Cardiometabolic Health in Asian American Children

BACKGROUND

The aim was to compare cardiometabolic health between Asian American children and Non-Hispanic White (NHW) children as well as to compare cardiometabolic health among Asian American children by birthplace.

METHODS

Children aged 6-17 years enrolled in the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2018 who self-identified as non-Hispanic Asian and NHW were included. Among Asian Americans, place of birth was defined as foreign born vs United States (US) born. Regression models were adjusted for age, sex, household income, food insecurity, passive smoke exposure, and body mass index (BMI) z-score.

RESULTS

Among 3369 children, 8.4% identified as Asian American (age 11.7 years) and 91.6% identified as NHW (age 11.7 years). Compared to NHW children, Asian American children had significantly lower BMI z-scores and odds of obesity. Asian American children had higher HOMA-IR, and greater odds of dyslipidemia and microalbuminuria compared to NHW children. Among Asian Americans, 30.5% were foreign born. Compared to foreign-born Asian American children, US-born Asian American children had significantly higher non-HDL, triglycerides, and uric acid, lower HDL, and lower odds of hyperfiltration. There were no differences in blood pressure by racial group or place of birth.

CONCLUSIONS

Although Asian American children have lower odds of obesity, they have significantly worse glucose intolerance, more dyslipidemia, and more microalbuminuria compared to NHW children. US-born Asian American children have worse cardiometabolic health profiles compared to foreign-born Asian Americans.

Cardiometabolic Health in Asian American Children

Background

The aim was to compare cardiometabolic health between Asian American children and Non-Hispanic White (NHW) children as well as to compare cardiometabolic health among Asian American children by birthplace.

Methods

Children aged 6-17 years enrolled in the National Health and Nutrition Examination Survey (NHANES) from 2011-2018 who self-identified as non-Hispanic Asian and NHW were included. Among Asian Americans, place of birth was defined as foreign-born vs United States (US)-born. Regression models were adjusted for age, sex, household income, food insecurity, passive smoke exposure, and body mass index (BMI) z-score.

Results

Among 3369 children, 8.4% identified as Asian American (age 11.7 years) and 91.6% identified as NHW (age 11.7 years). Compared to NHW children, Asian American children had significantly lower BMI z-scores and odds of obesity. Asian American children had higher HOMA-IR and uric acid, and greater odds of dyslipidemia, microalbuminuria and glomerular hyperfiltration compared to NHW children. Among Asian Americans, 30.5% were foreign-born. Compared to foreign-born Asian American children, US-born Asian American children had significantly higher non-HDL, triglycerides, HOMA-IR and uric acid, lower HDL, and lower odds of hyperfiltration. There were no differences in blood pressure by racial group or place of birth.

Conclusions

Although Asian American children have lower odds of obesity, they have significantly worse glucose intolerance, higher serum uric acid levels, more dyslipidemia and more microalbuminuria compared to NHW children. US-born Asian American children have worse cardiometabolic health profiles compared to foreign-born Asian Americans.

Comparing Kidney Health Outcomes in Children, Adolescents, and Adults With Focal Segmental Glomerulosclerosis

IMPORTANCE

Focal segmental glomerulosclerosis (FSGS) is a common cause of end-stage kidney disease (ESKD) across the lifespan. While 10% to 15% of children and 3% of adults who develop ESKD have FSGS, it remains uncertain whether the natural history differs in pediatric vs adult patients, and this uncertainty contributes to the exclusion of children and adolescents in clinical trials.

OBJECTIVE

To examine whether there are differences in the kidney health outcomes among children, adolescents, and adults with FSGS.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used pooled and parallel analyses, completed July 5, 2022, from 3 complimentary data sources: (1) Nephrotic Syndrome Rare Disease Clinical Research Network (NEPTUNE); (2) FSGS clinical trial (FSGS-CT); and (3) Kidney Research Network (KRN). NEPTUNE is a multicenter US/Canada cohort study; FSGS-CT is a multicenter US/Canada clinical trial; and KRN is a multicenter US electronic health record-based registry from academic and community nephrology practices. NEPTUNE included 166 patients with incident FSGS enrolled at first kidney biopsy; FSGS-CT included 132 patients with steroid-resistant FSGS randomized to cyclosporine vs dexamethasone with mycophenolate; and KRN included 184 patients with prevalent FSGS. Data were collected from November 2004 to October 2019 and analyzed from October 2020 to July 2022.

EXPOSURES

Age: children (age <13 years) vs adolescents (13-17 years) vs adults (≥18 years). Covariates of interest included sex, disease duration, APOL1 genotype, urine protein-to-creatinine ratio, estimated glomerular filtration rate (eGFR), edema, serum albumin, and immunosuppressive therapy.

MAIN OUTCOMES AND MEASURES

ESKD, composite outcome of ESKD or 40% decline in eGFR, and complete and/or partial remission of proteinuria.

RESULTS

The study included 127 (26%) children, 102 (21%) adolescents, and 253 (52%) adults, including 215 (45%) female participants and 138 (29%) who identified as Black, 98 (20%) who identified as Hispanic, and 275 (57%) who identified as White. Overall, the median time to ESKD was 11.9 years (IQR, 5.2-19.1 years). There was no difference in ESKD risk among children vs adults (hazard ratio [HR], 0.67; 95% CI, 0.43-1.03) or adolescents vs adults (HR, 0.85; 95% CI, 0.52-1.36). The median time to the composite end point was 5.7 years (IQR 1.6-15.2 years), with hazard ratio estimates for children vs adults of 1.12 (95% CI, 0.83-1.52) and adolescents vs adults of 1.06 (95% CI, 0.75-1.50).

CONCLUSIONS AND RELEVANCE

In this study, the association of FSGS with kidney survival and functional outcomes was comparable at all ages.

Determinants of medication adherence in childhood nephrotic syndrome and associations of adherence with clinical outcomes

BACKGROUND

Pediatric patients with nephrotic syndrome take medications long-term with significant toxicity and complex regimens, yet data on medication adherence are limited.

METHODS

In a multicenter observational study of patients with nephrotic syndrome, NEPTUNE (NCT01209000), we surveyed caregivers of patients <19 years old and adolescent patients on medication adherence during longitudinal follow-up beginning in June 2015. Data extraction was in October 2020. We described the proportion of nonadherent patients at first survey. Participant social and economic factors, condition-related factors, therapy-related factors, and patient-related factors were examined for relationships with nonadherence by generalized linear mixed models using the longitudinal data. In exploratory fashion, we assessed the relationship between adherence and subsequent steroid response classification by binary logistic regression and adherence with healthcare utilization by Poisson regression.

