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Borzych-Dużałka D, Shroff R, Ranchin B, Zhai Y, Paglialonga F, Kari JA, Ahn YH, Awad HS, Loza R, Hooman N, Ericson R, Drożdz D, Kaur A, Bakkaloglu SA, Samaille C, Lee M, Tellier S, Thumfart J, Fila M, Warady BA, Schaefer F, Schmitt CP. Prospective Study of Modifiable Risk Factors of Arterial Hypertension and Left Ventricular Hypertrophy in Pediatric Patients on Hemodialysis. Kidney Int Rep 2024; 9:1694-1704. [PMID: 38899176 PMCID: PMC11184401 DOI: 10.1016/j.ekir.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 06/21/2024] Open
Abstract
Introduction Fluid and salt overload in patients on dialysis result in high blood pressure (BP), left ventricular hypertrophy (LVH) and hemodynamic instability, resulting in cardiovascular morbidity. Methods Analysis of 910 pediatric patients on maintenance hemodialysis/hemodiafiltration (HD/HDF), prospectively followed-up with 2758 observations recorded every 6-months in the International Pediatric Hemodialysis Network (IPHN). Results Uncontrolled hypertension was present in 55% of observations, with 27% of patients exhibiting persistently elevated predialysis BP. Systolic and diastolic age- and height-standardized BP (BP-SDS) were independently associated with the number of antihypertensive medications (odds ratio [OR] = 1.47, 95% confidence interval 1.39-1.56, 1.36 [1.23-1.36]) and interdialytic weight gain (IDWG; 1.19 [1.14-1.22], 1.09 [1.06-1.11]; all P < 0.0001). IDWG was related to urine output (OR = 0.27 [0.23-0.32]) and dialysate sodium (dNa; 1.06 [1.01-1.10]; all P < 0.0001). The prevalence of masked hypertension was 24%, and HD versus HDF use was an independent risk factor of elevated age- and height-standardized mean arterial pressure (MAP-SDS) (OR = 2.28 [1.18-4.41], P = 0.01). Of the 1135 echocardiograms, 51% demonstrated LVH. Modifiable risk factors included predialysis systolic BP-SDS (OR = 1.06 [1.04-1.09], P < 0.0001), blood hemoglobin (0.97 [0.95-0.99], P = 0.004), HD versus HDF modality (1.09 [1.02-1.18], P = 0.01), and IDWG (1.02 [1.02-1.03], P = 0.04). In addition, HD modality increased the risk of LVH progression (OR = 1.23 [1.03-1.48], P = 0.02). Intradialytic hypotension (IDH) was prevalent in patients progressing to LVH and independently associated with predialysis BP-SDS below 25th percentile, lower number of antihypertensives, HD versus HDF modality, ultrafiltration (UF) rate, and urine output, but not with dNa. Conclusion Uncontrolled hypertension and LVH are common in pediatric HD, despite intense pharmacologic therapy. The outcome may improve with use of HDF, and superior anemia and IDWG control; the latter via lowering dNa, without increasing the risk of IDH.
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Affiliation(s)
- Dagmara Borzych-Dużałka
- Department for Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland
| | - Rukshana Shroff
- UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Bruno Ranchin
- Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Yihui Zhai
- Children’s Hospital of Fudan University, Shanghai, China
| | - Fabio Paglialonga
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jameela A. Kari
- King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Yo H. Ahn
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Hazem S. Awad
- Aljalila Children’s Specialty Hospital, Department of Pediatric Nephrology, Dubai, United Arab Emirates
| | | | | | | | - Dorota Drożdz
- Jagellonian University Medical College, Kraków, Poland
| | - Amrit Kaur
- Royal Manchester Children’s Hospital, Manchester, UK
| | | | | | - Marsha Lee
- The University of California, San Francisco, California, USA
| | | | - Julia Thumfart
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité Universitätsmedizin Berlin, Germany
| | - Marc Fila
- Department of Pediatric Nephrology, CHU de Montpellier, Montpellier, France
| | | | - Franz Schaefer
- Centre for Pediatric and Adolescent Medicine, University of Heidelberg, Germany
| | - Claus P. Schmitt
- Centre for Pediatric and Adolescent Medicine, University of Heidelberg, Germany
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Douglas CE, Roem J, Flynn JT, Furth SL, Warady BA, Halbach SM. Effect of Age on Hypertension Recognition in Children With Chronic Kidney Disease: A Report From the Chronic Kidney Disease in Children Study. Hypertension 2023; 80:1048-1056. [PMID: 36861464 PMCID: PMC10133176 DOI: 10.1161/hypertensionaha.122.20354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/20/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Young age has been associated with poorer control of hypertension in children with chronic kidney disease (CKD). Using data from the CKiD Study (Chronic Kidney Disease in Children), we examined the relationship between age, hypertensive blood pressure (BP) recognition, and pharmacologic BP control in children with nondialysis-dependent CKD. METHODS Participants included 902 CKiD Study participants with CKD stages 2 to 4. A total of 3550 annual study visits met inclusion criteria and participants were stratified by age (0 to <7, ≥7 to <13, ≥13 to ≤18 years). Generalized estimating equations to account for repeated measures were applied to logistic regression analyses to evaluate the association of age with unrecognized hypertensive BP and medication use. RESULTS Children <7 years of age had a higher prevalence of hypertensive BP and a lower prevalence of antihypertensive medication use compared with older children. At visits where participants <7 years of age had hypertensive BP readings, 46% had unrecognized, untreated hypertensive BP compared with 21% of visits for children ≥13 years of age. The youngest age group was associated with higher odds of unrecognized hypertensive BP (adjusted odds ratio, 2.11 [95% CI, 1.37-3.24]) and lower odds of antihypertensive medication use among those with unrecognized hypertensive BP (adjusted OR, 0.51 [95% CI, 0.27-0.996]). CONCLUSIONS Children younger than 7 years of age with CKD are more likely to have both undiagnosed and undertreated hypertensive BP. Efforts to improve BP control in young children with CKD are needed to minimize development of cardiovascular disease and slow CKD progression.
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Affiliation(s)
| | - Jennifer Roem
- Department of Epidemiology, Johns Hopkins Bloomberg School
of Public Health, Baltimore, MD
| | - Joseph T Flynn
- Division of Nephrology, Seattle Children’s Hospital,
WA
- Department of Pediatrics, University of Washington School
of Medicine, Seattle
| | - Susan L Furth
- Departments of Pediatrics and Epidemiology, Perelman School
of Medicine at the University of Pennsylvania, Division of Nephrology, Children's
Hospital of Philadelphia
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children’s Mercy
Kansas City, MO
| | - Susan M Halbach
- Division of Nephrology, Seattle Children’s Hospital,
WA
- Department of Pediatrics, University of Washington School
of Medicine, Seattle
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Ateya AM, El Hakim I, Shahin SM, El Borolossy R, Kreutz R, Sabri NA. Effects of Ramipril on Biomarkers of Endothelial Dysfunction and Inflammation in Hypertensive Children on Maintenance Hemodialysis: the SEARCH Randomized Placebo-Controlled Trial. Hypertension 2022; 79:1856-1865. [PMID: 35686561 DOI: 10.1161/hypertensionaha.122.19312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypertension, endothelial dysfunction, and inflammation are associated with increased cardiovascular mortality in end-stage kidney disease. We evaluated the effects of ACE (angiotensin-converting enzyme) inhibition on biomarkers of endothelial dysfunction and inflammation in hypertensive children with end-stage kidney disease on maintenance hemodialysis. METHODS In a randomized, double-blind, placebo-controlled trial, 135 (72 males/63 females) children and adolescents (age 7-15 years) were randomly assigned to treatment with either 2.5 mg once daily ramipril (n=68) or placebo (n=67) for 16 weeks. Primary outcome were the serum concentrations of asymmetrical dimethylarginine, a marker of endothelial dysfunction and hs-CRP (high-sensitivity C-reactive protein), a marker of inflammation. Changes in IL-6 (interleukin-6), TNF-α (tumor necrosis factor-alpha), systolic (S), and diastolic (D) blood pressure were secondary outcomes. Change in potassium levels and incidence of hyperkalemia were among the safety parameters. RESULTS Ramipril, but not placebo, significantly reduced serum levels of asymmetrical dimethylarginine (-79.6%; P<0.001), hs-CRP (-46.5%; P<0.001), IL-6 (-27.1%; P<0.001), and TNF-α (-51.7%; P<0.001). Systolic blood pressure and diastolic blood pressure were significantly lowered in both groups with a greater reduction in children receiving ramipril (median between-group differences -12.0 [95% CI -18.0 to -9.5] and -9.0 [95% CI -12.0 to -4.5]; P<0.001, respectively). Changes in asymmetrical dimethylarginine, hs-CRP, IL-6, or TNF-α in the ramipril group did not significantly correlate with blood pressure reductions. No severe cases of hyperkalemia or other serious treatment-associated adverse events were observed. CONCLUSIONS Ramipril improves biomarkers of endothelial dysfunction and inflammation in hypertensive children on maintenance hemodialysis in addition to its efficacious and safe potential to lower blood pressure. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04582097.
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Affiliation(s)
- Areej Mohamed Ateya
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt (A.M.A., S.M.S., R.E.B., N.A.S.).,Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany (A.M.A., R.K.)
| | - Ihab El Hakim
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt (I.E.H.)
| | - Sara Mahmoud Shahin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt (A.M.A., S.M.S., R.E.B., N.A.S.)
| | - Radwa El Borolossy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt (A.M.A., S.M.S., R.E.B., N.A.S.)
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany (A.M.A., R.K.)
| | - Nagwa Ali Sabri
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt (A.M.A., S.M.S., R.E.B., N.A.S.)
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High blood pressure in children and adolescents: current perspectives and strategies to improve future kidney and cardiovascular health. Kidney Int Rep 2022; 7:954-970. [PMID: 35570999 PMCID: PMC9091586 DOI: 10.1016/j.ekir.2022.02.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 02/08/2023] Open
Abstract
Hypertension is one of the most common causes of preventable death worldwide. The prevalence of pediatric hypertension has increased significantly in recent decades. The cause of this is likely multifactorial, related to increasing childhood obesity, high dietary sodium intake, sedentary lifestyles, perinatal factors, familial aggregation, socioeconomic factors, and ethnic blood pressure (BP) differences. Pediatric hypertension represents a major public health threat. Uncontrolled pediatric hypertension is associated with subclinical cardiovascular disease and adult-onset hypertension. In children with chronic kidney disease (CKD), hypertension is also a strong risk factor for progression to kidney failure. Despite these risks, current rates of pediatric BP screening, hypertension detection, treatment, and control remain suboptimal. Contributing to these shortcomings are the challenges of accurately measuring pediatric BP, limited access to validated pediatric equipment and hypertension specialists, complex interpretation of pediatric BP measurements, problematic normative BP data, and conflicting society guidelines for pediatric hypertension. To date, limited pediatric hypertension research has been conducted to help address these challenges. However, there are several promising signs in the field of pediatric hypertension. There is greater attention being drawn on the cardiovascular risks of pediatric hypertension, more emphasis on the need for childhood BP screening and management, new public health initiatives being implemented, and increasing research interest and funding. This article summarizes what is currently known about pediatric hypertension, the existing knowledge-practice gaps, and ongoing research aimed at improving future kidney and cardiovascular health.
