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Kogon AJ, Hooper SR. Mental health and social-emotional functioning in children and adolescents with chronic kidney disease. Pediatr Nephrol 2024; 39:2015-2031. [PMID: 37878136 DOI: 10.1007/s00467-023-06151-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/24/2023] [Accepted: 08/19/2023] [Indexed: 10/26/2023]
Abstract
For children and young adults, living with chronic kidney disease (CKD) poses physical, mental, and social challenges. The mental health functioning of children and adolescents with CKD plays an important role in the medical, educational, vocational, and quality of life outcomes, yet receives little systematic attention in the busy pediatric nephrology clinic. This article will provide an overview of the prevalence of mental illness and symptoms in children and young adults with CKD, strategies to assess for dysfunction, and the long-term outcomes associated with impaired functioning. While there is a relative dearth of literature regarding evidence-based interventions in this population to improve mental health functioning, we provide "best practice" strategies based on the available literature to address emotional and/or behavioral challenges once they are identified. More research is needed to define appropriate interventions to alleviate mental health issues and social-emotional distress, and this review of the literature will serve to provide directions for future research.
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Affiliation(s)
- Amy J Kogon
- Children's Hospital of Philadelphia, Division of Pediatric Nephrology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Stephen R Hooper
- Department of Health Sciences, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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2
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Zhang A, Furgeson S, Shapiro A, Bjornstad P, You Z, Tommerdahl KL, Dixon A, Stenson E, Oh E, Kendrick J. Assessing Cognition in CKD Using the National Institutes of Health Toolbox. KIDNEY360 2024; 5:834-840. [PMID: 38568010 PMCID: PMC11219111 DOI: 10.34067/kid.0000000000000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/29/2024] [Indexed: 06/01/2024]
Abstract
Key Points Participants with CKD had detectable cognitive deficits in fluid cognition, dexterity, and total cognition. Sex differences in cognition exist in people with CKD. Background CKD is largely an age-related clinical disorder with accelerated cognitive and cardiovascular aging. Cognitive impairment is a well-documented occurrence in midlife and older adults with CKD and affects multiple domains. We examined cognition function and potential sex differences in cognition in adults with CKD. Methods We included 105 individuals (49.5% women) with CKD stage 3b–4 (eGFR, 15–44 ml/min) from the Bicarbonate Administration in CKD Trial (NCT02915601 ). We measured cognitive function using the National Institutes of Health Toolbox Cognition Battery, which assesses cognitive and motor measures, such as executive function, attention, memory, and dexterity. All study measures were collected and analyzed at the study baseline. Results The mean (SD) age and eGFR were 61±12 years and 34.9±9.8 ml/min per 1.73 m2. Overall, when compared with the National Institutes of Health Toolbox reference population, participants scored, on average, below the 50th percentile across all cognitive domain tests and the dexterity test. Total cognition scores were also below the 50th percentile. Participants with stage 4 CKD had significantly lower fluid cognition scores compared with those with CKD stage 3b (β -estimate −5.4 [95% confidence interval, −9.8 to −0.9]; P = 0.03). Female participants with CKD performed significantly better on the episodic memory tests and dexterity tests (dominant and nondominant pegboard tests) and had higher crystallized cognition scores, on average, compared with male participants. Conclusions Participants with CKD had detectable cognitive deficits in fluid cognition, dexterity, and total cognition. In addition, sex differences in cognitive measures were found among people with CKD.
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Affiliation(s)
- Alexander Zhang
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Seth Furgeson
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Allison Shapiro
- Section of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Petter Bjornstad
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Section of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Zhiying You
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kalie L. Tommerdahl
- Section of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Angelina Dixon
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Erin Stenson
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ester Oh
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Mai K, Dawson AE, Gu L, LaMotte JE, Molitor S, Zimmerman CT. Common mental health conditions and considerations in pediatric chronic kidney disease. Pediatr Nephrol 2024:10.1007/s00467-024-06314-8. [PMID: 38456918 DOI: 10.1007/s00467-024-06314-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 01/30/2024] [Accepted: 01/30/2024] [Indexed: 03/09/2024]
Abstract
The mental health of youth with chronic kidney disease (CKD) has been increasingly recognized as an area of clinical need. The development of mental health concerns is influenced by a range of physiological, psychological, and environmental factors. Some of these factors are common across child development, but some are more unique to youth with CKD. Mental health concerns are associated with increased risk for a range of poor medical outcomes (e.g., adherence, risk of transplant rejection) and quality of life concerns. In this educational review, we discuss the current evidence base regarding the development of mental health concerns in youth with CKD. The review covers multiple domains including mood and anxiety disorders, traumatic stress, and neurodevelopmental disorders. Estimated prevalence and hypothesized risk factors are outlined, and the potential impact of mental health on medical care and functional outcomes are reviewed. Finally, we introduce options for intervention to support positive mental health and offer recommendations for building access to mental health care and improving the mental health education/training of medical professionals.
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Affiliation(s)
- Katherine Mai
- Division of Pediatric Nephrology, Cohen Children's Medical Center, 420 Lakeville Road, New Hyde Park, NY, 11364, USA.
| | - Anne E Dawson
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, OH, USA
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Lidan Gu
- Division of Clinical Behavioral Neuroscience, University of Minnesota, Minneapolis, MN, USA
| | - Julia E LaMotte
- Division of Child and Adolescent Psychiatry, Riley Children's Health, Indianapolis, IN, USA
| | - Stephen Molitor
- Division of Pediatric Psychology and Developmental Medicine, Department of Pediatrics, Medical College of Wisconsin Milwaukee, Milwaukee, WI, USA
| | - Cortney T Zimmerman
- Division of Psychology and Nephrology Service, Department of Pediatrics, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, 77030, USA
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Wijaya EA, Solek P, Rachmadi D, Rahayuningsih SE, Tarigan R, Hilmanto D. Effect of Executive Function on Health-Related Quality of Life in Children with Chronic Kidney Disease. Int J Nephrol Renovasc Dis 2024; 17:17-28. [PMID: 38223907 PMCID: PMC10785681 DOI: 10.2147/ijnrd.s428657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/21/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction As the highest function in the brain that regulates our daily activity, executive dysfunction might affect someone's health-related quality of life (HRQoL), especially in those with chronic diseases, including chronic kidney disease (CKD). Neurocognitive functions, including intelligence quotient (IQ) and executive function can be affected through various mechanisms in CKD. However, there was still no specific study regarding how IQ and executive function might affect HRQoL in children with CKD. Purpose To assess Executive Function's impact on HRQoL and to find association between treatment modalities and CKD stages with HRQoL in children with CKD. Methods A cross sectional study was conducted at Pediatric Nephrology Clinic at Hasan Sadikin General Hospital, Bandung, Indonesia from September 2022 to April 2023. We included 38 children whose age range were 6-16 years 11 months old with CKD stage III - V. Assessment tools used were: BRIEF questionnaire for executive function; WISC III tool for IQ; PedsQLTM questionnaire generic module for HRQoL. Data was analyzed using SPSS ver. 26.0. Results Total number of samples was 38. Complete examinations were done on 30 patients. Eight other patients did not undergo the IQ test. There was a negative correlation between executive function components scores (GEC, BRI, MI) with HRQoL scores on parents' proxy in all domains. We found no correlation between HRQoL and IQ scores, but we found a correlation between IQ and CKD stage. There was a significant difference in HRQoL from the children's perspective among the three modalities; children who underwent conservative treatment were having the best HRQoL scores. Conclusion Interventions to improve executive function of children with CKD should be done to improve their HRQoL in the future. Early diagnosis and treatment of CKD should be done at the earliest to improve neurocognitive function and HRQoL.
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Affiliation(s)
- Elrika Anastasia Wijaya
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Purboyo Solek
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Dedi Rachmadi
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Sri Endah Rahayuningsih
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Rodman Tarigan
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Dany Hilmanto
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
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Lullmann O, van der Plas E, Harshman LA. Understanding the impact of pediatric kidney transplantation on cognition: A review of the literature. Pediatr Transplant 2023; 27:e14597. [PMID: 37664967 PMCID: PMC11034761 DOI: 10.1111/petr.14597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a relatively rare childhood disease that is associated with a wide array of medical comorbidities. Roughly half of all pediatric patients acquire CKD due to congenital anomalies of the kidneys and urinary tract, and of those with congenital disease, 50% will progress to end-stage kidney disease (ESKD) necessitating a kidney transplantation. The medical sequelae of advanced CKD/ESKD improve dramatically following successful kidney transplantation; however, the impact of kidney transplantation on neurocognition in children is less clear. It is generally thought that cognition improves following kidney transplantation; however, our knowledge on this topic is limited by the sparsity of high-quality data in the context of the relative rarity of pediatric CKD/ESKD. METHOD We conducted a narrative review to gauge the scope of the literature, using the PubMed database and the following keywords: cognition, kidney, brain, pediatric, neurocognition, intelligence, executive function, transplant, immunosuppression, and neuroimaging. RESULTS There are few published longitudinal studies, and existing work often includes wide heterogeneity in age at transplant, variable dialysis exposure/duration prior to transplant, and unaccounted cofounders which persist following transplantation, including socio-economic status. Furthermore, the impact of long-term maintenance immunosuppression on the brain and cognitive function of pediatric kidney transplant (KT) recipients remains unknown. CONCLUSION In this educational review, we highlight what is known on the topic of neurocognition and neuroimaging in the pediatric KT population.
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Affiliation(s)
- Olivia Lullmann
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine; Iowa City, IA
| | - Ellen van der Plas
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine; Iowa City, IA
- Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine; Little Rock, AR
| | - Lyndsay A. Harshman
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine; Iowa City, IA
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Harshman LA, Ward RC, Matheson MB, Dawson A, Kogon AJ, Lande MB, Molitor SJ, Johnson RJ, Wilson C, Warady BA, Furth SL, Hooper SR. The Impact of Pediatric CKD on Educational and Employment Outcomes. KIDNEY360 2023; 4:1389-1396. [PMID: 37418621 PMCID: PMC10615373 DOI: 10.34067/kid.0000000000000206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/29/2023] [Indexed: 07/09/2023]
Abstract
Key Points This study evaluates educational and employment outcomes in patients with pediatric kidney disease and assesses predictors of educational attainment and employment in young adulthood. Despite high rates of high school graduation, nearly 20% of patients with CKD are unemployed or receiving disability at long-term follow-up. Background Pediatric patients with CKD are at risk for neurocognitive deficits and academic underachievement. This population may be at risk for lower educational attainment and higher rates of unemployment; however, published data have focused on patients with advanced CKD and exist in isolation from assessment of neurocognition and kidney function. Methods Data from the CKD in Children (CKiD) cohort study were used to characterize educational attainment and employment status in young adults with CKD. We used ratings of executive function as a predictor of future educational attainment and employment status. Linear regression models predicted the highest grade level completed. Logistic regression models predicted unemployment. Results A total of 296 CKiD participants aged 18 years or older had available educational data. In total, 220 of 296 had employment data. By age 22 years, 97% had completed high school and 48% completed 2+ years of college. Among those reporting employment status, 58% were part-time or full-time employed, 22% were nonworking students, and 20% were unemployed and/or receiving disability. In adjusted models, lower kidney function (P = 0.02), worse executive function (P = 0.02), and poor performance on achievement testing (P = 0.004) predicted lower grade level completed relative to expectation for age. Conclusions CKiD study patients appear to have a better high school graduation rates (97%) than the adjusted national high school graduation rate (86%). Conversely, roughly 20% of participants were unemployed or receiving disability at study follow-up. Tailored interventions may benefit patients with CKD with lower kidney function and/or executive function deficits to optimize educational/employment outcomes in adulthood.
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Affiliation(s)
- Lyndsay A. Harshman
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Ryan C. Ward
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Matthew B. Matheson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Anne Dawson
- Section of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio
| | - Amy J. Kogon
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Stephen J. Molitor
- Medical College of Wisconsin, Department of Pediatrics, Division of Pediatric Psychology, Milwaukee, Wisconsin
| | - Rebecca J. Johnson
- Division of Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Camille Wilson
- Section of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio
| | - Bradley A. Warady
- Division of Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Susan L. Furth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen R. Hooper
- Department of Health Sciences, School of Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
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Lullmann O, Conrad AL, Steinbach EJ, Wilgenbusch T, Harshman LA, van der Plas E. Neurocognitive deficits may not resolve following pediatric kidney transplantation. Pediatr Transplant 2023; 27:e14505. [PMID: 36932049 PMCID: PMC11001201 DOI: 10.1111/petr.14505] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/15/2023] [Accepted: 02/24/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Pediatric chronic kidney disease (CKD) patients are at risk for cognitive deficits with worsening disease progression. Limited, existing cross-sectional studies suggest that cognitive deficits may improve following kidney transplantation. We sought to assess cognitive performance in relationship to kidney transplantation and kidney-specific medical variables in a sample of pediatric kidney transplant patients who provided cross-sectional and longitudinal observations. METHODS A retrospective chart review was conducted in patients who completed pre- and/or post-transplant neurocognitive testing at the University of Iowa from 2015-2021. Cognitive outcomes were investigated with developmentally appropriate, standardized measures. Mixed linear models estimated the impact of transplant status on cognitive function (z-scores). Subsequent post-hoc t-tests on change scores were limited to patients who had provided pre- and post-transplant assessments. RESULTS Thirty eight patients underwent cognitive assessments: 10 had both pre- and post-transplant cognitive assessments, 11 had pre-transplant assessments only, and 17 had post-transplant data only. Post-transplant status was associated with significantly lower full-scale IQ and slower processing speed compared to pre-transplant status (estimate = -0.32, 95% confidence interval [CI] = -0.52: -0.12; estimate = -0.86, CI = -1.17: -0.55, respectively). Post-hoc analyses confirmed results from the mixed models (FSIQ change score = -0.34, 95% CI = -0.56: -0.12; processing speed change score = -0.98, CI = -1.28: -0.68). Finally, being ≥80 months old at transplant was associated with substantially lower FSIQ compared to being <80 months (estimate = -1.25, 95% CI = -1.94: -0.56). CONCLUSIONS Our results highlight the importance of monitoring cognitive function following pediatric kidney transplant and identify older transplant age as a risk factor for cognitive deficits.
