Disparities in treatment rates of paediatric end-stage renal disease across Europe: insights from the ESPN/ERA-EDTA registry

Social Deprivation and Incidence of Pediatric Kidney Failure in France

Introduction

Approximately 8 per million children and young adults aged < 20 years initiate kidney replacement therapy (KRT) per year in France. We hypothesize that social deprivation could be a determinant of childhood-onset kidney failure. The objective of this study was to estimate the incidence of pediatric KRT in France according to the level of social deprivation.

Methods

All patients < 20 years who initiated KRT from 2010 to 2015 in metropolitan France were included. Data were collected from the comprehensive French registry of KRT French Renal Epidemiology and Information network (REIN). We used a validated ecological index to assess social deprivation, the 2011 French version of the European Deprivation Index (EDI). We estimated the age standardized incidence rates according to the quintiles of EDI using direct standardization and incidence rate ratio using Poisson regression.

Results

We included 672 children with kidney failure (58.6% males, 30.7% with glomerular or vascular disease, 43.3% starting KRT between 11 and 17 years). 38.8% were from the most deprived areas (quintile 5 of EDI). The age standardized incidence rate increased with quintile of EDI, from 5.45 (95% confidence interval [CI] = 4.25-6.64) per million children per year in the least deprived quintile to 8.46 (95% CI = 7.41-9.51) in the most deprived quintile of EDI (incidence rates ratio Q5 vs. Q1 1.53-fold; 95% CI = 1.18-2.01).

Conclusion

This study showed that even in a country with a universal health care system, there is a strong association between the incidence of pediatric KRT and social deprivation showing that social health inequalities appear from KRT initiation. This study highlights the need to look further into social inequalities in the earliest stage of chronic kidney disease (CKD).

[Epidemiology of childhood chronic kidney diseases]

Major advances have been made in the management of children with chronic kidney disease (CKD) over the past 30 years. However, existing epidemiological data mainly relies on registries of chronic kidney replacement therapy. The incidence and prevalence of earlier stages of CKD remain largely unknown, but rare population-based studies suggest that the prevalence of all stages CKD may be as high as 1 % of the pediatric population. Congenital disorders including renal hypodysplasia and uropathy (CAKUT) and hereditary nephropathies account for one-half to two-thirds of childhood CKD cases in high-income countries, whereas acquired nephropathies predominate in developing countries. CKD progression is slower in children with congenital disorders than in those with glomerular nephropathy, and other risk factors for progression have also been identified. Children with CKD have poorer health-related quality of life when compared to healthy children. While survival of children with CKD has continuously improved over time, mortality remains 20 to 30 times higher than in the general pediatric population.

Paediatric kidney transplantation in under-resourced regions-a panoramic view

Kidney transplantation is the ideal choice of kidney replacement therapy in children as it offers a low risk of mortality and a better quality of life. A wide variance in the access to kidney replacement therapies exists across the world with only 21% of low- and low-middle income countries (LLMIC) undertaking kidney transplantation. Pediatric kidney transplantation rates in these under-resourced regions are reported to be as low as < 4 pmcp [per million child population]. A robust kidney failure care program forms the cornerstone of a transplant program. Even the smallest transplant program entails a multidisciplinary workforce and expertise besides ensuring family commitment towards long-term care and economic burden. In general, the short-term graft survival rates from under-resourced regions are comparable to most high-income countries (HIC) and the challenge lies in the long-term outcomes. This review focuses on specific issues relevant to kidney transplants in children in under-resourced regions by highlighting limitations in the capacity and health workforce, regulatory norms, medical issues, economic burden, factors beyond financial hardship and ethical considerations relevant to these regions. Finally, the perspective of strengthening transplant programs in these regions should factor in the bigger challenges that exist in achieving the health-related sustainable development goals by 2030.

Demographics and long-term outcomes of children with end-stage kidney disease: A 20-year territory-wide study

AIM

To evaluate the demographics and long-term patient outcomes of children with end-stage kidney disease in Hong Kong.

METHODS

We conducted a cohort study at the Paediatric Nephrology Centre, the designated site providing kidney replacement therapy (KRT) for children in Hong Kong. The clinical characteristics and outcomes of all children who initiated chronic KRT before 19 years, between 2001 and 2020, were analysed.

