COVID-19 is the illness caused by infection with the novel coronavirus SARS-CoV-2. Although myalgia is common in adults, it has not been noted as a common symptom in children. There have been a few ...reported cases of COVID-19-associated rhabdomyolysis in adults. This case report describes a 16-year-old boy who presented with fever, myalgias, mild shortness of breath with exertion, and dark-colored urine. COVID-19 PCR was positive. His initial creatinine kinase (CK) level was 427,656 U/L. Serum creatinine was normal for age. He was treated with isotonic intravenous fluids containing sodium bicarbonate to maintain urine output of 100–200 mL/h and urine pH > 7.0. His serum creatinine remained normal throughout the hospital stay and he was discharged on hospital day 12 with a CK of 6526 U/L. To our knowledge, no pediatric cases of COVID-19-associated rhabdomyolysis have been previously reported. Adult cases of rhabdomyolysis have been reported and a few reports have noted patients with elevated CK levels without rhabdomyolysis. Given this pediatric case of COVID-19-associated rhabdomyolysis, pediatric clinicians should be aware of this complication and manage fluids appropriately in order to prevent acute kidney injury.
Successful outcomes in pediatric kidney transplantation require the involvement of the transplant team as well as recipients and their caregivers. Enhancing patient and family understanding of the ...disease and of post-transplant care can result in improved adherence and outcomes. Educational strategies should aim to be broad, understandable, innovative, and inclusive while maintaining a tailored approach to individualized care. Teaching should not be viewed as a one-time event but rather as an ongoing conversation throughout the duration of care, emphasizing different aspects throughout the patient’s various developmental stages. The following review article discusses the content and methods of post-transplant education.
Background
The clinical course of SARS‐CoV‐2 in the pediatric kidney transplant population is not well described.
Methods
We performed a retrospective cohort study of a pediatric kidney transplant ...population at a New York transplant center. Baseline characteristics and clinical course of patients with SARS‐CoV‐2 positivity (Ab or PCR) were described, and comparison between COVID‐positive and COVID‐negative transplant patients was performed.
Results
Twenty‐two patients had COVID‐19 IgG testing performed, eight of whom also had PCR testing. 23% of our cohort had evidence of COVID‐19 infection. Four patients had positive IgG only, and one patient had a positive PCR. All five patients with a positive COVID test were female. Two patients had COVID‐19 symptoms, which were mild. Of the symptomatic patients, one had a positive PCR at time of symptoms, while the other had a negative PCR during symptoms but subsequently had positive IgG. As compared to patients with COVID‐19 negative results, those with COVID‐19 positivity were significantly more likely to have a known COVID‐19 exposure, and were also more likely to be female. There was no significant difference in time from transplant between the groups. Those in the COVID‐positive group had higher baseline antimetabolite dose and CNI troughs, although these did not reach statistical significance.
Conclusions
Pediatric kidney transplant recipients are at risk for development of COVID‐19 infection. While this population may be more at risk for SARS‐CoV‐2 infection due to their immunosuppressed status, their clinical course appears mild and similar to a healthy pediatric population.
Background
Obesity is a risk factor for poor transplant outcomes in the adult population. The effect of pre-transplant weight on pediatric kidney transplantation is conflicting in the existing ...literature.
Methods
Data was collected from the Organ Procurement and Transplantation Network (OPTN) database on recipients aged 2–21 years who received a kidney-only transplant from 1987 to 2017. Recipients were categorized into underweight, normal, overweight, and obese cohorts. Using adjusted regression models, the relationship between recipient weight and various graft outcomes (delayed graft function DGF, acute rejection, prolonged hospitalization, graft failure, mortality) was examined.
