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Kirpalani A, Prasad C, Jawa NA, Atkinson AR, Feldman M, Jeffers JM, Noone DG. Assessing nephrology competence in general paediatrics—A survey of general paediatricians, paediatric nephrologists, residents, and program directors. Paediatr Child Health 2022; 27:169-175. [DOI: 10.1093/pch/pxab089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 10/27/2021] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
The objective of this study was to identify nephrology topics of lowest perceived competency and importance for general paediatricians.
Methods
Surveys were distributed to general paediatricians, paediatric residents, paediatric residency program directors, and paediatric nephrologists. Perceived importance and competence were rated on a 5-point Likert scale. Means and 95% confidence intervals were calculated.
Results
Mean perceived competency from general paediatricians across all nephrology domains was 3.0, 95%CI (2.9 to 3.1) and mean importance was 3.2, 95%CI (3.1 to 3.3). Domains scoring below the means for competence and importance, respectively were kidney stones (2.5, 95%CI [2.2 to 2.7]) and 2.6, 95%CI [2.3 to 2.8]), acute kidney injury (2.5, 95%CI [2.2 to 2.8] and 2.4, 95%CI [2.1 to 2.8]), chronic kidney disease (1.9, 95%CI [1.7 to 2.2] and 2.1, 95%CI [1.8 to 2.4]), tubular disorders (1.8, 95%CI [1.6 to 2.0] and 2.0, 95%CI [1.8 to 2.3]), and kidney transplant (1.6, 95%CI [1.4 to 1.8] and 1.7, 95%CI [1.4 to 1.9]). Residents, program directors, and paediatric nephrologists agreed that stones, chronic kidney disease, tubular disorders, and transplant were of lower importance. However, acute kidney injury was the domain with the largest discrepancy in perceived importance between residents (4.4, 95%CI [4.2 to 4.6]), nephrologists (4.2, 95%CI [3.8 to 4.6]), and program directors (4.2, 95%CI [3.7 to 4.7]) compared to general paediatricians ([2.4, 95%CI [2.1 to 2.8]; P<0.05).
Conclusion
Paediatricians did not believe acute kidney injury was important to their practice, despite expert opinion and evidence of long-term consequences. Educational interventions must address deficits in crucial domains of renal health in paediatrics.
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Affiliation(s)
- Amrit Kirpalani
- Division of Nephrology, Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University , London, Ontario , Canada
- Lawson Health Research Institute , London, Ontario , Canada
| | - Charushree Prasad
- Division of Nephrology, Department of Paediatrics, McMaster University , Hamilton, Ontario , Canada
| | - Natasha A Jawa
- Division of Nephrology, Department of Paediatrics, The Hospital for Sick Children , Toronto, Ontario , Canada
| | - Adelle R Atkinson
- Department of Paediatrics, Faculty of Medicine, University of Toronto , Toronto, Ontario , Canada
| | - Mark Feldman
- Department of Paediatrics, Faculty of Medicine, University of Toronto , Toronto, Ontario , Canada
| | - Justin M Jeffers
- Department of Pediatrics, Johns Hopkins University , Baltimore, Maryland , USA
| | - Damien G Noone
- Division of Nephrology, Department of Paediatrics, The Hospital for Sick Children , Toronto, Ontario , Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto , Toronto, Ontario , Canada
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2
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Mulla I, Yeung RSM, Noone DG, Bell-Peter A, Pagnoux C. Paediatric-to-adult transition experience in vasculitis: report of a model of care and outcomes. Clin Exp Rheumatol 2022; 40:772-778. [PMID: 35238755 DOI: 10.55563/clinexprheumatol/uhsrnm] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/19/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Transitioning from paediatric to adult care can be challenging. Whereas transition models of care have been shared in some rheumatological conditions, reported experience in vasculitis is lacking. METHODS Retrospective chart review of adolescents aged 16-18 years assessed at the vasculitis transition clinic by paediatric and adult rheumatologists, and then scheduled for follow-up at the Adult Vasculitis Clinic (Toronto, Canada) from January 2013 until May 2020. RESULTS Twenty-eight patients were seen at the transition clinic and included. Mean age at transition was 17 years and 11 (± SD 2) months, with a mean follow up from diagnosis of 32 (± 24) months. Most patients had ANCA-associated vasculitis (N=19, 39%), followed by Takayasu's arteritis (N=4, 14%); all but one were in remission at the time of transition. Twenty-six (93%) patients showed up for their first booked adult visit (two did not, were called and rebooked), after a mean of 4 (± 2) months after transition clinic. Subsequently, two patients missed 1 appointment, and three missed ≥ 2 appointments; only one (4%) stopped coming, while in remission for >2 years post-transition. Five (18%) patients were identified to have medication non-adherence after transition. With a mean follow up post-transition of 32 (± 25) months, 7 (25%) patients had minor and five (18%) had major relapses, at a mean of 17 (± 9) and 25 (± 15) months post-transition, respectively (compared to 12 (43%) and 9 (32%) prior to transition). At their last visit, all were in remission, 18 (64%) off glucocorticoids, and damage had remained stable. CONCLUSIONS This model of care of vasculitis transition clinic resulted in favourable outcomes, as reflected by continuity of follow-up, and no increased risk of relapse.