RESULTS

One hundred forty-seven children (50% male) received KRT at a mean age of 11.4 ± 5.7 years. The incidence of ESKD was 6.28 per million age-related population (pmarp). The leading cause of ESKD was congenital anomalies (33%). Ten children (7%) had pre-emptive kidney transplants, 104 (71%) and 33 (22%) patients received automated peritoneal dialysis and haemodialysis as initial KRT. The incidence of ESKD increased over time, and were 4.38, 5.07, 6.15 and 9.17 pmarp during 2001-2005, 2006-2010, 2011-2015 and 2016-2020, respectively (p = .005). Ninty-seven patients (66%) received kidney transplants and the median time to receive a kidney graft was 3.7 years (95% CI 3.1-4.3). Only 10 patients had pre-emptive kidney transplants. The mortality rate was 9.1 deaths per 1000-patient-years (95%CI 4.6-16.2). The survival probabilities at 1-, 5-, 10- and 15-year were 100%, 94.8% (95%CI 90.7-98.9%), 89.7% (95% CI 83.4%-95.9%), 87.1% (95% CI 79.3%-94.9%), respectively. Standardised mortality ratio was 54.5. 72% of deaths were due to infections. Young infants and those without kidney transplants were associated with worse survival (p < .01). Multivariate analysis demonstrated that dialysis was the only factor associated with significantly increased risk of death (HR_adj 12.9, 95% CI 2.7-63.2, p = .002).

CONCLUSION

We observed an increasing incidence of paediatric ESKD in Hong Kong with considerable waiting time to kidney transplant. Mortality risk is comparable to other developed countries and is highest among dialysis population. Efforts should be made to facilitate early access to paediatric kidney transplantation in Hong Kong.

[Epidemiology of pediatric chronic kidney disease]

Major advances have been made in the management of children with chronic kidney disease over the past 30 years. However, existing epidemiology data are primarily from kidney replacement therapy registries, and information available at earlier stages of chronic kidney disease is limited. The incidence and prevalence of chronic kidney disease stages 2 to 5 remain poorly understood. However, rare population-based studies suggest that the prevalence of all-stage chronic kidney disease may be as high as 1% of the pediatric population. Congenital disorders including congenital abnormalities of the kidney and urinary tract and hereditary nephropathies account for one-half to two-thirds of pediatric chronic kidney disease cases in middle and high-income countries, whereas acquired nephropathies seem to predominate in low-income countries. The progression of chronic kidney disease is slower in children with congenital disorders than in those with acquired nephropathy, particularly glomerular disease, resulting in a lower proportion of congenital abnormalities of the kidney and urinary tract as a cause of end-stage kidney disease compared to less advanced stages of chronic kidney disease. The incidence of kidney replacement therapy in the pediatric population ranged by country from 1 to 14 per million children of the same age in 2018 (approximately 8 per million children in France) in patients younger than 20 years. The prevalence of kidney replacement therapy in children under 20 years of age in 2018 ranged from 15-30 per million children in some Eastern European and Latin American countries to 100 per million children in Finland and the United States (56 per million children in France). Most children with end-stage kidney disease initiate kidney replacement therapy with dialysis (more frequently hemodialysis than peritoneal dialysis). In about 20% of cases, the initial kidney replacement therapy modality is a pre-emptive kidney transplantation. In high-income countries, 60-80% of prevalent children with end-stage kidney disease live with a functioning transplant (75% in France). While the survival of children with chronic kidney disease has continuously improved over time, mortality remains about 30 times higher than in the general pediatric population.

