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Schwartz GJ, Roem JL, Hooper SR, Furth SL, Weaver DJ, Warady BA, Schneider MF. Longitudinal changes in uric acid concentration and their relationship with chronic kidney disease progression in children and adolescents. Pediatr Nephrol 2023; 38:489-497. [PMID: 35650320 PMCID: PMC9712592 DOI: 10.1007/s00467-022-05620-3] [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: 03/22/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Elevated serum uric acid concentration is a risk factor for CKD progression. Its change over time and association with CKD etiology and concomitant changes in estimated glomerular filtration rate (eGFR) in children and adolescents are unknown. METHODS Longitudinal study of 153 children/adolescents with glomerular (G) and 540 with non-glomerular (NG) etiology from the CKD in Children (CKiD) study. Baseline serum uric acid, change in uric acid and eGFR over time, CKD etiology, and comorbidities were monitored. Adjusted linear mixed-effects regression models quantified the relationship between within-person changes in uric acid and concurrent within-person changes in eGFR. RESULTS Participants with stable uric acid over follow-up had CKD progression which became worse for increased baseline uric acid (average annual percentage changes in eGFR were - 1.4%, - 7.7%, and - 14.7% in those with G CKD with baseline uric acid < 5.5 mg/dL, 5.5 - 7.5 mg/dL, and > 7.5 mg/dL, respectively; these changes were - 1.4%, - 4.1%, and - 8.6% in NG CKD). Each 1 mg/dL increase in uric acid over follow-up was independently associated with significant concomitant eGFR decreases of - 5.7% (95%CI - 8.4 to - 3.0%) (G) and - 5.1% (95%CI - 6.3 to - 4.0%) (NG) for those with baseline uric acid < 5.5 mg/dL and - 4.3% (95%CI - 6.8 to - 1.6%) (G) and - 3.3% (95%CI - 4.1 to - 2.6%) (NG) with baseline uric acid between 5.5 and 7.5 mg/dL. CONCLUSIONS Higher uric acid levels and increases in uric acid over time are risk factors for more severe progression of CKD in children and adolescents. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- George J Schwartz
- Pediatrics, University of Rochester Medical Center, 601 Elmwood Avenue Box 777, Rochester, NY, USA.
| | - Jennifer L Roem
- Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephen R Hooper
- Allied Health Sciences, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Susan L Furth
- Pediatrics, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Donald J Weaver
- Pediatrics, Atrium Health Levine Hospital, Charlotte, NC, USA
| | - Bradley A Warady
- Pediatrics, University of Missouri-Kansas City School of Medicine, Children's Mercy Hospital, Kansas City, MO, USA
| | - Michael F Schneider
- Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Bembea MM, Ng DK, Carroll M, Roem JL, Groopman J, Caprarola SD, Schwartz JM, Felling RJ, Salorio CF, Ellis G, Graham D, Everett AD. Cyclohexanone Exposure in Children on Extracorporeal Membrane Oxygenation Support. ASAIO J 2022; 68:419-425. [PMID: 33989209 PMCID: PMC8586036 DOI: 10.1097/mat.0000000000001463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to determine if plasma cyclohexanone and metabolites are associated with clinical outcomes of children on extracorporeal membrane oxygenation (ECMO) support. We performed a secondary analysis of a prospective observational study of children on ECMO support at two academic centers between July 2010 and June 2015. We measured plasma cyclohexanone and metabolites on the first and last days of ECMO support. Unfavorable outcome was defined as in-hospital death or discharge Pediatric Cerebral Performance Category score > 2 or decline ≥ 1 from baseline. Among 90 children included, 49 (54%) had unfavorable outcome at discharge. Cyclohexanediol, a cyclohexanone metabolite, was detected in all samples and at both time points; concentrations on the first ECMO day were significantly higher in those with unfavorable versus favorable outcome at hospital discharge (median, 5.7 ng/µl; interquartile range [IQR], 3.3-10.6 ng/µl vs. median, 4.2 ng/µl; IQR, 1.7-7.3 ng/µl; p = 0.04). Twofold higher cyclohexanediol concentrations on the first ECMO day were associated with increased risk of unfavorable outcome at hospital discharge (multivariable-adjusted hazard ratio [HR], 1.24 [95% CI, 1.05-1.48]). Higher cyclohexanediol concentrations on the first ECMO day were not significantly associated with new abnormal neuroimaging or 1-year Vineland Adaptive Behavior Scales-II score < 85 or death among survivors.