Results
18,261 transplant recipients (mean age 14.1 ± 5.5 years) were included, of which 8.7% were underweight, 14.8% were overweight, and 15% were obese. Obesity was associated with greater odds of DGF (OR 1.3 95% CI 1.13–1.49,
p
< 0.001), acute rejection (OR 1.23 95% CI 1.06–1.43,
p
< 0.01), and prolonged hospitalization (OR 1.35 95% CI 1.17–1.54,
p
< 0.001) as well as greater hazard of graft failure (HR 1.13 95% CI 1.05–1.22,
p
= 0.001) and mortality (HR 1.19 95% CI 1.05–1.35,
p
< 0.01). The overweight cohort had an increased risk of graft failure (HR 1.08 95% CI 1.001–1.16,
p
= 0.048) and increased odds of DGF (OR 1.2 95% CI 1.04–1.38,
p
= 0.01) and acute rejection (OR 1.18 95% CI 1.01–1.38,
p
= 0.04). When stratified by age group, the increased risk was realized among younger and older age groups for obese and overweight. Underweight had lower risk of 1-year graft failure (HR 0.82 95% CI 0.71–0.94,
p
< 0.01), overall graft failure in the 13–17-yr. age group (HR 0.84 95% CI 0.72–0.99,
p
= 0.03) and acute rejection in the 2–5-yr. age group (OR 0.24 95% CI 0.09–0.66,
p
< 0.01).
Conclusion
Pre-transplant weight status and age impact pediatric kidney transplant outcomes. Recipient underweight status seems to be protective against adverse outcomes while overweight and obesity may lead to poorer graft and patient outcomes.
Background
We report follow-up data from an ongoing prospective cohort study of COVID-19 in pediatric kidney transplantation through the Improving Renal Outcomes Collaborative (IROC).
Methods
...Patient-level data from the IROC registry were combined with testing, indication, and outcomes data collected to describe the epidemiology of COVID testing, treatment, and clinical outcomes; determine the incidence of a positive COVID-19 test; describe rates of COVID-19 testing; and assess for clinical predictors of a positive COVID-19 test.
Results
From September 2020 to February 2021, 21 centers that care for 2690 patients submitted data from 648 COVID-19 tests on 465 patients. Most patients required supportive care only and were treated as outpatients, 16% experienced inpatient care, and 5% experienced intensive care. Allograft complications were rare, with acute kidney injury most common (7%). There was 1 case of respiratory failure and 1 death attributed to COVID-19. Twelve centers that care for 1730 patients submitted complete testing data on 351 patients. The incidence of COVID-19 among patients at these centers was 4%, whereas the incidence among tested patients was 19%. Risk factors to predict a positive COVID-19 test included age > 12 years, symptoms consistent with COVID-19, and close contact with a confirmed case of COVID-19.
Conclusions
Despite the increase in testing and positive tests over this study period, the incidence of allograft loss or death related to COVID-19 remained extremely low, with allograft loss or death each occurring in < 1% of COVID-19-positive patients and in less than < 0.1% of all transplant patients within the IROC cohort.
Graphical abstract
A higher resolution version of the Graphical abstract is available as
Supplementary information
Introduction
To assess the prevalence of hyponatremia among pediatric patients with coronavirus disease 2019 (COVID-19) and Multisystem Inflammatory Syndrome in Children (MIS-C) and determine if ...pediatric hyponatremia was associated with an increased length of stay, higher rates of mechanical ventilation, and/or elevated inflammatory markers on admission as compared to eunatremic patients.
Methods
Electronic health records were retrospectively analyzed for 168 children less than 18 years old with COVID-19 or MIS-C who were admitted to pediatric units within the Northwell Health system. The primary exposure was hyponatremic status (serum sodium <135 mEq/L) and the primary outcomes were length of stay, mechanical ventilation usage and increased inflammatory markers.
Results
Of the 168 children in the study cohort, 95 (56%) were admitted for COVID-19 and 73 (43.5%) for MIS-C. Overall, 60 (35.7%) patients presented with hyponatremia on admission. Patients with hyponatremia had higher rates of intensive care unit admission when compared to eunatremic patients (32/60 53.3% vs. 39/108 36.1%,
p
= 0.030). In regression models, hyponatremia was not significantly associated with increased length of stay or mechanical ventilation rates. After adjustment for relevant confounders, hyponatremia remained associated with an increased square root CRP (β = 1.79: 95% CI: 0.22–3.36) and lower albumin levels (β = −0.22: 95% CI: −0.42–−0.01).
Conclusion
Hyponatremia is common in pediatric COVID-19 and MIS-C. Hyponatremia was associated with a lower albumin and higher square root CRP levels. This may suggest an association of inflammation with lower serum sodium levels.
