Racial and ethnic differences in pediatric access to preemptive kidney transplantation in the United States

Kidney transplantation access and outcomes for Aboriginal and Torres Strait Islander children and young adults, 1963-2020: an ANZDATA registry study

OBJECTIVES

To assess differences between Aboriginal and Torres Strait Islander and non-Indigenous Australian children and young adults in access to and outcomes of kidney transplantation.

STUDY DESIGN

A cohort study based on prospectively collected data; analysis of Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data.

SETTING, PARTICIPANTS

Children and young adults aged 0-24 years who commenced kidney replacement therapy in Australia during 1963-2020.

MAIN OUTCOME MEASURES

Proportions of children and young adults who received kidney transplants within five years of commencing dialysis; 5- and 10-year death-censored graft survival; and 5- and 10-year survival of children and young adults who received kidney transplants or who remained on dialysis.

RESULTS

During 1963-2020, 3736 children and young adults received kidney replacement therapy in Australia: 213 (5.8%) Aboriginal and Torres Strait Islander and 3523 (94.2%) non-Indigenous children and young adults. During follow-up (median, eight years; interquartile range [IQR], 2.6-15 years), 2762 children and young adults received kidney transplants: 93 Aboriginal and Torres Strait Islander (43.7% of those receiving kidney replacement therapy) and 2669 non-Indigenous children and young adults (75.8%). Smaller proportions of Aboriginal and Torres Strait Islander than of non-Indigenous children and young adults received transplants within five years of commencing dialysis (99, 46% v 2924, 83.0%), received living donor transplants (19, 20% v 1170, 43.9%), or underwent pre-emptive transplantation (one, 1.1% v 363, 13.6%). Five-year graft survival for Aboriginal and Torres Strait Islander recipients was similar to non-Indigenous recipients (61% v 75%; adjusted hazard ratio [aHR], 1.43; 95% confidence interval [CI], 0.02-2.05), but 10-year graft survival was lower (35% v 61%; aHR, 1.69; 95% CI, 1.25-2.28). Five- and 10-year survival after kidney transplantation was similar for Aboriginal and Torres Strait Islander and non-Indigenous people. Among those who remained on dialysis, 10-year survival was poorer for Aboriginal and Torres Strait Islander than non-Indigenous children and young adults (aHR, 1.50; 95% CI, 1.08-2.10).

CONCLUSIONS

Five-year graft and recipient survival were excellent for Aboriginal and Torres Strait Islander children and young adults who received kidney transplants; however, a lower proportion received transplants within five years of dialysis initiation, than non-Indigenous children and young adults. Improving transplant access within five years of dialysis commencement should be a priority.

Socioeconomic Position and Health Among Children and Adolescents With CKD Across the Life-Course

Children and adolescents in families of lower socioeconomic position (SEP) experience an inequitable burden of reduced access to healthcare and poorer health. For children living with chronic kidney disease (CKD), disadvantaged SEP may exacerbate their considerable disease burden. Across the life-course, CKD may also compromise the SEP of families and young people, leading to accumulating health and socioeconomic disadvantage. This narrative review summarizes the current evidence on relationships of SEP with kidney care and health among children and adolescents with CKD from a life-course approach, including impacts of family SEP on kidney care and health, and bidirectional impacts of CKD on SEP. It highlights relevant conceptual models from social epidemiology, current evidence, clinical and policy implications, and provides directions for future research. Reflecting the balance of available evidence, we focus primarily on high-income countries (HICs), with an overview of key issues in low- and middle-income countries (LMICs). Overall, a growing body of evidence indicates sobering socioeconomic inequities in health and kidney care among children and adolescents with CKD, and adverse socioeconomic impacts of CKD. Dedicated efforts to tackle inequities are critical to ensuring that all young people with CKD have the opportunity to live long and flourishing lives. To prevent accumulating disadvantage, the global nephrology community must advocate for local government action on upstream social determinants of health; and adopt a life-course approach to kidney care that proactively identifies and addresses unmet social needs, targets intervening factors between SEP and health, and minimizes adverse socioeconomic outcomes across financial, educational and vocational domains.

