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Author(s): Laurence Greenbaum [sup.1] , Victoria Norwood [sup.2] , Eileen Brewer [sup.3] , William Smoyer [sup.4] , Marva Moxey-Mims [sup.5] , Joseph Flynn [sup.6] , Barbara Fivush [sup.7] , Patrick [...]

Background Higher doses of erythropoiesis-stimulating agents (ESA) have been associated with an increased risk of adverse outcomes in adults with chronic kidney disease (CKD) and end-stage kidney disease (ESRD), but to our knowledge no trials have been performed in children. We examined the association between ESA dose and all-cause mortality in a prevalent pediatric dialysis population. Methods Retrospective cohort study utilizing national data on all prevalent dialysis patients aged Results Eight-hundred and twenty-nine children were included in the analysis; 7 % died during follow-up. A higher proportion of patients receiving ESA doses in the highest category (erythropoietin [greater than or equal to] 350 units/kg/week or darbepoetin [greater than or equal to] 1.5 units/kg/week) died (50 % vs 28 %, p=0.002), and also demonstrated a trend toward lower hemoglobin (11.0 vs 11.4 g/dL, p=0.05). In multivariate analysis, patients receiving the highest dose of ESA demonstrated an increased risk of mortality (hazard ratio 3.37;p value Conclusion Higher ESA dose is independently associated with mortality in children on chronic dialysis. Keywords Hemoglobin * Anemia * Death * Epogen * Darbepoetin alfa, Introduction Treatment with recombinant human erythropoietin has transformed the management of anemia related to chronic kidney disease (CKD) in children, and erythropoiesis-stimulating agents (ESA) are now a core component of [...]

Author(s): Laurence Greenbaum [sup.1] , Victoria Norwood [sup.2] , Eileen Brewer [sup.3] , William Smoyer [sup.4] , Marva Moxey-Mims [sup.5] , Joseph Flynn [sup.6] , Barbara Fivush [sup.7] , Patrick [...]

Background Like left ventricular hypertrophy (LVH), abnormal left ventricular (LV) geometry increases cardiovascular risk, but little data utilizing age and sex-specific norms are currently available on LV geometry in hypertensive children. Methods This was a cross-sectional study of 141 hypertensive children aimed at determining the prevalence of LVH and abnormal LV geometry in the patient population and whether clinical characteristics associated with these findings differ by race. LVH was defined as an LV mass index of ≥ 95th percentile or cardiologist diagnosis. Abnormal geometry was defined as the presence of LVH or a relative wall thickness of >0.41. Results The prevalence of LVH was 35 % overall. According to race, LVH prevalence was 49 % among African-Americans (AA) versus 30 % among non-AA (p Keywords Hypertension * Obesity * Heart * Hypertrophy * Left Ventricular * Ventricular Remodeling * Ethnology, Introduction Racial differences among adults with hypertension have been well described. Compared to white patients, African-American (AA) patients are not only at increased risk for hypertension [1-3], but they also [...]

Background Hypertension affects up to 5% of all children, but little is known about the role of medication adherence on blood pressure (BP) control. In this study we examined the association between adolescents' antihypertensive medication adherence and BP control, investigating for racial disparities. Methods A total of 21 adolescents with essential hypertension [mean age 14.7 [+ or -] 2.0 years, 57% male, 52% African American] were recruited from a pediatric nephrology clinic. Objective medication adherence measures were obtained with Medication Event Monitoring System (MEMS) caps and pharmacy refill records to determine medication possession ratios (MPRs). Results The African Americans adolescents had lower medication adherence than non-African Americans adolescents based on the MPR over the past 12 months (mean 0.54 [+ or -] 0.21 vs. 0.85 [+ or -] 0.16, respectively; p Conclusions Antihypertensive medication adherence measured by pharmacy refills was associated with BP control. AAs were more likely to have lower medication adherence. Targeting medication adherence through the use of electronic medical records may be a potential mechanism to reduce health disparities. Keywords Medication * Adherence * Disparities * Hypertension * Adolescents, Introduction The prevalence of hypertension in children and adolescents is increasing [1,2]. Recent estimates show that hypertension affects approximately 3.2-4.5% of all children [3,4]. Hypertension in children and adolescents is [...]