A roadmap for optimizing chronic kidney disease patient care and patient-oriented research in the Eastern European nephrology community

Chronic kidney disease (CKD) is a major health problem because of its high prevalence, associated complications and high treatment costs. Several aspects of CKD differ significantly in the Eastern European nephrology community compared with Western Europe because of different geographic, socio-economic, infrastructure, cultural and educational features. The two most frequent aetiologies of CKD, DM and hypertension, and many other predisposing factors, are more frequent in the Eastern region, resulting in more prevalent CKD Stages 3-5. Interventions may minimize the potential drawbacks of the high prevalence of CKD in Eastern Europe, which include several options at various stages of the disease, such as raising public, medical personnel and healthcare authorities awareness; early detection by screening high-risk populations; preventing progression and CKD-related complications by training health professionals and patients; promoting transplantation or home dialysis as the preferred modality; disseminating and implementing guidelines and guided therapy and encouraging/supporting country-specific observational research as well as international collaborative projects. Specific ways to significantly impact CKD-related problems in every region of Europe through education, science and networking are collaboration with non-nephrology European societies who have a common interest in CKD and its associated complications, representation through an advisory role within nephrology via national nephrology societies, contributing to the training of local nephrologists and stimulating patient-oriented research. The latter is mandatory to identify country-specific kidney disease-related priorities. Active involvement of patients in this research via collaboration with the European Kidney Patient Federation or national patient federations is imperative to ensure that projects reflect specific patient needs.

Caregiver burden in pediatric dialysis

In spite of improvements in expected survival, neurodevelopmental outcome, and quality of life, decision-making in neonatal dialysis remains controversial in high-resource countries. In part, this may be based upon the significant burdens experienced by the child, and also those experienced by the parents as caregivers. Emerging research offers a clearer description of the burdens experienced by dialysis caregivers worldwide. Caregiver burden represents an important area for nephrologists to advocate for patients and their families; however, nephrologists must also recognize the realities caregivers currently experience. Incorporation of caregiver burden into medical decision-making for children with end-stage kidney disease is necessary, but raises several ethical concerns.

Different sized slices of cake: macroeconomic impacts on access to transplantation and graft survival for children

Transplantation for children with end-stage kidney disease confers clear survival, health, and health economic benefits. Access to transplantation and graft survival has been clearly shown to be affected by macroeconomic and patient-level factors in adults. This commentary explores the findings and implications of the "Results in the ESPN/ERA-EDTA Registry Suggest Disparities in Access to Kidney Transplantation but Little Variation in Graft Survival of Children Across Europe" study by Bonthuis et al., including key priorities in future research.

Results in the ESPN/ERA-EDTA Registry suggest disparities in access to kidney transplantation but little variation in graft survival of children across Europe

One of the main objectives of the European health policy framework is to ensure equitable access to high-quality health services across Europe. Here we examined country-specific kidney transplantation and graft failure rates in children and explore their country- and patient-level determinants. Patients under 20 years of age initiating kidney replacement therapy from January 2007 through December 2015 in 37 European countries participating in the ESPN/ERA-EDTA Registry were included in the analyses. Countries were categorized as low-, middle-, and high-income based on gross domestic product. At five years of follow-up, 4326 of 6909 children on kidney replacement therapy received their first kidney transplant. Overall median time from kidney replacement therapy start to first kidney transplantation was 1.4 (inter quartile range 0.3-4.3) years. The five-year kidney transplantation probability was 48.8% (95% confidence interval: 45.9-51.7%) in low-income, 76.3% (72.8-79.5%) in middle-income and 92.3% (91.0-93.4%) in high-income countries and was strongly associated with macro-economic factors. Gross domestic product alone explained 67% of the international variation in transplantation rates. Compared with high-income countries, kidney transplantation was 76% less likely to be performed in low-income and 58% less likely in middle-income countries. Overall five-year graft survival in Europe was 88% and showed little variation across countries. Thus, despite large disparities transplantation access across Europe, graft failure rates were relatively similar. Hence, graft survival in low-risk transplant recipients from lower-income countries seems as good as graft survival among all (low-, medium-, and high-risk) graft recipients from high-income countries.

Hemodialysis versus peritoneal dialysis in resource-limited settings

PURPOSE OF REVIEW

To assess the use, access to and outcomes of hemodialysis and peritoneal dialysis in low-resource settings.

RECENT FINDINGS

Hemodialysis tends to predominate because of costs and logistics, however services tend to be located in larger cities, often paid for out of pocket. Outcomes of dialysis-requiring acute kidney injury and end-stage kidney disease may be similar with hemodialysis and peritoneal dialysis, and therefore choice of therapy is dominated by availability, accessibility and patient or physician choice. Some countries have implemented peritoneal dialysis-first policies to reduce costs and improve access, because peritoneal dialysis requires less infrastructure, can be scaled up more easily and can be cheaper when fluids are manufactured locally.

