion
Initial results with the KidneyCode panel demonstrate the utility of NGS and support the hypothesis that combining genetic testing with clinical presentation and medical history can significantly improve accuracy and precision of diagnosis in patients with hereditary CKD.
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Affiliation(s)
- Prasad Devarajan
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, Cincinnati, United States of America
| | - Geoffrey Block
- Reata Pharmaceuticals, Clinical Development, Plano, United States of America
| | - Keisha Gibson
- University of North Carolina at Chapel Hill, Department of Medicine, United States of America
| | - Jim McKay
- Reata Pharmaceuticals, Inc., Medical Affairs, Plano, United States of America
| | - Colin Meyer
- Reata Pharmaceuticals, Product Development, Plano, United States of America
| | | | - Bradley Warady
- Children's Mercy Kansas City, Department of Nephrology, Kansas City, United States of America
| | - Alexander Chang
- Geisinger Medical Center, Department of Nephrology, Danville, United States of America
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24
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Brown EA, Boudville N, Finkelstein F, Johnson D, Liew A, Moraes T, Teitelbaum I, Warady B. Reply to letter from A Karkar. Perit Dial Int 2020; 40:427-428. [PMID: 32323625 DOI: 10.1177/0896860820920144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Edwina A Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| | - Neil Boudville
- Faculty of Medicine and Health Sciences, Medical School, University of Western Australia, Nedlands, WA, Australia.,Department of Renal Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | | | - David Johnson
- University of Queensland at Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Adrian Liew
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
| | - Thyago Moraes
- Pontificia Universidade Catolica do Parana, Curitiba, Parana, Brazil
| | - Isaac Teitelbaum
- University of Colorado School of Medicine; Home Dialysis Program, University of Colorado Hospital, Aurora, CO, USA
| | - Bradley Warady
- Department of Paediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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25
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Greenberg JH, Abraham AG, Xu Y, Schelling JR, Feldman HI, Sabbisetti VS, Gonzalez MC, Coca S, Schrauben SJ, Waikar SS, Ramachandran VS, Shlipak MG, Warady B, Kimmel PL, Bonventre JV, Denburg M, Parikh CR, Furth S. Plasma Biomarkers of Tubular Injury and Inflammation Are Associated with CKD Progression in Children. J Am Soc Nephrol 2020; 31:1067-1077. [PMID: 32234829 DOI: 10.1681/asn.2019070723] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 02/09/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND After accounting for known risk factors for CKD progression in children, clinical outcomes among children with CKD still vary substantially. Biomarkers of tubular injury (such as KIM-1), repair (such as YKL-40), or inflammation (such as MCP-1, suPAR, TNF receptor-1 [TNFR-1], and TNFR-2) may identify children with CKD at risk for GFR decline. METHODS We investigated whether plasma KIM-1, YKL-40, MCP-1, suPAR, TNFR-1, and TNFR-2 are associated with GFR decline in children with CKD and in subgroups defined by glomerular versus nonglomerular cause of CKD. We studied participants of the prospective CKiD Cohort Study which enrolled children with an eGFR of 30-90 ml/min per 1.73 m2 and then assessed eGFR annually. Biomarkers were measured in plasma collected 5 months after study enrollment. The primary endpoint was CKD progression, defined as a composite of a 50% decline in eGFR or incident ESKD. RESULTS Of the 651 children evaluated (median age 11 years; median baseline eGFR of 53 ml/min per 1.73 m2), 195 (30%) had a glomerular cause of CKD. Over a median follow-up of 5.7 years, 223 children (34%) experienced CKD progression to the composite endpoint. After multivariable adjustment, children with a plasma KIM-1, TNFR-1, or TNFR-2 concentration in the highest quartile were at significantly higher risk of CKD progression compared with children with a concentration for the respective biomarker in the lowest quartile (a 4-fold higher risk for KIM-1 and TNFR-1 and a 2-fold higher risk for TNFR-2). Plasma MCP-1, suPAR, and YKL-40 were not independently associated with progression. When stratified by glomerular versus nonglomerular etiology of CKD, effect estimates did not differ significantly. CONCLUSIONS Higher plasma KIM-1, TNFR-1, and TNFR-2 are independently associated with CKD progression in children.
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Affiliation(s)
- Jason H Greenberg
- Department of Pediatrics, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut .,Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut
| | - Alison G Abraham
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yunwen Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeffrey R Schelling
- Division of Nephrology, Department of Internal Medicine, MetroHealth Campus, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Harold I Feldman
- Department of Medicine, Clinical Center for Biostatistics and Epidemiology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Venkata S Sabbisetti
- Department of Internal Medicine, Section of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mariana Cardenas Gonzalez
- Department of Internal Medicine, Section of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Steven Coca
- Department of Internal Medicine, Section of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sarah J Schrauben
- Department of Medicine, Clinical Center for Biostatistics and Epidemiology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sushrut S Waikar
- Department of Internal Medicine, Section of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Vasan S Ramachandran
- Departments of Medicine and Epidemiology, Boston University School of Medicine, Boston, Massachusetts
| | - Michael G Shlipak
- Department of Medicine, University of California, San Francisco, California
| | - Bradley Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Paul L Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Joseph V Bonventre
- Department of Internal Medicine, Section of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michelle Denburg
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chirag R Parikh
- Department of Internal Medicine, Section of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Susan Furth
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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26
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Wasik H, CHADHA V, Galbiati S, Warady B, Atkinson M. SAT-202 DIALYSIS OUTCOMES IN CHILDREN WITH LUPUS NEPHRITIS. Kidney Int Rep 2020. [DOI: 10.1016/j.ekir.2020.02.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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27
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Shaw V, Polderman N, Renken-Terhaerdt J, Paglialonga F, Oosterveld M, Tuokkola J, Anderson C, Desloovere A, Greenbaum L, Haffner D, Nelms C, Qizalbash L, Vande Walle J, Warady B, Shroff R, Rees L. Energy and protein requirements for children with CKD stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2020; 35:519-531. [PMID: 31845057 PMCID: PMC6968982 DOI: 10.1007/s00467-019-04426-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/08/2019] [Accepted: 11/19/2019] [Indexed: 02/08/2023]
Abstract
Dietary management in pediatric chronic kidney disease (CKD) is an area fraught with uncertainties and wide variations in practice. Even in tertiary pediatric nephrology centers, expert dietetic input is often lacking. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, was established to develop clinical practice recommendations (CPRs) to address these challenges and to serve as a resource for nutritional care. We present CPRs for energy and protein requirements for children with CKD stages 2-5 and those on dialysis (CKD2-5D). We address energy requirements in the context of poor growth, obesity, and different levels of physical activity, together with the additional protein needs to compensate for dialysate losses. We describe how to achieve the dietary prescription for energy and protein using breastmilk, formulas, food, and dietary supplements, which can be incorporated into everyday practice. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgment. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT.
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Affiliation(s)
- Vanessa Shaw
- University of Plymouth, Plymouth, PL6 8BH, UK.
