Relation between pediatric experience and treatment recommendations for children and adolescents with kidney failure

Association Between Dialysis Facility Ownership and Mortality Risk in Children With Kidney Failure

Importance

In adults, treatment at profit dialysis facilities has been associated with a higher risk of death.

Objective

To determine whether profit status of dialysis facilities is associated with the risk of death in children with kidney failure treated with dialysis and whether any such association is mediated by differences in access to transplant.

Design, Setting, and Participants

This retrospective cohort study reviewed US Renal Data System records of 15 359 children who began receiving dialysis for kidney failure between January 1, 2000, and December 31, 2019, in US dialysis facilities. The data analysis was performed between May 2, 2022, and June 15, 2023.

Exposure

Time-updated profit status of dialysis facilities.

Main Outcomes and Measures

Adjusted Fine-Gray models were used to determine the association of time-updated profit status of dialysis facilities with risk of death, treating kidney transplant as a competing risk. Cox proportional hazards regression models were also used to determine time-updated profit status with risk of death regardless of transplant status.

Results

The final cohort included 8465 boys (55.3%) and 6832 girls (44.7%) (median [IQR] age, 12 [3-15] years). During a median follow-up of 1.4 (IQR, 0.6-2.7) years, with censoring at transplant, the incidence of death was higher at profit vs nonprofit facilities (7.03 vs 4.06 per 100 person-years, respectively). Children treated at profit facilities had a 2.07-fold (95% CI, 1.83-2.35) higher risk of death compared with children at nonprofit facilities in adjusted analyses accounting for the competing risk of transplant. When follow-up was extended regardless of transplant status, the risk of death remained higher for children treated in profit facilities (hazard ratio, 1.47; 95% CI, 1.35-1.61). Lower access to transplant in profit facilities mediated 67% of the association between facility profit status and risk of death (95% CI, 45%-100%).

Conclusions and Relevance

Given the higher risk of death associated with profit dialysis facilities that is partially mediated by lower access to transplant, the study's findings indicate a need to identify root causes and targeted interventions that can improve mortality outcomes for children treated in these facilities.

Chronic Kidney Disease in Children

Chronic kidney disease (CKD) in children occurs mostly due to congenital anomalies of kidney and urinary tract and hereditary diseases. For advanced cases, a multidisciplinary team is needed to manage nutritional requirements and complications such as hypertension, hyperphosphatemia, proteinuria, and anemia. Neurocognitive assessment and psychosocial support are essential. Maintenance dialysis in children with end-stage renal failure has become the standard of care in many parts of the world. Children younger than 12 years have 95% survival after 3 years of dialysis initiation, whereas the survival rate for children aged 4 years or younger is about 82% at one year."

Growth and changes in the pediatric medical subspecialty workforce pipeline

BACKGROUND

To inform discussions of pediatric subspecialty workforce adequacy and characterize its pipeline, we examined trends in first-year fellows in the 14 American Board of Pediatrics (ABP)-certified pediatric medical subspecialties, 2001-2018.

METHODS

Data were obtained from the ABP Certification Management System. We determined, within each subspecialty, the annual number of first-year fellows. We assessed for changes in the population using variables available throughout the study period (gender, medical school location, program region, and program size). We fit linear trendlines and calculated χ² statistics.

RESULTS

The number of first-year pediatric medical subspecialty fellows increased from 751 in 2001 to 1445 in 2018. Fields with the growth of 3 or more fellows per year were Cardiology, Critical Care, Emergency Medicine, Gastroenterology, Neonatology, and Hematology Oncology (P value <0.05 for all). The number of fellows entering Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology increased at a rate of 0.5 fellows or fewer per year. Female American Medical Graduates represented the largest and growing proportions of several subspecialties. Distribution of programs by region and size were relatively consistent over time, but varied across subspecialties.

CONCLUSIONS

The number of pediatricians entering medical subspecialty fellowship training is uneven and patterns of growth differ between subspecialties.

