Journal of

Clinical Medicine

Article
Anemia and Iron Deficiency in Children with Chronic
Kidney Disease (CKD): Data from the Know-Ped
CKD Study
Keum Hwa Lee 1,2,† , Eujin Park 3,† , Hyun Jin Choi 4 , Hee Gyung Kang 4 , Il-Soo Ha 4 ,
Hae Il Cheong 4 , Young Seo Park 5 , Heeyeon Cho 6 , Kyoung Hee Han 7 , Seong Heon Kim 8 ,
Min Hyun Cho 9 , Joo Hoon Lee 5, *,‡ and Jae Il Shin 1,2,10, *,‡
1 Department of Pediatrics, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu,
C.P.O. Box 8044, Seoul 03722, Korea; azsagm@yuhs.ac
2 Division of Pediatric Nephrology, Severance Children’s Hospital, Seoul 03722, Korea
3 Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul 07441, Korea;
eujinpark@hallym.or.kr
4 Department of Pediatrics, Seoul National University Children’s Hospital & Seoul National University
College of Medicine, Seoul 03080, Korea; h_choi@daum.net (H.J.C.); kanghg@snu.ac.kr (H.G.K.);
ilsooha@snu.ac.kr (I.-S.H.); cheonghi@snu.ac.kr (H.I.C.)
5 Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of
Medicine, 88, Olympic-ro 43-Gil, Songpa-Gu, Seoul 05505, Korea; yspark@amc.seoul.kr
6 Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine,
Seoul 06351, Korea; heeyeon1.cho@samsung.com
7 Department of Pediatrics, Jeju National University School of Medicine, Jeju 63241, Korea;
hansyang78@gmail.com
8 Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan 50612, Korea;
pedkimsh@pusan.ac.kr
9 Department of Pediatrics, Kyungpook National University, School of Medicine, Daegu 41404, Korea;
chomh@knu.ac.kr
10 Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul 03722, Korea
* Correspondence: pedkid@gmail.com (J.H.L.); shinji@yuhs.ac (J.I.S.); Tel.: +82-2-3010-3926 (J.H.L.);
+82-2-2228-2050 (J.I.S.); Fax: +82-2-473-3725 (J.H.L.); +82-2-393-9118 (J.I.S.)
† These authors are contributed equally to this work.
‡ These authors are contributed equally to this work.




Received: 5 December 2018; Accepted: 15 January 2019; Published: 29 January 2019


Abstract: Children with chronic kidney disease (CKD) are at high risk of anemia, an important
risk factor for cardiovascular disease and poor quality of life. The present study used baseline
data from the Korean cohort study for Outcome in patients With Pediatric Chronic Kidney Disease
(KNOW-PedCKD). A Total of 437 patients was included in the analyses excluding missing data.
The characteristics of patients with and without anemia and those of patients with and without iron
deficiency were compared. Logistic regression analysis and Pearson correlation were conducted
to evaluate associated risk factors and correlations in children with CKD. Anemia in children with
CKD was associated with older age, low body weight and body mass index (BMI) z-score, birth age,
preceding glomerulonephritis, decreased estimated glomerular filtration rate (eGFR), low levels of
serum albumin and calcium, high levels of serum intact parathyroid hormone (iPTH), and serum
phosphorus. Anemia was correlated positively with changes in the BMI z-score, body weight, and
serum albumin and cholesterol levels, but correlated negatively with serum calcium, iPTH, ferritin
levels, and transferrin saturation. Iron deficiency in children with CKD was associated with young
age, low hemoglobin and serum ferritin levels, high BMI z-scores, and low levels of serum iPTH.
This is the first nationwide cohort study of anemia in Korean children with CKD and the first
prospective pediatric CKD cohort study in Asia. The study results demonstrated that anemia and iron

J. Clin. Med. 2019, 8, 152; doi:10.3390/jcm8020152 www.mdpi.com/journal/jcm

J. Clin. Med. 2019, 8, 152 2 of 14

deficiency are affected by various factors, including age, BMI, and levels of serum iPTH. To improve
the retrospective outcome of affected children, it is important to understand the effect of each of
these factors and to attempt an early intervention to prevent anemia and iron deficiency by regular
measurement of these parameters in children at risk.

Keywords: anemia; iron deficiency; chronic kidney disease

1. Introduction
Anemia is a major complication in children with chronic kidney disease (CKD). Data from the
North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) revealed the prevalence
of anemia in children with CKD, ranging from 73 to 93%, depending on the CKD stage [1]. Among
children with CKD, anemia is an important risk factor for the development and progression of
cardiovascular disease, including left ventricular hypertrophy [2,3]. In addition, anemia negatively
affects the quality of life of patients and their caregivers [4,5].
The chronic inflammatory state in patients with CKD results in decreased erythropoiesis in the
bone marrow, reduced production of erythropoietin (EPO) in the kidneys, and impaired iron absorption
and mobilization due to increased production of hepcidin in the liver. Uremia, oxidative stress, and
nutritional deficiencies also contribute to anemia in CKD [6]. Therefore, although therapeutic targets
involving hemoglobin and iron levels are controversial, use of an erythropoiesis-stimulating agent
(ESA) and iron supplementation are key approaches to the management of anemia in CKD patients [7,8].
However, treatment of anemia in children with CKD is known to be less effective than that in adults [9],
and studies of anemia and iron deficiency are limited due to the small numbers of pediatric patients
with CKD.
The objectives of this study were to examine the characteristics of patients with anemia and iron
deficiency among children with CKD and to identify associated risk factors and correlations using
baseline data from the Korean cohort study for Outcome in patients With Pediatric Chronic Kidney
Disease (KNOW-PedCKD).

2. Materials and Methods

2.1. Study Design and Population

The KNOW-PedCKD study is a nationwide observational prospective cohort study of pediatric
CKD patients with CKD stages 1–5 recruited from seven major pediatric nephrology centers in Korea.
Details on the study design and objectives have been published previously [10]. For the current analysis,
we included subjects enrolled from April 2011 to February 2016 (n = 437). A total of 437 patients
was included in the analysis. If the individual tests have missing data, they were excluded in the
final analysis.

