Safety and infectious outcomes in pediatric kidney transplant recipients after COVID-19 vaccination: A pediatric nephrology research consortium study.

BACKGROUND: Adult kidney transplant recipients (KTRs) fully vaccinated against COVID-19 have substantial morbidity and mortality related to SARS-CoV-2 infection compared with the general population. However, little is known regarding the safety and efficacy of the COVID-19 vaccination series in pediatric KTRs. METHODS: A multicenter, retrospective observational study was performed across nine pediatric transplantation centers. Eligible KTRs fully vaccinated against COVID-19 were enrolled and data were collected pertaining to SARS-CoV-2 infection incidence and severity, graft outcomes and post-vaccination safety profile, as well as overall patient survival. RESULTS: A total of 247 patients were included in this investigation with a median age at transplantation of 11 years (IQR 5-15). SARS-CoV-2 infection was observed in 30/110 (27.27%) of fully vaccinated patients, tested post-transplant, within the defined follow-up period. Of these patients, 6/30 (18.18%) required hospitalization and 3/30 (12.12%) required reduction in immunosuppression, with no reported deaths. De novo donor-specific antibodies (DSAs) were found in 8/86 (9.30%) of DSA-tested patients with two experiencing rejection and subsequent graft loss. The overall incidence of rejection and graft loss among the total cohort was 11/247 (4.45%) and 6/247 (3.64%), respectively. A 100% patient survival was observed. CONCLUSIONS: Observationally, infectious outcomes of SARS-CoV-2 in fully vaccinated pediatric KTRs are excellent, with a low incidence of infection requiring hospitalization and no associated deaths. Though de novo DSAs were observed, there was minimal graft rejection and graft loss reported in the total cohort.

Unique presentation of late-onset Pneumocystis pneumonia in a pediatric kidney transplant recipient.

BACKGROUND: Restrictive lung disease leading to abnormal lung function in kidney transplant recipients is commonly associated with noninfectious complications or medications used for post-transplant immunosuppression. Herein, we report an interesting case of pediatric kidney transplant recipient with weight loss and abnormal spirometry who was diagnosed to have late-onset Pneumocystis pneumonia. CASE REPORT: A 17-year-old male patient with a history of allergic rhinitis, mild persistent asthma, and deceased donor kidney transplant, performed 18 months prior, presented for routine evaluation of his asthma to the pulmonology clinic. He was clinically asymptomatic except for a weight loss of 8 kg over 6-month period prior to presentation. Patient's spirometry was suggestive of a restrictive pattern and further investigation using a high-resolution computed tomography (HRCT) of the chest showed bilateral diffuse ground-glass reticulonodular opacities with subpleural sparing suggestive of interstitial pneumonitis. A bronchoscopy with bronchoalveolar lavage revealed organisms consistent with Pneumocystis jirovecii on gomori-methenamine-silver (GMS) staining. Beta-d-glucan testing in serum revealed a level of >500 pg/mL (normal 0-59 pg/mL) further supportive of Pneumocystis jirovecii infection. Patient was treated with a 6-week course of trimethoprim-sulfamethoxazole. His weight loss and beta-d-glucan levels improved over a course of 6 months, and he continues to be on trimethoprim-sulfamethoxazole prophylaxis. CONCLUSION: Late-onset Pneumocystis jirovecii infection in kidney transplant recipients can have an atypical presentation. Treating physicians should consider PJP in the differential diagnosis of unexplained weight loss in pediatric kidney transplant recipients, especially those receiving a large cumulative burden of immunosuppression.

Nocturnal home hemodialysis in children: Advantages, implementation, and barriers.

Chronic kidney disease and end-stage renal disease (ESRD) in children are major health concerns worldwide with increasing incidence and prevalence. Renal replacement therapies and kidney transplants have remarkably improved the management of patients with ESRD in both adult and pediatric populations. Kidney transplant has the best patient outcomes, but many a time it has a considerable waiting period. In the meantime, the majority of patients with pediatric ESRD are dependent on dialysis. The conventionally utilized hemodialysis regimen is the three times weekly, in-center hemodialysis. Many studies have demonstrated the unfavorable long-term morbidity associated with the conventional regimen. Intensified dialysis programs, which include extended nocturnal hemodialysis or short daily hemodialysis, are being increasingly advocated over the past two decades. In addition to having much better clinical outcomes as compared with the conventional regimen, the flexibility to provide dialysis at home serves as a great incentive. PubMed/Medline, Embase and Cochrane databases for literature on nocturnal home hemodialysis in children with ESRD were extensively searched. Contrary to the noticeable literature available on adult home hemodialysis, a small number of studies exist in the pediatric population. In this review, the benefits, implementation and associated barriers of nocturnal home hemodialysis in children were addressed.

