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Wong Vega M, Vuong KT, Chmielewski J, Gollins L, Slagle C, Srivaths PR, Akcan Arikan A. Nutrition for critically ill children and neonates requiring dialysis: Application of clinical practice recommendations. Nutr Clin Pract 2023; 38 Suppl 2:S139-S157. [PMID: 37721460 DOI: 10.1002/ncp.11048] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/02/2023] [Accepted: 07/08/2023] [Indexed: 09/19/2023] Open
Abstract
Approximately 30% of all children and neonates admitted to the intensive care unit (ICU) experience acute kidney injury (AKI). Children with AKI are largely poorly fed and experience high rates of malnutrition. Nutrition prescription and provision are exceptionally challenging for critically ill neonates, infants, and children with AKI given the dynamic nature of AKI and its respective treatment modalities. Managing the nutrition prescription of critically ill neonates, infants, and children with AKI requires nutrition support clinicians to have a high-level understanding of the various treatment modalities for AKI, which can affect the patient's protein, fluid, electrolyte, and mineral needs. Accurate and timely nutrition assessment in critically ill neonates and children with AKI can be flawed owing to difficulty obtaining accurate anthropometric parameters. Recently, the Pediatric Renal Nutrition Taskforce introduced clinical practice recommendations for the nutrition management of children with AKI. In this review, we will discuss the practical implications of these recent guidelines and work to bridge the knowledge and practice gaps for pediatric and neonatal nutrition support clinicians providing nutrition therapy for patients with AKI in the ICU. We also appraise special nutrition-related considerations for neonates with AKI given newer available renal replacement treatment modalities.
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Affiliation(s)
- Molly Wong Vega
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Kim T Vuong
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Chmielewski
- Division of Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Laura Gollins
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Cara Slagle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Poyyapakkam R Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Ayse Akcan Arikan
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Criticial Care Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Montgomery A, Goff C, Adeyeri B, Ferreira LD, Kamepalli S, Lynn J, Galvan NTN, Srivaths PR, Brewer ED, Rana A. A modified Kidney Donor Risk Index for pediatric kidney transplant recipients. Pediatr Nephrol 2023; 38:1309-1317. [PMID: 36066770 DOI: 10.1007/s00467-022-05722-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/08/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Kidney Donor Risk Index (KDRI) by Rao et al. was developed to measure the quality of kidney allografts. While Rao's KDRI has been found to be a robust measure of kidney allograft survival for adult kidney transplant recipients, many studies have indicated the need to create a distinct pediatric KDRI. METHODS Our retrospective study utilized data from the United Network for Organ Sharing database. We examined 9295 deceased donor recipients' data for age < 18 years from 1990 to 2020. We performed a multivariate Cox regression to determine the significant recipient and transplant factors impacting pediatric kidney allograft survival. RESULTS Multivariate analysis found 5 donor factors to be independently associated with graft failure or recipient death: age, female sex, anoxia as the cause of death, history of cigarette use, and cold ischemia time. Using receiver operator characteristic (ROC) curve analysis and analyzing the predictive value of each KDRI at 1, 5, and 10 years, the proposed pediatric KDRI had a statistically significant and higher predictive value for pediatric recipients at 5 (0.60 versus 0.57) and 10 years (0.61 versus 0.57) than the Rao KDRI. CONCLUSIONS The proposed pediatric KDRI may provide a more accurate and simpler index to assess the quality of kidney allografts for pediatric recipients. However, due to the mild increase in predictive capabilities over the Rao index, the study serves as a proof of concept to develop a pediatric KDRI. Further studies should focus on increasing the index's predictive capabilities. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Ashley Montgomery
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA.
