Pediatric Nephrology最新文献

Background: The effect of continuous kidney replacement therapy (CKRT) with regional citrate anticoagulation (RCA) on bone mineral disease of acute kidney injury-disease (AKI-D) has not been well studied. We designed a case-control study to evaluate osteopenia and mineral balance markers in prolonged CKRT with RCA.

Methods: Cases were patients with AKI-D on CKRT with RCA; controls were patients immobilized ≥ 28 days, matched with propensity scoring. Data collected at day 0, 14, and 28. Two blinded radiologists independently evaluated for osteopenia/fractures.

Results: Osteopenia in cases was higher at day 14 (20/53 cases vs. 10/49 controls, p 0.05), and day 28 (21/53 cases vs. 11/49 controls, p 0.06). Younger age, CKRT, gastrointestinal/liver comorbidity increased the odds of osteopenia in cases and controls. Citrate rate adjusted for blood flow had higher odds of day 28 osteopenia. New fractures were higher in cases (13/53) than controls (3/49) (p 0.01). Younger age and osteopenia at baseline, day 14, and 28 had higher odds of fractures in cases. There was moderate agreement among radiologists for osteopenia (Kappa 0.62).

Conclusions: This is an important comparative study in children with AKI-D on prolonged CKRT and bone complications. Increased fractures and osteopenia were noted in children undergoing prolonged CKRT compared to immobilization alone. Increased risk of fractures was associated with the presence/persistence of osteopenia and younger age. Further research is needed to elucidate underlying mechanisms and optimize management strategies for osteopenia and fractures in patients receiving prolonged CKRT.

Background: Kidney scarring (KS) secondary to urinary tract infections is a common cause of secondary hypertension in children. We investigated the association between serum cystatin C and hypertension in children with KS using 24-h ABPM.

Methods: One hundred eleven children (aged 6-18 years) with DMSA-confirmed KS were included. All patients underwent 24-h ABPM, and serum cystatin C, creatinine, creatinine-based eGFR, and cystatin C-based eGFR were calculated. Hypertension was defined according to current AAP and ESH recommendations, using age and gender/height-specific threshold values in ABPM. The relationships between hypertension, biochemical parameters, and scar severity were assessed using multivariate analysis. No participant was taking antihypertensive medication at the time of ABPM.

Results: Hypertension was detected in 36.9% (n = 41) of patients. Serum cystatin C levels were significantly higher in the hypertensive group (1.06 mg/L vs. 0.94 mg/L, p = 0.004). When assessed for kidney function, both creatinine-based eGFR (p = 0.044) and cystatin C-based eGFR (67 [42-183] vs. 74.9 [30.9-183] mL/min/1.73 m², p = 0.004) were significantly lower in the hypertensive group than in the normotensive group. Mean systolic nocturnal dip was < 10% (non-dipper) in both groups. In multivariate logistic regression, only high-grade scarring (Grades 3-4) remained an independent risk factor, increasing the risk of hypertension by 3.44-fold (95% CI: 1.45-8.16, p = 0.005).

Conclusions: High-grade scarring is a significant independent risk factor for hypertension. Although cystatin C reflects the severity of kidney damage, its association with hypertension depends on the scar burden. Since circadian rhythm disturbances (non-dipping) are common, even in children with normal office blood pressure, ABPM may be necessary for monitoring those with KS.

Background: A 2017 international survey of neonatologist and pediatric nephrologist (PN) perceptions and practice showed that neonatal acute kidney injury (AKI) was underappreciated, and diagnosis and management varied significantly across centers. An updated survey was developed to determine whether perceptions and practices among international pediatric subspecialists have changed with increased awareness of AKI.

Methods: A 50-question electronic survey of AKI detection, monitoring, and follow-up was distributed to neonatologists, PNs, pediatric intensivists, and advanced practice providers (APPs) via 11 professional organizations (mid-March to mid-May 2024). Responses were compared by subspecialty and economic classification of respondents' countries.

