Nephrology and PUV Care Goals

So once you come to nephrology, our goal is to again, just like Cura Pis, our goal is to provide comprehensive care and the kidneys control a lot of things in the body. And so we came up with an acronym that really helps us provide comprehensive care to patients with chronic kidney disease, and an acronym is called GRABABUC, and it stands for all of the elements of care that really can be affected in someone with chronic kidney disease. So the first is growth. So we know that patients with pediatric chronic kidney disease can have a lot of growth problems for multiple reasons. Some of it can be feeding related, some of it can be some of the bone abnormalities that can occur. But we also know that patients with chronic kidney disease can also have resistance to the normal levels of growth hormone that are secreted by the pituitary gland in the brain. And therefore, we need to really pay attention to how well a patient is growing. Um, the second one is acidosis. So again, our bodies like to be in a certain pH and your kidneys help maintain that. And so that is something we can screen for and try to provide supplement if necessary. Again, I alluded to this, but the kidneys, um, do a lot of management with bone and mineral health. So the kidneys control a lot of the calcium and phosphorus within the body, and therefore, if those things are abnormal, we know that the, uh, can lead to not only poor bone growth, but also to calcium deposits in blood vessels. And so again, we really want to try to maintain normal growth, but also try to keep the cardiovascular system as healthy as possible. Um, again, the A in the middle stands for anemia management. So, the kidneys can typically make a hormone called erythropoietin that actually goes to the bone marrow and tells the bone marrow to make red blood cells. And so, as kidney function declines, um, the kidneys may have trouble making that erythropoietin, and so sometimes we do need to intervene to help understand how to effectively keep people's hemoglobin normal. Um, but probably the two most important parts from a pediatric nephrologists standpoint is really trying to manage the B and the U of grab a buck, the B standing for blood pressure management and the U standing for proteinuria or urine protein to creatinine ratios. So, definitely, when you look at all of the studies that are out there for pediatric chronic kidney disease, probably, um, Of course, in addition to bladder management is really from a pediatric nephrologist, um, we know that if your blood pressure is out of control or you have excessive protein in your urine, that you are more likely to have faster loss of your kidney function. And therefore, it's very important for us to really monitor and treat high blood pressure and protein in the urine as much as possible. And one of the gold standards of blood pressure, um, evaluation and someone with chronic kidney disease is doing a 24 hour blood pressure test. Um, so this is a machine that, um, puts on a kid's arm, and they wear it during sleep and during the day. Now, we typically start that at our program around age 7, and not every 7 year old is ready to wear a 24 hour blood pressure monitor, but definitely we start preparing families for that because we know that it gives us the best, um, The best evaluation of someone's blood pressure and therefore, um, gives us the ability to really intervene. Um, same way with urine protein to creatinine. So again, Doctor Reddy and Nicole make sure that our patients get at least a yearly, um, urine protein to creatinine ratio assessment. And if that is elevated, that's another reason to come see, um, pediatric nephrology and again to start having evaluation and more close management. And then finally, um, again, we talk about the overall growth issues. So, um, chronic kidney disease is a little bit, I always say like Goldilocks, too much, too little, just right. And we know that not only our patients can have some feeding issues and can have, um, are at risk of being underweight, but we also know that the overall goal is for us is to try to make them healthy as adults. We know that there's a strong link between cardiovascular disease and chronic kidney disease. And so our goal is to really try to keep their heart as healthy as possible. And a lot of that is even just the basics that you would tell anybody. So really trying to find a heart healthy diet and really trying to maintain a normal weight. So really trying to avoid obesity, promoting healthy lifestyle, but also just promoting healthy food choices in general. And then finally, again, the K of the overall health. Um, definitely with CKD just like with PUV in general, there can be a lot of anxiety about, um, going to progressing on to end-stage renal disease. And so our goal is really to ensure that, again, patients can cope with what's going on. Um, and we do know that, um, Again, CKD can progress, and historically, what we do see in the literature is about 60% of children with chronic kidney disease as a child will progress to end-stage renal disease before they become an adult. And so, um, our goal is to really kind of maneuver kids through that and to really help monitor and keep them in the best health, so we can, um, if they do need a kidney transplant, help them get there. Um, in terms of how the ability to do this, so we also developed a decision support tool to go along with our grab a Buck called the Grab a Buck Progress Towards therapy goals. So this is something that, again, when kids, um, patients with chronic kidney disease that are followed at Cincinnati Children's, um, we do pre-visit planning, um, so we prepare for their visits before they come, and we Really try to get a better assessment of where they are. And so this is an example of, I believe it's a, it might have been an 8 year old male, um, probably a patient with PUV. And this just gives us an assessment of what his kidney function is and how he's meeting all of these grab a buck outcomes. So as he comes to the clinic, we can be better prepared for how we should direct his care during the visit.