What are the risk factors for CKID progression? Should children with CKID be screened for cardiovascular risks? Can we predict relative time to a composite event?
These are a few of the questions being answered by the CKID study. To date, the translational research study has resulted in more than 90 publications.
Listen as Dr. Warady highlights some of the key findings that are shaping care and providing answers that matter now to pediatric patients with CKID.
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Lessons Learned from the CKID Study
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Learn more about Brad Warady, MD
Brad Warady, MD
Dr. Warady is Director of the Division of Nephrology at Children’s Mercy and Director of Dialysis and Transplantation. In spring 2015, Dr. Warady was presented with the Henry L. Barnett Award for outstanding teaching and clinical care for children with kidney disease by the American Academy of Pediatrics Section on Nephrology. Dr.Warady’s previous awards include the National Kidney Foundation’s 2013 J. Michael Lazarus Award for enhancing the clinical care of patients on dialysis or with chronic kidney disease (CKD) and the Patrick and Virginia Clune Award of Excellence by the National Kidney Foundation of Kansas and Western Missouri. Dr.Warady is Professor of Pediatrics at the University of Missouri-Kansas City School of Medicine. His major areas of research are chronic kidney disease and end-stage renal disease (ESRD) management of children. He is the senior editor of two leading books in the field, “Pediatric Dialysis” and “Pediatric Dialysis Case Studies.” He is also Co-Principal Investigator of the NIH funded “Chronic Kidney Disease in Children (CKiD) Study”, the largest study of CKD in children ever conducted in North America.Learn more about Brad Warady, MD
Transcription:
Lessons Learned from the CKID Study
Dr. Michael Smith (Host): Our topic today is lessons learned from the chronic kidney disease in children study. My guest is Dr. Brad Warady. Dr. Warady is the director of the division of nephrology at Children’s Mercy and director of dialysis and transplantation. Welcome to the show. Why did we need this study?
Dr. Brad Warady, MD (Guest): Chronic kidney disease is something that affects children and adults. One of the things that we've found over the years is that for those patients, those children, who go on to develop end-stage kidney disease or the need for dialysis or transplantation, they can shorten their life expectancy by as much as 50 years. This study was established to allow us to get a better handle on the factors that lead to the progression or worsening of chronic kidney disease with the hopes of ultimately being able to delay that progression or even prevent the progression to kidney failure.
Dr. Smith: When you were setting up this study – I know you're one of the co-authors of this study – what were some of the basic objectives you wanted to line up for this?
Dr. Warady: It was important that we have a number of different sites around the countries involved so that we can study an adequate number of children, and so we've had up to 54 different centers, all pediatric kidney centers, from around the nation and in Canada participating in this study. Our goal was to try to define risk factors that lead to the progression or worsening of chronic kidney disease as well as to look at the impact of that kidney impairment on cardiovascular or heart disease, neurocognitive or brain development as well as growth – three important outcomes of chronic kidney disease.
Dr. Smith: Setting up this study obviously getting as many centers involved was important to this. What's the basic setup for this study?
Dr. Warady: The study is what we call an observational study. We see these children on a yearly basis and obtained a battery of tests on them, everything from looking at their growth, looking at their weight gain, looking at their development function and looking at their heart function. We do this annually so that over time we can evaluate the progression of chronic kidney disease or any of these complications, and importantly, we can separate out those children who experience progression from those children who do not experience progression and try to define what's different between those two different cohorts.
Dr. Smith: There's a nice website that describes the study and I see here that one of the things that you guys are trying to do here is as there is this progressive decline in renal function, how are some of the other biomarkers, like cardiovascular biomarkers, affected? Can you tell us a little bit about why that’s important to look at in the study?
Dr. Warady: I think we may look at some of these biomarkers such as high blood pressure, which certainly affects your heart function, we know now that high blood pressure is one of those factors that not only can, in fact, lead to worsening of kidney function, but it's a modifiable risk factor. The suggestion is that if we more aggressively manage that high blood pressure, treat that high blood pressure successfully, we may be able to delay that progression of chronic kidney disease. Trying to evaluate these other biomarkers, especially those that are modifiable to treatment, may lend itself to interventional studies that ultimately show us how we can positively impact chronic kidney disease.