Results: Respondents totaled 676 (44.4% neonatologists, 38.3% PNs, 12.0% APPs, < 1.0% pediatric intensivists) representing 68 countries (36.7% high-income, 32.3% upper-middle income, 23.5% lower-middle income, 5.9% low-income, and 1.5% with unclassified economy). The modified, neonatal KDIGO criteria were most frequently used overall (46.1%) to diagnose AKI; however, only 30.7% of neonatologists and 14.8% of APPs utilized KDIGO. Most respondents reported no AKI identification (75.8%) nor monitoring protocol (75%). However, we identified higher rates of reported creatinine surveillance around aminoglycoside (72.9%) and indomethacin use (61.9%) than previously reported (34-36% and 24-62%, respectively) and improved creatinine access via a routine electrolyte panel (> 80% vs. 25-40% in the original survey). PN's availability increased from 75% to > 80%.

Conclusions: Neonatal AKI perceptions and practices continue to vary across subspecialities, though improvements in access to serum creatinine monitoring and nephrology consultation are noted. Standardized approaches for AKI detection, management, and follow-up remain lacking indicating opportunities to improve care through provider education and guideline development.

An underlying medical condition as a cause for elevated blood pressure is suspected when hypertension occurs in younger children or those with markedly high readings (hypertensive urgency or emergency). We highlight a unique presentation and underlying medical condition, polycythemia vera (PV), as the cause of secondary hypertension in an asymptomatic 5-year-old child presenting for a routine physical examination and found to have hypertensive urgency. Laboratory evaluations revealed leukocytosis, polycythemia, thrombocytosis, and low erythropoietin level. JAK2-V617F mutational analysis confirmed the diagnosis of PV. She was managed with antihypertensive medications, therapeutic phlebotomy, and cytoreductive therapy with notable improvement in hypertension over time. She continues regular follow-up with nephrology and hematology/oncology. She has not had any further serious complications or evolution of her PV. This case demonstrates the importance of a broad differential diagnosis in the setting of very early onset hypertension, including myeloproliferative disorders.

Background: The urinary calcium-to-citrate (Ca/Cit) ratio has emerged as a useful indicator of lithogenic risk in older children; however, no reference data exist for infants and toddlers. This study aimed to evaluate whether the spot Ca/Cit ratio can distinguish stone-forming from non-stone-forming children under 24 months of age and to assess its diagnostic performance compared with conventional urinary markers.

Methods: This retrospective single-center study included 181 children aged 1-24 months who underwent metabolic evaluation and ultrasonography at their first presentation to a tertiary pediatric nephrology clinic between 2012 and 2024. Based on urinary calcium excretion and ultrasonographic findings, participants were categorized as normocalciuric stone-free controls (n = 57), hypercalciuric stone-formers (n = 29), or non-hypercalciuric stone-formers (n = 95). Spot urine calcium, citrate, and related biochemical ratios were analyzed. The diagnostic accuracy of the Ca/Cit ratio for predicting stones was assessed using receiver operating characteristic (ROC) analysis.

Results: The Ca/Cit ratio differed significantly across groups, with the highest levels observed in hypercalciuric stone-formers (0.46 mg/mg) compared with controls (0.17 mg/mg; p < 0.001) and non-hypercalciuric stone-formers (0.31 mg/mg; p < 0.001). A Ca/Cit threshold > 0.23 mg/mg (≈ 1.10 mmol/mmol) demonstrated moderate diagnostic ability for stone detection (AUC 0.695; 95% CI 0.613-0.785), yielding 66.1% sensitivity and 63.2% specificity. Age showed no meaningful correlation with Ca/Cit values. Normocalciuric stone-free children provided an age-appropriate reference distribution for Ca/Cit ratios.

Conclusions: In infants and toddlers evaluated for suspected urinary stone disease, the Ca/Cit ratio offers moderate discriminatory power and may serve as a practical adjunctive marker of stone risk. A ratio > 0.23 mg/mg (≈ 1.10 mmol/mmol) appears to indicate increased lithogenic potential. Larger prospective studies are needed to validate reference intervals and refine clinically applicable cut-off values for this young age group.

Background: Acute kidney injury (AKI) is common in critically ill children, frequently necessitating continuous kidney replacement therapy (CKRT). Procalcitonin (PCT) is widely used as an infection biomarker, yet its interpretation during CKRT remains unclear. Adult data regarding extracorporeal clearance of PCT are inconsistent, while pediatric evidence is limited.

