Medication adherence and growth in children with CKD

Growth hormone in pediatric chronic kidney disease: more than just height

Recombinant human growth hormone therapy, which was introduced in the 1980s, is now routine for children with advanced chronic kidney disease (CKD) who are exhibiting growth impairment. Growth hormone usage remains variable across different centers, with some showing low uptake. Much of the focus on growth hormone supplementation has been on increasing height because of social and psychological effects of short stature. There are, however, numerous other changes that occur in CKD that have not received as much attention but are biologically important for pediatric growth and development. This article reviews the current knowledge about the multisystem effects of growth hormone therapy in pediatric patients with CKD and highlights areas where additional clinical research is needed. We also included clinical data on children and adults who had received growth hormone for other indications apart from CKD. Ultimately, having robust clinical studies which examine these effects will allow children and their families to make more informed decisions about this therapy.

Antihypertensive medication nonadherence and target organ damage in children with chronic kidney disease

BACKGROUND

Nonadherence is common in children with chronic kidney disease (CKD). This may contribute to inadequate blood pressure control and adverse outcomes. This study examined associations between antihypertensive medication nonadherence, ambulatory blood pressure monitoring (ABPM) parameters, kidney function, and cardiac structure among children with CKD.

METHODS

We performed secondary analyses of data from the CKD in Children (CKiD) study, including participants with treated hypertension who underwent ABPM, laboratory testing, and echocardiography biannually. Nonadherence was defined by self-report of any missed antihypertensive medication 7 days prior to the study visit. Linear regression and mixed-effects models were used to assess the association of nonadherence with baseline and time-updated ABPM profiles, estimated glomerular filtration rate (eGFR), urine protein to creatinine ratio (UPCR), and left ventricular mass index (LVMI).

RESULTS

Five-hundred and eight participants met inclusion criteria, followed for a median of 2.9 years; 212 (42%) were female, with median age 13 years (IQR 10-16), median baseline eGFR 49 (33-64) ml/min/1.73 m2 and median UPCR 0.4 (0.1-1.0) g/g. Nonadherence occurred in 71 (14%) participants. Baseline nonadherence was not significantly associated with baseline 24-h ABPM parameters (for example, mean 24-h SBP [β - 0.1, 95% CI - 2.7, 2.5]), eGFR (β 1.0, 95% CI - 0.9, 1.2), UCPR (β 1.1, 95% CI - 0.8, 1.5), or LVMI (β 0.6, 95% CI - 1.6, 2.9). Similarly, there were no associations between baseline nonadherence and time-updated outcome measures.

CONCLUSIONS

Self-reported antihypertensive medication nonadherence occurred in 1 in 7 children with CKD. We found no associations between nonadherence and kidney function or cardiac structure over time. A higher resolution version of the Graphical abstract is available as Supplementary information.

Response to oral iron therapy in children with anemia of chronic kidney disease

BACKGROUND

Anemia is a common complication of chronic kidney disease (CKD) and oral iron is recommended as initial therapy. However, response to iron therapy in children with non-dialysis CKD has not been formally assessed.

METHODS

We reviewed medical records of pediatric patients with stages II-IV CKD followed in two New York metropolitan area medical centers between 2010 and 2020 and identified subjects who received oral iron therapy. Response to therapy at follow-up visits was assessed by improvement of hemoglobin, resolution of anemia by the 2012 KDIGO definition, and changes in iron status. Potential predictors of response were examined using regression analyses (adjusted for age, sex, eGFR, and center).

RESULTS

Study criteria were met by 65 children (median age 12 years, 35 males) with a median time between visits of 81 days. Median eGFR was 44 mL/min/1.73 m2, and 40.7% had glomerular CKD etiology. Following iron therapy, hemoglobin improved from 10.2 to 10.8 g/dL (p < 0.001), hematocrit from 31.3 to 32.8% (p < 0.001), serum iron from 49 to 66 mcg/dL (p < 0.001), and transferrin saturation from 16 to 21.4% (p < 0.001). There was no significant change in serum ferritin (55.0 to 44.9 ng/mL). Anemia (defined according to KDIGO) resolved in 29.3% of children. No improvement in hemoglobin/hematocrit was seen in 35% of children, and no transferrin saturation improvement in 26.9%. There was no correlation between changes in hemoglobin and changes in transferrin saturation/serum iron, but there was an inverse correlation between changes in hemoglobin and changes in ferritin. The severity of anemia and alkaline phosphatase at baseline inversely correlated with treatment response.