2.2. Clinical and Laboratory Measurements

CKD was defined and staged according to the Kidney Disease Improving Global Outcomes
(KDIGO) criteria [7]. For patients enrolled in the KNOW-PedCKD study, the estimated glomerular
filtration rate (eGFR) was calculated using the bedside Chronic Kidney Disease in Children (CKiD)
formula [11]. Data on medical history and medication use were collected through a self-administered
questionnaire. Anemia was defined as hemoglobin below the 5th percentile for age/sex or treatment
with an erythropoiesis-stimulating agent (ESA) [7,12]. Iron deficiency was defined as serum ferritin
<100 ng/mL and transferrin saturation <20% [7,8]. Hypertension was defined as the average value
of the systolic and/or diastolic BP measurements above the 95th percentile for age, sex, and height.
 s expressed as percentages were compared between groups with the Chi-
sexact
expressed as percentages
test. Continuous were compared
variables betweenasgroups
were expressed a mean with the Chi-
± standard
yexact test. Continuous
the Kruskal–Wallis variables
test. A logistic were expressed
regression as a was
analysis mean ± standard
conducted to
by the Kruskal–Wallis test. A logistic regression analysis
s (ORs) and confidence intervals (CIs) of associated risk factors for anemia was conducted to
J. Clin. Med. 2019, 8, 152 3 of 14
scohort.
(ORs) andThe confidence intervals
correlations among (CIs) of associated
characteristics risk factors
of anemia for anemia
in the cohort were
. Clin. Med. 2019, 8, x FOR PEER REVIEW 3 of 13
rcohort. The correlations
correlation. All statistical among characteristics
analyses were performedof anemia in the
using SAScohort were
statistical
r3. correlation.
Windows, All
Statisticalversion
Analysesstatistical
The9.4;presenceanalyses
SAS institute, were performed using SAS statistical
Cary, NC).included heart failure, arrhythmia, urinary tract infection, diabetes,
of comorbidity
Windows, versionretinopathy,9.4; SAS institute, Cary, NC).
sensorineural hearing loss, developmental delay, and metabolic syndrome.
Categorical variables expressed as percentages were compared between groups with the Chi-
quare test and Fisher’s exact test.
2.3. Statistical Continuous variables were expressed as a mean ± standard
Analyses
eviation and analyzed
s of Overall CKD Cohort by the Kruskal–Wallis test. A logistic regression analysis was conducted to
Categorical variables expressed as percentages were compared between groups with the
setermine
of Overallthe CKDodds ratios (ORs) and confidence intervals (CIs) of associated risk factors for anemia
Cohort
aracteristics Chi-square
and clinical test and Fisher’s
manifestations of patientsexactwithtest.CKD
Continuous
are shown variables were expressed as a mean ± standard
nd iron deficiency in the cohort. The correlations among characteristics of in
anemia in the cohort were
aracteristics
the patients and clinical
deviation manifestations
and analyzed of patients
by with CKD
the Kruskal–Wallis are shown
totest. inAthe in
logistic regression analysis was conducted to
nalyzed withwas 9.5
a Pearson ± 5.3r correlation.
years, and most patients
All statistical were found
analyses were be
performed using SAS statistical
ng the thepatients
CKD was 9.5
patients, ± 5.3 patients
determine
male years, and
the odds weremost
ratios
morepatients
(ORs)
frequent were
and found
confidence
than femaleto be in the (CIs) of associated risk factors for anemia
intervals
patients
oftware (SAS system for Windows, version 9.4; SAS institute, Cary, NC).
ng the CKD
9 versus n patients,
= 138).and male
The iron patients
mostdeficiency
common were more
in disease
the frequent
cohort. Thethan
leading female
correlations
to CKD waspatients
among
renal characteristics of anemia in the cohort were
9 versus n = 138).
66 patients had analyzed
eResults The most common
with a Pearson
kidney dysplasia disease
with/out leading
r correlation.
vesico-ureteralto CKD was
All statistical
reflux (VUR)renal
analyses were performed using SAS statistical
e 66 patients had software
lomerulonephritis. kidney
Overall,dysplasia
(SAS
27.2% of with/out
systempatients vesico-ureteral
for Windows,
were version
in CKD reflux
9.4;2,SAS
stage (VUR)
whileinstitute,
a Cary, NC, USA).
lomerulonephritis.
stage
1. Overall,
5 in Characteristics
Baseline a pre-dialysis state. 27.2% of patients
of Overall CKD Cohort were in CKD stage 2, while a
3. Results
stage 5 in a pre-dialysis state.
The demographic characteristics and clinical manifestations of patients with CKD are shown in
ographics of the chronic kidney disease (CKD) patient cohort.
able
ographics 1. The mean
of the 3.1. kidney
age
chronic Baseline
of Characteristics
the patients
disease was 9.5
(CKD) of± Overall
patient 5.3cohort.CKD
years, andCohort
most patients were found to be in the
middle 10s (43.9%). Among Total Patients (%)
The the CKD patients,
demographic male patients
characteristics
Total andwere moremanifestations
clinical frequent than female patients
of patients with CKD are shown
egardless of age (n = 299 versus n = 138). The (nPatients
=most (%)
437) common disease leading to CKD was renal were found to be
in Table 1. The mean age of(nthe patients was 9.5 ± 5.3 years, and most patients
rs)
ypoplasia (41.4%),inwhile 66 patients had kidney 9.5=±437)
5.3
dysplasia with/out vesico-ureteral reflux (VUR)
rs)
ars the middle 10s (43.9%). Among
9.5 ± 5.3the CKD patients, male patients were more frequent than female
43 (9.8)
15.1%), and 27.7% patients had glomerulonephritis.
regardless of age (n77 Overall, 299 versus npatients
=(17.6) 27.2% of = 138). were
The most in CKD stage 2,
common while leading
disease a to CKD was
ars 43 (9.8)
minority
ars (3.9%) had CKD stage 5 in a pre-dialysis
renal hypoplasia (41.4%), while state.
66 patients had kidney dysplasia with/out vesico-ureteral reflux (VUR)
77 (17.6)
ears 125 (28.6)
ears
years (15.1%), and 27.7% had glomerulonephritis. 125 (43.9)
192 (28.6) Overall, 27.2% of patients were in CKD stage 2, while a
yearsTable 1. Baseline demographics of the chronic 192 kidney(43.9) disease (CKD) patient cohort.
e/female) minority (3.9%) had CKD stage 299/1385 in a pre-dialysis state.
e/female) CKD
preceding 299/138 Total Patients (%)
preceding CKD
y glomerulopathy * Variable
Table 1. Baseline 61 (14.0)
demographics of the chronic (n =kidney
437) disease (CKD) patient cohort.
y glomerulopathy
dary glomerulopathy * * 61 (13.7)
60 (14.0)
Age (years) 9.5 ± 5.3
dary glomerulopathy
y dysplasia with/out0–2*
vesico-ureteral reflux 60 (15.1)
66 (13.7) Total Patients (%)
yearsVariable 43 (9.8)
ylasia
dysplasia with/out vesico-ureteral reflux 66 (15.1)
181 (41.4) (n = 437)
2–6 years 77 (17.6)
plasia Age (years) 181 (41.4)
69 (15.8) 9.5 ± 5.3
6–12 years 125 (28.6)
ges 0–2 years 69 (15.8) 43 (9.8)
12–17 years 192 (43.9)
ges 2–6 years 79 (18.1) 77 (17.6)
Sex (male/female) 299/138
6–12 years 79 (18.1)
119 (27.2) 125 (28.6)
Disease preceding CKD
12–17 years 192 (43.9)
119 (27.2)
74 (16.9)
Primary glomerulopathy
Sex (male/female) * 61 (14.0) 299/138
74 (16.3)
71 (16.9)
Secondary glomerulopathy
Disease preceding*CKD 60 (13.7)
71 (17.6)
77 (16.3)
Kidney dysplasia
Primary with/out vesico-ureteral
glomerulopathy * reflux 66 (15.1) 61 (14.0)
77
17 (17.6)
(3.9)
HypoplasiaSecondary glomerulopathy * 181 (41.4) 60 (13.7)
ight (kg) Kidney dysplasia with/out 17 (3.9)
3.0 ± 0.7 vesico-ureteral reflux 66 (15.1)
Other 69 (15.8)
eight (kg)
(weeks) CKD stages Hypoplasia
3.0 ±±0.7
38.3 3.1 181 (41.4)
(weeks)(years) †
eduration Other 38.3 ±
5.7 ± 4.7 3.1 69 (15.8)
I 79 (18.1)
nduration † II function (years) ‡
(years)renal
of aggravated
CKD stages 5.7 ±
2.9 ± 3.4
4.7 119 (27.2)
I 79 (18.1)
neported
of aggravated renal ※
function
IIIa
as n (%); CKD, chronic (years) ‡ 2.9 ± 3.4 74 (16.9)
※
IIkidney disease; n, number of patients. * More 119 (27.2)
eported IIIb chronicIIIa
as n (%); CKD, kidney disease; * More71 (16.3)
stagen,IIInumber of patients.
※
ribed in supplementary Table S1; CKD is divided into subgroup 74 (16.9)
ribed in IV Table IIIb
supplementary S1;
※
CKD stage III is divided into subgroup 77 (17.6) 71 (16.3)
rding to the eGFR (estimated glomerular filtration rate), stage IIIa is an eGFR
rding V IV 17 (3.9) 77 (17.6)
Stage to3bthe eGFR
is an eGFR(estimated
between glomerular
30 and 44; †filtration rate), stage
Disease duration IIIato
refers is the
an eGFR
years
Birth weight V (kg) 3.0 ± 0.7 17 (3.9)
Stage 3b data
baseline is ancollection
eGFR between
and the 30CKDand 44; † Disease
diagnosis duration refers to the years
(kg) date; ‡ Duration of aggravated38.3 ± 3.1
‡
Birth
Birth age (weeks) weight 3.0 ± 0.7
hebaseline data collection
years between the dateand the
the CKD
of Birth baseline
age diagnosis date; Duration
data collection
(weeks) and theof aggravated
date of onset 38.3 ± 3.1
Disease duration (years) † 5.7 ± 4.7
he years
e to CKD. between the date of the baseline data
Disease duration (years) † collection and the date of onset 5.7 ± 4.7
e to CKD. Duration ofDuration
aggravated renal function
of aggravated renal(years)
function‡ (years) ‡ 2.9 ± 3.4 2.9 ± 3.4
Numerical values areNumerical
reported values
as n (%); CKD, chronic
are reported as n (%);kidney disease;kidney
CKD, chronic n, number
disease;ofn,patients.
number of* More
patients. * More detailed data
are described
detailed data are described in supplementary
in supplementary TableS1;
Table S1; ※ CKD
CKDstagestageIIIIII
is divided into subgroup
is divided stage IIIa and IIIb according to
into subgroup
the eGFR (estimated glomerular filtration rate), stage IIIa is an eGFR between 45 and 59 and Stage 3b is an eGFR
stage IIIa and IIIb according to the eGFR (estimated glomerular filtration rate), stage IIIa is an eGFR
between 30 and 44; † Disease duration refers to the years between the date of the baseline data collection and the
between 45 and 59 and CKD Stage 3b is an
diagnosis eGFR
date; between
‡ Duration 30 and 44;renal
of aggravated † Disease
functionduration
means the refers
years to the years
between the date of the baseline data
collection and the
between the date of the baseline data collectiondate of onsetandof the
thepreceding disease date;
CKD diagnosis to CKD. ‡ Duration of aggravated

