Dr Tammy Brady Discusses the Role of the Pediatric Nephrologist on the Care Team for Metabolic Syndrome

Pediatric nephrologists are a key piece of the care team for children with metabolic syndrome because they have continual opportunities to identify and treat risk factors for cardiovascular disease, according to Tammy Brady, MD, PhD, medical director of the Pediatric Hypertension Program and associate professor of pediatrics at Johns Hopkins University.

What is the role of the pediatric nephrologist on the care team when treating children with metabolic syndrome?
When I think about metabolic syndrome, I like to instead think about it as cardiovascular disease risk factors, because when you use that terminology and you think of it in that way, it becomes a little more clear how important pediatric nephrology is in the treatment of metabolic syndrome per se. All of those component risk factors of the metabolic syndrome—obesity, hypertension, dyslipidemia, and insulin resistance—are all associated with accelerated atherosclerosis and ultimately with cardiovascular outcomes. In pediatric nephrology, sudden cardiac death is the leading cause of mortality in children with kidney disease, so we really as peds nephrologists have a responsibility to screen for these cardiovascular disease risk factors and work on treating them aggressively and early.

I think within pediatric nephrology we have a great opportunity for frequent engagement with the families and the patients because we see these children longitudinally. Many of us have the privilege of caring for children from infancy to adulthood, and those relationships can be pretty intense with lots of follow-up, so lots of opportunity again to screen for and treat those cardiovascular disease risk factors, which could really make a big difference long-term in their both pediatric health but also in terms of outcomes as they become adults.

Another thing to be mindful of is that one of the biggest things we get referred as a pediatric nephrologist is hypertension, and with hypertension it often comes comorbid with obesity, and with that you often will see dyslipidemia as well as insulin resistance. And so as a pediatric nephrologist getting a new referral for hypertension, it’s important for us to remember this and to screen for those cardiovascular disease risk factors, which helps you risk-stratify the patient and really helps to optimize their health, again both in the pediatric period as well as in adulthood. We know that those cardiovascular disease risk factors, when they’re present in childhood, they’re much more likely to be present in adulthood, and it’s in adulthood where you have those cardiac events.

Also, a lot of the conditions that we treat as pediatric nephrologists, these chronic long-term conditions, require medications that can have side effects that increase your cardiovascular risk. Many of the medications that we rely on can lead to increased weight, increased blood pressure, elevated glucose, as well as dyslipidemia. And so as we prescribe these, we really need to be vigilant to screen for these risk factors and also treat them as they become apparent or become manifest.

As a pediatric nephrologist, a lot of our focus is on cardiovascular health promotion, treating these risk factors to avoid cardiac end points, but newer evidence is coming out that a lot of these risk factors also lead to accelerated kidney disease or kidney disease progression and ultimately even end-stage renal disease, so as a pediatric nephrologist we really have a unique opportunity to make a real big difference in the ultimate health of these children as they become adults.
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