Optimal Hemodialysis Prescription: Do Children Need More Than a Urea Dialysis Dose?

When prescribing hemodialysis in children, the clinician should first establish an adequate regimen, before seeking to optimize the treatment (Fischbach et al. 2005). A complete dialysis dose should consist of a urea dialysis dose and a determined convective volume. Intensified and more frequent dialysis regimens should not be considered exclusively as rescue therapy. Interestingly, a recent single-center study demonstrated that frequent on-line HDF provides an optimal dialysis prescription, both in terms of blood pressure control (and therefore avoidance of left ventricular hypertrophy), and catch-up growth, that is, no malnutrition or cachexia and less resistance to growth hormone. Nevertheless, this one-center experience would benefit from a prospective randomized study

Front Pediatr

INTRODUCTION: Primary infection or reactivation of Epstein-Barr Virus (EBV) is a significant cause of morbidity and mortality in pediatric kidney transplantation. Valganciclovir (VGC) treatment is recommended for prophylaxis of cytomegalovirus infection, but its role for the prevention of EBV infection remains controversial. PATIENTS AND METHODS: All pediatric kidney transplant recipients aged 4.5 log/ml. Outcomes were compared between patients receiving VGC prophylaxis (group P+) and those not receiving VGC prophylaxis (group P-). RESULTS: A total of 79 patients were included, 57 (72%) in the P+ group and 22 (28%) in the P- group; 25 (31%) were at risk of primary infection and 54 (69%) at risk of reactivation. During the first year post-transplant, the occurrence of severe EBV infection was not different between the P+ group (n = 13, 22.8%) and the P- group (n = 5, 22.7%) (p = 0.99). Among patients at risk of primary infection, the rate of severe EBV infection was not different between the two groups (42.1% in P+ vs. 33.3% in P-). A higher frequency of neutropenia was found in the P+ group (66.6%) than in the P- group (33.4%) (p < 0.01). CONCLUSION: Our observational study suggests no effect of VGC for the prevention of EBV infection in pediatric kidney transplant recipients, irrespective of their EBV status. Adverse effects revealed an increased risk of neutropenia

National survey of prevention and management of CMV infection in pediatric kidney transplantation in comparison to clinical practice guidelines

BackgroundCytomegalovirus (CMV) is one of the most frequent opportunistic infections in kidney transplant (KT) recipients and is a risk factor for patient and graft survival after KT. Center-to-center variation, optimal prevention and treatment strategies in pediatric KT are currently unknown. This survey aimed to assess current CMV prevention and treatment strategies used among French pediatric KT centers.MethodsA web-based survey was sent to all 13 French pediatric kidney transplantation centers.ResultsTwelve (92%) centers responded to the survey. All centers used prophylaxis for the donor-positive/recipient-negative (D+/R-) group. For R + patients, 54% used prophylaxis, 37% used a pre-emptive strategy. In the low-risk group, D-/R-, 50% used a pre-emptive approach and 50% had no specific prevention strategy. The antiviral used by all centers for prophylaxis was valganciclovir (VGCV). The duration of prophylaxis varied from 3 to 7 months and the duration of viral load monitoring varied from 6 months to indefinitely. No center used a hybrid/sequential approach. For the treatment of CMV DNAemia, VGCV or intravenous GCV were used. Therapeutic drug monitoring of VGCV was performed in 5 centers (42%). Five centers reported drug resistance. Eight centers (67%) administered VGCV during the treatment of acute graft rejection.ConclusionsThere is uniformity in CMV management in some areas among pediatric KT centers in France but not in others which remain diverse and are not up to date with current guidelines, suggesting unnecessary variation which could be reduced with better evidence to inform practice

Serum indoxyl sulfate concentrations associate with progression of chronic kidney disease in children

