Epidemiology and Outcomes of Children with Kidney Failure Receiving Kidney Replacement Therapy in Australia and New Zealand

Hypertension and Cardiovascular Risk Among Children with Chronic Kidney Disease

PURPOSE OF REVIEW

Cardiovascular disease is the most common cause of mortality across the lifespan of children with chronic kidney disease (CKD). Hypertension is a common and important contributor, but other factors such as obesity, dyslipidemia and mineral bone disease play a role. This narrative review focusses on studies published in the past five years that have investigated hypertension and cardiovascular risk among children with CKD.

RECENT FINDINGS

Cohort studies such as Chronic Kidney Disease in Children (CKiD) and Cardiovascular Comorbidity in Children with CKD (4C) have continued to develop our understanding of blood pressure (BP) phenotypes, and of progressive changes in the structure and function of the heart and blood vessels occurring in children with CKD. Metabolic risk factors, such as dyslipidemia, may represent an under-recognized component of care. Trial data are less common than observational evidence, but support lifestyle interventions currently used, mainly the low sodium dietary approaches to stop hypertension (DASH) diet. The findings of the recently reported Hypertension Optimal Treatment in Children with Chronic Kidney Disease trial (HOT-KID) are described in relation to the use of office BP treatment targets. Cardiovascular health is critical to the long-term outcomes of children with CKD. Recognizing and treating hypertension remains a critical component to improving outcomes, along with measures to improve concurrent cardiovascular risk factors. Some cardiovascular changes may not be reversible with transplantation and further research is needed for children at all stages of CKD.

Assessment of South Asian Pediatric Acute Kidney Injury: Epidemiology and Risk Factors (ASPIRE)-a prospective study on "severe dialysis dependent pediatric AKI"

BACKGROUND

Pediatric acute kidney injury (AKI) is a global health concern with an associated mortality risk disproportionately pronounced in resource-limited settings. There is a pertinent need to understand the epidemiology of pediatric AKI in vulnerable populations. Here, we proposed a prospective study to investigate the epidemiology and associated risk factors of "severe dialysis dependent AKI" in children among South Asian nations which would be the first and largest of its kind.

METHODS

The ASPIRE study (part of PCRRT-ICONIC Foundation initiative) is a multi-center, prospective observational study conducted in South Asian countries. All children and adolescents ≤ 18 years of age who required dialysis for AKI in any of the collaborating medical centers were enrolled. Data collection was performed until one of the following endpoints was observed: (1) discharge, (2) death, and (3) discharge against medical advice.

RESULTS

From 2019 to 2022, a total of 308 children with severe AKI were enrolled. The mean age was 6.17 years (63% males). Secondary AKI was more prevalent than primary AKI (67.2%), which predominantly occurred due to infections, dehydration, and nephrotoxins. Common causes of primary AKI were glomerulonephritis, hemolytic uremic syndrome, lupus nephritis, and obstructive uropathy. Shock, need for ventilation, and coagulopathy were commonly seen in children with severe AKI who needed dialysis. The foremost kidney replacement therapy used was peritoneal dialysis (60.7%). The mortality rate was 32.1%.

CONCLUSIONS

Common causes of AKI in children in South Asia are preventable. Mortality is high among these children suffering from "severe dialysis dependent AKI." Targeted interventions to prevent and identify AKI early and initiate supportive care in less-resourced nations are needed.

Comparison of three spot proteinuria measurements for pediatric nephrotic syndrome: based on the International pediatric Nephrology Association 2022 Guidelines

BACKGROUND

Pediatric nephrotic syndrome (NS) requires routine proteinuria monitoring, which is costly and affects patients' quality of life. The gold-standard 24-h urine protein (UP) measurement is challenging in children, and first-morning urine collection requires specific conditions, making it difficult in outpatient settings. Studies have reported comparability of second or random morning urine sample to the first-morning specimen. This study aimed to compare outcomes of random morning proteinuria measurements to 24-h UP and the roles of the urinary protein creatinine ratio (UPCR) and dipstick tests in pediatric NS, based on International Pediatric Nephrology Association (IPNA) 2022 Guidelines.

METHOD

Twenty-four-hour and morning urine samples were collected from 92 pediatric NS patients. These were subjected to automated analyses for 24-h UP, UPCR, and semi-automated dipstick analysis. A blinded doctor performed manual dipstick analysis.

RESULTS

UPCR had a stronger correlation with 24-h UP than with automated and manual urine dipstick tests. UPCR had the highest sensitivity and specificity for predicting no remission/relapse and high sensitivity but low specificity for complete remission. The optimal UPCR cutoff for remission was 0.44 mg/mg and for no remission/relapse was 2.08 mg/mg. Automated and manual dipstick tests demonstrated limited sensitivity but high specificity and similar AUC values for remission/relapse.

CONCLUSION

UPCR was sensitive and specific for diagnosing no remission/relapse and sensitive but not specific for detecting remission. Manual and automated urine dipstick tests were comparable for remission and no remission/relapse detection. This study supports the IPNA 2022 Guidelines, as 2 mg/mg was the optimal UPCR cutoff for no remission/relapse, while for remission the optimal cutoff was 0.4 mg/mg.