renal function means the years between the date of the baseline data collection and the date of onset
of the preceding disease to CKD.
of Overall CKD Cohort
of Overall CKD Cohort
racteristics and clinical manifestations of patients with CKD are shown in
racteristics
he patients and
was clinical
9.5 ± 5.3manifestations
years, and most of patients
patients were
with CKD
foundare
to shown in
be in the
he patients was 9.5 ± 5.3 years, and most patients were found to
g the CKD patients, male patients were more frequent than female patients be in the
g versus
the CKD n patients, male
= 138). The patients
most were disease
common more frequent
leadingthan female
to CKD patients
was renal
versus n = 138). TheJ.
66 patients hadJ. kidney most
Clin.
Clin. Med. common
Med.
dysplasia2019, disease
8, 152
2019, 8, xwith/out
FOR PEER leading to CKD
vesico-ureteral
REVIEW was renal
reflux (VUR) 3 of 13 4 of 14
66 patients had kidney
omerulonephritis. Overall,dysplasia
27.2% of with/out vesico-ureteral
patients were reflux
in CKD stage (VUR)
2, while a
omerulonephritis. Overall,
stage 5 in a pre-dialysis 27.2% of patients were in CKD stage 2, while a
state.
2.3. Statistical Analyses
3.2.state.
stage 5 in a pre-dialysis CKD Patients with Anemia
raphics of the chronic Categorical variables
kidney disease (CKD) patient expressed
cohort. as percentages were compared between groups with the Chi-
graphics of the chronic kidneyCharacteristics
disease (CKD) patient of the CKD patients with and without anemia are listed in Table 2. Overall, older
cohort.
square test and Fisher’s Totalexact
Patientstest.
(%) Continuous variables were expressed as a mean ± standard
age (p < 0.001), glomerulonephritis
Total
as a preceding disease (p < 0.001), higher CKD stages (p < 0.001),
deviation and analyzed by (nPatients
the (%)
= 437)Kruskal–Wallis test. A logistic regression analysis was conducted to
higher diastolic blood9.5pressure (DBP) (p = 0.029), lower body weight (p = 0.036), proteinuria (p < 0.001),
s) determine the odds ratios(n =±437)
(ORs) 5.3 and confidence intervals (CIs) of associated risk factors for anemia
s)s and use of a renin-angiotensin 9.5 ± 5.3
43 (9.8) system inhibitor (p = 0.002) were significantly associated with CKD
s
and iron deficiency in the cohort. 7743(17.6)
(9.8) The correlations among characteristics of anemia in the cohort were
patients with anemia, compared to those without. CKD patients with anemia were treated with
s
ars analyzed with a Pearson 125 r77correlation.
(17.6)
(28.6) All statistical analyses were performed using SAS statistical
ars
erythropoietin (EPO)-stimulating 125 (28.6)
agents (21.6%, p = 0.001) and supplemental iron therapy (36.3%,
ears software (SAS system for 192 Windows,
(43.9) version 9.4; SAS institute, Cary, NC).
ears
female) p = 0.001), and showed 192 significantly
(43.9)
299/138 lower ferritin levels (p < 0.001) than those without anemia. There
/female) CKD
receding were no significant differences 299/138 in sex distribution, platelet counts, systolic blood pressure, or transferrin
receding CKD 3.* Results
glomerulopathy
saturation according61to(14.0) the presence of anemia.
glomerulopathy
ry glomerulopathy * * 61 (13.7)
60 (14.0)
ry glomerulopathy
dysplasia 3.1.vesico-ureteral
with/out * Baseline Characteristics
reflux of(15.1)
60
66 Overall CKD Cohort
(13.7)
dysplasia with/out vesico-ureteral Table
asia reflux 2. Comparisons (41.4) of characteristics of patients with anemia in the CKD cohort analysis.
66 (15.1)
181
asia The demographic characteristics 181 (41.4)
69 (15.8) and clinical manifestations of patients with CKD are shown in
69 (15.8) Patients with Anemia Patients without Anemia
es Table 1. The mean age of the patients was 9.5 ± 5.3 years, and most patients(nwere = 261)found to be in the
Variable P Value
(n = 172)
es 79 (18.1)
middle 10s Age(43.9%).
(years) Among the CKD patients, male patients
79 (18.1) 172 were more frequent 261than female patients
<0.001 ††
119 (27.2)
regardless 0–2 of years
age (n = 299 119 versus
(27.2)
74 (16.9) n = 138). The most 11common
(6.4) disease leading
28 (10.7)to CKD was renal
hypoplasia2–6 years
(41.4%),
6–12 years
while71 7466(16.9)
patients had kidney dysplasia
(16.3)
17 (9.9)
49 (28.5)
60 (23.0)
with/out vesico-ureteral
76 (29.1)
reflux (VUR)
71 (17.6)
77 (16.3)
(15.1%), and 12–1727.7%
yearshad glomerulonephritis. Overall, 27.2% 95 (55.2)of patients were 97 in(37.2)
CKD stage 2, while a
77
17 (17.6)
(3.9)
minority Sex (male/female)
(3.9%) had CKD 3.0 stage 119/53 175/86 0.641 ††
ght (kg) Disease preceding CKD ± 0.75 in a pre-dialysis state. 150
17 (3.9) 228 <0.001 ††
ght (kg)
(weeks) Glomerulonephritis38.3 3.0 ±±0.7
3.1 49 (32.7) 30 (13.2)
(weeks)(years) †
uration Table 1. Baseline demographics
Non-glomerulonephritis 38.3
5.7 ±±4.73.1 of the chronic kidney 101 disease
(67.3) (CKD) patient cohort.
198 (86.8)
uration
of † function
(years)renal
aggravated
CKD stages
(years) ‡
5.7 ± 4.7
2.9 ± 3.4
172 261 <0.001 ††
of aggravated renal function
I
‡Variable 2.9 ± 3.4 of patients. * More
8 (4.7) Total Patients (%)
71 (27.2)
ported as n (%); CKD, chronic(years)
IIkidney disease; n, number 26 (15.1) 92 (35.2)
ported as n (%); CKD, chronic kidney disease;
(n = 437)
stagen,IIInumber of patients. * More
※
bed in supplementary Table IIIa
S1; CKD is divided into subgroup 32 (18.6) 41 (15.7)
bed in
ding supplementary
to the eGFR (estimated IIIb ※
Tableglomerular
S1; CKD Age (years)
stage
filtrationIIIrate),
is divided intoissubgroup
stage IIIa an eGFR 38 (22.1) 9.5 ± 5.3
33 (12.6)
ding to the eGFR (estimated IV
glomerular 0–2 years
filtration rate), stage
Stage 3b is an eGFR between 30 and 44; † Disease duration refers to the years IIIa is an eGFR 54 (31.4) 43 (9.8)
21 (8.0)
V 2–6 years 14 (9.9) 77 (17.6)3 (1.1)
Stage 3b is an eGFR between
baseline data collection and the 30 and
CKD(kg)44; † Disease duration refers
diagnosis date; Duration of aggravated
‡ to the years
Weight 171 255 0.036 ††
baseline data collection
e years between the dateand
of the CKD
theLowbaseline
weight 6–12collection
diagnosis
data years Duration
date; ‡
and theof aggravated
date of onset 60 (35.1) 125 (28.6)
61 (23.9)
etoyears
CKD. between the date of theNormalbaseline data
12–17collection
years and the date of onset 107 (62.6) 192 (43.9)
184 (72.2)
to CKD. Overweight Sex (male/female) 4 (2.3) 299/138 10 (3.9)
Height (cm) 171 255 0.058 †
Disease preceding CKD
Short stature 48 (28.1) 49 (19.2)
Normal Primary glomerulopathy * 122 (71.4) 61 (14.0)
201 (78.8)
Tall stature Secondary glomerulopathy * 1 (0.6) 60 (13.7) 5 (2.0)
HypertensionKidney dysplasia with/out vesico-ureteral 156reflux 66 (15.1)216
SBP hypertension 24 (15.4) 34 (15.7) 0.926 ††
Hypoplasia
DBP hypertension 43 (27.6) 181 (41.4)
39 (18.1) 0.029 ††
Other
Proteinuria (mg/mg) 172 69 (15.8)261 <0.001 ††
<0.5 CKD stages 69 (15.9) 162 (37.4)
≥0.5 103 (37.4) 99 (22.9)
I 79 (18.1)
Ferritin (ng/mL) 163 233 <0.001 ††
≥100 II 51 (31.3) 119 (27.2)
33 (14.2)
※
<100 IIIa 112 (68.7) 74 (16.9)
200 (85.8)
Transferrin saturation
IIIb
※ (%) 170 71 (16.3)253 0.694 ††
<20 54 (31.8) 85 (33.6)
≥20 IV 116 (68.2) 77 (17.6)
168 (66.4)
V
Use of EPO stimulating agents 167 17 (3.9)261 0.001 ††
Yes * Birth weight (kg) 36 (21.6) 3.0 ± 0.7 7 (2.7)
171
Iron supplementation treatment
Birth age (weeks) 38.3 ± 3.1261 0.001 ††
Yes ** 62 (36.3) 29 (11.1)
Disease duration
Use of renin-angiotensin system (RAS) †
(years) 5.7 ± 4.7
172 261 0.002 ††
inhibitors
110 (70.0)‡
Yes *** Duration of aggravated renal function (years)
2.9 ± 123
3.4 (47.1)
Numerical values
Numerical are are
values reported
reportedasasn n(%);
(%);CKD,
CKD, chronic kidneydisease;
chronic kidney disease; n, number
n, number of patients.
of patients; * More
EPO, erythropoietin;
※
SBP,data
detailed systolic
areblood pressure;
described in DBP, diastolic blood
supplementary pressure;
Table S1; CKDCKDstage
stage III III
is divided into subgroup
is divided stage IIIa and
into subgroup
IIIb according to the eGFR (estimated glomerular filtration rate), stage IIIa is an eGFR between 45 and 59 and Stage
stage IIIa and IIIb according to the eGFR (estimated glomerular filtration rate), stage IIIa is an eGFR
3b is an eGFR between 30 and 44; * EPO stimulating agents: Epoetin alfa, Epoetin beta; ** Iron agents: any agent
between 45 andintravenous
including 59 and Stage 3b intake;
or oral is an eGFR between
*** RAS 30 Angiotensin-converting
inhibitors: and 44; † Disease duration enzyme refers to theangiotensin
inhibitors, years II
receptor
between blockers;
the date of the† Statistically
baseline data significant differences
collection and thewere
CKD demonstrated using‡ Fisher’s
diagnosis date; Duration exact test; †† Statistically
of aggravated
significant differences were demonstrated using the Chi-square test.
renal function means the years between the date of the baseline data collection and the date of onset
of the preceding disease to CKD.
J. Clin. Med. 2019, 8, 152 5 of 14

