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Nehus EJ, Sheanon NM, Zhang W, Marcovina SM, Setchell KDR, Mitsnefes MM. Urinary sphingolipids in adolescents and young adults with youth-onset diabetes. Pediatr Nephrol 2024; 39:1875-1883. [PMID: 38172468 DOI: 10.1007/s00467-023-06257-6] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/17/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND This study evaluated urinary sphingolipids as a marker of diabetic kidney disease (DKD) in adolescents and young adults with youth-onset type 1 and type 2 diabetes. METHODS A comprehensive panel of urinary sphingolipids, including sphingomyelin (SM), glucosylceramide (GC), ceramide (Cer), and lactosylceramide (LC) species, was performed in patients with youth-onset diabetes from the SEARCH for Diabetes in Youth cohort. Sphingolipid levels, normalized to urine creatinine, were compared in 57 adolescents and young adults with type 1 diabetes, 59 with type 2 diabetes, and 44 healthy controls. The association of sphingolipids with albumin-to-creatinine (ACR) ratio and estimated glomerular filtration rate (eGFR) was evaluated. RESULTS The median age (interquartile range [IQR]) of participants was 23.1 years (20.9, 24.9) and the median duration of diabetes was 9.3 (8.5, 10.2) years. Urinary sphingolipid concentrations in patients with and without DKD (ACR ≥ 30 mg/g) were significantly elevated compared to healthy controls. There were no significant differences in sphingolipid levels between participants with type 1 and type 2 diabetes. In multivariable analysis, many sphingolipid species were positively correlated with ACR. Most significant associations were evident for the following species: C18 SM, C24:1 SM, C24:1 GC, and C24:1 Cer (all p < 0.001). Sphingolipid levels were not associated with eGFR. However, several interaction terms (diabetes type*sphingolipid) were significant, indicating diabetes type may modify the association of sphingolipids with eGFR. CONCLUSION Urinary sphingolipids are elevated in adolescents and young adults with youth-onset diabetes and correlate with ACR. Urinary sphingolipids may therefore represent an early biomarker of DKD.
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Affiliation(s)
- Edward J Nehus
- Department of Pediatrics, West Virginia University School of Medicine Charleston Campus, Charleston, WV, USA.
| | - Nicole M Sheanon
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Wujuan Zhang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Clinical Mass Spectroscopy Facility, Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Kenneth D R Setchell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Clinical Mass Spectroscopy Facility, Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark M Mitsnefes
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Sabulski A, Nehus EJ, Jodele S, Ricci K. Diagnostic Considerations in H1N1 Influenza-induced Thrombotic Microangiopathy. J Pediatr Hematol Oncol 2022; 44:e237-e240. [PMID: 33369997 DOI: 10.1097/mph.0000000000002036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022]
Abstract
Influenza virus can trigger atypical hemolytic uremic syndrome and present with complement-driven thrombotic microangiopathy (TMA). When administered promptly, complement-blocking therapies can spare organ injury and be lifesaving. However, diagnosing TMA in the setting of a severe viral infection can be challenging, as a significant overlap of symptoms and disease complications exists. This is particularly true in influenza virus infections and more recently, Coronavirus disease 2019 (COVID-19) infections. We present a 16-year-old male with H1N1 influenza-induced atypical hemolytic uremic syndrome who quickly improved with complement-blocking therapy, highlighting an urgent need to include TMA in the differential diagnosis of severe viral infections.
