Body Mass Index Increased at a Large Midwestern Children's Hospital During the COVID-19 Pandemic

Background: The COVID-19 pandemic has presented a great challenge to children and their families with stay-at-home orders, school closures, decreased exercise opportunities, stress, and potential overeating with home confinement. Our study describes the body mass index (BMI) changes over an entire decade, including a year of the COVID-19 pandemic at a large children's hospital. Methods: With our retrospective observational study, data were extracted from Cincinnati Children's Hospital's Epic electronic medical record, a free-standing children's hospital with 670 inpatient beds and >1.2 million patient encounters per year. Children aged 19 years and under with at least one height and weight were included in the analysis. Results: In all, 2,344,391 encounters were analyzed with 712,945 visits in years 2018-2021. The prevalence of overweight/obesity was relatively stable with a gradual rise from 35% to 36.4% from 2011 to 2020. However, the year of the COVID-19 stay at home and restrictions (2020-2021) showed an increase in overweight/obesity to 39.7% (8.3% increase), with the greatest increase in those with Class 3 obesity from 3.0% to 3.8%. When viewing the change in BMI percentile during the pandemic year compared with the 2 years prior, there was a significantly increasing trend (p < 0.0001). Conclusions: Children attending a large children's hospital showed an increase in overweight/obesity during the COVID-19 pandemic. These data suggest greater efforts are needed to reverse the increase in weight status from the COVID-19 pandemic as obesity is a risk factor for poor outcomes with COVID-19.

Occult Diastolic Dysfunction and Adverse Clinical Outcomes in Adolescents and Young Adults With Fontan Circulation

Background In Fontan circulation, diastolic dysfunction portends a worse clinical outcome but may be concealed during routine assessment. Invasive evaluation with rapid volume expansion (RVE) can identify patients with occult diastolic dysfunction (ODD). We sought to evaluate the association between ODD and adverse clinical outcomes at medium-term follow-up. Methods and Results We conducted a single-center observational study of patients with Fontan circulation who underwent clinical catheterization with RVE from 2012 to 2017. ODD was defined as post-RVE end-diastolic pressure ≥15 mm Hg. A composite adverse clinical outcome included mortality, cardiac transplant, ventricular assist device, plastic bronchitis, protein-losing enteropathy, arrhythmia, stroke/thrombus, or cardiac-related hospital admission. Proportional hazards regression was used to compare the ODD-positive and ODD-negative groups for risk of the composite adverse clinical outcome. Eighty-nine patients with Fontan circulation (47% female patients) were included at a median age of 14 years. ODD was identified in 31%. Fontan duration was longer in the ODD group (P=0.001). The composite adverse clinical outcome occurred more frequently in the ODD group (52 versus 26%, P=0.03) during a median follow-up duration of 2.9 years after catheterization. ODD (hazard ratio [HR], 2.68 [95% CI, 1.28-5.66]; P=0.02) and Fontan duration (HR, 1.07 [95% CI, 1.02-1.12]; P=0.003) were associated with the composite adverse clinical outcome. When stratified by Fontan duration, ODD remained significantly associated with the hazard of adverse clinical outcomes in patients with a Fontan duration ≥10 years (HR, 2.57 [95% CI, 1.03-6.57]; P=0.04). Conclusions Cardiac catheterization with rapid volume expansion reveals a significant incidence of ODD, which relates to Fontan duration. ODD is associated with an increased hazard of adverse clinical outcomes during medium-term follow-up, especially in patients with longer Fontan duration. ODD may portend a worse prognosis in Fontan circulation.

POS0836 EFFICACY OF MEPOLIZUMAB IN PATIENTS WITH EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS AND A VASCULITIC PHENOTYPE

Background

Patients with eosinophilic granulomatosis with polyangiitis (EGPA) can present with vasculitic or eosinophilic phenotypes.1 The Phase III MIRRA study demonstrated that patients with EGPA spent more time in remission and had reduced oral corticosteroid (OCS) use with mepolizumab versus placebo.2

Objectives

To evaluate the efficacy of mepolizumab in patients with a vasculitic EGPA phenotype enrolled in the MIRRA study.

Methods

MIRRA was a Phase III, multicentre, double-blind, parallel-group trial in adult patients with relapsing/refractory EGPA and ≥4 weeks stable OCS treatment. Patients were randomised to receive standard of care plus mepolizumab (300 mg subcutaneously every 4 weeks) or placebo for 52 weeks. Primary endpoints were: accrued weeks of remission (defined as Birmingham Vasculitis Activity Score [BVAS] of 0 and OCS dose ≤4 mg/day prednisolone or equivalent) over the 52-week study period categorised in weeks (0, >0 to <12, 12 to <24, 24 to <36 and ≥36 weeks), and the proportion of patients in remission at both Weeks 36 and 48. This post hoc analysis used data from the MIRRA study to evaluate these endpoints according to patients’ antineutrophil cytoplasmic antibody (ANCA) history (current or previous positive test for myeloperoxidase[MPO]/proteinase 3[PR3]-ANCA at study baseline versus no history of a positive MPO/PR3-ANCA test at baseline), baseline BVAS (=0 vs >0) and Vasculitis Damage Index (VDI) score (<5 vs ≥5). Types of disease relapse (vasculitis [BVAS >0], asthma [active asthma symptoms and/or signs with a worsening in Asthma Control Questionnaire-6 score] and sinonasal [active nasal and/or sinus disease with a worsening in ≥1 sinonasal symptom questions]) reported during the treatment period were also described. EGPA disease characteristics focusing on vasculitic components were assessed in patients who did and did not achieve remission at any point during the study.

Results

Of the 136 patients in the study, 26 (19%) had a history of a positive ANCA test at study baseline and 110 (81%) did not. In addition, 51 (38%) had a BVAS =0 at baseline while 85 (63%) had a BVAS >0; 74 (54%) had a VDI <5 at baseline and 62 (46%) had a VDI ≥5. Accrued remission duration was greater with mepolizumab versus placebo, irrespective of ANCA positive status, baseline BVAS or baseline VDI score (Figure 1). Across all the subgroups, a larger proportion of patients achieved remission at both Weeks 36 and 48 with mepolizumab versus placebo (Figure 1). Among patients receiving mepolizumab, the numbers (proportion) of patients achieving remission at both Weeks 36 and 48 were: 7 (54%) for patients with a history of an ANCA-positive test and 15 (27%) for patients without a history of an ANCA-positive test; 14 (45%) in the BVAS =0 and 8 (22%) in the BVAS >0 groups; 11 (29%) in the VDI score <5 and 11 (37%) in the VDI score ≥5 groups. Mepolizumab reduced all types of disease relapse assessed during the treatment period, including vasculitis, asthma and sinonasal relapses, compared with placebo. Vasculitic characteristics including neuropathy, glomerulonephritis, alveolar haemorrhage, palpable purpura and ANCA positivity were generally similar among patients who did and did not achieve remission during the study.

