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Dușa CP, Bejan V, Pislaru M, Starcea IM, Serban IL. A Multimodal Fuzzy Approach in Evaluating Pediatric Chronic Kidney Disease Using Kidney Biomarkers. Diagnostics (Basel) 2024; 14:1648. [PMID: 39125525 PMCID: PMC11312138 DOI: 10.3390/diagnostics14151648] [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: 05/29/2024] [Revised: 07/28/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
Chronic kidney disease (CKD) is one of the most important causes of chronic pediatric morbidity and mortality and places an important burden on the medical system. Current diagnosis and progression monitoring techniques have numerous sensitivity and specificity limitations. New biomarkers for monitoring CKD progression have been assessed. Neutrophil gelatinase-associated lipocalin (NGAL) has had some promising results in adults, but in pediatric patients, due to the small number of patients included in the studies, cutoff values are not agreed upon. The small sample size also makes the statistical approach limited. The aim of our study was to develop a fuzzy logic approach to assess the probability of pediatric CKD progression using both NGAL (urinary and plasmatic) and routine blood test parameters (creatinine and erythrocyte sedimentation rate) as input data. In our study, we describe in detail how to configure a fuzzy model that can simulate the correlations between the input variables ESR, NGAL-P, NGAL-U, creatinine, and the output variable Prob regarding the prognosis of the patient's evolution. The results of the simulations on the model, i.e., the correlations between the input and output variables (3D graphic presentations) are explained in detail. We propose this model as a tool for physicians which will allow them to improve diagnosis, follow-up, and interventional decisions relative to the CKD stage. We believe this innovative approach can be a great tool for the clinician and validates the feasibility of using a fuzzy logic approach in interpreting NGAL biomarker results for CKD progression.
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Affiliation(s)
- Cristian Petru Dușa
- Department of Pediatrics, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Valentin Bejan
- Department of Surgery, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Marius Pislaru
- Department of Engineering and Management, Faculty of Industrial Design and Business Management, “Gheorghe Asachi” Technical University of Iași, 700050 Iasi, Romania
| | - Iuliana Magdalena Starcea
- Department of Pediatrics, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ionela Lacramioara Serban
- Department of Morpho-Functional Sciences II, Discipline of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
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Tullus K, De Mutiis C. Outcome of lupus nephritis in children. Rheumatology (Oxford) 2024; 63:906-907. [PMID: 37847665 DOI: 10.1093/rheumatology/kead554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/19/2023] Open
Affiliation(s)
- Kjell Tullus
- Paediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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Stevens PE, Ahmed SB, Carrero JJ, Foster B, Francis A, Hall RK, Herrington WG, Hill G, Inker LA, Kazancıoğlu R, Lamb E, Lin P, Madero M, McIntyre N, Morrow K, Roberts G, Sabanayagam D, Schaeffner E, Shlipak M, Shroff R, Tangri N, Thanachayanont T, Ulasi I, Wong G, Yang CW, Zhang L, Levin A. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int 2024; 105:S117-S314. [PMID: 38490803 DOI: 10.1016/j.kint.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 03/17/2024]
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Schaefer F, Montini G, Kang HG, Walle JV, Zaritsky J, Schreuder MF, Litwin M, Scalise A, Scott H, Potts J, Iveli P, Breitenstein S, Warady BA. Investigating the use of finerenone in children with chronic kidney disease and proteinuria: design of the FIONA and open-label extension studies. Trials 2024; 25:203. [PMID: 38509517 PMCID: PMC10956186 DOI: 10.1186/s13063-024-08021-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION Proteinuria is a modifiable risk factor for chronic kidney disease (CKD) progression in children. Finerenone, a selective, non-steroidal, mineralocorticoid receptor antagonist (MRA) has been approved to treat adults with CKD associated with type 2 diabetes mellitus (T2DM) following results from the phase III clinical trials FIDELIO-DKD (NCT02540993) and FIGARO-DKD (NCT02545049). In a pre-specified pooled analysis of both studies (N = 13,026), finerenone was shown to have an acceptable safety profile and was efficacious in decreasing the risk of adverse kidney and cardiovascular outcomes and of proteinuria. OBJECTIVE FIONA and the associated open-label extension (OLE) study aim to demonstrate that combining finerenone with an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) is safe, well-tolerated, and effective in sustainably reducing urinary protein excretion in children with CKD and proteinuria. DESIGN FIONA (NCT05196035; Eudra-CT: 2021-002071-19) is a randomized (2:1), double-blind, placebo-controlled, multicenter, phase III study of 6 months' duration in approximately 219 pediatric patients. Patients must have a clinical diagnosis of CKD (an eGFR ≥ 30 mL/min/1.73 m2 if ≥ 1 to < 18 years or a serum creatinine level ≤ 0.40 mg/dL for infants 6 months to < 1 year) with significant proteinuria despite ACEi or ARB usage. The primary objective is to demonstrate that finerenone, added to an ACEi or ARB, is superior to placebo in reducing urinary protein excretion. FIONA OLE (NCT05457283; Eudra-CT: 2021-002905-89) is a single-arm, open-label study, enrolling participants who have completed FIONA. The primary objective of FIONA OLE is to provide long-term safety data. FIONA has two primary endpoints: urinary protein-to-creatinine ratio (UPCR) reduction of ≥ 30% from baseline to day 180 and percent change in UPCR from baseline to day 180. A sample size of 198 participants (aged 2 to < 18 years) in FIONA will provide at least 80% power to reject the null hypothesis of either of the two primary endpoints. CONCLUSION FIONA is evaluating the use of finerenone in children with CKD and proteinuria. Should safety, tolerability, and efficacy be demonstrated, finerenone could become a useful additional therapeutic agent in managing proteinuria and improving kidney outcomes in children with CKD. TRIAL REGISTRATION ClinicalTrials.gov NCT05196035. Registered on 19 January 2022.
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Affiliation(s)
- Franz Schaefer
- Pediatric Nephrology Division, Heidelberg University Hospital, Heidelberg, Germany.
| | - Giovanni Montini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Erknet Center, C4C, Ghent, Belgium
| | - Joshua Zaritsky
- Department of Nephrology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Mieczyslaw Litwin
- Department of Nephrology and Arterial Hypertension, Children's Memorial Health Institute, Warsaw, Poland
| | | | - Helen Scott
- Bayer U.S Pharmaceuticals, Whippany, NJ, USA
| | - James Potts
- Bayer U.S Pharmaceuticals, Whippany, NJ, USA
| | | | | | - Bradley A Warady
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
- Children's Mercy Kansas City, Kansas City, MO, USA
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Huang VW, Behairy M, Abelson B, Crane A, Liu W, Wang L, Dell KM, Rhee A. Kidney disease progression in pediatric and adult posterior urethral valves (PUV) patients. Pediatr Nephrol 2024; 39:829-835. [PMID: 37658873 DOI: 10.1007/s00467-023-06128-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Posterior urethral valves (PUV) is the most common cause of obstructive uropathy in boys; approximately 15% develop kidney failure by early adulthood. However, rates of kidney function decline are poorly defined in PUV children and adults, as is the impact of potentially modifiable chronic kidney disease (CKD) progression risk factors. METHODS We conducted a retrospective review of all PUV patients followed at our institution from 1995 to 2018. Inclusion criteria were estimated glomerular filtration rate (eGFR) > 20 ml/min/1.73 m2 after 1 year of age, no dialysis or kidney transplant history, and ≥ 2 yearly serum creatinine values after age 1 year. eGFRs were calculated using creatinine-based estimating formulas for children (CKID U25) or adults (CKD-EPI). The primary outcome was annualized change in eGFR, assessed with linear mixed effects models. We also examined the association of acute kidney injury (AKI), proteinuria, hypertension (HTN), and recurrent febrile urinary tract infections (UTIs) with eGFR decline. RESULTS Fifty-two PUV patients met the inclusion criteria. Median (interquartile range) eGFR decline was 2.6 (2.1, 3.1) ml/min/1.73 m2/year. Children (n = 35) and adults (n = 17) demonstrated progressive decline. Proteinuria and recurrent UTIs were significantly associated with faster progression; AKI and HTN were also associated but did not reach significance. CONCLUSION PUV patients show progressive loss of kidney function well into adulthood. Proteinuria and recurrent UTIs are associated with faster progression, suggesting potential modifiable risk factors. This is the first study to report annualized eGFR decline rates in PUV patients, which could help inform the design of clinical trials of CKD therapies.
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Affiliation(s)
- Victoria W Huang
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mohga Behairy
- Department of Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | | | - Alice Crane
- Department of Urology, Cleveland Clinic, Cleveland, OH, USA
| | - Wei Liu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Katherine M Dell
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
- Department of Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
- Center for Pediatric Nephrology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
| | - Audrey Rhee
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Urology, Cleveland Clinic, Cleveland, OH, USA
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Kusumi K, Raina R, Samuels J, Tibrewal A, Furth S, Mitsnefes M, Devineni S, Warady BA. Evidence of increased vascular stiffness and left ventricular hypertrophy in children with cystic kidney disease. Pediatr Nephrol 2023; 38:4093-4100. [PMID: 37428222 DOI: 10.1007/s00467-023-06081-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the most common cause of mortality in chronic kidney disease (CKD). Children with early-onset CKD arguably experience the greatest lifetime CVD burden. We utilized data from the Chronic Kidney Disease in Children Cohort Study (CKiD) to evaluate two pediatric CKD cohorts: congenital anomalies of the kidney and urinary tract (CAKUT) and cystic kidney disease for CVD risks and outcomes. METHODS CVD risk factors and outcomes including blood pressures, left ventricular hypertrophy (LVH), left ventricular mass index (LVMI), and ambulatory arterial stiffness index (AASI) scores were evaluated. RESULTS Forty-one patients in the cystic kidney disease group were compared to 294 patients in the CAKUT group. Cystic kidney disease patients had higher cystatin-C levels, despite similar iGFR. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) indexes were higher in the CAKUT group, but a significantly higher proportion of cystic kidney disease patients was on anti-hypertensive medications. Cystic kidney disease patients had increased AASI scores and a higher incidence of LVH. CONCLUSIONS This study provides a nuanced analysis of CVD risk factors and outcomes including AASI and LVH in two pediatric CKD cohorts. Cystic kidney disease patients had increased AASI scores, higher incidence of LVH, and higher rates of anti-hypertensive medication use which could imply a greater burden of CVD despite similar GFR. Our work suggests that additional mechanisms may contribute to vascular dysfunction in cystic kidney disease, and that these patients may need additional interventions to prevent the development of CVD. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Kirsten Kusumi
- Division of Nephrology, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Rupesh Raina
- Division of Nephrology, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA.
- Northeast Ohio Medical University, Rootstown, OH, USA.
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, USA.
| | - Joshua Samuels
- Division of Pediatric Nephrology and Hypertension, University of Texas Medical School at Houston, Houston, TX, USA
| | - Abhishek Tibrewal
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, OH, USA
| | - Susan Furth
- Pediatrics, Division of Nephrology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania Philadelphia, Philadelphia, PA, USA
| | - Mark Mitsnefes
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Bradley A Warady
- Division of Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
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Walawender L, Becknell B, Matsell DG. Congenital anomalies of the kidney and urinary tract: defining risk factors of disease progression and determinants of outcomes. Pediatr Nephrol 2023; 38:3963-3973. [PMID: 36867265 PMCID: PMC10914409 DOI: 10.1007/s00467-023-05899-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 03/04/2023]
Abstract
Congenital anomalies of the kidney and urinary tract (CAKUT) result from disruptions in normal kidney and urinary tract development during fetal life and collectively represent the most common cause of kidney failure in children worldwide. The antenatal determinants of CAKUT are diverse and include mutations in genes responsible for normal nephrogenesis, alterations in maternal and fetal environments, and obstruction within the normal developing urinary tract. The resultant clinical phenotypes are complex and depend on the timing of the insult, the penetrance of underlying gene mutations, and the severity and timing of obstruction related to the sequence of normal kidney development. Consequently, there is a broad spectrum of outcomes for children born with CAKUT. In this review, we explore the most common forms of CAKUT and those most likely to develop long-term complications of their associated kidney malformations. We discuss the relevant outcomes for the different forms of CAKUT and what is known about clinical characteristics across the CAKUT spectrum that are risk factors of long-term kidney injury and disease progression.