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Leader HE, Mambwe T. Elevated Blood Pressure in Hospitalized Children Predicts True Elevated Blood Pressure Outpatient. Hosp Pediatr 2021:e2021006314. [PMID: 34966944 DOI: 10.1542/hpeds.2021-006314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine if elevated blood pressure (EBP) in hospitalized children accurately predicts EBP outpatient. METHODS A multicenter retrospective chart review was conducted at a large hospital system in Northeastern United States. Mean blood pressures during hospitalizations were classified as elevated or not elevated, by using the American Academy of Pediatrics (AAP) 2017 parameters. Mean blood pressure was then compared with each patient's mean blood pressure measured 3 times postdischarge. The data were analyzed to determine if inpatient EBP is an accurate predictor of outpatient EBP. RESULTS Of 5367 hospitalized children, 656 (12.2%) had EBP inpatient. Inpatient EBP was highly predictive of outpatient EBP, with a positive predictive value of 96% and negative predictive value of 98%. CONCLUSIONS Diagnosing hospitalized children with EBP, as defined by the AAP 2017 guidelines, accurately predicts true EBP outpatient.
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Affiliation(s)
- Hadassa E Leader
- K Hovnanian Children's Hospital, Hackensack Meridian Health Network, Neptune City, New Jersey
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Leader Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Twiza Mambwe
- University of Texas Health San Antonio, San Antonio, Texas
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Végh A, Bárczi A, Cseprekál O, Kis É, Kelen K, Török S, Szabó AJ, Reusz GS. Follow-Up of Blood Pressure, Arterial Stiffness, and GFR in Pediatric Kidney Transplant Recipients. Front Med (Lausanne) 2021; 8:800580. [PMID: 34977101 PMCID: PMC8716619 DOI: 10.3389/fmed.2021.800580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/18/2021] [Indexed: 11/17/2022] Open
Abstract
Pediatric renal transplant recipients (RTx) were studied for longitudinal changes in blood pressure (BP), arterial stiffness by pulse wave velocity (PWV), and graft function. Patients and Methods: 52 RTx patients (22 males) were included; office BP (OBP) and 24 h BP monitoring (ABPM) as well as PWV were assessed together with glycemic and lipid parameters and glomerular filtration rate (GFR) at 2.4[1.0–4.7] (T1) and 9.3[6.3–11.8] years (T2) after transplantation (median [range]). Results: Hypertension was present in 67 and 75% of patients at T1 and T2, respectively. Controlled hypertension was documented in 37 and 44% by OBP and 40 and 43% by ABPM. Nocturnal hypertension was present in 35 and 30% at T1 and T2; 24 and 32% of the patients had masked hypertension, while white coat hypertension was present in 16 and 21% at T1 and T2, respectively. Blood pressure by ABPM correlated significantly with GFR and PWV at T2, while PWV also correlated significantly with T2 cholesterol levels. Patients with uncontrolled hypertension by ABPM had a significant decrease in GFR, although not significant with OBP. Anemia and increased HOMAi were present in ~20% of patients at T1 and T2. Conclusion: Pediatric RTx patients harbor risk factors that may affect their cardiovascular health. While we were unable to predict the evolution of renal function based on PWV and ABPM at T1, these risk factors correlated closely with GFR at follow-up suggesting that control of hypertension may have an impact on the evolution of GFR.
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Affiliation(s)
- Anna Végh
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
| | - Adrienn Bárczi
- Medical Imaging Centre Semmelweis University, Budapest, Hungary
| | - Orsolya Cseprekál
- Department of Transplantation and Surgery Semmelweis University, Budapest, Hungary
| | - Éva Kis
- Gottsegen National Cardiovascular Center, Budapest, Hungary
| | - Kata Kelen
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
| | - Szilárd Török
- Department of Transplantation and Surgery Semmelweis University, Budapest, Hungary
| | - Attila J. Szabó
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
| | - György S. Reusz
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
- *Correspondence: György S. Reusz
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Hemodiafiltration maintains a sustained improvement in blood pressure compared to conventional hemodialysis in children-the HDF, heart and height (3H) study. Pediatr Nephrol 2021; 36:2393-2403. [PMID: 33629141 DOI: 10.1007/s00467-021-04930-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/08/2020] [Accepted: 01/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hypertension is prevalent in children on dialysis and associated with cardiovascular disease. We studied the blood pressure (BP) trends and the evolution of BP over 1 year in children on conventional hemodialysis (HD) vs. hemodiafiltration (HDF). METHODS This is a post hoc analysis of the "3H - HDF-Hearts-Height" dataset, a multicenter, parallel-arm observational study. Seventy-eight children on HD and 55 on HDF who had three 24-h ambulatory BP monitoring (ABPM) measures over 1 year were included. Mean arterial pressure (MAP) was calculated and hypertension defined as 24-h MAP standard deviation score (SDS) ≥95th percentile. RESULTS Poor agreement between pre-dialysis systolic BP-SDS and 24-h MAP was found (mean difference - 0.6; 95% limits of agreement -4.9-3.8). At baseline, 82% on HD and 44% on HDF were hypertensive, with uncontrolled hypertension in 88% vs. 25% respectively; p < 0.001. At 12 months, children on HDF had consistently lower MAP-SDS compared to those on HD (p < 0.001). Over 1-year follow-up, the HD group had mean MAP-SDS increase of +0.98 (95%CI 0.77-1.20; p < 0.0001), whereas the HDF group had a non-significant increase of +0.15 (95%CI -0.10-0.40; p = 0.23). Significant predictors of MAP-SDS were dialysis modality (β = +0.83 [95%CI +0.51 - +1.15] HD vs. HDF, p < 0.0001) and higher inter-dialytic-weight-gain (IDWG)% (β = 0.13 [95%CI 0.06-0.19]; p = 0.0003). CONCLUSIONS Children on HD had a significant and sustained increase in BP over 1 year compared to a stable BP in those on HDF, despite an equivalent dialysis dose. Higher IDWG% was associated with higher 24-h MAP-SDS in both groups.
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Should ACE inhibitors or calcium channel blockers be used for post-transplant hypertension? Pediatr Nephrol 2021; 36:539-549. [PMID: 32060819 DOI: 10.1007/s00467-020-04485-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/14/2020] [Accepted: 01/17/2020] [Indexed: 10/25/2022]
Abstract
Arterial hypertension in renal transplant recipients warrants antihypertensive treatment. The preferable choice of antihypertensives that should be used in patients after kidney transplantation remains a matter of debate; however, calcium channel blockers (CCB) and angiotensin-converting enzyme inhibitors (ACEI) are currently the most commonly used antihypertensives. This educational review summarizes the current evidence about the effects of these two classes of medications in transplant recipients. Several studies have demonstrated that both classes of drugs can reduce blood pressure (BP) to similar extents. Meta-analyses of adult randomized controlled trials have shown that graft survival is improved in patients treated with ACEIs and CCBs, and that CCBs increase, yet ACEIs decrease, graft function. Proteinuria is usually decreased by ACEIs but remains unchanged with CCBs. In children, no randomized controlled study has ever been performed to compare BP or graft survival between CCBs and ACEIs. Post-transplant proteinuria could be reduced in children along with BP by ACEIs. The results of the most current meta-analyses recommend that due to their positive effects on graft function and survival, along with their lack of negative effects on serum potassium, CCBs could be the preferred first-line antihypertensive agent in renal transplant recipients. However, antihypertensive therapy should be individually tailored based on other factors, such as time after transplantation, presence of proteinuria/albuminuria, or hyperkalemia. Furthermore, due to the difficulty in controlling hypertension, combination therapy containing both CCBs and ACEIs could be a reasonable first-step therapy in treating children with severe post-transplantation hypertension.
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Sex and age as determinants for high blood pressure in pediatric renal transplant recipients: a longitudinal analysis of the CERTAIN Registry. Pediatr Nephrol 2020; 35:415-426. [PMID: 31811541 DOI: 10.1007/s00467-019-04395-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/25/2019] [Accepted: 10/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND High prevalence of arterial hypertension is known in pediatric renal transplant patients, but how blood pressure (BP) distribution and control differ between age groups and whether sex and age interact and potentially impact BP after transplantation have not been investigated. METHODS This retrospective analysis included 336 pediatric renal transplant recipients (62% males) from the Cooperative European Pediatric Renal Transplant Initiative Registry (CERTAIN) with complete BP measurement at discharge and 1, 2 and 3 years post-transplant. RESULTS At discharge and 3 years post-transplant, arterial hypertension was highly prevalent (84% and 77%); antihypertensive drugs were used in 73% and 68% of the patients. 27% suffered from uncontrolled and 9% from untreated hypertension at 3 years post-transplant. Children transplanted at age < 5 years showed sustained high systolic BP z-score and received consistently less antihypertensive treatment over time. Younger age, shorter time since transplantation, male sex, higher body mass index (BMI), high cyclosporine A (CSA) trough levels, and a primary renal disease other than congenital anomalies of the kidney and urinary tract (CAKUT) were significantly associated with higher systolic BP z-score. Sex-stratified analysis revealed a significant association between high CSA and higher systolic BP in older girls that likely had started puberty already. An association between BP and estimated glomerular filtration rate was not detected. CONCLUSIONS BP control during the first 3 years was poor in this large European cohort. The description of age- and sex-specific risk profiles identified certain recipient groups that may benefit from more frequent BP monitoring (i.e. young children) or different choices of immunosuppression (i.e. older girls).
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End-stage kidney disease in infancy: an educational review. Pediatr Nephrol 2020; 35:229-240. [PMID: 30465082 PMCID: PMC6529305 DOI: 10.1007/s00467-018-4151-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/05/2018] [Accepted: 11/12/2018] [Indexed: 12/15/2022]
Abstract
An increasing number of infants with end-stage kidney disease (ESKD) are surviving and receiving renal replacement therapy (RRT). Unique clinical issues specific to this age group of patients influence their short- and long-term outcomes. This review summarizes current epidemiology, clinical characteristics, ethical dilemmas, management concerns, and outcomes of infants requiring chronic dialysis therapy. Optimal care during infancy requires a multidisciplinary team working closely with the patient's family. Nutritional management, infection prevention, and attention to cardiovascular status are important treatment targets. Although mortality rates remain higher among infants on dialysis compared to older pediatric dialysis patients, outcomes have improved over time. Most importantly, infants who subsequently receive a kidney transplant are now experiencing graft survival rates that are comparable to older pediatric patients.
