Browsing Category

Nephrology

Inside Pediatrics, Nephrology

Neonatal Kidney Collaborative Advances Understanding of Acute Kidney Injury

David Askenazi, M.D., is a pediatric nephrologist at Children’s of Alabama and a professor in the Division of Nephrology in the University of Alabama at Birmingham Department of Pediatrics.

David Askenazi, M.D., is a pediatric nephrologist at Children’s of Alabama and a professor in the Division of Nephrology in the University of Alabama at Birmingham Department of Pediatrics.

A bunch of pediatric nephrologists and neonatologists walk into a National Institutes of Health meeting on neonatal acute kidney injury (AKI) in 2013. The punchline? They are inspired to form the Neonatal Kidney Collaborative (NKC) with the clever website address of babykidney.org.

“At that NIH meeting, we recognized that bringing people to work together on multicenter studies was a critical step in moving the field forward,” said Children’s of Alabama pediatric nephrologist David J. Askenazi, M.D., one of the founding members and current NKC Board chair.

Today, the collaborative boasts 77 participating institutions with 168 members and 19 published manuscripts. Several of those publications come from the group’s inaugural study called AWAKEN (Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates), the first multinational, multicenter study on neonatal AKI.

The study involved a retrospective review of three months of data on 2,162 infants in Level 2 or 3 neonatal intensive care units in four countries, a third of whom had AKI. The investigators found those with AKI were 4.6 times more likely to die and stayed in the hospital an average of 8.8 days longer than those without. Other results from AWAKEN include risk factors for mortality and the development of AKI (such as low albumin and hemoglobin levels) and hypo- and hypernatremia, as well as a link between intraventricular hemorrhage (bleeding in the brain) and AKI.

“We chose the name AWAKEN because we felt like the field needed to be awakened,” Dr. Askenazi said. And it’s worked, he said, with the number of studies, initiatives and young people interested in neonatal nephrology growing exponentially.

The collaborative, he said, “not only provides opportunities to study neonatal kidney disease, but we also have committees to address the educational, advocacy, and research needs of this evolving field.”

The group recently received a significant research grant from Nuwellis, a global company focused on fluid management solutions for pediatric and adult patients, to perform the ALMOND (Assessing Longitudinal Micropreemie Outcomes in Neonates at Risk for Renal Disease) study. “This research effort will expand our understanding of neonatal kidney disease in extremely premature neonates who were enrolled in a multicenter trial called PENUT (Preterm Erythropoietin Neuroprotection Trial),” he said.

The study will use the PENUT database, which contains thousands of clinical data points and hundreds of thousands of urine biomarker data points from more than 900 babies. “It’s a goldmine,” said Dr. Askenazi. “It will allow the NKC to pose and answers questions about kidney disease in extremely premature neonates, including whether caffeine, commonly prescribed to these infants, can prevent AKI; determine the fluid provision to improve clinical outcomes; and identify additional risk factors for neonatal AKI, among other questions.”

“The work of this collaborative is contagious, and it drives me,” he said. “It makes me want to continue to help move the field forward and support young doctors who are filled with energy and excitement.”

Inside Pediatrics, Nephrology

Tracking Kidney Transplant Rejection in the Blood and Urine 

Michael Seifert, M.D., is a pediatric nephrologist at Children’s of Alabama and an associate professor in the Division of Nephrology in the University of Alabama at Birmingham Department of Pediatrics.

Michael Seifert, M.D., is a pediatric nephrologist at Children’s of Alabama and an associate professor in the Division of Nephrology in the University of Alabama at Birmingham Department of Pediatrics.

Children who receive kidney transplants at Children’s of Alabama undergo a routine biopsy six months after the procedure to look for signs of rejection. In about 20 percent of patients, those signs are there, even if their blood and urine tests look normal. “On the flip side,” said Children’s pediatric nephrologist Michael E. Seifert, M.D., “that means about 80 percent of our patients are getting biopsies that are normal.” 

