1
|
Mekahli D, Guay-Woodford LM, Cadnapaphornchai MA, Goldstein SL, Dandurand A, Jiang H, Jadhav P, Debuque L. Estimating risk of rapid disease progression in pediatric patients with autosomal dominant polycystic kidney disease: a randomized trial of tolvaptan. Pediatr Nephrol 2024; 39:1481-1490. [PMID: 38091246 PMCID: PMC10942936 DOI: 10.1007/s00467-023-06239-8] [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: 07/11/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 03/16/2024]
Abstract
BACKGROUND Tolvaptan preserves kidney function in adults with autosomal dominant polycystic kidney disease (ADPKD) at elevated risk of rapid progression. A trial (NCT02964273) evaluated tolvaptan safety and pharmacodynamics in children (5-17 years). However, progression risk was not part of study eligibility criteria due to lack of validated criteria for risk assessment in children. As risk estimation is important to guide clinical management, baseline characteristics of the study participants were retrospectively evaluated to determine whether risk of rapid disease progression in pediatric ADPKD can be assessed and to identify parameters relevant for risk estimation. METHODS Four academic pediatric nephrologists reviewed baseline data and rated participant risk from 1 (lowest) to 5 (highest) based on clinical judgement and the literature. Three primary reviewers independently scored all cases, with each case reviewed by two primary reviewers. For cases with discordant ratings (≥ 2-point difference), the fourth reviewer provided a secondary rating blinded to the primary evaluations. Study participants with discordant ratings and/or for whom data were lacking were later discussed to clarify parameters relevant to risk estimation. RESULTS Of 90 evaluable subjects, primary reviews of 69 (77%) were concordant. The proportion considered at risk of rapid progression (final mean rating ≥ 3.5) by age group was: 15-17 years, 27/34 (79%); 12- < 15, 9/32 (28%); 4- < 12, 8/24 (33%). The panelists agreed on characteristics important for risk determination: age, kidney imaging, kidney function, blood pressure, urine protein, and genetics. CONCLUSIONS High ratings concordance and agreement among reviewers on relevant clinical characteristics support the feasibility of pediatric risk assessment.
Collapse
Affiliation(s)
- Djalila Mekahli
- PKD Research Group, Laboratory of Ion Channel Research, Department of Cellular and Molecular Medicine, KU Leuven, Louvain, Belgium.
- Department of Pediatric Nephrology, University Hospital of Leuven, Herestraat 49, B-3000, Louvain, Belgium.
| | - Lisa M Guay-Woodford
- Center for Translational Research, Children's National Research Institute, Washington, DC, USA
| | - Melissa A Cadnapaphornchai
- Rocky Mountain Pediatric Kidney Center, Rocky Mountain Hospital for Children at Presbyterian/St. Luke's Medical Center, Denver, CO, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Ann Dandurand
- Cerevel Therapeutics, Cambridge, MA, USA
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA
| | - Huan Jiang
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA
| | | | - Laurie Debuque
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA
| |
Collapse
|
2
|
Yen PW, Chen YA, Wang W, Mao FS, Chao CT, Chiang CK, Lin SH, Tarng DC, Chiu YW, Wu MJ, Chen YC, Kao JTW, Wu MS, Lin CL, Huang JW, Hung KY. The screening, diagnosis, and management of patients with autosomal dominant polycystic kidney disease: A national consensus statement from Taiwan. Nephrology (Carlton) 2024; 29:245-258. [PMID: 38462235 DOI: 10.1111/nep.14287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/29/2024] [Accepted: 02/25/2024] [Indexed: 03/12/2024]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited cause of end-stage kidney disease (ESKD) worldwide. Guidelines for the diagnosis and management of ADPKD in Taiwan remains unavailable. In this consensus statement, we summarize updated information on clinical features of international and domestic patients with ADPKD, followed by suggestions for optimal diagnosis and care in Taiwan. Specifically, counselling for at-risk minors and reproductive issues can be important, including ethical dilemmas surrounding prenatal diagnosis and pre-implantation genetic diagnosis. Studies reveal that ADPKD typically remains asymptomatic until the fourth decade of life, with symptoms resulting from cystic expansion with visceral compression, or rupture. The diagnosis can be made based on a detailed family history, followed by imaging studies (ultrasound, computed tomography, or magnetic resonance imaging). Genetic testing is reserved for atypical cases mostly. Common tools for prognosis prediction include total kidney volume, Mayo classification and PROPKD/genetic score. Screening and management of complications such as hypertension, proteinuria, urological infections, intracranial aneurysms, are also crucial for improving outcome. We suggest that the optimal management strategies of patients with ADPKD include general medical care, dietary recommendations and ADPKD-specific treatments. Key points include rigorous blood pressure control, dietary sodium restriction and Tolvaptan use, whereas the evidence for somatostatin analogues and mammalian target of rapamycin (mTOR) inhibitors remains limited. In summary, we outline an individualized care plan emphasizing careful monitoring of disease progression and highlight the need for shared decision-making among these patients.
