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Patients with chronic kidney disease (CKD) frequently experience unpleasant symptoms. These can be gastrointestinal (constipation, nausea, vomiting and diarrhoea), psychological (anxiety and sadness), neurological (lightheadedness, headache and numbness), cardiopulmonary (shortness of breath and oedema), dermatological (pruritus and dry skin), painful (muscle cramps, chest pain and abdominal pain) or involve sexual dysfunction, sleep disorders and fatigue. These symptoms often occur in clusters, with one of them as the lead symptom and others as secondary symptoms. Uraemic toxins (also called uremic toxins) are often considered to be the main cause of CKD-associated symptom burden, but treatment of uraemia by dialysis often fails to resolve them and can engender additional symptoms. Indeed, symptoms can be exacerbated by comorbid conditions, pharmacotherapies, lifestyle and dietary regimens, kidney replacement therapy and ageing. Patients with kidney disease, including those who depend on dialysis or transplantation, should feel actively supported in their symptom management through the identification and targeting of unpleasant symptoms via a tailored palliative care approach. Such an approach may help minimize the burden and consequences of kidney disease, and lead to improved patient outcomes including health-related quality of life and better life participation.

Living with chronic kidney disease (CKD) is associated with hardships for patients and their care partners. Empowering patients and their care partners, including family members and friends involved in their care, may help minimize the burden and consequences of CKD-related symptoms to enable increased life participation. There is a need to broaden the focus on living well with kidney disease and reengagement in life, including emphasis on the patient being in control. The World Kidney Day (WKD) Joint Steering Committee has declared 2021 the year of “Living Well with Kidney Disease” in an effort to increase education about and awareness of the important goal of patient empowerment and life participation. This calls for the development and implementation of validated patient-reported outcome measures to assess and address areas of life participation in routine care. It could be supported by regulatory agencies as a metric for quality care or to support labeling claims for medicines and devices. Funding agencies could establish targeted calls for research that address the priorities of patients. Patients with kidney disease and their care partners should feel supported to live well through concerted efforts by kidney care communities, including during pandemics. In the overall wellness program for patients with kidney disease, the need for prevention should be reiterated. Early detection with prolonged course of wellness despite kidney disease, after effective secondary and tertiary prevention programs, should be promoted. WKD 2021 continues to call for increased awareness of the importance of preventive measures across populations, professionals, and policy makers, applicable to both developed and developing countries.

Alport syndrome is an inherited disease characterized by progressive loss of kidney function. We aimed to evaluate the safety and efficacy of bardoxolone methyl in patients with Alport syndrome.We randomly assigned patients with Alport syndrome, ages 12-70 years and eGFR 30-90 ml/min per 1.73 mPatients randomized to bardoxolone methyl experienced preservation in eGFR relative to placebo at 48 and 100 weeks (between-group differences: 9.2 [97.5% confidence interval, 5.1 to 13.4;In adolescent and adult patients with Alport syndrome receiving standard of care, treatment with bardoxolone methyl resulted in preservation in eGFR relative to placebo after a 2-year study period; off-treatment results using all available data were not significantly different.A Phase 2/3 Trial of the Efficacy and Safety of Bardoxolone Methyl in Patients with Alport Syndrome - CARDINAL (CARDINAL), NCT03019185.