The holy grail, then, would be a non-invasive biomarker test using blood or urine that can identify kidney transplant injury without needing a biopsy — which is exactly what Dr. Seifert and his lab are working on. Their research relies on a biorepository of patients’ blood, urine, and kidney biopsy tissue collected throughout and after the transplant process. 

One of the blood tests they’re working on uses technology originally developed to screen maternal blood for signs of fetal abnormalities. The test looks for cell-free DNA, or cfDNA, which comes from the fetus and differs from maternal DNA. Since transplanted kidneys also have DNA different from the patient’s own kidney, “you can look in the bloodstream for the proportion of the DNA coming from the transplant versus the normal background from the recipient’s non-transplant cells,” Dr. Seifert said. High levels of cfDNA is a sign of acute kidney injury that could be due to rejection.  

Studies in adults validate this as a good method to detect rejection. “But the problem is, those are done in adults whose native kidneys would be roughly similar in size to the transplant they’re carrying,” Dr. Seifert said. Children often have a much larger, adult-sized transplant compared to the size of their native kidneys, so the cutoff levels used for diagnosing rejection in adults may not work in children. “We’re trying to make these existing diagnostic tests more pediatric specific,” he said. 

The story is different for urinary biomarkers. It’s been known for years that the kidney releases certain proteins when it’s injured. Tests to detect those proteins, however, can take days. But a new device called SimplePlex, currently available only in the research setting, can measure several of these proteins at one time in a single sample in less than an hour.   

“We’re looking at ways to get this technology closer to the clinic, so you’re not just profiling kidney transplant patients’ risk for injury based on their standard blood tests like creatinine, but you’re also adding these additional biomarkers that can tell you more information about what’s happening inside the organ,” Dr. Seifert said.  

Being able to determine via blood and urine tests who needs a biopsy and who doesn’t would have a huge impact for pediatrics, particularly at Children’s, where these biopsies are done on a universal basis, he said. Ideally, the tests could also provide information on the underlying cause of the rejection. For instance, the cfDNA test is good at picking up antibody-mediated rejection, but not as good at recognizing cell-mediated rejection. The urine biomarkers are good at identifying both rejection types, but not at identifying rejection related to viral infections. 

“Once we understand more about the clinical scenarios in which the biomarkers perform well,” said Dr. Seifert, “we’ll be able to design interventional trials to treat the patient based on the biomarker changes rather than just the standard clinical tests such as creatinine.”  

Inside Pediatrics, Nephrology

Childhood Household Dysfunction Predicts Hypertension, Vascular Injury in Adolescents 

Dan Feig, M.D., Ph.D., is a pediatric nephrologist at Children’s of Alabama and a professor in the Division of Nephrology in the University of Alabama at Birmingham Department of Pediatrics.

Dan Feig, M.D., Ph.D., is a pediatric nephrologist at Children’s of Alabama and a professor in the Division of Nephrology in the University of Alabama at Birmingham Department of Pediatrics.

Verbal and physical abuse; neglect; and household dysfunction such as divorce, domestic violence, and poverty in early childhood (called adverse childhood experiences, or ACEs) affect approximately 25 percent to 30 percent of children in the United States. They also put those children at significantly increased risk for health issues like hypertension and cardiovascular disease as adults.  

“Ideally, we would like to prevent neglect, maltreatment, abuse, and household dysfunction,” said Children’s of Alabama pediatric nephrologist Daniel Feig, M.D., Ph.D. “But until that can be achieved, we need to work on mitigating their long-term effects.” Dr. Feig’s work looks at whether experiences have already changed the vascular function of individuals exposed to ACEs and whether those changes are reversible.  

“We want to see if there’s a detectable signal, something that puts them in the risk category for future disease and identify those who would benefit from intervention or therapy,” he said. 

Dr. Feig and his team used validated questionnaires to screen 78 teens for the three types of ACEs: abuse, neglect, and household dysfunction. Nearly 70 percent had been exposed to at least one ACE. The investigators also tracked the adolescents’ blood pressure with a 24-hour continuous ambulatory blood pressure monitor; measured their pulse wave velocity (a marker of blood vessel elasticity and reactivity); and looked for markers of inflammation and increased vascular tone in their bloodwork. 

