Background
Information on the course of SARS-CoV-2 infection in children with chronic kidney disease (CKD) is limited.
Methods
We retrospectively reviewed the presentation and outcomes of SARS-CoV-2 ...infection in patients with CKD followed at any of the four pediatric nephrology centers in New Delhi from April 2020 to June 2021. Outcomes, including cardiopulmonary and renal complications, were reported in relation to underlying disease category and illness severity at presentation.
Results
Underlying illness in 88 patients included nephrotic syndrome (50%), other CKD stages 1–4 (18.2%), CKD 5D (17%), and CKD 5T (14.8%). Thirty-two of 61 patients with symptomatic COVID-19 and 9/27 asymptomatic patients were admitted for median 10 (interquartile range 7–15) days. Seventeen (19.3%) patients developed moderate or severe COVID-19. Systemic complications, observed in 30 (34.1%), included acute kidney injury (AKI, 34.2%), COVID-19 pneumonia (15.9%), unrelated pulmonary disease (2.3%), and shock (4.5%). Nineteen (21.6%) had severe complications (AKI stage 2–3, encephalopathy, respiratory failure, shock). Eight (11%) of twelve (16.4%) patients with severe AKI required dialysis. Three (3.4%) patients, two with steroid-resistant nephrotic syndrome in relapse and one with CKD 1–4, died due to respiratory failure. Univariate logistic regression indicated that patients presenting with nephrotic syndrome in relapse or moderate to severe COVID-19 were at risk of AKI (respective odds ratio, 95%CI: 3.62, 1.01–12.99; 4.58, 1.06–19.86) and/or severe complications (respective odds ratio, 95%CI: 5.92, 1.99–17.66; 61.2, 6.99–536.01).
Conclusions
Children with CKD presenting with moderate-to-severe COVID-19 or in nephrotic syndrome relapse are at risk of severe complications, including severe AKI and mortality.
Graphical abstract
A higher resolution version of the Graphical abstract is available as
Supplementary information
Background: The development of acute kidney injury (AKI) in patients infected with COVID-19 has been observed to be associated with poor outcomes. Our study aimed to measure the outcomes of COVID-19 ...in cancer patients who developed AKI during hospitalization and the predictive baseline clinical and laboratory factors associated with the development of AKI. Materials and Methods: This retrospective cohort study was conducted at a COVID hospital that included only cancer patients with COVID-19 infection. Acute kidney injury (AKI) was defined according to KDIGO (Kidney Disease: Improving Global Outcomes) criteria. The demographic, clinical, laboratory and outcomes data were collected from the hospital electronic database and abstracted from the case files. Results: Thirteen (12.8%) of the total 102 cancer patients developed AKI during hospitalization. Out of 13, 11 (84.6%) patients presented with hypoxemia during admission and required oxygen support. Breathlessness Odds Ratio (OR) (95% CI): 5.8 (1.1-31.3) or hypoxemia OR 22.6 (2.6-194.5) at the time of presentation and requirement of oxygen support OR 7.5 (1.4-40.5) were significantly associated with AKI after adjusting for age, gender, vaccination status and comorbidities. Median baseline values of inflammatory markers were significantly higher among those who developed AKI. Out of 102, 27 (26.5%) patients had in-hospital mortality. Mortality was high among those who developed AKI compared to those who didn’t develop AKI (92.3% vs 16.1%, p-value: <0.001). Conclusions: The cancer patients infected by COVID-19 and who developed AKI were more vulnerable to poor outcomes in terms of in-hospital mortality. The patients with severe disease at presentation and higher levels of baseline inflammatory markers CRP, ferritin, and D-Dimer were more susceptible to the development of AKI and in turn, led to a higher risk of in-hospital mortality in these patients.
Background
In pediatric steroid-resistant nephrotic syndrome (SRNS), calcineurin inhibitors (CNIs) are recommended as first-line therapy, with efficacy ranging between 60 and 80%, implying a ...substantial proportion will exhibit CNI resistance. Which alternate immunosuppressive therapy should be used in non-genetic pediatric SRNS exhibiting CNI resistance is especially relevant in low- to middle-income countries (LMIC), where the prohibitive costs of certain drugs such as monoclonal antibodies often determine therapy choice.
Methods
The primary objective was to assess the efficacy of intravenous cyclophosphamide in a proportion of children aged 1–18 years with CNI-resistant SRNS with a complete response (CR) or partial response (PR) at 6 months from commencement of pulse therapy. The secondary objectives were to assess the proportion and profile of infections and adverse effects.