For the World Kidney Day Steering Committee Kidney disease is a global public health problem that affects more than 750 million persons worldwide. The burden of kidney disease varies substantially across the world, as does its detection and treatment. Although the magnitude and impact of kidney disease is better defined in developed countries, emerging evidence suggests that developing countries have a similar or even greater kidney disease burden. In many settings, rates of kidney disease and the provision of its care are defined by socioeconomic, cultural, and political factors, leading to significant disparities in disease burden, even in developed countries. These disparities exist across the spectrum of kidney disease - from preventive efforts to curb development of acute kidney injury or chronic kidney disease, to screening for kidney disease among persons at high risk, to access to subspecialty care and treatment of kidney failure with renal replacement therapy. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. In this editorial, we highlight these disparities and emphasize the role of public policies and organizational structures in addressing them. We outline opportunities to improve our understanding of disparities in kidney disease, the best ways for them to be addressed, and how to streamline efforts toward achieving kidney health equity across the globe.Для Организационного комитета Всемирного дня почки Заболевания почек - глобальная проблема общественного здравоохранения, затрагивающая более 750 млн человек во всем мире Распространенность заболеваний почек, а также их диагностика и лечение в разных странах существенно различаются. Значение и последствия заболеваний почек наиболее хорошо изучены в развитых странах, но в последнее время появляется все больше данных, свидетельствующих об аналогичной и даже более высокой распространенности заболеваний почек и в развивающихся странах. Во многих ситуациях частота заболеваний почек и обеспечение медицинской помощью определяются социально - экономическими, культурными и политическими факторами, что даже в развитых странах приводит к существенным различиям наносимого болезнью ущерба. Эти различия наблюдаются на разных этапах оказания помощи при заболеваниях болезнях почек: от профилактических мероприятий, направленных на предотвращение развития острого повреждения почек и хронической болезни почек, до скрининга на наличие болезни почек у лиц с высоким риском заболевания и доступа к специализированной медицинской помощи и проведению заместительной почечной терапии для лечения почечной недостаточности. Всемирный день почки - 2019 дает возможность повысить осведомленность о заболеваниях почек, а также осветить несоответствия между причиняемым ими ущербом и потенциальными возможностями их профилактики и лечения. В публикуемой передовой статье мы хотим заострить внимание на этих несоответствиях и подчеркиваем роль общественной политики и организационных структур в их устранении. Мы намечаем пути улучшения понимания этих различий, определяем основные подходы к достижению этого понимания, а также возможности оптимизации усилий для обеспечения равенства в вопросах поддержания здоровья почек во всем мире. Данная статья опубликована в журнале «Kidney International» и одновременно перепечатана в нескольких журналах. Эти публикации включают идентичные понятия и формулировки, но немного различаются по стилю и орфографии, мелким подробностям и объему рукописи в зависимости от стиля каждого журнала. Любая из этих версий может быть использована при цитировании данной статьи. Все авторы внесли равный вклад в концепцию, подготовку и редактирование рукописи. Авторы благодарят Рабочую группу по разработке Global Kidney Health Atlas, M. Lunney и M.A. Osman. Приложение Члены Организационного комитета Всемирного дня почки: Филипп Кам Тао Ли (Philip Kam Tao Li), Гильермо Гарсиа-Гарсиа (Guillermo Garcia-Garcia), Шэрон Андреоли (Sharon Andreoli), Дейдра Крю (Deidra Crews), Камьяр Калантар-Заде (Kamyar Kalantar-Zadeh), Чарльз Кернан (Charles Kernahan), Лата Кумарасвами (Latha Kumaraswami), Гамаль Саади (Gamal Saadi) и Луиза Страни (Luisa Strani). Перевод с английского Е.С. Камышовой и И.Н. Бобковой под редакцией Е.В. Захаровой. Перевод осуществлен по инициативе Российского диализного общества и одобрен Организационным комитетом Всемирного дня почки.

Living with chronic kidney disease (CKD) is associated with hardships for patients and their care partners. Empowering patients and their care partners, including family members or friends involved in their care, may help minimize the burden and consequences of CKD-related symptoms to enable life participation. There is a need to broaden the focus on living well with kidney disease and re-engagement in life, including an emphasis on patients being in control. The World Kidney Day (WKD) Joint Steering Committee has declared 2021 the year of ‘Living Well with Kidney Disease’ in an effort to increase education and awareness on the important goal of patient empowerment and life participation. This calls for the development and implementation of validated patient-reported outcome measures to assess and address areas of life participation in routine care. It could be supported by regulatory agencies as a metric for quality care or to support labeling claims for medicines and devices. Funding agencies could establish targeted calls for research that address the priorities of patients. Patients with kidney disease and their care partners should feel supported to live well through concerted efforts by kidney care communities including during pandemics. In the overall wellness program for kidney disease patients, the need for prevention should be reiterated. Early detection with a prolonged course of wellness despite kidney disease, after effective secondary and tertiary prevention programs, should be promoted. WKD 2021 continues to call for increased awareness of the importance of preventive measures throughout populations, professionals and policymakers, applicable to both developed and developing countries.

