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He G, Wang Y, Cheng C, Guo J, Lin Z, Liang Z, Jin B, Tao L, Rong L, Chen L, Lin T, Hua Y, Park S, Mo Y, Li J, Jiang X. PM 2.5 constituents associated with mortality and kidney failure in childhood-onset lupus nephritis: A 19-year cohort study. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 949:175333. [PMID: 39111418 DOI: 10.1016/j.scitotenv.2024.175333] [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: 05/29/2024] [Revised: 07/22/2024] [Accepted: 08/04/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Childhood-onset lupus nephritis (cLN) is a severe form of systemic lupus erythematosus (SLE) with high morbidity and mortality. The impact of long-term exposure to fine particulate matter (PM2.5) on adverse outcomes in cLN remains unclear. METHODS We combined a 19-years cLN cohort from seven provinces in China with high-resolution PM2.5 dataset from 2001 to 2020, investigating the association between long-term exposure to PM2.5 and its constituents (sulfate, nitrate, organic matter, black carbon, ammonium) with the risk of death and kidney failure, analyzed with multiple variables Cox models. We also evaluated the association between 3-year average PM2.5 exposure before study entry and baseline SLE disease activity index (SLEDAI) scores using linear regression models. RESULTS Each 10 μg/m3 increase in annual average PM2.5 exposure was associated with an increased risk of death and kidney failure (HR = 1.58, 95 % CI: 1.24-2.02). Black carbon showed the strongest association (HR = 2.14, 95 % CI: 1.47-3.12). Higher 3-year average exposures to PM2.5 and its constituents were significantly associated with higher baseline SLEDAI scores. CONCLUSIONS These findings highlight the significant role of environmental pollutants in cLN progression and emphasize the need for strategies to mitigate exposure to harmful PM2.5 constituents, particularly in vulnerable pediatric populations.
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Affiliation(s)
- Guohua He
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Yaqi Wang
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing 100191, China
| | - Cheng Cheng
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Jianhui Guo
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing 100191, China
| | - Zhilang Lin
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Ziyun Liang
- The First Clinical School of Medicine, Southern Medical University, Guangzhou 510091, China
| | - Bei Jin
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Liyuan Tao
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing 100191, China
| | - Liping Rong
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Lizhi Chen
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Tianxin Lin
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China; Guangdong Provincial Clinical Research Centre for Urological Diseases, Guangzhou 510120, China
| | - Yining Hua
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, Boston, MA 02115, USA
| | - Seungkyo Park
- Division of Integrated Medicine, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul 03722, Republic of Korea
| | - Ying Mo
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Jing Li
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing 100191, China.
| | - Xiaoyun Jiang
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China.
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Roussel M, Bacchetta J, Sellier-Leclerc AL, Lemoine S, De Mul A, Derain Dubourg L. Creatinine-based formulas are not ideal to estimate glomerular filtration rate in selected pediatric patients: data from a tertiary pediatric nephrology center. Pediatr Nephrol 2024; 39:3023-3036. [PMID: 38884786 DOI: 10.1007/s00467-023-06275-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 06/18/2024]
Abstract
BACKGROUND Evaluating glomerular filtration rate (GFR) remains challenging in pediatrics; new formulas were developed to increase performance of GFR estimation (eGFR). We aimed to evaluate the recently published formulas as applied to another pediatric population. METHODS A retrospective study was conducted in a cohort of 307 patients with a "kidney risk" (mean age 12.1 ± 4.5 years, sex ratio 1/1) assessed in a tertiary pediatric nephrology center and a mean measured GFR (mGFR) using plasma iohexol clearance of 85.5 ± 25.3 mL/min/1.73 m2; creatinine levels were measured by IDMS-standardized enzymatic method and cystatin C by immunonephelometry. The following eGFRs were calculated: Schwartz2009, Schwartz-Lyon, CKiDU25creat, and EKFC for eGFR using creatinine (eGFR-creat), CKiDU25cys and FAScys for eGFR using cystatin (eGFR-cys) as well as combined SchwartzCreat-Cys, average (CKiDU25creat-CKiDU25cys), and average (EKFC-FAScys) for eGFR using both biomarkers. The performance of the different formulas was evaluated compared to mGFR by absolute bias measurement and accuracy (p10%, p30%). Results are expressed as mean ± SD. RESULTS Creatinine-based formulas and especially the new CKiDU25 and EKFC overestimate GFR, even in children with normal kidney function. However, the bias is constant with these two formulas whatever the age group or gender, contrary to the previously published formulas. In contrast, cystatin C-based equations and combined formulas showed good performance in all age groups and all medical conditions with an acceptable bias and p30%. CONCLUSIONS In our pediatric population, the performance of all creatinine-based formulas is inadequate with significant GFR overestimation, mainly in subjects with mGFR > 75 mL/min/1.73 m2. Conversely, cystatin C-based or combined formulas have acceptable performance in patients followed in a tertiary pediatric nephrology unit.
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Affiliation(s)
- Mathilde Roussel
- Service de Néphrologie Rhumatologie et Dermatologie Pédiatrique, Centre de Référence Des Maladies Rénales Rares, Filière Maladies Rares ORKID and ERKNet, Hospices Civils de Lyon, Bron, France
| | - Justine Bacchetta
- Service de Néphrologie Rhumatologie et Dermatologie Pédiatrique, Centre de Référence Des Maladies Rénales Rares, Filière Maladies Rares ORKID and ERKNet, Hospices Civils de Lyon, Bron, France
- Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France
- INSERM 1033 Research Unit, Université de Lyon, Lyon, France
| | - Anne Laure Sellier-Leclerc
- Service de Néphrologie Rhumatologie et Dermatologie Pédiatrique, Centre de Référence Des Maladies Rénales Rares, Filière Maladies Rares ORKID and ERKNet, Hospices Civils de Lyon, Bron, France
| | - Sandrine Lemoine
- Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France
- Hospices Civils de Lyon, Hôpital E. Herriot, Service de Néphrologie, Dialyse, Hypertension et Exploration Fonctionnelle Rénale, 69003, Lyon, France
- CarMeN Laboratory, Inserm U1060, INRA U1397, Université Claude Bernard Lyon 1, 69500, Bron, France
| | - Aurélie De Mul
- Service de Néphrologie Rhumatologie et Dermatologie Pédiatrique, Centre de Référence Des Maladies Rénales Rares, Filière Maladies Rares ORKID and ERKNet, Hospices Civils de Lyon, Bron, France
- Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France
- Hospices Civils de Lyon, Hôpital E. Herriot, Service de Néphrologie, Dialyse, Hypertension et Exploration Fonctionnelle Rénale, 69003, Lyon, France
| | - Laurence Derain Dubourg
- Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France.
- Hospices Civils de Lyon, Hôpital E. Herriot, Service de Néphrologie, Dialyse, Hypertension et Exploration Fonctionnelle Rénale, 69003, Lyon, France.
- University of Lyon 1, CNRS UMR 5305, Lyon, France.
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Nkoy AB, Matoka TT, Bukabau JB, Sumaili EK, Labarque V, van den Heuvel LP, Levtchenko E, Cavalier E, Delanaye P, Ekulu PM, Pottel H. Estimated glomerular filtration rate: applicability of creatinine-based equations in African children. Pediatr Nephrol 2024; 39:3013-3022. [PMID: 38546762 DOI: 10.1007/s00467-024-06349-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/20/2024] [Accepted: 03/05/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND The Schwartz equation is the most widely used serum creatinine (SCr)-based formula to estimate the glomerular filtration rate (GFR) in children of European descent, but whether this applies to African children is unclear. METHODS In a cross-sectional study, 513 apparently healthy African children aged 6 to 16 years were randomly recruited in school area of Kinshasa, the Democratic Republic of Congo (DRC). SCr was measured using calibrated enzymatic method. SCr was normalized using Q-values designed for European descent children, due to the absence of Q-values for African children. Commonly used eGFR equations were applied in this population. RESULTS Normalization of SCr using Q-values for European descent children was effective in this cohort. The majority of African children (93.4%) have normalized SCr (SCr/Q) values within the reference interval (0.67-1.33) of children of European descent. The bedside-Schwartz equation was associated with significant age and sex dependency. However, the FAS-Age formula showed no sex and age dependency. The new CKiDU25 equation did not show a significant sex dependency. The recently introduced EKFC and LMR18 equations also showed no age and sex dependency, although the distribution of eGFR-values was not symmetrical. On the other hand, the FAS-Height and the Schwartz-Lyon equations showed significant sex dependency but no age dependency. CONCLUSIONS The reference interval for SCr designed for European descent children can be applied to African children. Of all the equations studied, FAS-Age performed best and is most suitable because no height measurements are required. Establishment of specific Q-values for the widespread Jaffe-measured creatinine in Africa can further broaden applicability.
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Affiliation(s)
- Agathe Bikupe Nkoy
- Division of Nephrology, Department of Pediatrics, University Hospital of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo.
- Laboratory of Pediatric Nephrology, Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - Therance Tobo Matoka
- Division of Nephrology, Department of Pediatrics, University Hospital of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Justine Busanga Bukabau
- Division of Nephrology, Department of Internal Medicine, University Hospital of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Ernest Kiswaya Sumaili
- Division of Nephrology, Department of Internal Medicine, University Hospital of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Veerle Labarque
- Department of Pediatric Hematology, University Hospital Leuven, Leuven, Belgium
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Lambertus P van den Heuvel
- Laboratory of Pediatric Nephrology, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pediatric Nephrology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Elena Levtchenko
- Laboratory of Pediatric Nephrology, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pediatric Nephrology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Etienne Cavalier
- Division of Clinical Chemistry, CHU Sart Tilman, University of Liège, Liège, Belgium
| | - Pierre Delanaye
- Department of Nephrology, Dialysis, Hypertension and Transplantation, CHU Sart Tilman, University of Liège , Liège, Belgium
- Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
| | - Pépé Mfutu Ekulu
- Division of Nephrology, Department of Pediatrics, University Hospital of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Hans Pottel
- Department of Public Health and Primary Care, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
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Filler G, Guzmán Núñez APM. The need for validation of eGFR formulae in different populations. Pediatr Nephrol 2024; 39:2827-2829. [PMID: 38502223 DOI: 10.1007/s00467-024-06351-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 03/21/2024]
Affiliation(s)
- Guido Filler
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, 800 Commissioners Road East, London, ON, N6A 5W9, Canada.
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5W9, Canada.
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada.
- Child Health Research Institute, Part of Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada.
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Sachan N, Dabas A, Mantan M, Dabla PK. Urinary biomarkers NG AL and beta-2 microglobulin in children with type 1 diabetes mellitus. J Pediatr Endocrinol Metab 2024; 37:764-772. [PMID: 39166792 DOI: 10.1515/jpem-2024-0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 07/14/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVES To study the urinary neutrophil gelatinase-associated lipocalin (NGAL) and beta-2-microglobulin (β2M) levels as markers of tubular damage in children with type 1 diabetes (T1DM). METHODS Forty T1DM children and 40 age-matched controls were enrolled. Subjects with coexisting kidney disorder, intake of oral glucose lowering drugs and syndromic diabetes mellitus were excluded. Fasting plasma glucose, glycated hemoglobin (HbA1c), kidney function, urinary albumin-creatinine ratio (UACR), NGAL and β2M were measured and compared in cases and controls. RESULTS The median (IQR) age of cases and controls was 10.6 (8, 14.2) and 10.7 (8.4, 13.7) years, respectively. Cases had disease duration of 4 (3, 6.8) years and HbA1c 10.9 (9, 13.1) %. Microalbuminuria was seen in 14 (35 %). Median (IQR) levels of UACR were higher in cases than controls [19.38 (10.27, 35.26) and 6.49 (3.10, 11.65) µg/mg; p<0.001], similarly NGAL/creatinine [352.21 (191.49, 572.45) and 190.54 (125.91, 322.83) ng/mg; p=0.006], unlike β2M/creatinine [1.7 (0.43, 6.02) and 2.12 (1.05, 4.47) µg/mg; p=0.637]. Children with higher HbA1c (≥10 %) had higher urinary ACR and tubular biomarkers than HbA1c<10 % (p>0.05). Urinary ACR showed positive correlation with NGAL/creatinine (r=0.38, p=0.019) and β2M/creatinine (r=0.42, p=0.009). CONCLUSIONS Urinary biomarkers NGAL and β2M were elevated in the presence of normal urinary microalbumin levels suggestive of early tubular damage in T1DM.
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Affiliation(s)
- Nimisha Sachan
- Department of Pediatrics, 28862 Maulana Azad Medical College and Lok Nayak Hospital , New Delhi, India
| | - Aashima Dabas
- Department of Pediatrics, 28862 Maulana Azad Medical College and Lok Nayak Hospital , New Delhi, India
| | - Mukta Mantan
- Department of Pediatrics, 28862 Maulana Azad Medical College and Lok Nayak Hospital , New Delhi, India
| | - Pradeep K Dabla
- Department of Biochemistry, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Elliott MD, Vena N, Marasa M, Cocchi E, Bheda S, Bogyo K, Shang N, Zanoni F, Verbitsky M, Wang C, Kolupaeva V, Jin G, Sofer M, Gras Pena R, Canetta PA, Bomback AS, Guay-Woodford LM, Hou J, Gillespie BW, Robinson BM, Klein JB, Rheault MN, Smoyer WE, Greenbaum LA, Holzman LB, Falk RJ, Parsa A, Sanna-Cherchi S, Mariani LH, Kretzler M, Kiryluk K, Gharavi AG. Increased risk of kidney failure in patients with genetic kidney disorders. J Clin Invest 2024; 134:e178573. [PMID: 39225089 PMCID: PMC11364380 DOI: 10.1172/jci178573] [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: 12/15/2023] [Accepted: 07/10/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUNDIt is unknown whether the risk of kidney disease progression and failure differs between patients with and without genetic kidney disorders.METHODSThree cohorts were evaluated: the prospective Cure Glomerulonephropathy Network (CureGN) and 2 retrospective cohorts from Columbia University, including 5,727 adults and children with kidney disease from any etiology who underwent whole-genome or exome sequencing. The effects of monogenic kidney disorders and APOL1 kidney-risk genotypes on the risk of kidney failure, estimated glomerular filtration rate (eGFR) decline, and disease remission rates were evaluated along with diagnostic yields and the impact of American College of Medical Genetics secondary findings (ACMG SFs).RESULTSMonogenic kidney disorders were identified in 371 patients (6.5%), high-risk APOL1 genotypes in 318 (5.5%), and ACMG SFs in 100 (5.2%). Family history of kidney disease was the strongest predictor of monogenic disorders. After adjustment for traditional risk factors, monogenic kidney disorders were associated with an increased risk of kidney failure (hazard ratio [HR] = 1.72), higher rate of eGFR decline (-3.06 vs. 0.25 mL/min/1.73 m2/year), and lower risk of complete remission (odds ratioNot achieving CR = 5.25). High-risk APOL1 genotypes were associated with an increased risk of kidney failure (HR = 1.67) and faster eGFR decline (-2.28 vs. 0.25 mL/min/1.73 m2), replicating prior findings. ACMG SFs were not associated with personal or family history of associated diseases, but were predicted to impact care in 70% of cases.CONCLUSIONSMonogenic kidney disorders were associated with an increased risk of kidney failure, faster eGFR decline, and lower rates of complete remission, suggesting opportunities for early identification and intervention based on molecular diagnosis.TRIAL REGISTRATIONNA.FUNDINGNational Institute of Diabetes and Digestive and Kidney Diseases grants U24DK100845 (formerly UM1DK100845), U01DK100846 (formerly UM1DK100846), U01DK100876 (formerly UM1DK100876), U01DK100866 (formerly UM1DK100866), U01DK100867 (formerly UM1DK100867), U24DK100845, DK081943, RC2DK116690, 2U01DK100876, 1R01DK136765, 5R01DK082753, and RC2-DK122397; NephCure Kidney International; Department of Defense Research Awards PR201425, W81XWH-16-1-0451, and W81XWH-22-1-0966; National Center for Advancing Translational Sciences grant UL1TR001873; National Library of Medicine grant R01LM013061; National Human Genome Research Institute grant 2U01HG008680.
