Ibrahim F. Shatat

Increasing Incidence of Kidney Stones in Children Evaluated in the Emergency Department

OBJECTIVE To test the hypothesis that there is an increase in the incidence of childhood nephrolithiasis in the state of South Carolina. STUDY DESIGN We analyzed demographic data from a statewide database on incidence of kidney stones from emergency department data and financial charges. Data were compared with population data from the US Census to control for population growth. RESULTS There was a significant increase in the incidence of kidney stones in children between 1996 and 2007. The greatest rate of increase was seen in adolescents, pre-adolescents, and Caucasian children. Infants, toddlers, and African-American children did not show significantly increased incidence in the period. Girls show a growing predominance in our population. The amount of money charged for care of children with kidney stones has gone up >4-fold in our state. CONCLUSION The incidence of kidney stone disease has risen dramatically in the state of South Carolina since 1996. Further studies investigating potential contributing factors are needed to prevent this costly and painful condition.

Closing the Gap in Hypertension Control Between Younger and Older Adults National Health and Nutrition Examination Survey (NHANES) 1988 to 2010

Background —Joint National Committee goal blood pressure (BP) for all adults was <140/<90 mmHg or lower from 1984 to 2013. Adults ≥60 years (older) have mainly isolated systolic hypertension (ISH) with major trials attaining systolic BP <150 but not <140. The main objective was to assess changes in hypertension control to <140/<90 in younger (<60 years) and older adults and <150/<90 in the latter. Methods and Results —National Health and Nutrition Examination Surveys (NHANES) 1988-1994, 1999-2004, 2005-2010 were analyzed in adults ≥18 years. From 1988-1994 to 2005-2010, hypertension control to <140/<90 improved in older (31.6% to 53.1%, p<0.001) and younger (45.7% to 55.9%, p<0.001) patients. The age gap in control declined from 14.1% (p<0.01) in 1988-1994 to 2.8% (p=0.13) in 2005-2010. Better hypertension control reflected increased percentages of older (55.6% to 77.5%) and younger (34.6% to 54.7%) patients on treatment and treated older (45.7% to 64.9%) and younger patients (56.8% to 73.4%) controlled (all p<0.001). Control to <150/<90 rose from 48.8% to 69.9% in older adults. Antihypertensive medication number and percentages on ≥3 medications increased in both age groups but more in older patients (p<0.01). BP control was higher in both age groups with ≥2 healthcare visits/year and statin therapy. Conclusions —The age gap in hypertension control to <140/<90 was virtually eliminated in 2005-2010 as clinicians intensified therapy, especially in older patients where ISH predominates controlling 70% to <150/<90. More frequent healthcare and statin therapy may improve hypertension control in all adults.Background— Joint National Committee goal blood pressure for all adults was <140/<90 mm Hg or lower from 1984 to 2013. Adults aged ≥60 years (older) have mainly isolated systolic hypertension, with major trials attaining systolic blood pressure <150 but not <140 mm Hg. The main objective was to assess changes in hypertension control to <140/<90 mm Hg in younger (aged <60 years) and older adults and <150/<90 mm Hg in the latter. Methods and Results— National Health and Nutrition Examination Surveys (NHANES) 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed in adults aged ≥18 years. From 1988 to 1994 to 2005 to 2010, hypertension control to <140/<90 mm Hg improved in older (31.6% to 53.1%; P<0.001) and younger (45.7% to 55.9%; P<0.001) patients. The age gap in control declined from 14.1% (P<0.01) in 1988 to 1994 to 2.8% (P=0.13) in 2005 to 2010. Better hypertension control reflected increased percentages of older (55.6% to 77.5%) and younger (34.6% to 54.7%) patients on treatment and treated older (45.7% to 64.9%) and younger (56.8% to 73.4%) patients controlled (all P<0.001). Control to <150/<90 mm Hg rose from 48.8% to 69.9% in older adults. Antihypertensive medication number and percentages on ≥3 medications increased in both age groups but increased more in older patients (P<0.01). Blood pressure control was higher in both age groups with ≥2 healthcare visits per year and on statin therapy. Conclusions— The age gap in hypertension control to <140/<90 mm Hg was virtually eliminated in 2005 to 2010 as clinicians intensified therapy, especially in older patients in whom isolated systolic hypertension predominates, controlling 70% to <150/<90 mm Hg. More frequent healthcare visits and the use of statin therapy may improve hypertension control in all adults.