IMPACT

The number of individuals entering fellowship training has increased between 2001 and 2018. Growth in the number of first-year fellows is uneven. Fields with the greatest growth: Critical Care, Emergency Medicine, and Neonatology. Fields with limited growth: Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology. Concerns about the pediatric medical subspecialty workforce are not explained by the number of individuals entering the fellowship.

The Continuum of Chronic Kidney Disease and End-Stage Renal Disease: Challenges and Opportunities for Chronic Peritoneal Dialysis in the United States

End-stage renal disease (ESRD) patients undergoing renal replacement therapy have a high mortality rate and suffer from considerable morbidity. Degree of nutritional decline, disordered mineral metabolism, and vascular calcification are some of the abnormalities that predict an adverse outcome for ESRD patients. All these abnormalities begin early during the course of chronic kidney disease (CKD), long before the need for maintenance dialysis. Thus, CKD represents a continuum of metabolic and vascular abnormalities. Treatment of these abnormalities early during the course of CKD and a timely initiation of dialysis have the potential of improving patient outcomes. However, the thesis that successful management of these abnormalities will favorably modify the outcomes of dialysis patients remains untested.

The proportion of incident USA ESRD patients starting chronic peritoneal dialysis (CPD) has historically been low. Limited physician training and inadequate predialysis patient education appear to underlie the low CPD take-on in the USA. Furthermore, two key changes have occurred in the USA: steep decline in CPD take-on and progressive increase in the use of automated peritoneal dialysis. The decline in CPD take-on has afflicted virtually every subgroup examined and has occurred, paradoxically, when the CPD outcomes in the country have improved. Understanding the reasons for historically low CPD take-on and recent steep declines in utilization may allow the development of plans to reverse these trends.

Factors influencing the timing of initiation of renal replacement therapy and choice of modality in children with end-stage kidney disease

BACKGROUND

Decision-making in pediatric end-stage renal disease (ESRD) is a complex process for patients, families, and physicians. We evaluated the factors influencing the timing of initiation of renal replacement therapy (RRT) and choice of modality in children with ESRD.

METHODS

We retrospectively reviewed the RRT decision-making process for all children up to 19 years of age with ESRD, who underwent RRT over an 11-year period (2004 to 2014), at a Canadian pediatric tertiary care center. RRT modalities included peritoneal dialysis (PD), hemodialysis (HD), pre-emptive kidney transplant (PKT), and continuous renal replacement therapy (CRRT).

RESULTS

Ninety-two patients progressed to ESRD. RRT was started electively for 58 patients, and urgently for 34 patients. For elective patients, modalities included PD (34%), HD (19%), and PKT (47%). The glomerular filtration rate at initiation of RRT was higher in patients who underwent PKT as opposed to dialysis (11.7 vs. 9.1 ml/min/1.73m²). Medical and quality of life factors, including fatigue and poor concentration, influenced the timing of initiation of elective RRT. Medical factors were primarily important in urgent RRT, including oligoanuria and metabolic disturbances. Medical factors, patient/family preference, and contextual factors such as location of residence influenced choice of modality.

CONCLUSIONS

Our study found that the decision-making process in ESRD is multifactorial and involves not only medical factors, but also assessment of social factors, quality of life, and patient/family preference. Bettering our understanding of this decision-making process will positively impact patients and families through more informed decision-making.

Association of incident dialysis modality with mortality: a protocol for systematic review and meta-analysis of randomized controlled trials and cohort studies

BACKGROUND

At least 2.6 million adults and children receive dialysis treatment for end-stage kidney disease (ESKD) worldwide. The large majority of these receive hemodialysis (HD), while the remaining receive peritoneal dialysis (PD). Peritoneal dialysis may be associated with similar mortality outcomes as HD, and patient-reported outcomes are potentially increased with PD. Existing evidence for the mortality associated with PD was summarized over 20 years ago, and there has been greater marginal improvement in survival with PD relative to HD since that time. It is therefore timely to reexamine the question of differential mortality by modality and summarize evidence from more contemporary practice settings.