Patients with CKD showed a bimodal distribution with low hemoglobin levels at ages 0–2 years
(11.14 ± 1.64 g/dL) and at ages 6–12 years (11.65 ± 1.79 g/dL) (Table 3). Hemoglobin levels decreased
significantly with increases in CKD stage, with a mean of 12.22 ± 1.94 g/dL (p < 0.001) (Table 4).
Hemoglobin distribution according to the disease preceding CKD is summarized in Table 5. Patients
with primary glomerulonephritis had significantly lower hemoglobin levels, compared to other kidney
diseases (p = 0.003).
In children with CKD who did not receive ESA, anemia was associated with older age (OR 1.075,
p < 0.001), low weight (OR 0.853, p = 0.008), low body mass index (BMI) z-score (OR 0.779, p = 0.003),
existence of glomerulonephritis (OR 3.263, p < 0.001), high levels of ionized parathyroid hormone
(iPTH) (OR 1.007, p < 0.001) and serum phosphorus (OR 1.773, p < 0.001), low serum albumin (OR 0.498,
p < 0.001) and calcium (OR 0.494, p < 0.001) levels, and low eGFR (OR 0.966, p < 0.001) in the
univariate logistic regression. The multiple logistic regression analysis revealed the existence of
glomerulonephritis (OR 3.263, p < 0.001) to be an independent risk factor associated with anemia in
children with CKD (Table 6).
Anemia correlated positively with changes in BMI z-score (r = 0.434, p < 0.001), weight (r = 0.324,
p < 0.001), serum albumin (r = 0.288, p < 0.001), and cholesterol (r = 0.398, p < 0.001), but correlated
negatively with serum calcium (r = −0.403, p < 0.001), iPTH (r = −0.616, p < 0.001), ferritin (r = −0.119,
p = 0.019), and transferrin saturation (r = −0.253, p < 0.001) (Table 7).