Collapse
Affiliation(s)
- Pao-Wen Yen
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Yung-An Chen
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Wei Wang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Fang-Sheng Mao
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chia-Ter Chao
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan City, Taiwan
| | - Chih-Kang Chiang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Wen Chiu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Ju Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung City, Taiwan
| | - Yung-Chang Chen
- Kidney Research Center, Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Juliana Tze-Wah Kao
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang-Ho Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
- Division of Nephrology, Department of Internal Medicine, Fu-Jen Catholic University Hospital, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang-Ho Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chun-Liang Lin
- Division of Nephrology, Department of Internal Medicine, Chia-Yi Chang Gung Memorial Hospital, Chia-Yi County, Taiwan
| | - Jenq-Wen Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Kuan-Yu Hung
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang-Ho Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
| |
Collapse
|
3
|
Hogan MC, Simmons K, Ullman L, Gondal M, Dahl NK. Beyond Loss of Kidney Function: Patient Care in Autosomal Dominant Polycystic Kidney Disease. KIDNEY360 2023; 4:1806-1815. [PMID: 38010035 PMCID: PMC10758524 DOI: 10.34067/kid.0000000000000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 10/26/2023] [Indexed: 11/29/2023]
Abstract
Patients with autosomal dominant polycystic kidney disease benefit from specialized care over their lifetimes, starting with diagnosis of the condition with ongoing discussion of both the renal course and extra-renal issues. Both renal and extra-renal issues may continue to cause major morbidity even after successful kidney transplant or initiation of RRT, and extra-renal disease aspects should always be considered as part of routine management. In this review, we will focus on updates in pain/depression screening, cardiac manifestations, liver and pancreatic cysts, kidney stone management, and genetic counseling. In some instances, we have shared our current clinical practice rather than an evidence-based guideline. We anticipate more standardization of care after the release of the Kidney Disease Improving Global Outcomes guidelines for management in autosomal dominant polycystic kidney disease later this year.
Collapse
Affiliation(s)
- Marie C. Hogan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Kathryn Simmons
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Lawrence Ullman
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Maryam Gondal
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Neera K. Dahl
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
4
|
Trutin I, Oletić L, Nikuševa-Martić T. Unraveling the Complexity of Childhood Polycystic Kidney Disease: A Case Study of Three Sisters. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1700. [PMID: 37892363 PMCID: PMC10605507 DOI: 10.3390/children10101700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/11/2023] [Accepted: 10/15/2023] [Indexed: 10/29/2023]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disorder, estimated to affect 1 in 1000 people. It displays a high level of variability in terms of onset and severity among affected individuals within the same family. In this case study, three sisters (4, 8, and 10 years of age) were suspected of having ADPKD due to their positive family history. While the two younger sisters aged 8 and 4 showed no disease complications and had normal kidney function, the oldest sister was found to have no dipping status on ambulatory blood pressure measurement (ABPM). Two of the sisters were discovered to have a PKD1 mutation, while the third sister aged 8 was heterozygous for TTC21B c.1593_1595del, p. (Leu532del), which is a variant of uncertain significance (VUS). Environmental factors and genetic modifying factors are believed to contribute to the phenotypic variability observed in ADPKD. Identifying and understanding potential genetic and environmental modifiers of ADPKD could pave the way to targeted treatments for childhood ADPKD.
