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Rhee CM, Zhou M, Woznick R, Mullon C, Anger MS, Ficociello LH. A real-world analysis of the influence of age on maintenance hemodialysis patients: managing serum phosphorus with sucroferric oxyhydroxide as part of routine clinical care. Int Urol Nephrol 2023; 55:377-387. [PMID: 35953565 PMCID: PMC9859895 DOI: 10.1007/s11255-022-03327-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/25/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Despite the growing number of elderly hemodialysis patients, the influence of age on nutritional parameters, serum phosphorus (sP), and use of phosphate-binder (PB) medications has not been well characterized. We aimed to describe age-related differences in patient characteristics in a large, real-world cohort of maintenance hemodialysis patients, and to examine the impact of age on sP management with sucroferric oxyhydroxide (SO). METHODS We retrospectively analyzed de-identified data from 2017 adult, in-center hemodialysis patients who switched from another PB to SO monotherapy as part of routine clinical care. Changes in baseline PB pill burden, sP levels, and nutritional and dialytic clearance parameters were assessed across varying age groups through 6 months. RESULTS At baseline, older patients had lower mean sP, serum albumin, and pre-dialysis weights compared with younger patients. Prescription of SO was associated with a 62% increase in the proportion of patients achieving sP ≤ 5.5 mg/dl and a 42% reduction in daily pill burden. The proportion of patients achieving sP ≤ 5.5 mg/dl after transitioning to SO increased by 113, 96, 68, 77, 61, 37 and 40% among those aged 19-29, 30-39, 40-49, 50-59, 60-69, 70-79, and ≥ 80 years, respectively. CONCLUSIONS Older patients had worse nutritional parameters, lower pill burden, and lower sP at baseline versus younger counterparts. Prescription of SO was associated with improved sP control and reduced pill burden across all ages.
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Affiliation(s)
- Connie M. Rhee
- grid.266093.80000 0001 0668 7243Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA USA
| | - Meijiao Zhou
- grid.419076.d0000 0004 0603 5159Global Medical Office, Fresenius Medical Care, 920 Winter Street, Waltham, MA 02451 USA
| | | | - Claudy Mullon
- grid.419076.d0000 0004 0603 5159Global Medical Office, Fresenius Medical Care, 920 Winter Street, Waltham, MA 02451 USA
| | - Michael S. Anger
- grid.419076.d0000 0004 0603 5159Global Medical Office, Fresenius Medical Care, 920 Winter Street, Waltham, MA 02451 USA
| | - Linda H. Ficociello
- grid.419076.d0000 0004 0603 5159Global Medical Office, Fresenius Medical Care, 920 Winter Street, Waltham, MA 02451 USA
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2
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Dyussenova SB, Gordiyenko MY, Serikova GB, Turlybekova SA, Issayeva AA, Yerimbetova NA, Goroshko VO. Vitamin D Deficiency in Children with Chronic Renal Disease. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Vitamin D is essential for children and adults for healthy bone growth. Lack of this vitamin in children can cause rickets, and in adults, softening of the bones and an increased risk of fractures. Vitamin D deficiency can cause immune disorders, increased susceptibility to infections, the development of certain types of cancer, diabetes mellitus, and cardiovascular diseases.
AIM: The article presents the literature data and the results of our own research on the analysis of the relationship between chronic kidney disease (CKD) and Vitamin D provision in children from 1 to 17 years old. The aim of the study was to establish the level of Vitamin D in children with different stages of CKD.
METHODS: Between January 2020 and September 2020, we examined 40 children (16 boys and 24 girls). The patients’ age ranged from 1 to 17 years inclusive.
RESULTS: Vitamin D deficiency was found in 62.5% of children with CKD. Vitamin D deficiency was noted in 25% of cases. The prevalence of Vitamin D deficiency correlates with a decrease in glomerular filtration rate.
CONCLUSION: Determination of Vitamin D level in children with CKD is important for timely correction and prevention of further progression of CKD. Timely substitution therapy will improve the quality of life of a child with CKD and prevent the development of complications.