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Affiliation(s)
- Isra Mulla
- Vasculitis clinic, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | - Rae S M Yeung
- Division of Rheumatology, Toronto SickKids Hospital, University of Toronto, Ontario, Canada
| | - Damien G Noone
- Division of Nephrology, Toronto SickKids Hospital, University of Toronto, Ontario, Canada
| | - Audrey Bell-Peter
- Division of Rheumatology, Toronto SickKids Hospital, University of Toronto, Ontario, Canada
| | - Christian Pagnoux
- Vasculitis clinic, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, and Division of Rheumatology, Toronto SickKids Hospital, University of Toronto, Ontario, Canada.
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Noone DG, Silverman ED. Treatment of Childhood-onset Proliferative Lupus Nephritis in the 21st Century: A Call to Catch Up With the Evidence. J Rheumatol Suppl 2022; 49:552-554. [PMID: 35365579 DOI: 10.3899/jrheum.220196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Proliferative lupus nephritis (PLN) is associated with significant morbidity, mortality, and kidney failure, especially in childhood-onset PLN (cPLN). Therefore, it is important to treat it promptly and aggressively, while being cognizant of the risk-benefit ratio and side effects of therapies.
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Affiliation(s)
- Damien G Noone
- D. Noone, MB BCh BAO, MSc, Division of Nephrology, The Hospital for Sick Children, and Associate Professor, Department of Paediatrics, University of Toronto; E.D. Silverman, MD, FRCPC, Division of Rheumatology, The Hospital for Sick Children, Senior Associate Scientist, Physiology & Experimental Medicine Program, SickKids Research Institute, and Professor of Paediatrics and Immunology, University of Toronto, Toronto, Ontario, Canada. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. E.D. Silverman, The Hospital for Sick Children, Division of Rheumatology, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Earl D Silverman
- D. Noone, MB BCh BAO, MSc, Division of Nephrology, The Hospital for Sick Children, and Associate Professor, Department of Paediatrics, University of Toronto; E.D. Silverman, MD, FRCPC, Division of Rheumatology, The Hospital for Sick Children, Senior Associate Scientist, Physiology & Experimental Medicine Program, SickKids Research Institute, and Professor of Paediatrics and Immunology, University of Toronto, Toronto, Ontario, Canada. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. E.D. Silverman, The Hospital for Sick Children, Division of Rheumatology, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
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4
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Snauwaert E, Wagner S, Jawa NA, Bruno V, McKay A, Kirpalani A, Nemec R, Teoh CW, Harvey EA, Zappitelli M, Licht C, Noone DG. Implementing a fluid volume management program to decrease intra-dialytic hypotensive events in a paediatric in-centre haemodialysis unit: a quality improvement project. Pediatr Nephrol 2022; 37:1105-1115. [PMID: 34643809 PMCID: PMC8513548 DOI: 10.1007/s00467-021-05298-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intra-dialytic hypotension (IDH) is the most common serious adverse event in paediatric haemodialysis (HD). Repeated IDH results in chronic multi-organ damage and increased mortality. At the Hospital for Sick Children, Toronto, retrospective data from all in-centre HD sessions revealed frequently occurring IDH events (16.5 ± 5.6% of HD sessions per week). Based on literature review and clinical expertise, fluid volume management was selected as a potential modifiable risk factor to decrease IDH. Root causes identified as contributing to IDH were incorporated into a Paediatric haemodialysis fluid volume management (PedHDfluid) program using the Model for Improvement methodology including rapid cycles of change. METHODS Multiple measures were evaluated including (i) Outcome: IDH events per number of HD sessions per week; (ii) Process: number of changes to estimated dry weight per number of HD sessions per week; (iii) Balancing: time spent on dry weight meeting per week. Data was analysed using statistical process control charts. We aimed to decrease IDH in our dialysis unit to < 10% of HD sessions per week over a 6-month period by implementing a PedHDfluid program, including a multifaceted dry weight assessment protocol, multidisciplinary meetings and electronic health records "Dry Weight Evaluation flow sheet/synopsis". RESULTS The project resulted in a decline in IDH events from 16.5 ± 5.6% to 8.8 ± 3.3% of HD sessions per week. More frequent dry weight changes and increased awareness of fluid removal goals were noted. CONCLUSIONS A multidisciplinary approach including regular assessment, guidelines and systematic discussion, with an embedded electronic health record assessment and data gathering tool may sustainably reduce IDH events. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Evelien Snauwaert
