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Akchurin O, Molino AR, Schneider MF, Atkinson MA, Warady BA, Furth SL. Longitudinal Relationship Between Anemia and Statural Growth Impairment in Children and Adolescents With Nonglomerular CKD: Findings From the Chronic Kidney Disease in Children (CKiD) Study. Am J Kidney Dis 2023; 81:457-465.e1. [PMID: 36481700 PMCID: PMC10038884 DOI: 10.1053/j.ajkd.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/27/2022] [Indexed: 12/09/2022]
Abstract
RATIONALE & OBJECTIVE Anemia and statural growth impairment are both prevalent in children with nonglomerular chronic kidney disease (CKD) and are associated with poor quality of life and increased morbidity and mortality. However, to date no longitudinal studies have demonstrated a relationship between anemia and statural growth in this population. STUDY DESIGN The CKD in Children (CKiD) study is a multicenter prospective cohort study with over 15 years of follow-up observation. SETTING & PARTICIPANTS CKiD participants younger than 22 years with nonglomerular CKD who had not reached final adult height. EXPOSURE Age-, sex-, and race-specific hemoglobin z score. OUTCOME Age- and sex-specific height z score. ANALYTICAL APPROACH The relationship between hemoglobin and height was quantified using (1) multivariable repeated measures paired person-visit analysis, and (2) multivariable repeated measures linear mixed model analysis. Both models were adjusted for age, sex, body mass index, estimated glomerular filtration rate, acidosis, and medication use. RESULTS Overall, 67% of the 510 participants studied had declining hemoglobin z score trajectories over the follow-up period, which included 1,763 person-visits. Compared with average hemoglobin z scores of≥0, average hemoglobin z scores of less than -1.0 were independently associated with significant growth impairment at the subsequent study visit, with height z score decline ranging from 0.24 to 0.35. Importantly, in 50% of cases hemoglobin z scores of less than -1.0 corresponded to hemoglobin values higher than those used as cutoffs defining anemia in the KDIGO clinical practice guideline for anemia in CKD. When stratified by age, the magnitude of the association peaked in participants aged 9 years. In line with paired-visit analyses, our mixed model analysis demonstrated that in participants with baseline hemoglobin z score less than -1.0, a hemoglobin z score decline over the follow-up period was associated with a statistically significant concurrent decrease in height z score. LIMITATIONS Limited ability to infer causality. CONCLUSIONS Hemoglobin decline is associated with growth impairment over time in children with mild to moderate nonglomerular CKD, even before hemoglobin levels reach the cutoffs that are currently used to define anemia in this population.
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Affiliation(s)
- Oleh Akchurin
- Department of Pediatrics, Weill Cornell Medicine and New York-Presbyterian Hospital, New York, New York.
| | - Andrea R Molino
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Michael F Schneider
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Susan L Furth
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Prevalence and risk factors for functional iron deficiency in children with chronic kidney disease. Clin Exp Nephrol 2023; 27:66-71. [PMID: 36192566 DOI: 10.1007/s10157-022-02281-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 09/21/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Anemia in chronic kidney disease (CKD) is multifactorial. The presence of functional iron deficiency (FID), whereby, there is a block in the transport of iron from macrophage to erythroid marrow is one possible etiology. In this study, we aim to assess the prevalence and risk factors of FID in pediatric CKD. METHODS A cross-sectional study was performed from March to December 2018, after obtaining Institute Ethical Clearance. Children aged ≤ 12 years with CKD, with or without iron supplementation who consented were enrolled. Patients on erythropoietin or on maintenance dialysis were excluded. Details of patients and diseases characteristics were recorded. Various laboratory parameters including complete blood count, red blood cell indices, hypochromic RBC, reticulocyte hemoglobin content, and serum ferritin were measured. Appropriate statistical tests were applied. RESULTS Out of 174 children, 127 (73%) had structural kidney disease as an etiology of CKD, and 110 (63%) had anemia. Prevalence of anemia was 44%, 43%, 74%, 64% and 92% in CKD stage 1, 2, 3, 4 and 5, respectively. Absolute iron deficiency was found in 66 (38%) even when some children were already on iron supplementation. FID was seen in 44 (25%) and on multivariate analysis, lower estimated glomerular filtration rate and mineral bone disease are associated risk factors. CONCLUSION FID is present in one-fourth of our CKD cohort. It should be considered when the response to adequate measures of improving hemoglobin level fails. More studies are required to know its impact on short-term and long-term patient-related outcomes such as quality of life and mortality.