Renal replacement therapy in the management of intoxications in children: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) workgroup.

BACKGROUND: Intentional or unintentional ingestions among children and adolescents are common. There are a number of ingestions amenable to renal replacement therapy (RRT). METHODS: We systematically searched PubMed/Medline, Embase, and Cochrane databases for literature regarding drugs/intoxicants and treatment with RRT in pediatric populations. Two experts from the PCRRT (Pediatric Continuous Renal Replacement Therapy) workgroup assessed titles, abstracts, and full-text articles for extraction of data. The data from the literature search was shared with the PCRRT workgroup and two expert toxicologists, and expert panel recommendations were developed. RESULTS AND CONCLUSIONS: We have presented the recommendations concerning the use of RRTs for treatment of intoxications with toxic alcohols, lithium, vancomycin, theophylline, barbiturates, metformin, carbamazepine, methotrexate, phenytoin, acetaminophen, salicylates, valproic acid, and aminoglycosides.

Electrophoretic characterization of protein interactions suggesting limited feasibility of accelerated shelf-life testing of ultra-high temperature milk.

Accelerated shelf-life testing is applied to a variety of products to estimate keeping quality over a short period of time. The industry has not been successful in applying this approach to ultra-high temperature (UHT) milk because of chemical and physical changes in the milk proteins that take place during processing and storage. We investigated these protein changes, applying accelerated shelf-life principles to UHT milk samples with different fat levels and using native- and sodium dodecyl sulfate-PAGE. Samples of UHT skim and whole milk were stored at 20, 30, 40, and 50°C for 28d. Irrespective of fat content, UHT treatment had a similar effect on the electrophoretic patterns of milk proteins. At the start of testing, proteins were bonded mainly through disulfide and noncovalent interactions. However, storage at and above 30°C enhanced protein aggregation via covalent interactions. The extent of aggregation appeared to be influenced by fat content; whole milk contained more fat than skim milk, implying aggregation via melted or oxidized fat, or both. Based on reduction in loss in absolute quantity of individual proteins, covalent crosslinking in whole milk was facilitated mainly by products of lipid oxidation and increased access to caseins for crosslinking reactions. Maillard and dehydroalanine products were the main contributors involved in protein changes in skim milk. Protein crosslinking appeared to follow a different pathway at higher temperatures (≥40°C) than at lower temperatures, making it very difficult to extrapolate these changes to protein interactions at lower temperatures.

Detection of Adulterants and Contaminants in Liquid Foods-A Review.

Milk and fruit juices have paramount importance in human diet. Increasing demand of these liquid foods has made them vulnerable to economic adulteration during processing and in supply chain. Adulterants are difficult to detect by consumers and thus necessitating the requirement of rapid, accurate and sensitive detection. The potential adulterants in milk and fruit juices and their limits set by different regulatory bodies have been briefly described in this review. Potential advantages and limitations of various techniques such as physicochemical methods, chromatography, immunoassays, molecular, electrical, spectroscopy with chemometrics, electronic nose, and biosensors have been described. Spectroscopy in combination with chemometrics has shown potential for rapid, precise, and sensitive detection of potential adulterants in these liquid foods.

Detection of poultry meat specific bacteria using FTIR spectroscopy and chemometrics.

FTIR spectra of poultry meat specific bacteria viz. Salmonella enteritidis, Pseudomonas ludensis, Listeria monocytogenes and Escherichia coli were collected and investigated for identification of spectral windows capable of bacterial classification and quantification. Two separate datasets obtained at different times were used in the study to check reproducibility of results. Multivariate data analysis techniques viz. principal component analysis (PCA), partial least-squares discriminant analysis (PLSDA) and soft independent modelling of class analogy (SIMCA) were used in the analysis. Using full cross-validation and separate calibration and prediction datasets, the highest correct classification results for SIMCA and PLSDA were achieved in spectral window (1800-1200 cm-1) for both datasets. The window was also tested then for quantification of different bacteria and it had been observed that PLS models had better R values for classification (R = 0.984) than predicting various concentration levels (R = 0.939) of all four poultry specific bacteria inoculated in distilled water. The identified spectral window 1800-1200 cm-1 also demonstrated potential for 100% correct classification of chicken salami samples contaminated with S. enteritidis and P. ludensis from control using SIMCA. However, this wavenumber range yielded few misclassifications using PLS-DA approach. Thus FTIR spectroscopy in combination with chemometrics is a powerful technique that can be developed further to differentiate bacteria directly on poultry meat surface.