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Querfeld U, Schaefer F. Cardiovascular risk factors in children on dialysis: an update. Pediatr Nephrol 2020; 35:41-57. [PMID: 30382333 DOI: 10.1007/s00467-018-4125-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/16/2018] [Accepted: 10/19/2018] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease (CVD) is a life-limiting comorbidity in patients with chronic kidney disease (CKD). In childhood, imaging studies have demonstrated early phenotypic characteristics including increases in left ventricular mass, carotid artery intima-media thickness, and pulse wave velocity, which occur even in young children with early stages of CKD. Vascular calcifications are the signature of an advanced phenotype and are mainly found in adolescents and young adults treated with dialysis. Association studies have provided valuable information regarding the significance of a multitude of risk factors in promoting CVD in children with CKD by using intermediate endpoints of measurements of surrogate parameters of CVD. Dialysis aggravates pre-existing risk factors and accelerates the progression of CVD with additional dialysis-related risk factors. Coronary artery calcifications in children and young adults with CKD accumulate in a time-dependent manner on dialysis. Identification of risk factors has led to improved understanding of principal mechanisms of CKD-induced damage to the cardiovascular system. Treatment strategies include assessment and monitoring of individual risk factor load, optimization of treatment of modifiable risk factors, and intensified hemodialysis if early transplantation is not possible.
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Affiliation(s)
- Uwe Querfeld
- Department of Pediatrics, Division of Gastroenterology, Nephrology and Metabolic Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Franz Schaefer
- Pediatric Nephrology Division, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
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12
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Sobhy R, Moustafa B, Zekry H, Hashim R, Salah D, Abdelfattah A. Echocardiographic findings in children with chronic kidney disease. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2020; 31:1234-1244. [DOI: 10.4103/1319-2442.308332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Wati DK, Yuliyatni PCD, Dinata IMK, Nilawati GAP, Widiana IGR, Sutawan IBR, Sunantara IGNPMA. Child Blood Pressure Profile in Bali, Indonesia. Open Access Maced J Med Sci 2019; 7:1962-1967. [PMID: 31406537 PMCID: PMC6684429 DOI: 10.3889/oamjms.2019.466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND: Mortality and morbidity in an adult will be reduced by controlling hypertension from an early age. Uncontrolled blood pressure since children can contribute to diseases such as heart disease, organ damage, and decreased quality of life. As changes in lifestyle, it is estimated that hypertension in children will continue to increase. Until now, data regarding the profile of blood pressure in children in Indonesia is still lacking. AIM: The purpose of this study was to determine the prevalence of increased blood pressure and hypertension in children in Bali. METHODS: This study was a cross-sectional study. The sampling technique in this study was multistage random sampling, that is, from 9 regencies in Bali, the selection of 3 regencies to be sampled according to socio-economic stratification based on regional economic growth and regional per capita income in Bali Province. RESULTS: From 1257, samples examined the prevalence of increased blood pressure, and hypertension was 689 children (54.8%). From the age group, the prevalence of an increase in blood pressure and hypertension in the age group ≤ , 12 years was 47.3%, and in the age group > 12 years was 62.2%. Increased blood pressure in nutritional status including Obesity 51.4%, Nutrition More 52.9%, Good Nutrition 42.2%, Nutrition Less 43.9%, Malnutrition 50.0%. In families with a history of hypertension, the prevalence of increased blood pressure and hypertension in subjects was 60.3% and in families without a history of hypertension was 43.4%. CONCLUSION: It can be concluded that there is still a prevalence of hypertension in children in Bali. Health efforts are needed so that they can minimise the further health impact that might occur. It should also be noted that various factors can influence the prevalence of increased blood pressure and hypertension in children.
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Affiliation(s)
- Dyah Kanya Wati
- Department of Child Health, School of Medicine Udayana University, Sanglah Denpasar Hospital, Denpasar, Indonesia
| | | | - I Made Krisna Dinata
- Department of Physiology, School of Medicine Udayana University, Denpasar, Indonesia
| | - Gusti Ayu Putu Nilawati
- Department of Child Health, School of Medicine Udayana University, Sanglah Denpasar Hospital, Denpasar, Indonesia
| | - I Gede Raka Widiana
- Department of Internal Medicine, School of Medicine Udayana University , Sanglah Denpasar Hospital, Denpasar, Indonesia
| | - Ida Bagus Ramajaya Sutawan
- Department of Child Health, School of Medicine Udayana University, Sanglah Denpasar Hospital, Denpasar, Indonesia
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Steroid withdrawal improves blood pressure control and nocturnal dipping in pediatric renal transplant recipients: analysis of a prospective, randomized, controlled trial. Pediatr Nephrol 2019; 34:341-348. [PMID: 30178240 DOI: 10.1007/s00467-018-4069-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Variable effects of steroid minimization strategies on blood pressure in pediatric renal transplant recipients have been reported, but data on the effect of steroid withdrawal on ambulatory blood pressure and circadian blood pressure rhythm have not been published so far. METHODS In a prospective, randomized, multicenter study on steroid withdrawal in pediatric renal transplant recipients (n = 42) on cyclosporine, mycophenolate mofetil, and methylprednisolone, we performed a substudy in 28 patients, aged 11.2 ± 3.8 years, for whom ambulatory blood pressure monitoring (ABPM) data were available. RESULTS In the steroid-withdrawal group, the percentage of patients with arterial hypertension, defined as systolic and/or diastolic blood pressure values recorded by ABPM > 1.64 SDS and/or antihypertensive medication, at month 15 was significantly lower (35.7%, p = 0.002) than in controls (92.9%). The need of antihypertensive medication dropped significantly by 61.2% (p < 0.000 vs. control), while in controls, it even rose by 69.3%. One year after steroid withdrawal, no patient exhibited hypertensive blood pressure values above the 95th percentile, compared to 35.7% at baseline (p = 0.014) and to 14.3% of control (p = 0.142). The beneficial impact of steroid withdrawal was especially pronounced for nocturnal blood pressure, leading to a recovered circadian rhythm in 71.4% of patients vs. 14.3% at baseline (p = 0.002), while the percentage of controls with an abnormal circadian rhythm (35.7%) did not change. CONCLUSIONS Steroid withdrawal in pediatric renal transplant recipients with well-preserved allograft function is associated with less arterial hypertension recorded by ABPM and recovery of circadian blood pressure rhythm by restoration of nocturnal blood pressure dipping.
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15
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Abstract
PURPOSE OF REVIEW Review epidemiology, pathophysiology, and management of hypertension in the pediatric dialysis population. RECENT FINDINGS Interdialytic blood pressure measurement, especially with ambulatory blood pressure monitoring, is the gold standard to assess for hypertension. Tools to assess dry weight aid in achievement of euvolemia, the primary therapy for management of hypertension. Persistent hypertension should be treated with antihypertensive medications and potentially with native nephrectomies. Cardiovascular disease continues to be the primary cause of morbidity and mortality in the dialysis population with hypertension as an important modifiable factor. Achievement on dry weight and limiting both aggressiveness of interdialytic weight gain and ultrafiltration rate underlie the best approach. Tools to assess volume status beyond clinical assessment have shown promise in achieving euvolemia. When hypertension persists despite achievement of euvolemia, antihypertensive medications may be required and in some cases native nephrectomies. Future studies in children are needed to determine the best antihypertensive class and ideal rate of ultrafiltration on hemodialysis towards achievement of normotension and reduction of cardiovascular risk.
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16
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Blood pressure management in children on dialysis. Pediatr Nephrol 2018; 33:239-250. [PMID: 28600736 DOI: 10.1007/s00467-017-3666-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 03/27/2017] [Accepted: 03/27/2017] [Indexed: 12/12/2022]
Abstract
Hypertension is a leading cause of cardiovascular complications in children on dialysis. Volume overload and activation of the renin-angiotensin-aldosterone system play a major role in the pathophysiology of hypertension. The first step in managing blood pressure (BP) is the careful assessment of ambulatory BP monitoring. Volume control is essential and should start with the accurate identification of dry weight, based on a comprehensive assessment, including bioimpedance analysis and intradialytic blood volume monitoring (BVM). Reduction of interdialytic weight gain (IDWG) is critical, as higher IDWG is associated with a worse left ventricular mass index and poorer BP control: it can be obtained by means of salt restriction, reduced fluid intake, and optimized sodium removal in dialysis. Optimization of peritoneal dialysis and intensified hemodialysis or hemodiafiltration have been shown to improve both fluid and sodium management, leading to better BP levels. Studies comparing different antihypertensive agents in children are lacking. The pharmacokinetic properties of each drug should be considered. At present, BP control remains suboptimal in many patients and efforts are needed to improve the long-term outcomes of children on dialysis.
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17
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Tjaden LA, Jager KJ, Bonthuis M, Kuehni CE, Lilien MR, Seeman T, Stefanidis CJ, Tse Y, Harambat J, Groothoff JW, Noordzij M. Racial variation in cardiovascular disease risk factors among European children on renal replacement therapy-results from the European Society for Paediatric Nephrology/European Renal Association - European Dialysis and Transplant Association Registry. Nephrol Dial Transplant 2017; 32:1908-1917. [PMID: 28158862 DOI: 10.1093/ndt/gfw423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/07/2016] [Indexed: 01/23/2023] Open
Abstract
Background Racial differences in overall mortality rates have been found in children on renal replacement therapy (RRT). We used data from the European Society for Paediatric Nephrology/European Renal Association - European Dialysis and Transplant Association Registry to study racial variation in the prevalence of cardiovascular disease (CVD) risk factors among European children on RRT. Methods We included patients aged <20 years between 2006-13 who (i) initiated dialysis treatment or (ii) had a renal transplant vintage of ≥1 year. Racial groups were defined as white, black, Asian and other. The CVD risk factors assessed included uncontrolled hypertension, obesity, hyperphosphataemia and anaemia. Differences between racial groups in CVD risk factors were examined using generalized estimating equation (GEE) models while adjusting for potential confounders. Results In this study, 1161 patients on dialysis and 1663 patients with a transplant were included. The majority of patients in both groups were white (73.8% and 79.9%, respectively). The crude prevalence of the CVD risk factors was similar across racial groups. However, after adjustment for potential confounders, Asian background was associated with higher risk of uncontrolled hypertension both in the dialysis group [odds ratio (OR): 1.27; 95% confidence interval (CI): 1.01-1.64] and the transplant group (OR: 1.37; 95% CI: 1.11-1.68) compared with white patients. Patients of Asian and other racial background with a renal transplant had a higher risk of anaemia compared with white patients (OR: 1.50; 95% CI: 1.15-1.96 and OR: 1.45; 95% CI: 1.01-2.07, respectively). Finally, the mean number of CVD risk factors among dialysis patients was higher in Asian patients (1.83, 95% CI: 1.64-2.04) compared with white patients (1.52, 95% CI: 1.40-1.65). Conclusions We found a higher prevalence of modifiable CVD risk factors in Asian children on RRT. Early identification and management of these risk factors could potentially improve long-term outcomes.
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Affiliation(s)
- Lidwien A Tjaden
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands.,Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Kitty J Jager
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands
| | - Marjolein Bonthuis
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands
| | - Claudia E Kuehni
- Swiss Pediatric Renal Registry, Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Marc R Lilien
- Department of Pediatric Nephrology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Tomas Seeman
- Department of Pediatrics, University Hospital Motol, Charles University Prague, 2nd Faculty of Medicine, Prague, Czech Republic
| | | | - Yincent Tse
- Department of Pediatric Nephrology, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| | - Jaap W Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Marlies Noordzij
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands
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Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140:peds.2017-1904. [PMID: 28827377 DOI: 10.1542/peds.2017-1904] [Citation(s) in RCA: 1857] [Impact Index Per Article: 265.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.