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada
| | - Stéphanie Wagner
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada
| | - Natasha A. Jawa
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada
| | - Valentina Bruno
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada
| | - Ashlene McKay
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada
| | - Amrit Kirpalani
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada
| | - Rosaleen Nemec
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada
| | - Chia Wei Teoh
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Department of Paediatrics, University of Toronto, Toronto, ON Canada
| | - Elizabeth A. Harvey
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Department of Paediatrics, University of Toronto, Toronto, ON Canada
| | - Michael Zappitelli
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Department of Paediatrics, University of Toronto, Toronto, ON Canada
| | - Christoph Licht
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Department of Paediatrics, University of Toronto, Toronto, ON Canada
| | - Damien G. Noone
- grid.42327.300000 0004 0473 9646Division of Nephrology, The Hospital for Sick Children, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Department of Paediatrics, University of Toronto, Toronto, ON Canada ,grid.42327.300000 0004 0473 9646Division of Paediatric Nephrology, SickKids, 555 University Avenue, Toronto, ON M5G 1X8 Canada
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Chen A, Mammen C, Guzman J, Al-Abadi E, Benseler SM, Berard RA, Gerstbacher D, Heshin-Bekenstein M, Kim S, Klein-Gitelman M, Chavan PP, James KE, Martin N, McErlane F, Myrup C, Noone DG, Raghuram J, Shenoi S, Sivaraman V, Tanner T, Yeung RS, Cabral DA, Morishita KA. Wide variation in glucocorticoid dosing in paediatric ANCA-associated vasculitis with renal disease: a paediatric vasculitis initiative study. Clin Exp Rheumatol 2021; 40:841-848. [DOI: 10.55563/clinexprheumatol/iol4k2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Audrea Chen
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Cherry Mammen
- BC Children’s Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Jaime Guzman
- BC Children’s Hospital, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | | | - Susan Kim
- University of California, San Francisco, CA, and Boston Children’s Hospital, Boston, MA, USA
| | | | | | | | | | - Flora McErlane
- Great North Children’s Hospital, Newcastle upon Tyne, Institute for Health and Population, Newcastle University, UK
| | | | - Damien G. Noone
- Division of Nephrology, Toronto SickKids Hospital, University of Toronto, ON, Canada
| | - Jyothi Raghuram
- Aster Women & Children’s Hospital, Whitefield, Bangalore, India
| | - Susan Shenoi
- Seattle Children's Hospital and Research Center, University of Washington, Seattle, WA, USA
| | | | | | - Rae S.M. Yeung
- Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - David A. Cabral
- BC Children’s Hospital, University of British Columbia, Vancouver, BC, Canada
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Riedl Khursigara M, Schlam D, Noone DG, Bruno V, Ortiz-Sandoval CG, Pluthero FG, Kahr WHA, Bowman ML, James P, Grinstein S, Licht C. Vascular endothelial cells evade complement-mediated membrane injury via Weibel-Palade body mobilization. J Thromb Haemost 2020; 18:1484-1494. [PMID: 32073731 DOI: 10.1111/jth.14767] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 02/10/2020] [Accepted: 02/18/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Defective complement inhibition can lead to the formation of membrane attack complexes (MAC; C5b-9) on the plasma membranes of vascular endothelial cells, resulting in injury that drives the progression of thrombotic microangiopathy (TMA), a key pathology in kidney disease. OBJECTIVE/METHODS We examined the response of human endothelial cells to complement-mediated damage using blood outgrowth endothelial cells (BOECs) derived from healthy donors. BOECs were sensitized to complement factors present in normal human serum to induce the formation of C5b-9 on their plasma membranes. RESULTS This