Collapse
Affiliation(s)
- Ivana Trutin
- Department of Pediatrics, Sestre Milosrdnice University Hospital Center, 10000 Zagreb, Croatia; (I.T.); (L.O.)
| | - Lea Oletić
- Department of Pediatrics, Sestre Milosrdnice University Hospital Center, 10000 Zagreb, Croatia; (I.T.); (L.O.)
| | | |
Collapse
|
5
|
Hanna C, Iliuta IA, Besse W, Mekahli D, Chebib FT. Cystic Kidney Diseases in Children and Adults: Differences and Gaps in Clinical Management. Semin Nephrol 2023; 43:151434. [PMID: 37996359 DOI: 10.1016/j.semnephrol.2023.151434] [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] [Indexed: 11/25/2023]
Abstract
Cystic kidney diseases, when broadly defined, have a wide differential diagnosis extending from recessive diseases with a prenatal or pediatric diagnosis, to the most common autosomal-dominant polycystic kidney disease primarily affecting adults, and several other genetic or acquired etiologies that can manifest with kidney cysts. The most likely diagnoses to consider when assessing a patient with cystic kidney disease differ depending on family history, age stratum, radiologic characteristics, and extrarenal features. Accurate identification of the underlying condition is crucial to estimate the prognosis and initiate the appropriate management, identification of extrarenal manifestations, and counseling on recurrence risk in future pregnancies. There are significant differences in the clinical approach to investigating and managing kidney cysts in children compared with adults. Next-generation sequencing has revolutionized the diagnosis of inherited disorders of the kidney, despite limitations in access and challenges in interpreting the data. Disease-modifying treatments are lacking in the majority of kidney cystic diseases. For adults with rapid progressive autosomal-dominant polycystic kidney disease, tolvaptan (V2-receptor antagonist) has been approved to slow the rate of decline in kidney function. In this article, we examine the differences in the differential diagnosis and clinical management of cystic kidney disease in children versus adults, and we highlight the progress in molecular diagnostics and therapeutics, as well as some of the gaps meriting further attention.
Collapse
Affiliation(s)
- Christian Hanna
- Division of Pediatric Nephrology and Hypertension, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Ioan-Andrei Iliuta
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Whitney Besse
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Djalila Mekahli
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Fouad T Chebib
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL.
| |
Collapse
|
6
|
Dachy A, Van Loo L, Mekahli D. Autosomal Dominant Polycystic Kidney Disease in Children and Adolescents: Assessing and Managing Risk of Progression. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:236-244. [PMID: 37088526 DOI: 10.1053/j.akdh.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/07/2023] [Accepted: 01/19/2023] [Indexed: 04/25/2023]
Abstract
The clinical management of autosomal dominant polycystic kidney disease (ADPKD) in adults has shifted from managing complications to delaying disease progression through newly emerging therapies. Regarding pediatric management of the disease, there are still specific hurdles related to the management of children and adolescents with ADPKD and, unlike adults, there are no specific therapies for pediatric ADPKD or stratification models to identify children and young adults at risk of rapid decline in kidney function. Therefore, early identification and management of factors that may modify disease progression, such as hypertension and obesity, are of most importance for young children with ADPKD. Many of these risk factors could promote disease progression in both ADPKD and chronic kidney disease. Hence, nephroprotective measures applied early in life can represent a window of opportunity to prevent the decline of the glomerular filtration rate especially in young patients with ADPKD. In this review, we highlight current challenges in the management of patients with pediatric ADPKD, the importance of early modifying factors in disease progression as well as the gaps and future perspectives in the pediatric ADPKD research field.
Collapse
Affiliation(s)
- Angélique Dachy
- PKD Research Group, Department of Cellular and MoleculMedar icine, KU Leuven, Leuven, Belgium; Department of Pediatrics, ULiège Academic Hospital, Liège, Belgium; Laboratory of Translational Research in Nephrology (LTRN), GIGA Cardiovascular Sciences, ULiège, Liège, Belgium
| | - Liselotte Van Loo
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium.
| | - Djalila Mekahli
- PKD Research Group, Department of Cellular and MoleculMedar icine, KU Leuven, Leuven, Belgium; Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium.
