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Chae HH, Ahmed A, Bone JN, Abdulhussein FS, Amed S, Patel T, Blydt-Hansen TD. Adrenal insufficiency in pediatric kidney transplantation recipients. Pediatr Transplant 2024; 28:e14768. [PMID: 38770694 DOI: 10.1111/petr.14768] [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: 09/27/2023] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Immunosuppression of pediatric kidney transplant (PKT) recipients often includes corticosteroids. Prolonged corticosteroid exposure has been associated with secondary adrenal insufficiency (AI); however, little is known about its impact on PKT recipients. METHODS This was a retrospective cohort review of PKT recipients to evaluate AI prevalence, risk factors, and adverse effects. AI risk was assessed using morning cortisol (MC) and diagnosis confirmed by an ACTH stimulation test. Potential risk factors and adverse effects were tested for associations with MC levels and AI diagnosis. RESULTS Fifty-one patients (60.8% male, age 7.4 (IQR 3.8, 13.1) years; 1 patient counted twice for repeat transplant) were included. Patients at risk for AI (MC < 240 nmol/L) underwent definitive ACTH stimulation testing, confirming AI in 13/51 (25.5%) patients. Identified risk factors for AI included current prednisone dosage (p = .001), 6-month prednisone exposure (p = .02), daily prednisone administration (p = .002), and rejection episodes since transplant (p = .001). MC level (2.5 years (IQR 1.1, 5.1) post-transplant) was associated with current prednisone dosage (p < .001), 6-month prednisone exposure (p = .001), daily prednisone administration (p = .006), rejection episodes since transplant (p = .003), greater number of medications (β = -16.3, p < .001), 6-month hospitalization days (β = -3.3, p = .013), creatinine variability (β = -2.4, p = .025), and occurrence of acute kidney injury (β = -70.6, p = .01). CONCLUSION Greater corticosteroid exposure was associated with a lower MC level and confirmatory diagnosis of AI noted with an ACTH stimulation test. Adverse clinical findings with AI included greater medical complexity and kidney function lability. These data support systematic clinical surveillance for AI in PKT recipients treated with corticosteroids.
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Affiliation(s)
- Hyunwoong Harry Chae
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Azim Ahmed
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey N Bone
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Fatema S Abdulhussein
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Endocrinology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shazhan Amed
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Endocrinology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Trisha Patel
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Endocrinology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tom D Blydt-Hansen
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Nephrology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Bonthuis M, Harambat J, Jager KJ, Vidal E. Growth in children on kidney replacement therapy: a review of data from patient registries. Pediatr Nephrol 2021; 36:2563-2574. [PMID: 34143298 PMCID: PMC8260545 DOI: 10.1007/s00467-021-05099-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
Growth retardation is a major complication in children with chronic kidney disease (CKD) and on kidney replacement therapy (KRT). Conversely, better growth in childhood CKD is associated with an improvement in several hard morbidity-mortality endpoints. Data from pediatric international registries has demonstrated that improvements in the overall conservative management of CKD, the search for optimal dialysis, and advances in immunosuppression and kidney transplant techniques have led to a significant improvement of final height over time. Infancy still remains a critical period for adequate linear growth, and the loss of stature during the first years of life influences final height. Preliminary new original data from the European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry confirm an association between the final height and the height attained at 2 years in children on KRT.
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Affiliation(s)
- Marjolein Bonthuis
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, J1B-108.1, P.O. Box 22700, 1100 DE, Amsterdam, The Netherlands.
| | - Jérôme Harambat
- Department of Pediatrics, Bordeaux University Hospital, Bordeaux Population Health Research Center UMR 1219, University of Bordeaux, Bordeaux, France
| | - Kitty J Jager
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, J1B-108.1, P.O. Box 22700, 1100 DE, Amsterdam, The Netherlands
| | - Enrico Vidal
- Division of Pediatrics, Department of Medicine, University of Udine, Udine, Italy
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Ramsey LB, Janke LJ, Payton MA, Cai X, Paugh SW, Karol SE, Kamdem LK, Cheng C, Williams RT, Jeha S, Pui CH, Evans WE, Relling MV. Antileukemic Efficacy of Continuous vs Discontinuous Dexamethasone in Murine Models of Acute Lymphoblastic Leukemia. PLoS One 2015; 10:e0135134. [PMID: 26252865 PMCID: PMC4529108 DOI: 10.1371/journal.pone.0135134] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/17/2015] [Indexed: 11/24/2022] Open
Abstract
Osteonecrosis is one of the most common, serious, toxicities resulting from the treatment of acute lymphoblastic leukemia. In recent years, pediatric acute lymphoblastic leukemia clinical trials have used discontinuous rather than continuous dosing of dexamethasone in an effort to reduce the incidence of osteonecrosis. However, it is not known whether discontinuous dosing would compromise antileukemic efficacy of glucocorticoids. Therefore, we tested the efficacy of discontinuous dexamethasone against continuous dexamethasone in murine models bearing human acute lymphoblastic leukemia xenografts (n = 8 patient samples) or murine BCR-ABL+ acute lymphoblastic leukemia. Plasma dexamethasone concentrations (7.9 to 212 nM) were similar to those achieved in children with acute lymphoblastic leukemia using conventional dosages. The median leukemia-free survival ranged from 16 to 59 days; dexamethasone prolonged survival from a median of 4 to 129 days in all seven dexamethasone-sensitive acute lymphoblastic leukemias. In the majority of cases (7 of 8 xenografts and the murine BCR-ABL model) we demonstrated equal efficacy of the two dexamethasone dosing regimens; whereas for one acute lymphoblastic leukemia sample, the discontinuous regimen yielded inferior antileukemic efficacy (log-rank p = 0.002). Our results support the clinical practice of using discontinuous rather than continuous dexamethasone dosing in patients with acute lymphoblastic leukemia.