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Affiliation(s)
- Melania M. Bembea
- Department of Anesthesiology and Critical Care Medicine,
Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Derek K. Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School
of Public Health, Baltimore, Maryland
| | - Megan Carroll
- Department of Epidemiology, Johns Hopkins Bloomberg School
of Public Health, Baltimore, Maryland
| | - Jennifer L. Roem
- Department of Epidemiology, Johns Hopkins Bloomberg School
of Public Health, Baltimore, Maryland
| | - John Groopman
- Department of Epidemiology, Johns Hopkins Bloomberg School
of Public Health, Baltimore, Maryland
| | - Sherrill D. Caprarola
- Department of Pediatrics, Division of Pediatric Cardiac
Critical Care, Children’s National Hospital, Washington, DC
| | - Jamie McElrath Schwartz
- Department of Anesthesiology and Critical Care Medicine,
Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ryan J. Felling
- Department of Neurology, Johns Hopkins School of Medicine,
Baltimore, Maryland
| | - Cynthia F. Salorio
- Kennedy Krieger Institute, Baltimore, MD, USA
- Department of Physical Medicine and Rehabilitation, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Greg Ellis
- Molecular Determinants Core, Johns Hopkins All
Children’s Hospital, St Petersburg, Florida
| | - David Graham
- Department of Anesthesiology and Critical Care Medicine,
Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Allen D. Everett
- Department of Pediatrics, Johns Hopkins School of Medicine,
Baltimore, Maryland
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Abraham AG, Xu Y, Roem JL, Greenberg JH, Weidemann DK, Sabbisetti VS, Bonventre JV, Denburg M, Warady BA, Furth SL. Variability in CKD Biomarker Studies: Soluble Urokinase Plasminogen Activator Receptor (suPAR) and Kidney Disease Progression in the Chronic Kidney Disease in Children (CKiD) Study. Kidney Med 2021; 3:712-721.e1. [PMID: 34693253 PMCID: PMC8515077 DOI: 10.1016/j.xkme.2021.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Rationale & Objective Biomarker studies are important for generating mechanistic insight and providing clinically useful predictors of chronic kidney disease (CKD) progression. However, variability across studies can often muddy the evidence waters. Here we evaluated real-world variability in biomarker studies using two published studies, independently conducted, of the novel plasma marker soluble urokinase-type plasminogen activator receptor (suPAR) for predicting CKD progression in children with CKD. Study Design A comparison of 2 prospective cohort studies. Setting & Participants 541 children from the Chronic Kidney Disease in Children (CKiD) study, median age 12 years, median glomerular filtration rate (GFR) of 54 mL/min/1.73m2. Outcome The first occurrence of either a 50% decline in GFR from baseline or incident end-stage kidney disease. Analytical Approach The suPAR plasma marker was measured using the Quantikine ELISA immunoassay in the first study and Meso Scale Discovery (MSD) platform in the second. The analytical approaches varied. We used suPAR data from the 2 assays and mimicked each analytical approach in an overlapping subset. Results We found that switching assays had the greatest impact on inferences, resulting in a 38% to 66% change in the magnitude of the effect estimates. Covariate and modeling choices resulted in an additional 8% to 40% variability in the effect estimate. The cumulative variability led to different inferences despite using a similar sample of CKiD participants and addressing the same question. Limitations The estimated variability does not represent optimal repeatability but instead illustrates real-world variability that may be present in the CKD biomarker literature. Conclusions Our results highlight the importance of validation, avoiding conclusions based on P value thresholds, and providing comparable metrics. Further transparency of data and equal weighting of negative and positive findings in explorations of novel biomarkers will allow investigators to more quickly weed out less promising biomarkers.