Progress made toward equitable transplantation in children and young adults with kidney disease

Racial disparities in pediatric kidney transplantation have been well described over the last two decades and include disparities in preemptive transplantation, waitlisting, time from activation to transplantation, living donation, and graft outcomes. Changes to the organ allocation system including the institution of Share 35 in 2005 and the Kidney Allocation System (KAS) of 2014 have resulted in resolution of some, but not all racial-ethnic disparities. Despite overall improvements in time from waitlist activation to transplant, disparities remain in preemptive transplantation, time to waitlisting, and living donor transplantation. Although improving under the KAS, racial disparities remain in graft survival as well. Racial disparity in kidney transplant access and graft survival is an international problem within pediatric nephrology. Although the racial group affected may differ, various minoritized pediatric groups across the world are affected by transplant disparities. Social determinants of health including financial access, language barriers, and the presence of a healthy living donor play a role in mediating these disparities. Further investigation is needed to better understand and intervene upon modifiable social, biological, and cultural factors driving the remaining disparity in transplant outcomes.

Disparities in lung transplantation in children

Lung transplantation is a recognized therapy for end-stage respiratory failure in children and young people. It is only available in selected countries and is limited by access to suitable organs. Data on disparities in access and outcomes for children undergoing lung transplantation are limited. It is clear from data from studies in adults, and from studies in other solid organ transplants in children, that systemic inequities exist in this field. While data relating specifically to pediatric lung transplantation are relatively sparse, professionals should be aware of the risk that healthcare systems may result in disparities in access and outcomes following lung transplantation in children.

Preemptive living donor kidney transplantation: Access, fate, and review of the status in Egypt

BACKGROUND

Preemptive living donor kidney transplantation (PLDKT) is recommended as the optimal treatment for end-stage renal disease.

AIM

To assess the rate of PLDKT among patients who accessed KT in our center and review the status of PLDKT in Egypt.

METHODS

We performed a retrospective review of the patients who accessed KT in our center from November 2015 to November 2022. In addition, the PLDKT status in Egypt was reviewed relative to the literature.

RESULTS

Of the 304 patients who accessed KT, 32 patients (10.5%) had preemptive access to KT (PAKT). The means of age and estimated glomerular filtration rate were 31.7 ± 13 years and 12.8 ± 3.5 mL/min/1.73 m², respectively. Fifty-nine patients had KT, including 3 PLDKTs only (5.1% of total KTs and 9.4% of PAKT). Twenty-nine patients (90.6%) failed to receive PLDKT due to donor unavailability (25%), exclusion (28.6%), regression from donation (3.6%), and patient regression on starting dialysis (39.3%). In multivariate analysis, known primary kidney disease (P = 0.002), patient age (P = 0.031) and sex (P = 0.001) were independent predictors of achievement of KT in our center. However, PAKT was not significantly (P = 0.065) associated with the achievement of KT. Review of the literature revealed lower rates of PLDKT in Egypt than those in the literature.

CONCLUSION

Patient age, sex, and primary kidney disease are independent predictors of achieving living donor KT. Despite its non-significant effect, PAKT may enhance the low rates of PLDKT. The main causes of non-achievement of PLDKT were patient regression on starting regular dialysis and donor unavailability or exclusion.

The unfinished journey toward transplant equity: an analysis of racial/ethnic disparities for children after the implementation of the Kidney Allocation System in 2014

BACKGROUND

Disparities in pediatric kidney transplantation (KT) result in reduced access and worse outcomes for minority children. We assessed the impact of recent systems changes on these disparities.

METHODS

This is a retrospective cohort study of pediatric patients utilizing data from the US Renal Data System (n = 7547) and Scientific Registry of Transplant Recipients (n = 6567 waitlisted and n = 6848 transplanted patients). We compared access to transplantation, time to deceased donor kidney transplant (DDKT), and allograft failure (ACGF) in the 5 years preceding implementation of the Kidney Allocation System (KAS) to the 5 years post-KAS implementation 2010-2014 vs. 2015-2019, respectively.

