The prevalence and outcome of children with failure to thrive after pediatric kidney transplantation

Assessment and management of vitamin status in children with CKD stages 2-5, on dialysis and post-transplantation: clinical practice points from the Pediatric Renal Nutrition Taskforce

Children with chronic kidney disease (CKD) are at risk for vitamin deficiency or excess. Vitamin status can be affected by diet, supplements, kidney function, medications, and dialysis. Little is known about vitamin requirements in CKD, leading to practice variation.The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric kidney dietitians and pediatric nephrologists, was established to develop evidence-based clinical practice points (CPPs) to address challenges and to serve as a resource for nutritional care. Questions were formulated using PICO (Patient, Intervention, Comparator, Outcomes), and literature searches undertaken to explore clinical practice from assessment to management of vitamin status in children with CKD stages 2-5, on dialysis and post-transplantation (CKD2-5D&T). The CPPs were developed and finalized using a Delphi consensus approach. We present six CPPs for vitamin management for children with CKD2-5D&T. We address assessment, intervention, and monitoring. We recommend avoiding supplementation of vitamin A and suggest water-soluble vitamin supplementation for those on dialysis. In the absence of evidence, a consistent structured approach to vitamin management that considers assessment and monitoring from dietary, physical, and biochemical viewpoints is needed. Careful consideration of the impact of accumulation, losses, comorbidities, and medications needs to be explored for the individual child and vitamin before supplementation can be considered. When supplementing, care needs to be taken not to over-prescribe. Research recommendations are suggested.

Managing the Nutritional Requirements of the Pediatric End-Stage Kidney Disease Graduate

The pediatric patient with end-stage kidney disease who transitions to the adult dialysis unit or nephrology center requires a unique nutritional focus. Clinicians in the adult center may be faced with complex issues that have often been part of the patient's journey since early childhood. The causes of kidney disease in children are often quite different than those which affect the adult population and may require different nutritional priorities. Abnormal growth including severe short stature, underweight, overweight or obesity, and poor musculature may affect the long-term health and psychosocial well-being of these patients. Nutritional assessment of these patients should include a focus on past growth and anthropometric data, dietary information, including appetite, quality of diet, and assessment of biochemical data through a pediatric lens. This review discusses the unique factors that must be considered when transitioning pediatric patients and notes major recommendations from a compilation of pediatric guideline statements.

Undernutrition and Hypoleptinemia Modulate Alloimmunity and CMV-specific Viral Immunity in Transplantation

BACKGROUND

Immunological mechanisms linking undernutrition to infection and the alloimmune response are poorly understood in transplantation. We aimed to determine how undernutrition and hypoleptinemia impact T-cell allospecific and cytomegalovirus (CMV) viral-specific immunity in a murine model.

METHODS

Fed, fasted for 48 h (model of undernutrition), and fasted with leptin injections (leptin rescue), C57BL/6 mice received skin grafts from either C57BL/6 (syngeneic) or BALB/c (allogeneic) mice donors. Allograft rejection and survival were monitored. Fed, fasted, and leptin rescue C57BL/6 mice were inoculated with murine cytomegalovirus (mCMV). Mouse spleens were retrieved for T-cell flow cytometry analysis, mCMV DNA extraction, and quantitative polymerase chain reaction. Serum leptin levels were measured with ELISA.

RESULTS

Fasted mice had prolonged rejection-free and graft survival compared with fed mice (P = 0.0002 and P = 0.043). Leptin administration did not alter rejection-free survival or allograft failure. CD8+ central memory T cell and CD8+ effector T cell proportions were significantly lower in fasted mice receiving allogeneic skin transplants compared with fed mice (P = 0.0009 and P = 0.0015). Fasted mice had higher viral loads (P = 0.0028) and impaired mCMV-specific interferon-gamma-producing CD8+ T cells (P = 0.0007), which improved with leptin rescue (P = 0.032).

CONCLUSIONS

Undernutrition and its associated hypoleptinemia correlated with impaired allospecific and viral-specific immunities. Leptin administration decreased mCMV viral burden and increased mCMV-specific T-cell immunity, however, it did not increase rejection or worsen graft survival in complete major histocompatibility complex-mismatched skin allografts. Leptin may be a potential adjunctive therapy for CMV viremia in undernourished transplant recipients.

CX3CR1 at V249M and T280M Gene Polymorphism and Its Potential Risk for End-Stage Renal Diseases in Egyptian Patients

CX3CL1-CX3CR1 pathway may be one of the future treatment targets to delay the progression of end-stage renal diseases. This study aimed to evaluate the CX3CR gene polymorphism in Egyptian patients with ESRD and its relation to fractalkine blood level. The study included 100 patients with ESRD on dialysis, 61 males and 39 females with mean age 51.02 ± 7.8 years. The V2491 genotype revealed a significant increase in the frequency of GG genotype in healthy control (83%) compared to patients [69%] with a significant increase in GA in patients [30%] compared to control subjects [15%], P = 0.03. T280M study showed a statistically significant prevalence of TT genotype in healthy control subjects [86%-OR 95% CI 1.7] compared to patients [70%] with a significant increase in the prevalence of TA in patients [29%] compared to control subjects [13%], P = 0.01. There was a significant increase in fractalkine levels in genotypes GA + AA [503.04±224.1] pg/ml compared to genotype GG [423.6 210.3], P = 0.03. Moreover, there was a significant increase in the blood level of fractalkine in genotype TA + AA [498.8 219.6] compared to genotype TT [426.8±212.8], P = 0.05. In conclusion, our study showed that both V2491-GA genotype and T280M-TA are associated with potential risk for end-stage renal disease in Egyptian patients.

Assessment of nutritional status in children with kidney diseases-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

In children with kidney diseases, an assessment of the child's growth and nutritional status is important to guide the dietary prescription. No single metric can comprehensively describe the nutrition status; therefore, a series of indices and tools are required for evaluation. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. Herein, we present CPRs for nutritional assessment, including measurement of anthropometric and biochemical parameters and evaluation of dietary intake. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Audit and research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT.