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Long-term prognosis after childhood kidney disease

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Self-limiting kidney conditions are common in children, and we expect most of those with pyelonephritis, glomerulonephritis and other glomerular diseases to make a full recovery. However, a very long-term cohort study from Israel suggests that we should not be so complacent (Calderon-Margalit R et al NEJM 2018. 10.1056/NEJMoa1700993).

In Israel, military conscription has been compulsory for many years, for all men and most women of Jewish ethnicity. All conscripts undergo a thorough medical assessment at recruitment, which affords a unique opportunity to examine the health status of the entire population. Recruiting medical officers also have access to all past medical records.

Between 1967 and 1997 over 1.5 million Israelis aged 16 to 25 years (mean 17.7) were recruited. They all underwent examination, including blood pressure measurement and urine dipstick testing. They joined the cohort only if this assessment showed no signs of kidney disease. They were then followed for a mean of 30 years to identify those who later appeared on the national end-stage renal disease (ESRD) registry: these numbered 2490, of whom 940 had died. Overall, those that had any form of childhood kidney disease were four times as likely to develop ESRD (HR 4.2; 95% CI 3.5 to 5.0). The risk didn’t vary much whether they originally had congenital renal anomalies (HR 3.4), pyelonephritis (HR 4.0) or glomerular disease (HR 3.8). Those who had any childhood kidney disease tended to develop ESRD at a younger age than those who didn’t. About 30% were female, but gender didn’t appear to be an important influence.

So why should those in apparently good renal health in adolescence be so much more at risk of deteriorating renal function later in life? An editorial gives one possible explanation: we are all born with a fixed finite number of nephrons, and if, for whatever reason, someone has fewer than normal, then not only will they have less renal reserve, but also they will be at higher risk of further significant nephron loss (Ingelfinger J. doi:10.1056/NEJMe1716499). The editorial suggests that all children who had significant kidney disease should be followed up into adulthood indefinitely, which might prove difficult in practice.

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