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Objective Among adolescents and young adults (AYAs) with chronic illness, effective provider communication is essential for patient-centered care during a sensitive developmental period. However, communication in chronic illness care for AYAs is not well studied. Our objectives were to describe the provider communication skills in pediatric chronic kidney disease (CKD) care visits; and determine if communication skills differ by AYA characteristics. Methods We adapted a global consultation rating system for pediatric subspecialty care using audiotaped clinic encounters of 18 pediatric nephrologists with 99 AYAs (age M(SD) = 14.9(2.6)) with CKD stages 1–5 and 96 caregivers. We hypothesized that provider communication skills would differ by AYA characteristics (age, gender, and race). Results The strongest provider skills included initiating the session and developing rapport; lowest rated skills were asking patient’s perspective and checking understanding. Communication scores did not consistently differ by AYA age or race, but were rated higher with female AYAs in several domains (ps Conclusions Pediatric providers generally had adequate or good communication scores with AYAs, but improvement in certain skills, particularly with male AYAs, may further support patient-centered care. Practice implications To achieve consistent, patient-centered communication with AYAs, an observation-based global assessment may identify areas for provider improvement.

To explore how sponsorship functions as a professional relationship in academic medicine.The authors conducted semistructured interviews with Johns Hopkins University School of Medicine faculty in 2016: department chairs (sponsors) and faculty participants of an executive leadership development program (protégés). Using editing analysis style, the authors coded interview transcripts for thematic content; a coding framework and themes were derived using an iterative process.Five themes were identified from 23 faculty interviews (12 sponsors, 11 protégés): (1) Mentorship is different: Sponsorship is episodic and focused on specific opportunities; (2) Effective sponsors are career-established and well-connected talent scouts; (3) Effective protégés rise to the task and remain loyal; (4) Trust, respect, and weighing risks are key to successful sponsorship relationships; (5) Sponsorship is critical to career advancement. Sponsorship is distinct from mentorship, though mentors can be sponsors if highly placed and well connected. Effective sponsors have access to networks and provide unequivocal support when promoting protégés. Effective protégés demonstrate potential and make the most of career-advancing opportunities. Successful sponsorship relationships are based on trust, respect, mutual benefits, and understanding potential risks. Sponsorship is critical to advance to high-level leadership roles. Women are perceived as being less likely to seek sponsorship but as needing the extra support sponsorship provides to be successful.Sponsorship, in addition to mentorship, is critical for successful career advancement. Understanding sponsorship as a distinct professional relationship may help faculty and academic leaders make more informed decisions about using sponsorship as a deliberate career-advancement strategy.

Objective To evaluate whether engagement and affective communication among adolescents and young adults (AYAs) with chronic kidney disease (CKD), caregivers, and pediatric nephrology providers during outpatient clinic visits predicts antihypertensive medication adherence. Methods AYAs (n = 60, M age = 15.4 years, SD = 2.7, 40% female, 43% African American/Black) and caregivers (n = 60, 73% female) attended audio-recorded clinic visits with pediatric nephrologists (n = 12, 75% female). Recordings were analyzed using global affect ratings of the Roter Interactional Analysis System. Antihypertensive medication adherence was monitored electronically before and after clinic visits. A linear regression model evaluated associations between affect ratings and post-visit adherence. Results AYAs took 84% of doses (SD = 20%) pre-visit and 82% of doses (SD = 24%) post-visit. Higher AYA engagement (β = 0.03, p = .01) and the absence of provider negative affect (β=-0.15, p = .04) were associated with higher post-visit adherence, controlling for pre-visit adherence, AYA sex, age, and race, and clustered by provider. Conclusions Post-visit adherence was higher when AYAs were rated as more engaged and providers as less negative. Practice Implications AYAs with lower engagement may benefit from further adherence assessment. Communication strategies designed to more actively engage AYAs in their care and diminish provider conveyance of negative affect during clinic visits may positively influence adherence among AYAs with CKD.

BACKGROUND: Women remain underrepresented in top leadership positions in academic medicine. In business settings, a person with power and influence actively supporting the career advancement of a junior person is referred to as a sponsor and sponsorship programs have been used to diversify leadership. Little is known about how sponsorship functions in academic medicine. OBJECTIVE: To explore perceptions of sponsorship and its relationship to gender and career advancement in academic medicine. DESIGN: Qualitative study using semi-structured, one-on-one interviews with sponsors and protégés. PARTICIPANTS: Twelve sponsors (clinical department chairs) and 11 protégés (participants of a school of medicine executive leadership program [N = 23]) at the Johns Hopkins School of Medicine. KEY RESULTS: All sponsors were men and all were professors, six of the 11 protégés were women, and four of the 23 participants were underrepresented minorities in medicine. We identified three themes: (1) people (how and who): women seek out and receive sponsorship differently; (2) process (faster and further): sponsorship provides an extra boost, especially for women; and (3) politics and culture (playing favorites and paying it forward): sponsorship and fairness. Informants acknowledge that sponsorship provides an extra boost for career advancement especially for women. Sponsors and protégés differ in their perceptions of how sponsorship happens. Informants describe gender differences in how sponsorship is experienced and specifically noted that women were less likely to actively seek out sponsorship and be identified as protégés compared to men. Informants describe a tension between sponsorship and core academic values such as transparency, fairness, and merit. CONCLUSION: Sponsorship is perceived to be critical to high-level advancement and is experienced differently by women. Increased understanding of how sponsorship works in academic medicine may empower individual faculty to utilize this professional relationship for career advancement and provide institutions with a strategy to diversify top leadership positions.