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3
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Azzouz JZ, Safdar OY, Awaleh FI, Khoja AA, Alattas AA, Jawhari AA. Nutritional Assessment and Management in Paediatric Chronic Kidney Disease. J Nutr Metab 2021; 2021:8283471. [PMID: 34676115 PMCID: PMC8526268 DOI: 10.1155/2021/8283471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/07/2021] [Indexed: 11/17/2022] Open
Abstract
Nutrition in paediatrics has always been one of the most important factors for optimal growth. Children with chronic kidney disease (CKD) need special consideration for better long-term outcomes, including nutritional status, optimal height, and cognitive function. Nonetheless, there are many obstacles to overcome to attain optimal linear growth and nutritional status in children with CKD. This review highlights the need for tools to assess the growth parameters in CKD. In addition, recommendations for dietary intake play a major role in controlling electrolyte disturbances in patients with CKD. For example, it is still unclear whether it is better to restrict phosphate sources in inorganic, organic, or food additives. The review also summarises different factors such as fluid intake, route of feeding, and essential nutrients that require particular attention in paediatric patients with CKD. In summary, a multidisciplinary team is needed to devise individual nutritional plans to achieve the best outcome and improve the quality of life of patients.
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Affiliation(s)
| | - Osama Yousef Safdar
- Center of Excellence in Pediatric Nephrology, King Abdulaziz University, Jeddah, Saudi Arabia
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4
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Bakkaloglu SA, Bacchetta J, Lalayiannis AD, Leifheit-Nestler M, Stabouli S, Haarhaus M, Reusz G, Groothoff J, Schmitt CP, Evenepoel P, Shroff R, Haffner D. Bone evaluation in paediatric chronic kidney disease: clinical practice points from the European Society for Paediatric Nephrology CKD-MBD and Dialysis working groups and CKD-MBD working group of the ERA-EDTA. Nephrol Dial Transplant 2021; 36:413-425. [PMID: 33245331 DOI: 10.1093/ndt/gfaa210] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Indexed: 11/13/2022] Open
Abstract
Mineral and bone disorder (MBD) is widely prevalent in children with chronic kidney disease (CKD) and is associated with significant morbidity. CKD may cause disturbances in bone remodelling/modelling, which are more pronounced in the growing skeleton, manifesting as short stature, bone pain and deformities, fractures, slipped epiphyses and ectopic calcifications. Although assessment of bone health is a key element in the clinical care of children with CKD, it remains a major challenge for physicians. On the one hand, bone biopsy with histomorphometry is the gold standard for assessing bone health, but it is expensive, invasive and requires expertise in the interpretation of bone histology. On the other hand, currently available non-invasive measures, including dual-energy X-ray absorptiometry and biomarkers of bone formation/resorption, are affected by growth and pubertal status and have limited sensitivity and specificity in predicting changes in bone turnover and mineralization. In the absence of high-quality evidence, there are wide variations in clinical practice in the diagnosis and management of CKD-MBD in childhood. We present clinical practice points (CPPs) on the assessment of bone disease in children with CKD Stages 2-5 and on dialysis based on the best available evidence and consensus of experts from the CKD-MBD and Dialysis working groups of the European Society for Paediatric Nephrology and the CKD-MBD working group of the European Renal Association-European Dialysis and Transplant Association. These CPPs should be carefully considered by treating physicians and adapted to individual patients' needs as appropriate. Further areas for research are suggested.