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Affiliation(s)
- Anthony Sabulski
- Department of Pediatrics, University of Cincinnati College of Medicine
- Cancer and Blood Diseases Institute
| | - Edward J Nehus
- Department of Pediatrics, University of Cincinnati College of Medicine
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sonata Jodele
- Department of Pediatrics, University of Cincinnati College of Medicine
- Cancer and Blood Diseases Institute
| | - Kiersten Ricci
- Department of Pediatrics, University of Cincinnati College of Medicine
- Cancer and Blood Diseases Institute
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3
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Tommerdahl KL, Shapiro ALB, Nehus EJ, Bjornstad P. Early microvascular complications in type 1 and type 2 diabetes: recent developments and updates. Pediatr Nephrol 2022; 37:79-93. [PMID: 33852054 PMCID: PMC8527882 DOI: 10.1007/s00467-021-05050-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/01/2021] [Accepted: 03/09/2021] [Indexed: 12/30/2022]
Abstract
The prevalence of youth-onset diabetes is progressing rapidly worldwide, and poor glycemic control, in combination with prolonged diabetes duration and comorbidities including hypertension, has led to the early development of microvascular complications including diabetic kidney disease, retinopathy, and neuropathy. Pediatric populations with type 1 (T1D) and type 2 (T2D) diabetes are classically underdiagnosed with microvascular complications, and this leads to both undertreatment and insufficient attention to the mitigation of risk factors that could help attenuate further progression of complications and decrease the likelihood for long-term morbidity and mortality. This narrative review aims to present a comprehensive summary of the epidemiology, risk factors, symptoms, screening practices, and treatment options, including future opportunities for treatment advancement, for microvascular complications in youth with T1D and T2D. We seek to uniquely focus on the inherent challenges of managing pediatric populations with diabetes and discuss the similarities and differences between microvascular complications in T1D and T2D, while presenting a strong emphasis on the importance of early identification of at-risk youth. Further investigation of possible treatment mechanisms for microvascular complications in youth with T1D and T2D through dedicated pediatric outcome trials is necessary to target the brief window where early pathological vascular changes may be significantly attenuated.
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Affiliation(s)
- Kalie L Tommerdahl
- Department of Pediatrics, Section of Pediatric Endocrinology, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, 13123 E. 16th Avenue, Box B265, Aurora, CO, 80045, USA
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
- Center for Women's Health Research, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Allison L B Shapiro
- Department of Pediatrics, Section of Pediatric Endocrinology, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, 13123 E. 16th Avenue, Box B265, Aurora, CO, 80045, USA
- Lifecourse Epidemiology of Adiposity and Diabetes Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Petter Bjornstad
- Department of Pediatrics, Section of Pediatric Endocrinology, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, 13123 E. 16th Avenue, Box B265, Aurora, CO, 80045, USA.
- Center for Women's Health Research, University of Colorado School of Medicine, Aurora, CO, USA.
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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4
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Benoit SW, Kathman T, Patel J, Stegman M, Cobb C, Hoehn J, Devarajan P, Nehus EJ. GFR Estimation After Cystatin C Reference Material Change. Kidney Int Rep 2020; 6:429-436. [PMID: 33615068 PMCID: PMC7879112 DOI: 10.1016/j.ekir.2020.11.028] [Citation(s) in RCA: 1] [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] [Received: 05/06/2020] [Revised: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction Glomerular filtration rate (GFR) is routinely estimated with cystatin C. In June 2010, the International Federation of Clinical Chemistry (IFCC) released a certified cystatin C reference material (ERM-DA471/IFCC), and new cystatin C glomerular filtration rate estimation (eGFR) equations were developed with the IFCC standard. Early in 2018, Siemens discontinued their nonstandardized cystatin C reagent kits and replaced them with IFCC-calibrated kits in the US market. The aim of the current study was to assess the effect of IFCC calibration on cystatin C values and corresponding GFR estimations. Methods Cystatin C concentration was measured in 81 pediatric patients using a plasma sample from their nuclear GFR measurement with 99mTc-diethylenetriaminepentaaccetic acid. Calibration curves were generated using Siemens nonstandardized and IFCC-standardized kits to measure paired cystatin C concentrations in each sample. GFR-estimating equations using pre-IFCC and IFCC cystatin C values were compared using Bland-Altman analyses. Results The IFCC-standardized assay resulted in a mean increase in the measured cystatin C value of 24%. Estimating equations consistently overestimated GFR prior to IFCC standardization. Following incorporation of the IFCC standard, the Full Age Spectrum equation demonstrated the best overall performance, whereas the Chronic Kidney Disease in Children (CKiD) equation was more accurate in children with decreased GFR. Conclusion Incorporation of the IFCC standard significantly increased cystatin C values and affected the performance of GFR estimating equations. Clinical laboratories and providers may need to update the equation used for cystatin C-based estimation of GFR following adoption of the IFCC reference standard.
