Management of Pediatric Kidney Transplant Patients During the COVID-19 Pandemic: Guidance From the Canadian Society of Transplantation Pediatric Group.

PURPOSE OF THE PROGRAM: To provide guidance on the management of pediatric kidney transplant patients during the COVID-19 pandemic. SOURCES OF INFORMATION: Program-specific documents, preexisting, and related to COVID-19; documents from provincial, national, and international kidney transplant societies/agencies and organ procurement agencies; national and international webinars, including webinars that we hosted for input and feedback; with additional information from formal and informal review of published academic literature. METHODS: Challenges in the care of pediatric kidney transplant patients during the COVID-19 pandemic were highlighted within the Canadian Society of Transplantation (CST) Pediatric Group. It identified pediatric kidney transplant nephrologists (including a pediatric nephrologist ethicist) across the country and formed a workgroup. The initial guidance document was drafted and members of the workgroup reviewed and discussed all suggestions in detail via e-mail and virtual meetings. Disagreements were resolved by consensus. The document was reviewed by the CST Kidney Transplant Working Group, by the Canadian Society of Nephrology (CSN) COVID-19 Rapid Response Team (RRT), and an infectious disease expert. The suggestions were presented at an interactive webinar sponsored by CSN in collaboration with the CST and Canadian Association of Pediatric Nephrologists (CAPN), and attended by pediatric kidney health care professionals for further peer input. Final revisions were made based on feedback received. CJKHD editors reviewed the parallel process peer review and edited the manuscript for clarity. KEY FINDINGS: We identified 8 key areas of pediatric kidney transplant care that may be affected by the COVID-19 pandemic: (1) transplant activity, (2) outpatient clinic activity, (3) monitoring, (4) multidisciplinary care, (5) medications (immunosuppression and others), (6) patient/family education/support, (7) school and employment, and (8) management of pediatric kidney transplant patients who are COVID-19 positive. We make specific suggestions for each of these areas. LIMITATIONS: A full systematic review of available literature was not undertaken for the sake of expediency in development of this guideline. There is a paucity of literature to support evidence-based recommendations at this time. Instead, these guidelines were formulated based on expert opinion derived from available knowledge/experience and are subject to the biases associated with this level of evidence. The parallel review process that was created to expedite the publication of this work may not be as robust as standard arms' length peer review processes. IMPLICATIONS: These recommendations are meant to serve as a guide to pediatric kidney transplant directors, clinicians, and administrators for providing the best patient care in the context of limited resources while protecting patients and health care providers wherever possible by limiting exposure to COVID-19. We recognize that recommendations may not be applicable to all provincial/local health authority practices and that they may not be delivered to all patients given the time and resource constraints affecting the individual provincial/local health jurisdiction.

Quality improvement in pediatric nephrology-a practical guide.

Improving quality of care delivery is an important focus for all practicing physicians. Frontline clinicians are in a great position to identify clinical problems and find innovative solutions. The current review describes the method used for quality improvement based on the Model for Improvement, a structural framework to guide improvement work. At its basis are three fundamental questions: What are we trying to accomplish? How will I know that a change will lead to improvement? And what changes could we make that will result in improvement? This preparation phase aims to identify and understand the problem, choose an intervention, and determine reliable measures to gauge improvement. The intervention is then tested using PLAN-DO-STUDY-ACT (PDSA) cycles, an iterative approach to systematically improve processes and outcomes. PLAN focuses on defining the goal of the cycle and describing in details what will be done. DO concentrates on the concrete application of the plan. STUDY focuses on data analyses as ACT identifies lessons learned from the cycle and orientate the goals of the following PDSA cycle. Learning from each cycle, developing an interdisciplinary team and repeated interventions are core principles involved in implementing a sustainable quality improvement program. The Model for Improvement will be illustrated by a common quality problem in pediatric nephrology.

Severe Acute Kidney Injury and Multiple Organ Failure in a 17-Day-Old Newborn: When Pathology Makes the Difference.

RATIONALE: Acute tubulointerstitial nephritis (ATIN) in children is most commonly due to allergic drug reactions. In neonates, diagnosis of ATIN is clinically suspected and a kidney biopsy is not routinely performed. PRESENTING CONCERN: A 17-day-old newborn presented with vomiting and dehydration, along with anuric acute kidney injury, severe electrolyte disturbances, hypocomplementemia, and thrombocytopenia. Abdominal ultrasound revealed bilateral nephromegaly and hepatosplenomegaly. The patient was promptly started on intravenous (IV) fluid and broad-spectrum antibiotics. His electrolyte disturbances were corrected as per standard guidelines. The rapid progressive clinical deterioration despite maximal treatment and the unclear etiology influenced the decision to proceed to a kidney biopsy. Histopathological findings revealed diffuse interstitial edema with a massive polymorphic cellular infiltrate and destruction of tubular structures, consistent with severe ATIN. Elements of thrombotic microangiopathy (TMA) were observed. DIAGNOSIS: The clinical presentation combined with imaging and histopathological findings was suggestive of ATIN caused by a severe acute bacterial pyelonephritis. INTERVENTION: Methylprednisolone pulses followed by oral prednisolone were administered. Antibiotics were continued for 10 days. The patient was kept on invasive mechanical ventilation and on peritoneal dialysis for 12 days. OUTCOME: His condition stabilized following steroid pulses. His renal function progressively improved, and renal replacement therapy was weaned off. His renal ultrasound normalized. He has maintained a normal blood pressure, urinalysis, and renal function over the past 5 years. NOVEL FINDING: This case reports a severe presentation of acute bacterial pyelonephritis in a neonate. It highlighted the involvement of complement activation in severe infectious process. Histopathological findings of ATIN and TMA played a crucial role in understanding the physiopathology and severity of the disease.