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Affiliation(s)
- Olivia Lullmann
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Amy L Conrad
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Emily J Steinbach
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Tammy Wilgenbusch
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Lyndsay A Harshman
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ellen van der Plas
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
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Singh NS, Johnson RJ, Matheson MB, Carlson J, Hooper SR, Warady BA. A longitudinal analysis of the effect of anemia on executive functions in children with mild to moderate chronic kidney disease. Pediatr Nephrol 2023; 38:829-837. [PMID: 35861871 PMCID: PMC10659592 DOI: 10.1007/s00467-022-05682-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 06/09/2022] [Accepted: 07/01/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Children with chronic kidney disease (CKD) are at risk for cognitive dysfunction. The aim of this study was to investigate associations between executive functions (EF), anemia, and iron deficiency. METHODS A total of 688 children > 6 years of age enrolled in the Chronic Kidney Disease in Children (CKiD) study who underwent evaluation for EF were included. Hemoglobin (Hgb) was characterized as low (1st-5th percentile) or very low (< 1st percentile) compared to normative values for age, sex, and race irrespective of erythropoiesis-stimulating agent (ESA) usage. Longitudinal analysis was conducted using consecutive visit pairs, with anemia status defined as new onset, resolved, or persistent. Linear mixed models with random intercept were used and adjusted for key covariates. RESULTS Anemia was present in 41% of children, and median Hgb was 11.8 gm/dl. New onset anemia was associated with lower digit span total score (- 0.75, 95% CI - 1.36, - 0.15, p = 0.01). Persistent anemia was associated with lower scores on color-word inhibition/switching (β = - 0.98; 95% CI - 1.78, - 0.18, p = 0.02). Errors of omission were significantly higher (worse) in those with persistent anemia (β = 2.67, 95% CI 0.18, 5.17, p = 0.04). Very low Hgb levels were significantly associated with lower color-word inhibition/switching scores (β = - 1.33, 95% CI - 2.16, - 0.51; p = 0.002). Anemia and low GFR were associated with lower category fluency scores compared to non-anemic subjects with higher GFR (β = - 1.09, 95% CI - 2.09, - 0.10, p = 0.03). CONCLUSIONS The presence of anemia, in addition to its severity and duration in children with CKD, is associated with poorer scores on select measures of EF. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Nisha S Singh
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA.
| | | | - Matthew B Matheson
- Division of Developmental and Behavioral Health, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Joann Carlson
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, Rutgers/Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Stephen R Hooper
- Department of Health Sciences, School of Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
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Engen RM, Kirmani S. Pediatric impacts of multiorgan transplant allocation policy in the United States. Pediatr Transplant 2023; 27 Suppl 1:e14253. [PMID: 36468327 DOI: 10.1111/petr.14253] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Multiorgan transplantation is increasingly common, driving recent increased attention to multiorgan allocation policies. METHODS In this review, we summarize current multiorgan transplant allocation policies in the United States, with attention to recent and proposed changes and their impact on pediatric candidates. RESULTS Existing multiorgan transplant policies attempt to balance equity and utility. Currently, there are clear allocation policies for some, but not all, multiorgan transplant combinations, and there are no mandatory outcomes reporting. Multiorgan candidates are prioritized above all kidney-alone transplant candidates, which negatively affect pediatric kidney transplant wait times. Pediatric candidates are typically exempt from multiorgan listing criteria. CONCLUSION Multiorgan transplant allocation presents unique challenges for policy development. As the United States Network for Organ Sharing begins exploring continuous distribution allocation, multiorgan allocation will require special consideration and the development of clear and equitable policies.
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Affiliation(s)
- Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Sonya Kirmani
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
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Engen R, Shepherd D, Bradford MC, Foutz J, Bartosh SM, Smith JM. Impact of multiorgan and kidney-pancreas allocation policies on pediatric kidney-alone transplant candidates in the United States. Pediatr Transplant 2022; 26:e14394. [PMID: 36134704 DOI: 10.1111/petr.14394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/06/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The United States organ allocation policies prioritize kidney-pancreas and other multiorgan candidates above pediatric kidney-alone candidates, but the effects of these policies are unclear. METHODS We used OPTN data to describe trends in multiorgan and kidney-pancreas transplantation and identify 377 next-sequential pediatric kidney-alone candidates between 4/1/2015 and 10/31/2019 for individual-level analysis. RESULTS Eleven percent of all kidneys were allocated as part of a multiorgan or kidney-pancreas transplant and 6% of pediatric kidney candidates were impacted. Pediatric next-sequential candidates accrued a median of 118 days (IQR 97-135 days) of additional wait time, and this was significantly longer for children who were Hispanic (p = .02), blood type B or O (p = .01), or had a cPRA ≥20% (p < .01). Eight pediatric next-sequential candidates (2%) were removed from the waitlist due to death or "too sick to transplant." 63% were transplanted with a kidney with a higher KDPI than the original multiorgan match (p < .01). Donor service areas with higher volumes of kidney-pancreas transplants had significantly longer additional wait times for pediatric next-sequential candidates (p = .01). CONCLUSIONS Current allocation policy results in longer waiting times and higher KDPI kidneys for pediatric kidney candidates. As multiorgan transplant volume is increasing, further consideration of allocation policy is necessary to maximize equality and utility.
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Affiliation(s)
- Rachel Engen
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Danielle Shepherd
- Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Miranda C Bradford
- Core for Biostatistics, Epidemiology, and Analytics in Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Julia Foutz
- United Network for Organ Sharing, Richmond, Virginia, USA
| | - Sharon M Bartosh
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Jodi M Smith
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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Engen RM, Smith JM, Bartosh SM. The kidney allocation system and pediatric transplantation at 5 years. Pediatr Transplant 2022; 26:e14369. [PMID: 35919967 DOI: 10.1111/petr.14369] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/07/2022] [Accepted: 07/17/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND A new Kidney Allocation System (KAS) was implemented in the United States in 2014 with the goal of improving equity and utility. METHODS In this study, we compare outcomes for kidney-alone candidates less than 18 years of age, at the time of listing, in the 5 years prior to and following policy implementation using Organ Procurement and Transplantation Network data. RESULTS While the pediatric deceased donor transplant rate increased under KAS, this increase was due solely to improved access for children aged 11-17 years; there was an 18.9% decrease in the deceased donor transplant rate among children 0-5 years old, from 117.94 to 95.8 transplants per 100 person-years (p = .001). The cumulative incidence of deceased donor transplantation by 1 year after listing decreased from 39.3% in the pre-KAS era to 35.5% in the post-KAS era (p = .004), a decline that was driven entirely by longer wait times for children 0-5 years old (p = .017). Candidates with a calculated panel reactive antibody of 98%-100% experienced a significant increase in transplant rate, but there was no change in transplant rate for Black or Hispanic candidates. CONCLUSION Overall, KAS increased transplantation access for teenaged and highly sensitized candidates but resulted in decreased access for the youngest children with no improvement in racial/ethnic equality.
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Affiliation(s)
- Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Jodi M Smith
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Sharon M Bartosh
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
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12
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Wijaya EA, Solek P, Hakim DDL, Rossanti R, Widiasta A, Hilmanto D. Factors Affecting Neurocognitive Function in Children with Chronic Kidney Disease: A Systematic Review. Int J Nephrol Renovasc Dis 2022; 15:277-288. [PMID: 36329897 PMCID: PMC9624145 DOI: 10.2147/ijnrd.s375242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/05/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose In children, chronic kidney disease (CKD) has been known to affect neurocognitive function which can impair the quality of life. This study aims to determine the factors and treatment modalities which might affect neurocognitive function in pediatric population with CKD. Patients and Methods A systematic review was done using 3 electronic databases: PubMed, ScienceDirect, SpringerLink, and carried out based on PRISMA guidelines. Our review included articles published in the last 10 years (2011–2021) in English, on children aged 0–18 years with CKD. Factors affecting the children’s neurocognitive function were assessed. Results Eight articles were included in this study. Three articles reported that parent’s education, especially maternal education affect the neurocognitive function of children with CKD. In relation with modalities, in general, children with CKD who had kidney transplant had a better neurocognitive outcome. A longer duration of hemodialysis (HD) was associated with poorer neurocognitive outcomes. Other factors that can affect the neurocognitive function included depression, a history of abnormal births, seizures, and hypertension. Conclusion In children, CKD might cause neurocognitive function disorders through various complex and interconnected mechanisms. Further studies are needed to determine the mechanism and prevention of neurocognitive disorders, as well as the best choice of therapeutic modality to improve both kidney function and neurocognitive function in children with CKD.
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Affiliation(s)
- Elrika A Wijaya
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Purboyo Solek
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Dzulfikar D L Hakim
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Rini Rossanti
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Ahmedz Widiasta
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Dany Hilmanto
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia,Correspondence: Dany Hilmanto, Tel +628122266879, Email
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13
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Duquette PJ, Gipson DS, Hooper SR. Differential Attention Functioning in Pediatric Chronic Kidney Disease. Front Hum Neurosci 2022; 16:897131. [PMID: 35814956 PMCID: PMC9269323 DOI: 10.3389/fnhum.2022.897131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/08/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To compare specific attention functions for school-age children with chronic kidney disease (CKD) to those of a typically developing control group. Methods A cross-sectional study examined attention dimensions for children and adolescents with CKD (n = 30) in comparison to a typically developing control group (n = 41). The CKD group consisted of those receiving maintenance dialysis (n = 15) and those with mild/moderate CKD treated conservatively (n = 15). Measures aligning with Mirsky’s conceptual multidimensional model of attention were selected to compare groups across five dimensions of attention: Focus/Execute, Sustain, Stability, Shift, and Encode. Results Significant group differences were revealed, with the CKD group performing worse than controls on the Focus/Execute, Sustain, and Encode dimensions. The CKD group also had a larger proportion of children with scores one standard deviation or more below the mean on the Shift and Encode domains, suggesting an at-risk level of functioning in these dimensions. Secondary analyses showed disease severity to be correlated with worse attention functions for children with CKD. Conclusion Children with CKD may be vulnerable to subtle, specific deficits in numerous attention dimensions relative to their typically developing peers, particularly for those with more severe disease.
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Affiliation(s)
- Peter J. Duquette
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Debbie S. Gipson
- Department of Pediatrics, Division of Nephrology, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, United States
| | - Stephen R. Hooper
- Department of Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- *Correspondence: Stephen R. Hooper,
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14
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Associations between neurofilament light-chain protein, brain structure, and chronic kidney disease. Pediatr Res 2022; 91:1735-1740. [PMID: 34274959 PMCID: PMC8761779 DOI: 10.1038/s41390-021-01649-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/24/2021] [Accepted: 06/30/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neurofilament light-chain (NfL) protein is a blood-based marker of neuroaxonal injury. We sought to (1) compare plasma NfL levels in children with chronic kidney disease (CKD) and healthy peers, (2) characterize the relationship between NfL level and kidney function, and (3) evaluate NfL as a predictor of abnormal brain structure in CKD. METHODS Sixteen children with CKD due to congenital kidney anomalies and 23 typically developing peers were included. Plasma NfL was quantified using single-molecule array immunoassay. Participants underwent structural magnetic resonance imaging. Multiple linear regression models were used to evaluate the association between plasma NfL levels, kidney function, and brain structure. RESULTS An age × group interaction was identified whereby NfL levels increased with age in the CKD group only (estimate = 0.65; confidence interval (CI) = 0.08-1.22; p = 0.026). Decreased kidney function was associated with higher NfL levels (estimate = -0.10; CI = -0.16 to -0.04; p = 0.003). Lower cerebellar gray matter volume predicted increased plasma NfL levels (estimate = -0.00024; CI = -0.00039 to 0.00009; p = 0.004) within the CKD group. CONCLUSIONS Children with CKD show accelerated age-related increases in NfL levels. NfL level is associated with lower kidney function and abnormal brain structure in CKD. IMPACT NfL is a component of the neuronal cytoskeleton providing structural axonal support. Elevated NfL has been described in relation to gray and white matter brain volume loss. We have previously described the abnormal cerebellar gray matter in CKD. We explored the relationship between NfL, CKD, and brain volume. There is an accelerated, age-related increase in NfL level in CKD. Within the CKD sample, NfL level is associated with abnormal kidney function and brain structure. Decreased kidney function may be linked to abnormal neuronal integrity in pediatric CKD.