Potentiation of vincristine toxicity with concomitant fluconazole prophylaxis in children with acute lymphoblastic leukemia.

Use of azole antifungals as prophylaxis is becoming an increasingly common practice in acute lymphoblastic leukemia (ALL). Limited literature in adults heightened the awareness of possible increased vincristine (VCR) toxicity in patients receiving concomitant azole therapy. This is due to inhibition of cytochrome P450 3A4, which may increase overall exposure to VCR, resulting in dose reductions or omissions. The primary objective of this study was to determine whether the use of fluconazole prophylaxis increases vincristine toxicity in children with ALL. The authors retrospectively evaluated children with ALL between January 2004 and December 2009. Patients were subdivided into 2 groups based on whether or not they received fluconazole prophylaxis during induction therapy. Data were collected for up to 3 months following the completion of induction therapy. Thirty-one patients were included for analysis. There was no significant difference in gender, race, steroid use, gastrointestinal (GI) toxicity, VCR dose modification, and the rate of fungal or bacterial infections between these 2 groups. Only advanced age is an independent predictor of neuropathy. Patients receiving fluconazole were 4.5 times more likely to experience neuropathy than those not receiving azole; however, this was not statistically significant. The authors report an increased incidence of VCR toxicity in patients with ALL receiving concomitant fluconazole prophylaxis. Judicious use of azole anitfungals is warranted in children with ALL.

Renin Angiotensin System Blocker Fetopathy: A Midwest Pediatric Nephrology Consortium Report

OBJECTIVES Fetuses continue to be exposed to renin angiotensin system (RAS) blockers despite their known teratogenicity and a black box warning. We hypothesized that fetopathy from in utero exposure to RAS blockers has a broader spectrum of clinical manifestations than described previously and that there are a variety of clinical scenarios leading to such exposures. STUDY DESIGN This was a retrospective study performed through the Midwest Pediatric Nephrology Consortium. Cases of RAS blocker fetopathy were identified, with determination of renal and extrarenal manifestations, timing of exposure, and the explanation for the fetal exposure. RESULTS Twenty-four cases were identified. RAS blocker exposure after the first trimester was associated with more severe renal manifestations. Chronic dialysis or kidney transplantation was required in 8 of 17 (47%) patients with RAS blocker exposure after the first trimester and 0 of 7 patients with exposure restricted to the first trimester (P = .05). Extrarenal manifestations, some not previously noted in the literature, included central nervous system anomalies (cystic encephalomalacia, cortical blindness, sensorineural hearing loss, arachnoid cysts) and pulmonary complications (pneumothorax, pneumomediastinum). RAS blocker exposure usually was secondary to absent or poor prenatal care or undiagnosed pregnancy. CONCLUSION RAS blocker fetopathy continues to be a cause of considerable morbidity, with more severe renal manifestations associated with exposure after the first trimester. A variety of significant extrarenal manifestations occur in these patients. Clinicians should emphasize the risk of fetopathy when prescribing RAS blockers to women of childbearing age.

Therapy of Acute Hypertension in Hospitalized Children and Adolescents

Acute hypertension (HTN) in hospitalized children and adolescents occurs relatively frequently, and in some cases, if not recognized and treated promptly, it can lead to hypertensive crisis with potentially significant morbidity and mortality. In contrast to adults, where acute HTN is most likely due to uncontrolled primary HTN, children and adolescents with acute HTN are more likely to have secondary HTN. This review will briefly cover evaluation of acute HTN and various age-specific etiologies of secondary HTN and provide more in-depth discussion on treatment targets, potential risks of acute HTN therapy, and available pediatric data on intravenous and oral antihypertensive agents, and it proposes treatment schema including unique therapy of specific secondary HTN scenarios.