| |
Collapse
|
7
|
Breysem L, De Keyzer F, Schellekens P, Dachy A, De Rechter S, Janssens P, Vennekens R, Bammens B, Irazabal MV, Van Ongeval C, Harris PC, Mekahli D. Risk Severity Model for Pediatric Autosomal Dominant Polycystic Kidney Disease Using 3D Ultrasound Volumetry. Clin J Am Soc Nephrol 2023; 18:581-591. [PMID: 36800517 PMCID: PMC10278786 DOI: 10.2215/cjn.0000000000000122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/02/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Height-adjusted total kidney volume (htTKV) measured by imaging defined as Mayo Imaging Class (MIC) is a validated prognostic measure for autosomal dominant polycystic kidney disease (ADPKD) in adults to predict and stratify disease progression. However, no stratification tool is currently available in pediatric ADPKD. Because magnetic resonance imaging and computed tomography in children are difficult, we propose a novel 3D ultrasound-based pediatric Leuven Imaging Classification to complement the MIC. METHODS A prospective study cohort of 74 patients with genotyped ADPKD (37 female) was followed longitudinally with ultrasound, including 3D ultrasound, and they underwent in total 247 3D ultrasound assessments, with patients' median age (interquartile range [IQR]) at diagnosis of 3 (IQR, 0-9) years and at first 3D ultrasound evaluation of 10 (IQR, 5-14) years. First, data matching was done to the published MIC classification, followed by subsequent optimization of parameters and model type. RESULTS PKD1 was confirmed in 70 patients (95%), PKD2 in three (4%), and glucosidase IIα unit only once (1%). Over these 247 evaluations, the median height was 143 (IQR, 122-166) cm and total kidney volume was 236 (IQR, 144-344) ml, leading to an htTKV of 161 (IQR, 117-208) ml/m. Applying the adult Mayo classification in children younger than 15 years strongly underestimated ADPKD severity, even with correction for height. We therefore optimized the model with our pediatric data and eventually validated it with data of young patients from Mayo Clinic and the Consortium for Radiologic Imaging Studies of Polycystic Kidney Disease used to establish the MIC. CONCLUSIONS We proposed a five-level Leuven Imaging Classification ADPKD pediatric model as a novel classification tool on the basis of patients' age and 3D ultrasound-htTKV for reliable discrimination of childhood ADPKD severity.
Collapse
Affiliation(s)
- Luc Breysem
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Pieter Schellekens
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospitals of Leuven, Leuven, Belgium
| | - Angélique Dachy
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Pediatrics, ULiège Academic Hospital, Liège, Belgium
| | - Stephanie De Rechter
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Peter Janssens
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Nephrology and Arterial Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel, Brussels, Belgium
| | - Rudi Vennekens
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Laboratory of Ion Channel Research, Department of Cellular and Molecular Medicine, VIB Center for Brain and Disease Research, KU Leuven, Leuven, Belgium
| | - Bert Bammens
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospitals of Leuven, Leuven, Belgium
| | - Maria V. Irazabal
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | | | - Peter C. Harris
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Djalila Mekahli
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
8
|
De Groof J, Dachy A, Breysem L, Mekahli D. Cystic kidney diseases in children. Arch Pediatr 2023; 30:240-246. [PMID: 37062654 DOI: 10.1016/j.arcped.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/24/2022] [Accepted: 02/12/2023] [Indexed: 04/18/2023]
Abstract
Cystic kidney disease comprises a broad group of heterogeneous diseases, which differ greatly in age at onset, disease manifestation, systemic involvement, disease progression, and long-term prognosis. As our understanding of these diseases continues to evolve and new treatment strategies continue to emerge, correctly differentiating and diagnosing these diseases becomes increasingly important. In this review, we aim to highlight the key features of the most relevant cystic kidney diseases, underscore important diagnostic characteristics of each disease, and present specific management options if applicable.
Collapse
Affiliation(s)
- J De Groof
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - A Dachy
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Pediatrics, ULiège Academic Hospital, Liège, Belgium
| | - L Breysem
- Department of Pediatric Radiology, University Hospitals Leuven, Leuven, Belgium
| | - D Mekahli
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium; PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
| |
