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Huang VW, Behairy M, Abelson B, Crane A, Liu W, Wang L, Dell KM, Rhee A. Kidney disease progression in pediatric and adult posterior urethral valves (PUV) patients. Pediatr Nephrol 2024; 39:829-835. [PMID: 37658873 DOI: 10.1007/s00467-023-06128-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Posterior urethral valves (PUV) is the most common cause of obstructive uropathy in boys; approximately 15% develop kidney failure by early adulthood. However, rates of kidney function decline are poorly defined in PUV children and adults, as is the impact of potentially modifiable chronic kidney disease (CKD) progression risk factors. METHODS We conducted a retrospective review of all PUV patients followed at our institution from 1995 to 2018. Inclusion criteria were estimated glomerular filtration rate (eGFR) > 20 ml/min/1.73 m2 after 1 year of age, no dialysis or kidney transplant history, and ≥ 2 yearly serum creatinine values after age 1 year. eGFRs were calculated using creatinine-based estimating formulas for children (CKID U25) or adults (CKD-EPI). The primary outcome was annualized change in eGFR, assessed with linear mixed effects models. We also examined the association of acute kidney injury (AKI), proteinuria, hypertension (HTN), and recurrent febrile urinary tract infections (UTIs) with eGFR decline. RESULTS Fifty-two PUV patients met the inclusion criteria. Median (interquartile range) eGFR decline was 2.6 (2.1, 3.1) ml/min/1.73 m2/year. Children (n = 35) and adults (n = 17) demonstrated progressive decline. Proteinuria and recurrent UTIs were significantly associated with faster progression; AKI and HTN were also associated but did not reach significance. CONCLUSION PUV patients show progressive loss of kidney function well into adulthood. Proteinuria and recurrent UTIs are associated with faster progression, suggesting potential modifiable risk factors. This is the first study to report annualized eGFR decline rates in PUV patients, which could help inform the design of clinical trials of CKD therapies.
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Affiliation(s)
- Victoria W Huang
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mohga Behairy
- Department of Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | | | - Alice Crane
- Department of Urology, Cleveland Clinic, Cleveland, OH, USA
| | - Wei Liu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Katherine M Dell
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
- Department of Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
- Center for Pediatric Nephrology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
| | - Audrey Rhee
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Urology, Cleveland Clinic, Cleveland, OH, USA
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Gluck CA, Forrest CB, Davies AG, Maltenfort M, Mcdonald JR, Mitsnefes M, Dharnidharka VR, Dixon BP, Flynn JT, Somers MJ, Smoyer WE, Neu A, Hovinga CA, Skversky AL, Eissing T, Kaiser A, Breitenstein S, Furth SL, Denburg MR. Evaluating Kidney Function Decline in Children with Chronic Kidney Disease Using a Multi-Institutional Electronic Health Record Database. Clin J Am Soc Nephrol 2023; 18:173-182. [PMID: 36754006 PMCID: PMC10103199 DOI: 10.2215/cjn.0000000000000051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 12/03/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND The objectives of this study were to use electronic health record data from a US national multicenter pediatric network to identify a large cohort of children with CKD, evaluate CKD progression, and examine clinical risk factors for kidney function decline. METHODS This retrospective cohort study identified children seen between January 1, 2009, to February 28, 2022. Data were from six pediatric health systems in PEDSnet. We identified children aged 18 months to 18 years who met criteria for CKD: two eGFR values <90 and ≥15 ml/min per 1.73 m2 separated by ≥90 days without an intervening value ≥90. CKD progression was defined as a composite outcome: eGFR <15 ml/min per 1.73 m2, ≥50% eGFR decline, long-term dialysis, or kidney transplant. Subcohorts were defined based on CKD etiology: glomerular, nonglomerular, or malignancy. We assessed the association of hypertension (≥2 visits with hypertension diagnosis code) and proteinuria (≥1 urinalysis with ≥1+ protein) within 2 years of cohort entrance on the composite outcome. RESULTS Among 7,148,875 children, we identified 11,240 (15.7 per 10,000) with CKD (median age 11 years, 50% female). The median follow-up was 5.1 (interquartile range 2.8-8.3) years, the median initial eGFR was 75.3 (interquartile range 61-83) ml/min per 1.73 m2, 37% had proteinuria, and 35% had hypertension. The following were associated with CKD progression: lower eGFR category (adjusted hazard ratio [aHR] 1.44 [95% confidence interval (95% CI), 1.23 to 1.69], aHR 2.38 [95% CI, 2.02 to 2.79], aHR 5.75 [95% CI, 5.05 to 6.55] for eGFR 45-59 ml/min per 1.73 m2, 30-44 ml/min per 1.73 m2, 15-29 ml/min per 1.73 m2 at cohort entrance, respectively, when compared with eGFR 60-89 ml/min per 1.73 m2), glomerular disease (aHR 2.01 [95% CI, 1.78 to 2.28]), malignancy (aHR 1.79 [95% CI, 1.52 to 2.11]), proteinuria (aHR 2.23 [95% CI, 1.89 to 2.62]), hypertension (aHR 1.49 [95% CI, 1.22 to 1.82]), proteinuria and hypertension together (aHR 3.98 [95% CI, 3.40 to 4.68]), count of complex chronic comorbidities (aHR 1.07 [95% CI, 1.05 to 1.10] per additional comorbid body system), male sex (aHR 1.16 [95% CI, 1.05 to 1.28]), and younger age at cohort entrance (aHR 0.95 [95% CI, 0.94 to 0.96] per year older). CONCLUSIONS In large-scale real-world data for children with CKD, disease etiology, albuminuria, hypertension, age, male sex, lower eGFR, and greater medical complexity at start of follow-up were associated with more rapid decline in kidney function.
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Affiliation(s)
- Caroline A. Gluck
- Division of Pediatric Nephrology, Nemours Children's Health, Wilmington, Delaware
| | - Christopher B. Forrest
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amy Goodwin Davies
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mitchell Maltenfort
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jill R. Mcdonald
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mark Mitsnefes
- Division of Pediatric Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Vikas R. Dharnidharka
- Division of Pediatric Nephrology, Hypertension, Pheresis, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, Missouri
| | - Bradley P. Dixon
- Division of Pediatric Nephrology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joseph T. Flynn
- Division of Pediatric Nephrology, Seattle Children's Hospital, Seattle, Washington
| | - Michael J. Somers
- Division of Pediatric Nephrology, Boston Children's, Boston, Massachusetts
| | - William E. Smoyer
- Division of Pediatric Nephrology, Nationwide Children's Hospital, Columbus, Ohio
| | - Alicia Neu
- Division of Pediatric Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Collin A. Hovinga
- Clinical and Scientific Development, Institute for Advanced Clinical Trials for Children, Rockville, Maryland
| | - Amy L. Skversky
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Thomas Eissing
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Andreas Kaiser
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Stefanie Breitenstein
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Susan L. Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle R. Denburg
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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