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Affiliation(s)
- Sevcan A Bakkaloglu
- Department of Paediatric Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Justine Bacchetta
- Department of Paediatric Nephrology, Rheumatology and Dermatology, University Children's Hospital, Lyon, France
| | - Alexander D Lalayiannis
- Renal Unit, UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK
| | - Maren Leifheit-Nestler
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | - Stella Stabouli
- First Department of Paediatrics, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Mathias Haarhaus
- Division of Renal Medicine and Baxter Novum, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Diaverum AB, Stockholm, Sweden
| | - George Reusz
- First Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Jaap Groothoff
- Department of Paediatric Nephrology, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Claus Peter Schmitt
- Division of Paediatric Nephrology, Center for Paediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Pieter Evenepoel
- Department of Microbiology and Immunology, Laboratory of Nephrology, KU Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK
| | - Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
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Schmitz L, Hoermann P, Trutnau B, Jankauskiene A, Zaloszyc A, Edefonti AC, Schmitt CP, Klaus G. Enteral Ca-Intake May Be Low and Affects Serum-PTH-Levels in Pre-school Children With Chronic Kidney Disease. Front Pediatr 2021; 9:666101. [PMID: 34354967 PMCID: PMC8329332 DOI: 10.3389/fped.2021.666101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Treatment of chronic kidney disease (CKD) mineral bone disorder (MBD) is challenging in growing children due to the high amount of calcium needed for normal bone mineralization and the required dietary phosphate restriction, which often includes intake of calcium-rich products such as milk. Therefore, enteral calcium-intake (Ca-I) was calculated. Patients: We looked at pediatric CKD-Patients aged 0-6 years. Design: We used a retrospective analysis of Ca-I from dietary data collections. Ca-I below 60% or above 100% of the D-A-CH and the KDOQI reference values were considered as severe Ca deficiency or Ca overload, respectively. Results: We had 41 children, median age 1.1 (range 0-5.8) years, body weight 7.3 (2.4-19.9) kg, and length 68 (48-105) cm at the time of first dietary data collection. Renal function was classified as CKD stage III in 20, IV in 28, V in 44, and VD in 142 dietary data collections. At the first dietary data collection, 5 children were in the CKD stage III, 10 in IV, 9 in V, and 17 were on dialysis. Only one child progressed to a higher CKD stage. In total, 234 dietary data collections were analyzed, and 65 follow-up collections were available from 33 children after a time interval of 26 (1-372) days. The median caloric intake was 120 (47-217)% of D-A-CH RDI. In 149 (63.6%) of the dietary data collections, enteral Ca-I was below the target (<100% of the D-A-CH and KDOQI RDI). Severe Ca-deficiency was found in 11 (26%) and 4 (12%) of the children at the first and second dietary data collection, respectively. In total, 11 children were on Ca-containing phosphate binders. In dietary data collection 1 and 2, there were seven children. From these, 4/7 and 4/7 patients had an enteral total Ca-I above the 100% D-A-CH-limit or above the KDOQI limit, respectively. Absolute dietary Ca-I and Ca-I normalized to body weight correlated negatively with PTH (r = -0.196, p < 0.005 and r = -0.13, p < 0.05). Conclusion: Enteral Ca-I should repeatedly be monitored in CKD children because many may may otherwise be underexposed to enteral calcium and overexposed when calcium-containing phosphate binders are given. Our findings suggest a major impact of dietary calcium supply on bone health in pediatric CKD.
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Affiliation(s)
- Lilith Schmitz
- Department of Pediatric Nephrology, University of Marburg, Marburg, Germany
| | - Pamela Hoermann
- KfH Pediatric Kidney Center and University Hospital, University of Marburg, Marburg, Germany
| | - Birgit Trutnau
- KfH Pediatric Kidney Center and University Hospital, University of Marburg, Marburg, Germany
| | | | - Ariane Zaloszyc
- Division of Pediatric Nephrology, University Hospital Strassbourg, Strassbourg, France
| | - Alberto Carlo Edefonti
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Cà Granda, Ospedale Policlinico, Milan, Italy
| | - Claus Peter Schmitt
- Division of Pediatric Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Guenter Klaus
- Department of Pediatric Nephrology, University of Marburg, Marburg, Germany.,KfH Pediatric Kidney Center and University Hospital, University of Marburg, Marburg, Germany
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6
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Bacchetta J, Schmitt CP, Ariceta G, Bakkaloglu SA, Groothoff J, Wan M, Vervloet M, Shroff R, Haffner D. Cinacalcet use in paediatric dialysis: a position statement from the European Society for Paediatric Nephrology and the Chronic Kidney Disease-Mineral and Bone Disorders Working Group of the ERA-EDTA. Nephrol Dial Transplant 2020; 35:47-64. [PMID: 31641778 DOI: 10.1093/ndt/gfz159] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Indexed: 12/11/2022] Open
Abstract
Secondary hyperparathyroidism (SHPT) is an important complication of advanced chronic kidney disease (CKD) in children, which is often difficult to treat with conventional therapy. The calcimimetic cinacalcet is an allosteric modulator of the calcium-sensing receptor. It has proven to be effective and safe in adults to suppress parathyroid hormone (PTH), but data on its use in children are limited. To date, studies in children only consist of two randomized controlled trials, nine uncontrolled interventional or observational studies, and case reports that report the efficacy of cinacalcet as a PTH-lowering compound. In 2017, the European Medical Agency approved the use of cinacalcet for the treatment of SHPT in children on dialysis in whom SHPT is not adequately controlled with standard therapy. Since evidence-based guidelines are so far lacking, we present a position statement on the use of cinacalcet in paediatric dialysis patients based on the available evidence and opinion of experts from the European Society for Paediatric Nephrology, Chronic Kidney Disease-Mineral and Bone Disorder and Dialysis Working Groups, and the ERA-EDTA. Given the limited available evidence the strength of these statements are weak to moderate, and must be carefully considered by the treating physician and adapted to individual patient needs as appropriate. Audit and research recommendations to study key outcome measures in paediatric dialysis patients receiving cinacalcet are suggested.
