Division Of Nephrology Research Articles

Rituximab treatment in pediatric patients with steroid-dependent nephrotic syndrome: A tertiary hospital

BackgroundCorticosteroids have had a central role in the treatment of nephrotic syndrome. The management of these patients who become dependent to steroids is complex, involving different immunosuppressive drugs patterns. The monoclonal antibody anti CD20, Rituximab, is likely to have beneficial effects in cases of steroid-dependent nephrotic syndrome patients with no easy resolution, even when we cannot make a statement about the specific role in the impact. We bring our personal experience in pediatric patients treated with this medication during the last years, to provide a thorough overview and useful information about the role of Rituximab in this pathology. MethodsRetrospective study in patients with steroid-dependent idiopathic nephrotic syndrome controlled in the division of Pediatric Nephrology of a Spanish tertiary hospital in those patients who had received at least one treatment cycle of Rituximab, at any moment along the evolution of the disease. ResultsThe study involved 8 patients. All of them previously received immunosuppressive therapy. The Rituximab were administered as an intravenous infusion, in a dose of 375 mg/m2, and all doses were administered in a period during which the disease was in remission. The depletion of lymphocytes B (CD19, 0%) were confirmed after the first dose of Rituximab except for one, with a lymphocyte count of 1%. The period of depletion lasts 10,3 months (median; range 6,5–16 months), and only one of the patients registered a relapse of the disease in this period. A reduction of relapses suffered by patients has been shown after the treatment began (3,6 relapses/year in the previous year to the start of the treatment versus 0,1 relapses/year during the first year post-rituximab). The relapse-free survival in the first year reached 83,3% in patients who suffered more than one relapse (75% of patients), and without a relapse after the treatment began in 2 cases. One or more drugs could be removed in 87,5% of patients after the first cycle of rituximab. After the rituximab treatment, we reached a 96,5% decrease in the corticosteroids doses administered (28,5 mg/m2/day during the 3 months pre-treatment versus 1 mg/m2/day in the last 3 months of patient monitoring). Not a significant observed adverse effect attributed to the drug after the post-rituximab monitoring period (median 46,5 months, range 5–97 months). ConclusionThe favorable results reported after rituximab treatment in our patients seems to confirm the effectiveness of this drug in the steroid-dependent nephrotic syndrome, making that therapeutic option into consideration and legitimating the use of the drug in complex cases involving pediatric patients. Even so, it seems recommendable to design pertinent studies to clarify, among others, the optimum regimen of the treatment (dose, interval and cycles), clinical repercussion and potential adverse effects in long terms.

Challenges to improve the Coronavirus disease 2019 (COVID-19) Immunization among dialysis population in Hamad General Hospital in the Nephrology Division, Hamad Medical Corporation, Doha, State of Qatar

Background: Hamad General Hospital (HGH) Nephrology Department is the main provider for dialysis services in Qatar, serving almost 900 patients. The introduction of the COVID-19 vaccination is a crucial step in protecting End Stage Renal Disease (ESRD) patients who are vulnerable and prone to infections due to their immunocompromised status.1 They are at high risk because they are unable to practice adequate safe physical distancing as the majority of them are dependent on others due to age and the medical condition. During the first wave of the COVID 19 pandemic, the mortality rate was 20-30% among the dialysis population.2 Several challenges were faced since February 2020 to manage and control COVID-19 infection in dialysis units. Vaccination is the most important preventive measure in facing COVID-19. Hence, a multidisciplinary team was formulated in March 2020 aiming to raise the patients and staff awareness of the importance of COVID-19 vaccination. Methods: The assessment of dialysis patients’ knowledge and educational needs was done by conducting multidisciplinary focus group activities, providing educational materials in many languages, education through hospital TV channels, WhatsApp group activities with patient educators, and direct education during physicians’ monthly dialysis assessment. Monitoring the compliance rate was done by monthly data collection and targeting non-compliant groups. Results: After the implementation of COVID-19 immunization strategic plan by the end of June 2021, 75% (666 patients) out of 884 dialysis patients were vaccinated (Figure 1). The current vaccination update for over 16-year-old in Qatar is 62.8% 3. Moreover, COVID-19 positive patients were properly managed since the beginning of 2020 by following Ministry of Public Health (MOPH) guidelines to control the spread among the dialysis population and the successful initiation of COVID-19 vaccination program (Figure 2). Conclusion: Continuous educational activities and awareness campaigns have increased COVID-19 immunization percentage among the dialysis population and probably contributed to saving lives.

