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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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2
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Eaton CK, Comer M, Pruette CS, Riekert KA. Medication adherence in youths with CKD: habits for success. Pediatr Nephrol 2023; 38:3791-3802. [PMID: 37306720 DOI: 10.1007/s00467-023-05976-0] [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: 10/28/2022] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Poor adherence habits are key contributors to nonadherence but there are few clinically feasible methods for evaluating adherence habits, particularly for youths with chronic kidney disease (CKD). This study investigated how participants' qualitative responses to three interview questions about adherence habits mapped to primary principles of habit formation and objectively measured medication adherence in youths with CKD. METHODS Participants (ages 11-21 years) were recruited from a pediatric nephrology clinic as part of a larger study. Participants' daily objective antihypertensive medication adherence was measured with an electronic pill bottle over a 4-week baseline period. Qualitative interviews about adherence habits and routines were conducted with a subset of participants (N = 18). RESULTS Clear qualitative differences emerged in how participants with high-medium adherence (80-100%) discussed adherence habits compared to participants with low adherence (0-79%). Participants with high-medium adherence discussed situational cues for taking medicine, including locations that cue adherence, step-by-step events leading up to taking medicine, and people who cue adherence. Participants with high-medium adherence regularly described taking medicine as "automatic," "second nature," and a "habit." Participants with low adherence rarely discussed these habit features nor did they explicitly acknowledge currently missing doses. Participants with low adherence tended to discuss challenges with organization and routines for taking medicine. CONCLUSIONS Evaluating patient responses to questions about adherence habits may uncover challenges with adherence habit formation, provide direction for habit-strengthening intervention focused on developing automatic cues for taking medication, and support adherence successes for youths with CKD. CLINICAL TRIAL REGISTRATION NUMBER NCT03651596. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Cyd K Eaton
- Johns Hopkins University School of Medicine, 4200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Margaret Comer
- Johns Hopkins University School of Medicine, 4200 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Cozumel S Pruette
- Johns Hopkins University School of Medicine, 4200 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Kristin A Riekert
- Johns Hopkins University School of Medicine, 4200 Eastern Avenue, Baltimore, MD, 21224, USA
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3
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Zeng M, Di H, Liang J, Liu Z. Effectiveness of renin-angiotensin-aldosterone system blockers in patients with Alport syndrome: a systematic review and meta-analysis. Nephrol Dial Transplant 2023; 38:2485-2493. [PMID: 37218713 DOI: 10.1093/ndt/gfad105] [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: 01/04/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Although renin-angiotensin-aldosterone system (RAAS) blockers have been considered the primary treatment for patients with Alport syndrome (AS) for a decade, there is no comprehensive review with evidence-based analysis evaluating the effectiveness of RAAS blockers in AS. METHODS A systematic review and meta-analysis was performed of published studies that compared outcomes related to disease progression between patients with AS receiving RAAS blockers with those taking non-RAAS treatment. Outcomes were meta-analyzed using the random effects models. Cochrane risk-of-bias, Newcastle-Ottawa Scale and Grading of Recommendations Assessment, Development and Evaluation methodology (GRADE) assessment determined the certainty of evidence. RESULTS A total of eight studies (1182 patients) were included in the analysis. Overall, the risk of bias was low to moderate. Compared with non-RAAS treatment, RAAS blockers could reduce the rate of progression to end-stage kidney disease (ESKD) [four studies; hazard ratio (HR) 0.33, 95% confidence interval (CI) 0.24-0.45; moderate certainty evidence]. After stratified by genetic types, a similar benefit was detected: male X-linked AS (XLAS) (HR 0.32, 95% CI 0.22-0.48), autosomal recessive AS (HR 0.25, 95% CI 0.10-0.62), female XLAS and autosomal dominant AS (HR 0.40, 95% CI 0.21-0.75). In addition, RAAS blockers showed a clear gradient of benefit depending on the stage of disease at the initiation of treatment. CONCLUSION This meta-analysis suggested that RAAS blockers could be considered as a specific therapy to delay of ESKD for AS with any genetic type, especially at the early stage of the disease, and every further more-effective therapy would be advised to be applied on top of this standard of care.
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Affiliation(s)
- Mengyao Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Hongling Di
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Ju Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Antihypertensives in Children and Adolescents. Curr Hypertens Rep 2022; 24:581-587. [PMID: 36114998 DOI: 10.1007/s11906-022-01220-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To review target organ outcomes and current pharmacologic treatment options for children and adolescents with hypertension. RECENT FINDINGS There is an increased prevalence of pediatric hypertension. Following the 2017 AAP clinical practice guidelines, there is a growing body of literature illustrating the association between pediatric hypertension and end organ damage, though few studies looking at long-term outcomes. There is also new data to support the use of n-of-1 trials to identify the best antihypertensive therapy for an individual. Pediatric hypertension is increasing in prevalence and is associated with end organ damage. Treatment of hypertensive children has been shown to reverse end organ damage. Due to the lack of large, randomized trials assessing antihypertensive classes against one another, n-of-1 studies may serve as a viable and safe option to optimize patient care.
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Ateya AM, El Hakim I, Shahin SM, El Borolossy R, Kreutz R, Sabri NA. Effects of Ramipril on Biomarkers of Endothelial Dysfunction and Inflammation in Hypertensive Children on Maintenance Hemodialysis: the SEARCH Randomized Placebo-Controlled Trial. Hypertension 2022; 79:1856-1865. [PMID: 35686561 DOI: 10.1161/hypertensionaha.122.19312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypertension, endothelial dysfunction, and inflammation are associated with increased cardiovascular mortality in end-stage kidney disease. We evaluated the effects of ACE (angiotensin-converting enzyme) inhibition on biomarkers of endothelial dysfunction and inflammation in hypertensive children with end-stage kidney disease on maintenance hemodialysis. METHODS In a randomized, double-blind, placebo-controlled trial, 135 (72 males/63 females) children and adolescents (age 7-15 years) were randomly assigned to treatment with either 2.5 mg once daily ramipril (n=68) or placebo (n=67) for 16 weeks. Primary outcome were the serum concentrations of asymmetrical dimethylarginine, a marker of endothelial dysfunction and hs-CRP (high-sensitivity C-reactive protein), a marker of inflammation. Changes in IL-6 (interleukin-6), TNF-α (tumor necrosis factor-alpha), systolic (S), and diastolic (D) blood pressure were secondary outcomes. Change in potassium levels and incidence of hyperkalemia were among the safety parameters. RESULTS Ramipril, but not placebo, significantly reduced serum levels of asymmetrical dimethylarginine (-79.6%; P<0.001), hs-CRP (-46.5%; P<0.001), IL-6 (-27.1%; P<0.001), and TNF-α (-51.7%; P<0.001). Systolic blood pressure and diastolic blood pressure were significantly lowered in both groups with a greater reduction in children receiving ramipril (median between-group differences -12.0 [95% CI -18.0 to -9.5] and -9.0 [95% CI -12.0 to -4.5]; P<0.001, respectively). Changes in asymmetrical dimethylarginine, hs-CRP, IL-6, or TNF-α in the ramipril group did not significantly correlate with blood pressure reductions. No severe cases of hyperkalemia or other serious treatment-associated adverse events were observed. CONCLUSIONS Ramipril improves biomarkers of endothelial dysfunction and inflammation in hypertensive children on maintenance hemodialysis in addition to its efficacious and safe potential to lower blood pressure. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04582097.
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Affiliation(s)
- Areej Mohamed Ateya
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt (A.M.A., S.M.S., R.E.B., N.A.S.).,Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany (A.M.A., R.K.)
| | - Ihab El Hakim
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt (I.E.H.)
| | - Sara Mahmoud Shahin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt (A.M.A., S.M.S., R.E.B., N.A.S.)
| | - Radwa El Borolossy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt (A.M.A., S.M.S., R.E.B., N.A.S.)
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany (A.M.A., R.K.)
| | - Nagwa Ali Sabri
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt (A.M.A., S.M.S., R.E.B., N.A.S.)
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Assadi F. Rising serum potassium and creatinine concentrations after prescribing renin-angiotensin-aldosterone system blockade: how much should we worry? World J Pediatr 2021; 17:552-554. [PMID: 34476759 DOI: 10.1007/s12519-021-00455-8] [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: 06/29/2021] [Accepted: 08/16/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Farahnak Assadi
- Division of Nephrology, Department of Pediatrics, Rush University Medical Center, 445 E. North Water Street, Suite 1804, Chicago, IL, USA.
