By Jessica Walker
On an anatomy diagram, the kidneys could be mistaken for a pair of fist-sized lima beans on either side of the spine. These organs are tireless filters for the blood, particularly for removing waste and balancing the body’s water and electrolytes like sodium and potassium. Despite their work, the kidneys often go unnoticed. Unnoticed, that is, until kidney disease strikes. The patient and family then are left searching for a skilled hospital with a knowledgeable team of doctors and nurses, one that can help with the multifarious issues surrounding kidney disease.
Especially when that patient is a child.
“Any chronic disease requires an interdisciplinary approach. For childhood kidney disease, you especially need expertise in nutrition, social work, and psychology to go along with the medical support,” says Dr. David Rozansky, pediatric nephrologist and professor of pediatrics at Oregon Health & Science University (OHSU) Doernbecher Children’s Hospital in Portland. “We work closely with our patients and their families to educate and help them deal with the variable consequences of what happens when kidneys don’t work well.”
OHSU Doernbecher is the sole academic healthcare center in Oregon. Supported in part by generous funds from the Henry L. Hillman Jr. Foundation, the pediatric nephrology department cares for patients with kidney disease and hypertension, trains medical students and residents, and conducts research into the treatment of kidney disorders.
“People think of kidney disease in the adult context where a lot of people who are in kidney failure are there because of diabetes and high blood pressure. Pediatric kidney disease is very different,” says Dr. Rozansky. “It’s these other diseases that occur in pediatrics that make the discipline and the patient care challenges unique.”
Children can be born with an inadequate amount of kidney tissue, called nephrons, Dr. Rozansky explains. Other children might have a condition where the body’s immune system attacks the kidney’s filters, which can lead to significant morbidity or kidney failure. Even medications for certain conditions, such as those for bone marrow transplants, can injure the kidney.
The kidney also plays a key role in blood pressure control in children, as alterations in how the kidney balances sodium can cause high blood pressure. Pediatric nephrologists at OHSU led by division head Dr. Randall Jenkins and Dr. Rozansky recently observed and described a pattern of high blood pressure, or hypertension, afflicting premature infants. The work, funded in part from the Henry L. Hillman, Jr. Foundation, was published in the journal Pediatric Nephrology.
“Every time we tested and characterized how these infants developed high blood pressure, we noted a particular set of features in their clinical characteristics, including usually undetectable levels of a hormone created by the kidney, called renin,” says Dr. Rozansky. The clinical features of the condition suggest that sodium transport is occurring outside of the normal process. As a result, the patient reabsorbs both sodium and water into the body, and develops abnormally high blood pressure.
A medicine called spironolactone successfully lowered the high blood pressure into a normal range. However, additional research must be conducted to determine what’s happening in the kidney to cause the medical issue. Dr. Rozansky says infants normally outgrow the problem, but long-term high blood pressure can affect other organ systems. “We are working hard to characterize the condition, and are most appreciative of the Henry L. Hillman Jr. Foundation funds for being instrumental in giving us the time to really focus on the project,” he says.
OHSU Doernbecher hosts the only pediatric residency program in Oregon and accepts 16 residents per year. As part of training, residents spend time in the nephrology division, caring for patients and learning about the unique challenges facing the patients and their families.
“The residents rotate through nephrology and come out with a better understanding of the important role the kidneys play in childhood,” says Dr. Rozansky, who helps direct the residency program. Residents treat hospitalized patients and learn about dialysis, as well as conduct outpatient work.
Patients come from all across Oregon and nearby states, including rural regions. “Most people live in very small communities, and that’s true for portions of Idaho, Washington, and California,” says OHSU director of development Liz Arrington. “People are often traveling sometimes eight hours each way by car because there are not other services available to them in their home communities.”
OHSU Doernbecher provides outreach to assist these communities. Dr. Rozansky himself spends several days throughout the year performing outreach. “It’s impressive the number of thank-yous I receive at every outreach clinic, as the families are so appreciative that the hospital supports a program where expertise is available closer to their homes,” he says. “[Patients] sometimes need to come to the hospital for major imaging studies and procedures, but we can often otherwise deliver the services needed.”
“To the best of our abilities, we’ll empower doctors like David to meet patients in their home communities, save them the expense of travel, and make it easier for children,” says Arrington.
Making healthcare easier for children and their families is also the goal of a new program called Novel Interventions in Children’s Healthcare (NICH). Caring for a child’s complex disease can be overwhelming. Daily tasks might include administering medications at specific times, attending medical appointments, and diligently providing treatments. When coupled with psychosocial or familial problems, these tasks can seem impossible.
NICH is there to ensure each child–and family–receives proper care.
“Every family dynamic is different,” says Dr. Rozansky. “Rather than try and do a cookie cutter approach that everyone’s done in the past, the goal is to intervene with the family, to figure out what’s going on, to make the adjustments, and try to enforce the adjustments in a cooperative way.”
Under the guidance of Dr. Michael Harris, head of the division of child psychology, NICH interventionists form partnerships with various services catered toward each family’s success. Family-based interventions include psychoeducation and behavioral therapy. Interventionists assist with navigation of the healthcare system, transportation to clinic appointments, and communication with primary care providers. They also engage with social service agencies and additional resources that address food, housing, or economic insecurity.
Arrington says academic healthcare institutions like Doernbecher form partnerships between doctors and other professionals that “knit together all these bright stars, and you create this constellation around this kid that gives her the support she needs to thrive.”
The Henry L. Hillman, Jr. Foundation’s “generosity has allowed us to pioneer discovery, and to improve healthy outcomes for kids with kidney disease,” she adds.
Kidney disorders might not be going away just yet, but OHSU Doernbecher is committed to providing exceptional care for its children, no matter the obstacles or barriers.
“At the end of the day,” says Arrington, “it comes down to the kids, and making sure they have what they need.”