METHODS/DESIGN

Electronic databases will be systematically searched for publications that report the association between dialysis modality (HD or PD) with death from any cause and cause-specific death in incident patients with end-stage kidney disease. The database searches will be supplemented by searching through citations and references and consultation with experts. Studies published before 1995 will be excluded. Screening of both titles and abstracts will be done by two independent reviewers. All disagreements will be resolved by an independent third reviewer. A quantitative meta-analysis of effect sizes and standard errors will be applied.

DISCUSSION

Our systematic review will update previous evidence summaries and provide a quantitative and standardized assessment of the contemporary literature comparing HD and PD including published and unpublished non-English studies from greater China, Taiwan, and Japan. This review will inform shared decision-making around initial dialysis modality choice and jurisdiction-level considerations of dialysis practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018111829.

Medicare's New Prospective Payment System on Facility Provision of Peritoneal Dialysis

BACKGROUND AND OBJECTIVES

Peritoneal dialysis is a self-administered, home-based treatment for ESKD associated with equivalent mortality, higher quality of life, and lower costs compared with hemodialysis. In 2011, Medicare implemented a comprehensive prospective payment system that makes a single payment for all dialysis, medication, and ancillary services. We examined whether the prospective payment system increased dialysis facility provision of peritoneal dialysis services and whether changes in peritoneal dialysis provision were more common among dialysis facilities that are chain affiliated, located in nonurban areas, and in regions with high dialysis market competition.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a longitudinal retrospective cohort study of n=6433 United States nonfederal dialysis facilities before (2006-2010) and after (2011-2013) the prospective payment system using data from the US Renal Data System, Medicare, and Area Health Resource Files. The outcomes of interest were a dichotomous indicator of peritoneal dialysis service availability and a discrete count variable of dialysis facility peritoneal dialysis program size defined as the annual number of patients on peritoneal dialysis in a facility. We used general estimating equation models to examine changes in peritoneal dialysis service offerings and peritoneal dialysis program size by a pre- versus post-prospective payment system effect and whether changes differed by chain affiliation, urban location, facility size, or market competition, adjusting for 1-year lagged facility-, patient with ESKD-, and region-level demographic characteristics.

RESULTS

We found a modest increase in observed facility provision of peritoneal dialysis and peritoneal dialysis program size after the prospective payment system (36% and 5.7 patients in 2006 to 42% and 6.9 patients in 2013, respectively). There was a positive association of the prospective payment system with peritoneal dialysis provision (odds ratio, 1.20; 95% confidence interval, 1.13 to 1.18) and PD program size (incidence rate ratio, 1.27; 95% confidence interval, 1.22 to 1.33). Post-prospective payment system change in peritoneal dialysis provision was greater among nonurban (P<0.001), chain-affiliated (P=0.002), and larger-sized facilities (P<0.001), and there were higher rates of peritoneal dialysis program size growth in nonurban facilities (P<0.001).

CONCLUSIONS

Medicare's 2011 prospective payment system was associated with more facilities' availability of peritoneal dialysis and modest growth in facility peritoneal dialysis program size.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_11_19_CJASNPodcast_18_12_.mp3.

Primary Care Physicians' Decision Making Regarding Initial Oncology Referral for Adolescents and Young Adults With Cancer

PURPOSE

The objectives of this study were to determine whether pediatricians are more likely than other primary care physicians (PCPs) to refer newly diagnosed adolescent and young adult patients with cancer to pediatric oncological specialists, and to assess the physician and patient characteristics that affect patterns of referral.

METHODS

A cross-sectional vignette survey was mailed to PCPs to examine hypothetical referral decisions as a function of physician characteristics and patient characteristics, including diagnosis, age, gender, race/ethnicity, family support, transportation, insurance, and patient preference for site of care. Pediatrician PCPs and nonpediatrician PCPs (family medicine, internal medicine, and emergency medicine physicians) practicing in North Carolina and in Washington State participated in the study.