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Affiliation(s)
- Stefanie W Benoit
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Thelma Kathman
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jay Patel
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Melinda Stegman
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cristina Cobb
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jonathan Hoehn
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Prasad Devarajan
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Edward J Nehus
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
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Hughley E, Nehus EJ, VandenHeuvel K, Augsburger BD, Jain NG, Lucky AW. Glomerulonephritis in Youth With Dystrophic Epidermolysis Bullosa. Kidney Int Rep 2020; 6:538-543. [PMID: 33615081 PMCID: PMC7879098 DOI: 10.1016/j.ekir.2020.10.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Erica Hughley
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katherine VandenHeuvel
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bret D Augsburger
- Division of Dermatology and Cincinnati Children's Epidermolysis Bullosa Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Namrata G Jain
- Division of Pediatric Nephrology, Columbia University Medical Center, New York, NY, USA
| | - Anne W Lucky
- Division of Dermatology and Cincinnati Children's Epidermolysis Bullosa Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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6
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Affiliation(s)
- Anthony Sabulski
- Department of Pediatrics, University of Cincinnati College of Medicine; Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center
| | - Erica Hughley
- Department of Pediatrics, University of Cincinnati College of Medicine; Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center
| | - Edward J Nehus
- Department of Pediatrics, University of Cincinnati College of Medicine; Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center
| | - David D Grier
- Division of Pathology, Cincinnati Children's Hospital Medical Center
| | - Omar Niss
- Department of Pediatrics, University of Cincinnati College of Medicine; Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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7
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Taylor VA, Kirby CL, Nehus EJ, Goebel J, Hooper DK. Composite Health Outcomes in Pediatric and Young Adult Kidney Transplant Recipients. J Pediatr 2019; 204:196-202. [PMID: 30274920 DOI: 10.1016/j.jpeds.2018.08.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/27/2018] [Accepted: 08/29/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess composite health outcomes in pediatric and young adult kidney transplant recipients following kidney transplantation. STUDY DESIGN We conducted a cross-sectional study of all recipients at our center who had a 1-, 3-, 5-, and/or 10-year transplant anniversary visit between October 2008 and February 2015. The kidney transplant recipients were assessed at each time point according to an outcome measure consisting of 15 pass/fail criteria in 5 domains: allograft health, rejection and immunology, infection, cardiovascular health, and growth. RESULTS We analyzed 148 patients at 231 transplantation anniversary visit time points; 52 of 82 (63%) patients assessed at 1 year had an ideal outcome, meeting at least 13 of the 15 criteria. This decreased to 37% at year 3, 40% at year 5, and 26% at year 10 (P < .01). The most common failures across all time points occurred in the domains of growth (43%-52% passing) and cardiovascular health (33%-51% passing). Allograft health declined significantly, decreasing from 74% at year 1 to 33% at year 10 (P < .01). The percentage of patients with graft failure increased from 2.4% at 1 year to 39.5% at 10 years (P < .01), and patient deaths increased from 0 to 11% (P < .01) in the same time frame. CONCLUSIONS Ideal outcomes for pediatric kidney transplant recipients decrease over time with growth, cardiovascular health, and allograft health as the primary failure modes. Understanding the composite health of young recipients will allow primary care providers and nephrologists alike to evaluate the overall health of kidney transplant recipients and focus clinical care on the most common sequelae.
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Affiliation(s)
- Veronica A Taylor
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Cassie L Kirby
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jens Goebel
- Section of Nephrology, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO
| | - David K Hooper
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; University of Cincinnati College of Medicine, Cincinnati, OH
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8
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Kim HJ, Lu B, Nehus EJ, Kim MO. Estimating heterogeneous treatment effects for latent subgroups in observational studies. Stat Med 2018; 38:339-353. [PMID: 30232820 DOI: 10.1002/sim.7970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 06/15/2018] [Accepted: 08/21/2018] [Indexed: 12/12/2022]
Abstract
Individuals may vary in their responses to treatment, and identification of subgroups differentially affected by a treatment is an important issue in medical research. The risk of misleading subgroup analyses has become well known, and some exploratory analyses can be helpful in clarifying how covariates potentially interact with the treatment. Motivated by a real data study of pediatric kidney transplant, we consider a semiparametric Bayesian latent model and examine its utility for an exploratory subgroup effect analysis using secondary data. The proposed method is concerned with a clinical setting where the number of subgroups is much smaller than that of potential predictors and subgroups are only latently associated with observed covariates. The semiparametric model is flexible in capturing the latent structure driven by data rather than dictated by parametric modeling assumptions. Since it is difficult to correctly specify the conditional relationship between the response and a large number of confounders in modeling, we use propensity score matching to improve the model robustness by balancing the covariates distribution. Simulation studies show that the proposed analysis can find the latent subgrouping structure and, with propensity score matching adjustment, yield robust estimates even when the outcome model is misspecified. In the real data analysis, the proposed analysis reports significant subgroup effects on steroid avoidance in kidney transplant patients, whereas standard proportional hazards regression analysis does not.