Living with chronic kidney disease (CKD) is associated with hardships for patients and their care-partners. Empowering patients and their care-partners, including family members or friends involved in their care, may help minimize burden and consequences of CKD-related symptoms to enable life participation. There is a need to broaden the focus on living well with kidney disease and re-engagement in life, including emphasis on patients being in control. The World Kidney Day (WKD) Joint Steering Committee has declared 2021 the year of "Living Well with Kidney Disease" in an effort to increase education and awareness on the important goal of patient empowerment and life participation. This calls for the development and implementation of validated patient-reported outcome measures to assess and address areas of life participation in routine care. It could be supported by regulatory agencies as a metric for quality care or to support labeling claims for medicines and devices. Funding agencies could establish targeted calls for research that address the priorities of patients. Patients with kidney disease and their care-partners should feel supported to live well through concerted efforts by kidney care communities including during pandemics. In the overall wellness program for kidney disease patients, the need for prevention should be reiterated. Early detection with prolonged course of wellness despite kidney disease, after effective secondary and tertiary prevention programs, should be promoted. WKD 2021 continues to call for increased awareness of the importance of preventive measures throughout populations, professionals, and policy makers, applicable to both developed and developing countries.Vivre avec l’insuffisance rénale chronique (IRC) représente un fardeau pour les patients et leurs partenaires soignants, dont leurs familles et amis. Une façon d’alléger ce fardeau et de réduire les conséquences des symptômes de l’IRC sur la participation à la vie serait de favoriser une plus grande autonomie des patients et de leurs partenaires soignants. Pour ce faire, l’accent mis sur le bien vivre avec la maladie et sur la participation à la vie doit être élargi en privilégiant notamment de mettre les patients en contrôle. Pour accroître l’éducation et la sensibilisation sur la responsabilisation des patients et, ultimement, encourager leur participation à la vie, le Comité directeur bipartite de la Journée Mondiale du Rein (JMR) a déclaré 2021 l’année du « bien vivre avec une maladie rénale ». Une stratégie qui nécessite l’élaboration et la mise en œuvre de mesures validées des résultats signalés par le patient afin d’aborder la participation à la vie dans les soins courants. Cette stratégie pourrait être appuyée par les organismes de réglementation comme mesure de qualité des soins ou pour appuyer les demandes relatives à l’étiquetage des médicaments et des dispositifs. Les organismes subventionnaires pourraient quant à eux établir des appels d’offres à objectifs de recherche définis afin de répondre aux priorités des patients. Les patients et leurs partenaires soignants devraient se sentir soutenus, même en contexte de pandémie, par des efforts concertés des communautés de soins en santé rénale. Dans le cadre du program de bien-être global destiné aux patients atteints d’une néphropathie, il convient de réitérer la prévention. À la suite de programs efficaces de prévention secondaire et tertiaire, il convient également de promouvoir une détection précoce avec une évolution prolongée du bien-être malgré une maladie rénale. La JMR 2021 continue d’appeler à une plus grande sensibilisation des populations, des professionnels et des décideurs quant à l’importance de mesures préventives applicables tant dans les pays développés que dans les pays en développement.

The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle–income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide.

Author(s): Crews, Deidra C; Bello, Aminu K; Saadi, Gamal; World Kidney Day Steering Committee

Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world, as does its detection and treatment. In many settings, rates of kidney disease and the provision of its care are defined by socio-economic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight that many countries still lack access to basic diagnostics, a trained nephrology workforce, universal access to primary health care, and renal replacement therapies. We point to the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage worldwide by 2030 is one of the World Health Organization's Sustainable Development Goals. While universal health coverage may not include all elements of kidney care in all countries, understanding what is feasible and important for a country or region with a focus on reducing the burden and consequences of kidney disease would be an important step toward achieving kidney health equity.

Chronic Kidney Disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.

Chronic kidney disease (CKD) affects ∼10% of the world's adult population: it is one of the top 20 causes of death worldwide and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day coincide in 2018, thus offering an opportunity to reflect on the importance of women's health, and specifically their kidney health, on the community and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply these learnings more broadly. Girls and women, who make up ∼50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for the diagnosis of kidney disease, and also a state where acute and chronic kidney diseases may manifest and that may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for childbearing and on the fetus. Women have different complications on dialysis than men and are more likely to be donors than recipients of kidney transplants. In this editorial we focus on what we do and do not know about women, kidney health and kidney disease and what we might learn in the future to improve outcomes worldwide.