OBJECTIVE The purpose of this study was to evaluate associations between executive functioning and caregiver adherence monitoring with objective antihypertensive medication adherence over 24 months in adolescents with chronic kidney disease (CKD). METHODS Adolescents (N = 97, 11-20 years old) with CKD taking antihypertensive medication and their caregivers were recruited from three pediatric nephrology clinics. At baseline, adolescents and caregivers reported on adolescents' executive functioning and caregivers reported on their adherence monitoring. Antihypertensive medication adherence was objectively assessed via electronic monitoring at baseline and every 6 months after for 24 months. Associations between executive functioning, caregiver monitoring, and longitudinal adherence were evaluated with linear mixed models. RESULTS Up to 38% of adolescents had elevated executive functioning scores indicating more severe impairments, with rates varying by scale and reporter (adolescent vs. caregiver). Caregiver monitoring showed a significant, negative association with adherence, but adolescents' executive functioning was not significantly associated with adherence. Neither variable was associated with the rate of change in adherence over time. CONCLUSIONS Given that adolescents' executive functioning was not associated with antihypertensive medication adherence or changes in adherence over time, adherence to daily pill-form medications may involve less cognitive effort than more complex medical regimens. Higher levels of caregiver monitoring were unexpectedly associated with lower adherence levels. This unanticipated finding may reflect increased caregiver monitoring efforts when faced with adolescents' medication nonadherence, but this finding warrants further investigation. Adolescents with CKD who are nonadherent may benefit from medication adherence-promoting strategies beyond increasing caregiver monitoring. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

BACKGROUND: Medical provider assessment of nonadherence is known to be inaccurate. Researchers have suggested using a multimethod assessment approach; however, no study has demonstrated how to integrate different measures to improve accuracy. This study aimed to determine if using additional measures improves the accurate identification of nonadherence beyond provider assessment alone. METHODS: Eighty-seven adolescents and young adults (AYAs), age 11–19 years, with chronic kidney disease (CKD) [stage 1–5/end-stage renal disease (ESRD)] and prescribed antihypertensive medication, their caregivers, and 17 medical providers participated in the multisite study. Five adherence measures were obtained: provider report, AYA report, caregiver report, electronic medication monitoring (MEMS), and pharmacy refill data [medication possession ratio (MPR)]. Concordance was calculated using kappa statistic. Sensitivity, specificity, positive predictive power, and negative predictive power were calculated using MEMS as the criterion for measuring adherence. RESULTS: There was poor to fair concordance (kappas = 0.12–0.54), with 35–61% of AYAs classified as nonadherent depending on the measure. While both providers and MEMS classified 35% of the AYAs as nonadherent, sensitivity (0.57) and specificity (0.77) demonstrated poor agreement between the two measures on identifying which AYAs were nonadherent. Combining provider report of nonadherence and MPR < 75% resulted in the highest sensitivity for identifying nonadherence (0.90) and negative predictive power (0.88). CONCLUSIONS: Nonadherence is prevalent in AYAs with CKD. Providers inaccurately identify nonadherence, leading to missed opportunities to intervene. Our study demonstrates the benefit to utilizing a multimethod approach to identify nonadherence in patients with chronic disease, an essential first step to reduce nonadherence.

Background: Women in academic medicine are not attaining parity with men in several domains. This issue is not only one of fairness; some funding agencies are requesting data on gender ben...

Importance Despite progress in narrowing gender-based salary gaps, notable disparities persist in the scientific community. The significance of pay difference may be underestimated, with little data evaluating its effect on lifetime wealth after accounting for factors like time to promotion and savings. Objectives To characterize gender disparities in salary and assess the outcomes associated with a gender equity initiative (GEI). Design, Setting, and Participants Quality improvement study with simulations of salary and additional accumulated wealth (AAW) using retrospectively reviewed Johns Hopkins University School of Medicine annual salary and promotion data. All academic faculty were included in the faculty salary analysis from 2005 (n = 1481) and 2016 (n = 1885). Main Outcomes and Measures Salary and longitudinal promotion data from 2005 to 2016 were used to estimate gender-based differences in salary and time to promotion. The effect of these differences on total salary and AAW, including retirement and salary-based investments, was simulated for a representative male and female faculty member over a 30-year career in 3 scenarios: (1) pre-GEI, (2) post-GEI, and (3) in real time for GEI, beginning with and progressing through these initiatives. Results Analyses of salaries of 1481 faculty (432 women) in 2005 and 1885 faculty (742 women) in 2016 revealed that a decade after GEI implementation, the overall mean (SE) salary gap by gender decreased from −2.6% (1.2%) (95% CI, −5.6% to −0.3%) to −1.9% (1.1%) (95% CI, −4.1% to 0.3%). Simulation of pre-GEI disparities correlated with male faculty collecting an average lifetime AAW of $501 416 more than the equivalent woman, with disparities persisting past retirement. The AAW gap decreased to $210 829 in the real-time GEI simulation and to $66 104 using post-GEI conditions, reflecting success of GEI efforts. Conclusions and Relevance Even small gender-based salary gaps are associated with substantial differences in lifetime wealth, but an institutional commitment to achieving equitable promotion and compensation for women can appreciably reduce these disparities. The findings of this study support broad implementation of similar initiatives without delay, as results may take more than a decade to emerge. A modifiable version of the simulation is provided so that external users may assess the potential disparities present within their own institutions.

OBJECTIVE: To investigate longitudinal associations of health beliefs, which included self-efficacy, outcome expectancies, and perceived barriers, and demographic risk factors (i.e., age, gender, race, and family income) with antihypertensive medication adherence in adolescents with chronic kidney disease (CKD) over 24 months. METHOD: The sample included 114 adolescents (M age = 15.03 years, SD = 2.44) diagnosed with CKD. Adolescents reported their self-efficacy for taking medications, medication outcome expectancies, and barriers to adherence at baseline and 12 and 24 months after baseline. Antihypertensive medication adherence was assessed via electronic monitoring for 2 weeks at baseline and 6, 12, 18, and 24 months after baseline. RESULTS: Adherence increased and then decreased over the 2-year study period (inverted U-shape). Self-efficacy, outcome expectancies, and barriers did not change over time. Older adolescent age, female gender, African American race

