Nephrology and Hypertension

Significant Accomplishments

Improving Survival for Children on Dialysis

Children with end stage kidney disease (ESKD) face enormous health hurdles, and a significantly shorter life expectancy. But a recent report shows that the outcome of dialysis treatment they require is dramatically improving. In a study published in the Journal of the American Medical Association, lead author Mark Mitsnefes, MD, MS, found that death rates among children and adolescents undergoing dialysis for ESKD in the United States have declined significantly over the past two decades. The study identified 23,401 children and adolescents in the United States who began ESKD treatment with dialysis between 1990 and 2010, and noted a significant decrease in mortality rates among the patients over that period. Children under age 5 who started dialysis in 1990-1994 had a mortality rate of 112.2 per 1,000 person-years. For those who began dialysis in 2005-2010, the rate fell to 83.4 per 1,000 person-years. Among those aged 5 and older, mortality rates declined from 44.6 per 1,000 person-years to 25.9. Significant decline also occurred in cardiovascular and infection-related mortality. Improved pre-dialysis care, advances in dialysis technology and greater experience of clinicians providing dialysis care may each have played a role in reducing the mortality rates.

Controlling Cholesterol in Pediatric Kidney Transplant Recipients

Cardiovascular disease is the leading cause of death for young adults who received a kidney transplant in childhood. High cholesterol is an important modifiable cardiovascular risk factor in these patients, yet research suggests that only about 50 percent of adolescents have even a single cholesterol test before they become adults, and fewer than 40 percent of adult transplant patients have controlled cholesterol. In a study published in Pediatrics, David Hooper, MD, MS, and Jens Goebel, MD, demonstrated that using health information technology and reliable systems of care can dramatically improve outcomes. These more reliable systems led to 100 percent of eligible patients with high cholesterol being appropriately treated and 97 percent of kidney transplant patients with LDL cholesterol controlled below the recommended target of 130 mg/dl. Important components of their system redesign include: standardized protocols for personalized cholesterol monitoring based on risk; use of health information technology for decision support, population management and pre-visit planning; and well-defined roles and responsibilities among team members. This study demonstrates powerful techniques that can be used to improve important outcomes for children and adults with many chronic illnesses.

Reducing Harm From Nephrotoxic Medication

Nephrotoxic medication exposure is one of the most common causes of acute kidney injury (AKI) in hospitalized children. In a recent study published in Pediatrics, Stuart Goldstein, MD, Director of the Center for Acute Care Nephrology, demonstrated for the first time that the electronic health record can be programmed to reliably identify patients at-risk for nephrotoxic medication associated AKI. Through systematic kidney function assessment using a daily serum creatinine in at-risk patients, the research team found that 25 percent of all at-risk patients developed AKI. In addition, the team observed a 42 percent reduction in nephrotoxic medication associated AKI days, which translates to 900 AKI free days over a one year period.