Tribute to Lewis Landsberg: A Giant of Academic Medicine.

Tribute to Lewis Landsberg: A Giant of Academic Medicine.

First Author Spotlight

First Author Spotlight

Determination of a new constant to estimate glomerular filtration rate in pediatrics.

In pediatrics, glomerular filtration rate (GFR) may be estimated by measured corrected creatinine clearance (mcCrCl) (mL/min/1.73 m2) or the Schwartz formula (eGFR = height/plasma creatinine x k). The constant k depends on the plasma creatinine determination method: k = 0.55 for the Jaffe colorimetric method and k = 0.413 for the enzymatic method. Our laboratory uses the compensated kinetic colorimetric assay (CKC), and differences are observed between the estimated and measured GFR. Hypothesis: The proposed values of k do not adjust to the CKC method for plasma creatinine. To calculate a k value that allows to estimate GFR through creatinine measurement with CKC. Correlational, descriptive design. Patients aged 3-18 years seen at the Division of Pediatric Nephrology between July 2017 and January 2018 with normal or altered GFR, bladder and bowel control, and signed consent were included. Malnourished and myelomeningocele patients were excluded. Studied variables were plasma and urine creatinine, height, and 24-hour urine output. A total of 184 patients were analyzed, their mean age was 10 years. Median mcCrCl was 123 mL/min/1.73 m2. The linear correlation between height and plasma creatinine and mcCrCl resulted in a k value of 0.499 (r = 0.974 and r2 = 0.949). The linear correlation between the estimated GFR (k = 0.499) and mcCrCl resulted in a 0.999 ß coefficient (r = 0.951 and r2 = 0.903). According to this study, the constant that allows to estimate GFR when measuring plasma creatinine with the CKC method is 0.499.

Blood Pressure Differences in Nephrotic Syndrome Patients with Steroid Resistant Nephrotic Syndrome Patients and Steroid Sensitive Nephrotic Syndrome

BACKGROUND: Syndrome nephrotic is the most common kidney disease found in pediatric kidney disease, classification based on clinical response to steroids or histopathological characteristics. Increased blood pressure in steroid-resistant nephrotic syndrome (NS) is still a complication to be aware of in cases of NS. AIM: The aim of the study was to determine the differences in systolic and diastolic blood pressure in patients with steroid-sensitive NS and steroid-resistant NS. METHODS: Analytical correctional study in 50 children with NS divided into 25 Steroid Resistant NS (SRNS) groups and 25 steroid sensitive NS (SSNS) people who met inclusion and exclusion criteria to assess systolic and diastolic blood pressure in each group in pediatric nephrology division of the general hospital of Haji Adam Malik Medan. RESULTS: There is a difference in systolic blood pressure in the SRNS and SSNS groups which mean p = 0.024 and there is no difference in diastolic blood pressure in the SRNS group with SSNS p = 0.358. If linked levels of proteinuria to blood pressure, systolic and diastolic in both groups found no significant link p>0.05 high blood pressure with the degree of proteinuria in both group. CONCLUSION: There are differences in systolic blood pressure in the SRNS and SSNS groups.

Editorial introductions.