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Affiliation(s)
- Hang J Kim
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Bo Lu
- Division of Biostatistics, The Ohio State University, Columbus, Ohio
| | - Edward J Nehus
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
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9
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Nehus EJ, Liu C, Lu B, Macaluso M, Kim MO. Graft survival of pediatric kidney transplant recipients selected for de novo steroid avoidance-a propensity score-matched study. Nephrol Dial Transplant 2018; 32:1424-1431. [PMID: 28810723 DOI: 10.1093/ndt/gfx193] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 04/20/2017] [Indexed: 01/19/2023] Open
Abstract
Background Steroid-avoidance protocols have gained popularity in pediatric kidney transplant recipients at low immunologic risk. The long-term safety of steroid avoidance in children with immunologic risk factors remains unknown. Methods Pediatric kidney transplant recipients from 2004 to 2014 in the Organ Procurement and Transplantation Network database who received tacrolimus and mycophenolate immunosuppression were investigated. Propensity score matching was used to compare graft survival in 1624 children who received steroid avoidance with 1624 children who received steroid-based immunosuppression. The effect of steroid avoidance on graft failure among immunologic risk strata was estimated using Cox proportional hazards regression in this propensity score-matched cohort. Results It was observed that 5-year graft survival was mildly improved in children receiving steroid avoidance (84.8% versus 81.2%, P = 0.03). This improvement in graft survival occurred in the first 2 years following transplant, when the hazard ratio (HR) for allograft failure in children receiving steroid avoidance was 0.62 [95% confidence interval (CI) 0.45-0.86]. In contrast, steroid avoidance was not associated with improved allograft survival during Years 2-10 following transplant (HR = 0.93; 95% CI 0.75-1.15). During this time period, HRs (95% CIs) for allograft failure within immunologic risk strata were not significantly different from the null value of 1: repeat kidney transplants, 1.84 (0.84-4.05); African-Americans, 1.02 (0.67-1.56); sensitized recipients, 1.24 (0.63-2.43); recipients of deceased donor kidneys, 1.02 (0.79-1.32); recipients of completely human leukocyte antigen-mismatched kidneys, 0.80 (0.47-1.37); and recipients with pretransplant glomerular disease, 0.94 (0.71-1.23). Conclusions In pediatric kidney transplant recipients receiving tacrolimus- and mycophenolate-based immunosuppression, steroid avoidance can be safely practiced in children with immunologic risk factors.
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Affiliation(s)
- Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bo Lu
- Division of Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Maurizio Macaluso
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
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10
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Hamdani G, Nehus EJ, Hanevold CD, VanSickle JS, Hooper DK, Blowey D, Warady BA, Mitsnefes MM. Ambulatory Blood Pressure Control in Children and Young Adults After Kidney Transplantation. Am J Hypertens 2017; 30:1039-1046. [PMID: 28575139 DOI: 10.1093/ajh/hpx092] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 05/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ambulatory blood pressure (BP) monitoring (ABPM) is the preferred method to characterize BP status, and its use in kidney transplant recipients is increasing. Data on longitudinal ambulatory BP (ABP) trends in pediatric and young adult kidney transplant recipients are limited. METHODS Retrospective review of a large cohort of children and young adults following kidney transplantation and evaluation of their ABP status over time and its associations with any patient and clinical characteristics. RESULTS Two hundred and two patients had baseline ABPM available for analysis, and 123 of them had a follow up (median time 2.3 years) ABPM. At the time of follow up, more patients were treated for hypertension (80% vs. 72%, P = 0.02), and less patients had ambulatory hypertension (36% vs. 54%, P = 0.005), uncontrolled or untreated, compared with baseline, with 45% of all patients classified as having controlled hypertension (compared to 26% at baseline, P = 0.002). Prevalence of ambulatory hypertension decreased only in patients who were less than 18 years old at baseline. High baseline mean 24-hour systolic BP was independently associated with persistent hypertension. CONCLUSIONS In young kidney transplant recipients followed by ABPM, the prevalence of ambulatory hypertension decreases over time, mainly due to the increased number of patients with controlled hypertension.