RESULTS

A total of 225 participants completed a median of 3 surveys during follow-up (IQR, 2-5), with a total of 743 surveys. Overall, 80 (36%) reported nonadherence with medications. In adjusted analysis, older age (per 1 year; OR 1.08; 95% CI, 1.03 1.12), lower maternal educational level (≥ high school vs. < high school; OR 0.47; 95% CI 0.25 to 0.89), and increased parent and self-identification of medications barriers (per 1 point; OR 1.57; 95% CI, 1.15-2.15) were significantly associated with nonadherence. No relationship between nonadherence and subsequent frequency of healthcare utilization was observed. A trend toward increased subsequent steroid resistance classification was seen with nonadherence, though not statistically significant.

CONCLUSIONS

Medication nonadherence is common in pediatric nephrotic syndrome. Investigations into the use of surveys in the clinic setting to identify at-risk patients and ways to support families over time are needed. A higher resolution version of the Graphical abstract is available as Supplementary information.

Cardiovascular Risk Factors and Target Organ Damage in Adolescents: The SHIP AHOY Study

BACKGROUND

Development of cardiovascular disease in adults has been directly linked to an adverse metabolic phenotype. While there is evidence that development of these risk factors in childhood persists into adulthood and the development of cardiovascular disease, less is known about whether these risk factors are associated with target organ damage during adolescence.

METHODS

We collected data from 379 adolescents (mean age 15.5, 60% male) with blood pressure between the 75th and 95th percentile to determine if there is a metabolic phenotype that predicts cardiovascular changes (left ventricular mass, systolic and diastolic function, pulse wave velocity, and renal function). We determined the number of risk factors for cardiovascular disease (hypertension, dyslipidemia, obesity, and insulin resistance) present in each participant. Generalized linear models were constructed to determine if the number of cardiovascular risk factors (CVRFs) were associated with measures of target organ damage.

RESULTS

The number of CVRFs present were associated with statistically significant differences in increased left ventricular mass index, increased pulse wave velocity, decreased peak longitudinal strain, urine albumin to creatine ratio and echocardiographic parameters of diastolic dysfunction. Generalized linear models showed that dyslipidemia and insulin resistance were independently associated with markers of diastolic dysfunction (P ≤ .05) while increased blood pressure was associated with all makers of target organ damage (P ≤ .03).

CONCLUSIONS

These data suggest the of the number of CVRFs present is independently associated with early changes in markers of target organ damage during adolescence.

Left Ventricular Measurements and Strain in Pediatric Patients Evaluated for Systemic Hypertension and the Effect of Adequate Anti-hypertensive Treatment

Pediatric hypertension (HTN) is an epidemic that is associated with HTN in adulthood and adverse cardiovascular outcomes. We hypothesized that children with HTN would have left ventricular (LV) hypertrophy and abnormal LV global longitudinal strain (GLS) on echocardiogram and that these values would differ by weight, race, and HTN treatment. Data were collected from first visits to the HTN Program from 12/2011 to 9/2018, excluding patients with cardiac disease or heart transplantation. LV measurements including LV mass index (LVMI), LV GLS, and diastolic indices were compared between groups. Multivariable logistic regression was used to identify risk factors for an abnormal LVMI. There were 212 patients with an interquartile age range of 13-18 years. On univariate analysis, LVMI was higher in hypertensive, obese, and African American patients. LV strain was less negative in obese and African American patients. Adequately treated patients with HTN had a higher LVMI and a higher E/e' ratio compared to patients with no HTN. On multivariate analysis, only obesity was associated with an LVMI ≥ 95th percentile (OR 2.9, 95% CI 1.4, 5.8). LVMI is higher in hypertensive, obese, and African American patients; however, in the multivariate analysis, obesity was the only independent risk factor for an abnormal LVMI. LVMI was still higher in those adequately treated for HTN compared to patients without HTN, possibly due to concomitant obesity. Future studies should focus on subclinical changes in LV performance seen in obese and hypertensive patients and the impact on long-term health.

Expanding the phenotypic spectrum of Mendelian connective tissue disorders to include prominent kidney phenotypes

Heritable connective tissue disorders are a group of diseases, each rare, characterized by various combinations of skin, joint, musculoskeletal, organ, and vascular involvement. Although kidney abnormalities have been reported in some connective tissue disorders, they are rarely a presenting feature. Here we present three patients with prominent kidney phenotypes who were found by whole exome sequencing to have variants in established connective tissue genes associated with Loeys-Dietz syndrome and congenital contractural arachnodactyly. These cases highlight the importance of considering connective tissue disease in children presenting with structural kidney disease and also serves to expand the phenotype of Loeys-Dietz syndrome and possibly congenital contractural arachnodactyly to include cystic kidney disease and cystic kidney dysplasia, respectively.

Abstract 51: Ambulatory Blood Pressure Phenotype And Cardiovascular Risk In Youth: The Ship-ahoy Study

We investigated whether blood pressure (BP) phenotype based on clinic & 24-hour ambulatory BP (ABP) was associated with intermediate markers of cardiovascular disease (CVD) in 374 adolescents enrolled in a study of the relationship of BP to CV risk. Clinic BP was measured by auscultation and categorized using the 2017 AAP guideline. ABP was measured for 24 hours by an oscillometric device and analyzed using the adult ABP wake SBP cut-point (130 mmHg). This created 4 BP phenotype groups: normal BP (n=224), white coat hypertensive (n=48), ambulatory hypertensive (n=57) & masked hypertensive (n=45). Echocardiographic parameters & carotid-femoral pulse wave velocity (PWVcf) were measured to assess CVD risk. Left ventricular mass (LVM) was lowest in the normal BP group, whereas multiple measures of cardiac function and PWVcf were worse in the masked and ambulatory hypertensive groups:

Generalized linear models adjusted for body mass index (BMI) were constructed to examine the associations between BP phenotype and the measured CVD variables. ABP phenotype was an independent predictor of LVM, diastolic and systolic function and PWVcf in the unadjusted model. ABP phenotype remained significantly associated with diastolic function (E/e’, e’/a’), systolic function (ejection fraction) and increased arterial stiffness (PWVcf) after adjustment for BMI percentile (all p<=0.05). We conclude that BP phenotype is an independent predictor of markers of increased CVD risk in adolescents, including impaired cardiac function and increased vascular stiffness. ABP monitoring has an important role in CVD risk assessment in youth.