The uremic toxins indoxyl sulfate (IS) and p-cresyl sulfate (pCS) accumulate in patients with chronic kidney disease (CKD) as a consequence of altered gut microbiota metabolism and a decline in renal excretion. Despite of solid experimental evidence for nephrotoxic effects, the impact of uremic toxins on the progression of CKD has not been investigated in representative patient cohorts. In this analysis, IS and pCS serum concentrations were measured in 604 pediatric participants (mean eGFR of 27 ± 11 ml/min/1.73m2) at enrolment into the prospective Cardiovascular Comorbidity in Children with CKD study. Associations with progression of CKD were analyzed by Kaplan-Meier analyses and Cox proportional hazard models. During a median follow up time of 2.2 years (IQR 4.3-0.8 years), the composite renal survival endpoint, defined as 50% loss of eGFR, or eGFR <10ml/min/1.73m2 or start of renal replacement therapy, was reached by 360 patients (60%). Median survival time was shorter in patients with IS and pCS levels in the highest versus lowest quartile for both IS (1.5 years, 95%CI [1.1,2.0] versus 6.0 years, 95%CI [5.0,8.4]) and pCS (1.8 years, 95%CI [1.5,2.8] versus 4.4 years, 95%CI [3.4,6.0]). Multivariable Cox regression disclosed a significant association of IS, but not pCS, with renal survival, which was independent of other risk factors including baseline eGFR, proteinuria and blood pressure. In this exploratory analysis we provide the first data showing a significant association of IS, but not pCS serum concentrations with the progression of CKD in children, independent of other known risk factors. In the absence of comorbidities, which interfere with serum levels of uremic toxins, such as diabetes, obesity and metabolic syndrome, these results highlight the important role of uremic toxins and accentuate the unmet need of effective elimination strategies to lower the uremic toxin burden and abate progression of CKD

Hemodialysis in children with ventriculoperitoneal shunts: prevalence, management and outcomes

Peer reviewe

Social Deprivation Is Associated With Lower Access to Pre-emptive Kidney Transplantation and More Urgent-Start Dialysis in the Pediatric Population

Introduction Socioeconomic status (SES) is recognized as an important determinant of kidney health. We aimed to evaluate the association of social deprivation with different indicators at kidney replacement therapy (KRT) initiation in the French pediatric metropolitan population. Methods All patients with end-stage kidney disease (ESKD) who started KRT before 20 years old in France between 2002 and 2015 were included. We investigated different indicators at KRT initiation, which are as follows: KRT modality (dialysis vs. pre-emptive transplantation), late referral to a nephrologist, and dialysis modality (hemodialysis [HD] vs. peritoneal dialysis [PD], urgent vs. planned start of dialysis, use of catheter vs. use of fistula for HD vascular access). An ecological index (European Deprivation Index [EDI]) was used as a proxy for social deprivation. Results A total of 1115 patients were included (males 59%, median age at dialysis 14.4 years, glomerular/vascular diseases 36.8%). The most deprived group represented 38.7% of the patients, suggesting pediatric patients with ESKD come from a more socially deprived background. The most deprived group was more likely to initiate KRT with dialysis versus kidney transplantation. Among patients on HD, the odds of starting treatment in emergency with a catheter was >2-fold higher for the most deprived compared with the least deprived children (adjusted odds ratio [aOR] 2.35, 95% CI 1.16–4.78). Conclusion Children from the most deprived area have lower access to pre-emptive transplantation, have lower access to PD, tend to be late referred to a nephrologist, and have more urgent initiation of HD with a catheter

The ANTENATAL multicentre study to predict postnatal renal outcome in fetuses with posterior urethral valves: objectives and design

Abstract Background Posterior urethral valves (PUV) account for 17% of paediatric end-stage renal disease. A major issue in the management of PUV is prenatal prediction of postnatal renal function. Fetal ultrasound and fetal urine biochemistry are currently employed for this prediction, but clearly lack precision. We previously developed a fetal urine peptide signature that predicted in utero with high precision postnatal renal function in fetuses with PUV. We describe here the objectives and design of the prospective international multicentre ANTENATAL (multicentre validation of a fetal urine peptidome-based classifier to predict postnatal renal function in posterior urethral valves) study, set up to validate this fetal urine peptide signature. Methods Participants will be PUV pregnancies enrolled from 2017 to 2021 and followed up until 2023 in >30 European centres endorsed and supported by European reference networks for rare urological disorders (ERN eUROGEN) and rare kidney diseases (ERN ERKNet). The endpoint will be renal/patient survival at 2 years postnatally. Assuming α = 0.05, 1–β = 0.8 and a mean prevalence of severe renal outcome in PUV individuals of 0.35, 400 patients need to be enrolled to validate the previously reported sensitivity and specificity of the peptide signature. Results In this largest multicentre study of antenatally detected PUV, we anticipate bringing a novel tool to the clinic. Based on urinary peptides and potentially amended in the future with additional omics traits, this tool will be able to precisely quantify postnatal renal survival in PUV pregnancies. The main limitation of the employed approach is the need for specialized equipment. Conclusions Accurate risk assessment in the prenatal period should strongly improve the management of fetuses with PUV

Role of the Gαq/11 intracellular pathway in the parathyroid hormone bone action : study in a bone specific Gαq/11 deficient mice with chronic renal failure

