[Epidemiology of pediatric chronic kidney disease]

Social Deprivation and Incidence of Pediatric Kidney Failure in France

Introduction

Approximately 8 per million children and young adults aged < 20 years initiate kidney replacement therapy (KRT) per year in France. We hypothesize that social deprivation could be a determinant of childhood-onset kidney failure. The objective of this study was to estimate the incidence of pediatric KRT in France according to the level of social deprivation.

Methods

All patients < 20 years who initiated KRT from 2010 to 2015 in metropolitan France were included. Data were collected from the comprehensive French registry of KRT French Renal Epidemiology and Information network (REIN). We used a validated ecological index to assess social deprivation, the 2011 French version of the European Deprivation Index (EDI). We estimated the age standardized incidence rates according to the quintiles of EDI using direct standardization and incidence rate ratio using Poisson regression.

Results

We included 672 children with kidney failure (58.6% males, 30.7% with glomerular or vascular disease, 43.3% starting KRT between 11 and 17 years). 38.8% were from the most deprived areas (quintile 5 of EDI). The age standardized incidence rate increased with quintile of EDI, from 5.45 (95% confidence interval [CI] = 4.25-6.64) per million children per year in the least deprived quintile to 8.46 (95% CI = 7.41-9.51) in the most deprived quintile of EDI (incidence rates ratio Q5 vs. Q1 1.53-fold; 95% CI = 1.18-2.01).

Conclusion

This study showed that even in a country with a universal health care system, there is a strong association between the incidence of pediatric KRT and social deprivation showing that social health inequalities appear from KRT initiation. This study highlights the need to look further into social inequalities in the earliest stage of chronic kidney disease (CKD).

Safety Profile and Effectiveness of Dapagliflozin in Pediatric Patients with Chronic Kidney Disease

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.

Classification of Glomerular Pathology Images in Children Using Convolutional Neural Networks with Improved SE-ResNet Module

Classification of glomerular pathology based on histology sections is the key to diagnose the type and degree of kidney diseases. To address problems in the classification of glomerular lesions in children, a deep learning-based complete glomerular classification framework was designed to detect and classify glomerular pathology. A neural network integrating Resnet and Senet (RS-INet) was proposed and a glomerular classification algorithm implemented to achieve high-precision classification of glomerular pathology. SE-Resnet was applied with improvement by transforming the convolutional layer of the original Resnet residual block into a convolutional block with smaller parameters as well as reduced network parameters on the premise of ensuring network performance. Experimental results showed that our algorithm had the best performance in differentiating mesangial proliferative glomerulonephritis (MsPGN), crescent glomerulonephritis (CGN), and glomerulosclerosis (GS) from normal glomerulus (Normal) compared with other classification algorithms. The accuracy rates were 0.960, 0.940, 0.937, and 0.968, respectively. This suggests that the classification algorithm proposed in the present study is able to identify glomerular lesions with a higher precision, and distinguish similar glomerular pathologies from each other.

Understanding Similarities and Differences in CKD and Dialysis Care in Children and Adults

In lower-income settings there is often a dearth of resources and nephrologists, especially pediatric nephrologists, and individual physicians often find themselves caring for patients with chronic kidney diseases and end-stage kidney failure across the age spectrum. The management of such patients in high-income settings is relatively protocolized and permits high-volume services to run efficiently. The basic principles of managing chronic kidney disease and providing dialysis are similar for adults and children, however, given the differences in body size, causes of kidney failure, nutrition, and growth between children and adults with kidney diseases, nephrologists must understand the relevance of these differences, and have an approach to providing quality and safe dialysis to each group. Prevention, early diagnosis, and early intervention with simple therapeutic and lifestyle interventions are achievable goals to manage symptoms, complications, and reduce progression, or avoid kidney failure in children and adults. These strategies currently are easier to implement in higher-resource settings with robust health systems. In many low-resource settings, kidney diseases are only first diagnosed at end stage, and resources to pay out of pocket for appropriate care are lacking. Many barriers therefore exist in these settings, where specialist nephrology personnel may be least accessible. To improve management of patients at all ages, we highlight differences and similarities, and provide practical guidance on the management of children and adults with chronic kidney disease and kidney failure. It is important that children are managed with a view to optimizing growth and well-being and maximizing future options (eg, maintaining vein health and optimizing cardiovascular risk), and that adults are managed with attention paid to quality of life and optimization of physical health.

[Towards understanding chronic kidney disease]

Chronic kidney disease (CKD) is a global health problem affecting almost 15% of the population worldwide. After renal injury, there is a nephron loss and remaining nephrons ensure the glomerular filtration rate (GFR) with compensatory hyperplasia and hypertrophy: This is called the nephron reduction. After nephron reduction, renal function will gradually decline and lead to chronic end-stage renal failure. Whatever the initial cause of the renal injury, recent data suggest there are common molecular mechanisms at the origin of CKD progression. Moreover, the renal lesions are very reproducible with glomerulosclerosis, tubular atrophy and partial epithelio-mesenchymal transition, interstitial fibrosis and vascular abnormalities. The physiopathology of CKD progression is unclear but some hypotheses have been described: i) the nephron "overwork", supported by recent works showing that the nephron reduction leads to hyperfiltration by the remaining nephrons and the stability of the GFR; ii) the "podocyte adaptation" theory, reflected by the importance of the podocytopathy in CKD progression and the crucial role of residual proteinuria in renal lesion development; iii) the activation of EGFR signaling pathways in surgical nephron reduction model and its involvement in CKD progression. Finally, CKD progression remains poorly understood and further studies will be necessary to discover new CKD molecular pathways and to develop new therapeutic insight in CKD management.

Chronic kidney disease emerging trends in children and what to do about it

Chronic Kidney disease (CKD) is a major public health problem associated with increased health costs, morbidity, and mortality. There is a 30-fold higher mortality rate and severely impaired quality of life in children with chronic kidney disease (CKD), requiring dialysis or kidney transplant compared to the aged-match general population. The early diagnosis and treatment of pediatric CKD can reverse, delay or prevent progression to advanced kidney disease. It is worth noting that CKD with rapid progression, which carries a poor prognosis, is more common in African American children. Thus, the development of a universal pediatric CKD screening program for high-risk children can be vital for social equity. The disparity in prevalence and severity of CKD is likely due to a complex interaction between biological and nonbiological risk factors that influence the development and progression of CKD in children of African descent. For example, high-risk alleles in the gene encoding for apolipoprotein L1 (APOL1) have been recognized as the most important factor in the high incidence of some chronic kidney diseases in African Americans. In this review, we will focus on the trends in the incidence of pediatric CKD and management strategies aimed at enhancing health outcomes and reducing disease progression.