IntroductionChildren with systemic lupus erythematosus (SLE) have an increased prevalence of kidney disease compared to their adult counterparts. Our goal was to identify potential clinical and laboratory predictors of renal disease.MethodsWe performed a cohort study of incident and prevalent patients with SLE aged ≤19 years. Retrospective data from initial presentation until study enrollment was also collected. Laboratory and clinic data were recorded from each clinic visit including disease activity indices, autoantibodies, urinalyses, blood counts, and metabolic profile. Kidney disease was defined as the presence of abnormal renal biopsy or by American College of Rheumatology case definition for lupus nephritis. Logistic regression analyses were used to determine the association between clinical and laboratory data with kidney disease in those who had renal involvement within 30 days of SLE diagnosis. We also performed a time to event analysis to identify antecedents of renal disease.ResultsForty-seven children and adolescents with SLE were followed in the cohort, 91% female and 68% black. All of the males in the cohort developed renal disease, and all within one month of the diagnosis of SLE. In logistic regression, low serum albumin (odds ratio (OR): 4.8, 95% CI: 1.9–12.5) and positive dsDNA antibodies (OR: 3.2, 95% CI: 1.7–5.9) were associated with kidney disease. In longitudinal analyses, isolated sterile pyuria (hazard ratio (HR): 3, 95% CI: 1.1–6.4) and low serum albumin (HR: 3.4, 95% CI: 1.7–6.9) were predictors of future kidney disease. The presence of antibodies against Ro were protective against renal disease (HR: 0.2, 95% CI: 0.05–0.5).ConclusionWe identified variables associated with kidney disease, both at initial diagnosis of SLE and in longitudinal follow-up in a cohort of children with SLE. The recognition of these abnormal laboratory values may help clinicians identify patients at risk for kidney disease before its onset thus preventing long-term complications.

OBJECTIVE: To compare the relative quantity of talk between providers, caregivers, and adolescents and young adults (AYAs) with chronic kidney disease (CKD) and how communication differs by age. METHODS: During nephrology clinic visits, conversations between AYAs with CKD (N = 99, ages 11 –20, median = 15), their caregivers, and providers (N=19) were audiotaped and coded using the Roter Interaction Analysis System. Linear mixed models tested AYA age differences in talk frequency by AYAs, caregivers, and providers. Post-hoc analyses tested differences in talk using AYA age groups. RESULTS: During clinic visits, providers spoke the most (63.7%), and caregivers spoke more (22.6%) than AYAs (13.7%). Overall talk differed by AYA age in AYAs (p < 0.001) and caregivers (p

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.Retrospective cohort study utilizing national data on all prevalent dialysis patients aged18 years from the Centers for Medicare and Medicaid Services' 2005 ESRD Clinical Performance Measures (CPM) project, linked to 18-month mortality records from the United States Renal Data System. Multivariate Cox proportional hazards regression was performed to determine the risk of mortality by mean weekly ESA dose.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 ≥350 units/kg/week or darbepoetin ≥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 value0.01).Higher ESA dose is independently associated with mortality in children on chronic dialysis.

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. A total of 21 adolescents with essential hypertension [mean age 14.7 ± 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). 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 ± 0.21 vs. 0.85 ± 0.16, respectively; p

Women represent approximately half of students entering medical schools and more than half of those entering PhD programs. When advancing through the academic and professional fields, however, women continually face barriers that men do not. In this Commentary, the authors offer ideas for coordinating the efforts of organizations, academic institutions, and leaders throughout the scientific and medical professions to reduce barriers that result in inequities and, instead, strive for gender parity. Specific areas of focus outlined by the authors include facilitating women’s access to formal and informal professional networks, acknowledging and addressing the gender pay gap as well as the lack of research funding awarded to women in the field, and updating workplace policies that have not evolved to accommodate women’s lifestyles. As academic institutions seek access to top talent and the means to develop those individuals capable of generating the change medicine and science needs, the authors urge leaders and change agents within academic medicine to address the systemic barriers to gender equity that impede us from achieving the mission to improve the health of all.

Background: Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect almost any organ system, including the kidneys. Using a large national dataset, our goal was to compare the morbidity as measured by hospitalization and mortality rates between hemodialysis patients with end-stage renal disease (ESRD) secondary to SLE to those with ESRD due to other causes. Methods: The risk of hospitalization was calculated by Poisson regression with clustering for repeated measures using the United States Renal Data System (USRDS) Hospitalization Analytic File in strata of pediatric and adult patients. Cox proportional hazard ratio was used to assess the mortality risk in hospitalized patients. Subjects were censored at transplantation or end of follow-up. Results: Adult patients with ESRD secondary to SLE were hospitalized more frequently than other adults (incidence rate ratio (IRR): 1.43, 95% confidence interval (CI): 1.15–1.77) and had a higher risk of death (hazard ratio (HR): 1.89, 95% CI: 1.66–2.5). Mortality was higher in hospitalized pediatric patients with SLE compared to pediatric patients with other causes of ESRD (HR: 2.01, 95% CI: 1.75–2.31) and adults with SLE (HR: 2.05, 95% CI: 1.79–2.34). Conclusion: Our study demonstrates that there is a trend toward increased hospitalization rates in pediatric and adult patients with SLE. Among these hospitalized patients with SLE, there is an increased risk of death due to cardiovascular disease.

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 (

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 m2) or low (≤15 ml/min/1.73 m2). We determined predictors of eGFR at baseline, and associations between baseline eGFR and subsequent hospitalization for hypertension (HTN) or pulmonary edema (PE) in a longitudinal nonconcurrent pediatric end-stage renal disease (ESRD) cohort. Twenty percent of children had a high eGFR at initiation. Black children were less likely to initiate dialysis with a high eGFR [adjusted odds ratio (adjOR) 0.71, p

Background Arteriovenous fistulas (AVFs) and grafts (AVGs) have been associated with improved clinical outcomes in children and adults with end-stage renal disease (ESRD) on maintenance hemodialysis (HD) therapy, but use of vascular catheters is high. Identifying the reasons for the high prevalence of vascular catheters in children on HD therapy is necessary to assess whether targeted interventions may increase the prevalence of AVFs/AVGs. Study Design Retrospective cohort study. Setting & Participants Children younger than 18 years on HD therapy in the 2001 to 2003 ESRD Clinical Performance Measures (CPM) Projects followed up in the US Renal Data System transplant files through December 31, 2004. Predictor Vascular access type and reasons for use of a vascular catheter. Outcomes & Measurements Demographic/clinical characteristics, including the reason provided for use of a vascular catheter, and the association of type of vascular access and (1) patient size and (2) time to kidney transplantation. Results Of 1,284 prevalent pediatric CPM patients examined, 529 (41%) had an AVF/AVG and 755 (59%) had a vascular catheter. Of 755 children with a catheter, "small body size" was a commonly listed reason (N = 142); 49% of these children weighed 20 kg or more. Of 53 patients with catheters described as having an "AVF/AVG maturing" and present in the consecutive ESRD CPM project year, 64% had a functioning AVF/AVG the following year. For those with "transplantation scheduled" listed as a reason for a vascular catheter (N = 83), 69% underwent transplantation within 1 year, and median time to transplantation was 115 days. Of all children with vascular catheters (N = 755), 32.2% underwent transplantation within 1 year, and median time to transplantation was 264 days compared with 21.7% and 347 days for those with AVFs/AVGs, respectively (N = 529). Of the 445 incident children in this cohort, 89% had a vascular catheter at dialysis therapy initiation. Limitations Because of study design, only associations can be described. Conclusions Vascular catheter use in children on HD therapy is high. This is partially explained by expeditious transplantation and technical barriers to AVF/AVG placement in small children; however, only one-third of patients with a vascular catheter underwent transplantation within 1 year. Interventions to decrease vascular catheter use in this population may be necessary.

