Joyce P. Samuel

Long-term Outcome of Renal Transplantation Patients with Henoch-Schönlein Purpura

BACKGROUND AND OBJECTIVES Although Henoch-Schönlein purpura (HSP) is the most common form of renal vasculitis in childhood, progression to ESRD is rare, and there are few data on outcomes of renal transplantation in patients with HSP. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This is a matched retrospective cohort study of renal allografts using the United Network of Organ Sharing database (1987 to 2005). Of the 189,211 primary renal allografts, there were 339 with a diagnosis of HSP. The primary end point was allograft survival. RESULTS Compared with the remainder of the database, the HSP population was younger (25 years versus 46 years), and had a higher proportion of women (47% versus 40%), live donors (50% versus 35%), and Caucasians (77% versus 60%). Controlling for age, gender, donor source, ethnicity, and year of transplantation, death-censored graft survival for patients with HSP was 80.0% at 5 years and 58.8% at 10 years compared with 79.0% at 5 years and 55.4% at 10 years in the non-HSP population. Among patients with reported causes of graft loss, failure from recurrent disease occurred in 13.6% of patients with HSP, compared with 6.6% in the non-HSP population. When analyzing allograft survival in recipients with HSP compared with those with IgA nephropathy, there was no difference in 10-year allograft survival (58.4% and 59.3%, respectively). CONCLUSIONS These data indicate that although there is an increased risk of graft failure attributable to recurrent disease in patients with HSP, a diagnosis of HSP has little effect on overall renal allograft survival.

Race and Obesity in Adolescent Hypertension

By using data collected from school-based screenings, this study reveals unique relationships between body mass and hypertension amongst adolescents of different races and ethnicities. BACKGROUND AND OBJECTIVES: The overall prevalence of essential hypertension in adolescents may be growing. Differences in blood pressure (BP) are well established in adults, but are less clear in adolescents. We hypothesize that the prevalence of hypertension differs by race/ethnicity among adolescents at school-based screenings. METHODS: We performed school-based BP screening in over 20 000 adolescents from 2000 to 2015. Race/ethnicity was self-reported. Height and weight were measured to determine BMI, and BP status was confirmed on 3 occasions to diagnose sustained hypertension according to Fourth Working Group Report criteria. RESULTS: We successfully screened 21 062 adolescents aged 10 to 19 years (mean, 13.8 years). The final prevalence of sustained hypertension in all subjects was 2.7%. Obesity rates were highest among African American (3.1%) and Hispanic (2.7%) adolescents. The highest rate of hypertension was seen in Hispanic (3.1%), followed by African American (2.7%), white (2.6%), and Asian (1.7%) adolescents (P = .019). However, obese white adolescents had the highest prevalence of sustained hypertension (7.4%) compared with obese African American adolescents (4.5%, P < .001). At lower BMI percentiles (<60th percentile), Hispanic adolescents actually had the lowest predicted prevalence of hypertension among the 4 groups. CONCLUSIONS: The prevalence of hypertension varies among different race/ethnicities. Although obesity remains the strongest predictor of early hypertension, the strength of this relationship is intensified in Hispanic and white adolescents, whereas it is lessened in African American adolescents.

Management of Hypertension in Children and Adolescents

Hypertension in children and adolescents is becoming a greater problem in the developed world. Although traditionally thought of as usually secondary to renal, vascular, or endocrine causes, primary hypertension is becoming the most common form seen in childhood. This changing epidemiology is related to the recent obesity epidemic. The evaluation of high blood pressure in children is more involved than in adults and is aimed both at identifying secondary causes and to identify other co-morbidities of cardiovascular risk. Treatment of hypertension in childhood and adolescence is aimed at reducing cardiovascular risk. While there are a growing number of antihypertensive agents with FDA labeling for children, there remain far fewer options than for adults. This paper reviews the epidemiology, definitions, evaluations, and management of elevated blood pressure in children and adolescents.

