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Inside Pediatrics, Nephrology, Uncategorized

Food as Medicine: Bringing Nutrition to Dialysis Patients with Food Insecurity

Children’s of Alabama Dialysis Director Sahar Fathallah-Shaykh, M.D., and her team developed the Food as Medicine Program in spring 2020. Families who qualify based on income and expenses receive a monthly box of non-perishable supplies for their child, as well as support from a renal dietician in how to use them.

When it comes to kids on dialysis, food really is medicine. “We can provide state-of-the-art dialysis treatment and medications, but if they don’t follow a strict diet, they don’t do well,” said Children’s of Alabama Dialysis Director Sahar Fathallah-Shaykh, M.D. That includes a higher risk of hospital admission, infections and even mortality. Plus, it may make them ineligible for transplant because of poor healing, increased risk of infection and poor outcome.

The strict diets are very low in potassium, salt and phosphorus, with no processed or fast food. “This leaves a majority of our patients with a very difficult-to-obtain diet,” she said, particularly since half have significant food insecurity. “If we can’t meet the basic need of food, we’re not helping them that much.”

Which is why she and her team developed the Food as Medicine program in the spring of 2020. Families who qualify based on income and expenses receive a monthly box of non-perishable supplies for their child, as well as support from a renal dietician in how to use them.

“When we started we were hoping to provide them with fresh ingredients once a week, but then COVID came,” Fathallah-Shaykh said, restricting the ability of families to pick up the food on a weekly basis.

Packages include almond milk, rice, pasta, butter, animal crackers, dried herbs and seasonings, grains, cereals, oils for cooking, canned fruits and unsalted vegetables, canned tuna and chicken, and even snacks such as unsalted pretzels and Rice Krisipies Treats. Once the pandemic ends, “we hope that fresh vegetables will join the mix,” Fathallah-Shaykh said.

The unit typically has about 25 patients on dialysis and about half qualify for the program. They claim their boxes when they come for treatment.

The program has been funded, in part, by the Children’s Table fundraiser, a food event and fundraiser to raise awareness about the importance of dietary choices in the health of children and management of pediatric disease. In past years, participants enjoyed tasting plates, signature cocktails, beer, wine and dessert from some of the top chefs in the state. The event has raised more than $100,000 over the past three years to support families’ nutritional needs.

Now the team is trying to figure out how to keep the program going given the COVID-19 pandemic and the challenge it presents for in-person events.

“Without that funding,” Fathallah-Shaykh said, “these children may die if we don’t help them with their basic dietary needs. It’s really that serious.”

Inside Pediatrics, Neonatology, Nephrology

Teaching the Rest of the World How to Care for Babies and Small Children on Dialysis

A Children’s of Alabama team member attends to an infant patient simulator during a NICKS presentation in the Children’s Simulation Center. NICKS, the Neonatal and Infant Course for Kidney Support, is an education program combining specialist instruction, parent perspectives and hands-on training and support.

Children’s of Alabama provides more days of dialysis to babies than any institution in the world. Indeed, Children’s nephrologists and intensivists pioneered the use of dialysis in newborns and young children by retrofitting a machine used for adult heart failure patients. Now, with U.S. Food and Drug Administration-approved dialysis machines for young children on the market, the team has been inundated with requests from other hospitals for training and information.

The result is the Neonatal and Infant Course for Kidney Support (NICKS), a one-and-a-half day educational program that combines didactic teaching from a variety of specialists, an opportunity to have a parental perspective, “hands-on” skills sessions and virtual small group case simulations.

 “As medicine advances and we continue to create innovative answers to problems, it is imperative that we offer up what we have learned in a practical, ‘hands-on’ way,” said course co-founder and acute dialysis nurse practitioner Kara Short, MSN, CRNP.

“There’s a huge need across the country and across the world for people to understand how dialysis is different for newborns and small kids,” said course co-founder David Askenazi, M.D., MsPH, FASN, who directs the Pediatric and Infant Center for Acute Nephrology (PICAN) at Children’s. “We cover the whole gamut of how to build a program with the hope that we can educate them, inspire them and provide them with tools so they can go back to their institutions and succeed in caring for small kids.”

While the course was originally designed to be held in person, COVID-19 forced it online. That hasn’t hurt its popularity. The first course, held in July, sold out in a few days and by early September there was a 20-person waiting list for the October program. Participants have come from throughout the world, including Israel, Qatar, and Canada. The interest has been so great that Short and Askenazi doubled the number of participants from 20 to 40.

“The feedback has been tremendous,” said Short. Among the comments she’s received from participants:

  • “I loved this! I was very impressed with the overall quality. Well done, I really enjoyed it!”
  • “The conference was extremely well run, efficient and very informative. I know I learned a lot.”
  • “Excellent job on your inaugural course. Would highly recommend.”
  • “Enjoyed attending with lots of good information.  Looking forward to reviewing policies to help grow our own program.”

The plan is to continue offering the virtual course every three to four months. For information, contactDavid Askenazi, M.D., MsPH, FASN at daskenazi@peds.uab.edu or Kara Short, MSN, CRNP at kara.short@childrensal.org.