RESULTS

Compared to the pre-KAS era, post-KAS candidates were more likely to be pre-emptively listed (26.8% vs. 38.1%, p < 0.001), pre-emptively transplanted (23.8% vs. 28.0%, p < 0.001), and less likely to have private insurance (35.6% vs. 32.3%, p = 0.01), but these were not uniform across racial groups. Compared to white children, Black and Hispanic children had a lower likelihood of transplant listing within 2 years of first dialysis service (aHR 0.590.670.76 and 0.730.820.92, respectively) in the post-KAS era. Time to DDKT was comparable across all racial groups in the post-KAS era. Compared to white children, Black DDKT recipients have more 5-year ACGF (aHR 1.001.432.06 p = 0.05) while there was no difference in 3- or 5-year ACGF among LDKT recipients.

CONCLUSIONS

After KAS implementation, there is equity in time to DDKT. Pre-KAS increased hazard of ACGF among Black children has decreased in the post-KAS era; however, persistent disparities exist in time to transplant listing among Black and Hispanic children when compared to white children. A higher resolution version of the Graphical abstract is available as Supplementary information.

A systematic review of social determinants of health in pediatric organ transplant outcomes

BACKGROUND

Equitable access to pediatric organ transplantation is critical, although risk factors negatively impacting pre- and post-transplant outcomes remain. No synthesis of the literature on SDoH within the pediatric organ transplant population has been conducted; thus, the current systematic review summarizes findings to date assessing SDoH in the evaluation, listing, and post-transplant periods.

METHODS

Literature searches were conducted in Web of Science, Embase, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases.

RESULTS

Ninety-three studies were included based on pre-established criteria and were reviewed for main findings and study quality. Findings consistently demonstrated disparities in key transplant outcomes based on racial or ethnic identity, including timing and likelihood of transplant, and rates of rejection, graft failure, and mortality. Although less frequently assessed, variations in outcomes based on geography were also noted, while findings related to insurance or SES were inconsistent.

CONCLUSION

This review underscores the persistence of SDoH and disparity in equitable transplant outcomes and discusses the importance of individual and systems-level change to reduce such disparities.

An ethical analysis of obesity as a contraindication of pediatric kidney transplant candidacy

The inclusion of body mass index (BMI) as a criterion for determining kidney transplant candidacy in children raises clinical and ethical challenges. Childhood obesity is on the rise and common among children with kidney failure. In addition, obesity is reported as an independent risk factor for the development of CKD and kidney failure. Resultantly, more children with obesity are anticipated to need kidney transplants. Most transplant centers around the world use high BMI as a relative or absolute contraindication for kidney transplant. However, use of obesity as a relative or absolute contraindication for pediatric kidney transplant is controversial. Empirical data demonstrating poorer outcomes following kidney transplant in obese pediatric patients are limited. In addition, pediatric obesity is distributed inequitably among groups. Unlike adults, most children lack independent agency to choose their food sources and exercise opportunities; they are dependent on their families for these choices. In this paper, we define childhood obesity and review (1) the association and impact of obesity on kidney disease and kidney transplant, (2) existing adult guidelines and rationale for using high BMI as a criterion for kidney transplant, (3) the prevalence of childhood obesity among children with kidney failure, and (4) the existing literature on obesity and pediatric kidney transplant outcomes. We then discuss ethical considerations related to the use of obesity as a criterion for kidney transplant.

The global survival rate of graft and patient in kidney transplantation of children: a systematic review and meta-analysis

Background

This study is a systematic review and meta-analysis on published studies about the Global Survival Rate of Graft and Patients in the Kidney Transplantation of children.

Methods

Studies that investigated the survival rate of kidney transplants published until the 30th of December 2020 were selected using a systematic search strategy in the following databases: Medline, Embase, Scopus, ProQuest, ISI Web of Science, and Cochrane. The extracted data were entered into the Excel software and STATA 16.0. The search identified 6007 study references. From the total, we excluded 1348 duplicates, 3688 reference titles and abstracts that were deemed irrelevant, and 846 references that were not original articles (i.e., letter, commentary, review) or did not meet the inclusion criteria. As such, 89 studies involving 12,330 participants were included in this meta-analysis.

Results

In this study 1, 3, 5, 7 and 10-year survival rates of graft were estimated to be 92, 83, 74.40, 67.10, and 63.50%, respectively. Also, 1, 3, 5, 7 and 10-year survival rates of patients were estimated to be 99.60, 97.30, 95.20, 74.60, and 97.90%, respectively.