CONCLUSIONS

Anemia was resistant to 3 months of oral iron therapy in ~ 30% of children with CKD. Children with more severe anemia at baseline had better treatment response, calling for additional studies to refine approaches to iron therapy in children with anemia of CKD and to identify additional predictors of treatment response.

Iron therapy mitigates chronic kidney disease progression by regulating intracellular iron status of kidney macrophages

Systemic iron metabolism is disrupted in chronic kidney disease (CKD). However, little is known about local kidney iron homeostasis and its role in kidney fibrosis. Kidney-specific effects of iron therapy in CKD also remain elusive. Here, we elucidate the role of macrophage iron status in kidney fibrosis and demonstrate that it is a potential therapeutic target. In CKD, kidney macrophages exhibited depletion of labile iron pool (LIP) and induction of transferrin receptor 1, indicating intracellular iron deficiency. Low LIP in kidney macrophages was associated with their defective antioxidant response and proinflammatory polarization. Repletion of LIP in kidney macrophages through knockout of ferritin heavy chain (Fth1) reduced oxidative stress and mitigated fibrosis. Similar to Fth1 knockout, iron dextran therapy, through replenishing macrophage LIP, reduced oxidative stress, decreased the production of proinflammatory cytokines, and alleviated kidney fibrosis. Interestingly, iron markedly decreased TGF-β expression and suppressed TGF-β-driven fibrotic response of macrophages. Iron dextran therapy and FtH suppression had an additive protective effect against fibrosis. Adoptive transfer of iron-loaded macrophages alleviated kidney fibrosis, validating the protective effect of iron-replete macrophages in CKD. Thus, targeting intracellular iron deficiency of kidney macrophages in CKD can serve as a therapeutic opportunity to mitigate disease progression.

A review of ferric citrate clinical studies, and the rationale and design of the Ferric Citrate and Chronic Kidney Disease in Children (FIT4KiD) trial

Pediatric chronic kidney disease (CKD) is characterized by many co-morbidities, including impaired growth and development, CKD-mineral and bone disorder, anemia, dysregulated iron metabolism, and cardiovascular disease. In pediatric CKD cohorts, higher circulating concentrations of fibroblast growth factor 23 (FGF23) are associated with some of these adverse clinical outcomes, including CKD progression and left ventricular hypertrophy. It is hypothesized that lowering FGF23 levels will reduce the risk of these events and improve clinical outcomes. Reducing FGF23 levels in CKD may be accomplished by targeting two key stimuli of FGF23 production-dietary phosphate absorption and iron deficiency. Ferric citrate is approved for use as an enteral phosphate binder and iron replacement product in adults with CKD. Clinical trials in adult CKD cohorts have also demonstrated that ferric citrate decreases circulating FGF23 concentrations. This review outlines the possible deleterious effects of excess FGF23 in CKD, summarizes data from the adult CKD clinical trials of ferric citrate, and presents the Ferric Citrate and Chronic Kidney Disease in Children (FIT4KiD) study, a randomized, placebo-controlled trial to evaluate the effects of ferric citrate on FGF23 in pediatric patients with CKD stages 3-4 (ClinicalTrials.gov Identifier NCT04741646).

Erythropoiesis-independent effects of iron in chronic kidney disease

Chronic kidney disease (CKD) leads to alterations of iron metabolism, which contribute to the development of anemia and necessitates iron supplementation in patients with CKD. Elevated hepcidin accounts for a significant iron redistribution in CKD. Recent data indicate that these alterations in iron homeostasis coupled with therapeutic iron supplementation have pleiotropic effects on many organ systems in patients with CKD, far beyond the traditional hematologic effects of iron; these include effects of iron on inflammation, oxidative stress, kidney fibrosis, cardiovascular disease, CKD-mineral and bone disorder, and skeletal growth in children. The effects of iron supplementation appear to be largely dependent on the route of administration and on the specific iron preparation. Iron-based phosphate binders exemplify the opportunity for using iron for both traditional (anemia) and novel (hyperphosphatemia) indications. Further optimization of iron therapy in patients with CKD may inform new approaches to the treatment of CKD complications and potentially allow modification of disease progression.

Growth hormone treatment in the pre-transplant period is associated with superior outcome after pediatric kidney transplantation

BACKGROUND

Recombinant human growth hormone (rhGH) is frequently used for treatment of short stature in children with chronic kidney disease (CKD) prior to kidney transplantation (KT). To what extent this influences growth and transplant function after KT is yet unknown.