FC 023SAFETY OF BARDOXOLONE METHYL IN PEDIATRIC PATIENTS WITH ALPORT SYNDROME IN CARDINAL PHASE 3 TRIAL

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 &lt; 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.

Ciliopathies: Coloring outside of the lines

Ciliopathy syndromes are a diverse spectrum of disease characterized by a combination of cystic kidney disease, hepatobiliary disease, retinopathy, skeletal dysplasia, developmental delay, and brain malformations. Though generally divided into distinct disease categories based on the pattern of system involvement, ciliopathy syndromes are known to display certain phenotypic overlap. We performed next-generation sequencing panel testing, clinical exome sequencing, and research-based exome sequencing reanalysis on patients with suspected ciliopathy syndromes with additional features. We identified biallelic pathogenic variants in BBS1 in a child with features of cranioectodermal dysplasia, and biallelic variants in BBS12 in a child with the clinical stigmata of Bardet-Biedl syndrome, but also with anal atresia. We additionally identified biallelic pathogenic variants in WDR35 and DYNC2H1 in children with predominant liver disease and ductal plate malformation without skeletal dysplasia. Our study highlights the phenotypic and genetic diversity of ciliopathy syndromes, the importance of considering ciliopathy syndromes as a disease-spectrum and screening for all associated complications in all patients, and describes exclusive extra-skeletal manifestations in two classical skeletal dysplasia syndromes.

Abstract 6: Comparison Between Ambulatory BP Percentile And Load As Predictors Of Target Organ Damage In Youth

Ambulatory BP (ABP) is increasingly used to confirm the diagnosis of hypertension. Pediatric but not adult guidelines consider BP load (% readings above 95 th %ile) in risk-stratification of the ABP phenotype. We compared ABP sex- and height- specific percentile and BP load as predictors of left ventricular hypertrophy (LVH) in youth. We measured casual BP, ABP, anthropometrics, and calculated LV mass by echo as (g)/height (m) 2.7 (LVMI) in 357 adolescents (mean age 15.5 + 1.7 years, 63% white, 59% male). ABPM was performed with the Ontrak device (Spacelabs Inc., Snoqualmie, WA). ABP index was defined as mean ABP/sex- and height-specific 95 th %ile. LVH was defined as LVMI ≥38.6 (pediatric cut-point). Logistic regression was used to assess different ABP measures as predictors of LVH. Sensitivity and specificity of different ABP cut points as predictors of LVH were calculated. Seventy (19.6%) participants had LVH. Systolic 24-hour, wake and sleep ABP indices as well as 24-hour SBP load were all significantly associated with LVH, while wake and sleep SBP load were not. When adjusted for BMI percentile and sex, only the associations between ABP indices and LVH remained statistically significant (table). SBP percentiles also had better balanced sensitivities and specificities in predicting LVH (24-hour 65 th percentile: 63% and 59%; wake 70 th percentile: 54% and 62%; sleep 75 th percentile: 60% and 61%). There was no significant association between diastolic BP measures and LVH. We conclude that there is no significant contribution of BP load in predicting LVH in youth. Systolic ABP percentiles lower than the commonly used 95 th percentile are the best predictors of LVH in this population.

Abstract MP16: Metabolic Predictors Of Target Organ Damage In Adolescents: The SHIP AHOY Study

The development of cardiovascular disease in adults has been directly linked to a metabolic phenotype that includes hypertension, obesity and dyslipidemia. While there is evidence that the development of these risk factors in childhood is linked with persistence into adulthood and eventual development of cardiovascular disease, less is known about whether these risk factors contribute to target organ damage during childhood. We collected data from 379 otherwise healthy adolescents (mean age 15.5 +/- 1.8, 60% male, 37% Non-White) across the blood pressure spectrum to determine if there is a metabolic phenotype that predicts target organ damage in adolescents. A cardiovascular risk score was calculated (1 point each for: LDL >155 or HDL <40 or TG >150; BMI > 95%; fasting glucose >100; HOMA-IR > 2.5). Generalized linear models were constructed to determine if the cardiovascular risk score was independently associated with measures of target organ damage. Cardiovascular risk score was significantly associated increased left ventricular mass index (β = 1.64, R 2 0.19) , increased pulse wave velocity (β = 0.05, R 2 0.21) and several echocardiographic parameters of diastolic dysfunction (e’/a’: β = -0.07 R 2 0.27; E/A: β = -0.04, R 2 0.11; E/e’: β =0.03, R 2 0.13) after correction for age, sex, race, HR, creatinine, uric acid and log CRP (all models P<0.0009). We found no association with peak longitudinal strain or microalbuminuria. Our study suggests that presence of cardiovascular risk factors in adolescence predicts target organ damage at a young age and could potentially be modified to prevent progression of disease.

Persistent Disease Activity in Patients With Long-Standing Glomerular Disease

Introduction

Methods

Results

Conclusion

Pediatric Renovascular Hypertension: Manifestations and Management

Renovascular hypertension (RVHTN) is an important contributor to secondary etiologies of hypertension in the pediatric population. A delay in diagnosis can be associated with adverse outcomes. The etiologies of renal artery stenosis (RAS) vary from anatomical, inflammatory, genetic syndromes, intra-luminal, external compression and idiopathic. It is a silent disease with isolated hypertension as its primary clinical manifestation. Laboratory values can be notable for electrolyte derangements and renal dysfunction, but are not universally present. The diagnosis requires a high index of clinical suspicion and entails ruling out other secondary causes of hypertension while monitoring for target organ damage. Imaging of individuals with suspected RAS includes: renal ultrasound, computed tomography angiography, magnetic resonance angiography and renal scintigraphy, but angiography continues to be the gold standard. Various factors are used to determine the most appropriate method for ongoing care: anti-hypertensive therapy, with or without radiological or surgical intervention. In all instances, a multi-disciplinary team approach should be used to provide optimal care to these children and adolescents.