Current Opinion in Nephrology and Hypertension was launched in 1992. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of nephrology and hypertension are divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Aline MartinAline MartinDr Aline Martin, PhD, MSc, is Associate Professor of Medicine in the Division of Nephrology and Hypertension at the Northwestern University Feinberg School of Medicine, Chicago, USA. She is a graduate of the University Jean Monnet, Saint-Etienne, France, and completed her postdoctoral training at the Jared Grantham Kidney Institute, Kansas University Medical Center, Kansas City, USA. Dr Martin conducts basic and translational science research in the area of bone and mineral metabolism disorders and actively mentors undergraduate, graduate and postdoctoral trainees. Dr Martin's research involves multiple national and international collaborations. She has received research support from the National Institute of Health and is a current member of the American Society for Bone and Mineral Research, American Society of Nephrology and American Heart Association. Tamara IsakovaTamara IsakovaDr Tamara Isakova, MD, MMSc, is Associate Professor of Medicine in the Division of Nephrology and Hypertension at the Northwestern University Feinberg School of Medicine, Chicago, USA. She is also Director of the Center for Translational Metabolism and Health within the Institute for Public Health and Medicine at Northwestern. She is a graduate of the State University of New York Downstate College of Medicine, USA, and she completed internal medicine training at the Massachusetts General Hospital, Boston, USA. She also received nephrology training in the combined Massachusetts General Hospital and Brigham & Women's Hospital nephrology fellowship program. Dr Isakova conducts clinical research in the area of disordered mineral metabolism in chronic kidney disease. She has received research support from the American Kidney Fund, the American Heart Association, the American Society of Nephrology, and the National Institute of Health. Dr Isakova provides clinical care for patients with chronic kidney disease, bone and mineral metabolism disorders, and kidney stones. Orson W. MoeOrson W. MoeDr Orson W. Moe received his medical degree from the University of Toronto, Canada and is currently Professor of Internal Medicine and Physiology at the University of Texas Southwestern Medical Center, Dallas, USA. He serves administratively as the Director of the Charles and Jane Pak Center of Mineral Metabolism and Clinical Research and Chief of the Division of Nephrology. He is an active clinician, researcher, and educator holding the Charles and Jane Pak Distinguished Chair in Mineral Metabolism Research and the Donald Seldin Professorship in Clinical Investigation. Dr Moe conducts both basic science and patient-oriented research on renal physiology and metabolism, as well as epithelial biology. His research strives to cross from the level of the whole patient, to animal and cell culture models, and down to single molecules. He is active in teaching at the undergraduate and post-graduate levels, nationally and internationally. In addition to editing Current Opinion in Nephrology and Hypertension, Dr Moe also edits the textbook, The Kidney: Physiology and Pathophysiology by Seldin and Giebisch. He is currently a member of the American Society of Clinical Research, American Association of Physicians, American Society of Nephrology, International Society of Nephrology, and the American Physiologic Society. Susan E. QuagginSusan E. QuagginSusan E. Quaggin, MD, FRCP(C), FASN, is a graduate of the University of Toronto, Canada, where she completed her residency and served as chief medical resident for the University's St. Michael's Hospital. She completed her nephrology fellowship at the University of Toronto and Yale University, USA, where she also completed research and post-doctoral training. Dr Quaggin's research focuses on fundamental processes needed to establish and maintain the integrity of the specialized vascular beds in the kidney and other organs. To understand and identify new therapeutic targets, she has worked to develop genetic mouse models that allow cell and time-specific manipulation of functional genes. Translation of her group's findings regarding the vasculature reveals pathogenic mechanisms and new therapeutic targets for a number of diseases, including diabetic kidney and eye disease, nephrotic syndrome, and glaucoma. She is currently the Charles Horace Mayo Professor of Medicine at Northwestern University, USA, where she serves as the Chief of the Division of Nephrology and Hypertension and the Director of the Feinberg Cardiovascular and Renal Research Institute, USA. Dr Quaggin was elected to the American Society for Clinical Investigation in 2006, the Association of American Physicians in 2013, and the National Academy of Medicine in 2019. She is also President of the American Society of Nephrology.

Cholesterol Embolization Syndrome After Kidney Transplantation: A Case Series and Systematic Review.