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Los-Stegienta A, Borkowska A, Cypryk K. Assessment of microvascular function using a novel technique Flow Mediated Skin Fluorescence (FMSF) in patients with diabetic kidney disease: A preliminary study. Microvasc Res 2022; 144:104417. [PMID: 35931125 DOI: 10.1016/j.mvr.2022.104417] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 07/13/2022] [Accepted: 07/28/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Diabetic kidney disease (DKD) plays an important role in morbidity and mortality in patients with diabetes mellitus. The pathogenesis of this microangiopathy is mainly due to impaired vascular endothelial function. The Flow Mediated Skin Fluorescence (FMSF) method is an innovative, non-invasive tool for assessing the microcirculation function (especially microcirculatory response to hypoxia), also in patients with complications of diabetes mellitus (DM). MATERIAL AND METHODS The study was conducted at the Medical University of Lodz, Poland. Total of 84 volunteers including 30 patients with DKD, 33 patients with DM without complications, and 21 healthy subjects underwent microvascular function assessments using FMSF. This technique measures changes in the intensity of nicotinamide adenine dinucleotide (NADH) fluorescence from the skin on the forearm as a function of time, in response to blocking and releasing blood flow in the forearm. In this study we asses two key parameters: Reactive Hyperemia Response (RHR) and Hypoxia Sensitivity [log(HS)] to characterize vascular circulation in patients with DKD and their response to transient ischemia. RESULTS The patients with low reactive hyperemic response (the RHR parameter) had a significantly higher sCr than patients with moderate and high RHR value (p < 0.001, p < 0.05, respectively) and a significantly lower eGFR than the patients with moderate and high RHR parameter (p < 0.001, p < 0.01, respectively). The patients with very low and low log(HS) values had a significantly higher sCr than the patients with high log(HS) (p < 0.001, p < 0.01, respectively), and a significantly lower eGFR than the patients with high log(HS) parameter (p < 0.001, p < 0.01, respectively). The patients with very low log(HS) had a significantly higher sCr and a significantly lower eGFR than the patients with moderate (p < 0.05, p < 0.01, respectively). The mean value of the RHR parameter was significantly lower in DKD patients (18.31 ± 5.06 %) compared to both healthy subjects (34.37 ± 8.18 %, p < 0.001) and DM without complications subgroup (28.75 ± 7.12 %, p < 0.001). Similar trends were noted with the mean value of log(HS) parameter in DKD subgroup (1.03 ± 0.5) vs. healthy subjects (1.59 ± 0.53, p < 0.001), and vs. DM without complications subgroup (1.73 ± 0.52, p < 0.001). We observed a significant inverse correlation between the RHR parameter and serum creatinine (sCr) and a significant positive correlations with eGFR (R = -0.3; p < 0.05, R = 0.61; p < 0.001, respectively). We found also a significant negative correlations of the log(HS) measure with sCr and a significant positive correlations with eGFR (R = -0.33; p < 0.01, R = 0.55; p < 0.001, respectively). We observed also a significant inverse correlation between the RHR and log(HS) parameters and advanced glycation end products (AGEs) (R = -0.6; p < 0.001, R = -0.32; p < 0.01, respectively). The AGEs parameter was also a significantly higher in patients with low RHR parameter than in patients with moderate (p < 0.01) and high (p < 0.001). CONCLUSIONS The FMSF technique makes it possible to identify impairments of the microvascular function in patients with DKD. This study confirms that the simple two-parametric approach diagnostic tool perfectly characterizes the state of the microvascular system in diabetic patients with impaired renal function. These preliminary results require further validation in a larger patients cohort.