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Affiliation(s)
- Joseph T Flynn
- Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - David C Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Douglas Blowey
- Children's Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado-Denver and Pediatrician in Chief, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah D de Ferranti
- Director, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan K Flinn
- Consultant, American Academy of Pediatrics, Washington, District of Columbia
| | - Samuel S Gidding
- Cardiology Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine and Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Corinna Rea
- Associate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts
| | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas
| | - Madeline Simasek
- Pediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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19
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Milani GP, Groothoff JW, Vianello FA, Fossali EF, Paglialonga F, Edefonti A, Agostoni C, Consonni D, van Harskamp D, van Goudoever JB, Schierbeek H, Oosterveld MJS. Bioimpedance and Fluid Status in Children and Adolescents Treated With Dialysis. Am J Kidney Dis 2017; 69:428-435. [PMID: 28089477 DOI: 10.1053/j.ajkd.2016.10.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 10/09/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Assessment of hydration status in patients with chronic kidney failure treated by dialysis is crucial for clinical management decisions. Dilution techniques are considered the gold standard for measurement of body fluid volumes, but they are unfit for day-to-day care. Multifrequency bioimpedance has been shown to be of help in clinical practice in adults and its use in children and adolescents has been advocated. We investigated whether application of multifrequency bioimpedance is appropriate for total-body water (TBW) and extracellular water (ECW) measurement in children and adolescents on dialysis therapy. STUDY DESIGN A study of diagnostic test accuracy. SETTING & PARTICIPANTS 16 young dialysis patients (before a hemodialysis session or after peritoneal dialysis treatment) from the Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy, and the Emma Children's Hospital-Academic Medical Center, Amsterdam, the Netherlands. INDEX TEST TBW and ECW volumes assessed by multifrequency bioimpedance. REFERENCE TESTS TBW and ECW volumes measured by deuterium and bromide dilution, respectively. RESULTS Mean TBW volumes determined by multifrequency bioimpedance and deuterium dilution were 19.2±8.7 (SD) and 19.3±8.3L, respectively; Bland-Altman analysis showed a mean bias between the 2 methods of -0.09 (95% limits of agreement, -2.1 to 1.9) L. Mean ECW volumes were 8.9±4.0 and 8.3±3.3L measured by multifrequency bioimpedance and bromide dilution, respectively; mean bias between the 2 ECW measurements was +0.6 (95% limits of agreement, -2.3 to 3.5). LIMITATIONS Participants ingested the deuterated water at home without direct supervision by investigators, small number of patients, repeated measurements in individual patients were not performed. CONCLUSIONS Multifrequency bioimpedance measurements were unbiased but imprecise in comparison to dilution techniques. We conclude that multifrequency bioimpedance measurements cannot precisely estimate TBW and ECW in children receiving dialysis.
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Affiliation(s)
- Gregorio P Milani
- Department of Pediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Jaap W Groothoff
- Pediatric Nephrology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Federica A Vianello
- Department of Pediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emilio F Fossali
- Department of Pediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Paglialonga
- Department of Pediatric Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Edefonti
- Department of Pediatric Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlo Agostoni
- Department of Pediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dewi van Harskamp
- Pediatrics, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Johannes B van Goudoever
- Pediatrics, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands; Pediatrics VU University Medical Center, Amsterdam, the Netherlands
| | - Henk Schierbeek
- Pediatrics, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Michiel J S Oosterveld
- Pediatric Nephrology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
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20
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Is there such a thing as biocompatible peritoneal dialysis fluid? Pediatr Nephrol 2017; 32:1835-1843. [PMID: 27722783 PMCID: PMC5579143 DOI: 10.1007/s00467-016-3461-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 07/01/2016] [Accepted: 07/01/2016] [Indexed: 10/31/2022]
Abstract
Introduction of the so-called biocompatible peritoneal dialysis (PD) fluids was based on a large body of experimental evidence and various clinical trials suggesting important clinical benefits. Of these, until now, only preservation of residual renal function-likely due to lower glucose degradation product load and, in case of icodextrin, improved fluid and blood pressure control-have consistently been proven, whereas the impact on important clinical endpoints such as infectious complications, preservation of PD membrane transport function, and patient outcome, are still debated. In view of the high morbidity and mortality rates of PD patients, novel approaches are warranted and comprise the search for alternative osmotic agents and enrichment of PD fluids with specific pharmacologic agents, such as alanyl-glutamine, potentially counteracting local but also systemic sequelae of uremia and PD.
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Tkaczyk M, Stańczyk M, Miklaszewska M, Zachwieja K, Wierciński R, Stankiewicz R, Firszt-Adamczyk A, Zachwieja J, Borzęcka H, Zagożdżon I, Leszczyńska B, Medyńska A, Adamczyk P, Szczepańska M, Fendler W. What has changed in the prevalence of hypertension in dialyzed children during the last decade? Ren Fail 2016; 39:283-289. [PMID: 27882810 PMCID: PMC6014511 DOI: 10.1080/0886022x.2016.1260033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Hypertension very often accompanies progression of chronic kidney disease (CKD) in children. A cross-sectional analysis of hypertension prevalence in dialyzed children in Poland was designed with a comparison with the data previously recorded 10 years earlier. METHODS Two cohorts of children were analyzed: 59 subjects dialyzed in 2013, and 134 children from the previous study performed in 2003 that were reevaluated according to the current methodology. The incidence of hypertension (defined by SDS of sBP or dBP >1.64), clinical data, medical history, dialysis modalities and selected biochemical parameters of dialysis adequacy were analyzed. RESULTS The prevalence of hypertension increased from 64% in 2003 to 78% in 2013. The efficacy of antihypertensive treatment remained unsatisfactory (61% proper BP control). Preservation of residual urine output and strict fluid balance may prevent development of hypertension in children on dialysis. CONCLUSIONS Despite the higher awareness of hypertension and its complications in dialyzed children, the incidence of this entity has increased during the last decade, with the percentage of undertreated patients comparable to that observed 10 years ago. Thus, more attention should be paid to therapy efficacy in this population to prevent further damage to the cardiovascular system and to decrease morbidity.
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Affiliation(s)
- Marcin Tkaczyk
- a Department of Pediatrics, Immunology and Nephrology , Polish Mother's Memorial Hospital Research Institute , Lodz , Poland.,b IV Chair of Pediatrics , Medical University of Lodz , Lodz , Poland
| | - Małgorzata Stańczyk
- a Department of Pediatrics, Immunology and Nephrology , Polish Mother's Memorial Hospital Research Institute , Lodz , Poland
| | - Monika Miklaszewska
- c Department of Pediatric Nephrology , Jagiellonian University Medical College , Krakow , Poland
| | - Katarzyna Zachwieja
- c Department of Pediatric Nephrology , Jagiellonian University Medical College , Krakow , Poland
| | - Ryszard Wierciński
- d Department of Pediatrics and Nephrology , Medical University of Bialystok , Bialystok , Poland
| | | | | | - Jacek Zachwieja
- f Department of Cardiology and Nephrology , Medical University of Poznan , Poznan , Poland
| | - Halina Borzęcka
- g Department of Pediatric Nephrology , Medical University of Lublin , Lublin , Poland
| | - Ilona Zagożdżon
- h Department of Nephrology and Hypertension of Children and Adolescents , Medical University of Gdansk , Gdansk , Poland
| | - Beata Leszczyńska
- i Department of Pediatric Nephrology , Medical University of Warsaw , Warsaw , Poland
| | - Anna Medyńska
- j Department of Pediatric Nephrology , Medical University of Wroclaw , Wroclaw , Poland
| | - Piotr Adamczyk
- k Department of Pediatric Nephrology , Silesian Medical University , Zabrze , Poland
| | - Maria Szczepańska
- k Department of Pediatric Nephrology , Silesian Medical University , Zabrze , Poland
| | - Wojciech Fendler
- l Department of Pediatrics, Hematology, Oncology and Diabetology , Medical University of Lodz , Lodz , Poland
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22
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Zaloszyc A, Schmitt CP, Schaefer B, Doutey A, Terzic J, Menouer S, Higel L, Fischbach M. [Peritoneal equilibration test: Conventional versus adapted. Preliminary study]. Nephrol Ther 2016; 13:30-36. [PMID: 27810276 DOI: 10.1016/j.nephro.2016.07.444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 07/08/2016] [Indexed: 11/30/2022]
Abstract
Conventional automated peritoneal dialysis (APD) is prescribed as a repetition of cycles with the same dwell time and the same fill volume. Water and sodium balance remains a common problem among patients on peritoneal dialysis. More recently, adapted automated peritoneal dialysis was described, as a combination of short dwells with a low volume, in order to enhance ultrafiltration, followed by long dwells with a large fill volume to favor solute removal. We performed a preliminary crossover study on 4 patients. The total amount of dialysate was the same, i.e. 2L/m2 as well as the total duration of the test, i.e. 150 minutes. The conventional test was made with two identical cycles, each cycle had a fill volume of 1L/m2 and a duration of 75 minutes, while the adapted test was performed with one short cycle, i.e. 30 minutes with a low fill volume, i.e. 0.6L/m2, followed by a long cycle, i.e. 120 minutes, with a large fill volume, i.e. 1.4L/m2. Sodium extraction was improved by 29.3mmol/m2 (169%) in the adapted test in comparison to the conventional test. Ultrafiltration was enhanced by 159mL/m2 (128%) in the adapted test compared to the conventional one. Glucose absorption was decreased by 35% in the adapted test in comparison to the conventional test and osmotic conductance was also improved. In conclusion, adapted dialysis may allow for a better volume and sodium balance, since we observed an improvement in sodium extraction and ultrafiltration. This pre-study authorizes an improvement of the European Pediatric Study's protocol on Adapted APD, already started and which will continue in the next months.