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Affiliation(s)
- Alison G Abraham
- Department of Epidemiology, School of Public Health, University of Colorado, Aurora, CO.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yunwen Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jennifer L Roem
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jason H Greenberg
- Department of Pediatrics, Section of Nephrology, School of Medicine, Yale University, New Haven, CT.,Program of Applied Translational Research, School of Medicine, Yale University, New Haven, CT
| | - Darcy K Weidemann
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, MO
| | - Venkata S Sabbisetti
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joseph V Bonventre
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michelle Denburg
- Department of Pediatrics, Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City School of Medicine, University of Missouri, Kansas City, MO
| | - Susan L Furth
- Department of Pediatrics and Department of Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
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Atkinson MA, Roem JL, Gajjar A, Warady BA, Furth SL, Muñoz A. Correction to: Mode of initial renal replacement therapy and transplant outcomes in the chronic kidney disease in children (CKiD) study. Pediatr Nephrol 2020; 35:1141-1142. [PMID: 32124026 DOI: 10.1007/s00467-020-04506-6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The original version of this article unfortunately contained a mistake.
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Affiliation(s)
- Meredith A Atkinson
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, 200 N. Wolfe St., 3rd Floor, Baltimore, MD, 21287, USA.
| | - Jennifer L Roem
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Susan L Furth
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alvaro Muñoz
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Atkinson MA, Roem JL, Gajjar A, Warady BA, Furth SL, Muñoz A. Mode of initial renal replacement therapy and transplant outcomes in the chronic kidney disease in children (CKiD) study. Pediatr Nephrol 2020; 35:1015-1021. [PMID: 31797095 PMCID: PMC7278892 DOI: 10.1007/s00467-019-04416-2] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/16/2019] [Accepted: 11/08/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Kidney transplant is the renal replacement therapy (RRT) of choice for children with end stage kidney disease (ESKD). Only 21.3% of children who initiate RRT receive a preemptive kidney transplant (PKT). We characterized the transition to RRT in children in the CKiD cohort including the prevalence of dialysis as first RRT vs. PKT and graft survival. METHODS 258 children enrolled in CKiD have initiated RRT, and 202 had post-RRT initiation data collected through phone or in-person follow-up. Characteristics by first RRT modality were compared using Chi-square and Kruskal-Wallis tests. Parametric-accelerated failure time models were fit for transplantation. Graft failure was characterized using Kaplan-Meier methods and log rank tests. RESULTS Sixty-one percent received dialysis as first RRT modality and 39% PKT. Those with PKT were less likely to have glomerular disease and to be African-American, and had higher household-income. African-American subjects were nearly twice as likely to undergo dialysis prior to transplant. Those with a living donor and a college-educated mother had 40%-decreased odds of being dialysis experienced. Children with PKT were more likely to receive a living donor transplant. Only 5% of PKT subjects had graft failure by 4 years compared to 16% of those initially treated with dialysis (p = 0.092); however, after adjustment the effect of dialysis exposure was attenuated (p = 0.206). CONCLUSION CKiD subjects undergo PKT more often compared to nationally-reported rates, and are more likely to receive a kidney transplant within 1 year of starting dialysis. African-American race and lower household-income are associated with decreased access to PKT.