Author(s): Piccoli, Giorgina B; Alrukhaimi, Mona; Liu, Zhi-Hong; Zakharova, Elena; Levin, Adeera; World Kidney Day Steering Committee

Thursday, March 8, 2007, is World Kidney Day! World Kidney Day was proposed by the International Society of Nephrology and International Federation of Kidney Foundations in 2006 to broadcast a message about kidney diseases to the public, government health officials, general physicians, allied health

Functional stability of the peritoneal membrane is necessary for maintenance of peritoneal dialysis (PD) as a therapeutic option. Few studies have investigated this issue in children. We evaluated the peritoneal membrane solute transport capacity longitudinally in 26 children (mean age 11.0+/-5.5 years) receiving long-term PD. Each patient underwent a standardized peritoneal equilibration test on two occasions (mean interval between studies 19.8+/-5.9 months) to determine solute dialysate to plasma (D/P) ratios, dialysate glucose to initial dialysate glucose (D/D(0)) ratios, and mass transfer area coefficients (MTAC). The correlation of transport capacity with peritonitis history was also assessed. No significant change in MTAC, D/P, or D/D(0) values were found when comparing original and follow-up data of the group overall. However, transport of creatinine and glucose was significantly (P

The effect of peritonitis on peritoneal membrane solute transport characteristics was determined as part of a multicenter study in children on continuous ambulatory/cycling peritoneal dialysis. Ninety-three children each underwent a 4-h peritoneal equilibration test (PET) with 1,100 ml/m2 2.5% Dianeal for determination of mass transfer area coefficients (MTAC), dialysate to plasma ratios (D/P) for creatinine and urea at 0, 30, 60, 120, 180, and 240 min and dialysate glucose levels at 0, 30, 60, 120, 180, and 240 min for calculation of D/Do. The mean age of the study cohort was 10.1 +/- 5.6 years (range 0.1-19 years). There were 162 historical episodes of peritonitis; at the time of the PET tests, 36 children had never had an episode of peritonitis (group I) while 57 children had a history of one or more episodes of peritonitis (group II). In group II children, the 4-h glucose D/Do was significantly lower and the 4-h D/P creatinine ratio, the creatinine MTAC, and the glucose MTAC were significantly higher (each P < 0.05) than in group I. In children with a history of peritonitis caused by Gram-negative organisms, the 4-h glucose D/Do (P < 0.05) and the creatinine MTAC (P < 0.05) were significantly lower and the glucose MTAC (P = 0.07) nearly significantly lower than in children without a history of peritonitis. Linear regression analysis did not demonstrate a correlation between any of the variables and duration of peritoneal dialysis, while the rate of peritonitis was weakly correlated with glucose MTAC (r = 0.34, P < 0.05) and with 4-h glucose D/Do (r = -0.222, P < 0.01). We conclude that children with a history of peritonitis have peritoneal membranes that are more permeable to glucose and creatinine than children without a history of peritonitis, and that the peritoneal membranes of children who have had peritonitis caused by Gram-negative organisms are also more permeable to creatinine and glucose. Such changes are likely to have an adverse effect on membrane function and could eventually contribute to ultrafiltration failure.

T HE DEVELOPMENT of comprehensive systems for the identification and follow-up of patients with IgA nephropathy (IgAN) will better establish the importance of IgAN as a cause of end-stage renal disease (ESRD); provide a readily available resource for testing hypotheses about the pathogenesis, natural history, and possible treatment interventions for IgAN; and gain epidemiologic data about IgAN in the United States. On April 12 and 13, 1996, a group of renal pathologists and nephrologists met at the Medical Education and Research Institute in Memphis, TN, to discuss the development of a regional databank for IgAN and to reach a consensus on how renal biopsy data will be managed in that databank. The term “databank” is used instead of “registry” to emphasize the concept that the information stored in the database is meant to be accessible to all serious investigators interested in IgAN. For over 15 years, Drs Robert J. Wyatt and Bruce A. Julian, with the collaboration of many renal pathologists and nephrologists in the fourstate region of Kentucky, Tennessee, Alabama, and Mississippi, have identified many of the known cases of IgAN in the region. The IgAN databank has been established in Memphis for entry of the clinical data for these patients. At the time of this conference, 987 patients from this region had been identified, and clinical data for almost 300 (mostly from the Lexington, KY, and Memphis, TN, areas) have been entered into the IgAN databank. The database was designed using the Macintosh-based relational database, 4th Dimension (ACIUS, Cupertino, CA) and may be accessed via modem. The latest version of 4th Dimension is platform independent, allowing use by both Windows and Macintosh operating systems. The purpose of the presentations on April 12, 1996, was to develop the framework for a discussion on the development of a system for the management of renal biopsy data in the IgAN data