triggered an expected abrupt rise in intracellular Ca2+ reflecting membrane leakage. Remarkably, while intracellular Ca2+ remained elevated, membrane leakage ceased within 30 minutes, and cells did not show significant death. Extensive mobilization of Weibel-Palade bodies (WPBs) was observed along with secretion of von Willebrand factor (VWF). The potential role of WPBs and VWF in mitigating complement-mediated damage was examined by comparing the effects of C5b-9 on BOECs derived from von Willebrand disease (VWD) patients expressing reduced amounts of VWF, lacking expression of functional VWF, or lacking both VWF and WPBs. BOECs lacking WPBs were not resistant to complement-mediated damage, but became resistant when transfected to express VWF (and thus WPBs). CONCLUSION We conclude that BOECs exposed to C5b-9 attack respond by mobilizing WPBs, which mitigate and repair damage by fusing with the plasma membrane. We propose that a similar cell-specific response may protect the vascular endothelium from complement-mediated damage in vivo.
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Affiliation(s)
- Magdalena Riedl Khursigara
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, Innsbruck Medical University, Innsbruck, Austria
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Daniel Schlam
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Damien G Noone
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Valentina Bruno
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | | | - Fred G Pluthero
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Walter H A Kahr
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada
| | | | - Paula James
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Sergio Grinstein
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre, St. Michael's Hospital, Toronto, ON, Canada
| | - Christoph Licht
- Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
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7
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Selewski DT, Ambruzs JM, Appel GB, Bomback AS, Matar RB, Cai Y, Cattran DC, Chishti AS, D'Agati VD, D'Alessandri-Silva CJ, Gbadegesin RA, Hogan JJ, Iragorri S, Jennette JC, Julian BA, Khalid M, Lafayette RA, Liapis H, Lugani F, Mansfield SA, Mason S, Nachman PH, Nast CC, Nester CM, Noone DG, Novak J, O'Shaughnessy MM, Reich HN, Rheault MN, Rizk DV, Saha MK, Sanghani NS, Sperati CJ, Sreedharan R, Srivastava T, Swiatecka-Urban A, Twombley K, Vasylyeva TL, Weaver DJ, Yin H, Zee J, Falk RJ, Gharavi AG, Gillespie BW, Gipson DS, Greenbaum LA, Holzman LB, Kretzler M, Robinson BM, Smoyer WE, Flessner M, Guay-Woodford LM, Kiryluk K. Clinical Characteristics and Treatment Patterns of Children and Adults With IgA Nephropathy or IgA Vasculitis: Findings From the CureGN Study. Kidney Int Rep 2018; 3:1373-1384. [PMID: 30450464 PMCID: PMC6224619 DOI: 10.1016/j.ekir.2018.07.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 04/27/2018] [Accepted: 07/30/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction The Cure Glomerulonephropathy Network (CureGN) is a 66-center longitudinal observational study of patients with biopsy-confirmed minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, or IgA nephropathy (IgAN), including IgA vasculitis (IgAV). This study describes the clinical characteristics and treatment patterns in the IgA cohort, including comparisons between IgAN versus IgAV and adult versus pediatric patients. Methods Patients with a diagnostic kidney biopsy within 5 years of screening were eligible to join CureGN. This is a descriptive analysis of clinical and treatment data collected at the time of enrollment. Results A total of 667 patients (506 IgAN, 161 IgAV) constitute the IgAN/IgAV cohort (382 adults, 285 children). At biopsy, those with IgAV were younger (13.0 years vs. 29.6 years, P < 0.001), more frequently white (89.7% vs. 78.9%, P = 0.003), had a higher estimated glomerular filtration rate (103.5 vs. 70.6 ml/min per 1.73 m2, P < 0.001), and lower serum albumin (3.4 vs. 3.8 g/dl, P < 0.001) than those with IgAN. Adult and pediatric individuals with IgAV were more likely than those with IgAN to have been treated with immunosuppressive therapy at or prior to enrollment (79.5% vs. 54.0%, P < 0.001). Conclusion This report highlights clinical differences between IgAV and IgAN and between children and adults with these diagnoses. We identified differences in treatment with immunosuppressive therapies by disease type. This description of baseline characteristics will serve as a foundation for future CureGN studies.
