Pediatric Nephrology Developments Anticipated for 2021

Children are our future, and the year ahead in pediatric nephrology holds tremendous promise to advance healthcare for children with kidney diseases. The pediatric nephrology community has been hard at work championing the innovations and advocating for the change necessary to make a brighter future a reality for children with kidney diseases, their families, and those who care for them. With so many exciting advances across the spectrum of pediatric kidney care, here are a few of the areas to follow closely in 2021.

Neonatal nephrology—the nascent field is now full term

There is growing appreciation for the role of prenatal and neonatal kidney health in nephron endowment at birth and long-term risks for chronic kidney disease (CKD). Despite the technical limitations that make studying the mechanisms of neonatal kidney pathophysiology so challenging, advances continue, particularly in the area of neonatal acute kidney injury (AKI) (1).

Recent research has resulted in a better understanding of the prevalence of neonatal AKI, and strategies for AKI mitigation and nephrotoxicity reduction are emerging (2, 3). Now with the help of the Neonatal Kidney Collaborative, a coalition of neonatologists, nephrologists, and scientists dedicated to improving kidney outcomes in neonates, pediatric kidney professionals around the world are connecting and sharing best practices (4). Several children’s hospitals [including Riley Children’s in Indiana, Nationwide Children’s in Ohio, and Medical University of South Carolina (MUSC) Shawn Jenkins Children’s in South Carolina] have launched jointly run clinical services with both nephrology and neonatology. These partnerships serve to streamline referrals, facilitate the identification of neonatal kidney disease, and improve outcomes. The field of neonatal nephrology will continue to mature in the year to come.

Kidney support therapies—little machines that pack a big punch

The adage “children are not little adults” is as old as the field of pediatrics itself. Yet, when it comes to the use of kidney support therapies, children have been treated as little adults. The year 2020 saw the introduction of the first pediatric-specific kidney support device ever approved by the US Food and Drug Administration (FDA) for use in children under 10 kg: the Cardio-Renal Pediatric Dialysis Emergency Machine (CARPEDIEM) (5). Along with the Newcastle Infant Dialysis and Ultrafiltration System (NIDUS) (6) and the adaptation of ultrafiltration-specific devices for modified kidney replacement therapy (7), the emergence of pediatric-specific, miniaturized devices, which feature lower blood flows and circuit volumes, is something to watch this year.

Coronavirus infectious disease 2019 (COVID-19), kids, and kidneys—are we sure the kids are alright (8)?

Mercifully, children have been spared much of the morbidity and mortality associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. In summer 2020, early data suggested that the incidence of COVID-19 was no different for children with kidney disease on systemic immunosuppression (e.g., those with kidney transplants, glomerulonephritis) than children not on immunosuppression (9). However, data from late 2020 demonstrated an AKI prevalence of 44% in children critically ill with COVID-19, which mirrors the prevalence among critically ill adults (10) and is higher than that of critically ill children without SARS-CoV-2 (11). As the course of the pandemic changes and novel coronavirus vaccines become widely available, pediatric nephrologists will be watching closely for clues as to the long-term impact on our patients.

References

1. Harer MW, et al. Preterm birth and neonatal acute kidney injury: Implications on adolescent and adult outcomes. J Perinatol 2020; 40:1286–1295. doi: 10.1038/s41372-020-0656-7

2. Stoops C, et al. Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): Reduction of nephrotoxic medication-associated acute kidney injury in the Neonatal Intensive Care Unit. J Pediatr 2019; 215:223–228.e6. doi: 10.1016/j.jpeds.2019.08.046

3. Askenazi DJ. AWAKEN-ing a new frontier in neonatal nephrology. Front Pediatr 2020; 8:21. doi: 10.3389/fped.2020.00021

4. Selewski DT, et al. Neonatal acute kidney injury. Pediatrics 2015; 136:e463–e473. doi: 10.1542/peds.2014-3819

5. Vidal E, et al. Continuous veno-venous hemodialysis using the Cardio-Renal Pediatric Dialysis Emergency MachineTM: First clinical experiences. Blood Purif 2019; 47:149–155. doi: 10.1159/000494437

6. Coulthard MG, et al. Haemodialysing babies weighing <8 kg with the Newcastle Infant Dialysis and Ultrafiltration System (NIDUS): Comparison with peritoneal and conventional haemodialysis. Pediatr Nephrol 2014; 29:1873–1881. doi: 10.1007/s00467-014-2923-3

7. Menon S, et al. Kidney support in children using an ultrafiltration device: A multicenter, retrospective study. Clin J Am Soc Nephrol 2019; 14:1432–1440. doi: 10.2215/CJN.03240319

8. Townshend P. “The Kids Are Alright” in My Generation (Brunswick Records, UK), 1965.

9. Marlais M, et al. The severity of COVID-19 in children on immunosuppressive medication. Lancet Child Adolesc Health 2020; 4:e17–e18. doi: 10.1016/S2352-4642(20)30145-0.

10. Bjornstad EC, et al. Preliminary assessment of acute kidney injury in critically ill children associated with SARS-CoV-2 infection: A multicenter cross-sectional analysis [published online ahead of print November 12, 2020]. Clin J Am Soc Nephrol doi: 10.2215/CJN.11470720; https://cjasn.asnjournals.org/content/early/2020/11/11/CJN.11470720

11. Kaddourah A, et al. Epidemiology of acute kidney injury in critically ill children and young adults. N Engl J Med 2017; 376:11–20. doi: 10.1056/NEJMoa1611391

January 2021 (Vol. 13, Number 1)