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15
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Alhamed AA, Toly VB, Hooper SR, Dell KM. The link between executive function, socio-emotional functioning and health-related quality of life in children and adolescents with mild to moderate chronic kidney disease. Child Care Health Dev 2022; 48:455-464. [PMID: 34893999 DOI: 10.1111/cch.12946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/29/2021] [Accepted: 12/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Children and adolescents with mild to moderate chronic kidney disease (CKD) are at high risk for mild but persistent impairment in executive functions, which have been associated with low health-related quality of life (HRQOL) among children and adolescents with chronic health conditions. However, no similar link has been established among children and adolescents with mild to moderate CKD. Given the essential role executive functions play in the development of adequate cognitive, emotional and social skills, it is essential to gain a clearer understating of the magnitude and attributes of executive functions and its link to HRQOL in order to inform appropriate medical and educational interventions for this patient population. OBJECTIVE The aim of this study is to examine the relationship between executive functions, socio-emotional functioning and HRQOL in children and adolescents with mild to moderate CKD. METHODS A cross-sectional design was used for this secondary data analysis of 199 children and adolescents (ages 6-17) with mild to moderate CKD from the United States and Canada who receive care at hospitals associated with the Chronic Kidney Disease in Children Study (CKiD). RESULTS The presence of impairment in executive functions and socio-emotional functioning (internalizing problems) significantly predicted lower HRQOL after controlling for key covariates (i.e., maternal education, anaemia and hypertension). Further, internalizing problems partially mediated the relationship between executive functions and HRQOL such that impairment in executive functions predicted lower HRQOL directly and indirectly by contributing to higher internalizing problems, which further contributed to low HRQOL. CONCLUSION This study underscores the importance of executive functions and socio-emotional functioning in the manifestation of HRQOL. Given that HRQOL is potentially compromised for many children and adolescents with mild to moderate CKD, it will be important for both clinicians and researchers to examine a range of factors, including executive functions and socio-emotional functioning, in order to optimize HRQOL.
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Affiliation(s)
- Arwa A Alhamed
- Nursing Department, College of Nursing, King Saud bin Abdulaizz University for Health Sciences, Riyadh, Saudi Arabia
| | - Valerie B Toly
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA
| | - Stephen R Hooper
- Department of Allied Health Sciences, School of Medicine, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Katherine M Dell
- Pediatric Institute, Cleveland Clinic, Case Western Reserve University, Cleveland, Ohio, USA
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16
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Kurzinski KL, Weidemann DK. The Burden of Mental Health Conditions in Children With CKD. Kidney Med 2022; 4:100478. [PMID: 35620086 PMCID: PMC9127687 DOI: 10.1016/j.xkme.2022.100478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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17
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Leveraging neuroimaging to understand the impact of chronic kidney disease on the brain. Pediatr Nephrol 2022; 37:921-925. [PMID: 34731310 PMCID: PMC9035041 DOI: 10.1007/s00467-021-05332-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 10/19/2022]
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18
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Robinson J, Uzun O, Loh NR, Harris IR, Woolley TE, Harwood AJ, Gardner JF, Syed YA. The association of neurodevelopmental abnormalities, congenital heart and renal defects in a tuberous sclerosis complex patient cohort. BMC Med 2022; 20:123. [PMID: 35440050 PMCID: PMC9019964 DOI: 10.1186/s12916-022-02325-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/07/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare multi-system genetic disorder characterised by the presence of benign tumours throughout multiple organs including the brain, kidneys, heart, liver, eyes, lungs and skin, in addition to neurological and neuropsychiatric complications. Intracardiac tumour (rhabdomyoma), neurodevelopmental disorders (NDDs) and kidney disorders (KD) are common manifestations of TSC and have been linked with TSC1 and TSC2 loss-of-function mutations independently, but the dynamic relationship between these organ manifestations remains unexplored. Therefore, this study aims to characterise the nature of the relationship specifically between these three organs' manifestations in TSC1 and TSC2 mutation patients. METHODS Clinical data gathered from TSC patients across South Wales registered with Cardiff and Vale University Health Board (CAV UHB) between 1990 and 2020 were analysed retrospectively to evaluate abnormalities in the heart, brain and kidney development. TSC-related abnormalities such as tumour prevalence, location and size were analysed for each organ in addition to neuropsychiatric involvement and were compared between TSC1 and TSC2 mutant genotypes. Lastly, statistical co-occurrence between organ manifestations co-morbidity was quantified, and trajectories of disease progression throughout organs were modelled. RESULTS This study found a significantly greater mutational frequency at the TSC2 locus in the cohort in comparison to TSC1. An equal proportion of male and female patients were observed in this group and by meta-analysis of previous studies. No significant difference in characterisation of heart involvement was observed between TSC1 and TSC2 patients. Brain involvement was seen with increased severity in TSC2 patients, characterised by a greater prevalence of cortical tubers and communication disorders. Renal pathology was further enhanced in TSC2 patients, marked by increased bilateral angiomyolipoma prevalence. Furthermore, co-occurrence of NDDs and KDs was the most positively correlated out of investigated manifestations, regardless of genotype. Analysis of disease trajectories revealed a more diverse clinical outcome for TSC2 patients: however, a chronological association of rhabdomyoma, NDD and KD was most frequently observed for TSC1 patients. CONCLUSIONS This study marks the first empirical investigation of the co-morbidity between congenital heart defects (CHD), NDDs, and KDs in TSC1 and TSC2 patients. This remains a unique first step towards the characterisation of the dynamic role between genetics, heart function, brain function and kidney function during the early development in the context of TSC.
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Affiliation(s)
- Jessica Robinson
- Neuroscience and Mental Health Research Institute, Hadyn Ellis Building, Cardiff, CF24 4HQ, UK.,School of Bioscience, The Sir Martin Evans Building, Museum Ave, Cardiff, CF10 3AX, UK
| | - Orhan Uzun
- University Hospital of Wales, Heath Park, Cardiff, CF10 3AX, UK.
| | - Ne Ron Loh
- University Hospital of Wales, Heath Park, Cardiff, CF10 3AX, UK.,Royal United Hospitals Bath NHS Foundation Trust, Bath, BA1 3NG, UK
| | - Isabelle Rose Harris
- Neuroscience and Mental Health Research Institute, Hadyn Ellis Building, Cardiff, CF24 4HQ, UK.,School of Bioscience, The Sir Martin Evans Building, Museum Ave, Cardiff, CF10 3AX, UK
| | - Thomas E Woolley
- School of Mathematics, Cardiff University, Cardiff, CF24 4AG, UK
| | - Adrian J Harwood
- Neuroscience and Mental Health Research Institute, Hadyn Ellis Building, Cardiff, CF24 4HQ, UK.,School of Bioscience, The Sir Martin Evans Building, Museum Ave, Cardiff, CF10 3AX, UK
| | | | - Yasir Ahmed Syed
- Neuroscience and Mental Health Research Institute, Hadyn Ellis Building, Cardiff, CF24 4HQ, UK. .,School of Bioscience, The Sir Martin Evans Building, Museum Ave, Cardiff, CF10 3AX, UK.
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19
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Hooper SR, Johnson RJ, Gerson AC, Lande MB, Shinnar S, Harshman LA, Kogon AJ, Matheson M, Bartosh S, Carlson J, Warady BA, Furth SL. Overview of the findings and advances in the neurocognitive and psychosocial functioning of mild to moderate pediatric CKD: perspectives from the Chronic Kidney Disease in Children (CKiD) cohort study. Pediatr Nephrol 2022; 37:765-775. [PMID: 34110493 PMCID: PMC8660930 DOI: 10.1007/s00467-021-05158-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/13/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022]
Abstract
The Chronic Kidney Disease in Children (CKiD) prospective cohort study was designed to address the neurocognitive, growth, cardiovascular, and disease progression of children and adolescents with mild to moderate CKD. The study has had continuous funding from NIDDK for 17 years and has contributed significant advances in pediatric CKD. The goals of this educational review are threefold: (1) to provide an overview of the neurocognitive and psychosocial studies from CKiD to date; (2) to provide best practice recommendations for those working with the neurocognitive and psychosocial aspects of pediatric CKD based on CKiD findings; and (3) to help chart future goals and directives for both research and clinical practice. This collection of 22 empirical studies has produced a number of key findings for children and adolescents with mild to moderate CKD. While various studies suggest a relatively positive presentation for this population as a whole, without evidence of significant impairment or deterioration, findings do indicate the presence of neurocognitive dysfunction, emotional-behavioral difficulties, and lower quality of life for many children with CKD. These findings support the promotion of best practices that are accompanied by additional future clinical and research initiatives with this patient population.
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Affiliation(s)
- Stephen R Hooper
- Department of Allied Health Sciences, University of North Carolina School of Medicine, Chapel Hill, NC, 27599, USA.
| | - Rebecca J Johnson
- Division of Developmental and Behavioral Health, Department of Pediatrics, Children's Mercy Kansas City, UMKC School of Medicine, Kansas City, MO, USA
| | - Arlene C Gerson
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Marc B Lande
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Shlomo Shinnar
- Departments of Neurology, Pediatrics and Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Lyndsay A Harshman
- Division of Pediatric Nephrology, University of Iowa Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Amy J Kogon
- Children's Hospital of Philadelphia, Division of Pediatric Nephrology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Matheson
- Department of Epidemiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sharon Bartosh
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Joann Carlson
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Susan L Furth
- Children's Hospital of Philadelphia, Division of Pediatric Nephrology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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20
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Stahl JL, Wightman AG, Flythe JE, Weiss NS, Hingorani SR, Stoep AV. Psychiatric Diagnoses in Children With CKD Compared to the General Population. Kidney Med 2022; 4:100451. [PMID: 35620082 PMCID: PMC9127686 DOI: 10.1016/j.xkme.2022.100451] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Rationale & Objective Children with chronic kidney disease (CKD) are subject to physical and psychosocial challenges, which may confer greater risk of developing psychiatric disorders. We sought to examine key psychiatric diagnoses in children with CKD compared with those in the general pediatric population and assess the correlation between parent-reported diagnosis and self-reported symptoms of depression. Study Design Cross-sectional. Setting & Participants Children ages 2-17 years receiving current medical care who participated in the Chronic Kidney Disease in Children Study (CKiD) or the National Survey of Children’s Health. Exposure CKD. Outcomes Parent-reported diagnoses of depression, anxiety, or attention-deficit and hyperactivity disorder (ADHD). Analytical Approach Using Poisson regression, we determined the age, sex, and race-adjusted prevalence ratio comparing diagnoses between children with CKD and those in the general population overall and within subgroups of sex, race, maternal education status, and CKD stage. Secondarily, we examined the correlation between depression status using standardized self-reported screening instrument scores and parent-reported diagnosis. Results Eight hundred seventy-five children with CKD and 72,699 children in the general population were included. Those with CKD had an adjusted prevalence ratio of 1.32 (95% CI, 1.01-1.73) for depression, 0.72 (95% CI, 0.52-0.99) for anxiety, and 1.03 (95% CI, 0.86-1.25) for ADHD. The results were similar across subgroups of CKD stage, sex, race, or maternal education. The correlation between parent-reported diagnosis and instrument-detected depression was weak, r = 0.13 (95% CI, 0.03-0.23). Limitations Retrospective parent- or self-reported data were used. Conclusions Children with CKD had a higher prevalence of parent-reported depression, equivalent prevalence of attention-deficit and hyperactivity disorder, and lower prevalence of anxiety diagnoses compared to other children. These findings are inconsistent with results of prior studies and suggest that baseline assessments used in CKiD may have limited utility in describing psychiatric disorders among children with CKD. Improved mental health assessment approaches in pediatric nephrology are needed.