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Affiliation(s)
- Laura Walawender
- Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
- Division of Nephrology and Hypertension, Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian Becknell
- Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's, Columbus, OH, USA
- Division of Nephrology and Hypertension, Nationwide Children's Hospital, Columbus, OH, USA
| | - Douglas G Matsell
- University of British Columbia, British Columbia Children's Hospital Research Institute, 4480 Oak Street, Vancouver, BC, Canada.
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Denburg MR, Razzaghi H, Goodwin Davies AJ, Dharnidharka V, Dixon BP, Flynn JT, Glenn D, Gluck CA, Harshman L, Jovanovska A, Katsoufis CP, Kratchman AL, Levondosky M, Levondosky R, McDonald J, Mitsnefes M, Modi ZJ, Musante J, Neu AM, Pan CG, Patel HP, Patterson LT, Schuchard J, Verghese PS, Wilson AC, Wong C, Forrest CB. The Preserving Kidney Function in Children With CKD (PRESERVE) Study: Rationale, Design, and Methods. Kidney Med 2023; 5:100722. [PMID: 37965485 PMCID: PMC10641283 DOI: 10.1016/j.xkme.2023.100722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
Rationale & Objective PRESERVE seeks to provide new knowledge to inform shared decision-making regarding blood pressure (BP) management for pediatric chronic kidney disease (CKD). PRESERVE will compare the effectiveness of alternative strategies for monitoring and treating hypertension on preserving kidney function; expand the National Patient-Centered Clinical Research Network (PCORnet) common data model by adding pediatric- and kidney-specific variables and linking electronic health record data to other kidney disease databases; and assess the lived experiences of patients related to BP management. Study Design Multicenter retrospective cohort study (clinical outcomes) and cross-sectional study (patient-reported outcomes [PROs]). Setting & Participants PRESERVE will include approximately 20,000 children between January 2009-December 2022 with mild-moderate CKD from 15 health care institutions that participate in 6 PCORnet Clinical Research Networks (PEDSnet, STAR, GPC, PaTH, CAPRiCORN, and OneFlorida+). The inclusion criteria were ≥1 nephrologist visit and ≥2 estimated glomerular filtration rate (eGFR) values in the range of 30 to <90 mL/min/1.73 m2 separated by ≥90 days without an intervening value ≥90 mL/min/1.73 m2 and no prior dialysis or kidney transplant. Exposures BP measurements (clinic-based and 24-hour ambulatory BP); urine protein; and antihypertensive treatment by therapeutic class. Outcomes The primary outcome is a composite event of a 50% reduction in eGFR, eGFR of <15 mL/min/1.73 m2, long-term dialysis or kidney transplant. Secondary outcomes include change in eGFR, adverse events, and PROs. Analytical Approach Longitudinal models for dichotomous (proportional hazards or accelerated failure time) and continuous (generalized linear mixed models) clinical outcomes; multivariable linear regression for PROs. We will evaluate heterogeneity of treatment effect by CKD etiology and degree of proteinuria and will examine variation in hypertension management and outcomes based on socio-demographics. Limitations Causal inference limited by observational analyses. Conclusions PRESERVE will leverage the PCORnet infrastructure to conduct large-scale observational studies that address BP management knowledge gaps for pediatric CKD, focusing on outcomes that are meaningful to patients. Plain-Language Summary Hypertension is a major modifiable contributor to loss of kidney function in chronic kidney disease (CKD). The purpose of PRESERVE is to provide evidence to inform shared decision-making regarding blood pressure management for children with CKD. PRESERVE is a consortium of 16 health care institutions in PCORnet, the National Patient-Centered Clinical Research Network, and includes electronic health record data for >19,000 children with CKD. PRESERVE will (1) expand the PCORnet infrastructure for research in pediatric CKD by adding kidney-specific variables and linking electronic health record data to other kidney disease databases; (2) compare the effectiveness of alternative strategies for monitoring and treating hypertension on preserving kidney function; and (3) assess the lived experiences of patients and caregivers related to blood pressure management.
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Affiliation(s)
- Michelle R. Denburg
- Children’s Hospital of Philadelphia, Philadelphia, PA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - Vikas Dharnidharka
- St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Bradley P. Dixon
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Joseph T. Flynn
- Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Dorey Glenn
- University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Lyndsay Harshman
- University of Iowa Stead Family Children’s Hospital, Iowa City, IA
| | | | | | | | | | | | - Jill McDonald
- Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Mark Mitsnefes
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Zubin J. Modi
- C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | | | - Alicia M. Neu
- Johns Hopkins Children’s Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Cynthia G. Pan
- Medical College of Wisconsin, Children’s Wisconsin, Milwaukee, WI
| | - Hiren P. Patel
- Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | | | | | - Priya S. Verghese
- Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Amy C. Wilson
- Riley Children’s Health, Indiana University School of Medicine, Indianapolis, IN
| | - Cynthia Wong
- Stanford Children’s Health, Stanford University School of Medicine, Palo Alto, CA
| | - Christopher B. Forrest
- Children’s Hospital of Philadelphia, Philadelphia, PA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Ng DK, Matheson MB, Schwartz GJ, Wang FM, Mendley SR, Furth SL, Warady BA. Development of an adaptive clinical web-based prediction tool for kidney replacement therapy in children with chronic kidney disease. Kidney Int 2023; 104:985-994. [PMID: 37391041 PMCID: PMC10592093 DOI: 10.1016/j.kint.2023.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 07/02/2023]
Abstract
Clinicians need improved prediction models to estimate time to kidney replacement therapy (KRT) for children with chronic kidney disease (CKD). Here, we aimed to develop and validate a prediction tool based on common clinical variables for time to KRT in children using statistical learning methods and design a corresponding online calculator for clinical use. Among 890 children with CKD in the Chronic Kidney Disease in Children (CKiD) study, 172 variables related to sociodemographics, kidney/cardiovascular health, and therapy use, including longitudinal changes over one year were evaluated as candidate predictors in a random survival forest for time to KRT. An elementary model was specified with diagnosis, estimated glomerular filtration rate and proteinuria as predictors and then random survival forest identified nine additional candidate predictors for further evaluation. Best subset selection using these nine additional candidate predictors yielded an enriched model additionally based on blood pressure, change in estimated glomerular filtration rate over one year, anemia, albumin, chloride and bicarbonate. Four additional partially enriched models were constructed for clinical situations with incomplete data. Models performed well in cross-validation, and the elementary model was then externally validated using data from a European pediatric CKD cohort. A corresponding user-friendly online tool was developed for clinicians. Thus, our clinical prediction tool for time to KRT in children was developed in a large, representative pediatric CKD cohort with an exhaustive evaluation of potential predictors and supervised statistical learning methods. While our models performed well internally and externally, further external validation of enriched models is needed.
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Affiliation(s)
- Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Matthew B Matheson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - George J Schwartz
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | - Frances M Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Susan R Mendley
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Susan L Furth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Division of Nephrology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri, USA
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Crane CR, Garimella PS, Heinze G. Predicting pediatric kidney disease progression-are 3 variables all you need? Kidney Int 2023; 104:885-887. [PMID: 37863637 DOI: 10.1016/j.kint.2023.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/07/2023] [Accepted: 08/11/2023] [Indexed: 10/22/2023]
Abstract
Accurate estimation of chronic kidney disease (CKD) progression risk is vital for clinical decision-making. Existing risk equations lack validation in pediatric CKD populations. Ng et al. developed new risk equations using the CKD in Children and European Study Consortium for Chronic Kidney Disorders Affecting Pediatric Patients cohorts. The elementary model, incorporating estimated glomerular filtration rate, urine protein-creatinine ratio, and diagnosis, exhibited excellent discrimination and calibration at external validation. External validation of enriched models is pending. The equations have the potential to aid pediatric CKD centers in patient counseling and care planning.
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Affiliation(s)
- Clarkson R Crane
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA; Division of Pediatric Nephrology, Department of Pediatrics, University of California San Diego, San Diego, California, USA
| | - Pranav S Garimella
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Georg Heinze
- Center for Medical Data Science, Institute of Clinical Biometrics, Medical University of Vienna, Vienna, Austria.
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Ng DK, Patel A, Cox C. Data quality control in longitudinal epidemiologic studies: conditional studentized residuals from linear mixed effects models for outlier detection in the setting of pediatric chronic kidney disease. Ann Epidemiol 2023; 85:38-44. [PMID: 37454831 PMCID: PMC10538390 DOI: 10.1016/j.annepidem.2023.07.005] [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: 02/01/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE Quality control in longitudinal cohort studies is critical for valid epidemiologic inference. Conditional studentized residuals (CSRs) derived from linear mixed effects models offer efficient individual-specific quality control. We present the utility of CSRs for outlier detection in an applied example using data from the Chronic Kidney Disease in Children cohort. METHODS Longitudinal linear mixed effects models with glomerular filtration rate (GFR) as the outcome were fit for observations prior to kidney replacement therapy, stratified by nonglomerular or glomerular diagnosis, and for a subset after receiving a kidney transplant. For each model, CSRs were calculated and values ≥±5 were considered potential outliers for further investigation. RESULTS A total of 1096 participants contributed 6881 annual measures of GFR across the two diagnostic groups and after transplant. In all models, the fixed effects captured progressive GFR decline. CSRs provided measures of individual-level deviations from the modeled trajectories (random + fixed effects) and were easily visualized in longitudinal plots. A total of 38 potential outliers from 32 participants were detected and further investigated for quality control. CONCLUSIONS This example demonstrated how longitudinal models can provide CSRs to detect individual-specific outliers. CSRs should be considered as part of quality control for longitudinal epidemiologic studies.
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Affiliation(s)
- Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Ankur Patel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Christopher Cox
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Yu X, Li J, Tao C, Jiao J, Wan J, Zhong C, Yang Q, Shi Y, Zhang G, Yang H, Li Q, Wang M. Validation of the children international IgA nephropathy prediction tool based on data in Southwest China. Front Pediatr 2023; 11:1183562. [PMID: 37425278 PMCID: PMC10327563 DOI: 10.3389/fped.2023.1183562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/08/2023] [Indexed: 07/11/2023] Open
Abstract
Background Immunoglobulin A nephropathy (IgAN) is one of the most common kidney diseases leading to renal injury. Of pediatric cases, 25%-30% progress into end-stage kidney disease (ESKD) in 20-25 years. Therefore, predicting and intervening in IgAN at an early stage is crucial. The purpose of this study was to validate the availability of an international predictive tool for childhood IgAN in a cohort of children with IgAN treated at a regional medical centre. Methods An external validation cohort of children with IgAN from medical centers in Southwest China was formed to validate the predictive performance of the two full models with and without race differences by comparing four measures: area under the curve (AUC), the regression coefficient of linear prediction (PI), survival analysis curves for different risk groups, and R2D. Results A total of 210 Chinese children, including 129 males, with an overall mean age of 9.43 ± 2.71 years, were incorporated from this regional medical center. In total, 11.43% (24/210) of patients achieved an outcome with a GFR decrease of more than 30% or reached ESKD. The AUC of the full model with race was 0.685 (95% CI: 0.570-0.800) and the AUC of the full model without race was 0.640 (95% CI: 0.517-0.764). The PI of the full model with race and without race was 0.816 (SE = 0.006, P < 0.001) and 0.751 (SE = 0.005, P < 0.001), respectively. The results of the survival curve analysis suggested the two models could not well distinguish between the low-risk and high-risk groups (P = 0.359 and P = 0.452), respectively, no matter the race difference. The evaluation of model fit for the full model with race was 66.5% and without race was 56.2%. Conclusions The international IgAN prediction tool has risk factors chosen based on adult data, and the validation cohort did not fully align with the derivation cohort in terms of demographic characteristics, clinical baseline levels, and pathological presentation, so the tool may not be highly applicable to children. We need to build IgAN prediction models that are more applicable to Chinese children based on their particular data.