Published data on the comparative achievement of The Kidney Disease Dialysis Outcome Quality Initative (KDOQI) recommended clinical performance targets between children and young adults on dialysis are scarce. To characterize the achievement of KDOQI targets among children (, Author(s): Meredith A. Atkinson [sup.1] , Rachel M. Lestz [sup.1] , Barbara A. Fivush [sup.1] , Douglas M. Silverstein [sup.2] Author Affiliations: (1) grid.21107.35, 0000000121719311, Division of Pediatric Nephrology, Johns [...]

Published data on the comparative achievement of The Kidney Disease Dialysis Outcome Quality Initative (KDOQI) recommended clinical performance targets between children and young adults on dialysis are scarce. To characterize the achievement of KDOQI targets among children ( Keywords Dialysis * Young adults * Targets * KDOQI, Introduction The Kidney Disease Dialysis Outcomes Quality Initiative (KDOQI) was initiated in 1995 by the National Kidney Foundation with the purpose of improving the quality of care delivered to patients [...]

Urologic disorders are the most common cause of chronic kidney disease in children. To determine whether children with urologic etiology of end-stage renal disease (ESRD) fare better than children with ESRD from other causes while on dialysis, we conducted a cross-sectional study of children, Author(s): Rachel M. Lestz [sup.1] , Meredith Atkinson [sup.1] , Barbara Fivush [sup.1] , Susan L. Furth [sup.2] Author Affiliations: (1) grid.21107.35, 0000000121719311, Division of Pediatric Nephrology, Johns Hopkins University, [...]

Urologic disorders are the most common cause of chronic kidney disease in children. To determine whether children with urologic etiology of end-stage renal disease (ESRD) fare better than children with ESRD from other causes while on dialysis, we conducted a cross-sectional study of children Keywords Pediatrics * Dialysis * Outcomes * Urologic disorders * ESRD, Introduction Congenital abnormalities of the kidney and urinary tract (CAKUT) represent a wide variety of disorders with a broad range of severity. With an incidence rate between 0.3 and 1.6 [...]

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that can cause significant kidney disease. Our goal was to assess the relative mortality risk associated with SLE in pediatric and adult populations with end-stage renal disease (ESRD) maintained on hemodialysis (HD). We performed Kaplan-Meier survival analysis from data collected by the United States Renal Data System (USRDS) in strata of pediatric and adult patients. This file includes data on all Medicare-reimbursed renal replacement patients. Cox proportional hazard models were used to assess mortality after adjusting for race and gender. Subjects were censored at transplantation or at end of follow-up. Pediatric patients with ESRD secondary to SLE had a 2-fold increased risk of death compared with other pediatric patients with ESRD (hazard ratio [HR]: 2.4, 95% confidence interval [CI]: 1.5-3.7). Adult patients with ESRD secondary to SLE were also at increased risk of death compared with other adult patients (HR: 1.7, 95% CI: 1.2-2.7). The most common causes of death in both pediatric and adult patients with SLE were cardiovascular disease and cardiac arrest. Our study demonstrates that there is a significant increase in mortality secondary to cardiovascular disease in pediatric and adult patients with ESRD secondary to SLE. Patients with ESRD secondary to SLE may need aggressive monitoring for traditional risk factors for atherosclerosis and the diagnosis of SLE alone may be an independent risk factor for death in patients with ESRD. Keywords Systemic lupus erythematosus * Pediatrics * Dialysis * Mortality, Introduction Systemic lupus erythematosus (SLE) is an autoimmune disease with varied clinical presentations. SLE accounts for up to 10% of patients with pediatric rheumatic diseases with an estimated prevalence of [...]