- University College London Institute of Child Health, London, UK.
| | | | - José Renken-Terhaerdt
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Fabio Paglialonga
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michiel Oosterveld
- Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jetta Tuokkola
- Children's Hospital and Clinical Nutrition Unit, Internal Medicine and Rehabilitation, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Caroline Anderson
- Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Dieter Haffner
- Children's Hospital, Hannover Medical School, Hannover, Germany
| | | | | | | | | | - Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- The Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health, University College London, London, UK
| | - Lesley Rees
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- The Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health, University College London, London, UK
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28
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McAlister L, Pugh P, Greenbaum L, Haffner D, Rees L, Anderson C, Desloovere A, Nelms C, Oosterveld M, Paglialonga F, Polderman N, Qizalbash L, Renken-Terhaerdt J, Tuokkola J, Warady B, Walle JV, Shaw V, Shroff R. The dietary management of calcium and phosphate in children with CKD stages 2-5 and on dialysis-clinical practice recommendation from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2020; 35:501-518. [PMID: 31667620 PMCID: PMC6969014 DOI: 10.1007/s00467-019-04370-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/01/2019] [Accepted: 09/17/2019] [Indexed: 12/19/2022]
Abstract
In children with chronic kidney disease (CKD), optimal control of bone and mineral homeostasis is essential, not only for the prevention of debilitating skeletal complications and achieving adequate growth but also for preventing vascular calcification and cardiovascular disease. Complications of mineral bone disease (MBD) are common and contribute to the high morbidity and mortality seen in children with CKD. Although several studies describe the prevalence of abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels as well as associated clinical and radiological complications and their medical management, little is known about the dietary requirements and management of calcium (Ca) and phosphate (P) in children with CKD. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists, who develop clinical practice recommendations (CPRs) for the nutritional management of various aspects of renal disease management in children. We present CPRs for the dietary intake of Ca and P in children with CKD stages 2-5 and on dialysis (CKD2-5D), describing the common Ca- and P-containing foods, the assessment of dietary Ca and P intake, requirements for Ca and P in healthy children and necessary modifications for children with CKD2-5D, and dietary management of hypo- and hypercalcemia and hyperphosphatemia. The statements have been graded, and statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. These CPRs will be regularly audited and updated by the PRNT.
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Affiliation(s)
- Louise McAlister
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK
| | - Pearl Pugh
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Dieter Haffner
- Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Lesley Rees
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK
| | - Caroline Anderson
- Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Michiel Oosterveld
- Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Fabio Paglialonga
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - José Renken-Terhaerdt
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jetta Tuokkola
- Children's Hospital and Clinical Nutrition Unit, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | - Vanessa Shaw
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK
- University of Plymouth and University College London Institute of Child Health, London, UK
| | - Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK.
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29
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Affiliation(s)
- B. Warady
- Nephrology Section The Children's Mercy Hospital 24th and Gillham Kansas City, Missouri 64108
| | - M. Kriley
- Nephrology Section The Children's Mercy Hospital 24th and Gillham Kansas City, Missouri 64108
| | - U. Alon
- Nephrology Section The Children's Mercy Hospital 24th and Gillham Kansas City, Missouri 64108
| | - S. Hellerstein
- Nephrology Section The Children's Mercy Hospital 24th and Gillham Kansas City, Missouri 64108
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30
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Affiliation(s)
- B. Warady
- The Children's Mercy Hospital 2401 Gillham Road Kansas City, Missouri 64108 U.S.A
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31
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Jacobson MH, Liu M, Wu Y, Furth S, Warady B, Trachtman H, Trasande L. Oxidant stress and renal function among children with chronic kidney disease: a repeated measures study. Sci Rep 2020; 10:3129. [PMID: 32081951 PMCID: PMC7035390 DOI: 10.1038/s41598-020-59962-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 02/03/2020] [Indexed: 02/07/2023] Open
Abstract
It is hypothesized that chronic kidney disease (CKD) induces oxidant stress which contributes to the decline in kidney function. However, few studies have incorporated longitudinal designs and no studies have investigated this association among children. Using data from the Chronic Kidney Disease in Children (CKiD) study, we examined longitudinal associations between urinary biomarkers of oxidant stress, 8-OH deoxyguanosine (8-OHdG) and F2-isoprostane, and measures of renal function and blood pressure among children with CKD. Baseline levels of 8-OHdG were positively associated with estimated glomerular filtration rate (eGFR) over time and a log-unit increase in baseline 8-OHdG predicted a 5.68 ml/min/1.73 m2 increase in eGFR (95% Confidence Interval (CI): 3.75, 7.61). This association was attenuated when longitudinal measures of 8-OHdG were analyzed in relation to longitudinal eGFR (per log-unit increase in 8-OHdG, β = 0.81, 95% CI: 0.22, 1.39). Baseline 8-OHdG concentrations were also associated with decreased proteinuria over time, as measured by urinary protein:creatinine ratio. In addition, F2-isoprostane concentrations were associated with increases in eGFR, but only when baseline levels (vs. longitudinal levels) were considered in relation to longitudinal eGFR. There were no significant associations between either 8-OHdG or F2-isoprostane and blood pressure over time. Urinary measures of oxidant stress are not associated with worsening GFR over time. Our findings suggest that excretion of these biomarkers may be influenced by changes in glomerular and tubular function in varying patterns, which would limit their value in evaluating the impact of oxidant stress on CKD progression in children.