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Glenn TW, Riekert KA, Roter D, Eakin MN, Pruette CS, Brady TM, Mendley SR, Tuchman S, Fivush BA, Eaton CK. Engagement and Affective Communication During Pediatric Nephrology Clinic Visits: Associations with Medication Adherence. PATIENT EDUCATION AND COUNSELING 2021; 104:578-584. [PMID: 32948401 PMCID: PMC7933303 DOI: 10.1016/j.pec.2020.08.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To evaluate whether engagement and affective communication among adolescents and young adults (AYAs) with chronic kidney disease (CKD), caregivers, and pediatric nephrology providers during outpatient clinic visits predicts antihypertensive medication adherence. METHODS AYAs (n = 60, M age = 15.4 years, SD = 2.7, 40% female, 43% African American/Black) and caregivers (n = 60, 73% female) attended audio-recorded clinic visits with pediatric nephrologists (n = 12, 75% female). Recordings were analyzed using global affect ratings of the Roter Interactional Analysis System. Antihypertensive medication adherence was monitored electronically before and after clinic visits. A linear regression model evaluated associations between affect ratings and post-visit adherence. RESULTS AYAs took 84% of doses (SD = 20%) pre-visit and 82% of doses (SD = 24%) post-visit. Higher AYA engagement (β = 0.03, p = .01) and the absence of provider negative affect (β=-0.15, p = .04) were associated with higher post-visit adherence, controlling for pre-visit adherence, AYA sex, age, and race, and clustered by provider. CONCLUSIONS Post-visit adherence was higher when AYAs were rated as more engaged and providers as less negative. PRACTICE IMPLICATIONS AYAs with lower engagement may benefit from further adherence assessment. Communication strategies designed to more actively engage AYAs in their care and diminish provider conveyance of negative affect during clinic visits may positively influence adherence among AYAs with CKD.
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Affiliation(s)
- Trevor W Glenn
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA.
| | - Kristin A Riekert
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA.
| | - Debra Roter
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA.
| | - Michelle N Eakin
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA.
| | - Cozumel S Pruette
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA.
| | - Tammy M Brady
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA.
| | - Susan R Mendley
- University of Maryland School of Medicine, Baltimore MD - 655 W Baltimore St S, Baltimore, MD, 21201, USA.
| | - Shamir Tuchman
- Children's National Medical Center, Washington DC - 110 Irving St NW, Washington, DC, 20010, USA.
| | - Barbara A Fivush
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA.
| | - Cyd K Eaton
- Johns Hopkins University School of Medicine, Baltimore MD - 733 N Broadway, Baltimore, MD, 21205, USA.
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Pavlidis G, Papageorgiou SG, Bazani E, Bouchla A, Glezou E, Gkontopoulos K, Thomopoulos T, Pappa V, Vlahakos DV. Discontinuation of the renin-angiotensin system inhibitors improves erythropoiesis in patients with lower-risk myelodysplastic syndromes. Ther Adv Hematol 2021; 12:2040620720958299. [PMID: 33489062 PMCID: PMC7809530 DOI: 10.1177/2040620720958299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/20/2020] [Indexed: 11/15/2022] Open
Abstract
Renin–angiotensin system (RAS) blockade by angiotensin-converting enzyme inhibitors (ACEis) or angiotensin-receptor blockers (ARBs) has been related to anemia in various situations. We aimed to investigate whether discontinuation of RAS inhibitors improves erythropoiesis in patients with lower-risk myelodysplastic syndromes (LR-MDSs). Seventy-four patients with LR-MDS were divided into three groups matched for gender and age. Group A consisted of 20 hypertensive patients who discontinued RAS inhibitors and received alternative medications. Group B consisted of 26 patients who continued to receive ACEi/ARB and Group C included 28 patients (50% hypertensive) never exposed to ACEi/ARB. Half of the patients in each group were under treatment with recombinant human erythropoietin (rHuEPO). Data were collected at baseline and after 3, 6 and 12 months. Group A showed a significant increase in hemoglobin from 10.4 ± 1g/dL at baseline to 12.6 ± 1.2 g/dL after 12 months (p = 0.035) and in hematocrit (31.4 ± 3% versus 37.9 ± 4%, p = 0.002). Incident anemia decreased from 100% at baseline to 60% at 12 months (p = 0.043) despite a concomitant dose reduction in rHuEPO by 18% (p = 0.035). No changes in hemoglobin and hematocrit were observed in both Group B and Group C. In the subset of patients not treated with rHuEPO, improvement of erythropoiesis was found only in Group A, as measured by changes in hemoglobin (11.5 ± 1 g/dL versus 12.4 ± 1.3 g/dL, p = 0.041) and hematocrit (34.5 ± 3% versus 37.1 ± 4%, p = 0.038) after 12 months. In contrast, Group B and Group C decreased hemoglobin and hematocrit after 12 months (p < 0.05). In conclusion, discontinuation of ACEi/ARB in LR-MDS patients is followed by a significant recovery of erythropoiesis after 12 months.
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Affiliation(s)
- George Pavlidis
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Sotirios G Papageorgiou
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", 1 Rimini St., Haidari, Athens, 12462, Greece
| | - Efthimia Bazani
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Anthi Bouchla
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Eirini Glezou
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Konstantinos Gkontopoulos
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Thomas Thomopoulos
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Vasiliki Pappa
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
| | - Demetrios V Vlahakos
- 2nd Department of Internal Medicine - Propaedeutic and Research Unit, National and Kapodistrian University of Athens, Medical School, University General Hospital "Attikon", Athens, Greece
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Effects of losartan and enalapril on serum uric acid and GFR in children with proteinuria. Pediatr Nephrol 2021; 36:3211-3219. [PMID: 33881639 PMCID: PMC8445872 DOI: 10.1007/s00467-021-05045-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/24/2021] [Accepted: 03/04/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Studies have shown that losartan reduces serum uric acid in adults, unlike angiotensin-converting enzyme inhibitors. A previous study demonstrated that losartan and enalapril had comparable effects on proteinuria in children. METHODS We conducted a post hoc analysis of results from a prospective trial in which the proteinuria-reducing effects of losartan and enalapril were compared. We have now evaluated (a) the effects of these medications on SUA in 248 children with proteinuria and (b) the correlation between changes in SUA and eGFR. RESULTS SUA levels after 36 months were found to be increased when compared to baseline in both losartan and enalapril groups. The mean change in SUA from baseline was significantly different at 12 months between 23 hypertensive patients randomised to losartan (3.69% decrease [95% CI 11.31%, 3.93%]) and 24 randomised to enalapril (12.57% increase [95% CI 3.72%, 21.41%]), p = 0.007. This significant difference remained after 24, 30 and 36 months but was observed in the entire group of 248 patients only at 12 months. There was a statistically significant negative correlation between changes in SUA and changes in eGFR at each time point over 36 months. CONCLUSIONS Losartan may have long-term beneficial effects on SUA and eGFR in children with proteinuria.
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Siddiqui S, Malatesta-Muncher R. Hypertension in Children and Adolescents: A Review of Recent Guidelines. Pediatr Ann 2020; 49:e250-e257. [PMID: 32520365 DOI: 10.3928/19382359-20200513-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pediatric hypertension (HTN) is a growing problem worldwide that can be attributed to various risk factors, including the upward trend in obesity and poor lifestyle choices. Pediatric HTN will eventually lead to adult HTN and cardiovascular disease. There is concern that HTN in children and adolescents is often underdiagnosed. This article highlights important risk factors and chronic conditions associated with HTN along with complications such as end organ damage and cardiovascular disease. This article also outlines cost-effective diagnostic evaluations and step-wise treatment options, including nonpharmacological interventions such as lifestyle modifications as well as medical management based on the most recent American Academy of Pediatrics Clinical Practice Guidelines. [Pediatr Ann. 2020;49(6):e250-e257.].
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Arterial Hypertension in Children. Handb Exp Pharmacol 2020. [PMID: 32458136 DOI: 10.1007/164_2020_359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
Abstract
Pharmacological treatment of arterial hypertension in children is mainly based on individual experience, but there is evidence that blocking the angiotensin system reduces systolic and diastolic blood when compared to placebo, and these drugs are safe to use for a short duration, also in children under 6 years of age. Blocking the angiotensin system either by angiotensin-converting enzyme inhibitors or by antagonizing the angiotensin 1 receptor is effective, but did not display a consistent dose-response relationship with escalating doses, but the effective doses are known. Calcium channel antagonists are effective antihypertensives in children, but the evidence is limited. Based on small-sized studies, beta-blockers modestly reduce systolic blood pressure, but have no significant effect on diastolic blood pressure compared to placebo. They act in combination to antagonize reflex tachycardia induced by vasodilators. The most commonly used antihypertensive agents are safe to use in short-term studies.
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12
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Eaton CK, Eakin MN, Coburn S, Pruette CS, Brady TM, Fivush BA, Mendley S, Tuchman S, Riekert KA. Patient Health Beliefs and Characteristics Predict Longitudinal Antihypertensive Medication Adherence in Adolescents With CKD. J Pediatr Psychol 2020; 44:40-51. [PMID: 30252092 DOI: 10.1093/jpepsy/jsy073] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/21/2018] [Indexed: 11/14/2022] Open
Abstract
Objective To investigate longitudinal associations of health beliefs, which included self-efficacy, outcome expectancies, and perceived barriers, and demographic risk factors (i.e., age, gender, race, and family income) with antihypertensive medication adherence in adolescents with chronic kidney disease (CKD) over 24 months. Method The sample included 114 adolescents (M age = 15.03 years, SD = 2.44) diagnosed with CKD. Adolescents reported their self-efficacy for taking medications, medication outcome expectancies, and barriers to adherence at baseline and 12 and 24 months after baseline. Antihypertensive medication adherence was assessed via electronic monitoring for 2 weeks at baseline and 6, 12, 18, and 24 months after baseline. Results Adherence increased and then decreased over the 2-year study period (inverted U-shape). Self-efficacy, outcome expectancies, and barriers did not change over time. Older adolescent age, female gender, African American race, <$50,000 annual family income, and public health insurance were associated with lower adherence. However, family income was the primary demographic risk factor that predicted adherence over time (≥$50,000 annual family income was longitudinally associated with higher adherence). Higher self-efficacy and more positive and less negative outcome expectancies across time were also associated with higher antihypertensive medication adherence across time. Conclusions Clinical interventions should be developed to target medication self-efficacy and outcome expectancies to improve long-term antihypertensive medication adherence in adolescents with CKD. Family income may be considered when conceptualizing contextual factors that likely contribute to adolescents' consistent challenges with medication adherence over time.