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Affiliation(s)
- David T. Selewski
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
- Correspondence: David T. Selewski, University of Michigan, 1540 East Hospital Drive, Room 12-250, Ann Arbor, Michigan 48109-4297, USA.
| | | | - Gerald B. Appel
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Andrew S. Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Raed Bou Matar
- Center for Pediatric Nephrology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yi Cai
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Daniel C. Cattran
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aftab S. Chishti
- Division of Nephrology, Hypertension and Renal Transplantation, University of Kentucky, Lexington, Kentucky, USA
| | - Vivette D. D'Agati
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York, USA
| | | | - Rasheed A. Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan J. Hogan
- Renal Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sandra Iragorri
- Division of Nephrology and Hypertension, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Bruce A. Julian
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Myda Khalid
- Division of Nephrology, Department of Pediatrics, JW Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richard A. Lafayette
- Division of Nephrology and Hypertension, Stanford University, Stanford, California, USA
| | | | | | | | - Sherene Mason
- Section of Pediatric Nephrology, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Patrick H. Nachman
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Cynthia C. Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carla M. Nester
- Division of Pediatric Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
- Molecular Otolaryngology and Renal Research Laboratory, University of Iowa, Iowa City, Iowa, USA
| | - Damien G. Noone
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jan Novak
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Heather N. Reich
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Rheault
- Division of Nephrology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Dana V. Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Manish K. Saha
- Division of Nephrology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Neil S. Sanghani
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C. John Sperati
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rajasree Sreedharan
- Division of Nephrology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Tarak Srivastava
- Children's Mercy Hospital and University of Missouri−Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Agnieszka Swiatecka-Urban
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Katherine Twombley
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tetyana L. Vasylyeva
- Department of Pediatrics, Division of Nephrology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Donald J. Weaver
- Division of Nephrology and Hypertension, Levine Children's Hospital at Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Hong Yin
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Ronald J. Falk
- Division of Nephrology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ali G. Gharavi
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Brenda W. Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Debbie S. Gipson
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Larry A. Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Lawrence B. Holzman
- Department of Medicine, University of Pennsylvania Medical School, Philadelphia, Pennsylvania, USA
| | - Matthias Kretzler
- Department of Computational Medicine and Bioinformatics, University of Michigan School of Medicine, Ann Arbor, Michigan USA
- Division of Nephrology, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | | | - William E. Smoyer
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Michael Flessner
- Division of Kidney, Urology, and Hematology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa M. Guay-Woodford
- Center for Translational Science, Children’s National Health System, Washington, DC, USA
| | - Krzysztof Kiryluk
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Krzysztof Kiryluk, Columbia University, Department of Medicine, Division of Nephrology, 1150 St Nicholas Avenue, Russ Berrie Pavilion #412, New York, New York 10032, USA.
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8
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Abstract
The incidence of idiopathic nephrotic syndrome (NS) is 1·15-16·9 per 100 000 children, varying by ethnicity and region. The cause remains unknown but the pathogenesis of idiopathic NS is thought to involve immune dysregulation, systemic circulating factors, or inherited structural abnormalities of the podocyte. Genetic risk is more commonly described among children with steroid-resistant disease. The mainstay of therapy is prednisone for the vast majority of patients who are steroid responsive; however, the disease can run a frequently relapsing course, necessitating the need for alternative immunosuppressive agents. Infection and venous thromboembolism are the main complications of NS with also increased risk of acute kidney injury. Prognosis in terms of long-term kidney outcome overall is excellent for steroid-responsive disease, and steroid resistance is an important determinant of future risk of chronic or end-stage kidney disease.