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Affiliation(s)
- Agnieszka Los-Stegienta
- Department of Internal Diseases and Diabetology, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland.
| | - Anna Borkowska
- Department of Internal Diseases and Diabetology, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland.
| | - Katarzyna Cypryk
- Department of Internal Diseases and Diabetology, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland.
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Liu L, Xu W, Kong P, Dou Y. The relationships among gut microbiota, hypoxia‐inducible factor and anemia with chronic kidney disease. Nephrology (Carlton) 2022; 27:851-858. [PMID: 35603584 DOI: 10.1111/nep.14064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/10/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Lifen Liu
- Nephrology Department Zhengzhou University First Affiliated Hospital, NO.1 Jianshe Eastern Road, Erqi District Zhengzhou Henan China
| | - Wenwen Xu
- Nephrology Department Zhengzhou University First Affiliated Hospital, NO.1 Jianshe Eastern Road, Erqi District Zhengzhou Henan China
| | - Pingping Kong
- Nephrology Department Zhengzhou University First Affiliated Hospital, NO.1 Jianshe Eastern Road, Erqi District Zhengzhou Henan China
| | - Yanna Dou
- Nephrology Department Zhengzhou University First Affiliated Hospital, NO.1 Jianshe Eastern Road, Erqi District Zhengzhou Henan China
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Atkinson MA, Ng DK, Warady BA, Furth SL, Flynn JT. The CKiD study: overview and summary of findings related to kidney disease progression. Pediatr Nephrol 2021; 36:527-538. [PMID: 32016626 PMCID: PMC7396280 DOI: 10.1007/s00467-019-04458-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/10/2019] [Accepted: 12/16/2019] [Indexed: 12/15/2022]
Abstract
The Chronic Kidney Disease in Children (CKiD) cohort study is a North American (USA and Canada) multicenter, prospective study of children with chronic kidney disease (CKD). The original aims of the study were (1) to identify novel risk factors for CKD progression; (2) to measure the impact of kidney function decline on growth, cognition, and behavior; and (3) to characterize the evolution of cardiovascular disease risk factors. CKiD has developed into a national and international resource for the investigation of a variety of factors related to CKD in children. This review highlights notable findings in the area of CKD progression and outlines ongoing opportunities to enhance understanding of CKD progression in children. CKiD's contributions to the clinical care of children with CKD include updated and more accurate glomerular filtration rate estimating equations for children and young adults, and resources designed to help estimate the CKD progression timeline. In addition, results from CKiD have strengthened the evidence that treatment of hypertension and proteinuria should continue as a primary strategy for slowing the rate of disease progression in children.
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Affiliation(s)
| | - Derek K Ng
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | | | - Susan L Furth
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Genetic associations of hemoglobin in children with chronic kidney disease in the PediGFR Consortium. Pediatr Res 2019; 85:324-328. [PMID: 30140068 PMCID: PMC6377354 DOI: 10.1038/s41390-018-0148-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/30/2018] [Accepted: 06/04/2018] [Indexed: 12/04/2022]
Abstract
BACKGROUND Genome-wide association studies (GWAS) in healthy populations have identified variants associated with erythrocyte traits, but genetic causes of hemoglobin variation in children with CKD are incompletely understood. METHODS The Pediatric Investigation of Genetic Factors Linked with Renal Progression (PediGFR) Consortium comprises three pediatric CKD cohorts: Chronic Kidney Disease in Children (CKiD), Effect of Strict Blood Pressure Control and ACE Inhibition on the Progression of CRF in Pediatric Patients (ESCAPE), and Cardiovascular Comorbidity in Children with CKD (4C). We performed cross-sectional and longitudinal association studies of single-nucleotide polymorphisms (SNPs) in 1125 patients. RESULTS Children of European (n = 725) or Turkish (n = 400) ancestry (EA or TA) were included. In cross-sectional analysis, two SNPs (rs10758658 and rs12718597) previously associated with RBC traits were significantly associated with hemoglobin levels in children of EA and TA. In longitudinal analysis, SNP rs2540917 was nominally associated with hemoglobin in EA and TA children. CONCLUSIONS SNPs associated with erythrocyte traits in healthy populations were marginally significant for an association with hemoglobin. Further analyses/replication studies are needed in larger CKD cohorts to investigate SNPs of unknown significance associated with hemoglobin. Functional studies will be required to confirm that the observed associations between SNPs and clinical phenotype are causal.
