Browsing Category

Nephrology

Nephrology

Cutting Out Sugar Intake, One Kid at a Time

The average American consumes almost 152 pounds of sugar a year, about three pounds a week or 42.5 teaspoons a day — more than triple the recommended amount.[1] While sugar consumption isn’t the only cause of the country’s obesity epidemic, it is definitely a major contributing factor — particularly in children. And the problem is not only obesity, says pediatric nephrologist Daniel I. Feig, M.D., Ph.D., who directs the University of Alabama at Birmingham (UAB) Division of Pediatric Nephrology at Children’s of Alabama, but all the downstream health effects of being overweight, including cardiovascular disease, hypertension, liver disease, kidney disease and type 2 diabetes.

One reason for the high sugar intake is economic. Over the past 35 years, the price of fruits and vegetables has tripled, he said, while the price of sugar-sweetened foods such as beverages fell 75%. “The availability of calories and nourishment in a low-sugar fashion is much more expensive than it was a few decades ago,” he said. “We can talk until we’re blue in the face in low-income, urban clinics about eating fruits and veggies, but that isn’t the only barrier to kids not eating them; their families can’t afford it.

Then there’s the issue of high-fructose corn syrup (HFCS), used as a sweetener and preservative in many foods. Research from Feig and others has found that HFCS is not simply sugar in another form but has a high relative fraction of fructose compared to glucose, which alters cellular carbohydrate metabolism. This results in a greater rise in triglycerides and uric acid than with sugar from sugar cane or sugar beets.

Researchers have also demonstrated that high levels of uric acid stiffen and thicken blood vessel walls, resulting in hypertension, as well as activating the renin-angiotensin system system, causing immediate vasoconstriction.

Clinical trials find that lowering uric acid levels in hypertensive adolescents, but not adults, improves blood pressure. “So we have a window of opportunity in children to reduce their long-term cardiovascular and renal risk factors by controlling sugar intake,” Feig said.

That’s why clinicians and nutritionists at the hypertension clinic at Children’s counsel patients and their families about the effects of sugar as well as where the sugar is found (i.e., the sweet tea that is ubiquitous throughout the South). “Adolescents get about 48% of their sugar from sugar-sweetened beverages,” Feig said, “so it isn’t a function of just telling them not to eat candy.”

“When I see a child in our hypertension clinic with obesity-related hypertension, about a third of the time very high sugar and caloric intake in their beverages, up to 2,000 calories a day, is a major contributing factor,” he said. “Simply eliminating those liquids could make a huge difference in their health.”

He cites a recent study that polled new parents about the sugar content of various foods. More than 80% of parents underestimated the sugar content of foods with a “health halo,” like fruit juice and yogurt. “We have an educational deficit in terms of dietary literacy,” he said.

“So a big push in our clinic is helping families learn more about the nutritional content of food.”

Blood Pressure Control

Learn more about the hypertension clinic at Children’s of Alabama.


[1] Department of Health and Human Services. How Much Sugar Do You Eat? You May Be Surprised! https://www.dhhs.nh.gov/dphs/nhp/documents/sugar.pdf.

Nephrology

Children’s of Alabama Becomes First to Safely Provide Dialysis to Tiny Babies

Didactic and hands-on teaching on the use of CRRT using the Aquadex Pureflow.

Despite the frequent use of dialysis for critically ill children and adults, the procedure has historically been used sparingly in neonatal intensive care units (NICU) because dialysis  machines designed for adults can cause severe complications in babies. That’s no longer the case at Children’s of Alabama.

The problem is that continuous renal replacement therapy in these tiny patients requires at least 100 ml of blood to initiate the therapy. This can be half or even more of the baby’s entire blood volume, said David Askenazi, M.D., MSPH, who directs the Pediatric and Infant Center for Acute Care Nephrology. “Many times, when we started the machine, we had to open the crash cart to resuscitate infants who were coding,” he said.

That changed in 2013, when Askenazi realized that a machine designed to remove fluid and sodium from blood in adults with heart failure — the Aquadex FlexFlow® System — could be repurposed for neonate dialysis.

“If we could adapt a machine that requires one-third of the blood of the traditional machine volume to do what we needed, we knew we could improve our ability to support these babies,” he said. So the team learned as much as they could about the device, developed a safety net of processes to maximize the likelihood of success and convinced the hospital to buy its first machine.

Today, the hospital has fiveAquadex machines and two or three babies are typically receiving dialysis at any one time. “Now we have complete control over their fluids, electrolytes and waste products,” Askenazi said, “while the nurses feel comfortable doing the therapy and the babies don’t even know they’re on it.” Last year, babies in the NICU spent a total of 800 days on dialysis compared to just 30 days in 2013.