3.3. CKD Patients with Iron Deficiency

Characteristics of the CKD patients with iron deficiency are summarized in Table 8. Age (p = 0.002),
existence of glomerulonephritis as a preceding disease (p = 0.017), systolic blood pressure (p = 0.036),
and presence of comorbidities (p = 0.009) were significantly higher in patients with iron deficiency than
in those without. Other variables, including sex, weight, CKD stages, and use of iron supplementation
agents, did not differ between the two groups.
In CKD patients with iron deficiency, ferritin levels were significantly lower in the 2–6 year-old
age group (44.86 ± 53.08 ng/mL, p < 0.001); however, the lowest age group with transferrin saturation
was 0–2 years (21.68 ± 13.51%, p = 0.001) (Table 3). Interestingly, ferritin levels showed a significant
increase as the CKD stage increased (p < 0.001). In contrast, there were no significant differences in
transferrin saturation across the CKD stages (Table 4). As shown in Table 5, kidney dysplasia with/out
VUR, pyelonephritis, and children with interstitial nephritis had the lowest ferritin levels, compared to
other kidney diseases (55.79 ± 43.59 ng/mL, p < 0.001). Transferrin saturation showed a significantly
lower percentage in the congenital, hereditary, cystic disease group (24.28 ± 11.44%, p < 0.001).
In children with CKD who did not take iron supplements, iron deficiency was associated with
younger age (OR 0.908, p < 0.001), lower hemoglobin (OR 0.843, p = 0.015), and lower ferritin (OR 0.980,
p < 0.001) levels in the univariate logistic regression analysis. The multiple logistic regression analysis
demonstrated that an increased BMI z-score (OR 1.318, p = 0.024) and decreased iPTH (OR 0.993,
p = 0.007), hemoglobin (OR 0.693, p < 0.001), and ferritin (OR 0.976, p < 0.001) levels were risk factors
associated with iron deficiency in children with CKD (Table 9).
 Age (years)
middle 10s (43.9%). Among the CKD patients, male patients were moreAge (years)than female patients
frequent 9.5 ± 5.3 9.5 ± 5.3
0–2 years 0–2 years 43 (9.8) 43 (9.8)
regardless of age (n = 299 versus n = 138). The most common disease leading to CKD was renal
2–6 years 2–6 years 77 (17.6) 77 (17.6)
hypoplasia (41.4%), while 66 patients had kidney dysplasia with/out vesico-ureteral reflux (VUR)
6–12 years 6–12 years 125 (28.6) 125 (28.6)
(15.1%), and 27.7% had glomerulonephritis. Overall, 27.2% ofyears
12–17 patients were inyears
12–17 CKD stage 2, while a 192 (43.9) 192 (43.9)
J. Clin. Med. 2019, 8, 152
minority (3.9%) had CKD stage 5 in a pre-dialysis state. 6 of 14
Sex (male/female)Sex (male/female) 299/138 299/138
Disease precedingDisease CKD preceding CKD
Table 1. Baseline demographics of the chronic kidney disease Primary (CKD) patient
glomerulopathy cohort.
Primary * glomerulopathy * 61 (14.0) 61 (14.0)
Table 3. Hemoglobin, transferrin saturation, and ferritin levels stratified by age in the CKD cohort.
Secondary glomerulopathy Secondary * glomerulopathy * 60 (13.7) 60 (13.7)
Total Patients (%)
Variable Kidney dysplasia0–2
Total with/out
Kidney
Years dysplasia
vesico-ureteral
with/out
2–6 reflux
Yearsvesico-ureteral
66 (15.1)
6–12reflux
Years 66 (15.1)
12–18 Years
(n = 437) P Value
Hypoplasia Hypoplasia 181 (41.4) 181 (41.4)
Age (years) (n = 437) (n =
9.5 43)
± 5.3 (n = 77) (n = 125) (n = 192)
Other Other 69 (15.8) 69 (15.8)
0–2 years ± 1.94 43 (9.8)
Hemoglobin (g/dL) 12.15CKD stages CKD±stages
11.14 1.64 12.34 ± 1.43 11.65 ± 1.79 12.55 ± 2.12 <0.001 *
2–6 years Male 12.37 ± 2.01 77 (17.6)
11.35 ± 1.92 12.58 ± 1.34 11.6 ± 1.8 13.04 ± 2.11 <0.001 *
I I 79 (18.1) 79 (18.1)
6–12 years Female 11.9 ± 1.74 11.43 ± 1.7
125 (28.6) 12.39 ± 1.48 11.85 ± 1.71 11.8 ± 1.87 0.227 *
II II 119 (27.2) 119 (27.2)
12–17 years saturation (%) 27.86 ± 192 (43.9)
± 13.51 23.05 ± 10.87 ± 21.63 (16.9)± 14.15
※ ※
Transferrin 16.49
IIIa 21.68 IIIa 29.84
74 (16.9) 74 29.25 0.001 *
Sex (male/female)
Male 27.47 ± 16.02※ 299/138
21.35 ± 10.89
※ 23.38 ± 11.51 29.19 ± 23.02 29.02 ± 11.53 0.001 *
IIIb IIIb 71 (16.3) 71 (16.3)
Disease preceding
FemaleCKD 27.68 ± 15.92 20.66 ± 15.99 22.9 ± 9.96 30.23 ± 13.92 30.31 ± 18.53 0.04 *
IV IV 77 (17.6) 77 (17.6)
Primary glomerulopathy * 61 (14.0)
Ferritin (ng/mL) 99.47 ±V211.51 96.2V± 114.5 44.86 ± 53.08 111.03 ± 270.89
17 (3.9) 17 (3.9) ± 217.17
113.12 <0.001 *
Secondary glomerulopathy * ± 172.19 60 (13.7)
Male 93.43Birth weight (kg) Birth±weight
105.65 129.99 (kg) 49.6 ± 65.59 105.02 ± 262.15
3.0 ± 0.7 ± 0.7± 114.86
3.097.21 <0.001 *
Kidney dysplasia
Femalewith/out vesico-ureteral ± reflux 66 (15.1)
112.75Birth 279.6
age (weeks)76.44 Birth±age 73.84(weeks) 38.1 ± 26.41 38.3 ± ±
128.25 3.1298.59 ± 3.1± 351.2
38.3148.9 0.016 *
Hypoplasia 181 (41.4)
CKD, chronic kidney Disease n, number
disease;duration (years)
Disease †duration
of patients; * Statistical
(years) †
significance was demonstrated
5.7 ± 4.7 using the Kruskal–Wallis
5.7 ± 4.7 test.
Other 69 (15.8)
CKD stages Duration of aggravated Duration renal offunction
aggravated renal‡function (years)
(years) 2.9 ± 3.4 ‡ 2.9 ± 3.4
Table 4. Hemoglobin, transferrin saturation, and ferritin levels stratified by CKD stage.
I Numerical values are Numerical as79n (18.1)
reportedvalues (%);
are reported
CKD, chronicas n (%);
kidneyCKD,disease;
chronicn, kidney
numberdisease;
of patients.
n, number
* Moreof patients. * More
II Total (n data
detailed = 437)are described
I (n = 79)
detailed data 119
are (27.2)
II (n = 119)
in supplementary
described in
Table IIIa
S1; (n
※
supplementary CKD= 74)
stage IIIb
Table III
※
(n = 71)
S1;is divided
CKD stage
into III IV
subgroup(n = 77) into subgroup
is divided V (n = 17) P Value
※
IIIa stage IIIa 74 (16.9)
Hemoglobin
※
(g/dL) 12.22 ± and
1.94 IIIb stage
according
13.1 IIIa and
± 1.46to theIIIbeGFR
according
13.03(estimated
± 1.73 to theglomerular
eGFR
12.34 (estimated
filtration
± 1.75 glomerular
rate),±stage
11.75 filtration
1.77 IIIa is an
rate),
10.85eGFR
±stage
1.72IIIa is an eGFR
10.14 ± 2.17 <0.001 *
IIIb Male 12.37 ±452.01
between and 59between
and ± 45
13.41Stage 3b
1.49andis71an
59(16.3)
and
eGFR
13.21 ±between
Stage1.833b is 30
an12.48
and
eGFR ±
44;between
† Disease
1.67 and ±
3011.84
duration44;1.82
†refers
Diseaseto the
duration ± 1.8
years
10.84 refers to the ± 2.18
years
10.38 <0.001 *
IV Female 11.9 ±the1.74date ofbetween
12.39 ± the
1.14date77 (17.6) ± 1.46 ± ±diagnosis ± 1.56 of aggravated
9.58 ± 2.31
between the baseline dataof12.65
collection
the baseline the12.05
anddata CKD 1.93and the
collection
diagnosis 11.58
date;
CKD 1.69 of date;
‡ Duration 10.87
aggravated
‡ Duration <0.001 *
V 17 (3.9)
Transferrin saturation (%) renal function
27.54 ± 15.97 meansrenalthefunction
years
27.87 ± 23.68 between
means the
the years
date
26.06 ± 12.56 of
between
the baseline
the date
26.88 ± 14.12 dataofcollection
the baselineand
29.34 ± 13.66 data
the date
collection
of onset
and
27.19 ± 13.29 the date of onset
33.19 ± 20.44 0.449 *
Birth weight (kg) 3.0 ± 0.7
Male 27.47 ± 16.02
of the preceding disease 28.65
of the to± 26.55
preceding 27.43
CKD. disease to CKD. ± 12.57 25.55 ± 12.13 28.32 ± 10.63 26.74 ± 13.34 30.32 ± 15.85 0.722 *
Birth Female
age (weeks) 27.68 ± 15.92 25.91 ± 14.51 38.323.03 ± 3.1 ± 12.19 29.58 ± 17.48 31.23 ± 18.06 28.25 ± 13.41 40.1 ± 29.93 0.338 *
Disease duration (years) † 5.7 ± 4.7
Ferritin (ng/mL) 99.47 ± 211.51 53.27 ± 51.2 81.58 ± 135.93 83.15 ± 131.44 122.96 ± 335.38 139.63 ± 284.45 201.81 ± 231.99 <0.001 *
DurationMaleof aggravated renal function
93.43 ± 172.19 ‡ ± 57.3 2.9 78.42
(years)60.25 ± 3.4 ± 75.42 77 ± 111.18 61.98 ± 59.64 171.92 ± 342.43 191.83 ± 263.38 <0.001 *
Numerical values are Female
reported as n (%); CKD, ± 279.6kidney
112.75chronic 33.51 ± 16.37
disease; n, number ± 218.8
88.6 of patients. 96.26
* More ± 168.89 239.62 ± 555.72 75.03 ± 60.18 225.78 ± 153.27 0.013 *
※
CKD, chronic kidney disease; n, number of patients; CKD stage III is divided
detailed data are described in supplementary Table S1; CKD stage III is divided into subgroup into subgroup stage IIIa and IIIb according to the eGFR (estimated glomerular filtration rate), stage IIIa is an
eGFR between 45 and 59 and Stage 3b is an eGFR between 30 and 44; * Statistical significance was demonstrated using the Kruskal–Wallis test.
stage IIIa and IIIb according to the eGFR (estimated glomerular filtration rate), stage IIIa is an eGFR
between 45 and 59 and Stage 3b is an eGFR between 30 and 44; † Disease duration refers to the years
between the date of the baseline data collection and the CKD diagnosis date; ‡ Duration of aggravated
renal function means the years between the date of the baseline data collection and the date of onset
of the preceding disease to CKD.
J. Clin. Med. 2019, 8, 152 7 of 14

Table 5. Hemoglobin, transferrin saturation, and ferritin levels stratified by disease preceding CKD.