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Affiliation(s)
| | | | - Shayna Coburn
- Children's National Health System.,George Washington School of Medicine
| | | | | | | | - Susan Mendley
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health
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Siddiqi N, Shatat IF. Antihypertensive agents: a long way to safe drug prescribing in children. Pediatr Nephrol 2020; 35:2049-2065. [PMID: 31676933 PMCID: PMC7515858 DOI: 10.1007/s00467-019-04314-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/12/2019] [Accepted: 07/23/2019] [Indexed: 01/07/2023]
Abstract
Recently updated clinical guidelines have highlighted the gaps in our understanding and management of pediatric hypertension. With increased recognition and diagnosis of pediatric hypertension, the use of antihypertensive agents is also likely to increase. Drug selection to treat hypertension in the pediatric patient population remains challenging. This is primarily due to a lack of large, well-designed pediatric safety and efficacy trials, limited understanding of pharmacokinetics in children, and unknown risk of prolonged exposure to antihypertensive therapies. With newer legislation providing financial incentives for conducting clinical trials in children, along with publication of pediatric-focused guidelines, literature available for antihypertensive agents in pediatrics has increased over the last 20 years. The objective of this article is to review the literature for safety and efficacy of commonly prescribed antihypertensive agents in pediatrics. Thus far, the most data to support use in children was found for angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), and calcium channel blockers (CCB). Several gaps were noted in the literature, particularly for beta blockers, vasodilators, and the long-term safety profile of antihypertensive agents in children. Further clinical trials are needed to guide safe and effective prescribing in the pediatric population.
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Affiliation(s)
- Nida Siddiqi
- Department of Pharmacy, Sidra Medicine, Doha, Qatar
| | - Ibrahim F. Shatat
- Pediatric Nephrology and Hypertension, Sidra Medicine, HB. 7A. 106A, PO Box 26999, Doha, Qatar ,Weill Cornell College of Medicine-Qatar, Ar-Rayyan, Qatar ,grid.259828.c0000 0001 2189 3475Medical University of South Carolina, Charleston, SC USA
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Gimpel C, Bergmann C, Bockenhauer D, Breysem L, Cadnapaphornchai MA, Cetiner M, Dudley J, Emma F, Konrad M, Harris T, Harris PC, König J, Liebau MC, Marlais M, Mekahli D, Metcalfe AM, Oh J, Perrone RD, Sinha MD, Titieni A, Torra R, Weber S, Winyard PJD, Schaefer F. International consensus statement on the diagnosis and management of autosomal dominant polycystic kidney disease in children and young people. Nat Rev Nephrol 2019; 15:713-726. [PMID: 31118499 PMCID: PMC7136168 DOI: 10.1038/s41581-019-0155-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
These recommendations were systematically developed on behalf of the Network for Early Onset Cystic Kidney Disease (NEOCYST) by an international group of experts in autosomal dominant polycystic kidney disease (ADPKD) from paediatric and adult nephrology, human genetics, paediatric radiology and ethics specialties together with patient representatives. They have been endorsed by the International Pediatric Nephrology Association (IPNA) and the European Society of Paediatric Nephrology (ESPN). For asymptomatic minors at risk of ADPKD, ongoing surveillance (repeated screening for treatable disease manifestations without diagnostic testing) or immediate diagnostic screening are equally valid clinical approaches. Ultrasonography is the current radiological method of choice for screening. Sonographic detection of one or more cysts in an at-risk child is highly suggestive of ADPKD, but a negative scan cannot rule out ADPKD in childhood. Genetic testing is recommended for infants with very-early-onset symptomatic disease and for children with a negative family history and progressive disease. Children with a positive family history and either confirmed or unknown disease status should be monitored for hypertension (preferably by ambulatory blood pressure monitoring) and albuminuria. Currently, vasopressin antagonists should not be offered routinely but off-label use can be considered in selected children. No consensus was reached on the use of statins, but mTOR inhibitors and somatostatin analogues are not recommended. Children with ADPKD should be strongly encouraged to achieve the low dietary salt intake that is recommended for all children.
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Affiliation(s)
- Charlotte Gimpel
- Division of Pediatric Nephrology, Department of General Pediatrics, Adolescent Medicine and Neonatology, Center for Pediatrics, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - Carsten Bergmann
- Department of Medicine IV, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Human Genetics, Bioscientia, Ingelheim, Germany
| | - Detlef Bockenhauer
- University College London, Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - Luc Breysem
- Department of Pediatric Radiology, University Hospital of Leuven, Leuven, Belgium
| | - Melissa A Cadnapaphornchai
- Rocky Mountain Pediatric Kidney Center, Rocky Mountain Hospital for Children at Presbyterian St Luke's Medical Center, Denver, CO, USA
| | - Metin Cetiner
- Department of Pediatrics II, University Hospital Essen, Essen, Germany
| | - Jan Dudley
- Renal Department, Bristol Royal Hospital for Children, Bristol, UK
| | - Francesco Emma
- Division of Nephrology and Dialysis, Ospedale Pediatrico Bambino Gesù-IRCCS, Rome, Italy
| | - Martin Konrad
- Department of General Pediatrics, University Children's Hospital, Münster, Germany
| | - Tess Harris
- PKD International, Geneva, Switzerland
- PKD Charity, London, UK
| | - Peter C Harris
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Jens König
- Department of General Pediatrics, University Children's Hospital, Münster, Germany
| | - Max C Liebau
- Department of Pediatrics and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Matko Marlais
- University College London, Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - Djalila Mekahli
- Department of Pediatric Nephrology, University Hospital of Leuven, Leuven, Belgium
- PKD Research Group, Laboratory of Pediatrics, Department of Development and Regeneration, GPURE, KU Leuven, Leuven, Belgium
| | - Alison M Metcalfe
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
| | - Jun Oh
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ronald D Perrone
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Manish D Sinha
- Kings College London, Department of Paediatric Nephrology, Evelina London Children's Hospital, London, UK
| | - Andrea Titieni
- Department of General Pediatrics, University Children's Hospital, Münster, Germany
| | - Roser Torra
- Department of Nephrology, University of Barcelona, Barcelona, Spain
| | - Stefanie Weber
- Department of Pediatrics, University of Marburg, Marburg, Germany
| | - Paul J D Winyard
- University College London, Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University Hospital, Heidelberg, Germany
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15
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Inhibition of the renin-angiotensin system in the cardiorenal syndrome with anaemia: a double-edged sword. J Hypertens 2019; 37:2145-2153. [PMID: 31490340 DOI: 10.1097/hjh.0000000000002111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
: The term 'cardiorenal syndrome' (CRS) was introduced to describe problems related to the simultaneous existence of heart and renal insufficiency. The prevalence of anaemia in CRS is high and increases the risk of hospitalizations and death. Renin-angiotensin system (RAS) inhibition is the cornerstone therapy in cardiovascular and renal medicine. As angiotensin II regulates both glomerular filtration rate (GFR) and erythropoiesis, RAS inhibition can further deteriorate renal function and lower hematocrit or cause anaemia in patients with heart failure. The aim of this review is to explore the relationship among CRS, anemia and administration of angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) and summarize the evidence suggesting that RAS inhibition may be considered an iatrogenic cause of deterioration of CRS with anemia. It should be emphasized however, that RAS inhibition reduces mortality in both groups with and without worsening of renal function, and therefore, no patient with CRS should be denied an ACEi or ARB trial without careful evaluation.
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16
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Gabriele MM, Koch Nogueira PC. Management of Hypertension in CAKUT: Protective Factor for CKD. Front Pediatr 2019; 7:222. [PMID: 31214554 PMCID: PMC6558057 DOI: 10.3389/fped.2019.00222] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 05/17/2019] [Indexed: 12/01/2022] Open
Abstract
Patients with congenital kidney and urinary tract abnormalities (CAKUT) will often develop end-stage renal disease at some point and the need for renal replacement therapy is associated with high rates of morbidity and mortality. Hence, efforts to slow the progression of the disease are essential. Hypertension has been proven to be an independent risk factor for faster decline of glomerular filtration rate in renal patients, but studies involving only children with CAKUT are scarce. We performed a literature review to explore the association of hypertension with faster chronic kidney disease progression in children with CAKUT and also treatment options in this condition. A recent study reported an annual decline in GFR of 1.8 ml/min/1.73 m2 among hypertensive patients with non-glomerular CKD, compared with 0.8 ml/min/1.73 m2 in normotensive children. A multicenter prospective cohort in Brazil showed that a 1-unit increase in systolic blood pressure Z-score was associated with a 1.5-fold higher risk of disease progression. Since renin-angiotensin-aldosterone system activation is the most important mechanism of hypertension in these children, the first-line therapy involves the use of inhibitors of this axis, including angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers type I, which also promote an anti-fibrotic effect. Recent studies have shown a good safety profile for use in patients with chronic kidney disease and also in those with solitary kidneys. Hypertension is an independent risk factor for kidney disease progression and should be promptly managed for renal protection, especially among patients with CAKUT, the primary cause of chronic kidney disease in the pediatric population.