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Affiliation(s)
- Jessica L. Stahl
- Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, University of North Carolina Kidney Center, Chapel Hill, NC
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
- Address for Correspondence: Jessica Stahl, MD, MS, 7025 Burnett Womack Building; Chapel Hill, NC 27599-7155
| | - Aaron G. Wightman
- Department of Pediatrics, University of Washington, Seattle, WA
- Division of Nephrology, Seattle Children’s Hospital, Seattle, WA
| | - Jennifer E. Flythe
- Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, University of North Carolina Kidney Center, Chapel Hill, NC
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | - Noel S. Weiss
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Sangeeta R. Hingorani
- Department of Pediatrics, University of Washington, Seattle, WA
- Division of Nephrology, Seattle Children’s Hospital, Seattle, WA
| | - Ann Vander Stoep
- Department of Epidemiology, University of Washington, Seattle, WA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
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21
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Kelly DM, Rothwell PM. Disentangling the Relationship Between Chronic Kidney Disease and Cognitive Disorders. Front Neurol 2022; 13:830064. [PMID: 35280286 PMCID: PMC8914950 DOI: 10.3389/fneur.2022.830064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/03/2022] [Indexed: 12/12/2022] Open
Abstract
Chronic kidney disease (CKD) is a rapidly rising global health burden that affects nearly 40% of older adults. Epidemiologic data suggest that individuals at all stages of chronic kidney disease (CKD) have a higher risk of developing cognitive disorders and dementia, and thus represent a vulnerable population. It is currently unknown to what extent this risk may be attributable to a clustering of traditional risk factors such as hypertension and diabetes mellitus leading to a high prevalence of both symptomatic and subclinical ischaemic cerebrovascular lesions, or whether other potential mechanisms, including direct neuronal injury by uraemic toxins or dialysis-specific factors could also be involved. These knowledge gaps may lead to suboptimal prevention and treatment strategies being implemented in this group. In this review, we explore the mechanisms of susceptibility and risk in the relationship between CKD and cognitive disorders.
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Affiliation(s)
- Dearbhla M. Kelly
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Peter M. Rothwell
- Wolfson Center for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
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22
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Kelly DM, Pendlebury ST, Rothwell PM. Associations of Chronic Kidney Disease With Dementia Before and After Transient Ischemic Attack and Stroke: Population-Based Cohort Study. Neurology 2022; 98:e711-e720. [PMID: 34996878 PMCID: PMC8865890 DOI: 10.1212/wnl.0000000000013205] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 11/23/2021] [Indexed: 11/29/2022] Open
Abstract
Background and Objectives Individuals with chronic kidney disease (CKD) appear to be at increased risk of cognitive impairment, with both vascular and neurodegenerative mechanisms postulated. To explore the vascular hypothesis, we studied the association between CKD and dementia before and after TIA and stroke. Methods In a prospective, population-based cohort study of TIA and stroke (Oxford Vascular Study; 2002–2012), pre-event and new postevent dementia were ascertained through direct patient assessment and follow-up for 5 years, supplemented by review of hospital/primary care records. Associations between pre-event dementia and CKD (defined as an estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2) were examined using logistic regression and between postevent dementia and CKD using Cox and competing risk regression models, adjusted for age, sex, education, stroke severity, prior stroke, white matter disease, diabetes mellitus, and dysphasia. Results Among 2,305 patients with TIA/stroke (median [interquartile range] age, 77 [67–84] years, 1,133 [49%] male, 688 [30%] TIA), 1,174 (50.9%) had CKD. CKD was associated with both pre-event (odds ratio [OR] 2.04 [95% confidence interval (CI) 1.52–2.72]; p < 0.001) and postevent dementia (hazard ratio [HR] 2.01 [95% CI 1.65–2.44]; p < 0.001), but these associations attenuated after adjustment for covariates (OR 0.92 [0.65–1.31]; p = 0.65 and HR 1.09 [0.85–1.39]; p = 0.50). The results were similar when a competing risk model was used (subdistribution HR [SHR] 1.74 [1.43–2.12]; p < 0.001, attenuating to 1.01 [0.78–1.33]; p = 0.92 with adjustment). CKD was more strongly associated with late (>1 year) postevent dementia (SHR 2.32 [1.70–3.17]; p < 0.001), particularly after TIA and minor stroke (SHR 3.08 [2.05–4.64]; p < 0.001), but not significantly so after adjustment (SHR 1.53 [0.90–2.60]; p = 0.12). Discussion In patients with TIA and stroke, CKD was not independently associated with either pre- or postevent dementia, suggesting that renal-specific mechanisms are unlikely to play an important role in aetiology.
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Affiliation(s)
- Dearbhla M Kelly
- Wolfson Center for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Sarah T Pendlebury
- Wolfson Center for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Peter M Rothwell
- Wolfson Center for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom.
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23
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Hooper SR, Johnson RJ, Lande M, Matheson M, Shinnar S, Kogon AJ, Harshman L, Spinale J, Gerson AC, Warady BA, Furth SL. The Similarities and Differences Between Glomerular vs. Non-glomerular Diagnoses on Intelligence and Executive Functions in Pediatric Chronic Kidney Disease: A Brief Report. Front Neurol 2022; 12:787602. [PMID: 34987470 PMCID: PMC8720880 DOI: 10.3389/fneur.2021.787602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/30/2021] [Indexed: 11/27/2022] Open
Abstract
Pediatric chronic kidney disease (CKD) appears to be a heterogeneous group of conditions, but this heterogeneity has not been explored with respect to its impact on neurocognitive functioning. This study investigated the neurocognitive functioning of those with glomerular (G) vs. non-glomerular (NG) diagnoses. Data from the North American CKiD Study were employed and the current study included 1,003 children and adolescents with mild to moderate CKD. The G Group included 260 participants (median age = 14.7 years) and the NG Group included 743 individuals (median age = 9.0 years). Neurocognitive measures assessed IQ, inhibitory control, attention regulation, problem solving, working memory, and overall executive functioning. Data from all visits were included in the linear mixed model analyses. After adjusting for sociodemographic and CKD-related covariates, results indicated no differences between the diagnostic groups on measures of IQ, problem solving, working memory, and attention regulation. There was a trend for the G group to receive better parent ratings on their overall executive functions (p < 0.07), with a small effect size being present. Additionally, there was a significant G group X hypertension interaction (p < 0.003) for inhibitory control, indicating that those with both a G diagnosis and hypertension performed more poorly than the NG group with hypertension. These findings suggest that the separation of G vs. NG CKD produced minimal, but specific group differences were observed. Ongoing examination of the heterogeneity of pediatric CKD on neurocognition, perhaps at a different time point in disease progression or using a different model, appears warranted.
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Affiliation(s)
- Stephen R Hooper
- Department of Allied Health Sciences, School of Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC, United States
| | - Rebecca J Johnson
- Department of Pediatrics, Children's Mercy Kansas City, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Marc Lande
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, United States
| | - Matthew Matheson
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, United States
| | - Shlomo Shinnar
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Amy J Kogon
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Lyndsay Harshman
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, United States
| | - Joann Spinale
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Arlene C Gerson
- Department of Pediatrics, Johns Hopkins Medical School, Baltimore, MD, United States
| | - Bradley A Warady
- Department of Pediatrics, Children's Mercy Kansas City, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Susan L Furth
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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24
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Viriyapak E, Chantaratin S, Sommai K, Sumboonnanonda A, Pattaragarn A, Supavekin S, Piyaphanee N, Lomjansook K, Chaiyapak T. Prevalence of cognitive dysfunction and its risk factors in children with chronic kidney disease in a developing country. Pediatr Nephrol 2022; 37:1355-1364. [PMID: 34713357 PMCID: PMC8552608 DOI: 10.1007/s00467-021-05280-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 09/05/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with cognitive dysfunction. Cognitive function in children with CKD residing in developing countries has not been previously reported. METHODS This cross-sectional study included children aged 6-18 years with CKD stages 2-5D and kidney transplant. Cognitive function was assessed by WISC-V for children from 6-16 years of age. In adolescents 17-18 years of age, WAIS-III was used. Factors associated with cognitive dysfunction were identified using multivariable regression analysis. RESULTS Thirty-seven children with median age 13.9 (11.3-15.7) years were recruited. The median full-scale intelligence quotient (FSIQ) was 83.0 (71.0-95.0). Below-average cognitive function (FSIQ <90) was identified in 24 children (64.8%), 24.3% of whom had cognitive impairment (FSIQ <70). Most children (94.6%) scored lower than average on at least 1 cognitive domain. Kidney replacement therapy (p = 0.03) and low family income (p = 0.02) were associated with below-average cognitive function in multivariable logistic regression analysis. Children who left school and low family income were significantly associated with cognitive function. The FSIQ of children who had left school was 12.94 points lower than the educated group (p = 0.046). In addition, every 10,000 Thai Baht (approximately 330 United States dollars) increase in family income correlated with 1.58 increase in FSIQ (p = 0.047). CONCLUSION Cognitive dysfunction was commonly found in children with CKD. Socioeconomic factors, particularly school attendance and family income, were associated with cognitive dysfunction. Cognitive evaluation is suggested for children with CKD who have socioeconomic risk factors. "A higher resolution version of the Graphical abstract is available as Supplementary information."
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Affiliation(s)
- Elawin Viriyapak
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sasitorn Chantaratin
- Division of Psychiatry, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanokwan Sommai
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Achra Sumboonnanonda
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anirut Pattaragarn
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suroj Supavekin
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nuntawan Piyaphanee
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kraisoon Lomjansook
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanaporn Chaiyapak
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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25
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Pande CK, Smith MB, Soranno DE, Gist KM, Fuhrman DY, Dolan K, Conroy AL, Akcan-Arikan A. The Neglected Price of Pediatric Acute Kidney Injury: Non-renal Implications. Front Pediatr 2022; 10:893993. [PMID: 35844733 PMCID: PMC9279899 DOI: 10.3389/fped.2022.893993] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/23/2022] [Indexed: 01/03/2023] Open
Abstract
Preclinical models and emerging translational data suggest that acute kidney injury (AKI) has far reaching effects on all other major organ systems in the body. Common in critically ill children and adults, AKI is independently associated with worse short and long term morbidity, as well as mortality, in these vulnerable populations. Evidence exists in adult populations regarding the impact AKI has on life course. Recently, non-renal organ effects of AKI have been highlighted in pediatric AKI survivors. Given the unique pediatric considerations related to somatic growth and neurodevelopmental consequences, pediatric AKI has the potential to fundamentally alter life course outcomes. In this article, we highlight the challenging and complex interplay between AKI and the brain, heart, lungs, immune system, growth, functional status, and longitudinal outcomes. Specifically, we discuss the biologic basis for how AKI may contribute to neurologic injury and neurodevelopment, cardiac dysfunction, acute lung injury, immunoparalysis and increased risk of infections, diminished somatic growth, worsened functional status and health related quality of life, and finally the impact on young adult health and life course outcomes.
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Affiliation(s)
- Chetna K Pande
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Mallory B Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, United States.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, United States
| | - Danielle E Soranno
- Section of Nephrology, Departments of Pediatrics, Bioengineering and Medicine, University of Colorado, Aurora, CO, United States
| | - Katja M Gist
- Division of Cardiology, Department of Pediatrics, Cioncinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Dana Y Fuhrman
- Division of Critical Care Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Division of Nephrology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Kristin Dolan
- Division of Critical Care Medicine, Department of Pediatrics, University of Missouri Kansas City, Children's Mercy Hospital, Kansas City, MO, United States
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States.,Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
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26
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Neurocognition in Pediatric Chronic Kidney Disease: A Review of Data From the Chronic Kidney Disease in Children (CKiD) Study. Semin Nephrol 2021; 41:446-454. [PMID: 34916006 DOI: 10.1016/j.semnephrol.2021.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pediatric chronic kidney disease (CKD) is associated with deficits in neurocognitive functioning, ranging from mild to severe, and correlated with the severity of kidney disease. Clinical variables that are associated with neurocognitive deficits include lower kidney function, hypertension, proteinuria, and metabolic acidosis. Commonly reported neurocognitive difficulties include academic underachievement and deficits in attention regulation and executive function as well as somewhat lower intellectual abilities compared with peer and normative data. Although often mild, these neurocognitive deficits may have broad implications for quality of life and likely contribute to both poorer high school graduation rates and long-term underemployment in the adult CKD population. The presence of neurocognitive deficits in predialytic CKD has been well characterized, but further longitudinal research is warranted to describe cognitive changes as children progress from early stage CKD to kidney replacement therapy. Such studies should include both cognitive and neuroimaging evaluations to better inform the impact of CKD progression on neurocognitive outcomes.
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27
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Greenberg JH, Abraham AG, Xu Y, Schelling JR, Feldman HI, Sabbisetti VS, Ix JH, Jogalekar MP, Coca S, Waikar SS, Shlipak MG, Warady BA, Vasan RS, Kimmel PL, Bonventre JV, Denburg M, Parikh CR, Furth S. Urine Biomarkers of Kidney Tubule Health, Injury, and Inflammation are Associated with Progression of CKD in Children. J Am Soc Nephrol 2021; 32:2664-2677. [PMID: 34544821 PMCID: PMC8722795 DOI: 10.1681/asn.2021010094] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 06/28/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Novel urine biomarkers may improve identification of children at greater risk of rapid kidney function decline, and elucidate the pathophysiology of CKD progression. METHODS We investigated the relationship between urine biomarkers of kidney tubular health (EGF and α-1 microglobulin), tubular injury (kidney injury molecule-1; KIM-1), and inflammation (monocyte chemoattractant protein-1 [MCP-1] and YKL-40) and CKD progression. The prospective CKD in Children Study enrolled children aged 6 months to 16 years with an eGFR of 30-90ml/min per 1.73m2. Urine biomarkers were assayed a median of 5 months [IQR: 4-7] after study enrollment. We indexed the biomarker to urine creatinine by dividing the urine biomarker concentration by the urine creatinine concentration to account for the concentration of the urine. The primary outcome was CKD progression (a composite of a 50% decline in eGFR or kidney failure) during the follow-up period. RESULTS Overall, 252 of 665 children (38%) reached the composite outcome over a median follow-up of 6.5 years. After adjustment for covariates, children with urine EGF concentrations in the lowest quartile were at a seven-fold higher risk of CKD progression versus those with concentrations in the highest quartile (fully adjusted hazard ratio [aHR], 7.1; 95% confidence interval [95% CI], 3.9 to 20.0). Children with urine KIM-1, MCP-1, and α-1 microglobulin concentrations in the highest quartile were also at significantly higher risk of CKD progression versus those with biomarker concentrations in the lowest quartile. Addition of the five biomarkers to a clinical model increased the discrimination and reclassification for CKD progression. CONCLUSIONS After multivariable adjustment, a lower urine EGF concentration and higher urine KIM-1, MCP-1, and α-1 microglobulin concentrations were each associated with CKD progression in children.