Dr. Smith: So far, what are some of the key findings?
Dr. Warady: I think of the key findings was that many of our children have what we call masked hypertension, or elevated blood pressure that is not detectable when one utilized a 24-hour blood pressure monitor. As many as nearly 40% of our kids had masked hypertension, and so I think that finding early on in the study highlighted the fact that conducting 24-hour blood pressure assessments or ABPM in children with chronic kidney disease is essential and it really should be part of the standard of care.
Dr. Smith: When I look at the study and everything that you’ve mentioned so far, the ultimate goal here is to make sure that we slow the progression, make sure that we can delay that need for transplantation for as long as possible. You mentioned once there's a transplant, what was the stat you gave about mortality?
Dr. Warady: If you're on chronic dialysis, you may lose as much as nearly 50 years of life expectancy. Again, we want to prevent that development.
Dr. Smith: As this study continues and as you continue to evaluate the children in the study, what are some of the things that you are most excited about that you're seeing come out of this?
Dr. Warady: I think one of the recent publications evaluated what is called the kidney failure risk equation. This is a newly published study just published this month and it provides us with information for those kids who are progressing how rapidly they are progressing and when are they likely to move onto the need for dialysis transplants. I think the utilization of this equation is important because it can allow us to plan for transplants so as to prevent the need for dialysis in many of these children. This equation seems to allow us to predict the development of end-stage kidney disease in these children with respect to about a two-year period of time. While we want to prevent the development of end-stage kidney disease, we know that some of these kids will move on to the need for transplants and the use of this equation may help us plan the process much earlier than what's been planned in the past.
Dr. Smith: When you put it all together, what would you like the general pediatrician, the general family physician, the nurse practitioners out in the community to know about chronic kidney disease in children?
Dr. Warady: I think the most important thing to recognize is that while many of these children with chronic kidney disease will progress, will have worsening of their kidney function, there are things that we can do to slow that progression. Treating their high blood pressure is exceedingly important. Treating the protein they have in their urine is another risk factor; we can often times treat that with medication. Controlling their diet. There's a number of factors that are modifiable factors that can lend itself to a better outcome for these children. I think the most important thing is to evaluate for these potential risk factors and then aggressively treat them.
Dr. Smith: I want to thank you for the work that you are doing at Children’s Mercy and thank you for coming on the show today. You're listening to Transformational Pediatrics with Children’s Mercy, Kansas City. For more information, you can go to childrenmercy.org. That’s childrenmercy.org. I'm Dr. Mike Smith. Thanks for listening.
Lessons Learned from the CKID Study
Dr. Michael Smith (Host): Our topic today is lessons learned from the chronic kidney disease in children study. My guest is Dr. Brad Warady. Dr. Warady is the director of the division of nephrology at Children’s Mercy and director of dialysis and transplantation. Welcome to the show. Why did we need this study?
Dr. Brad Warady, MD (Guest): Chronic kidney disease is something that affects children and adults. One of the things that we've found over the years is that for those patients, those children, who go on to develop end-stage kidney disease or the need for dialysis or transplantation, they can shorten their life expectancy by as much as 50 years. This study was established to allow us to get a better handle on the factors that lead to the progression or worsening of chronic kidney disease with the hopes of ultimately being able to delay that progression or even prevent the progression to kidney failure.
Dr. Smith: When you were setting up this study – I know you're one of the co-authors of this study – what were some of the basic objectives you wanted to line up for this?
Dr. Warady: It was important that we have a number of different sites around the countries involved so that we can study an adequate number of children, and so we've had up to 54 different centers, all pediatric kidney centers, from around the nation and in Canada participating in this study. Our goal was to try to define risk factors that lead to the progression or worsening of chronic kidney disease as well as to look at the impact of that kidney impairment on cardiovascular or heart disease, neurocognitive or brain development as well as growth – three important outcomes of chronic kidney disease.