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Affiliation(s)
- Marina M Gabriele
- Pediatric Nephrology Department, Instituto da Criança Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Paulo C Koch Nogueira
- Pediatric Nephrology Department, UNIFESP-Escola Paulista de Medicina and Samaritano Hospital of São Paulo, São Paulo, Brazil
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17
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Watt KM, Avant D, Sherwin J, Benjamin DK, Hornik C, Benjamin DK, Li JS, Smith PB. Effect of renal function on antihypertensive drug safety and efficacy in children. Pediatr Nephrol 2018; 33:139-146. [PMID: 28779238 PMCID: PMC5700840 DOI: 10.1007/s00467-017-3763-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 06/13/2017] [Accepted: 06/14/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hypertension and chronic kidney disease (CKD) are common comorbidities. Guidelines recommend treating hypertension in children with CKD because it is a modifiable risk factor for subsequent cardiovascular disease. Children with CKD are frequently excluded from antihypertensive drug trials. Consequently, safety and efficacy data for antihypertensive drugs are lacking in children with CKD. METHODS We determined the incidence of adverse events in 10 pediatric antihypertensive trials to determine the effect of renal function on antihypertensive safety and efficacy in children. These trials were submitted to the US Food and Drug Administration from 1998 to 2005. We determined the number and type of adverse events reported during the trials and compared these numbers in participants with normal renal function and those with decreased function (defined as an estimated glomerular filtration rate [eGFR] <90 mL/min/1.73 m2 calculated using the original Schwartz equation). RESULTS Among the 1,703 children in the 10 studies, 315 had decreased renal function. We observed no difference between the two cohorts in the incidence of adverse events or adverse drug reactions related to study drug. Only 5 participants, all with decreased renal function, experienced a serious adverse event; none was recorded by investigators to be study drug-related. Among treated participants, children with decreased renal function who received a high dose of study drug had a significantly larger drop in diastolic blood pressure compared with children with normal renal function. CONCLUSIONS These data show that antihypertensive treatment in children with renal dysfunction can be safe and efficacious, and consideration should be given to their inclusion in selected drug development programs.
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Affiliation(s)
- Kevin M Watt
- Department of Pediatrics, Duke University, Durham, NC, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
| | - Debbie Avant
- Office of Pediatric Therapeutics, Office of the Commissioner, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | | | | | - Christoph Hornik
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel K Benjamin
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Jennifer S Li
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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18
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Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140:peds.2017-1904. [PMID: 28827377 DOI: 10.1542/peds.2017-1904] [Citation(s) in RCA: 1857] [Impact Index Per Article: 265.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.
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Affiliation(s)
- Joseph T Flynn
- Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - David C Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Douglas Blowey
- Children's Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado-Denver and Pediatrician in Chief, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah D de Ferranti
- Director, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan K Flinn
- Consultant, American Academy of Pediatrics, Washington, District of Columbia
| | - Samuel S Gidding
- Cardiology Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine and Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Corinna Rea
- Associate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts
| | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas
| | - Madeline Simasek
- Pediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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19
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Atmaca M, Gulhan B, Korkmaz E, Inozu M, Soylemezoglu O, Candan C, Bayazıt AK, Elmacı AM, Parmaksiz G, Duzova A, Besbas N, Topaloglu R, Ozaltin F. Follow-up results of patients with ADCK4 mutations and the efficacy of CoQ10 treatment. Pediatr Nephrol 2017; 32:1369-1375. [PMID: 28337616 DOI: 10.1007/s00467-017-3634-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 02/18/2017] [Accepted: 02/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND ADCK4-related glomerulopathy is an important differential diagnosis in adolescents with steroid-resistant nephrotic syndrome (SRNS) and/or chronic kidney disease (CKD) of unknown origin. We screened adolescent patients to determine the frequency of ADCK4 mutation and the efficacy of early CoQ10 administration. METHODS A total of 146 index patients aged 10-18 years, with newly diagnosed non-nephrotic proteinuria, nephrotic syndrome, or chronic renal failure and end-stage kidney disease (ESKD) of unknown etiology were screened for ADCK4 mutation. RESULTS Twenty-eight individuals with bi-allelic mutation from 11 families were identified. Median age at diagnosis was 12.4 (interquartile range [IQR] 8.04-19.7) years. Upon first admission, all patients had albuminuria and 18 had CKD (6 ESKD). Eight were diagnosed either through the screening of family members following index case identification or during genetic investigation of proteinuria in an individual with a history of a transplanted sibling. Median age of these 8 patients was 21.5 (range 4.4-39) years. CoQ10 supplementation was administered following genetic diagnosis. Median estimated glomerular filtration rate (eGFR) just before CoQ10 administration was 140 (IQR 117-155) ml/min/1.73m2, proteinuria was 1,008 (IQR 281-1,567) mg/m2/day. After a median follow-up of 11.5 (range 4-21) months following CoQ10 administration, proteinuria was significantly decreased (median 363 [IQR 175-561] mg/m2/day, P=0.025), whereas eGFR was preserved (median 137 [IQR 113-158] ml/min/1.73m2, P=0.61). CONCLUSIONS ADCK4 mutations are one of the most common causes of adolescent-onset albuminuria and/or CKD of unknown etiology in Turkey. CoQ10 supplementation appears efficacious at reducing proteinuria, and may thereby be renoprotective.
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Affiliation(s)
- Mustafa Atmaca
- Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Bora Gulhan
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, 06100, Sihhiye, Ankara, Turkey
| | - Emine Korkmaz
- Nephrogenetics Laboratory, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mihriban Inozu
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, 06100, Sihhiye, Ankara, Turkey
| | - Oguz Soylemezoglu
- Department of Pediatric Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Cengiz Candan
- Division of Pediatric Nephrology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Aysun Karabay Bayazıt
- Division of Pediatric Nephrology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ahmet Midhat Elmacı
- Pediatric Nephrology, Dr Faruk Sukan Maternity and Children's Hospital, Konya, Turkey
| | - Gonul Parmaksiz
- Adana Dr Turgut Noyan Training and Research Center, Başkent University, Adana, Turkey
| | - Ali Duzova
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, 06100, Sihhiye, Ankara, Turkey
| | - Nesrin Besbas
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, 06100, Sihhiye, Ankara, Turkey
| | - Rezan Topaloglu
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, 06100, Sihhiye, Ankara, Turkey
| | - Fatih Ozaltin
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, 06100, Sihhiye, Ankara, Turkey. .,Nephrogenetics Laboratory, Hacettepe University Faculty of Medicine, Ankara, Turkey. .,Hacettepe University Center for Biobanking and Genomics, Ankara, Turkey.
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20
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Fathallah-Shaykh SA. Proteinuria and progression of pediatric chronic kidney disease: lessons from recent clinical studies. Pediatr Nephrol 2017; 32:743-751. [PMID: 27350622 DOI: 10.1007/s00467-016-3448-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/09/2016] [Accepted: 06/10/2016] [Indexed: 12/29/2022]
Abstract
Proteinuria in children with chronic kidney disease (CKD) is common and its etiology differs from that in adults. How proteinuria influences the rate of progression of CKD has been analyzed in multiple retrospective clinical studies and more recently in a few prospective ones. In this review I summarize the results, strengths and weaknesses of each of these studies. The findings of several retrospective studies in children with CKD have confirmed what we have learned from adult studies on the association between proteinuria and worsening kidney function. Larger prospective clinical studies have examined the effects of proteinuria on the rate of decline of kidney function and the risk of end-stage kidney disease. They have also considered children with glomerular and, more importantly, the more common, congenital causes of CKD. Current studies have important strengths but also a few weaknesses that limit the validity of the conclusions which can be drawn. There is still a need for large clinical trials that focus primarily on studying the influence of proteinuria on kidney function and on finding remedies that delay progression.
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Affiliation(s)
- Sahar A Fathallah-Shaykh
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham, 516 Lowder Building, 1600 7th Avenue South, Birmingham, AL, 35233, USA.
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21
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Nourbakhsh N, Mak RH. Steroid-resistant nephrotic syndrome: past and current perspectives. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2017; 8:29-37. [PMID: 29388620 PMCID: PMC5774596 DOI: 10.2147/phmt.s100803] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients with steroid-resistant nephrotic syndrome (SRNS) represent a challenging subset of patients with nephrotic syndrome who often fail standard immunosuppression and have a higher likelihood of progressing to end-stage renal disease. Appropriate treatment of SRNS requires an adequate understanding of the historical treatment, renal histopathology, and genetics associated with the disease. The aim of this review is to present a comprehensive appraisal of the history, role of renal biopsy, genetics, and treatment of SRNS.
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Affiliation(s)
- Noureddin Nourbakhsh
- Division of Pediatric Nephrology, Rady Children's Hospital San Diego, University of California, San Diego, La Jolla, CA, USA
| | - Robert H Mak
- Division of Pediatric Nephrology, Rady Children's Hospital San Diego, University of California, San Diego, La Jolla, CA, USA
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22
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Abstract
In this commentary, I review recent advances in Alport syndrome genetics, diagnostics, and therapeutics. I also offer some opinions regarding strategies to optimize the early identification of affected individuals to promote early therapeutic intervention.