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Affiliation(s)
- Ariane Zaloszyc
- Service de pédiatrie I, hôpitaux universitaires de Strasbourg, CHU de Hautepierre, 1, avenue Molière, 67098 Strasbourg, France.
| | - Claus Peter Schmitt
- Kinder Nephrologie, Uni-klinikum Heidelberg Zentrum für Kinder-Jugendmedizin, INF 430, 69120 Heidelberg, Allemagne
| | - Betti Schaefer
- Kinder Nephrologie, Uni-klinikum Heidelberg Zentrum für Kinder-Jugendmedizin, INF 430, 69120 Heidelberg, Allemagne
| | - Armelle Doutey
- Service de pédiatrie I, hôpitaux universitaires de Strasbourg, CHU de Hautepierre, 1, avenue Molière, 67098 Strasbourg, France
| | - Joëlle Terzic
- Service de pédiatrie I, hôpitaux universitaires de Strasbourg, CHU de Hautepierre, 1, avenue Molière, 67098 Strasbourg, France
| | - Soraya Menouer
- Service de pédiatrie I, hôpitaux universitaires de Strasbourg, CHU de Hautepierre, 1, avenue Molière, 67098 Strasbourg, France
| | - Laetitia Higel
- Service de pédiatrie I, hôpitaux universitaires de Strasbourg, CHU de Hautepierre, 1, avenue Molière, 67098 Strasbourg, France
| | - Michel Fischbach
- Service de pédiatrie I, hôpitaux universitaires de Strasbourg, CHU de Hautepierre, 1, avenue Molière, 67098 Strasbourg, France
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23
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Harambat J, Bonthuis M, Groothoff JW, Schaefer F, Tizard EJ, Verrina E, van Stralen KJ, Jager KJ. Lessons learned from the ESPN/ERA-EDTA Registry. Pediatr Nephrol 2016; 31:2055-64. [PMID: 26498279 DOI: 10.1007/s00467-015-3238-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/20/2015] [Accepted: 09/21/2015] [Indexed: 01/10/2023]
Abstract
End-stage renal disease (ESRD) in children is a medically challenging condition. Due to its rarity and special features, methodologically sound collaborative studies are required. In 2007, a new European registry of pediatric renal replacement therapy (RRT), the ESPN/ERA-EDTA Registry, was launched. In recent years, the Registry has provided comprehensive data on incidence, prevalence, patient characteristics, RRT modalities, and mortality in pediatric ESRD, along with relevant insights into cardiovascular risk, anemia, nutrition and growth, transplantation outcomes, and rare diseases. In this review, we describe the study design and structure underlying the ESPN/ERA-EDTA Registry, summarize the major research findings from more than 20 publications, and discuss current limitations and the future challenges to overcome.
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Affiliation(s)
- Jérôme Harambat
- Department of Pediatrics, Bordeaux University Hospital, Bordeaux, France.
| | - Marjolein Bonthuis
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, Netherlands
| | - Jaap W Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands
| | - Franz Schaefer
- Department of Pediatric Nephrology, University Children's Hospital, Heidelberg, Germany
| | - E Jane Tizard
- Department of Pediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK
| | - Enrico Verrina
- Dialysis Unit, Gaslini Children's Hospital, Genoa, Italy
| | - Karlijn J van Stralen
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, Netherlands
| | - Kitty J Jager
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, Netherlands
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Stabouli S, Printza N, Dotis J, Gkogka C, Kollios K, Kotsis V, Papachristou F. Long-Term Changes in Blood Pressure After Pediatric Kidney Transplantation. Am J Hypertens 2016; 29:860-5. [PMID: 26657420 DOI: 10.1093/ajh/hpv192] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/13/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Hypertension presents high prevalence rates following kidney transplantation (Tx). The aims of the present study were to investigate the prevalence and possible risk factors for hypertension and blood pressure (BP) control over time after pediatric kidney Tx, as well as to assess possible effects of hypertension on graft survival. METHODS We reviewed the medical records of all pediatric kidney recipients followed up in our pediatric nephrology department. Hypertension was defined as systolic and/or diastolic BP greater than the 95th percentile for age and sex, or as being on antihypertensive medication. BP control was defined as normotension while on antihypertensive medication. RESULTS The study population included 74 pediatric kidney recipients (median age 11 years). The prevalence of hypertension was found 77% before Tx, 82.4%, 71.7%, and 61% at 1, 5, and 10 years after Tx, respectively. Deceased donor Tx and pre-transplant hypertension on antihypertensive medication were significant risk factors for hypertension after kidney Tx over the follow-up period. BP control among patients on antihypertensive treatment was 16.7% before Tx, 43.8%, 66.7%, and 42.9% at 1, 5, and 10 years post-Tx, respectively. Hypertensive patients at 10 years post-Tx had 8.079 times higher hazard of graft loss compared to normotensives (95% CI 1.561-41.807, P < 0.05). CONCLUSIONS Hypertension remains a frequent complication in pediatric kidney recipients even years after kidney Tx. BP control by antihypertensive treatment is unsatisfactory in about half of the patients. The adverse effects of hypertension on graft survival may appear in the long-term.
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Affiliation(s)
- Stella Stabouli
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece;
| | - Nikoleta Printza
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - John Dotis
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Chrysa Gkogka
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Kollios
- 3rd Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios Kotsis
- 3rd Department of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotios Papachristou
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Dobrowolski LC, van Huis M, van der Lee JH, Peters Sengers H, Liliën MR, Cransberg K, Cornelissen M, Bouts AH, de Fijter JW, Berger SP, van Zuilen A, Nurmohamed SA, Betjes MH, Hilbrands L, Hoitsma AJ, Bemelman FJ, Krediet P, Groothoff JW. Epidemiology and management of hypertension in paediatric and young adult kidney transplant recipients in The Netherlands. Nephrol Dial Transplant 2016; 31:1947-1956. [DOI: 10.1093/ndt/gfw225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 04/18/2016] [Indexed: 12/16/2022] Open
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Cameron C, Krmar RT. Single-center assessment of nutritional counseling in preventing excessive weight gain in pediatric renal transplants recipients. Pediatr Transplant 2016; 20:388-94. [PMID: 26787256 DOI: 10.1111/petr.12668] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2015] [Indexed: 12/21/2022]
Abstract
Post-transplantation obesity is a common complication that is associated with a higher risk for decreased allograft function and hypertension. However, the role of diet intervention on reducing post-transplantation obesity is relatively unknown. We investigated the clinical relevance of dietary counseling on the prevalence of overweight/obesity during the first two yr following renal transplantation. The computerized patient records of 42 recipients (31 males) aged 6.3 ± 4.8 yr at transplantation were reviewed. All patients systematically underwent yearly dietary assessment/counseling (motivational interviewing technique) and measurement of renal function and ABPM. At transplantation, 14.2% of patients were overweight/obese, which increased to 42.8% by two yr post-transplantation (p = 0.004). The majority of patients experienced a significant increase in BMI SDS during the first six months post-transplantation that remained sustained throughout the duration of the follow-up period (p = 0.001). By two yr post-transplantation, there were no observable differences between patients classified as having normal BMI or being overweight/obese with regard to renal function and controlled hypertension. The application of yearly tailored dietary assessment/counseling had a poor effect on preventing post-transplantation weight gain, suggesting the need for more comprehensive interventions to reduce post-transplant obesity.
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Affiliation(s)
- Camilla Cameron
- Division of Pediatrics, Department for Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Rafael T Krmar
- Division of Pediatrics, Department for Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
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Schaefer F, Hoppe B, Jungraithmayr T, Klaus G, Pape L, Farouk M, Addison J, Manamley N, Vondrak K. Safety and usage of darbepoetin alfa in children with chronic kidney disease: prospective registry study. Pediatr Nephrol 2016; 31:443-53. [PMID: 26482252 PMCID: PMC4756039 DOI: 10.1007/s00467-015-3225-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/22/2015] [Accepted: 09/22/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Limited prospective data are available on the long-term safety of darbepoetin alfa (DA) for treating anemia in children with chronic kidney disease (CKD). METHODS In this prospective, phase IV, observational registry study, children ≤16 years of age with CKD anemia and receiving DA were observed for ≤2 years. Adverse events (AEs), DA dosing, hemoglobin (Hb) concentrations, and transfusions were recorded. RESULTS A total of 319 patients were included in the analysis (mean age, 9.1 years), 158 (49.5%) of whom were on dialysis at study entry. Of 434 serious AEs reported in 162 children, the most common were peritonitis (10.0%), gastroenteritis (6.0%), and hypertension (4.1%). Six patients (1.9%) died (unrelated to DA). Four patients (1.3%) experienced six serious adverse drug reactions. The geometric mean DA dose range was 1.4-2.0 μg/kg/month. Mean baseline Hb concentration was 11.1 g/dl; mean values for children receiving and not receiving dialysis at baseline ranged between 10.9 and 11.5 g/dl and 11.2-11.7 g/dl, respectively. Overall, 48 patients (15.0%) received ≥1 transfusion. CONCLUSIONS No new safety signals for DA were identified in children receiving DA for CKD anemia for ≤2 years. Based on Hb concentrations and transfusion requirements, DA was effective at managing anemia in these patients.
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Affiliation(s)
- Franz Schaefer
- University of Heidelberg, Heidelberg, Germany. .,Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
| | | | | | | | - Lars Pape
- Hannover Medical School, Hannover, Germany
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Impact of Pediatric Chronic Dialysis on Long-Term Patient Outcome: Single Center Study. Int J Nephrol 2016; 2016:2132387. [PMID: 27597898 PMCID: PMC5002458 DOI: 10.1155/2016/2132387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 05/14/2016] [Accepted: 06/21/2016] [Indexed: 11/18/2022] Open
Abstract
Objective. Owing to a shortage of kidney donors in Israel, children with end-stage renal disease (ESRD) may stay on maintenance dialysis for a considerable time, placing them at a significant risk. The aim of this study was to understand the causes of mortality. Study Design. Clinical data were collected retrospectively from the files of children on chronic dialysis (>3 months) during the years 1995–2013 at a single pediatric medical center. Results. 110 patients were enrolled in the study. Mean age was 10.7 ± 5.27 yrs. (range: 1 month–24 yrs). Forty-five children (42%) had dysplastic kidneys and 19 (17.5%) had focal segmental glomerulosclerosis. Twenty-five (22.7%) received peritoneal dialysis, 59 (53.6%) hemodialysis, and 6 (23.6%) both modalities sequentially. Median dialysis duration was 1.46 years (range: 0.25–17.54 years). Mean follow-up was 13.5 ± 5.84 yrs. Seventy-nine patients (71.8%) underwent successful transplantation, 10 (11.2%) had graft failure, and 8 (7.3%) continued dialysis without transplantation. Twelve patients (10.9%) died: 8 of dialysis-associated complications and 4 of their primary illness. The 5-year survival rate was 84%: 90% for patients older than 5 years and 61% for younger patients. Conclusions. Chronic dialysis is a suitable temporary option for children awaiting renal transplantation. Although overall long-term survival rate is high, very young children are at high risk for life-threatening dialysis-associated complications.
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Gupta D, Chaturvedi S, Chandy S, Agarwal I. Role of 24-h ambulatory blood pressure monitoring in children with chronic kidney disease. Indian J Nephrol 2015; 25:355-61. [PMID: 26664211 PMCID: PMC4663773 DOI: 10.4103/0971-4065.148305] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hypertension is common in children with chronic kidney disease (CKD) and is a major determinant of CKD progression. Ambulatory blood pressure monitoring (ABPM) has been proposed to be better in detecting hypertension as compared to casual blood pressure (CBP). This study aims to study the usefulness of ABPM in detecting masked hypertension, evaluating the adequacy of blood pressure (BP) control and predicting left ventricular hypertrophy (LVH) amongst children with CKD. A prospective cross-sectional study of 46 children with stage 3–5 CKD was conducted at the Pediatric Nephrology department of a tertiary hospital in South India. All children underwent CBP, ABPM and an echocardiography. Results were categorized as normal BP; confirmed hypertension; masked hypertension and white coat hypertension. Out of 46 children studied, 11 were undergoing dialysis. While 39.1% children had stage 3 and 4 CKD each, 21.7% had stage 5 CKD. Masked hypertension was detected in 19.6% and 21.7% had confirmed hypertension. Thirty-four (73.9%) children were already receiving antihypertensive medication. In these, CBP was elevated in 23.5% and ABP in 47%. Among children with hypertension as defined by ABPM, LVH was detected in 32.2%. We found that higher the number of abnormal ABPM indices (assessed by BP Index, nocturnal dipping and BP Load) higher the likelihood of LVH (P = 0.046). ABPM is better in detecting hypertension and monitoring adequacy of treatment in children with CKD. The high prevalence of masked hypertension and its association with LVH supports early echocardiography and ambulatory BP monitoring to evaluate cardiovascular risks in this population.