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Lee KH, Park E, Choi HJ, Kang HG, Ha IS, Cheong HI, Park YS, Cho H, Han KH, Kim SH, Cho MH, Lee JH, Shin JI. Anemia and Iron Deficiency in Children with Chronic Kidney Disease (CKD): Data from the Know-Ped CKD Study. J Clin Med 2019; 8:E152. [PMID: 30700016 PMCID: PMC6406575 DOI: 10.3390/jcm8020152] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/14/2019] [Accepted: 01/15/2019] [Indexed: 11/16/2022] Open
Abstract
Children with chronic kidney disease (CKD) are at high risk of anemia, an important risk factor for cardiovascular disease and poor quality of life. The present study used baseline data from the Korean cohort study for Outcome in patients With Pediatric Chronic Kidney Disease (KNOW-PedCKD). A Total of 437 patients was included in the analyses excluding missing data. The characteristics of patients with and without anemia and those of patients with and without iron deficiency were compared. Logistic regression analysis and Pearson correlation were conducted to evaluate associated risk factors and correlations in children with CKD. Anemia in children with CKD was associated with older age, low body weight and body mass index (BMI) z-score, birth age, preceding glomerulonephritis, decreased estimated glomerular filtration rate (eGFR), low levels of serum albumin and calcium, high levels of serum intact parathyroid hormone (iPTH), and serum phosphorus. Anemia was correlated positively with changes in the BMI z-score, body weight, and serum albumin and cholesterol levels, but correlated negatively with serum calcium, iPTH, ferritin levels, and transferrin saturation. Iron deficiency in children with CKD was associated with young age, low hemoglobin and serum ferritin levels, high BMI z-scores, and low levels of serum iPTH. This is the first nationwide cohort study of anemia in Korean children with CKD and the first prospective pediatric CKD cohort study in Asia. The study results demonstrated that anemia and iron deficiency are affected by various factors, including age, BMI, and levels of serum iPTH. To improve the retrospective outcome of affected children, it is important to understand the effect of each of these factors and to attempt an early intervention to prevent anemia and iron deficiency by regular measurement of these parameters in children at risk.
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Affiliation(s)
- Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, C.P.O. Box 8044, Seoul 03722, Korea.
- Division of Pediatric Nephrology, Severance Children's Hospital, Seoul 03722, Korea.
| | - Eujin Park
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul 07441, Korea.
| | - Hyun Jin Choi
- Department of Pediatrics, Seoul National University Children's Hospital & Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital & Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital & Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital & Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Young Seo Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-Gil, Songpa-Gu, Seoul 05505, Korea.
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
| | - Kyoung Hee Han
- Department of Pediatrics, Jeju National University School of Medicine, Jeju 63241, Korea.
| | - Seong Heon Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan 50612, Korea.
| | - Min Hyun Cho
- Department of Pediatrics, Kyungpook National University, School of Medicine, Daegu 41404, Korea.
| | - Joo Hoon Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-Gil, Songpa-Gu, Seoul 05505, Korea.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, C.P.O. Box 8044, Seoul 03722, Korea.
- Division of Pediatric Nephrology, Severance Children's Hospital, Seoul 03722, Korea.
- Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul 03722, Korea.