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Weidemann DK, Abraham AG, Roem JL, Furth SL, Warady BA. Plasma Soluble Urokinase Plasminogen Activator Receptor (suPAR) and CKD Progression in Children. Am J Kidney Dis 2020; 76:194-202. [PMID: 31987488 DOI: 10.1053/j.ajkd.2019.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 05/20/2019] [Accepted: 11/04/2019] [Indexed: 12/21/2022]
Abstract
RATIONALE & OBJECTIVE Soluble urokinase plasminogen activator receptor (suPAR) is a novel biomarker associated with incident chronic kidney disease (CKD) and has been identified as an independent risk factor for CKD progression in children, although these findings remain preliminary, limited to a single point in time, and unreplicated in pediatric cohorts. STUDY DESIGN Prospective longitudinal cohort study. SETTING & PARTICIPANTS 565 participants aged 1 to 16 years enrolled in the Chronic Kidney Disease in Children (CKiD) Study. EXPOSURE Plasma suPAR levels, categorized by quartiles, measured at study entry and a 6-month follow-up interval. OUTCOME CKD progression, defined as the initiation of kidney replacement therapy (dialysis or transplantation) or >50% decline in estimated glomerular filtrate rate (eGFR). ANALYTIC APPROACH Associations between plasma suPAR quartiles and risk for CKD progression were estimated using lognormal survival models, adjusting for potential confounders. RESULTS Participants in the highest suPAR quartile experienced 54% faster progression compared with the lowest quartile after adjustment for demographic and traditional CKD risk factors (P < 0.001). Addition of eGFR to the model attenuated the risk, although those in the highest quartile experienced 33% faster progression compared with the lowest quartile (P = 0.008). Plasma suPAR levels showed little change over 6 months. LIMITATIONS Potential for residual confounding, reliance on observational data, relatively fewer patients with higher eGFRs for subgroup analysis. CONCLUSIONS Higher suPAR levels are associated with shorter time to kidney replacement therapy or halving of eGFR in children with CKD. This association is attenuated slightly with inclusion of eGFR in regression modeling but remains a significant association for participants with the highest suPAR levels.
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Affiliation(s)
- Darcy K Weidemann
- Division of Pediatric Nephrology, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO.
| | - Alison G Abraham
- Johns Hopkins School of Medicine, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jennifer L Roem
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan L Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO
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Lovejoy DA, Roem JL, Blomquist JL, Pandya PR, Handa VL. Breastfeeding and pelvic floor disorders one to two decades after vaginal delivery. Am J Obstet Gynecol 2019; 221:333.e1-333.e8. [PMID: 31108062 DOI: 10.1016/j.ajog.2019.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/02/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Postpartum recovery from pelvic floor trauma associated with vaginal delivery may be impaired by the transient hypoestrogenic state associated with breastfeeding. OBJECTIVE The aim of our study was to examine the association between exclusive breastfeeding and pelvic floor disorders 1-2 decades after the first vaginal delivery. We hypothesize that compared with women who did not breastfeed following vaginal delivery, women who breastfeed would have a higher proportion of pelvic floor disorders s, and those women who practiced sustained exclusive/unsupplemented breastfeeding would have the highest proportion. STUDY DESIGN This is a secondary analysis of the Mothers' Outcomes After Delivery study, a prospective cohort study of pelvic floor disorders after childbirth. Participants were recruited 5-10 years after their first delivery and followed up annually for up to 9 years. This analysis focused on participants who experienced at least 1 vaginal delivery. Each participant completed a self-administered questionnaire regarding breastfeeding. Based on questionnaire responses, breastfeeding status was classified into 3 ordinal categories: unexposed (did not breastfeed or breastfed <1 week); limited exclusive breastfeeding (breastfed without supplementation for ≥1 week but <12 weeks); and sustained exclusive breastfeeding (unsupplemented breastfeeding ≥12 weeks). Our primary outcomes of interest were the proportions of stress urinary incontinence, anal incontinence, and pelvic organ prolapse. The outcomes of interest were defined using the Epidemiology of Prolapse and Incontinence Questionnaire and the Pelvic Organ Prolapse Quantification Examination at enrollment and annually for up to 9 years thereafter. Additionally, a subanalysis examined the relationship