METHODS

Post-transplant growth (height, sitting height, leg length) and clinical parameters of 146 CKD patients undergoing KT before the age of 8 years, from two German pediatric nephrology centers, were prospectively investigated with a mean follow-up of 5.56 years. Outcome in patients with (rhGH group) and without (non-prior rhGH group) prior rhGH treatment was assessed by the use of linear mixed-effects models.

RESULTS

Patients in the rhGH group spent longer time on dialysis and less frequently underwent living related KT compared to the non-prior rhGH group but showed similar height z-scores at the time of KT. After KT, steroid exposure was lower and increments in anthropometric z-scores were significantly higher in the rhGH group compared to those in the non-prior rhGH group, although 18% of patients in the latter group were started on rhGH after KT. Non-prior rhGH treatment was associated with a faster decline in transplant function, lower hemoglobin, and higher C-reactive protein levels (CRP). After adjustment for these confounders, growth outcome did statistically differ for sitting height z-scores only.

CONCLUSIONS

Treatment with rhGH prior to KT was associated with superior growth outcome in prepubertal kidney transplant recipients, which was related to better transplant function, lower CRP, less anemia, lower steroid exposure, and earlier maturation after KT. A higher resolution version of the Graphical abstract is available as Supplementary information.

Patterns of recombinant growth hormone therapy use and growth responses among children with chronic kidney disease

BACKGROUND

Recombinant growth hormone (rGH) is an efficacious therapy for growth failure in children with chronic kidney disease (CKD). We described rGH use and estimated its relationship with growth and kidney function in the Chronic Kidney Disease in Children (CKiD) cohort.

METHODS

Participants included those with growth failure, prevalent rGH users, and rGH initiators who did not meet growth failure criteria. Among those with growth failure, height z scores and GFR were compared between rGH initiators and non-initiators across 42 months. Inverse probability weights accounted for differences in baseline variables in weighted linear regressions.

RESULTS

Among 148 children with growth failure and no previous rGH therapy, 42 (28%) initiated rGH therapy. Of the initiators, average age was 8.9 years, height z score was 2.50 standard deviations (SDs) (0.6^th percentile), and GFR was 44 ml/min/1.73m². They were compared to 106 children with growth failure who never initiated therapy (8.8 years, -2.33 SDs, and 51 ml/min/1.73m²). At 30 and 42 months after rGH, height increased +0.26 (95%CI: -0.11, +0.62) and +0.35 (95%CI: -0.17, +0.87) SDs, respectively, relative to those who did not initiate rGH. rGH was not associated with GFR.

CONCLUSIONS

Participants with growth failure receiving rGH experienced significant growth, although this was attenuated relative to RCTs, and were more likely to have higher household income and lower GFR. A substantial number of participants, predominantly boys, without diagnosed growth failure received rGH and had the highest achieved height relative to mid-parental height. Since rGH was not associated with accelerated GFR decline, increasing rGH use in this population is warranted.

Determinants of growth after kidney transplantation in prepubertal children

BACKGROUND

Short stature is a frequent complication after pediatric kidney transplantation (KT). Whether the type of transplantation and prior treatment with recombinant human growth hormone (GH) affects post-transplant growth, is unclear.

METHODS

Body height, leg length, sitting height, and sitting height index (as a measure of body proportions) were prospectively investigated in 148 prepubertal patients enrolled in the CKD Growth and Development study with a median follow-up of 5.0 years. We used linear mixed-effects models to identify predictors for body dimensions.

RESULTS

Pre-transplant Z scores for height (- 2.18), sitting height (- 1.37), and leg length (- 2.30) were reduced, and sitting height index (1.59) was increased compared to healthy children, indicating disproportionate short stature. Catch-up growth in children aged less than 4 years was mainly due to stimulated trunk length, and in older children to improved leg length, resulting in normalization of body height and proportions before puberty in the majority of patients. Use of GH in the pre-transplant period, congenital CKD, birth parameters, parental height, time after KT, steroid exposure, and transplant function were significantly associated with growth outcome. Although, unadjusted growth data suggested superior post-transplant growth after (pre-emptive) living donor KT, this was no longer true after adjusting for the abovementioned confounders.

CONCLUSIONS

Catch-up growth after KT is mainly due to stimulated trunk growth in young children (< 4 years) and improved leg growth in older children. Beside transplant function, steroid exposure and use of GH in the pre-transplant period are the main potentially modifiable factors associated with better growth outcome.