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Affiliation(s)
- Justine Bacchetta
- Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,Reference Center for Rare Renal Diseases, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,INSERM, UMR 1033, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France.,Lyon Est Medical School, University Lyon 1, Lyon, France
| | - Claus Peter Schmitt
- Pediatric Nephrology, Center for Pediatric and Adolescent Medicine Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma of Barcelona, Barcelona, Spain
| | | | - Jaap Groothoff
- Pediatric Nephrology, University of Amsterdam, Amsterdam, The Netherlands
| | - Mandy Wan
- Renal Unit, Great Ormond Street Hospital for Children, London, UK
| | - Marc Vervloet
- Amsterdam UMC, Vrije Universiteit Amsterdam, Nephrology, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Rukshana Shroff
- Renal Unit, Great Ormond Street Hospital for Children, London, UK
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Children's Hospital, Hannover, Germany.,Center for Congenital Kidney Diseases, Center for Rare Diseases, Hannover Medical School, Hannover, Germany
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7
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Bacchetta J. Treatment of hyperphosphatemia: the dangers of high PTH levels. Pediatr Nephrol 2020; 35:493-500. [PMID: 31696357 DOI: 10.1007/s00467-019-04400-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/10/2019] [Accepted: 10/14/2019] [Indexed: 12/01/2022]
Abstract
The control of secondary hyperparathyroidism (SHPT) in pediatric chronic kidney disease is of utmost importance. Even though parathyroid hormone (PTH) is an important biomarker of mineral and bone disorders associated to CKD (CKD-MBD), calcium, phosphate, alkaline phosphatase, and vitamin D are also crucial and should be assessed together. In pediatric dialysis, high PTH levels have been associated with impaired longitudinal growth, bone disease, cardiovascular comorbidities, left ventricular hypertrophy, anemia, and even mortality (when PTH levels were above 500 pg/mL, i.e., 8.3-fold the upper normal limit (UNL)). As such, high PTH levels are for sure deleterious, but too low PTH levels have also been shown to impair growth and to promote vascular calcifications because of the underlying adynamic bone. This manuscript is part of a pros and cons debate for keeping PTH levels within the normal range in pediatric CKD, focusing on the pros. High bone turnover lesions can occur at lower PTH levels than "current" guidelines would suggest; thus, PTH alone is not a good predictor of the underlying osteodystrophy. PTH results can vary locally depending on the assay. Existing guidelines for PTH targets are conflicting and based on a very little evidence. However, the 120-180 pg/mL (2- to 3-fold the UNL) range is common to most of the guidelines; it seems to be a reasonable target in children undergoing dialysis, even though it does not correspond to "normal" PTH levels. As always, the philosophy of PTH levels in pediatric dialysis may be balanced, i.e., "not too low, not too high, and keep phosphate under control."
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Affiliation(s)
- Justine Bacchetta
- Centre de Référence des Maladies Rénales Rares, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France. .,Université de Lyon, Lyon, France. .,INSERM 1033 Research Unit, Université de Lyon, Lyon, France.