SUMMARY

Access to both hemodialysis and peritoneal dialysis remains highly inequitable in lower-resource settings. Although challenges associated with dialysis in low-resource settings are similar, and there are more adults who require dialysis in low-resource settings, addressing hemodialysis and peritoneal dialysis needs of children in low-resource settings requires attention as the global inequities are greatest in this area. Lower-income countries are increasingly seeking to improve access to dialysis through various strategies, but meeting the costs of the entire dialysis population continues to be a major challenge.

Renal Replacement Therapy in Children in Lithuania: Challenges, Trends, and Outcomes

Background and Objectives: Pediatric renal replacement therapy (RRT) in Lithuania resumed in 1994 after a 12-year pause in renal transplantation. Management of end stage renal disease (ESRD) has changed, and outcomes have improved over decades. Our aim was to evaluate the dynamics of RRT in Lithuania in the period 1994⁻2015, describe its distinctive features, and compare our results with other countries. Materials and Methods: Data between 1994 and 2015 were collected from patients under the age of 18 years with ESRD receiving RRT. The data included: Hemodialysis (HD), peritoneal dialysis (PD), transplantation incidence and prevalence, transplant waiting time, dialysis modalities before transplantation, causes of ESRD and gender distribution in transplanted patients, and patient and graft survival. Results: RRT incidence and prevalence maintained an increase up until 2009. Sixty-four transplantations were performed. Juvenile nephronophthisis (25.9%) was the primary cause of ESRD in transplanted children. The transplant waiting time median was 8.0 months. The male to female ratio post-transplantation was 1.02. Patient survival after transplantation at 10 years was 90.0%, while graft survival for living (related) was 77.0% and 51.1% for deceased. Twelve patients died while on RRT. Conclusions: RRT numbers are increasing in Lithuania. HD is the primary treatment of choice before transplantation, with continued low numbers of preemptive transplantation. Patient survival post-transplantation is favorable, though graft survival is less satisfactory.

[Renal transplantation: Opportunities and risks for medical refugees]

BACKGROUND

Families with children and adolescents with end-stage renal disease came to Germany from the former Eastern Bloc countries before the wave of refugees in 2015, in order to enable their children to survive with adequate kidney replacement therapy and in the best case a kidney transplant.

METHODS

In a case study, medical records of 4 childen and adolescents were retrospectively analyzed. These patients who fled to Germany for the treatment of terminal renal failure applied for asylum and were successfully transplanted after the usual waiting period.

RESULTS

Four of the eight children and adolescents who came to Erlangen for treatment of terminal renal failure between 2003 and 2013 received a functioning kidney transplant (deceased donor kidney) after dialysis therapy was difficult due to lack of compliance to drug and dietary recommendations such as fluid restriction. Since children and adolescents are treated with chronic dialysis only with the aim of kidney transplantation, a living donation was discussed but was not possible for medical reasons. 3 recipients are symptom-free with a functional graft.

DISCUSSION

The case study demonstrates that children and adolescents fleeing to Germany due to their end stage renal disease are better integrated after kidney transplantation, have better chances of obtaining a good education and can be expected to live independently with their own income in the future.

Survival in children requiring chronic renal replacement therapy

Survival in the pediatric end-stage renal disease (ESRD) population has improved substantially over recent decades. Nonetheless, mortality remains at least 30 times higher than that of healthy peers. Patient survival is multifactorial and dependent on various patient and treatment characteristics and degree of economic welfare of the country in which a patient is treated. In this educational review, we aim to delineate current evidence regarding mortality risk in the pediatric ESRD population and provide pediatric nephrologists with up-to-date information required to counsel affected families.

Renal replacement therapy for children throughout the world: the need for a global registry

BACKGROUND

To describe the factors affecting the incidence of renal replacement therapy (RRT) among children, information from RRT registries is required. We aimed to give an overview of existing pediatric RRT registries worldwide, identify regions with a need to commence or increase data collection on pediatric RRT, and provide a rationale for developing a global RRT registry.