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Affiliation(s)
- Xixi Yu
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Jiacheng Li
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Chengrong Tao
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Jia Jiao
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Junli Wan
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Cheng Zhong
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Qin Yang
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Yongqi Shi
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Gaofu Zhang
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Haiping Yang
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Qiu Li
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Mo Wang
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
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Menon G, Pierce CB, Ng DK. Revisiting the Application of an Adult Kidney Failure Risk Prediction Equation to Children With CKD. Am J Kidney Dis 2023; 81:734-737. [PMID: 36586560 PMCID: PMC10548839 DOI: 10.1053/j.ajkd.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/05/2022] [Indexed: 12/29/2022]
Affiliation(s)
- Gayathri Menon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Christopher B Pierce
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
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Gavrilovici C, Dusa CP, Iliescu Halitchi C, Lupu VV, Spoiala EL, Bogos RA, Mocanu A, Gafencu M, Lupu A, Stoica C, Starcea IM. The Role of Urinary NGAL in the Management of Primary Vesicoureteral Reflux in Children. Int J Mol Sci 2023; 24:ijms24097904. [PMID: 37175609 PMCID: PMC10177906 DOI: 10.3390/ijms24097904] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
Vesicoureteral reflux (VUR) is the most frequent congenital urinary tract malformation and an important risk factor for urinary tract infections (UTIs). Up to 50% of children with VUR may develop reflux nephropathy (RN), and the diagnosis and monitoring of renal scars are invasive and costly procedures, so it is paramount to find a non-invasive and accurate method to predict the risk of renal damage. Neutrophil gelatinase-associated lipocalin (NGAL) has already proven to be a good predictive biomarker in acute kidney injuries, but there are few studies that have investigated the role of NGAL in primary VUR in children. Our aim is to review the predictive value of urine NGAL (uNGAL) as a non-invasive biomarker of RN in children with primary VUR, as well as its ability to predict the evolution of chronic kidney disease (CKD). Based on our analysis of the available original studies, uNGAL can be an accurate and reliable biomarker of RN and its progression to CKD. Some studies suggested a good correlation between VUR severity and uNGAL levels, but other studies found no significant correlation. The relationship between VUR severity and uNGAL levels is likely complex and influenced by factors such as UTIs, the timing of the urine sample collection, and the age and overall health of the patient.
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Affiliation(s)
- Cristina Gavrilovici
- Department of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Cristian Petru Dusa
- Department of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Codruta Iliescu Halitchi
- Department of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Department of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Elena Lia Spoiala
- Department of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Roxana Alexandra Bogos
- Department of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Adriana Mocanu
- Department of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihai Gafencu
- Department of Pediatrics, "Victor Babeş" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Ancuta Lupu
- Department of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Cristina Stoica
- Department of Pediatrics, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucuresti, Romania
| | - Iuliana Magdalena Starcea
- Department of Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
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15
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Kogon AJ, Roem J, Schneider MF, Mitsnefes MM, Zemel BS, Warady BA, Furth SL, Rodig NM. Associations of body mass index (BMI) and BMI change with progression of chronic kidney disease in children. Pediatr Nephrol 2023; 38:1257-1266. [PMID: 36018433 PMCID: PMC10044533 DOI: 10.1007/s00467-022-05655-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Obesity is prevalent among children with chronic kidney disease (CKD) and is associated with cardiovascular disease and reduced quality of life. Its relationship with pediatric CKD progression has not been described. METHODS We evaluated relationships between both body mass index (BMI) category (normal, overweight, obese) and BMI z-score (BMIz) change on CKD progression among participants of the Chronic Kidney Disease in Children study. Kaplan-Meier survival curves and multivariable parametric failure time models depict the association of baseline BMI category on time to kidney replacement therapy (KRT). Additionally, the annualized percentage change in estimated glomerular filtration rate (eGFR) was modeled against concurrent change in BMIz using multivariable linear regression with generalized estimating equations which allowed for quantification of the effect of BMIz change on annualized eGFR change. RESULTS Participants had median age of 10.9 years [IQR: 6.5, 14.6], median eGFR of 50 ml/1.73 m2 [IQR: 37, 64] and 63% were male. 160 (27%) of 600 children with non-glomerular and 77 (31%) of 247 children with glomerular CKD progressed to KRT over a median of 5 years [IQR: 2, 8]. Times to KRT were not significantly associated with baseline BMI category. Children with non-glomerular CKD who were obese experienced significant improvement in eGFR (+ 0.62%; 95% CI: + 0.17%, + 1.08%) for every 0.1 standard deviation concurrent decrease in BMI. In participants with glomerular CKD who were obese, BMIz change was not significantly associated with annualized eGFR change. CONCLUSION Obesity may represent a target of intervention to improve kidney function in children with non-glomerular CKD. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Amy J Kogon
- Pediatrics, Division of Nephrology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania Philadelphia, Philadelphia, PA, USA.
| | - Jennifer Roem
- Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michael F Schneider
- Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mark M Mitsnefes
- Pediatrics, Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Babette S Zemel
- Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Bradley A Warady
- Pediatrics, Division of Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Susan L Furth
- Pediatrics, Division of Nephrology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania Philadelphia, Philadelphia, PA, USA
| | - Nancy M Rodig
- Pediatrics, Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
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16
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Hamada R, Kikunaga K, Kaneko T, Okamoto S, Tomotsune M, Uemura O, Kamei K, Wada N, Matsuyama T, Ishikura K, Oka A, Honda M. Urine alpha 1-microglobulin-to-creatinine ratio and beta 2-microglobulin-to-creatinine ratio for detecting CAKUT with kidney dysfunction in children. Pediatr Nephrol 2023; 38:479-487. [PMID: 35589989 DOI: 10.1007/s00467-022-05577-3] [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: 03/27/2021] [Revised: 04/03/2022] [Accepted: 04/05/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND The leading cause of advanced chronic kidney disease (CKD) in children is congenital anomalies of the kidney and urinary tract (CAKUT). However, the most appropriate parameters of biochemical urine analysis for detecting CAKUT with kidney dysfunction are not known. METHODS The present observational study analyzed data on children with CAKUT (stage 2-4 CKD) and the general pediatric population obtained from school urine screenings. The sensitivity and specificity of urine alpha 1-microglobulin-, beta 2-microglobulin-, protein-, and the albumin-to-creatinine ratios (AMCR, BMCR, PCR, ACR, respectively) in detecting CAKUT with kidney dysfunction were compared with those of the conventional urine dipstick, and the most appropriate of these four parameters were evaluated. RESULTS In total, 77 children with CAKUT and 1712 subjects in the general pediatric population fulfilled the eligibility criteria. Conventional dipstick urinalysis was insufficient due to its low sensitivity; even when the threshold of proteinuria was +/-, its sensitivity was only 29.7% for stage 2 and 44.1% for stage 3 CKD. Among the four parameters assessed, the AMCR and BMCR were adequate for detecting CAKUT in children with stage 3-4 CKD (the respective sensitivity and specificity of the AMCR for detecting CAKUT in stage 3 CKD was 79.4% and 97.5% while that of BMCR was 82.4% and 97.5%). These data were validated using national cohort data. CONCLUSION AMCR and BMCR are superior to dipstick urinalysis, PCR, and ACR in detecting CAKUT with kidney dysfunction, particularly stage 3 CKD. However, for AMCR, external validation is required. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kaori Kikunaga
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan. .,Department of Pediatrics, Fussa Hospital, Tokyo, Japan. .,Department of Pediatrics, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara-shi, Kanagawa, 252-0374, Japan.
| | - Tetsuji Kaneko
- Teikyo Academic Research Center, Teikyo University, Tokyo, Japan.,Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | | | - Masako Tomotsune
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Osamu Uemura
- Ichinomiya Medical Treatment and Habilitation Center, Aichi, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Naohiro Wada
- Department of Pediatrics, Shizuoka Children's Hospital, Shizuoka, Japan
| | | | - Kenji Ishikura
- Department of Pediatrics, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara-shi, Kanagawa, 252-0374, Japan
| | - Akira Oka
- Saitama Children's Medical Center, Saitama, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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17
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Gluck CA, Forrest CB, Davies AG, Maltenfort M, Mcdonald JR, Mitsnefes M, Dharnidharka VR, Dixon BP, Flynn JT, Somers MJ, Smoyer WE, Neu A, Hovinga CA, Skversky AL, Eissing T, Kaiser A, Breitenstein S, Furth SL, Denburg MR. Evaluating Kidney Function Decline in Children with Chronic Kidney Disease Using a Multi-Institutional Electronic Health Record Database. Clin J Am Soc Nephrol 2023; 18:173-182. [PMID: 36754006 PMCID: PMC10103199 DOI: 10.2215/cjn.0000000000000051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 12/03/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND The objectives of this study were to use electronic health record data from a US national multicenter pediatric network to identify a large cohort of children with CKD, evaluate CKD progression, and examine clinical risk factors for kidney function decline. METHODS This retrospective cohort study identified children seen between January 1, 2009, to February 28, 2022. Data were from six pediatric health systems in PEDSnet. We identified children aged 18 months to 18 years who met criteria for CKD: two eGFR values <90 and ≥15 ml/min per 1.73 m2 separated by ≥90 days without an intervening value ≥90. CKD progression was defined as a composite outcome: eGFR <15 ml/min per 1.73 m2, ≥50% eGFR decline, long-term dialysis, or kidney transplant. Subcohorts were defined based on CKD etiology: glomerular, nonglomerular, or malignancy. We assessed the association of hypertension (≥2 visits with hypertension diagnosis code) and proteinuria (≥1 urinalysis with ≥1+ protein) within 2 years of cohort entrance on the composite outcome. RESULTS Among 7,148,875 children, we identified 11,240 (15.7 per 10,000) with CKD (median age 11 years, 50% female). The median follow-up was 5.1 (interquartile range 2.8-8.3) years, the median initial eGFR was 75.3 (interquartile range 61-83) ml/min per 1.73 m2, 37% had proteinuria, and 35% had hypertension. The following were associated with CKD progression: lower eGFR category (adjusted hazard ratio [aHR] 1.44 [95% confidence interval (95% CI), 1.23 to 1.69], aHR 2.38 [95% CI, 2.02 to 2.79], aHR 5.75 [95% CI, 5.05 to 6.55] for eGFR 45-59 ml/min per 1.73 m2, 30-44 ml/min per 1.73 m2, 15-29 ml/min per 1.73 m2 at cohort entrance, respectively, when compared with eGFR 60-89 ml/min per 1.73 m2), glomerular disease (aHR 2.01 [95% CI, 1.78 to 2.28]), malignancy (aHR 1.79 [95% CI, 1.52 to 2.11]), proteinuria (aHR 2.23 [95% CI, 1.89 to 2.62]), hypertension (aHR 1.49 [95% CI, 1.22 to 1.82]), proteinuria and hypertension together (aHR 3.98 [95% CI, 3.40 to 4.68]), count of complex chronic comorbidities (aHR 1.07 [95% CI, 1.05 to 1.10] per additional comorbid body system), male sex (aHR 1.16 [95% CI, 1.05 to 1.28]), and younger age at cohort entrance (aHR 0.95 [95% CI, 0.94 to 0.96] per year older). CONCLUSIONS In large-scale real-world data for children with CKD, disease etiology, albuminuria, hypertension, age, male sex, lower eGFR, and greater medical complexity at start of follow-up were associated with more rapid decline in kidney function.