Carbonyl iron and iron dextran therapies cause adverse effects on bone health in juveniles with chronic kidney disease

Anemia is a frequent complication of chronic kidney disease (CKD), related in part to the disruption of iron metabolism. Iron therapy is very common in children with CKD and excess iron has been shown to induce bone loss in non-CKD settings, but the impact of iron on bone health in CKD remains poorly understood. Here, we evaluated the effect of oral and parenteral iron therapy on bone transcriptome, bone histology and morphometry in two mouse models of juvenile CKD (adenine-induced and 5/6-nephrectomy). Both modalities of iron therapy effectively improved anemia in the mice with CKD, and lowered bone Fgf23 expression. At the same time, iron therapy suppressed genes implicated in bone formation and resulted in the loss of cortical and trabecular bone in the mice with CKD. Bone resorption was activated in untreated CKD, but iron therapy had no additional effect on this. Furthermore, we assessed the relationship between biomarkers of bone turnover and iron status in a cohort of children with CKD. Children treated with iron had lower levels of circulating biomarkers of bone formation (bone-specific alkaline phosphatase and the amino-terminal propeptide of type 1 procollagen), as well as fewer circulating osteoblast precursors, compared to children not treated with iron. These differences were independent of age, sex, and glomerular filtration rate. Thus, iron therapy adversely affected bone health in juvenile mice with CKD and was associated with low levels of bone formation biomarkers in children with CKD.

Strategies for Optimizing Growth in Children With Chronic Kidney Disease

Growth failure is a hallmark in children with chronic kidney disease (CKD). Therefore, early diagnosis and adequate management of growth failure is of utmost importance in these patients. The risk of severe growth retardation is the higher the younger the child is, which places an additional burden on patients and their families and hampers the psychosocial integration of these children. Careful monitoring of growth, and effective interventions are mandatory to prevent and treat growth failure in children with CKD at all ages and all stages of kidney failure. Early intervention is critical, as all therapeutic interventions are much more effective if they are started prior to the initiation of dialysis. Prevention and treatment of growth failure focuses on: (i) preservation of renal function, e.g., normalization of blood pressure and proteinuria by use of inhibitors of the renin-angiotensin aldosterone system, (ii) adequate energy intake, including tube feeding or gastrostomy in case of persisting malnutrition, (iii) substitution of water and electrolytes, especially in children with renal malformation, (iv) correction of metabolic acidosis, (v) control of parathyroid hormone levels within the CKD-dependent target range, (vi) use of recombinant human growth hormone in cases of persistent growth failure, and, (vii) early/preemptive kidney transplantation using steroid-minimizing immunosuppressive protocols in children with end-stage CKD. This review discusses these measures based on recent guidelines.

Summary of Expert Opinion on the Management of Children With Chronic Kidney Disease and Growth Failure With Human Growth Hormone

Background: The management of children and adolescents with chronic kidney disease (CKD) and growth failure candidate for recombinant human growth hormone therapy (rhGH) is based on an appraisal of the literature established on a 2006 consensus statement and 2019 Clinical practice recommendations. The performance of these guidelines has never been tested. Aims: The objective of this study was to establish the level of adherence to international guidelines based on the 2006 consensus and the 2019 criteria that lead to the initiation of growth hormone treatment by both pediatric endocrinologists and pediatric nephrologists. Methods: A multidisciplinary team of pediatric endocrinologists and pediatric nephrologists, members of the Italian Society of Pediatric Endocrinology or of the Italian Society of Pediatric Nephrology, discussed and reviewed the main issues related to the management of pediatric patients with CKD who need treatment with rhGH. Experts developed 11 questions focusing on risk assessment and decision makings in October 2019 and a survey was sent to forty pediatric endocrinologists (n = 20) and nephrologists (n = 20) covering the whole national territory. The results were then analyzed and discussed in light of current clinical practice guidelines and recent recommendations. Results: Responses were received from 32 of the 40 invited specialists, 17 of whom were pediatric endocrinologists (42.5%) and 15 pediatric nephrologists (37.5%). Although all the centers that participated in the survey agreed to follow the clinical and biochemical diagnostic work-up and the criteria for the treatment of patients with CKD, among the Italian centers there was a wide variety of decision-making processes. Conclusions: Despite current guidelines for the management of children with CKD and growth failure, its use varies widely between centers and rhGH is prescribed in a relatively small number of patients and rarely after kidney transplantation. Several raised issues are not taken into account by international guidelines and a multidisciplinary approach with mutual collaboration between specialists will improve patient care based on their unmet needs.