They found that compared to teens with no exposure or with exposure to abuse and neglect, individuals exposed to household dysfunction had a significantly higher 24-hour diastolic blood pressure without the normal drop that occurs at night. They also found a significantly increased baseline inflammatory state. Those who experienced sexual abuse had substantially altered pulse wave velocity, which meant their blood vessels were stiffer. Despite these changes, the children had normal blood pressure. 

“This tells us that even as early as 10 to 12 years after exposure there are detectable alterations in vascular biology associated with the ACEs,” Dr. Feig said. “These individuals might benefit from interventions to reverse or slow those changes to prevent the progression of hypertension and the later risk of cardiovascular disease.” 

The team expected to see more changes in children with a history of exposure to abuse. Dr. Feig hypothesizes that the chronic nature of household dysfunction may be behind the vascular changes. “Things that reset the biology of the vessels are slow and steady effectors,” he said. “That can be dietary, that can be obesity, that can be emotional stressors, or chronic inflammation. I think that the household dysfunction category might have a greater continuous effect as opposed to episodes of horrific injury.” 

The next step is to intervene with medications to try and reduce inflammation and prevent the progression of vascular dysfunction.  

The group is currently following the study participants and hope to secure funding for larger longitudinal studies. 

Inside Pediatrics, Nephrology

Overflow at Children’s of Alabama’s Dialysis Unit

As the only pediatric dialysis unit in the state, Children’s of Alabama’s hemodialysis unit is used to being busy. But with COVID-19, “Our census has doubled,” said Children’s nephrologist Sahar Fathallah-Shaykh, M.D. One reason is that transplants were paused during the height of the pandemic, leaving many children who might have been able to stop dialysis forced to continue.  

Another reason is that more infants born with chronic kidney disease (CKD) are surviving because of new equipment capable of providing them dialysis. “We have seen many patients with CKD surviving who, just a few years ago, had no chance of surviving,” Dr. Fathallah-Shaykh said. Because these infants are so small, they must come to the hospital up to five times a week for the procedure, compared to three times a week for older children. Once infants are older, the team tries to transition them to peritoneal dialysis at home; but babies may have medical contraindications that require continuing on hemodialysis. 

The impact on the staff is significant, she said. “It’s a challenge.” Dialysis charge nurse Suzanne White, RN, ECP agrees. “It takes a lot of coordination to schedule treatments for 18 patients,” she said, particularly when treatment times last up to four hours. “Our days last 10 to 12 hours,” she said. 

One reason caring for infants on dialysis calls for intense attention, said Dr. Fathallah-Shayk, is that “nurses are at the bedside the entire time monitoring these babies. Babies move a lot, and if they move, the dialysis may not work as well.” The nurses console the babies, try to distract them and sometimes even hold them while they are dialyzed.  

The team includes a child life specialist who also tries to distract the infants during dialysis; social workers who support the families, including coordinating transportation and ensuring families keep their appointments; a dietician to help with nutrition and ensure proper growth; and a pharmacist to help with medications. “We all work as a team to make this happen,” Dr. Fathallah-Shayk said, “otherwise we couldn’t do it.”  

And, said White, “we have a good support system from the administration on down,” which helps avoid burnout. The unit also added more staff in anticipation of continued growth. “We are trying to coordinate their care to the best of our ability, troubleshoot and really communicate and work with each other,” she said. 

Inside Pediatrics, Nephrology

Welcoming the new PRISMAX Dialysis Machines to the PICU & CVICU

When you’re talking about continuous dialysis and plasmapheresis for sick kids, you want state-of-the-art technology. And that’s just what Children’s of Alabama got this year when hospital administrators approved a significant investment in the newest generation of the PRISMAX system for the Pediatric and Infant Center for Acute Nephrology (PICAN).  

The PICAN team is no stranger to these therapies; after all, the team has provided them for more than 500 children for over 10,000 days since 2013 in the pediatric, neonatal and cardiac intensive care units. In 2020, the newest PRISMAX became available, and Children’s became the first hospital in the state and one of the first children’s hospitals in the country to receive the new machines, said David Askenazi, M.D., who directs the PICAN. “We are very grateful to the hospital for making this available to us and our patients,” he said. “We know that patients will benefit.” 