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Affiliation(s)
- Mark D. Elliott
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Natalie Vena
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Maddalena Marasa
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Enrico Cocchi
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- Neonatal and Pediatric Intensive Care Unit, Bufalini Hospital, AUSL Romagna, Ravenna, Italy
| | - Shiraz Bheda
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Kelsie Bogyo
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Ning Shang
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Francesca Zanoni
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Miguel Verbitsky
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Chen Wang
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Victoria Kolupaeva
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Gina Jin
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Maayan Sofer
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Rafael Gras Pena
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Pietro A. Canetta
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Andrew S. Bomback
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Lisa M. Guay-Woodford
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jean Hou
- Department of Laboratory Medicine and Pathology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | | | - Bruce M. Robinson
- Department of Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jon B. Klein
- Department of Internal Medicine, Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Robley Rex VA Medical Center, Louisville, Kentucky, USA
| | - Michelle N. Rheault
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - William E. Smoyer
- Department of Pediatrics, The Research Institute at Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Larry A. Greenbaum
- Department of Pediatrics, Division of Pediatric Nephrology, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Larry B. Holzman
- Perelman School of Medicine, Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ronald J. Falk
- Department of Medicine, Division of Nephrology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Afshin Parsa
- Division of Kidney, Urologic & Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, Maryland, USA
| | - Simone Sanna-Cherchi
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- Institute for Genomic Medicine, Columbia University, New York, New York, USA
| | - Laura H. Mariani
- Department of Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthias Kretzler
- Department of Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Krzysztof Kiryluk
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Ali G. Gharavi
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
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7
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Zeitler EM, Glenn DA, Hu Y, Falk RJ, Hogan SL, Mottl AK. Association of Obesity With Kidney and Cardiac Outcomes Among Patients With Glomerular Disease: Findings From the Cure Glomerulonephropathy Network. Am J Kidney Dis 2024; 84:306-319.e1. [PMID: 38750877 PMCID: PMC11344669 DOI: 10.1053/j.ajkd.2024.03.020] [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: 07/25/2023] [Revised: 02/18/2024] [Accepted: 03/09/2024] [Indexed: 07/10/2024]
Abstract
RATIONALE & OBJECTIVE The influence of obesity on cardiorenal outcomes in individuals with glomerular disease is incompletely known. This study examined the association between obesity and kidney and cardiovascular outcomes in children and adults with glomerular kidney disease. STUDY DESIGN Prospective, multicenter, observational study. SETTING & PARTICIPANTS Participants in the Cure Glomerulonephropathy Network (CureGN) who were≥5 years of age at enrollment. EXPOSURE Adult body mass index (BMI) groups: 20-24 (healthy) versus 25-34 (overweight/class 1 obesity) versus≥35 (class 2-3 obesity); and pediatric BMI percentiles: 5th-84th (healthy) versus 85th-94th (overweight) versus≥95th (obese). OUTCOME A composite kidney outcome (40% estimated glomerular filtration rate [eGFR] decline or kidney failure) and a composite cardiovascular outcome (myocardial infarction, stroke, heart failure, or death). ANALYTICAL APPROACH Time to composite primary outcomes by BMI strata were estimated using Kaplan-Meier analysis. The adjusted associations between BMI and outcomes were estimated using Cox proportional hazards analysis. RESULTS The study included 2,301 participants (1,548 adults and 753 children). The incidence of the primary kidney end point was 90.8 per 1,000 person-years in adults with class 2-3 obesity, compared with 58.0 in normal weight comparators. In the univariable analysis, class 2-3 obesity was associated with the primary kidney outcome only in adults (HR, 1.6 [95% CI, 1.1-2.2], P=0.006) compared with the healthy weight groups. In the multivariable adjusted analysis, class 2-3 obesity did not remain significant among adults when controlling for baseline eGFR and proteinuria. Adults with class 2-3 obesity had an incidence of 19.7 cardiovascular events per 1,000 person-years and greater cardiovascular risk (HR, 3.9 [95% CI, 1.4-10.7], P=0.009) in the fully adjusted model. LIMITATIONS BMI is an imperfect indicator of adiposity. Residual confounding may exist from socioeconomic factors. CONCLUSIONS Among adult patients in CureGN, class 2-3 obesity is associated with cardiovascular but not kidney outcomes when adjusted for potential confounding factors. PLAIN-LANGUAGE SUMMARY Obesity is a risk factor for adverse heart and kidney outcomes in patients with chronic kidney disease, but whether it is associated with these outcomes in patients with glomerulonephropathy is not known. This study used existing data from a large sample of adults and children with glomerular diseases to address this question. The findings suggest that obesity increases the risk of cardiovascular but not kidney disease events in adult patients with glomerular disease.
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Affiliation(s)
- Evan M Zeitler
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Dorey A Glenn
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Yichun Hu
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Susan L Hogan
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Amy K Mottl
- Division of Nephrology and Hypertension, Department of Medicine, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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8
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Flogelova H, Bouchalova K, Smakal O, Halek J, Langova K, Cizkova K. Early diagnosis of solitary functioning kidney: comparing the prognosis of kidney agenesis and multicystic dysplastic kidney. Pediatr Nephrol 2024; 39:2645-2654. [PMID: 38622348 PMCID: PMC11272688 DOI: 10.1007/s00467-024-06360-2] [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: 12/19/2023] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Individuals with congenital solitary functioning kidney (SFK) are at an increased risk of kidney damage. According to some studies, the risk is higher in unilateral kidney agenesis (UKA) than in unilateral multicystic dysplastic kidney (UMCDK). We hypothesized that with early detection of children with UKA and UMCDK, there would be no difference in the presence of hypertension, proteinuria, and reduced glomerular filtration rate (GFR) between UKA and UMCDK. METHODS Based on a long-term follow-up protocol, we evaluated a cohort of 160 children followed from birth for SFK (84 with UKA and 76 with UMCDK) detected by prenatal or routine neonatal ultrasound screening. Hypertension, proteinuria, and reduced GFR were monitored as markers of kidney damage. We compared the characteristics and outcomes of the subgroups of children with UKA and UMCDK. RESULTS GFR was reduced in 42 (26.2%) children, of whom 41 showed only mild reduction. Hypertension and proteinuria were found in 22 (13.8%) and 14 (8.8%) children, respectively. Combined kidney damage was present in 57 (35.6%) children. The UMCDK and UKA subgroups differed in GFR at final examination, with UMCDK patients being significantly more likely to have normal GFR compared to UKA patients (82% vs. 67%; p = 0.039). CONCLUSIONS One third of the children showed signs of SFK damage, albeit mild. Patients with UKA had reduced GFR significantly more often than those with UMCDK, but did not differ in the rates of hyperfiltration injury or congenital anomalies of the kidneys and urinary tract (CAKUT) in SFK.
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Affiliation(s)
- Hana Flogelova
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Zdravotniku 248/7, 779 00, Olomouc, Czech Republic.
| | - Katerina Bouchalova
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Zdravotniku 248/7, 779 00, Olomouc, Czech Republic
| | - Oldrich Smakal
- Department of Urology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Jan Halek
- Department of Neonatology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Katerina Langova
- Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Katerina Cizkova
- Department of Histology and Embryology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
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9
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Cirrincione LR, Huang KJ, Sequeira GM. Clinical pharmacology in adolescent transgender medicine. Br J Clin Pharmacol 2024. [PMID: 39187392 DOI: 10.1111/bcp.16213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 08/28/2024] Open
Abstract
Adolescent transgender medicine is a growing clinical field. Gender-affirming medications for transgender youth may include gonadotropin-releasing hormone (GnRH) agonists, gender-affirming hormones or both. To evaluate the potential effects of GnRH agonists (puberty suppression) on pharmacokinetic processes for transgender youth, we searched PubMed from inception to May 2024 for publications on the effects of GnRH agonists on drug absorption, distribution, metabolism or excretion for transgender adolescents or effects on hormones (including gonadotropins, adrenal androgens, sex steroids) that are associated with changes in drug metabolism during puberty in the general adolescent population. No publications discussed the effects of GnRH agonist treatment on pharmacokinetic processes for adolescent transgender people. Sixteen publications observed marked decreases in gonadotropins and sex steroids for both adolescent transgender men and adolescent transgender women and slight effects on adrenal androgens. During GnRH agonist treatment, changes in body composition and body shape were greater for adolescent transgender people than for cisgender adolescent people. Further research is needed to better understand the effects of GnRH agonists on drug metabolism and other pharmacokinetic processes for transgender adolescents receiving GnRH agonists and other gender-affirming medications.
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Affiliation(s)
| | - Kai J Huang
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Gina M Sequeira
- Seattle Children's Hospital, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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10
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Pavia K, Girdwood ST, Paice K, Dong M, Mizuno T, Tang P, Mangeot C, Vinks AA, Kaplan J. Acute kidney injury is associated with abnormal cefepime exposure among critically ill children and young adults. Pediatr Nephrol 2024:10.1007/s00467-024-06477-4. [PMID: 39150525 DOI: 10.1007/s00467-024-06477-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 07/14/2024] [Accepted: 07/15/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Elevated cefepime blood concentrations can cause neurotoxicity in adults. The consequences of elevated cefepime concentrations among pediatric patients are unknown. Future exploration of such effects requires first identifying patients at risk for elevated cefepime exposure. We investigated the role of acute kidney injury as a risk factor for increased cefepime concentrations in critically ill children. METHODS This was a retrospective analysis at a single pediatric intensive care unit. Analyzed patients received at least 24 h of cefepime and had at least two opportunistic samples collected for total cefepime concentration measurement. Individual pharmacokinetic (PK) profiles during treatment courses were reconstructed using Bayesian estimation with an established population PK model. Elevated trough concentration (Cmin) was defined as ≥ 30 mg/L based on adult toxicity studies. The effect of kidney dysfunction on cefepime PK profiles was interrogated using a mixed-effect model. RESULTS Eighty-seven patients were included, of which 13 (14.9%) had at least one estimated Cmin ≥ 30 mg/L. Patients with elevated Cmin were more likely to have acute kidney injury (AKI) during their critical illness (92% vs. 57%, p = 0.015 for any AKI; 62% vs. 26%, p = 0.019 for severe AKI). Patients who had AKI during critical illness had significantly higher cefepime exposure, as quantified by the area under the concentration-time curve over 24 h (AUC24h) and Cmin. CONCLUSIONS Among critically ill children, AKI is associated with elevated cefepime concentrations. Identifying these high-risk patients is the first step toward evaluating the clinical consequences of such exposures.
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Affiliation(s)
- Kathryn Pavia
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA.
| | - Sonya Tang Girdwood
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kelli Paice
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Min Dong
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Peter Tang
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Colleen Mangeot
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jennifer Kaplan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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11
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Choi N, Kim JH, Park PG, Lee H, Min J, Park HW, Ahn YH, Kang HG. Efficacy and safety of dapagliflozin in children with kidney disease: real-world data. Pediatr Nephrol 2024:10.1007/s00467-024-06481-8. [PMID: 39103536 DOI: 10.1007/s00467-024-06481-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/15/2024] [Accepted: 07/23/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, has shown results in slowing estimated glomerular filtration rate (eGFR) decline and reducing proteinuria in adult patients with chronic kidney disease. This retrospective study examines dapagliflozin's effects in 22 children with kidney disease and proteinuria. METHODS Children with a median age of 15.6 years were treated with dapagliflozin for > 3 months between July 2022 and December 2023. All children had been treated with either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for at least 1 month before starting dapagliflozin. RESULTS The most common kidney disease diagnoses in this study included Alport syndrome (n = 7) and medication-resistant nephrotic syndrome or focal segmental glomerulosclerosis (n = 7). After 6.1 months of treatment, dapagliflozin treatment did not result in significant changes in eGFR or proteinuria. However, at the latest follow-up, a statistically significant decrease in eGFR was noted (65.5 compared to the baseline 71.1 mL/min/1.73 m2, P = 0.003). Proteinuria remained stable between baseline and the last follow-up (final spot urine protein/creatinine ratio (uPCR) 0.7 vs. baseline uPCR 0.6 mg/mg, P = 0.489). In the subgroup analysis of children treated for > 8 months, the eGFR decline post-treatment changed from - 0.5 to - 0.2 ml/min/1.73 m2 per month (P = 0.634). Only two children discontinued dapagliflozin due to suspected adverse events. CONCLUSIONS Dapagliflozin has not been associated with serious side effects. Further prospective clinical trials are needed to confirm the efficacy and safety of dapagliflozin in children with kidney disease.
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Affiliation(s)
- Naye Choi
- Department of Pediatrics, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Ji Hyun Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Peong Gang Park
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Hyeonju Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Jeesu Min
- Department of Pediatrics, Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Hye Won Park
- Suwon Center for Environmental Disease Atopy, Ajou University Hospital, Suwon, Republic of Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.
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Fulchiero R, Galea L, Hewlett J, Savant JD, Lopez S, Amaral S, Viteri B. Bortezomib for antibody-mediated rejection of kidney transplant in youth: Associations with donor-specific antibody. Pediatr Transplant 2024; 28:e14774. [PMID: 38808699 PMCID: PMC11189613 DOI: 10.1111/petr.14774] [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: 12/05/2023] [Revised: 04/12/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Antibody-mediated rejection is one of the most significant risk factors for allograft dysfunction and failure in children and adolescents with kidney transplants, yet optimal treatment remains unidentified. To date, there are mixed findings regarding the use of Bortezomib, a plasma cell apoptosis inducer, as an adjunct therapy in the treatment of antibody-mediated rejection. METHODS In a retrospective single center study, we reviewed the efficacy and tolerability of bortezomib as adjunct therapy for treatment-refractory antibody-mediated rejection. RESULTS Six patients with a median age of 14.6 years (range 6.9-20.1 years) received bortezomib at a mean of 71 months (range 15-83 months) post-kidney transplant. Four patients experienced decline in estimated glomerular filtration rate (eGFR) from 4% to 42%. One patient started bortezomib while on hemodialysis and did not recover graft function, and another patient progressed to hemodialysis 6 months after receiving bortezomib. Although DSA did not completely resolve, there was a statistically significant decline in DSA MFI pre and 12-months post-BZ (p = .012, paired t-test) for the subjects who were not on dialysis at the time of bortezomib. Chronic Allograft Damage Index (CADI) score of ≥3 was seen in all six subjects at their biopsy prior to therapy. No adverse effects were reported. CONCLUSIONS Bortezomib was well tolerated and resulted in improvements in MFI of DSA among four pediatric subjects without allograft failure, although no effects were observed on eGFR trajectory. Further studies are needed to clarify whether earlier intervention with bortezomib could prevent renal failure progression.
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Affiliation(s)
- Rosanna Fulchiero
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Nephrology Division, Inova Children's Hospital, Falls Church, Virginia, USA
| | - Lauren Galea
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer Hewlett
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jonathan D Savant
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sonya Lopez
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sandra Amaral
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bernarda Viteri
- Nephrology Division, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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13
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Alao MA, Ibrahim OR, Asinobi AO, Ademola DA, Ekrikpo UE, Olowu WA. Evaluation of eGFR methods in a sub-Saharan African community-based pediatric population. Pediatr Nephrol 2024; 39:2435-2449. [PMID: 38488898 DOI: 10.1007/s00467-024-06323-7] [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: 10/14/2023] [Revised: 02/09/2024] [Accepted: 02/09/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Accurate assessment of the estimated glomerular filtration rate (eGFR) plays a pivotal role in the early detection, management, and optimal medication dosing for chronic kidney disease (CKD). However, validation of eGFR, utilizing cystatin C-based equations, is limited in African children and adolescents with CKD. We evaluate the agreement of eGFR equations incorporating both cystatin C and creatinine in this specific population. METHODS This community-based study assessed CKD in children (2-15 years) using cystatin C and serum creatinine. eGFR agreement with the reference was evaluated with Bland-Altman plots, ROC curves, and Lin's CCC, using the Under-25 serum creatinine-cystatin C equation as the reference standard. Pairwise ROC comparisons assess the statistical differences in estimation equation agreement. RESULTS Among 666 children (mean age, 7.8 ± 3.8 years; 48.6% male), CKD prevalence was 11.6% (95% CI, 9.2-14.2%). Notably, the Chehade equation, using combined biomarkers, aligned best with the reference, displaying the lowest mean deviation (- 0.59; 95% CI, - 1.19 to 0.01), superior agreement (P10, 91.0%; P30, 96.70%), and highest discriminatory power (0.989). In contrast, CKD-EPI 2012 cystatin C had the highest mean deviation (- 35.90) and lowest discriminatory power (0.79). Equations combining creatinine and cystatin C (Schwartz, Chehade, Full Age Spectrum) demonstrated strong positive Lin's CCC with CKiD U25 creatinine-cystatin C, while Bouvet showed a notably weak correlation (Lin's CCC, 0.22). CONCLUSION In African children with CKD, the Chehade, CKiD Under 25 creatinine-based equations, and the Full Age Spectrum equations show promise for CKD diagnosis. However, a measured GFR is essential to identifying the most accurate eGFR equation in this population.