A less energy intensive process for dehydrating onion.

Onion powder has an extensive demand and wide application worldwide as flavour additive in convenience foods and medicinal products. Conventionally onion powder is prepared by hot air drying of onion slices followed by grinding. Convective air drying when used alone demands longer drying time and thus has a high expense of energy. As bulk of onion is water (82-87 %), removal of moisture prior to drying can reduce moisture loading on dryer and hence the energy consumption. Keeping this in view, onions were partially dewatered using centrifugal force before convective drying. The effect of partial mechanical dewatering and drying air temperature was studied on drying time, specific energy consumption and onion powder quality (colour and flavour). The combination process was also optimized to achieve increased drying rate and product quality comparable to products obtained using convective drying alone. Onions subjected to 60 % partial mechanical dewatering and hot air drying at 70 °C exhibited significantly (p ≤ 0.5) shortened drying time, decreased energy consumption and maintained colour and flavour of the dried product.

Vasculitis and Kidney Disease.

Pediatric vasculitis is a complex group of disorders that commonly presents with multisystem involvement. Renal vasculitis can be isolated to the kidneys or can occur as part of a broader multiorgan vasculitis. Depending on severity, renal vasculitis may present as acute glomerulonephritis (AGN) often associated with hypertension and sometimes with a rapidly deteriorating clinical course. Prompt diagnosis and initiation of therapy are key to preserving kidney function and preventing long-term morbidity and mortality. This review focuses on the clinical presentation, diagnosis, and treatment objectives for common forms of renal vasculitis seen in pediatric patients.

Duration of initial prednisolone therapy for first episode of childhood nephrotic syndrome based on time to response.

Background: The duration of initial corticosteroid therapy in newly diagnosed Idiopathic nephrotic syndrome (INS) is about 3 months. Our study was designed to test the feasibility of a shorter duration of corticosteroid therapy in newly diagnosed INS who show a quicker response. Methods: Patients who responded within 10 days (Group A) received 8 weeks of corticosteroid therapy as compared to 12-14 weeks of standard therapy in those who responded between >10 days to 28 days (Group B), and follow up for 52 weeks. The primary endpoint is time to first relapse after treatment completion. (NCT03878914, March 18, 2019). Results: A total of 33 children with INS were enrolled and the follow-up data were analyzed. The clinical and laboratory characteristics of patients in both groups were similar. No significant difference was found in time to first relapse [65(14.5, 159) days for Group A vs. 28(17, 61.5) days for Group B, P = 0.371], the incidence of frequently relapsing nephrotic syndrome [6/18 (33.3%) vs. 5/10(50%), P = 0.644] or requirement for alternative immunosuppressant [4/18 (22.2%) vs. 1/10 (10%), P = 0.769]. Group A received similar corticosteroid dose compare with Group B (3511 ± 2421 mg/m2 vs. 4117 ± 2556 mg/m2, P = 0.524). Frequency and severity of corticosteroid-related complications was similar in both groups. Conclusions: The time to first relapse and the number of relapses per patient were comparable between the two groups. However, more patients in Group A relapsed and the mean total dose of prednisolone for the study period was very similar between the two groups.

Acute Kidney Injury in Pediatric Acute SARS-CoV-2 Infection and Multisystem Inflammatory Syndrome in Children (MIS-C): Is There a Difference?

Objective: To evaluate the prevalence and factors associated with the risk of acute kidney injury (AKI) in pediatric patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and multisystem inflammatory syndrome in children (MIS-C). Study Design: We performed a retrospective chart review of 113 patients with SARS-CoV-2 infection with or without MIS-C admitted at Children's Hospital of Michigan (CHM) from March to August 2020. Patient demographic details, laboratory data, imaging studies, echocardiography reports, and treatment data were collected. Results: Of the 92 patients included in the final analysis, 22 (24%) developed AKI with 8/22 (36%) developing stage 3 AKI. The prevalence of AKI was much higher in patients with MIS-C 15/28 (54%) vs. those with acute SARS-CoV-2 infection 7/64 (11%), (p < 0.001). Overall, when compared to patients without AKI, patients with AKI were older in age (11 vs. 6.5 years, p = 0.007), African American (86 vs. 58%, p = 0.028), had MIS-C diagnosis (68 vs. 19%, p < 0.001), required ICU admission (91 vs. 20%, p < 0.001), had cardiac dysfunction (63 vs. 16%, p < 0.001), required inotropic support (59 vs. 6%, p < 0.001) and had a greater elevation in inflammatory markers. In a multivariate analysis, requirement of inotropes [Odds Ratio (OR)-22.8, p < 0.001], African American race (OR-8.8, p = 0.023) and MIS-C diagnosis (OR-5.3, p = 0.013) were the most significant predictors for AKI. All patients had recovery of kidney function, and none required kidney replacement therapy. Conclusion: Children with acute SARS-CoV-2 infection and MIS-C are at risk for AKI, with the risk being significantly greater with MIS-C. The pathogenesis of AKI in acute SARS-CoV-2 infection appears to be a combination of both renal hypo-perfusion and direct renal parenchymal damage whereas in MIS-C, the renal injury appears to be predominantly pre-renal from cardiac dysfunction and capillary leak from a hyperinflammatory state. These factors should be considered by clinicians caring for these children with a special focus on renal protective strategies to aid in recovery and prevent additional injury to this high-risk subgroup.