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Atkinson MA, Warady BA. Anemia in chronic kidney disease. Pediatr Nephrol 2018; 33:227-238. [PMID: 28412770 DOI: 10.1007/s00467-017-3663-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 03/22/2017] [Accepted: 03/24/2017] [Indexed: 12/12/2022]
Abstract
Anemia is common and associated with adverse outcomes in children with chronic kidney disease (CKD). Many factors contribute to declining hemoglobin as CKD progresses, but impaired production of erythropoietin by failing kidneys is a central cause. Hepcidin-mediated iron restriction also contributes to anemia by downregulating both intestinal iron absorption and release of stored iron for erythropoiesis. The core components of anemia management remain erythropoiesis-stimulating agents (ESA) and iron supplementation, but despite these therapies, a substantial number of children remain anemic. Although escalating ESA dose to target higher hemoglobin has been associated with adverse outcomes in adults, no trials have investigated this association in children, and maintaining hemoglobin levels in a narrow range with conservative ESA dosing is challenging. Judicious use of iron supplementation can enhance the response to ESAs, but the iron storage markers most commonly used in clinical practice have limitations in distinguishing which patients will benefit most from additional iron. Several novel anemia therapies, including hypoxia-inducible factor stabilizers, prolyl hydroxylase inhibitors, and dialysate-delivered iron supplements, have been developed and may offer options for alternative anemia management. However, the safety and efficacy of these agents in children with CKD has yet to be assessed.
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Affiliation(s)
- Meredith A Atkinson
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, 200 N. Wolfe St, Baltimore, MD, 21287, USA.
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
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Tjaden LA, Jager KJ, Bonthuis M, Kuehni CE, Lilien MR, Seeman T, Stefanidis CJ, Tse Y, Harambat J, Groothoff JW, Noordzij M. Racial variation in cardiovascular disease risk factors among European children on renal replacement therapy-results from the European Society for Paediatric Nephrology/European Renal Association - European Dialysis and Transplant Association Registry. Nephrol Dial Transplant 2017; 32:1908-1917. [PMID: 28158862 DOI: 10.1093/ndt/gfw423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/07/2016] [Indexed: 01/23/2023] Open
Abstract
Background Racial differences in overall mortality rates have been found in children on renal replacement therapy (RRT). We used data from the European Society for Paediatric Nephrology/European Renal Association - European Dialysis and Transplant Association Registry to study racial variation in the prevalence of cardiovascular disease (CVD) risk factors among European children on RRT. Methods We included patients aged <20 years between 2006-13 who (i) initiated dialysis treatment or (ii) had a renal transplant vintage of ≥1 year. Racial groups were defined as white, black, Asian and other. The CVD risk factors assessed included uncontrolled hypertension, obesity, hyperphosphataemia and anaemia. Differences between racial groups in CVD risk factors were examined using generalized estimating equation (GEE) models while adjusting for potential confounders. Results In this study, 1161 patients on dialysis and 1663 patients with a transplant were included. The majority of patients in both groups were white (73.8% and 79.9%, respectively). The crude prevalence of the CVD risk factors was similar across racial groups. However, after adjustment for potential confounders, Asian background was associated with higher risk of uncontrolled hypertension both in the dialysis group [odds ratio (OR): 1.27; 95% confidence interval (CI): 1.01-1.64] and the transplant group (OR: 1.37; 95% CI: 1.11-1.68) compared with white patients. Patients of Asian and other racial background with a renal transplant had a higher risk of anaemia compared with white patients (OR: 1.50; 95% CI: 1.15-1.96 and OR: 1.45; 95% CI: 1.01-2.07, respectively). Finally, the mean number of CVD risk factors among dialysis patients was higher in Asian patients (1.83, 95% CI: 1.64-2.04) compared with white patients (1.52, 95% CI: 1.40-1.65). Conclusions We found a higher prevalence of modifiable CVD risk factors in Asian children on RRT. Early identification and management of these risk factors could potentially improve long-term outcomes.