Incidence, risk factors, and outcomes of opportunistic infections in pediatric renal transplant recipients.

OIs present significant risks to patients following solid organ transplantation. The purpose of this study was to identify risk factors for the development of OIs after kidney transplantation in pediatric patients and to evaluate the impact of OIs on outcomes in this patient population. A single‐center retrospective longitudinal cohort analysis including pediatric patients 21 yr of age or younger transplanted from July 1999 to June 2013 at an academic medical center was conducted. Patients were excluded if they received multi‐organ transplant. A total of 175 patients were included in the study. Patients who developed OIs were more likely to be female and younger at the time of transplant. A six‐factor risk model for OI development was developed. Death, disease recurrence, and PTLD development were similar between groups but trended toward increased incidence in the OI group. Incidence of rejection was significantly higher in the OI group (p = 0.04). Patients who developed OIs had several important risk factors, including younger age, EBV‐negative serostatus, CMV donor (+)/recipient (−), biopsy‐proven acute rejection, ANC <1000, MMF dose >500 mg/m2, and any infection. Incidence of rejection was higher in the OI group, but rate of graft loss was not statistically different.

Prediction of medication non-adherence and associated outcomes in pediatric kidney transplant recipients.

Studies have continued to evaluate risk factors associated with post‐transplant non‐adherence in pediatric patients. However, many of these studies fail to evaluate how risk factors can be utilized to predict MNA. The aims of this study were to (i) determine salient risk factors associated with MNA to develop an adequate predictive risk model and (ii) assess transplant outcomes based on the presence of MNA in a large, diverse cohort of pediatric KTX recipients. One hundred and seventy‐five solitary pediatric KTX recipients transplanted from 1999 to 2013 were included. AA, males, older patients, those who lived in urban environments, had legal issues, and lived shorter distances from the transplant center were more likely to have MNA. Using logistic regression, a parsimonious model applying nine risk factors together was developed for predicting MNA, demonstrating a PPV of 69% and a NPV of 81%. Patients with MNA had more than twice the risk of biopsy proven acute rejection, 1.6 times the risk of hospitalization, and 1.8 times the risk of graft loss. Utilization of a predictive model to determine risk of MNA after pediatric KTX may offer clinicians the ability to efficiently and effectively monitor MNA following transplant.

Closing the Gap in Hypertension Control between Younger and Older Adults: NHANES 1988 to 2010