Nonadherence after pediatric renal transplantation: detection and treatment

PURPOSE OF REVIEW

Nonadherence is a problem in adolescents and young adults. Risk factors are classified as those of the individual, family, health-care-system, or community. I present the latest reports and how to tackle nonadherence.

RECENT FINDINGS

Nonadherence risk is independent of one's origin in a high-poverty or low-poverty neighborhood or having private or public insurance in respect to African Americans. Females with male grafts have higher graft-failure risks than do males. Female recipients aged 15-24 with grafts from female donors have higher graft-failure risk than do males. In study of nonadherence risks, such findings must be taken into account. Antibody-mediated rejection is seen in nonadherence. The sirolimus and tacrolimus coefficient of variation is associated with nonadherence, donor-specific antibodies, and rejection. Adolescents had electronically monitored compliance reported by e-mail, text message or visual dose reminders and meetings with coaches. These patients had significantly greater odds of taking medication than did controls. Transition programs have an impact on renal function and rejection episodes.

SUMMARY

Individual risk factors are many, and methods for measuring nonadherence exist. Each transplant center should have a follow-up program to measure nonadherence, especially in adolescence, and a transition program to adult care.

Adherence to long-term use of renin-angiotensin II-aldosterone system inhibitors in children with chronic kidney disease

BACKGROUND

Although renin-angiotensin II-aldosterone system inhibitor (RASI) use for renal protection is well-documented, adherence to RASI therapy in the pediatric population is unclear. This study aimed to evaluate patient characteristics associated with adherence to chronic RASI use in patients with childhood chronic kidney disease (CKD).

METHODS

Childhood CKD was identified using ICD-9 codes in the population-based, Taiwan national health insurance research database between 1997 and 2011. Patients continuously receiving RASIs for ≥3 months without interruption > 30 days after CKD diagnosis were defined as incident users. Medication adherence was measured as the proportion of days covered (PDC) by RASI prescription refills during the study period. Multivariate logistic regression was employed to assess the odds for adherence (PDC ≥80%) to RASI refills.

RESULTS

Of 1271 incident users of RASI chronic therapy, 16.9% (n = 215) had PDC ≥80%. Compared to the group with PDC < 80%, patients in the high adherence group more often had proteinuria (aOR [adjusted odds ratio]1.93; 95%CI [confidence interval], 1.18-3.17), anemia (aOR, 1.76; 95% CI, 1.20-2.58), and time to start of chronic use > 2 years (aOR, 1.12; 95%CI, 1.06-1.19). Odds of being non-adherent were increased by hypertension and older ages (comparing to < 4 years) at start of chronic use, 9-12 years (aOR, 0.38; 95%CI, 0.17-0.82), 13-17 years (aOR, 0.45; 95%CI, 0.22-0.93),≥18 years (aOR, 0.34; 95%CI 0.16-0.72) and males (aOR, 0.68; 95%CI, 0.49-0.94).

CONCLUSIONS

The rate of RASI prescription refilling adherence was relatively low and associated with CKD-specific comorbid conditions. This study identifies factors associated with low adherence and highlights the need to identify those who should be targeted for intervention to achieve better blood pressure control, preventing CKD progression.

Chronic Kidney Disease and Dietary Measures to Improve Outcomes

Chronic kidney disease is an ongoing deterioration of renal function that often progresses to end-stage renal disease. Management goals in children include slowing disease progression, prevention and treatment of complications, and optimizing growth, development, and quality of life. Nutritional management is critically important to achieve these goals. Control of blood pressure, proteinuria, and metabolic acidosis with dietary and pharmacologic measures may slow progression of chronic kidney disease. Although significant progress in management has been made, further research is required to resolve many outstanding controversies. We review recent developments in pediatric chronic kidney disease, focusing on dietary measures to improve outcomes.

Associations Between Weight Loss, Kidney Function Decline, and Risk of ESRD in the Chronic Kidney Disease in Children (CKiD) Cohort Study

BACKGROUND

Anorexia and malnutrition are associated with poor outcomes in children with chronic kidney disease (CKD).

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

We assessed changes in body mass index (BMI) as kidney function declines and its association with risk for end-stage renal disease (ESRD) among 854 participants followed between 2005 to 2013 in the CKD in Children (CKiD) Study.