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8
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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: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [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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9
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Rees L. Assessment of dialysis adequacy: beyond urea kinetic measurements. Pediatr Nephrol 2019; 34:61-69. [PMID: 29582148 PMCID: PMC6244854 DOI: 10.1007/s00467-018-3914-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 12/18/2022]
Abstract
Adequacy of dialysis is a term that has been used for many years based on measurement of small solute clearance using urea and creatinine. This has been shown in some but not all studies in adults to correlate with survival. However, small solute clearance is just one minor part of the effectiveness of dialysis and in fact 'optimum' dialysis, rather than 'adequate' dialysis is what most paediatric nephrologists would want for their patients. Additional ways to assess the success of dialysis in children would include dialysis access complications and longevity, preservation of residual kidney function, body composition, biochemical and haematological control, nutrition and growth, discomfort during the dialysis process and psychosocial adjustment including hospitalisation and school attendance. These criteria need to be balanced against a dialysis programme that has the least possible adverse effects on quality of life.
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Affiliation(s)
- Lesley Rees
- Renal Office, Gt Ormond St Hospital for Children NHS Foundation Trust, WC1N 3JH, London, UK.
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10
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Fathallah-Shaykh S, Drozdz D, Flynn J, Jenkins R, Wesseling-Perry K, Swartz SJ, Wong C, Accomando B, Cox GF, Warady BA. Efficacy and safety of sevelamer carbonate in hyperphosphatemic pediatric patients with chronic kidney disease. Pediatr Nephrol 2018; 33:325-333. [PMID: 28900759 DOI: 10.1007/s00467-017-3787-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Treatment for hyperphosphatemia in chronic kidney disease (CKD) involves dietary control of phosphorus intake, dialysis, and treatment with oral phosphate binders, none of which were approved by the Federal Food and Drug Administration in pediatric patients at the time of this study. METHODS This was a phase 2, multicenter study (NCT01574326) with a 2-week, randomized, placebo-controlled, fixed-dose period (FDP) followed by a 6-month, single-arm, open-label, dose-titration period (DTP), with the aim to evaluate the safety and efficacy of sevelamer carbonate (SC) in hyperphosphatemic pediatric patients with CKD. Following a 2-4 week screening phase, pediatric patients with a serum phosphorus level higher than age-appropriate levels were randomized to receive either SC or placebo as powder/tablets in 0.4-1.6 g doses, based on body surface area. The primary efficacy outcome was the change in serum phosphorus from baseline to end of the FDP in the SC versus placebo arms (analysis of covariance). The secondary outcome was mean change in serum phosphorus from baseline to end of DTP by treatment group and overall. Treatment-emergent/serious adverse events (AEs) were recorded. RESULTS Of 101 enrolled patients (29 centers), 66 completed the study. The majority of patients were adolescents (74%; mean age 14.1 years) and on dialysis (77%). Renal transplant was the main reason for discontinuation. SC significantly reduced serum phosphorus from baseline levels (7.16 mg/dL) during the FDP compared to placebo (least square mean difference - 0.90 mg/dL, p = 0.001) and during the DTP (- 1.18 mg/dL, p < 0.0001). The safety and tolerability of SC and placebo were similar during the FDP, with patients in both groups reporting mild/moderate gastrointestinal AEs during the DTP. CONCLUSIONS Sevelamer carbonate significantly lowered serum phosphorus levels in hyperphosphatemic children with CKD, with no serious safety concerns identified.
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Affiliation(s)
| | - Dorota Drozdz
- Jagiellonian University Medical College, Krakow, Poland
| | | | | | | | - Sarah J Swartz
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Craig Wong
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | | | - Gerald F Cox
- Sanofi, Cambridge, MA, USA
- Editas Medicine, Cambridge, MA, USA
| | - Bradley A Warady
- Children's Mercy Kansas City, 2401 Gilham Road, Kansas City, MO, 64108, USA.
