Nutrition in critically ill children with acute kidney injury on continuous kidney replacement therapy: a 2023 executive summary

OBJECTIVES

Nutrition plays a vital role in the outcome of critical illness in children, particularly those with acute kidney injury. Currently, there are no established guidelines for children with acute kidney injury treated with continuous kidney replacement therapy. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with acute kidney injury receiving continuous kidney replacement therapy.

METHODS

An electronic search using PubMed and an inclusive academic library search (including MEDLINE, Cochrane, and Embase databases) was conducted to find relevant English-language articles on nutrition therapy for children (<18 y of age) receiving continuous kidney replacement therapy.

RESULTS

The existing literature was reviewed by our work group, comprising pediatric nephrologists and experts in nutrition. The modified Delphi method was then used to develop a total of 45 clinical practice points. The best methods for nutritional assessment are discussed. Indirect calorimetry is the most reliable method of predicting resting energy expenditure in children on continuous kidney replacement therapy. Schofield equations can be used when indirect calorimetry is not available. The non-intentional calories contributed by continuous kidney replacement therapy should also be accounted for during caloric dosing. Protein supplementation should be increased to account for the proteins, peptides, and amino acids lost with continuous kidney replacement therapy.

CONCLUSIONS

Clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with acute kidney injury and on continuous kidney replacement therapy based on the existing literature and expert opinions of a multidisciplinary panel.

Nutrition in Critically Ill Children with AKI on Continuous RRT: Consensus Recommendations

BACKGROUND

Nutrition plays a vital role in the outcome of critically ill children, particularly those with AKI. Currently, there are no established guidelines for children with AKI treated with continuous RRT (CRRT). A thorough understanding of the metabolic changes and nutritional challenges in AKI and CRRT is required. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with AKI receiving CRRT.

METHODS

PubMed, MEDLINE, Cochrane, and Embase databases were searched for articles related to the topic. Expertise of the authors and a consensus of the workgroup were additional sources of data in the article. Available articles on nutrition therapy in pediatric patients receiving CRRT through January 2023.

RESULTS

On the basis of the literature review, the current evidence base was examined by a panel of experts in pediatric nephrology and nutrition. The panel used the literature review as well as their expertise to formulate clinical practice points. The modified Delphi method was used to identify and refine clinical practice points.

CONCLUSIONS

Forty-four clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with AKI and on CRRT on the basis of the existing literature and expert opinions of a multidisciplinary panel.

Iodine-induced hypothyroidism (IIH) in paediatric patients receiving peritoneal dialysis: Is risk mitigation possible?

Children with kidney failure who receive maintenance peritoneal dialysis (PD) are at increased risk for thyroid dysfunction. A poorly appreciated cause of hypothyroidism related to PD is iodine overload from exposure to iodine-containing cleaning solutions, iodinated contrast agents or povidone-iodine-containing PD caps, particularly in infants and small children. An international survey was conducted to understand current practices regarding iodine exposure in PD patients, the frequency of iodine-induced hypothyroidism (IIH) in patients receiving PD, and to assess awareness of this issue among paediatric nephrologists. Eighty-nine paediatric nephrology centres responded to the survey. Hypothyroidism in PD patients was diagnosed in 64% (n = 57) of responding centres, although only 19 of these centres (33%) suspected or diagnosed IIH. Aetiologies of IIH included exposure to povidone-iodine-containing PD caps (53%), cleaning solutions with iodine (37%) and iodinated contrast (10%). While most centres (58%, n = 52) routinely evaluate thyroid function, only 34% (n = 30) specifically aim to limit iodine exposure. Of centres not routinely evaluating for or utilising methods to prevent iodine exposure and hypothyroidism, 81% reported being unaware of the risk of IIH in PD patients. Hypothyroidism is diagnosed in a substantial percentage of paediatric PD programmes internationally. Increased education on the risk of iodine exposure in children receiving PD may decrease the incidence of IIH as an aetiology of hypothyroidism.

Embracing the (r)evolution of social media and digital scholarship in pediatric nephrology education

Free Open-Access Medical Education (FOAMed) has transformed medical education in the past decade by complementing and substituting for traditional medical education when needed. The attractiveness of FOAMed resources is due to their inexpensive nature, wide availability, and user ability to access on demand across a variety of devices, making it easy to create, share, and participate. The subject of nephrology is complex, fascinating, and challenging. Traditional didactic lectures can be passive and ineffective in uncovering these difficult concepts and may need frequent revisions. Active teaching methods like flipped classrooms have shown some benefits, and these benefits can only be multifold with current social media tools. Social media will inspire the involvement of students and allow them to create and share educational content in a "trendy way," encouraging the participation of their peers and thus building an educational environment more conducive to them while promoting revision and retainment. FOAMed also promotes asynchronous learning, spaced learning, microlearning, and multimodal presentation with a meaningful variation. This article discusses the evolution of digital education, social media platforms, tools for creating and developing FOAMed resources, and digital scholarship.