The Centers for Medicare and Medicaid Services' End Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project monitors clinical measure attainment in pediatric hemodialysis (HD) patients. Targets include hemoglobin [greater than or equal to] 11 g/dL, albumin [greater than or equal to] 3.5/3.2 g/dL (bromcresol green/purple), single-pooled Kt/V [greater than or equal to] 1.2, and the use of subcutaneous access. We hypothesized that the achievement of multiple targets by adolescent HD patients is associated with decreased morbidity. Data on patients aged 12-18 years included in the ESRD CPM Project from 2000 to 2004 with Medicare as primary payer were linked to the U. S. Renal Data System data from October 1, 1999 to December 31, 2004. Hospitalization rates by number of targets achieved were determined with Poisson regression analysis adjusted for dialysis vintage, short stature, and race. A total of 1534 patients with 1774 patient-years of follow-up, with 580 hospitalizations, were included in the analysis. In their first year in the ESRD CPM Project, 22% of the patients achieved four targets, with 34 and 28% achieving three and two targets, respectively. Subcutaneous access was least frequently attained target; spKt/V [greater than or equal to] 1.2 was the most frequently attained target. After adjustment, there was decreased hospitalization risk with increasing target attainment (incidence rate ratio 0.74, 95% confidence interval 0.67-0.80, p < 0.001). Based on this analysis, meeting adult-defined targets is associated with decreases in the hospitalization rate of adolescent HD patients. Tracking adult-defined HD measures is appropriate for assessing hospitalization risk in adolescent patients, although no evidence for a cause-and-effect relationship exists. Keywords Hemodialysis * Pediatrics * Guidelines * Outcomes, Introduction The National Kidney Foundation developed Dialysis Outcomes Quality Initiative (DOQI) guidelines for adult dialysis patients in 1997 [1]. Based on these guidelines, the Centers for Medicare & Medicaid Services [...]

There have been no studies in pediatric dialysis patients to evaluate the impact of higher estimated glomerular filtration rate (eGFR) at dialysis initiation on clinical outcomes. Baseline clinical and demographic information was collected for children aged 1-18 years undergoing incident dialysis from 1995-2002 within the United States Renal Data System. Baseline eGFRs calculated by the Schwartz formula were categorized as high (>15 ml/min/1.73 [m.sup.2]) or low ( Keywords Residual kidney function * End-stage renal disease * Pediatric * Morbidity * Hospitalization, Introduction Dialysis initiation in children is typically based on clinical manifestations of end-stage renal disease (ESRD) or complications such as inadequate growth or poor nutrition. Standard practice is that children [...]

Abstract Current formulas that estimate the delivered dose of hemodialysis rely upon pre- and post-treatment blood urea nitrogen (BUN) concentrations for calculation. Single-pool kinetic modeling (spKt/V) uses a convenient 30-s [...]

Abstract End-stage renal disease (ESRD) causes growth retardation in children, and poor growth has been linked to worse outcomes. Recombinant human growth hormone (rhGH) can increase growth velocity and final [...]

Abstract The Centers for Medicare & Medicaid Services' (CMS) end-stage renal disease (ESRD) Clinical Performance Measures (CPM) Project has collected data on all adolescent hemodialysis patients since 2000. Thus, by [...]