Subclinical Systolic and Diastolic Dysfunction Is Evident in Youth With Elevated Blood Pressure

Hypertension is associated with cardiovascular events in adults. Subclinical changes to left ventricular strain and diastolic function have been found before development of decreased left ventricular ejection fraction and cardiovascular events. Our objective was to study effects of blood pressure (BP) on ventricular function in youth across the BP spectrum. Vital signs and labs were obtained in 346 participants aged 11 to 19 years who had BP categorized as low-risk (N=144; systolic BP <75th percentile), mid-risk (N=83; systolic BP ≥80th and <90th percentile), and high-risk (N=119; systolic BP ≥90th percentile). Echocardiography was performed to assess left ventricular strain and diastolic function. Differences between groups were analyzed by ANOVA. General linear models were constructed to determine independent predictors of systolic and diastolic function. Mid-risk and high-risk participants had greater adiposity and more adverse metabolic labs (lower HDL [high-density lipoprotein], higher glucose, and higher insulin) than the low-risk group. Mid-risk and high-risk participants had significantly lower left ventricular ejection fraction and peak global longitudinal strain than the low-risk group (both P≤0.05). The E/e' ratio was higher in the high-risk group versus the low-risk and mid-risk groups, and the e'/a' ratio was lower in the high-risk versus the low-risk group (both P≤0.05). BP and adiposity were statistically significant determinants of left ventricular systolic and diastolic function. Subclinical changes in left ventricular systolic and diastolic function can be detected even at BP levels below the hypertensive range as currently defined.

Clinical Innovation: A Multidisciplinary Program for the Diagnosis and Treatment of Systemic Hypertension in Children and Adolescents

Pediatric systemic hypertension (HTN) is underdiagnosed and undertreated. The Divisions of Cardiology and Nephrology at our institution developed a comprehensive outpatient HTN program to (1) screen children at risk for HTN, (2) assess cardiovascular health, and (3) optimize medical management. We report our findings during all initial visits (n = 304) from December 2011 to September 2018. Of the cohort, 38% were obese and 36% reported little to no exercise. More than half of patients ≥11 years old did not have recommended lipid screening. When evaluating ambulatory blood pressure monitoring results, clinic blood pressure did not accurately diagnose patients with or without HTN and many patients on antihypertensive medications were inadequately treated. Visit recommendations included addition of or changes to antihypertensive medication in 35% of patients. A multidisciplinary program dedicated to pediatric HTN helps screen patients who are at risk. Ambulatory blood pressure monitoring identifies HTN in patients with normal clinic blood pressure and those on antihypertensive medication.

Abstract 110: Association of Blood Pressure Phenotype With Measures of Target Organ Damage

Ambulatory hypertension (HT) and masked hypertension (MH, normal in clinic, high on ambulatory BP monitoring, ABPM) are associated with target organ damage (TOD) in adults, while white coat hypertension (WC, high in clinic, normal on monitor) is felt to be benign. We sought to determine if BP phenotype is associated with TOD in youth. We measured casual BP, ABPM, adiposity, LV mass index (LVMI), systolic and diastolic function (E/e’ ratio) and pulse wave velocity (PWV) in 365 adolescents (15.6 + 1.7 years, 63% white, 58% male). BP phenotype was determined by mean of 6 casual aneroid SBPs, and 24-hour SBP on ABPM (Spacelabs Inc., Snoqualmie, WA) by age, sex and height specific pediatric cut-points (normotensive, NT=224; WC=90; MH=23; HT=28). ANOVA was used to evaluate differences in CV risk factors and TOD across ABP phenotypes. General linear models were used to determine if BP phenotype was an independent predictor of TOD after adjusting for age, demographics, and adiposity. There were no differences in age, race/ethnicity. MH had more females, HT were heavier than NT. There was no difference in dipping but 24-hour SBP load (%readings above 95 th %ile) increased across groups (NT=12, WC=18, MH=55, HT=64, p≤0.02). There was no difference in LVM index (NT=31.8, WC=33.5, MH=32.6, HT=33.1 g/m 2.7 ). WC had reduced strain compared to MH (-19.5 vs -23%). There were significant differences in diastolic function, and arterial stiffness. BP phenotype remained a significant determinant of E/e’ and PWV after adjustment for age, sex and BMI z-score (p≤0.0006). We conclude that 24-hour BP phenotype adds to prediction of diastolic dysfunction and arterial stiffness but not LVMI or systolic function.

Abstract P2056: Effect of Ambulatory BP Load on Target Organ Damage in Youth

Ambulatory BP (ABP) is increasingly used for diagnosis of hypertension (HTN). Pediatric but not adult guidelines consider BP load (%readings above 95th%) in risk-stratification of the ABP phenotype. We evaluated load as a predictor of target organ damage (TOD) in youth. We measured casual BP, ABPM (Spacelabs Inc., Snoqualmie, WA), body mass index (BMI), LV mass index (LVMI), systolic and diastolic function (E’/e’ ratio) and pulse wave velocity (PWV) in 367 adolescents (15.6 +/- 1.7 years, 63% white, 58% male). Subjects were stratified by load (<25% Low=215, 25-<50% Mid=62, >=50% High=47) by sex- and height-specific pediatric cut-points. ANOVA was used to evaluate differences in CV risk factors and TOD across groups. General linear models were used to determine if load was an independent predictor of TOD after adjustments. There were no differences in age, demographics or BMI by group. There was a graded increase in most clinic and ambulatory BP means and loads across groups (all p ≤0.05). There was only a trend for higher LVMI (p=0.06) and reduced strain (p=0.05) in low vs high groups. Diastolic function (E/e’) was lower in high vs low and mid groups and there was a graded increase in arterial stiffness (PWV) across groups. Daytime SBP load was an independent determinant of all forms of TOD after adjusting for age and sex but lost significance for LVMI after adjusting for BMI%. Load percent and load group remained significant determinants of PWV & E/e’ after adjusting for age, sex, BMI% and mean daytime ambulatory SBP (all p ≤ 0.0001). We conclude that daytime SBP load adds to prediction of diastolic dysfunction and arterial stiffness but not LVMI or systolic function.

Association of Blood Pressure Level With Left Ventricular Mass in Adolescents

Hypertension is associated with left ventricular hypertrophy (LVH), a risk factor for cardiovascular events. Since cardiovascular events in youth are rare, hypertension has historically been defined by the 95th percentile of the normal blood pressure (BP) distribution in healthy children. The optimal BP percentile associated with LVH in youth is unknown. We aimed to determine the association of systolic BP (SBP) percentile, independent of obesity, on left ventricular mass index (LVMI), and to estimate which SBP percentile best predicts LVH in youth. We evaluated SBP, anthropometrics, and echocardiogram in 303 adolescents (mean age 15.6 years, 63% white, 55% male) classified by SBP as low-risk (L=141, <80th percentile), mid-risk (M=71, 80-<90th percentile), or high-risk (H=91, ≥90th percentile) using the mean of 6 measurements at 2 visits according to the 2017 guidelines. Logistic regression was used to determine the sensitivity and specificity of various SBP percentiles associated with LVH. Results: BP groups did not differ by age or demographics but differed slightly by body mass index. Mean BP, LVMI, and prevalence of LVH increased across groups (BP: L=111/75, M=125/82, and H=133/92 mm Hg; LVMI: L=31.2, M=34.2, and H=34.9 g/m^2.7; LVH: L=13%, M=21%, H=27%, all P<0.03). SBP percentile remained a significant determinant of LVMI after adjusting for covariates. The 90th percentile for SBP resulted in the best balance between sensitivity and specificity for predicting LVH (LVMI≥38.6 g/m^2.7). Abnormalities in cardiac structure in youth can be found at BP levels below those used to define hypertension.