Conclusions

The findings suggest differences in graft and patient survival among children with kidney transplants. Although differences in ethnic origin, incompatibility with deceased donor kidneys, and types of kidney disease are unavoidable, interventions to improve preventive and living-donor transplantation are particularly needed in minority groups. In addition, more research is needed to establish and address the contribution of medical and sociocultural barriers to preferential treatment of these groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03545-2.

Overview of pediatric kidney transplantation

Kidney transplantation is the treatment of choice for pediatric patients with end-stage kidney disease. Unlike adult recipients undergoing transplantation, special considerations must be taken when transplanting children based on the underlying etiology of kidney disease, previous surgical procedures, anatomical limitations and necessary technical adjustments. Additionally, the choice of donor must be measured to ensure optimal graft survival given a longer post-transplant life expectancy. Those topics as well as frequently encountered postoperative complications are also discussed in this publication.

Is Preemptive Kidney Transplantation Associated With Improved Outcomes when Compared to Non-preemptive Kidney Transplantation in Children? A Systematic Review and Meta-Analysis

Main Problem: Preemptive kidney transplantation (PKT) is performed prior to dialysis initiation to avoid dialysis-related morbidity and mortality in children and adolescents. We undertook a systematic review to compare clinical outcomes in PKT versus kidney transplantation after dialysis initiation in paediatric patients.

Methods: The bibliographic search identified studies that compared paediatric recipients of a first or subsequent, living or deceased donor PKT versus non-preemptive kidney transplant. Methodological quality was assessed for all studies. Data were pooled using the random-effects model.

Results: Twenty-two studies (n = 22,622) were included. PKT reduced the risk of overall graft loss (relative risk (RR) .57, 95% CI: .49–.66) and acute rejection (RR: .81, 95% CI: .75–.88) compared to transplantation after dialysis. Although no significant difference was observed in overall patient mortality, the risk of patient death was found to be significantly lower in PKT patients with living donor transplants (RR: .53, 95% CI: .34–.83). No significant difference was observed in the incidence of delayed graft function.

Conclusion: Evidence from observational studies suggests that PKT is associated with a reduction in the risk of acute rejection and graft loss. Efforts should be made to promote and improve rates of PKT in this group of patients (PROSPERO).

Systematic Review Registration:https://clinicaltrials.gov/, CRD42014010565

Seeking justice, equity, diversity and inclusion in pediatric nephrology

Inequity, racism, and health care disparities negatively impact the well-being of children with kidney disease. This review defines social determinants of health and describes how they impact pediatric nephrology care; outlines the specific impact of systemic biases and racism on chronic kidney disease care and transplant outcomes; characterizes and critiques the diversity of the current pediatric nephrology workforce; and aims to provide strategies to acknowledge and dismantle bias, address barriers to care, improve diversity in recruitment, and strengthen the pediatric nephrology community. By recognizing historical and current realities and limitations, we can move forward with strategies to address racism and bias in our field and clinical practices, thereby cultivating inclusive training and practice environments.

Addressing the Ethical Challenges of Providing Kidney Failure Care for Children: A Global Stance

Children with kidney failure require kidney replacement therapy (KRT), namely maintenance dialysis and kidney transplant. Adequate kidney failure care consists of KRT or conservative treatment with palliative care. In the context of kidney failure, children depend on parents who are their surrogate decision-makers, and the pediatric nephrology team for taking decisions about KRT or conservative care. In this paper, we discuss the ethical challenges that arise relating to such decision-making, from a global perspective, using the framework of pediatric bioethics. While many ethical dilemmas in the care of children with KRT are universal, the most significant ethical dilemma is the inequitable access to KRT in low & middle income countries (LMICs) where rates of morbidity and mortality depend on the family's ability to pay. Children with kidney failure in LMICs have inadequate access to maintenance dialysis, timely kidney transplant and palliative care compared to their counterparts in high income countries. Using case vignettes, we highlight how these disparities place severe burdens on caregivers, resulting in difficult decision-making, and lead to moral distress among pediatric nephrologists. We conclude with key action points to change this status-quo, the most important being advocacy by the global pediatric nephrology community for better access to affordable kidney failure care for children.