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Affiliation(s)
- Caroline A. Gluck
- Division of Pediatric Nephrology, Nemours Children's Health, Wilmington, Delaware
| | - Christopher B. Forrest
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amy Goodwin Davies
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mitchell Maltenfort
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jill R. Mcdonald
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mark Mitsnefes
- Division of Pediatric Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Vikas R. Dharnidharka
- Division of Pediatric Nephrology, Hypertension, Pheresis, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, Missouri
| | - Bradley P. Dixon
- Division of Pediatric Nephrology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joseph T. Flynn
- Division of Pediatric Nephrology, Seattle Children's Hospital, Seattle, Washington
| | - Michael J. Somers
- Division of Pediatric Nephrology, Boston Children's, Boston, Massachusetts
| | - William E. Smoyer
- Division of Pediatric Nephrology, Nationwide Children's Hospital, Columbus, Ohio
| | - Alicia Neu
- Division of Pediatric Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Collin A. Hovinga
- Clinical and Scientific Development, Institute for Advanced Clinical Trials for Children, Rockville, Maryland
| | - Amy L. Skversky
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Thomas Eissing
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Andreas Kaiser
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Stefanie Breitenstein
- Bayer AG, Pharmaceuticals Research & Development, Leverkusen/Wuppertal/Berlin, Germany
| | - Susan L. Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle R. Denburg
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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18
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How common is chronic kidney disease in children with lupus nephritis? Pediatr Nephrol 2022; 38:1701-1705. [PMID: 36525081 DOI: 10.1007/s00467-022-05848-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022]
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Bakhoum CY, Phadke M, Deng Y, Samuels JA, Garimella PS, Furth SL, Wilson FP, Ix JH. Nocturnal Dipping and Kidney Function Decline: Findings From the CKD in Children Study. Kidney Int Rep 2022; 7:2446-2453. [PMID: 36531891 PMCID: PMC9751682 DOI: 10.1016/j.ekir.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/02/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022] Open
Abstract
Introduction Normally, blood pressure (BP) declines by at least 10% from daytime to nighttime. In adults, blunted nocturnal dipping has been associated with more rapid decline in kidney function. Nondipping is prevalent in children with chronic kidney disease (CKD). We sought to determine whether nondipping is associated with proteinuria and progression to kidney failure in children with CKD. Methods In the prospective CKD in children (CKiD) cohort, Cox proportional hazards models were used to evaluate the relationship between baseline nondipping and progression to kidney failure. Linear mixed effects models were used to evaluate the relationship between nondipping and changes in iohexol glomerular filtration rate (GFR) and urine protein-to-creatinine ratio (log-UPCR, mg/mg) over time. Results Among 620 participants, mean age was 11 (± 4) years, mean iohexol GFR was 52 (± 22) ml/min per 1.73 m2, and 40% were nondippers at baseline. There were 169 kidney failure events during 2.9 years (median) of follow-up. Dipping status was not significantly associated with kidney failure overall (hazard ratio [HR] 1.08; 95% confidence interval [CI] 0.77, 1.51) or in those with (HR 1.21; 95% CI 0.53, 2.77) or without (HR 1.05; 95% CI 0.71, 1.55) glomerular disease. Dipping status did not modify the relationship between time and change in iohexol GFR or log (UPCR) from baseline (interaction P values = 0.20 and 0.054, respectively). Conclusion Nondipping is not associated with end-stage kidney disease, GFR decline, or change in proteinuria within the CKiD cohort.
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Affiliation(s)
- Christine Y. Bakhoum
- Department of Pediatrics, Section of Pediatric Nephrology, Yale University, New Haven, Connecticut, USA
| | - Manali Phadke
- Yale School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Yanhong Deng
- Yale School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Joshua A. Samuels
- Division of Pediatric Nephrology and Hypertension, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Pranav S. Garimella
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Susan L. Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - F. Perry Wilson
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| | - Joachim H. Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, California, USA
- Nephrology Section, Medicine Service, Veterans Affairs San Diego Health Care System, La Jolla, California, USA
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20
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Husain SA, King KL, Owen-Simon NL, Fernandez HE, Ratner LE, Mohan S. Access to kidney transplantation among pediatric candidates with prior solid organ transplants in the United States. Pediatr Transplant 2022; 26:e14303. [PMID: 35615911 PMCID: PMC9378581 DOI: 10.1111/petr.14303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 03/30/2022] [Accepted: 04/24/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric kidney transplant candidates require timely access to transplant to optimize growth and neurodevelopmental outcomes. We studied access to transplant for pediatric candidates with prior organ transplants. METHODS We used US registry data to identify pediatric kidney transplant candidates added to the waiting list 2015-2019 and used competing risk regression to study the association between prior transplant status and probability of receiving a kidney transplant, treating wait-list removal and death as competing events. RESULTS Of 4962 pediatric kidney transplant candidates included, 89% had no prior transplant and 11% had received a prior organ transplant (kidney 87%, liver 5%, heart 5%). Prior transplant recipients were older at listing (median 15 vs. 12 years) and more likely to have PRA≥98% (22% vs. 0.3%) (both p < .001). There was no significant difference in the proportion of candidates from each group who were preemptively wait-listed. Unadjusted competing risk regression showed a lower risk of kidney transplant after wait-listing among candidates with prior organ transplant (HR 0.52, 95%CI 0.47-0.59, p < .001). This association remained significant after adjusting for candidate characteristics (HR 0.73, 95%CI 0.63-0.83, p < .001). Among deceased donor kidney recipients, median KDPI was similar between groups, but recipients with prior transplants were more likely to receive kidneys from donors with hypertension (4% vs. 1%, p = .01) and donors after cardiac death (11% vs. 4%, p < .001). CONCLUSIONS Pediatric kidney transplant candidates with prior organ transplants have reduced access to transplant after wait-listing. Allocation system changes are needed to improve timely access to transplant for this vulnerable group.
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Affiliation(s)
- S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Nina L. Owen-Simon
- Department of Surgery, Columbia University College of Physicians & Surgeons, New York, New York
| | - Hilda E. Fernandez
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, NY
- Department of Pediatrics, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, NY
| | - Lloyd E. Ratner
- Department of Surgery, Columbia University College of Physicians & Surgeons, New York, New York
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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21
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Panzarino V, Lesser J, Cassani FA. Pediatric Chronic Kidney Disease. Adv Pediatr 2022; 69:123-132. [PMID: 35985704 DOI: 10.1016/j.yapd.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chronic kidney disease (CKD) in children has a significant impact on morbidity, mortality, and quality of life. The degree of renal dysfunction should be calculated using pediatric-specific formulas and the degree of CKD staged; this allows for appropriate dosing of medications based on renal function and monitoring for progression and comorbid conditions including metabolic acidosis, bone disease, anemia, cardiovascular complications, malnutrition and electrolyte abnormalities, growth failure, and psychosocial issues. Treatment strategies include treating the underlying disease and using general renal protective measures. Effective management of these complex issues requires a specialized multidisciplinary team approach.
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Affiliation(s)
- Valerie Panzarino
- Department of Pediatrics, Division of Pediatric Nephrology, University of South Florida Health, 2 Tampa General Circle, Fifth Floor, Tampa, FL 33606, USA.
| | - Jake Lesser
- University of South Florida Health, 2 Tampa General Circle, Fifth Floor, Tampa, FL 33606, USA
| | - Frank Ayestaran Cassani
- Department of Pediatrics, Division of Pediatric Nephrology, University of South Florida Health, 2 Tampa General Circle, Fifth Floor, Tampa, FL 33606, USA
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22
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Epidemiology of pediatric chronic kidney disease/kidney failure: learning from registries and cohort studies. Pediatr Nephrol 2022; 37:1215-1229. [PMID: 34091754 DOI: 10.1007/s00467-021-05145-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 05/02/2021] [Accepted: 05/18/2021] [Indexed: 01/13/2023]
Abstract
Although the concept of chronic kidney disease (CKD) in children is similar to that in adults, pediatric CKD has some peculiarities, and there is less evidence and many factors that are not clearly understood. The past decade has witnessed several additional registry and cohort studies of pediatric CKD and kidney failure. The most common underlying disease in pediatric CKD and kidney failure is congenital anomalies of the kidney and urinary tract (CAKUT), which is one of the major characteristics of CKD in children. The incidence/prevalence of CKD in children varies worldwide. Hypertension and proteinuria are independent risk factors for CKD progression; other factors that may affect CKD progression are primary disease, age, sex, racial/genetic factors, urological problems, low birth weight, and social background. Many studies based on registry data revealed that the risk factors for mortality among children with kidney failure who are receiving kidney replacement therapy are younger age, female sex, non-White race, non-CAKUT etiologies, anemia, hypoalbuminemia, and high estimated glomerular filtration rate at dialysis initiation. The evidence has contributed to clinical practice. The results of these registry-based studies are expected to lead to new improvements in pediatric CKD care.
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23
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Molino AR, Minnick MLG, Jerry-Fluker J, Karita Muiru J, Boynton SA, Furth SL, Warady BA, Ng DK. Health and Dental Insurance and Health Care Utilization Among Children, Adolescents, and Young Adults With CKD: Findings From the CKiD Cohort Study. Kidney Med 2022; 4:100455. [PMID: 35518833 PMCID: PMC9062328 DOI: 10.1016/j.xkme.2022.100455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Rationale & Objective To understand the association between health and dental insurance status and health and dental care utilization, and their relationship with disease severity in a population with childhood-onset chronic kidney disease (CKD). Study Design Observational cohort study. Settings & Participants Nine hundred fifty-three participants contributing 4,369 person-visits (unit of analysis) in the United States enrolled in the Chronic Kidney Disease in Children (CKiD) Study from 2005 to 2019. Exposures Health insurance (private vs public vs none) and dental insurance (presence vs absence) self-reported at annual visits. Outcomes Self-reported suboptimal health care utilization in the past year, defined separately as not visiting a private physician, visiting the emergency room, visiting the emergency room at least twice, being hospitalized, and self-reported suboptimal dental care utilization over the past year, defined as not receiving dental care. Analytical Approach Repeated measures Poisson regression models were fit to estimate and compare utilization by insurance type and disease severity at the prior visit. Additional unadjusted and adjusted models were fit, as well as models including interactions between insurance and Black race, maternal education, and income. Results Those with public health insurance were more likely to report suboptimal health care utilization across the CKD severity spectrum, and lack of dental insurance was strongly associated with lack of dental care. These relationships varied depending on strata of socioeconomic status and race but the effect measure modification was not significant. Limitations Details of insurance coverage were unavailable; reasons for emergency care or type of private physician visited were unknown. Conclusions Pediatric nephrology programs may consider interventions to help direct supportive resources to families with public insurance who are at higher risk for suboptimal utilization of care. Insurance providers should identify areas to expand access for families of children with CKD.
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Affiliation(s)
- Andrea R. Molino
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Maria Lourdes G. Minnick
- Department of Pediatrics, Division of Nephrology, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Judith Jerry-Fluker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jacqueline Karita Muiru
- Department of Pediatrics, Division of Nephrology, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sara A. Boynton
- Department of Pediatrics, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Susan L. Furth
- Department of Pediatrics, Division of Nephrology, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Bradley A. Warady
- Department of Pediatrics, Division of Nephrology, Children’s Mercy Kansas City, Kansas City, MO
| | - Derek K. Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Chronic Kidney Disease in Children Study
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Pediatrics, Division of Nephrology, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pediatrics, Division of Nephrology, Children’s Mercy Kansas City, Kansas City, MO
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24
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Wehedy E, Shatat IF, Al Khodor S. The Human Microbiome in Chronic Kidney Disease: A Double-Edged Sword. Front Med (Lausanne) 2022; 8:790783. [PMID: 35111779 PMCID: PMC8801809 DOI: 10.3389/fmed.2021.790783] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/20/2021] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is an increasing global health burden. Current treatments for CKD include therapeutics to target factors that contribute to CKD progression, including renin–angiotensin–aldosterone system inhibitors, and drugs to control blood pressure and proteinuria control. Recently, associations between chronic disease processes and the human microbiota and its metabolites have been demonstrated. Dysbiosis—a change in the microbial diversity—has been observed in patients with CKD. The relationship between CKD and dysbiosis is bidirectional; gut-derived metabolites and toxins affect the progression of CKD, and the uremic milieu affects the microbiota. The accumulation of microbial metabolites and toxins is linked to the loss of kidney functions and increased mortality risk, yet renoprotective metabolites such as short-chain fatty acids and bile acids help restore kidney functions and increase the survival rate in CKD patients. Specific dietary interventions to alter the gut microbiome could improve clinical outcomes in patients with CKD. Low-protein and high-fiber diets increase the abundance of bacteria that produce short-chain fatty acids and anti-inflammatory bacteria. Fluctuations in the urinary microbiome are linked to increased susceptibility to infection and antibiotic resistance. In this review, we describe the potential role of the gut, urinary and blood microbiome in CKD pathophysiology and assess the feasibility of modulating the gut microbiota as a therapeutic tool for treating CKD.