ObjectiveOur goal is to determine if antimicrobial prophylaxis with trimethoprim/sulfamethoxazole prevents recurrent urinary tract infections and renal scarring in children who are found to have vesicoureteral reflux after a first or second urinary tract infection.Design, Participants, and MethodsThe Randomized Intervention for Children With Vesi-coureteral Reflux (RIVUR) study is a double-blind, randomized, placebo-controlled trial. Six hundred children aged 2 to 72 months will be recruited from both primary and subspecialty care settings at clinical trial centers throughout North America. Children who are found to have grades I to IV vesicoureteral reflux after the index febrile or symptomatic urinary tract infection will be randomly assigned to receive daily doses of either trimethoprim/sulfamethoxazole or placebo for 2 years. Scheduled follow-up contacts include in-person study visits every 6 months and telephone interviews every 2 months. Biospecimens (urine and blood) and genetic specimens (blood) will be collected for future studies of the genetic and biochemical determinants of vesicoureteral reflux, recurrent urinary tract infection, renal insufficiency, and renal scarring.ResultsThe primary outcome is recurrence of urinary tract infection. Secondary outcomes include time to recurrent urinary tract infection, renal scarring (assessed by dimercaptosuccinic acid scan), treatment failure, renal function, resource utilization, and development of antimicrobial resistance in stool flora.ConclusionsThe RIVUR study will provide useful information to clinicians about the risks and benefits of prophylactic antibiotics for children who are diagnosed with vesicoureteral reflux after a first or second urinary tract infection. The data and specimens collected over the course of the study will allow researchers to better understand the pathophysiology of recurrent urinary tract infection and its sequelae. Pediatrics 2008;122:240-250

Objective Pediatric dysfunctional voiding (DV) presents physical and emotional challenges as well as risk of progression to renal disease. Manual physical therapy and osteopathic treatment have been successfully used to treat DV in adult women; a pediatric trial of manual physical therapy based on an osteopathic approach (MPT-OA) has not been reported. The aim of this study was to determine whether MPT-OA added to standard treatment (ST) improves DV more effectively than ST alone. Methods Twenty-one children (aged 4–11 years) with DV were randomly assigned to receive MPT-OA plus standard treatment (treatment group) or standard treatment alone (control group). Pre-treatment and post-treatment evaluations of DV symptoms, MPT-OA evaluations and inter-rater reliability of DV symptom resolution were completed. Results The treatment group exhibited greater improvement in DV symptoms than did the control group ( Z = −2.63, p = 0.008, Mann–Whitney U -test). Improved or resolution of vesicoureteral reflux and elimination of post-void urine residuals were more prominent in the treatment group. Conclusions Results suggest that MPT-OA treatment can improve short-term outcomes in children with DV, beyond improvements observed with standard treatments, and is well liked by children and parents. Based on these results, a multi-center randomized clinical trial of MPT-OA in children with vesicoureteral reflux and/or post-void urinary retention is warranted.

Ethnicity information was collected for all pediatric peritoneal dialysis patients from the End-Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project for the period October 2004 through March 2005. Associations between intermediate outcomes and Hispanic ethnicity were determined. Thirty percent (207/696) of patients in the final cohort were Hispanic, 24% (165/696) non-Hispanic black, and 46% (324/696) non-Hispanic white. Hispanics were more likely to be female, older, and have a lower mean height standard deviation score (SDS). There were no significant differences among ethnic/racial groups regarding clearance parameters. More Hispanics had a mean hemoglobinor = 11 g/dl compared with non-Hispanic blacks and non-Hispanic whites (77% vs. 55% and 70%, P0.0001). More Hispanics compared with non-Hispanic blacks and non-Hispanic whites had a mean serum albuminor = 4.0/3.7 g/dl [bromcresol green/bromcresol purple laboratory method (BCG/BCP)] (50% vs. 24% and 27%, respectively, P0.0001). In multivariate analyses, Hispanics remained significantly more likely to achieve a mean serum albuminor = 4.0/3.7 g/dl (BCG/BCP) compared with non-Hispanic whites (referent) and were as likely to achieve clearance and hemoglobin targets. Pediatric Hispanic peritoneal dialysis patients experience equivalent or better intermediate outcomes of dialytic care compared with non-Hispanics. Further study is needed to understand associations of Hispanic ethnicity with outcomes such as hospitalization, transplantation, and mortality.

Background Arthritis is one of the most common manifestations of systemic lupus erythematosus (SLE). Although typically non-erosive and non-deforming, children with SLE arthritis can have significant morbidity with decreased quality of life. Our goal was to identify potential clinical and laboratory predictors of arthritis in a cohort of pediatric patients with SLE. Methods We performed a cohort study of incident and prevalent patients with SLE aged ≤ 19 years. In cross sectional analysis, we compared demographic and clinical characteristics at initial clinic presentation between patients with arthritis noted at any time during follow-up and those without arthritis. We performed time to event analysis using Cox proportional hazard ratios to identify predictors of arthritis, clustering for repeated measures. Results Forty seven children and adolescents with SLE were followed in the cohort, 91 % female and 68 % Black. In cross-sectional analyses, presence of malar rash was associated with arthritis. In longitudinal analyses, controlling for gender and race, increased age (HR: 1.4, 95 % CI: 1.1–1.7), malar rash (HR: 2.1, 95 % CI: 1.1–3.6), and presence of RNP antibodies (HR: 1.9, 95 % CI: 1.1–3.4) were predictive of arthritis. When controlling for gender, race, and medication use, anemia (HR: 8.5, 95 % CI: 2.9–24.2) and thrombocytopenia (HR: 6.1, 95 % CI: 2.4–15.6) were associated with increased risk of arthritis. Conclusions We identified markers predictive of arthritis in a longitudinal cohort of children with SLE. The recognition of these markers may help clinicians identify patients at risk for arthritis before its onset thus improving quality of life in children with SLE.