Barriers to pre-emptive kidney transplantation in New Zealand children

AIM

Pre-emptive kidney transplantation (PKT) is generally considered the optimal treatment for kidney failure as it minimises dialysis-associated morbidity and mortality and is associated with improved allograft survival. This study aimed to determine rates of paediatric PKT in New Zealand, identify barriers to PKT and consider potential interventions to influence future rates of pre-emptive transplantation.

METHODS

Children commencing kidney replacement therapy between 2005 and 2017 in New Zealand were included. Descriptive analysis considered those referred late (referral <3 months prior to kidney replacement therapy initiation) or early based on referral timing to paediatric nephrology. Additional analysis compared characteristics of children receiving dialysis versus pre-emptive transplant as their first mode of kidney replacement therapy.

RESULTS

PKT occurred in 15 of 90 children (17%). One-third of all patients were referred late. No late referrals received a pre-emptive transplant. Pre-emptively transplanted children were referred younger (median age 0.49 years), lived in less deprived areas, were more likely to have congenital anomalies of the kidney and urinary tract and none were Māori or Pasifika ethnicity.

CONCLUSIONS

Late referral, higher deprivation levels and Māori and Pasifika ethnicity confer a greater risk of not receiving pre-emptive transplantation. Improved education amongst health professionals about recognition of paediatric chronic kidney disease and the importance of timely referral to paediatric nephrology is recommended to reduce rates of late referral. A modified approach including enhanced culturally appropriate support for those diagnosed with chronic kidney disease during transplant evaluation should be pursued to improve equity.

Policy in pediatric nephrology: successes, failures, and the impact on disparities

Pediatric nephrology has a history rooted in pediatric advocacy and has made numerous contributions to child health policy affecting pediatric kidney diseases. Despite this progress, profound social disparities remain for marginalized and socially vulnerable children with kidney disease. Different risk factors, such as genetic predisposition, environmental factors, social risk factors, or health care access influence the emergence and progression of pediatric kidney disease, as well as access to life-saving interventions, leading to disparate outcomes. This review will summarize the breadth of literature on social determinants of health in children with kidney disease worldwide and highlight policy-based initiatives that mitigate the adverse social factors to generate greater equity in pediatric kidney disease.

Long-term outcomes during 37 years of pediatric kidney transplantation: a cohort study comparing ethnic groups

BACKGROUND

This study aimed to evaluate short- and long-term outcomes of kidney transplantation over 37 years in a national referral center and compare outcomes between Israeli Jewish and Arab children.

METHODS

Data on 599 pediatric transplantations performed in 545 children during 1981-2017, including demographic parameters, kidney failure disease profile, and pre-transplant dialysis duration, were retrieved from our computerized database and patient files. Patient and graft survival were estimated using the Kaplan-Meier method.

RESULTS

Twenty-year patient survival was 91.4% for live donor (LD) and 80.2% for deceased donor (DD) kidney recipients. Respective 10-year and 20-year graft survival rates for first kidney-only transplants were 75.2% and 47.0% for LD and 60.7% and 38.4% for DD grafts. Long-term graft survival improved significantly (p < 0.001) over the study period for recipients of both LD and DD allografts and reached 7-year graft survival of 92.0% and 71.3%, respectively. The proportion of DD transplantations was higher in the Arab subpopulation: 73.8% vs. 48.4% (p < 0.001). Graft survival was not associated with age at transplantation and did not differ between the Arab (N = 202) and Jewish children (N = 343). Median (IQR) waiting time on dialysis did not differ significantly between the Arab and Jewish children: 18 (10-30) and 15 (9-30) months, respectively (p Mann-Whitney = 0.312).

CONCLUSIONS

Good and progressively improving long-term results were obtained in pediatric kidney transplantation at our national referral center, apparently due to expertise gained over time and advances in immunosuppression. Equal access to DD kidney transplant and similar graft survival were found between ethnic groups.