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Affiliation(s)
- Michael Abel Alao
- College of Medicine, University of Ibadan, CW22+H4W, Queen Elizabeth I I Road, Agodi, Ibadan, 200285, Oyo, Nigeria.
| | | | - Adanze Onyenonachi Asinobi
- College of Medicine, University of Ibadan, CW22+H4W, Queen Elizabeth I I Road, Agodi, Ibadan, 200285, Oyo, Nigeria
| | - Debo Adebowale Ademola
- College of Medicine, University of Ibadan, CW22+H4W, Queen Elizabeth I I Road, Agodi, Ibadan, 200285, Oyo, Nigeria
| | | | - Wasiu Adekunle Olowu
- Paediatric Nephrology and Hypertension Unit, Obafemi Awolowo University Teaching Hospitals Complex, Obafemi Awolowo University, PMB 5538, Ile-Ife, 220005, Osun, Nigeria
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14
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Filler G, Emile D. Should We Switch to the U25 Creatinine and CysC eGFR to Monitor Pediatric Kidney Transplant Recipients? Pediatr Transplant 2024; 28:e14805. [PMID: 38853136 DOI: 10.1111/petr.14805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/27/2024] [Indexed: 06/11/2024]
Affiliation(s)
- Guido Filler
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
- Child Health Research Institute, Part of Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Dougenie Emile
- Department of Pediatrics, Hôpital Universitaire de Mirebalais, Port-au-Prince, Haiti
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Isaac JS, Troost JP, Wang Y, Garrity K, Kaskel F, Gbadegesin R, Reidy KJ. Association of Preterm Birth with Adverse Glomerular Disease Outcomes in Children and Adults. Clin J Am Soc Nephrol 2024; 19:1016-1024. [PMID: 38728081 PMCID: PMC11321729 DOI: 10.2215/cjn.0000000000000475] [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: 11/23/2023] [Accepted: 05/06/2024] [Indexed: 05/12/2024]
Abstract
Key Points Preterm birth was a risk factor for adverse outcomes in this heterogeneous cohort of children and adults with glomerular disease. In analyses adjusted for diagnosis and apolipoprotein L1 risk status, there was less remission and faster progression of kidney disease in those born preterm. A novel finding from this study is that adults born preterm were more likely to have an apolipoprotein L1 high-risk genotype. Background While some studies of children with nephrotic syndrome have demonstrated worse outcomes in those born preterm compared with term, little data exist on associations of preterm birth with outcomes in adult-onset glomerular disease. Cardiovascular outcomes in those born preterm with glomerular disease are unknown. Methods We performed a cross-sectional and longitudinal analysis of participants in the Cure Glomerulonephropathy cohort. Preterm (<37 weeks' gestation) was compared with term (≥37 weeks' gestation). A survival analysis and adjusted Cox proportional hazards model were used to examine a composite outcome of 40% decline in eGFR or progression to kidney failure. An adjusted logistic regression model was used to examine remission of proteinuria. Results There were 2205 term and 235 preterm participants. Apolipoprotein L1 (APOL1 ) risk alleles were more common in those born preterm. More pediatric than adult participants in Cure Glomerulonephropathy were born preterm: 12.8% versus 7.69% (P < 0.001). Adults born preterm compared with term had a higher prevalence of FSGS (35% versus 25%, P = 0.01) and APOL1 high-risk genotype (9.4% versus 4.2%, P = 0.01). Participants born preterm had a shorter time interval to a 40% eGFR decline/kidney failure after biopsy (P = 0.001). In adjusted analysis, preterm participants were 28% more likely to develop 40% eGFR decline/kidney failure (hazard ratio: 1.28 [1.07 to 1.54], P = 0.008) and 38% less likely to attain complete remission of proteinuria (odds ratio: 0.62 [0.45 to 0.87], P = 0.006). There was no significant difference in cardiovascular events. Conclusions Preterm birth was a risk factor for adverse outcomes in this heterogeneous cohort of children and adults with glomerular disease. Adults born preterm were more likely to have an APOL1 high-risk genotype and FSGS. In analyses adjusted for FSGS and APOL1 risk status, there was less remission and faster progression of kidney disease in those born preterm.
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Affiliation(s)
- Jaya S. Isaac
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital at Montefiore/Einstein, Bronx, New York
| | - Jonathan P. Troost
- Michigan Institute for Clinical Health Research, University of Michigan, Ann Arbor, Michigan
| | - Yujie Wang
- Medical Data Science Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Kelly Garrity
- Division of Pediatric Nephrology, Department of Pediatrics, University of California Los Angeles, Los Angeles, California
| | - Frederick Kaskel
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital at Montefiore/Einstein, Bronx, New York
| | - Rasheed Gbadegesin
- Division of Pediatric Nephrology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Kimberly J. Reidy
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Hospital at Montefiore/Einstein, Bronx, New York
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16
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White CA, Gaynor-Sodeifi K, Norman PA, Furman M, Sochett E. Accuracy of Shorter Iohexol GFR Measurement Protocols in Individuals with Preserved Kidney Function. KIDNEY360 2024; 5:1178-1185. [PMID: 39008636 PMCID: PMC11371346 DOI: 10.34067/kid.0000000000000511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/08/2024] [Indexed: 07/17/2024]
Abstract
Key Points Shorter measured GFR protocols are accurate and precise compared with the reference standard measured GFR protocol in patients with preserved GFR. These shorter protocols can potentially improve the adoption of GFR measurement more widely by reducing procedural time and cost. Background Measured GFR (mGFR) using exogenous tracers is recommended in a number of settings. Plasma one-compartment multisample protocols (MSPs) are the most commonly used, with iohexol being the dominant tracer. The accuracy of MSPs has mostly been evaluated in the setting of reduced GFR where delayed initial and final samples are recommended. Much less is known about MSPs when GFR is not decreased, and the default protocol tends to include initial sampling at 120 minutes and final sampling at 240 minutes after iohexol injection. The recent Kidney Disease Improving Global Outcomes 2024 Clinical Practice Guideline for the Evaluation and Management of CKD includes research recommendations for the development of shorter more efficient mGFR protocols. The objective of this study was to assess the performance of shorter MSPs with earlier initial (60 and 90 minutes) and final (150, 180, and 210 minutes) sampling times in individuals with preserved GFR. Reference mGFR (R-mGFR) was calculated using five samples collected between 120 and 240 minutes. Methods Four different combinations of shorter sampling strategies were investigated. Performance was evaluated using measurements of bias, precision, and accuracy (P2, P5, and mean absolute error). Results The mean R-mGFR of the 43 participants was 102.3±13.7 ml/min per 1.73 m2. All shorter mGFRs had biases <1 ml/min per 1.73 m2 and mean absolute error <1.6 ml/min per 1.73 m2. All shorter mGFRs were within 5% of the R-mGFR, and the majority were within 2%. Conclusions These results demonstrate that shortening the mGFR procedure in individuals with preserved GFR provides similar results to the current standard while significantly decreasing procedure time.
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Affiliation(s)
- Christine A. White
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kaveh Gaynor-Sodeifi
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Patrick A. Norman
- Kingston Health Science Centre, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Michelle Furman
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Etienne Sochett
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Fan F, Liu Q, Zee J, Ozeki T, Demeke D, Yang Y, Farris AB, Wang B, Shah M, Jacobs J, Mariani L, Lafata K, Rubin J, Chen Y, Holzman L, Hodgin JB, Madabhushi A, Barisoni L, Janowczyk A. Clinical Relevance of Computationally Derived Tubular Features: Spatial Relationships and the Development of Tubulointerstitial Scarring in MCD/FSGS. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.07.19.24310619. [PMID: 39072032 PMCID: PMC11275675 DOI: 10.1101/2024.07.19.24310619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Background Visual scoring of tubular damage has limitations in capturing the full spectrum of structural changes and prognostic potential. We investigate if computationally quantified tubular features can enhance prognostication and reveal spatial relationships with interstitial fibrosis. Methods Deep-learning and image-processing-based segmentations were employed in N=254/266 PAS-WSIs from the NEPTUNE/CureGN datasets (135/153 focal segmental glomerulosclerosis and 119/113 minimal change disease) for: cortex, tubular lumen (TL), epithelium (TE), nuclei (TN), and basement membrane (TBM). N=104 pathomic features were extracted from these segmented tubular substructures and summarized at the patient level using summary statistics. The tubular features were quantified across the biopsy and in manually segmented regions of mature interstitial fibrosis and tubular atrophy (IFTA), pre-IFTA and non-IFTA in the NEPTUNE dataset. Minimum Redundancy Maximum Relevance was used in the NEPTUNE dataset to select features most associated with disease progression and proteinuria remission. Ridge-penalized Cox models evaluated their predictive discrimination compared to clinical/demographic data and visual-assessment. Models were evaluated in the CureGN dataset. Results N=9 features were predictive of disease progression and/or proteinuria remission. Models with tubular features had high prognostic accuracy in both NEPTUNE and CureGN datasets and increased prognostic accuracy for both outcomes (5.6%-7.7% and 1.6%-4.6% increase for disease progression and proteinuria remission, respectively) compared to conventional parameters alone in the NEPTUNE dataset. TBM thickness/area and TE simplification progressively increased from non- to pre- and mature IFTA. Conclusions Previously under-recognized, quantifiable, and clinically relevant tubular features in the kidney parenchyma can enhance understanding of mechanisms of disease progression and risk stratification.
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Affiliation(s)
- Fan Fan
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA, USA
| | - Qian Liu
- Children's Hospital of Philadelphia Research Institute, Philadelphia, PA
| | - Jarcy Zee
- Children's Hospital of Philadelphia Research Institute, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Takaya Ozeki
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Dawit Demeke
- Department of Pathology, University of Michigan, Ann Arbor, MI, United States
| | - Yingbao Yang
- Department of Pathology, University of Michigan, Ann Arbor, MI, United States
| | - Alton B Farris
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Bangcheng Wang
- Department of Pathology, Division of AI & Computational Pathology, Duke University, Durham, NC, United States
| | - Manav Shah
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA, USA
| | - Jackson Jacobs
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA, USA
| | - Laura Mariani
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Kyle Lafata
- Department of Radiation Oncology, Duke University, Durham, NC, United States
| | - Jeremy Rubin
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yijiang Chen
- Department of Radiation Oncology, School of Medicine, Stanford University, Stanford, CA, USA
| | - Lawrence Holzman
- Department of Medicine, Division of Nephrology and Hypertension, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeffrey B Hodgin
- Department of Pathology, University of Michigan, Ann Arbor, MI, United States
| | - Anant Madabhushi
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA, USA
- Atlanta Veterans Administration Medical Center, Atlanta, GA, USA
| | - Laura Barisoni
- Department of Pathology, Division of AI & Computational Pathology, Duke University, Durham, NC, United States
- Department of Medicine, Division of Nephrology, Duke University, Durham, NC, USA
| | - Andrew Janowczyk
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA, USA
- Department of Oncology, Division of Precision Oncology, University Hospital of Geneva, Geneva, Switzerland
- Department of Diagnostics, Division of Clinical Pathology, University Hospital of Geneva, Geneva, Switzerland
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18
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Harer M, Zapata H, Todurkar N, Favel K, Griffin R, Starr M, Charlton J, McAdams R, Askenazi D, Kulkarni T, Menon S, Mammen C. Association of delayed cord clamping with acute kidney injury and two-year kidney outcomes in extremely premature neonates: a secondary analysis of the Preterm Erythropoietin Neuroprotection Trial (PENUT). RESEARCH SQUARE 2024:rs.3.rs-4631779. [PMID: 39070632 PMCID: PMC11276018 DOI: 10.21203/rs.3.rs-4631779/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Background Delayed cord clamping (DCC) occurs in most preterm births. Objective Evaluate the association of DCC with acute kidney injury (AKI) and two-year kidney outcomes. Methods Secondary analysis of the Preterm Erythropoietin Neuroprotection Trial of neonates born 240/7 to 276/7 weeks' gestation. AKI and two year kidney outcomes were compared in neonates with DCC (≥30 seconds after delivery) to those with early cord clamping (ECC) (<30 seconds after delivery). Results The incidence and severity of AKI did not differ between the DCC and ECC groups (aOR 1.17 [95%CI 0.76-1.80]). At two years corrected age, DCC was associated with a 4.5-fold times increased adjusted odds of eGFR <90 mL/min/1.73m2. No significant associations were noted between DCC and albuminuria or elevated BP. Conclusions DCC was not associated with decreased neonatal AKI, but was associated with higher adjusted odds of eGFR <90 mL/min/1.73m2 at two years.
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Affiliation(s)
- Matthew Harer
- University of Wisconsin School of Medicine and Public Health
| | - Henry Zapata
- University of Florida School of Medicine -Jacksonville
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19
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Ha D, Halstead NV, Blanchette ED, Wilcox DT, Vemulakonda VM, Wood DN, Rove KO. Risk of acute kidney injury after lower urinary tract reconstruction with early NSAID therapy: A propensity matched retrospective analysis. J Pediatr Urol 2024:S1477-5131(24)00360-7. [PMID: 39089953 DOI: 10.1016/j.jpurol.2024.07.005] [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: 07/10/2023] [Revised: 06/17/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION The opioid epidemic response led to increased use of postoperative, non-opioid analgesia. Some pediatric urologists do not routinely use non-steroidal anti-inflammatory drugs (NSAIDs) for fear of causing acute kidney injury (AKI). While previous studies have demonstrated the safety and efficacy of NSAIDs in children, safety after lower urinary tract reconstruction has not been well characterized. OBJECTIVE ptUsing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for AKI (increase in creatinine ≥0.3 mg/dL or increase in creatinine ≥1.5x baseline or urine output <0.5 mL/kg/hr for 6 h), we hypothesized there would be a difference in the incidence of postoperative AKI between patients who did and did not receive NSAIDs following surgery. STUDY DESIGN Patients 2-18 years old who underwent lower urinary tract reconstruction (i.e., bladder augmentation and/or creation of a catheterizable channel) from 2009 to 2021 and had documented urine output were retrospectively reviewed. Chronic kidney disease (CKD) stage was calculated from creatinine and cystatin C within 6 months of surgery using the CKiD U25 equations. Patients who received NSAIDs were propensity matched on 11 characteristics with patients undergoing similar surgeries who did not receive NSAIDs. The primary outcome was incidence of AKI within 48 h of surgery. RESULTS The unmatched cohorts included 243 patients. Propensity matching identified 166 patients in the NSAID arm and 41 in the no NSAID arm. 26 patients with CKD stage 2-3 were included. There was no significant difference in the incidence of postoperative AKI based on any KDIGO criteria (17.1% no NSAID versus 16.3% NSAID, p = 0.87). Median postoperative opioids fell from 0.88 mg/kg in the no NSAID arm to 0.37 mg/kg morphine equivalents in the NSAID arm, although this was not statistically significant. Log-rank testing by Kaplan-Meier analysis demonstrated no difference in time to incidence of low urine output between the groups (p = 0.32). In the whole population not stratified by NSAID use, no differences were seen in AKI between those with and without CKD (16.7% with versus 17.9% without CKD). DISCUSSION There was no difference in the incidence of postoperative AKI among patients who did and did not receive NSAIDs after lower urinary tract reconstruction, excluding those with advanced CKD. CONCLUSION These results support that postoperative NSAIDs were an unlikely source of AKI. However, AKI remained a risk following these surgeries, regardless of NSAID use, likely owing to underlying disease, longer operations, and fluid shifts.
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Affiliation(s)
- Darren Ha
- Pediatric Urology Research Enterprise, Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - N Valeska Halstead
- Department of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA
| | - Eliza D Blanchette
- Department of Pediatrics, Division of Nephrology, Children's Hospital Colorado, Aurora, CO, USA
| | - Duncan T Wilcox
- Pediatric Urology Research Enterprise, Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Vijaya M Vemulakonda
- Pediatric Urology Research Enterprise, Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel N Wood
- Pediatric Urology Research Enterprise, Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Kyle O Rove
- Pediatric Urology Research Enterprise, Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA.
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20
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Li L, Huang X, Liu J, Li C, Lin Z, Ren R, Zhang Y, Ding H, Chen J, Mao Y. Efficacy and Safety Factors Related to Plasma Concentration-Optimized Polymyxin B Therapy in Treating Carbapenem-Resistant Gram-Negative Bacterial Infections in China. Infect Drug Resist 2024; 17:3057-3071. [PMID: 39050834 PMCID: PMC11268568 DOI: 10.2147/idr.s468890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 07/11/2024] [Indexed: 07/27/2024] Open
Abstract
Background Polymyxin B (PMB)-based combination therapies are used to treat severe carbapenem-resistant gram-negative bacterial (CR-GNB) infections. This observational study investigated the relationship between clinical factors, including PMB concentration, and clinical efficacy and safety. Patients and Methods Polymyxin B regimens were optimized through therapeutic drug monitoring (TDM) and area under the concentration-time curve (AUC). In all, 382 samples were tested from 130 patients. Logistic regression was used to analyze the relationships between variables with clinical efficacy and 30-day mortality factors were analyzed by Cox regression. The sensitivity and specificity of Cmin and AUC for the occurrence of acute kidney injury (AKI) were determined by ROC curve analysis. Results The clinical effectiveness of PMB was 65.4%. Multivariate logistic regression analysis revealed that lung infection, continuous renal replacement therapy, and C-reactive protein were independent factors significantly associated with efficacy. AKI occurred in 14.6% of the patients during treatment; age > 73 years (OR: 3.63; 95% CI: 1.035-12.727; P = 0.044), Cmin greater than 2.3 µg/mL (OR: 7.37; 95% CI: 1.571-34.580; P = 0.011), combined vancomycin (OR: 9.47; 95% CI: 1.732-51.731; P = 0.009), and combined piperacillin-tazobactam (OR: 21.87; 95% CI: 3.139-152.324; P = 0.002) were independent risk factors. The identified PMB cut-offs for predicting AKI were Cmin = 2.3 µg/mL and AUC = 82.0 mg h/L. Conclusion Polymyxin B-based combination regimens are effective in treating CR-GNB infections, particularly bloodstream infections, but have shown unsatisfactory for lung infections. Cmin ≥ 2.3 µg /mL and AUC ≥ 82.0 mg h/L may increase PMB-associated AKI incidence. PMB dose should be adjusted based on TDM to ensure efficacy.
