Nephrology Delivering Best Outcomes in Nephrology
The field of nephrology faces any number of challenges, and the clinician-scientists at Nationwide Children s Hospital are at the forefront of identifying them. Recent publications from my colleagues here have highlighted the increasing number of kidney stone cases among children and identified sub-groups of children with renal disease at increased risk venous thromboembolism who also have increased mortality and health care costs. But at Nationwide Children s, we re not only identifying challenges. We are meeting them head-on. As you will see in this report, members of the Nationwide Children s Section of Nephrology have helped demonstrate the potential of biomarkers for thrombotic disease in nephrotic syndrome. A multidisciplinary team is now researching the role antimicrobial peptides could play in treating urinary tract infection. A drug has been shown to be safe and effective in preventing bone fractures and improving bone mineral density for very young children with osteogenesis imperfecta. Our clinician-researchers are also meeting clinical challenges by treating children in the most comprehensive way possible. We treat patients with renal involvement in a large number of syndromes and chronic disorders. The combined Urology/Nephrology Clinic draws on expertise from both specialties to care for patients with congenital anomalies of the kidneys and urinary tract in a collaborative setting. One of our fundamental programs remains the multidisciplinary care of children through the stages of chronic kidney disease, dialysis and kidney transplantation. At Nationwide Children s, we strive to provide the best care, the best outcomes, and the solutions to challenges all of us in nephrology face. Hiren P. Patel, MD Section Chief, Nephrology Nationwide Children s Hospital 2 Nationwide Children s Hospital Nephrology Nationwide Children s Hospital Nephrology 3
Proteinuria and Hypoalbuminemia May Help Identify Risk for Thrombotic Disease in Nephrotic Syndrome Prompt and accurate identification of patients most at risk could greatly improve our ability to prevent life-threatening thrombotic episodes. William E. Smoyer, MD While hypercoagulopathy is highly correlated with nephrotic disease severity, nephrologists still struggle to identify which patients should be treated with prophylactic anticoagulants. A study led by researchers from Nationwide Children s Hospital may make it easier. The team found that proteinuria and/or hypoalbuminemia could be developed as clinically meaningful surrogate biomarkers of hypercoagulopathy, aiding physicians in identifying patients with the greatest risk of thrombotic disease. Nephrotic-range proteinuria is associated with an acquired complex hypercoagulopathy, the result of derangements of proteins in the hemostatic regulatory cascade, leading to an enhanced capacity for thrombin generation. The study s findings strongly suggest this enhanced capacity is responsible for the predisposition to clot formation, and the capacity increases with disease severity. Testing a patient s thrombin activity in the clinic setting can be difficult, so using comparatively easy to measure noninvasive biomarkers to assess thrombosis risk is appealing. Researchers used animal models of nephrotic syndrome to investigate the relationship between levels of proteinuria and albumin and thrombotic tendency. The team is now working on validating the findings in humans. Kerlin BA, Waller AP, Sharma R, Chanley MA, Nieman MT, Smoyer WE. Disease severity correlates with thrombotic capacity in experimental nephrotic syndrome. Journal of the American Society of Nephrology. 2015 Apr 8. [Epub ahead of print]. 4 Nationwide Children s Hospital Nephrology Nationwide Children s Hospital Nephrology 5
Pediatric Kidney Stone Cases and Costs on the Rise Knowing adults with urolithiasis have long-term complications, it s concerning that more and more children are seen with this disease. Kirsten Kusumi, MD Researchers at Nationwide Children s Hospital have found evidence that increasing numbers of children are suffering from kidney stones and that the burden on the health care system is growing. The 18,620 emergency department visits across the country in 2011 represent a 9 percent increase since 2006, and along with a slight decrease in inpatient discharges during the same period, indicates a shift to outpatient care. The research team from Nationwide Children s evaluated data from the Kids Inpatient Database of the Healthcare Costs and Utilization Project (HCUP) for six years between 1997 and 2012 and the HCUP National Emergency Department Sample from 2006 to 2011. HCUP provides data from a sample of American pediatric hospitals. The study took into account