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Affiliation(s)
- Laura B. Ramsey
- Pharmaceutical Sciences Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Laura J. Janke
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Monique A. Payton
- Pharmaceutical Sciences Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Xiangjun Cai
- Pharmaceutical Sciences Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Steven W. Paugh
- Pharmaceutical Sciences Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Seth E. Karol
- Pharmaceutical Sciences Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Landry Kamdem Kamdem
- Harding University College of Pharmacy, Searcy, Arkansas, United States of America
| | - Cheng Cheng
- Biostatistics Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | | | - Sima Jeha
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - William E. Evans
- Pharmaceutical Sciences Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Mary V. Relling
- Pharmaceutical Sciences Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
- * E-mail:
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Mehls O, Hoyer PF. Dosing of glucocorticosteroids in nephrotic syndrome. Pediatr Nephrol 2011; 26:2095-8. [PMID: 21904778 DOI: 10.1007/s00467-011-1993-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 08/08/2011] [Indexed: 12/17/2022]
Affiliation(s)
- Otto Mehls
- University Hospital for Children and Adolescents, Heidelberg, 69120, Germany.
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Pharmacokinetic, pharmacodynamic, and pharmacogenetic determinants of osteonecrosis in children with acute lymphoblastic leukemia. Blood 2010; 117:2340-7; quiz 2556. [PMID: 21148812 DOI: 10.1182/blood-2010-10-311969] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Osteonecrosis is a severe glucocorticoid-induced complication of acute lymphoblastic leukemia treatment. We prospectively screened children (n = 364) with magnetic resonance imaging of hips and knees, regardless of symptoms; the cumulative incidence of any (grade 1-4) versus symptomatic (grade 2-4) osteonecrosis was 71.8% versus 17.6%, respectively. We investigated whether age, race, sex, acute lymphoblastic leukemia treatment arm, body mass, serum lipids, albumin and cortisol levels, dexamethasone pharmacokinetics, and genome-wide germline genetic polymorphisms were associated with symptomatic osteonecrosis. Age more than 10 years (odds ratio, = 4.85; 95% confidence interval, 2.5-9.2; P = .00001) and more intensive treatment (odds ratio = 2.5; 95% confidence interval, 1.2-4.9; P = .011) were risk factors and included as covariates in all analyses. Lower albumin (P = .05) and elevated cholesterol (P = .02) associated with symptomatic osteonecrosis, and severe (grade 3 or 4) osteonecrosis was linked to poor dexamethasone clearance (P = .0005). Adjusting for clinical features, polymorphisms of ACP1 (eg, rs12714403, P = 1.9 × 10(-6), odds ratio = 5.6; 95% confidence interval, 2.7-11.3), which regulates lipid levels and osteoblast differentiation, were associated with risk of osteonecrosis as well as with lower albumin and higher cholesterol. Overall, older age, lower albumin, higher lipid levels, and dexamethasone exposure were associated with osteonecrosis and may be linked by inherited genomic variation.
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Schonder KS, Mazariegos GV, Weber RJ. Adverse effects of immunosuppression in pediatric solid organ transplantation. Paediatr Drugs 2010; 12:35-49. [PMID: 20034340 DOI: 10.2165/11316180-000000000-00000] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Solid organ transplantation is a life-saving treatment for end-stage organ failure in children. Immunosuppressant medications are used to prevent rejection of the organ transplant. However, these medications are associated with significant adverse effects that impact growth and development, quality of life (QOL), and sometimes long-term survival after transplantation. Adverse effects can differ between the immunosuppressants, but many result from the overall state of immunosuppression. Strategies to manage immunosuppressant adverse effects often involve minimizing exposure to the drugs while balancing the risk for rejection. Early recognition of immunosuppressant adverse effects may help to reduce morbidities associated with solid organ transplantation, improve QOL, and possibly increase overall patient survival.
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Affiliation(s)
- Kristine S Schonder
- Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, Pennsylvania 15213, USA.