Total 1’ GN 2’ GN RN/PN/IN CG/HD/CD Other

P Value
(n = 437) (n = 61) (n = 60) (n = 66) (n = 181) (n = 69)
Hemoglobin (g/dL) 12.22 ± 1.94 11.39 ± 1.94 12.3 ± 1.5 12.77 ± 1.87 12.29 ± 1.88 12.18 ± 2.29 0.003 *
Male 12.37 ± 2.01 11.64 ± 2.09 12.41 ± 1.65 12.94 ± 1.84 12.36 ± 1.92 12.34 ± 2.46 0.043 †
Female 11.9 ± 1.74 10.92 ± 1.55 12.14 ± 1.26 11.81 ± 1.83 12.15 ± 1.79 11.9 ± 1.97 0.097
Transferrin saturation (%) 27.54 ± 15.97 36.44 ± 27.36 27.66 ± 13.13 25.92 ± 10.6 24.28 ± 11.44 29.86 ± 16.6 <0.001 *
Male 27.47 ± 16.02 36.31 ± 30.69 27.47 ± 11.12 26.77 ± 10.45 24.55 ± 11.74 28.49 ± 14.1 0.009 *
Female 27.68 ± 15.92 36.69 ± 20.01 27.93 ± 15.93 21.25 ± 10.77 23.73 ± 10.85 32.54 ± 20.75 0.056
Ferritin (ng/mL) 99.47 ± 211.51 90.08 ± 77.22 92.98 ± 183.59 55.79 ± 43.59 70.03 ± 102.28 242.3 ± 460.64 <0.001 *
Male 93.43 ± 172.19 101.24 ± 87.55 70.11 ± 64.22 59.46 ± 45.55 76.02 ± 115.35 204.69 ± 387.22 <0.001 *
Female 112.75 ± 279.6 67.19 ± 43.32 127.8 ± 280.81 34.19 ± 19.77 57.59 ± 66.85 310.36 ± 574.81 0.003 *
CKD, chronic kidney disease; n, number of patients; GN, glomerulonephritis; RN, kidney dysplasia with/out vesico-ureteral reflux; PN, pyelonephritis, IN, interstitial nephritis; CG,
congenital disease; HD, hereditary disease; CD, cystic disease; * Statistical significance was demonstrated using the Kruskal–Wallis test; † Statistical significance was demonstrated using
the Anova test.

Table 6. Associated risk factors for anemia in patients with CKD who did not take erythropoietin-stimulating agents.

Univariate Logistic Regression in Anemia Patients Multivariable Logistic Regression in Anemia Patients
Unadjusted OR (95% CI) P-Value Adjusted OR (95% CI) P Value
Age 1.075 (1.031, 1.121) 0.0006 - -
Weight z-score 0.853 (0.758, 0.960) 0.0081 - -
Height z-score 0.901(0.79, 1.029) 0.1247 - -
BMI z-score 0.779 (0.661, 0.918) 0.0029 - -
Birth age 1.132 (1.039, 1.233) 0.0046 - -
Glomerulonephritis 3.263 (1.905, 5.590) <0.0001 3.263 (1.905, 5.590) <0.0001
Hypertension 1.184 (0.731, 1.915) 0.4928 - -
Serum albumin 0.498 (0.355, 0.698) <0.0001 - -
eGFR 0.966 (0.957, 0.975) <0.0001 - -
iPTH 1.007 (1.004, 1.011) <0.0001 - -
Serum Ca 0.494 (0.389, 0.628) <0.0001 - -
Serum P 1.773 (1.352, 2.324) <0.0001 - -
Urine protein creatinine ratio 1.001 (0.968, 1.035) 0.9482 - -
Hemoglobin 0.138 (0.091, 0.208) <0.0001 - -
Ferritin 1.001 (1.000, 1.003) 0.0667 - -
Transferrin saturation 1.003 (0.990, 1.016) 0.6548 - -
Iron supplementation use ** 3.652 (2.058, 6.482) <0.0001 - -
CKD, chronic kidney disease; OR, odds ratio; CI, confidence interval; BMI, body mass index; GFR, estimated glomerular filtration rate; iPTH, ionized parathyroid hormone; Ca, serum
calcium; P, serum phosphorus; ** Iron agents: any agents including intravenous or oral intake.
J. Clin. Med. 2019, 8, 152 8 of 14

Table 7. Correlations among key characteristics of anemic children in the CKD cohort.