RESULTS

A total of 406 surveys were completed (35.8% response rate). Sixty percent of pediatric PCPs referred their hypothetical patients with cancer to pediatric specialists (PSs), compared with only 37% of nonpediatric PCPs. Patient age also influenced referral patterns; 89% of 13-year-olds, 74% of 16-year-olds, 25% of 19-year-olds, and only 9% of 22-year-old patients were referred to a PS. Multivariate logistic regression demonstrated that diagnosis and physician practice setting also were associated with referral patterns.

CONCLUSIONS

Both patient age and PCP specialty were significant predictors of referral patterns in hypothetical vignettes of newly diagnosed adolescent and young adult patients with cancer. Pediatricians were more likely than nonpediatrician PCPs to refer patients to a PS. Referrals to PSs decreased dramatically between ages 16 and 19. Because the site of oncological care can impact outcomes, these data have the potential to inform awareness and education initiatives directed at PCPs.

Assessment of physical and psychosocial status of children with ESRD under regular hemodialysis, a single centre experience

BACKGROUND AND OBJECTIVES

Children with end stage renal disease (ESRD) under regular hemodialysis suffer from various health problems that result either from the sequelae of disease itself or its various lines of therapy. The aim of this study is to clarify biodemographic characteristics, common complaints, and physical, and psychosocial status of children with ESRD under regular maintenance hemodialysis.

PATIENTS AND METHODS

This study was conducted on forty children (13 males, 17 females) aged 6-16 years with ESRD under regular hemodialysis, selected from the Pediatric Nephrology Unit at Tanta University Hospitals. Three structured questionnaires were used that measured the biodemographic data of children and their parents, common complaints before and after the onset of hemodialysis, and a physical and psychosocial status assessment sheet comprising of nutritional habits, sleeping patterns, daily physical activities, school achievement, the emotional, behavioral and social aspects of children, and different social relationships.

RESULTS

Most children with ESRD exhibited abnormal nutritional habits, disturbed sleep, decreased physical daily activities, impaired school achievement, and changing emotions and behaviors, and depressed social relationships.

CONCLUSION

Common adverse effects of ESRD and hemodialysis in our center are inadequate nutritional status, abnormal sleep patterns, decreased physical activity, low school achievement, and psychosocial deterioration.

RECOMMENDATIONS

Great efforts on the part of parents, pediatric nephrologists, nurses, psychologist, and school teachers are needed to improve the physical and psychosocial health of dialysis patients and thereby improve their quality of life.

Caring for youth living with HIV across the continuum: turning gaps into opportunities

With the increasing proportion of youth living with human immunodeficiency virus (YLHIV) and the aging of the perinatally infected population, there is a need for clinical services that are "youth friendly" to address the multiple challenges YLHIV face in terms of engagement in care and maintenance of combination antiretroviral therapy (cART). Little is known about how and where YLHIV receive their care. Further, the impact of the care structure on engagement and retention outcomes for YLHIV is ill defined. In order to better classify how YLHIV receive care in the United States, we performed a review of published literature characterizing the structure and outcomes of care for YLHIV. Several key concepts emerged: 1. The majority of YLHIV (13-24 years old) are cared for at adult sites, 2. Clinics providing care to YLHIV are varied in terms of the services offered and the types of services offered can impact outcomes, 3. YLHIV cared for in adult clinical sites have poor retention and antiretroviral treatment initiation, and 4. YLHIV cared for at adult sites had poorer retention and cART outcomes compared to YLHIV cared for at pediatric sites. There were no studies identified that specifically examined "youth friendly" care for YLHIV within the context of adult clinical sites. The results of this review highlight disparities for YLHIV and the need for interventions to improve outcomes for YLHIV in the context of adult care.

Hemodialysis outcomes in a global sample of children and young adult hemodialysis patients: the PICCOLO MONDO cohort

BACKGROUND

The aim of this study was to describe the experience of pediatric and young adult hemodialysis (HD) patients from a global cohort.