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Affiliation(s)
- Clifford Kashtan
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis, MN, USA
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23
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Snauwaert E, Vande Walle J, De Bruyne P. Therapeutic efficacy and safety of ACE inhibitors in the hypertensive paediatric population: a review. Arch Dis Child 2017; 102:63-71. [PMID: 27682140 DOI: 10.1136/archdischild-2016-310582] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 07/08/2016] [Accepted: 09/04/2016] [Indexed: 11/03/2022]
Abstract
PURPOSE Since 1997, strong incentives have been introduced worldwide to improve access to safe and effective medicines addressing the therapeutic needs of children. ACE inhibitors, the most prescribed antihypertensive drugs in the paediatric population, are one of the prototype drugs targeted by the legislation initiatives. Our purpose in assembling this review is to evaluate and describe the current evidence for the efficacy and safety profile of ACE inhibitors in the paediatric population. METHODS The authors made a descriptive review of the literature from 1980 to 2015 using the following search terms: hypertension, child, paediatric, ACE (inhibitors), renin-angiotensin aldosterone system, captopril, lisinopril, enalapril, ramipril and fosinopril. RESULTS A total of 16 studies evaluating efficacy and safety of ACE inhibitors were included in this review. The included studies demonstrate that ACE inhibitors have the potency to decrease the systolic and/or diastolic blood pressure with an overall favourable safety profile in a short-term period. More importantly, the incentives resulted in an improvement of the overall availability of paediatric labelling, dosing and safety information for ACE inhibitors. However, they failed to fulfil several of paediatric needs: absence of long-term safety data on growth and maturation, absence of commercially available child-friendly formulations and incomplete evaluation of the entire paediatric hypertension population. CONCLUSION Additional efforts are needed to close the gap between the availability of drugs that are labelled and indicated for paediatric use and the actual drug usage in children, especially in young children, neonates and children with severe hypertension, renal transplantation or severe renal impairment.
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Affiliation(s)
- Evelien Snauwaert
- Department of Paediatrics and Medical Genetics, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
| | | | - Pauline De Bruyne
- Department of Paediatrics and Medical Genetics, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
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Erythropoiesis and Blood Pressure Are Regulated via AT1 Receptor by Distinctive Pathways. PLoS One 2015; 10:e0129484. [PMID: 26107632 PMCID: PMC4479565 DOI: 10.1371/journal.pone.0129484] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 05/08/2015] [Indexed: 11/19/2022] Open
Abstract
The renin–angiotensin system (RAS) plays a central role in blood pressure regulation. Although clinical and experimental studies have suggested that inhibition of RAS is associated with progression of anemia, little evidence is available to support this claim. Here we report that knockout mice that lack angiotensin II, including angiotensinogen and renin knockout mice, exhibit anemia. The anemia of angiotensinogen knockout mice was rescued by angiotensin II infusion, and rescue was completely blocked by simultaneous administration of AT1 receptor blocker. To genetically determine the responsible receptor subtype, we examined AT1a, AT1b, and AT2 knockout mice, but did not observe anemia in any of them. To investigate whether pharmacological AT1 receptor inhibition recapitulates the anemic phenotype, we administered AT1 receptor antagonist in hypotensive AT1a receptor knockout mice to inhibit the remaining AT1b receptor. In these animals, hematocrit levels barely decreased, but blood pressure further decreased to the level observed in angiotensinogen knockout mice. We then generated AT1a and AT1b double-knockout mice to completely ablate the AT1 receptors; the mice finally exhibited the anemic phenotype. These results provide clear evidence that although erythropoiesis and blood pressure are negatively controlled through the AT1 receptor inhibition in vivo, the pathways involved are complex and distinct, because erythropoiesis is more resistant to AT1 receptor inhibition than blood pressure control.
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25
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Yanagihara T, Hamada R, Ishikura K, Uemura O, Matsuyama T, Takahashi S, Honda M. Urinary screening and urinary abnormalities in 3-year-old children in Japan. Pediatr Int 2015; 57:354-8. [PMID: 25827222 DOI: 10.1111/ped.12653] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 09/08/2014] [Accepted: 03/18/2015] [Indexed: 11/28/2022]
Abstract
In Japan, urinary screening for preschool children has been obligatory since 1961. The system was reconsidered and has been under review since 2012, because many problems in the system had been identified, and its usefulness was uncertain. In the process, the following were analyzed: (i) frequency of urinary abnormalities identified on screening; (ii) diseases identified from urinary abnormalities; (iii) clinical course of children found to have urinary abnormalities; and (iv) screening for asymptomatic urinary tract infection (UTI) as a way of screening for congenital anomalies of the kidney and urinary tract. A computerized literature search was conducted, and study reports issued by the Ministry of Health, Labour and Welfare study group, and data of Akita City and Chiba City were reviewed. The prevalence of abnormal results at the first urinalysis was high, but at the second urinalysis the prevalence decreased in the range 1/6-1/20. The prevalence of tentative diagnosis at the third urinalysis was similar to the school urinary screening results. Serious illness was not found in children who had hematuria alone. In contrast, diseases requiring immediate attention were found in children with proteinuria, although the prevalence of proteinuria was not high. The dipstick method for leukocyturia was inefficient. The importance of two consecutive urinalyses before detailed examination, the lack of usefulness of screening for hematuria in 3-year-old children, and the importance of proteinuria were confirmed. Screening for asymptomatic UTI using urinary leukocytes was very inefficient.
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Affiliation(s)
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center
| | - Kenji Ishikura
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center
| | - Osamu Uemura
- Department of Pediatric Nephrology, Aichi Children's Health and Medical Center, Aichi, Japan
| | | | - Shori Takahashi
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center
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Fathallah-Shaykh SA, Flynn JT, Pierce CB, Abraham AG, Blydt-Hansen TD, Massengill SF, Moxey-Mims MM, Warady BA, Furth SL, Wong CS. Progression of pediatric CKD of nonglomerular origin in the CKiD cohort. Clin J Am Soc Nephrol 2015; 10:571-7. [PMID: 25635034 DOI: 10.2215/cjn.07480714] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 01/05/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Congenital anomalies of the kidney and urinary tract and genetic disorders cause most cases of CKD in children. This study evaluated the relationships between baseline proteinuria and BP and longitudinal changes in GFR in children with these nonglomerular causes of CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Urine protein-to-creatinine ratio, casual systolic and diastolic BP (normalized for age, sex, and height), and GFR decline were assessed in the prospective CKD in Children cohort study. RESULTS A total of 522 children, median age 10 years (interquartile range, 7, 14 years) with nonglomerular CKD were followed for a median of 4.4 years. The mean baseline GFR in the cohort was 52 ml/min per 1.73 m(2) (95% confidence interval [95% CI], 50 to 54) and declined 1.3 ml/min per 1.73 m(2) per year on average (95%CI, 1.6 to 1.1). A 2-fold higher baseline urine protein-to-creatinine ratio was associated with an accelerated GFR decline of 0.3 ml/min per 1.73 m(2) per year (95% CI, 0.4 to 0.1). A 1-unit higher baseline systolic BP z-score was associated with an additional GFR decline of 0.4 ml/min per 1.73 m(2) per year (95% CI, 0.7 to 0.1). Among normotensive children, larger GFR declines were associated with larger baseline urine protein-to-creatinine ratios; eGFR declines of 0.8 and 1.8 ml/min per 1.73 m(2) per year were associated with urine protein-to-creatinine ratio <0.5 and ≥0.5 mg/mg, respectively. Among children with elevated BP, average GFR declines were evident but were not larger in children with higher levels of proteinuria. CONCLUSIONS Baseline proteinuria and systolic BP levels are independently associated with CKD progression in children with nonglomerular CKD.
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Affiliation(s)
- Sahar A Fathallah-Shaykh
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
| | - Joseph T Flynn
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Christopher B Pierce
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Alison G Abraham
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Tom D Blydt-Hansen
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Susan F Massengill
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Marva M Moxey-Mims
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Bradley A Warady
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Susan L Furth
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Craig S Wong
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Out-of-office blood pressure and target organ damage in children and adolescents. J Hypertens 2014; 32:2315-31; discussion 2331. [DOI: 10.1097/hjh.0000000000000384] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Wong G, Medway M, Didsbury M, Tong A, Turner R, Mackie F, McTaggart S, Walker A, White S, Howard K, Kim S, Craig JC. Health and wealth in children and adolescents with chronic kidney disease (K-CAD study). BMC Public Health 2014; 14:307. [PMID: 24708535 PMCID: PMC4233636 DOI: 10.1186/1471-2458-14-307] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 03/31/2014] [Indexed: 11/30/2022] Open
Abstract
Background The impact of reduced kidney function in children is substantial. End-stage kidney disease (ESKD), the most severe form of chronic kidney disease (CKD), is a devastating illness associated with substantially increased mortality, impaired growth and psychosocial maladjustment in children. Understanding how to address the complex causes of mortality and morbidity in children with CKD requires explicit information about the risk factors that lead to adverse outcomes. In addition to biological influences, the socioeconomic circumstances of caregivers may play a significant role in the health and well-being of children with CKD. Methods/Design A prospective cohort study (n = 380 children and n = 380 caregivers) will be conducted to determine the prevalence of economic hardship among caregivers of children with CKD. All participants will be followed biennially over a period of 5 years to determine the association between the changing socioeconomic status of the caregivers and the health and overall well-being of school-aged children with CKD. Face to face, semi-structured interviews with the caregivers (n = 45) will also be conducted to understand their perspectives on the economic, financial and psychosocial impact of CKD and how this affects the health outcomes of their child with CKD. The primary outcomes of the study are the effects of the socioeconomic status of the caregivers and self-reported health status of the children. Secondary outcomes included the prevalence of economic hardship and the distribution of wealth among the caregivers of children with CKD. Discussion Findings from this study presents not only a snapshot of the current economic and social situation of the caregivers of children and adolescents with CKD but will also provide definitive evidence of determining whether a link between socioeconomic status of caregivers and outcomes of children with CKD exists.