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Affiliation(s)
- Melanie H Jacobson
- Department of Pediatrics, Division of Environmental Pediatrics, NYU Langone Medical Center, New York, NY, USA
| | - Mengling Liu
- Departments of Population Health and Environmental Medicine, NYU Langone Medical Center, New York, NY, USA
| | - Yinxiang Wu
- Departments of Population Health and Environmental Medicine, NYU Langone Medical Center, New York, NY, USA
| | - Susan Furth
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bradley Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, 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
- Departments of Population Health and Environmental Medicine, NYU Langone Medical Center, New York, NY, USA
- NYU Wagner School of Public Service, New York, NY, USA
- NYU College of Global Public Health, New York, NY, USA
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32
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Brown EA, Blake PG, Boudville N, Davies S, de Arteaga J, Dong J, Finkelstein F, Foo M, Hurst H, Johnson DW, Johnson M, Liew A, Moraes T, Perl J, Shroff R, Teitelbaum I, Wang AYM, Warady B. International Society for Peritoneal Dialysis practice recommendations: Prescribing high-quality goal-directed peritoneal dialysis. Perit Dial Int 2020; 40:244-253. [PMID: 32063219 DOI: 10.1177/0896860819895364] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- Edwina A Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| | - Peter G Blake
- Division of Nephrology, Western University London, ON, Canada
| | - Neil Boudville
- Faculty of Medicine and Health Sciences, Medical School, Sir Charles Gairdner Hospital, Department of Renal Medicine, University of Western Australia, Nedlands, Western Australia, Australia
| | - Simon Davies
- Institute for Applied Clinical Sciences, Keele University, Stoke on Trent, UK.,Renal Department, University Hospitals of North Midlands, Stoke on Trent, UK
| | - Javier de Arteaga
- Hospital Privado Universitario de Córdoba, Postgrado en Nefrologia, Universidad Católica de Córdoba Argentina, Cordoba, Argentina
| | - Jie Dong
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, China
| | | | - Marjorie Foo
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Helen Hurst
- The University of Manchester, Manchester Academic Health Science Centre, Manchester University NHS Trust, Manchester, UK
| | - David W Johnson
- University of Queensland at Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Mark Johnson
- Patient Research Group, Manchester Royal Infirmary, Manchester, UK
| | - Adrian Liew
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
| | - Thyago Moraes
- Pontificia Universidade Catolica do Parana, Curitiba, Parana, Brazil
| | - Jeff Perl
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Isaac Teitelbaum
- Home Dialysis Program, University of Colorado Hospital, Aurora, CO, USA
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Bradley Warady
- Department of Paediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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33
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Marsenic O, Rodean J, Richardson T, Swartz S, Claes D, Day JC, Warady B, Neu A. Tunneled hemodialysis catheter care practices and blood stream infection rate in children: results from the SCOPE collaborative. Pediatr Nephrol 2020; 35:135-143. [PMID: 31654224 DOI: 10.1007/s00467-019-04384-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative seeks to reduce hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) by increasing implementation of standardized HD catheter care bundles. We report HD catheter care practices and HD CA-BSI rates from SCOPE. METHODS Catheter care practices and infection events were collected prospectively during the study period, from collaborative implementation in June 2013 through May 2017. For comparative purposes, historical data, including patient demographics and HD CA-BSI events, were collected from the 12 months prior to implementation. Catheter care bundle compliance in 5 care bundle categories was monitored across the post-implementation reporting period at each center via monthly care observation forms. CA-BSI rates were calculated monthly, and reported as number of infections per 100 patient months. Changes in CA-BSI rates were assessed using generalized linear mixed model (GLMM) techniques. RESULTS Three hundred twenty-five patients with tunneled HD catheters [median (IQR) age 12 years (6, 16), M 53%, F 47%] at 15 centers were included. A total of 3996 catheter care observations over 4170 patient months were submitted with a median (IQR) 5 (2, 14) observations per patient. Overall bundle compliance was high at 87.6%, with a significant and progressive increase (p < 0.001) in compliance for 4/5 bundle categories over the 48-month study period. The adjusted CA-BSI rate significantly decreased over time from 3.3/100 patient months prior to implementation of the care bundles to 0.8/100 patient months 48 months after care bundle implementation (p < 0.001). CONCLUSIONS Using quality improvement methodology, SCOPE has demonstrated a significant increase in compliance with a majority of HD catheter care practices and a significant reduction in the rate of CA-BSI among children maintained on HD.
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MESH Headings
- Adolescent
- Catheter-Related Infections/epidemiology
- Catheter-Related Infections/etiology
- Catheterization, Central Venous/adverse effects
- Catheterization, Central Venous/instrumentation
- Catheterization, Central Venous/standards
- Catheterization, Central Venous/statistics & numerical data
- Central Venous Catheters/adverse effects
- Central Venous Catheters/standards
- Central Venous Catheters/statistics & numerical data
- Child
- Child, Preschool
- Female
- Guideline Adherence/statistics & numerical data
- Humans
- Infant
- Infant, Newborn
- Intersectoral Collaboration
- Kidney Failure, Chronic/therapy
- Male
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/organization & administration
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Program Evaluation
- Prospective Studies
- Quality Improvement/organization & administration
- Renal Dialysis/adverse effects
- Renal Dialysis/instrumentation
- Renal Dialysis/standards
- Renal Dialysis/statistics & numerical data
- Sepsis/epidemiology
- Sepsis/etiology
- Standard of Care/organization & administration
- Standard of Care/statistics & numerical data
- Young Adult
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Affiliation(s)
- Olivera Marsenic
- Pediatric Nephrology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
| | | | | | | | - Donna Claes
- Cincinnati Children's Hospital, Cincinnati, OH, USA
| | | | | | - Alicia Neu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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34
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Goldstein SL, Dahale D, Kirkendall ES, Mottes T, Kaplan H, Muething S, Askenazi DJ, Henderson T, Dill L, Somers MJG, Kerr J, Gilarde J, Zaritsky J, Bica V, Brophy PD, Misurac J, Hackbarth R, Steinke J, Mooney J, Ogrin S, Chadha V, Warady B, Ogden R, Hoebing W, Symons J, Yonekawa K, Menon S, Abrams L, Sutherland S, Weng P, Zhang F, Walsh K. A prospective multi-center quality improvement initiative (NINJA) indicates a reduction in nephrotoxic acute kidney injury in hospitalized children. Kidney Int 2019; 97:580-588. [PMID: 31980139 DOI: 10.1016/j.kint.2019.10.015] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/26/2019] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
Abstract
Nephrotoxic medication (NTMx) exposure is a common cause of acute kidney injury (AKI) in hospitalized children. The Nephrotoxic Injury Negated by Just-in time Action (NINJA) program decreased NTMx associated AKI (NTMx-AKI) by 62% at one center. To further test the program, we incorporated NINJA across nine centers with the goal of reducing NTMx exposure and, consequently, AKI rates across these centers. NINJA screens all non-critically ill hospitalized patients for high NTMx exposure (over three medications on the same day or an intravenous aminoglycoside over three consecutive days), and then recommends obtaining a daily serum creatinine level in exposed patients for the duration of, and two days after, exposure ending. Additionally, substitution of equally efficacious but less nephrotoxic medications for exposed patients starting the day of exposure was recommended when possible. The main outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) serum creatinine criteria (increase of 50% or 0.3 mg/dl over baseline). The primary outcome measure was AKI episodes per 1000 patient-days. Improvement was defined by statistical process control methodology and confirmed by Autoregressive Integrated Moving Average (ARIMA) modeling. Eight consecutive bi-weekly measure rates in the same direction from the established baseline qualified as special cause change for special process control. We observed a significant and sustained 23.8% decrease in NTMx-AKI rates by statistical process control analysis and by ARIMA modeling; similar to those of the pilot single center. Thus, we have successfully applied the NINJA program to multiple pediatric institutions yielding decreased AKI rates.
