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kidney

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.