METHODS

A survey assessing pediatric RRT registry status was sent to International Pediatric Nephrology Associateion (IPNA) members in 127 countries in January 2016. The survey was complemented by a systematic literature search for active pediatric RRT registries.

RESULTS

Complete survey responses were retrieved from 94 countries (representing 86.2% of the world childhood population), with 84 (81.2%) having the means to provide RRT to children, given that there are no other limitations such as financial, social, or religious restraints. Fifty-one (35.3%) countries had national registries for both dialysis and transplantation, nine (30.0%) either had a dialysis or a transplant registry, six participated in international registries only (2.7%), and in 18 (13.2%), children on RRT were not followed in any registry. The search identified 92 pediatric RRT registries, primarily national registries located in Europe, North America, and Asia.

CONCLUSIONS

Although pediatric RRT can be provided in 84 countries representing 81.2% of the world's childhood population, national pediatric RRT registries are unavailable in many countries. To improve knowledge about the incidence and outcomes of pediatric RRT around the globe, an international population-based pediatric RRT registry has recently been initiated.

Chronic dialysis in children and adolescents: challenges and outcomes

Chronic dialysis is rarely required during childhood. Despite technical advances that have facilitated the treatment of even the youngest children, morbidity and mortality remain higher with chronic dialysis than after renal transplantation. The cost of equipment and skilled personnel to provide the service compromises the availability of such dialysis in parts of the world where financial resources are constrained. This Review describes the incidence and causes of end-stage kidney disease in children on long-term dialysis, and highlights management issues, including dialysis modality selection, complications, and patient outcome data.

Lessons learned from the ESPN/ERA-EDTA Registry

End-stage renal disease (ESRD) in children is a medically challenging condition. Due to its rarity and special features, methodologically sound collaborative studies are required. In 2007, a new European registry of pediatric renal replacement therapy (RRT), the ESPN/ERA-EDTA Registry, was launched. In recent years, the Registry has provided comprehensive data on incidence, prevalence, patient characteristics, RRT modalities, and mortality in pediatric ESRD, along with relevant insights into cardiovascular risk, anemia, nutrition and growth, transplantation outcomes, and rare diseases. In this review, we describe the study design and structure underlying the ESPN/ERA-EDTA Registry, summarize the major research findings from more than 20 publications, and discuss current limitations and the future challenges to overcome.

The state of renal replacement therapy for children in South Africa: Data from the first report of the re-established National Renal Registry

BACKGROUND

The South African Renal Registry (SARR) was re-established in 2010. The first report was produced in 2014. It revealed that only 3182 patients out of 43.6 million people who were dependent on the state for medical care, received renal replacement therapy (RRT) in 2012 (73 per million population).

AIM

To describe the state of RRT for children in South Africa in 2012.

METHODS

From the SARR report and 2012 dataset, a cross-sectional study was performed of children under 14 years of age who received chronic dialysis, and incident renal transplants in 2012. Patient demographics, treatment modalities and outcome were recorded and RRT rates computed.

RESULTS

Fifty-nine children received dialysis in South Africa in 2012, a rate of 3.8 per million age-related population (pmarp). The mean age was 9 years 11 months. The most common cause of end stage renal failure (ESRF) was acquired glomerular disorders (83%). Ninety percent of the children received treatment in two of the nine provinces. Six children (10%) were treated in the only private dialysis unit. Eleven patients received kidney transplants (19%): six private and five public sector patients. Sixteen patients (27.1%) died: seven due to cardiovascular and three due to cerebrovascular events.

CONCLUSION

There was a low RRT rate of 3.8 pmarp for children in South Africa in 2012. Private sector patients were likely to receive more optimal treatment. The poor performance of the state health sector can largely be ascribed to a deficiency of funding for RRT facilities and trained personnel.