| | - Cameron Goff
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Bolatito Adeyeri
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Liam D Ferreira
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Spoorthi Kamepalli
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Jake Lynn
- Department of Student Affairs, Baylor College of Medicine, Houston, TX, USA
| | - Nhu Thao Nguyen Galvan
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Eileen D Brewer
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Abbas Rana
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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Gerzina EA, Brewer ED, Guhan M, Geha JD, Huynh AP, O'Conor D, Thorsen AC, Tan GC, Bhakta K, Hosek K, Malik TH, O'Mahony CA, Faraone ME, Fuller K, Rana A, Swartz SJ, Srivaths PR, Galván NTN. Good outcomes after pediatric intraperitoneal kidney transplant. Pediatr Transplant 2022; 26:e14294. [PMID: 35470524 DOI: 10.1111/petr.14294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 09/08/2021] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Kidney transplantation in small children is technically challenging. Consideration of whether to use intraperitoneal versus extraperitoneal placement of the graft depends on patient size, clinical history, anatomy, and surgical preference. We report a large single-center experience of intraperitoneal kidney transplantation and their outcomes. METHODS We conducted a retrospective review of pediatric patients who underwent kidney transplantation from April 2011 to March 2018 at a single large volume center. We identified those with intraperitoneal placement and assessed their outcomes, including graft and patient survival, rejection episodes, and surgical or non-surgical complications. RESULTS Forty-six of 168 pediatric kidney transplants (27%) were placed intraperitoneally in children mean age 5.5 ± 2.3 years (range 1.6-10 years) with median body weight 18.2 ± 5 kg (range 11.4-28.6 kg) during the study period. Two patients (4%) had vascular complications; 10 (22%) had urologic complications requiring intervention; all retained graft function. Thirteen patients (28%) had prolonged post-operative ileus. Eight (17%) patients had rejection episodes ≤6 months post-transplant. Only one case resulted in graft loss and was associated with recurrent focal segmental glomerular sclerosis (FSGS). Two patients (4%) had chronic rejection and subsequent graft loss by 5-year follow-up. At 7-year follow-up, graft survival was 93% and patient survival was 98%. CONCLUSIONS The intraperitoneal approach offers access to the great vessels, which allows greater inflow and outflow and more abdominal capacity for an adult donor kidney, which is beneficial in very small patients. Risk of graft failure and surgical complications were not increased when compared to other published data on pediatric kidney transplants.
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Affiliation(s)
| | - Eileen D Brewer
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, Texas, USA
| | - Maya Guhan
- Baylor College of Medicine, Houston, Texas, USA
| | - Joseph D Geha
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Anh P Huynh
- Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Gail C Tan
- Baylor College of Medicine, Houston, Texas, USA
| | - Kirti Bhakta
- Transplant Services, Texas Children's Hospital, Houston, Texas, USA
| | - Kat Hosek
- Outcomes and Impact Service, Texas Children's Hospital, Houston, Texas, USA
| | | | - Christine A O'Mahony
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Kelby Fuller
- Transplant Services, Texas Children's Hospital, Houston, Texas, USA
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sarah J Swartz
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, Texas, USA
| | - Poyyapakkam R Srivaths
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, Texas, USA
| | - N Thao N Galván
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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Valencia Deray KG, Taylor MG, Blessing MM, Bocchini CE, Schallert EK, Ruderfer D, Srivaths PR, Malatesta Muncher R. Necrotizing enterovirus myositis in a pediatric renal transplant recipient. Pediatr Transplant 2022; 26:e14275. [PMID: 35340121 DOI: 10.1111/petr.14275] [Citation(s) in RCA: 1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 02/08/2022] [Accepted: 03/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Enteroviruses can cause severe infections, including viral myocarditis, meningitis, acute flaccid myelitis, and viral myositis. METHODS/RESULTS We report a 3-year-old female renal transplant recipient who presented to a tertiary care hospital with elevated serum liver aminotransferases and subsequently developed proximal muscle pain, weakness, and respiratory distress during the first week of hospitalization. Imaging of the lower extremities revealed diffuse myositis of the proximal thigh and pelvic muscles. A muscle biopsy was obtained and revealed necrotizing myositis with immunostaining positive for enterovirus, consistent with a diagnosis of enterovirus necrotizing myositis. She had complete resolution of symptoms with steroids, intravenous immune globulin, reduced tacrolimus dose, and physical therapy. CONCLUSIONS Enterovirus myositis should be included in the differential diagnosis for necrotizing myositis following renal transplantation in children.