But first, everyone had to be trained to use the new machines. While it sounds like replacing the old with the new should be a relatively simple switch, the staff required intense education. 

“The educational part of the rollout was very important,” said acute dialysis coordinator Daryl Ingram, RN, BSN, CDN. “We had to make sure the nurses and physicians were comfortable with them before they started using them on patients.” He was pleasantly surprised at how the entire team embraced the new technology and the groundbreaking opportunity the new machines offered, he said. 

One reason could be the improvements the new system brought. For instance, nurses no longer have to manually empty 5-liter effluent bags. “It definitely saves time,” said Suzanne Gurosky, RN, ECP, the dialysis charge nurse. She also touted the battery backup in the machines, which enables patients to ambulate and even do physical therapy while still connected. Another plus is the ability of the machines to decipher the cause for an alarm—because someone moved or jostled the fluids, or because there was a real issue going on. That helps avoid disruptive alarms and alarm fatigue. 

It does this through artificial intelligence, “so it understands what’s happening better than it used to,” said Dr. Askenazi.  

The new PRISMAX also sports improved safety features, such as correcting itself for fluid removal. In addition, it provides extensive data that can be integrated into the department’s quality-improvement initiatives. “We’re excited to dig into that information and incorporate it into our practice,” said Dr. Askenazi.  

After the training and the successful integration of the new PRISMAX machines into the unit, there was one more thing the team needed to do: name them. “We like to name our machines to help the kids feel more comfortable,” said Ingram. The winners were Rosie, Max, and Astro from the old “The Jetsons” cartoon, Johnny 5 from the movie “Short Circuit,” and C3PO from, of course, “Star Wars.” 

Inside Pediatrics, Nephrology

COVID-19 Infection May Leave Kids with Kidney Problems

Although children were far less likely to contract COVID-19 during the early days of the pandemic, they were affected. As of July 1, 2021, the American Academy of Pediatrics and the Children’s Hospital Association reported more than 4.04 million children had been diagnosed with COVID-19 in the United States; 50,439 in Alabama.1 Since the pandemic’s start, Children’s of Alabama has treated over 500 infants and children with COVID-19 and almost 100 with multisystem inflammatory syndrome (MIS-C), the long-term repercussions of which are just now emerging. 

Many affected children, like adults, have developed acute kidney injury (AKI) during hospitalization for severe disease, particularly children who have been hospitalized with MIS-C. One study of 152 children who had either acute COVID-19 or MIS-C found that AKI occurred in 10 percent of patients. These children had longer lengths of stay in the hospital and increased risk of other medical conditions.2 Another study of 52 patients with COVID-19 found that nearly 30 percent developed AKI.3 

“The jury is out on how much of that was due to severe illness versus how much the virus plays a direct role,” said Children’s nephrologist Erica C. Bjornstad, M.D. Some reports surmise that the virus is toxic to the kidney, but, Dr. Bjornstad said, more evidence is needed. Nonetheless, it appears that children who developed AKI while hospitalized need long-term follow-up as the long-term implications are not yet fully understood, she added. 

Thus, primary care physicians caring for these children after discharge should have a “high level of suspicion” if urine tests show high levels of protein, or children demonstrate new onset hypertension,” Dr. Bjornstad said. “They should look for COVID-19 as a culprit.” In fact, she suggests urine tests for all children who had COVID-19, even if they had a mild form of the disease, although no formal guidelines have been released. If the problem doesn’t resolve, the children should be referred to a nephrologist. “We don’t have a good handle if it goes away,” she said.  

“We’re still learning how this plays out since the pandemic is still not over,” Dr. Bjornstad said. Plus, “we don’t know what the fall holds with the Delta variant and as more people move indoors,” she added. 

Dr. Bjornstad and others at Children’s are involved with a large study that is mining an international registry of COVID-19 patients (children and adults) to tease out the effects on the kidney. Ideally, she would like to obtain funding to follow former patients for a prolonged period of time, “so we can keep learning and have data to support standard guidelines,” she said. 