Figure 1.

Mepolizumab efficacy by patient baseline characteristics

ANCA, antineutrophil cytoplasmic antibody; BVAS, Birmingham Vasculitis Activity Score; CI, confidence interval; NA, data not available – estimate could not be calculated owing to a lack of patients in the placebo group achieving remission at Weeks 36 and 48; VDI, Vasculitis Damage Index.

Conclusion

Mepolizumab is associated with clinical benefits in patients with EGPA, including those with and without a vasculitic phenotype.

References

[1]Latorre M et al. Eur Respir J. 2013;42(Suppl 57):1797.

[2]Wechsler ME et al. N Engl J Med. 2017;376(20):1921–32.

Acknowledgements

Funding: GSK (MEA115921; NCT02020889); the Division of Intramural Research, NIAID, NIH funded in part time spent on this abstract by one of the authors (PK).

Disclosure of Interests

Benjamin Terrier Consultant of: Roche, Chugai, GSK, AstraZeneca, Bristol Myers Squibb, Terumo BCT, Sanofi, LFB and Grifols, David Jayne Speakers bureau: Amgen Vifor, Consultant of: AstraZeneca, Aurinia, BMS, Boehringer Ingelheim, ChemoCentryx, GSK, Janssen, Novartis, Roche/Genentech, Takeda and Vifor, Grant/research support from: AstraZeneca, Aurinia, BMS, Boehringer Ingelheim, ChemoCentryx, GSK, Janssen, Novartis, Roche/Genentech, Takeda and Vifor, Bernhard Hellmich Speakers bureau: AbbVie, BMS, Boehringer Ingelheim, Chugai, GSK, InflaRx, Novartis, Pfizer, Roche and Vifor Pharma, Consultant of: AbbVie, BMS, Boehringer Ingelheim, Chugai, GSK, InflaRx, Novartis, Pfizer, Roche and Vifor Pharma, Grant/research support from: Ab2Bio, AbbVie, AstraZeneca, Bristol Myers Squibb, ChemoCentryx, GSK, InflaRx, Kiniksa, Nippon Kayaku, Novartis, Roche, and Sanofi (my institution received payments for participation in multicentre clinical trials and the institution or myself did not receive money for any other kind of research projects), Jane H. Bentley Shareholder of: GSK, Employee of: GSK, Jonathan Steinfeld Shareholder of: GSK, Employee of: GSK, Steven W Yancey Shareholder of: GSK, Employee of: GSK, Namhee Kwon Shareholder of: GSK, Employee of: GSK, Praveen Akuthota Paid instructor for: AstraZeneca, Consultant of: AstraZeneca, GSK, Sanofi, Grant/research support from: GSK, AstraZeneca and Regeneron, Paneez Khoury: None declared, Lee Baylis Shareholder of: GSK, Employee of: GSK, Michael Wechsler Consultant of: GSK, Genentech, Sanofi, Regeneron, AstraZeneca, Teva, Novartis, Boehringer Ingelheim, Sentien, and Equillium, Grant/research support from: National Institute of Allergy and Infectious Diseases and the National Heart, Lung, and Blood Institute

Prevalence Implications of the 2017 American Academy of Pediatrics Hypertension Guideline and Associations with Adult Hypertension

OBJECTIVE

To evaluate the impact of the 2017 American Academy of Pediatrics hypertension Clinical Practice Guideline (CPG), compared with the previous guideline ("Fourth Report"), on the frequency of hypertensive blood pressure (BP) measurements in childhood and associations with hypertension in adulthood using data from the International Childhood Cardiovascular Cohort Consortium.

STUDY DESIGN

Childhood BPs were categorized in normal, prehypertensive/elevated, and hypertensive (stage 1 and 2) ranges using the Fourth Report and the CPG. Participants were contacted in adulthood to assess self-reported hypertension. The associations between childhood hypertensive range BPs and self-reported adult hypertension were evaluated.

RESULTS

Data were available for 34 014 youth (10.4 ± 3.1 years, 50.6% female) with 92 751 BP assessments. Compared with the Fourth Report, the CPG increased hypertensive readings from 7.6% to 13.5% and from 1.3% to 2.5% for stage 1 and 2 hypertensive range, respectively (P < .0001). Of 12 761 adults (48.8 ± 7.9 years, 43% male), 3839 (30.1%) had self-reported hypertension. The sensitivity for predicting adult hypertension among those with hypertensive range BPs at any point in childhood, as defined by the Fourth Report and the CPG, respectively, was 13.4% and 22.4% (specificity 92.3% and 85.9%, P < .001), with no significant impact on positive and negative predictive values. Associations with self-reported adult hypertension were similar and weak (c-statistic range 0.61-0.68) for hypertensive range BPs as defined by the Fourth Report and CPG.

CONCLUSIONS

The CPG significantly increased the prevalence of childhood BPs in hypertensive ranges and improved the sensitivity, without an overall strengthened association, of predicting self-reported adult hypertension.

Abstract 51: Ambulatory Blood Pressure Phenotype And Cardiovascular Risk In Youth: The Ship-ahoy Study

We investigated whether blood pressure (BP) phenotype based on clinic & 24-hour ambulatory BP (ABP) was associated with intermediate markers of cardiovascular disease (CVD) in 374 adolescents enrolled in a study of the relationship of BP to CV risk. Clinic BP was measured by auscultation and categorized using the 2017 AAP guideline. ABP was measured for 24 hours by an oscillometric device and analyzed using the adult ABP wake SBP cut-point (130 mmHg). This created 4 BP phenotype groups: normal BP (n=224), white coat hypertensive (n=48), ambulatory hypertensive (n=57) & masked hypertensive (n=45). Echocardiographic parameters & carotid-femoral pulse wave velocity (PWVcf) were measured to assess CVD risk. Left ventricular mass (LVM) was lowest in the normal BP group, whereas multiple measures of cardiac function and PWVcf were worse in the masked and ambulatory hypertensive groups:

Generalized linear models adjusted for body mass index (BMI) were constructed to examine the associations between BP phenotype and the measured CVD variables. ABP phenotype was an independent predictor of LVM, diastolic and systolic function and PWVcf in the unadjusted model. ABP phenotype remained significantly associated with diastolic function (E/e’, e’/a’), systolic function (ejection fraction) and increased arterial stiffness (PWVcf) after adjustment for BMI percentile (all p<=0.05). We conclude that BP phenotype is an independent predictor of markers of increased CVD risk in adolescents, including impaired cardiac function and increased vascular stiffness. ABP monitoring has an important role in CVD risk assessment in youth.