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Affiliation(s)
- Kristen G Valencia Deray
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Margaret G Taylor
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Melissa M Blessing
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
| | - Claire E Bocchini
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Erica K Schallert
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel Ruderfer
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Poyyapakkam R Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Anand A, Malik TH, Dunson J, McDonald MF, Christmann CR, Galvan NTN, O'Mahony C, Goss JA, Srivaths PR, Brewer ED, Rana A. Factors associated with long-term graft survival in pediatric kidney transplant recipients. Pediatr Transplant 2021; 25:e13999. [PMID: 33704871 DOI: 10.1111/petr.13999] [Citation(s) in RCA: 10] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/22/2020] [Accepted: 02/24/2021] [Indexed: 12/13/2022]
Abstract
Pediatric kidney transplant recipients generally have good outcomes post-transplantation. However, the younger age and longer life span after transplantation in the pediatric population make understanding the multifactorial nature of long-term graft survival critical. This investigation analyzes factors associated with 10-year survival to identify areas for improvement in patient care. Kaplan-Meier with log-rank test and univariable and multivariable logistic regression methods were used to retrospectively analyze 7785 kidney transplant recipients under the age of 18 years from January 1, 1998, until March 9, 2008, using United Network for Organ Sharing (UNOS) data. Our end-point was death-censored 10-year graft survival after excluding recipients whose grafts failed within one year of transplant. Recipients aged 5-18 years had lower 10-year graft survival, which worsened as age increased: 5-9 years (OR: 0.66; CI: 0.52-0.83), 10-14 years (OR: 0.43; CI: 0.33-0.55), and 15-18 years (OR: 0.34; CI: 0.26-0.44). Recipient African American ethnicity (OR: 0.67; CI: 0.58-0.78) and Hispanic donor ethnicity (OR: 0.82; CI: 0.72-0.94) had worse outcomes than other donor and recipient ethnicities, as did patients on dialysis at the time of transplant (OR: 0.82; CI: 0.73-0.91). Recipient private insurance status (OR: 1.35; CI: 1.22-1.50) was protective for 10-year graft survival. By establishing the role of age, race, and insurance status on long-term graft survival, we hope to guide clinicians in identifying patients at high risk for graft failure. This study highlights the need for increased allocation of resources and medical care to reduce the disparity in outcomes for certain patient populations.
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Affiliation(s)
- Adrish Anand
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Tahir H Malik
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Jordan Dunson
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | - Malcolm F McDonald
- Department of Student Affairs, Baylor College of Medicine, Houston, Texas, USA
| | | | - Nhu Thao Nguyen Galvan
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Christine O'Mahony
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - John A Goss
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Poyyapakkam R Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Eileen D Brewer
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Abbas Rana
- Division of Abdominal Transplant, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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Ruderfer D, Wu M, Wang T, Srivaths PR, Krance RA, Naik S, Bocchini CE. BK Virus Epidemiology, Risk Factors, and Clinical Outcomes: An Analysis of Hematopoietic Stem Cell Transplant Patients at Texas Children's Hospital. J Pediatric Infect Dis Soc 2021; 10:492-501. [PMID: 33416086 DOI: 10.1093/jpids/piaa147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 11/11/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND BK virus-associated hemorrhagic cystitis (BKV-HC) is a serious complication after hematopoietic stem cell transplantation (HSCT). METHODS A retrospective review was performed to determine the frequency of BKV-HC and identify risk factors and renal morbidity associated with BKV-HC in pediatric HSCT recipients at our institution. RESULTS A total of 314 pediatric recipients underwent allogeneic HSCT for either malignant (173, 55.1%) or nonmalignant disorders (141, 44.9%) from January 1, 2011, to December 31, 2015, with a minimum follow-up of 5 years post-HSCT. Severe BKV-HC (grades 3 and 4) was prevalent in 46 out of 67 (68.7%) recipients. Timing to presentation of severe BKV-HC (grades 3 and 4) occurred at a median of 37 days (26, 74; IQ1, IQ3) post-HSCT, with the duration of macroscopic hematuria lasting a median of 37.5 days (18, 71; IQ1, IQ3). In the first 60 days post-HSCT, peak acute kidney injury (AKI) stages 2 and 3 were seen more frequently in HSCT recipients who developed BKV-HC than those without (P = .004). Similarly, during post-HSCT days 61 to 100, peak AKI stage 3 was also more frequently seen in HSCT recipients who already developed BKV-HC prior to or during this time period than those without BKV-HC (P = .0002). Recipients who developed BKV-HC within 1 year of HSCT had more frequent mild to moderate chronic kidney disease (CKD stages 2-3) than those without BKV-HC (P = .002 and .007, respectively). On multivariate analysis, BKV-HC was associated with all-cause mortality (hazard ratio [HR]: 2.22; 95% confidence interval [CI]: 1.35-3.65). The following clinical variables were associated with time to development of HC on multivariate analysis: age (subdistribution HR [sHR] 1.11; 95% CI: 1.06-1.16) and myeloabalative conditioning regimen (sHR 4.2; 95% CI: 2.12-8.34). CONCLUSIONS Pediatric HSCT patients with BKV-HC experience significant morbidity and mortality. Renal morbidity, including AKI and CKD, is associated with BKV-HC.