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Affiliation(s)
- Lixia Li
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Xiaohui Huang
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Jingxian Liu
- Department of Clinical Laboratory, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Chao Li
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Zhiyan Lin
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Rongrong Ren
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Yan Zhang
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Haoshu Ding
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Jihui Chen
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Yanfei Mao
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
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21
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Dharnidharka VR, Scobell RR, Kallash M, Davies AJG, Marchesani N, Maltenfort MG, Walther L, Kelton M, Bock M, Blanchette E, Stone HK, Gluck C, Hullekes F, Riella LV, Smoyer WE, Mitsnefes M, Dixon BP, Flynn JT, Somers MJG, Forrest CB, Furth S, Denburg MR. Clinical characteristics and favorable treatment responses of recurrent focal segmental glomerulosclerosis or steroid-resistant nephrotic syndrome in children after kidney transplantation. Pediatr Nephrol 2024:10.1007/s00467-024-06452-z. [PMID: 39001911 DOI: 10.1007/s00467-024-06452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Recurrence of focal segmental glomerulosclerosis (FSGS) or steroid-resistant nephrotic syndrome (SRNS) after kidney transplant leads to significant morbidity and potentially earlier allograft loss. To date however, reported rates, risk factors and treatment outcomes have varied widely. METHODS We applied computational phenotypes to a multicenter aggregation of electronic health records data from 7 large pediatric health systems in the USA, to identify recurrence rates, risk factors, and treatment outcomes. We refined the data collection by chart review. RESULTS From > 7 million patients, we compared children with primary FSGS/SRNS who received a kidney transplant between 2009 and 2020 and who either developed recurrence (n = 67/165; 40.6%) or did not (n = 98/165). Serum albumin level at time of transplant was significantly lower and recipient HLA DR7 presence was significantly higher in the recurrence group. By 36 months post-transplant, complete remission occurred in 58.2% and partial remission in 17.9%. Through 6 years post-transplant, no remission after recurrence was associated with an increased risk of allograft loss over time (p < 0.0001), but any remission showed similar allograft survival and function decline to those with no recurrence. Since treatments were used in non-random fashion, using spline curves and multivariable non-linear analyses, complete + partial remission chance was significantly higher with greater plasmapheresis sessions, CTLA4-Ig doses or LDL-apheresis sessions. Only treatment with anti-CD20, CTLA4-Ig agents, or LDL-apheresis sessions were associated with complete remission. Excluding 25 patients with mutations did not significantly change our results. CONCLUSIONS Our contemporary high-risk cohort had higher favorable response rates than most prior reports, from combinations of agents.
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Affiliation(s)
- Vikas R Dharnidharka
- Washington University School of Medicine and St. Louis Children's Hospital, Room NWT 10-119, CB 8116, 660 South Euclid Avenue, St. Louis, MO, 63110, USA.
| | | | - Mahmoud Kallash
- Department of Pediatrics, The Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | | | | | | | - Leslie Walther
- Washington University School of Medicine and St. Louis Children's Hospital, Room NWT 10-119, CB 8116, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Megan Kelton
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Margret Bock
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Eliza Blanchette
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hillarey K Stone
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | - William E Smoyer
- Department of Pediatrics, The Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Mark Mitsnefes
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bradley P Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | | | | | - Susan Furth
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle R Denburg
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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22
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Reidy KJ, Guillet R, Selewski DT, Defreitas M, Stone S, Starr MC, Harer MW, Todurkar N, Vuong KT, Gogcu S, Askenazi D, Tipple TE, Charlton JR. Advocating for the inclusion of kidney health outcomes in neonatal research: best practice recommendations by the Neonatal Kidney Collaborative. J Perinatol 2024:10.1038/s41372-024-02030-1. [PMID: 38969825 DOI: 10.1038/s41372-024-02030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/21/2024] [Accepted: 06/06/2024] [Indexed: 07/07/2024]
Abstract
Acute kidney injury (AKI) occurs in nearly 30% of sick neonates. Chronic kidney disease (CKD) can be detected in certain populations of sick neonates as early as 2 years. AKI is often part of a multisystem syndrome that negatively impacts developing organs resulting in short- and long-term pulmonary, neurodevelopmental, and cardiovascular morbidities. It is critical to incorporate kidney-related data into neonatal clinical trials in a uniform manner to better understand how neonatal AKI or CKD could affect an outcome of interest. Here, we provide expert opinion recommendations and rationales to support the inclusion of short- and long-term neonatal kidney outcomes using a tiered approach based on study design: (1) observational studies (prospective or retrospective) limited to data available within a center's standard practice, (2) observational studies involving prospective data collection where prespecified kidney outcomes are included in the design, (3) interventional studies with non-nephrotoxic agents, and (4) interventional studies with known nephrotoxic agents. We also provide recommendations for biospecimen collection to facilitate ancillary kidney specific research initiatives. This approach balances the costs of AKI and CKD ascertainment with knowledge gained. We advocate that kidney outcomes be included routinely in neonatal clinical study design. Consistent incorporation of kidney outcomes across studies will increase our knowledge of neonatal morbidity.
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Affiliation(s)
- Kimberly J Reidy
- Division of Nephrology, Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | - Ronnie Guillet
- Division of Neonatology, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Marissa Defreitas
- Division of Nephrology, Department of Pediatrics, University of Miami/Holtz Children's Hospital, Miami, FL, USA
| | - Sadie Stone
- Department of Pharmacy, Children's of Alabama, Birmingham, AL, UK
| | - Michelle C Starr
- Division of Pediatric Nephrology, Division of Child Health Service Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Matthew W Harer
- Division of Neonatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Namrata Todurkar
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kim T Vuong
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Semsa Gogcu
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - David Askenazi
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Trent E Tipple
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Box 800386, Charlottesville, VA, 22903, USA.
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23
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van Dam MJCM, Pottel H, Delanaye P, Vreugdenhil ACE. The evaluation of kidney function estimation during lifestyle intervention in children with overweight and obesity. Pediatr Nephrol 2024:10.1007/s00467-024-06435-0. [PMID: 38963556 DOI: 10.1007/s00467-024-06435-0] [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: 04/24/2024] [Revised: 05/29/2024] [Accepted: 05/29/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Children with overweight and obesity are at risk for developing chronic kidney disease (CKD). During lifestyle adjustment, the first step in the treatment of childhood obesity, body proportions are likely to change. The aim of this study was to examine how lifestyle intervention affects creatinine-based kidney function estimation in children with overweight and obesity. METHODS This longitudinal lifestyle intervention study included 614 children with overweight and obesity (mean age 12.17 ± 3.28 years, 53.6% female, mean BMI z-score 3.32 ± 0.75). Loss to follow-up was present: 305, 146, 70, 26, and 10 children were included after 1, 2, 3, 4, and 5 (about yearly) follow-up visits, respectively. Serum creatinine (SCr) was rescaled using Q-age and Q-height polynomials. RESULTS At baseline, 95-97% of the children had a SCr/Q-height and SCr/Q-age in the normal reference range [0.67-1.33]. SCr/Q significantly increased each (about yearly) follow-up visit, and linear mixed regression analyses demonstrated slopes between 0.01 and 0.04 (corresponding with eGFR FAS reduction of 1.1-4.1 mL/min/1.73 m2) per visit. BMI z-score reduced in both sexes and this reduction was significantly higher in males. No correlation between change in rescaled SCr and BMI z-score reduction could be demonstrated. CONCLUSIONS Rescaled serum creatinine (SCr/Q) slightly increases during multidiscipline lifestyle intervention in this cohort of children with overweight and obesity. This effect seems to be independent from change in BMI z-score. Whether this minor decrease in estimated kidney function has clinical consequences in the long term remains to be seen in trials with a longer follow-up period. CLINICAL TRIAL REGISTRATION ClinicalTrial.gov; Registration Number: NCT02091544.
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Affiliation(s)
- Mark J C M van Dam
- Centre for Overweight Adolescent and Children's Healthcare (COACH), Department of Pediatrics, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center +, MosaKids Children's Hospital, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Hans Pottel
- Department of Public Health and Primary Care, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Anita C E Vreugdenhil
- Centre for Overweight Adolescent and Children's Healthcare (COACH), Department of Pediatrics, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center +, MosaKids Children's Hospital, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
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24
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Carboni J, Thomas E, Gipson DS, Brady TM, Srivastava T, Selewski DT, Greenbaum LA, Wang CS, Dell KM, Kaskel F, Massengill S, Reidy K, Tran CL, Trachtman H, Lafayette R, Almaani S, Hingorani S, Gbadegesin R, Gibson KL, Sethna CB. Longitudinal analysis of blood pressure and lipids in childhood nephrotic syndrome. Pediatr Nephrol 2024; 39:2161-2170. [PMID: 38319465 DOI: 10.1007/s00467-024-06301-z] [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: 09/25/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND In the current study, longitudinal BP and lipid measurements were examined in a NEPTUNE cohort of children with newly diagnosed nephrotic syndrome (cNEPTUNE). We hypothesized that hypertensive BP and dyslipidemia would persist in children with nephrotic syndrome, regardless of steroid treatment response. METHODS A multi-center longitudinal observational analysis of data obtained from children < 19 years of age with new onset nephrotic syndrome enrolled in the Nephrotic Syndrome Study Network (cNEPTUNE) was conducted. BP and lipid data were examined over time stratified by disease activity and steroid exposure. Generalized estimating equation regressions were used to find determinants of hypertensive BP and dyslipidemia. RESULTS Among 122 children, the prevalence of hypertensive BP at any visit ranged from 17.4% to 57.4%, while dyslipidemia prevalence ranged from 40.0% to 96.2% over a median of 30 months of follow-up. Hypertensive BP was found in 46.2% (116/251) of study visits during active disease compared with 31.0% (84/271) of visits while in remission. Dyslipidemia was present in 88.2% (120/136) of study visits during active disease and in 66.0% (101/153) while in remission. Neither dyslipidemia nor hypertensive BP were significantly different with/without medication exposure (steroids and/or CNI). In regression analysis, male sex and urine protein:creatinine ratio (UPC) were significant determinants of hypertensive BP over time, while eGFR was found to be a determinant of dyslipidemia over time. CONCLUSIONS Results demonstrate persistent hypertensive BPs and unfavorable lipid profiles in the cNEPTUNE cohort regardless of remission status or concurrent steroid or calcineurin inhibitor treatment.
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Affiliation(s)
- Johnathon Carboni
- Division of Nephrology, Department of Pediatrics, Cohen Children's Medical Center of NY, New Hyde Park, NY, USA
| | - Elizabeth Thomas
- Division of Nephrology, Department of Pediatrics, Dell Children's Medical Center, University of Texas, Austin, TX, USA
| | - Debbie S Gipson
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Tammy M Brady
- Division of Nephrology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tarak Srivastava
- Section of Nephrology, Children's Mercy Hospital and University of Missouri, Kansas City, MO, USA
| | - David T Selewski
- Division of Pediatric Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Larry A Greenbaum
- Division of Nephrology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Chia-Shi Wang
- Division of Nephrology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Katherine M Dell
- Center for Pediatric Nephrology and Hypertension, Cleveland Clinic Children's, Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
| | - Frederick Kaskel
- Division of Nephrology, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Susan Massengill
- Division of Nephrology, Department of Pediatrics, Levine Children's Hospital, Charlotte, NC, USA
| | - Kimberly Reidy
- Division of Nephrology, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Cheryl L Tran
- Division of Pediatric Nephrology, Department of Pediatrics and Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Howard Trachtman
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Richard Lafayette
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Salem Almaani
- Division of Nephrology, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sangeeta Hingorani
- Division of Nephrology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Rasheed Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, NC, USA
| | - Keisha L Gibson
- Division of Pediatric Nephrology, UNC Kidney Center, Chapel Hill, North Carolina, USA
| | - Christine B Sethna
- Division of Nephrology, Department of Pediatrics, Cohen Children's Medical Center of NY, New Hyde Park, NY, USA.
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25
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Lee AM, Xu Y, Hu J, Xiao R, Hooper SR, Hartung EA, Coresh J, Rhee EP, Vasan RS, Kimmel PL, Warady BA, Furth SL, Denburg MR. Longitudinal Plasma Metabolome Patterns and Relation to Kidney Function and Proteinuria in Pediatric CKD. Clin J Am Soc Nephrol 2024; 19:837-850. [PMID: 38709558 PMCID: PMC11254025 DOI: 10.2215/cjn.0000000000000463] [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: 12/20/2023] [Accepted: 04/29/2024] [Indexed: 05/08/2024]
Abstract
Key Points Longitudinal untargeted metabolomics. Children with CKD have a circulating metabolome that changes over time. Background Understanding plasma metabolome patterns in relation to changing kidney function in pediatric CKD is important for continued research for identifying novel biomarkers, characterizing biochemical pathophysiology, and developing targeted interventions. There are a limited number of studies of longitudinal metabolomics and virtually none in pediatric CKD. Methods The CKD in Children study is a multi-institutional, prospective cohort that enrolled children aged 6 months to 16 years with eGFR 30–90 ml/min per 1.73 m2. Untargeted metabolomics profiling was performed on plasma samples from the baseline, 2-, and 4-year study visits. There were technologic updates in the metabolomic profiling platform used between the baseline and follow-up assays. Statistical approaches were adopted to avoid direct comparison of baseline and follow-up measurements. To identify metabolite associations with eGFR or urine protein-creatinine ratio (UPCR) among all three time points, we applied linear mixed-effects (LME) models. To identify metabolites associated with time, we applied LME models to the 2- and 4-year follow-up data. We applied linear regression analysis to examine associations between change in metabolite level over time (∆level) and change in eGFR (∆eGFR) and UPCR (∆UPCR). We reported significance on the basis of both the false discovery rate (FDR) <0.05 and P < 0.05. Results There were 1156 person-visits (N : baseline=626, 2-year=254, 4-year=276) included. There were 622 metabolites with standardized measurements at all three time points. In LME modeling, 406 and 343 metabolites associated with eGFR and UPCR at FDR <0.05, respectively. Among 530 follow-up person-visits, 158 metabolites showed differences over time at FDR <0.05. For participants with complete data at both follow-up visits (n =123), we report 35 metabolites with ∆level–∆eGFR associations significant at FDR <0.05. There were no metabolites with significant ∆level–∆UPCR associations at FDR <0.05. We report 16 metabolites with ∆level–∆UPCR associations at P < 0.05 and associations with UPCR in LME modeling at FDR <0.05. Conclusions We characterized longitudinal plasma metabolomic patterns associated with eGFR and UPCR in a large pediatric CKD population. Many of these metabolite signals have been associated with CKD progression, etiology, and proteinuria in previous CKD Biomarkers Consortium studies. There were also novel metabolite associations with eGFR and proteinuria detected.
