Think together; kidney-liver-lung-spleen-heart-gut interactions

Recent data from basic and clinical research have begun to elucidate complex organ interactions in AKI between kidney and distant organs, including heart, lung, spleen, brain, liver, and gut. This review serves to update the topic of organ cross talk in AKI and focuses on potential therapeutic targets to improve patient outcomes during AKI-associated multiple organ failure.
Link to the Kidney International Article

Fluid overload as an adverse marker for neonatal mortality

Another study from Seoul, shows that neonates with a higher percentage fluid overload and higher levels of serum creatinine at CRRT initiation showed poor outcomes. Early initiation of CRRT before the development of severe FO or azotemia might improve the outcomes of neonates requiring CRRT.

The survival rates of patients with an FO of ≥30 % at the time of CRRT initiation were lower than those of patients with an FO of <30 % at the same time-point.

Early RRT may help in these sick children! 

Ultilising FE-urea for differentiating types of AKI

The fractional excretion of urea nitrogen (FEUN) is less influenced by furosemide, which inhibits sodium and chloride reabsorption at the thick ascending loop of Henle. In adults, FEUN has been shown to be a useful biomarker in the differential diagnosis of prerenal AKI and ATN, especially in patients receiving diuretic therapy.
Current issue of Pediatric Nephrology has an excellent paper on FE-urea vs FENa in children with AKI, and finding the etiology.

Free Online articles on Pediatric Nephrology

This month ERA-EDTA provides free online articles for all for childhood renal disorders.

Following are my favourites:

• Editorial on "World Kidney Day"
• Excellent prospective study on biomarkers and renal angina index in critically ill children by Dr Goldstein's group
• A chapter on Pediatric AKI by Dr Rees
• A chapter on Pediatric transplantation by Dr Minnie Sarwal
• Plasmapheresis experience from CMC Vellore, India
• A chapter on Pediatric Hypertension

CMV prophylaxis in Pediatric Renal Transplantation

This week's Transplantation journal has an excellent study on CMV prophylaxis in pediatric renal transplantation.
It shows:

• chemoprophylaxis was associated with a better preservation of transplant function at 3 years posttransplant
• CMV replication was associated with a more pronounced decline of graft function 

Conclusions: Antiviral chemoprophylaxis with VGCV or GCV in recipients with a high or moderate CMV risk is associated with a better preservation of transplant function. Hence, the prevention of CMV replication in this patient population has the potential to improve transplant outcome.

This week's 'Times of India' has our patient's success story!

Today's "Times of India" talks of "Healthy Kidneys"

An article written by me in Today's ' Times of India'

My article in Times of India- "Better Kidney Health for Kids"

Better kidney health for kids: What you should know!

Today in "Times of India", there is an educational article by me on how to maintain better kidney health in children. 

Did you know that kidney diseases can start young? Literally. Unlike in the case of grown-ups, children can develop kidney diseases due to congenital defect, prematurity, or past hospitalization. "Also, children with a high-risk birth and early childhood history should be watched closely in order to help detect early signs of kidney disease in time to provide effective prevention or treatment. Needless to say that the sooner the issue is diagnosed, better can be the results," adds Dr Sidharth Kumar Sethi, Consultant, Pediatric Nephrology, Medanta, The Medicity, Gurgaon.

Early signs of kidney disease in kids
Early diagnose of kidney problem can help treat the ailment in time. Here are some signs that you should watch out for:
- Swelling around the eyes-face -feet- abdomen- whole body - Bed wetting (5 years or older) can be since birth or if the problem recurs after the child had stopped bed wetting for some time -Frequent urination - Crying during urination (in infants) - Painful urination (in older kids) - Unpleasant-smelling urine -Unexplained low-grade fever or recurrent fever episodes - Urine that is cloudy, bloody or dark brown - Persistent abdominal pain - Childhood renal stones - Frequent severe headaches - High blood pressure - Producing less urine -Producing more than 2 litre urine/ day -Poor appetite (in older children) - Poor eating habits, vomiting (in newborns & infants) - Slow growth or weight gain -Weak urinary stream, dribbling of urine stream - Weakness, excessive tiredness or loss of energy - Pale skin appearance

The whole article can be accessed here. 

Today is "World Kidney Day"

Spread the word!
Act Early to prevent complications!

World Kidney Day 2016 Theme: Kidney Disease & Children

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World Kidney Day 2016 focuses on kidney disease in childhood and the antecedents of adult kidney disease that can begin in earliest childhood. Our hope is that World Kidney Day will inform the general public, policy makers, and caregivers about the needs and possibilities surrounding kidney disease in childhood.