nephrolithiasis, which is formation of stones in the kidney, as well as ureterolithiasis, stones found in the ureter. Researchers found that costs associated with kidney stone care have been increasing. Total aggregate charges increased from $8.3 million to $17.6 million, an increase of 20 percent when adjusted for inflation. Knowing adults with kidney stones have long-term complications, it s concerning that more and more children are seen with this disease, says Kirsten Kusumi, MD, a fellow in the Section of Nephrology at Nationwide Children s and lead author of the study. Kusumi K, Becknell B, Schwaderer A. Trends in pediatric urolithiasis: patient characteristics, associated diagnoses, and financial burden. Pediatric Nephrology. 2015 May; 30(5):805-810. Study Finds Multifactorial VTE Risk in Renal Disease Patients; Children with VTE Face Higher Costs and In-Hospital Mortality Children with chronic renal diseases suffer from significantly increased morbidity and mortality when they develop blood clots. Studies like this one may lead to studies defining the best methods to prevent this life-threatening complication. Bryce A. Kerlin, MD Researchers at Nationwide Children s Hospital and the Centers for Disease Control and Prevention have found that the overall risk of venous thromboembolism (VTE) among children with chronic renal diseases depends on disease sub-group; comorbidities; recent surgery, trauma or infection; and hemodialysis. In addition, the study found both higher in-hospital mortality and health care expenditures among children with VTE compared to those without. The study examined VTE events within six months of an initial diagnosis of any chronic renal disease among 23,000 children included in the MarketScan Research databases from 2003-2012. VTE affected 0.55 percent of children with chronic renal diseases. Only 0.32 percent of children with congenital anomalies of the urinary system were affected with VTE, but as many as 6.32 percent of all children on hemodialysis experienced an event. VTE was also significantly more common among older children, those with a recent infection and those with an additional non-renal, chronic condition who had also experienced a recent trauma or surgery. When VTE did occur, it put children at 12 times the risk of in-hospital mortality and resulted in 16 times the average inpatient health care expenditures, says Bryce A. Kerlin, MD, lead author of the study and a hematologist specializing in blood clotting disorders at Nationwide Children s. The complication resulted in a four-fold increase in outpatient expenditures as well. Children with VTE were admitted to the hospital more than twice as often as patients without VTE, attended nearly three times as many clinic visits and had more than three times the number of prescriptions filled, according to the study. Kerlin BA, Smoyer WE, Tsai J, Boulet SL. Healthcare burden of venous thromboembolism in childhood chronic renal diseases. Pediatric Nephrology. 2015 May;30(5):829-37. 6 Nationwide Children s Hospital Nephrology Nationwide Children s Hospital Nephrology 7
Using Antibiotics for Pediatric UTI in an Era of Drug Resistance To prevent resistance, it is important to not over-prescribe antibiotics and to discontinue empiric antibiotics if urine cultures are negative. Brian Becknell, MD, PhD The judicious use of antibiotics to treat or prevent pediatric urinary tract infection (UTI) remains a complicated issue, according to a review of current understandings regarding diagnosis, evaluation and management of pediatric UTIs by researchers at Nationwide Children s Hospital and The Ohio State University. Targeted antibiotic therapy for UTI requires isolation of the bacterial uropathogen by urine culture and antibiotic susceptibility testing. This typically results in a two- to three-day delay. Broad-spectrum antibiotics can be administered in the meantime, but their overuse and misuse have contributed to the emergence of multidrug-resistant uropathogens. More than 30 percent of UTIs are caused by E. coli resistant to trimethoprimsulfamethoxazole (TMP-SMX). Antibiotic prophylaxis for recurrent UTI has been debated heavily. However, a recent randomized trial cited in the review showed a benefit, particularly for females with febrile UTI and those with bladder and bowel dysfunction. Finding new strategies to reduce the use of broad-spectrum antibiotics is critical, says Brian Becknell, MD, a nephrologist, principal investigator at the Center for Clinical and Translational Research at The Research Institute at Nationwide Children s and lead author on the paper. Physician-scientists at Nationwide Children s and elsewhere are now researching antimicrobial peptides for possible diagnostic, prognostic and