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Affiliation(s)
- Eman Wehedy
- College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Souhaila Al Khodor
- College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
- Research Department, Sidra Medicine, Doha, Qatar
- *Correspondence: Souhaila Al Khodor
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Ng DK, Pierce CB. Kidney Disease Progression in Children and Young Adults With Pediatric CKD: Epidemiologic Perspectives and Clinical Applications. Semin Nephrol 2021; 41:405-415. [PMID: 34916001 DOI: 10.1016/j.semnephrol.2021.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Chronic kidney disease (CKD) progression is typically characterized as either time to a clinically meaningful event (such as dialysis or transplant), or longitudinal changes in kidney function. This review describes pediatric kidney disease progression using these two distinct frameworks by reviewing and discussing data from the Chronic Kidney Disease in Children study. We first describe new equations to estimate glomerular filtration rate (GFR) for patients younger than age 25 years, and how the average of serum creatinine-based and cystatin C-based GFR equations yield valid estimates than either alone. Next, we present a life course description of CKD onset to kidney replacement therapy, prediction models based on clinical measurements, and show the importance of diagnosis (broadly classified as nonglomerular and glomerular in origin), GFR level, and proteinuria on progression. Literature on longitudinal GFR in children and young adults are reviewed and new data are presented to characterize nonlinear changes in estimated GFR in patients younger than age 25 years. These models showed accelerated progression associated with glomerular diagnosis, lower GFR level, and higher proteinuria, which was congruent with time-to-event analyses. Descriptions of online tools for GFR estimation and risk stratification for clinical applications are presented and we offer key epidemiologic considerations for the analysis of longitudinal pediatric CKD studies.
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Affiliation(s)
- Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Christopher B Pierce
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Factors associated with the absence of pharmacological treatment for common modifiable complications in children with chronic kidney disease. Pediatr Nephrol 2021; 36:3181-3189. [PMID: 33959814 PMCID: PMC8981496 DOI: 10.1007/s00467-021-05087-8] [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: 02/05/2021] [Revised: 03/30/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with many comorbidities requiring complex management. We described treatment patterns for common modifiable CKD complications (high blood pressure, anemia, hyperphosphatemia, and acidosis) according to severity of CKD and examined factors associated with the absence of drug therapy, among participants with a persistent comorbidity, for 1 year in children enrolled in the CKiD study. METHODS A total of 703 CKiD participants contributed 2849 person-visits over a median 3.5 years of follow-up. Using pairs of annual visits, we examined whether participants with abnormal biomarker levels at the first (index) visit persisted in the abnormal levels 1 year later according to CKD risk stage. Multivariate analyses identified demographic and clinical factors associated with the absence of drug therapy among those with persistent comorbid conditions for 1 year. RESULTS The overall proportions of person-visits prescribing therapy at 1-year follow-up for treating anemia, acidosis, hyperphosphatemia, and high blood pressure were 54%, 45%, 29%, and 81%, respectively. The frequency of therapy increased with advanced CKD risk stage for all comorbidities; however, 19-23% of participants with acidosis, 24-27% with anemia, and 30-39% with hyperphosphatemia at high-risk stages (E and F) were not prescribed appropriate therapy despite the persistence of abnormal levels of these biomarkers for at least 1 year. The resolution of comorbidities at advanced CKD stages without treatment was unlikely. CONCLUSIONS Many children with CKD in the CKiD cohort did not receive pharmacological treatment for common and persistent modifiable comorbidities, even in severe CKD risk stages.
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Predictors of progression in autosomal dominant and autosomal recessive polycystic kidney disease. Pediatr Nephrol 2021; 36:2639-2658. [PMID: 33474686 PMCID: PMC8292447 DOI: 10.1007/s00467-020-04869-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/19/2020] [Accepted: 11/20/2020] [Indexed: 12/15/2022]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) and autosomal recessive polycystic kidney disease (ARPKD) are characterized by bilateral cystic kidney disease leading to progressive kidney function decline. These diseases also have distinct liver manifestations. The range of clinical presentation and severity of both ADPKD and ARPKD is much wider than was once recognized. Pediatric and adult nephrologists are likely to care for individuals with both diseases in their lifetimes. This article will review genetic, clinical, and imaging predictors of kidney and liver disease progression in ADPKD and ARPKD and will briefly summarize pharmacologic therapies to prevent progression.
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28
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Denburg MR, Xu Y, Abraham AG, Coresh J, Chen J, Grams ME, Feldman HI, Kimmel PL, Rebholz CM, Rhee EP, Vasan RS, Warady BA, Furth SL. Metabolite Biomarkers of CKD Progression in Children. Clin J Am Soc Nephrol 2021; 16:1178-1189. [PMID: 34362785 PMCID: PMC8455058 DOI: 10.2215/cjn.00220121] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/17/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Metabolomics facilitates the discovery of biomarkers and potential therapeutic targets for CKD progression. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We evaluated an untargeted metabolomics quantification of stored plasma samples from 645 Chronic Kidney Disease in Children (CKiD) participants. Metabolites were standardized and logarithmically transformed. Cox proportional hazards regression examined the association between 825 nondrug metabolites and progression to the composite outcome of KRT or 50% reduction of eGFR, adjusting for age, sex, race, body mass index, hypertension, glomerular versus nonglomerular diagnosis, proteinuria, and baseline eGFR. Stratified analyses were performed within subgroups of glomerular/nonglomerular diagnosis and baseline eGFR. RESULTS Baseline characteristics were 391 (61%) male; median age 12 years; median eGFR 54 ml/min per 1.73 m2; 448 (69%) nonglomerular diagnosis. Over a median follow-up of 4.8 years, 209 (32%) participants developed the composite outcome. Unique association signals were identified in subgroups of baseline eGFR. Among participants with baseline eGFR ≥60 ml/min per 1.73 m2, two-fold higher levels of seven metabolites were significantly associated with higher hazards of KRT/halving of eGFR events: three involved in purine and pyrimidine metabolism (N6-carbamoylthreonyladenosine, hazard ratio, 16; 95% confidence interval, 4 to 60; 5,6-dihydrouridine, hazard ratio, 17; 95% confidence interval, 5 to 55; pseudouridine, hazard ratio, 39; 95% confidence interval, 8 to 200); two amino acids, C-glycosyltryptophan, hazard ratio, 24; 95% confidence interval 6 to 95 and lanthionine, hazard ratio, 3; 95% confidence interval, 2 to 5; the tricarboxylic acid cycle intermediate 2-methylcitrate/homocitrate, hazard ratio, 4; 95% confidence interval, 2 to 7; and gulonate, hazard ratio, 10; 95% confidence interval, 3 to 29. Among those with baseline eGFR <60 ml/min per 1.73 m2, a higher level of tetrahydrocortisol sulfate was associated with lower risk of progression (hazard ratio, 0.8; 95% confidence interval, 0.7 to 0.9). CONCLUSIONS Untargeted plasma metabolomic profiling facilitated discovery of novel metabolite associations with CKD progression in children that were independent of established clinical predictors and highlight the role of select biologic pathways.
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Affiliation(s)
- Michelle R. Denburg
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yunwen Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alison G. Abraham
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jingsha Chen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Harold I. Feldman
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul L. Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Casey M. Rebholz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eugene P. Rhee
- Department of Medicine, Massachusetts General Hospital, Department of Medicine, Harvard University, Boston, Massachusetts
| | - Ramachandran S. Vasan
- Department of Medicine, Boston University School of Medicine, Boston University School of Public Health, and Boston University Center for Computing and Data Science, Boston, Massachusetts
| | - Bradley A. Warady
- Children’s Mercy Kansas City, Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Susan L. Furth
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Schneider MF, Muñoz A, Ku E, Warady BA, Furth SL, Schwartz GJ. Estimation of Albumin-Creatinine Ratio From Protein-Creatinine Ratio in Urine of Children and Adolescents With CKD. Am J Kidney Dis 2021; 77:824-827. [DOI: 10.1053/j.ajkd.2020.07.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 07/06/2020] [Indexed: 11/11/2022]
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Molino AR, Jerry-Fluker J, Atkinson MA, Furth SL, Warady BA, Ng DK. Alcohol, cigarette, e-cigarette and marijuana use among adolescents and young adults with chronic kidney disease in North America. Ann Epidemiol 2021; 59:56-63. [PMID: 33894386 DOI: 10.1016/j.annepidem.2021.04.001] [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] [Received: 09/18/2020] [Revised: 03/18/2021] [Accepted: 04/05/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE This study aimed to describe substance use (SU) among adolescents and young adults (AYA) with chronic kidney disease, compare these findings with the general population, and identify associated risk factors. METHODS 708 AYA participants contributing 2475 person-visits from the Chronic Kidney Disease in Children Study were used to estimate prevalence rates of past year and 30-day alcohol, cigarette, e-cigarette and marijuana use, and were compared with national surveys. Repeated measures logistic regression estimated the association between SU and participant characteristics. RESULTS There was nearly no SU among those 12 to 14 years, but use increased with age, and past year alcohol use was about 80% for those greater than or equal to 22 years. Rates of use among males were constant or increased with age, while rates of use among females were lower after age 22 compared to ages 18 to 22. Associated risk factors included non-Black and non-Hispanic identity, older age, and worse disease severity. Participants were less likely to use substances compared to the general population, especially those 14-18 years. CONCLUSIONS SU was less common in AYA with chronic kidney disease than the general population, but differences were attenuated among those greater than or equal to 18 years. Ages 12-14 appear to be the ideal time for prevention efforts. As the landscape of e-cigarette and marijuana policies change, these results underscore the need to understand how similar high-risk populations engage in SU.
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Affiliation(s)
- Andrea R Molino
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD
| | - Judith Jerry-Fluker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD
| | - Meredith A Atkinson
- Department of Pediatrics, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD
| | - Susan L Furth
- Department of Pediatrics, Division of Nephrology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA
| | - Bradley A Warady
- Department of Pediatrics, Division of Nephrology, Children's Mercy Kansas City, 2401 Gillham Rd, Kansas City, MO
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD.
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31
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Querfeld U. Cardiovascular disease in childhood and adolescence: Lessons from children with chronic kidney disease. Acta Paediatr 2021; 110:1125-1131. [PMID: 33080082 DOI: 10.1111/apa.15630] [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: 09/04/2020] [Revised: 10/14/2020] [Accepted: 10/16/2020] [Indexed: 11/26/2022]
Abstract
Children suffering from chronic kidney disease (CKD) have the apparent highest risk for the development of cardiovascular disease (CVD) at a young age. While symptoms of CVD are characteristically absent in childhood and adolescence, remodelling of the myocardium, medium and large-sized arteries and of the microcirculation is clinically significant and can be assessed with non-invasive technology. Kidney disease and its progression are the driver of CVD, mediated by an unparalleled accumulation of risk factors converging on several comorbid conditions including hypertension, anaemia, dyslipidaemia, disturbed mineral metabolism and chronic persistent inflammation. Large prospective paediatric cohorts studies have provided valuable insights into the pathogenesis and the progression of CKD-induced cardiovascular comorbidity and have characterised the cardiovascular phenotype in young patients. They have also provided the rationale for close monitoring of risk factors and have defined therapeutic targets. Recently discovered new biomarkers could help identify the individual risk for CVD. Prevention of CVD by aggressive therapy of modifiable risk factors is essential to enable long-term survival of young patients with CKD.