Abstract
Background
Alport syndrome is a hereditary kidney disease characterized by hematuria and proteinuria. Although there have been reports of autosomal dominant
COL4A4
variants, this is likely ...an underdiagnosed condition. Improved access to affordable genetic testing has increased the diagnosis of Alport syndrome. As genetic testing becomes ubiquitous, it is imperative that clinical nephrologists understand the benefits and challenges associated with clinical genetic testing.
Case Presentation
We present a family of Mexican descent with a heterozygous
COL4A4
variant (c.5007delC, ClinVar accession numbers: SCV001580980.2, SCV001993731.1) not previously discussed in detail in the literature. The proband received a biopsy diagnosis suggestive of Fabry disease 18 years after she first developed hematuria and progressed to chronic kidney disease stage III. One year later, the proband was provisionally diagnosed with Alport syndrome after a variant of uncertain significance in the
COL4A4
gene was identified following targeted family variant testing of her daughter. Upon review of the medical histories of the proband’s children and niece, all but one had the same variant. Of the four with the variant, three display clinical symptoms of hematuria, and/or proteinuria. The youngest of the four, only months old, has yet to exhibit clinical symptoms. Despite these findings there was a considerable delay in synthesizing this data, as patients were tested in different commercial genetic testing laboratories. Subsequently, understanding this family’s inheritance pattern, family history, and clinical symptoms, as well as the location of the
COL4A4
variant resulted in the upgrade of the variant’s classification. Although the classification of this variant varied among different clinical genetic testing laboratories, the consensus was that this variant is likely pathogenic.
Conclusions
This
COL4A4
variant (c.5007delC) not yet discussed in detail in the literature is associated with Alport syndrome. The inheritance pattern is suggestive of autosomal dominant inheritance. This report highlights the intricacies of variant interpretation and classification, the siloed nature of commercial genetic testing laboratories, and the importance of a thorough family history for proper variant interpretation. Additionally, the cases demonstrate the varied clinical presentations of Alport syndrome and suggest the utility of early screening, diagnosis, monitoring, and treatment.
Existing literature has demonstrated the significant relationship between race and kidney transplant outcomes; however, there are conflicting and limited data on the influence of donor race or ...donor-recipient race-matching on pediatric kidney transplant outcomes.
Analysis included kidney-only transplant recipients between ages 2 and 17 from 2000 to 2017 enrolled in the Organ Procurement and Transplantation Network and their associated donors. Multivariable regression models were used to compare outcomes by donor race and donor-recipient race-matched status.
Of the total 7343 recipients, 4458 (60.7%) recipients received a kidney from a White donor, 1009 (13.7%) from a Black donor, 1594 (21.7%) from Hispanic donor, and 169 (4.1%) from an Asian donor; 4089 (55.7%) were race-matched. No donor races were significantly associated with transplant outcomes (all
> 0.05). Race-matched status was not associated with graft failure (hazard ratio, 1.03; 95% confidence interval CI = 0.89-1.2;
= 0.68), mortality (hazard ratio, 1.1; 95% CI, 0.79-1.53;
= 0.56), acute rejection at 1 y (odds ratio, 0.94; 95% CI, 0.77-1.15;
= 0.53), or delayed graft function (odds ratio, 1.02; 95% CI, 0.80-1.29;
= 0.91).
Neither donor race nor race-matched status is associated with better transplant outcomes. Further studies are necessary to confirm the impact of donor race and race-matching more fully on pediatric kidney transplant outcomes.
The ambulatory arterial stiffness index (AASI) and the symmetric ambulatory arterial stiffness index (s-AASI) have been shown to correlate to arterial stiffness in adults. This study assesses these ...indices with anthropometric and blood pressure (BP) measures in children. A total of 102 children at a pediatric hypertension clinic who had ambulatory blood pressure monitoring (ABPM) done from 2009 to 2013 were included (75% males, 7-22yo, 47% hypertensive, 24% prehypertensive, and 34% white-coat hypertensives). AASI is 1 minus the regression slope of diastolic BP values on systolic BP values from a 24-hour ambulatory blood pressure monitoring. s-AASI is the symmetric regression of AASI. Obese patients had a significantly higher AASI. s-AASI correlated with systolic BP variability. In multivariable regression, BP variability independently correlated with AASI and s-AASI. s-AASI is related to systolic dipping.AASI and s-AASI are highly dependent on BP variability in children. Further studies are necessary to assess their utility.
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