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Affiliation(s)
- Jason H. Greenberg
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut,Department of Medicine Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Alison G. Abraham
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yunwen Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeffrey R. Schelling
- Department of Internal Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Harold I. Feldman
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Joachim H. Ix
- Division of Nephrology-Hypertension, University of California San Diego, San Diego, California,Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, California
| | - Manasi P. Jogalekar
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Steven Coca
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sushrut S. Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Michael G. Shlipak
- UCSF Division of General Internal Medicine at the VA, Kidney Health Research Collaborative, San Francisco Veterans Affairs Health Care System and University of California, San Francisco, California
| | - Bradley A. Warady
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Ramachandran S. Vasan
- Departments of Medicine and Epidemiology, Boston University Schools of Medicine and Public Health, Boston, Massachusetts
| | - Paul L. Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Joseph V. Bonventre
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michelle Denburg
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chirag R. Parikh
- Department of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, New York
| | - Susan Furth
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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28
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Paterson EN, Maxwell AP, Kee F, Cruise S, Young IS, McGuinness B, McKay GJ. Association of renal impairment with cognitive dysfunction in the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA). Nephrol Dial Transplant 2021; 36:1492-1499. [PMID: 34038557 PMCID: PMC8311575 DOI: 10.1093/ndt/gfab182] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/17/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction Chronic kidney disease (CKD) is a recognized risk factor for cognitive impairment. Identification of those at greatest risk of cognitive impairment may facilitate earlier therapeutic intervention. This study evaluated associations between estimated glomerular filtration rate (eGFR) and cognitive function in the Northern Ireland Cohort for the Longitudinal Study of Ageing. Methods Data were available for 3412 participants ≥50 years of age living in non-institutionalized settings who attended a health assessment between February 2014 and March 2016. Measures of serum creatinine (SCr) and cystatin C (cys-C) were used for eGFR. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE). Results Following adjustment for potential confounders, a single unit decrease in eGFR was significantly associated with reduced cognitive function defined by an MMSE ≤24/30 {eGFR calculated using serum cys-C [eGFRcys]: β = −0.01 [95% confidence interval (CI) −0.001 to −0.01], P = 0.01} and MoCA <26/30 [β = −0.01 (95% CI −0.002 to −0.02), P = 0.02]. Similarly, CKD Stages 3–5 were also associated with a moderate increase in the odds of cognitive impairment (MMSE ≤24) following adjustment for confounders [eGFRcys: odds ratio 2.73 (95% CI 1.38–5.42), P = 0.004]. Conclusions Decreased eGFRcys was associated with a significantly increased risk of cognitive impairment in a population-based cohort of older adults. However, there was no evidence of an association between cognitive impairment and the more commonly used eGFR calculated using SCr. eGFRcys may offer improved sensitivity over eGFRcr in the determination of renal function and associated risk of cognitive impairment.
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Affiliation(s)
- Euan N Paterson
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Alexander P Maxwell
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Frank Kee
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Sharon Cruise
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Ian S Young
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
| | | | - Gareth J McKay
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
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29
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Koren MJ, Blumen HM, Ayers EI, Verghese J, Abramowitz MK. Cognitive Dysfunction and Gait Abnormalities in CKD. Clin J Am Soc Nephrol 2021; 16:694-704. [PMID: 33824156 PMCID: PMC8259490 DOI: 10.2215/cjn.16091020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/11/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Cognitive impairment is a major cause of morbidity in CKD. We hypothesized that gait abnormalities share a common pathogenesis with cognitive dysfunction in CKD, and therefore would be associated with impaired cognitive function in older adults with CKD, and focused on a recently defined gait phenotype linked with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Gait assessments and neuropsychological testing were performed in 312 nondisabled, community-dwelling older adults (aged ≥65 years). A subset (n=115) underwent magnetic resonance imaging. The primary cognitive outcome was the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) total scale score. Associations with cognitive function were tested using multivariable linear regression and nearest-neighbor matching. The risk of developing mild cognitive impairment syndrome was assessed using Cox proportional hazards models. RESULTS Lower eGFR was associated with lower RBANS score only among participants with the gait phenotype (P for interaction =0.04). Compared with participants with neither CKD nor the gait phenotype, adjusted RBANS scores were 5.4 points (95% confidence interval, 1.8 to 9.1) lower among participants with both, who demonstrated poorer immediate memory, visuospatial ability, delayed memory, and executive function. In a matched analysis limited to participants with CKD, the gait phenotype was similarly associated with lower RBANS scores (-6.9; 95% confidence interval, -12.2 to -1.5). Neuroimaging identified a pattern of gray matter atrophy common to both CKD and the gait phenotype involving brain regions linked with cognition. The gait phenotype was associated with higher risk of mild cognitive impairment (hazard ratio, 3.91; 95% confidence interval, 1.46 to 10.44) independent of eGFR. CONCLUSIONS The gait phenotype was associated with poorer function in a number of cognitive domains among older adults with CKD, and was associated with incident mild cognitive impairment independent of eGFR. CKD and the gait phenotype were associated with a shared pattern of gray matter atrophy.
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Affiliation(s)
- Melanie J. Koren
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Helena M. Blumen
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York,Department of Neurology, Albert Einstein College of Medicine, Bronx, New York
| | - Emmeline I. Ayers
- Department of Neurology, Albert Einstein College of Medicine, Bronx, New York
| | - Joe Verghese
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York,Department of Neurology, Albert Einstein College of Medicine, Bronx, New York,Institute for Aging Research, Albert Einstein College of Medicine, Bronx, New York
| | - Matthew K. Abramowitz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York,Institute for Aging Research, Albert Einstein College of Medicine, Bronx, New York,Diabetes Research Center, Albert Einstein College of Medicine, Bronx, New York,Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, New York
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30
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Amatya K, Monnin K, Steinberg Christofferson E. Psychological functioning and psychosocial issues in pediatric kidney transplant recipients. Pediatr Transplant 2021; 25:e13842. [PMID: 33012109 DOI: 10.1111/petr.13842] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/17/2020] [Accepted: 08/13/2020] [Indexed: 12/13/2022]
Abstract
Research demonstrates that psychological factors are important for positive transplant outcomes, though there is little literature that synthesizes these factors in a comprehensive model among pediatric kidney transplant patients. This review analyzes psychological and psychosocial factors related to medical outcomes and overall well-being post-transplant by utilizing the PPPHM and referencing the existing literature on risk and resilience. Pediatric kidney transplant recipients are more susceptible to mental health concerns such as depression, anxiety, and ADHD, as well as developmental and neurocognitive delays, compared to healthy peers. Complex medical care and psychosocial needs for patients have implications for family functioning, parental and sibling mental health, and youth readiness to transition to adult care. It is important to carefully monitor patient functioning with empirically validated tools and to intervene in a multidisciplinary setting as early as possible to identify patients at risk and reduce potential negative impact. Psychologists are uniquely trained to assess and address these issues and are a valuable component of multidisciplinary, culturally competent care. While research in this expansive field is improving, more data are needed to establish gold standard approaches to mental health and psychosocial care in this population.
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Affiliation(s)
- Kaushalendra Amatya
- Divisions of Nephrology and Cardiology, Children's National Hospital, Washington, DC, USA.,Pediatrics and Psychiatry & Behavioral Sciences, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Kara Monnin
- Pediatric Mental Health Institute, Children's Hospital Colorado, Aurora, CO, USA
| | - Elizabeth Steinberg Christofferson
- Solid Organ Transplant Surgery, Children's Hospital Colorado, Aurora, CO, USA.,Departments of Psychiatry and Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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31
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Early pediatric chronic kidney disease is associated with brain volumetric gray matter abnormalities. Pediatr Res 2021; 89:526-532. [PMID: 33069166 PMCID: PMC7981243 DOI: 10.1038/s41390-020-01203-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 09/03/2020] [Accepted: 09/10/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND The impact of pediatric chronic kidney disease (pCKD) on the brain remains poorly defined. The objective of this study was to compare brain morphometry between children with early-stage pCKD and typically developing peers using structural magnetic resonance imaging (MRI). METHODS The sample age range was 6-16 years. A total of 18 children with a diagnosis of pCKD (CKD stages 1-3) due to congenital anomalies of the kidney and urinary tract and 24 typically developing peers were included. Volumetric data from MRI and neurocognitive testing were compared using linear models including pCKD status, age, maternal education level, and socioeconomic status. RESULTS Cerebellar gray matter volume was significantly smaller in pCKD, t(38) = -2.71, p = 0.01. In contrast, cerebral gray matter volume was increased in pCKD, t(38) = 2.08, p = 0.04. Reduced cerebellum gray matter volume was associated with disease severity, operationalized as estimated glomerular filtration rate (eGFR), t(14) = 2.21, p = 0.04 and predicted lower verbal fluency scores in the pCKD sample. Enlarged cerebral gray matter in the pCKD sample predicted lower scores on mathematics assessment. CONCLUSIONS This study provides preliminary evidence for a morphometric underpinning to the cognitive deficits observed in pCKD. IMPACT The impact of pediatric chronic kidney disease (CKD) on the brain remains poorly defined, with no data linking brain morphometry and observed cognitive deficits noted in this population. We explored the relationship between brain morphometry (using structural magnetic resonance imaging), cognition, and markers of CKD. Cerebellar and cerebral gray matter volumes are different in early CKD. Volumetric decreases in cerebellar gray matter are predicted by lower eGFR, suggesting a link between disease and brain morphometry. Reduced cerebellar gray matter predicted lower verbal fluency for those with pCKD. Enlarged cerebral gray matter in the pCKD sample predicted lower mathematics performance.
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32
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Chronic kidney disease impacts health-related quality of life of children in Uganda, East Africa. Pediatr Nephrol 2021; 36:323-331. [PMID: 32737578 DOI: 10.1007/s00467-020-04705-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/22/2020] [Accepted: 06/30/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Limited data exist about causes of chronic kidney disease (CKD) and impact on health-related quality of life (HRQoL) in African children. We evaluated types of kidney disease in Ugandan children 0-18 years and compared HRQoL in children with CKD or with benign or resolving kidney disease (non-CKD) to assess predictors of HRQoL. METHODS Demographic, socioeconomic, and clinical data were obtained for this cross-sectional study. Pediatric Quality of Life Core Scale™ (PedsQL) was used to survey 4 domains and overall HRQoL. CKD and non-CKD scores were compared using unpaired t test. HRQoL predictors were evaluated using linear and logistic regression analyses. RESULTS One hundred forty-nine children (71 CKD, 78 non-CKD; median age 9 years; male 63%) had the following primary diseases: nephrotic syndrome (56%), congenital anomalies of the urinary tract (CAKUT) (19%), glomerulonephritis (17%), and other (8%). CAKUT was the predominant etiology (39%) for CKD; 63% had advanced stages 3b-5. Overall HRQoL scores were significantly lower for CKD (57 vs. 86 by child report, p < 0.001; 63 vs. 86 by parent proxy report, p < 0.001). Predictors of lower HRQoL were advanced CKD stages 3b-5, primary caregiver non-parent, vitamin D deficiency, and anemia. CONCLUSION Like other parts of the world, CAKUT was the main cause of CKD. Most CKD children presented at late CKD stages 3b-5. Compared with non-CKD, HRQoL in CKD was much lower; only two-thirds attended school. Vitamin D deficiency and anemia were potentially modifiable predictors of low HRQoL. Interventions with vitamin D, iron, and erythropoietin-stimulating agents might lead to improved HRQoL.