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Affiliation(s)
- Germaine Wong
- Centre for Kidney Research, Kids Research Institute, The Children's Hospital at Westmead, Sydney, Australia.
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Fadrowski JJ, Abraham AG, Navas-Acien A, Guallar E, Weaver VM, Furth SL. Blood lead level and measured glomerular filtration rate in children with chronic kidney disease. ENVIRONMENTAL HEALTH PERSPECTIVES 2013; 121:965-70. [PMID: 23694739 PMCID: PMC3734488 DOI: 10.1289/ehp.1205164] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 05/20/2013] [Indexed: 05/24/2023]
Abstract
BACKGROUND The role of environmental exposure to lead as a risk factor for chronic kidney disease (CKD) and its progression remains controversial, and most studies have been limited by a lack of direct glomerular filtration rate (GFR) measurement. OBJECTIVE We evaluated the association between lead exposure and GFR in children with CKD. METHODS In this cross-sectional study, we examined the association between blood lead levels (BLLs) and GFR measured by the plasma disappearance of iohexol among 391 participants in the Chronic Kidney Disease in Children (CKiD) prospective cohort study. RESULTS Median BLL and GFR were 1.2 µg/dL and 44.4 mL/min per 1.73 m2, respectively. The average percent change in GFR for each 1-µg/dL increase in BLL was -2.1 (95% CI: -6.0, 1.8). In analyses stratified by CKD diagnosis, the association between BLL and GFR was stronger among children with glomerular disease underlying CKD; in this group, each 1-µg/dL increase in BLL was associated with a -12.1 (95% CI: -22.2, -1.9) percent change in GFR. In analyses stratified by anemia status, each 1-µg/dL increase in BLL among those with and without anemia was associated with a -0.3 (95% CI: -7.2, 6.6) and -4.6 (95% CI: -8.9, -0.3) percent change in GFR, respectively. CONCLUSIONS There was no significant association between BLL and directly measured GFR in this relatively large cohort of children with CKD, although associations were observed in some subgroups. Longitudinal analyses are needed to examine the temporal relationship between lead and GFR decline, and to further examine the impact of underlying cause of CKD and anemia/hemoglobin status among patients with CKD.
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Affiliation(s)
- Jeffrey J Fadrowski
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Csohány R, Prókai A, Kosik A, Szabó JA. [The cortical collecting duct plays a pivotal role in the kidney's local renin-angiotensin system]. Orv Hetil 2013; 154:643-9. [PMID: 23608311 DOI: 10.1556/oh.2013.29597] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The renin-angiotensin system is one of the most important hormone systems in the body, and the regulations as well as the role in the juxtaglomerular apparatus are well known. The present review focuses on renin secretion in a recently described localization, the cortical collecting duct. The authors display it in parallel of the copying strategy of an adult and a developing kidney. Furthermore, based on different animal studies it highlights the local role of renin released from the collecting duct. In chronic angiotensin II-infused, 2-kidney, 1-clip hypertensive model as well as in diabetic rats the major source of (pro)renin is indeed the collecting duct. In this localization this hormone can reach both the systemic circulation and the interstitial renin-angiotensin system components including the newly described (pro)renin receptor, by which (pro)renin is able to locally activate pro-fibrotic intracellular signal pathways. Consequently, one can postulate that in the future renin may serve either as a new therapeutic target in nephropathy associated with both hypertension and diabetes or as an early diagnostic marker in chronic diseases leading to nephropathy.
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Affiliation(s)
- Rózsa Csohány
- Semmelweis Egyetem, Általános Orvostudományi Kar, I. Gyermekgyógyászati Klinika és MTA Nefrológiai Kutatólaboratórium, Budapest, Bókay J. u. 53. 1083
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Batisky DL. What is the optimal first-line agent in children requiring antihypertensive medication? Curr Hypertens Rep 2013; 14:603-7. [PMID: 22986908 DOI: 10.1007/s11906-012-0302-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
There has been an evolution in the understanding of the treatment of hypertension in children and adolescents over the past decade. This has been fueled in part by the increased attention paid to the clinical problem, given the increasing numbers of children and adolescents being diagnosed with this condition. There has also been a growing number of clinical trials performed and completed that demonstrate the blood pressure (BP)-lowering effects of antihypertensives and the side effect profiles of these medications, and that has led to FDA-labeling of many antihypertensive medications for use in children and adolescents. However, none of these trials has provided definitive data on the optimal first line agent for this patient population. Clinical experience and other approaches discussed in this review are still necessary to guide treatment of hypertension in the young. The quest for the optimal antihypertensive agent is just beginning, and it is going to take some extraordinary effort to reach that goal.
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Affiliation(s)
- Donald L Batisky
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Spagnolo A, Giussani M, Ambruzzi AM, Bianchetti M, Maringhini S, Matteucci MC, Menghetti E, Salice P, Simionato L, Strambi M, Virdis R, Genovesi S. Focus on prevention, diagnosis and treatment of hypertension in children and adolescents. Ital J Pediatr 2013; 39:20. [PMID: 23510329 PMCID: PMC3615950 DOI: 10.1186/1824-7288-39-20] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 11/16/2012] [Indexed: 12/20/2022] Open
Abstract
The European Society of Hypertension has recently published its recommendations on prevention, diagnosis and treatment of high blood pressure in children and adolescents. Taking this contribution as a starting point the Study Group of Hypertension of the Italian Society of Pediatrics together with the Italian Society of Hypertension has conducted a reappraisal of the most recent literature on this subject. The present review does not claim to be an exhaustive description of hypertension in the pediatric population but intends to provide Pediatricians with practical and updated indications in order to guide them in this often unappreciated problem. This document pays particular attention to the primary hypertension which represents a growing problem in children and adolescents. Subjects at elevated risk of hypertension are those overweight, with low birth weight and presenting a family history of hypertension. However, also children who do not present these risk factors may have elevated blood pressure levels. In pediatric age diagnosis of hypertension or high normal blood pressure is made with repeated office blood pressure measurements that show values exceeding the reference values. Blood pressure should be monitored at least once a year with adequate methods and instrumentation and the observed values have to be interpreted according to the most updated nomograms that are adjusted for children’s gender, age and height. Currently other available methods such as ambulatory blood pressure monitoring and home blood pressure measurement are not yet adequately validated for use as diagnostic instruments. To diagnose primary hypertension it is necessary to exclude secondary forms. The probability of facing a secondary form of hypertension is inversely proportional to the child’s age and directly proportional to blood pressure levels. Medical history, clinical data and blood tests may guide the differential diagnosis of primary versus secondary forms. The prevention of high blood pressure is based on correct lifestyle and nutrition, starting from childhood age. The treatment of primary hypertension in children is almost exclusively dietary/behavioral and includes: a) reduction of overweight whenever present b) reduction of dietary sodium intake c) increase in physical activity. Pharmacological therapy will be needed rarely and only in specific cases.
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Kashtan CE, Ding J, Gregory M, Gross O, Heidet L, Knebelmann B, Rheault M, Licht C. Clinical practice recommendations for the treatment of Alport syndrome: a statement of the Alport Syndrome Research Collaborative. Pediatr Nephrol 2013; 28:5-11. [PMID: 22461141 PMCID: PMC3505543 DOI: 10.1007/s00467-012-2138-4] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 01/29/2012] [Accepted: 01/31/2012] [Indexed: 12/21/2022]
Abstract
We present clinical practice recommendations for the treatment of children with Alport syndrome who are not enrolled in clinical trials. Our goal is to promote early initiation of a standard therapeutic approach that will facilitate assessment of the safety and efficacy of the protocol. The treatment protocol is based on the reduction of proteinuria, intraglomerular pressure, and renal fibrosis via interference with the renin-angiotensin-aldosterone system.
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Affiliation(s)
- Clifford E. Kashtan
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis, MN USA
| | - Jie Ding
- Pediatric Department, Peking University First Hospital, Beijing, People’s Republic of China
| | - Martin Gregory
- Division of Nephrology, University of Utah Health Sciences Center, Salt Lake City, UT USA
| | - Oliver Gross
- Department of Nephrology and Rheumatology, University Medicine Goettingen, Goettingen, Germany
| | - Laurence Heidet
- Centre de référence pour les Maladies Rénales Héréditaires de l’Enfant et de l’Adulte (MARHEA) and Service de Néphrologie Pédiatrique, Hôpital Necker-Enfants malades, Paris, France
| | - Bertrand Knebelmann
- Centre de référence pour les Maladies Rénales Héréditaires de l’Enfant et de l’Adulte (MARHEA) and Service de Néphrologie Pédiatrique, Hôpital Necker-Enfants malades, Paris, France
| | - Michelle Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis, MN USA
| | - Christoph Licht
- The Hospital for Sick Children, Division of Nephrology, Toronto, Canada
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Kruegel J, Rubel D, Gross O. Alport syndrome--insights from basic and clinical research. Nat Rev Nephrol 2012; 9:170-8. [PMID: 23165304 DOI: 10.1038/nrneph.2012.259] [Citation(s) in RCA: 165] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In 1927, Arthur C. Alport first published his description of a triad of symptoms in a family with hereditary congenital haemorrhagic nephritis, deafness and ocular changes. A few years after his death, this group of symptoms was renamed Alport syndrome. To this day, Alport syndrome still inevitably leads to end-stage renal disease and the need for renal replacement therapy, starting in young adulthood. During the past two decades, research into this rare disease has focused on the effects of mutations in collagen type IV and the role of changes in podocytes and the glomerular basement membrane that lead to early kidney fibrosis. Animal models of Alport syndrome also demonstrate the pathogenetic importance of interactions between podocytes and the extracellular matrix. Such models might also help researchers to answer basic questions about podocyte function and the development of fibrosis, and to develop new therapeutic approaches that might be of use in other kidney diseases. In this Review, we discuss the latest basic and clinical research on Alport syndrome, focusing on the roles of podocyte pathology and the extracellular matrix. We also highlight early diagnosis and treatment options for young patients with this disorder.