Hb Reti Tran Sat Ferritin iPTH eGFR Alb Ca P Chole Weight BMI−z
0.0282 −0.2531 −0.119 −0.6155 0.0297 0.2877 −0.4025 0.0993 0.3976 0.3235 0.4339
Hb .
0.5569 <0.0001 (−) 0.0194 (−) <0.0001 (−) 0.5473 <0.0001 <0.0001 (−) 0.1048 <0.0001 <0.0001 <0.0001
0.0282 −0.1441 0.1535 −0.1766 0.3302 0.1117 −0.038 0.1182 −0.0391 0.0082 0.3593
Reti .
0.5569 0.0026 (−) 0.0013 0.0002 (−) <0.0001 0.0244 0.5237 (−) 0.0537 0.4257 (−) 0.8654 <0.0001
−0.2531 −0.1441 0.1941 0.2095 0.0062 −0.0082 0.2913 0.0791 −0.0846 −0.0724 −0.3134
Tran sat .
<0.0001 (−) 0.0026 (−) <0.0001 <0.0001 0.8994 0.8688 (−) <0.0001 0.1975 0.0842 (−) 0.1343 (−) <0.0001 (−)
−0.119 0.1535 0.1941 0.1567 0.2422 0.1265 0.0746 0.0901 −0.1143 −0.0186 −0.0317
Ferritin .
0.0194 (−) 0.0013 <0.0001 0.0011 <0.0001 0.0107 0.2100 0.1422 0.0194 (−) 0.7004 (−) 0.5087 (−)
−0.6155 −0.1766 0.2095 0.1567 −0.1159 −0.1963 0.2178 −0.0552 −0.2078 −0.0933 −0.3635
iPTH .
<0.0001 (−) 0.0002 (−) <0.0001 0.0011 0.0185 (−) <0.0001 (−) 0.0002 0.3691 (−) <0.0001 (−) 0.0548 (−) <0.0001 (−)
0.0297 0.3302 0.0062 0.2422 −0.1159 0.1851 −0.0656 0.0993 0.0253 −0.1289 0.0957
eGFR .
0.5473 <0.0001 0.8994 <0.0001 0.0185 (−) 0.0002 0.2759 (−) 0.1075 0.6117 0.0092 (−) 0.052
0.2877 0.1117 −0.0082 0.1265 −0.1963 0.1851 −0.123 −0.028 0.0632 0.0154 0.0693
Alb .
<0.0001 0.0244 0.8688 (−) 0.0107 <0.0001 (−) 0.0002 0.0431 (−) 0.6528 (−) 0.2074 0.7589 0.1631
−0.4025 −0.038 0.2913 0.0746 0.2178 −0.0656 −0.123 0.0391 −0.2098 −0.0454 −0.2708
Ca .
<0.0001 (−) 0.5237 (−) <0.0001 0.2100 0.0002 0.2759 (−) 0.0431 (−) 0.587 0.0004 (−) 0.4455 (−) <0.0001 (−)
0.0993 0.1182 0.0791 0.0901 −0.0552 0.0993 −0.028 0.0391 0.0666 0.415 0.1246
P .
0.1048 0.0537 0.1975 0.1422 0.3691 (−) 0.1075 0.6528 (−) 0.587 0.2821 <0.0001 0.0415
0.3976 −0.0391 −0.0846 −0.1143 −0.2078 0.0253 0.0632 −0.2098 0.0666 0.1959 0.2174
Chole .
<0.0001 0.4257 (−) 0.0842 (−) 0.0194 (−) <0.0001 (−) 0.6117 0.2074 0.0004 (−) 0.2821 <0.0001 <0.0001
0.3235 0.0082 −0.0724 −0.0186 −0.0933 −0.1289 0.0154 −0.0454 0.415 0.1959 0.214
Weight .
<0.0001 0.8654 0.1343 (−) 0.7004 (−) 0.0548 (−) 0.0092 (−) 0.7589 0.4455 (−) <0.0001 <0.0001 <0.0001
0.4339 0.3593 −0.3134 −0.0317 −0.3635 0.0957 0.0693 −0.2708 0.1246 0.2174 0.214
BMI−z .
<0.0001 <0.0001 <0.0001 (−) 0.5087 (−) <0.0001 (−) 0.052 0.1631 <0.0001 (−) 0.0415 <0.0001 <0.0001
CKD, chronic kidney disease; Hb, hemoglobin; Reti, reticulocyte count; Tran sat, transferrin saturation; iPTH, ionized parathyroid hormone; eGFR, estimated glomerular filtration rate; Alb,
albumin; Ca, serum calcium; P, serum phosphorus; Chole, cholesterol; BMI-z, body mass index z-score. The first column of each angle is the r-value and the second column is the p-value.
 0–2 years
2–6 7743(17.6)
(9.8)
2–6 years
6–12 years 77 (17.6)
125 (28.6)
3.1. Baseline Characteristics of Overall CKD Cohort
6–12 years
12–17 years 125 (43.9)
192 (28.6)
The demographic characteristics and clinical manifestations of patients with CKD ar
Sex 12–17 years
(male/female) 192 (43.9)
299/138
Table 1. The mean age of the patients was 9.5 ± 5.3 years, and most patients were found t
Sex (male/female)
Disease preceding CKD 299/138
Disease preceding
J. CKD
Clin.
Primary glomerulopathy * Med. 2019, 8, 152 61 (14.0) middle 10s (43.9%). Among the CKD patients, male patients were more 9 of 14frequent than fema
Primary glomerulopathy
Secondary glomerulopathy * * 61 (13.7)
60 (14.0) regardless of age (n = 299 versus n = 138). The most common disease leading to CKD
Secondary
Kidney glomerulopathy
dysplasia *
with/out vesico-ureteral reflux 60 (15.1)
66 (13.7) hypoplasia (41.4%), while 66 patients had kidney dysplasia with/out vesico-ureteral ref
Kidney dysplasia with/out vesico-ureteral reflux
Hypoplasia Table
66
181 8. Comparisons of characteristics of patients with
(15.1)
(41.4) iron deficiency
(15.1%), and 27.7% in had
the CKD cohort.
glomerulonephritis. Overall, 27.2% of patients were in CKD stage
Hypoplasia
Other 181 (41.4)
69 (15.8)
Patients with Iron Deficiency minority (3.9%) had CKD stage
Patients without Iron Deficiency 5 in a pre-dialysis state.
CKD Otherstages Variable 69 (15.8) P Value
(n = 107) (n = 290)
CKD
I stages 79 (18.1)
Age (years) 107 Table 1. Baseline
290 demographics of the chronic
0.002 ††kidney disease (CKD) patient cohort.
I
II 79 (18.1)
119 (27.2)
II ※
IIIa 0–2 years 119 (27.2)
74 (16.9) 16 (15.0) 18 (6.2)
Total Patients (%)
IIIa
※
※ 2–6 years 74 (16.9) 25 (23.4) 42 (14.5)
Variable
IIIb 71 (16.3) (n = 437)
※ 6–12 years 30 (28.0) 85 (29.3)
IIIb
IV 71 (17.6)
77 (16.3)
12–17 years 36 (33.6) Age (years)
145 (50.0) 9.5 ± 5.3
VIV 77
17 (17.6)
(3.9)
Sex (male/female) 68/39 205/85 0–2 years 0.173 †† 43 (9.8)
V weight (kg)
Birth Disease preceding CKD 17 (3.9)
3.0 ± 0.7 95 254 2–6 years 0.017 ††
weight (kg) 3.0 ±±0.7 77 (17.6)
Birth age (weeks) Glomerulonephritis38.3 3.1 12 (12.6) 62 (24.4)
(weeks)(years) †
Birth ageduration 38.3 6–12 years 125 (28.6)
Disease Non-glomerulonephritis 5.7 ±±4.7
3.1 83 (87.3) 192 (75.6)
12–17 years 192 (43.9)
Disease duration
Duration † function
(years)renal
of aggravated
CKD stages
(years) ‡
5.7 ± 4.7
2.9 ± 3.4
107 290 0.057 ††
I 23 (21.5) Sex (male/female)
46 (15.9) 299/138
Duration
al values of aggravated
are reported renal
as n (%); CKD, function
chronic(years) ‡ 2.9 ± 3.4
IIkidney disease; n, number of patients. * More 28 (26.2) Disease preceding CKD
75 (25.9)
al values are reported as n (%); CKD,
data are described in supplementary Table IIIa chronic kidney
※
disease; n, number
S1; CKD stage III is divided of patients. * More
into subgroup 26 (24.3) 46 (15.9)Primary glomerulopathy * 61 (14.0)
※
data
and are
IIIb described
according in supplementary
to the eGFR (estimated IIIb
Tableglomerular
S1; CKDfiltration
stage IIIrate),
is divided intoissubgroup
stage IIIa an eGFR 15 (14.0) 50 (17.2)Secondary glomerulopathy * 60 (13.7)
and IIIb IV 14 (13.1) 57 (20.0)
45 and 59according
and Stage to 3bthe eGFR
is an eGFR (estimated
between glomerular
30 and 44; †filtration rate), stage
Disease duration IIIato
refers is the
an eGFR
years Kidney dysplasia with/out vesico-ureteral reflux 66 (15.1)
V 1 (1.0) 16 (5.5)
45 and
the date59 ofand Stage 3b data
the baseline is ancollection
eGFR betweenand the30CKD
and 44; † Disease
diagnosis duration
date; refers
‡ Duration of to the years
aggravated Hypoplasia 181 (41.4)
Weight (kg) 105 285 0.213 ††
the date
ction meansof the
thebaseline data collection
years between the dateand
of the CKD
theLow diagnosis
baseline
weight data date;
collection‡ Duration of aggravated
and the date of onset 33 (30.8) 76 (26.7) Other 69 (15.8)
ction means
eceding diseasethetoyears
CKD. between the date of theNormal baseline data collection and the date of onset 66 (61.7) CKD stages
201 (70.5)
eceding disease to CKD. Overweight 6 (5.6) 8 (2.8) I 79 (18.1)
Height (cm) 105 285 II 0.835 † 119 (27.2)
Short stature 25 (23.8) 61 (21.4) ※
IIIa 74 (16.9)
Normal 78 74.3) 219 (76.8) ※
Tall stature 2 (1.9) 5 (1.8)
IIIb 71 (16.3)
Hypertension 91 251 IV 77 (17.6)
SBP hypertension 20 (22.2) 32 (12.7) V 0.036 †† 17 (3.9)
DBP hypertension 16 (17.6) 60 (23.9)
Birth weight (kg) 0.214 †† 3.0 ± 0.7
Comorbidity 107 290Birth age (weeks) 0.009 †† 38.3 ± 3.1
Present 71 (66.4) 150 (51.7)
Absent 36 (33.6)
Disease duration (years) †
140 (48.3)
5.7 ± 4.7
Iron supplementation treatment 107 289Duration of aggravated renal
0.692 function
†† (years) ‡ 2.9 ± 3.4
Yes ** 21 (19.6) 62 (21.5)
Numerical values are reported as n (%); CKD, chronic kidney disease; n, number of patients.
Numerical values are reported as n (%); CKD, chronic kidney disease; n, number of patients; EPO, erythropoietin; SBP,data
detailed systolic
areblood pressure;
described in DBP, diastolic blood
supplementary pressure;
Table S1; CKD
※
CKDstage
stage III is divided into sub
III is divided into subgroup stage IIIa and IIIb according to the eGFR (estimated glomerular filtration rate), stage IIIa is an eGFR between 45 and 59 and Stage 3b is an eGFR between 30
stage IIIa and IIIb according to the eGFR (estimated glomerular filtration
and 44; ** Iron agents: Any agent including intravenous or oral intake; † Statistically significant differences were demonstrated using Fisher’s exact test; †† Statistical significance was rate), stage IIIa is an
demonstrated using the Chi-square test. between 45 and 59 and Stage 3b is an eGFR between 30 and 44; † Disease duration refers to the
between the date of the baseline data collection and the CKD diagnosis date; ‡ Duration of aggr
renal function means the years between the date of the baseline data collection and the date o
of the preceding disease to CKD.
J. Clin. Med. 2019, 8, 152 10 of 14

Table 9. Associated risk factors for iron deficiency in patients with CKD who did not take iron supplements.