RONC-31. ADVANCED ECHOCARDIOGRAPHY WITH MYOCARDIAL-STRAIN-ANALYSIS DESCRIBES SUBCLINICAL CARDIAC DYSFUNCTION AFTER CRANIOSPINAL IRRADIATION (CSI) IN PEDIATRIC AND YOUNG ADULT PATIENTS WITH CENTRAL NERVOUS SYSTEM (CNS) TUMORS

CSI is part of the treatment of CNS tumors and is associated with cardiovascular disease; data in pediatric/young-adult patients are limited. Myocardial-strain-analysis can reveal subclinical dysfunction. Retrospective, single-center study in CNS tumor patients managed with CSI from 1986–2018. Clinical details, and echocardiography including myocardial-strain-analysis were collected at T1=first echocardiogram after CSI, and T2=most recent echocardiogram. Data are mean±standard deviation. Echocardiograms were available in 44 patients (36%female, 14±8.0years) at T1 and 39 patients (38%female, 21.0±11.3years) at T2. Standard echocardiography was normal for all subjects. At T1, global longitudinal peak systolic strain (GLS) was -16.3%±3.7% in CSI vs. -21.6%±3.5% in controls (p&lt;0.0001); global radial peak systolic strain (GRS) was 21.5%±10.1% in CSI vs. 26.5%±7.4% in controls, and global circumferential peak systolic strain (GCS) was -19.5%±6.0% in CSI vs. -21.4%±3.4% in controls (p&lt;0.05, both comparisons). At T2, GLS was -15.8%±5.2% in CSI vs. -21.9±3.5% in controls (p&lt;0.0001); GRS was 22.6%±10.4% in CSI vs. 27.1±8.2% in controls (p&lt;0.05); GCS was -20.5%±6.9% in CSI vs. -21.8±3.5% in controls (p=0.10). For 17 patients with myocardial-strain-analysis available for both time points: difference in GLS was 0.06±7.2% (p&gt;0.95); GRS was 5.5±9.5% (p&lt;0.05); GCS was -3.4±4.9% (p&lt;0.05). Subclinical dysfunction is present at first echocardiogram after CSI. Myocardial impairment may recover with time, however further analysis is needed to identify risk factors and trends. These results argue for inclusion of baseline cardiovascular assessment and longitudinal follow-up in CNS tumor patients post CSI.

Left Ventricular Magnetic Resonance Imaging Strain Predicts the Onset of Duchenne Muscular Dystrophy-Associated Cardiomyopathy

BACKGROUND

Early detection of left ventricular (LV) dysfunction before the onset of overt Duchenne muscular dystrophy-associated cardiomyopathy (DMDAC) may direct clinical management to slow onset of dysfunction. We aimed to assess whether LV strain will predict those who develop DMDAC.

METHODS

We performed a single center retrospective case control study of patients with Duchenne muscular dystrophy who underwent serial cardiac magnetic resonance between 2006 and 2019. Patients with Duchenne muscular dystrophy with an LV ejection fraction ≥55% on ≥1 cardiac magnetic resonance were identified and grouped into age-matched +DMDAC and -DMDAC. Within 3 years, +DMDAC had a subsequent cardiac magnetic resonance with a decline in LV ejection fraction ≥10% and absolute LV ejection fraction ≤50%. -DMDAC maintained an LV ejection fraction ≥55% on serial cardiac magnetic resonances. Two-dimensional and 3-dimensional global radial strain, global circumferential strain (GCS), and global longitudinal strain were measured using tissue tracking software and their ability to predict DMDAC onset was assessed. Multivariable analysis adjusted for late gadolinium enhancement.

RESULTS

Thirty +DMDAC and 30 age-matched -DMDAC patients were included with a total of 164 studies analyzed. Before DMDAC onset, 2-dimensional global radial strain and GCS were significantly worse in +DMDAC compared with -DMDAC (25.1±6.0 versus 29.0±6.3, P=0.011; -15.4%±2.4 versus -17.3%±2.6, P=0.003). Three-dimensional GCS and global radial strain had similar findings. Among strain measures, 3-dimensional GCS had the highest area under the curve to predict DMDAC in our cohort. These findings persisted after adjusting for the presence of late gadolinium enhancement.

CONCLUSIONS

Reduced global radial strain and GCS may predict those at risk for developing DMDAC before onset of LV dysfunction and its clinical utility warrants further exploration.

OR07-5 A Cross-Sectional Study of IGF-I Bioavailability through Childhood: Associations with PAPP-A2 and Anthropometric Data

Insulin-like growth factor I (IGF-I) is one of the essential hormonal mediators of human growth. Circulating IGF-I exists in a ternary complex bound to the acid-labile subunit (ALS) and an IGF binding protein, predominantly IGFBP-3. Pregnancy Associated Plasma Protein-A2 (PAPP-A2), which cleaves intact IGFBP-3, liberates IGF-I from the ternary complex to interact with cell surface receptors. Genome-wide association studies have linked PAPPA2 to adult stature, and mutations in PAPPA2 cause short stature with decreased IGF-I bioavailability. As little is known about PAPP-A2 concentrations throughout childhood and its association with IGF-I bioavailability, we evaluated normal serum concentrations of free IGF-I, intact IGFBP-3, and PAPP-A2 throughout childhood and their relationship with anthropometry. We assessed serum samples from 838 individuals (Age: 3-18, Male: 48%, Caucasian: 83%) who participated in the Cincinnati Genomic Control Cohort, a population-based study of generally healthy children. Patients on medications known to affect growth or with significant medical comorbidities were excluded. Subjects were evaluated at a single visit. Height and weight were measured and a blood sample was drawn. Serum samples were aliquoted and stored at −80 ° C without thawing until the current assays were performed. Total and free IGF-I, total and intact IGFBP-3 and PAPP-A2 were measured using ELISA kits developed by Ansh Laboratories. Age-specific reference interval curves were generated by sex. Correlation and regression analyses were used to examine relationships among analytes and association between each analyte and age, sex, race, height, and BMI. Statistical analyses were performed using SAS®, version 9.4. Free IGF-I increased with age. Serum PAPP-A2 consistently decreased throughout childhood. Serum intact IGFBP-3 increased from early childhood into adolescence with a more marked rise than total IGFBP-3. In multiple regression analysis, height Z-score was positively associated with free and total IGF-I (P=0.01; P<0.0001). Free IGF-I was positively associated with total IGF-I (M; F, r=0.32; r=0.39, P<0.0001). Intact IGFBP-3 was negatively associated with PAPP-A2 (M; F, r=−0.58; r=−0.65, P<0.0001) and the percentage of free to total IGF-I in both sexes (r=−0.53, P<0.0001). PAPP-A2 was positively associated with the percentage of free to total IGF-I (M; F, r=0.18; r=0.38, P<0.001) but not with absolute free IGF-I levels. In conclusion, this is the first study describing PAPP-A2 and intact IGFBP-3 concentrations throughout childhood. Surprisingly, PAPP-A2, a positive modulator of IGF-I bioavailability, decreased with age, but was not positively associated with absolute levels of free IGF-I. Higher levels of PAPP-A2 led to more cleavage of intact IGFBP-3 and thus increased the percentage of free to total IGF-I in this population.