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Affiliation(s)
- Damien G Noone
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Rulan Parekh
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada; Dalla Lana School of Public Health, and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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9
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Downie ML, Mulder J, Schneider R, Lim L, Tehrani N, Wasserman JD, Fuchs S, John R, Noone DG, Hebert D. A curious case of growth failure and hypercalcemia: Answers. Pediatr Nephrol 2018; 33:995-999. [PMID: 28785985 DOI: 10.1007/s00467-017-3769-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 07/12/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Sarcoidosis is a multisystem granulomatous disease of unknown etiology that rarely presents in childhood. Here, we report a case of pediatric sarcoidosis, presenting with renal failure and hypercalcemia. CASE DIAGNOSIS/TREATMENT A previously well 14-year-old Caucasian boy was admitted to the Hospital for Sick Children, Canada, for hypertension and renal failure following work-up by his family physician for initial concerns of growth failure. On admission, his weight was 35 kg (<3rd percentile), his height was 148 cm (<<3rd percentile), and his blood pressure was 154/116 mmHg (>99th percentile for height). Laboratory findings showed elevated creatinine (218 umol/L), hypercalcemia (3.21 mmol/L), and normocytic anemia (hemoglobin 105 g/L). His further assessment showed a urinary concentrating defect with hypercalciuria (calcium/creatinine 1.76 mmol/mmol) and nephrocalcinosis on ultrasound. His eye examination showed uveitis with conjunctival biopsy remarkable for granulomas, which led to pursuit of a diagnosis of possible sarcoidosis. Angiotensin Angiotensin-converting enzyme was found to be high at 96 U/L, and he had a renal biopsy that was consistent with interstitial nephritis with granulomas. Treatment was started with prednisone leading to resolution of his hypercalcemia but persistence of his mild chronic kidney disease. CONCLUSIONS This case represents an atypical presentation of a rare pediatric disease and highlights the spectrum of renal manifestations and treatment options in sarcoidosis.
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Affiliation(s)
- Mallory L Downie
- Division of Nephrology, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jaap Mulder
- Division of Nephrology, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Rayfel Schneider
- Division of Rheumatology, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lillian Lim
- Division of Rheumatology, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nasrin Tehrani
- Division of Ophthalmology, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jonathan D Wasserman
- Division of Endocrinology, Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Shai Fuchs
- Division of Endocrinology, Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Rohan John
- Department of Pathology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Damien G Noone
- Division of Nephrology, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Diane Hebert
- Division of Nephrology, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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10
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Abstract
Nephrotic syndrome is defined by nephrotic-range proteinuria (≥40 mg/m2/hour or urine protein/creatinine ratio ≥200 mg/mL or 3+ protein on urine dipstick), hypoalbuminaemia (<25 g/L) and oedema. This review focuses on the classification, epidemiology, pathophysiology, management strategies and prognosis of idiopathic nephrotic syndrome of childhood, and includes a brief overview of the congenital forms.
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Affiliation(s)
- Mallory L Downie
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada
| | - Claire Gallibois
- d Department of Medicine , Royal College of Surgeons in Ireland , Dublin , Ireland
| | - Rulan S Parekh
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada.,d Department of Medicine , Royal College of Surgeons in Ireland , Dublin , Ireland.,e Child Health Evaluative Sciences, Research Institute , The Hospital for Sick Children , Toronto , Canada.,f Division of Nephrology , University Health Network , Toronto , Canada.,g Dalla Lana School of Public Health , University of Toronto , Toronto , Canada
| | - Damien G Noone
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada
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11
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Abstract
In contrast to adults where hypertension is a leading cause of chronic kidney disease, in pediatrics, hypertension is predominantly a sequela, however, an important one that, like in adults, is likely associated with a more rapid decline in kidney function or progression of chronic kidney disease to end stage. There is a significant issue with unrecognized, or masked, hypertension in childhood chronic kidney disease. Recent evidence and, therefore, guidelines now suggest targeting a blood pressure of <50th percentile for age, sex, and height in children with proteinuria and chronic kidney disease. This often cannot be achieved by monotherapy and additional agents need to be added. Blockade of the renin angiotensin aldosterone system represents the mainstay of therapy, although often limited by the side effect of hyperkalemia. The addition of a diuretic, at least in the earlier stages of chronic kidney disease, might help mitigate this problem.