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Affiliation(s)
- Gilad Hamdani
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Coral D Hanevold
- Division of Pediatric Nephrology, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Judith S VanSickle
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri, USA
| | - David K Hooper
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Doug Blowey
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri, USA
| | - Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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11
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Hamdani G, Nehus EJ, Hooper DK, Mitsnefes MM. Masked hypertension and allograft function in pediatric and young adults kidney transplant recipients. Pediatr Transplant 2016; 20:1026-1031. [PMID: 27353352 DOI: 10.1111/petr.12752] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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] [Accepted: 06/07/2016] [Indexed: 11/27/2022]
Abstract
Masked hypertension is a common complication of pediatric kidney transplantation. While office hypertension is known to be associated with worse short- and long-term graft function, the role of masked hypertension in allograft dysfunction is not clear. We conducted a retrospective cross-sectional analysis of 77 consecutive pediatric kidney transplant recipients who had routine 24-h ambulatory blood pressure monitoring with the aims to estimate the prevalence of masked hypertension and examine its association with allograft function. Masked hypertension was defined as a 24-h systolic or diastolic blood pressure load ≥25%. Twenty-nine percent of patients had masked hypertension. Patients with masked hypertension had significantly lower allograft function estimated using the creatinine-based Schwartz-Lyon formula, a cystatin C-based formula, and combined cystatin C and creatinine-based formulas than patients with normal blood pressure (all p values <0.05). In a multivariable analysis, masked hypertension remained independently associated with worse allograft function after adjustment for age, sex, race, time post-transplant, rejection history, antihypertensive treatment, and hemoglobin level. We conclude that in young kidney transplant recipients, masked hypertension is common and is associated with worse allograft function. These results support the case for routine ambulatory blood pressure monitoring as the standard of care in these patients to detect and treat masked hypertension.
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Affiliation(s)
- Gilad Hamdani
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David K Hooper
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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12
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Nehus EJ, Mizuno T, Cox S, Goldstein SL, Vinks AA. Pharmacokinetics of meropenem in children receiving continuous renal replacement therapy: Validation of clinical trial simulations. J Clin Pharmacol 2015. [PMID: 26222329 DOI: 10.1002/jcph.601] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [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: 11/08/2022]
Abstract
Meropenem is frequently prescribed in critically ill children receiving continuous renal replacement therapy (CRRT). We previously used clinical trial simulations to evaluate dosing regimens of meropenem in this population and reported that a dose of 20 mg/kg every 12 hours optimizes target attainment. Meropenem pharmacokinetics were investigated in this prospective, open-label study to validate our previous in silico predictions. Seven patients received meropenem (13.8-22 mg/kg) administered intravenously every 12 hours as part of standard care. A mean dose of 18.6 mg/kg of meropenem was administered, resulting in a mean peak concentration of 80.1 μg/mL. Meropenem volume of distribution was 0.35 ± 0.085 L/kg. CRRT clearance was 40.2 ± 6.6 mL/(min · 1.73 m(2) ) and accounted for 63.4% of the total clearance of 74.8 ± 36.9 mL/(min · 1.73 m(2) ). Simulations demonstrated that a dose of 20 mg/kg every 12 hours resulted in a time above the minimum inhibitory concentration (%fT > MIC) of 100% in 5 out of 7 subjects, with a %fT > MIC of 93% and 43% in the remaining 2 subjects. We conclude that CRRT contributed significantly to the total clearance of meropenem. A dosing regimen of 20 mg/kg achieved good target attainment in critically ill children receiving CRRT, which is consistent with our previously published in silico predictions.