To define glomerular filtration rate (GFR) decline, hypertension (HTN), and proteinuria in subjects with autosomal recessive polycystic kidney disease (ARPKD) and compare with 2 congenital kidney disease control groups in the Chronic Kidney Disease in Children cohort.GFR decline (iohexol clearance), rates of HTN (ambulatory/casual blood pressures), antihypertensive medication usage, left ventricular hypertrophy, and proteinuria were analyzed in subjects with ARPKD (n = 22) and 2 control groups: aplastic/hypoplastic/dysplastic disorders (n = 44) and obstructive uropathies (n = 44). Differences between study groups were examined with the Wilcoxon rank sum test.Annualized GFR change in subjects with ARPKD was -1.4 mL/min/1.73 m(2) (-6%), with greater decline in subjects age ≥ 10 years (-11.5%). However, overall rates of GFR decline did not differ significantly in subjects with ARPKD vs controls. There were no significant differences in rates of HTN or left ventricular hypertrophy, but subjects with ARPKD had a greater percent on ≥ 3 blood pressure medications (32% vs 0%, P.0001), more angiotensin-converting enzyme inhibitor use (82% vs 27% vs 36%, P.0005), and less proteinuria (urine protein: creatinine = 0.1 vs 0.6, P.005).This study reports rates of GFR decline, HTN, and proteinuria in a small but well-phenotyped ARPKD cohort. The relatively slow rate of GFR decline in subjects with ARPKD and absence of significant proteinuria suggest that these standard clinical measures may have limited utility in assessing therapeutic interventions and highlight the need for other ARPKD kidney disease progression biomarkers.

To assess depression in children with chronic kidney disease and to determine associations with patient characteristics, intellectual and educational levels, and health-related quality of life (HRQoL).Subjects aged 6-17 years from the Chronic Kidney Disease in Children cohort study completed the Children's Depression Inventory (CDI), Wechsler Abbreviated Scales of Intelligence, Wechsler Individual Achievement Test-II-Abbreviated, and the Pediatric Inventory of Quality of Life Core Scales 4.0. Regression analyses determined associations of CDI score and depression status with subject characteristics, intellectual and educational levels, and HRQoL. A joint linear mixed model and Weibull model were used to determine the effects of CDI score on longitudinal changes in glomerular filtration rate and time to renal replacement therapy.A total of 344 subjects completed the CDI. Eighteen (5%) had elevated depressive symptoms, and another 7 (2%) were being treated for depression. In adjusted analyses, maternal education beyond high school was associated with 5% lower CDI scores (estimate, 0.95; 95% CI, 0.92-0.99). Depression status was associated with lower IQ (99 vs 88; P = .053), lower achievement (95 vs 77.5; P.05), and lower HRQoL by parent and child reports (effect estimates, -15.48; 95% CI, -28.71 to -2.24 and -18.39; 95% CI, -27.81 to -8.96, respectively). CDI score was not related to change in glomerular filtration rate.Children with depression had lower psychoeducational skills and worse HRQoL. Identifying and treating depression should be evaluated as a means of improving the academic performance and HRQoL of children with chronic kidney disease.

Anti-glomerular basement membrane (anti-GBM) disease, which is extremely uncommon in children, is characterized by rapidly progressive glomerulonephritis (RPGN) and autoantibodies against GBM collagen. Pulmonary hemorrhage is the third component in Goodpasture Syndrome. Cigarette smoking and exposure to hydrocarbons have been linked to anti-GBM disease in adults, but such an association has not been established in children. We reviewed renal biopsy and autopsy specimens over 25 years from a major tertiary care U.S. children's hospital, diagnosing anti-GBM by clinical RPGN, crescentic glomerulonephritis, and linear immunofluorescence (IF) immunoglobulin G staining in patients under 18 years of age. We identified four patients, with and without pulmonary manifestations. The sole autopsy case showed diagnostic IF despite undetectable serum anti-GBM antibodies and positive testing for serum anti-neutrophil cytoplasmic antibodies (ANCA). Three patients have survived 1–18 years following diagnosis, one of whom is recovering renal function. One adolescent had a history of smoking cigarettes and one had a probable hydrocarbon exposure. Anti-GBM disease is unusual in children, and the relationship to inhaled agents is incompletely understood. Serum anti-GBM antibodies are typically present, but cases with undetectable levels can occur. Some patients are anti-GBM and ANCA positive, with a small subset ANCA-positive, anti-GBM-negative. Ours is the first such described pediatric case.