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Affiliation(s)
- Jenny Kruegel
- Department of Nephrology and Rheumatology, University Medicine Göttingen, Robert-Koch-Straße 40, 37075 Göttingen, Germany
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Matteucci MC, Chinali M, Rinelli G, Wühl E, Zurowska A, Charbit M, Pongiglione G, Schaefer F. Change in cardiac geometry and function in CKD children during strict BP control: a randomized study. Clin J Am Soc Nephrol 2012; 8:203-10. [PMID: 23124781 DOI: 10.2215/cjn.08420811] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Left ventricular hypertrophy (LVH) and abnormal systolic function are present in a high proportion of children with CKD. This study evaluated changes in left ventricular (LV) geometry and systolic function in children with mild to moderate CKD as an ancillary project of the Effect of Strict Blood Pressure Control and ACE Inhibition on Progression of Chronic Renal Failure in Pediatric Patients trial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Echocardiograms and ambulatory BP monitoring were performed at baseline and at 1- or 2-year follow-up in 84 patients with CKD and 24-hour mean BP above the 50th percentile and/or receiving fixed high-dose angiotensin converting enzyme inhibition and randomized to conventional or intensified BP control. RESULTS LVH prevalence decreased from 38% to 25% (P<0.05). Changes in LV mass index (LVMI) were restricted to patients with LVH at baseline (-7.9 g/m(2.7); P<0.02). Changes in LVMI were independent of randomization, reduction in BP, hemoglobin, and estimated GFR. A significant increase in midwall fractional shortening was observed in the total cohort (P<0.05), and was greater in the intensified group compared with the conventional BP control group (12%±1.9% versus 8%±1.5%; P=0.05). In multivariate analysis, improvement in myocardial function was associated with reduction in BP (r=-0.4; P<0.05), independently of LVMI reduction. CONCLUSIONS In children with CKD, angiotensin converting enzyme inhibition with improved BP control, LVH regression, and improved systolic function was observed within 12 months. Lowering BP to the low-normal range led to a slightly more marked improvement in myocardial function but not in LVMI.
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Affiliation(s)
- Maria Chiara Matteucci
- Departments of Pediatric Nephrology and Urology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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Wong CJ, Moxey-Mims M, Jerry-Fluker J, Warady BA, Furth SL. CKiD (CKD in children) prospective cohort study: a review of current findings. Am J Kidney Dis 2012; 60:1002-11. [PMID: 23022429 DOI: 10.1053/j.ajkd.2012.07.018] [Citation(s) in RCA: 153] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 07/02/2012] [Indexed: 11/11/2022]
Abstract
Chronic kidney disease (CKD) is a life-long condition associated with substantial morbidity and premature death due to complications from a progressive decrease in kidney function. The incidence and prevalence of all stages of CKD in children continues to increase worldwide. Between 2000 and 2008, the kidney replacement therapy incidence rate in those aged 0-19 years increased 5.9% to 15 per million population, highlighting the importance of CKD research in children. Many comorbid conditions seen in adults with CKD, including cardiovascular disease and cognitive impairment, also are highly prevalent in children, implicitly demonstrating the crucial need for initiating therapy early to improve health outcomes in children with CKD. The CKiD (Chronic Kidney Disease in Children) Study is a prospective cohort study of 586 children aged 1-16 years with an estimated glomerular filtration rate of 30-90 mL/min/1.73 m(2). Since its inception, CKiD has identified risk factors for CKD progression and cardiovascular disease in children with CKD and highlighted the effects of CKD on outcomes unique to children, including neurocognitive development and growth. This review summarizes the findings to date, illustrating the spectrum of CKD-associated complications in children and emphasizing areas requiring further investigation. Taken in sum, these elements stress that initiating treatment at an early age is essential for reducing long-term morbidity and mortality in children with CKD.
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Affiliation(s)
- Cynthia J Wong
- Department of Pediatrics, Division of Nephrology, Lucile Packard Children's Hospital, Palo Alto, CA, USA.
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Gross O, Friede T, Hilgers R, Görlitz A, Gavénis K, Ahmed R, Dürr U. Safety and Efficacy of the ACE-Inhibitor Ramipril in Alport Syndrome: The Double-Blind, Randomized, Placebo-Controlled, Multicenter Phase III EARLY PRO-TECT Alport Trial in Pediatric Patients. ISRN PEDIATRICS 2012; 2012:436046. [PMID: 22811928 PMCID: PMC3395192 DOI: 10.5402/2012/436046] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Accepted: 04/11/2012] [Indexed: 01/27/2023]
Abstract
Introduction. Retrospective observational data show that ACE-inhibitor therapy delays renal failure and improves life expectancy in Alport patients with proteinuria. The EARLY PRO-TECT Alport trial assesses the safety and efficacy of early therapy onset with ramipril in pediatric Alport patients. Methods and analysis. This double-blind, randomized, placebo-controlled, multicenter phase III trial (NCT01485978; EudraCT-number 2010-024300-10) includes 120 pediatric patients aged 24 months to 18 years with early stages of Alport syndrome (isolated hematuria or microalbuminuria). From March 2012, up to 80 patients will be randomized 1:1 to ramipril or placebo. In the event of disease progression during 3-year treatment, patients are unblinded and ramipril is initiated, if applicable. Approximately 40 patients receive open-label ramipril contributing to the safety database. Primary end-points are “time to progression to next disease level” and “incidence of adverse drug events before disease progression.” Treatment effect estimates from the randomized comparison and Alport registry data will be combined in supportive analyses to maximize evidence. Conclusion. Without this trial, ACE inhibitors may become standard off-label treatment in Alport syndrome without satisfactory evidence base. The results are expected to be of relevance for therapy of all pediatric patients with kidney disease, and the trial protocol might serve as a model for other rare pediatric glomerulopathies.
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Affiliation(s)
- Oliver Gross
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Robert-Koch Stra β e 40, 37075 Göttingen, Germany
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Webb NJA, Shahinfar S, Wells TG, Massaad R, Gleim GW, Santoro EP, Sisk CM, Lam C. Losartan and enalapril are comparable in reducing proteinuria in children. Kidney Int 2012; 82:819-26. [PMID: 22739977 DOI: 10.1038/ki.2012.210] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Angiotensin-converting enzyme inhibitors and angiotensin II type I receptor blockers delay progression of chronic kidney disease and have antiproteinuric effects beyond their effects on blood pressure. They are routinely used in adults; however, their efficacy and safety in children, in whom the causes of chronic kidney disease are significantly different relative to adults, is uncertain. Here we assessed an open-label extension of a previous 3-month blinded trial, in which the efficacy and tolerability of losartan was compared to placebo or amlodipine in 306 normotensive and hypertensive children with proteinuria. In this study, 268 children were re-randomized to losartan or enalapril and followed until 100 patients completed 3 years of follow-up for proteinuria and renal function. The least squares percent mean reduction from baseline in the urinary protein/creatinine ratio was 30.01% for losartan and 40.45% for enalapril. The least squares mean change from baseline in eGFR was 3.3 ml/min per 1.73 m2 for losartan and 7.0 ml/min per 1.73 m2 for enalapril. The incidence of specific adverse events such as hyperkalemia and renal dysfunction was low and similar in both groups. Both were generally well tolerated and, overall, fewer drug-related adverse events occurred with losartan than with enalapril. Thus, in children with proteinuria, losartan and enalapril significantly reduced proteinuria without any appreciable changes in eGFR, effects that were maintained throughout the study. Both losartan and enalapril were generally well tolerated.
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Affiliation(s)
- Nicholas J A Webb
- Department of Paediatric Nephrology and Wellcome Trust Children's Clinical Research Facility, The University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, UK.