Consensus guidelines for management of hyperammonaemia in paediatric patients receiving continuous kidney replacement therapy.

Hyperammonaemia in children can lead to grave consequences in the form of cerebral oedema, severe neurological impairment and even death. In infants and children, common causes of hyperammonaemia include urea cycle disorders or organic acidaemias. Few studies have assessed the role of extracorporeal therapies in the management of hyperammonaemia in neonates and children. Moreover, consensus guidelines are lacking for the use of non-kidney replacement therapy (NKRT) and kidney replacement therapies (KRTs, including peritoneal dialysis, continuous KRT, haemodialysis and hybrid therapy) to manage hyperammonaemia in neonates and children. Prompt treatment with KRT and/or NKRT, the choice of which depends on the ammonia concentrations and presenting symptoms of the patient, is crucial. This expert Consensus Statement presents recommendations for the management of hyperammonaemia requiring KRT in paediatric populations. Additional studies are required to strengthen these recommendations.

Optimal management of atypical hemolytic uremic disease: challenges and solutions.

Atypical hemolytic uremic syndrome (aHUS) is a chronic life threatening condition that arises from genetic abnormalities resulting in uncontrolled complement amplifying activity. The introduction of eculizumab, the humanized monoclonal antibody, has brought about a paradigm shift in the management of aHUS. However, there are many knowledge gaps, diagnostic issues, access and cost issues, and patient or physician challenges associated with the use of this agent. Limited data on the natural history of aHUS along with the underlying genetic mutations make it difficult to predict the relapses and thereby raising concerns about the appropriate duration and monitoring of treatment. In this review, we discuss the safety and efficacy of eculizumab in patients with aHUS and its associated challenges.

Structural changes of native milk proteins subjected to controlled shearing and heating.

Processing of milk results in structural modifications of proteins creating a foundation for various interactions. The present study aimed at identifying the effects of simulated processing conditions, the combination of temperature and shear, on native proteins in raw skim milk. The temperatures chosen (72 and 140 °C) were combined with selected shear rates (0, 500, or 1000 s-1) during processing. Impact of shear appeared temperature dependent, but it induced either reversible or irreversible changes in the secondary structure of milk proteins at all temperatures. Increase in shear may result in reversible structural modifications at 20 °C, while it could contribute to fragmentation of hydrophobically-linked protein aggregates at 500 s-1 and also reformation at 1000 s-1 during heating at 72 °C. The shearing at 140 °C appeared to enhance the formation of protein aggregates primarily by hydrophobic interactions, as well possibly thiol/disulphide interactions to a lesser extent.

Detection and quantification of soymilk in cow-buffalo milk using Attenuated Total Reflectance Fourier Transform Infrared spectroscopy (ATR-FTIR).

Milk consumption is steadily increasing, especially in India and China, due to rising income. To bridge the gap between supply and demand, unscrupulous milk vendors add milk-like products from vegetable sources (soymilk) to milk without declaration. A rapid detection technique is required to enforce the safety norms of food regulatory authorities. Fourier Transform Infrared (FTIR) spectroscopy has demonstrated potential as a rapid quality monitoring method and was therefore explored for detection of soymilk in milk. In the present work, spectra of milk, soymilk (SM), and milk adulterated with known quantity of SM were acquired in the wave number range of 4000-500cm(-1) using Attenuated Total Reflectance (ATR)-FTIR. The acquired spectra revealed differences amongst milk, SM and adulterated milk (AM) samples in the wave number range of 1680-1058cm(-1). This region encompasses the absorption frequency of amide-I, amide-II, amide-III, beta-sheet protein, α-tocopherol and Soybean Kunitz Trypsin Inhibitor. Principal component analysis (PCA) showed clustering of samples based on SM concentration at 5% level of significance and thus SM could be detected in milk using ATR-FTIR. The SM was best predicted in the range of 1472-1241cm(-1) using multiple linear regression with coefficient of determination (R(2)) of 0.99 and 0.92 for calibration and validation, respectively.