between breastfeeding and anal incontinence in an obstetric anal sphincter injury-specific population. Generalized estimating equations were utilized to determine the relationship between breastfeeding and the outcomes of interest. RESULTS Among 705 women, 189 (27%) were classified as unexposed, 145 (20%) were categorized as limited exclusive breastfeeding, and the remaining 371 women (53%) met our definition of sustained exclusive breastfeeding. Median follow-up was 5 years, contributing to a total of 3079 person years. The proportion of each pelvic floor disorder, based on 3079 person-years of follow-up was: stress urinary incontinence (27%), pelvic organ prolapse (20%), or anal incontinence (25%). Using generalized estimating equations adjusting for race, education, parity, and body mass index, sustained exclusive breastfeeding was not significantly associated with stress urinary incontinence (adjusted odds ratio, 0.82, 95% confidence interval, 0.55-1.23), pelvic organ prolapse (adjusted odds ratio, 0.78, 95% confidence interval, 0.49-1.26), and anal incontinence (adjusted odds ratio, 0.67, 95% confidence interval, 0.44-1.00). Regarding our obstetric anal sphincter injury subanalysis, 123 women within our cohort experienced obstetric anal sphincter injuries at delivery. Anal incontinence was reported in 32% of these women. However, there was no observed relationship between breastfeeding and the development of anal incontinence during study follow-up in this population. CONCLUSION Breastfeeding after vaginal childbirth was not associated with the development of stress urinary incontinence, pelvic organ prolapse, or anal incontinence 1-2 decades after the first vaginal delivery.
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Myer EN, Roem JL, Lovejoy DA, Abernethy MG, Blomquist JL, Handa VL. Longitudinal changes in pelvic floor muscle strength among parous women. Am J Obstet Gynecol 2018; 219:482.e1-482.e7. [PMID: 29902445 DOI: 10.1016/j.ajog.2018.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 05/25/2018] [Accepted: 06/05/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND There is limited knowledge of the effects of time on change in pelvic floor muscle strength after childbirth. OBJECTIVE The objectives of this study were to estimate the change in pelvic floor muscle strength in parous women over time and to identify maternal and obstetric characteristics associated with the rate of change. STUDY DESIGN This is an institutional review board-approved prospective cohort study of parous women. Participants were recruited 5-10 years after first delivery and followed annually. Pelvic floor muscle strength (peak pressure with voluntary contraction) was measured at 2 annual visits approximately 4 years apart with the use of a perineometer. We calculated the change in peak pressures, which were standardized per 5-year interval. Linear regression was used to identify maternal and obstetric characteristics that are associated with the rate of change in peak pressure. The obstetric variable of greatest interest was delivery group. Participants were classified into 3 delivery groups (considering all deliveries for each multiparous woman). Delivery categories included cesarean only, at least 1 vaginal birth but no forceps-assisted deliveries, and at least 1 forceps-assisted vaginal birth. Statistical analysis was completed with statistical software. RESULTS Five hundred forty-three participants completed 2 perineometer measurements with a median 4 years between measures (interquartile range, 3.1-4.8). At initial measurement, women were, on average, 40 years old and 8 years from first delivery. Initial strength was higher in participants who delivered all their children by cesarean (38.5 cm H2O) as compared with women with any vaginal non-forceps delivery (26.0 cm H2O) or vaginal forceps delivery (13.5 cm H2O; P<.001). There was a strong correlation between the first and second perineometry measurement (r=0.84). Median change in pelvic floor muscle strength was small at 1.2 cm H2O per 5 years (interquartile range, -5.6, 9.9 cm H2O). In multivariable analysis, women who delivered by cesarean only demonstrated almost no change in strength over 5 years (0.2 increase cm H2O per 5 years); those who experienced at least 1 vaginal or vacuum delivery increased strength (4.8 cm H2O per 5 years) as did women with at least 1 forceps delivery (5.0 cm H2O per 5 years). Additionally, obese women had a significant reduction in strength (-3.1 cm H2O per 5 years) compared with normal weight participants (0.2 cm H2O per 5 years). CONCLUSION Among parous women, pelvic muscle strength increased minimally over time with an average change of 1.2 cm H2O per 5 years; change in strength was associated with mode of delivery and obesity.
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