Evaluation of Hypertension in Pediatric Patients

The management of hypertension in the pediatric population begins with a thorough diagnostic evaluation which can be tailored to the individual patient based on age, symptoms, and severity of hypertension. We outline four phases of evaluation which are integral to the optimal management of hypertension in children. The first phase seeks to answer whether the patient is truly hypertensive in the nonmedical setting. This can be confirmed with either ambulatory blood pressure monitoring or self-monitored blood pressure monitoring. Once it is determined that the patient is truly hypertensive, the second phase provides screening for etiology of hypertension, hypertensive end-organ damage, and comorbidities. The third phase of evaluation defines the underlying abnormality which could be causing the hypertension, and the fourth phase determines the significance and remediability of the abnormality. By systematically using the four phases outlined in this chapter, the clinician can conduct a thorough evaluation of the hypertensive patient.

Evidence-Based Practice in Nephrology: Systematic Reviews

A systematic review, the careful search and comprehensive analysis of all available data on a particular clinical question, is a useful tool for the busy clinician seeking to practice evidence-based medicine. When performed appropriately, they can provide a concise overview of the available literature. Meta-analysis is a method of mathematically combining the results of multiple individual studies, and it must be done in the setting of conceptual and statistical homogeneity. However, as with all forms of research, one must become familiar with the strengths and drawbacks of this type of evidence to critically appraise its validity.

Randomized n-of-1 trials: Quality improvement, research, or both?

The regulatory demarcations between clinical research and quality improvement (QI) are ambiguous and controversial. Some projects that were undertaken as a form of QI were deemed by regulatory agencies to be research and thus to require institutional review board approval. In the era of personalized medicine, some physicians may ask some patients to participate in n-of-1 trials in an effort to personalize and optimize each patient’s medical treatment. Should such activities be considered research, QI, or just excellent personalized medicine? Experts in research, research regulation, and bioethics analyze these issues.

Unique Study Designs in Nephrology: N-of-1 Trials and Other Designs

Alternatives to the traditional parallel-group trial design may be required to answer clinical questions in special populations, rare conditions, or with limited resources. N-of-1 trials are a unique trial design which can inform personalized evidence-based decisions for the patient when data from traditional clinical trials are lacking or not generalizable. A concise overview of factorial design, cluster randomization, adaptive designs, crossover studies, and n-of-1 trials will be provided along with pertinent examples in nephrology. The indication for analysis strategies such as equivalence and noninferiority trials will be discussed, as well as analytic pitfalls.

Cefepime-induced neurotoxicity in a pediatric patient on chronic hemodialysis: a case report

Impaired renal function increases the risk for cefepime‐induced neurotoxicity. Symptoms include disorientation, myoclonus, status epilepticus, ataxia, gait disturbance, coma, and death. A high index of suspicion and early recognition of symptoms can minimize the risk of progression of symptoms to permanent neurologic impairment or death.

Office blood pressure measurement alone often misclassifies treatment status in children with primary hypertension

Objective Clinicians frequently rely on office blood pressure (BP) measurements alone to assess hypertension control, despite widespread acceptance of 24-h ambulatory blood pressure monitoring (ABPM) as the reference standard in the initial diagnosis of hypertension. This study was designed to investigate how often the hypertensive status differed between concurrent office BP versus ABPM measurements, and whether any patient-specific characteristics predict the risk for misclassification by office BP. Participants and methods This study evaluated 42 children with primary hypertension who underwent repeated ambulatory monitoring (190 total recordings) with concurrent office BP measurement as part of their participation in n-of-1 trials. Results In nearly 40% of the visits, the treatment status by office measurement was opposite to the status by ambulatory monitoring. Office BP underestimated the ambulatory hypertensive status (masked uncontrolled hypertension) in 25% of visits and overestimated ambulatory BP (white coat effect) in 14% of visits. The difference between office BP and ambulatory monitoring was consistent within patients across repeated visits. Patients whose office measurement underestimated or overestimated the ambulatory BP at the first visit were more likely to show persistent discrepancy at subsequent visits. Conclusion The underuse of ambulatory monitoring in management decisions of children treated for primary hypertension may result in systematic misclassification of hypertension control.