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A must read paper by World Kidney Day Steering Committtee, including Dr Schaefer

“For in every adult there dwells the child that was, and in every child there lies the adult that will be” -John Connolly, The Book of Lost Things

Eculizumab is safe in children with aHUS

Current issue of Kidney International has an excellent original article on Eculizumab in aHUS in children, with a commentary on the paper as well.

Atypical hemolytic uremic syndrome (aHUS) is caused by alternative complement pathway dysregulation, leading to systemic thrombotic microangiopathy (TMA) and severe end-organ damage. Based on 2 prospective studies in mostly adults and retrospective data in children, eculizumab, a terminal complement inhibitor, is approved for aHUS treatment.

Greenbaum et al. report the first prospective trial of eculizumab in pediatric atypical hemolytic uremic syndrome. As in adult trials, eculizumab appears effective and no serious safety signals were reported.

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In summary, Eculizumab appears effective in treating both adult and pediatric aHUS. It remains to define the optimal treatment regimen to minimize the infectious complications of terminal pathway complement blockade.

Soliris is currently not available in India, and is not marketed.

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Kidney transplantation in children with congenital anamolies: improved outcomes

Congenital uropathy included chronic pyelonephritis/reflux, prune belly syndrome and congenital obstructive uropathy. Congenital pediatric kidney disease included polycystic kidney disease, hypoplasia, dysplasia, dysgenesis, agenesis and familial nephropathy.

Analysis of trends in the last 14 years in SRTR (Scientific Registry of Transplant Recipients)demonstrates that patients with both lower and upper tract congenital anomalies experienced delayed time to the first renal transplant. Furthermore, patients had similar age matched graft and patient survival whether the primary source of renal demise was the congenital lower or upper tract. These findings may indicate that improved urological and nephrological care are promoting renal preservation in both groups.

Encouraging indeed! 

Take home message: 
Important to screen CAKUT and manage them well early to prevent renal deterioration. 

Supportive care in Childhood Nephrotic Syndrome

Pediatric Nephrology publishes a really important article for pediatricians which includes all non-immunosuppressive management of Nephrotic syndrome in children.

Important salient features of paper:

• Prevention of infections- Pneumococcal, Influenza and Varicella immunization
• Stress dose of steroids during infections
• Preventing thromboembolism
• Judicious management of edema, dyslipidemia and hypertension
• Management of edema

Seven steps for physicians taking care of children undergoing any transplant

A recent paper published in Pediatric Transplantation from UK elegantly discusses 7 steps for every physician taking care of a child post transplantation,whether it is liver/ bone marrow/ stem cell.

1. Renal function should be monitored regularly in organ transplant recipients, utilizing assessment of serum creatinine
   
2. Also by cystatin C
3. GFR should be calculated using the new Schwartz formula. 
4. Transplant physicians should also monitor blood pressure using automated oscillometric devices and 
5. Confirm repeated abnormal measures with manual blood pressure readings and ambulatory 24-h blood pressure monitoring. 
6. Proteinuria and microalbuminuria should also be assessed regularly. 
7. Referrals to a pediatric nephrologist should be made for non-renal organ transplant recipients with repeated blood pressures >95th percentile using the Fourth Task Force reference intervals, microalbumin/creatinine ratio >32.5 mg/g (3.7 mg/mmol) creatinine on repeated testing and/or GFR <90 mL/min/1.73 m(2) .

Need for more studies on drug monitoring of MMF

As Pediatric Nephrologists, we do not do routing therapeutic drug monitoring of MMF, and neither it is available as a part of routine lab test. Current edition of Pediatric Nephrology reviews this topic, and makes us feel that maybe we should be doing more studies on this aspect, and do this in addition to Tacrolimus in Pediatric renal transplantation in the world.

The paper says- ' In terms of short-term efficacy, there is strong evidence that a MPA area under the time-concentration curve of >30 mg × h/L reduces acute rejection episodes early after renal transplantation, and there is evolving evidence that aiming for the same exposure over the long term may be a viable strategy to reduce the formation of donor-specific antibodies.'
Link to the Original Review
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Diagnosing CKD early: supAR

It's interesting to read todays's correspondence in NEJM and thoughts that suPAR might be an early marker of CKD in patients in the long run. Though we are still waiting for evidence, and also suPAR in multiple type of renal disorders.