Cholesterol embolization syndrome (CES) is an uncommon but well-known cause of renal failure in native kidneys, but little is known about CES in kidney transplant recipients. The aim of this study was to determine the incidence, clinical characteristics, histopathology, and prognosis of CES after kidney transplantation. CES cases in both transplanted and native kidneys (control group) were identified by searching the databases of the divisions of Nephrology and Pathology of our institution. Clinical data were retrospectively collected. Biopsies were classified according to the latest Banff 2019 Update. Second, a systematic literature search was performed (December 01, 2020) of Ovid MEDLINE, EMBASE, the Cochrane Central Register of controlled trials, Google Scholar, and Web of Science. CES was observed in for-cause biopsies of 11 out of 2350 (0.47%) kidney transplant recipients transplanted between January 1, 2006, and December 31, 2018 (0.0009 cases per person-year). All patients had ≥1 cardiovascular risk factor, and 9 donors were expanded criteria donors. Graft loss occurred in 27.3% of the patients diagnosed with CES. Eight transplant biopsies with CES were also classified as biopsy-proven acute rejection. Transplant biopsies showed signs of inflammation (arteritis, n = 7; interstitial inflammation, n = 5; tubulitis, n = 7). One patient with CES in a native kidney was identified. The biopsy of the native kidney only showed arteritis and classified as an isolated "v" lesion. The literature search resulted in 188 unique articles of which 20 were included. A total of 47 cases of CES after kidney transplantation was reported. Cholesterol emboli were found in <1% of all kidney transplant biopsies. In 57.8% of the kidney transplant biopsies with CES described in literature, concomitant inflammation was present. CES is an uncommon cause of kidney transplant failure, although the incidence of CES may be underestimated. CES may mimic rejection as it can be accompanied by arteritis.

Editorial introductions.

Current Opinion in Nephrology and Hypertension was launched in 1992. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of nephrology and hypertension is divided into 12 sections that are each reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Agnes B. FogoAgnes B. FogoProfessor Agnes Borge Fogo completed her medical training at Vanderbilt University Medical School, USA. She has remained at Vanderbilt for residency in pathology and fellowship in renal pathology and experimental kidney disease models. Her main research interests are focused on potential regression of chronic kidney disease and tubular-glomerular crosstalk in this process, pursued with funding from the National Institutes of Health and other sources. She is also dedicated to diagnostic renal pathology and has created an online Atlas of Renal Pathology with the American Journal of Kidney Disease and the National Kidney Foundation. She has also authored two books on renal pathology. Prof. Fogo enjoys teaching renal pathology and received the Robert G. Narins award from the American Society of Nephrology in 2011, as well as the Roscoe R. Robinson award from the International Society of Nephrology in 2019, for her contributions in teaching. She is currently President of the ISN and the John L. Shapiro Professor of Pathology, Microbiology and Immunology, Professor of Medicine and Paediatrics and Director of the Renal/Electron Microscopy Laboratory at Vanderbilt University Medical Center, Nashville, Tennessee, USA. Navdeep TangriNavdeep TangriDr Tangri is an attending physician and Associate Professor in the Division of Nephrology, Department of Medicine and the Department of Community Health Sciences at the University of Manitoba, Canada. Dr Tangri's research program is clinical and translational and focused on improving clinical decision making for patients with advanced chronic kidney disease. He developed and validated the Kidney Failure Risk Equation (KFRE) to predict the need for dialysis in patients with Chronic Kidney Disease (CKD) and is presently engaged in multiple validation and implementation exercises to increase the uptake of the KFRE. In addition, Dr Tangri is conducting a large prospective study on frailty, physical and cognitive function in advanced CKD, as well as leading a multinational randomized trial on the safety and efficacy of a new therapy in this population. He has published over 250 manuscripts and presented at multiple national and international scientific meetings. He is also a recipient of the CIHR New Investigator Award and a CIHR Foundation grant.

How accurate are citations of frequently cited papers in biomedical literature?