Univariate Logistic Regression in Iron Deficiency Patients Multivariable Logistic Regression in Iron Deficiency Patients
Unadjusted OR (95% CI) P-value Adjusted OR (95% CI) P Value
Age 0.908 (0.865, 0.954) 0.0001 - -
Weight z-score 1.041 (0.895, 1.212) 0.6002 - -
Height z-score 1.002(0.847, 1.184) 0.9856
BMI z-score 1.148 (0.939, 1.403) 0.1783 1.318 (1.038, 1.675) 0.0235
Birth age 0.783 (0.545, 1.125) 0.1858 - -
Glomerulonephritis 0.569 (0.277, 1.168) 0.1243 - -
Hypertension 1.327 (0.752, 2.34) 0.3292 - -
Serum albumin 0.791 (0.543, 1.152) 0.2209 - -
eGFR 1.004 (0.996, 1.012) 0.3357 - -
iPTH 0.997 (0.993, 1.001) 0.107 0.993 (0.988, 0.998) 0.007
Serum Ca 1.008 (0.804, 1.264) 0.9467 - -
Serum P 1.09 (0.797, 1.493) 0.589 - -
Hemoglobin 0.843 (0.734, 0.967) 0.0145 0.693 (0.565, 0.85) 0.0004
Ferritin 0.980 (0.970, 0.989) <0.0001 0.976 (0.965, 0.987) <0.0001
Transferrin saturation 1.018 (0.990, 1.047) 0.2164 - -
Erythropoietin stimulating use ** 0.985 (0.255, 3.802) 0.9825 - -
CKD, chronic kidney disease; OR, odds ratio; CI, confidence interval; BMI, body mass index; GFR, glomerular filtration rate; iPTH, ionized parathyroid hormone; Ca, serum calcium; P,
serum phosphorus; ** Iron agents: any agents including intravenous or oral intake.
J. Clin. Med. 2019, 8, 152 11 of 14

4. Discussion
Anemia and iron deficiency are important complications in pediatric patients with CKD. The aim
of aggressive treatment of anemia is to avoid regular red blood cell transfusions and to improve the
quality of life, cognitive function, exercise capacity, and cardiovascular function of children [13]. The
best treatment options for anemia and iron deficiency are EPO-stimulating and iron supplementation
agents; nonetheless, their use in hemodialysis or peritoneal dialysis patients is known to be less
effective than that in adults [14]. Therefore, it is important to identify the status of anemia and iron
deficiency and to actively correct these in pediatric CKD patients.
KNOW-PedCKD is the first prospective pediatric CKD cohort study about the clinical
characteristics and prevalence of anemia and iron deficiency in Asia. In addition, this is the first
attempt to analyze risk factors for anemia in CKD children. Other pediatric CKD cohort studies, such
as CKiD or “The Functional Outcomes in Adolescent CKD study”, showed hemoglobin levels and only
in part reported the prevalence of anemia [15,16] In contrast, we performed comprehensive analyses
firstly in the pediatric area.
In our KNOW-PedCKD cohort study, the proportion of CKD patients with anemia was the lowest
at 2–5 years of age and then increased with older age. This result was comparable to that reported
in a previous study on a pediatric CKD cohort, NAPRTCS [1]. Thus, school-aged patients of ages
12–17 years with CKD are more likely to have anemia, making it is necessary for clinicians to detect
and treat anemia appropriately.
Individual studies, such as the ItalKid study [17], the British Association of Pediatric
Nephrology [18], and NAPRTCS [1,19], have reported the major causes of CKD. These studies suggest
that glomerulonephritis is the cause of end-stage renal disease (ESRD) in 20% of cases, while congenital
abnormalities of the kidney and urinary tract (CAKUT) occur in 50% of patients. Other congenital
diseases (CG) and hereditary diseases (HD) are considered causative in 20% of patients [1,17–19].
However, studies are lacking with regard to the relationships between diseases leading to
CKD and anemia. Interestingly, our study showed that anemia is more severe in patients with
glomerulonephritis than in those without. Recent evidence indicates that medications for the blockade
of the renin-angiotensin system (RAS) pathway to reduce proteinuria in glomerulonephritis modulate
erythropoiesis by regulation of angiotensin II signaling. Angiotensin II is involved in the proliferation
and differentiation of hematopoietic cell types, especially those of red blood cell lineage. Both
angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) induce
adverse effects related to decreased hematocrits [20]. Notwithstanding, iron deficiency was more
prominent in patients with non-glomerulonephritis (kidney dysplasia with/out VUR, pyelonephritis,
interstitial nephritis, congenital disease, hereditary disease, cystic disease, and others) (Table 8).
Ferritin increased as the CKD stage increased in our cohort. According to another report, ferritin
itself could act as an inflammatory marker [21]. In addition, according to Goyal et al., cytokines, such
as hepcidin and high-sensitivity C-reactive protein (hs-CRP), increase with increasing CKD stages
and ferritin showed a positive correlation with hepcidin [22]. This indicates that ferritin itself can
reflect inflammation in CKD patients. Because of the limited possibility to take blood in the pediatric
population, the fact that ferritin alone can detect both inflammation and iron deficiency in pediatric
CKD patients is a very important achievement in our study (Table 4).
The correlation results in our study indicated that anemia was positively correlated with low body
weight and BMI z-score (r = 0.324, p < 0.001 and r = 0.434, p < 0.001, respectively, Table 7). Although
it was not found to be an independent risk factor in the multivariate analysis, anemia and growth
are closely related in children with CKD. The underlying mechanism to explain low body weight
and BMI z-score with anemia are not very well-understood, although both may be related to CKD
progression. Low body weight and BMI z-score are considered to be results of the progression of
CKD, a combination of anorexia, increased energy expenditure, and muscle wasting [23], and anemia
has also been proposed to be associated with renal function itself. The relationship between eGFR
and anemia in childhood CKD has been studied in several studies [13,23]. Recently, Atkinson et al.
J. Clin. Med. 2019, 8, 152 12 of 14

analyzed data calculated using the CKiD and reported that, when the eGFR is reduced by 20%, the
hemoglobin level tends to decrease by 0.2–0.4 g/dL [15]. Similar to the CKiD results, the distribution
of anemia according to CKD stage in the KNOW-PedCKD cohort also increased according to higher
CKD stages (Table 2).
Hypertension is one of the major causes of CKD worldwide [24]. Our results indicated that
hypertension is associated with anemia based on diastolic blood pressure and iron deficiency based
on systolic blood pressure in children with CKD (Tables 2 and 8). However, in the univariate and
multivariate analyses, hypertension was not independently associated with anemia and iron deficiency
(Tables 6 and 9).
Anemia and iron deficiency are associated risk factors of CKD. Despite the established treatment
of anemia and iron deficiency in CKD patients, our result suggests the importance of simultaneous use
of EPO-stimulating agents and iron supplements as an effective treatment approach.
There are several limitations in this study. First, there could be unavailable data or information
of patients of the CKD cohort. Second, we could not include the patients’ diets and calorie intake in
this report. Third, we may not have excluded potential significant inter-study variations in the study
setting. In addition, it is not clear in CKD patients as to whether these indicators are the effect of CKD
itself or impact of anemia. We plan in future studies to examine the relationship between the impact of
anemia on quality of life, cognitive function, exercise capacity, and cardiovascular function and anemia
in the KNOW-pedCKD cohort.

5. Conclusions
This article is noteworthy because it is the first multicenter cohort study investigating the impact
of anemia in Korean pediatric patients with CKD and the first prospective pediatric CKD cohort
study in Asia. Supported by clinical evidence, our results indicate that anemia and iron deficiency
are key factors associated with CKD in pediatric patients. Understanding the multiple risk factors
causing anemia in CKD will improve the outcomes of children with CKD. Furthermore, ESA and
iron-replacement therapy have revolutionized the treatment of anemia in children and the negative
effects of anemia can be improved by these treatments. Additional studies are necessary to address the
issue of anemia in pediatric CKD according to each patient’s diet or quality of life in the future.

Supplementary Materials: The supplementary materials are available online at http://www.mdpi.com/2077-

0383/8/2/152/s1.
Author Contributions: Conceptualization, K.H.L., E.P., H.G.K., I.-S.H., H.I.C., Y.S.P., H.C., K.H.H., S.H.K.,
M.H.C., J.H.L. and J.I.S.; Data curation, H.J.C.; Formal analysis, K.H.L. and H.J.C.; Funding acquisition, H.G.K.;
Methodology, H.J.C., J.H.L. and J.I.S.; Resources, I.-S.H., H.I.C., Y.S.P., H.C., K.H.H., S.H.K. and M.H.C.;
Supervision, E.P., H.G.K., I.-S.H., H.I.C., Y.S.P., H.C., K.H.H., S.H.K., M.H.C., J.H.L. and J.I.S.; Visualization,
K.H.L. and E.P.; Writing—original draft, K.H.L. and E.P.; Writing—review & editing, J.H.L. and J.I.S.
Acknowledgments: This work was supported by the Research Program funded by the Korea Centers for Disease
Control and Prevention (fund code 1st year: 2011E3300300, 2nd year: 2012E3301100, 3rd year: 2013E3301600,
4th year: 2013E3301601, 5th year: 2013E3301602, 6th year: 2016E3300200, 7th year: 2016E3300201). The help of the
following persons at the Medical Research Collaborating Center (Biomedical Research Institute of Seoul National
University Hospital) is gratefully acknowledged: Heejung Ahn, Sungkyung Kim (data management), and Jayoun
Kim, Nanhee Park (biostatistics).
Compliance with Ethical Standards: This study was approved by the institutional review board at each
participating clinical center. Informed consent was obtained from all individual participants included in this study.
Conflicts of Interest: The authors disclose no conflict of interest.

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