METHODS

The Pediatric Investigation and Close Collaborative Consortium for Ongoing Life Outcomes for MONitoring Dialysis Outcomes (PICCOLO MONDO) study provided de-identified electronic information of 3244 patients, ages 0-30 years from 2000 to 2012 in four regions: Asia, Europe, North America and South America. The study sample was categorized into pediatric (≤18 years old) and young adult (19-30 years old) groups based on the age at dialysis initiation.

RESULTS

For those with known end-stage renal disease etiology, glomerular disease was the most common diagnosis in children and young adults. Using Europe as a reference group, North America [odds ratio (OR) 2.69; CI 1.29, 5.63] and South America (OR 4.21; CI 2.32, 7.63) had the greatest mortality among young adults. North America also had higher rates of overweight, obesity, hypertension, cardiovascular disease, hospitalizations and secondary diabetes compared with all other regions. Initial catheter use was greater for North American (86.4% in pediatric patients and 75.2% in young adults) and South America (80.6% in pediatric patients and 75.9% in young adults). Catheter use at 1-year follow-up was most common in North American children (77.3%) and young adults (62.9%). Asia had the lowest rate of catheter use. For both age groups, dialysis adequacy (equilibrated Kt/V) ranged between 1.4 and 1.5. In Asia, patients in both age groups had significantly longer treatment times than in any other region.

CONCLUSIONS

The PICCOLO MONDO study has provided unique baseline and 1-year follow-up information on children and young adults receiving HD around the globe. This cohort has brought to light aspects of care in these age groups that warrant further investigation.

Nutritional vitamin D use in chronic kidney disease: a survey of pediatric nephrologists

BACKGROUND

Vitamin D deficiency may contribute to risk of cardiovascular disease, diabetes, and infections, in addition to known effects on mineral metabolism. Controversy remains regarding the use of nutritional vitamin D supplementation in chronic kidney disease (CKD), and the supplementation practices of pediatric nephrologists are unknown.

METHODS

An electronic survey containing eight vignettes was sent to physician members of the International Pediatric Nephrology Association in 2011 to identify physician and patient characteristics that influence nephrologists to supplement CKD patients with nutritional vitamin D. Vignettes contained patient characteristics including light vs dark skin, CKD stage, cause of renal disease, parathyroid hormone (PTH), and 25(OH) vitamin D levels. Multivariate logistic generalized estimating equation regression was used to identify predictors of supplementation.

RESULTS

Of 1,084 eligible physicians, 504 (46%) completed the survey. Supplementation was recommended in 73% of cases overall (ranging from 91% of those with vitamin D levels <10 ng/mL to 35% with levels >30). Greater CKD severity was associated with greater recommendation of supplementation, especially for patients with higher vitamin D levels (test for interaction p < 0.0001). PTH level above target for CKD stage was associated with greater recommendation to supplement in pre-dialysis CKD, but did not have an impact on recommendations in dialysis patients (test for interaction p < 0.0001). Skin color, cause of CKD, and albumin levels were not associated with supplementation recommendation.

CONCLUSIONS

Recommending nutritional vitamin D is common worldwide, driven by CKD stage and vitamin D and PTH levels. Future studies are needed to establish the risks and benefits of supplementation.

Predictors of highly active antiretroviral therapy utilization for behaviorally HIV-1-infected youth: impact of adult versus pediatric clinical care site

OBJECTIVES

We evaluated highly active antiretroviral therapy (HAART) utilization in youth infected with HIV through risk behaviors who met treatment criteria for HAART. We assessed the impact of receiving care at an adult or pediatric HIV clinical site on initiation and discontinuation of the first HAART regimen in behaviorally infected youth (BIY).

METHODS

This was a retrospective analysis of treatment-naive BIY, aged 12-24 years, who enrolled in the HIV Research Network between 2002 and 2008 and who met criteria for HAART. The outcomes were time from meeting criteria to initiation of HAART and time to discontinuation of the first HAART regimen. Analyses were conducted using Cox proportional hazards regression.