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Affiliation(s)
- Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| | - Devesh Dahale
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Eric S Kirkendall
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Theresa Mottes
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Heather Kaplan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stephen Muething
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David J Askenazi
- Division of Nephrology, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | - Traci Henderson
- Division of Nephrology, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | - Lynn Dill
- Division of Nephrology, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | | | - Jessica Kerr
- Division of Nephrology, Children's Hospital, Boston, Massachusetts, USA
| | - Jennifer Gilarde
- Division of Nephrology, Children's Hospital, Boston, Massachusetts, USA
| | - Joshua Zaritsky
- Division of Nephrology, A.I. Dupont Children's Hospital, Wilmington, Delaware, USA
| | - Valerie Bica
- Division of Nephrology, A.I. Dupont Children's Hospital, Wilmington, Delaware, USA
| | - Patrick D Brophy
- Division of Nephrology, Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Jason Misurac
- Division of Nephrology, Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Richard Hackbarth
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Julia Steinke
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Joann Mooney
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Sara Ogrin
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Vimal Chadha
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Bradley Warady
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Richard Ogden
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Wendy Hoebing
- Division of Nephrology, Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - Jordan Symons
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Karyn Yonekawa
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Shina Menon
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Lisa Abrams
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Scott Sutherland
- Division of Nephrology, Lucille Packard Stanford Children's Hospital, Palo Alto, California, USA
| | - Patricia Weng
- Division of Nephrology, Mattel Children's Hospital, Los Angeles, California, USA
| | - Fang Zhang
- Division of Biostatistics, Harvard Medical School, Boston, Massachusetts, USA; Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Kathleen Walsh
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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35
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Knebelmann B, Appel G, Block G, Chin M, Goldsberry A, Inker L, Kashtan C, Meyer C, Nozu K, Pergola P, Rastogi A, Rheault M, Silva A, Sprague S, Warady B, Gross O. FP179BASELINE CHARACTERISTICS IN THE “CARDINAL” TRIAL: A PHASE 3 STUDY OF THE EFFICACY AND SAFETY OF BARDOXOLONE METHYL IN PATIENTS WITH ALPORT SYNDROME. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz106.fp179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Gerald Appel
- Columbia University College of Physicians and Surgeons, New York, United States of America
| | - Geoffrey Block
- Reata Pharmaceuticals, Inc., Irving, United States of America
| | - Melanie Chin
- Reata Pharmaceuticals, Inc., Irving, United States of America
| | | | - Lesley Inker
- Tufts University, Boston, United States of America
| | | | - Colin Meyer
- Reata Pharmaceuticals, Inc., Irving, United States of America
| | - Kandai Nozu
- Kobe University Graduate School of Medicine, Kobe, Japan
| | - Pablo Pergola
- Renal Associates, San Antonio, United States of America
| | - Anjay Rastogi
- University of California, Los Angeles, Los Angeles, United States of America
| | | | - Arnold Silva
- Boise Kidney & Hypertension Institute, Meridian, United States of America
| | - Stuart Sprague
- NorthShore University HealthSystem, Evanston, United States of America
| | - Bradley Warady
- University of Missour-Kansas City School of Medicine, Kansas City, United States of America
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36
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Warady B, Gross C, Ono R, Li L, Schulmann T. SP778IN VITRO BINDING POTENTIAL BETWEEN PATIROMER AND TWO IMMUNOSUPPRESSANT DRUGS. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz103.sp778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bradley Warady
- School of Medicine, Unviersity of Missouri-Kansas City, Kansas City, United States of America
| | - Coleman Gross
- Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, United States of America
| | - Reyn Ono
- Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, United States of America
| | - Lingyun Li
- Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, United States of America
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37
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Brooks ER, Lin DC, Langman CB, Thompson JW, St John-Williams L, Furth SL, Warady B, Haymond S. Metabolomic Patterns in Adolescents With Mild to Moderate CKD. Kidney Int Rep 2019; 4:720-723. [PMID: 31080927 PMCID: PMC6506724 DOI: 10.1016/j.ekir.2019.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 12/26/2018] [Accepted: 01/14/2019] [Indexed: 11/21/2022] Open
Affiliation(s)
- Ellen R Brooks
- Division of Kidney Diseases, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David C Lin
- Department of Pathology and Laboratory Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pathology, Northwestern University Feinberg School of Medicine Chicago, Illinois, USA
| | - Craig B Langman
- Division of Kidney Diseases, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - J Will Thompson
- Proteomics and Metabolomics Shared Resource, Center for Genomics and Computational Biology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa St John-Williams
- Proteomics and Metabolomics Shared Resource, Center for Genomics and Computational Biology, Duke University Medical Center, Durham, North Carolina, USA
| | - Susan L Furth
- Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bradley Warady
- Division of Pediatric Nephrology, The Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Shannon Haymond
- Department of Pathology and Laboratory Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pathology, Northwestern University Feinberg School of Medicine Chicago, Illinois, USA
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38
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Brady TM, Roem J, Cox C, Schneider M, Wilson A, Furth S, Warady B, Mitsnefes M. Abstract P393: Sex Modifies the Longitudinal Association of Adiposity With Left Ventricular Hypertrophy Among Children With Chronic Kidney Disease. Hypertension 2018. [DOI: 10.1161/hyp.72.suppl_1.p393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
Adiposity, not blood pressure (BP), is associated with left ventricular hypertrophy (LVH) among hypertensive children without chronic kidney disease (CKD). We aimed to determine the longitudinal association of BMI z-score with LVH and left ventricular mass index (LVMI) among children with CKD.
Methods:
696 participants of the Chronic Kidney Disease in Children study with echocardiography results who contributed a total of 1,300 visits were included. Mixed models, adjusting for repeated visits with a random subject effect, were used to determine the longitudinal association of body mass index (BMI) z-score with LVMI and LVH (LVMI> age-sex specific 95
th
%ile). Models were adjusted for age, sex, race, systolic and diastolic BP z-score, glomerular diagnosis, time with CKD, glomerular filtration rate and calcium*phosphorus product and accounted for informative censoring.
Results:
Baseline characteristics are in the table. Among females, a 1 unit increase in BMI z-score was associated with an 8.5% increase in LVMI and 3.4 greater odds of LVH, whereas with boys, a 1 unit increase in BMI z-score was associated with a 5.2% increase in LVMI and a 1.4 greater odds of LVH (p<0.05 for all).
Conclusions:
Among children with mild-moderate CKD, adiposity is independently associated with LVMI and LVH over time. This association is greater among females, a finding that may have future clinical and research implications.
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Affiliation(s)
| | | | | | | | - Amy Wilson
- J.W. Riley Hosp for Children, Indianapolis, IN
| | - Susan Furth
- Children's Hosp of Philadelphia, Philadelphia, PA
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39
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Sgambat K, Roem J, Mitsnefes M, Portale AA, Furth S, Warady B, Moudgil A. Waist-to-height ratio, body mass index, and cardiovascular risk profile in children with chronic kidney disease. Pediatr Nephrol 2018; 33:1577-1583. [PMID: 29872963 PMCID: PMC6281775 DOI: 10.1007/s00467-018-3987-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 05/10/2018] [Accepted: 05/21/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cardiovascular (CV) risk is high in children with chronic kidney disease (CKD), and further compounded in those who are overweight. Children with CKD have a unique body habitus not accurately assessed by body mass index (BMI). Waist-to-height ratio (WHr), a better predictor of CV risk in populations with short stature, has not been investigated in children with CKD. METHODS Analysis of 1723 visits of 593 participants enrolled in the Chronic Kidney Disease in Children (CKiD) study was conducted. CKiD participants had BMI and WHr measured and classified as follows: (1) lean (WHr ≤ 0.49, BMI < 85th percentile); (2) WHr-overweight (WHr > 0.49, BMI < 85th percentile); (3) BMI-overweight (WHr ≤ 0.49, BMI ≥ 85th percentile); or (4) overweight by both BMI and WHr. Left ventricular mass index (LVMI), fasting lipids, fibroblast growth factor 23 (FGF23), blood pressure, and glucose were measured as markers of CV risk. Linear mixed-effects regression was used to evaluate differences in CV markers between overweight and lean groups. RESULTS Participants were 12.2 years old, 60% male, and 17% African-American. Approximately 15% were overweight by WHr but not by BMI. Overweight status by WHr-only or both WHr and BMI was associated with lower high-density lipoprotein (HDL) and higher LVMI, triglycerides, and non-HDL cholesterol compared to lean. CV markers of participants overweight by BMI-only were similar to those of lean children. CONCLUSIONS WHr-adiposity is associated with an adverse CV risk profile in children with CKD. A significant proportion of children with central adiposity are missed by BMI. WHr should be utilized as a screening tool for CV risk in this population.