SHIP-AHOY (Study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth)

Although hypertension is identifiable in children and adolescents, there are many knowledge gaps on how to best define and manage high blood pressure in the young. SHIP-AHOY (Study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth) is being conducted to address these knowledge gaps. Five hundred adolescents will be recruited and will undergo ambulatory blood pressure monitoring, echocardiographic, vascular, and cognitive assessments, as well as epigenetic studies to identify mechanisms that underlie the development of hypertensive target organ damage. Details of the design and methods that will be utilized in SHIP-AHOY are presented here, as well as baseline characteristics of the first 264 study participants. The primary aim of the study is to develop a risk-based definition of hypertension in the young that will result in better understanding of the transition from blood pressure in youth to adult cardiovascular disease.

Abstract P391: Ambulatory Blood Pressure Phenotypes and Cardiovascular Target Organ Damage in Adolescents: The SHIP AHOY Study

Hypertensive target organ damage (TOD) is associated with increased risk for cardiovascular (CV) events. Ambulatory blood pressure (ABP) allows better prediction of TOD than clinic BP in adults, but data in youth are lacking. We aimed to determine if BP phenotype, based on a combination of clinic BP and ABP, predicts underlying CV TOD in otherwise healthy adolescents. We evaluated clinic BP (mean of 6 auscultatory BP’s), ABP (Spacelabs OnTrak), left ventricular mass index (LVMI), pulse wave velocity (PWV), diastolic function (E/e’), and systolic function (longitudinal strain) in 244 adolescents (median age 15.7 yrs, 63% white, 54% male). Clinic HTN was defined according to pediatric guidelines, and ambulatory HTN was defined as wake systolic BP > 95 th percentile for sex and height. General linear models were used to evaluate associations between BP phenotype and TOD. Normal BP phenotype was found in 162 participants (66%), while 44 (18%), 16 (7%), and 22 (9%) had white coat (WCH), masked (MH), and ambulatory (AH) HTN, respectively. Participants with an abnormal BP phenotype had higher LVMI and PWV compared to those with normal BP (table). Participants with AH also had significantly higher PWV than those with WCH or MH. Adolescents with MH or AH had worse diastolic function (higher E/e’) compared to those with normal BP or WCH. Only participants with AH had significantly worse systolic function (less negative strain) compared to those with normal BP; there was no significant difference in strain among subjects with normal BP, WCH and MH. In conclusion, ABPM improves TOD risk stratification in adolescents evaluated for HTN.

Abstract 150: Target Organ Damage Occurs at SBP Levels Below the 95th Percentile in Adolescents: The SHIP AHOY Study

HTN leads to LV hypertrophy, increasing risk for CV events. The BP level at which LVH develops is not clear. We hypothesized that target organ damage (TOD: LVH; arterial stiffness; pulse wave velocity, PWV) occurs below the definition of HTN in youth (95 th %ile of BP). We evaluated BP, anthropometrics, lab, LVM, and PWV in 180 adolescents (mean 15.8 + 1.5 yrs, 64% white, 57% male). Subjects were classified as normal (L=104, SBP<80 th %ile), mid-risk (M=38, SBP 80-<90 th %ile); or high-risk (H=38, SBP >=90 th %ile) by mean of 6 aneroid SBPs according age, sex and height-specific pediatric cut-points. ANOVA was used to evaluate differences in CV risk factors and TOD across groups. General linear models were used to determine if SBP %ile was an independent predictor of TOD. Logistic regression was used to determine the SBP %ile most sensitive and specific for predicting LVH. Groups did not differ by age, sex, race or BMI %ile. Mean BP increased across groups (L=109/74, M=126/82, H=135/87 mmHg, p < 0.0001). LVM, and PWV also increased (LVM L=31.5, M=34.7, H=35.3 g/m 2.7 ; PWV L=4.8, M=5.2, H=5.3 m/sec, p < 0.01). SBP %ile remained a significant determinant of TOD after adjusting for covariates including demographics, age, BMI, HR (LVM: SBP %ile β=0.04, R 2 0.32; PWV: SBP %ile β=0.01, R 2 0.29, all p < 0.0001). The 90 th %ile for SBP resulted in the best balance between false + (14%) and false - (13%) for LVH, however even at the 80 th %ile, 8% of cases of LVH were missed and 16% (29 of 180) had LVH at SBP < 95 th %ile. TOD occurs at levels lower than the pediatric definition of HTN even after controlling for BMI. Guidelines should consider TOD when setting cut-points for treatment.

Abstract 048: Systolic and Diastolic Ambulatory Blood Pressure Affect Target Organ Damage Differently in Adolescents: The SHIP AHOY Study

Hypertensive target organ damage (TOD) is associated with increased risk for CV events. Ambulatory BP (ABP) measures are more strongly related to TOD than casual BP in adults but data in youth are lacking. Our objective was to determine which ABP parameters associated with TOD in adolescents. We evaluated casual BP (mean of 6 measures by auscultation), ABP (Spacelabs OnTrak), anthropometrics, labs, LVM, pulse wave velocity (PWV), diastolic function (E/E’ ratio), and systolic function (global longitudinal strain, GLS) in 132 adolescents (mean 15.8 + 1.4 yrs, 66% white, 57% male). Day, night and 24H SBP and DBP index (mean/95 th %ile for sex and height) and loads (%readings above the 95 th %ile) were defined according to sex and height-specific pediatric cut-points. General linear models were used to determine independent associations between ABP and TOD. Only systolic ABP means and loads were associated with LVMI and diastolic function, while both systolic and diastolic ABP means and loads were associated with PWV. There was a weak association between systolic and diastolic loads and GLS. In multiple regression analysis (full model: demographics, age, BMI, HR, ABP, metabolic profile, CRP) day SBP index was the strongest predictor of LVMI (β=15.2, R 2 0.4, p=0.006) and E/E’ (β=5.2, R 2 0.23, all p=0.007), while day DBP index was the strongest predictor of PWV (β=3.0, R 2 0.37, p<0.0001). Day DBP load was the sole independent ABP predictor of GLS (β=0.05, R 2 0.25, p=0.02). We conclude that during adolescence, systolic and diastolic ABP parameters are differentially associated with TOD: SBP predicted LVMI, while DBP predicted PWV. ABP parameters may be used to evaluate risk for BP-related TOD.