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Affiliation(s)
- D Gupta
- Department of Community Medicine, Christian Medical College and Hospital, Vellore, India
| | - S Chaturvedi
- Department of Pediatric Nephrology, Christian Medical College and Hospital, Vellore, India
| | - S Chandy
- Department of Cardiology, Christian Medical College and Hospital, Vellore, India
| | - I Agarwal
- Department of Community Medicine, Christian Medical College and Hospital, Vellore, India
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Sinha MD, Keehn L, Milne L, Sofocleous P, Chowienczyk PJ. Decreased arterial elasticity in children with nondialysis chronic kidney disease is related to blood pressure and not to glomerular filtration rate. Hypertension 2015; 66:809-15. [PMID: 26259592 DOI: 10.1161/hypertensionaha.115.05516] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 07/16/2015] [Indexed: 12/26/2022]
Abstract
We compared large artery mechanical properties in children with nondialysis stages of chronic kidney disease with those in children with normal renal function, examining the potential effect of blood pressure (BP) components and level of renal dysfunction. Common carotid artery mechanical properties, carotid-femoral pulse wave velocity, and carotid and peripheral BP were measured in children (n=226) with nondialysis chronic kidney disease (n=188; 11.9±3.7 years; 26%, 25%, 30%, 16%, and 3% in stages 1, 2, 3, 4 and 5, respectively) and healthy controls (n=38; 11.5±3.3 years). In children with nondialysis chronic kidney disease when compared with healthy controls, at similar levels of peripheral and carotid BP, carotid artery diastolic diameter and wall thickness were similar. In those with suboptimal BP (≥75th percentile), indices of arterial elasticity indicated greater stiffness than in healthy normotensive controls (distensibility: 92±31 versus 114±33 kPa(-1)×10(-3), P=0.03; compliance: 2.1±0.7 versus 2.6±0.7 m(2) kPa(-1)×10(-6), P=0.02; Young elastic modulus: 0.151±0.068 versus 0.109±0.049 kPa×10(3), P=0.02; and wall stress: 83.6±23.5 versus 68.7±14.9 kPa, P=0.02). In all children, mechanical properties were independently related to carotid and peripheral BP components but not to estimated glomerular filtration rate. In children with nondialysis chronic kidney disease, changes in elastic properties of the carotid artery are primarily related to BP and not to glomerular renal function.
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Affiliation(s)
- Manish D Sinha
- From the King's College London British Heart Foundation Centre, Department of Clinical Pharmacology, St Thomas' Hospital, Kings College London, London, United Kingdom (M.D.S., L.K., L.M., P.J.C.); and Department of Paediatric Nephrology, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom (M.D.S., P.S.).
| | - Louise Keehn
- From the King's College London British Heart Foundation Centre, Department of Clinical Pharmacology, St Thomas' Hospital, Kings College London, London, United Kingdom (M.D.S., L.K., L.M., P.J.C.); and Department of Paediatric Nephrology, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom (M.D.S., P.S.)
| | - Laura Milne
- From the King's College London British Heart Foundation Centre, Department of Clinical Pharmacology, St Thomas' Hospital, Kings College London, London, United Kingdom (M.D.S., L.K., L.M., P.J.C.); and Department of Paediatric Nephrology, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom (M.D.S., P.S.)
| | - Paula Sofocleous
- From the King's College London British Heart Foundation Centre, Department of Clinical Pharmacology, St Thomas' Hospital, Kings College London, London, United Kingdom (M.D.S., L.K., L.M., P.J.C.); and Department of Paediatric Nephrology, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom (M.D.S., P.S.)
| | - Phil J Chowienczyk
- From the King's College London British Heart Foundation Centre, Department of Clinical Pharmacology, St Thomas' Hospital, Kings College London, London, United Kingdom (M.D.S., L.K., L.M., P.J.C.); and Department of Paediatric Nephrology, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, United Kingdom (M.D.S., P.S.)
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Hypertension in children with end-stage renal disease. Adv Med Sci 2015; 60:342-8. [PMID: 26275711 DOI: 10.1016/j.advms.2015.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 06/23/2015] [Accepted: 07/02/2015] [Indexed: 11/21/2022]
Abstract
This review summarizes current data on the epidemiology, pathophysiology, and treatment of hypertension (HTN) in children with end-stage renal disease (ESRD). Worldwide prevalence of ESRD ranges from 5.0 to 84.4 per million age-related population. HTN is present in 27-79% of children with ESRD, depending on the modality of renal replacement therapy and the exact definition of hypertension. Ambulatory BP monitoring has been recommended for the detection of HTN and evaluation of treatment effectiveness. HTN in dialyzed patients is mostly related to hypervolemia, sodium overload, activation of the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system, impaired nitric oxide synthesis, reduced vitamin D levels, and effects of microRNA. In children undergoing chronic dialysis therapy, important factors include optimization of renal replacement therapy and preservation of residual renal function, allowing reduction of volume- and sodium-overload, along with appropriate drug treatment, particularly with calcium channel blockers, RAAS inhibitors, and loop diuretics.
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Lofaro D, Jager KJ, Abu-Hanna A, Groothoff JW, Arikoski P, Hoecker B, Roussey-Kesler G, Spasojević B, Verrina E, Schaefer F, van Stralen KJ. Identification of subgroups by risk of graft failure after paediatric renal transplantation: application of survival tree models on the ESPN/ERA-EDTA Registry. Nephrol Dial Transplant 2015; 31:317-24. [PMID: 26320038 DOI: 10.1093/ndt/gfv313] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 08/01/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Identification of patient groups by risk of renal graft loss might be helpful for accurate patient counselling and clinical decision-making. Survival tree models are an alternative statistical approach to identify subgroups, offering cut-off points for covariates and an easy-to-interpret representation. METHODS Within the European Society of Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry data we identified paediatric patient groups with specific profiles for 5-year renal graft survival. Two analyses were performed, including (i) parameters known at time of transplantation and (ii) additional clinical measurements obtained early after transplantation. The identified subgroups were added as covariates in two survival models. The prognostic performance of the models was tested and compared with conventional Cox regression analyses. RESULTS The first analysis included 5275 paediatric renal transplants. The best 5-year graft survival (90.4%) was found among patients who received a renal graft as a pre-emptive transplantation or after short-term dialysis (<45 days), whereas graft survival was poorest (51.7%) in adolescents transplanted after long-term dialysis (>2.2 years). The Cox model including both pre-transplant factors and tree subgroups had a significantly better predictive performance than conventional Cox regression (P < 0.001). In the analysis including clinical factors, graft survival ranged from 97.3% [younger patients with estimated glomerular filtration rate (eGFR) >30 mL/min/1.73 m(2) and dialysis <20 months] to 34.7% (adolescents with eGFR <60 mL/min/1.73 m(2) and dialysis >20 months). Also in this case combining tree findings and clinical factors improved the predictive performance as compared with conventional Cox model models (P < 0.0001). CONCLUSIONS In conclusion, we demonstrated the tree model to be an accurate and attractive tool to predict graft failure for patients with specific characteristics. This may aid the evaluation of individual graft prognosis and thereby the design of measures to improve graft survival in the poor prognosis groups.
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Affiliation(s)
- Danilo Lofaro
- Department of Nephrology, Dialysis and Transplantation, "Kidney and Transplantation" Research Centre, Annunziata Hospital, Cosenza, Italy de-Health Lab, DIMEG, University of Calabria, Rende, Italy
| | - Kitty J Jager
- Department of Medical Informatics, ERA-EDTA Registry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Department of Medical Informatics, ESPN/ERA-EDTA Registry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaap W Groothoff
- Department of Medical Informatics, ESPN/ERA-EDTA Registry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Department of Pediatric Nephrology, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Pekka Arikoski
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Britta Hoecker
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | | | | | - Enrico Verrina
- Department of Pediatric Nephrology, Gaslini Children's Hospital, Genoa, Italy
| | - Franz Schaefer
- Department of Medical Informatics, ESPN/ERA-EDTA Registry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Karlijn J van Stralen
- Department of Medical Informatics, ESPN/ERA-EDTA Registry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Halbach S, Flynn J. Treatment of hypertension in children with chronic kidney disease. Curr Hypertens Rep 2015; 17:503. [PMID: 25432895 DOI: 10.1007/s11906-014-0503-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Hypertension (HTN) is increasingly recognized as a common feature of pediatric chronic kidney disease (CKD). A growing body of evidence demonstrates that HTN is both underdiagnosed and undertreated in this population. The consequences of untreated HTN include adverse effects on CKD progression, markers of cardiovascular morbidity, and neurocognitive functioning. Consensus guidelines issued over the past decade have incorporated recent research on the consequences of HTN in recommendations for the diagnosis and treatment of HTN in pediatric CKD and include lower BP targets. Agents which target the renin-angiotensin-aldosterone system (RAAS) should be considered first-line therapy in CKD-associated HTN in children, though multiple medications may be required to achieve sufficient BP control.
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Affiliation(s)
- Susan Halbach
- Division of Nephrology, Seattle Children's Hospital, 4800 Sand Point Way NE, M/S OC.9.820, Seattle, WA, 98105, USA,
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Roszkowska-Blaim M, Skrzypczyk P, Jander A, Tkaczyk M, Bałasz-Chmielewska I, Żurowska A, Drożdż D, Pietrzyk JA. Effect of hypertension and antihypertensive medications on residual renal function in children treated with chronic peritoneal dialysis. Adv Med Sci 2015; 60:18-24. [PMID: 25240137 DOI: 10.1016/j.advms.2014.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 06/12/2014] [Accepted: 08/19/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the effect of hypertension (HTN) and antihypertensive medications (AHM) on residual renal function (RRF) in children on CAPD and APD. MATERIAL/METHODS We retrospectively evaluated underlying kidney disease, systolic and diastolic blood pressure (SBP/DBP), presence and control of HTN (SBP/DBP≥95th percentile), AHM, RRF (daily diuresis, residual glomerular filtration rate [rGFR]), biochemical parameters, BMI Z-score, and dialysis parameters during 12-month follow-up in 87 children (38 CAPD, 49 APD) aged 10.22±4.31 years. The rate of RRF loss was expressed as absolute and relative [%] reduction. RESULTS At baseline, HTN was found in 74.7% patients (CAPD/APD: 84.2%/67.3%, P=0.06), most commonly in HUS and least frequently in CAKUT. The proportion of CAPD/APD patients with poorly controlled HTN was 70.0%/63.3% (P=0.50). Relative daily diuresis loss in children with uncontrolled HTN was higher (P=0.017) compared to children with SBP/DBP <95th percentile. No effect of AHM on the rate of RRF loss was found. In multivariate analysis, absolute daily diuresis loss was related to baseline diuresis (β=-0.30, P<0.001) and proteinuria (β=-0.31, P=0.004); absolute rGFR loss to baseline rGFR (β=-0.73, P<0.001) and glucose load after 12 months (β=-0.36, P=0.02); relative daily diuresis loss to mean BMI Z-score (β=-0.44, P=0.04); and relative rGFR to baseline rGFR (β=-0.37, P<0.001) and SBP percentile (β=-0.21, P=0.045).