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Affiliation(s)
- Daniel Ruderfer
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Mengfen Wu
- Biostatistics Shared Resource, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Tao Wang
- Biostatistics Shared Resource, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Poyyapakkam R Srivaths
- Department of Pediatrics, Section of Nephrology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Robert A Krance
- Department of Pediatrics, Section of Hematology and Oncology, Bone Marrow/Stem Cell Transplant Program, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Swati Naik
- Department of Pediatrics, Section of Hematology and Oncology, Bone Marrow/Stem Cell Transplant Program, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Claire E Bocchini
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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Idrovo A, Geer J, Solomon CH, Devaraj S, Swartz SJ, Akcan-Arikan A, Srivaths PR. Correlation of Venous Oxygen Saturations from Noninvasive Hematocrit Monitoring Using Blood Gas Measured Oximetry in Chronic Pediatric Hemodialysis Patients. Blood Purif 2020; 49:665-669. [PMID: 32640449 DOI: 10.1159/000508059] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/20/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Noninvasive hematocrit monitoring (NIVHM) during pediatric hemodialysis (pedHD) provides data in real time regarding changes in hematocrit and blood volume and also provides venous oxygen saturations. The latter has been proposed to indicate changes in tissue oxygen consumption. It is not known how well NIVHM oxygen saturations (O2sat) approximate blood gas measured oximetry saturation (mO2sat) in the course of pedHD. We aimed to assess the validity and reliability of NIVHM O2sat compared to mO2sat. METHODS This is a prospective study in 15 patients <21 years old with >90 days on hemodialysis (HD) without congenital heart disease. HD access was fistula (AVF) in 4 patients and tunneled catheters in the remainder. Pulse oximetry (spO2) was continuously monitored; mO2sat was measured via oximetry in a blood gas analyzer and NIVHM O2sat values collected at the start, middle, and end of HD treatment. RESULTS A total of 45 dyad measurements were obtained. NIVHM O2sat correlated well with mO2sat (R = 0.89, p < 0.0001); the same was seen at pre, mid, and post HD time points (R = 0.86-0.95, p < 0.001). NIVHM O2sat was lower than mO2sat; with catheter as access, the difference was 9.3 ± 8.6 (CI: 12.3-6.22, p < 0.0001) and with AVF was 2.1 ± 0.78 (CI: 2.6-1.7, p < 0.0001). Bland-Altman analysis demonstrated the difference but did not show any systematic bias. Continuous monitor of spO2 showed no hypoxia. DISCUSSION/CONCLUSION Intradialytic NIVHM O2sat correlates well with mO2sat but yield lower values. Future studies can include NIVHM O2sat changes as a surrogate for central venous O2 saturation changes and potentially yield useful information regarding tissue oxygen consumption in pedHD patients.
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Affiliation(s)
- Alexandra Idrovo
- Department of Pediatrics, Renal Section, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA,
| | - Jessica Geer
- Department of Pediatrics, Renal Section, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Catharina H Solomon
- Department of Pediatrics, Renal Section, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Sridevi Devaraj
- Department of Pathology & Immunology, Baylor College of Medicine Chemistry and Point of Care, Houston, Texas, USA
| | - Sarah J Swartz
- Department of Pediatrics, Renal Section, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Renal Section, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Critical Care Section, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Poyyapakkam R Srivaths
- Department of Pediatrics, Renal Section, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
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Affiliation(s)
| | - Poyyapakkam R Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine, 1102 Bates St, Suite 245, Houston, TX, 77030, USA
| | - Shweta Shah
- Renal Section, Department of Pediatrics, Baylor College of Medicine, 1102 Bates St, Suite 245, Houston, TX, 77030, USA.