Cardiovascular Disease Risk Factors and Left Ventricular Hypertrophy in Girls and Boys With CKD

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.

Renal outcomes in children with lupus and a family history of autoimmune disease

Genetic factors play an important role in systemic lupus erythematosus (SLE) susceptibility and development of lupus nephritis (LN). The significance, however, of a positive family history of autoimmune disease on renal outcome in SLE patients is unknown. This retrospective study of 64 children with LN investigates whether children with LN and a family history of AID (autoimmune disease; 34 patients) had worse renal outcomes when compared with children who did not have a family history (26 patients) of AID. In four patients the family history was unknown. The primary endpoint was doubling of serum creatinine (sCr) and the secondary endpoint was requiring dialysis or transplant (ESRD). Demographic variables for family history + versus mean age in years (range) at onset of LN were 13.5 (7.4-15.9) versus 13.2 (6.4-19.7); female 26: 34 (76%) versus 24: 26 (92%), P = 0.097; race Black 23 (68%), Caucasian 7 (21%), Asian 1 (2%), Hispanic 3(9%) versus Black 14 (54%), Caucasian 6 (23%), Asian 2 (8%), Hispanic 4 (15%). Three patients died (1.6%); sCr doubled in 6/34 (17.6%) versus 2/26 (7.7%), P = 0.45, followed for 2.8 years (0.8-5.8) and 1.8 years (1.8-1.9), respectively, P = 0.24; sCr doubled plus ESRD in 10/34 (29%) versus 6/26 (23%), P = 0.77, followed for 2.7 years (0.8-5.8) and 2.0 years (0.7-4.1) respectively, P = 0.29. In the family history + group, more Black versus non-Black patients doubled their sCr or reached ESRD, 8/23 (35%) versus 2/11 (18%), P = 0.44. More males and Black patients with LN had a positive family history for AID and were more likely to double their sCr or reach ESRD. These results suggest that a family history of AID impacts on renal outcome in children with SLE.

The Effect of a Gluten-Free Diet in Children With Difficult-to-Manage Nephrotic Syndrome

Case reports have linked childhood nephrotic syndrome to food sensitivity, including gluten. We report our experience with 8 children (6 boys, 2 girls; age at implementation of special diet 2-14 years) with difficult-to-manage nephrotic syndrome who were placed on a gluten-free diet for 3.4 ± 4.3 years (range, 0.6-14 years) and who had clinical improvement enabling reduction or discontinuation in steroid dosage.

Changes in biomarkers associated with living kidney donation

Living donor kidneys have been associated with better graft and overall survival in kidney transplant recipients. Although a living kidney donation is generally considered safe in carefully selected living donors, concerns of possible adverse effects related to kidney donation remain, especially in younger and high-risk donors. In this study, we examined the changes in a panel of traditional and novel serum biomarkers linked with cardiovascular conditions in a cohort of 34 healthy living kidney donors with a mean age ± SD of 40 ± 10 years and estimated predonation glomerular filtration rate (GFR) of 86 ± 10 ml/min/1.73 m(2). At 6 months after donation, there were no significant changes in the clinical parameters including body mass index and blood pressure despite a significant decline in the mean estimated GFR to 60 ml/min/1.73 m(2). Among the panel of markers, the levels of symmetric dimethylarginine and fibroblast growth factor 23 increased significantly compared to baseline, suggesting that living kidney donation may result in changes in biomarkers that are associated with cardiovascular risk in other cohorts.

The role of CT angiography in the evaluation of pediatric renovascular hypertension

Historically, the evaluation of renovascular hypertension has been accomplished by US, renal scintigraphy and digital subtraction angiography. Based on its high accuracy reported in adults renal CT angiography (CTA) with pediatric-appropriate low radiation dose techniques has become an important tool in the workup of renovascular hypertension in children. Renal CTA has several advantages over more conventional imaging modalities, including rapid and non-invasive acquisition, high resolution and easy reproducibility. Additionally, in our experience high-quality renal CTA can be performed using low-dose radiation exposures and can be acquired without sedation in most instances. This article illustrates by examples the usefulness of renal CTA for diagnosis of childhood renovascular hypertension and provides an overview of renal CTA findings in the most common childhood renovascular diseases.

Abstract 284: A Pilot Study Comparing Two Ambulatory Blood Pressure Monitors Worn at the Same Time

Introduction Ambulatory blood pressure monitoring (ABPM) has been proposed as the most effective way to characterize a person’s BP profile. However, there are very limited data in the literature comparing two simultaneously worn ABPM devices. Therefore, we compared an eight hour daytime simultaneous ABPM using two monitors (Mobil-O-Graph [I.E.M., Stolberg, Germany] and Spacelabs 90207 [Spacelabs Medical, Issequah, WA]).

Methods Simultaneous BP and heart rate data were measured on 13 adult volunteers at the University of Pennsylvania using the two monitors over an 8 hour period. Other demographic data were also collected. Standard seated BPs were obtained in triplicate at the beginning and end of the 8 hour monitoring period using an Accutor (Datascope, Mahwah, NJ) device. Three blood pressures were obtained at 1 minute intervals, recorded and averaged for each arm using the Accutor device.

Results The data show high concordance of measured mean arterial pressures (Mobil-O-Graph 101.4 [SEM-2.0] mmHg, Spacelabs 100.6 [SEM-2.4] mmHg) and heart rates (Mobil-O-Graph measuring 82.4 [ SEM- 4.1] beats/minute, Spacelabs 81.7 [4.0] beats/minute) between the monitors. Spacelabs measured a 10 mmHg higher systolic pressure (p=0.0016) and a non-statistically significant, but numerically higher (2.8 mmHg) diastolic pressure (Figure 1).

Conclusion The systolic BP difference between the two devices has public health importance. These differences if confirmed in larger cohorts, ABPM manufacturers should consider developing a normative database to help practitioners interpret ABPM data obtained with their device.