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33
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The brain in pediatric chronic kidney disease-the intersection of cognition, neuroimaging, and clinical biomarkers. Pediatr Nephrol 2020; 35:2221-2229. [PMID: 31897717 PMCID: PMC8493603 DOI: 10.1007/s00467-019-04417-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/03/2019] [Accepted: 11/08/2019] [Indexed: 10/25/2022]
Abstract
Brain growth and development occur at peak rates in early childhood through adolescence, and for some children, this must happen in conjunction with chronic kidney disease (CKD), associated medical conditions, and their treatment(s). This review provides an overview of key findings to date on the topic of the brain in pediatric CKD. Here, we specifically address the topics of neuroimaging and cognition in pediatric CKD with consideration to biomarkers of disease progression that may impact cognition. Current cognitive data suggest that most children with mild to moderate CKD do not exhibit significant cognitive impairments, but, rather, the presence of somewhat lower intellectual abilities and subtle deficits in selected executive functions. Although promising, modern neuroimaging data remain inconclusive in linking cognitive findings to neuroimaging correlates in the pediatric CKD population. Certainly, it is important to note that even subtle cognitive concerns can present barriers to learning, social functioning, and overall quality of life if not appropriately recognized or addressed. Further longitudinal research utilizing concurrent and targeted cognitive and neuroimaging evaluations is warranted to better understand the impact of CKD progression on brain development and associated neurocognitive outcomes.
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34
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Hanson CS, Craig JC, Logeman C, Sinha A, Dart A, Eddy AA, Guha C, Gipson DS, Bockenhauer D, Yap HK, Groothoff J, Zappitelli M, Webb NJA, Alexander SI, Furth SL, Samuel S, Neu A, Viecelli AK, Ju A, Sharma A, Au EH, Desmond H, Shen JI, Manera KE, Azukaitis K, Dunn L, Carter SA, Gutman T, Cho Y, Walker A, Francis A, Sanchez-Kazi C, Kausman J, Pearl M, Benador N, Sahney S, Tong A. Establishing core outcome domains in pediatric kidney disease: report of the Standardized Outcomes in Nephrology-Children and Adolescents (SONG-KIDS) consensus workshops. Kidney Int 2020; 98:553-565. [PMID: 32628942 DOI: 10.1016/j.kint.2020.05.054] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/17/2020] [Accepted: 05/07/2020] [Indexed: 02/08/2023]
Abstract
Trials in children with chronic kidney disease do not consistently report outcomes that are critically important to patients and caregivers. This can diminish the relevance and reliability of evidence for decision making, limiting the implementation of results into practice and policy. As part of the Standardized Outcomes in Nephrology-Children and Adolescents (SONG-Kids) initiative, we convened 2 consensus workshops in San Diego, California (7 patients, 24 caregivers, 43 health professionals) and Melbourne, Australia (7 patients, 23 caregivers, 49 health professionals). This report summarizes the discussions on the identification and implementation of the SONG-Kids core outcomes set. Four themes were identified; survival and life participation are common high priority goals, capturing the whole child and family, ensuring broad relevance across the patient journey, and requiring feasible and valid measures. Stakeholders supported the inclusion of mortality, infection, life participation, and kidney function as the core outcomes domains for children with chronic kidney disease.
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Affiliation(s)
- Camilla S Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia.
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Charlotte Logeman
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Allison Dart
- Department of Pediatrics and Child Health, The Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allison A Eddy
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Chandana Guha
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Debbie S Gipson
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Detlef Bockenhauer
- University College London Department of Renal Medicine, Great Ormond Street Hospital for Children, National Health Service Foundation Trust, London, UK
| | - Hui-Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jaap Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital Academic Medical Center, Amsterdam, The Netherlands
| | | | - Nicholas J A Webb
- Department of Paediatric Nephrology and National Institute for Health Research/Wellcome Trust Clinical Research Facility University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, UK
| | - Stephen I Alexander
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Susan L Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan Samuel
- Department of Pediatrics, Section of Nephrology, University of Calgary, Calgary, Alberta, Canada
| | - Alicia Neu
- Division of Pediatric Nephrology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
| | - Angela Ju
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Ankit Sharma
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Eric H Au
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Hailey Desmond
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Jenny I Shen
- Division of Nephrology and Hypertension, Lundquist Institute at Harbor-University of California Los Angeles Medical Center, Torrance, California, USA
| | - Karine E Manera
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Karolis Azukaitis
- Center of Pediatrics, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Louese Dunn
- Sheffield Teaching Hospitals, National Health Service Foundation Trust, Sheffield, UK
| | - Simon A Carter
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia; Department of Nephrology and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Talia Gutman
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
| | - Amanda Walker
- Department of Nephrology and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Anna Francis
- Child and Adolescent Renal Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Cheryl Sanchez-Kazi
- Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, California, USA
| | - Joshua Kausman
- Department of Nephrology and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Meghan Pearl
- Department of Pediatrics, Division of Nephrology, University of California Los Angeles, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Nadine Benador
- Rady Children's Hospital, University of California at San Diego, San Diego, California, USA
| | - Shobha Sahney
- Department of Pediatrics, Division of Nephrology, University of California Los Angeles, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
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Charnaya O, Verghese P, Goldberg A, Ladin K, Porteny T, Lantos JD. Access to Transplantation for Undocumented Pediatric Patients. Pediatrics 2020; 146:peds.2019-3692. [PMID: 32591437 DOI: 10.1542/peds.2019-3692] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2019] [Indexed: 11/24/2022] Open
Abstract
Clinicians in the United States today regularly face dilemmas about health disparities. Many patients and families cannot afford the medical care that doctors recommend. These problems are most stark when the medical care that is needed is lifesaving and expensive and involves scarce resources. Transplants are the best example of this. The most ethically disturbing situations occur when an undocumented immigrant child needs a transplant. We present such a case and analyze the ethical, legal, and policy issues that arise.
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Affiliation(s)
- Olga Charnaya
- Division of Pediatric Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Priya Verghese
- Division of Pediatric Nephrology, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Aviva Goldberg
- Section of Nephrology, Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Keren Ladin
- Research on Ethics, Aging, and Community Health Lab and.,Departments of Occupational Therapy and Community Health, School of Arts and Sciences, Tufts University, Medford, Massachusetts; and
| | | | - John D Lantos
- Bioethics Center, Children's Mercy Hospital, Kansas City, Missouri
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Harshman LA, Kogon AJ, Matheson MB, Johnson RJ, Shinnar S, Gerson AC, Warady BA, Furth SL, Hooper SR, Lande MB. Bicarbonate, blood pressure, and executive function in pediatric CKD-is there a link? Pediatr Nephrol 2020; 35:1323-1330. [PMID: 32297000 PMCID: PMC8077226 DOI: 10.1007/s00467-020-04507-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/23/2020] [Accepted: 02/12/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND In adult chronic kidney disease (CKD), metabolic acidosis is associated with diminished cognition, notably executive function (EF). Data from the Chronic Kidney Disease in Children (CKiD) study demonstrate a risk for impairment of EF, a finding associated with heightened blood pressure variability (BPV). We sought to determine whether low serum bicarbonate is also associated with performance on tests of EF in pediatric CKD and to investigate potential interaction with BPV. METHODS CKiD participants with serum bicarbonate, blood pressure, and selected cognitive measurements available were evaluated. An EF summary score was derived from scores on the Delis-Kaplan Executive Function System, Conners' Continuous Performance Test, and Digit Span Backwards subtest from the Wechsler Intelligence Scale for Children-IV-Integrated. Parents completed the Behavioral Rating Inventory of Executive Function (BRIEF) to yield a Global Executive Composite (GEC) score. Linear mixed models with bicarbonate and hypertension as predictors and linear regression with bicarbonate and BPV were used to predict EF level. RESULTS Data were available for 865 children. Twenty-two percent had low bicarbonate (CO2 ≤ 20 mmol/L) at baseline. On multivariate analysis, there was no relationship between bicarbonate, hypertension, and EF. There was no significant CO2×hypertension interaction found. A significant interaction (p = 0.01) between high CO2 (≥ 26 mmol/L) and BPV was detected in the model with GEC as the EF outcome, indicating that while higher BPV was associated with worse EF in the low and normal CO2 groups, higher BPV was associated with better EF in the high CO2 group. CONCLUSIONS Our analyses revealed an interaction between one measure of BPV and low bicarbonate on neurocognition in pediatric CKD, suggesting a potential role for control of both bicarbonate and blood pressure in preserving cognition in early CKD. Further research is needed to confirm and further define this association.
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Affiliation(s)
- Lyndsay A. Harshman
- Division of Pediatric Nephrology, University of Iowa Stead Family Department of Pediatrics
| | - Amy J. Kogon
- Division of Nephrology, Children’s Hospital of Philadelphia,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania
| | | | - Rebecca J. Johnson
- Children’s Mercy Kansas City, Division of Developmental and Behavioral Sciences
| | - Shlomo Shinnar
- Departments of Neurology, Pediatrics and Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine
| | | | | | - Susan L. Furth
- Division of Nephrology, Children’s Hospital of Philadelphia,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania
| | - Stephen R. Hooper
- Department of Allied Health Sciences, School of Medicine, University of North Carolina-Chapel Hill
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A longitudinal examination of parent-reported emotional-behavioral functioning of children with mild to moderate chronic kidney disease. Pediatr Nephrol 2020; 35:1287-1295. [PMID: 32157444 PMCID: PMC8210580 DOI: 10.1007/s00467-020-04511-9] [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: 09/06/2019] [Revised: 01/20/2020] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Children with mild to moderate chronic kidney disease (CKD) are at increased risk for deficits in neurocognition. Less is known about how CKD affects emotional-behavioral functioning in this population. METHODS Parent ratings of emotional-behavioral functioning at baseline and over time were examined for 845 children with mild to moderate CKD using the Behavior Assessment System for Children, Second Edition Parent Rating Scales (BASC-2 PRS). Associations with demographic and disease-related predictors were also examined. RESULTS Children with mild to moderate CKD had parent-reported emotional-behavioral functioning largely within normal limits, at baseline and over time. The proportion with T-scores at least 1 SD above the mean was 24% for Internalizing Problems and 28% for Attention Problems. A greater proportion of participants scored lower than expected (worse) on scales measuring adaptive skills (25%). Persistent hypertension predicted attention problems (β = 1.59, 95% CI = 0.24 to 2.94, p < 0.02) and suggested worse behavioral symptoms (β = 1.36, 95% CI = - 0.01 to 2.73, p = 0.05). Participants with proteinuria at baseline, but not at follow-up, had fewer attention problems than participants whose proteinuria had not resolved (β = - 3.48, CI = - 6.79 to - 0.17, p < 0.04). Glomerular diagnosis was related to fewer (β = - 2.68, 95% CI = - 4.93 to - 0.42, p < 0.02) internalizing problems. CONCLUSIONS Although children with CKD generally have average emotional-behavioral parent ratings, a notable percentage of the population may be at risk for problems with attention and adaptive behavior. Providers working with this population should facilitate psychosocial referrals when indicated.
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38
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Eaton CK, Duraccio KM, Eakin MN, Brady TM, Pruette CS, Eckmann T, Mendley SR, Tuchman S, Fivush BA, Riekert KA. Executive functioning, caregiver monitoring, and medication adherence over time in adolescents with chronic kidney disease. Health Psychol 2020; 39:509-518. [PMID: 32202823 PMCID: PMC8344353 DOI: 10.1037/hea0000851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate associations between executive functioning and caregiver adherence monitoring with objective antihypertensive medication adherence over 24 months in adolescents with chronic kidney disease (CKD). METHODS Adolescents (N = 97, 11-20 years old) with CKD taking antihypertensive medication and their caregivers were recruited from three pediatric nephrology clinics. At baseline, adolescents and caregivers reported on adolescents' executive functioning and caregivers reported on their adherence monitoring. Antihypertensive medication adherence was objectively assessed via electronic monitoring at baseline and every 6 months after for 24 months. Associations between executive functioning, caregiver monitoring, and longitudinal adherence were evaluated with linear mixed models. RESULTS Up to 38% of adolescents had elevated executive functioning scores indicating more severe impairments, with rates varying by scale and reporter (adolescent vs. caregiver). Caregiver monitoring showed a significant, negative association with adherence, but adolescents' executive functioning was not significantly associated with adherence. Neither variable was associated with the rate of change in adherence over time. CONCLUSIONS Given that adolescents' executive functioning was not associated with antihypertensive medication adherence or changes in adherence over time, adherence to daily pill-form medications may involve less cognitive effort than more complex medical regimens. Higher levels of caregiver monitoring were unexpectedly associated with lower adherence levels. This unanticipated finding may reflect increased caregiver monitoring efforts when faced with adolescents' medication nonadherence, but this finding warrants further investigation. Adolescents with CKD who are nonadherent may benefit from medication adherence-promoting strategies beyond increasing caregiver monitoring. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | | | - Susan R. Mendley
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health
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39
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Murthy VS, Shukla VS. A Study of Executive Function in Patients with Chronic Kidney Disease before and after a Single Session of Hemodialysis. J Neurosci Rural Pract 2020; 11:250-255. [PMID: 32367979 PMCID: PMC7195962 DOI: 10.1055/s-0040-1703961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Executive functions (EFs) are critical to daily life and sensitive to our physiological functioning and emotional states. The number of people living with chronic kidney disease (CKD) on hemodialysis (HD) globally is increasing steadily. We aimed to determine the impact of a single session of HD on EFs in patients with CKD receiving maintenance HD (MHD). Methods This was a quasi-experimental study conducted at the department of psychiatry and dialysis unit of a tertiary hospital. Patients undergoing MHD underwent screening to rule out delirium, using the Confusion Assessment Method prior to EF testing. The tests of EF used were the Trail-Making Test-Part B (TMT-B) and Frontal Assessment Battery (FAB), both of which were administered before and after a session of HD. Statistical tests used were Wilcoxon matched pairs signed ranks test, paired t -test, single sample t -test, and correlation analyses. Results The mean time taken on TMT-B before HD was 195.36 seconds and after HD, 171.1 seconds; difference is significant ( p = 0.0001). The mean FAB score was 13.19 before HD and 14.83 after HD; the difference is significant ( p < 0.0001). Significant differences were observed on similarities (p = 0.003), lexical fluency (p = 0.02), and go-no go ( p = 0.003) subtests of FAB. Mean TMT-B scores before and after HD differed significantly from that of a reference study (reference TMT-B 150.69 seconds), p = 0.0002 and 0.04, respectively. Conclusion We conclude that patients with CKD on MHD, in general, have worse executive cognitive functioning compared with healthy populations. A session of HD results in significant improvement in these functions.