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Affiliation(s)
- Arthur M. Lee
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yunwen Xu
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Jian Hu
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia
| | - Rui Xiao
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen R. Hooper
- Department of Health Sciences, School of Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
| | - Erum A. Hartung
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- NYU Grossman School of Medicine, New York, New York
| | - Eugene P. Rhee
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Ramachandran S. Vasan
- Boston University School of Medicine, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Paul L. Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Bradley A. Warady
- Division of Nephrology, Children’s Mercy Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Susan L. Furth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Children’s Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
- Department of Pediatrics and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle R. Denburg
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Pizzo H, Nguyen J, Schwartz GJ, Wesseling-Perry K, Ettenger R, Chambers ET, Weng P. Comparison of estimated GFR using cystatin C versus creatinine in pediatric kidney transplant recipients. Pediatr Nephrol 2024; 39:2177-2186. [PMID: 38427073 PMCID: PMC11147893 DOI: 10.1007/s00467-024-06316-6] [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: 09/06/2023] [Revised: 02/01/2024] [Accepted: 02/01/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND An accurate, rapid estimate of glomerular filtration rate (GFR) in kidney transplant patients affords early detection of transplant deterioration and timely intervention. This study compared the performance of serum creatinine (Cr) and cystatin C (CysC)-based GFR equations to measured GFR (mGFR) using iohexol among pediatric kidney transplant recipients. METHODS CysC, Cr, and mGFR were obtained from 45 kidney transplant patients, 1-18 years old. Cr- and CysC-estimated GFR (eGFR) was compared against mGFR using the Cr-based (Bedside Schwartz, U25-Cr), CysC-based (Gentian CysC, CAPA, U25-CysC), and Cr-CysC combination (CKiD Cr-CysC, U25 Cr-CysC) equations in terms of bias, precision, and accuracy. Bland-Altman plots assessed the agreement between eGFR and mGFR. Secondary analyses evaluated the formulas in patients with biopsy-proven histological changes, and K/DOQI CKD staging. RESULTS Bias was small with Gentian CysC (0.1 ml/min/1.73 m2); 88.9% and 37.8% of U25-CysC estimations were within 30% and 10% of mGFR, respectively. In subjects with histological changes on biopsy, Gentian CysC had a small bias and U25-CysC were more accurate-both with 83.3% of and 41.7% of estimates within 30% and 10% mGFR, respectively. Precision was better with U25-CysC, CKiD Cr-CysC, and U25 Cr-CysC. Bland-Altman plots showed the Bedside Schwartz, Gentian CysC, CAPA, and U25-CysC tend to overestimate GFR when > 100 ml/min/1.72 m2. CAPA misclassified CKD stage the least (whole cohort 24.4%, histological changes on biopsy 33.3%). CONCLUSIONS In this small cohort, CysC-based equations with or without Cr may have better bias, precision, and accuracy in predicting GFR.
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Affiliation(s)
- Helen Pizzo
- Department of Pediatrics, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA.
| | - John Nguyen
- Children's Hospital of Orange County, Orange, CA, USA
| | | | - Katherine Wesseling-Perry
- Phoenix Children's Hospital, Phoenix, AZ, USA
- University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Robert Ettenger
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Patricia Weng
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Ward RC, Kogon AJ, Matheson MB, Dawson A, Hooper SR, Molitor S, Wong C, Furth SL, Warady BA, Harshman LA. Psychotropic Medication Usage in Pediatric CKD: Reporting from the CKD in Children Cohort. KIDNEY360 2024; 5:967-973. [PMID: 38739451 PMCID: PMC11296547 DOI: 10.34067/kid.0000000000000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
Key Points Psychotropic medication use is prevalent in the pediatric CKD population. Central nervous system stimulant usage was more common in male patients, and antidepressant usage was more frequently reported at follow-up visits during teenage years. Background Mental health disorders within the pediatric CKD population are prevalent. The frequency is unknown with which psychotropic medications that commonly treat these conditions are used in this population. Methods Data from the CKD in Children (CKiD) cohort study were used to describe the use of psychotropic medications and patient-related characteristics of use. Medications were classified into three groups: antidepressants, central nervous system (CNS) stimulants, and antipsychotic/mood stabilizing medications. Participant age, sex, CKD severity, and duration of medication use were ascertained. Medication use was evaluated in parallel with CKD disease type, presence of urological comorbidity, and hypertension. Chi-square tests compared subgroup medication use. Results Among 1074 CKiD participants (median baseline age 9.8 years), 6% (n =60) used psychotropic medications at study entry with 11% reporting incident use of any medication category (n =120). CNS stimulants were most common at baseline. Antidepressants were more frequent among incident users at 7%. Use of two or more medications was rare (3%). Median eGFR at medication initiation was 45 ml/min per 1.73 m2. CNS stimulants were reported at a higher rate in male compared with female participants (P < 0.05). Conclusions Eleven percent of CKiD patients report incident use of any psychotropic medication, with 7% reporting incident use of antidepressants. Future work is warranted to better ascertain the frequency, safety, and efficacy of psychotropic medication usage in relationship to formal mental health disorder diagnoses in the pediatric CKD population.
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Affiliation(s)
- Ryan C. Ward
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Amy J. Kogon
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew B. Matheson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Anne Dawson
- Nationwide Children's Hospital, Ohio State University, Columbus, Ohio
| | - Stephen R. Hooper
- Department of Health Sciences, School of Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
| | - Stephen Molitor
- Division of Pediatrics Psychology and Developmental Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cynthia Wong
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Susan L. Furth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bradley A. Warady
- Division of Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Lyndsay A. Harshman
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Ibrahim RB, Srivaths P, Tam E, Devaraj S. Utility of Cystatin C-based Equation for the Estimation of Glomerular Filtration Rate in a Pediatric Population. J Appl Lab Med 2024; 9:803-808. [PMID: 38656545 DOI: 10.1093/jalm/jfae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/22/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND The accurate assessment of kidney function is vital for the early detection of kidney damage. The estimated glomerular filtration rate GFR (eGFR) from serum cystatin C (CysC) and creatinine-based equations are commonly used in clinical practice as an alternative to the invasive measured glomerular filtration rate (mGFR), which is the usually accepted overall best index of kidney function in health and disease. Recently the CKiD under 25 (CkiD U25) equations have been shown to perform well in children and young adults with chronic kidney disease (CKD). In this focused report, we evaluated the performance of the CkiD U25 equations alongside 3 non-race-corrected (NRC) eGFR equations commonly used in pediatrics in our cohort. METHODS mGFR measured following the intravenous injection of tracer Tc-99mDTPA was retrospectively compared with eGFR from these equations in 57 patients (6 months to 22 years) from different races/ethnicities. Ordinary least squares regression analyses were used to assess correlation between the mGFRs and eGFRs. RESULTS The average mGFR for this cohort was 84.1 mL/min/1.73 m2. The NRC creatinine equations overestimated eGFR across all groups, with the lowest bias for CKiD U25-creatinine (22.59 mL/min/1.73 m2). The best correlations to mGFR, P30, and lowest biases were the CKiD U25-CysC (0.6281, 80.7%, 3.72 mL/min/1.73 m2) and Schwartz CysC (0.6372, 77.2%, -4.68 mL/min/1.73 m2). CONCLUSIONS Overall, both CKiD U25-CysC and Schwartz CysC provide a good estimation of mGFR with the CKiD U25-CysC having the overall best performance compared to mGFR in our study.
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Affiliation(s)
- Ridwan B Ibrahim
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
- Department of Pathology, Texas Children's Hospital, Houston, TX, United States
| | - Poyyapakkam Srivaths
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Estella Tam
- Department of Pathology, Texas Children's Hospital, Houston, TX, United States
| | - Sridevi Devaraj
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United States
- Department of Pathology, Texas Children's Hospital, Houston, TX, United States
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Ng DK, Muñoz A. Assessing bias in GFR estimating equations: improper GFR stratification can yield misleading results. Pediatr Nephrol 2024; 39:2139-2145. [PMID: 38396091 PMCID: PMC11232499 DOI: 10.1007/s00467-024-06318-4] [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: 11/27/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Assessing bias (estimated - measured) is key to evaluating glomerular filtration rate (GFR). Stratification by subgroups can indicate where equations perform differently. However, there is a fallacy in the assessment of two instruments (e.g., eGFR and mGFR) when stratifying on the level of only one of those instruments. Here, we present statistical aspects of the problem and a solution for GFR stratification along with an empirical investigation using data from the CKiD study. METHODS Compared and contrasted biases (eGFR relative to mGFR) with 95% confidence intervals within strata of mGFR only, eGFR only, and the average of mGFR and eGFR using data from the Chronic Kidney Disease in Children (CKiD) study. RESULTS A total of 304 participants contributed 843 GFR studies with a mean mGFR of 48.46 (SD = 22.72) and mean eGFR of 48.67 (SD = 22.32) and correlation of 0.904. Despite strong agreement, eGFR significantly overestimated mGFR when mGFR < 30 (+ 6.2%; 95%CI + 2.9%, + 9.7%) and significantly underestimated when mGFR > 90 (-12.2%; 95%CI - 17.3%, - 7.0%). Significant biases in opposite direction were present when stratifying by eGFR only. In contrast, when stratifying by the average of eGFR and mGFR, biases were not significant (+ 1.3% and - 1.0%, respectively) congruent with strong agreement. CONCLUSIONS Stratifying by either mGFR or eGFR only to assess eGFR biases is ubiquitous but can lead to inappropriate inference due to intrinsic statistical issues that we characterize and empirically illustrate using data from the CKiD study. Using the average of eGFR and mGFR is recommended for valid inferences in evaluations of eGFR biases.
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Affiliation(s)
- Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E7642, Baltimore, MD, 21205, USA.
| | - Alvaro Muñoz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E7642, Baltimore, MD, 21205, USA
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Li L, Zhou T, Lu Y, Chen J, Lei Y, Wu Q, Arnold J, Becich MJ, Bisyuk Y, Blecker S, Chrischilles E, Christakis DA, Geary CR, Jhaveri R, Lenert L, Liu M, Mirhaji P, Morizono H, Mosa ASM, Onder AM, Patel R, Smoyer WE, Taylor BW, Williams DA, Dixon BP, Flynn JT, Gluck C, Harshman LA, Mitsnefes MM, Modi ZJ, Pan CG, Patel HP, Verghese PS, Forrest CB, Denburg MR, Chen Y. Post-acute and Chronic Kidney Function Outcomes of COVID-19 in Children and Adolescents: An EHR Cohort Study from the RECOVER Initiative. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.25.24309488. [PMID: 38978683 PMCID: PMC11230320 DOI: 10.1101/2024.06.25.24309488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
We investigated the risks of post-acute and chronic adverse kidney outcomes of SARS-CoV-2 infection in the pediatric population via a retrospective cohort study using data from the RECOVER program. We included 1,864,637 children and adolescents under 21 from 19 children's hospitals and health institutions in the US with at least six months of follow-up time between March 2020 and May 2023. We divided the patients into three strata: patients with pre-existing chronic kidney disease (CKD), patients with acute kidney injury (AKI) during the acute phase (within 28 days) of SARS-CoV-2 infection, and patients without pre-existing CKD or AKI. We defined a set of adverse kidney outcomes for each stratum and examined the outcomes within the post-acute and chronic phases after SARS-CoV-2 infection. In each stratum, compared with the non-infected group, patients with COVID-19 had a higher risk of adverse kidney outcomes. For patients without pre-existing CKD, there were increased risks of CKD stage 2+ (HR 1.20; 95% CI: 1.13-1.28) and CKD stage 3+ (HR 1.35; 95% CI: 1.15-1.59) during the post-acute phase (28 days to 365 days) after SARS-CoV-2 infection. Within the post-acute phase of SARS-CoV-2 infection, children and adolescents with pre-existing CKD and those who experienced AKI were at increased risk of progression to a composite outcome defined by at least 50% decline in estimated glomerular filtration rate (eGFR), eGFR <15 mL/min/1.73m2, End Stage Kidney Disease diagnosis, dialysis, or transplant.
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Affiliation(s)
- Lu Li
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Ting Zhou
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Yiwen Lu
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Jiajie Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Yuqing Lei
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Qiong Wu
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan Arnold
- Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Michael J. Becich
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yuriy Bisyuk
- Office of Research, University Medical Center New Orleans, New Orleans, LA
| | - Saul Blecker
- Department of Population Health, NYU Grossman School of Medicine
| | | | - Dimitri A Christakis
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, WA 98105, USA
| | - Carol Reynolds Geary
- Department of Pathology, Microbiology, and Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Leslie Lenert
- Biomedical Informatics Center, Medical University of South Carolina
| | - Mei Liu
- Department of Health Outcomes and Biomedical Informatics, University of Florida, College of Medicine
| | - Parsa Mirhaji
- Albert Einstein College of Medicine, Bronx, NY 10461
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children’s National Hospital, Washington DC
| | | | - Ali Mirza Onder
- Division of Pediatric Nephrology, Nemours Children’s Hospital, Wilmington, DE
| | - Ruby Patel
- Division of Pediatric Nephrology, Stanford Medicine Children’s Health, Palo Alto, CA
| | - William E. Smoyer
- Center for Clinical and Translational Research, Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University
| | - Bradley W. Taylor
- Clinical and Translational Science Institute, The Medical College of Wisconsin, Milwaukee, WI 53226
| | | | - Bradley P. Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | | | - Caroline Gluck
- Nemours Children’s Health, Division of Pediatric Nephrology, Wilmington, DE
| | | | - Mark M Mitsnefes
- Cincinnati Children’s Hospital medical Center and University of Cincinnati
| | - Zubin J. Modi
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
- Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Cynthia G. Pan
- Department of Pediatrics, Section of Nephrology, Medical College of Wisconsin
| | - Hiren P. Patel
- Nationwide Children’s Hospital
- Ohio State University College of Medicine
| | - Priya S. Verghese
- Ann & Robert H Lurie Children’s Hospital
- Northwestern University, Feinberg School of Medicine
| | - Christopher B. Forrest
- Applied Clinical Research Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle R. Denburg
- Division of Pediatric Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Yong Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
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Alladin A, Hahn D, Hodson EM, Ravani P, Pfister K, Quinn RR, Samuel SM. Immunosuppressive therapy for IgA nephropathy in children. Cochrane Database Syst Rev 2024; 6:CD015060. [PMID: 38864363 PMCID: PMC11167693 DOI: 10.1002/14651858.cd015060.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
BACKGROUND IgA nephropathy (IgAN) is the most common cause of primary glomerulonephritis. It is a heterogeneous disease with different presentations and high morbidity. Thirty per cent of adults and 20% of children (followed into adulthood) will have a 50% decline in kidney function or develop kidney failure after 10 years. OBJECTIVES To determine the benefits and harms of immunosuppressive therapy for the treatment of IgAN in children. SEARCH METHODS We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 03 October 2023 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) investigating the treatment of IgAN in children with immunosuppressive therapies compared to placebo, no treatment, supportive care, standard therapy (Japanese protocol), other immunosuppressive therapies or non-immunosuppressive therapies. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the risk of bias. Random effects meta-analyses were used to summarise estimates of treatment effects. Treatment effects were expressed as risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and the mean difference (MD) and 95% CI for continuous outcomes. The risk of bias was assessed using the Cochrane risk of bias tool for RCTs and the ROBIN-I tool for NRSIs. The certainty of the evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). MAIN RESULTS This review included 13 studies with 686 participants. Ten RCTs included 334 children and 191 adults, and three NRSIs included 151 participants, all children. Most participants had mild kidney disease. The risk of bias was unclear for most of the domains relating to allocation concealment, blinding of participants, personnel, and outcome assessment. In children with IgAN, it is uncertain if corticosteroid (steroid) therapy, compared to placebo reduces proteinuria (1 study, 64 children and young adults: RR 0.47, 95% CI 0.13 to 1.72; low certainty evidence) or the decline in estimated glomerular filtration rate (eGFR) (1 study, 64 children and young adults: RR 0.47, 95% CI 0.09 to 2.39; low certainty evidence). It is uncertain if steroids reduce proteinuria compared to supportive care (2 studies, 61 children: RR 0.04, 95% CI -0.83 to 0.72; low certainty evidence). Adverse events associated with steroid therapy were not assessed due to heterogeneity in steroid protocols, including dose and duration, and lack of systematic assessment for adverse events in the included studies. Azathioprine, mycophenolate mofetil, mizoribine, or cyclophosphamide alone or in combination with steroid therapy had uncertain effects on improving proteinuria or preventing eGFR decline in children with IgAN. Fish oil, vitamin E and tonsillectomy had uncertain effects on improving proteinuria or preventing eGFR decline. Effects of other immunosuppressive therapies, secondary outcomes and adverse events were not assessed due to insufficient data. AUTHORS' CONCLUSIONS There is a lack of high-quality evidence to guide the management of IgAN in children. There is no evidence to indicate that steroids, other immunosuppressive therapies, or tonsillectomy, when added to optimal supportive care, prevent a decline in eGFR or proteinuria in children with IgAN. Available studies were few, with small numbers, low-quality evidence, high or uncertain risk of bias, did not systematically assess harms associated with treatment, or report net benefits or harms. Severe cases and atypical presentations of IgAN were not included in the reviewed studies, and our findings cannot be generalised to these situations.
