Anemia is a common complication of chronic kidney disease (CKD) in adult and pediatric patients. It has traditionally been treated with erythropoietin therapy and iron supplementation, with great success. With the discovery of the major transcription factor hypoxia inducible factor (HIF) for the erythropoietin gene in 1992, molecules were created that inhibit the HIF prolylhydroxylase enzyme. This new class of drug-called HIF stabilizers, or HIF prolyl-hydroxylase inhibitors-prevents the proteasomal degradation of HIF-α, thereby inducing upregulation of the erythropoietin gene. This new strategy for treating CKD anemia is already in phase III clinical trials in adults, and the potential advantages of this therapy are that it is orally active (thereby avoiding injections), and patients are exposed to lower circulating levels of erythropoietin. The long-term safety of this strategy, however, requires elucidation in these trials, particularly since there are many other hypoxia-sensitive genes, notably, angiogenic factors such as vascular endothelial growth factors (VEGF), as well as glycolytic enzymes. As with all new therapies, it is only once a positive benefit: risk profile has been ascertained in adults that the treatment will translate across into pediatrics. Specific issues in the pediatric CKD population are discussed in this review.

Conclusion: This report discusses the outcomes of a large cohort of dialysis patients with SARS-CoV-2, infection affecting more diabetics and non-Caucasians; with a high case fatality ratio, which increased significantly with age, frailty, smoking, increasing CRP and neutrophil:lymphocyte ratio at presentation.

Socioeconomic status (SES) is associated with childhood anthropometry, but little is known about how it is associated with tissue growth and body composition. To investigate this, we looked at components of SES at birth with growth in early and mid‐childhood, and body composition in a longitudinal study in Nepal. The exposure variables (material assets, land ownership, and maternal education) were quantified from questionnaire data before birth. Anthropometry data at birth, 2.5 and 8.5 years, were normalized using WHO reference ranges and conditional growth calculated. Associations with child growth and body composition were explored using multiple regression analysis. Complete anthropometry data were available for 793 children. There was a positive association between SES and height‐for‐age and weight‐for‐age, and a reduction in odds of stunting and underweight for each increase in rank of SES variable. Associations tended to be significant when moving from the lower to the upper asset score, from none to secondary education, and no land to >30 dhur (~500 m2). The strongest associations were for maternal secondary education, showing an increase of 0.6–0.7 z scores in height‐for‐age and weight‐for‐age at 2.5 and 8.5 years and 0.3 kg/m2 in fat and lean mass compared to no education. There was a positive association with conditional growth in the highest asset score group and secondary maternal education, and generally no association with land ownership. Our results show that SES at birth is important for the growth of children, with a greater association with fat mass. The greatest influence was maternal secondary education.

Background States which reduce foetal oxygen delivery are associated with impaired intrauterine growth. Hypoxia results when barometric pressure falls with ascent to altitude, and with it the partial pressure of inspired oxygen (‘hypobaric hypoxia’). birthweight is reduced when native lowlanders gestate at such high altitude (HA)—an effect mitigated in native (millennia) HA populations. Studying HA populations offer a route to explore the mechanisms by which hypoxia impacts foetal growth. Methods Between February 2017 and January 2019, we prospectively studied 316 pregnant women, in Leh, Ladakh (altitude 3524 m, where oxygen partial pressure is reduced by 1/3) and 101 pregnant women living in Delhi (low altitude, 216 m above sea level). Results Of Ladakhi HA newborns, 14% were small for gestational age (<10th birthweight centile) vs 19% of newborn at low altitude. At HA, increased maternal body mass index, age, and uterine artery (UtA) diameter were positively associated with growth >10th weight centile. Conclusions This study showed that Ladakhi offspring birthweight is relatively spared from the expected adverse HA effects. Furthermore, maternal body composition and greater UtA size may be physiological HA adaptations and warrant further study, as they offer potential mechanisms to overcome hypoxia-related growth issues. Impact Reduced foetal oxygen delivery seen in native lowlanders who gestate at HA causes foetal growth restriction—an effect thought to be mitigated in native HA populations. We found that greater maternal body mass and UtA diameter were associated with increased offspring birthweight in a (Ladakh) HA population. This supports a role for them as physiological mediators of adaptation and provides insights into potential mechanisms that may treat hypoxia-related growth issues.

Food security exists when people have access at all times to adequate, safe and nutritious food for a healthy and active life. Food insecurity contributes to poor health and nutritional outcomes (1) . We assessed food security status in a cohort of households in Nepal's central Terai.Data were collected in Dhanusha district. Food insecurity was assessed with the Household Food Insecurity Access Scale (HFIAS) (1) , Household Dietary Diversity Score (HDDS) (2) (7 day recall) and Months of Adequate Household Food Provisioning (MAHFP) (3) . Socioeconomic status (SES) was determined by principal components analysis (4) . Chi-squared tests were used to compare urban and rural households, and univariable regression models to assess associations between socioeconomic status and food security measures.In 837 households (340 urban), mean HFIAS score was 0.69 (SD 2.80) and the prevalence of food insecurity was 8.6% (n = 72). There was no difference between urban and rural households. Mean HDDS was 9.24, and higher in urban households. 92% of respondents had no difficulty obtaining food in the past 12 months; 3% reported difficulty obtaining food for 3 months or longer. There was no difference between rural and urban locations except in the post-monsoon season, when rural households had greater food insecurity. A test for trend showed an inverse relationship between socioeconomic quintile and HFIAS score (p < 0.001). A positive association was seen between socioeconomic quintile and consumption of meat, dairy or eggs. Our data suggest a greater proportion of food secure households (50% vs 92%) than described in the Nepal Demographic and Health Survey (NDHS) for the central Terai (5) . Most households in our cohort were food secure all year round and had a diverse dietary intake, considerably better than that shown in the NDHS. The likelihood of being food secure was related to SES and rural residents were more vulnerable than urban residents in the post-monsoon period.

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Pathological low birth weight due to fetal growth restriction (FGR) is an important predictor of adverse obstetric and neonatal outcomes. It is more common amongst native lowlanders when gestating in the hypoxic environment of high altitude, whilst populations who have resided at high altitude for many generations are relatively protected. Genetic study of pregnant populations at high altitude permits exploration of the role of hypoxia in FGR pathogenesis, and perhaps of FGR pathogenesis more broadly. We studied the umbilical cord blood DNA of 316 neonates born to pregnant women managed at the Sonam Norboo Memorial Hospital, Ladakh (altitude 3540m) between February 2017 and January 2019. Principal component, admixture and genome wide association studies (GWAS) were applied to dense single nucleotide polymorphism (SNP) genetic data, to explore ancestry and genetic predictors of low birth weight. Our findings support Tibetan ancestry in the Ladakhi population, with subsequent admixture with neighboring Indo-Aryan populations. Fetal growth protection was evident in Ladakhi neonates. Although no variants achieved genome wide significance, we observed nominal association of seven variants across genes (ZBTB38, ZFP36L2, HMGA2, CDKAL1, PLCG1) previously associated with birthweight.

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