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Affiliation(s)
- Kristen Sgambat
- Department of Nephrology, Children's National Health System, 111 Michigan Avenue NW, Washington, DC, 20010, USA.
| | - Jennifer Roem
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mark Mitsnefes
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Susan Furth
- The Children's Hospital of Philadelphia, Department of Pediatrics, Philadelphia, PA, USA
| | | | - Asha Moudgil
- Department of Nephrology, Children's National Health System, 111 Michigan Avenue NW, Washington, DC, 20010, USA
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40
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Gross O, Appel G, Block G, Chin M, Goldsberry A, Inker L, Meyer C, Pergola P, Simon J, Warady B, Zaoui P, Rheault M, Kashtan C. SP121A PHASE 2/3 STUDY OF THE EFFICACY AND SAFETY OF BARDOXOLONE METHYL IN PATIENTS WITH ALPORT SYNDROME. Nephrol Dial Transplant 2018. [DOI: 10.1093/ndt/gfy104.sp121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Oliver Gross
- Nephrology and Rheumatology, University Medicine Goettingen, Goettingen, Germany
| | - Gerald Appel
- Glomerular Kidney Disease Center, Columbia University Medical Center, New York, NY, United States
| | | | - Melanie Chin
- Product Development, Reata Pharmaceuticals, Irving, TX, United States
| | - Angie Goldsberry
- Product Development, Reata Pharmaceuticals, Irving, TX, United States
| | - Lesley Inker
- Department of Medicine, Tufts Medical Center, Boston, MA, United States
| | - Colin Meyer
- Product Development, Reata Pharmaceuticals, Irving, TX, United States
| | | | - James Simon
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, United States
| | - Bradley Warady
- Division of Nephrology, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Phillip Zaoui
- Nephrology Clinic, CHU Grenoble Alpes, Grenoble, France
| | - Michelle Rheault
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Clifford Kashtan
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
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41
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Thumfart J, Müller D, Wagner S, Jayanti A, Borzych-Duzalka D, Schaefer F, Warady B, Schmitt CP. Barriers for implementation of intensified hemodialysis: survey results from the International Pediatric Dialysis Network. Pediatr Nephrol 2018; 33:705-712. [PMID: 29103152 DOI: 10.1007/s00467-017-3831-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/20/2017] [Accepted: 10/13/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients on conventional hemodialysis (HD), morbidity is high and quality of life is poor. Intensified HD programs have been developed to help overcome these shortcomings, , but very few pediatric dialysis centers have reported the implementation of such a HD program. METHODS An online survey was sent to all 221 pediatric dialysis centers which participate in the International Pediatric Dialysis Network (IPDN). The aim of the survey was to assess the attitude of pediatric nephrologists towards intensified HD, the penetrance of intensified HD into their clinical practice and barriers to implementation. RESULTS Of the 221 pediatric dialysis centers sent the survey, respondents from 61% (134) replied. Among these respondents, 69% acknowledged being aware of the evidence in support of the use of intensified HD, independent of whether intensified HD was offered at their own center, and 50% associated the use of daily nocturnal HD with the best overall patient outcome. In contrast, only 2% of respondents were in favor of conventional HD. Overall, 38% of the respondents stated that at their center intensified HD is prescribed to a subgroup of patients, most commonly in the form of short daily HD sessions. The most important barriers to expansion of intensified HD programs were lack of adequate funding (66%) and shortage of staff (63%), whereas lack of expertise and of motivation were reported infrequently as obstacles (21 and 14%, respectively). CONCLUSION Intensified HD is considered by many pediatric nephrologists to be the dialysis modality most likely associated with the best patient outcome. The limited use of this treatment approach highlights the importance of defining and successfully addressing the barriers to implementation.
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Affiliation(s)
- Julia Thumfart
- Department of Pediatric Nephrology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Dominik Müller
- Department of Pediatric Nephrology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | | | - Anuradha Jayanti
- Manchester Institute of Nephrology & Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Dagmara Borzych-Duzalka
- Department Pediatrics, Nephrology & Hypertension, Medical University of Gdansk, Gdansk, Poland
| | - Franz Schaefer
- Department of Pediatric Nephrology, University Hospital for Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Claus Peter Schmitt
- Department of Pediatric Nephrology, University Hospital for Pediatric and Adolescent Medicine, Heidelberg, Germany
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42
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Chen W, Ducharme-Smith K, Davis L, Hui AWF, Warady B, Furth SL, Abraham AG, Betoko A. Dietary sources of energy and nutrient intake among children and adolescents with chronic kidney disease. Pediatr Nephrol 2017; 32:1233-1241. [PMID: 28210840 PMCID: PMC5633852 DOI: 10.1007/s00467-017-3580-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 12/19/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Our purpose was to identify the main food contributors to energy and nutrient intake in children with chronic kidney disease (CKD). METHODS In this cross-sectional study of dietary intake assessed using Food Frequency Questionnaires (FFQ) in the Chronic Kidney Disease in Children (CKiD) cohort study, we estimated energy and nutrient intake and identified the primary contributing foods within this population. RESULTS Completed FFQs were available for 658 children. Of those, 69.9% were boys, median age 12 (interquartile range (IQR) 8-15 years). The average daily energy intake was 1968 kcal (IQR 1523-2574 kcal). Milk was the largest contributor to total energy, protein, potassium, and phosphorus intake. Fast foods were the largest contributors to fat and sodium intake, the second largest contributors to energy intake, and the third largest contributors to potassium and phosphorus intake. Fruit contributed 12.0%, 8.7%, and 6.7% to potassium intake for children aged 2-5, 6-13, and 14-18 years old, respectively. CONCLUSIONS Children with CKD consumed more sodium, protein, and calories but less potassium than recommended by the National Kidney Foundation (NKF) guidelines for pediatric CKD. Energy, protein, and sodium intake is heavily driven by consumption of milk and fast foods. Limiting contribution of fast foods in patients with good appetite may be particularly important for maintaining recommended energy and sodium intake, as overconsumption can increase the risk of obesity and cardiovascular complications in that population.