Inside Pediatrics, Nephrology

Working to Improve Kidney Health in Developing Countries

Children’s of Alabama pediatric nephrologist Erica Christen Bjornstad, M.D., Ph.D., MPH, hopes to bring her deep knowledge of unmet nephrology needs in underdeveloped countries through the hospital’s existing relationship with the Centre for Infectious Disease Research in Zambia (CIDRZ).

Pediatric nephrologist Erica Christen Bjornstad, M.D., Ph.D., MPH, has been working inglobal health since college. As a Peace Corps volunteer she served as a rural public health volunteer in Ecuador, and in the years after brought her public health expertise to Peru, Afghanistan, Malawi, and Tanzania. In fact, it was her work with trauma surgeons in Malawi, one of the five poorest countries in the world, during her fellowship at the University of North Carolina-Chapel Hill that stoked her interest in acute kidney injury (AKI).

The condition is a significant cause of morbidity and mortality in the post-surgical and ICU setting and is typically diagnosed late in the disease state when severe kidney damage may have already occurred. In poor countries like Malawi, which don’t have the infrastructure required to obtain and run laboratory blood tests, the diagnosis may never come. Patients then develop end-stage renal failure but have little, if any, access to dialysis.

During her fellowship, Bjornstad brought a point-of-care urine dipstick test to Malawi to provide instant results on kidney function. Now at Children’s of Alabama, she hopes to bring that test – and her deep knowledge of the unmet nephrology needs in developing countries— to Zambia through the hospital’s existing relationship with the Centre for Infectious Disease Research in Zambia (CIDRZ). “Zambia is better off than Malawi,” she said, “but still struggles with a lot of scarcities and lab shortages.” COVID-19 has exacerbated those problems exponentially, she said. “Having a point-of-care test would be quite valuable.”

Such partnerships are what enticed her to Children’s in 2019 when she finished her fellowship. It was important, she said, that the pediatrics department at the University of Alabama Birmingham (UAB) wants to build its global health presence in a sustainable way, “not popping in and popping out.”

That means providing the education and support to work alongside a developing country improving its own medical infrastructure. The people who live in the country “are 100 times more prepared to ask the right questions and provide potential solutions that we never would have thought of,” she said, “because they are there and they know what works and what doesn’t.”

The relationships we build with these institutions, if done right, can lead to great changes in both,” she said. “But we have to be careful that it is done in a thoughtful way and that the U.S. side is not doing all the benefitting.” The CIDRZ/UAB partnership, she said, exemplifies sustainability.

But there needs to be more focus on kidney disease. “The need for nephrology is underappreciated and often overlooked in global health until there is a very dire medical emergency,” she said. So finding ways to bring the specialty to areas with few resources – as with a dipstick – is critical. “I can’t take a lab machine on the plane with me,” she said. “But if I can throw some dipsticks in my pack and diagnose AKI, that could be revolutionary.”

Cardiology, Inside Pediatrics, Nephrology

Children’s of Alabama Leads Consortium Dedicated to Improving Outcomes in Cardiac Surgery-Acute Kidney Injury

NEPHRON_WEB

Children’s of Alabama is one of 22 hospitals in the U.S. that is a member of the Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON).

Neonatal acute kidney injury (AKI) occurs in 52 to 64 percent of patients undergoing cardiac surgery (CS) and is associated with increased morbidity and mortality.

However, because CS-AKI rates vary widely between centers, it appears that interventions to prevent or mitigate the condition could reduce the overall rate.

Yet, noted Santiago Borasino, M.D., medical director of Children’s of Alabama’s Cardiovascular Intensive Care Unit (CVICU), “there are critical gaps in our understanding as to how to best define CS-AKI, who is at risk, and which patients could best benefit from interventions to prevent or  mitigate the effects of CS-AKI.”

To improve understanding of CS-AKI in this population, Borasino is one of the leaders of the Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON), composed of 22 children’s hospitals around the country. The consortium’s goals are to describe neonatal kidney injury epidemiology, evaluate variability in diagnosis and management, identify risk factors, investigate the impact of fluid overload and explore associations with outcomes. It involves multidisciplinary teams including clinicians from cardiac critical care, cardiology, nephrology, and cardiac surgery.

“NEPHRON is providing multicenter data on CS-AKI for the first time,” Borasino said. “The large size of the cohort will enable us to look at details that are not possible with single-center studies.”

NEPHRON published its preliminary results in April 2019, reporting an overall incidence of 54 percent among 2,240 patients in its database.[1] In November 2019, NEPHRON presented additional results during the American Heart Association’s annual meeting, showing a threefold variation in rates among centers, from 27 percent to 86 percent, with significant variations in KDIGO stage (adult AKI definition) to identify AKI (65 percent by oligo oligo-anuria versus 35 percent by creatinine).

The results also showed that the use of cardiopulmonary bypass, but not time spent on bypass, increased the odds of CS-AKI, and that only KDIGO Stage 3 was associated with mortality. There was no impact of CS-AKI on the duration of mechanical ventilation or hospital length of stay.[2]

“NEPHRON preliminary results highlight the limitations of the KDIGO definition and the need to better understand CS-AKI as it occurs with incredible variability among centers, opening the door for future quality improvement intervention,” Borasino said.