“For our babies born with diseased or absent kidneys, Aquadex has given them a chance at life,” said NICU nurse practitioner Kara Short, MSN, CRNP, “because in the past, there were no options to treat these patients.”

The team published the results of its first 12 patients in the journal Pediatric Nephrology in 2016. Since then, they have treated more than 90 patients, the smallest just 1.2 kg (2 pounds, 7 ounces) and taught nephrologists at several other children’s hospitals around the country to use the Aquadex. However, there are still only a handful of hospitals offering the procedure.

“We have shown we can now support these babies safely,” Askenazi said. “The impetus now is on us to make sure the patients who can benefit from this therapy make it to Children’s so we can give them a chance for life.”

And the machine’s manufacturer? It is now pursuing a pediatric indication for Aquadex.

A Team Effort

Learn more about the neonatology program and team at Children’s of Alabama.

Nephrology

Continual Performance Improvement in Pediatric Kidney Transplantation

The renal transplant team at Children’s of Alabama has performed more than 500 kidney transplants since 1968. To this day, continuous improvement remains at the heart of everything it does.

The hospital is part of the Improving Renal Outcomes Collaborative (IROC), a learning health system of 32 pediatric kidney transplant centers in the U.S. that share data and best practices in an effort to improve transplant outcomes.

“We know we can achieve better things more efficiently together than if we’re working individually,” said Children’s pediatric nephrologist Michael E. Seifert, M.D. 

Improvement Projects

One recent project involved improving blood pressure assessments. “We know that if we control blood pressure we get better patient outcomes and the transplant does better,” Seifert said. Yet an analysis of 17 IROC transplant centers found that blood pressure was being measured appropriately based on current guidelines at just 12% of transplant clinic visits.

Each IROC center had the freedom to design custom tools to fit its needs for improving blood pressure measurement. The answer at Children’s was paper-based tracking logs and regular meetings to review progress. The team also educated all staff on the importance of measuring blood pressure and how to measure it according to the most recent guidelines. “It was pretty simple things that, when applied systematically and consistently, led to prolonged improvement,” Seifert said. Today, at least 85% of clinic visits include an appropriately measured blood pressure and the team is working to improve that number.

The next project is to improve adherence to immunosuppressive drugs, a major risk factor for rejection and loss of the kidney transplant. The team is developing a questionnaire for parents and patients so they can identify the barriers to adherence and develop targeted interventions. “We have to get away from an accusatory approach to a partnership and ask, ‘How can we work with you to make it easier to take your medications?’” Seifert said.

Children’s is also a national leader in studying surveillance biopsies to help reduce acute rejection rates. Most pediatric transplant centers do not perform early surveillance biopsies at pre-specified time points because of their invasive nature, but Seifert and his team demonstrated that surveillance biopsies in the first six months after transplant can detect subclinical inflammation, which is associated with a nearly threefold increased risk of acute rejection and allograft failure. Treating patients who demonstrated such inflammation, they recently reported, significantly reduces that risk. Importantly, they also demonstrated that the  surveillance biopsy procedure was safe for pediatric patients, with extremely low rates of mild adverse events.

Bringing the Bench and the Clinic Closer

The transplant team also runs a robust translational research program, with half of transplant patients enrolled in at least one research study. One is a biorepository study in which patients’ blood, urine and kidney biopsy tissue is collected throughout and after the transplant process. “Then we can develop biomarkers of kidney transplant diseases that impact the survival of the transplant,” Seifert said.

The second study will identify determinants of cardiovascular health in pediatric and young adult kidney transplant recipients who have a high burden of cardiovascular risk. “Transplantation improves but doesn’t eliminate this risk,” Seifert said. “This study is

designed to understand certain unique cardiovascular risk factors, such as the impact of

early life stress, on cardiovascular and renal outcomes.”

The Transplant Experts

Learn more about kidney transplantation at Children’s of Alabama.

Nephrology

Kidney Stone Clinic Stresses Prevention

Nephrology_Kidney Stone ClinicThe incidence of pediatric nephrolithiasis, or kidney stones, is increasing between 6 to 10 percent a year, driven in part by obesity and poor diets.[1] To counter this rise, pediatric urologist Pankaj Dangle, M.D.,  an assistant professor and director of robotic surgery in the division pediatric urology at the University of Alabama at Birmingham (UAB), spearheaded the effort to establish a multidisciplinary pediatric kidney stone clinic at Children’s of Alabama.

The clinic, the only one of its kind Southeast, is a collaboration among Dangle, pediatric nephrologist  Michael E. Seifert, M.D., an associate professor in the division of pediatric nephrology at the University of Alabama at Birmingham (UAB), and Children’s clinical nutritionist Perrin Tamblyn Bickert, MS, RD, LDN, CLC, to provide coordinated care for the prevention of kidney stones.  Patient visits are coordinated through the urology specialty care clinic at Children’s.