1 Children and COVID-19: State-Level Data Report. American Academy of Pediatrics. July 1, 2021. Available at: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/. Accessed July 7, 2021.

2 Basalely A, Gurusinghe S, Schneider J, et al. Acute kidney injury in pediatric patients hospitalized with acute COVID-19 and multisystem inflammatory syndrome in children associated with COVID-19. Clin Invest. 2021;100(1): 138-145

3 Knight, P.P., Deep, A. Save the kidneys in COVID-19. Pediatr Res (2020). https://doi.org/10.1038/s41390-020-01280-x

Inside Pediatrics, Nephrology

Becoming the Leaders in Treating Congenital Nephrotic Syndrome

It is one of the most challenging congenital kidney conditions pediatric nephrologists see. Called  congenital nephrotic syndrome (CNS), it is an extremely rare genetic disease that affects the glomerular filtration system of the kidneys, leading to tremendous loss of protein through the urine. The result is extensive edema, skin breakdown and impaired respiration.

And that’s just the beginning, said Daniel Feig, M.D., Ph.D., the Margaret M. Porter Endowed Chair in Pediatric Nephology at Children’s of Alabama and the University of Alabama at Birmingham (UAB).“These kids are very susceptible to infections because so many immune chemicals are lost in the urine,” he said. They are also prone to blood clots because of low water volume and poor circulation, which can severely damage other organs, leading to bowel infarction and stroke. “They also become very malnourished because they can’t take in enough protein to keep up with the losses through the urine,” he said.

Symptoms usually appear by 2 months of age. “But because this is a structural problem in the kidney filters, there is no medicine that stops it,” he said. Early management involves trying to replace lost protein, “but that’s usually not enough.” Second-line management includes medications to slow kidney function, “but now we’re walking a tightrope of impaired kidney function to reduce protein losses.”

Eventually, the kidneys need to be removed so the child can receive enough nourishment. That means dialysis until they can receive a transplant.

“They’re a challenge,” he said. “But over the years, we’ve had very good success in moving down the pathway and getting them transplanted and they do well.” Because the condition is so rare, most pediatric nephrologists only see one or two patients their entire career. But word of Children’s program has spread, and today the team is treating patients from throughout the south.

“As a program we are happy to take care of these kids and share our expertise with other programs,” Feig said. One challenge has been reimbursement since health insurance may not cover out-of-state care. “We’re negotiating with other states and our own internal services to accept what we can get and then just take care of the kids, he said, adding, “A big shout out to the flexibility of the institution to allow us to do this.”

The goal is to build a center of excellence for children with CNS that demonstrates not only superior outcomes, he said, but cost savings.  

Becoming a referral center also allows greater clinical research into the disease, Feig said. Clinical trials for new therapies are difficult to conduct because there are so few children with the disease. But Children’s is slowly building a repository of biometric information and tissue for future research. “We don’t have a faculty researcher right now who is focused on CNS, but as we continue to recruit faculty that’s an untapped opportunity.” All the challenges of caring for these kids, he said, is worth it once they get a transplant. “They grow and develop and play just like all other small children. It’s a boon to these families who go through this terrible neonatal course and then get their kids back.”

Inside Pediatrics, Nephrology

Managing COVID-19 in the Dialysis Unit

When COVID-19 hit in early March, hospitals, including Children’s of Alabama, pivoted to telehealth appointments and canceled non-urgent procedures. But that’s not an option for children who need dialysis, particularly since Children’s is the only hospital in Alabama providing pediatric dialysis.

“We were running at full staff and operating as usual,” said Suzanne White, dialysis director at Children’s renal care center. That meant seeing hemodialysis patients three times a week, home dialysis patients once a month, and implementing protocols to reduce the risk of infection to patients and staff. It also meant that even if a patient tested positive for COVID-19, they still had to come to the hospital for dialysis. “You can’t reschedule dialysis if you have COVID,” said Sahar Fathallah-Shaykh, M.D., a pediatric nephrologist at Children’s and the University of Alabama at Birmingham (UAB). The task was made more challenging as with kidney transplants on hold, the dialysis center was seeing twice as many patients.