Calcineurin inhibitor (CNI) use in pediatric liver and kidney transplant (Tx) patients is associated with increased risk of obesity and impaired T-regulatory (Treg) cell function. (126.19)

CNI use can cause hyperlipidemia and new onset diabetes, and obesity may have adverse effects on allograft and patient survival, but the mechanisms are unclear. Design: We assessed if CNI or rapamycin (Rapa) use correlated with the metabolic status of children (n = 62) with stable, long-term liver (26 M, 27 F) or kidney (6 M, 3 F) allografts, and if being overweight or obese (Ow/Ob) was associated with impaired Treg phenotype or function. Results: Most patients had CNI (39) or Rapa (9) monotherapy, though 12 received CNI (8) or Rapa (4) plus MMF, Aza or steroids. 45 children had normal weight, but 7 were overweight and 10 were obese. The CNI group had more Ow/Ob patients (p=0.045) and higher BMI-for age percentile (BMI) than the Rapa group (61.7 vs. 42.9, p=0.047). CNI dose correlated with BMI (0.521, p=0.013), while Rapa use negatively correlated with BMI (-0.888, p=0.044). Also, Ow/Ob patients had reduced Treg suppressive function compared to patients with normal weight (153 vs. 100 units for autologous CD4 responders, 166 vs. 92 for standard CD4 responders, 114 vs. 43 for CD8 responders, p=0.031), and BMI was negatively correlated with CTLA-4 expression in Tregs (-0.555, p=0.011). Conclusions: CNI use is associated with being overweight or obese post-Tx, and the latter are associated with impaired Treg function and phenotype. The metabolic consequences of being overweight or obese post-Tx may include disruption of immune regulation and favor a pro-inflammatory phenotype.

Part II--Sexual misconduct by professionals. Safeguarding yourself and your practice against allegations of sexual abuse or patient impropriety

By drawing boundaries between their personal and professional lives, physicians can protect their practices and themselves while also still achieving their true goal: providing quality care to their patients.

Renal anomalies in Alagille syndrome: a disease-defining feature

Alagille syndrome (ALGS) is an autosomal dominant condition, primarily caused by mutations in JAGGED1. ALGS is defined by cholestatic liver disease, cardiac disease and involvement of the face, skeleton, and eyes with variable expression of these features. Renal involvement has been reported though not formally described. The objective of this study was to systematically characterize the renal involvement in ALGS. We performed a retrospective review of 466 JAGGED1 mutation-positive ALGS patients. Charts were reviewed for serum biochemistries, renal ultrasounds or other imaging, urinalysis, and clinical reports from pediatric nephrologists. The clinical data were reviewed by two pediatric hepatologists and a pediatric nephrologist. Of 466 charts reviewed we found 187 yielded evaluable renal information. Of these, 73/187 were shown to have renal involvement, representing 39% of the study cohort. Renal dysplasia was the most common anomaly seen. Genotype analysis of the JAGGED1 mutations in the patients with and without renal involvement did not reveal an association with mutation type. From the study we concluded that renal involvement has a prevalence of 39% in ALGS in our evaluable patients. Renal dysplasia is the most common renal anomaly. This finding correlates with the known role of the Notch pathway in glomerular development. Since renal disease of the type seen in ALGS can impair growth and impact liver transplantation, there is a clear need for a prospective study of renal involvement in ALGS and the development of guidelines for evaluation and management. These data also suggest that renal involvement be considered the sixth defining criterion for ALGS.

Spectrum of renal findings in pediatric fibromuscular dysplasia and neurofibromatosis type 1

BACKGROUND

Fibromuscular dysplasia (FMD) and neurofibromatosis type 1 (NF1) are the most common causes of pediatric renal artery stenosis (RAS) in western countries, and characterization of their angiographic features could aid in an accurate diagnosis and in treatment.

OBJECTIVE

This study characterizes renal angiographic findings in pediatric fibromuscular dysplasia (FMD) and neurofibromatosis type 1(NF1).

MATERIALS AND METHODS

We reviewed 68 angiograms performed over 11 years on 43 children with renovascular hypertension (20 male, 23 females; ages 1 month to -19 years; median/average 9.8 years). Ten patients were diagnosed with NF1, and 33 had presumed FMD. The frequency, extent and distribution of lesions were determined and analyzed.

RESULTS

Stenosis was found in 91% of patients (n=39/43), with 86% showing stenosis of 1st or 2nd order arteries, and 12% distal to 2nd order. Stenoses in multiple 1st/2nd order arteries were found in 32% of patients, and 36/43 patients had 1-2 stenoses. The most common lesion was a ≤ 5 mm stenosis in a 1st/2nd order artery, in 42%. Mean percentage of stenosis in a 1st/2nd order vessel was 62%; ≥ 70% stenosis was found in 53%, and ≥ 90% stenosis in 29%. Bilateral disease was noted in 30% of patients. Intraparenchymal disease, distal to 2nd order branches, was seen in 30%. Aneurysms were seen in 28%, beading in 19% and collaterals in 51% (associated with ≥ 70% stenosis). Mid-aortic narrowing was seen in 16%, more often in patients with NF1.

CONCLUSION

We provide a descriptive characterization of renal angiographic findings in pediatric FMD and NF1.

Solid organ transplants following hematopoietic stem cell transplant in children

SOT may be indicated for a select group of pediatric patients who experience permanent organ failure following HSCT. However, there is limited information available about outcomes. We identified eight children at our center who received an SOT following an HSCT. Patients were six months to 18 yr at HSCT. Diseases for which children underwent HSCT included thalassemia, Wiskott-Aldrich syndrome, Shwachman-Diamond/bone marrow failure, sickle cell disease (SCD), erythropoietic porphyria (EP), ALL, chronic granulomatous disease, and neuroblastoma. Time from HSCT to SOT was 13 days to seven yr (median, 27 months. Lung SOT was performed for two patients with BO, kidney transplants for three patients, and liver transplants for three patients (VOD, chronic GVHD). Seven patients are alive with functioning allografts 6-180 months from SOT. Advances in organ procurement, operative technique, immunosuppressant therapy, and infection control may allow SOT for a select group of patients post-HSCT. However, scarcity of donor organs available in a timely fashion continues to be a limiting factor. Children who have undergone HSCT and develop single organ failure should be considered for an SOT if there is a high likelihood of cure of the primary disease.

Epidemiology of hypertension in children and adolescents

The diagnosis of hypertension in children relies upon blood pressure distribution tables adjusted for gender, age, and height. Unlike in adults, specific blood pressure levels corresponding to long-term adverse outcomes in children have not been established. However, there are known surrogate markers of target organ injury associated with elevated blood pressure, such as left ventricular hypertrophy, retinal changes, thickening of the carotid artery wall, cognitive changes, and even evidence of early atherosclerosis. Moreover there is corroboration that hypertension in children predicts adult hypertension.In view of the global childhood obesity epidemic, in conjunction with the well-established association of obesity and hypertension, evaluation of blood pressure in the pediatric population has become an important health concern. With this insight, efforts continue worldwide to accurately measure, determine prevalence and monitor recent trends of hypertension in children and adolescents.