Seifert, who treated many of these children while training in Boston, knew he wanted to find a better way of managing children with kidney stones and preventing their recurrence.

“One reason we started the clinic is that kidney stones are typically identified in the acute stage, when children present to the emergency department,” Seifert said. Patients usually see a urologist who determines whether to handle the stone medically or surgically. “But that doesn’t do anything about preventing future stones,” Seifert said. And, given that a child who develops a kidney stone has a 50 percent chance of developing another stone in the next 12 to 18 months, “just getting rid of it is only part of the story.”

With the clinic approach, Seifert said, children can see three specialists during one visit, and the clinicians can talk to the patient and family together to develop a comprehensive treatment plan focused on prevention of future kidney stones.  “To have an all-in-one clinic at the same time makes this a novel clinic and a great resource for kids,” he said.

“The most important thing is that we are now able to provide comprehensive care to our patients so that all aspects of the disease are addressed,” said Dangle, who, prior to joining UAB/Children’s, treated children while training in Chicago. “The urologist deals with it surgically; then the nephrologist assesses blood serum levels of minerals and vitamin D, how well their kidneys function and obtains a 24-hour urine analysis.” After that, Bickert enters the picture and calculates the nutritional formula.

“When all three of us are in the room at the same time, it reinforces what each of us are saying,” Dangle said.

Nutrition and inadequate hydration play a major role in kidney stone development, which is why the nutritional part of the management plan is so important, said Bickert, who is one of only two pediatric renal nutritionists in the state. She works with children and their families to modify the amount of sodium in their diet, increase fluids and limit oxalate intake. “We ask kids to participate as much as possible,” she said.

Bickert’s job can be challenging, she admits, particularly since she may be asking families to change long-entrenched eating habits. “A lot of our patients live off chicken fingers and French fries,” she said. Both are salty, and potatoes are very high in oxalate, which contributes to stone development. “So reducing sodium intake after years of a high-sodium diet can be a very big lifestyle adjustment.” Bickert also works with schools to ensure that children can carry a water bottle with them. The schools send her their lunch menus in advance, and she circles the items her patients can eat.

“We know that prevention is better than any cure in medicine,” Dangle said. “And the clinic is helping us with that.”

[1] Miah T, Kamat D. Pediatric Nephrolithiasis: A Review. Pediatr Ann. 2017 Jun 1;46(6):e242-e244.

Kidney Care
Learn more about nephrology clinics and services at Children’s of Alabama.

Nephrology

Telenephrology: Bringing the Nephrologist to the Patient—Virtually

Nephrology_Telemedicine

With only six pediatric nephrologists in the state, families must often drive hundreds of miles—and many times stay overnight—for appointments with Children’s of Alabama physicians. In fact, 48 percent of the hospital’s transplantation patients come from more than 100 miles for each appointment, and 32 percent  from more than 200 miles, said Daniel Feig, M.D., Ph.D., who directs the pediatric nephrology and renal transplantation program.

“It’s more than a slight challenge to get here,” Feig said.  “It entails missed school and work and the cost of getting back and forth.”

And that, in turn, can compromise the quality of care or even lead to missed opportunities for care.

Now, however, families can “see” a doctor just a few miles from home thanks to the practice’s new telenephrology program. The program, which began in June, builds on the success of the adult telenephrology program for dialysis patients started by Director of Telehealth Eric L. Wallace, M.D. in collaboration with the Alabama Department of Public Health. It involves teaming with the public health department in each of the state’s 67 counties to see patients remotely.

“So all families are within 25 miles of a site of care,” said Feig.

Families Appreciate the Convenience

To date, seven patients have been seen a total of 16 times remotely.

“Every family said they would like to continue the remote visits,” Feig said.

The primary difference in the visits, of course, is that the patient and doctor are not in the same place. Other than that, nearly everything else is the same. Lab and radiology tests are obtained before the visit so the doctor can evaluate them prior to meeting; a high-resolution camera enables the physician to examine the skin, mouth and ears; and Bluetooth technology allows for a heart and lung exam. A nurse in the room facilitates the exam.

“What we lose is the physical feel of the belly exam or the pulse,” Feig said.

This is why patients chosen for telehealth are those who are most amenable to visual exam evaluations.

Still, nephrologists deliberately started the program with renal transplant patients—“the most complex patients possible, said Feig. These patients see a multitude of providers when they come to the on-site clinic, including the pharmacist, child life and social workers, the transplant nurse and transplant counselor – all of whom participate in the virtual visit.

“If we can manage the most complex patients through telemedicine, we can leverage the scale to those who need less in the way of specific practitioners involved in the visit,” Feig said.

Moving forward, Feig and Wallace said they plan to significantly increase the number of patients seen, including first-time patients. Challenges include not only the physical infrastructure, but training staff to schedule telehealth visits versus inpatient visits.