Severe Obesity Decreasing in Children in Cincinnati, Ohio

Childhood obesity rates appear to be leveling off. Studies not looking at severe obesity may be masking a rightward shift in the distribution of body mass indexes. Our objective was to provide current prevalence rates and examine trends in overweight, obesity, class 2 obesity, and class 3 obesity for youth in Cincinnati, Ohio. We performed a retrospective chart review of children 2 to 18 years old seen at Cincinnati Children's Hospital Medical Center between July 1, 2011, and June 30, 2014. Data from 217 037 BMIs were obtained; 35.2% of children were found to have an elevated BMI. Prevalence rates were highest in older, Hispanic, and Medicaid-insured children. The only significant trend over the 3-year period was a downward shift in class 3 obesity ( P = .02), contrary to national findings. Further studies assessing which clinical/community efforts have led to this downward trend will be essential to target future resources and facilitate continued progress.

Clinical features predict responsiveness to imatinib in platelet-derived growth factor receptor-alpha-negative hypereosinophilic syndrome

BACKGROUND

With the exception of the presence of the FIP1L1-PDGFRA fusion gene, little is known about predictors of imatinib response in clinically-defined hypereosinophilic syndrome (HES).

METHODS

Subjects with FIP1L1-PDGFRA-myeloid neoplasm (FP; n =12), PDGFRA-negative HES with ≥4 criteria suggestive of a myeloid neoplasm (MHES; n =10), or steroid-refractory PDGFRA-negative HES with <4 myeloid criteria (SR; n = 5) were enrolled in a prospective study of imatinib therapy (NCT00044304: registered at clinicaltrials.gov). The primary outcome was an eosinophil count <1.5 × 109/L at one month and improvement of clinical symptoms. Clinical, molecular, and bone marrow responses to imatinib were assessed. A retrospective cohort of 18 subjects with clinically-defined HES who received imatinib (300-400 mg daily ≥ 1 month) were classified according to the criteria used in the prospective study.

RESULTS

Overall, imatinib response rates were 100% in the FP group (n = 16), 54% in the MHES group (n = 13) and 0% in the SR group (n = 16). The presence of ≥ 4 myeloid features was the sole predictor of response. After ≥ 18 months in complete remission, imatinib was tapered and discontinued in 8 FP and 1 MHES subjects. Seven subjects (6 FP, 1 MHES) remain in remission off therapy for a median of 29 months (range 14-36).

CONCLUSIONS

Clinical features of MHES predict imatinib response in PDGFRA-negative HES.

Serum biomarkers are similar in Churg-Strauss syndrome and hypereosinophilic syndrome

RATIONALE

Churg-Strauss syndrome (CSS) and hypereosinophilic syndrome (HES) overlap considerably in clinical presentation. A reliable means of distinguishing between these groups of patients is needed, especially in the setting of glucocorticoid therapy.

METHODS

A retrospective chart review of 276 adult subjects referred for evaluation of eosinophilia > 1500/μl was performed, and subjects with a documented secondary cause of eosinophilia or a PDGFR -positive myeloproliferative neoplasm were excluded. The remaining subjects were assessed for the presence of American College of Rheumatology (ACR) criteria. Laboratory and clinical parameters were compared between subjects with biopsy-proven vasculitis (CSS; n = 8), ≥4 ACR criteria (probable CSS; n = 21), HES with asthma and/or sinusitis without other CSS-defining criteria (HESwAS; n = 20), HES without asthma or sinusitis (HES; n = 18), and normal controls (n = 8). Serum biomarkers reported to be associated with CSS were measured using standard techniques.

RESULTS

There were no differences between the subjects with definite or probable CSS or HES with respect to age, gender, or maintenance steroid dose. Serum CCL17, IL-8, and eotaxin levels were significantly increased in eosinophilic subjects as compared to normal controls, but were similar between the eosinophilic groups. Serum CCL17 correlated with eosinophil count (P < 0.0001, r = 0.73), but not with prednisone dose.

CONCLUSIONS

In patients with a history of asthma and sinusitis, distinguishing between ANCA-negative CSS and PDGFR-negative HES is difficult because of significant overlap in clinical presentation and biomarker profiles.

Gender differences in the relationships among obesity, adiponectin and brachial artery distensibility in adolescents and young adults

BACKGROUND

Obesity-related cardiovascular diseases (CVDs) are a major cause of cardiovascular (CV) mortality. Obesity-related reduction in vascular protective adipose-derived proteins, such as adiponectin (APN), has an important role.

METHODS

We compared brachial artery distensibility (BrachD) with APN, the level of adiposity and other CV risk factors (CVRFs) in 431 post-pubertal subjects (mean 17.9 years). Gender differences in average values were examined by t-tests. Correlations among BrachD, obesity and other CVRFs were examined. Regression analysis was performed to determine whether APN provided an independent contribution to BrachD, while controlling for obesity and other CVRFs.

RESULTS

Male subjects had lower BrachD (5.72+/-1.37 vs 6.45+/-1.60% change per mm Hg, P<0.0001) and lower APN (10.50+/-4.65 vs 13.20+/-6.53; all P<0.04) than female subjects. BrachD correlated with APN (r=0.25, P< 0.0001). Both BrachD and APN correlated with measures of body size, including height, weight and body mass index (BMI). Both correlated with higher systolic blood pressure, glucose, insulin and lower high-density lipoprotein cholesterol (all P<0.01). In multivariate analysis, APN, gender, APN*gender and BMI z-score predicted BrachD (r(2)=0.305). On the basis of gender difference, only BMI z-score was significant for male subjects (r(2)=0.080), whereas APN and BMI z-score contributed for female subjects (r(2)=0.242, all P<0.0001).

CONCLUSIONS

BrachD is independently influenced by obesity in both male and female subjects. In female subjects, APN exerts an additional independent effect even after adjusting for blood pressure (BP), lipid levels and insulin. Differences in the effect of the APN-adiposity relationship on obesity-related vascular disease may be one reason for gender differences in the development and progression of atherosclerosis.