Among the changes the unit implemented:

  • Moving hemodialysis patients to peritoneal (home) dialysis whenever possible to limit visits to the hospital. This posed its own challenges, including training family members and coordinating with surgeons. “We did more peritoneal dialysis surgeries in those early months than we had done in years,” Fathallah-Shaykh said.
  • Limiting visitors in the unit. “We could accommodate eight patients at one time but we couldn’t have people gathering,” White said.” That meant families calling from the parking lot when they arrived, mask wearing, initial screening when they entered the hospital, and more advanced screening before they entered the dialysis unit. We drilled down to avoid screening fatigue,” she said.
  • Extensive education with families about COVID-19 and risk mitigation. “We had to make sure they realized the impact of this illness,” Fathallah-Shaykh said.
  • Treating COVID-positive patients in an isolation room when the unit was empty and implementing a special deep cleaning process.

“We were diligent because we knew what the illness could cause,” White said. The team was particularly concerned about the staff. Dialysis nurses require extensive training, and there are few available if one becomes sick. “If several got sick, it would be a disaster,” Fathallah-Shaykh said. In the end, just four staff and four patients tested positive, all community acquired. And, Fathallah-Shaykh stressed, “We never relaxed our standards. We added COVID to our high standard of care; we didn’t adjust our standard of care for COVID.”

Inside Pediatrics, Nephrology

Improving Renal Transplant Outcomes

Blood pressure is one of the most basic biometrics, taken nearly every time someone visits a health care provider. It’s also one of the most important indicators of kidney problems in both native and transplanted kidneys, with studies suggesting a direct benefit of maintaining normal blood pressures on transplant outcomes.

But taking a child’s blood pressure when they’re seen in clinic provides just a snapshot in time in a non-standard environment that can be associated with high anxiety, said Michael E. Seifert, M.D., a pediatric nephrologist at Children’s of Alabama and the University of Alabama at Birmingham (UAB). That’s why the gold standard for assessing blood pressure control is a 24-hour ambulatory blood pressure monitor, which the Pediatric Kidney Transplant Program strives to perform at least once a year in each eligible patient. The device takes and records blood pressure every 30-60 minutes, providing a slew of important information for clinicians. In fact, studies suggest that ambulatory blood pressures are a better predictor of long-term cardiovascular outcomes than clinic blood pressures.

It can also highlight unique blood pressure patterns in children with transplants that can’t be detected with the occasional clinic visit, such as masked hypertension, when blood pressure is normal in the clinic but high the rest of the day. Or nocturnal hypertension, in which it is only high at night or when the patient is asleep. A normal pattern for blood pressure over a 24-hour period is called nocturnal dipping, where the blood pressure is lower during the nighttime and sleep periods than when patients are awake.

However, when the staff dug into its data, they found that only about 20% to 25% of their eligible patients had had an ambulatory blood pressure monitor in the past year. So they launched a quality improvement project as 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. The quality improvement project was supported by a Quality Improvement Award from the Kaul Pediatric Research Institute at Children’s of Alabama.

The team already had a weekly pre-visit planning meeting in place that helped prepare for each patient’s needs during the next week of clinics. They used that opportunity to generate lists of patients who had not had the ambulatory blood pressure monitor, and systematically made it a part of the transplant anniversary visits. After just six months, placement rates jumped to over 40%, even throughout the pandemic and telehealth visits.

“We are really proud of our team for being able to improve and sustain that during some pretty challenging conditions,” Seifert said.

Even more important, in about three-fourths of the patients, the ambulatory blood pressures turned up a problem that required intervention.

“We assumed we were doing a great job with this because we’re nephrologists and we have hypertension clinics focused on proper blood pressure measurement and control,” Seifert said. “But until you start looking hard at your data, you can’t presume you’re doing as well as you think you are. We didn’t know we needed to improve until we turned the lens on it.” The project has been so successful other solid organ transplant programs at Children’s are also considering implementing it as part of their cardiovascular risk assessments.

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.”