Left ventricular hypertrophy (LVH) is prevalent among hypertensive children; however, blood pressure (BP) does not predict its presence. The authors conducted a 1-year prospective cohort study to examine the hypothesis that obesity-related risk factors are associated with left ventricular mass index (LVMI) in hypertensive children, and the association between adiposity and LVMI is mediated by BP-dependent and -independent pathways. A total of 49 hypertensive children were enrolled: 51% were overweight/obese and 41% had LVH at baseline. Children overweight/obese at baseline and follow-up had a greater LVMI increase than those of healthy weight at each visit: mean change of 6.4 g/m(2.7) vs 0.95 g/m(2.7) . Baseline body mass index z score was independently associated with LVMI change (β=4.08, 1.54-6.61; P=.002). Only pulse pressure and serum aldosterone partially mediated this relationship. Hypertensive youth manifest multiple cardiovascular disease risk factors that worsen over time despite treatment. Of these, adiposity is most associated with LVH and increasing LVMI.

Limited research has described clinical outcomes that are associated with the type of vascular access in pediatric patients who receive maintenance hemodialysis. This retrospective cohort study examined prevalent pediatric patients who were aged 12 to18 yr and identified in the 2000 ESRD Clinical Performance Measures Project as receiving in-center hemodialysis. Vascular access type as of December 31, 1999, was identified. These patients were linked with 1 yr of data (January 1, 2000, through December 31, 2000) from US Renal Data System standard analytic files that allow for the comparison of rates of hospitalizations and access complications by access type. Of the 418 patients who met inclusion criteria, the mean age was 15.6 yr, 53% were male, 49% were white, the mean time on dialysis was 22 mo, and 42% had a structural/urologic cause of ESRD; 42% of patients had an arteriovenous graft or fistula, and 58% had a vascular catheter. Patients with a vascular catheter as compared with those with a graft or fistula had the following adjusted relative risks (95% confidence interval): 1.84 (1.38 to 2.44) for hospitalization for any cause, 4.74 (2.02 to 11.14) for hospitalization as a result of infection, and 2.72 (2.00 to 3.69) for a complication of vascular access. Vascular catheters are the predominant access type in adolescent patients who receive maintenance hemodialysis and are associated with significantly more hospitalizations and complications.

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 post-dialysis BUN sample but does not take urea rebound into account. Double-pool modeling (eKt/V) uses an equilibrated BUN (eqBUN) and is the best reflection of the true urea mass removed by hemodialysis but is inconvenient for patients and costly to the dialysis unit to wait to obtain an eqBUN sample. We compared simple spKt/V and eKt/V estimation formulas using data obtained from the Centers for MedicareMedicaid Services (CMS) End Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project to determine how frequently these two results would lead to different prescription management. We set an expected difference Kt/V (spKt/V-eKt/V) of 0.20 based on results of the Hemodialysis (HEMO) Study; 1,513 paired spKt/V and estimated eKt/V results were available for comparison. For patients with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) (n=720), mean spKt/V and estimated eKt/V were 1.62+/-0.30 and 1.37+/-0.26, respectively. For patients with a catheter (n=793), mean spKt/V and estimated eKt/V were 1.53+/-0.32 and 1.33+/-0.29, respectively. Examination of the different spKt/V and estimated eKt/V pairings revealed a greater adequacy discordance rate between a 0.20 difference in spKt/V and estimated eKt/V at higher Kt/V values, but Kt/V discordance rates only varied from 0.3 to 5.5% depending on the paired Kt/V values used.

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 2002 data were available on all adolescents on hemodialysis in the USA for 3 consecutive years. Possible associations between clinical parameters and linear growth in this cohort were evaluated. Ninety-four adolescents were on hemodialysis for the 3 study years. The mean height standard deviation score (ht SDS) fell from -1.97 to -2.36 over the 3 study years. Compared with patients with ht SDS > or =-1.88, patients with ht SDS

In 2000 and 2001, The Centers for MedicareMedicaid Services (CMS) End-Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) project collected data on all in-center hemodialysis (HD) patients in the United States agedor=12 and18 years. There were 433 of 486 (89%) patients and 435 of 516 (84%) patients who had the minimum required data submitted and were included in the 2000 and 2001 study years, respectively. There were 188 patients (43%) who had data submitted in both study years, providing longitudinal data on this cohort. A comparison of clinical parameters on these 188 patients in the 2000 and 2001 study years reveals significant improvement in mean calculated spKt/V (1.50+/-0.36 vs. 1.58+/-0.30, P0.01), mean hemoglobin (11.0+/-1.6 g/dl vs. 11.5+/-1.3 g/dl, P0.001), mean ferritin (286+/-278 ng/ml vs. 460+/-353 ng/ml, P0.001), mean transferrin saturation (27.8+/-15.1% vs. 31.3+/-15.0%, P0.05), mean serum albumin as measured by the bromocresol green method (3.83+/-0.54 g/dl vs. 3.95+/-0.42 g/dl, P0.01), and mean height standard deviation score (-1.814+/-1.756 vs. -1.699+/-1.657, P0.05). In addition, 20 of 29 (69%) patients who had a spKt/V1.2 in the 2000 study year had a spKt/V1.2 in the 2001 study year. Of 68 (44%) patients who had a catheter as their HD access in the 2000 study year, 30 had an arteriovenous fistula or graft in the 2001 study year and 49 of 80 (61%) patients who had a mean hemoglobin11 g/dl in the 2000 study year had a hemoglobin11 g/dl in the 2001 study year. In summary, these longitudinal data demonstrate significant improvements in nearly all clinical parameters studied in these adolescent HD patients.