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Affiliation(s)
| | - Piotr Skrzypczyk
- Department of Pediatrics and Nephrology, Medical University of Warsaw, Warsaw, Poland.
| | - Anna Jander
- Nephrology Division, Department of Pediatrics and Immunology, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - Marcin Tkaczyk
- Nephrology Division, Department of Pediatrics and Immunology, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - Irena Bałasz-Chmielewska
- Department of Pediatric and Adolescent Nephrology and Hypertension, Medical University of Gdańsk, Gdańsk, Poland
| | - Aleksandra Żurowska
- Department of Pediatric and Adolescent Nephrology and Hypertension, Medical University of Gdańsk, Gdańsk, Poland
| | - Dorota Drożdż
- Dialysis Unit, Jagiellonian University Medical College, Cracow, Poland
| | - Jacek A Pietrzyk
- Dialysis Unit, Jagiellonian University Medical College, Cracow, Poland
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Weir MR, Burgess ED, Cooper JE, Fenves AZ, Goldsmith D, McKay D, Mehrotra A, Mitsnefes MM, Sica DA, Taler SJ. Assessment and management of hypertension in transplant patients. J Am Soc Nephrol 2015; 26:1248-60. [PMID: 25653099 DOI: 10.1681/asn.2014080834] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hypertension in renal transplant recipients is common and ranges from 50% to 80% in adult recipients and from 47% to 82% in pediatric recipients. Cardiovascular morbidity and mortality and shortened allograft survival are important consequences of inadequate control of hypertension. In this review, we examine the epidemiology, pathophysiology, and management considerations of post-transplant hypertension. Donor and recipient factors, acute and chronic allograft injury, and immunosuppressive medications may each explain some of the pathophysiology of post-transplant hypertension. As observed in other patient cohorts, renal artery stenosis and adrenal causes of hypertension may be important contributing factors. Notably, BP treatment goals for renal transplant recipients remain an enigma because there are no adequate randomized controlled trials to support a benefit from targeting lower BP levels on graft and patient survival. The potential for drug-drug interactions and altered pharmacokinetics and pharmacodynamics of the different antihypertensive medications need to be carefully considered. To date, no specific antihypertensive medications have been shown to be more effective than others at improving either patient or graft survival. Identifying the underlying pathophysiology and subsequent individualization of treatment goals are important for improving long-term patient and graft outcomes in these patients.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland;
| | - Ellen D Burgess
- Division of Renal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - James E Cooper
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado, Denver, Colorado
| | - Andrew Z Fenves
- Division of Nephrology, Department of Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - David Goldsmith
- Division of Cardio-Renal Medicine, St. Thomas and Guy's Hospital, London, United Kingdom
| | - Dianne McKay
- Division of Nephrology, Department of Medicine, University of California, San Diego, San Diego, California
| | - Anita Mehrotra
- Division of Nephrology, Department of Medicine, Mount Sinai School of Medicine, New York, New York
| | - Mark M Mitsnefes
- Division of Nephrology, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Domenic A Sica
- Division of Nephrology, Department of Medicine, Virginia Commonwealth University, Richmond, Virginia; and
| | - Sandra J Taler
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Optimizing peritoneal dialysis prescription for volume control: the importance of varying dwell time and dwell volume. Pediatr Nephrol 2014; 29:1321-7. [PMID: 23903692 DOI: 10.1007/s00467-013-2573-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 07/01/2013] [Accepted: 07/09/2013] [Indexed: 01/24/2023]
Abstract
Not only adequate uremic toxin removal but also volume control is essential in peritoneal dialysis (PD) to improve patient outcome. Modification of dwell time impacts on both ultrafiltration (UF) and purification. A short dwell favors UF but preferentially removes small solutes such as urea. A long dwell favors uremic toxin removal but also peritoneal fluid reabsorption due to the time-dependent loss of the crystalloid osmotic gradient. In particular, the long daytime dwell in automated PD may result in significant water and sodium reabsorption, and in such cases icodextrin should be considered. Increasing dwell volume favors the removal of solutes such as sodium due to the increased volume of diffusion and the recruitment of peritoneal surface area. A very large fill volume with too high an intraperitoneal pressure (IPP) may, however, result in back-filtration and thus reduced UF and sodium clearance. Based on these principles and the individual transport and pressure kinetics obtained from peritoneal equilibration tests and IPP measurements, we suggest combining short dwells with a low fill volume to favor UF with long dwells and a large fill volume to favor solute removal. Results from a recent randomized cross-over trial and earlier observational data in children support this concept: the absolute UF and UF relative to the administered glucose increased and solute removal and blood pressure improved.
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Agarwal R, Flynn J, Pogue V, Rahman M, Reisin E, Weir MR. Assessment and management of hypertension in patients on dialysis. J Am Soc Nephrol 2014; 25:1630-46. [PMID: 24700870 PMCID: PMC4116052 DOI: 10.1681/asn.2013060601] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Hypertension is common, difficult to diagnose, and poorly controlled among patients with ESRD. However, controversy surrounds the diagnosis and treatment of hypertension. Here, we describe the diagnosis, epidemiology, and management of hypertension in dialysis patients, and examine the data sparking debate over appropriate methods for diagnosing and treating hypertension. Furthermore, we consider the issues uniquely related to hypertension in pediatric dialysis patients. Future clinical trials designed to clarify the controversial results discussed here should lead to the implementation of diagnostic and therapeutic techniques that improve long-term cardiovascular outcomes in patients with ESRD.
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Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana;
| | - Joseph Flynn
- Division of Nephrology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Velvie Pogue
- formerly Division of Nephrology, Harlem Hospital, Columbia University College of Physicians & Surgeons, New York, New York
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Efrain Reisin
- Division of Nephrology and Hypertension, Louisiana State University Health Science Center, New Orleans, Louisiana; and
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Warady BA, Neu AM, Schaefer F. Optimal Care of the Infant, Child, and Adolescent on Dialysis: 2014 Update. Am J Kidney Dis 2014; 64:128-42. [DOI: 10.1053/j.ajkd.2014.01.430] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 01/28/2014] [Indexed: 12/18/2022]
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Survival and clinical outcomes of children starting renal replacement therapy in the neonatal period. Kidney Int 2014; 86:168-74. [DOI: 10.1038/ki.2013.561] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 11/20/2013] [Accepted: 11/21/2013] [Indexed: 01/06/2023]
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Cameron C, Vavilis G, Kowalski J, Tydén G, Berg UB, Krmar RT. An observational cohort study of the effect of hypertension on the loss of renal function in pediatric kidney recipients. Am J Hypertens 2014; 27:579-85. [PMID: 23955604 DOI: 10.1093/ajh/hpt140] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Post-transplant hypertension impacts negatively on renal graft survival. Our primary objective was to analyze the effect of hypertension on the glomerular filtration rate (GFR) slope. METHODS All clinical charts of children who underwent renal transplantation since the introduction of the routine use of ambulatory blood pressure monitoring (ABPM) were reviewed. Eligibility criteria for inclusion were measurement of GFR at 3 months, at 1 year post-transplant, and thereafter at yearly intervals; ABPM performed annually after transplantation; and functioning graft for a minimum of 2 years. RESULTS Sixty-eight (39 males) of 79 patients, aged 9.1±5.3 years, met the inclusion criteria. The mean follow-up was 6.2±2.8 years. Twenty-four patients had normotension or controlled hypertension throughout their follow-up (normotensive group). Forty-four patients had hypertension or noncontrolled hypertension at some point(s) during the follow-up period (hypertensive group). GFR slope was -1.6ml/min/1.73 m(2) per year (95% confidence interval (CI = -3.7 to 0.4) in the normotensive group and -2ml/min/1.73 m(2) per year (95% CI = -3 to -1.1) in the hypertensive group (P = 0.42). There was no difference between groups with regard to the change in GFR values from 3 months to 1 year and to last control (P = 0.87). At most recent control, the overall prevalence of controlled hypertension was 78.2% (95% CI = 63.6-89.1). CONCLUSIONS Although the results of our study are encouraging, they need to be confirmed in a larger prospective study using the same post-transplant follow-up protocol.
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Affiliation(s)
- Camilla Cameron
- Department for Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska University Hospital, Huddinge, Sweden
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41
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Zaloszyc A, Schaefer B, Schaefer F, Krid S, Salomon R, Niaudet P, Schmitt CP, Fischbach M. Hydration measurement by bioimpedance spectroscopy and blood pressure management in children on hemodialysis. Pediatr Nephrol 2013; 28:2169-77. [PMID: 23832099 DOI: 10.1007/s00467-013-2540-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 04/30/2013] [Accepted: 06/05/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hypertension is frequent in chronic hemodialyzed patients and usually treated by reducing extracellular fluid. Probing dry weight only based on a clinical evaluation may be hazardous, especially in case of volume independent hypertension. METHODS We performed a 1-year retrospective study in three pediatric centers to define the relation between blood pressure (BP) and hydration status, assessed by whole-body bioimpedance spectroscopy (BIS). We analyzed 463 concomitant measurements of BP, relative overhydration (rel.OH), and plasma sodium (Napl) in 23 children (mean age 13.9 ± 5.1 years). RESULTS Pre-dialytic under-hydration (rel.OH < -7%) was present in 5.4% of the sessions, out of which 24% showed hypertension. Normohydration (rel.OH -7 - +7%) was observed in 62.4% of the sessions, 45.3% of them revealed hypertension. Moderate OH (rel.OH +7 - +15%) was present in 21% of the sessions, 47.4% of them showed normal BP. In 11.2% of the sessions, severe overhydration (rel.OH > +15%) was assessed, however, the majority (73%) showed normal BP. Patient-specific Napl setpoint could not be described. Mean dialysate sodium concentration was higher than mean Napl. CONCLUSIONS Hypertension is not always related to overhydration. Therefore, BIS should restrict the practice of "probing dry weight" in hypertensive children. Moreover, sodium dialytic balance needs to be considered to improve BP management.
