Abiodun Omoloja

Racial Differences in Graft Survival: A Report from the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS)

Multiple studies have documented racial differences in graft survival in kidney transplant recipients. Although several studies in adult kidney transplant recipients have evaluated risk factors that might predispose to these differences, studies in pediatric patients are lacking. This study retrospectively analyzed data from the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) to identify racial differences in kidney transplant outcomes and evaluate factors that might contribute to those differences. The study was restricted to the first NAPRTCS registry-reported kidney transplant for pediatric patients (age < or =21 yr) whose race was reported as either black or white. Univariate graft survival analyses were performed using the log rank statistic. Relative hazard rates for the effect of race on graft failure were determined using proportional hazards models. Multivariate analyses were restricted to patients with >30 d of graft survival and were adjusted for initial diagnosis, donor source, presence of delayed graft function, era of transplantation, estimated GFR at 30 d after transplantation, and number of days hospitalized in the first month after transplantation. Graft survival was significantly lower in black transplant recipients at 3 yr (70.9 versus 83.3%) and 5 yr (59.9 versus 77.7%). After controlling for confounding factors, black recipients continued to have a higher risk for graft failure than white recipients (adjusted hazard rate 1.65; 95% confidence interval 1.46 to 1.86). Significant racial differences in kidney transplant outcomes exist among pediatric patients even after controlling for confounding factors.

Common Childhood Bacterial Infections

Children with infectious diseases are commonly encountered in primary care settings. Identification of the subset of patients with bacterial infections is key in guiding the best possible management. Clinicians frequently care for children with infections of the upper respiratory tract, including acute otitis media, otitis externa, sinusitis, and pharyngitis. Conjunctivitis is not an uncommon reason for office visits. Bacterial pneumonia, urinary tract infections, and gastroenteritis are regularly seen. Over the last decade, a growing number of children have had infections of the skin and soft tissue, driven by the increased prevalence of infections caused by methicillin-resistant Staphylococcus aureus. The following review addresses the epidemiology and risk factors for specific infections and examines the clinical presentation and selection of appropriate diagnostic methods in such conditions. Methods to prevent these bacterial infections and recommendations for follow-up are suggested. Management of these infections requires that antimicrobial agents be used in a judicious manner in the outpatient setting. Such antibiotic therapy is recommended using both available clinical evidence and review of disease-specific treatment guidelines.

Post‐biopsy renal arteriovenous fistula

Abstract:

Pediatric obesity at renal transplantation: a single center experience.

Abstract:  Obesity is a major issue affecting health care delivery. While studies have been done in adults with end‐stage renal disease, similar studies are lacking in pediatric patients with this disease. We retrospectively analyzed our renal transplant database from 1978 to 2002, to identify prevalence and predisposing factors to obesity in a pediatric end‐stage renal disease population. Obesity, particularly in younger individuals, was found to be prevalent at transplantation.

Cigarette smoking and second-hand smoking exposure in adolescents with chronic kidney disease: a study from the Midwest Pediatric Nephrology Consortium

BACKGROUND Smoking and second-hand smoking [SHS] cause significant cardiovascular mortality and morbidity. In healthy individuals and adults with chronic kidney disease [CKD], cigarette smoking is associated with albuminuria, increased risk for CKD, increased graft loss and progression of renal insufficiency. In children, SHS has been associated with higher blood pressure variability, blood pressure load, elevated C-reactive protein and decreased cognitive function. Using a survey document and urine cotinine, we sought to investigate prevalence of cigarette use and SHS in adolescents with CKD. METHODS A cross-sectional study was conducted in which adolescents aged 13 to 18 years with CKD were asked to complete a single anonymous self-administered survey. In addition, a single freshly voided urine sample for cotinine measurement was obtained from eligible subjects. RESULTS Of 182 subjects, 60 (34%), 25 (14%) and 93 (52%) were transplant recipients, were dialysis dependent and had a glomerulopathy, respectively. Renal status was lacking in four. Twenty-four per cent (24%) had smoked at some point in their lives, and 13% had smoked within the last 30 days of taking the survey. Fifty-two per cent (52%) of all respondents reported living with an adult who smoked, and 54% reported having friends that smoked. Forty-seven per cent (47%) and 44% of those who had never smoked lived with an adult and had friends that smoked, respectively. There was a discrepancy rate of 7% between self-reported non-smokers and urine cotinine, suggesting smoking rates were higher. The highest cotinine/creatinine levels among the non-smokers were observed in those who lived with a smoker and had friends that smoked. CONCLUSION Among adolescents with CKD, cigarette smoking and SHS exposure are prevalent and may be important variables to consider when evaluating renal and cardiovascular risk factors and outcomes in children with CKD.