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Affiliation(s)
- Lidwien A Tjaden
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands.,Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Kitty J Jager
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands
| | - Marjolein Bonthuis
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands
| | - Claudia E Kuehni
- Swiss Pediatric Renal Registry, Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Marc R Lilien
- Department of Pediatric Nephrology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Tomas Seeman
- Department of Pediatrics, University Hospital Motol, Charles University Prague, 2nd Faculty of Medicine, Prague, Czech Republic
| | | | - Yincent Tse
- Department of Pediatric Nephrology, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| | - Jaap W Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Marlies Noordzij
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands
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Warady BA, Silverstein DM. Management of anemia with erythropoietic-stimulating agents in children with chronic kidney disease. Pediatr Nephrol 2014; 29:1493-505. [PMID: 24005791 DOI: 10.1007/s00467-013-2557-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/29/2013] [Accepted: 06/20/2013] [Indexed: 11/28/2022]
Abstract
Anemia management is an important component of the care provided to children with chronic kidney disease (CKD) and influences both morbidity and mortality risk. The introduction of recombinant human erythropoietin to the treatment regimen three decades ago revolutionized the therapy and significantly decreased the need for repeated blood transfusions and exposure to associated risks. Recent data on the efficacy and complications associated with erythropoietic-stimulating agent (ESA) usage has, however, prompted a reassessment of treatment-related recommendations. This review will address these recommendations, in addition to describing pediatric outcomes associated with current ESAs and presenting information on alternative ESAs, many of which will likely soon be incorporated into clinical practice.
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Affiliation(s)
- Bradley A Warady
- Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO, 64108, USA,
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Kassebaum NJ, Jasrasaria R, Naghavi M, Wulf SK, Johns N, Lozano R, Regan M, Weatherall D, Chou DP, Eisele TP, Flaxman SR, Pullan RL, Brooker SJ, Murray CJL. A systematic analysis of global anemia burden from 1990 to 2010. Blood 2014; 123:615-24. [PMID: 24297872 PMCID: PMC3907750 DOI: 10.1182/blood-2013-06-508325] [Citation(s) in RCA: 1151] [Impact Index Per Article: 115.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/08/2013] [Indexed: 12/14/2022] Open
Abstract
Previous studies of anemia epidemiology have been geographically limited with little detail about severity or etiology. Using publicly available data, we estimated mild, moderate, and severe anemia from 1990 to 2010 for 187 countries, both sexes, and 20 age groups. We then performed cause-specific attribution to 17 conditions using data from the Global Burden of Diseases, Injuries and Risk Factors (GBD) 2010 Study. Global anemia prevalence in 2010 was 32.9%, causing 68.36 (95% uncertainty interval [UI], 40.98 to 107.54) million years lived with disability (8.8% of total for all conditions [95% UI, 6.3% to 11.7%]). Prevalence dropped for both sexes from 1990 to 2010, although more for males. Prevalence in females was higher in most regions and age groups. South Asia and Central, West, and East sub-Saharan Africa had the highest burden, while East, Southeast, and South Asia saw the greatest reductions. Iron-deficiency anemia was the top cause globally, although 10 different conditions were among the top 3 in regional rankings. Malaria, schistosomiasis, and chronic kidney disease-related anemia were the only conditions to increase in prevalence. Hemoglobinopathies made significant contributions in most populations. Burden was highest in children under age 5, the only age groups with negative trends from 1990 to 2010.