Etiology and Management of Edema: A Review

The development of peripheral edema can often pose a significant diagnostic and therapeutic challenge for practitioners due to its association with a wide variety of underlying disorders ranging in severity. Updates to the original Starling's principle have provided new mechanistic insights into edema formation. Additionally, contemporary data highlighting the role of hypochloremia in the development of diuretic resistance provide a possible new therapeutic target. This article reviews the pathophysiology of edema formation and discusses implications for treatment.

Does kidney biopsy in pediatric lupus patients "complement" the management and outcomes of silent lupus nephritis? Lessons learned from a pediatric cohort

BACKGROUND

Silent lupus nephritis (SLN) is systemic lupus erythematosus (SLE) without clinical and laboratory features of kidney involvement but with biopsy-proven nephritis. This study aims to describe and compare the baseline characteristics and outcomes of pediatric SLN with overt LN (OLN) and to identify associated risk factors and biochemical markers.

METHODS

In this retrospective, observational study, multivariate logistic regression and receiver operating characteristic (ROC) analyses studied age, sex, race, serum complements, anti-double-stranded-DNA antibody, anti-Smith antibody, eGFR, and proliferative nephritis.

RESULTS

In our cohort of 69 patients, 47 were OLN, and 22 were SLN. OLN (OR = 4.9, p = 0.03) and non-African Americans (AA) (OR = 13.0, p < 0.01) had higher odds, and increasing C3 and C4 were associated with lower odds of proliferative nephritis (OR 0.95 and 0.65 per one unit increase in C3 and C4, respectively, p < 0.01). They demonstrated a good discriminative ability to detect proliferative nephritis as assessed by the area under the ROC curve (C3 = 0.78, C4 = 0.78). C3 and C4 in proliferative SLN and OLN were comparable and significantly lower than their non-proliferative counterparts. No association was observed between age, sex, anti-double-stranded-DNA antibody, anti-Smith antibody, eGFR, and proliferative nephritis. Proliferative SLN and OLN patients received similar treatments. Adverse events were identified in the proliferative OLN only.

CONCLUSIONS

Lower complement levels are associated with proliferative lesions in pediatric LN-both SLN and OLN. The non-AA population had higher odds of having proliferative nephritis than the AA. Prospective, randomized, long-term follow-up of proliferative SLN patients is needed to ascertain the beneficial effect of early diagnosis and treatment. A higher resolution version of the Graphical abstract is available as Supplementary information.

When Hypertension Grows Up: Implications for Transitioning Care of Adolescents and Young Adults With Hypertension From Pediatric to Adult Health Care Providers

Hypertension (HTN) is an important cause of morbidity and mortality in children as well as adults. HTN and related adverse cardiovascular health develop and progress on a continuum across an individual's life course. Pediatric HTN, or even isolated elevated blood pressure as a child, increases the risk of sustained HTN and cardiovascular disease in later adulthood. Transitioning the care of adolescents and young adults who have HTN is an important but unmet health care need that could potentially have a dramatic effect on mitigating the risk of cardiovascular disease in adulthood. However, very little has been published about the transition process in this population, and considerable gaps in the field remain. We discuss the epidemiology, etiology, and management approach in youth with HTN and how they differ from adults. We contextualize HTN and cardiovascular health on a continuum across the life course. We discuss key considerations for the transition process for adolescents and young adults with HTN including the major barriers that exist. Finally, we review key immediate health care needs that are particularly important around the time of the transfer of care.

Hypothyroidism Due to Iodine Overload in Children Receiving Peritoneal Dialysis: A Report of 4 Cases

Children who receive peritoneal dialysis (PD) are at increased risk for thyroid dysfunction. A rarely appreciated cause is iodine overload. We report 4 children who developed iodine overload and secondary hypothyroidism. All had kidney failure treated by PD. Each previously had normal thyroid function screening test results. At the time hypothyroidism was detected, the duration of PD ranged from 1 week to 27 months (median, 6 months). Three children had high thyrotropin values and all had high serum iodine levels. The sole source of iodine exposure in each child was a povidone-iodine-impregnated gauze in the sterile transfer set cap associated with PD. Iodine overload is a poorly appreciated problem associated with the provision of PD in infants and small children and can lead to thyroid dysfunction. Increased awareness among pediatric nephrologists should lead to the development of optimal monitoring and prevention recommendations.

Renovascular Hypertension

Renovascular hypertension (RVH) is relatively common but underrecognized cause of resistant hypertension in clinical practice. Most patients with RVH have suboptimal control of hypertension in spite of being on multiple anti hypertensive medications. Prompt diagnosis and management is crucial to prevent long term morbidity and mortality. Initial evaluation by primary care physicians can expedite this to improve patient outcomes by co-managing hypertension specialists. In addition to pharmacologic and nonpharmacologic measures, some patients may benefit from angioplasty. This article discusses various definitions of hypertension, approach to diagnosis of RVH, and management. Data from clinical trials are discussed with evidence-based medicine practice recommendations.