Citations are an important, but often overlooked, part of every scientific paper. They allow the reader to trace the flow of evidence, serving as a gateway to relevant literature. Most scientists are aware of citations' errors, but few appreciate the prevalence of these problems. The purpose of the present study was to examine how often frequently cited papers in biomedical scientific literature are cited inaccurately. The study included an active participation of the first authors of included papers; to first-hand verify the citations accuracy. Findings from feasibility study, where we reviewed 1540 articles containing 2526 citations of 14 most cited articles in which the authors were affiliated with the Faculty of Medicine University of Belgrade, were further evaluated for external confirmation in an independent verification set of articles. Verification set included 4912 citations identified in 2995 articles that cited 13 most cited articles published by authors affiliated with the Mayo Clinic Division of Nephrology and Hypertension. A citation was defined as being accurate if the cited article supported or was in accordance with the statement by citing authors. At least one inaccurate citation was found in 11 and 15% of articles in the feasibility study and verification set, respectively, suggesting that inaccurate citations are common in biomedical literature. The most common problem was the citation of nonexistent findings (38.4%), followed by an incorrect interpretation of findings (15.4%). One-fifth of inaccurate citations were due to chains of inaccurate citations. Based on these findings, several actions to reduce citation inaccuracies have been proposed.

Eculizumab use in a tertiary care nephrology center: data from the Vienna TMA cohort

BackgroundPractice patterns of eculizumab use are not well described. We examined indications for, and outcomes of, eculizumab therapy in a tertiary care nephrology center.MethodsWe used the “Vienna TMA cohort” and the hospital pharmacy database at the Medical University of Vienna to identify patients that received eculizumab treatment between 2012 and 2019. We describe clinical characteristics, details of eculizumab use, and outcomes of patients with complement gene-variant mediated TMA (cTMA), secondary TMA (sTMA) and C3 glomerulopathy (C3G).ResultsAs of December 2019, 23 patients received complement blockade at the Division of Nephrology and Dialysis: 15 patients were diagnosed with cTMA, 6 patients with sTMA and 2 patients with C3G. Causes of sTMA were bone marrow transplantation (n = 2), malignant hypertension, malignant tumor, systemic lupus erythematosus, antiphospholipid syndrome and lung transplantation (each n = 1). Across all indications, patients had a median age of 31 and were predominantly female (78%) and the median duration of treatment was 227 days. Hematological recovery was seen in most patients, while renal response was best in patients with cTMA. Adverse events were recorded in 26%.ConclusionsIn summary, eculizumab is the treatment of choice for cTMA patients that do not respond to plasma therapy. In patients with sTMA and C3G, the response rates to therapy are much lower and therefore, the decision to start therapy needs to be considered carefully.Graphic abstract

Tratamiento con rituximab en pacientes pediátricos con síndrome nefrótico córtico-dependiente. Experiencia en un hospital terciario

BackgroundCorticosteroids have had a central role in the treatment of nephrotic syndrome. The management of these patients who become dependent to steroids is complex, involving different immunosuppressive drugs patterns. The monoclonal antibody anti CD20, Rituximab, is likely to have beneficial effects in cases of steroid-dependent nephrotic syndrome patients with no easy resolution, even when we cannot make a statement about the specific role in the impact. We bring our personal experience in pediatric patients treated with this medication during the last years, to provide a thorough overview and useful information about the role of Rituximab in this pathology. MethodsRetrospective study in patients with steroid-dependent idiopathic nephrotic syndrome controlled in the division of Pediatric Nephrology of a spanish tertiary hospital in those patients who had received at least one treatment cycle of Rituximab, at any moment along the evolution of the disease. ResultsThe study involved 8 patients. All of them previously received immunosuppressive therapy. The Rituximab were administered as an intravenous infusion, in a dose of 375 mg/m2, and all doses were administered in a period during which the disease was in remission. The depletion of lymphocytes B (CD 19%) were confirmed after the first dose of Rituximab except for one, with a lymphocyte count of 1%. The period of depletion lasts 10.3 months (median; range 6.5-16 months), and only one of the patients registered a relapse of the disease in this period. A reduction of relapses suffered by patients has been shown after the treatment began (3.6 relapses/year in the previous year to the start of the treatment vs. 0.1 relapses/year during the first year post-rituximab). The relapse-free survival in the first year reached 83.3% in patients who suffered more than one relapse (75% of patients), and without a relapse after the treatment began in 2 cases. One or more drugs could be removed in 87.5% of patients after the first cycle of rituximab. After the rituximab treatment, we reached a 96.5% decrease in the corticosteroids doses administered (28.5 mg/m2/day during the 3 months pre-treatment vs. 1 mg/m2/day in the last 3 months of patient monitoring). Not a significant observed adverse effect attributed to the drug after the post-rituximab monitoring period (median 46.5 months, range 5-97 months). ConclusionThe favorable results reported after rituximab treatment in our patients seems to confirm the effectiveness of this drug in the steroid-dependent nephrotic syndrome, making that therapeutic option into consideration and legitimating the use of the drug in complex cases involving pediatric patients. Even so, it seems recommendable to design pertinent studies to clarify, among others, the optimum regimen of the treatment (dose, interval and cycles), clinical repercussion and potential adverse effects in long terms.