Understanding Substance use Policies and Associated Ethical Concerns: A survey of Pediatric Transplant Centers

Psychosocial risk factors, such as substance use, have been linked to poor post-transplant outcomes for solid organ transplant patients, including poor medication adherence, increased risk for rejection, and even graft failure. Despite universal consensus that substance use is an increasing problem among youth, many pediatric transplant centers do not have policies in place to address substance use and no universal guidelines exist regarding assessment during the pre-transplant evaluation in this population. An online survey was administered via REDCap™ and directed toward medical leaders (ie, medical and surgical directors) of national heart, kidney, and liver transplant centers. Questions examined the following: perspectives on the need for a universal transplant center policy on pediatric substance use, abuse, and dependence; timing and frequency of evaluation for substance use; specific substances which would elicit respondents' concerns; and ethical concerns surrounding substance use. Data were analyzed using descriptive statistics. Data were collected from 52 respondents from 38 transplant centers, with the majority (n = 40; 77%) reporting no substance use policy in place for pediatric transplant patients. However, many endorsed concerns if a pediatric patient was found to be using specific substances. Our findings further highlight the need for a universal substance use policy across pediatric solid organ transplant centers. The results from the distributed survey will help to provide guidelines and best practices when establishing a universal policy for substance use.

Preemptive Kidney Transplantation is Associated With Transplantation Outcomes in Children: Results From the French Kidney Replacement Therapy Registry

BACKGROUND

Kidney transplantation (KT) is the optimal treatment for children with end-stage kidney disease (ESKD). The aim of this study was to evaluate the impact of PKT and of pretransplant dialysis duration on graft survival among French pediatric kidney transplant recipients.

METHODS

We analyzed all first pediatric kidney-only transplantations performed in France between 1993 and 2012. A Cox multivariable model was used to investigate the association of PKT and pretransplant dialysis time with the hazard of graft failure defined as death, return to dialysis or retransplant, whichever occurred first.

RESULTS

1911 patients were included, of which 380 (19.8%) received a PKT. Median time of follow-up was 7.0 years. PKT was associated with a 55% reduction of the hazard of graft failure at any time after KT compared to patients transplanted after dialysis (HR 0.45; 95%CI 0.33-0.62), after adjustment for recipient sex and age, primary kidney disease, donor age and type (living or deceased donor), number of HLA mismatches, cold ischemia time and year of transplantation. A reduction of the hazard of graft failure was found in PKT whatever the compared duration of dialysis, even when less than 6 months and whatever the dialysis modality. Results were similar in multiple sensitivity analyses.

CONCLUSIONS

In France, PKT among pediatric patients is associated with a better graft survival when compared to KT after dialysis, even when less than 6 months. Based on these findings, we suggest that PKT should be considered as the treatment of choice for children with ESKD.

Resident foreign patients receive adequate dialysis but fewer preemptive transplantations: data from the Italian pediatric dialysis registry

BACKGROUND

Sociocultural issues play a key role in children needing kidney replacement therapy (KRT).

METHODS

Data of incident patients < 18 years treated with chronic dialysis or preemptive kidney transplantation (pTx) between 2007 and 2016 were retrospectively collected from the Italian Pediatric Dialysis Registry; KRT modality and outcome were compared between patients with at least one non-Italian parent ("resident foreign patients," RFPs) and those from native parents ("domestic patients," DPs) and between the quinquennium 2007-2011 (period 1) and 2012-2016 (period 2).

RESULTS

We included 448 children (26.8% RFPs). The percentage of RFPs increased from 23 to 30.3% (p = 0.08) from periods 1 to 2. They were younger (6.7 vs. 9.4 years, p = 0.025) and less often treated with pTx (3.3 vs. 13.4%, p = 0.009) than DPs. The percentage of pTx increased from period 1 to 2 in RFPs only (8.4-18.6%, p = 0.006). Independent predictors of a lower probability of pTx were lower age, belonging to RFPs group, starting KRT in period 1 and focal segmental glomerulosclerosis or glomerulopathy as primary kidney disease. Peritoneal dialysis was the preferred dialysis modality in both groups. Age, primary kidney disease, and center size were independently associated with dialysis modality choice. Patient survival, waiting time to Tx, and dialysis modality survival were not different between the two groups.

