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Claes D, Markham KB, Cortezzo DE. An Ethical Analysis of Therapy for Severe Congenital Kidney and Urinary Tract Anomalies. Pediatrics 2024; 153:e2023064720. [PMID: 38784992 DOI: 10.1542/peds.2023-064720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 05/25/2024] Open
Abstract
Technological advancements before and after delivery have greatly altered the counseling of pregnant patients facing a fetal diagnosis of severe oligohydramnios or anhydramnios secondary to congenital anomalies of the kidneys and urinary tract. Once considered a nearly uniformly lethal abnormality, long-term survival may now be possible secondary to prenatal innovations aimed at restoring the amniotic fluid volume and the availability of more advanced neonatal dialysis techniques. However, these available therapies are far from perfect. The procedures are onerous for pregnant patients without a guarantee of success, and families must prepare themselves for the complex life-long medical care that will be necessary for surviving individuals. Multidisciplinary counseling is imperative to help pregnant individuals understand the complexity of these conditions and assist them in exercising their right to informed decision-making. Moreover, as with any developing field of medicine, providers must contend with ethical questions related to the treatment options, including questions regarding patient-hood, distributive justice, and the blurred lines between research, innovation, and standard care. These ethical questions are best addressed in a multidisciplinary fashion with consideration of multiple points of view from various subspecialties. Only by seeing the entirety of the picture can we hope to best counsel patients about these highly complex situations and help navigate the most appropriate care path.
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Affiliation(s)
- Donna Claes
- Divisions of Nephrology
- Departments of Pediatrics
| | - Kara B Markham
- Cincinnati Children's Fetal Care Center
- Obstetrics and Gynecology and Division of Maternal Fetal Medicine
| | - DonnaMaria E Cortezzo
- Cincinnati Children's Fetal Care Center
- Neonatal and Pulmonary Biology
- Pain and Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Departments of Pediatrics
- Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Divisions of Neonatology
- Pain and Palliative Care
- Fetal Care Program, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut
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Hsu CN, Tain YL, Lu PC, Lin HW. Comparisons of EQ-5D-Y and PedsQL in pediatric patients with mild-to-moderate chronic kidney disease in longitudinal analyses. Health Qual Life Outcomes 2023; 21:117. [PMID: 37891615 PMCID: PMC10605985 DOI: 10.1186/s12955-023-02197-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
OBJECTIVE To characterize longitudinal changes and correlations between the measures of EQ-5D-Y and generic PedsQL and their associations with clinical changes in children and adolescents with mild-to-moderate chronic kidney disease (CKD). METHODS Participants were recruited from January 2017 to September 2021 in a medical center in Taiwan. Both instruments were administered in their initial visits and every 6-month subsequent visits. Spearman's Rho (ρ) was used to assess correlations between the scores of EQ-5D-Y and PedsQL measures in longitudinal changes. Cohen's effect size (ES) was used to evaluate the changes of scores/subscales over time. In addition, factors associated with longitudinal changes in the score/subscales were explored. RESULTS A total of 121 participants were enrolled, and 83 with ≥ 3 HRQOL measures during the 3.5 years follow-up were assessed their changes of HRQOL measures. The correlations (ρ > 0.3) appeared between the changes in the visual analog scale (VAS) of EQ-5D-Y and emotional and social subscales of PedsQL. ES was small (< 0.5) in the VAS and level-sum-score (LSS) of EQ-5D-Y scores for the clinical changes in comorbidities, while some PedsQL subscales were medium to high (0.5-0.8 or > 0.8). Hypertension, mineral bone disorder/anemia, and hyperuricemia associated with the changes in both HRQOL scores were varied by their various domains. CONCLUSION Both EQ-5D-Y and PedsQL of HRQOL measures were responsive to worsened childhood CKD-related comorbidities during the follow-up; however, convergent validity between them was limited in some domains. The LSS of EQ-5D-Y showed greater changes than the VAS by comorbidity status; further comparison with utility weight is needed to determine the better performance of EQ-5D-Y.
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Affiliation(s)
- Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - You-Lin Tain
- Division of Pediatric Nephrology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan
| | - Pei-Chen Lu
- Division of Pediatric Nephrology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan
| | - Hsiang-Wen Lin
- School of Pharmacy and Graduate Institute, College of Pharmacy, China Medical University, No. 100, Sec. 1, Jingmao Rd., Taichung City, 406040, Taiwan.
- Department of Pharmacy, China Medical University Hospital, Taichung, Taiwan.
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
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Guha C, van Zwieten A, Khalid R, Kim S, Walker A, Francis A, Didsbury M, Teixeira-Pinto A, Barton B, Prestidge C, Lancsar E, Mackie F, Kwon J, Howard K, Mallitt KA, Howell M, Jaure A, Hayes A, Raghunandan R, Petrou S, Lah S, McTaggart S, Craig JC, Wong G. Longitudinal assessment of the health-related quality of life of children and adolescents with chronic kidney disease. Kidney Int 2023; 103:357-364. [PMID: 36374824 DOI: 10.1016/j.kint.2022.09.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/27/2022] [Accepted: 09/01/2022] [Indexed: 11/11/2022]
Abstract
In this multi-center longitudinal cohort study conducted in Australia and New Zealand, we assessed the trajectories of health-related quality of life (HRQoL) in children with chronic kidney disease (CKD) over time. A total of 377 children (aged 6-18 years) with CKD stages 1-5 (pre-dialysis), dialysis, or transplant, were followed biennially for four years. Multi Attribute Utility (MAU) scores of HRQoL were measured at baseline and at two and four years using the McMaster Health Utilities Index Mark 3 tool, a generic multi-attribute, preference-based system. A multivariable linear mixed model was used to assess the trajectories of HRQoL over time in 199 children with CKD stage 1-5, 43 children receiving dialysis and 135 kidney transplant recipients. An interaction between CKD stage at baseline and follow-up time indicated that the slopes of the HRQoL scores differed between children by CKD stage at inception. Over half of the cohort on dialysis at baseline had received a kidney transplant by the end of year four and the MAU scores of these children increased by a meaningful amount averaging 0.05 (95% confidence interval 0.01 to 0.09) per year in comparison to those who were transplant recipients at baseline. The mean difference between baseline and year two MAU scores was 0.09 (95% confidence interval -0.05, 0.23), (Cohen's d effect size 0.31). Thus, improvement in HRQoL over time of children on dialysis at baseline was likely to have been driven by their transition from dialysis to transplantation. Additionally, children with CKD stage 1-5 and transplant recipients at baseline had no changes in their disease stage or treatment modality and experienced stable HRQoL over time.
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Affiliation(s)
- Chandana Guha
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.
| | - Anita van Zwieten
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Rabia Khalid
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Siah Kim
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Amanda Walker
- Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Anna Francis
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Centre for Kidney Disease Research, Translational Research Institute, Brisbane, Queensland, Australia; Child and Adolescent Renal Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Madeleine Didsbury
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Belinda Barton
- The Children's Hospital at Westmead and Paediatrics and Child Health (CHERI), University of Sydney, Sydney, New South Wales, Australia
| | | | - Emily Lancsar
- Department of Health Services Research and Policy, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Fiona Mackie
- Sydney Children's Hospital, Randwick, New South Wales, Australia; School of Women's and Child Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Joseph Kwon
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kirsten Howard
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Menzies Centre for Health Policy & Economics, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kylie-Ann Mallitt
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Allison Jaure
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Alison Hayes
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rakhee Raghunandan
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Suncica Lah
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Steven McTaggart
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Child and Adolescent Renal Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Germaine Wong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
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