ObjectiveTo evaluate the impact of the “flush before fill” technique on the frequency of peritonitis in children receiving automated peritoneal dialysis (APD).DesignRandomized prospective multicenter study.SettingParticipating pediatric dialysis programs of the Pediatric Peritoneal Dialysis Study Consortium.Patients121 pediatric (< 21 years of age) patients that had received peritoneal dialysis for > 2 months and that were currently receiving APD were randomized to use (flush group) or non-use (no flush group) of the “flush before fill” option. 66 patients were followed for> 12 months.Main Outcome MeasurePeritonitis rates.ResultsOverall, patients enrolled in the flush group experienced a peritonitis rate of 1 infection every 16.8 patient months; patients in the no flush group experienced a rate of 1 infection every 12.6 patient months ( p= 0.193). However, analysis by gender revealed the peritonitis rate of females in the flush group (1 infection every 44.7 patient months) to be significantly better than females in the no flush group (1 infection every 12.4 patient months) ( p ≤ 0.01). There was no difference noted in the male patients.ConclusionThe use of the “flush before fill” option in pediatric patients receiving APD is associated with a marked improvement in the peritonitis rate of female but not male patients. Further study is indicated to explain the gender differences.

Using the North American Renal Transplant Cooperative Study (NAPRTCS) database, we performed a retrospective cohort study of 986 pediatric renal transplant recipients (index transplant 1997-2000) who were treated either with Cyclosporine A (CSA), Mycophenolate Mofetil (MMF) and steroids (n = 766) or tacrolimus (TAC), MMF and steroids (n = 220) to examine potential difference in clinical outcomes between these two groups. In the first year post-transplant, time to first rejection (29.1% vs. 29%, p = 0.840), risk for rejection [Adjusted Relative Risk (aRR) 1.01, 95% Confidence Interval (CI) 0.77, 1.323], graft survival (96.8% vs. 97.9%, p = 0.607) and risk for graft failure (aRR 0.988, 95% CI 0.64, 1.928) were not significantly different in TAC and CSA-treated patients. At 2 yr post-transplant, there was also no difference in risk for rejection (aRR 0.918, 95% CI 0.669, 1.259), graft survival (91.4% vs. 95.1%, p = 0.152) and risk for graft failure (aRR 0.702, 95% CI 0.461, 1.762) in the subset of 391 CSA-treated patients and 77 TAC-treated patients on whom 2 yr follow data were available in the database. TAC-treated patients were significantly less likely to require antihypertensive medication at 1 yr [aRR 0.74 (95% CI 0.454, 0.637)] and 2 yr post-transplant [aRR 0.67 (95% CI 0.56, 0.793)]. At 1 yr post-transplant, TAC-treated patients enjoyed a higher mean GFR as estimated by the Schwartz formula [89.1 mL/min/1.73 m(2) (SE 2.64) vs. 78.6 mL/min/1.73 m(2) (SE 1.07), p = 0.0003]. In addition, in the subset of patients with 2 yr of follow-up, TAC patients had a higher mean GFR at both 1 yr [98.6 mL/min/1.73 m(2) (SE 3.83) vs. 78.0 mL/min/1.73 m(2) (SE 1.44), p = 0.0003] and 2 yr post-transplant [96.7 mL/min/1.73 m(2) (SE 3.33) vs. 73.2 mL/min/1.73 m(2) (SE 1.48), p < 0.0001]. In summary, TAC and CSA, in combination with MMF and steroids, produce similar rejection rates and graft survival in pediatric renal transplant recipients. However, TAC is associated with improved graft function at 1 and 2 yr post-transplant. Further analysis as more patient data are obtained will be necessary to determine if this difference in graft function persists and translates into improved graft survival.

Objective To evaluate the safety and immunogenicity of varicella vaccine in children with nephrotic syndrome, including those taking low-dose, alternate-day prednisone. Study design Prospective, open-label, multicenter clinical trial of varicella vaccine in a 2-dose regimen in US and Canadian children (12 months to

Children with kidney disease are at risk for serious varicella-related complications. To evaluate the safety and immunogenicity of a two-dose regimen of varicella vaccine in children (aged 1-19 years) with chronic renal insufficiency and on dialysis, the Southwest Pediatric Nephrology Study Group (SPNSG) undertook an open-label, multi-center, prospective 3-year clinical trial. Ninety-six patients without history of varicella were enrolled. Fifty (mean age 4.2 years) had no detectable varicella zoster virus (VZV) antibody; 98% seroconverted after the two-dose regimen. At 1, 2, and 3 years' follow-up, all patients studied maintained VZV antibody, including 16 who received a transplant. No significant vaccine-associated adverse events were seen. One subject developed mild varicella (10-50 maculopapular lesions) 16 months post transplant. In multivariate regression analysis, patients vaccinated after age 6 years had VZV antibody levels 73% (95% confidence interval 33%-89%) lower than patients vaccinated before age 6 years after controlling for gender, estimated glomerular filtration rate, and dialysis treatment. Adjusted analysis also showed that VZV antibody levels were lower after kidney transplantation, but this appeared to be a transient phenomenon. In this study, varicella vaccination with a two-dose regimen of varicella vaccine was generally well tolerated and highly immunogenic in children with chronic kidney disease.

Transplantation is the treatment goal for youth with kidney failure. To assess the effects of compliance, parental education and race on nephrologists' recommendations for transplantation in children, we surveyed a national random sample of adult and pediatric nephrologists. We elicited transplant recommendations for case vignettes created from random combinations of patient age, gender, race, cause of renal failure, family structure, parental education and compliance. Of 519 eligible physicians, 316 (61%) responded. Nephrologists were more likely to recommend transplantation for children of college-educated parents than children of parents who did not finish high school, despite identical clinical and demographic characteristics (adjusted OR 1.48, 95% CI 1.18, 1.86). Patient noncompliance negatively influenced transplant recommendations (adjusted OR 0.1, 95% CI 0.08, 0.13). Additionally, compliance had a different effect on transplant recommendations for white compared with black patients. The adjusted OR of a white, compliant patient being referred for transplantation were twice that of a black compliant patient (OR 2.06, 95% CI 1.17, 3.6). Education and compliance with therapy independently influence nephrologists' recommendations for transplantation in youth with kidney failure. Among the most compliant candidates, referral for transplantation may vary with patient race.