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Affiliation(s)
- Uwe Querfeld
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
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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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Stavas J, Diaz-Gonzalez de Ferris M, Johns A, Jain D, Bertram T. Protocol and Baseline Data on Renal Autologous Cell Therapy Injection in Adults with Chronic Kidney Disease Secondary to Congenital Anomalies of the Kidney and Urinary Tract. Blood Purif 2021; 50:678-683. [PMID: 33647913 DOI: 10.1159/000512586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Advanced cell therapies with autologous, homologous cells show promise to affect reparative and restorative changes in the chronic kidney disease (CKD) nephron. We present our protocol and preliminary analysis of an IRB-approved, phase I single-group, open-label trial that tests the safety and efficacy of Renal Autologous Cell Therapy (REACT; NCT04115345) in adults with congenital anomalies of the kidney and urinary tract (CAKUT). METHODS Adults with surgically corrected CAKUT and CKD stages 3 and 4 signed an informed consent and served as their "own" baseline control. REACT is an active biological ingredient acquired from a percutaneous tissue acquisition from the patient's kidney cortex. The specimen undergoes a GMP-compliant manufacturing process that harvests the selected renal cells composed of progenitors for renal repair, followed by image-guided locoregional reinjection into the patient's renal cortex. Participants receive 2 doses at 6-month intervals. Primary outcomes are stable renal function and stable/improved quality of life. Additional exploratory endpoints include the impact of REACT on blood pressure, vitamin D levels, hemoglobin, hematocrit and kidney volume by MRI analysis. RESULTS Four men and 1 woman were enrolled and underwent 5 cell injections. Their characteristics were as follows: mean 52.8 years (SD 17.7 years), 1 Hispanic, 4 non-Hispanic, and 5 white. There were no renal tissue acquisition, cell injection, or cell product-related complications at baseline. CONCLUSION REACT is demonstrating feasibility and patient safety in preliminary analysis. Autologous cell therapy treatment has the potential to stabilize or improve renal function in CAKUT-associated CKD to delay or avert dialysis. Patient enrollment and follow-up are underway.
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Affiliation(s)
- Joseph Stavas
- ProKidney, Grand Cayman, George Town, Cayman Islands,
| | | | - Ashley Johns
- ProKidney, Grand Cayman, George Town, Cayman Islands
| | - Deepak Jain
- ProKidney, Grand Cayman, George Town, Cayman Islands
| | - Tim Bertram
- ProKidney, Grand Cayman, George Town, Cayman Islands
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35
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Sebastião YV, Cooper JN, Becknell B, Ching CB, McLeod DJ. Prediction of kidney failure in children with chronic kidney disease and obstructive uropathy. Pediatr Nephrol 2021; 36:111-118. [PMID: 32583045 PMCID: PMC10928559 DOI: 10.1007/s00467-020-04661-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/29/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Obstructive uropathy (OU) is a leading cause of pediatric kidney injury. Accurate prediction of kidney disease progression may improve clinical outcomes. We aimed to examine discrimination and accuracy of a validated kidney failure risk equation (KFRE), previously developed in adults, in children with OU. METHODS We identified 118 children with OU and an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 in the Chronic Kidney Disease in Children study, a national, longitudinal, observational cohort. Each patient's 5-year risk of kidney failure was estimated using baseline data and published parameters for the 4- and 8-variable KFREs. Discriminative ability of the KFRE was estimated using the C statistic for time-to-event analysis. Sensitivity and specificity were evaluated across varying risk thresholds. RESULTS Among the 118 children, 100 (85%) were boys, with median baseline age of 10 years (interquartile range, 6-14). Median eGFR was 42 mL/min/1.73m 2 (32-53), with a median follow-up duration of 4.5 years (2.7-7.2); 23 patients (19.5%) developed kidney failure within 5 years. The 4-variable KFRE discriminated kidney failure risk with a C statistic of 0.75 (95% CI, 0.68-0.82). A 4-variable risk threshold of ≥ 30% yielded 82.6% sensitivity and 75.0% specificity. Results were similar using the 8-variable KFRE. CONCLUSIONS In children with OU, the KFRE discriminated the 5-year risk of kidney failure at C statistic values lower than previously published in adults but comparable with suboptimal values reported in the overall CKiD population. The 8-variable equation did not improve model discrimination or accuracy, suggesting the need for continued research into additional, disease-specific markers.
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Affiliation(s)
- Yuri V Sebastião
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Epidemiology, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Brian Becknell
- Center For Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, Section of Nephrology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christina B Ching
- Center For Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Daryl J McLeod
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA.
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He G, Li C, Zhong X, Wang F, Wang H, Shi Y, Gan L, Ding J. Risk Factors for Progression of Chronic Kidney Disease With Glomerular Etiology in Hospitalized Children. Front Pediatr 2021; 9:752717. [PMID: 34746063 PMCID: PMC8570116 DOI: 10.3389/fped.2021.752717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/28/2021] [Indexed: 11/18/2022] Open
Abstract
Aim: To Identify association between risk factors to Chronic kidney disease (CKD) stage 5 in children with glomerular diseases in children in China. Methods: The Hospital Quality Monitoring System database was used to extract data for the study cohort. The primary outcome included progression to CKD stage 5 or dialysis. Cox regression was used to assess potential risk factors. Patients with lower stages (CKD stage 1 and 2) and higher stages (CKD stage 3 and 4) at baseline were analyzed separately. Results: Of 819 patients (4,089 hospitalization records), 172 (21.0%) patients reached the primary outcome during a median followed-up of 11.4 months. In the lower stages group, factors associated with the primary outcome included older age [Hazard Ratio (HR), 1.21; 95% confidence interval (CI), 1.10-1.34] and out-of-pocket payment (HR, 4.14; 95% CI, 1.57-10.95). In the higher stages group, factors associated with the primary outcome included CKD stage 4 (HR, 2.31; 95% CI, 1.48-3.62) and hypertension (HR, 1.99; 95% CI, 1.29-3.07). The medical migration rate was 38.2% in this study population. Conclusion: There are different risk factors for progression to the primary outcome in different stages in CKD with glomerular etiology. Further prospective studies are needed to assess these risk factors. The high medical migration rate reflected the regional disparities in the accessibility of pediatric kidney care between regions.
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Affiliation(s)
- Guohua He
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Chenglong Li
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Xuhui Zhong
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Fang Wang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Haibo Wang
- Clinical Trial Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ying Shi
- China Standard Medical Information Research Center, Shenzhen, China
| | - Lanxia Gan
- China Standard Medical Information Research Center, Shenzhen, China
| | - Jie Ding
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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Bowen DK, Balmert LC, Meyer T, Rosoklija I, Hodgkins KS, Ghossein C, Cheng EY, Yerkes EB, Isakova T, Chu DI. Variability in Kidney Function Estimates in Emerging Adults With Spina Bifida: Implications for Transitioning From Pediatric to Adult Care. Urology 2020; 148:306-313. [PMID: 33242556 DOI: 10.1016/j.urology.2020.10.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/05/2020] [Accepted: 10/08/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To examine the variability of estimated glomerular filtration rate (eGFR) in emerging adults with spina bifida (SB) by comparing multiple equations across the transitional age period, hypothesizing that creatinine (Cr)-based equations show greater variability than cystatin-C (CysC)- or combination-based equations. METHODS A retrospective cohort study was performed from 2012 to 2017 at a multidisciplinary SB clinic. Emerging adults were defined as patients ages 18-28 years old. Four pediatric, 3 adult, and 3 averaged eGFR equations were considered. Cross-sectional variability in eGFR data was assessed using coefficients of variation, chronic kidney disease (CKD) stage classification, and pairwise percent relative difference in eGFR between analogous pediatric and adult equations based on included lab values. Longitudinal changes in eGFR over time were compared across equations using a covariance pattern model accounting for repeated measures. RESULTS Seventy-five emerging adults with SB (median age 21.8 years; 55% female; 83% with myelomeningocele) were included in cross-sectional analyses. Adult equations gave higher median eGFRs by 22%-27% and generally milder CKD stage classification than analogous pediatric equations. In longitudinal analyses (median follow-up of 22 months), all equations conferred negative eGFR changes over time (range -1.9 to -4.3 mL/min/1.73m2 per year) that were not significantly different. CONCLUSION In emerging adults with SB, adult equations demonstrated higher median eGFRs by 22%-27% compared to analogous pediatric equations, even with Cystatin-C, and generally downstaged CKD stage classification. The same eGFR equation should be used for serial kidney function monitoring in emerging adults with SB who transition care from pediatric to adult services.
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Affiliation(s)
- Diana K Bowen
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
| | - Lauren C Balmert
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Theresa Meyer
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ilina Rosoklija
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Kavita S Hodgkins
- Division of Kidney Diseases, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Cybele Ghossein
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Earl Y Cheng
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Elizabeth B Yerkes
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David I Chu
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Timing of patient-reported renal replacement therapy planning discussions by disease severity among children and young adults with chronic kidney disease. Pediatr Nephrol 2020; 35:1925-1933. [PMID: 32363486 PMCID: PMC8989139 DOI: 10.1007/s00467-020-04542-2] [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: 10/24/2019] [Revised: 02/27/2020] [Accepted: 03/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Preparing children with chronic kidney disease (CKD) for renal replacement therapy (RRT) begins with a discussion about transplant and dialysis, but its typical timing in the course of CKD management is unclear. We aimed to describe participant-reported RRT planning discussions by CKD stage, clinical and sociodemographic characteristics, in the Chronic Kidney Disease in Children (CKiD) cohort. METHODS Participants responded to the question "In the past year, have you discussed renal replacement therapy with your doctor or healthcare provider?" at annual study visits. Responses were linked to the previous year CKD risk stage based on GFR and proteinuria. Repeated measure logistic models estimated the proportion discussing RRT by stage, with modification by sex, age, race, socioeconomic status, and CKD diagnosis (glomerular vs. non-glomerular). RESULTS A total of 721 CKiD participants (median age = 12, 62% boys) contributed 2856 person-visits. Proportions of person-visits reporting RRT discussions increased as CKD severity increased (10% at the lowest disease stage and 87% at the highest disease stage). After controlling for CKD risk stage, rates of RRT discussions did not differ by sex, age, race, and socioeconomic status. CONCLUSIONS Despite participant-reported RRT discussions being strongly associated with CKD severity, a substantial proportion with advanced CKD reported no discussion. While recall bias may lead to underreporting, it is still meaningful that some participants with severe CKD did not report or remember discussing RRT. Initiating RRT discussions early in the CKD course should be encouraged to foster comprehensive preparation and to align RRT selection for optimal health and patient preferences.
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Should we abandon GFR in the decision to initiate chronic dialysis? Pediatr Nephrol 2020; 35:1593-1600. [PMID: 31418062 DOI: 10.1007/s00467-019-04333-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/31/2019] [Accepted: 08/06/2019] [Indexed: 12/20/2022]
Abstract
The best time to start chronic dialysis during the course of CKD stage 5 is controversial. The first randomised control trial of dialysis initiation either in early or late CKD stage 5 in adults (IDEAL study), and 3 studies from the two largest paediatric registries, the U.S. Renal Data System (USRDS) and the European Society of Paediatric Nephrology (ESPN) Registry, have now provided us with evidence to guide us in this important decision-making process. The message 'no benefit from early start of dialysis' is the conclusion from all four studies. However, what are the limitations of these studies? Can GFR be assessed at CKD stages 4 and 5? What are the factors used to assess the benefit of early or late start? These issues are discussed in this review.