RESULTS

Of 287 treatment-eligible youth, 198 (69%) received HAART; of these 198 youth, 58 (29.3%) subsequently discontinued HAART. In multivariable analyses, there was no significant difference in the time between meeting treatment criteria and initiating HAART for BIY followed at adult or pediatric HIV clinical sites. However, BIY followed at adult sites discontinued HAART sooner than BIY followed at pediatric HIV clinical sites (adjusted hazard ratio [AHR]: 3.19 [1.26-8.06]).

CONCLUSIONS

Two-thirds of treatment-eligible BIY in the HIV Research Network cohort initiated HAART; however, one-third who initiated HAART discontinued it during the study period. Identifying factors associated with earlier HAART initiation and sustainability can inform interventions to enhance HAART utilization among treatment-eligible youth. The finding of earlier HAART discontinuation for youth at adult care sites deserves further study.

Advances in pediatric renal replacement therapy

Advances in the understanding and clinical application of hemodialysis, peritoneal dialysis, and continuous renal replacement therapy have resulted in strategies designed to further improve their safety and efficacy. These advances have been particularly important to children, in whom a variety of clinical and technical issues must be taken into consideration for optimum dialysis across a broad spectrum of patient size and need. This manuscript reviews recent data pertaining to the use of renal replacement therapy, with an emphasis on those aspects of dialysis management that are especially pertinent to pediatric ESRD and acute kidney injury care.

Longitudinal analysis of market factors associated with provision of peritoneal dialysis services

Despite the appeal of peritoneal dialysis (PD) among patients, payers, and providers, its use in the United States has been limited and declining. Prior research has found that patient factors explain little variation in PD utilization, and little is known about the contribution of dialysis facility factors. The authors examined market factors associated with the provision of PD services in dialysis facilities between 1995 and 2003. Less than half of dialysis facilities offered PD. PD provision was not explained by disease trends or patient characteristics commonly associated with PD use. Facilities were more likely to offer PD in less competitive and less spatially concentrated markets. PD services may not be available to all patients who would benefit from it and there may be insufficient demand, economics of scale, or incentives for facilities to provide PD. These findings warrant further investigation on dialysis facilities' provision of a preferred, potentially beneficial, and cost-effective therapy.

Geographic and temporal trends in peritoneal dialysis services in the United States between 1995 and 2003

BACKGROUND

Peritoneal dialysis (PD) is the preferred dialysis modality for many patients with end-stage renal disease (ESRD) in the United States. However, in sharp contrast to the high rates of PD use in other industrialized countries, PD use in the United States is low and decreasing. PD availability is a necessary condition for PD use; however, little is known about the availability and geographic distribution of PD services. This study describes trends in the regional supply of PD services in dialysis facilities between 1995 and 2003.

STUDY DESIGN

Longitudinal cohort study.

SETTING & PARTICIPANTS

Nonfederal outpatient dialysis facilities treating patients with ESRD in the United States using data from the US Renal Data System.

PREDICTORS

Annual ESRD patient and dialysis facility composition in hospital referral regions.

OUTCOME

Annual proportion of dialysis facilities offering PD treatment services in hospital referral regions.

RESULTS

The average proportion of facilities offering PD services in hospital referral regions was 56% in 1996, which decreased to 47% in 2003. There was geographic variation in PD services, with greater PD availability in metropolitan cities (compared with rural regions) and the Northeast (relative to the South and Midwest). Variation in PD availability was not explained by disease trends or patient characteristics believed to be important for PD use. An increasing regional presence of chain-affiliated facilities was associated with less PD supply.

LIMITATIONS

Accuracy of patient registry data, inability to account for consolidation of PD services among chain providers, sensitivity of results to definition of regional markets.

CONCLUSIONS

The small and decreasing availability of PD therapy seems counterintuitive given its demonstrated appeal to patients and payers. Further research is needed to investigate dialysis facilities' role in the underuse of a potentially useful therapy.