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Affiliation(s)
- Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shareen Cox
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
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Riar SK, Mitsnefes MM, Nehus EJ, Patel HP, Steinke JM, Crumb T, Abraham EC, Kamel MW, Greenbaum LA. Kidney transplantation in children with decreased left ventricular systolic function: a Midwest Pediatric Nephrology Consortium study. Pediatr Nephrol 2015; 30:1343-8. [PMID: 25750075 DOI: 10.1007/s00467-015-3066-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 08/26/2014] [Revised: 01/28/2015] [Accepted: 02/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Left ventricular (LV) systolic dysfunction is a relatively uncommon but serious complication of pediatric chronic kidney disease, and may be related to uremia and uncontrolled hypertension. There is limited information on the strategy for managing these children. In some cases, combined heart-kidney transplant may be considered or kidney transplant delayed until cardiac function improves. It is unknown whether these patients are at increased risk for poor outcomes after kidney transplantation. METHODS We conducted a retrospective, multicenter study on the outcomes of children with severe and symptomatic cardiomyopathy who underwent kidney transplantation. RESULTS Eleven patients receiving maintenance dialysis with systolic dysfunction underwent kidney transplantation without simultaneous heart transplant. Nine patients had congestive heart failure in the pre-transplant period. There were no identified complications post-transplant related to the underlying cardiac dysfunction. LV systolic function normalized in all patients and the mean shortening fraction increased from 19.0 ± 4.6 % to 32.0 ± 4.4 % (p < 0.0001). CONCLUSIONS Kidney transplantation should be considered for children receiving maintenance dialysis with severe LV dysfunction.
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Affiliation(s)
- Sandeep K Riar
- Division of Pediatric Nephrology, University of Kansas Medical Center, Kansas City, KS, USA,
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Nehus EJ, Mouksassi S, Vinks AA, Goldstein S. Meropenem in children receiving continuous renal replacement therapy: clinical trial simulations using realistic covariates. J Clin Pharmacol 2014; 54:1421-8. [PMID: 25042683 DOI: 10.1002/jcph.360] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 07/03/2014] [Indexed: 11/06/2022]
Abstract
Meropenem is frequently prescribed in children receiving continuous renal replacement therapy (CRRT). Fluid overload is often present in critically ill children and affects drug disposition. The purpose of this study was to develop a pharmacokinetic model to (1) evaluate target attainment of meropenem dosing regimens against P. aeruginosa in children receiving CRRT and (2) estimate the effect of fluid overload on target attainment. Clinical trial simulations were employed to evaluate target attainment of meropenem in various age groups and degrees of fluid overload in children receiving CRRT. Pharmacokinetic parameters were extracted from published literature, and 287 patients from the prospective pediatric CRRT registry database provided realistic clinical covariates including patient weight, fluid overload, and CRRT prescription characteristics. Target attainment at 40% and 75% time above the minimum inhibitory concentration was evaluated. Clinical trial simulations demonstrated that children greater than 5 years of age achieved acceptable target attainment with a dosing regimen of 20 mg/kg every 12 hours. In children less than 5, however, increased dosing of 20 mg/kg every 8 hours was needed to optimize target attainment. Fluid overload did not affect target attainment. These in silico model predictions will need to be verified in vivo in children receiving meropenem and CRRT.
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Affiliation(s)
- Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
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Nehus EJ, Laskin BL, Kathman TI, Bissler JJ. Performance of cystatin C-based equations in a pediatric cohort at high risk of kidney injury. Pediatr Nephrol 2013; 28:453-61. [PMID: 23142864 DOI: 10.1007/s00467-012-2341-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [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: 05/08/2012] [Revised: 09/11/2012] [Accepted: 10/01/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Limited data exist on the performance of cystatin C-based glomerular filtration rate (GFR) equations in pediatric transplant recipients and other high-risk patients. The aim of our study was therefore to evaluate the performance of current cystatin C-based equations in this population. METHODS This was a retrospective, cross-sectional study of 141 consecutive patients (58 % post-transplant) who received a nuclear medicine GFR (NucGFR) examination using (99m)Tc- diethylenetriaminepentaacetic acid at our institution. Subjects included children receiving liver, kidney or hematopoietic stem cell transplants and patients with oncologic or urologic disease. GFR estimates using published GFR estimating equations, including those based on cystatin C (Filler, Zappitelli, Larsson, Hoek, Rule and Le Bricon equations, respectively) and on both cystatin C and creatinine (Zappitelli, Bouvet and Schwartz equations, respectively), were evaluated and compared to the NucGFR measurement using Bland-Altman analysis. RESULTS The mean NucGFR was 95 (interquartile range 76-111) ml/min/1.73 m(2). Of the cystatin C-based equations, the Rule, Hoek, Zappitelli and Schwartz (2009 CKiD equation) formulas provided the closest agreement to the NucGFR estimate. All other formulas overestimated the GFR in our cohort. CONCLUSION Cystatin C-based GFR formulas can provide an accurate estimation of NucGFR in a pediatric population with a high proportion of transplant recipients and oncology patients.
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Affiliation(s)
- Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH 45229-3039, USA
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