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Brown DD, Roem J, Ng DK, Reidy KJ, Kumar J, Abramowitz MK, Mak RH, Furth SL, Schwartz GJ, Warady BA, Kaskel FJ, Melamed ML. Low Serum Bicarbonate and CKD Progression in Children. Clin J Am Soc Nephrol 2020; 15:755-765. [PMID: 32467307 PMCID: PMC7274283 DOI: 10.2215/cjn.07060619] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 04/09/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Studies of adults have demonstrated an association between metabolic acidosis, as measured by low serum bicarbonate levels, and CKD progression. We evaluated this relationship in children using data from the Chronic Kidney Disease in Children study. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The relationship between serum bicarbonate and a composite end point, defined as 50% decline in eGFR or KRT, was described using parametric and semiparametric survival methods. Analyses were stratified by underlying nonglomerular and glomerular diagnoses, and adjusted for demographic characteristics, eGFR, proteinuria, anemia, phosphate, hypertension, and alkali therapy. RESULTS Six hundred and three participants with nonglomerular disease contributed 2673 person-years of follow-up, and 255 with a glomerular diagnosis contributed 808 person-years of follow-up. At baseline, 39% (237 of 603) of participants with nonglomerular disease had a bicarbonate level of ≤22 meq/L and 36% (85 of 237) of those participants reported alkali therapy treatment. In participants with glomerular disease, 31% (79 of 255) had a bicarbonate of ≤22 meq/L, 18% (14 of 79) of those participants reported alkali therapy treatment. In adjusted longitudinal analyses, compared with participants with a bicarbonate level >22 meq/L, hazard ratios associated with a bicarbonate level of <18 meq/L and 19-22 meq/L were 1.28 [95% confidence interval (95% CI), 0.84 to 1.94] and 0.91 (95% CI, 0.65 to 1.26), respectively, in children with nonglomerular disease. In children with glomerular disease, adjusted hazard ratios associated with bicarbonate level ≤18 meq/L and bicarbonate 19-22 meq/L were 2.16 (95% CI, 1.05 to 4.44) and 1.74 (95% CI, 1.07 to 2.85), respectively. Resolution of low bicarbonate was associated with a lower risk of CKD progression compared with persistently low bicarbonate (≤22 meq/L). CONCLUSIONS In children with glomerular disease, low bicarbonate was linked to a higher risk of CKD progression. Resolution of low bicarbonate was associated with a lower risk of CKD progression. Fewer than one half of all children with low bicarbonate reported treatment with alkali therapy. Long-term studies of alkali therapy's effect in patients with pediatric CKD are needed.
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Affiliation(s)
- Denver D. Brown
- Division of Pediatric Nephrology, Children’s National Hospital, Washington, DC
| | - Jennifer Roem
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Derek K. Ng
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kimberly J. Reidy
- Division of Pediatric Nephrology, The Children’s Hospital at Montefiore, Bronx, New York
| | - Juhi Kumar
- Division of Pediatric Nephrology, Weill Cornell Medicine, New York, New York
| | | | - Robert H. Mak
- Division of Pediatric Nephrology, Rady Children’s Hospital San Diego, University of California San Diego, San Diego, California
| | - Susan L. Furth
- Division of Pediatric Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - George J. Schwartz
- Division of Pediatric Nephrology, University of Rochester, Rochester, New York
| | - Bradley A. Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri
| | - Frederick J. Kaskel
- Division of Pediatric Nephrology, The Children’s Hospital at Montefiore, Bronx, New York
| | - Michal L. Melamed
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
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Abstract
PURPOSE OF REVIEW Although the concept of risk prediction in chronic kidney disease (CKD) is not new, how to integrate risk prediction models into CKD care remains largely unknown, particularly in the prevention and early management of CKD. The present review presents a timely overview of recent CKD risk prediction models and conceptualizes how these may be integrated into the care of patients with CKD. RECENT FINDINGS In recent literature, prediction of time-to-ESKD has been thoroughly validated in multiple international cohorts, new models focused on CKD incidence, morbidity, and mortality have been developed, and ongoing work will determine the impact of integrating risk prediction models into CKD care on patients, nephrologists, and health systems. SUMMARY With the availability of new models focused on CKD incidence, the United States Preventive Task Force should reconsider its determination of insufficient evidence for primary screening of CKD, which was due in part to the absence of validated risk models to guide CKD screening. Models predicting CKD morbidity and mortality present a new opportunity to standardize the intensity and frequency of care across nephrology practices.
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Shroff R, Calder F, Bakkaloğlu S, Nagler EV, Stuart S, Stronach L, Schmitt CP, Heckert KH, Bourquelot P, Wagner AM, Paglialonga F, Mitra S, Stefanidis CJ. Vascular access in children requiring maintenance haemodialysis: a consensus document by the European Society for Paediatric Nephrology Dialysis Working Group. Nephrol Dial Transplant 2020; 34:1746-1765. [PMID: 30859187 DOI: 10.1093/ndt/gfz011] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/30/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There are three principle forms of vascular access available for the treatment of children with end stage kidney disease (ESKD) by haemodialysis: tunnelled catheters placed in a central vein (central venous lines, CVLs), arteriovenous fistulas (AVF), and arteriovenous grafts (AVG) using prosthetic or biological material. Compared with the adult literature, there are few studies in children to provide evidence based guidelines for optimal vascular access type or its management and outcomes in children with ESKD. METHODS The European Society for Paediatric Nephrology Dialysis Working Group (ESPN Dialysis WG) have developed recommendations for the choice of access type, pre-operative evaluation, monitoring, and prevention and management of complications of different access types in children with ESKD. RESULTS For adults with ESKD on haemodialysis, the principle of "Fistula First" has been key to changing the attitude to vascular access for haemodialysis. However, data from multiple observational studies and the International Paediatric Haemodialysis Network registry suggest that CVLs are associated with a significantly higher rate of infections and access dysfunction, and need for access replacement. Despite this, AVFs are used in only ∼25% of children on haemodialysis. It is important to provide the right access for the right patient at the right time in their life-course of renal replacement therapy, with an emphasis on venous preservation at all times. While AVFs may not be suitable in the very young or those with an anticipated short dialysis course before transplantation, many paediatric studies have shown that AVFs are superior to CVLs. CONCLUSIONS Here we present clinical practice recommendations for AVFs and CVLs in children with ESKD. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system has been used to develop and GRADE the recommendations. In the absence of high quality evidence, the opinion of experts from the ESPN Dialysis WG is provided, but is clearly GRADE-ed as such and must be carefully considered by the treating physician, and adapted to local expertise and individual patient needs as appropriate.
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Affiliation(s)
- Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Francis Calder
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Sam Stuart
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lynsey Stronach
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Claus P Schmitt
- Center for Paediatric & Adolescent Medicine, Heidelberg, Germany
| | - Karl H Heckert
- Center for Paediatric & Adolescent Medicine, Heidelberg, Germany
| | | | - Ann-Marie Wagner
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Fabio Paglialonga
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sandip Mitra
- Manchester Academy of Health Sciences Centre, Manchester University Hospitals & NIHR Devices for Dignity, Manchester, UK
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Bonnéric S, Karadkhele G, Couchoud C, Patzer RE, Greenbaum LA, Hogan J. Sex and Glomerular Filtration Rate Trajectories in Children. Clin J Am Soc Nephrol 2020; 15:320-329. [PMID: 32111703 PMCID: PMC7057295 DOI: 10.2215/cjn.08420719] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 01/21/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Differences in CKD progression by sex have been hypothesized to explain disparities in access to kidney transplantation in children. This study aims to identify distinct trajectories of eGFR decline and to investigate the association of sex with eGFR decline. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used data from the CKD in Children study. Latent class mixed models were used to identify eGFR trajectories and patient characteristics were compared between trajectories. Progression was studied to two outcomes: ESKD (dialysis or transplantation) and a combined outcome of ESKD or 50% eGFR decline from baseline, using multivariable parametric failure time models. RESULTS Among 888 patients, 613 with nonglomerular and 275 with glomerular diseases, we observed four and two distinct GFR trajectories, respectively. Among patients with nonglomerular diseases, there was a higher proportion of males in the group with a low baseline GFR. This group had an increased risk of ESKD or 50% GFR decline, despite a similar absolute decline in GFR. Eight patients with nonglomerular diseases, mostly males with obstructive uropathies, had a more rapid absolute GFR decline. However, the association between male sex and rapid absolute GFR decline was NS after adjustment for age, baseline GFR, and proteinuria. Among patients with glomerular diseases, a subgroup including mostly females with systemic immunologic diseases or crescentic GN had a rapid absolute GFR decline. CONCLUSIONS This study identifies different trajectories of CKD progression in children and found a faster progression of CKD in females in patients with glomerular diseases, but no significant sex difference in patients with nonglomerular diseases. The differences in progression seem likely explained by sex differences in the underlying primary kidney disease and in baseline GFR rather than by a direct effect of sex on progression.
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Affiliation(s)
- Stéphanie Bonnéric
- Department of Pediatric Nephrology, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Geeta Karadkhele
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia
| | - Cécile Couchoud
- Renal Epidemiology and Information Network (REIN) Registry, French Biomedicine Agency, La Plaine-Saint Denis, France
| | - Rachel E Patzer
- Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; and
| | - Larry A Greenbaum
- Department of Pediatric Nephrology, Children's Healthcare of Atlanta, Emory School of Medicine, Atlanta, Georgia
| | - Julien Hogan
- Department of Pediatric Nephrology, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; .,Department of Surgery, Emory Transplant Center, Emory School of Medicine, Atlanta, Georgia
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Reynolds BC, Roem JL, Ng DKS, Matsuda-Abedini M, Flynn JT, Furth SL, Warady BA, Parekh RS. Association of Time-Varying Blood Pressure With Chronic Kidney Disease Progression in Children. JAMA Netw Open 2020; 3:e1921213. [PMID: 32058554 PMCID: PMC7236873 DOI: 10.1001/jamanetworkopen.2019.21213] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Optimal blood pressure (BP) management in children with chronic kidney disease (CKD) slows progression to end-stage renal disease. Studies often base progression risk on a single baseline BP measurement, which may underestimate risk. OBJECTIVE To determine whether time-varying BP measurements are associated with a higher risk of progression of CKD than baseline BP measurements. DESIGN, SETTING, AND PARTICIPANTS The ongoing longitudinal, prospective cohort study Chronic Kidney Disease in Children (CKID) recruited children from January 19, 2005, through March 19, 2014, from pediatric nephrology centers across North America, with data collected at annual study visits. Participants included children aged 1 to 16 years with a diagnosis of CKD and a glomerular filtration rate (GFR) of 30 to 90 mL/min/1.73 m2. Data were analyzed from February 11, 2005, through February 13, 2018. EXPOSURES Office BP measurement classified as less than 50th percentile, 50th to less than 90th percentile, or at least 90th percentile. Blood pressure categories were treated as time fixed (baseline) or time varying (updated at each visit) in models. MAIN OUTCOMES AND MEASURES A composite renal outcome (50% GFR reduction from baseline, estimated GFR less than 15 mL/min/1.73 m2, or dialysis or transplant). Pooled logistic models using inverse probability weighting estimated the hazard odds ratio (HOR) of the composite outcome associated with each BP category stratified by CKD diagnosis. RESULTS A total of 844 children (524 [62.1%] male; median age, 11 [interquartile range, 8-15] years; 151 [17.9%] black; 580 [68.7%] with nonglomerular CKD; and 264 [31.3%] with glomerular CKD) with complete baseline data and median follow-up of 4 (interquartile range, 2-6) years were included. One hundred ninety-six participants with nonglomerular diagnoses (33.8%) and 99 with glomerular diagnoses (37.5%) reached the composite outcome. Baseline systolic BP in at least the 90th percentile was associated with a higher risk of the composite outcome (HOR for nonglomerular disease, 1.58 [95% CI, 1.07-2.32]; HOR for glomerular disease, 2.85 [95% CI, 1.64-4.94]) compared with baseline systolic BP in less than the 50th percentile. Time-fixed estimates were substantially lower compared with time-varying systolic BP percentile categories (HOR among those with nonglomerular CKD, 3.75 [95% CI, 2.53-5.57]; HOR among those with glomerular diagnoses, 5.96 [95% CI, 3.37-10.54]) comparing those at or above the 90th percentile vs below the 50th percentile. Adjusted models (adjusted for proteinuria and use of antihypertensives) attenuated the risk in nonglomerular CKD (adjusted HOR for baseline measurement, 1.52 [95% CI, 0.98-2.36]; adjusted HOR for time-varying measurement, 2.25 [95% CI, 1.36-3.72]) and in glomerular CKD (adjusted HOR for baseline, 0.97 [95% CI, 0.39-2.36]; adjusted HOR for time-varying measurement, 1.41 [95% CI, 0.65-3.03]). Similar results were observed for diastolic BP. CONCLUSIONS AND RELEVANCE Among children with nonglomerular CKD included in this study, elevated time-varying BP measurements were associated with a greater risk of CKD progression compared with baseline BP measurement. This finding suggests that previous studies using only baseline BP likely underestimated the association between BP and CKD progression.