Is the declining use of long-term peritoneal dialysis justified by outcome data?

In the past decade, peritoneal dialysis use among patients with end-stage renal disease has declined in many countries. Studies from the United States indicate that many academic centers do not have adequate resources to train fellows, most incident dialysis patients are not offered peritoneal dialysis, and more than half of dialysis clinics do not have the infrastructure to support peritoneal dialysis. Some are concerned that the outcomes of peritoneal dialysis and maintenance hemodialysis patients may not be equivalent, a notion that is not supported by outcome studies. Given the effect of modality selection on patients' lifestyle, attempts to conduct a randomized, controlled comparison of maintenance hemodialysis and peritoneal dialysis have been unsuccessful. Most observational studies showed that peritoneal dialysis is associated with a survival advantage that diminishes over time; it is unclear whether any of the differences over time are attributable to the modality. Between 1996 and 2003, the early outcomes of peritoneal dialysis patients further improved, whereas those for maintenance hemodialysis patients remained unchanged. Differences in outcomes may be due to residual statistical confounding; however, several biologic mechanisms can be postulated: The early survival advantage may be related to the better preservation of residual renal function with peritoneal dialysis, and the diminution of the survival advantage may be related to worsened volume control. There is a need for large observational and interventional studies among peritoneal dialysis patients to sustain and enforce the improvements in both dialysis therapies.

Impact of pretransplant dialysis on early graft function in pediatric kidney recipients

Delayed graft function (DGF) is a frequent complication of kidney transplantation (KT) that may affect both short- and long-term graft outcome. It has been reported that pretransplantation peritoneal dialysis was correlated with a better recovery of graft function than hemodialysis in adult kidney recipients. However, the effect of pretransplantation dialysis mode (PDM) seemed to be unclear on the early outcome of KT in pediatric recipients. In this study, the potential impact of PDM on early graft function was evaluated in 174 pediatric patients who underwent KT by using cadaveric donors. The primary outcome parameter was the time to reach a serum creatinine (SCr) level 50% of the pretransplantation value [T(1/2(SCr))], while DGF was defined as a T(1/2(SCr)) >3 days after KT (n = 40). By stratifying kidney recipients for normal function graft or DGF, this latter group showed a significantly higher body weight (BW) on the day of KT (P = 0.014), body surface area (BSA) (P = 0.005), warm ischemia time (WIT) (P = 0.022), early SCr on the day 1 after KT (P < 0.001), and T(1/2(SCr)) (P < 0.001), whereas lower urine volume (UV) collected in the first 24 h after KT (P < 0.001) and fluid load (P < 0.001) occurred. Univariate exponential correlation that was carried out between T(1/2(SCr)) and all the other variables had shown a better value than the linear correlation for BW (R(2) = 0.28 vs. R(2) = 0.04), BSA (R(2) = 0.29 vs. R(2) = 0.03), and SCr (R(2) = 0.51 vs. R(2) = 0.28). In a multivariate regression analysis performed by entering T(1/2(SCr)) as dependent variable and following a forward stepwise method, cold ischemia time (CIT) (P = 0.027) but not PDM (P = 0.195) reached significance. In a Cox regression analysis carried out with T(1/2(SCr)) as dependent variable, neither CIT nor PDM gained significance. This study suggests that PDM does not affect early graft function in pediatric kidney recipients.

The impact of international medical graduate status on primary care physicians' choice of specialist

BACKGROUND

Approximately one fourth of practicing physicians in the United States graduated from medical schools in other countries. It is unknown how the role of international medical graduate status affects physician decision-making.

OBJECTIVE

The objective of this study was to determine whether a primary care physicians' knowledge of a specialist's international medical graduate status affects his or her decision to refer patients to that specialist.

