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Pediatric Transplantation Journal Cover

Special issue of Pediatric Transplantation features Children’s National experts

Pediatric Transplantation Journal Cover

While much has been written about advances in the field of pediatric transplantation, there have been relatively few publications that address the social, psychological and day‐to‐day struggles faced by pediatric transplant recipients and their families. A special February 2021 issue of the journal Pediatric Transplantation, guest edited by Children’s National Hospital nephrologist and medical director of transplant Asha Moudgil, M.D., features a compilation of articles from a diverse group of professionals who share their expertise on topics related to healthy living in pediatric transplantation. Among these leaders in their fields are several clinicians from Children’s National, including Jonathan Albert M.D., Benjamin Hanisch M.D., Kristen Sgambat R.D., Melissa R. Meyers, M.D. and Kaushalendra Amatya, Ph.D.

In an editorial co-written with Priya Verghese, M.D., of Ann & Robert H. Lurie Children’s Hospital of Chicago, Dr. Moudgil writes, “It is widely acknowledged by those practicing in the field of transplant medicine that taking care of pediatric transplant recipients is a complex endeavor for all parties involved, including patients, families, and providers. In this compendium, we bring you expertise from a diverse group of professionals — including physicians, psychologists, social workers, and nutritionists. These authors provide a concise summary of the literature and evidence when available, and offer personal insight where there is paucity of literature in topics related to healthy living in pediatric transplantation.”

Dr. Albert, Dr. Hanisch and Sgambat provide their expertise in an article titled “Approaches to safe living and diet after solid organ transplantation,” which reviews the risks that pediatric and adolescent solid organ transplant recipients encounter through exposures such as household contacts, outdoor activities, travel, animal exposures and dietary choices.

Like their peers, transplant recipients go through challenges of sexual development, but are at greater risk for sexually transmitted diseases due to their chronic immunosuppression. To address this need, Dr. Meyers and colleagues provide an introductory sexual preventive care resource for adolescent and young adult solid organ transplant recipients in their article “Promoting safe sexual practices and sexual health maintenance in pediatric and young adult solid organ transplant recipients.

And, in an article titled “Psychological functioning and psychosocial issues in pediatric kidney transplant recipients,” Dr. Amatya and colleagues analyze psychological and psychosocial factors related to medical outcomes and overall well‐being post‐transplant.

Pediatric Transplantation articles written by experts from Children’s National in the 2021 February issue:

Asha Moudgil examines patient

Social determinants of cardiovascular health in African American children with CKD

Asha Moudgil examines patient

In a recent study, Asha Moudgil, M.D., and colleagues looked at differences in socioeconomic factors and subclinical cardiovascular disease markers by race in chronic kidney disease patients.

Children with chronic kidney disease (CKD) are known to have an increased risk for cardiovascular (CV) disease. African American children with CKD are also disproportionately affected by socioeconomic disadvantages related to systemic racism.

In a recent analysis of 3,103 visits from 628 children enrolled in the Chronic Kidney Disease in Children (CKiD) study, Children’s National Hospital researchers Kristen Sgambat, Ph.D., and Asha Moudgil, M.D., and their colleagues found that African American children with CKD had increased left ventricular mass index, more ambulatory hypertension and differences in lipid profile compared with Caucasian children. After adjusting for socioeconomic factors (public health insurance, household income, maternal education, food insecurity, abnormal birth history), a trend towards attenuation of the differences in these CV markers was observed.

The authors of the study conclude that, “as many social determinants of health were not captured by our study, future research should examine effects of systemic racism on CV health in this population.”

Read the full study in the American Journal of Kidney Diseases.

close up of an IV bag

Carnitine may improve heart function in children receiving CRRT

close up of an IV bag

A first-of-its-kind study demonstrated that IV carnitine supplementation is associated with improvement in myocardial strain and repletion of plasma total and free carnitine in children with AKI receiving CRRT.

Supplementation of a special nutrient could help improve heart function in children receiving continuous dialysis in critical care units. The nutrient carnitine plays an essential role in producing energy for use by heart and skeletal muscles. Critically ill children with acute kidney dysfunction often need a continuous dialysis therapy (also known as CRRT, continuous renal replacement therapy) to help remove toxins while kidneys are not working. An unintended consequence of this CRRT is removal of carnitine. Often these critically ill children are unable to eat by mouth and therefore can’t receive carnitine unless it is supplemented. Children’s National Hospital researchers have proven that intravenous carnitine supplementation is associated with repletion of the body’s carnitine supply and may cause improvement in heart function as shown by heart strain analysis (which detects subclinical cardiac dysfunction that may not be apparent by traditional echocardiography).

In a first-of-its-kind study, the Children’s National researchers, Asha Moudgil, M.D., Kristen Sgambat, M.D., and Sarah Clauss, M.D., investigated carnitine deficiency in children receiving CRRT. They demonstrated for the first time that these children become severely deficient in carnitine after being on CRRT for >1 week, and that carnitine supplementation is associated with carnitine repletion and improved heart function. This knowledge can help to guide clinical care, as carnitine can be easily added to the IV nutritional formulations that are typically given to these patients.

Although little was previously known about carnitine status in patients with acute kidney injury (AKI) receiving CRRT, iatrogenic carnitine deficiency related to chronic hemodialysis (HD) in patients with end stage renal disease is a well-known phenomenon. It was theorized that given the continuous removal of solutes by CRRT in combination with lack of dietary intake and impaired production of endogenous carnitine by the kidney in critically ill children with AKI, carnitine would be rapidly depleted.

The latest controlled pilot study (NCT01941823) of 48 children hypothesized that carnitine supplementation would improve left ventricular function in children receiving CRRT. Children ages 1-21 years with AKI requiring CRRT, who were admitted to the pediatric intensive care unit at Children’s National Hospital from 2015 to 2018 were eligible to prospectively enroll in the “CRRT Intervention group,” if they were total parenteral nutrition (TPN)-dependent and not receiving any enteral or IV carnitine prior to enrollment.

The researchers say that “An exciting collaborative effort between nephrology and cardiology made it possible to use a sophisticated technology known as speckle tracking imaging to study the effects of carnitine on heart in this population.” This technology can identify early changes in heart motion, also known as cardiac strain that may not be detected using standard heart imaging techniques.

This is the first study to demonstrate that IV carnitine supplementation is associated with improvement in myocardial strain and repletion of plasma total and free carnitine in children with AKI receiving CRRT. A cohort of pediatric chronic HD patients demonstrated similar benefits in a prior study conducted by Drs. Moudgil and Sgambat. Compared with chronic HD, carnitine is even more rapidly depleted by CRRT, with losses approximating 80% of intake. The effect of carnitine deficiency and supplementation on cardiovascular function in patients receiving CRRT had not been previously investigated.

The pilot study by Drs. Moudgil, Sgambat, and Clauss was single center and limited by small sample size. The small sample size may have limited the ability to detect significant differences in demographics and clinical characteristics and multivariable analyses could not be performed. However, given that it is a pilot study, the findings provide a solid launching point for future investigations to show how supplementation can be best utilized to optimize cardiac outcomes in children receiving CRRT.