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Affiliation(s)
| | - Jennifer Lynn Roem
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Derek Kai Sing Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mina Matsuda-Abedini
- Division of Nephrology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Thomas Flynn
- Department of Pediatrics, University of Washington, Seattle
- Division of Nephrology, Seattle Children’s Hospital, Seattle, Washington
| | - Susan Lynn Furth
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bradley Alan Warady
- Division of Pediatric Nephrology, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Rulan Savita Parekh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Division of Nephrology, Department of Pediatrics and Medicine, Hospital for Sick Children, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Ng DK, Matheson MB, Warady BA, Mendley SR, Furth SL, Muñoz A. Incidence of Initial Renal Replacement Therapy Over the Course of Kidney Disease in Children. Am J Epidemiol 2019; 188:2156-2164. [PMID: 31595948 PMCID: PMC7036655 DOI: 10.1093/aje/kwz220] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 08/29/2019] [Accepted: 10/19/2019] [Indexed: 12/18/2022] Open
Abstract
The Chronic Kidney Disease in Children Study, a prospective cohort study with data collected from 2003 to 2018, provided the first opportunity to characterize the incidence of renal replacement therapy (RRT) initiation over the life course of pediatric kidney diseases. In the current analysis, parametric generalized gamma models were fitted and extrapolated for RRT overall and by specific treatment modality (dialysis or preemptive kidney transplant). Children were stratified by type of diagnosis: nonglomerular (mostly congenital; n = 650), glomerular–hemolytic uremic syndrome (HUS; n = 49), or glomerular–non-HUS (heterogeneous childhood onset; n = 216). Estimated durations of time to RRT after disease onset for 99% of the nonglomerular and glomerular–non-HUS groups were 42.5 years (95% confidence interval (CI): 31.0, 54.1) and 25.4 years (95% CI: 14.9, 36.0), respectively. Since onset for the great majority of children in the nonglomerular group was congenital, disease duration equated with age. A simulation-based estimate of age at RRT for 99% of the glomerular population was 37.9 years (95% CI: 33.6, 63.2). These models performed well in cross-validation. Children with glomerular disease received dialysis earlier and were less likely to have a preemptive kidney transplant, while the timing and proportions of dialysis and transplantation were similar for the nonglomerular group. These diagnosis-specific estimates provide insight into patient-centered prognostic information and can assist in RRT planning efforts for children with moderate-to-severe kidney disease who are receiving regular specialty care.
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Affiliation(s)
- Derek K Ng
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Matthew B Matheson
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri
| | - Susan R Mendley
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Susan L Furth
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alvaro Muñoz
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Winnicki E, Johansen KL, Cabana MD, Warady BA, McCulloch CE, Grimes B, Ku E. Higher eGFR at Dialysis Initiation Is Not Associated with a Survival Benefit in Children. J Am Soc Nephrol 2019; 30:1505-1513. [PMID: 31320460 DOI: 10.1681/asn.2018111130] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 05/05/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Study findings suggest that initiating dialysis at a higher eGFR level in adults with ESRD does not improve survival. It is less clear whether starting dialysis at a higher eGFR is associated with a survival benefit in children with CKD. METHODS To investigate this issue, we performed a retrospective cohort study of pediatric patients aged 1-18 years who, according to the US Renal Data System, started dialysis between 1995 and 2015. The primary predictor was eGFR at the time of dialysis initiation, categorized as higher (eGFR>10 ml/min per 1.73 m2) versus lower eGFR (eGFR≤10 ml/min per 1.73 m2). RESULTS Of 15,170 children, 4327 (29%) had a higher eGFR (median eGFR, 12.8 ml/min per 1.73 m2) at dialysis initiation. Compared with children with a lower eGFR (median eGFR, 6.5 ml/min per 1.73 m2), those with a higher eGFR at dialysis initiation were more often white, girls, underweight or obese, and more likely to have GN as the cause of ESRD. The risk of death was 1.36 times higher (95% confidence interval, 1.24 to 1.50) among children with a higher (versus lower) eGFR at dialysis initiation. The association between timing of dialysis and survival differed by treatment modality-hemodialysis versus peritoneal dialysis (P<0.001 for interaction)-and was stronger among children initially treated with hemodialysis (hazard ratio, 1.56, 95% confidence interval, 1.39 to 1.75; versus hazard ratio, 1.07, 95% confidence interval, 0.91 to 1.25; respectively). CONCLUSIONS In children with ESRD, a higher eGFR at dialysis initiation is associated with lower survival, particularly among children whose initial treatment modality is hemodialysis.
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Affiliation(s)
| | - Kirsten L Johansen
- Division of Nephrology, Department of Medicine, Hennepin Healthcare Medical Center, Minneapolis, Minnesota.,Division of Nephrology, University of Minnesota, Minneapolis, Minnesota; and
| | | | - Bradley A Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | | | | | - Elaine Ku
- Division of Nephrology.,Departments of Pediatrics.,Epidemiology and Biostatistics, and.,Department of Medicine, University of California, San Francisco, California
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Widening the lens to childhood: relevance and lifetime risk of kidney failure. Curr Opin Nephrol Hypertens 2019; 28:233-237. [PMID: 30844883 DOI: 10.1097/mnh.0000000000000494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Lifetime risk of outcomes is emerging as a highly relevant health indicator, even in the context of low absolute risk of disease progression in short time frames. Evidence to support this concept for kidney failure is increasing, with growing emphasis on the long-term impact of risk factors occurring early in life. RECENT FINDINGS Proteinuria and stage of chronic kidney disease (CKD) are now established predictors of CKD progression in children, and youth with type 2 diabetes are emerging as a group at significant risk. Recent population-based studies have also examined the lifetime risk of end-stage renal disease in individuals with any childhood CKD. A recent study found that even in the absence of biomarkers of renal injury, childhood CKD can increase the lifetime risk of end-stage renal disease four-fold, and up to 10-fold in adults less than 40 years of age. SUMMARY Children with CKD are at high lifetime risk of kidney failure and require follow-up. Identifying children at highest lifetime risk through the use of biomarkers and risk equations, and determining the optimal duration and intensity of follow-up requires further research.
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McLeod DJ, Ching CB, Sebastião YV, Greenberg JH, Furth SL, McHugh KM, Becknell B. Common clinical markers predict end-stage renal disease in children with obstructive uropathy. Pediatr Nephrol 2019; 34:443-448. [PMID: 30317433 PMCID: PMC6500428 DOI: 10.1007/s00467-018-4107-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/12/2018] [Accepted: 09/28/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Obstructive uropathy (OU) is a common cause of end-stage renal disease (ESRD) in children. Children who escape the newborn period with mild-to-moderate chronic kidney disease (CKD) continue to be at increased risk. The predictive ability of clinically available markers throughout childhood is poorly defined. METHODS Patients with OU were identified in the Chronic Kidney Disease in Children Study. The primary outcome of interest was renal replacement therapy (RRT) (cases). Controls were age matched and defined as patients within the OU cohort who did not require RRT during study follow-up. RESULTS In total, 27 cases and 41 age-matched controls were identified. Median age at baseline and age at outcome measurement were 10 vs. 16 years, respectively. First available glomerular filtration rate (GFR) (36.9 vs. 53.5 mL/min per 1.73 m2), urine protein/creatinine (Cr) (0.40 vs. 0.22 mg/mg) and microalbumin/Cr (0.58 vs. 0.03 mg/mg), and serum CO2 (20 vs. 22 mmol/L) and hemoglobin (12.4 vs. 13.2 g/dL) differed significantly between cases and controls, respectively. GFR declined 3.07 mL/min per 1.73 m2/year faster in cases compared to that in controls (p < 0.0001). Urine protein/Cr and microalbumin/Cr increased by 0.16 and 0.11 per year more in cases compared to those in controls, respectively (p ≤ 0.001 for both). Serum phosphate increased by 0.11 mg/dL and serum albumin and hemoglobin decreased by 0.04 (g/dL) and 0.14 (g/dL) per year more for cases compared to those for controls, respectively (p < 0.05 for all). CONCLUSIONS Age-specific baseline and longitudinal measures of readily available clinical measures predict progression to ESRD in children with mild-to-moderate CKD from OU.
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Affiliation(s)
- Daryl J. McLeod
- Section of Urology, Nationwide Children’s Hospital, Columbus, OH 43205, USA,Center for Surgical Outcomes Research, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Christina B. Ching
- Section of Urology, Nationwide Children’s Hospital, Columbus, OH 43205, USA,Center for Clinical and Translational Research, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Yuri V. Sebastião
- Center for Surgical Outcomes Research, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Jason H. Greenberg
- Department of Pediatrics, Section of Nephrology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Susan L. Furth
- Department of Pediatrics, Division of Nephrology, Perelman School of Medicine at the University of Pennsylvania and the Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Kirk M. McHugh
- Center for Clinical and Translational Research, Nationwide Children’s Hospital, Columbus, OH 43205, USA,Department of Biomedical Education & Anatomy, Ohio State University College of Medicine, Columbus, OH 43210, USA
| | - Brian Becknell
- Center for Clinical and Translational Research, Nationwide Children’s Hospital, Columbus, OH 43205, USA,Department of Pediatrics, Section of Nephrology, Nationwide Children’s Hospital, Columbus, OH 43205, USA
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Abstract
Chronic kidney disease is an ongoing deterioration of renal function that often progresses to end-stage renal disease. Management goals in children include slowing disease progression, prevention and treatment of complications, and optimizing growth, development, and quality of life. Nutritional management is critically important to achieve these goals. Control of blood pressure, proteinuria, and metabolic acidosis with dietary and pharmacologic measures may slow progression of chronic kidney disease. Although significant progress in management has been made, further research is required to resolve many outstanding controversies. We review recent developments in pediatric chronic kidney disease, focusing on dietary measures to improve outcomes.
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50
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De Rechter S, Bammens B, Schaefer F, Liebau MC, Mekahli D. Unmet needs and challenges for follow-up and treatment of autosomal dominant polycystic kidney disease: the paediatric perspective. Clin Kidney J 2018; 11:i14-i26. [PMID: 30581562 PMCID: PMC6295604 DOI: 10.1093/ckj/sfy088] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/27/2018] [Indexed: 12/11/2022] Open
Abstract
Awareness is growing that the clinical course of autosomal dominant polycystic kidney disease (ADPKD) already begins in childhood, with a broad range of both symptomatic and asymptomatic features. Knowing that parenchymal destruction with cyst formation and growth starts early in life, it seems reasonable to assume that early intervention may yield the best chances for preserving renal outcome. Interventions may involve lifestyle modifications, hypertension control and the use of disease-modifying treatments once these become available for the paediatric population with an acceptable risk and side-effect profile. Until then, screening of at-risk children is controversial and not generally recommended since this might cause psychosocial and financial harm. Also, the clinical and research communities are facing important questions as to the nature of potential interventions and their optimal indications and timing. Indeed, challenges include the identification and validation of indicators, both measuring and predicting disease progression from childhood, and the discrimination of slow from rapid progressors in the paediatric population. This discrimination will improve both the cost-effectiveness and benefit-to-risk ratio of therapies. Furthermore, we will need to define outcome measures, and to evaluate the possibility of a potential therapeutic window of opportunity in childhood. The recently established international register ADPedKD will help in elucidating these questions. In this review, we provide an overview of the current knowledge on paediatric ADPKD as a future therapeutic target population and its unmet challenges.
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Affiliation(s)
- Stéphanie De Rechter
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
- PKD Research Group, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Bert Bammens
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Leuven, Leuven, Belgium
| | - Franz Schaefer
- Division of Pediatric Nephrology, Centre for Pediatrics and Adolescent Medicine, Heidelberg University Medical Centre, Heidelberg, Germany
| | - Max C Liebau
- Department of Pediatrics and Center for Molecular Medicine, University Hospital of Cologne, Cologne, Germany
| | - Djalila Mekahli
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
- PKD Research Group, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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