Novel genetic testing model: A collaboration between genetic counselors and nephrology.

Many barriers to genetic testing currently exist which delay or prevent diagnosis. These barriers include wait times, staffing, education, and cost. Specialists are able to identify patients with disease that may need genetic testing, but lack the genetics support to facilitate that testing in the most cost, time, and medically effective manner. The Nephrology Division and the Genetic Testing Stewardship Program at Nemours A.I. duPont Hospital for Children created a novel service delivery model in which nephrologists and genetic counselors collaborate in order to highlight their complementary strengths (clinical expertise of nephrologists and genetics and counseling skills of genetic counselors). This collaboration has reduced many barriers to care for our patients. This workflow facilitated the offering of genetic testing to 76 patients, with 86 tests completed over a 20-month period. Thirty-two tests were deferred. Twenty-seven patients received a diagnosis, which lead to a change in their medical management, three of whom were diagnosed by cascade family testing. Forty-two patients had a negative result and 16 patients had one or more variants of uncertain significance on testing. The inclusion of genetic counselors in the workflow is integral toward choosing the most cost and time effective genetic testing strategy, as well as providing psychosocial support to families. The genetic counselors obtain informed consent, and review genetic test results and recommendations with the patient and their family. The availability of this program to our patients increased access to genetic testing and helps to provide diagnoses and supportive care.

The assesment of prothrombotic potential using thrombin generation assay in pediatric patients with nephrotic syndrome: preliminary study.

Nephrotic syndrome (NS) is a common kidney disease associated with an increased risk of thrombotic events. The aim of this study was to assess the prothrombotic potential of patients with NS using the thrombin generation assay (TGA). A total of 35 patients with NS, who were followed in the Division of Pediatric Nephrology in Behcet Uz Children`s Hospital, were included in the study. After the patients with Steroid Resistant NS (n:3) were excluded, 32 patients in total were evaluated for TGA. Patients were primarily classified according to their response to corticosteroid therapy. The control group consisted of 34 healthy volunteers with similar gender and age distribution to the patients. Blood urine nitrogen, creatinine, albumin, triglyceride, cholesterol, 24-hour proteinuria, platelets, erythrocyte sedimentation rate, C-reactive protein and thrombin generation values in activation and remission period of NS were compared. Moreover, TGA values of the patients in their remission period were compared with the values of those in the control group. Endogenous thrombin potential (ETP) and peak thrombin levels were significantly higher in the activation period than remission period of NS. Additionally, after the patients achieved remission, their ETP was still higher than the control group. There was a negative correlation between both ETP and peak thrombin levels of patients with serum albumin, whereas a significant positive correlation was detected with platelet levels. Thromboembolic events were not observed in any of the patients during follow-up. Nephrotic syndrome is strongly associated with hypercoagulopathy as assessed by TGA during active NS. The present study reinforces the usefulness of TGA as a marker of hypercoagulability in pediatric patients with NS. Further studies are needed in this regard.