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11
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Abstract
PURPOSE OF REVIEW This review summarizes recent findings on musculoskeletal health in three chronic renal conditions of childhood: chronic kidney disease stages 2-5D, nephrotic syndrome, and urolithiasis. Findings with important clinical implications warranting further investigation are highlighted. RECENT FINDINGS Recent cohort studies have demonstrated a high burden of fracture and progressive deficits of cortical bone in children with chronic kidney disease. Lower cortical density is associated with incident fracture and may be an important therapeutic target. Parathyroid hormone and calcium are independent correlates of cortical density, and modifiable factors for fracture include parathyroid hormone and phosphate binder use. Children with nephrotic syndrome, even with normal renal function, have evidence of abnormal bone metabolism and structure, and vitamin D deficiency may be an important modifiable risk factor in this population. Urolithiasis has been associated with reduced bone mineral density and is increasingly common in children and adolescents. Population-based data found a significantly increased risk of fracture in adolescent males and young women. SUMMARY Recent findings substantiate concern regarding the particular vulnerability of the growing skeleton to chronic renal disease. Studies are needed to determine how to optimize assessment and management of bone health in children with these conditions, particularly in terms of calcium and vitamin D requirements, with the goal of improving childhood bone accrual for lifelong fracture prevention.
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12
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Silverstein DM. Growth and Nutrition in Pediatric Chronic Kidney Disease. Front Pediatr 2018; 6:205. [PMID: 30155452 PMCID: PMC6103270 DOI: 10.3389/fped.2018.00205] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/28/2018] [Indexed: 12/14/2022] Open
Abstract
Children with chronic kidney disease (CKD) feature significant challenges to the maintenance of adequate nutrition and linear growth. Moreover, the impaired nutritional state contributes directly to poor growth. Therefore, it is necessary to consider nutritional status in the assessment of etiology and treatment of sub-optimal linear growth. The major causes of poor linear growth including dysregulation of the growth hormone/insulin-like growth factor-I (IGF-I) axis, nutritional deficiency, metabolic acidosis, anemia, renal osteodystrophy/bone mineral disease, and inflammation. This review summarizes the causes and assessment tools of growth and nutrition while providing a summary of state of the art therapies for these co-morbidities of pediatric CKD.
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Affiliation(s)
- Douglas M Silverstein
- Division of Reproductive, Gastrorenal, and Urology Devices, Office of Device Evaluation, Center for Devices and Radiological Health, United States Food and Drug Administration, Silver Spring, MD, United States
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Dzingarski D, Mladenovska K. Pharmacotherapy in chronic kidney disease hyperphosphatemia – effects on vascular calcification and bone health. MAKEDONSKO FARMACEVTSKI BILTEN 2017. [DOI: 10.33320/maced.pharm.bull.2017.63.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Hyperphosphatemia (HP) in patients with chronic kidney disease (CKD) leads to complications such as renal osteodistrophy, cardiovascular calcification and hemodynamic abnormalities, all of them having a serious impact on the survival rate and quality of life. Also, HP is a key pathogenic factor in the development of secondary hyperparathyroidism (SHPT) in CKD. Having in regard the significance of controlling serum phosphorus levels (Pi), in this paper, the needs and obstacles to successful pharmacological management of HP in CKD are presented, with an overview of major classes of phosphate binders (PBs) and other drugs affecting Pi level, such as active vitamin D sterols and calcimimetics (CMs). In addition, their effects on progression of cardiovascular calcification and bone health are elaborated. In this regard, a PubMed search was carried out to capture all abstracts and articles relevant to the topic of CKD, HP and mineral metabolism, bone disorders and vascular/valvular calcification (VC), published from January 2007 to August 2017. The search was limited to English language, with the search terms including drug name AND hyperphosphatemia or cardiovascular calcification or bone disorder. Comparative studies, clinical studies/trials and meta-analyses related to different classes/representatives of PBs, vitamin D analogues and CMs were reviewed and research data related to their efficacy and safety compared.