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Mysore KR, Himes RW, Rana A, Teruya J, Desai MS, Srivaths PR, Zaruca K, Calvert A, Guffey D, Minard CG, Morita E, Hensch L, Losos M, Kostousov V, Hui SKR, Orange JS, Goss JA, Nicholas SK. ABO-incompatible deceased donor pediatric liver transplantation: Novel titer-based management protocol and outcomes. Pediatr Transplant 2018; 22:e13263. [PMID: 30070010 PMCID: PMC6197909 DOI: 10.1111/petr.13263] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 06/18/2018] [Indexed: 12/16/2022]
Abstract
ABO-ILT have re-emerged as an alternate option for select patients awaiting transplant. However, treatment protocols for children undergoing deceased donor ABO-ILT are not standardized. We implemented a novel IS protocol for children undergoing deceased donor ABO-ILT based on pretransplant IH titers. Children with high pretransplant IH titers (≥1:32) underwent an enhanced IS protocol including plasmapheresis, rituximab, IVIG, and mycophenolate, while children with IH titers ≤1:16 received steroids and tacrolimus. We retrospectively assessed our outcomes of ABO-ILT with ABO-compatible recipients of similar age and diagnosis over a 2-year period. Ten children with median age of 8.9 months underwent ABO-ILT, 4 of 10 patients underwent enhanced IS due to high IH titers. Rates of complications (rejection, infections, biliary, and vascular) at both 1 year and up to 3 years post-transplant were comparable between the groups. Patients with ABO-ILT had good graft function with 100% survival at a median follow-up of 3.3 years. In conclusion, IS tailored to pretransplant IH titers in pediatric deceased donor ABO-ILT is feasible and can achieve outcomes similar to ABO-CLT at 1 and 3 years post-transplantation.
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Affiliation(s)
- Krupa R. Mysore
- Section of Pediatric Gastroenterology, Texas Children’s Hospital, Baylor College of Medicine
| | - Ryan W. Himes
- Section of Pediatric Gastroenterology, Texas Children’s Hospital, Baylor College of Medicine
| | - Abbas Rana
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Jun Teruya
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Moreshwar S. Desai
- Section of Pediatric Critical Care, Texas Children’s Hospital, Baylor College of Medicine
| | | | - Kimberly Zaruca
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | | | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine
| | - Charles G. Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine
| | - Eda Morita
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Lisa Hensch
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Michael Losos
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Vadim Kostousov
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Shiu-Ki Rocky Hui
- Department of Pathology, Transfusion Medicine, Baylor College of Medicine
| | - Jordan S. Orange
- Section of Pediatric Allergy & Immunology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - John A. Goss
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Sarah K. Nicholas
- Section of Pediatric Allergy & Immunology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
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Wong Vega M, Beer S, Juarez M, Srivaths PR. Malnutrition Risk in Hospitalized Children: A Descriptive Study of Malnutrition-Related Characteristics and Development of a Pilot Pediatric Risk-Assessment Tool. Nutr Clin Pract 2018; 34:406-413. [PMID: 30294809 DOI: 10.1002/ncp.10200] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 01/08/2023] Open
Abstract
BACKGROUND Underrecognition of pediatric malnutrition may affect nutrition interventions and outcomes. Pediatric malnutrition uses more specific etiology-based criteria but lacks clarity in implementation guidelines. Study goals were to identify malnutrition and risk among hospitalized patients, characterize malnutrition risk factors, and assess reliability of criteria against outcome measures. MATERIALS AND METHODS All children 44 weeks postmenstrual age-18 years, admitted for 48 hours during a 16-day period, were included (n = 528). Trained dietitians assessed patients in physical assessments (PA), growth, energy intake, increased nutrient losses (IL), altered absorption of nutrients (AA), hypermetabolism and inflammation, laboratory information, micronutrient deficiency, and functional status. Outcome data assessed were length of stay (LOS), intensive care unit (ICU) LOS, ventilation days, nutrition support, and dietitian intervention. RESULTS Malnutrition prevalence upon admission was 19.7%. Weight/length or BMI/age z-score (ZS) had no effect on LOS. AA and IL upon admission were independently associated with malnutrition (both, P<.01). Wasting and hypermetabolism were independently associated with longer LOS (P<.01). Other factors associated with longer LOS included IL and inflammation (P < .05). Those with hypermetabolism had significant ZS improvements if followed by a dietitian (P < .05). Wasting via PA was the only factor associated with longer ICU LOS (P < .05). CONCLUSIONS Identification of risk factors (wasting, hypermetabolism, AA, IL) beyond anthropometrics to define malnutrition and risk is important in prioritizing care in a tertiary pediatric facility. Of great significance is the ability of dietitian-based PA to predict LOS and need for intervention.