Inequalities in access to pediatric ESRD care: a global health challenge

The increasing attention paid to chronic kidney disease (CKD) as a major cause of mortality and disability, as well as the advances in management of CKD in children, have created a growing demand for pediatric renal replacement therapy (RRT) worldwide. A study by Koch Nogueira and colleagues of children on the transplant waiting list showed large disparities in access to pediatric kidney transplantation between regions in Brazil. This finding raises a wider question about inequalities in access to CKD care in children. Here we review the available data on the global burden of end-stage renal disease in children, the need for pediatric RRT, and its actual provision worldwide. We focus on inequalities in access to renal care for children that currently exist between and within countries. Reduction in worldwide inequalities in access to RRT in children remains a challenge, which requires greater awareness and effective interventions and policies.

Inequality in pediatric kidney transplantation in Brazil

BACKGROUND

The aim of this study was to describe the access and factors associated with kidney transplantation for children in different regions of Brazil.

METHODS

We analyzed a cohort of 1211 children enrolled on the transplant list from January 2011 to December of 2013. We fitted regression models to investigate factors associated with: (a) undergoing kidney transplantation from a deceased donor, and (b) being removed from the waiting list.

RESULTS

The incidence of transplantation was uneven across regions, with the lowest rate at 0.4 per million age-related population (pmarp) in the Midwest and the highest incidence rate of 8.3 cases pmarp in the South. Children from the North and the Midwest regions had a 3-4 times lower probability of undergoing a deceased donor transplant (p < 0.05). Apart from the geographic region, age of recipients and GDP influenced the outcome. The likelihood of undergoing transplantation was very low in the youngest children in the North and Midwest. The number of transplant centers was not associated with either outcome.

CONCLUSIONS

Factors of inequality in transplantation in Brazil are of macroeconomic origin, but there is room to reduce inequalities. Training existing transplant center professionals in the care of children could diminish the discrepancies.

[Etiologies of end-stage renal disease of children in Tunisia]

BACKGROUND

The end-stage renal disease (ESRD) in children has special features in terms of etiologies, therapeutic modalities and access to renal transplantation. In Tunisia, there are no data on the epidemiology of ESRD in children. The aim of our study was to describe epidemiology of ESRD among Tunisian children.

METHODS

This retrospective study was conducted in pediatric departments in Charles-Nicolle Hospital, Tunis and Hedi Chaker hospital, Sfax, during a period of 15 years (1st January 1998-31st December 2013). We included children who develop ESRD before the age of 15 years.

RESULTS

In total, 166 patients were included. The median duration of follow-up was 48 months. We collected respectively 24 children (14.5%) aged less than 2 years, 24 children (14.5%) aged between 2 and 6 years and 118 children (71%) older than 6 years. The sex ratio was equal to 1.4. The mean incidence was 4.25 cases per million children. The main causes were represented by congenital anomalies of the kidneys and urinary tract (35.5%), hereditary renal disease (31.3%) and glomerular kidney disease (9.6%). All patients were treated in kidney transplant dialysis programs; the main mode of dialysis was represented by peritoneal dialysis, which represented the initial dialysis mode in 81% of cases. The transition to hemodialysis was noted in 43.4% cases. Thirty-eight patients (22.8%) were transplanted. The mortality rate was 27.1%. The leading cause of death was cardiovascular diseases (37.7%) and infections (22.2%).

CONCLUSION

The creation of a national registry of kidney disease in Tunisia is necessary for a better knowledge of needs for dialysis and renal transplantation in children.

Social and economic determinants of pediatric health inequalities: the model of chronic kidney disease

Purpose of this review is to deal with priorities and strategies to significantly tackle inequalities in the management of pediatric diseases in low-middle-income countries. This issue has become a focal point of epidemiological and public health, with special reference to chronic nontransmissible diseases. We will provide our readership with an essential overview of the cultural, institutional, and political events, which have occurred over the last 20 y and which have produced the current general framework for epidemiology and public health. Then the most recent epidemiological data will be evaluated, in order to quantify the interaction between the medical components of the disease profiles and their socioeconomic determinants. Finally, a focus will be added on models of pediatric chronic kidney diseases, which are in our opinion amongst the most sensitive markers of the interplay between health and society. Collaborative, pediatrician-initiated, multicentre projects in these fields should be given priority in calls for grants supported by public agencies. The involvement of a critical mass of those working in the "fringes" of pediatric care is a final, essential mean by which significant results can be produced under the sole responsibility and research interest of centers of excellence.