Follow-up for laparoscopic renal denervation and nephropexy for autosomal dominant polycystic kidney disease-related pain in pediatrics

PURPOSE

To present our medium-term experience with laparoscopic renal denervation and nephropexy for autosomal dominant polycystic kidney disease (ADPKD)-related pain in the pediatric patient.

MATERIALS AND METHODS

Twelve patients aged 8 to 19 years (mean age 12.4 years) with ADPKD presented with chronic pain refractory to narcotic analgesics. These 12 patients underwent laparoscopic renal denervation of 16 kidneys.

RESULTS

Mean operative time was 152 minutes and mean hospital stay was 2.17 days. All patients were pain-free at discharge and remain pain-free at a mean follow-up of 25.5 months. Three adolescent patients each had an episode of flank pain. One was associated with pyelonephritis, another with stones, and the third with trauma and a hematoma.

CONCLUSIONS

Laparoscopic renal denervation and nephropexy is a promising option for pediatric patients with uncontrolled ADPKD-related pain.

De novo gene conversion in the RCA gene cluster (1q32) causes mutations in complement factor H associated with atypical hemolytic uremic syndrome

Many of the complement regulatory genes within the RCA cluster (1q32) have arisen through genomic duplication and the resulting high degree of sequence identity is likely to predispose to gene conversion events. The highest degree of identity is between the genes for factor H (CFH) and five factor H-related proteins--CFHL1, CFHL2, CFHL3, CFHL4, and CFHL5. CFH mutations are associated with atypical hemolytic uremic syndrome (aHUS). In the Newcastle cohort of 157 aHUS patients we have identified CFH mutations in 25 families or individuals. Eleven of these 25 independent mutations are either c.3226C>G,Q1076E; c.3572C>T,S1191L; c.3590T>C,V1197A or combined c.3572C>T,S1191L/c.3590T>C,V1197A. Sequence analysis shows that all four of these changes could have arisen as a result of gene conversion between CFH and CFHL1. Analysis of parental samples in two patients with S1191L/V1197A has shown that the changes are de novo thus providing conclusive evidence that gene conversion is the mutational mechanism in these two cases. To confirm that S1191L and V1197A are disease predisposing we examined their functional significance in three ways - analysis of the C3b/C3d binding characteristics of recombinant mutant S1191L/V1197A protein, heparin affinity chromatography and haemolytic assays of serum samples from aHUS patients carrying these changes. The results showed that these changes resulted in impaired C3b binding and a defective capacity to control complement activation on cellular surfaces. We, therefore, provide conclusive evidence that gene conversion is responsible for functionally significant CFH mutations in aHUS.

Safety and efficacy of a calcineurin inhibitor avoidance regimen in pediatric renal transplantation

Thirty-four children were entered into a pilot trial of calcineurin inhibitor avoidance after living-donor kidney transplantation, the CN-01 study. Patients were treated with anti-CD25 mAb, prednisone, mycophenolate mofetil, and sirolimus. Twenty patients were maintained on the protocol for up to 3 yr of follow-up. One enrolled patient did not receive the transplant because of a donor problem, eight terminated because of one or more rejection episodes, four terminated because of adverse events, and one was lost to follow-up. Two grafts were lost, one as a result of chronic rejection and the other as a result of posttransplantation lymphoproliferative disorder. There were no deaths. The 6- and 12-mo acute rejection rates were 21.8 and 31.5%, respectively. GFR were stable throughout the course of the study, with a slight downward trend by 6 mo after transplantation followed by a slight upward trend to a mean of 70 ml/min thereafter. Early surveillance graft biopsies frequently showed focal interstitial mononuclear cellular infiltrates without overt vasculitis or tubulitis, but these infiltrates disappeared without treatment. Anti-HLA class I and II antibodies were detected in three patients before transplantation, and all three had acute rejections, including the two patients who lost their grafts. De novo anti-HLA Ab production occurred in only one patient after transplantation. There were two episodes of Epstein Barr virus-related posttransplantation lymphoproliferative disorder, one of which developed after the patient had been terminated from the study. It is concluded that calcineurin inhibitor-free immunosuppression can be safe and effective in pediatric living-donor renal transplantation. However, further modifications that are designed to lessen early rejection rates and decrease complications should be tested before this approach is used routinely.

Treatment of acute neuropsychiatric lupus with intravenous immunoglobulin (IVIG): a case report and review of the literature

Neuropsychiatric lupus can be difficult to diagnose, and little prospective data exists to help direct management. In this case report we describe the acute onset of symptoms of depression, mania, and psychosis and their complete resolution 48 h following a 5-day treatment course of intravenous immunoglobulin (IVIG) in a 20-year-old woman with systemic lupus erythematosus (SLE). We review the literature on IVIG for the management of neuropsychiatric lupus. We propose that when more toxic therapies are refused or symptoms do not remit with other treatments, IVIG should be considered in patients with neuropsychiatric lupus.

Early use of plasmapheresis for recurrent post-transplant FSGS

Recurrence of focal segmental glomerulosclerosis (FSGS) in an allograft is a challenging clinical situation because it frequently results in graft loss. We report our experience with early use of plasmapheresis in recurrent FSGS. Of the 18 (33%) children with biopsy-proven FSGS (in their native kidneys) transplanted at our institution, 6 had recurrence (elevated urine protein/creatinine ratios) post transplant and were treated with plasmapheresis. Patients who received treatment within 1 day of the recurrence (4/6) went into remission after 5-13 plasmapheresis treatments, within 5-27 days of starting treatment. Patients who did not respond to plasmapheresis (2/6) were treated 7 and 17 days after onset of proteinuria; 1 of these had acute tubular necrosis and acute rejection leading to graft loss and the other developed acute rejections, ongoing proteinuria, and subsequent graft loss. All 4 patients who went into remission have maintained good graft function, 22-53 months post transplant. In our experience early institution of plasmapheresis for recurrent post-transplant proteinuria in FSGS is effective.

Repeated injections with dexamethasone in healthy lactating sows and the effect on growth rate of their suckling piglets

Twelve lactating sows were given two doses of 14 mg of dexamethasone and 12 controls were given two doses (7.0 mL) of physiological saline. During the treatment period, total litter weight gain in litters of dexamethasone-treated sows was significantly less (P = 0.02) than weight gain of control litters. Key words: Swine, glucocorticoids, growth rate