CONCLUSIONS

The proportion of patients receiving KRT born from immigrant families increased in recent years in Italy. They were younger and less often treated with pTx than domestic patients. In case of dialysis, the outcome was not different between the two groups. Graphical abstract.

Associations between Deprivation, Geographic Location, and Access to Pediatric Kidney Care in the United Kingdom

BACKGROUND AND OBJECTIVES

Pre-emptive kidney transplantation is advocated as best practice for children with kidney failure who are transplant eligible; however, it is limited by late presentation. We aimed to determine whether socioeconomic deprivation and/or geographic location (distance to the center and rural/urban residence) are associated with late presentation, and to what degree these factors could explain differences in accessing pre-emptive transplantation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A cohort study using prospectively collected United Kingdom Renal Registry and National Health Service Blood and Transplant data from January 1, 1996 to December 31, 2016 was performed. We included children aged >3 months to ≤16 years at the start of KRT. Multivariable logistic regression models were used to determine associations between the above exposures and our outcomes: late presentation (defined as starting KRT within 90 days of first nephrology review) and pre-emptive transplantation, with a priori specified covariates.

RESULTS

Analysis was performed on 2160 children (41% females), with a median age of 3.8 years (interquartile range, 0.2-9.9 years) at first nephrology review. Excluding missing data, 478 were late presenters (24%); 565 (26%) underwent pre-emptive transplantation, none of whom were late presenting. No association was seen between distance or socioeconomic deprivation with late presentation, in crude or adjusted analyses. Excluding late presenters, greater area affluence was associated with higher odds of pre-emptive transplantation, (odds ratio, 1.20 per quintile greater affluence; 95% confidence interval, 1.10 to 1.31), with children of South Asian (odds ratio, 0.52; 95% confidence interval, 0.36 to 0.76) or Black ethnicity (odds ratio, 0.31; 95% confidence interval, 0.12 to 0.80) less likely to receive one. A longer distance to the center was associated with pre-emptive transplantation on crude analyses; however, this relationship was attenuated (odds ratio, 1.02 per 10 km; 95% confidence interval, 0.99 to 1.05) in the multivariable model.

CONCLUSIONS

Socioeconomic deprivation or geographic location are not associated with late presentation in children in the United Kingdom. Geographic location was not independently associated with pre-emptive transplantation; however, children from more affluent areas were more likely to receive a pre-emptive transplant.

Psychological functioning and psychosocial issues in pediatric kidney transplant recipients

Research demonstrates that psychological factors are important for positive transplant outcomes, though there is little literature that synthesizes these factors in a comprehensive model among pediatric kidney transplant patients. This review analyzes psychological and psychosocial factors related to medical outcomes and overall well-being post-transplant by utilizing the PPPHM and referencing the existing literature on risk and resilience. Pediatric kidney transplant recipients are more susceptible to mental health concerns such as depression, anxiety, and ADHD, as well as developmental and neurocognitive delays, compared to healthy peers. Complex medical care and psychosocial needs for patients have implications for family functioning, parental and sibling mental health, and youth readiness to transition to adult care. It is important to carefully monitor patient functioning with empirically validated tools and to intervene in a multidisciplinary setting as early as possible to identify patients at risk and reduce potential negative impact. Psychologists are uniquely trained to assess and address these issues and are a valuable component of multidisciplinary, culturally competent care. While research in this expansive field is improving, more data are needed to establish gold standard approaches to mental health and psychosocial care in this population.

Racial and Ethnic Disparities in Kidney Transplant Access Within a Theoretical Context of Medical Eligibility

BACKGROUND

Non-Hispanic black (NHB) and Hispanic patients have lower access to kidney transplantation compared to non-Hispanic whites (NHWs). We examined whether differences in the prevalence of comorbidities that affect eligibility for transplant contribute to disparities in receipt of transplantation.

METHODS

We performed a retrospective study of 986 019 adults who started dialysis between 2005 and 2014, according to the United States Renal Data System. We compared prevalence of comorbidities that could influence transplant eligibility by race/ethnicity. We examined time to first transplant by race/ethnicity in this overall cohort and in a very healthy sub-cohort without conditions that could be contraindications to transplantation.