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Affiliation(s)
- Nicholas J Kassebaum
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
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Atkinson MA, Melamed ML, Kumar J, Roy CN, Miller ER, Furth SL, Fadrowski JJ. Vitamin D, race, and risk for anemia in children. J Pediatr 2014; 164:153-158.e1. [PMID: 24112861 PMCID: PMC3872204 DOI: 10.1016/j.jpeds.2013.08.060] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 07/24/2013] [Accepted: 08/26/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine the association between 25-hydroxyvitamin D [25(OH)D] deficiency and anemia in a cohort of otherwise-healthy children and to determine whether race modifies the association between 25(OH)D status and hemoglobin (Hgb). STUDY DESIGN Cross-sectional study of 10,410 children and adolescents ages 1-21 years from the 2001-2006 National Health and Nutrition Examination Survey. Anemia was defined as Hgb less than the 5th percentile for age and sex based on National Health and Nutrition Examination Survey III (1988-1994) data. RESULTS Lower 25(OH)D levels were associated with increased risk for anemia; <30 ng/mL, adjusted OR 1.93, 95% CI 1.21-3.08, P = .006, and <20 ng/mL, OR 1.47, 95% CI 1.14-1.89, P = .004. In linear regression, small but significant increases in Hgb were noted in the upper quartiles of 25(OH)D compared with the lowest quartile (<20 ng/mL) in the full cohort. Results of race-stratified linear regression by 25(OH)D quartile in white children were similar to those observed in the full cohort, but in black children, an increase in Hgb in the upper 25(OH)D quartiles was only apparent compared with the lowest black race-specific quartile (<12 ng/mL). CONCLUSION 25(OH)D deficiency is associated with increased risk of anemia in healthy US children, but the 25(OH)D threshold levels for lower Hgb are lower in black children in comparison with white children.
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Affiliation(s)
- Meredith A. Atkinson
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michal L. Melamed
- Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Juhi Kumar
- Division of Pediatric Nephrology, Weill Cornell Medical College, New York, NY
| | - Cindy N. Roy
- Divisions of Hematology and Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Edgar R. Miller
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Susan L. Furth
- The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jeffrey J. Fadrowski
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
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Wong CJ, Moxey-Mims M, Jerry-Fluker J, Warady BA, Furth SL. CKiD (CKD in children) prospective cohort study: a review of current findings. Am J Kidney Dis 2012; 60:1002-11. [PMID: 23022429 DOI: 10.1053/j.ajkd.2012.07.018] [Citation(s) in RCA: 153] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 07/02/2012] [Indexed: 11/11/2022]
Abstract
Chronic kidney disease (CKD) is a life-long condition associated with substantial morbidity and premature death due to complications from a progressive decrease in kidney function. The incidence and prevalence of all stages of CKD in children continues to increase worldwide. Between 2000 and 2008, the kidney replacement therapy incidence rate in those aged 0-19 years increased 5.9% to 15 per million population, highlighting the importance of CKD research in children. Many comorbid conditions seen in adults with CKD, including cardiovascular disease and cognitive impairment, also are highly prevalent in children, implicitly demonstrating the crucial need for initiating therapy early to improve health outcomes in children with CKD. The CKiD (Chronic Kidney Disease in Children) Study is a prospective cohort study of 586 children aged 1-16 years with an estimated glomerular filtration rate of 30-90 mL/min/1.73 m(2). Since its inception, CKiD has identified risk factors for CKD progression and cardiovascular disease in children with CKD and highlighted the effects of CKD on outcomes unique to children, including neurocognitive development and growth. This review summarizes the findings to date, illustrating the spectrum of CKD-associated complications in children and emphasizing areas requiring further investigation. Taken in sum, these elements stress that initiating treatment at an early age is essential for reducing long-term morbidity and mortality in children with CKD.
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Affiliation(s)
- Cynthia J Wong
- Department of Pediatrics, Division of Nephrology, Lucile Packard Children's Hospital, Palo Alto, CA, USA.