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Affiliation(s)
- Wen Chen
- Department of Nutrition and Food Hygiene, School of Public health, Tianjin Medical University, Tianjin, China,Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, MO
| | | | | | - Alvin Wun Fung Hui
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Bradley Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, MO
| | - Susan L. Furth
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alison G Abraham
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD,Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Aisha Betoko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
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43
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Savant JD, Betoko A, Meyers KEC, Mitsnefes M, Flynn JT, Townsend RR, Greenbaum LA, Dart A, Warady B, Furth SL. Vascular Stiffness in Children With Chronic Kidney Disease. Hypertension 2017; 69:863-869. [PMID: 28373588 DOI: 10.1161/hypertensionaha.116.07653] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 11/12/2016] [Accepted: 02/08/2017] [Indexed: 12/30/2022]
Abstract
Carotid-femoral pulse wave velocity (cfPWV) is a measure of arterial stiffness associated with cardiovascular events in the general population and in adults with chronic kidney disease. However, few data exist regarding cfPWV in children with chronic kidney disease. We compared observed cfPWV assessed via applanation tonometry in children enrolled in the CKiD cohort study (Chronic Kidney Disease in Children) to normative data in healthy children and examined risk factors associated with elevated cfPWV. cfPWV Z score for height/gender and age/gender was calculated from and compared with published pediatric norms. Multivariable linear regression was used to assess the relationship between cfPWV and age, gender, race, body mass index, diagnosis, urine protein-creatinine ratio, mean arterial pressure, heart rate, number of antihypertensive medications, uric acid, and serum low-density lipoprotein. Of the 95 participants with measured cfPWV, 60% were male, 19% were black, 46% had glomerular cause of chronic kidney disease, 22% had urine protein-creatinine ratio 0.5 to 2.0 mg/mg and 9% had >2.0 mg/mg, mean age was 15.1 years, average mean arterial pressure was 80 mm Hg, and median glomerular filtration rate was 63 mL/min per 1.73 m2 Mean cfPWV was 5.0 m/s (SD, 0.8 m/s); mean cfPWV Z score by height/gender norms was -0.1 (SD, 1.1). cfPWV increased significantly with age, mean arterial pressure, and black race in multivariable analysis; no other variables, including glomerular filtration rate, were independently associated with cfPWV. In this pediatric cohort with mild kidney dysfunction, arterial stiffness was comparable to that of normal children. Future research is needed to examine the impact of chronic kidney disease progression on arterial stiffness and associated cardiovascular parameters in children.
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Affiliation(s)
- Jonathan D Savant
- From the Department of Pediatrics, The Children's Hospital of Philadelphia, PA (J.D.S., K.E.C.M., S.L.F.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (A.B.); Perelman School of Medicine at the University of Pennsylvania, Philadelphia (K.E.C.M., R.R.T., S.L.F.); Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.); Division of Nephrology, Seattle Children's Hospital, WA (J.T.F.); Emory University and Children's Healthcare of Atlanta, GA (L.A.G.); Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada (A.D.); and Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO (B.W.)
| | - Aisha Betoko
- From the Department of Pediatrics, The Children's Hospital of Philadelphia, PA (J.D.S., K.E.C.M., S.L.F.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (A.B.); Perelman School of Medicine at the University of Pennsylvania, Philadelphia (K.E.C.M., R.R.T., S.L.F.); Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.); Division of Nephrology, Seattle Children's Hospital, WA (J.T.F.); Emory University and Children's Healthcare of Atlanta, GA (L.A.G.); Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada (A.D.); and Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO (B.W.)
| | - Kevin E C Meyers
- From the Department of Pediatrics, The Children's Hospital of Philadelphia, PA (J.D.S., K.E.C.M., S.L.F.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (A.B.); Perelman School of Medicine at the University of Pennsylvania, Philadelphia (K.E.C.M., R.R.T., S.L.F.); Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.); Division of Nephrology, Seattle Children's Hospital, WA (J.T.F.); Emory University and Children's Healthcare of Atlanta, GA (L.A.G.); Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada (A.D.); and Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO (B.W.)
| | - Mark Mitsnefes
- From the Department of Pediatrics, The Children's Hospital of Philadelphia, PA (J.D.S., K.E.C.M., S.L.F.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (A.B.); Perelman School of Medicine at the University of Pennsylvania, Philadelphia (K.E.C.M., R.R.T., S.L.F.); Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.); Division of Nephrology, Seattle Children's Hospital, WA (J.T.F.); Emory University and Children's Healthcare of Atlanta, GA (L.A.G.); Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada (A.D.); and Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO (B.W.)
| | - Joseph T Flynn
- From the Department of Pediatrics, The Children's Hospital of Philadelphia, PA (J.D.S., K.E.C.M., S.L.F.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (A.B.); Perelman School of Medicine at the University of Pennsylvania, Philadelphia (K.E.C.M., R.R.T., S.L.F.); Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.); Division of Nephrology, Seattle Children's Hospital, WA (J.T.F.); Emory University and Children's Healthcare of Atlanta, GA (L.A.G.); Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada (A.D.); and Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO (B.W.)
| | - Raymond R Townsend
- From the Department of Pediatrics, The Children's Hospital of Philadelphia, PA (J.D.S., K.E.C.M., S.L.F.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (A.B.); Perelman School of Medicine at the University of Pennsylvania, Philadelphia (K.E.C.M., R.R.T., S.L.F.); Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.); Division of Nephrology, Seattle Children's Hospital, WA (J.T.F.); Emory University and Children's Healthcare of Atlanta, GA (L.A.G.); Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada (A.D.); and Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO (B.W.)
| | - Larry A Greenbaum
- From the Department of Pediatrics, The Children's Hospital of Philadelphia, PA (J.D.S., K.E.C.M., S.L.F.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (A.B.); Perelman School of Medicine at the University of Pennsylvania, Philadelphia (K.E.C.M., R.R.T., S.L.F.); Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.); Division of Nephrology, Seattle Children's Hospital, WA (J.T.F.); Emory University and Children's Healthcare of Atlanta, GA (L.A.G.); Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada (A.D.); and Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO (B.W.)
| | - Allison Dart
- From the Department of Pediatrics, The Children's Hospital of Philadelphia, PA (J.D.S., K.E.C.M., S.L.F.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (A.B.); Perelman School of Medicine at the University of Pennsylvania, Philadelphia (K.E.C.M., R.R.T., S.L.F.); Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.); Division of Nephrology, Seattle Children's Hospital, WA (J.T.F.); Emory University and Children's Healthcare of Atlanta, GA (L.A.G.); Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada (A.D.); and Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO (B.W.)
| | - Bradley Warady
- From the Department of Pediatrics, The Children's Hospital of Philadelphia, PA (J.D.S., K.E.C.M., S.L.F.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (A.B.); Perelman School of Medicine at the University of Pennsylvania, Philadelphia (K.E.C.M., R.R.T., S.L.F.); Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.); Division of Nephrology, Seattle Children's Hospital, WA (J.T.F.); Emory University and Children's Healthcare of Atlanta, GA (L.A.G.); Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada (A.D.); and Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO (B.W.)
| | - Susan L Furth
- From the Department of Pediatrics, The Children's Hospital of Philadelphia, PA (J.D.S., K.E.C.M., S.L.F.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (A.B.); Perelman School of Medicine at the University of Pennsylvania, Philadelphia (K.E.C.M., R.R.T., S.L.F.); Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.); Division of Nephrology, Seattle Children's Hospital, WA (J.T.F.); Emory University and Children's Healthcare of Atlanta, GA (L.A.G.); Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada (A.D.); and Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO (B.W.).