“A true telemedicine clinic is the goal,” Feig said.

Wallace agreed.

“For many in Alabama, the reality is that it is telehealth versus no care,” Wallace said.

For instance, 17 percent of families in Wilcox County do not own vehicles.

“A big part of telehealth is reaching people who would never have been able to be seen,” Wallace said.

Nephrology Research
Learn more about research conducted by Daniel Feig, M.D., Ph.D., and other nephrology specialists at https://www.childrensal.org/nephrologyresearch.

Nephrology

Baby NINJA Fights Back Against AKI

Nephrology_Baby_NINJA

The Pediatric and Infancy Center for Acute Nephrology (PICAN) at Children’s of Alabama, in partnership with the University of Alabama at Birmingham (UAB) Department of Pediatrics, has served children in Alabama and across the world since its 2013 inception. PICAN’s three-pronged model provides the best available comprehensive multidisciplinary clinical care, education, and research for children with acute kidney injury (AKI) and neonates with kidney disease.

“We believe that if we provide the best care, make important discoveries and educate our staff and those beyond our institution, we can make a huge impact in this field,” said David Askenazi, M.D., MSPH, PICAN director and UAB professor of pediatrics.

As a part of its efforts, PICAN implemented Nephrotoxic Injury Negated by Just-in-Time Action (NINJA), a collaboration between Children’s and Cincinnati Children’s Hospital Medical Center. Via NINJA, hospitalized patients receiving medications that can cause kidney injury are automatically identified by using the electronic medical record system and scheduled for dose adjustments and increased renal function surveillance. The rate of acute renal injury in inpatients has been decreased by more than 60 percent, resulting in substantially decreased morbidity across the hospital and reduced hospitalization duration. The NINJA program is so successful that this year it became the first new program added to the Solutions For Patient Safety consortium and instituted at 147 children’s hospitals worldwide.

A recent application of NINJA in Children’s Neonatal Intensive Care Unit (NICU) referred to as Baby NINJA, a project exclusive to Children’s, has nearly eliminated medication associated acute kidney injury in the most vulnerable premature infants. In March 2018, Baby NINJA won the Best Abstract Award at the 23rd International Conference on Advances in Critical Care Nephrology in San Diego, California.

“What’s exciting about Baby NINJA is the simplicity of the approach,” said Christine Stoops, D.O., MPH, Baby NINJA co-investigator and UAB assistant professor in the Division of Neonatology. “It’s looking at all infants exposed to nephrotoxic medications for potential kidney injury with a daily lab level (serum creatinine), and paying careful attention to whether a baby still needs these medications or can benefit from a lower daily dose.”

“With that easy shift in our mindset, we have shown greater than an 80 percent reduction in kidney injury in high-risk patients,” Stoops said. “This has the potential to reduce chronic kidney disease in these already at-risk infants.”

In addition, PICAN has one of the most successful Continuous Renal Replacement Therapy (CRRT) programs to support critically ill patients who have lost kidney function. For example, PICAN in 2014 studied a new dialysis device called Aquadex FlexFlow ™ and adapted the device to treat neonates and premature infants with kidney failure who are too small for hemodialysis. As a result, children as small 1 kilogram can now receive this lifesaving therapy. Children’s is the first pediatric hospital in the country to successfully adapt Aquadex for use on infants, and the device is now being used at other major children’s hospitals, including Cincinnati Children’s, Boston Children’s Hospital and Seattle Children’s Hospital.

“We do more dialysis in newborns than other hospitals in the world,” Askenazi said. “We have cared for 70 babies with CRRT and have great success in initiating the machine without cardiovascular compromise, which was a problem before using Aquadex. Our survival rate in babies has increased from 30 percent to 55 percent over the last few years.”

PICAN is also the driving force behind the international Neonatal Kidney Collaborative (NKC). Under the direction of Askenazi, this network of neonatologists, pediatric nephrologists, epidemiologists and statisticians from the U.S., as well as India, Canada, and Australia, are committed better understanding AKI in neonates.

The inaugural project of NKC is the Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) study. The 24-center study captured data from over 2,000 neonates admitted to the NICU who were on intravenous fluids for at least 48 hours.

“We have learned a tremendous amount from the AWAKEN database. We can now show that AKI is very common in select groups of patients. Those patients with AKI were four times more likely to die, even after controlling other factors that are associated with neonatal death,” Askenazi said.

“We have recently reported that caffeine can be a protective agent against AKI, and we have 12 other manuscripts in preparation as well. Our plans are to submit a [National Institutes of Health] grant to continue our research and answer more questions on this topic in the future.”


Nephrology Fellowship Program

Learn more about the Pediatric Nephrology Fellowship Program at UAB at https://www.childrensal.org/FellowshipProgram.