Collapse
|
9
|
Severe parental phenotype associates with hypertension in children with ADPKD. Pediatr Nephrol 2023:10.1007/s00467-022-05870-1. [PMID: 36645493 DOI: 10.1007/s00467-022-05870-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Early detection of hypertension in children with autosomal polycystic kidney disease (ADPKD) may be beneficial, but screening children at risk of ADPKD remains controversial. We investigated determinants of hypertension in children with ADPKD to help identify a subgroup of children at risk of ADPKD for whom screening for the disease and/or its complications would be more relevant. METHODS In a retrospective study including consecutive children with ADPKD aged 5-18 years and followed at Saint-Luc Hospital Brussels between 2006 and 2020, we investigated the potential association between genotype, clinical characteristics and parental phenotype, and presence of hypertension. Hypertension was defined as blood pressure > P95 during 24-h ambulatory monitoring or anti-hypertensive therapy use. Parental phenotype was considered severe based on age at kidney failure, Mayo Clinic Imaging Classification and rate of eGFR decline. RESULTS The study enrolled 55 children with ADPKD (mean age 9.9 ± 2.2 years, 45% male), including 44 with a PKD1 mutation and 5 with no mutation identified. Nine (16%) children had hypertension. Hypertension in children was associated with parental phenotype severity (8/27 (30%) children with severe parental phenotype vs. 1/23 (4%) children with non-severe parental phenotype (p = 0.03)) and height-adjusted bilateral nephromegaly (6/9 (67%) children with bilateral nephromegaly vs. 3/44 (7%) children without bilateral nephromegaly (p < 0.001)). CONCLUSIONS Severe parental phenotype is associated with higher prevalence of hypertension in children with ADPKD. Hence, children of parents with severe ADPKD phenotype may be those who will most benefit from screening of the disease and/or yearly BP measures. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
|
10
|
Mekahli D, Guay-Woodford LM, Cadnapaphornchai MA, Greenbaum LA, Litwin M, Seeman T, Dandurand A, Shi L, Sikes K, Shoaf SE, Schaefer F. Tolvaptan for Children and Adolescents with Autosomal Dominant Polycystic Kidney Disease: Randomized Controlled Trial. Clin J Am Soc Nephrol 2023; 18:36-46. [PMID: 36719158 PMCID: PMC10101612 DOI: 10.2215/cjn.0000000000000022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 11/03/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Tolvaptan slows expansion of kidney volume and kidney function decline in adults with autosomal dominant polycystic kidney disease (ADPKD). Progression during childhood could be treated before irreversible kidney damage occurs, but trial data are lacking. We evaluated the safety and efficacy of tolvaptan in children/adolescents with ADPKD. METHODS This was the 1-year, randomized, double-blind, portion of a phase 3b, two-part trial being conducted at 20 academic pediatric nephrology centers. Key eligibility criteria were ADPKD and eGFR ≥60 ml/min per 1.73 m2. Participants aged 12-17 years were the target group (group 1, enrollment goal n≥60); participants aged 4-11 years could additionally enroll (group 2, anticipated enrollment approximately 40). Treatments were tolvaptan or placebo titrated by body weight and tolerability. Coprimary end points, change from baseline in spot urine osmolality and specific gravity at week 1, assessed inhibition of antidiuretic hormone activity. The key secondary end point was change in height-adjusted total kidney volume (htTKV) to month 12 in group 1. Additional end points were safety/tolerability and quality of life. Statistical comparisons were exploratory and post hoc. RESULTS Among the 91 randomized (group 1, n=66; group 2, n=25), least squares (LS) mean reduction (±SEM) in spot urine osmolality at week 1 was greater with tolvaptan (-390 [28] mOsm/kg) than placebo (-90 [29] mOsm/kg; P<0.001), as was LS mean reduction in specific gravity (-0.009 [0.001] versus -0.002 [0.001]; P<0.001). In group 1, the 12-month htTKV increase was 2.6% with tolvaptan and 5.8% with placebo (P>0.05). For tolvaptan and placebo, respectively, 65% and 16% of subjects experienced aquaretic adverse events, and 2% and 0% experienced hypernatremia. There were no elevated transaminases or drug-induced liver injuries. Four participants discontinued tolvaptan, and three discontinued placebo. Quality-of-life assessments remained stable. CONCLUSIONS Tolvaptan exhibited pharmacodynamic activity in pediatric ADPKD. Aquaretic effects were manageable, with few discontinuations. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Safety, Pharmacokinetics, Tolerability and Efficacy of Tolvaptan in Children and Adolescents With ADPKD (Autosomal Dominant Polycystic Kidney Disease) NCT02964273.