Keywords: chronic kidney disease, hyperphosphatemia, phosphate binders, active vitamin D sterols, calcimimetics, bone disorders, cardiovascular calcification
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Affiliation(s)
- Dimce Dzingarski
- Faculty of Pharmacy, University “Ss Cyril and Methodius”, Mother Theresa St. 47, 1000 Skopje, Republic of Macedonia
| | - Kristina Mladenovska
- Faculty of Pharmacy, University “Ss Cyril and Methodius”, Mother Theresa St. 47, 1000 Skopje, Republic of Macedonia
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Rees L, Schaefer F, Schmitt CP, Shroff R, Warady BA. Chronic dialysis in children and adolescents: challenges and outcomes. THE LANCET CHILD & ADOLESCENT HEALTH 2017; 1:68-77. [PMID: 30169229 DOI: 10.1016/s2352-4642(17)30018-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/09/2017] [Accepted: 06/14/2017] [Indexed: 12/23/2022]
Abstract
Chronic dialysis is rarely required during childhood. Despite technical advances that have facilitated the treatment of even the youngest children, morbidity and mortality remain higher with chronic dialysis than after renal transplantation. The cost of equipment and skilled personnel to provide the service compromises the availability of such dialysis in parts of the world where financial resources are constrained. This Review describes the incidence and causes of end-stage kidney disease in children on long-term dialysis, and highlights management issues, including dialysis modality selection, complications, and patient outcome data.
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Affiliation(s)
- Lesley Rees
- Renal Office, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - Franz Schaefer
- Division of Pediatric Nephrology and Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Claus Peter Schmitt
- Division of Pediatric Nephrology and Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Rukshana Shroff
- Renal Office, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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15
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Ware NA, Oni L, O'Brien KO, Abrams SA, Rees L. The dual-tracer stable isotope method to measure calcium absorption in children on dialysis: a new use for an old technique. Pediatr Nephrol 2016; 31:1713-4. [PMID: 27344561 DOI: 10.1007/s00467-016-3435-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 05/25/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Nicholas A Ware
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Louise Oni
- Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, UK
| | | | - Steven A Abrams
- Dell Medical School, The University of Texas at Austin, Austin, TX, 78712, USA
| | - Lesley Rees
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
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16
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Becherucci F, Roperto RM, Materassi M, Romagnani P. Chronic kidney disease in children. Clin Kidney J 2016; 9:583-91. [PMID: 27478602 PMCID: PMC4957724 DOI: 10.1093/ckj/sfw047] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 05/04/2016] [Indexed: 12/20/2022] Open
Abstract
Chronic kidney disease (CKD) is a major health problem worldwide. Although relatively uncommon in children, it can be a devastating illness with many long-term consequences. CKD presents unique features in childhood and may be considered, at least in part, as a stand-alone nosologic entity. Moreover, some typical features of paediatric CKD, such as the disease aetiology or cardiovascular complications, will not only influence the child's health, but also have long-term impact on the life of the adult that they will become. In this review we will focus on the unique issues of paediatric CKD, in terms of aetiology, clinical features and treatment. In addition, we will discuss factors related to CKD that start during childhood and require appropriate treatments in order to optimize health outcomes and transition to nephrologist management in adult life.
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Affiliation(s)
| | - Rosa Maria Roperto
- Nephrology and Dialysis Unit , Meyer Children's Hospital , Florence , Italy
| | - Marco Materassi
- Nephrology and Dialysis Unit , Meyer Children's Hospital , Florence , Italy
| | - Paola Romagnani
- Nephrology andDialysis Unit, Meyer Children's Hospital, Florence, Italy; Department ofBiomedical Experimental and Clinical Sciences 'Mario Serio', University of Florence, Florence, Italy