therapeutic applications. While this work is in the discovery phase, we feel it has the potential to significantly impact child health, said Dr. Becknell. Leadership Hiren P. Patel, MD Chief, Section of Nephrology Andrew L. Schwaderer, MD Research Director, Section of Nephrology Meet Our Team Physician Team Rose M. Ayoob, MD Brian Becknell, MD, PhD Susan E. Ingraham, MD, PhD Amy J. Kogon, MD, MPH John D. Mahan, MD William E. Smoyer, MD John David Spencer, MD Surgeon Team Ronald P. Pelletier, MD Amer Rajab, MD, PhD Nurse Practitioner Amy H. Wright, CPNP-PC Becknell B, Schober M, Korbel L, Spencer JD. The diagnosis, evaluation and treatment of acute and recurrent pediatric urinary tract infections. Expert Review in Anti-Infective Therapy. 2015 Jan, 13(1):81-90. Nationwide Children s Hospital Nephrology 8 9 Nationwide Children s Hospital Nephrology
Clinical Capabilities in the Section of Nephrology NEPHROLOGY CLINIC The Nephrology Clinic at Nationwide Children s gives comprehensive treatment to children and adolescents with kidney and urinary tract problems. Among the conditions addressed are kidney failure, developmental abnormalities of the kidneys, urinary tract infections, kidney stones, nephrotic syndrome, high blood pressure, metabolic bone disease and inflammatory diseases of the kidneys such as glomerulonephritis. DIALYSIS SERVICES KIDNEY TRANSPLANT PROGRAM For pediatric patients with end-stage kidney disease, Nationwide Children s offers a complete transplant program with individualized care throughout the transplant process. The program team consists of nephrologists, transplant surgeons, transplant nurses, dietitians, a social worker, living donor advocates and pharmacists who provide consistent patient support with a familiar group of caregivers. The transplant nurse coordinator and social worker help families navigate a sometimes complex health care system and connect them with resources if needed. Nationwide Children s has a pediatric-specific dialysis unit on site to provide acute and chronic dialysis therapy for children with severe kidney failure. Hemodialysis, peritoneal dialysis, and continuous renal replacement therapy are available depending on the patient s need. All chronic dialysis patients are taken care of by a multidisciplinary team including a primary nephrologist, primary dialysis nurse, pediatric surgeon, pediatric interventional radiologist, dietitian, social worker, psychologist, teacher and massage therapy. METABOLIC BONE CLINIC Once considered a disease primarily affecting postmenopausal women, osteopenia/osteoporosis is increasingly recognized as concern for children. Disturbances in normal bone growth and mineralization can have long-term consequences for their health. The Metabolic Bone Clinic at Nationwide Children s offers children and adolescents with lone bow density access to evaluation, diagnosis and management of various skeletal disorders. The clinic provides treatment of primary bone conditions and secondary conditions related to disorders such as chronic kidney disease, cancer, sickle cell disease, cystic fibrosis, immobilization and many others. The multidisciplinary clinic team includes members from the hospital s nephrology, endocrinology, genetics, orthopedics, radiology and complex health care programs. RELATED: RESEARCH IDENTIFIES SAFE DRUG FOR EARLY FRACTURE PREVENTION Clinician-scientists from Nationwide Children s Metabolic Bone Clinic published research in 2015 showing that intravenous pamidronate is a safe and effective fracture prevention treatment for very young children with osteogenesis imperfecta (OI), a genetic disorder characterized by bone fragility and low bone mass. The drug can be administered as early as a child s first month of life. Traditionally, the condition has been managed with surgery and orthotics. Pamidronate, however, prevented fractures and improved bone mineral density while preserving linear growth, and that makes it an attractive treatment option, says John D. Mahan, MD, a nephrologist, director of the Metabolic Bone Clinic and senior author of the study, which appeared in the Journal of Bone and Mineral Metabolism. Now we know that infants with OI can safely get IV pamidronate therapy early, before fractures and problems like the need for major bone surgeries inevitably occur, Dr. Mahan says. 10 Nationwide Children s Hospital Nephrology Nationwide Children s Hospital Nephrology 11
Referrals and Consultations Online: NationwideChildrens.org/Nephrology Phone: (614) 722-6200 or (877) 722-6220 Fax: (614) 722-4000 Physician Direct Connect Line for 24-hour urgent physician consultations: (614) 355-0221 or (877) 355-0221 Mailing address: Nationwide Children s Hospital, 700 Children s Drive Columbus, Ohio 43205 11322