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Affiliation(s)
- Molly Wong Vega
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Stacey Beer
- Gastroenterology, Hepatology and Nutrition Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Marisa Juarez
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Poyyapakkam R Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Wong Vega M, Srivaths PR. Air Displacement Plethysmography Versus Bioelectrical Impedance to Determine Body Composition in Pediatric Hemodialysis Patients. J Ren Nutr 2017; 27:439-444. [DOI: 10.1053/j.jrn.2017.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 04/05/2017] [Accepted: 04/19/2017] [Indexed: 12/28/2022] Open
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12
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Rodriguez K, Srivaths PR, Tal L, Watson MN, Riley AA, Himes RW, Desai MS, Braun MC, Akcan Arikan A. Regional citrate anticoagulation for continuous renal replacement therapy in pediatric patients with liver failure. PLoS One 2017; 12:e0182134. [PMID: 28792509 PMCID: PMC5549692 DOI: 10.1371/journal.pone.0182134] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/12/2017] [Indexed: 01/20/2023] Open
Abstract
Pediatric liver failure patients frequently develop multiple organ failure and require continuous renal replacement therapy (CRRT) as part of supportive therapy in the pediatric intensive care unit. While many centers employ no anticoagulation for fear of bleeding complications, balanced coagulation disturbance predisposes these patients to clotting as well as bleeding, making maintenance of longer circuit life to deliver adequate dialysis clearance challenging. Regional citrate anticoagulation (RCA) is an attractive option as it avoids systemic anticoagulation, but since citrate metabolism is impaired in liver failure, concerns about toxicity has limited its use. Pediatric data on RCA with liver failure is very scarce. We aimed to establish safety and efficacy of RCA in pediatric liver failure patients on CRRT. Retrospective review of pediatric patients with liver failure receiving CRRT over 30 months. Demographic data and CRRT related data were collected by chart review. Citrate accumulation (CA) was defined as total calcium (mg/dl) /ionized calcium (mmol/L) ratio >2.5 for > 48 hours. Efficacy was assessed by filter life. Safety was assessed by frequency of adverse events ((AEs) defined as bleeding, hemodynamic instability, arrhythmias). Fifty-one patients (median age 3.5 (IQR 0.75-14.2) years) received 861 CRRT days; 70% experienced at least one episode of CA, only 37% were recorded as such in the medical record. AE rate was 93/1000 CRRT days and did not differ between CA days and others. Median filter life was 66 hours (IQR 29-74); 63% filters lasted longer than 48 hrs. Though common, CA was not associated with increased AEs on in pediatric liver failure patients on CRRT receiving RCA. Filter life was adequate. RCA appears an effective anticoagulation for CRRT in pediatric liver failure. Application of a structured definition would increase recognition of CA to allow timely intervention.