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Sinha MD, Turner C, Booth CJ, Waller S, Rasmussen P, Goldsmith DJA, Simpson JM. Relationship of FGF23 to indexed left ventricular mass in children with non-dialysis stages of chronic kidney disease. Pediatr Nephrol 2015; 30:1843-52. [PMID: 25975437 DOI: 10.1007/s00467-015-3125-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 04/13/2015] [Accepted: 04/28/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the association of serum intact fibroblast growth factor 23 (FGF23) concentrations with indexed left ventricular mass in children with non-dialysis stages 3-5 of chronic kidney disease (CKD). METHODS The study cohort comprised 83 children (51 boys; mean age 12.1 ± 3.2 years) with a mean estimated glomerular filtration rate (eGFR) of 32.3 ± 14.6 ml/min/1.73 m(2) who underwent clinic and ambulatory blood pressure measurement (ABPM), echocardiography and evaluation of biochemical markers of CKD-associated mineral bone disease. RESULTS The mean left ventricular mass index (LVMI) was 35.9 ± 8.5 g/m(2.7) (± standard deviation), with 30 (36.1 %) children showing left ventricular hypertrophy (LVH), all eccentric, as defined using age-specific criteria. For all subjects, the mean FGF23 concentration was 142.2 ± 204.4 ng/l and the normalised distribution following log transformation was 1.94 ± 0.39. There was significant univariate correlation of LVMI with GFR, body mass index (BMI) z-score and calcium intake, but not with 24-h systolic ABPM z-score, log intact parathyroid hormone or log FGF23. On multivariate analysis following adjustment for confounders, only elemental calcium content (g/kg/day) estimated from prescribed calcium-based phosphate binder dose (β = 154.9, p < 0.001) and BMI z-score (β = 2.397, p = 0.003) maintained a significant positive relationship with LVMI (model r (2) = 0.225). CONCLUSIONS We observed no significant relationship of FGF23 with LVMI. Larger studies in children are needed to clarify the roles of calcium-containing phosphate binders and FGF23 with LV mass and their roles in the evolution of the development of adverse cardiovascular outcomes.
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Affiliation(s)
- Manish D Sinha
- Department of Paediatric Nephrology, Evelina London Children's Hospital, Guys & St Thomas' NHS Foundation Trust, Room 64, Sky Level, Westminster Bridge Road, London, SE1 7EH, UK,
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18
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Denburg MR, Kumar J, Jemielita T, Brooks ER, Skversky A, Portale AA, Salusky IB, Warady BA, Furth SL, Leonard MB. Fracture Burden and Risk Factors in Childhood CKD: Results from the CKiD Cohort Study. J Am Soc Nephrol 2015; 27:543-50. [PMID: 26139439 DOI: 10.1681/asn.2015020152] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 04/29/2015] [Indexed: 12/30/2022] Open
Abstract
Childhood chronic kidney disease (CHD) poses multiple threats to bone accrual; however, the associated fracture risk is not well characterized. This prospective cohort study included 537 CKD in Children (CKiD) participants. Fracture histories were obtained at baseline, at years 1, 3, and 5 through November 1, 2009, and annually thereafter. We used Cox regression analysis of first incident fracture to evaluate potential correlates of fracture risk. At enrollment, median age was 11 years, and 16% of patients reported a prior fracture. Over a median of 3.9 years, 43 males and 24 females sustained incident fractures, corresponding to 395 (95% confidence interval [95% CI], 293-533) and 323 (95% CI, 216-481) fractures per 10,000 person-years, respectively. These rates were 2- to 3-fold higher than published general population rates. The only gender difference in fracture risk was a 2.6-fold higher risk in males aged ≥15 years (570/10,000 person-years, adjusted P=0.04). In multivariable analysis, advanced pubertal stage, greater height Z-score, difficulty walking, and higher average log-transformed parathyroid hormone level were independently associated with greater fracture risk (all P≤0.04). Phosphate binder treatment (predominantly calcium-based) was associated with lower fracture risk (hazard ratio, 0.37; 95% CI, 0.15-0.91; P=0.03). Participation in more than one team sport was associated with higher risk (hazard ratio, 4.87; 95% CI, 2.21-10.75; P<0.001). In conclusion, children with CKD have a high burden of fracture. Regarding modifiable factors, higher average parathyroid hormone level was associated with greater risk of fracture, whereas phosphate binder use was protective in this cohort.
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Affiliation(s)
- Michelle R Denburg
- The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania;
| | - Juhi Kumar
- Weill Cornell Medical College, New York, New York
| | - Thomas Jemielita
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ellen R Brooks
- Ann and Robert Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amy Skversky
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Anthony A Portale
- University of California, San Francisco School of Medicine, San Francisco, California
| | - Isidro B Salusky
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Bradley A Warady
- Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri; and
| | - Susan L Furth
- The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary B Leonard
- Stanford University School of Medicine, Stanford, California
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