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Blowey DL. Update on the Pharmacologic Treatment of Hypertension in Pediatrics. J Clin Hypertens (Greenwich) 2012; 14:383-7. [DOI: 10.1111/j.1751-7176.2012.00659.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Samuels J, Ng D, Flynn JT, Mitsnefes M, Poffenbarger T, Warady BA, Furth S. Ambulatory blood pressure patterns in children with chronic kidney disease. Hypertension 2012; 60:43-50. [PMID: 22585950 DOI: 10.1161/hypertensionaha.111.189266] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ambulatory blood pressure (BP) monitoring (ABPM) is the best method of detecting abnormal BP in patients with chronic kidney disease (CKD), whose hypertension may be missed with casual BP measurements. We report ABPM findings in 332 children 1 year after entry in the Chronic Kidney Disease in Children cohort study. All of the subjects underwent casual and ambulatory BP measurement. BP was categorized based on casual and ABPM results into normal (42%), white-coat (4%), masked (35%), and ambulatory (14%) hypertension. Only half of the subjects had a normal ABPM. BP load was elevated (>25%) in 52% (n = 172), whereas mean BP was elevated in 32% (n = 105). In multivariate analysis, those using an angiotensin-converting enzyme inhibitor were 89% more likely to have a normal ABPM than those who did not report using an angiotensin-converting enzyme inhibitor (odds ratio, 1.89 [95% CI, 1.17-3.04]). For every 20% faster decline in annualized glomerular filtration rate change, the odds of an abnormal ABPM increased 26% (odds ratio, 1.26 [95% CI, 0.97-1.64]). A 2.25-fold increase in urine protein:creatinine ratio annualized change was associated with a 39% higher odds of an abnormal ABPM (odds ratio, 1.39 [95% CI, 1.06-1.82]). Abnormalities on ABPM are common in children with chronic kidney disease and are strongly associated with known risk factors for end-stage renal disease. Individuals on angiotensin-converting enzyme inhibitors were less likely to have abnormal ABPM, suggesting a possible therapeutic intervention. ABPM should be used to monitor risk and guide therapy in children with chronic kidney disease.
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Affiliation(s)
- Joshua Samuels
- University of Texas Health Science Center at Houston, Houston, TX 77030, USA.
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Ono M, Fukuda M, Miura T, Mizuno M, Kato Y, Sato R, Naito T, Togawa H, Sasakawa Y, Tomonari T, Ichikawa T, Shirasawa Y, Ito A, Yoshida A, Kimura G. Predictors of proteinuria reduction by monotherapy with an angiotensin receptor blocker, olmesartan. J Renin Angiotensin Aldosterone Syst 2012; 13:239-43. [PMID: 22333486 DOI: 10.1177/1470320311434817] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION It is known that reduced glomerular filtration rate (GFR) is a crucial factor to limit the blood pressure lowering effect of antihypertensives. In the present study, we tested whether the effects of monotherapy with an angiotensin receptor blocker (ARB) to lower proteinuria could be restricted by reduced GFR. MATERIALS AND METHODS Thirty-five renal patients who had albuminuria more than 30 mg/day, but did not have diabetic nephropathy or nephrotic syndrome, were studied before and during eight weeks of monotherapy with ARB, olmesartan. RESULTS Blood pressure was lowered from 129 ± 18/79 ± 12 to 116 ± 18/72 ± 12 mmHg (p < 0.0001), while albuminuria was reduced from 614±630 to 343±472 mg/day (p < 0.0001). Albuminuria was inversely correlated with GFR both before and during treatment. Albuminuria reduction was enhanced as plasma renin activity (p = 0.047) and dose of olmesartan were increased (p = 0.04). Although the absolute reduction in proteinuria was not correlated with GFR (p = 0.56), the % reduction was significantly proportional with GFR (p = 0.027). Multiple regression analysis demonstrated that 64% of proteinuria reduction could be explained by baseline levels of albuminuria, GFR and renin activity. CONCLUSIONS The reduction in proteinuria by olmesartan may be roughly predicted using baseline GFR and other parameters. These findings clarify that the effect of ARB on proteinuria reduction is restricted by reduced GFR.
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Affiliation(s)
- Minamo Ono
- Department of Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Meyers RS, Siu A. Pharmacotherapy Review of Chronic Pediatric Hypertension. Clin Ther 2011; 33:1331-56. [DOI: 10.1016/j.clinthera.2011.09.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 08/31/2011] [Accepted: 09/05/2011] [Indexed: 12/16/2022]
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Effect of diet, enalapril, or losartan in post-diarrheal hemolytic uremic syndrome nephropathy. Pediatr Nephrol 2011; 26:1247-54. [PMID: 21533629 DOI: 10.1007/s00467-011-1867-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 03/09/2011] [Accepted: 03/10/2011] [Indexed: 10/18/2022]
Abstract
Proteinuria is the main indicator of renal disease progression in many chronic conditions. There is currently little information available on the efficacy, safety, and individual tolerance of patients with post-diarrheal hemolytic uremic syndrome (D+ HUS) nephropathy to therapies involving diet, enalapril, or losartan. A multicenter, double-blind, randomized controlled trail was conducted to evaluate the effect of a normosodic-normoproteic diet (Phase I) and the effect of normosodic-normoproteic diet plus enalapril (0.18-0.27 mg/kg/day) or losartan (0.89-1.34 mg/kg/day) (Phase II) on children with D+ HUS, normal renal function, and persistent, mild (5.1-49.9 mg/kg/day) proteinuria. Dietary intervention reduced the mean protein intake from 3.4 to 2.2 mg/kg/day. Of 137 children, proteinuria normalized in 91 (66.4 %) within 23-45 days; the remaining 46 patients were randomized to diet plus placebo (group 1, n = 16), plus losartan (group 2, n = 16), or enalapril (group 3, n = 14). In groups 1, 2, and 3, proteinuria was reduced by 30.0, 82.0, and 66.3%, respectively, and normalized in six (37.5%), three (81.3%), and 11 (78.6%) patients, respectively (χ(2)= 8.9, p = 0.015). These results suggest that: (1) a normosodic-normoproteic diet can normalize proteinuria in the majority of children with D+ HUS with mild sequelae, (2) the addition of enalapril or losartan to such dietary restrictions of protein further reduces proteinuria, and (3) these therapeutic interventions are safe and well tolerated. Whether these short-term effects can be extended to the long-term remains to be demonstrated.
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Copelovitch L, Warady BA, Furth SL. Insights from the Chronic Kidney Disease in Children (CKiD) study. Clin J Am Soc Nephrol 2011; 6:2047-53. [PMID: 21784815 PMCID: PMC4898858 DOI: 10.2215/cjn.10751210] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Over the last 5 years, the Chronic Kidney Disease in Children (CKiD) prospective cohort study has enrolled close to 600 children ages 1 to 16 years with mild to moderate chronic kidney disease (CKD). The main purpose of this interim report is to review the initial cross-sectional data and conclusions derived from the clinical studies conducted within CKiD in the context of findings from other pediatric CKD and end-stage renal disease (ESRD) registry and cohort studies. In particular, special emphasis was placed on studying four aspects of chronic kidney disease in children, including the identification of risk factors related to disease progression, the impact of CKD on neurocognition and quality of life (QoL), the cardiovascular morbidity associated with CKD, and identifying the causes and effects of growth failure in the context of mild to moderate kidney failure.
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Kanitkar M. Chronic Kidney Disease in Children: An Indian Perspective. Med J Armed Forces India 2011; 65:45-9. [PMID: 27408190 DOI: 10.1016/s0377-1237(09)80055-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Accepted: 08/09/2008] [Indexed: 01/10/2023] Open
Affiliation(s)
- M Kanitkar
- Professor & Head (Department of Pediatrics), Armed Forces Medical College, Pune-411040
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Hladunewich MA, Schaefer F. Proteinuria in special populations: pregnant women and children. Adv Chronic Kidney Dis 2011; 18:267-72. [PMID: 21782133 DOI: 10.1053/j.ackd.2011.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 06/17/2011] [Accepted: 06/22/2011] [Indexed: 12/17/2022]
Abstract
Proteinuria is the hallmark of glomerular kidney disease. It is used diagnostically to follow disease progression and to determine response to therapy. Thus, it is necessary to have an understanding of the mechanisms of proteinuria and the limitations to its accurate assessment in special populations. In this article, we review 2 special populations--pregnant women and children--providing insight into their unique circumstances that require consideration when assessing proteinuria.
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Webb NJA, Lam C, Shahinfar S, Strehlau J, Wells TG, Gleim GW, Le Bailly De Tilleghem C. Efficacy and safety of losartan in children with Alport syndrome--results from a subgroup analysis of a prospective, randomized, placebo- or amlodipine-controlled trial. Nephrol Dial Transplant 2011; 26:2521-6. [DOI: 10.1093/ndt/gfq797] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Congenital anomalies of the kidney and urinary tract anatomy (CAKUT) are common in children and represent approximately 30% of all prenatally diagnosed malformations. CAKUT is phenotypically variable and can affect the kidney(s) alone and/or the lower urinary tract. The spectrum includes more common anomalies such as vesicoureteral reflux and, rarely, more severe malformations such as bilateral renal agenesis. In young children, congenital anomalies are the leading cause of kidney failure and for kidney transplantation or dialysis. CAKUT can also lead to significant renal problems in adulthood and may present itself with hypertension and/or proteinuria. Congenital renal anomalies can be sporadic or familial, syndromic (also affecting nonrenal or non-urinary tract tissues), or nonsyndromic. Genetic causes have been identified for the syndromic forms and have shed some light into the molecular mechanisms of kidney development in human beings. The genetic causes for the more common nonsyndromic forms of CAKUT are unknown. The role of prenatal interventions and postnatal therapies as well as the benefits of screening affected individuals and their family members are not clear.
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Affiliation(s)
- Hakan R Toka
- Renal Division, Brigham and Women's Hospital, Boston, MA 02115, USA.
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