Results
Of 90 children with idiopathic SRNS presenting between January 2013 and December 2022, 29 (32.2%) had CNI resistance and were enrolled. They were administered monthly intravenous cyclophosphamide pulses (6 pulses). Median (IQR) duration of follow-up was 48 (29.5, 63.5) months. At the end of 6 months of cyclophosphamide therapy, 13 (44.8%) attained CR and 4 (13.8%) attained PR, with an overall cyclophosphamide success rate of 58.6%. The efficacy of intravenous cyclophosphamide was higher in secondary (9/10; 90%) versus primary CNI resistance (8/19; 42.1%) (
p
= 0.029). Three children (3/29; 10.3%) developed systemic infections within 12 months of initiation of cyclophosphamide therapy, similar to the rate of systemic infections among children receiving CNI for SRNS management (6/41; 14.6%) (
p
= 0.85).
Conclusions
It is prudent to try intravenous cyclophosphamide in CNI-resistant SRNS in LMIC, given the reasonable cost and good efficacy rates (58.6%).
Graphical Abstract
A higher resolution version of the Graphical abstract is available as
Supplementary information
Summary
The SCOUT study is a multicenter, placebo-controlled, double-blind randomized controlled trial conducted to evaluate if a shorter 5-day course of antibiotics is non-inferior to a standard ...10-day course of antibiotics in children with urinary tract infection (UTI) 1. The eligible population included children aged 2 months to 10 years who were being treated for UTI with one of the five chosen antibiotics (amoxicillin-clavulanate, cefixime, cefdinir, cephalexin, or trimethoprim-sulfamethoxazole) and have become afebrile and free of symptoms of UTI after 5 days of therapy. At this time point, the eligible children were randomized to either the short-course arm, in which antibiotics were replaced by a matching placebo or the standard-course arm, in which antibiotics were continued. The study drugs (placebo or antibiotics) were continued to complete 10 days of therapy. The study’s primary outcome was the recurrence of symptomatic UTI between two hospital visits - first on day 6 i.e., at the time of randomization, and second between days 11 and 14. A definition with high specificity was used to identify the primary outcome and included three criteria: symptoms, pyuria, and positive urine culture. Secondary outcomes included the individual components of the primary outcome, and UTI between days 11–14 and days 38–44. The study also reported the adverse effects of the drugs and the incidence of gastrointestinal colonization with resistant organisms. The sample size was calculated for investigating the non-inferiority of the shorter antibiotic course. The study was powered to detect a non-inferiority margin of 5%. This meant that if the baseline incidence of treatment failure with the use of a standard course of antibiotics was 5%, investigators were willing to accept a treatment failure rate of 10% in the shorter antibiotic course to consider it as a ‘clinically’ non-inferior therapy. The primary analysis was conducted following the intention-to-treat (ITT) principle. The primary outcome was observed in 14 (4.2%) children in the short-course group and 2 (0.6%) children in the standard-course group. The upper margin of the confidence interval of the risk difference was 5.5%. As this was more than the preset non-inferiority margin of 5%, the non-inferiority of the short-course therapy could not be proven. Children randomized to the short-course therapy were also more likely to have asymptomatic bacteriuria and a positive urine culture. The two study groups had similar rates of adverse events and antimicrobial resistance of stool flora. The authors concluded that although the non-inferiority could not be proven, given the low incidence of failure (i.e., recurrence of symptomatic UTI) with the short-course therapy, the latter can be a reasonable option in children with UTI who show improvement after 5 days of antibiotics.
Acute kidney injury (AKI) is common in critically ill patients, affecting almost one in four critically ill children and one in three neonates. Higher stages of AKI portend worse outcomes. ...Identifying AKI timely and instituting appropriate measures to prevent and manage severe AKI is important, since it is independently associated with mortality. Methods to predict severe AKI should be applied to all critically ill patients. Assessment of volume status to prevent the development of fluid overload is useful to prevent adverse outcomes. Patients with metabolic or clinical complications of AKI need prompt kidney replacement therapy (KRT). Various modes of KRT are available, and the choice of modality depends most on the technical competence of the center, patient size, and hemodynamic stability. Given the significant risk of chronic kidney disease, patients with AKI require long-term follow-up. It is important to focus on improving awareness about AKI, incorporate AKI prevention as a quality initiative, and improve detection, prevention, and management of AKI with the aim of reducing acute and long-term morbidity and mortality.
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