Byline: Jeffrey J. Fadrowski (1), Susan L. Furth (1,2), Barbara A. Fivush (1) Keywords: Dialysis; End-stage renal disease; Anemia; Hemoglobin Abstract: To identify demographic and clinical characteristics associated with failure to achieve hemoglobin levels aY=11 g/dl in prevalent pediatric end-stage renal disease (ESRD) patients, a cross-sectional analysis of patient clinical data collected by the Mid-Atlantic Renal Coalition in conjunction with the 2000 and 2001 ESRD Clinical Performance Measures Projects was performed. Ninety-nine patients (mean age 12.6 years, SD 5.4) contributed 119 observations to this analysis. Of patients on hemodialysis, 36.6% were anemic, and 39.5% of patients on peritoneal dialysis (PD) were anemic. Associations between age, race, gender, assigned cause of ESRD, Kt/V, transferrin saturation, time on dialysis, serum albumin, dialysis modality, and the achievement of target hemoglobin were examined. In multivariate logistic regression analyses examining age, dialysis modality, time on dialysis, and serum albumin, each 1-year increase in age was significantly associated with hemoglobin levels &lt 11 g/dl [adjusted odds ratio (OR) 1.18, 95% confidence interval (CI) 1.06--1.32] and PD patients were more than twice as likely to have hemoglobin levels &lt 11 g/dl (adjusted OR 2.62, 95% CI 0.98--7.04). Patients on dialysis for 6 months or more were less likely to be anemic than those on dialysis for less than 6 months (adjusted OR 0.39, 95% CI 0.16--0.99). In conclusion, increasing age, dialysis for less than 6 months, and treatment with PD were predictive of anemia in this population. Author Affiliation: (1) Department of Pediatrics, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Park 335, 600 North Wolfe Street, Baltimore, MD 21287, USA (2) Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Article History: Registration Date: 19/05/2004 Received Date: 02/12/2003 Accepted Date: 12/05/2004 Online Date: 06/07/2004

Byline: B. A. Warady (1), Sandra L. Watkins (2), Barbara A. Fivush (3), Sharon P. Andreoli (4), Isidro Salusky (5), Edward C. Kohaut (6), Edward F. Vonesh (7) Keywords: KeywordsaPediatric; Peritoneal dialysis; Adequacy; Kinetics; Computer Abstract: Kinetic modeling has proven to be a valuable tool for peritoneal dialysis (PD) prescription in adult PD patients. The clinical application of this procedure has rarely been studied in children. We therefore evaluated the PD Adequest 2.0 for Windows program (Baxter Healthcare Co., Deerfield, IL) as a prescription aid for the management of pediatric PD patients by comparing the measured and predicted PD clearances, total drain volumes, and net ultrafiltration in 34 children (15 males) (mean age 10.9+-6.0 years) receiving long-term PD. In each case, a 4-h peritoneal equilibration test was conducted with a standardized test exchange volume of 1100 ml/m.sup.2 BSA. A total of 43 24-h dialysate (plus urine in 12) collections were analyzed. The levels of agreement between measured and predicted values for weekly peritoneal and total urea Kt/V, weekly peritoneal and total creatinine clearance, daily drain volume, net ultrafiltration and daily peritoneal urea and creatinine mass removal were assessed with correlation coefficients (r .sub.c) and Bland-Altman limits of agreement. The study revealed that there is a basic level of agreement between measured and modeled values for solute removal and total drain volume, with correlation coefficients ranging from 0.75 to 0.98. In contrast, the r .sub.c for net ultrafiltration was only 0.34. The majority (75%) of patients had modeled urea and creatinine clearances that were within 20% of their measured values. These data suggest that the PD Adequest 2.0 for Windows program can predict urea and creatinine clearances with reasonable accuracy in pediatric PD patients, making it a valuable resource in prescription management. Author Affiliation: (1) The Children&apos;s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA Fax: +1-816-234-3494, US (2) Children&apos;s Hospital and Regional Medical Center, Seattle, Washington, USA, US (3) Johns Hopkins Hospital, Baltimore, Maryland, USA, TP (4) Riley Hospital for Children, Indianapolis, Indiana, USA, IN (5) UCLA Medical Center, Los Angeles, California, USA, US (6) The Children&apos;s Hospital, Birmingham, Alabama, USA, US (7) Baxter Healthcare Corporation, Round Lake, Illinois, USA, US Article note: Received: 17 February 2000 / Revised: 7 September 2000 / Accepted: 23 September 2000