Children with hemolytic uremic syndrome (HUS) frequently develop acute kidney injury (AKI) requiring renal replacement therapy (RRT). Peritoneal dialysis (PD) is commonly used. Despite high rates of thrombocytopenia, there is concern that platelet transfusions may worsen HUS by exacerbating microthrombi formation. We evaluated bleeding risk for PD catheter placement with or without central venous catheter (CVC) placement in children with HUS. Records from 1998 to 2007 were searched. Data regarding patient demographics, PD catheter placement, CVC placement, occurrence of procedure-associated bleeding, and time from insertion to removal of PD catheter were collected. Patients were stratified according to those who received and those who did not receive platelet transfusions. Seventy-three patients were identified. Twenty-two (30%) patients received platelet transfusion while 51 (70%) did not. Mean preoperative platelet counts were 37,600+/-21,900/mm(3) in patients receiving transfusions and 64,800 +/- 38,800/mm(3) in patients not receiving transfusions. Sixty-seven children (92%) also underwent CVC placement. There were no bleeding complications related to these procedures in either group. No differences in time to removal of the PD catheter were detected. Although caution and sound clinical judgment must be exercised, our findings suggest that PD catheter and CVC placement can be accomplished safely in most children with HUS, without need for platelet transfusion in spite of the associated thrombocytopenia.

T hursday, March 8, 2007, is World Kidney Day! World Kidney Day was proposed by the International Society of Nephrology and International Federation of Kidney Foundations in 2006 to broadcast a message about kidney diseases to the public, government health officials, general physicians, allied health professionals, individuals, and families. It was launched on March 9, 2006, and will be fully inaugurated this year (http://www.worldkidneyday.org/). The message is that kidney disease is common, harmful, and treatable. In this article, we focus on chronic kidney disease (CKD) as a global public health problem and the urgent need for all countries to have a public health policy for CKD. Until recently, decision makers in public health and biomedical science had viewed CKD as uncommon, without consequences, and untreatable until the stage of kidney failure. The care of patients with CKD had been marginalized, relegated to the subspecialty of nephrology, with payment primarily directed at dialysis and transplantation, which are too costly for the vast majority of people who live outside the developed world. At the same time, costs for other chronic diseases have been mounting. In developed countries, hypertension, diabetes, and cardiovascular disease (CVD) consume a large fraction of resources for health care. The epidemic of obesity will magnify these costs, in the young as well as in the elderly. In developing countries, the burden of these noncommunicable diseases is rising even though communicable diseases are not yet under control. We now recognize that CKD is especially common in people with other chronic diseases and multiplies the risk for adverse outcomes and costs. The public health mandate now is clear. No country can afford to overlook the burden of CKD; prevention, early detection, and intervention are the only cost-effective strategies. In the following paragraphs, we outline the rationale for key elements of a public health policy for CKD and for integrating these elements with programs for other chronic diseases. Rationale Figure 1 shows a conceptual model for CKD as the basis for a public health approach, emphasizing stages of CKD, as well as antecedents, outcomes, and risk factors for development and progression of CKD. CKD is defined as either kidney damage, estimated from markers such as albuminuria, or GFR 60 ml/min per 1.73 m for 3 mo or more (1–3). Albuminuria usually is defined as spot urine protein-to-creatinine ratio 30 mg/g, and GFR usually is estimated from serum creatinine, age, gender, and race. In the United States, recent data from the National Health and Nutrition Examination Survey (NHANES) estimate the prevalence of CKD to be 9.6% in noninstitutionalized adults, corresponding to approximately 19 million people (Table 1) (4,5). The elderly, racial and ethnic minorities, and those with lower socioeconomic status are disproportionately affected. Prevalence estimates in other countries are difficult to interpret because of differences in serum and urine creatinine levels as a result of variability among studies in assays, muscle mass, and diet. Nonetheless, in both developed and developing nations, a consistent picture is emerging of increased risk for CKD among people with CVD risk factors or established CVD. The most important adverse outcomes of CKD include not only complications of decreased GFR and progression to kidney failure but also increased risk for CVD. Many studies show that albuminuria and decreased estimated GFR each consistently and in a graded manner increase the risk for CVD (6). Indeed, recent studies showed that patients with CKD are 100 times more likely to die, principally from CVD, than to develop kidney failure (7). There now are convincing data for efficacy of treatment to prevent complications of decreased GFR, to slow progression of kidney disease, and to reduce CVD risk. Testing for CKD is feasible in clinical practice, and the same methods can be applied in large-scale screening of people who are at increased risk. Therefore, the tools to improve outcomes for CKD are already available. It now is time to establish policies to translate these advances to public health.