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Hui WF, Betoko A, Savant JD, Abraham AG, Greenbaum LA, Warady B, Moxey-Mims MM, Furth SL. Assessment of dietary intake of children with chronic kidney disease. Pediatr Nephrol 2017; 32:485-494. [PMID: 27687620 PMCID: PMC5642285 DOI: 10.1007/s00467-016-3491-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 07/31/2016] [Accepted: 08/04/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Our aim was to characterize the nutrient intake of children with chronic kidney disease (CKD) relative to recommended intake levels. METHODS We conducted a cross-sectional study of dietary intake assessed by Food Frequency Questionnaire (FFQ) in The North American Chronic Kidney Disease in Children (CKiD) prospective cohort study. Nutrient intake was analyzed to estimate the daily consumption levels of various nutrients and compared with national guidelines for intake. RESULTS There were 658 FFQs available for analysis; 69.9 % of respondents were boys, with a median age [Interquartile range (IQR)] of 11 years (8-15). Median daily sodium, potassium, and phosphorus intake was 3089 mg (2294-4243), 2384 mg (1804-3076), and 1206 mg (894-1612) respectively. Sodium and phosphorus consumptions were higher than recommended in all age groups. Caloric intake decreased with dropping glomerular filtration rate (GFR) (p = 0.003). The median daily caloric intakes were 1307 kcal in male children 2-3 years old, 1875 kcal in children 4-8 years old, 1923 kcal in those 9-13 years old, and 2427 kcal in those 14-18 years old. Respective levels for girls were 1467 kcal, 1736 kcal, 1803 kcal, and 2281 kcal. Median protein intake exceeded recommended levels in all age groups, particularly among younger participants. Younger children were more likely than older children to exceed the recommended intakes for phosphorus (p < 0.001) and the age-specific recommended caloric intake (p < 0.001). Macronutrient distribution (carbohydrate:fat:protein) was consistent with recommendation. CONCLUSIONS Children in the CKiD cohort consumed more sodium, phosphorus, protein, and calories than recommended. The gap between actual consumption and recommendations indicates a need for improved nutritional counseling and monitoring.
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Affiliation(s)
- Wun Fung Hui
- Department of Pediatrics, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Aisha Betoko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jonathan D Savant
- Department of Pediatrics, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Alison G Abraham
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Larry A Greenbaum
- Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Marva M Moxey-Mims
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Susan L Furth
- Department of Pediatrics, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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Brady TM, Townsend K, Schneider MF, Cox C, Kimball T, Madueme P, Warady B, Furth S, Mitsnefes M. Cystatin C and Cardiac Measures in Children and Adolescents With CKD. Am J Kidney Dis 2016; 69:247-256. [PMID: 27856090 DOI: 10.1053/j.ajkd.2016.08.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 08/17/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is highly prevalent among children with chronic kidney disease (CKD). Cystatin C is an established marker of kidney function and an emerging biomarker for CVD events. We quantified the relationship between cystatin C level and cardiac structure and function over time among children with CKD and assessed whether cystatin C level and diastolic function retained an association after accounting for kidney function. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 678 children and adolescents with mild to moderate CKD enrolled in the CKD in Children (CKiD) Study with 1,228 echocardiographically obtained cardiac structure and function measurements. PREDICTOR Serum cystatin C (mg/L) measured annually. OUTCOMES Cardiac structure (left ventricular mass index [g/m2.7]) and cardiac function (shortening fraction; E/A, E'/A', E/E' ratios) measured every other year. MEASUREMENTS Demographics and anthropometrics, measured glomerular filtration rate (mGFR), heart rate, blood pressure, hemoglobin z score, serum albumin level, and calcium-phosphorus product. RESULTS Independent of time, each 1-mg/L increase in cystatin C level was independently associated with a concurrent 7.7% (95% CI, 5.3%-10.0%) increase in left ventricular mass index, a -4.7% (95% CI, -7.0% to -2.4%) change in E/A ratio, a -6.6% (95% CI, -9.0% to -4.2%) change in E'/A' ratio, and a 2.5% (95% CI, 0.3%-4.7%) increase in E/E' ratio. mGFR was also independently associated with E'/A' ratio. When cystatin C level and mGFR were included in the same model, cystatin C level remained independently associated with E'/A' ratio, whereas mGFR was not. LIMITATIONS 24% of the cohort was missing data for outcomes of interest or measurements; study population includes only children and adolescents with mild to moderate CKD. CONCLUSIONS In this study of children and adolescents with mild to moderate CKD, cystatin C level was independently associated with cardiac structure and diastolic function. Cystatin C level remained able to predict diastolic function decline via E'/A' ratio even after adjusting for mGFR, suggesting that cystatin C level may have an independent role in CVD risk stratification among children and adolescents with CKD.
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Affiliation(s)
- Tammy M Brady
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Kelly Townsend
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michael F Schneider
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Christopher Cox
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Thomas Kimball
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Peace Madueme
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO
| | - Susan Furth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Ruebner RL, Ng D, Mitsnefes M, Foster BJ, Meyers K, Warady B, Furth SL. Cardiovascular Disease Risk Factors and Left Ventricular Hypertrophy in Girls and Boys With CKD. Clin J Am Soc Nephrol 2016; 11:1962-1968. [PMID: 27630183 PMCID: PMC5108185 DOI: 10.2215/cjn.01270216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 07/22/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Prior studies suggested that women with CKD have higher risk for cardiovascular disease (CVD) and mortality than men, although putative mechanisms for this higher risk have not been identified. We assessed sex differences in (1) CVD risk factors and left ventricular hypertrophy (LVH), and (2) the relationship of left ventricular mass (LVM) with different measures of body size in children with CKD. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS The study population comprised 681 children with CKD from the Chronic Kidney Disease in Children cohort, contributing 1330 visits. CVD risk factors were compared cross-sectionally by sex. LVH was defined as LVM/height2.7 >95th percentile and LVM relative to estimated lean body mass (eLBM) >95th percentile for age and sex. Differences in LVM by sex were assessed by adjusting for age, weight, height, and eLBM using bivariate and multivariate regression models. RESULTS Girls were less likely to have uncontrolled hypertension (26% versus 38%, P=0.001), had lower diastolic BP z-scores (+0.3 versus +0.6, P=0.001), and had lower prevalence of high triglycerides (38% versus 47%, P=0.03) compared with boys. When LVH was defined by LVM indexed to height, girls had higher prevalence of LVH (16% versus 9%, P=0.01); when LVH was defined by LVM relative to eLBM, prevalence of LVH was similar between girls and boys (18% versus 17%, P=0.92). In regression models adjusting for eLBM, no sex differences in LVM were observed. CONCLUSIONS Despite lack of increased prevalence of CVD risk factors, indexing LVM to height showed a higher proportion of LVH among girls, while estimates of LVH based on eLBM showed no sex differences. Indexing LVM to eLBM may be an alternative to height indexing in children with CKD.
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Affiliation(s)
| | - Derek Ng
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Mark Mitsnefes
- Division of Nephrology, Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Bethany J. Foster
- Department of Pediatrics, Montreal Children’s Hospital, Montreal, Quebec, Canada
| | - Kevin Meyers
- Division of Nephrology, Department of Pediatrics, Children’s Hospital of Philadelphia, and
| | - Bradley Warady
- Division of Nephrology, Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | - Susan L. Furth
- Division of Nephrology, Department of Pediatrics, Children’s Hospital of Philadelphia, and
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania; and
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Wong C, Gerson A, Hooper SR, Matheson M, Lande M, Kupferman J, Furth S, Warady B, Flynn J. Effect of elevated blood pressure on quality of life in children with chronic kidney disease. Pediatr Nephrol 2016; 31:1129-36. [PMID: 26857712 PMCID: PMC5634383 DOI: 10.1007/s00467-015-3262-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 10/28/2015] [Accepted: 10/30/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although hypertension is known to have an adverse impact on health-related quality of life (HRQoL) in adults, little is known about the effects of hypertension and use of antihypertensive medications on HRQoL in hypertensive children with chronic kidney disease (CKD). METHODS Cross-sectional and longitudinal assessment of impact of elevated blood pressure (BP) and antihypertensive medication use on HRQoL scores obtained in children enrolled in the Chronic Kidney Disease in Children (CKiD) Study. Blood pressure was measured both manually and by ambulatory blood pressure monitoring. HRQoL was assessed with the PedsQL survey. RESULTS The study sample included 551 participants with sufficient data for cross-sectional and longitudinal analyses. Cross-sectional analysis of presence of prehypertension or hypertension and impact on HRQoL found mild associations between elevated BP and HRQoL scores with overall PedsQL parent and child scores averaging 79 vs. 76.5 and 83 vs. 78.5, respectively. However, no associations persisted under longitudinal multivariate analysis. CONCLUSIONS Despite apparent small effects of elevated BP on HRQoL at baseline, no association was found between the presence of elevated BP and HRQoL over time in children with mild-to-moderate CKD. In addition, antihypertensive medication use did not appear to have an impact on HRQoL in this population.