The next step is to develop an algorithm to predict which patients are more likely to develop AKI so physicians can intervene earlier. “Early recognition and proper management of AKI are at the forefront of critical care medicine,” said Children’s of Alabama pediatric nephrologist Tennille Webb, M.D. “However, most pediatric hospitals that perform cardiac surgeries do not have protocols in place for managing severe AKI post-operatively.” Webb is now working on developing a clinical pathway to identify patients at increased risk of AKI based on specific patient characteristics. “An advantage to developing this algorithm in the CVICU is that we are able to determine the exact timing and etiology of AKI development in individuals undergoing cardiopulmonary bypass,” she said. “If we can proactively identify risk factors that place these individuals at increased risk for AKI, we can provide earlier intervention, such as early initiation of renal replacement therapy, in an effort to mitigate some of the known severe consequences of AKI.”

“The work that we are doing is very important because we know that AKI post-cardiac surgery leads to worse outcomes and is associated with chronic kidney disease,” Webb said. “It’s great, and yet rare in other institutions, that we have been able to develop a strong relationship between the CVICU and nephrology to work as a cohesive team early AKI detection and prevention.”


[1] Gist KM, Blinder JJ, Bailly D, Neonatal and Paediatric Heart and Renal Outcomes Network: design of a multi-centre retrospective cohort study. Cardiol Young. 2019;29(4):511-518.

[2] Alten J, Cooper DS, Gist KM, et al. , Abstract 13177: Epidemiology of Neonatal Cardiac Surgery Induced Acute Kidney Injury From the Neonatal and Pediatric Heart and Renal Outcomes Network. Circulation. 2019;140(Suppl1).

 

Inside Pediatrics, Nephrology

Pediatric Extracorporeal Photopheresis Offers New Option for Transplant Patients at Children’s of Alabama

Photopheresis_WEB

Children’s of Alabama nurses Daryl Ingram and Suzanne Gurosky next to the hospital’s photopheresis machine. After months of planning and training, Children’s of Alabama’s first photopheresis treatment was successfully provided on April 12, 2017. Previously, Children’s of Alabama patients were being transported to and from the University of Alabama at Birmingham (UAB) for treatment.

Children’s of Alabama’s Acute Renal Therapy team is now able to offer extracorporeal photopheresis (ECP) for heart transplant patients experiencing chronic rejection and bone marrow transplant patients who develop graft-versus-host-disease (GVHD). It is the only program in the state to provide the service to pediatric patients.

The U.S. Food and Drug Administration first approved ECP in 1988 to treat patients with a certain form of cutaneous T-cell lymphoma. Since then, ECP has demonstrated efficacy in GVHD, solid organ transplant rejection and rheumatoid arthritis, among others.

During the three-hour procedure, the patient’s leukocytes are separated from the peripheral blood, combined with a photoreactive drug and then exposed to ultraviolet irradiation, resulting in massive apoptosis. The cells are then reinfused into the patient.

It’s not quite clear how the process works, although theories suggest that when antigen-presenting cells clear the apoptotic cells, they differentiate into a more tolerogenic phenotype, resulting in decreased stimulation or depletion of effector T cells. Another theory is that it results in greater production of anti-inflammatory cytokines (interleukin 10) and reduced production of pro-inflammatory cytokines (especially interleukin 12 and TNFα), or that it triggers the generation of several T-regulatory cells.[1]

“Basically”, said Sahar Fathallah-Shaykh, M.D., medical director the Pediatric Dialysis Unit at Children’s of Alabama, “the leukocytes are now less reactive to the foreign tissue, reducing organ rejection and GVHD. However, she said, while studies find good rates of success in reversing organ rejection and GVHD, it’s not a cure. “It is used in conjunction with other immunosuppressive medications when other things haven’t worked. We add this and hopefully it works.”

Previously, Children’s of Alabama patients had to be transported to and from the University of Alabama at Birmingham (UAB) for this treatment. “It wasn’t an ideal setup,” said David Askenazi, M.D., who directs the Pediatric and Infant Center for Acute Nephrology at Children’s of Alabama. “There were different medical record systems, which wasn’t optimal for timely patient care of pediatric patients in an adult hospital.” So when the cardiology and bone marrow transplant team needed to bring the therapy to Children’s, Askenazi and his team, which already had experience with extra-corporeal therapies, stepped forward to run it.

“Bringing the program to Children’s was challenging,” Fathallah-Shaykh said. “The medical staff and physicians required extensive training, particularly in using the single lumen port needed for vascular access, which is unique to this procedure. But it was worth it.”

“Even though we don’t have many patients who require ECP,” she said, “the message is that we’re here, we’re available and we can help improve the care of our patients in a pediatric-friendly environment with pediatric nursing care.”


[1] Klassen J. The role of photopheresis in the treatment of graft-versus-host disease. Curr Oncol. 2010 Apr; 17(2): 55–58.

 

 

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.