The pediatric ESRD patient is a member of a unique subpopulation of ESRD patients. The cause of ESRD in the pediatric patient differs markedly from the adult patient; treatment modality in the pediatric ESRD patient differs substantially from the adult patient; and outcomes such as growth

Background The development of asymptomatic gross or microscopic hematuria is relatively common in children. Objective To evaluate the clinical importance of hematuria in children and the necessity for such an evaluation using a defined diagnostic protocol. Design The protocol included a personal and family history, physical examination and blood pressure determination, and a set of comprehensive laboratory and radiological examinations. Results Of 342 children with microscopic hematuria, no cause was uncovered in 274 patients. The most common cause discovered was hypercalciuria (16%), followed by post–streptococcal glomerulonephritis (1%). Of 228 children with gross hematuria, no cause was uncovered in 86 patients. The most common cause discovered was hypercalciuria (22%). Ten patients had clinically important structural abnormalities. Fifty-three patients qualified for renal biopsy; 36 had IgA nephropathy. Conclusions Our results suggest that diagnostic evaluation for potential causes of asymptomatic microscopic hematuria in children may not be necessary. Because microscopic hematuria can, rarely, be the first sign of occult renal disease, Along-term follow-up is mandatory. As clinically important abnormalities of the urinary tract are commonly discovered in children with asymptomatic gross hematuria, a thorough diagnostic evaluation is warranted.

Kinetic modeling has proven to be a valuable tool for peritoneal dialysis (PD) prescription in adult PD patients. The clinical application of this procedure has rarely been studied in children. We therefore evaluated the PD Adequest 2.0 for Windows program (Baxter Healthcare Co., Deerfield, IL) as a prescription aid for the management of pediatric PD patients by comparing the measured and predicted PD clearances, total drain volumes, and net ultrafiltration in 34 children (15 males) (mean age 10.9 +/- 6.0 years) receiving long-term PD. In each case, a 4-h peritoneal equilibration test was conducted with a standardized test exchange volume of 1,100 ml/m2 BSA. A total of 43 24-h dialysate (plus urine in 12) collections were analyzed. The levels of agreement between measured and predicted values for weekly peritoneal and total urea Kt/V, weekly peritoneal and total creatinine clearance, daily drain volume, net ultrafiltration and daily peritoneal urea and creatinine mass removal were assessed with correlation coefficients (re) and Bland-Altman limits of agreement. The study revealed that there is a basic level of agreement between measured and modeled values for solute removal and total drain volume, with correlation coefficients ranging from 0.75 to 0.98. In contrast, the rc for net ultrafiltration was only 0.34. The majority (75%) of patients had modeled urea and creatinine clearances that were within 20% of their measured values. These data suggest that the PD Adequest 2.0 for Windows program can predict urea and creatinine clearances with reasonable accuracy in pediatric PD patients, making it a valuable resource in prescription management.

Two children with chronic renal failure developed aluminum intoxication as a result of long-term ingestion of aluminum hydroxide for the control of hyperphosphatemia. In each child, bone biopsy confirmed severe osteomalacia, the absence of features of hyperparathyroid bone disease, and massive aluminum deposition at the bone-osteoid junction. Radiographs during the period of aluminum intoxication demonstrated osteopenia, pathologic fractures, fraying of the metaphyses of the long bones, and widening of the physis. When aluminum hydroxide therapy was discontinued (each patient) and aluminum was removed with chelation therapy (one patient), radiographs demonstrated a distinctly unusual pattern of healing. Calcification of the long bones began at the most recently formed osteoid and then proceeded toward the diaphysis. This unusual healing pattern created lucent defects and a transient "bone within a bone" appearance, which resolved with further healing.