Methods: In this prospective observational study (May 2021-October 2023), 40 critically ill children receiving CKRT in a tertiary PICU were enrolled. Serum PCT was measured at CKRT initiation (T0), 12 h (T12), and 24 h (T24). CKRT modalities (CVVH, CVVHD, CVVHDF), effluent doses, and membrane types (PS, PAES, AN69-ST) were recorded. PCT kinetics were analyzed using non-parametric tests, with correlation assessed by Spearman's rank.

Results: Median baseline PCT was 3.6 ng/mL (IQR 0.5-27.2), rising to 7.4 (0.6-29.5) at T12 and stabilizing at 7.7 (0.6-30.5) at T24. Differences across time points were not statistically significant (p = 0.68). PCT trajectories were unaffected by CKRT modality, effluent dose, or membrane type, and no correlation was found between effluent dose and PCT changes. Stratification by high versus low effluent dosing revealed no significant differences. CKRT-related complications occurred in 17.5%, mainly filter clotting, without influencing PCT. PICU mortality was 35%, reflecting illness severity rather than CKRT.

Conclusions: In pediatric CKRT, short-term PCT dynamics are driven by the underlying septic or inflammatory process rather than CKRT parameters. PCT typically peaks within 12 h of CKRT initiation and then stabilizes, supporting its reliability for infection monitoring and antibiotic stewardship during early CKRT. Larger studies are warranted to define long-term PCT behavior and prognostic utility.

Chronic kidney disease (CKD) is a common non-communicable disease in children, and kidney dysfunction is the leading metabolic risk factor for death. Despite this, awareness of the CKD burden remains limited, and significant inequities exist in access to diagnosis and care worldwide. Kidney disease risk in children begins in utero and is dependent on the mother's health and wellbeing. This is further impacted each day by poverty, nutrition, education, infection, and safety. Greater community awareness is needed, especially in lower resource settings, where children present late and may have no access to care. Early diagnosis, possibly supported by screening at schools, can have important public and individual health consequences. Catastrophic health expenditure is common if families attempt to pay out of pocket for kidney replacement therapy. Health systems require strengthening from the antenatal clinic through tertiary care to ensure children with kidney disease are identified and treated early, appropriately, affordably, and well. Local non-governmental organizations have had some success in mitigating inequities. Governments must step up, measure, and acknowledge the burden of kidney disease in children, ensure appropriate public health measures to reduce risk, strengthen primary care to improve the quality of diagnosis and care, and progressively scale up equitable access to all forms of kidney care. Kidney disease risk is strongly linked with social and structural determinants of health. A holistic approach to supporting child wellbeing-outlined by the Sustainable Development Goals and a One Health Approach-will positively impact child kidney health and promote equity among all children.

Background: Acute kidney injury (AKI) is a significant complication for preterm infants, impacting both short- and long-term outcomes. This study aimed at identifying perinatal risk factors associated with early AKI and evaluating AKI's impact on long-term outcomes.

Methods: This retrospective cohort included 339 infants (born < 32 weeks gestational age or < 1500 g birth weight) admitted to a Level IV NICU between 2013 and 2017. AKI was defined either by serum creatinine (SCr) or urine output (UO) criteria. We examined gestational age, birth weight, perinatal factors, and medications (non-steroidal anti-inflammatory drugs [NSAIDs], inotropes) as predictors. Outcomes included early AKI, length of stay, growth at discharge, and neurodevelopment at 12 and 24 months corrected age. Univariate and multivariate logistic regression identified AKI risk factors, while linear regression assessed AKI's impact on neurodevelopment.

Results: AKI incidence varied by definition: AKI-SCr 42%, AKI-UO 7%. For AKI-SCr, extremely low birth weight (ELBW, OR 2.96, p = 0.002), NSAIDs (OR 2.14, p = 0.037), and inotropes (OR 2.26, p = 0.026) increased risk. Maternal hypertension (OR 0.51, p = 0.038) and female sex (OR 0.56, p = 0.037) were protective. For AKI-UO, ELBW (OR 6.52, p = 0.006) and inotropes (OR 3.60, p = 0.04) were the only risk factors. AKI-UO was linked to lower growth Z-scores and longer hospitalization. The relationship between AKI and poorer neurodevelopment disappeared after adjusting for neonatal comorbidities.

Conclusions: Neonatal early AKI incidence and risk factors depend on diagnostic criteria. Low gestational age, birth weight, and drug exposure are key risk factors. Refining AKI definitions and conducting longitudinal outcome studies are essential.