Collapse
Affiliation(s)
- Djalila Mekahli
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Pediatric Nephrology, University Hospital of Leuven, Leuven, Belgium
| | - Lisa M. Guay-Woodford
- Center for Translational Research, Children's National Research Institute, Washington, DC
| | - Melissa A. Cadnapaphornchai
- Rocky Mountain Pediatric Kidney Center, Rocky Mountain Hospital for Children at Presbyterian/St. Luke's Medical Center, Denver, Colorado
| | - Larry A. Greenbaum
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mieczyslaw Litwin
- Department of Nephrology, Kidney Transplantation and Arterial Hypertension, Children's Memorial Health Institute, Warsaw, Poland
| | - Tomas Seeman
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
- Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU Munich, Munich, Germany
| | - Ann Dandurand
- Cerevel Therapeutics, Cambridge, Massachusetts
- Otsuka Pharmaceutical Development & Commercialization, Princeton, New Jersey (former)
| | - Lily Shi
- Otsuka Pharmaceutical Development & Commercialization, Rockville, Maryland
| | - Kimberly Sikes
- Otsuka Pharmaceutical Development & Commercialization, Rockville, Maryland
| | - Susan E. Shoaf
- Otsuka Pharmaceutical Development & Commercialization, Princeton, New Jersey
| | - Franz Schaefer
- Division of Pediatric Nephrology, University Children's Hospital Heidelberg, Heidelberg, Germany
| |
Collapse
|
11
|
Affiliation(s)
- Djalila Mekahli
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
- Polycystic Kidney Disease Research Group, Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Hayley Womack
- Kansas City University College of Osteopathic Medicine, Kansas City, Missouri
| | - Neera K. Dahl
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
12
|
Liebau MC, Mekahli D. Translational research approaches to study pediatric polycystic kidney disease. Mol Cell Pediatr 2021; 8:20. [PMID: 34882278 PMCID: PMC8660924 DOI: 10.1186/s40348-021-00131-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/22/2021] [Indexed: 11/26/2022] Open
Abstract
Polycystic kidney diseases (PKD) are severe forms of genetic kidney disorders. The two main types of PKD are autosomal recessive and autosomal dominant PKD (ARPKD, ADPKD). While ARPKD typically is a disorder of early childhood, patients with ADPKD often remain pauci-symptomatic until adulthood even though formation of cysts in the kidney already begins in children. There is clinical and genetic overlap between both entities with very variable clinical courses. Subgroups of very early onset ADPKD may for example clinically resemble ARPKD. The basis of the clinical variability in both forms of PKD is not well understood and there are also limited prediction markers for disease progression for daily clinical life or surrogate endpoints for clinical trials in ARPKD or early ADPKD. As targeted therapeutic approaches to slow disease progression in PKD are emerging, it is becoming more important to reliably identify patients at risk for rapid progression as they might benefit from early therapy. Over the past years regional, national and international data collections to jointly analyze the clinical courses of PKD patients have been set up. The clinical observations are complemented by genetic studies and biorepositories as well as basic science approaches to elucidate the underlying molecular mechanisms in the PKD field. These approaches may serve as a basis for the development of novel therapeutic interventions in specific subgroups of patients. In this article we summarize some of the recent developments in the field with a focus on kidney involvement in PKD during childhood and adolescence and findings obtained in pediatric cohorts.
Collapse
Affiliation(s)
- Max Christoph Liebau
- Department of Pediatrics, Center for Rare Diseases and Center for Molecular Medicine, University Hospital Cologne and Medical Faculty, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Djalila Mekahli
- Department of Pediatric Nephrology and Organ Transplantation, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Development and Regeneration, PKD Research Group, Laboratory of Pediatrics, KU Leuven, Leuven, Belgium.
| |
Collapse
|
13
|
Abstract
Introduction Valid prediction models or predictors of disease progression in children and young patients with autosomal dominant polycystic kidney disease (ADPKD) are lacking. Although total kidney volume (TKV) and Mayo imaging classification are generally used to predict disease progression in patients with ADPKD, it remains unclear whether germline mutation types are associated with these factors. We therefore investigated the association between mutation type and TKV and Mayo imaging classification among patients with ADPKD. Methods A total of 129 patients with ADPKD who underwent genetic analyses were enrolled in the study. The associations between the severity of PKD (TKV ≥ 1000 ml and Mayo classes 1C–1E) and the PKD1 mutation types (nonsense mutation, frameshift or splicing mutation, and substitution) were evaluated. Results Among the mutation types, only PKD1 splicing/frameshift mutation had significant associations with TKV ≥ 1000 ml in sex-adjusted and multivariable logistic analyses. Similarly, only the PKD1 splicing/frameshift mutation was significantly associated with Mayo 1C–1E in sex-adjusted and multivariable logistic analyses. PKD1 nonsense mutation, PKD1 substitution, or PKD1 mutation position had no significant association with TKV ≥ 1000 ml or Mayo 1C–1E. Conclusion Kidney cyst severity differs according to the mutation types in PKD1. Patients with PKD1 splicing mutations or PKD1 frameshift mutations are associated with TKV ≥ 1000 ml or Mayo 1C–1E. Detailed assessment of mutation types may be useful for predicting renal prognosis in patients with ADPKD and may especially contribute to the care of a high-risk group of children with ADPKD.
Collapse
|