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Affiliation(s)
- Claire M Gallibois
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada.,Faculty of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Natasha A Jawa
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Damien G Noone
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
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12
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Teoh CW, Thakor AS, Amaral JG, Parra DA, Harvey EA, Noone DG. Successful Image-Guided Retrieval of an Embolized Fragment of a Fractured Haemodialysis Catheter Tip from the Pulmonary Artery. Case Rep Nephrol Dial 2016; 6:21-5. [PMID: 26998477 PMCID: PMC4772621 DOI: 10.1159/000443728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Cuffed, double-lumen, tunneled haemodialysis catheters are a common means of vascular access in paediatric haemodialysis, particularly in infants. Haemodialysis catheter fracture with distal embolization is a rare complication. Case Report A 2-year-old boy was receiving chronic haemodialysis via a right internal jugular cuffed, double-lumen, tunneled haemodialysis catheter, inserted 3 months previously. He was asymptomatic and was incidentally found to have had embolization of a fractured catheter tip into a segmental branch of the left pulmonary artery. The catheter was replaced and the embolized fragment successfully retrieved, non-surgically, using an image-guided endovascular approach with a loop snare device. Conclusion Haemodialysis catheter fracture with distal embolization is a rare complication in both adults and children and is usually associated with prolonged use and catheter fatigue. Retrieval of the embolized fragment should always be attempted to prevent possible complications. Awareness of this potential complication is important to facilitate diagnosis and management.
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Affiliation(s)
- Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada
| | - Avnesh S Thakor
- Image-Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada
| | - Joao G Amaral
- Image-Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada
| | - Dimitri A Parra
- Image-Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada
| | - Elizabeth A Harvey
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada
| | - Damien G Noone
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada
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13
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Noone DG, Twilt M, Hayes WN, Thorner PS, Benseler S, Laxer RM, Parekh RS, Hebert D. The new histopathologic classification of ANCA-associated GN and its association with renal outcomes in childhood. Clin J Am Soc Nephrol 2014; 9:1684-91. [PMID: 25147157 DOI: 10.2215/cjn.01210214] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES A proposed histopathologic classification for ANCA-associated GN is predictive of long-term renal outcome in adult populations. This study sought to validate this system in a pediatric cohort. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a retrospective, single-center, cohort study of 40 children diagnosed and followed until their transition to adult care at one institution between 1987 and 2012. Renal biopsy specimens were reviewed by a pathologist blinded to patient outcome and were classified using the new histopathologic classification system of focal, crescentic, mixed, and sclerotic groups. Time to the composite outcome of CKD stages 3 and 4 (determined by eGFR with repeated creatinine measures using the Schwartz equation) or ESRD (defined as dialysis dependence or transplantation) were ascertained. RESULTS The study population consisted of 40 children (70% female), followed for a median of 2.4 years. The biopsy specimens were categorized as focal in 13 patients (32.5%), crescentic in 20 (50%), mixed in two (5%), and sclerotic in five (12.5%). Mixed and crescentic were combined for analyses. Survival analysis of time to the composite renal endpoint of at least 3 months of eGFR<60 ml/min per 1.73 m(2) or ESRD differed significantly among the three biopsy groups log-rank P<0.001), with an adjusted hazard ratio of 3.14 (95% confidence interval, 0.68 to 14.4) in the crescentic/mixed group and 23.6 (95% confidence interval, 3.9 to 144.2) in the sclerotic category compared with the focal category. The probability of having an eGFR>60 ml/min per 1.73 m(2) at 2 years was 100% for the focal, 56.5% for the crescentic/mixed, and 0% for the sclerotic biopsy categories. CONCLUSIONS This study showed the clinical utility of this histopathologic classification system and its ability to discriminate renal outcomes among children with ANCA GN.