PREDICTORS

Repeated measurements of estimated glomerular filtration rate (eGFR) by serum creatinine concentration in our trajectory analysis using mixed models; change in BMI z score (per year) after eGFR decreased to <35mL/min/1.73m² in logistic regression models.

OUTCOMES

Repeated measurements of BMI z score (as a reflection of weight status) in our trajectory analysis; ESRD in logistic regression models.

RESULTS

During a mean longitudinal follow-up of 3.4 years, BMI z scores remained stable until eGFR decreased to <35mL/min/1.73m². When eGFR decreased to <35mL/min/1.73m², a mean decline in BMI z score of 0.13 (95% CI, 0.09-0.17) was noted with each 10-mL/min/1.73m² further decline in eGFR. This was statistically significantly different from the weight trajectory when eGFR was ≥35mL/min/1.73 m² (P<0.001). Among children and adolescents with significant weight loss (defined as decline in BMI z score > 0.2 per year) after eGFR decreased to <35mL/min/1.73m², the odds of ESRD was 3.28 (95% CI, 1.53-7.05) times greater compared with participants with stable BMI z scores (BMI z score change per year of 0-0.1).

LIMITATIONS

Observational nature of our study, lack of longitudinal assessments of inflammatory markers.

CONCLUSIONS

In children and adolescents with CKD, weight loss mostly occurs when eGFR decreases to <35mL/min/1.73m², and this weight loss was associated with higher risk for ESRD. Further studies are needed to define the reasons for the association between weight loss and more rapid progression to ESRD in children and adolescents.

Growth hormone therapy in children with CKD after more than two decades of practice

This review focuses on the evidence for the efficacy and safety of recombinant human growth hormone (rhGH) therapy in children with all stages of chronic kidney disease (CKD) and at all ages. It describes the improving height prognosis for our patients both with and without rhGH; explains the underlying hormonal abnormalities that provide the rationale for rhGH use in CKD and the endocrine changes that accompany treatment; and views on who warrants treatment, with what dose, and how long for.

Lack of hepcidin ameliorates anemia and improves growth in an adenine-induced mouse model of chronic kidney disease

Growth delay is common in children with chronic kidney disease (CKD), often associated with poor quality of life. The role of anemia in uremic growth delay is poorly understood. Here we describe an induction of uremic growth retardation by a 0.2% adenine diet in wild-type (WT) and hepcidin gene (Hamp) knockout (KO) mice, compared with their respective littermates fed a regular diet. Experiments were started at weaning (3 wk). After 8 wk, blood was collected and mice were euthanized. Adenine-fed WT mice developed CKD (blood urea nitrogen 82.8 ± 11.6 mg/dl and creatinine 0.57 ± 0.07 mg/dl) and were 2.1 cm shorter compared with WT controls. WT adenine-fed mice were anemic and had low serum iron, elevated Hamp, and elevated IL6 and TNF-α. WT adenine-fed mice had advanced mineral bone disease (serum phosphorus 16.9 ± 3.1 mg/dl and FGF23 204.0 ± 115.0 ng/ml) with loss of cortical and trabecular bone volume seen on microcomputed tomography. Hamp disruption rescued the anemia phenotype resulting in improved growth rate in mice with CKD, thus providing direct experimental evidence of the relationship between Hamp pathway and growth impairment in CKD. Hamp disruption ameliorated CKD-induced growth hormone-insulin-like growth factor 1 axis derangements and growth plate alterations. Disruption of Hamp did not mitigate the development of uremia, inflammation, and mineral and bone disease in this model. Taken together, these results indicate that an adenine diet can be successfully used to study growth in mice with CKD. Hepcidin appears to be related to pathways of growth retardation in CKD suggesting that investigation of hepcidin-lowering therapies in juvenile CKD is warranted.

Chronic Kidney Disease in Children: Recent Update

The incidence of end stage of renal disease (ESRD) in US children age 0-19 years is 12.9 per million/year (2012). The economic and social burden of diagnosing, treating and preventing chronic kidney disease (CKD) in children and adults remains substantial. Advances in identifying factors that predict development of CKD and its progression, as well as advances in the management of co-morbid conditions including anemia, cardiovascular disease, growth, mineral and bone disorder, and neurocognitive function are discussed. Despite recent reports from retrospective registry data analysis and multi-center prospective studies which have significantly advanced our knowledge of CKD, and despite advances in the understanding of the pathogenesis, diagnosis and treatment of CKD much work remains to be done to improve the long term outcome of this disease.