Thrombocytopenia and proteinuria: question

During a hospital admission for abdominal pain, hematuria (large blood) and proteinuria (>300 mg/dl) were discovered on routine urinalysis in a 15-year-old girl with a history of idiopathic congenital thrombocytopenia. On microscopy, red and white blood cells were 10–20 per high power field (HPF) and > 50 per HPF respectively; no casts were observed. Serum electrolytes were as follows: sodium (Na) 139 mmol/L, (2.1 mmol/L), potassium (K) 3.6 mmol/L, chloride (Cl) 103 mmol/L, carbon dioxide (CO2) 22.8 mmol/L, blood urea nitrogen (BUN) 6 mg/dl, creatinine (Cr) 0.6 mg/dl (53 μmol/L), albumin 2.8 g/dl (28 g/L), and fasting morning triglycerides 187 mg/dl (2.1 mmol/L). Platelet count was 12 [140–440] × 10/mm. Hemoglobin and white blood cell count were normal. A 10-h overnight urine collection showed a total protein of 131 mg/dl (1 g/L) with a protein/creatinine ratio of 2.7. She was normotensive without clinical signs of nephrotic syndrome. There was no prior history of proteinuria or hematuria, and family history was negative for renal failure. Other laboratory studies including C-reactive protein, hepatitis A, B, and C titers, antinuclear antibody (ANA), double-stranded antinuclear antibodies (ANA), human immunodeficiency virus titers, and complement C3 & C4 were negative or unremarkable. Renal ultrasound showed nonspecific findings of large echogenic kidneys without evidence of obstructive uropathy. Hematology evaluation prior to discovery of abnormal urinalysis showed platelets larger than lymphocytes, with no neutrophil inclusion bodies seen on blood smear or megakaryocytic hyperplasia on bone marrow evaluation, and platelet electron microscopy evaluation revealed no inclusion bodies or vacuoles within the platelets. There was no family history of thrombocytopenia. Since birth, she had been managed conservatively with platelet transfusions when symptomatic or prior to surgeries or dental procedures. Percutaneous renal biopsy performed on light microscopy revealed no globally sclerotic glomeruli or segmental lesions and mild to moderate increase in mesangial cellularity and matrix. Focal areas of tubular atrophy were also observed. Immunofluorescence was unremarkable, and electron microscopy revealed no immune complex deposition. However, laminated and abnormally thin (105–157 nm) lamina densa layers were observed (normal > 225 nm) in the glomerular basement membrane (GBM) (Fig. 1).

Evolution of antiglomerular basement membrane glomerulonephritis into membranous glomerulonephritis

Antiglomerular basement membrane glomerulonephritis (anti-GBM GN) is a rare disease characterized by autoantibodies to the alpha 3 chain of type IV collagen in the GBM. It is also known as Goodpasture’s syndrome when associated with pulmonary hemorrhage due to autoantibodies to the alpha 3 chain of type IV collagen also present in pulmonary alveoli. Even more rare is the evolution of anti-GBM GN into membranous nephropathy (MN). We report the management of a 9-year-old Caucasian girl with anti-GBM GN that evolved into MN and briefly review the literature.

Tobacco and the pediatric chronic kidney disease population

Tobacco use and exposure are preventable causes of morbidity and mortality. Whereas the impact of this public health issue is well described in adults with kidney disease, its role in the pediatric chronic kidney disease (CKD) population is largely unknown. This review discusses the prevalence of tobacco use and exposure in children with CKD, updates the reader on how tobacco affects the kidney, and presents intervention strategies relevant to this patient population.

Chronic Kidney Disease, Pediatric Nephrologists, and Tobacco Counseling: Perceptions and Practice Patterns. A Study from the Midwest Pediatric Nephrology Consortium

We sought to identify practice patterns of pediatric nephrologists for tobacco counseling, because of a high incidence of secondhand smoke exposure and tobacco use in adolescents with chronic kidney disease. Counseling was minimal for several reasons, thus increasing the risk for heart disease inherent in children with chronic kidney disease.

Thrombocytopenia and proteinuria: answer

1. History of hearing impairment. The patient had mild high-frequency hearing impairment diagnosed several years before abnormal urinalysis was discovered. She refused to wear hearing aids for cosmetic reasons. 2. Nonmuscle myosin heavy-chain-9-related disease (MYH9 RD) or Epstein syndrome (ES). 3. Genetic testing. MYH9 RD was confirmed via genetic testing that demonstrated the presence of a missense mutation C→T at position 287 in exon 1 of the MYH9 gene, resulting in the amino acid substitution of serine for leucine at amino acid 96 [1]. Commentary