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Abstract
Growth may be severely impaired in children with chronic renal insufficiency. Since short stature can have major consequences on quality of life and self-esteem, achieving a 'normal' height is a crucial issue for renal transplant recipients. However, despite successful renal transplantation, the final height attained by most recipients is not the calculated target height. Catch-up growth spurts post-transplantation are usually insufficient to compensate for the retardation in growth that has occurred during the pre-transplant period. Longitudinal growth post-transplantation is therefore influenced by the age at transplantation but also by subsequent allograft function and steroid exposure, both of which interfere with the growth hormone/insulin-like growth factor axis. The management of growth retardation in renal transplant recipients includes adequate nutritional intake, correction of metabolic acidosis, prevention of bone disease, steroid-sparing strategies and a supraphysiological dose of recombinant human growth hormone in selected cases.
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Affiliation(s)
- Jérôme Harambat
- Département de Pédiatrie and Inserm U820, Hôpital Edouard-Herriot and Université Claude-Bernard Lyon 1, Lyon, France
| | - Pierre Cochat
- Département de Pédiatrie and Inserm U820, Hôpital Edouard-Herriot and Université Claude-Bernard Lyon 1, Lyon, France
- Département de Pédiatrie, Unité de Néphrologie Pédiatrique, Hôpital Edouard Herriot, place d’Arsonval, 69437 Lyon, France
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Tönshoff B, Höcker B, Weber LT. Steroid withdrawal in pediatric and adult renal transplant recipients. Pediatr Nephrol 2005; 20:409-17. [PMID: 15650883 DOI: 10.1007/s00467-004-1765-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2004] [Revised: 11/02/2004] [Accepted: 11/02/2004] [Indexed: 01/10/2023]
Abstract
Corticosteroids are still a cornerstone in the immunosuppressive regimen in pediatric renal transplant recipients despite their numerous side effects, such as inhibition of longitudinal growth, body disfigurement, arterial hypertension, cardiovascular complications, osteopathy, and others. Previous attempts to spare steroids in cyclosporine (CsA)-based protocols have been associated with an increased risk for acute rejection episodes. The recent introduction of more-potent immunosuppressive medications, such as mycophenolate mofetil (MMF), have, however, renewed interest in steroid-sparing protocols to avoid or ameliorate steroid-associated side effects. Recent studies in Caucasian adult renal transplant recipients receiving CsA and MMF have shown a beneficial effect of late (>/=6 months post transplant) steroid withdrawal on steroid-associated side effects without the burden of an increased rate of acute rejection episodes. These favorable results compared with previous reports in patients on CsA and azathioprine (AZA) can be ascribed to the higher immunosuppressive potency of MMF compared with AZA. We have shown in a retrospective case control study in 40 pediatric renal transplant recipients that late steroid withdrawal is safe and successful in stable patients under an immunosuppressive maintenance therapy with CsA and MMF. The Mid-European Study Group on Pediatric Renal Transplantation and the Arbeitsgemeinschaft fur Padiatrische Nephrologie are currently performing a prospective randomized trial to validate these observations.
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Affiliation(s)
- Burkhard Tönshoff
- University Children's Hospital, Im Neuenheimer Feld 153, 69120 Heidelberg, Germany.
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Chavatte C, Guest G, Proust V, Le Bihan C, Gimenez F, Maisin A, Loirat C, Mogenet A, Bresson JL, Hankard R, Broyer M, Niaudet P, Singlas E. Glucocorticoid pharmacokinetics and growth retardation in children with renal transplants. Pediatr Nephrol 2004; 19:898-904. [PMID: 15197639 DOI: 10.1007/s00467-004-1497-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2003] [Revised: 03/19/2004] [Accepted: 03/24/2004] [Indexed: 10/26/2022]
Abstract
Long-term glucocorticoid treatment contributes to the growth retardation in children after renal transplantation. We investigated whether determination of prednisone (PN) and prednisolone (PL) in plasma and PN, PL, and 6-beta-hydroxyprednisolone (betaOH-PL) in urine could help to predict growth. PN and PL pharmacokinetics were studied in 36 children, from 5 to 15 years of age, receiving daily (D) or alternate-day (AD) oral PN treatment. Statural growth velocity was evaluated over a 1-year period. We compared three groups of children according to the growth kinetics during the study year (catch-up, stable, or decline) for clinical and pharmacokinetic parameters. A multiple linear regression analysis was performed in order to determine pharmacokinetic parameters able to explain height 1 year after inclusion. Height at the beginning of the study, creatinine clearance, and type of D or AD treatment explained 94.2% of height variance 1 year after inclusion. Only PL clearance was associated with growth evolution, but introduction of PL clearance in the multivariate model did not improve the variance of height accounted for by the previous model. We, therefore, do not recommend using glucocorticoid pharmacokinetics to predict growth retardation in children with renal transplantation.
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Affiliation(s)
- Claire Chavatte
- Service Pharmacie, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
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