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Affiliation(s)
- Areefa Alladin
- Departments of Paediatrics and Community Health Sciences, University of Calgary, Calgary, Canada
- School of Medicine, University of Guyana, Georgetown, Guyana
| | - Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
| | - Elisabeth M Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Pietro Ravani
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Kenneth Pfister
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Robert R Quinn
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Susan M Samuel
- Departments of Paediatrics and Community Health Sciences, University of Calgary, Calgary, Canada
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Whitney DG, Oliverio AL, Kreschmer J, Bolde S, Hurvitz EA, Wong KK. Feasibility and reliability of measured glomerular filtration rate with [I125]-iothalamate among young adults with mild-to-moderate cerebral palsy. Front Med (Lausanne) 2024; 11:1295104. [PMID: 38933110 PMCID: PMC11199527 DOI: 10.3389/fmed.2024.1295104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
Objective Despite the need, measuring glomerular filtration rate (mGFR) is not routinely performed for adults with cerebral palsy (CP), possibly due to unknown feasibility given the secondary complications of CP. This study aimed to assess the feasibility and reliability of mGFR and explore factors associated with eGFR-mGFR discordance among young adults with mild-to-moderate CP. Methods This single-center, cross-sectional study included 18- to 40-year-olds with CP gross motor function classification system (GMFCS) I-III. The participants were excluded if they were pregnant/lactating, had cognitive impairments, or had contraindications to mGFR. A routine clinical protocol for mGFR and eGFR was used. mGFR feasibility was assessed based on the number of participants who completed testing. mGFR reliability was assessed using the coefficient of variation (CV) across the four 30 min intervals. The association between age, sex, and GMFCS and the percentage of eGFR-mGFR discordance was assessed. Results Of the 19 participants enrolled, 18 completed the testing [mean age (SD), 29.9 (7.4) years, n = 10 female participants, n = 10/3/5 for GMFCS I/II/III] and most (n = 15) of the participants had an mGFR >90 mL/min; 14 participants (77.8%) had a CV <20%, 2 had a CV between 20 and 25%, and 2 had a CV >50%. eGFR overestimated mGFR by a median (interquartile range) of approximately 17.5% (2-38%); the full range of mis-estimation was -20.5 to 174.3%. Increasing age and GMFCS levels exhibited notable, but weak-to-modest, associations with a larger eGFR-mGFR discordance. Discussion Obtaining mGFR was feasible and reasonably reliable within this small sample. eGFR overestimated mGFR by a notable amount, which may be associated with patient-level factors.
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Affiliation(s)
- Daniel G. Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, United States
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Andrea L. Oliverio
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Jodi Kreschmer
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, United States
| | - Shannen Bolde
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, United States
| | - Edward A. Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, United States
| | - Ka Kit Wong
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, United States
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Lindvig TO, Simonsen JA, Gerke O, Thiesson HC. Comparison of cystatin C-based estimated glomerular filtration rate with measured glomerular filtration rate in a pediatric cohort of patients with chronic kidney disease. Pediatr Transplant 2024; 28:e14776. [PMID: 38778714 DOI: 10.1111/petr.14776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND It is essential to have an accurate assessment of the renal function of patients with chronic kidney disease to monitor, treat, and predict further development of the condition. Measurement of renal function in terms of glomerular filtration rate (GFR) requires either urine or blood sampling, but especially in children, more simple methods of measurement are preferable. The main objective of this study was to examine if the estimated GFR (eGFR) calculated with different cystatin-C-based equations was comparable to the GFR measured by a radiotracer (mGFR) in pediatric patients. METHODS In this retrospective study, 28 pediatric patients contributed with 73 pairs of measurements collected within 5 years. Bland-Altman Limits of Agreement were used to evaluate the performance and accuracy of two different cystatin-C-based estimates, the CKiDCrea-CysC and the CKiDU25 respectively, compared to an mGFR based on plasma clearance of technetium-99m-diethylenetriaminepentaacetic acid or chromium-51-ethylenediaminetetraacetic acid. RESULTS Using the CKiDCrea-CysC equation, 58.9% of the datasets were within P10 and 87.7% were within P30. The mean difference was 4.8 mL/min/1.73m2 (standard deviation: 8.5 mL/min/1.73m2) and tended to overestimate GFR and thereby overrate the kidney function within the entire GFR range. Using the CKiDU25 equation, 53.4% were within P10 and 93.2% within P30. The mean difference was -2.9 mL/min/1.73m2 (standard deviation: 8.4 mL/min/1.73m2), but the difference varied with the GFR value. CONCLUSIONS A cystatin-C-based eGFR provides a viable substitute for monitoring renal function in pediatric patients with chronic kidney disease. However, it has a lower accuracy than mGFR and can therefore not replace mGFR in clinical use.
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Affiliation(s)
- Tilde Ostendorf Lindvig
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jane Angel Simonsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, University of Southern Denmark, Odense, Denmark
| | - Oke Gerke
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, University of Southern Denmark, Odense, Denmark
| | - Helle Charlotte Thiesson
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Goswami S, Misseri R, Starr MC, Cater DT, Schwaderer AL. Objectified kidney ultrasound echogenicity and size metrics as potential predictors for kidney function in children. Int Urol Nephrol 2024; 56:2055-2063. [PMID: 38219260 DOI: 10.1007/s11255-023-03919-0] [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: 10/16/2023] [Accepted: 12/14/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Kidney echogenicity is typically determined subjectively but may have a quantifiable relationship to kidney function. Similarly, kidney length has been shown to correlate with kidney function. This study sought to quantify echogenicity using readily available software. Secondarily, we aimed to evaluate the correlation between quantified echogenicity and kidney length to the estimated glomerular filtration rate (eGFR) in children with acute kidney injury (AKI) and chronic kidney disease (CKD). METHODS In a single-center retrospective observational study, echogenicity index (EI) was determined using a ratio of right kidney to liver mean pixel density. The kidney length ratio (KLR) was determined by the actual to predicted lengths of both kidneys. Both variables were correlated to eGFR using correlation analyses and predictive capacity was determined with receiver operating characteristic curve (ROC) analysis. RESULTS Of 94 subjects, 46% (43/94) had AKI, 28% (26/95) had CKD and 26% (25/95) were controls. The higher the EI the lower the eGFR (r = - 0.46, p < 0.0001). EI between 1.0 and 1.1 predicted an eGFR < 90 ml/min/1.73m2 with an AUC of 0.71-0.78 while an EI between 1.1 and 1.2 predicted an eGFR < 60 ml/min/1.73m2 with AUC of 0.75-0.80. Overall, the larger the KLR the lower the eGFR (r = - 0.25, p 0.018). CONCLUSION We have developed an accessible methodology to quantify kidney echogenicity. Overall, there was an inverse correlation between EI and eGFR in pediatric CKD and AKI. However, these correlations did not persist within subgroups which could be due to small sample size and heterogeneity of etiologies. Overall, KLR had a weaker correlation to eGFR, compared to EI. Despite these correlations, both EI and KLR had "fair" to "good" performance as a biomarker for an eGFR < 60 ml/min/1.73m2.
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Affiliation(s)
- Shrea Goswami
- Department of Pediatrics, Division of Nephrology, Indiana University, Schwaderer Riley Children's Hospital, 705 Riley Drive, Indianapolis, IN, 46202, USA
| | - Rosalia Misseri
- Department of Urology, Division of Pediatric Urology, Indiana University, Indianapolis, IN, USA
| | - Michelle C Starr
- Department of Pediatrics, Division of Nephrology, Indiana University, Schwaderer Riley Children's Hospital, 705 Riley Drive, Indianapolis, IN, 46202, USA
| | - Daniel T Cater
- Department of Pediatrics, Division of Critical Care, Indiana University, Indianapolis, IN, USA
| | - Andrew L Schwaderer
- Department of Pediatrics, Division of Nephrology, Indiana University, Schwaderer Riley Children's Hospital, 705 Riley Drive, Indianapolis, IN, 46202, USA.
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Nehus EJ, Sheanon NM, Zhang W, Marcovina SM, Setchell KDR, Mitsnefes MM. Urinary sphingolipids in adolescents and young adults with youth-onset diabetes. Pediatr Nephrol 2024; 39:1875-1883. [PMID: 38172468 DOI: 10.1007/s00467-023-06257-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/17/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND This study evaluated urinary sphingolipids as a marker of diabetic kidney disease (DKD) in adolescents and young adults with youth-onset type 1 and type 2 diabetes. METHODS A comprehensive panel of urinary sphingolipids, including sphingomyelin (SM), glucosylceramide (GC), ceramide (Cer), and lactosylceramide (LC) species, was performed in patients with youth-onset diabetes from the SEARCH for Diabetes in Youth cohort. Sphingolipid levels, normalized to urine creatinine, were compared in 57 adolescents and young adults with type 1 diabetes, 59 with type 2 diabetes, and 44 healthy controls. The association of sphingolipids with albumin-to-creatinine (ACR) ratio and estimated glomerular filtration rate (eGFR) was evaluated. RESULTS The median age (interquartile range [IQR]) of participants was 23.1 years (20.9, 24.9) and the median duration of diabetes was 9.3 (8.5, 10.2) years. Urinary sphingolipid concentrations in patients with and without DKD (ACR ≥ 30 mg/g) were significantly elevated compared to healthy controls. There were no significant differences in sphingolipid levels between participants with type 1 and type 2 diabetes. In multivariable analysis, many sphingolipid species were positively correlated with ACR. Most significant associations were evident for the following species: C18 SM, C24:1 SM, C24:1 GC, and C24:1 Cer (all p < 0.001). Sphingolipid levels were not associated with eGFR. However, several interaction terms (diabetes type*sphingolipid) were significant, indicating diabetes type may modify the association of sphingolipids with eGFR. CONCLUSION Urinary sphingolipids are elevated in adolescents and young adults with youth-onset diabetes and correlate with ACR. Urinary sphingolipids may therefore represent an early biomarker of DKD.
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Affiliation(s)
- Edward J Nehus
- Department of Pediatrics, West Virginia University School of Medicine Charleston Campus, Charleston, WV, USA.
| | - Nicole M Sheanon
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Wujuan Zhang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Clinical Mass Spectroscopy Facility, Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Kenneth D R Setchell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Clinical Mass Spectroscopy Facility, Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark M Mitsnefes
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Hambrick HR, Fei L, Pavia K, Kaplan J, Mizuno T, Tang P, Schuler E, Benoit S, Girdwood ST. Cystatin C Outperforms Creatinine in Predicting Cefepime Clearance in Pediatric Stem Cell Transplant Recipients. Transplant Cell Ther 2024; 30:614.e1-614.e11. [PMID: 38522579 DOI: 10.1016/j.jtct.2024.03.021] [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: 12/19/2023] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 03/26/2024]
Abstract
Pediatric hematopoietic stem cell transplant (HSCT) patients are at risk of developing both sepsis and altered kidney function. Cefepime is used for empiric coverage post-HSCT and requires dose adjustment based on kidney function. Since cefepime's antimicrobial efficacy is determined by the time free concentrations exceed bacterial minimum inhibitory concentration (MIC), it is important to assess kidney function accurately to ensure adequate concentrations. Serum creatinine (SCr) is routinely used to estimate glomerular filtration rate (eGFR) but varies with muscle mass, which can be significantly lower in HSCT patients, making SCr an inaccurate kidney function biomarker. Cystatin C (CysC) eGFR is independent of muscle mass, though steroid use increases CysC. Objectives of this study were to describe how eGFR impacts cefepime pharmacokinetic/pharmacodynamic (PK/PD) target attainment in pediatric HSCT patients, to investigate which method of estimating GFR (SCr, CysC, combined) best predicts cefepime clearance, and to explore additional predictors of cefepime clearance. Patients admitted to the pediatric HSCT unit who received ≥2 cefepime doses were prospectively enrolled. We measured total cefepime peak/trough concentrations between the second and fourth cefepime doses and measured SCr and CysC if not already obtained clinically within 24h of cefepime samples. eGFRs were calculated with Chronic Kidney Disease in Children U25 equations. Bayesian estimates of cefepime clearance were determined with a pediatric cefepime PK model and PK software MwPharm++. Simple linear regression was used to compare cefepime clearance normalized to body surface area (BSA) to BSA-normalized SCr-, CysC-, and SCr-/CysC-eGFRs, while multiple linear regression was used to account for additional predictors of cefepime clearance. For target attainment, we assessed the percentage of time free cefepime concentrations exceeded 1x MIC (%fT>1x MIC) and 4x MIC (%fT>4x MIC) using a susceptibility breakpoint of 8 mg/L for Pseudomonas aeruginosa. We enrolled 53 patients (ages 1 to 30 years, median 8.9 years). SCr- and CysC-eGFRs were lower in patients who attained 100% fT>1xMIC compared to those who did not attain this target: 115 versus 156 mL/min/1.73m2 (p = .01) for SCr-eGFR and 73.5 versus 107 mL/min/1.73m2 (p < .001) for CysC-eGFR. SCr-eGFR was weakly positively correlated with cefepime clearance (adjusted [a]r2= 0.14), while CysC-eGFR and SCr-/CysC-eGFR had stronger positive correlations (ar2 = 0.30 CysC, ar2 = 0.28 combo. There was a weak, significant linear association between increasing CysC-eGFR and decreased %fT>1xMIC (ar2 = 0.32) and %fT>4xMIC (ar2 = 0.14). No patients with a CysC-eGFR >120 mL/min/1.73 m2 achieved 100% fT>1xMIC or 50% fT>4x MIC. In multiple regression models, underlying diagnosis of hemoglobinopathy (in all models) and being pretransplant (in SCr and combined models) were associated with increased cefepime clearance, while concomitant use of calcineurin inhibitors was associated with decreased cefepime clearance in all models. Overall, the combo-eGFR model with timing pretransplant, hemoglobinopathy, and use of calcineurin inhibitors had the best performance (ar2 = 0.63). CysC-based eGFRs (CysC alone and combined) predicted cefepime clearance better than SCr-eGFR, even after considering steroid use. Increasing CysC eGFR correlated with decreased probability of PD target attainment, raising concerns for underdosing at high eGFRs. CysC should be included when estimating kidney function to provide adequate dosing of cefepime in pediatric HSCT patients.
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Affiliation(s)
- H Rhodes Hambrick
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Lin Fei
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kathryn Pavia
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jennifer Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Tomoyuki Mizuno
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Peter Tang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Erin Schuler
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stefanie Benoit
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sonya Tang Girdwood
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Kim JS, Wray J, Ridout D, Plumb L, Nitsch D, Robb M, Marks SD. Protocol for a multicentre prospective exploratory mixed-methods study investigating the modifiable psychosocial variables influencing access to and outcomes after kidney transplantation in children and young people in the UK. BMJ Open 2024; 14:e078150. [PMID: 38806415 PMCID: PMC11138291 DOI: 10.1136/bmjopen-2023-078150] [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: 07/25/2023] [Accepted: 05/02/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Kidney transplantation is the preferred therapy for children with stage 5 chronic kidney disease (CKD-5). However, there is a wide variation in access to kidney transplantation across the UK for children. This study aims to explore the psychosocial factors that influence access to and outcomes after kidney transplantation in children in the UK using a mixed-methods prospective longitudinal design. METHODS Qualitative data will be collected through semistructured interviews with children affected by CKD-5, their carers and paediatric renal multidisciplinary team. Recruitment for interviews will continue till data saturation. These interviews will inform the choice of existing validated questionnaires, which will be distributed to a larger national cohort of children with pretransplant CKD-5 (n=180) and their carers. Follow-up questionnaires will be sent at protocolised time points regardless of whether they receive a kidney transplant or not. Coexisting health data from hospital, UK renal registry and National Health Service Blood and Transplant registry records will be mapped to each questionnaire time point. An integrative analysis of the mixed qualitative and quantitative data will define psychosocial aspects of care for potential intervention to improve transplant access. ANALYSIS Qualitative data will be analysed using thematic analysis. Quantitative data will be analysed using appropriate statistical methods to understand how these factors influence access to transplantation, as well as the distribution of psychosocial factors pretransplantation and post-transplantation. ETHICS AND DISSEMINATION This study protocol has been reviewed by the National Institute for Health Research Academy and approved by the Wales Research Ethics Committee 4 (IRAS number 270493/ref: 20/WA/0285) and the Scotland A Research Ethics Committee (ref: 21/SS/0038). Results from this study will be disseminated across media platforms accessed by affected families, presented at conferences and published in peer-reviewed journals.