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Affiliation(s)
- Vasantmeghna S. Murthy
- Department of Psychiatry, Krishna Institute of Medical Sciences, Karad, Maharashtra, India
| | - Vedant S. Shukla
- Department of Psychiatry, Krishna Institute of Medical Sciences, Karad, Maharashtra, India
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40
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Viggiano D, Wagner CA, Martino G, Nedergaard M, Zoccali C, Unwin R, Capasso G. Mechanisms of cognitive dysfunction in CKD. Nat Rev Nephrol 2020; 16:452-469. [PMID: 32235904 DOI: 10.1038/s41581-020-0266-9] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
Cognitive impairment is an increasingly recognized major cause of chronic disability and is commonly found in patients with chronic kidney disease (CKD). Knowledge of the relationship between kidney dysfunction and impaired cognition may improve our understanding of other forms of cognitive dysfunction. Patients with CKD are at an increased risk (compared with the general population) of both dementia and its prodrome, mild cognitive impairment (MCI), which are characterized by deficits in executive functions, memory and attention. Brain imaging in patients with CKD has revealed damage to white matter in the prefrontal cortex and, in animal models, in the subcortical monoaminergic and cholinergic systems, accompanied by widespread macrovascular and microvascular damage. Unfortunately, current interventions that target cardiovascular risk factors (such as anti-hypertensive drugs, anti-platelet agents and statins) seem to have little or no effect on CKD-associated MCI, suggesting that the accumulation of uraemic neurotoxins may be more important than disturbed haemodynamic factors or lipid metabolism in MCI pathogenesis. Experimental models show that the brain monoaminergic system is susceptible to uraemic neurotoxins and that this system is responsible for the altered sleep pattern commonly observed in patients with CKD. Neural progenitor cells and the glymphatic system, which are important in Alzheimer disease pathogenesis, may also be involved in CKD-associated MCI. More detailed study of CKD-associated MCI is needed to fully understand its clinical relevance, underlying pathophysiology, possible means of early diagnosis and prevention, and whether there may be novel approaches and potential therapies with wider application to this and other forms of cognitive decline.
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Affiliation(s)
- Davide Viggiano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.,Biogem Scarl, Ariano Irpino, Italy
| | - Carsten A Wagner
- Institute of Physiology, University of Zurich, Zurich, Switzerland, and National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
| | - Gianvito Martino
- IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Maiken Nedergaard
- University of Rochester Medical Center, School of Medicine and Dentistry, Rochester, NY, USA
| | - Carmine Zoccali
- Institute of Clinical Physiology, National Research Council (CNR), Reggio Calabria Unit, Reggio Calabria, Italy
| | - Robert Unwin
- Department of Renal Medicine, University College London (UCL), Royal Free Campus, London, UK.,Early Clinical Development, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Giovambattista Capasso
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy. .,Biogem Scarl, Ariano Irpino, Italy.
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Monteiro S, Nassr AA, Yun PS, Voigt R, Koh CJ, Roth DR, Braun M, Angelo J, Moscardo I, Espinoza J, Shamshirsaz AA, Belfort M, Ruano R, Sanz Cortes M. Neurodevelopmental Outcome in Infants with Lower Urinary Tract Obstruction Based on Different Degrees of Severity. Fetal Diagn Ther 2020; 47:587-596. [PMID: 32146466 DOI: 10.1159/000504977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 11/25/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine postnatal neurodevelopmental (ND) outcomes for children with congenital lower urinary tract obstruction (LUTO) based on disease severity. METHODS Twenty male infants with LUTO were classified prenatally as Stage 1 (normal amniotic fluid and renal function; n = 5), Stage 2 (signs of obstruction with preserved renal function; n = 13), and Stage 3 (signs of severe renal damage; n = 2). ND status was assessed using the Developmental Profile-3 test in 5 developmental domains (physical, adaptive behavior, social-emotional, cognitive, and communication). Each domain was considered to be delayed if standard scores were 2 or more SD below the mean. ND outcomes were compared between cases with an expected normal renal function (LUTO Stage 1) and those with impaired renal function (LUTO Stages 2 and 3). Results from cases with Stage 2 were also compared to those from Stage 3. ORs were calculated to predict risk for adverse ND outcome for each domain considering prenatal and postnatal factors. RESULTS Gestational age (GA) at the diagnosis of LUTO was similar between both groups (Stage 1: 24.85 ± 7.87 vs. Stages 2 and 3: 21.4 ± 4.31 weeks; p = 0.24). Twelve of 15 cases with Stage 2 or 3 underwent vesicoamniotic shunt placement compared to none of Stage 1 fetuses (p < 0.01). No differences in GA at delivery were detected between the groups (37.9 ± 1.6 vs. 35.1 ± 3.6 weeks; p = 0.1). One of the infants in the Stage 2 and 3 groups received a kidney transplant during follow-up. One case (20%) from Stage 1 group required dialysis during the first 6 months of life, and 1 case from Stage 2 to 3 group required it during the first 6 months (p = 1.0), whereas 3 additional cases needed dialysis from 6 to 24 months (p = 0.6). Mean age at Developmental Profile 3 (DP-3) testing was 20.3 ± 12.3 months (Stage 1: 11.2 ± 8.6 vs. Stages 2 and 3: 23.4 ± 13.4 months; p = 0.07). Fifteen of the 20 patients (75%) had no ND delays. Of the 5 patients with ND delays, 4 received dialysis. No differences in ND outcomes between infants with LUTO Stage 1 and those with Stages 2 and 3 were detected except for a trend toward better physical development in Stage 1 (102.6 ± 11.6 vs. 80.7 ± 34.9; p = 0.05). Infants diagnosed with LUTO Stage 3 showed significantly lower adaptive scores than those diagnosed with Stage 2 (Stage 2: 101.9 ± 22.3 vs. Stage 3: 41.5 ± 30.4; p = 0.04) and a nonsignificant trend for lower results in physical (85.8 ± 33.0 vs. 47.5 ± 38.9; p = 0.1) and socio-emotional (94.7 ±17.9 vs. 73.5 ± 13.4; p = 0.1) domains. Infants who received dialysis showed 15-fold increased risk (95% CI 0.89-251) for delayed socio-emotional development (p = 0.06). Diagnosis of fetal renal failure increased the risk for delays in the adaptive domain 30-fold (95% CI 1.29-93.1; p = 0.03). Infants with abnormal renal function had 19 times (95% CI 1.95-292) increased risk for delays in the physical domain (p = 0.03). CONCLUSIONS While most patients with LUTO do not exhibiting ND delays, our results support the importance of ND monitoring, especially in severe forms of LUTO, as increased severity of this condition may be associated with poorer ND outcomes.
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Affiliation(s)
- Sonia Monteiro
- Department of Developmental Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Peter S Yun
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Robert Voigt
- Department of Developmental Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Chester J Koh
- Division of Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
| | - David R Roth
- Division of Urology, Department of Surgery, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
| | - Michael Braun
- Department of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph Angelo
- Department of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Isabel Moscardo
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA.,Department of Obstetrics and Gynecology, Hospital Clinic, Valencia, Spain
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Michael Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, New York, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA,
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Curie A, Touil N, Gaillard S, Galanaud D, Leboucq N, Deschênes G, Morin D, Abad F, Luauté J, Bodenan E, Roche L, Acquaviva C, Vianey-Saban C, Cochat P, Cotton F, Bertholet-Thomas A. Neuropsychological and neuroanatomical phenotype in 17 patients with cystinosis. Orphanet J Rare Dis 2020; 15:59. [PMID: 32102670 PMCID: PMC7045592 DOI: 10.1186/s13023-019-1271-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 12/03/2019] [Indexed: 01/19/2023] Open
Abstract
Background Cystinosis is a rare autosomal recessive disorder caused by intracellular cystine accumulation. Proximal tubulopathy (Fanconi syndrome) is one of the first signs, leading to end-stage renal disease between the age of 12 and 16. Other symptoms occur later and encompass endocrinopathies, distal myopathy and deterioration of the central nervous system. Treatment with cysteamine if started early can delay the progression of the disease. Little is known about the neurological impairment which occurs later. The goal of the present study was to find a possible neuroanatomical dysmorphic pattern that could help to explain the cognitive profile of cystinosis patients. We also performed a detailed review of the literature on neurocognitive complications associated with cystinosis. Methods 17 patients (mean age = 17.6 years, [5.4–33.3]) with cystinosis were included in the study. Neuropsychological assessment was performed including intelligence (Intelligence Quotient (IQ) with Wechsler’s scale), memory (Children Memory Scale and Wechsler Memory Scale), visuo-spatial (Rey’s figure test) and visuo-perceptual skills assessments. Structural brain MRI (3 T) was also performed in 16 out of 17 patients, with high resolution 3D T1-weighted, 3D FLAIR and spectroscopy sequences. Results Intellectual efficiency was normal in patients with cystinosis (mean Total IQ = 93). However the Perceptual Reasoning Index (mean = 87, [63–109]) was significantly lower than the Verbal Comprehension Index (mean = 100, [59–138], p = 0.003). Memory assessment showed no difference between visual and verbal memory. But the working memory was significantly impaired in comparison with the general memory skills (p = 0.003). Visuospatial skills assessment revealed copy and reproduction scores below the 50th percentile rank in more than 70% of the patients. Brain MRI showed cortical and sub-cortical cerebral atrophy, especially in the parieto-occipital region and FLAIR hypersignals in parietal, occipital and brain stem/cerebellum. Patients with atrophic brain had lower Total IQ scores compared to non-atrophic cystinosis patients. Conclusions Patients with cystinosis have a specific neuropsychological and neuroanatomical profile. We suggest performing a systematic neuropsychological assessment in such children aiming at considering adequate management.
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Affiliation(s)
- Aurore Curie
- Service de neuropédiatrie Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Institut des Sciences Cognitives Marc Jeannerod, CNRS UMR 5304, 67 boulevard Pinel, 69675, Bron, France. .,Institut des Sciences Cognitives Marc Jeannerod, CNRS UMR 5304, L2C2, Bron, France. .,Faculté de médecine Lyon Est, Université Claude-Bernard Lyon 1, Lyon, France. .,EPICIME-CIC 1407/Inserm, UMR5558, Université de Lyon, Hospices Civils de Lyon, Bron, France.