Acquired renal cysts after pediatric liver transplantation: association with cyclosporine and renal dysfunction

ACKD has been observed in children on dialysis and with chronic renal insufficiency. In one report, ACKD was observed in 30% of pediatric liver transplant recipients after 10 yr. We retrospectively reviewed all renal imaging and measurements of GFR of 235 childhood liver transplant recipients with no known risk for renal cyst formation, no evidence of renal cyst(s) at the time of transplantation and renal imaging at least one yr post-transplant. Twenty-six patients (11%) developed one or more cyst(s). Mean GFR was significantly lower in patients with renal cyst(s). Two (1.4%) of the 146 patients treated with tacrolimus and 24 (27%) of the 89 patients treated with CsA acquired renal cyst(s) (p < 0.001). CsA-treated patients had significantly lower GFR. Multivariate analysis identified CsA as the only independent variable associated with ACKD. These results confirm that ACKD can be a late complication of pediatric liver transplantation. Those at most risk are at least 10-yr post-liver transplantation, have been treated with CsA and have impaired renal function. We speculate that ACKD in these patients is the result of calcineurin inhibitor nephrotoxicity. Whether patients with ACKD will be prone to develop solid renal tumors is unknown.

Decreased maximal aerobic capacity in pediatric chronic kidney disease

Adult and pediatric patients with ESRD have impaired maximum oxygen consumption (VO(2) max), a reflection of the cardiopulmonary system's ability to meet increased metabolic demands. We sought to determine factors associated with decreased VO(2) max in pediatric patients with different stages of CKD. VO(2) max was measured using a standardized exercise testing protocol in patients with stage 2 to 4 chronic kidney disease (CKD) (n = 46), in renal transplant recipients (n = 22), in patients treated with maintenance hemodialysis (n = 12), and in age-matched healthy controls (n = 33). VO(2) max was similar between children with stage 2 CKD and controls, whereas lower VO(2) max was observed among children with stage 3 to 4 CKD, those treated with hemodialysis, and transplant recipients. In univariate analysis, VO(2) max was significantly associated with body mass index, resting heart rate, C-reactive protein, serum triglycerides, serum creatinine, and measures of diastolic function; no significant associations with left ventricular structure or systolic function were identified. In multivariate regression analysis, patient category versus control and the presence of diastolic dysfunction were independent predictors of lower VO(2) max. These results suggest that aerobic capacity is decreased in the early stages of CKD in children and that lower VO(2) max can be predicted by the presence of diastolic dysfunction, even if systolic function is normal.

Early manifestations and spectrum of recipient twin cardiomyopathy in twin-twin transfusion syndrome: relation to Quintero stage

OBJECTIVES

To examine cardiac structural and functional changes in twin-twin transfusion syndrome (TTTS), relative to Quintero stage, as a means of evaluating the spectrum of cardiomyopathy in TTTS.

METHODS

This was a cross-sectional, retrospective study of 42 consecutive cases of TTTS referred to a single fetal therapy center. Quintero stages were assigned by standard criteria. Presence of ventricular hypertrophy, cardiomegaly, atrioventricular valve regurgitation (AVVR), ventricular systolic dysfunction and right ventricular outflow tract obstruction on fetal echocardiography were noted. The Doppler myocardial performance index (MPI), an index of global ventricular function, was calculated for both ventricles in subjects with adequate Doppler data. We compared cardiac changes across Quintero stages.

RESULTS

There was no cardiomyopathy observed in donor twins. The majority of subjects presented at Quintero Stage I (n = 14), II (n = 14) or III (n = 11), with fewer at Stages IV (n = 2) or V (n = 1). As early as Quintero Stages I and II, a significant proportion of recipient twins had ventricular hypertrophy (17/28, 61%), AVVR (6/28, 21%) or quantitative abnormalities in either right (12/24, 50%) or left (14/24, 58%) ventricular function. Increasing prevalence of biventricular systolic dysfunction and cardiomegaly accompanied advancing Quintero stage.

CONCLUSIONS

Changes in cardiac structure and function not reflected in Quintero staging occur in recipient twins early in the evolution of TTTS. Incorporation of cardiac findings into assessment of TTTS severity may prove useful in stratification of risk and treatment selection.

Diastolic filling abnormalities in children with essential hypertension

OBJECTIVE

To evaluate whether essential hypertension impacts diastolic function in children.

STUDY DESIGN

In this cross-sectional study, patients with essential hypertension (n = 50) were compared with a normotensive group (n = 53). Echocardiographic assessment of diastolic function included measures derived from transmitral, color M-mode, and tissue Doppler interrogation. Cardiac dimensions, wall thickness, geometry, and systolic function were also assessed. Multiple linear regression analysis was performed to identify predictors of altered diastolic function.

RESULTS

Diastolic filling abnormalities were found in 36% of the children with blood pressure elevation. Those subjects with concentric hypertrophy were more significantly affected. Abnormalities in indices reflective of left ventricular (LV) relaxation occurred more commonly (39%) than those of LV compliance (33%). Elevated indexed LV mass was found to be the most significant independent predictor of diastolic filling abnormalities.

CONCLUSIONS

LV diastolic filling abnormalities were found in one-third of the pediatric subjects with essential hypertension. Whether these changes represent an adaptive or maladaptive response requires further study.

Adiponectin in children with chronic kidney disease: role of adiposity and kidney dysfunction

Low serum adiponectin is a known cardiovascular risk in adult chronic kidney disease (CKD). However, adiponectin concentrations and their relation with other cardiovascular risks have not been studied in children with preterminal CKD. Forty-four children and adolescents who were aged 6 to 21 yr and had stages 2 to 4 CKD had serum adipocytes, lipoproteins, markers of inflammation, homocysteine, and insulin levels determined cross-sectionally. There were 29 lean (body mass index [BMI] <85th percentile) and 15 nonlean (BMI > or =85th percentile) patients. Mean serum adiponectin level was 30.6 +/- 14.1 microg/ml (range 7.1 to 67.8 microg/ml). A total of 83% of patients had elevated adiponectin level. Despite similar kidney function, lean patients had significantly higher adiponectin levels than nonlean patients (34.1 +/- 13.4 microg/ml versus 23.6 +/- 13.3 microg/ml; P = 0.02). In univariate analysis, serum adiponectin negatively correlated with age (r = -0.34, P = 0.02), BMI (r = -0.47, P = 0.001), leptin (r = -0.41, P = 0.006), GFR (r = -0.39, P = 0.02), and insulin (r = -0.36, P = 0.01) and positively correlated with ApoA2 (r = 0.30, P = 0.04); no significant associations were found with markers of inflammation or homocysteine. Multivariate stepwise analysis showed that GFR (beta = -0.008, P = 0.001), BMI (beta = -0.16, P = 0.015), and age (beta = -0.04, P = 0.018) independently predicted serum adiponectin levels. Separate analysis of lean patients showed no significant relations with age or BMI; only GFR independently predicted serum adiponectin level (beta = -0.01, P = 0.0008). It is concluded that serum adiponectin is elevated in children and adolescents with stages 2 to 4 CKD and that decreased kidney function is a major determinant of elevated adiponectin concentrations. Despite overall elevated adiponectin, overweight patients display lower serum adiponectin levels and might be at risk for future cardiovascular complications.