Interpersonal violence against wives by substance dependent men.

BACKGROUND: Indian research on intimate partner violence (IPV) with substance use covers only alcohol, and very few studies have reported on IPV with other substances. The study aims to assess IPV against wives by substance dependent men. METHODS: The study sample was recruited by convenient sampling from men (and their wives) seeking treatment at a de-addiction centre in North India between October, 2011 and February, 2012. The consenting wives self-administered the violence questionnaire. RESULTS: 267 wives were recruited into the study. The prevalence rates for IPV were: 55% for the whole sample, 63.19% for alcohol dependence and 42.33% for opioid dependence. IPV was associated with higher age of husband, lower education or unemployment of either spouse, lower income of family and nuclear family structure. CONCLUSIONS: Present research confirms that IPV against wives is highly prevalent among substance dependent men, more with alcohol dependence as compared to opioid dependence. Addressing IPV should be an integral part of substance abuse management.

Long acting contraception provision by rural primary care physicians.

OBJECTIVES: Unplanned pregnancy is a public health problem in the United States, including in rural areas. Primary care physicians are the main providers of health care to women in rural areas and are uniquely positioned to help reduce unplanned pregnancy in rural women. This study documents provision of contraception by rural primary care physicians, focusing on the most effective, long acting methods, intrauterine devices (IUDs) and contraceptive implants. METHODS: We surveyed all primary care physicians practicing in rural areas of Illinois and Wisconsin. Bivariate analysis was performed using chi squared and Fisher's exact test, and multivariable analysis was performed with logistic regression to determine factors associated with provision. RESULTS: The response rate was 862 out of 2312 physicians (37%). Nine percent of respondents place implants and 35% place IUDs. Eighty-seven percent of physicians had not had training in implant placement, and 41% had not had training in IUD placement. In multivariable analysis, factors associated with placement of long acting contraception include provision of maternity care, and female gender of the physician. The most common reasons for not providing the methods were lack of training and perceived low demand from patients. CONCLUSIONS: Many rural primary care providers do not place long acting contraceptive devices due to lack of training. Female physicians and those providing maternity care are the most likely to place these devices. Increased training for primary care physicians both during and after residency would help increase access to these options for women in rural areas.

Patient outcomes after total pancreatectomy: a single centre contemporary experience.

INTRODUCTION: Total pancreatectomy (TP) is associated with significant metabolic abnormalities leading to considerable morbidity. With the availability of modern pancreatic enzyme formulations and improvements in control of diabetes mellitus, the metabolic drawbacks of TP have diminished. As indications for TP have expanded, we examine our results in patients undergoing TP. MATERIALS AND METHODS: Retrospective study of 47 patients undergoing TP from January 2002 to January 2008 was performed. Patient data and clinical outcomes were collected and entered into a database. Disease-free survival and overall survival were estimated using the Kaplan-Meier method. RESULTS: Fifteen males and 32 females with a median age of 70 years underwent TP for non-invasive intraductal papillary mucinous neoplasms (IPMN) (21), pancreatic adenocarcinoma (20), other neoplasm (3), chronic pancreatitis (2) and trauma (1). Median hospital stay and intensive care stay were 11 days and 1 day, respectively. Thirty-day major morbidity and mortality was 19% and 2%, respectively. With a median follow-up length of 23 months, 33 patients were alive at last follow-up. Estimated overall survival at 1, 2 and 3 years for the entire cohort was 80%, 72% and 65%, and for those with pancreatic adenocarcinoma was 63%, 43% and 34%, respectively. Median weight loss at 3, 6 and 12 months after surgery was 6.8 kg, 8.5 kg and 8.8 kg, respectively. Median HbA1c values at 6, 12 and 24 months after surgery were 7.3, 7.5 and 7.7, respectively. Over one-half of the patients required re-hospitalization within 12 months post-operatively. CONCLUSION: TP results in significant metabolic derangements and exocrine insufficiency, diabetic control and weight maintenance remain a challenge and readmission rates are high. Survival in those with malignant disease remains poor. However, the mortality appears to be decreasing and the morbidities associated with TP appear acceptable compared with the benefits of resection in selected patients.