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Affiliation(s)
| | | | | | - Paul S Thorner
- Pathology, The Research Institute, and Department of Pathobiology and Laboratory Medicine and
| | - Susanne Benseler
- Rheumatology, and The Research Institute, and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Ronald M Laxer
- Rheumatology, and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Rulan S Parekh
- Divisions of Nephrology, The Research Institute, and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada, and
| | - Diane Hebert
- Divisions of Nephrology, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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14
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Riedl M, Fakhouri F, Le Quintrec M, Noone DG, Jungraithmayr TC, Fremeaux-Bacchi V, Licht C. Spectrum of complement-mediated thrombotic microangiopathies: pathogenetic insights identifying novel treatment approaches. Semin Thromb Hemost 2014; 40:444-64. [PMID: 24911558 DOI: 10.1055/s-0034-1376153] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Thrombotic microangiopathy (TMA) is a rare but severe disorder characterized by endothelial cell activation and thrombus formation. It manifests with the triad of hemolytic anemia, thrombocytopenia, and organ failure. Prompt diagnosis and treatment initiation are crucial for long-term outcome. TMA often manifests subsequent to infectious events, of which (enterohemorrhagic) Escherichia coli is the most frequently reported. TMA also occurs on the background of genetic/autoimmune defects in the complement system (atypical hemolytic uremic syndrome [aHUS]) and underlying conditions, such as pregnancy, transplantation, drugs, other glomerulopathies, vasculitides, or metabolic defects. Complement activation or defects in its regulation have now been described in an increasing number of acquired diseases with TMA. Coinciding with this expanding spectrum of complement-mediated diseases, the question arises which patients might benefit from a complement-targeted therapy. Success of therapy depends on the individual contribution of complement activation in disease pathogenesis. The advent of eculizumab, a monoclonal antibody that blocks terminal complement activation, has markedly improved outcome and quality of life in patients with aHUS. This review discusses the contribution of complement and highlights its complex interaction with inflammation, coagulation, and the endothelium. Treatment experiences focusing on eculizumab therapy are discussed in detail across the emerging spectrum of complement-mediated thrombotic microangiopathies.
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Affiliation(s)
- Magdalena Riedl
- Department of Pediatrics, Innsbruck Medical University, Innsbruck, Austria
| | - Fadi Fakhouri
- Department of Nephrology and Immunology, ITUN and INSERM UMR S-1064, CHU de Nantes, Nantes, France
| | - Moglie Le Quintrec
- Service de Nephrologie et de Transplantation Rénale, Hôpital Foch, Suresnes, France
| | - Damien G Noone
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
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15
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Noone DG, Marks SD. Hyperuricemia is associated with hypertension, obesity, and albuminuria in children with chronic kidney disease. J Pediatr 2013; 162:128-32. [PMID: 22809658 DOI: 10.1016/j.jpeds.2012.06.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 04/25/2012] [Accepted: 06/04/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the prevalence and associations of hyperuricemia in a cohort of pediatric patients with chronic kidney disease (CKD). STUDY DESIGN This was an observational cross-sectional study of clinical and laboratory data in pediatric patients being followed in a nephrology clinic. All patients with CKD were included. ORs and risk estimates of having stage III-V CKD (defined as an estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m(2)) with hyperuricemia were calculated. The relationships among eGFR, body mass index (BMI), and hyperuricemia were estimated using both correlation and regression models. RESULTS A total of 116 children (61% male), aged 0.4-17 years, were included in the analysis. The prevalence of hyperuricemia in those with an eGFR <60 mL/min/1.73 m(2) was 70%. Children with hyperuricemia were more likely to have an eGFR <60 mL/min/1.73 m(2) than those with a normal urate level (OR, 4.6) and were more likely to be hypertensive (OR, 2.1). Hyperuricemia was significantly associated with increased BMI, albuminuria, renal dysfunction with reduced eGFR, and hypertension. Significant linear relationships between eGFR and urate (P = .0001) and between BMI and urate (P = .0001) were detected. CONCLUSIONS Hyperuricemia is common in pediatric patients with CKD and is associated with renal dysfunction, hypertension, obesity, and albuminuria. Future prospective studies should be undertaken to further assess the role of hyperuricemia in pediatric patients with CKD.
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Affiliation(s)
- Damien G Noone
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children National Health Service Trust, London, United Kingdom
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