Left ventricular hypertrophy in pediatric kidney transplant recipients: long-term follow-up study

Cross-sectional studies indicate that LVH, known cardiovascular risk factor, is frequent in pediatric patients post-kidney transplant. We performed a retrospective longitudinal analysis of echocardiographic data collected in children and adolescents who received kidney transplant from 1998 to 2003. The first echo was performed at a median time post-transplant of 14 months in 47 children; a second echo (echo 2) was carried out at a median time of 33 months in 31 and a third echo (echo 3) was performed at a median time of 49 months in 14 children. LVH was defined as LV mass index >/=95th percentile for children. LVH was present in echo 1 in 25 (54%) subjects. Systolic blood pressure (p = 0.02) and BMI (p = 0.02) independently predicted the LVH seen in echo1 in multivariate logistic regression. In 14 subjects with three consecutive echocardiograms LVM index significantly decreased from echo 1 to echo 2 and from echo 1 to echo3 (p < 0.05), but no significant changes were observed between echo 2 and echo 3. The overall prevalence of LVH remained unchanged but its severity significantly decreased during the follow-up. The results of the study suggest that despite regression of LVM index overtime-pediatric patients post-kidney transplant are at continuous risk for developing cardiovascular disease.

Influence of obesity on timing of puberty

Timing of normal pubertal maturation has received increased attention over the past several years. Age of menarche showed a dramatic decrease in the first half of the 20th century in Western nations; since 1960, the decrease in age of menarche has slowed and, in some societies, has actually increased. More recently, age of onset of pubertal maturation appears to have decreased, especially in girls. Multiple studies have demonstrated that childhood levels of obesity and ponderosity are associated with earlier menarche in girls. Earlier maturation in boys, however, is associated with lower adiposity and ponderosity. Secular changes in the United States as well as around the world have noted increases in prevalence as well as extent of overweight. Factors contributing to these changes include increases in calories and fast food consumption, decreases in physical activity, and increases in television viewing. There appear to have been selective advantages to lower metabolic rate (the 'thrifty' gene hypothesis), and earlier maturation. However, changes in caloric consumption, caloric density and physical activity, combined with greater lifespan, may allow expression of the adverse consequences of these adaptations, such as the metabolic syndrome or cancers.

Predictors of attrition from a pediatric weight management program

OBJECTIVE

The current study examined characteristics of families who initiated weight management treatment for their obese child/adolescent and withdrew prematurely.

STUDY DESIGN

Participants (body mass index > or =95(th) percentile) were enrolled in a pediatric interdisciplinary weight management clinic. Retrospective chart review revealed noncompleters (n=116) completed > or =1 visit(s) but withdrew before completion of the initial 4-month treatment phase. Completers (n=96) completed the initial treatment phase. Completers and noncompleters were compared on baseline demographic, psychological, clinical, and laboratory measures. Regression analyses assessed the degree to which these factors predicted attrition.

RESULTS

Fifty-five percent of patients withdrew prematurely from treatment. Noncompleters were more likely to be Medicaid recipients, black, older, and self-report greater depressive symptomatology and lower self-concept.

CONCLUSIONS

These data have implications for the design of pediatric weight management intervention models that improve the rate of completion for economically disadvantaged and minority youth. Screening for depressive symptomatology may identify patients at risk for treatment dropout who could be targeted for increased support and retention strategies.

Impaired systemic ventricular relaxation affects postoperative short-term outcome in Fontan patients

OBJECTIVES

Systemic ventricular end-diastolic pressure has been used as a predictor of outcome in patients undergoing the Fontan operation. However, this index only evaluates late diastolic function and does not assess active ventricular relaxation during the phase of early diastole, a key component of systemic venous pathway flow. This study sought to examine whether impaired preoperative systemic ventricular relaxation, expressed as the time constant of isovolumic relaxation (tau), affects short-term postoperative outcome in Fontan patients.

METHODS

All patients who underwent Fontan operation between May 1998 and November 2001 were enrolled. Tau was calculated from digitized preoperative systemic ventricular pressure tracings. Standard preoperative invasive indices were also recorded and analyzed. These independent variables were then entered into a multiple stepwise regression model, with length of intensive care unit stay, length of hospital stay, and prolonged pleural effusion as outcome variables.

RESULTS

Twenty-seven patients fulfilled inclusion criteria. Systemic left ventricle predominated, and all patients had undergone prior staged palliation. Extracardiac Fontan was the commonest operative technique. Of the independent variables examined, tau was the only statistically significant predictor of length of intensive care unit stay (P <.001) and length of hospital stay (P =.002). None of the independent variables predicted pleural effusion greater than 10 days.

CONCLUSIONS

Tau was the only significant preoperative invasive predictor of short-term outcome in the Fontan patients. This illustrates the importance of systemic ventricular relaxation and highlights the need for a more comprehensive assessment of diastolic function before the Fontan operation.

Does assessment of pretest probability of disease improve the utility of echocardiography in suspected endocarditis in children?

OBJECTIVE

To compare the yield rate (YR) of echocardiography when evaluating children with suspected infectious endocarditis (IE) in both the actual clinical setting and in the hypothetic setting where strict clinical criteria are applied. Study design Medical records of 101 children undergoing echocardiography for suspected IE were reviewed. Echocardiograms with positive findings were identified and the actual diagnostic YR was calculated. With the use of clinical criteria proposed by von Reyn (VR), the probability of IE was retrospectively classified as (1) rejected, (2) possible, or (3) probable. Theoretic YR of echocardiography was calculated for each classification.

RESULTS

The actual YR of echocardiography was 12% (12/101). The YR of echocardiography by VR class was 0% in rejected, 20% in possible, and 80% in probable cases (chi(2) = 55.1, P <.0001). Echocardiography did not change the probability of IE in any patient classified as rejected, but allowed reassignment of disease probability in a significant proportion of patients with possible or probable IE.

CONCLUSIONS

The YR of echocardiography was significant when clinical probability of IE was intermediate-to-high, and low, with marginal clinical utility, when clinical probability was low. Strict pretest assessment of disease probability may lead to more effective utilization of echocardiography in this population.

Moderate-dose dobutamine maximizes left ventricular contractile response during dobutamine stress echocardiography in children

BACKGROUND

Assessment of ventricular contractile reserve by dobutamine stress echocardiography (DSE) may be a powerful tool for detection of subclinical ventricular dysfunction, however, the hemodynamic dose-response relationship during DSE in children has not been established.