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Affiliation(s)
- Cynthia Wong
- Division of Pediatric Nephrology, Stanford University, 300 Pasteur Drive, Stanford, CA, 94305, USA.
| | - Arlene Gerson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen R Hooper
- Department of Allied Health Sciences, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Matthew Matheson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marc Lande
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Juan Kupferman
- Division of Pediatric Nephrology and Hypertension, Maimonides Medical Center, Brooklyn, NY, USA
| | - Susan Furth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bradley Warady
- Division of Nephrology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Joseph Flynn
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA
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Rasu RS, Bawa WA, Suminski R, Snella K, Warady B. Health Literacy Impact on National Healthcare Utilization and Expenditure. Int J Health Policy Manag 2015; 4:747-55. [PMID: 26673335 DOI: 10.15171/ijhpm.2015.151] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 08/10/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Health literacy presents an enormous challenge in the delivery of effective healthcare and quality outcomes. We evaluated the impact of low health literacy (LHL) on healthcare utilization and healthcare expenditure. METHODS Database analysis used Medical Expenditure Panel Survey (MEPS) from 2005-2008 which provides nationally representative estimates of healthcare utilization and expenditure. Health literacy scores (HLSs) were calculated based on a validated, predictive model and were scored according to the National Assessment of Adult Literacy (NAAL). HLS ranged from 0-500. Health literacy level (HLL) and categorized in 2 groups: Below basic or basic (HLS <226) and above basic (HLS ≥226). Healthcare utilization expressed as a physician, nonphysician, or emergency room (ER) visits and healthcare spending. Expenditures were adjusted to 2010 rates using the Consumer Price Index (CPI). A P value of 0.05 or less was the criterion for statistical significance in all analyses. Multivariate regression models assessed the impact of the predicted HLLs on outpatient healthcare utilization and expenditures. All analyses were performed with SAS and STATA® 11.0 statistical software. RESULTS The study evaluated 22 599 samples representing 503 374 648 weighted individuals nationally from 2005-2008. The cohort had an average age of 49 years and included more females (57%). Caucasian were the predominant racial ethnic group (83%) and 37% of the cohort were from the South region of the United States of America. The proportion of the cohort with basic or below basic health literacy was 22.4%. Annual predicted values of physician visits, nonphysician visits, and ER visits were 6.6, 4.8, and 0.2, respectively, for basic or below basic compared to 4.4, 2.6, and 0.1 for above basic. Predicted values of office and ER visits expenditures were $1284 and $151, respectively, for basic or below basic and $719 and $100 for above basic (P < .05). The extrapolated national estimates show that the annual costs for prescription alone for adults with LHL possibly associated with basic and below basic health literacy could potentially reach about $172 billion. CONCLUSION Health literacy is inversely associated with healthcare utilization and expenditure. Individuals with below basic or basic HLL have greater healthcare utilization and expendituresspending more on prescriptions compared to individuals with above basic HLL. Public health strategies promoting appropriate education among individuals with LHL may help to improve health outcomes and reduce unnecessary healthcare visits and costs.
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Affiliation(s)
- Rafia S Rasu
- University of Kansas School of Pharmacy, Lawrence, KS, USA
| | | | - Richard Suminski
- Institute for Biobehavioral Health Research, National Development and Research Institutes (NDRI) New York, NY and Leawood, KS, USA
| | - Kathleen Snella
- Ben and Maytee Fisch College of Pharmacy, University of Texas at Tyler, Tyler, TX, USA
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Cullis B, Abdelraheem M, Abrahams G, Balbi A, Cruz DN, Frishberg Y, Koch V, McCulloch M, Numanoglu A, Nourse P, Pecoits-Filho R, Ponce D, Warady B, Yeates K, Finkelstein FO. Peritoneal dialysis for acute kidney injury. Perit Dial Int 2015; 34:494-517. [PMID: 25074995 DOI: 10.3747/pdi.2013.00222] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Brett Cullis
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USARenal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, U
| | - Mohamed Abdelraheem
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Georgi Abrahams
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Andre Balbi
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Dinna N Cruz
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Yaacov Frishberg
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Vera Koch
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Mignon McCulloch
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Alp Numanoglu
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Peter Nourse
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Roberto Pecoits-Filho
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Daniela Ponce
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Bradley Warady
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Karen Yeates
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
| | - Fredric O Finkelstein
- Renal Unit, Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units, Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit, Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission, Chennai, India; Department of Medicine, Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension, University of California, San Diego, USA; Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit, Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology, Queen's University, Kingston, Canada; and Yale University, New Haven, USA
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Nehus E, Furth S, Warady B, Mitsnefes M. Correlates of leptin in children with chronic kidney disease. J Pediatr 2014; 165:825-9. [PMID: 25066063 PMCID: PMC4177449 DOI: 10.1016/j.jpeds.2014.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 05/27/2014] [Accepted: 06/10/2014] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate the relative associations of renal function, obesity, and inflammation with serum leptin levels in children with chronic kidney disease (CKD). STUDY DESIGN This was a cross-sectional analysis of 317 children from the Chronic Kidney Disease in Children study, a large cohort of pediatric patients with stage II-IV CKD. Linear regression modeling was used to evaluate the association of serum leptin level with glomerular filtration rate calculated using the plasma iohexol disappearance curve, demographics, body mass index (BMI), and cardiovascular risk factors, including inflammatory cytokines, insulin resistance, and serum lipid levels. RESULTS In univariate analyses, elevated serum leptin level was significantly associated with increased BMI, older age, and female sex (P < .001 for all). Leptin level also correlated positively with serum triglycerides and insulin resistance (P < .001) and negatively with serum high-density lipoprotein cholesterol (P = .002). Leptin level was not associated with glomerular filtration rate calculated using the plasma iohexol disappearance curve or inflammatory cytokines. In multivariate analysis, BMI, age, female sex, and serum triglyceride levels were significantly associated with serum leptin level. CONCLUSION Increased leptin production was associated with female sex, older age, and adiposity in children with mild to moderate CKD. Renal function was not associated with serum leptin level, indicating that decreased clearance does not contribute to elevated leptin levels.
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Affiliation(s)
- Edward Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Susan Furth
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bradley Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri, USA
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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