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Affiliation(s)
- Keila Rodriguez
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States of America
| | - Poyyapakkam R. Srivaths
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Leyat Tal
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Mary N Watson
- Texas Children’s Hospital, Houston, Texas, United States of America
| | - Alyssa A. Riley
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Ryan W. Himes
- Baylor College of Medicine, Department of Pediatrics, Liver Section, Houston, Texas, United States of America
| | - Moreshwar S. Desai
- Baylor College of Medicine, Department of Pediatrics, Section of Critical Care Medicine, Houston, Texas, United States of America
| | - Michael C. Braun
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Ayse Akcan Arikan
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
- Baylor College of Medicine, Department of Pediatrics, Section of Critical Care Medicine, Houston, Texas, United States of America
- * E-mail:
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13
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Ayestaran FW, Schneider MF, Kaskel FJ, Srivaths PR, Seo-Mayer PW, Moxey-Mims M, Furth SL, Warady BA, Greenbaum LA. Perceived appetite and clinical outcomes in children with chronic kidney disease. Pediatr Nephrol 2016; 31:1121-7. [PMID: 26857711 PMCID: PMC5627603 DOI: 10.1007/s00467-016-3321-9] [Citation(s) in RCA: 26] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 01/11/2016] [Accepted: 01/11/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Children with chronic kidney disease (CKD) may have impaired caloric intake through a variety of mechanisms, with decreased appetite as a putative contributor. In adult CKD, decreased appetite has been associated with poor clinical outcomes. There is limited information about this relationship in pediatric CKD. METHODS A total of 879 participants of the Chronic Kidney Disease in Children (CKiD) study were studied. Self-reported appetite was assessed annually and categorized as very good, good, fair, or poor/very poor. The relationship between appetite and iohexol or estimated glomerular filtration rate (ieGFR), annual changes in anthropometrics z-scores, hospitalizations, emergency room visits, and quality of life were assessed. RESULTS An ieGFR < 30 ml/min per 1.73 m(2) was associated with a 4.46 greater odds (95 % confidence interval: 2.80, 7.09) of having a worse appetite than those with ieGFR >90. Appetite did not predict changes in height, weight, or BMI z-scores. Patients not reporting a very good appetite had more hospitalizations over the next year than those with a very good appetite. Worse appetite was significantly associated with lower parental and patient reported quality of life. CONCLUSIONS Self-reported appetite in children with CKD worsens with lower ieGFR and is correlated with clinical outcomes, including hospitalizations and quality of life.
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Affiliation(s)
| | | | | | | | | | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive Kidney Disease, National Institutes of Health, Bethesda, MD
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Srivaths PR, Sutherland S, Alexander S, Goldstein SL. Two-point normalized protein catabolic rate overestimates nPCR in pediatric hemodialysis patients. Pediatr Nephrol 2013; 28:797-801. [PMID: 23212562 DOI: 10.1007/s00467-012-2371-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 08/23/2012] [Revised: 10/25/2012] [Accepted: 10/26/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Normalized protein catabolic rate (nPCR) calculation depends on estimating the urea generation between consecutive hemodialysis (HD) treatments. Two-point nPCR using blood urea nitrogen (BUN) before and after the same HD treatment has not been validated in pediatric patients, who typically receive a more intense HD dose than adults. This study aimed to compare nPCR calculated with a two-point vs. a three-point nPCR model in pediatric HD patients. METHODS Pediatric patients receiving HD at 2 units were enrolled. Three BUN measurements were obtained around a midweek HD treatment: one prior to HD (preBUN1), one 30 s after HD (30sBUN), and one prior to the subsequent HD (preBUN2). The two-point nPCR model was calculated using preBUN1 and 30sBUN and the three-point nPCR model was calculated using preBUN2 and 30sBUN. RESULTS Seventy-six BUN sets from 35 patients were analyzed. Mean age was 16.4 ± 3.5 years. Mean dry weight was 51.4 ± 17.1 kg. Mean spKt/V was 1.54 ± 0.23. Mean preBUN2 was significantly lower than mean preBUN1 (60.2 ± 18.6 vs. 64.0 ± 18.9 mg/dl, p = 0.0001). nPCR obtained from the three-point model was significantly lower than nPCR obtained from the two-point model (1.07 ± 0.31 vs. 1.17 ± 0.31 g/kg/day, p = 0.00001). Seven of 76 (9.2 %) paired comparisons yielded three-point nPCR <1 vs. two-point nPCR >1. CONCLUSIONS Our data show that in pediatric patients receiving HD, the ((1) two-point and three-point models lead to significantly different nPCRs, and (2) inaccurate protein intake assessment may result from reliance on a two-point model for nPCR estimates.
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Affiliation(s)
- Poyyapakkam R Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX 77030, USA.
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Srivaths PR, Silverstein DM, Leung J, Krishnamurthy R, Goldstein SL. Malnutrition-inflammation-coronary calcification in pediatric patients receiving chronic hemodialysis. Hemodial Int 2010; 14:263-9. [PMID: 20491972 DOI: 10.1111/j.1542-4758.2010.00442.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Poyyapakkam R Srivaths
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, Texas, USA.