| | - Nathalie Touil
- EPICIME-CIC 1407/Inserm, UMR5558, Université de Lyon, Hospices Civils de Lyon, Bron, France
| | - Ségolène Gaillard
- EPICIME-CIC 1407/Inserm, UMR5558, Université de Lyon, Hospices Civils de Lyon, Bron, France
| | - Damien Galanaud
- Service de neuroradiologie, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Nicolas Leboucq
- Service de neuroradiologie, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Georges Deschênes
- Service de néphropédiatrie, Hôpital Robert-Debré, AP-HP, Paris, France
| | - Denis Morin
- Service de néphrologie et diabétologie pédiatrique, Service de pédiatrie I, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Fanny Abad
- EPICIME-CIC 1407/Inserm, UMR5558, Université de Lyon, Hospices Civils de Lyon, Bron, France
| | - Jacques Luauté
- Service de rééducation fonctionnelle, Hôpital neurologique, Hospices Civils de Lyon, Bron, France
| | - Eurielle Bodenan
- EPICIME-CIC 1407/Inserm, UMR5558, Université de Lyon, Hospices Civils de Lyon, Bron, France
| | - Laurent Roche
- Service de biostatistiques, Hospices Civils de Lyon, Bron, France
| | - Cécile Acquaviva
- Service maladies héréditaires du métabolisme et dépistage néonatal, Centre de Biologie et Pathologie Est, Groupement Hospitalier Est (GHE), Hospices Civils de Lyon, Bron, France
| | - Christine Vianey-Saban
- Service maladies héréditaires du métabolisme et dépistage néonatal, Centre de Biologie et Pathologie Est, Groupement Hospitalier Est (GHE), Hospices Civils de Lyon, Bron, France
| | - Pierre Cochat
- Faculté de médecine Lyon Est, Université Claude-Bernard Lyon 1, Lyon, France.,Centre de référence des maladies rénales rares - Néphrogones - Filière ORKiD, Bron, France
| | - François Cotton
- Faculté de médecine Lyon Est, Université Claude-Bernard Lyon 1, Lyon, France.,Service de radiologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre Bénite, France.,CREATIS, CNRS UMR5220, INSERM U1044, Université Lyon 1, INSA Lyon, Villeurbanne, France
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43
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Ruebner RL, Hooper SR, Parrish C, Furth SL, Fadrowski JJ. Environmental lead exposure is associated with neurocognitive dysfunction in children with chronic kidney disease. Pediatr Nephrol 2019; 34:2371-2379. [PMID: 31327061 PMCID: PMC6800774 DOI: 10.1007/s00467-019-04306-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/02/2019] [Accepted: 07/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Environmental lead exposure is associated with cognitive impairment in healthy children, with deficits seen in intelligence quotient (IQ), attention, and behavior. Neurocognitive dysfunction is also a well-described complication among children with chronic kidney disease (CKD). The objective was to evaluate the association between blood lead levels (BLL) and performance on neurocognitive assessments in a cohort of children with CKD. METHODS Cross-sectional study of children with mild to moderate CKD from the Chronic Kidney Disease in Children (CKiD) multicenter prospective cohort study. The primary exposure was BLL. The primary outcome was performance on age-specific neurocognitive assessments evaluating IQ, executive functioning, attention, hyperactivity, and behavior. Multivariable linear regression was used to evaluate the association between BLL and neurocognitive performance, adjusted for key sociodemographic and clinical variables. RESULTS A total of 412 subjects were included with median age 15.4 years, median estimated GFR 39 mL/min/1.732, median BLL 1.2 mcg/dL, and median IQ score 99. In multivariable linear regression, higher BLL was associated with significantly lower IQ score (- 2.1 IQ points for every 1-mcg/dL increase in BLL, p = 0.029). Higher BLL was associated with worse scores on the Conners' Continuous Performance Test II Variability T-Score, a measure of inattention (+ 1.8 T-Score points for every 1-mcg/dL increase in BLL, p = 0.033). CONCLUSIONS Low-level lead exposure is associated with significantly lower IQ and more inattention in children with CKD, a population already at high risk for neurocognitive dysfunction. Universal screening for elevated BLL should be considered for all children with CKD at age 12-24 months.
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Affiliation(s)
- Rebecca L. Ruebner
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, 200 N Wolfe St, Room 3055, Baltimore, MD 21287, USA
| | - Stephen R. Hooper
- Departments of Allied Health Sciences and Psychiatry, School of Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Carisa Parrish
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, 200 N Wolfe St, Room 3055, Baltimore, MD 21287, USA,Division of Child and Adolescent Psychiatry, Pediatric Medical Psychology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan L. Furth
- Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey J. Fadrowski
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, 200 N Wolfe St, Room 3055, Baltimore, MD 21287, USA
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Kogon AJ, Kim JY, Laney N, Radcliffe J, Hooper SR, Furth SL, Hartung EA. Depression and neurocognitive dysfunction in pediatric and young adult chronic kidney disease. Pediatr Nephrol 2019; 34:1575-1582. [PMID: 31049719 DOI: 10.1007/s00467-019-04265-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/20/2019] [Accepted: 04/18/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Depression affects 7-35% of children with chronic kidney disease (CKD), and in adults with CKD, the presence of depression links to poorer medical outcomes, social functioning difficulties, and neurocognitive impairments. The relationship between depression and neurocognitive function in youth with CKD is unclear. We sought to identify factors associated with depression in youth with CKD and to determine whether depression affects neurocognitive performance. METHODS We conducted cross-sectional analyses in 71 CKD and 64 control participants aged 8 to 25 years who completed depression inventories and neurocognitive assessments as part of the Neurocognitive Assessment and Magnetic Resonance Imaging Analysis of Children and Young Adults with CKD Study. In the CKD group, multivariable logistic regression analysis determined associations between clinical and demographic factors and depression. In the full study cohort, multivariable linear regression analyses, including an interaction term between CKD status and depression evaluated the effect of depression on 11 neurocognitive outcome domains. RESULTS Obesity significantly associated with depression in the CKD group (OR 10.25, P = 0.01). In adjusted analyses, depressed youth with CKD scored worse than non-depressed CKD participants by 0.6-1.0 standard deviations in 5 neurocognitive domains: attention, visual memory, visual-spatial, visual working memory, and problem solving. CONCLUSIONS CKD youth with obesity are more likely to be depressed, and those who are depressed exhibit worse neurocognitive performance. Depression may represent a therapeutic target to improve neurocognitive performance in youth with CKD.
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Affiliation(s)
- Amy J Kogon
- Division of Nephrology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19103, USA. .,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Ji Young Kim
- Biostatistics Core, the Center for Human Phenomic Science, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nina Laney
- Lifespan Brain Institute, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jerilynn Radcliffe
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephen R Hooper
- Department of Allied Health Sciences, School of Medicine University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| | - Susan L Furth
- Division of Nephrology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19103, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Erum A Hartung
- Division of Nephrology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19103, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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45
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Comorbidity Among Chronic Physical Health Conditions and Neurodevelopmental Disorders in Childhood. CURRENT DEVELOPMENTAL DISORDERS REPORTS 2019. [DOI: 10.1007/s40474-019-00173-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Kogon AJ, Harshman LA. Chronic Kidney Disease: Treatment of Comorbidities I: (Nutrition, Growth, Neurocognitive Function, and Mineral Bone Disease). CURRENT TREATMENT OPTIONS IN PEDIATRICS 2019; 5:78-92. [PMID: 31840017 PMCID: PMC6910661 DOI: 10.1007/s40746-019-00152-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW This review discusses the complications of nutrition, growth, neurocognitive function and mineral and bone disorder in pediatric chronic kidney disease. We discuss the most recent evidence-based methods for evaluation and prevention of these complications in addition to treatment strategies to address the complications and mitigate adverse effects. RECENT FINDINGS Frequent nutritional assessment is important, particularly for infants and young children. Due to anorexia, oral aversion and dietary restrictions, weight gain may be difficult to achieve. Adequate nutrition is important for growth. Children with CKD tend to be short, which can impact quality of life and social achievements. Once nutrition is optimized, growth hormone is an effective, but underutilized strategy to improving terminal height. Mineral and bone disorder is a difficult but common complication of CKD which may present with and be driven by abnormalities in calcium, phosphorus and parathyroid hormone levels. Treatment strategies include dietary phosphorus restriction, phosphorus binders, and inactive vitamin D and active vitamin D sterols. Effective treatment may reduce the risk for bone deformities, growth abnormalities, fractures, cardiovascular disease and mortality. Children with CKD also suffer from cognitive difficulties. Control of anemia, aggressive childhood nutrition, and decreased exposure to heavy metals (via dialysate and dietary binding agents) has provided substantial improvement to the more profound neurocognitive sequelae observed prior to the 1990s. Current prevention of cognitive sequelae may best be directed at improved blood pressure control and augmented school support. SUMMARY Pediatric CKD has systemic ramifications and can impact all aspects of normal development, including nutrition, growth, bone and mineral metabolism and neurocognitive function. Regular evaluation for disease complications and prompt treatment can reduce the untoward effects of CKD thereby improving the quality and duration of life.
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Affiliation(s)
- Amy J Kogon
- Division of Nephrology, Children's Hospital of Philadelphia
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania
| | - Lyndsay A Harshman
- Division of Pediatric Nephrology, University of Iowa Stead Family Department of Pediatrics
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daCruz K, Cousino MK, Smith T, Bilhartz J, Eder SJ, Fredericks EM. Educational needs in families of pediatric liver and kidney transplant recipients: A quality improvement project. Pediatr Transplant 2019; 23:e13412. [PMID: 30983080 DOI: 10.1111/petr.13412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 01/07/2019] [Accepted: 03/08/2019] [Indexed: 11/28/2022]
Abstract
Parents of pediatric liver and kidney transplant recipients were surveyed regarding their current education plans (eg, Individualized Education Program, 504), satisfaction with these plans, and interest in educational support from the psychosocial transplant team. Survey results indicate high rates of IEP and 504 plans, academic and related services, and accommodations among this population. The majority of parents/guardians reported satisfaction with their child's current school plan and did not report need for additional transplant team support specific to school services on the survey measure. However, other information highlights the importance for pediatric transplant teams to consider other ways to support this population's educational needs.
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Affiliation(s)
- Katelin daCruz
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Melissa K Cousino
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Tanya Smith
- Department of Social Work, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Jacob Bilhartz
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Sally J Eder
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
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48
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Harshman LA, Johnson RJ, Matheson MB, Kogon AJ, Shinnar S, Gerson AC, Warady BA, Furth SL, Hooper SR. Academic achievement in children with chronic kidney disease: a report from the CKiD cohort. Pediatr Nephrol 2019; 34:689-696. [PMID: 30448874 PMCID: PMC6453537 DOI: 10.1007/s00467-018-4144-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 10/22/2018] [Accepted: 11/06/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are limited data to describe academic achievement outcomes for children with mild to moderate pediatric chronic kidney disease (CKD). The objective of this study was to describe the prevalence of low academic achievement in patients with mild to moderate CKD. METHODS Wechsler Individual Achievement Test, Second Edition, Abbreviated (WIAT-II-A) data were collected at entry into the Chronic Kidney Disease in Children (CKiD) study. Achievement in basic reading, spelling, mathematics, and total achievement was evaluated with a focus on the effects of comorbid CKD-related variables, neurocognitive, and school-based characteristics on academic achievement. RESULTS WIAT-II-A data were available for 319 children in the CKiD cohort. Low total academic achievement was present in 34% percent of the sample. There was no significant effect of CKD-related medical variables on academic achievement. Mathematics had the lowest distribution of achievement scores. In univariate models, low achievement was significantly related to days of missed school (p = 0.006) and presence of individualized education plan (p < 0.0001). CONCLUSIONS Low academic achievement was seen in over one-third of children with CKD, with the most difficulty observed in the domain of mathematics. Providers and educators should monitor for academic difficulties in this population in order to facilitate early educational assistance and promote positive educational outcomes.
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Affiliation(s)
- Lyndsay A Harshman
- Division of Pediatric Nephrology, Dialysis and Transplantation, University of Iowa Stead Family Department of Pediatrics, 4037 Boyd Tower, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
| | - Rebecca J Johnson
- Division of Developmental and Behavioral Sciences, Children's Mercy Kansas City, Kansas City, MO, USA
| | | | - Amy J Kogon
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Shlomo Shinnar
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Arlene C Gerson
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Susan L Furth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen R Hooper
- Department of Allied Health Sciences, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Stabouli S, Gidaris D, Printza N, Dotis J, Papadimitriou E, Chrysaidou K, Papachristou F, Zafeiriou D. Sleep disorders and executive function in children and adolescents with chronic kidney disease. Sleep Med 2019; 55:33-39. [DOI: 10.1016/j.sleep.2018.11.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 11/07/2018] [Accepted: 11/14/2018] [Indexed: 10/27/2022]
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50
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Hegarty-Craver M, Gilchrist KH, Propper CB, Lewis GF, DeFilipp SJ, Coffman JL, Willoughby MT. Automated respiratory sinus arrhythmia measurement: Demonstration using executive function assessment. Behav Res Methods 2018; 50:1816-1823. [PMID: 28791596 PMCID: PMC5803481 DOI: 10.3758/s13428-017-0950-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Respiratory sinus arrhythmia (RSA) is a quantitative metric that reflects autonomic nervous system regulation and provides a physiological marker of attentional engagement that supports cognitive and affective regulatory processes. RSA can be added to executive function (EF) assessments with minimal participant burden because of the commercial availability of lightweight, wearable electrocardiogram (ECG) sensors. However, the inclusion of RSA data in large data collection efforts has been hindered by the time-intensive processing of RSA. In this study we evaluated the performance of an automated RSA-scoring method in the context of an EF study in preschool-aged children. The absolute differences in RSA across both scoring methods were small (mean RSA differences = -0.02-0.10), with little to no evidence of bias for the automated relative to the hand-scoring approach. Moreover, the relative rank-ordering of RSA across both scoring methods was strong (rs = .96-.99). Reliable changes in RSA from baseline to the EF task were highly similar across both scoring methods (96%-100% absolute agreement; Kappa = .83-1.0). On the basis of these findings, the automated RSA algorithm appears to be a suitable substitute for hand-scoring in the context of EF assessment.
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Affiliation(s)
| | - Kristin H Gilchrist
- RTI International, 3040 Cornwallis Rd., Research Triangle Park, NC, 27709, USA.
| | | | | | - Samuel J DeFilipp
- RTI International, 3040 Cornwallis Rd., Research Triangle Park, NC, 27709, USA
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