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Affiliation(s)
- Ji Soo Kim
- Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Jo Wray
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Deborah Ridout
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, UCL, London, UK
| | - Lucy Plumb
- UK Renal Registry, Bristol, UK
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Dorothea Nitsch
- UK Renal Registry, Bristol, UK
- Non-communicable disease epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew Robb
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - Stephen D Marks
- Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
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Grosyeux C, Alla A, Barbé F, Dubourg LD, Chardon L, Guéant JL, Frimat L, Oussalah A, Vrillon I. The EKFC equation outperforms the CKD-EPI and CKiD equations for GFR estimation in adolescent and young adult kidney transplant patients. Nephrology (Carlton) 2024. [PMID: 38803085 DOI: 10.1111/nep.14328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/28/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
AIM This study evaluated the bias and accuracy of the CKD-EPI/CKiD and EKFC equations compared with the reference exogenous tracer-based assessment of glomerular filtration rate (GFR) in adult and pediatric patients according to their renal transplant status. METHODS We assessed the bias and P30 accuracy of the CKD-EPI/CKiD and EKFC equations compared with iohexol-based GFR measurement. RESULTS In the overall population (n = 59), the median age was 29 years (IQR, 16.0-46.0) and the median measured GFR was 73.9 mL/min/1.73m2 (IQR, 57.3-84.6). Among non-kidney transplant patients, the median was 77.7 mL/min/1.73m2 (IQR, 59.3-86.5), while among kidney transplant patients, it was 60.5 mL/min/1.73m2 (IQR, 54.2-66.8). The bias associated with the EKFC and CKD-EPI/CKiD equations was significantly higher among kidney transplant patients than among non-kidney transplant patients, with a difference between medians (Hodges-Lehmann) of +10.4 mL/min/1.73m2 (95% CI, 2.2-18.9; p = .02) for the EKFC and +12.1 mL/min/1.73m2 (95% CI, 4.2-21.4; p = .006) for the CKD-EPI/CKiD equations. In multivariable analysis, kidney transplant status emerged as an independent factor associated with a bias of >3.4 mL/min/1.73m2 (odds ratio, 7.7; 95% CI, 1.4-43.3; p = .02) for the EKFC equation and a bias of >13.4 mL/min/1.73m2 (odds ratio, 15.0; 95% CI, 2.6-85.7; p = .002) for the CKD-EPI/CKiD equations. CONCLUSION In our study, which included adolescent and young adult kidney transplant patients, both the CKD-EPI/CKiD and EKFC equations tended to overestimate the measured glomerular filtration rate, with the EKFC equation exhibiting less bias. Renal transplant status significantly influenced the degree of estimation bias.
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Affiliation(s)
- Chloé Grosyeux
- Pediatric Nephrology Department, University Hospital of Nancy, Nancy, France
| | - Asma Alla
- Department of Nephrology, University of Lorraine, Nancy, France
| | - Françoise Barbé
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, Nancy, France
| | - Laurence Derain Dubourg
- Nephrology, Dialysis, Hypertension and Functional Renal Exploration, Edouard Herriot Hospital, Hospices Civils de Lyon and Université Lyon 1, Lyon, France
| | - Laurence Chardon
- Department of Biology and Hormonology, Lyon-Est Hospital, Bron, France
| | - Jean-Louis Guéant
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, Nancy, France
- INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Nancy, France
| | - Luc Frimat
- Department of Nephrology, University of Lorraine, Nancy, France
- INSERM CIC-EC CIE6, University of Lorraine, Nancy, France
| | - Abderrahim Oussalah
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, Nancy, France
- INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Nancy, France
| | - Isabelle Vrillon
- Pediatric Nephrology Department, University Hospital of Nancy, Nancy, France
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Van Reeth O, Caliment A, de la Fuente Garcia I, Niel O. Safety Profile and Effectiveness of Dapagliflozin in Pediatric Patients with Chronic Kidney Disease. Am J Nephrol 2024; 55:463-467. [PMID: 38735286 DOI: 10.1159/000539300] [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: 03/13/2024] [Accepted: 04/29/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Nephroprotection in pediatric chronic kidney disease (CKD) has a major positive impact, both on residual renal function and on quality of life, by delaying the need for renal replacement therapy. To this day, nephroprotective drugs used in children are mainly limited to angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers; interestingly, as suggested by trials conducted in adults with CKD, sodium-glucose cotransporter 2 inhibitors (SGLT2i) might also be beneficial to pediatric patients. However, there are no validated data to this date documenting the effect of SGLT2i in pediatric patients with CKD. METHODS We present a retrospective single-center study reporting the use of dapagliflozin in pediatric patients with CKD, aiming to evaluate dapagliflozin safety profile as well as its potential for renal protection. Our study describes 7 patients with a mean age of 13.3 years (+/- 7.029) presenting with identified glomerulopathy, leading to CKD and already treated by ACE inhibitors. Patients received a daily dose of dapagliflozin of 5 or 10 mg. RESULTS Over a period of 15 months, all patients reported the medication as easy to use. After an initial dip, estimated glomerular filtration rate decline slope stabilized in all patients. Urinary albumin-over-creatinine ratio had a strong tendency to decrease after 6 months of treatment (p = 0.0684). Systolic blood pressure also had a tendency to decrease after 6 months of treatment (p = 0.1). No significant side effect was reported by the patients. CONCLUSION The promising results presented in this study support the use of SGLT2i in pediatric patients with CKD, although larger, randomized controlled trials in pediatric patients are necessary to better characterize their effectiveness in this particular population.
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Affiliation(s)
- Olil Van Reeth
- Department of Pediatrics, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Ancuta Caliment
- Pediatric Nephrology, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Isabel de la Fuente Garcia
- Department of Pediatrics, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
- Faculty of Science, Technology and Medicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Olivier Niel
- Pediatric Nephrology, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
- Faculty of Science, Technology and Medicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
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Steflea RM, Stroescu R, Gafencu M, Stoicescu ER, Isac R, Olariu IC, Micsescu-Olah AM, Susa SR, Murariu M, Doros G. A Pilot Comparative Study between Creatinine- and Cystatin-C-Based Equations to Estimate GFR and Kidney Ultrasound Percentiles in Children with Congenital Anomalies of the Kidney and Urinary Tract. Diagnostics (Basel) 2024; 14:994. [PMID: 38786292 PMCID: PMC11119041 DOI: 10.3390/diagnostics14100994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
Congenital anomalies affecting the kidneys present significant challenges in pediatric nephrology, needing precise methods for assessing renal function and guiding therapeutic intervention. Bedside Schwartz formula with the cystatin-C-based Full Age Spectrum formula and Chronic Kidney Disease in Children (CKiD) U 25 formula used in estimating glomerular filtration rate (eGFR) and also to assess if the eGFR in association with kidney length percentiles can be a monitoring parameter for the progression of chronic kidney disease in children with congenital anomalies of the kidney and urinary tract (CAKUT). A total of 64 pediatric patients (median age at diagnostic was 12 months with an interquartile range of 2 to 60) were diagnosed with congenital anomalies in the kidney and urinary tract between June 2018 and May 2023 at "Louis Turcanu" Emergency Hospital for Children in Timisoara, Romania. Baseline characteristics, CAKUT types, associated pathologies, CKD staging, and eGFR using creatinine and cystatin C were analyzed. The mean age at the moment of examination was 116.50 months; (65, 180). Chronic kidney disease staging revealed a predominance of patients in CKD stages G1 and A1. Analysis of eGFR methods revealed a small mean difference between eGFR estimated by creatinine and cystatin C, with a moderate-strong positive correlation observed between the eGFR and ultrasound parameters. Using cystatin-C-based formulas for eGFR, in conjunction with ultrasound measurements, may offer reliable insights into renal function in pediatric patients with congenital anomalies affecting the kidney and urinary tract. However, the economic aspect must be taken into consideration because cystatin C determination is approximately eight times more expensive than that of creatinine. An interdisciplinary approach is crucial for managing patients with CAKUT.
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Affiliation(s)
- Ruxandra Maria Steflea
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (R.M.S.); (R.S.); (R.I.); (I.-C.O.); (A.M.M.-O.); (G.D.)
- “Louis Turcanu” Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania;
| | - Ramona Stroescu
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (R.M.S.); (R.S.); (R.I.); (I.-C.O.); (A.M.M.-O.); (G.D.)
- “Louis Turcanu” Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania;
| | - Mihai Gafencu
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (R.M.S.); (R.S.); (R.I.); (I.-C.O.); (A.M.M.-O.); (G.D.)
- “Louis Turcanu” Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania;
| | - Emil Robert Stoicescu
- Department of Radiology and Medical Imaging, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, 300041 Timisoara, Romania;
- Research Center for Pharmaco-Toxicological Evaluations, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, 300041 Timisoara, Romania
- Field of Applied Engineering Sciences, Specialization Statistical Methods and Techniques in Health and Clinical Research, Faculty of Mechanics, “Politehnica” University, Mihai Viteazu Boulevard No. 1, 300222 Timisoara, Romania
| | - Raluca Isac
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (R.M.S.); (R.S.); (R.I.); (I.-C.O.); (A.M.M.-O.); (G.D.)
- “Louis Turcanu” Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania;
| | - Ioana-Cristina Olariu
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (R.M.S.); (R.S.); (R.I.); (I.-C.O.); (A.M.M.-O.); (G.D.)
- “Louis Turcanu” Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania;
| | - Andrada Mara Micsescu-Olah
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (R.M.S.); (R.S.); (R.I.); (I.-C.O.); (A.M.M.-O.); (G.D.)
- “Louis Turcanu” Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania;
| | - Septimiu Radu Susa
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| | - Mircea Murariu
- “Louis Turcanu” Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania;
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| | - Gabriela Doros
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (R.M.S.); (R.S.); (R.I.); (I.-C.O.); (A.M.M.-O.); (G.D.)
- “Louis Turcanu” Emergency Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania;
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O'Hanlon CJ, Sumpter A, Anderson BJ, Hannam JA. Time-Varying Clearance in Milrinone Pharmacokinetics from Premature Neonates to Adolescents. Clin Pharmacokinet 2024; 63:695-706. [PMID: 38613610 PMCID: PMC11106138 DOI: 10.1007/s40262-024-01372-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND AND OBJECTIVES Milrinone is an inotrope and vasodilator used for prophylaxis or treatment of low cardiac output syndrome after weaning from cardiopulmonary bypass (CPB). It is renally eliminated and has an acceptable therapeutic range of 100-300 μg/L, but weight-based dosing alone is associated with poor target attainment. We aimed to develop a population pharmacokinetic model for milrinone from premature neonates to adolescents, and to evaluate how age, renal function and recovery from CPB may impact dose selection. METHODS Fifty paediatric patients (aged 4 days to 16 years) were studied after undergoing cardiac surgery supported by CPB. Data from 29 premature neonates (23-28 weeks' postmenstrual age) treated for prophylaxis of low systemic blood flow were available for a pooled pharmacokinetic analysis. Population parameters were estimated using non-linear mixed effects modelling (NONMEM 7.5.1). RESULTS There were 369 milrinone measurements available for analysis. A one-compartment model with zero-order input and first-order elimination was used to describe milrinone disposition. Population parameters were clearance 17.8 L/70 kg [95% CI 15.8-19.9] and volume 20.4 L/h/70 kg [95% CI 17.8-22.1]. Covariates included size, postmenstrual age and renal function for clearance, and size and postnatal age for volume. Milrinone clearance is reduced by 39.5% [95% CI 24.0-53.7] immediately after bypass, and recovers to baseline clearance with a half-time of 12.0 h [95% CI 9.7-15.2]. Milrinone volume was 2.07 [95% CI 1.87-2.27] times greater at birth than the population standard and decreased over the first days of life with a half-time of 0.977 days [95% CI 0.833-1.12]. CONCLUSION Milrinone is predominately renally eliminated and so renal function is an important covariate describing variability in clearance. Increasing clearance over time likely reflects increasing cardiac output and renal perfusion due to milrinone and return to baseline following CPB.
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Affiliation(s)
- Conor J O'Hanlon
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Anita Sumpter
- Department of Anaesthesia, Auckland Hospital, Auckland, New Zealand
| | - Brian J Anderson
- Department of Anaesthesia, Auckland Hospital, Auckland, New Zealand
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand.
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Dhont E, Van Der Heggen T, Snauwaert E, Willems J, Croubels S, Delanghe J, De Waele JJ, Colman R, Vande Walle J, De Paepe P, De Cock PA. Predictors of augmented renal clearance based on iohexol plasma clearance in critically ill children. Pediatr Nephrol 2024; 39:1607-1616. [PMID: 37994980 DOI: 10.1007/s00467-023-06221-4] [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: 06/19/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Augmented renal clearance (ARC) holds a risk of subtherapeutic drug concentrations. Knowledge of patient-, disease-, and therapy-related factors associated with ARC would allow predicting which patients would benefit from intensified dosing regimens. This study aimed to identify ARC predictors and to describe ARC time-course in critically ill children, using iohexol plasma clearance (CLiohexol) to measure glomerular filtration rate (GFR). METHODS This is a retrospective analysis of data from the "IOHEXOL" study which validated GFR estimating formulas (eGFR) against CLiohexol. Critically ill children with normal serum creatinine were included, and CLiohexol was performed as soon as possible after pediatric intensive care unit (PICU) admission (CLiohexol1) and repeated (CLiohexol2) after 48-72 h whenever possible. ARC was defined as CLiohexol exceeding normal GFR for age plus two standard deviations. RESULTS Eighty-five patients were included; 57% were postoperative patients. Median CLiohexol1 was 122 mL/min/1.73 m2 (IQR 75-152). Forty patients (47%) expressed ARC on CLiohexol1. Major surgery other than cardiac surgery and eGFR were found as independent predictors of ARC. An eGFR cut-off value of 99 mL/min/1.73 m2 and 140 mL/min/1.73 m2 was suggested to identify ARC in children under and above 2 years, respectively. ARC showed a tendency to persist on CLiohexol2. CONCLUSIONS Our findings raise PICU clinician awareness about increased risk for ARC after major surgery and in patients with eGFR above age-specific thresholds. This knowledge enables identification of patients with an ARC risk profile who would potentially benefit from a dose increase at initiation of treatment to avoid underexposure. TRIAL REGISTRATION ClinicalTrials.gov NCT05179564, registered retrospectively on January 5, 2022.
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Affiliation(s)
- Evelyn Dhont
- Pediatric Intensive Care Unit, Department of Intensive Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
| | - Tatjana Van Der Heggen
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Evelien Snauwaert
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pediatric Nephrology, ERKNet Center, Ghent University Hospital, Ghent, Belgium
| | - Jef Willems
- Pediatric Intensive Care Unit, Department of Intensive Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Siska Croubels
- Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Joris Delanghe
- Department of Diagnostic Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jan J De Waele
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Roos Colman
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Johan Vande Walle
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pediatric Nephrology, ERKNet Center, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Pieter A De Cock
- Pediatric Intensive Care Unit, Department of Intensive Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
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Pickett LR, Daukshus NP, Camacho-Bydume C, Mathew S, Mauguen A, Cohen N, Cancio M. Retrospective Evaluation of Cystatin C as a Measure of Renal Function in Pediatric Hematopoietic Stem Cell Transplant Patients Receiving Foscarnet for Cytomegalovirus Reactivation. Pediatr Infect Dis J 2024; 43:457-462. [PMID: 38190640 DOI: 10.1097/inf.0000000000004238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection following allogeneic hematopoietic cell transplantation has considerable morbidity and mortality, and foscarnet is a treatment option that requires renal dose adjustment. Serum creatinine (SCr)-based estimated glomerular filtration rate (eGFR) equations are used to estimate renal function for patients receiving foscarnet, but cystatin C (cysC) has been shown as a possible alternative. Data examining cysC-based eGFR in this population is sparse. Our primary objective was to evaluate outcomes of patients treated with foscarnet dosed utilizing cysC-based eGFR versus SCr-based eGFR. METHODS We analyzed patients on the transplantation and cellular therapies service at Memorial Sloan Kettering Kids from January 2011 to September 2021 who received allogeneic hematopoietic cell transplantation and ≥14 days of foscarnet for CMV infection. Patients with cysC-based eGFR were compared to a historical cohort of patients who only had SCr-based eGFR. Outcomes included time to CMV clearance, death or change in anti-CMV therapy. Cumulative incidence curves and cause-specific hazards model were used for analysis. RESULTS In 61 analyzed patients, no differences were found between the cohorts in cumulative incidence of change in anti-CMV therapy ( P = 0.17) or death ( P = 0.69). After adjustment for multiple confounders, patients in the SCr cohort seemed to have a higher chance of CMV clearance compared with the cysC cohort, but the difference was not statistically significant (hazard ratio = 2.42, P = 0.089). Patients who received corticosteroids appeared to have lower incidence of CMV clearance ( P = 0.056). CONCLUSIONS We did not find differences in outcomes when dosing foscarnet using cysC versus SCr for treatment of CMV infection.