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Affiliation(s)
- Ariane Zaloszyc
- Nephrology Dialysis Transplantation Children's Unit, University Hospital Hautepierre, 1, Avenue Molière, 67098, Strasbourg, France
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Harambat J, Bonthuis M, van Stralen KJ, Ariceta G, Battelino N, Bjerre A, Jahnukainen T, Leroy V, Reusz G, Sandes AR, Sinha MD, Groothoff JW, Combe C, Jager KJ, Verrina E, Schaefer F. Adult height in patients with advanced CKD requiring renal replacement therapy during childhood. Clin J Am Soc Nephrol 2013; 9:92-9. [PMID: 24178977 DOI: 10.2215/cjn.00890113] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Growth and final height are of major concern in children with ESRD. This study sought to describe the distribution of adult height of patients who started renal replacement therapy (RRT) during childhood and to identify determinants of final height in a large cohort of RRT children. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A total of 1612 patients from 20 European countries who started RRT before 19 years of age and reached final height between 1990 and 2011 were included. Linear regression analyses were performed to calculate adjusted mean final height SD score (SDS) and to investigate its potential determinants. RESULTS The median final height SDS was -1.65 (median of 168 cm in boys and 155 cm in girls). Fifty-five percent of patients attained an adult height within the normal range. Adjusted for age at start of RRT and primary renal diseases, final height increased significantly over time from -2.06 SDS in children who reached adulthood in 1990-1995 to -1.33 SDS among those reaching adulthood in 2006-2011. Older age at start of RRT, more recent period of start of RRT, cumulative percentage time on a functioning graft, and greater height SDS at initiation of RRT were independently associated with a higher final height SDS. Patients with congenital anomalies of the kidney and urinary tract and metabolic disorders had a lower final height than those with other primary renal diseases. CONCLUSIONS Although final height remains suboptimal in children with ESRD, it has consistently improved over time.
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Affiliation(s)
- Jérôme Harambat
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Kogon AJ, Pierce CB, Cox C, Brady TM, Mitsnefes MM, Warady BA, Furth SL, Flynn JT. Nephrotic-range proteinuria is strongly associated with poor blood pressure control in pediatric chronic kidney disease. Kidney Int 2013; 85:938-44. [PMID: 24048375 PMCID: PMC3959634 DOI: 10.1038/ki.2013.352] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 06/28/2013] [Accepted: 07/25/2013] [Indexed: 01/27/2023]
Abstract
Despite the importance of blood pressure (BP) control in chronic kidney disease (CKD), few longitudinal studies on its trends exist for pediatric patients with CKD. Here we longitudinally analyzed casual data in 578 children with CKD and annual BP measurements standardized for age, gender and height. At baseline, 124 children were normotensive, 211 had elevated BP and 243 had controlled hypertension. Linear mixed effects models accounting for informative dropout determined factors associated with BP changes over time and relative sub-hazards (RSH) identified factors associated with the achievement of controlled BP in children with baseline elevated BP. Younger age, black children, higher body mass index, and higher proteinuria at baseline were associated with higher standardized BP levels. Overall average BP decreased during follow-up, but nephrotic range proteinuria, and increased proteinuria and body mass index were risk factors for increasing BP over time. Only 46% of hypertensive patients achieved controlled BP during follow-up; least likely were those with nephrotic range proteinuria (RSH 0.19), black children (RSH 0.42) and children with baseline GFR under 40 ml/min/1.73m2 (RSH 0.58). Thus, of many coexisting factors, nephrotic range proteinuria was most strongly associated with poor BP control and worsening BP over time. Future research should focus on strategies to reduce proteinuria, as this may improve BP control and slow the progression of CKD.
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Affiliation(s)
- Amy J Kogon
- Columbia University Medical Center, New York, New York, USA
| | | | - Christopher Cox
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tammy M Brady
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Mark M Mitsnefes
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Susan L Furth
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Vogelzang JL, Heestermans LWAA, van Stralen KJ, Jager KJ, Groothoff JW. Simultaneous reversal of risk factors for cardiac death and intensified therapy in long-term survivors of paediatric end-stage renal disease over the last 10 years. Nephrol Dial Transplant 2013; 28:2545-52. [DOI: 10.1093/ndt/gft257] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Springel T, Laskin B, Shults J, Keren R, Furth S. Longer interdialytic interval and cause-specific hospitalization in children receiving chronic dialysis. Nephrol Dial Transplant 2013; 28:2628-36. [PMID: 23861468 DOI: 10.1093/ndt/gft276] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Previous studies have demonstrated a relationship between longer interdialytic intervals and hospitalization for cardiovascular causes in adults maintained on hemodialysis (HD). This association has not been previously demonstrated in children. We hypothesized that the risk of hospitalization for hypertension (HTN), fluid overload or electrolyte abnormalities would be increased on the days following a longer interdialytic interval in children. METHODS We queried the Pediatric Hospital Information System for all admissions of patients with chronic kidney disease stage V or V-D who received dialysis during the hospitalization. Admissions were divided into two categories: admissions for HTN, fluid overload or electrolyte abnormalities and admissions for all other causes. We assumed that HD patients did not receive dialysis on weekends, and therefore any admission on Monday occurred following a longer interval from the last dialysis. We assumed that all peritoneal dialysis (PD) patients received dialysis on a daily basis. We used mixed effects logistic regression, clustering by patient within each hospital, to assess the increased odds for cause-specific admission on Monday versus other days of the week. We stratified the analysis by dialysis modality, HD or PD. RESULTS Among HD patients, the odds ratio of admission for HTN, fluid overload or electrolyte abnormalities was 2.6 (95% CI = 1.4-4.7, P = 0.003) if the admission occurred on a Monday versus other days of the week. The odds of cause-specific admission among PD patients was not significantly different on Monday compared with other days of the week (95% CI =0.5-1.3, P = 0.8). CONCLUSION Children receiving chronic HD are more likely to be hospitalized for HTN, fluid overload or electrolyte abnormalities following a longer interdialytic interval. Changes to the frequency of outpatient dialysis treatments may decrease admissions in this population and decrease resource utilization in this high-risk population.
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Affiliation(s)
- Tamar Springel
- Department of Pediatrics, Cooper University Hospital, Camden, NJ, USA
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Seeman T, Gilík J. Long-term control of ambulatory hypertension in children: improving with time but still not achieving new blood pressure goals. Am J Hypertens 2013; 26:939-45. [PMID: 23645323 DOI: 10.1093/ajh/hpt048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Short-term therapy can decrease blood pressure (BP) to less than the 95th percentile in only about 50% of children. The aim of our study was to investigate the long-term control of hypertension (HT) in children using ambulatory BP monitoring (ABPM). METHODS We analyzed data from all children who started ramipril monotherapy in our center. Controlled HT was defined according to the most current guidelines as systolic and diastolic BP at daytime and nighttime <90th percentile in primary HT and <75th percentile in renoparenchymal HT. RESULTS Thirty-eight children who were on therapy ≥1 year were included. Thirty-two children had renoparenchymal, and 6 had primary HT. The median age at the beginning of therapy was 13.6 years (range = 4.1-18.0 years), and the median time of antihypertensive therapy was 2.6 years (range = 1.0-11.8 years). Thirty-four percent of children received combination therapy; the median number of antihypertensive drugs was 1.5 drugs/patient (range = 1-4). Sixty-eight percent of children had BP <95th percentile, but only 34% of the children had controlled HT. Children with uncontrolled HT had a tendency to have a higher daytime diastolic BP index before the start of therapy than children with controlled HT (0.99±0.11 vs. 0.94±0.11; P = 0.09). There was a significant decrease in prevalence of nondipping (from 47% to 16%; P = 0.006) with therapy. CONCLUSIONS This first pediatric study focusing on long-term control of HT using ABPM showed that long-term control of HT is better than short-term control, but still only one-third of children achieve the new BP goals. The low control of HT might be improved by more intensive therapy.
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Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics, University Hospital Motol, Charles University Prague, Second Medical School, Czech Republic and Biomedical Centre, Faculty of Medicine in Plzen, Charles University in Prague, Plzen, Czech Republic.
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Abstract
Hypertension is a common and serious complication after renal transplantation. It is an important risk factor for graft loss and adverse cardiovascular outcomes. Blood pressure (BP) in transplanted children should be measured not only by clinic BP (cBP) measurement, but also by ambulatory blood pressure monitoring (ABPM), because ABPM has distinct advantages over cBP, specifically the ability to reveal nocturnal, masked or white-coat hypertension. These types of hypertension are common in transplanted children (nocturnal hypertension 36-71 %, masked hypertension 24-45 %). It may also reveal uncontrolled hypertension in treated children, thereby improving control of hypertension. Regular use of ABPM and ABPM-guided therapy of hypertension may help to decrease cardiovascular and renal target organ damage in transplanted children. Therefore, ABPM should be routinely performed in all transplanted children at least once a year, regardless of the values of cBP.
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Abstract
More than a decade ago, cardiovascular disease (CVD) was recognized as a major cause of death in children with advanced CKD. This observation has sparked the publication of multiple studies assessing cardiovascular risk, mechanisms of disease, and early markers of CVD in this population. Similar to adults, children with CKD have an extremely high prevalence of traditional and uremia-related CVD risk factors. Early markers of cardiomyopathy, such as left ventricular hypertrophy and dysfunction, and early markers of atherosclerosis, such as increased carotid artery intima-media thickness, carotid arterial wall stiffness, and coronary artery calcification, are frequently present in these children, especially those on maintenance dialysis. As a population without preexisting symptomatic cardiac disease, children with CKD potentially receive significant benefit from aggressive attempts to prevent and treat CVD. Early CKD, before needing dialysis, is the optimal time to both identify modifiable risk factors and intervene in an effort to avert future CVD. Slowing the progression of CKD, avoiding long-term dialysis and, if possible, conducting preemptive transplantation may represent the best strategies to decrease the risk of premature cardiac disease and death in children with CKD.
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Affiliation(s)
- Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA.
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Flynn JT. Hypertension in pediatric patients with childhood-onset chronic kidney disease: much to be learned, more to be done. Kidney Int 2011; 80:1012-3. [PMID: 22042027 DOI: 10.1038/ki.2011.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pediatric patients with chronic kidney disease are increasingly recognized as being at increased risk of developing cardiovascular disease as adults. Numerous risk factors contribute, hypertension being one of the most identifiable and potentially modifiable. Despite this, numerous studies have demonstrated that hypertension is common and is frequently underrecognized and/or undertreated in this population. Greater efforts are needed to identify and effectively treat hypertension in these vulnerable patients to reduce the future burden of adult cardiovascular disease.
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Affiliation(s)
- Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington 98105, USA.
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50
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Schaefer F, Warady BA. Peritoneal dialysis in children with end-stage renal disease. Nat Rev Nephrol 2011; 7:659-68. [PMID: 21947118 DOI: 10.1038/nrneph.2011.135] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Peritoneal dialysis is the preferred chronic dialysis modality for most children owing to its almost universal applicability and superior compatibility with lifestyle over other modalities. Although technological advances and increasing clinical experience have impacted favorably on patient and technique survival, clinical research in pediatric peritoneal dialysis has been hampered by the low incidence of end-stage renal disease (ESRD) in the pediatric population. To overcome this limitation, several international registries have emerged in the past few years to complement other long-standing registries, which together have provided useful information regarding technique-specific complications and comorbidities associated with ESRD in children undergoing chronic peritoneal dialysis. In this Review, we summarize the most relevant findings from these studies, highlighting the substantial variation in patient conditions, peritoneal dialysis practices and management of comorbidities encountered in different parts of the world.
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Affiliation(s)
- Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany.
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