Dr. Smith: Setting up this study obviously getting as many centers involved was important to this. What's the basic setup for this study?
Dr. Warady: The study is what we call an observational study. We see these children on a yearly basis and obtained a battery of tests on them, everything from looking at their growth, looking at their weight gain, looking at their development function and looking at their heart function. We do this annually so that over time we can evaluate the progression of chronic kidney disease or any of these complications, and importantly, we can separate out those children who experience progression from those children who do not experience progression and try to define what's different between those two different cohorts.
Dr. Smith: There's a nice website that describes the study and I see here that one of the things that you guys are trying to do here is as there is this progressive decline in renal function, how are some of the other biomarkers, like cardiovascular biomarkers, affected? Can you tell us a little bit about why that’s important to look at in the study?
Dr. Warady: I think we may look at some of these biomarkers such as high blood pressure, which certainly affects your heart function, we know now that high blood pressure is one of those factors that not only can, in fact, lead to worsening of kidney function, but it's a modifiable risk factor. The suggestion is that if we more aggressively manage that high blood pressure, treat that high blood pressure successfully, we may be able to delay that progression of chronic kidney disease. Trying to evaluate these other biomarkers, especially those that are modifiable to treatment, may lend itself to interventional studies that ultimately show us how we can positively impact chronic kidney disease.
Dr. Smith: So far, what are some of the key findings?
Dr. Warady: I think of the key findings was that many of our children have what we call masked hypertension, or elevated blood pressure that is not detectable when one utilized a 24-hour blood pressure monitor. As many as nearly 40% of our kids had masked hypertension, and so I think that finding early on in the study highlighted the fact that conducting 24-hour blood pressure assessments or ABPM in children with chronic kidney disease is essential and it really should be part of the standard of care.
Dr. Smith: When I look at the study and everything that you’ve mentioned so far, the ultimate goal here is to make sure that we slow the progression, make sure that we can delay that need for transplantation for as long as possible. You mentioned once there's a transplant, what was the stat you gave about mortality?
Dr. Warady: If you're on chronic dialysis, you may lose as much as nearly 50 years of life expectancy. Again, we want to prevent that development.
Dr. Smith: As this study continues and as you continue to evaluate the children in the study, what are some of the things that you are most excited about that you're seeing come out of this?
Dr. Warady: I think one of the recent publications evaluated what is called the kidney failure risk equation. This is a newly published study just published this month and it provides us with information for those kids who are progressing how rapidly they are progressing and when are they likely to move onto the need for dialysis transplants. I think the utilization of this equation is important because it can allow us to plan for transplants so as to prevent the need for dialysis in many of these children. This equation seems to allow us to predict the development of end-stage kidney disease in these children with respect to about a two-year period of time. While we want to prevent the development of end-stage kidney disease, we know that some of these kids will move on to the need for transplants and the use of this equation may help us plan the process much earlier than what's been planned in the past.
Dr. Smith: When you put it all together, what would you like the general pediatrician, the general family physician, the nurse practitioners out in the community to know about chronic kidney disease in children?
Dr. Warady: I think the most important thing to recognize is that while many of these children with chronic kidney disease will progress, will have worsening of their kidney function, there are things that we can do to slow that progression. Treating their high blood pressure is exceedingly important. Treating the protein they have in their urine is another risk factor; we can often times treat that with medication. Controlling their diet. There's a number of factors that are modifiable factors that can lend itself to a better outcome for these children. I think the most important thing is to evaluate for these potential risk factors and then aggressively treat them.
Dr. Smith: I want to thank you for the work that you are doing at Children’s Mercy and thank you for coming on the show today. You're listening to Transformational Pediatrics with Children’s Mercy, Kansas City. For more information, you can go to childrenmercy.org. That’s childrenmercy.org. I'm Dr. Mike Smith. Thanks for listening.