Byline: B. A. Warady (1), Barbara Fivush (2), Sharon P. Andreoli (3), Edward Kohaut (4), Isidro Salusky (5), Linda Schlichting (6), Kewei Pu (7), Sandra Watkins (8) Keywords: Key wordsaPeritoneal dialysis; Peritoneal equilibration test; Peritonitis; Transport; Kinetics Abstract: Functional stability of the peritoneal membrane is necessary for maintenance of peritoneal dialysis (PD) as a therapeutic option. Few studies have investigated this issue in children. We evaluated the peritoneal membrane solute transport capacity longitudinally in 26 children (mean age 11.0+-5.5 years) receiving long-term PD. Each patient underwent a standardized peritoneal equilibration test on two occasions (mean interval between studies 19.8+-5.9 months) to determine solute dialysate to plasma (D/P) ratios, dialysate glucose to initial dialysate glucose (D/D.sub.0) ratios, and mass transfer area coefficients (MTAC). The correlation of transport capacity with peritonitis history was also assessed. No significant change in MTAC, D/P, or D/D.sub.0 values were found when comparing original and follow-up data of the group overall. However, transport of creatinine and glucose was significantly (P&lt 0.05) greater in the peritonitis group compared with the group without peritonitis, and differences in the change over time between the peritonitis groups was significant for MTAC creatinine (P=0.035) and D/D.sub.0 glucose (P=0.020). In summary, this experience demonstrates functional stability of the peritoneal membrane in pediatric patients receiving PD. However, follow-up assessments of peritoneal solute kinetics may be necessary in patients with a history of peritonitis in order to permit early identification of those who may be at risk for ultrafiltration failure and sclerosing peritonitis. Author Affiliation: (1) The Children&apos;s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA, e-mail: bwarady@cmh.edu, Tel.: +1-816-234-3494, Fax: +1-816-234-3494, US (2) Johns Hopkins Hospital, Baltimore, Maryland, USA, TP (3) Riley Hospital for Children, Indianapolis, Indiana, USA, IN (4) The Children&apos;s Hospital, Birmingham, Alabama, USA, US (5) UCLA Center for Health Sciences, Los Angeles, California, USA, US (6) Baxter Healthcare Corporation, McGaw Park, Illinois, USA, US (7) Baxter Healthcare Corporation, Round Lake, Illinois, USA, US (8) Children&apos;s Hospital and Regional Medical Center, Seattle, Washington, USA, US Article note: Received: 12 June 1998 / Revised: 8 December 1998 / Accepted: 13 December 1998

Byline: Barbara A. Fivush (1), Kathy Jabs (2), Alicia M. Neu (1), E. Kenneth Sullivan (3), Leonard Feld (4), Edward Kohaut (5), Richard Fine (6) Keywords: Key words: Chronic renal insufficiency; Creatinine; Epoetin; Growth hormone Abstract: The 1996 annual report of the Chronic Renal Insufficiency Arm of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) summarizes descriptive data and highlights important features on 1,725 patients from 130 centers. This database contains information on patients with an estimated glomerular filtration rate (GFR) a$?75 ml/min per 1.73 m.sup.2 as calculated by the Schwartz formula, who were treated on or after 1 January 1994. Thus this report reflects 2 years of data entry. Analysis of the data revealed that nearly two-thirds of patients registered had a structural anomaly. On average, patients were 1.5 standard deviations below age- and sex-specific norms for height, and 0.6 standard deviations below weight norms. Mean serum creatinine for the entire group was 2.4 mg/dl and 68% of patients had a baseline GFR of at least 25 ml/min per 1.73 m.sup.2. The mean hematocrit for all children at registration was 33.3+-6.3%, and did not vary among age groups. Overall, 30.9% of patients had a hematocrit &lt 30%. Only 12.8% of patients were receving Epoetin therapy. Although still in infancy, the Chronic Renal Insufficiency Arm of the NAPRTCS database in providing important insights into this disorder. Author Affiliation: (1) The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA, TP (2) Children&apos;s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA, US (3) The EMMES Corporation, Potomac, Maryland, USA, US (4) Children&apos;s Hospital of Buffalo, Buffalo, New York, USA, US (5) University of Alabama, Birmingham, Alabama, USA, US (6) State University of New York at Stony Brook, Stony Brook, New York, USA, US Article note: Received June 16, 1997 received in revised form December 1, 1997 accepted December 12, 1997