Safety of Kidney Biopsy when Performed as an Outpatient Procedure

Introduction: Kidney biopsy remains the gold standard for the diagnosis of most renal diseases. A major obstacle to performing a biopsy is safety concerns. However, many safety measures are not evidence based and therefore vary widely between centers. We sought to determine the rate and timing of kidney biopsy complications in our center, to compare the complication rate between native and transplant kidney biopsies, to evaluate the feasibility of performing kidney biopsies as an outpatient procedure and the value of a postbiopsy ultrasound before discharge, and to identify risk factors for complications. Methods: We performed a single-center, retrospective, observational study at the Division of Nephrology of the University Hospital Zurich including all patients who underwent renal biopsy between January 2005 and December 2017. Major bleeding (primary outcome) and any other bleeding or nonbleeding complications (secondary outcomes) were compared between native and transplant kidney biopsies and between inpatient and outpatient procedures and correlated with clinical factors possibly affecting bleeding risk. Results: Overall, 2,239 biopsies were performed in 1,468 patients, 732 as inpatient and 1,507 as outpatient procedures. Major bleeding was observed in 28 (3.8%) inpatient and in 15 (1.0%) outpatient procedures, totaling to 43 (1.9%) of all biopsies. Major bleeding requiring intervention amounted to 1.0% (0.5% of outpatient procedures). Rate of major bleeding was similar between native and transplant kidneys. 13/15 (87%) bleeding episodes in planned outpatient procedures were detected during the 4-h surveillance period. Risk factors for bleeding were aspirin use, low eGFR, anemia, cirrhosis, and amyloidosis. Routine postbiopsy ultrasound did not change management. Conclusions: Kidney biopsy is an overall safe procedure and can be performed as an outpatient procedure in most patients with an observation period as short as 4 h. The value of routine postbiopsy ultrasound is questionable.

1391. Enhanced Education and Administration of Influenza Vaccine in a Pediatric Subspecialty Practice

BackgroundStrategies to increase influenza (flu) immunization rates are desirable. Some children who are at increased risk for severe disease may only be seen in a subspecialty office during the months when flu vaccine is offered. Subspecialists may also provide education for families that are uncertain about benefits of vaccines.MethodsDuring the 2019- 2020 season, our multispecialty pediatric practice, which includes divisions of Endocrinology, Gastroenterology, Infectious Disease, Nephrology, Pulmonary, and Surgery, initiated a quality project to increase delivery of flu vaccine during visits. Beginning 10/1/19, providers were encouraged to use tools in the electronic medical record (EMR) to ask about flu vaccine status and administer if indicated and accepted. Flu immunizations given for all divisions, as well as individual divisions, were compared with the previous 2018–2019 season.ResultsFrom 9/1/19 -3/31/20, 615 doses of flu vaccine were administered for 5667 patients for a rate of 10.9 %. This was an increase from 9/1/18- 3/31/19 when 256 doses were given for 5760 patients (4.4%, p< .0001). All divisions had a significant increase in flu vaccine rates except for infectious disease. Review of certain high risk disorders showed significant increased rates for diabetes and asthma but not for inflammatory bowel disease, HIV infection, chronic renal disease, or cystic fibrosis. During this project an EMR flu tool was not used for 1788 patients (32%). Of the remaining 3879 patients, 1982 (51%) reported prior receipt of flu vaccine and 579 (15%) were not eligible for state supplied vaccine. For 1318 eligible patients, flu vaccine was accepted by 631 (48%) and given to 615 patients. Flu vaccine was declined by 687 (52%) patients.ConclusionThere is opportunity to provide education and flu vaccine during pediatric subspecialty visits. All specialties increased the number of flu vaccine given except for infectious disease. This is likely because this division has routinely offered flu vaccine and visits for travel declined in 2020. Although the practice overall gave more flu vaccine from the prior year, there appear to be missed opportunities. Further quality improvement work will strengthen the EMR flu screening tools to increase participation and learn more about why flu vaccine is declined.Disclosures All Authors: No reported disclosures

In-House Production of Dialysis Solutions to Overcome Challenges During the Coronavirus Disease 2019 Pandemic

In-House Production of Dialysis Solutions to Overcome Challenges During the Coronavirus Disease 2019 Pandemic

Twelve-Week Internet-Based Individualized Exercise Program in Adults With Systemic Lupus Erythematosus: Protocol for a Randomized Controlled Trial.