METHODS

To characterize changes in hemodynamics and ventricular contractility during DSE in children, 26 participants (age 8.3 +/- 4.8 years; 17 male/9 female) with normal resting left-ventricular function underwent DSE. Participants with abnormal wall motion at rest or during DSE, or rejection were excluded. Left ventricular M-mode echocardiography and carotid pulse tracings were obtained at each stage for calculation of shortening fraction, velocity of circumferential fiber shortening (VCFc), and end-systolic wall stress (WS). Contractility was expressed as the difference between actual and predicted VCFc for measured WS. Dose-response curves for shortening fraction, VCFc, WS, and contractility (the difference between actual and predicted VCFc for measured WS) were obtained.

RESULTS

Stepwise changes in contractility, systolic blood pressure, WS, and left ventricular shortening fraction were observed at doses up to, but not beyond, 20 microg/kg/min. Increases in double product were observed at doses up to 30 microg/kg/min.

CONCLUSIONS

DSE at a dobutamine dose of 20 microg/kg/min is optimal to fully assess contractile reserve in children. Lesser doses may provide insufficient stress, whereas higher doses may incur unnecessary increases in myocardial oxygen consumption and side effects.

Body mass index and allograft function in pediatric renal transplantation

Recent studies indicate that pre-transplant (Tx) obesity and increased body mass index (BMI) after renal Tx in adults are associated with decreased long-term renal allograft survival. This study examined whether obesity prior to renal Tx or the development of obesity within the 1st year after Tx in children is associated with worse allograft function at 1 year post Tx. This is a retrospective review of medical records from 76 pediatric renal allograft recipients between January 1994 and December 2000. Recipients had their renal allograft functioning at 1 year, and had a glomerular filtration rate (GFR) measured 1 year post Tx. Obesity was defined as body mass index (BMI)> or =95th percentile for age, sex, and race. Patients were divided into three groups: (1) children who had BMI> or =95th percentile at time of Tx, (2) children who had BMI<95th percentile at time of Tx but became obese at 1 year after Tx, and (3) children with BMI<95th percentile at time of Tx and 1 year later. The number of patients with BMI> or =95th percentile doubled at 1 year after Tx when compared with pre-Tx data: 10 (13%) versus 22 (29%), respectively. Fifteen (20%) patients developed obesity and 10 (13%) patients had BMI between the 85th and 95th percentile at 1 year post Tx. Children in group 1 had significantly lower mean GFR (46.1+/-15.0 ml/min per 1.73 m(2)) than children in group 2 (57.7+/-24.5 ml/min per 1.73 m(2), P<0.05) and group 3 (60.4+/-21.5 ml/min per 1.73 m(2), P<0.01). The difference remained significant after adjusting GFR to height: group 1 24.0+/-5.2 ml/min per m, group 2 31.5+/-11.2 ml/min per m, P<0.05, and group 3 32.2+/-10.6 ml/min per m, P<0.01. Children with pre-Tx obesity (group 1) had significantly higher indexed systolic blood pressure ( P<0.01) than children from other groups. We conclude that pre-Tx obesity is associated with decreased GFR in children at 1 year after Tx. The reason may be persistence or development of post-Tx hypertension in severely obese patients.

Noncircumferential myofiber function: impact on early diastolic filling in children

Circumferential and noncircumferential myofiber contraction may have varying impact on systolic and diastolic function. The purpose of this study was to determine the relation of circumferential, longitudinal, and oblique fiber shortening to early diastolic filling in children. Twenty-five patients (8.1 +/- 5.6 years of age; 12 boys and 13 girls) with normal echocardiograms and no heart disease had prospective echocardiographic evaluation of circumferential (shortening fraction, fractional area change), longitudinal (left ventricular axial shortening), combined circumferential and longitudinal (left ventricular ejection fraction), oblique (left ventricular systolic twist [LVST]) shortening, and early diastolic filling. Mean LVST was 16 +/- 8 degrees. There was no relation between early diastolic filling indexes and indexes of circumferential or longitudinal shortening. However, there was a significant inverse relation between heart rate-corrected E-wave acceleration time and LVST (r = 0.63, P <.001). Oblique fiber shortening affects early diastolic filling in children. Describing the functional role of noncircumferential left ventricular myofibers may improve our understanding of global left ventricular function.

Changes in left ventricular mass index in children and adolescents after renal transplantation

Recent reports indicate a high prevalence of left ventricular hypertrophy (LVH) in children on dialysis and after renal transplantation (Tx), as identified by cross-sectional analysis. However, the evolution of LVH in pediatric patients with end-stage renal disease after renal Tx is not well established. To assess changes of left ventricular mass (LVM), we prospectively performed echocardiography in 23 children and adolescents between November 1998 and July 2000. Each patient had an echocardiographic evaluation while on dialysis (for at least 6 weeks) and a follow-up evaluation at least 6 months after successful renal Tx (i.e. with a measured glomerular filtration rate [GFR] of at least 40 mL/min/1.73 m2). The LVM index was estimated by indexing LVM to height(2.7). Sixteen patients had a cadaveric transplant and seven had a live donor transplant; the mean duration between the two studies was 1.9 +/- 1.6 yr; and the mean GFR was 55.0 +/- 21.4 mL/min/1.73 m2. There was no significant difference in the mean values of the LVM index while on dialysis and after renal Tx (43.9 +/- 17.8 g/m2.7 and 39.3 +/- 12.0 g/m2.7, respectively, p = 0.19), or in the prevalence of LVH (52% and 56%, respectively). Interval changes in the LVM index in individual subjects between the two studies were significantly associated with interval changes in indexed systolic (r = 0.42, p = 0.04) and diastolic (r = 0.42, p = 0.05) blood pressures. Interval changes in hemoglobin, blood urea nitrogen (BUN), creatinine, and duration after Tx did not correlate with changes in the LVM index. There was no significant difference in LVM index change according to the type of dialysis, donor source, and the cause of renal failure. In multivariate analysis, the baseline LVM index and changes in indexed SBP were independent predictors for LVM index change after renal Tx. We conclude that LVH persists in children and adolescents after renal Tx. Control of blood pressure might be an important factor in regression or prevention of progression of LVH in these patients.

A phase I and pharmacologic study of capecitabine and paclitaxel in breast cancer patients

BACKGROUND

Based on preclinical studies demonstrating that treatment with paclitaxel upregulates intratumoral thymidine phosphorylase (dTHdPase), which catalyzes the final step in the conversion of the oral fluoropyrimidine capecitabine to 5-fluorouracil (5-FU), as well as the overlapping spectra of activity for these agents, particularly in metastatic breast cancer, this phase I study evaluated the feasibility of administering capecitabine on an intermittent schedule in combination with paclitaxel in previously-treated patients with locally advanced or metastatic breast cancer. The study also sought to recommend doses for subsequent disease-specific studies, identify clinically significant pharmacokinetic interactions, and detect preliminary antitumor activity.