Growth failure remains a significant problem for children with chronic renal insufficiency and end-stage renal disease (ESRD). We examined whether growth failure is associated with more-frequent hospitalizations or higher mortality in children with kidney disease. We studied data on prevalent United States pediatric patients with ESRD in 1990 who were followed through 1995. Patients were categorized according to the standard deviation score (SDS) of their incremental growth during 1990: severe (-3 SDS), moderate growth failure (-3 and-2 SDS), and normal growth (-2 SDS). Among 1,112 prevalent pediatric dialysis and transplant patients (17 years, Tanner I-IV), those with severe and moderate growth failure had higher hospitalization rates [relative risk (RR) 1.14 [95% confidence interval (CI) 1.1, 1.2] and 1.24 [95% CI 1.2, 1.3]] respectively than those with normal growth after adjustment for age, gender, race, cause and duration of ESRD, and treatment modality (dialysis or transplant) in 1990. Kaplan-Meier survival analysis showed 5-year survival of 85% and 90% for patients with severe and moderate growth failure, respectively, compared with 96% for patients with normal growth ( P0.001, log-rank). Cox proportional hazards analysis revealed that those with severe (RR 2.9, 95% CI 1.6, 5.3) and moderate growth failure (RR 2.01, 95% CI 1.1, 3.6) had an increased risk of death compared with youths with normal growth, after adjustment. A higher proportion of deaths in the severe and moderate growth failure groups were attributed to infectious causes (22% and 18.7%, respectively) than in the normal growth group (15.6%). We conclude that growth failure is associated with a more-complicated clinical course and increased risk of death for children with kidney failure.

Objective. We examined whether height less than the 1% for age (z score Design. National cohort study of children initiating dialysis, followed for a minimum of 1 month to a maximum of 8 years. Setting. Voluntary consortium of pediatric nephrology centers across the United States and Canada in the North American Pediatric Renal Transplant Cooperative Study. Patients. Two thousand three hundred six patients ≤21 years old initiated on dialysis between 1992 and 2000. Outcome Measures. School attendance, transplant wait listing, hospitalization rates, and survival. Results. Although there were no differences in transplant wait listings, school-aged children with short stature were less likely to be attending school full-time than were their counterparts with more normal height, even if medically capable. Short-stature patients have significantly more hospital days per month of dialysis follow-up than those patients with better growth (mean: 1.92 vs 1.58; median: 0.73 vs 0.44 hospital days per month of follow-up). Cox proportional hazards regression analyses show that children with height Conclusions. Poor growth during chronic renal insufficiency leading to short stature at dialysis initiation is a marker for a more complicated clinical course for children with kidney failure. Aggressive nutritional support and early referral to a nephrologist to optimize growth may improve long-term outcomes for children with chronic kidney disease.

Context. Renal transplantation is the treatment of choice for pediatric patients with end-stage renal disease (ESRD). Black patients wait longer for kidney transplants than do white patients. Objective. To determine whether the increased time to transplantation for black pediatric patients is attributable not only to a shortage of suitable donor organs, but also to racial differences in the time from a child's first treatment for ESRD until activation on the cadaveric kidney transplant waitlist. Design. National longitudinal cohort study. Setting. US Medicare-eligible, pediatric ESRD population. Patients. Children and adolescents ≤19 years old at the time of their first dialysis for ESRD between 1988 and 1993, followed through 1996. Patients who received living donor renal transplants were excluded from study. Main Outcome Measures. Time from first dialysis for ESRD until activation on the kidney transplant waiting list, relative hazard of activation on the waiting list for black compared with white pediatric patients. Results. Comparisons of the time from first dialysis for ESRD to waitlisting among the 2162 white (60.7%) and 1122 black (31.5%) patients studied using survival analysis revealed that blacks were less likely to be waitlisted at any given time in follow-up. In multivariate analysis, even after controlling for patient age, gender, socioeconomic status, geographic region, incident year of renal failure, and cause of ESRD, blacks were 12% less likely to be waitlisted than were whites at any point in time (relative hazard: .88: 95% confidence interval: .79–.97). Conclusions. Racial disparities in access to the renal transplant waiting list exist in pediatrics. Whether these disparities are attributable to differences in time of presentation to a nephrologist, physician bias in identification of transplant candidates, or patient preferences warrants further study.

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(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(0) values were found when comparing original and follow-up data of the group overall. However, transport of creatinine and glucose was significantly (P

This is a pediatric case report illustrating the development of antibody (Ab)-mediated rejection in a patient with low levels of pretransplant anti-human leucocyte antigen (HLA) panel reactive antibodies (PRA). The clinical course of this patient suggests that aggressive use of a combination of plasmapheresis, monoclonal anti-T-lymphocyte antibody therapy, and intravenous immunoglobulin (IVIG) therapy can reverse Ab-mediated rejection in previously allosensitized pediatric transplant recipients.

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) ≤75 ml/min per 1.73 m2 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 m2. 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

A range of renal diseases have been previously described in patients with Down syndrome. With increased survival, it appears that a growing number of these patients present with chronic renal failure. Definition of underlying causes of renal failure could potentially lead to prevention of progressive renal dysfunction in this population. We report two index cases of teenaged Down patients who presented with proteinuria and focal segmental glomerulosclerosis with hyalinosis, not previously described in this population. In addition, autopsy files were reviewed at the Johns Hopkins Hospital to assess renal and especially glomerular pathology in Down patients. Additional cases, including acute glomerulonephritis with early crescents and vasculitis, minimal change disease, and membranous nephropathy, were identified; the latter two diseases had not been previously reported in patients with Down syndrome. Semiquantitative studies on glomerular changes in all cases examined through autopsy also were performed. The only pathological finding that was significantly more common in the Down syndrome group, compared with age-matched cases from the autopsy files, was cystic dilation of Bowman's space. Histological findings described as increased in the Down population in previously published autopsy studies were also present in the control population, highlighting the need to adequately control such studies. The cases of acquired glomerular disease reported here were seen largely after the first decade of life. Monitoring of Down patients for renal and especially glomerular disease should be done regularly as patients age into the second and third decades.