BackgroundSystemic lupus erythematosus is a systemic autoimmune disease, which is associated with high cardiovascular risk, a predisposition to metabolic disorders, muscle wasting, and fatigue. Exercise therapy has become an important part of the long-term treatment of comorbidities in systemic lupus erythematosus. Exercise can lead to various benefits in patients with systemic lupus erythematosus such as increased aerobic capacity and exercise tolerance, resulting in an increased quality of life, decreased depression, and decreased fatigue. At the moment, no evidence-based treatment guidelines that recommend exercise for patients with systemic lupus erythematosus exist. Also, the efficacy of different training programs requires further investigation.ObjectiveThis study focuses on the feasibility, efficacy, and safety of an internet-based exercise program in patients with systemic lupus erythematosus. Furthermore, we investigate the feasibility and efficiency of anaerobic training compared to aerobic training.MethodsOverall, patients with systemic lupus erythematosus from the Division of Nephrology, Rheumatology, and Immunology outpatient clinic of the University Medical Center Mainz who are clinically stable status are included and randomized in an aerobic exercise group (n=10), anaerobic exercise group (n=10), or treatment as usual group (n=10). After completing initial clinical testing and physical fitness tests, patients undergo supervised 12-week online exercise programs, receiving weekly individualized training plans adapted to their physical performance. The primary outcome is change in physical fitness (VO2 peak) after 12 weeks compared to baseline. Secondary outcomes are disease activity measured via laboratory results (complement, autoantibodies) and questionnaires, as well as changes in muscle mass (anaerobic exercise group), results of the Chair-Stand test, and measurements of circulating cell-free DNA and extracellular vesicles.ResultsThe study was registered in May 2019. Enrollment began in May 2019. Of 40 patients who were initially screened, 30 patients fulfilled the inclusion criteria and were included in the study; 1 participant withdrew prior to the start of the exercise program. Among the 25 patients who completed the study, no serious adverse events have been reported; 3 participants withdrew during the program (due to frequent colds, n=1; Crohn relapse, n=1; physical strain, n=1), and 1 participant has not yet completed the program. Data analysis is ongoing, and results are expected to be submitted for publication in January 2021.ConclusionsWe expect the online exercise intervention to be a feasible and efficient tool to provide regular individualized exercise for patients with systemic lupus erythematosus.Trial RegistrationClinicalTrials.gov NCT03942718; http://clinicaltrials.gov/ct2/show/NCT03942718.International Registered Report Identifier (IRRID)DERR1-10.2196/18291

Cardio-Renal-Metabolic Care Models

Cardio-Renal-Metabolic Care Models

Electrolyte Disturbance in an Infant with Failure to Thrive.

1. Hannah Kim, MD* 2. Amanda Hesselton, MD† 3. Alicia M. Neu, MD* 4. Jeffrey Fadrowski, MD, MHS* 1. *Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD 2. †Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD A 6-week-old girl was born to a healthy mother via uncomplicated vaginal delivery at full term and subsequently had a normal newborn screen. She had a birthweight of 4.48 kg (large for gestational age, 97% percentile). At her 1-month health supervision visit, she weighed 3.7 kg. Although offered 2 to 3 oz of pumped human milk each feed, she was taking approximately 1 oz every 2 hours without cyanosis, tachypnea, or sweating. She had no trouble latching onto the bottle, a normal suck and swallow, and no choking with feeds. After feeding, she had frequent nonbloody/nonbilious vomiting episodes that most often occurred soon after a feed, but occasionally a few hours later. Her primary care provider recommended fortifying the human milk with formula to 22 kcal/ounce, but it was not well-tolerated due to vomiting. On a repeat weight check 2 weeks before admission, she demonstrated continued poor weight gain and was started on a histamine 2-blocker for possible gastrointestinal reflux. Two days before admission, this was switched to a proton-pump inhibitor with no improvement in symptoms. The primary care provider obtains bloodwork, urine studies, and an abdominal ultrasound as part of an evaluation for failure to thrive. The bloodwork shows the following: sodium 115 mmol/L, potassium 8.7 mmol/L, chloride 71 mmol/L, carbon dioxide 15 mmol/L, urea nitrogen 53 mg/dL, creatinine 0.8 mg/dL, and glucose 50 mg/dL. The mother is asked to …