Background —Joint National Committee goal blood pressure (BP) for all adults was <140/<90 mmHg or lower from 1984 to 2013. Adults ≥60 years (older) have mainly isolated systolic hypertension (ISH) with major trials attaining systolic BP <150 but not <140. The main objective was to assess changes in hypertension control to <140/<90 in younger (<60 years) and older adults and <150/<90 in the latter. Methods and Results —National Health and Nutrition Examination Surveys (NHANES) 1988-1994, 1999-2004, 2005-2010 were analyzed in adults ≥18 years. From 1988-1994 to 2005-2010, hypertension control to <140/<90 improved in older (31.6% to 53.1%, p<0.001) and younger (45.7% to 55.9%, p<0.001) patients. The age gap in control declined from 14.1% (p<0.01) in 1988-1994 to 2.8% (p=0.13) in 2005-2010. Better hypertension control reflected increased percentages of older (55.6% to 77.5%) and younger (34.6% to 54.7%) patients on treatment and treated older (45.7% to 64.9%) and younger patients (56.8% to 73.4%) controlled (all p<0.001). Control to <150/<90 rose from 48.8% to 69.9% in older adults. Antihypertensive medication number and percentages on ≥3 medications increased in both age groups but more in older patients (p<0.01). BP control was higher in both age groups with ≥2 healthcare visits/year and statin therapy. Conclusions —The age gap in hypertension control to <140/<90 was virtually eliminated in 2005-2010 as clinicians intensified therapy, especially in older patients where ISH predominates controlling 70% to <150/<90. More frequent healthcare and statin therapy may improve hypertension control in all adults.Background— Joint National Committee goal blood pressure for all adults was <140/<90 mm Hg or lower from 1984 to 2013. Adults aged ≥60 years (older) have mainly isolated systolic hypertension, with major trials attaining systolic blood pressure <150 but not <140 mm Hg. The main objective was to assess changes in hypertension control to <140/<90 mm Hg in younger (aged <60 years) and older adults and <150/<90 mm Hg in the latter. Methods and Results— National Health and Nutrition Examination Surveys (NHANES) 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed in adults aged ≥18 years. From 1988 to 1994 to 2005 to 2010, hypertension control to <140/<90 mm Hg improved in older (31.6% to 53.1%; P<0.001) and younger (45.7% to 55.9%; P<0.001) patients. The age gap in control declined from 14.1% (P<0.01) in 1988 to 1994 to 2.8% (P=0.13) in 2005 to 2010. Better hypertension control reflected increased percentages of older (55.6% to 77.5%) and younger (34.6% to 54.7%) patients on treatment and treated older (45.7% to 64.9%) and younger (56.8% to 73.4%) patients controlled (all P<0.001). Control to <150/<90 mm Hg rose from 48.8% to 69.9% in older adults. Antihypertensive medication number and percentages on ≥3 medications increased in both age groups but increased more in older patients (P<0.01). Blood pressure control was higher in both age groups with ≥2 healthcare visits per year and on statin therapy. Conclusions— The age gap in hypertension control to <140/<90 mm Hg was virtually eliminated in 2005 to 2010 as clinicians intensified therapy, especially in older patients in whom isolated systolic hypertension predominates, controlling 70% to <150/<90 mm Hg. More frequent healthcare visits and the use of statin therapy may improve hypertension control in all adults.

TREATMENT RESISTANT HYPERTENSION IN A COMMUNITY-BASED PRACTICE NETWORK

Treatment resistant hypertension (TRH) is defined by blood pressure (BP) uncontrolled on ≥3 or controlled on ≥4 BP medications including a diuretic at optimal doses. The prevalence of TRH is uncertain. Electronic record data were analyzed from >200 OQUIN practices in the Southeast US. From 2007

Practice patterns and approach to kidney biopsy in lupus: a collaboration of the Midwest pediatric nephrology consortium and the childhood arthritis and rheumatology research alliance

BackgroundThere is no clear consensus regarding optimal indications or timing of initial or repeat kidney biopsy in the management of pediatric systemic lupus erythematosus (pSLE).MethodsA web-based survey was designed to assess current practice patterns among pediatric nephrologists and pediatric rheumatologists and distributed to members of Midwest Pediatric Nephrology Consortium (MWPNC) and Childhood Arthritis and Rheumatology Research Alliance (CARRA).ResultsRespondents included 111 rheumatologists and 71 nephrologists from 65 and 34 centers, respectively. Numbers of years in sub-specialty practice were comparable. Rheumatologists and nephrologists frequently collaborate in the care of children with lupus nephritis (LN). More than 90 % of respondents refer patients to each either other after diagnosing LN. Over 60 % describe shared decision making regarding when to perform kidney biopsy and how to interpret biopsy findings. Many pediatric nephrologists consider biopsy to be of higher risk for complication in pSLE and alter their standard pre-or post-biopsy management.ConclusionsIt is uncommon for pediatric nephrologists to manage LN without input from pediatric rheumatologists and vice versa. Consensus exists between specialties in general, and practice differences that exist occur between individual physicians rather than between specialties. A systematic approach to biopsy may result in improved health related outcomes in pSLE.