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Affiliation(s)
- Logan R Pickett
- From the Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nicole P Daukshus
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Christine Camacho-Bydume
- Department of Pediatric Blood and Marrow Transplant and Cellular Therapy, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, New Jersey
| | - Sherry Mathew
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York City, New York
| | | | - Nina Cohen
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Maria Cancio
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York City, New York
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Vigraijaroenying K, Pirojsakul K, Katanyuwong P, Tangnararatchakit K, Saisawat P, Chantarogh S, Paksi W, Bunmee U. Control of blood pressure in hypertensive children and adolescents assessed by ambulatory blood pressure monitoring. BMC Pediatr 2024; 24:269. [PMID: 38658852 PMCID: PMC11044297 DOI: 10.1186/s12887-024-04732-z] [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: 11/30/2023] [Accepted: 03/31/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND There have been few studies evaluating the control of hypertension (HT) in children. This study aimed to assess the control of HT using ambulatory blood pressure monitoring (ABPM) and to compare the parameters between the uncontrolled HT and controlled HT groups. METHODS Hypertensive patients aged ≥ 5 years who underwent ABPM to assess the control of HT were enrolled. Demographics, office blood pressure (BP), ABPM, and echocardiographic data were collected. Controlled HT was defined using a BP goal recommended by the 2016 European Society of Hypertension guidelines. RESULTS There were 108 patients (64.8% males) with a mean age of 14.3 years and 51.9% had primary HT. Controlled HT was detected in 41.1% and 33.3% by office BP and ABPM, respectively. Based on ABPM, there was a greater prevalence of controlled HT in the primary HT than the secondary HT group (44.6% vs. 21.2%, P = 0.01). In the primary HT group, BMI z-score at the last follow-up had a significant decrease in the controlled HT than the uncontrolled HT group (-0.39 vs. 0.01, P = 0.032). Primary HT was negatively associated with uncontrolled HT by ABPM. In addition, ABPM showed greater sensitivity (77.8% vs. 55.8%) and negative predictive value (80.9% vs. 70.8%) to predict LVH than those of office BP measurement. CONCLUSION Only one-third of patients achieved the BP goal by ABPM and most were in the primary HT group. Weight reduction is an important measure of BP control in patients with primary HT to attenuate the risk of LVH.
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Affiliation(s)
- Kevalin Vigraijaroenying
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kwanchai Pirojsakul
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Poomiporn Katanyuwong
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kanchana Tangnararatchakit
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pawaree Saisawat
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Songkiat Chantarogh
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Witchuri Paksi
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Uthen Bunmee
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Provenzano M, Hu L, Abenavoli C, Cianciolo G, Coppolino G, De Nicola L, La Manna G, Comai G, Baraldi O. Estimated glomerular filtration rate in observational and interventional studies in chronic kidney disease. J Nephrol 2024; 37:573-586. [PMID: 38347343 PMCID: PMC11150208 DOI: 10.1007/s40620-024-01887-x] [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: 03/20/2023] [Accepted: 05/08/2023] [Indexed: 06/05/2024]
Abstract
Estimated glomerular filtration rate is considered the principal measure of kidney function and, together with albuminuria, is a relevant prognostic factor for the development of end-stage kidney disease. Due to the strong association between estimated glomerular filtration rate and clinical events, such as commencement of dialysis, cardiovascular outcomes and all-cause death, estimated glomerular filtration rate is crucial for clinical decision-making in terms of scheduling follow-up and pharmacological interventions, and planning renal replacement therapies in advanced chronic kidney disease. In this review we discuss the available methods for measuring glomerular filtration rate and for estimating it through mathematical equations developed over the last few decades. We summarize the prognostic association of different percentages of estimated glomerular filtration rate decline and the main clinical outcomes, and how treatments modify estimated glomerular filtration rate decline and the risk of future endpoints. We also examine the role of pre-clinical trial slope and that of estimated glomerular filtration rate as a useful biomarker when evaluating patients for inclusion into both observational and interventional studies.
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Affiliation(s)
- Michele Provenzano
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico Sant'Orsola, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, 40138, Bologna, Italy
| | - Lilio Hu
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico Sant'Orsola, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, 40138, Bologna, Italy
| | - Chiara Abenavoli
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico Sant'Orsola, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, 40138, Bologna, Italy
| | - Giuseppe Cianciolo
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico Sant'Orsola, Bologna, Italy
| | - Giuseppe Coppolino
- Renal Unit, Department of Health Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Luca De Nicola
- Renal Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico Sant'Orsola, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, 40138, Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico Sant'Orsola, Bologna, Italy.
| | - Olga Baraldi
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico Sant'Orsola, Bologna, Italy
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Schuchman M, Brady TM, Glenn DA, Tuttle KR, Cara-Fuentes G, Levy RV, Gonzalez-Vicente A, Alakwaa FM, Srivastava T, Sethna CB. Association of mental health-related patient reported outcomes with blood pressure in adults and children with primary proteinuric glomerulopathies. J Nephrol 2024; 37:647-660. [PMID: 38512380 DOI: 10.1007/s40620-024-01919-6] [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: 09/26/2023] [Accepted: 02/01/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION The prevalence of mental health disorders including anxiety and depression is increasing and is linked to hypertension in healthy individuals. However, the relationship of psychosocial patient-reported outcomes on blood pressure (BP) in primary proteinuric glomerulopathies is not well characterized. This study explored longitudinal relationships between psychosocial patient-reported outcomes and BP status among individuals with proteinuric glomerulopathies. METHODS An observational cohort study was performed using data from 745 adults and children enrolled in the Nephrotic Syndrome Study Network (NEPTUNE). General Estimating Equations for linear regression and binary logistic analysis for odds ratios were performed to analyze relationships between the exposures, longitudinal Patient-Reported Outcome Measurement Information System (PROMIS) measures and BP and hypertension status as outcomes. RESULTS In adults, more anxiety was longitudinally associated with higher systolic and hypertensive BP. In children, fatigue was longitudinally associated with increased odds of hypertensive BP regardless of the PROMIS report method. More stress, anxiety, and depression were longitudinally associated with higher systolic BP index, higher diastolic BP index, and increased odds of hypertensive BP index in children with parent-proxy patient-reported outcomes. DISCUSSION/CONCLUSION Chronically poor psychosocial patient-reported outcomes may be significantly associated with higher BP and hypertension in adults and children with primary proteinuric glomerulopathies. This interaction appears strong in children but should be interpreted with caution, as multiple confounders related to glomerular disease may influence both mental health and BP independently. That said, access to mental health resources may help control BP, and proper disease and BP management may improve overall mental health.
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Affiliation(s)
- Matthew Schuchman
- Northwell, Cohen Children's Medical Center, Division of Pediatric Nephrology, New Hyde Park, NY, USA
| | - Tammy M Brady
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorey A Glenn
- Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, WA, USA
- Division of Nephrology, University of Washington School of Medicine, Spokane, WA, USA
| | - Gabriel Cara-Fuentes
- Section of Pediatric Nephrology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Rebecca V Levy
- Division of Nephrology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
- Division of Pediatric Nephrology, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Agustin Gonzalez-Vicente
- Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Fadhl M Alakwaa
- Department of Internal Medicine, Nephrology Division, University of Michigan, Ann Arbor, MI, USA
| | - Tarak Srivastava
- Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Christine B Sethna
- Northwell, Cohen Children's Medical Center, Division of Pediatric Nephrology, New Hyde Park, NY, USA.
- Feinstein Institutes for Medical Research, Manhasset, NY, USA.
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Filler G, Ahmad F, Bhayana V, Díaz González de Ferris ME, Sharma AP. Limitations of U25 CKiD and CKD-EPI eGFR formulae in patients 2-20 years of age with measured GFR > 60 mL/min/1.73 m 2-a cross-sectional study. Pediatr Nephrol 2024; 39:1169-1176. [PMID: 37840039 DOI: 10.1007/s00467-023-06185-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND When applying Pierce U25 formula for estimating glomerular filtration rate (eGFR), we observed a higher proportion of eGFR < 90 mL/min/1.73 m2 (chronic kidney disease (CKD) stage 2). We compared agreement and accuracy of the Pierce U25 (ages 2-25), Pottel (ages 2-100), and CKD-EPI (ages 18-100) formulae to GFR measurements. METHODS Post hoc analysis of the three eGFRs compared to 367 99m technetium-diethylene-triamine penta-acetic acid (99Tc DTPA) GFR measurements (240 patients) using 3 sampling points and Brockner/Mørtensen correction (body surface area calculation based on ideal weight) on simultaneous serum creatinine and cystatin C measurements. RESULTS Overall, the U25 formula performed well with a Spearman r of 0.8102 (95% confidence interval 0.7706 to 0.8435, p < 0.0001) while diagnostic accuracy was low in patients with normal mGFR. The U25 formula reclassified 29.5% of patients with normal mGFR as CKD stage 2; whereas the average of the modified Schwartz formula based on serum creatinine and the Filler formula based on cystatin C, only over-diagnosed CKD stage 2 in 8.5%, 24.5% within 10% and 62.7% within 30%. We therefore combined both. The average Schwartz/Filler eGFR had 36.5% of results within 10%, 84.7% within 30%, and normal mGFR accuracy was 26.8%, 63.9% for 10% and 30%, respectively, outperforming the CKD-EPI and Pottel formulae. CONCLUSIONS The Pierce U25 formula results correlated well with mGFR < 75 mL/min/1.73 m2. Over the entire GFR range, accuracy was better for patients with a higher mGFR, when averaging the combined Schwartz/Filler formulae. More work is needed to prospectively confirm our findings in other centers.
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Affiliation(s)
- Guido Filler
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5W9, Canada.
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, 800 Commissioners Road East, E3-206, London, ON, N6A 5W9, Canada.
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, N6A 5W9, Canada.
| | - Fateh Ahmad
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5W9, Canada
| | - Vipin Bhayana
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5W9, Canada
| | | | - Ajay P Sharma
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5W9, Canada
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48
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Stevens PE, Ahmed SB, Carrero JJ, Foster B, Francis A, Hall RK, Herrington WG, Hill G, Inker LA, Kazancıoğlu R, Lamb E, Lin P, Madero M, McIntyre N, Morrow K, Roberts G, Sabanayagam D, Schaeffner E, Shlipak M, Shroff R, Tangri N, Thanachayanont T, Ulasi I, Wong G, Yang CW, Zhang L, Levin A. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int 2024; 105:S117-S314. [PMID: 38490803 DOI: 10.1016/j.kint.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 03/17/2024]
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49
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Pottel H, Nyman U, Björk J, Berg U, Bökenkamp A, Dubourg LD, Lemoine S, Goffin K, Grubb A, Hansson M, Larsson A, Littmann K, Åsling-Monemi K, Adeli K, Cavalier E, Delanaye P. Extending the cystatin C based EKFC-equation to children - validation results from Europe. Pediatr Nephrol 2024; 39:1177-1183. [PMID: 37875730 DOI: 10.1007/s00467-023-06192-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/27/2023] [Accepted: 09/29/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND A new cystatin C based European Kidney Function Consortium (EKFCCysC) equation was recently developed for adults, using the same mathematical form as the previously published full age spectrum creatinine based EKFC-equation (EKFCCrea). In the present study the cystatin C based EKFC-equation is extended to children, by defining the appropriate cystatin C rescaling factor QCysC. METHODS Rescaling factor QCysC for cystatin C was defined as: a) 0.83 mg/L, exactly as it was defined for young adults in the adult equation, and b) a more complex QCysC-age relationship based on 4th degree cystatin C-age polynomials after evaluation of data from Uppsala, Stockholm and Canada and aggregated data from Germany. The EKFCCysC equation was then validated in an independent dataset in European children (n = 2,293) with measured GFR, creatinine, cystatin C, age, height and sex available. RESULTS The EKFCCysC with the simple QCysC-value of 0.83 had a bias of -7.6 [95%CI -8.4;-6.5] mL/min/1.73 m2 and a P30-value of 85.8% [95%CI 84.4;87.3] equal to the EKFCCysC with the more complex 4th degree QCysC-value. The arithmetic mean of the EKFCCrea and EKFCCysC with the simple QCysC of 0.83 had a bias of -4.0 [95%CI -4.5;-3.1] mL/min/1.73 m2 and P30 of 90.4% [95%CI 89.2;91.6] similar to using the more complex 4th degree QCysC-polynomial. CONCLUSION Using exactly the same QCysC of 0.83 mg/L, the adult EKFCCysC can easily be extended to children, with some bias but acceptable P30-values. The arithmetic mean of EKFCCrea and EKFCCysC results in bias closer to zero and P30 slightly over 90%.
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Affiliation(s)
- Hans Pottel
- Department of Public Health and Primary Care, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium.
| | - Ulf Nyman
- Department of Translational Medicine, Division of Medical Radiology, Lund University, Malmö, Sweden
| | - Jonas Björk
- Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden
- Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
| | - Ulla Berg
- Department of Clinical Science, Intervention and Technology, Division of Paediatrics, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Arend Bökenkamp
- Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Laurence Derain Dubourg
- Néphrologie, Dialyse, Hypertension et Exploration Fonctionnelle Rénale, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, and Laboratory of Tissue Biology and Therapeutic Engineering, UMR 5305 CNRS, Université Claude Bernard Lyon 1, Lyon, France
| | - Sandrine Lemoine
- Néphrologie, Dialyse, Hypertension et Exploration Fonctionnelle Rénale, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, and Laboratory of Tissue Biology and Therapeutic Engineering, UMR 5305 CNRS, Université Claude Bernard Lyon 1, Lyon, France
| | - Karolien Goffin
- Department of Nuclear Medicine, Division of Nuclear Medicine and Molecular Imaging, University Hospital Leuven, KU Leuven, Louvain, Belgium
| | - Anders Grubb
- Department of Clinical Chemistry, Skåne University Hospital, Lund University, Lund, Sweden
| | - Magnus Hansson
- Function Area Clinical Chemistry, Karolinska University Laboratory, Karolinska University Hospital Huddinge and Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
| | - Anders Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Karin Littmann
- Department of Medicine Huddinge, and Medical Unit of Endocrinology, Theme Inflammation and Ageing, Karolinska Institutet, Stockholm, Sweden, Karolinska University Hospital, Stockholm, Sweden
| | - Kajsa Åsling-Monemi
- Department of Clinical Science, Intervention and Technology, Division of Paediatrics, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Khosrow Adeli
- Clinical Biochemistry, Paediatric Laboratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU Sart Tilman, Liège, Belgium
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium
- Department of Nephrology-Dialysis-Apheresis, Hopital Universitaire Caremeau, Nîmes, France
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50
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Wu Y, Allegaert K, Flint RB, Goulooze SC, Välitalo PAJ, de Hoog M, Mulla H, Sherwin CMT, Simons SHP, Krekels EHJ, Knibbe CAJ, Völler S. When will the Glomerular Filtration Rate in Former Preterm Neonates Catch up with Their Term Peers? Pharm Res 2024; 41:637-649. [PMID: 38472610 PMCID: PMC11024008 DOI: 10.1007/s11095-024-03677-3] [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: 12/11/2023] [Accepted: 02/10/2024] [Indexed: 03/14/2024]
Abstract
AIMS Whether and when glomerular filtration rate (GFR) in preterms catches up with term peers is unknown. This study aims to develop a GFR maturation model for (pre)term-born individuals from birth to 18 years of age. Secondarily, the function is applied to data of different renally excreted drugs. METHODS We combined published inulin clearance values and serum creatinine (Scr) concentrations in (pre)term born individuals throughout childhood. Inulin clearance was assumed to be equal to GFR, and Scr to reflect creatinine synthesis rate/GFR. We developed a GFR function consisting of GFRbirth (GFR at birth), and an Emax model dependent on PNA (with GFRmax, PNA50 (PNA at which half ofGFR max is reached) and Hill coefficient). The final GFR model was applied to predict gentamicin, tobramycin and vancomycin concentrations. RESULT In the GFR model, GFRbirth varied with birthweight linearly while in the PNA-based Emax equation, GA was the best covariate for PNA50, and current weight for GFRmax. The final model showed that for a child born at 26 weeks GA, absolute GFR is 18%, 63%, 80%, 92% and 96% of the GFR of a child born at 40 weeks GA at 1 month, 6 months, 1 year, 3 years and 12 years, respectively. PopPK models with the GFR maturation equations predicted concentrations of renally cleared antibiotics across (pre)term-born neonates until 18 years well. CONCLUSIONS GFR of preterm individuals catches up with term peers at around three years of age, implying reduced dosages of renally cleared drugs should be considered below this age.
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Affiliation(s)
- Yunjiao Wu
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Development and Regeneration, and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sebastiaan C Goulooze
- Leiden Experts On Advanced Pharmacokinetics and Pharmacodynamics (LAP&P), Leiden, The Netherlands
| | - Pyry A J Välitalo
- School of Pharmacy, University of Eastern Finland, Yliopistonranta 1 C, 70210, Kuopio, Finland
- Finnish Medicines Agency, Hallituskatu 12-14, 70100, Kuopio, Finland
| | - Matthijs de Hoog
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Hussain Mulla
- Department of Pharmacy, University Hospitals of Leicester, Glenfield Hospital, Leicester, LE39QP, England
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine/Dayton Children's Hospital, One Children's Plaza, Dayton, OH, USA
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elke H J Krekels
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands
- Certara Inc, Princeton, NJ, USA
| | - Catherijne A J Knibbe
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Swantje Völler
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2333CC, Leiden, The Netherlands.
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.
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