PATIENTS AND METHODS

Nineteen previously treated women with metastatic breast cancer whose prior treatment included neither paclitaxel or capecitabine received one hundred one courses of capecitabine and paclitaxel. Paclitaxel was administered as a three-hour intravenous (i.v.) infusion at a fixed dose of 175 mg/m2 and capecitabine was administered as 2 divided daily doses for 14 days followed by a seven-day rest period every 3 weeks. The dose of capecitabine was increased from a starting dose of 1650 mg/m2/d. The plasma sampling scheme in the first course permitted characterization of the pharmacokinetics of each agent given alone and concurrently to detect major pharmacokinetic interactions.

RESULTS

Palmar plantar erythrodysesthesia (hand foot syndrome) and neutropenia were the principal dose-limiting toxicities (DLT). Other toxicities included diarrhea and transient hyperbilirubinemia. Three of eight new patients treated with capecitabine 2000 mg/m2/d and paclitaxel 175 mg/m2 experienced DLT in the first course, whereas none of eleven new patients treated with capecitabine 1650 mg/m2/d and paclitaxel 175 mg/m2 developed DLT. Pharmacokinetic studies indicated that capecitabine did not grossly affect the pharmacokinetics of paclitaxel, and there were no major effects of paclitaxel on the pharmacokinetics of capecitabine and capecitabine metabolites. However, AUC values for the major 5-FU catabolite, fluorobeta-alanine (FBAL), were significantly lower in the presence of paclitaxel. Two complete and seven partial responses (56% response rate) were observed in sixteen patients with measurable disease; four of six patients whose disease was previously treated with high-dose chemotherapy and hematopoietic stem-cell support had major responses. Seven of nineteen patients had stable disease as their best response.

CONCLUSIONS

Recommended combination doses of capecitabine on an intermittent schedule and paclitaxel are capecitabine 1650 mg/m2/d orally for 14 days and paclitaxel 175 mg/m2 i.v. every 3 weeks. The favorable preclinical interactions between capecitabine and paclitaxel, as well as the acceptable toxicity profile and antitumor activity in patients with metastatic breast cancer, support further clinical evaluations to determine an optimal role for the combination of capecitabine and paclitaxel in breast cancer and other relevant malignancies.

Changes in left ventricular mass in children and adolescents during chronic dialysis

Left ventricular hypertrophy (LVH) is an independent risk factor for cardiac mortality in adults with end-stage renal disease (ESRD). It is prevalent in pediatric patients on chronic dialysis. The objectives of this study were to evaluate left ventricular mass (LVM) in children and adolescents at the initiation of dialysis and to assess its changes during chronic dialysis therapy. In this longitudinal analysis, 29 patients aged 4-18 years had an echocardiographic evaluation within 90 days of starting dialysis therapy and a follow-up study at least 6 months later. LVH was defined as LVM index (g/m2.7) > 95th percentile for normal children and adolescents. On the initial echocardiogram 20 of 29 (69%) patients had LVH and 24 patients (83%) had abnormal LV geometry (38% eccentric LVH, 31% concentric LVH, and 14% concentric remodelling). Patients with LVH were more likely to be on antihypertensive medications (16/20) than patients without LVH (3/9) (P = 0.005). Repeat echocardiogram, performed after 10 +/- 3 months on chronic dialysis, showed no significant difference in the mean LVM index (49.6 +/- 17.5 g/m2.7 and 49.7 +/- 16.1 g/m2.7, respectively) or in the prevalence of LVH or LV geometric pattern. However, 14 of 29 patients had a progressive increase in LVM index and 15 patients had regression. Multiple regression analysis showed that baseline LVM index (P = 0.005) and interval change in indexed systolic blood pressure (P = 0.027) were independent predictors for LVM index changes. In summary, LVH and abnormal LV geometry are already prevalent in children and adolescents with renal failure at the time of initiation of dialysis therapy, indicating that LVH develops during the pre-ESRD course. Early intervention to control blood pressure may be an important factor to improve and prevent progression of LVH in pediatric patients with ESRD.

Transverse cervical artery pseudoaneurysm: a rare complication of internal jugular vein cannulation

Internal jugular vein cannulation has become the preferred approach for temporary hemodialysis catheter placement following reports of an increased incidence of subclavian vein stenosis due to subclavian vein catheterization. Internal jugular vein catheterization is associated with a high rate of successful catheter placement. However, significant complications such as internal carotid artery (ICA) puncture, pneumothorax, vessel erosion, thrombosis, airway obstruction and infection can occur. The most common complication is ICA puncture. More recently a few cases of thyrocervical trunk pseudoaneurysm and fistula following internal jugular vein and subclavian vein catheterization attempts have been reported. Patients with renal failure who are on hemodialysis may have to undergo multiple catheter placements and vascular access interventions. This, along with their comorbid conditions, increases the risk of such complications. Here we report a patient on hemodialysis who developed transverse cervical artery pseudoaneurysm following an attempted right internal jugular vein catheterization. We report this case because of its rarity, to raise awareness of such a complication and to discuss different treatment options, in particular endovascular coil occlusion. A review of relevant literature is also presented.

Severe left ventricular hypertrophy in pediatric dialysis: prevalence and predictors

Left ventricular hypertrophy (LVH) has been recognized as an independent risk factor for cardiovascular morbidity and mortality in adults with end-stage renal disease. However, the prevalence and severity of LVH in children on chronic dialysis therapy is not well established. Retrospectively, 64 chronic dialysis patients, aged 20 months to 22 years, on chronic dialysis had echocardiographic evaluation of LV mass (LVM) and geometry. Forty-eight (75%) children had LVH, including 22 of 26 (85%) on hemodialysis (HD) and 26 of 38 (68%) on peritoneal dialysis (PD). The prevalence of LVH in patients on HD was significantly higher than those on PD (P=0.02). Abnormal LV geometry was found in 51 of 64 (80%) patients: 25 patients (39%) had eccentric hypertrophy, 3 (5%) had concentric remodelling, and 23 (36%) had concentric LVH. Twenty-six children (41%) had severe LVH, defined as LVM index greater than 51 g/m2.7, which is associated with a fourfold greater risk for development of cardiovascular disease in adults. Patients with severe LVH had a significantly lower hemoglobin level (P=0.027) and longer duration of renal disease prior to the start of dialysis therapy (P=0.003) than patients without LVH. Multiple logistic regression analysis revealed HD as opposed to PD as a significant independent predictor for severe LVH (P=0.036). Higher systolic blood pressure remained in the final model as an independent predictor with a borderline level of significance (P=0.065). The results indicate that severe LVH and abnormal left ventricular geometry are common in young dialysis patients. Better control of blood pressure, anemia, and hypervolemia may be important in prevention or improving LVH.