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Srivaths PR, Wong C, Goldstein SL. Nutrition aspects in children receiving maintenance hemodialysis: impact on outcome. Pediatr Nephrol 2009; 24:951-7. [PMID: 18293013 PMCID: PMC2772959 DOI: 10.1007/s00467-007-0728-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Revised: 12/04/2007] [Accepted: 12/05/2007] [Indexed: 11/24/2022]
Abstract
Children with end-stage renal disease (ESRD) have rates of mortality estimated to be 30-times higher than expected for age compared with those of healthy children. Physical manifestations of under-nutrition, such as body mass index (BMI) and low height standard deviation score (SDS), have been associated with increased risk of mortality. Traditional measures, such as height, weight and serum albumin concentration, may not be accurate indicators to assess the nutritional status of children receiving maintenance hemodialysis. Normalized protein catabolic rate (nPCR) has emerged as a better marker of nutritional status of such children. Meeting the special nutritional needs of these children often requires nutritional supplementation, by either the enteral or the parenteral route. Recently, in children receiving maintenance hemodialysis who are malnourished, intradialytic parenteral nutrition (IDPN) has been utilized as a means to provide additional protein and calories. This article is a state-of-the-art review of malnutrition in children receiving maintenance hemodialysis, with special focus on outcome, nPCR and IDPN.
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Affiliation(s)
- Poyyapakkam R Srivaths
- Department of Pediatrics, Baylor College of Medicine and Renal Services, Texas Children's Hospital, Houston, TX 77030, USA.
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Swartz SJ, Srivaths PR, Croix B, Feig DI. Cost-effectiveness of ambulatory blood pressure monitoring in the initial evaluation of hypertension in children. Pediatrics 2008; 122:1177-81. [PMID: 19047231 DOI: 10.1542/peds.2007-3432] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [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] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to determine the cost-effectiveness of ambulatory blood pressure monitoring in the initial evaluation of stage 1 hypertension. METHODS Retrospective chart review of data for children referred to Texas Children's Hospital hypertension clinic between January 2005 and August 2006 was performed. We compared the costs of standard evaluations versus the initial use of ambulatory blood pressure monitoring for children with clinic blood pressure measurements suggesting stage 1 hypertension. Charges for clinic visits, laboratory tests, and imaging were obtained from the Texas Children's Hospital billing department. RESULTS A total of 267 children were referred. One hundred thirty-nine children did not receive ambulatory blood pressure monitoring; 54 met clinical indications for ambulatory blood pressure monitoring but did not receive it because it was not a covered expense (44 children) or the family refused the study (10 children). One hundred twenty-six children received clinically indicated ambulatory blood pressure monitoring, paid for either through insurance or by the family. Fifty-eight children (46%) had confirmed white-coat hypertension, 62 (49%) stage 1 hypertension, and 6 (5%) stage 2 hypertension. With the observed prevalence of white-coat hypertension, initial ambulatory blood pressure monitoring use yielded net savings after evaluation of 3 patients, with projected savings of $2.4 million per 1000 patients. CONCLUSIONS Ambulatory blood pressure monitoring in the initial evaluation of suspected childhood hypertension is highly cost-effective. Awareness of cost saving potential may increase the availability of ambulatory blood pressure monitoring for evaluation of new-onset hypertension.
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Affiliation(s)
- Sarah J Swartz
- Department of Pediatrics, Renal Section, Baylor College of Medicine, 6621 Fannin St, MC3-2482, Houston, TX 77030, USA
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Abstract
Bacillus species are increasingly recognized as pathogens in immunocompromised patients. The authors report a case of Bacillus cereus infection of a central line in an immunocompetent patient with hemophilia, which required line removal for complete cure.
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Affiliation(s)
- Poyyapakkam R Srivaths
- Tulane University School of Medicine, Huey P. Long Medical Center, Department of Pediatrics, New Orleans, Louisiana, USA.
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Srivaths PR, Rath B, Prakash SK, Talukdar B. Usefulness of screening febrile infants for urinary tract infection. Indian Pediatr 1996; 33:218-20. [PMID: 8772841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- P R Srivaths
- Department of Pediatrics, Maulana Azad Medical College, New Delhi
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