La parathormone joue un rôle clé dans l’homéostasie osseuse. En se liant à l’ostéoblaste par son récepteur, elle active la voie de signalisation Gαs/PKA qui a un rôle ostéoanabolique, et la voie Gα q/11/PKC, dont le rôle n’est que partiellement connu. Lors de l’insuffisance rénale chronique, les patients présentent une hyperparathyroïdie (HPT) et des atteintes osseuses. Notre objectif était de décrire le rôle osseux de la voie PKC dans un modèle de souris transgéniques (Tg) inactivées pour Gα q/11/PKC au niveau osseux, avec ou sans HPT induite par un régime enrichi en phosphate et/ou une insuffisance rénale. Nous avons développé une méthode de quantification scintigraphique osseuse in vivo pour le suivi longitudinal ostéoblastique, et étudié les modifications biochimiques et structurales par µCT. Les souris Tg, comparées aux contrôles, avaient une activité ostéoblastique augmentée et des altérations de la structure osseuse. En cas d’insuffisance rénale, les altérations osseuses et l’activité ostéoblastique étaient moins importantes. L’inactivation de la voie PKC avait donc un rôle osseux protecteur lors de l’HPT modérée de l’insuffisance rénale.Parathyroid hormone (PTH) plays a crucial role in bone homeostasis. PTH binds to its receptor in osteoblasts and activates two distinct pathways, the Gαs/PKA and the Gαq/11/PKC pathway. Whereas Gαs/PKA has osteoanabolic action, the role of the latter is uncertain. Chronic kidney disease (CKD) leads to hyperparathyroidism and osteodystrophy. This study explores the role of Gα q/11/PKC signaling in osteoblast specific Gα q/11/PKC knockout (Ko) mice under physiological conditions and in hyperparathyroidism induced by high phosphate diet and/or CKD. To this end a quantitative bone planar scintigraphic method was established, allowing for in vivo follow up study of osteoblast activity and related to µCT and biochemical findings. Gα q/11/PKC Ko mice have increased osteoblast activity and bone microarchitectural impairment. CKD Ko mice exhibit a decreased osteoblast activity and preserved bone architecture compared to control. Thus, PKC inactivation may protect bone in case of moderate hyperparathyroidism secondary to CKD

Role of the Gαq/11 intracellular pathway in the parathyroid hormone bone action : study in a bone specific Gαq/11 deficient mice with chronic renal failure

La parathormone joue un rôle clé dans l’homéostasie osseuse. En se liant à l’ostéoblaste par son récepteur, elle active la voie de signalisation Gαs/PKA qui a un rôle ostéoanabolique, et la voie Gα q/11/PKC, dont le rôle n’est que partiellement connu. Lors de l’insuffisance rénale chronique, les patients présentent une hyperparathyroïdie (HPT) et des atteintes osseuses. Notre objectif était de décrire le rôle osseux de la voie PKC dans un modèle de souris transgéniques (Tg) inactivées pour Gα q/11/PKC au niveau osseux, avec ou sans HPT induite par un régime enrichi en phosphate et/ou une insuffisance rénale. Nous avons développé une méthode de quantification scintigraphique osseuse in vivo pour le suivi longitudinal ostéoblastique, et étudié les modifications biochimiques et structurales par µCT. Les souris Tg, comparées aux contrôles, avaient une activité ostéoblastique augmentée et des altérations de la structure osseuse. En cas d’insuffisance rénale, les altérations osseuses et l’activité ostéoblastique étaient moins importantes. L’inactivation de la voie PKC avait donc un rôle osseux protecteur lors de l’HPT modérée de l’insuffisance rénale.Parathyroid hormone (PTH) plays a crucial role in bone homeostasis. PTH binds to its receptor in osteoblasts and activates two distinct pathways, the Gαs/PKA and the Gαq/11/PKC pathway. Whereas Gαs/PKA has osteoanabolic action, the role of the latter is uncertain. Chronic kidney disease (CKD) leads to hyperparathyroidism and osteodystrophy. This study explores the role of Gα q/11/PKC signaling in osteoblast specific Gα q/11/PKC knockout (Ko) mice under physiological conditions and in hyperparathyroidism induced by high phosphate diet and/or CKD. To this end a quantitative bone planar scintigraphic method was established, allowing for in vivo follow up study of osteoblast activity and related to µCT and biochemical findings. Gα q/11/PKC Ko mice have increased osteoblast activity and bone microarchitectural impairment. CKD Ko mice exhibit a decreased osteoblast activity and preserved bone architecture compared to control. Thus, PKC inactivation may protect bone in case of moderate hyperparathyroidism secondary to CKD