To determine the current immunization recommendations of practicing pediatric nephrologists, a questionnaire was sent to the members of the North American Pediatric Renal Transplant Cooperative Society. Sixty-two percent of the centers responded. The results of the survey suggest that although consensus for approaching immunization does exist, recommendations do vary from center to center. Virtually all centers recommend standard vaccines [DTP, oral poliovirus (OPV), hepatitis B (Hep B), and Haemophilus influenzae B (Hib)] for their renal insufficiency and dialysis patients. Despite the fact that they are not infectious, standard killed vaccines (DTP, Hep B, Hib) are recommended less frequently for transplanted patients (86%) than their renal insufficiency (98%) and dialysis (near 100%) counterparts. Additionally, OPV and measles/mumps/rubella (MMR), both live viral vaccines, are rarely recommended post transplant. Almost 90% of centers recommend the use of influenza vaccine, while only 60% of centers recommend pneumococcal vaccine for children with renal disease. Over 70% of centers recommend the newly licensed varicella vaccine for patients on dialysis and those with renal insufficiency. Between 5% and 12% of centers recommend live viral vaccines, including OPV, MMR, and varicella vaccine, for immunosuppressed patients post renal transplant.

Previous reports have documented impaired cytokine production by peritoneal macrophages in chronic peritoneal dialysis (CPD) patients. To determine if this observed defect was a reflection of systemic mononuclear cell dysfunction, the function of peripheral blood mononuclear cells obtained from pediatric patients on CPD was assessed after stimulation with lipopolysaccharide (LPS). Levels of interleukin-1 beta (IL-1 beta) and tumor necrosis factor-alpha (TNF-alpha) mRNA and protein were measured before and after stimulation with LPS. There was no significant difference in the response of mononuclear cells from CPD patients and normal controls in terms of increase in TNF-alpha mRNA [median stimulation index (SI) = 6.6 vs. 3.7, P = 0.35] or IL-1 beta mRNA (median SI = 6.2 vs. 6.5, P = 1.0). There was also no significant difference between the median increase in TNF-alpha protein secretion (median 372 pg/ml vs. 373 pg/ml, P = 0.60). These results suggest that systemic mononuclear cell function may be intact in CPD patients, and therefore this does not account for the dysfunction of peritoneal macrophages that has been previously reported.

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. 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. The prevalence of LVH was 35 % overall. According to race, LVH prevalence was 49 % among African-Americans (AA) versus 30 % among non-AA (p

(1994). Resolution of Nephrocalcinosis Associated with Tumor Lysis Syndrome. Pediatric Hematology and Oncology: Vol. 11, No. 1, pp. 115-118.

OBJECTIVE: Race is a known risk factor for hypertension and cardiovascular disease in adults and influences blood pressure (BP) in children. We sought to determine if there are differences in clinical, laboratory, or echocardiographic characteristics among children with primary hypertension from different racial groups. PATIENTS AND METHODS: Study participants were 184 children aged 3 to 20 years with a diagnosis of primary hypertension who were examined at 1 of 3 participating centers at the time of initial evaluation of elevated BP. Black children were categorized as African American (AA) and nonblack children as non-AA. Comparisons were made for the entire group and after stratification according to age ( RESULTS: Overall, children categorized as AA had a higher prevalence of overweight/obesity and left ventricular hypertrophy and had higher plasma renin activity than children who were categorized as non-AA. After age stratification, these differences remained only in the children younger than 13 years old; there were no differences in these findings among children aged 13 years or older. AA children who were aged 13 years or older, however, had higher BPs for both casual and ambulatory measurements. Specifically, they had higher casual diastolic BP, higher 24-hour diastolic BP, higher daytime systolic and diastolic BP, and higher BP loads at night and over a 24-hour period compared with non-AA children who were aged 13 years or older. CONCLUSIONS: These data indicate that black children with primary hypertension may be at increased cardiovascular risk compared with nonblack children with primary hypertension. However, the high prevalence of overweight/obesity and left ventricular hypertrophy in all youth with primary hypertension demonstrates the need for greater preventive and therapeutic efforts aimed at reducing cardiovascular risk in this vulnerable population.

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.

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

Background Many patients treated using hemodialysis remain anemic despite exogenous erythropoietin therapy, suggesting that the anemia experienced by these patients is multifactorial in cause. Iron deficiency, infection, inflammation, and malnutrition have been implicated in this process. Additionally, secondary hyperparathyroidism has been associated with anemia in adults, but few data exist about this topic in children. Study Design Cross-sectional retrospective. Setting & Participants Children treated in hemodialysis centers (N = 588) within the Centers for Medicare & Medicaid Services' 2002 Clinical Performance Measures Project. Predictor Intact parathyroid hormone (iPTH) levels assessed in October, November, and December 2001 and categorized as quintiles. Outcomes & Measurements Achievement of serum hemoglobin level ≥ 11 g/dL was assessed using Poisson regression adjusting for sex, age, race, dialysis vintage, vascular access type, single-pool Kt/V, serum albumin level, normalized protein catabolic rate, calcium-phosphorus product, and erythropoietin alfa dose. Results Using the second quintile (iPTH, 103-224 pg/mL) as the reference quintile, there was no association between iPTH quintile and achievement of the hemoglobin goal: quintile 1 prevalence ratio, 1.0 (95% CI, 0.9-1.2); quintile 3, 0.95 (95% CI, 0.8-1.1); quintile 4, 0.99 (95% CI, 0.8-1.2); and quintile 5, 0.97 (95% CI, 0.8-1.1). Only serum albumin level ≥ 3.5 g/dL (bromocresol green assay method) or ≥ 3.2 g/dL (bromocresol purple assay method) was significantly associated with meeting the hemoglobin goal: 1.4 (95% CI, 1.2-1.6). Limitations The simultaneous collection of iPTH and hemoglobin limits causal inference. Iron stores and iron therapy are potential confounders not accounted for in this study. Conclusions In the largest study of this topic in children, no association was found between iPTH level and achievement of a hemoglobin level ≥ 11 g/dL. Serum albumin level was associated strongly with achievement of the hemoglobin goal.