JUSTIFICATION: La néphrite tubulo-interstitielle aiguë (NTIA) chez l'enfant est le plus souvent attribuée à une réaction allergique aux médicaments. Chez les nouveau-nés, le diagnostic de la NTIA est cliniquement suspecté et une biopsie des reins n'est pas pratiquée de façon systématique. PRÉSENTATION DU CAS: Un nouveau-né âgé de dix-sept jours pris de vomissements et déshydraté qui présentait une insuffisance rénale aiguë anurique, un grave déséquilibre électrolytique, une hypocomplémentémie et une thrombocytopénie. L'échographie abdominale a révélé une hypertrophie rénale bilatérale ainsi qu'une hépatosplénomégalie. Le patient a rapidement été traité avec des antibiotiques à large spectre par voie intraveineuse (IV), et les déséquilibres électrolytiques ont été corrigés conformément aux lignes directrices normalisées. La détérioration clinique rapide et progressive du patient malgré un traitement maximal et une étiologie incertaine a orienté la décision de procéder à une biopsie rénale. Les résultats histopathologiques ont révélé un œdème interstitiel diffus avec infiltrat cellulaire polymorphe et une destruction des structures tubulaires; des observations cohérentes avec une NTIA grave. Des éléments d'une microangiopathie thrombotique (MAT) avaient également été observés. DIAGNOSTIC: Le tableau clinique combiné aux résultats histopathologiques et d'imagerie suggérait une NTIA causée par une pyélonéphrite bactérienne grave. INTERVENTION: Le traitement a consisté en des injections répétées de méthylprednisolone suivies par l'administration orale de prednisolone. Le traitement aux antibiotiques s'est poursuivi sur une période de dix jours. Le patient a également été maintenu sous ventilation mécanique effractive et sous dialyse péritonéale pendant douze jours. RÉSULTATS: L'état du patient s'est stabilisé à la suite des injections répétées de stéroïdes; sa fonction rénale s'est progressivement améliorée et la thérapie de remplacement rénal a pu être cessée. L'échographie rénale s'est normalisée. Le patient a maintenu une tension artérielle, des analyses d'urine et une fonction rénale normales au cours des cinq dernières années. CONSTATATIONS: Ce rapport présente un cas grave de pyélonéphrite bactérienne aiguë chez un nouveau-né et a mis en lumière le rôle de l'activation du complément dans un processus infectieux grave. Les observations histopathologiques de la NTIA et de la MAT ont joué un rôle essentiel dans la compréhension de la physiopathologie et de la gravité de la maladie.

Age-related and blood pressure-independent reduction in aortic stiffness after kidney transplantation.

OBJECTIVES: Aortic stiffness is a novel cardiovascular risk factor in patients with chronic kidney disease (CKD). The purpose of the present study is to examine whether there is a blood pressure-independent improvement in aortic stiffness 3 months after successful kidney transplantation (KTx), and whether this improvement is age-dependent. METHOD: In this prospective, longitudinal observational study, we studied hemodynamic and biological parameters prior to and 3 months after a KTx in 52 stage 5 CKD patients. Aortic stiffness was measured by carotido-femoral pulse wave velocity (c-f PWV) and enhanced central wave reflection was evaluated by the heart rate-adjusted central augmentation index (AIx) by means of arterial tonometry. Endothelin-1, L-arginine, asymmetric dimethylarginine (biomarkers of endothelial dysfunction), pentosidine (advanced glycation end-products) and mineral metabolism parameters were also measured. RESULTS: After adjusting for the reduction in mean blood pressure, c-f PWV decreased significantly from 12.1 ± 3.3 to 11.6 ± 2.3 m/s (P < 0.05). In an analysis stratified by age, this improvement was only present in patients older than 50 years of age as compared with patients younger than 50 years of age (-5.5 ± 2.2 vs. 2.1 ± 1.9%, P < 0.05). AIx decreased from 22 ± 11 to 14 ± 13% (P < 0.01), but this reduction was not age-dependent. We also observed a similar degree of improvement in the biomarker levels of endothelial dysfunction and pentosidine in both groups. CONCLUSION: This study shows for the first time that there is an age-dependent improvement in aortic stiffness after KTx. These observations suggest that older patients may have an added cardiovascular risk reduction after a successful KTx.