RESEARCH DESIGN AND SUBJECTS

We studied a national, cross-sectional study of primary care physicians who see adult patients. The sample was drawn from the American Medical Association Physician's Professional Data. Each physician received 2 clinical case vignettes describing a patient for whom referral to a specialist was considered necessary. Each vignette was followed by 5 vignette specialist descriptions with medical school graduate status varied randomly alongside other physician characteristics.

MEASURE

We measured the decision to refer to an international versus U.S. medical graduate specialist.

RESULTS

Of 1054 eligible physicians, 623 (59.1%) responded. Respondents were significantly more likely to refer to a U.S. medical graduate (USMG) compared with an international medical graduate (IMG) (63% vs. 54%, P <0.05). After adjustment for age, race, sex, and referral characteristics of the vignette specialists, a positive referral decision was noted in a higher proportion of vignettes in which the vignette specialist was described as a USMG versus an IMG (63% vs. 51%, P <0.05).

CONCLUSION

With other factors being equal, vignette specialists described as IMGs versus USMGs were significantly less likely to be associated with a positive referral decision. Although specialist IMG status, relative to other factors, might not have a major effect on referral decisions, it is possible that negative views of international medical graduates could lead to suboptimal choices in referral decisions. Potentially, a patient could be referred to an USMG who happens to have inferior clinical skills than an IMG with superior clinical skills.

Effects of patient compliance, parental education and race on nephrologists' recommendations for kidney transplantation in children

Transplantation is the treatment goal for youth with kidney failure. To assess the effects of compliance, parental education and race on nephrologists' recommendations for transplantation in children, we surveyed a national random sample of adult and pediatric nephrologists. We elicited transplant recommendations for case vignettes created from random combinations of patient age, gender, race, cause of renal failure, family structure, parental education and compliance. Of 519 eligible physicians, 316 (61%) responded. Nephrologists were more likely to recommend transplantation for children of college-educated parents than children of parents who did not finish high school, despite identical clinical and demographic characteristics (adjusted OR 1.48, 95% CI 1.18, 1.86). Patient noncompliance negatively influenced transplant recommendations (adjusted OR 0.1, 95% CI 0.08, 0.13). Additionally, compliance had a different effect on transplant recommendations for white compared with black patients. The adjusted OR of a white, compliant patient being referred for transplantation were twice that of a black compliant patient (OR 2.06, 95% CI 1.17, 3.6). Education and compliance with therapy independently influence nephrologists' recommendations for transplantation in youth with kidney failure. Among the most compliant candidates, referral for transplantation may vary with patient race.

An analysis of dialysis training in the United States and Canada

BACKGROUND

Because the prevalence of end-stage renal disease (ESRD) has progressively increased in both the United States and Canada, patients with ESRD are likely to constitute progressively larger proportions of nephrology practices.

METHODS

We mailed a questionnaire to US and Canadian nephrology program directors to determine methods used in dialysis training; 53% of US and 73% of Canadian programs responded.

RESULTS

Training programs in the United States enrolled a larger median number of fellows and had a lower median faculty-fellow ratio compared with programs in Canada. However, the availability of faculty in providing training in the care of patients undergoing maintenance hemodialysis (MHD) or chronic peritoneal dialysis (CPD) was similar in both countries. There were wide variations in availability of patients in both the United States and Canada. US training programs offered trainees significantly lower numbers of MHD and CPD patients; 29% of US training programs had less than five CPD patients per fellow. Similarly, there were wide variations in the amount of time trainees spent providing care to MHD and CPD patients; in 14% of US training programs, fellows spent less than 5% of their time receiving training for patients undergoing CPD. Only a small proportion of training programs had faculty resources or ensured training for fellows in the placement of percutaneous tunneled venous hemodialysis catheters or peritoneal dialysis catheters.

CONCLUSIONS

To conclude, there are wide variations in dialysis training in both the United States and Canada. This survey raises concerns that many US training programs either do not have an appropriate number of CPD patients or do not allocate appropriate time to ensure the preparedness of fellows in providing independent care for patients with ESRD undergoing CPD.