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Chernin G, Gal-Oz A, Schwartz IF, Shashar M, Schwartz D, Weinstein T. Care of undocumented-uninsured immigrants in a large urban dialysis unit. BMC Nephrol 2012; 13:112. [PMID: 22992409 PMCID: PMC3615959 DOI: 10.1186/1471-2369-13-112] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 09/17/2012] [Indexed: 01/10/2023] Open
Abstract
Background Medical, ethical and financial dilemmas may arise in treating undocumented-uninsured patients with end-stage renal disease (ESRD). Hereby we describe the 10-year experience of treating undocumented-uninsured ESRD patients in a large public dialysis-unit. Methods We evaluated the medical files of all the chronic dialysis patients treated at the Tel-Aviv Medical Center between the years 2000–2010. Data for all immigrant patients without documentation and medical insurance were obtained. Clinical data were compared with an age-matched cohort of 77 insured dialysis patients. Results Fifteen undocumented-uninsured patients were treated with chronic scheduled dialysis therapy for a mean length of 2.3 years and a total of 4953 hemodialysis sessions, despite lack of reimbursement. All undocumented-uninsured patients presented initially with symptoms attributed to uremia and with stage 5 chronic kidney disease (CKD). In comparison, in the age-matched cohort, only 6 patients (8%) were initially evaluated by a nephrologist at stage 5 CKD. Levels of hemoglobin (8.5 ± 1.7 versus 10.8 ± 1.6 g/dL; p < 0.0001) and albumin (33.8 ± 4.8 versus 37.7 ± 3.9 g/L; p < 0.001) were lower in the undocumented-uninsured dialysis patients compared with the age-matched insured patients at initiation of hemodialysis therapy. These significant changes were persistent throughout the treatment period. Hemodialysis was performed in all the undocumented-uninsured patients via tunneled cuffed catheters (TCC) without higher rates of TCC-associated infections. The rate of skipped hemodialysis sessions was similar in the undocumented-uninsured and age-matched insured cohorts. Conclusions Undocumented-uninsured dialysis patients presented initially in the advanced stages of CKD with lower levels of hemoglobin and worse nutritional status in comparison with age-matched insured patients. The type of vascular access for hemodialysis was less than optimal with regards to current guidelines. There is a need for the national and international nephrology communities to establish a policy concerning the treatment of undocumented-uninsured patients with CKD.
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Affiliation(s)
- Gil Chernin
- Nephrology Department, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, 64239, Israel.
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15
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Abstract
Anemia is a common comorbidity in children with chronic kidney disease (CKD). This condition is associated with multiple adverse clinical consequences and its management is a core component of nephrology care. Increased morbidity and mortality, increased risk of cardiovascular disease and decreased quality of life have been associated with anemia of CKD in children. Although numerous complex factors interact in the development of this anemia, erythropoietin deficiency and iron dysregulation (including iron deficiency and iron-restricted erythropoiesis) are the primary causes. In addition to iron supplementation, erythropoietin-stimulating agents (ESAs) can effectively treat this anemia, but there are important differences in ESA dose requirements between children and adults. Also, hyporesponsiveness to ESA therapy is a common problem in children with CKD. Although escalating ESA doses to target increased hemoglobin values in adults has been associated with adverse outcomes, no studies have demonstrated this association in children. The question of appropriate target hemoglobin levels in children, and the approach by which to achieve these levels, remains under debate. Randomized, controlled studies are needed to evaluate whether normalization of hemoglobin concentrations is beneficial to children, and whether this practice is associated with increased risks.
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Copelovitch L, Warady BA, Furth SL. Insights from the Chronic Kidney Disease in Children (CKiD) study. Clin J Am Soc Nephrol 2011; 6:2047-53. [PMID: 21784815 PMCID: PMC4898858 DOI: 10.2215/cjn.10751210] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Over the last 5 years, the Chronic Kidney Disease in Children (CKiD) prospective cohort study has enrolled close to 600 children ages 1 to 16 years with mild to moderate chronic kidney disease (CKD). The main purpose of this interim report is to review the initial cross-sectional data and conclusions derived from the clinical studies conducted within CKiD in the context of findings from other pediatric CKD and end-stage renal disease (ESRD) registry and cohort studies. In particular, special emphasis was placed on studying four aspects of chronic kidney disease in children, including the identification of risk factors related to disease progression, the impact of CKD on neurocognition and quality of life (QoL), the cardiovascular morbidity associated with CKD, and identifying the causes and effects of growth failure in the context of mild to moderate kidney failure.
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Filler G, Huang SHS, Sharma AP. Racial disparities in hemoglobin concentration in children with CKD. Am J Kidney Dis 2010; 55:981-3. [PMID: 20497835 DOI: 10.1053/j.ajkd.2010.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 03/09/2010] [Indexed: 12/27/2022]
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