RESULTS

During 2.3 years of mean follow-up, 64 892 transplants occurred. NHBs and Hispanics had a lower prevalence of medical barriers to transplantation at the time of dialysis initiation than NHWs, including age >70 years (26% in NHB versus 47% in NHW) and malignancy (4% in Hispanics versus 10% in NHWs). Access to transplant was 65% lower (95% CI, 0.33-0.37) in NHBs and 43% lower (95% CI, 0.54-0.62) in Hispanics (versus NHWs) in the first year after end-stage renal disease, but by Year 4, access to transplantation was not statistically significantly different between Hispanics or NHBs (versus NHWs). In our very healthy cohort, racial and ethnic disparities in access to transplantation persisted up to Year 5 in NHBs and Year 4 in Hispanics after end-stage renal disease onset.

CONCLUSIONS

Differences in medical eligibility do not appear to explain racial/ethnic disparities in receipt of kidney transplantation and may mask the actual magnitude of the inequities that are present.

Epidemiology of Pediatric Surgery in the United States

BACKGROUND

The epidemiology of pediatric surgery in the United States and whether disparities in access to surgical care exist on a national level remain inadequately described.

AIMS

We determined rates of surgical intervention and associations with sociodemographic factors among children 0-17 years of age in the United States.

METHODS

Analysis of the 2005-2018 National Health Interview Survey samples included 155,064 children. Parents reported on whether their child had a surgery or surgical procedure either as an inpatient or outpatient over the past 12 months. Multivariate logistic regression models, adjusted for age, sex, race and ethnicity, income, language, parent education, region, having a usual source of care, and comorbid conditions, examined odds ratios for sociodemographic factors associated with surgery, analyzing the most recent data (2016-2018; 25 544 children).

RESULTS

In the most recent data, 4.7% of children had surgical intervention each year, with an average of 3.9 million surgeries performed annually. Rates of surgery were stable between 2005 and 2018. Minority children had lower adjusted odds (aOR) of surgical intervention as compared to white, non-Hispanic children (aOR = 0.6, 95%CI = 0.5-0.8 for black children, and aOR = 0.7, 95%CI = 0.5-0.9 for Hispanic children). Other sociodemographic factors associated with a lower adjusted odd of surgical intervention included uninsured status (aOR = 0.5; 95%CI = 0.3-0.9), and primary language other than English (aOR = 0.5; 95%CI 0.3-0.9). Income was not associated with surgical intervention.

CONCLUSIONS

On average, 3.9 million surgeries are performed on children 0-17 years of age in the United States each year. Significant disparities exist in surgical care for children, with black and Hispanic children having lower rates of surgery over and above contribution of other disparity domains. These findings in a nationally representative sample highlight the need for national policies to eliminate disparity of care received by minority children.

Mode of initial renal replacement therapy and transplant outcomes in the chronic kidney disease in children (CKiD) study

BACKGROUND

Kidney transplant is the renal replacement therapy (RRT) of choice for children with end stage kidney disease (ESKD). Only 21.3% of children who initiate RRT receive a preemptive kidney transplant (PKT). We characterized the transition to RRT in children in the CKiD cohort including the prevalence of dialysis as first RRT vs. PKT and graft survival.

METHODS

258 children enrolled in CKiD have initiated RRT, and 202 had post-RRT initiation data collected through phone or in-person follow-up. Characteristics by first RRT modality were compared using Chi-square and Kruskal-Wallis tests. Parametric-accelerated failure time models were fit for transplantation. Graft failure was characterized using Kaplan-Meier methods and log rank tests.

RESULTS

Sixty-one percent received dialysis as first RRT modality and 39% PKT. Those with PKT were less likely to have glomerular disease and to be African-American, and had higher household-income. African-American subjects were nearly twice as likely to undergo dialysis prior to transplant. Those with a living donor and a college-educated mother had 40%-decreased odds of being dialysis experienced. Children with PKT were more likely to receive a living donor transplant. Only 5% of PKT subjects had graft failure by 4 years compared to 16% of those initially treated with dialysis (p = 0.092); however, after adjustment the effect of dialysis exposure was attenuated (p = 0.206).

CONCLUSION

CKiD subjects undergo PKT more often compared to nationally-reported rates, and are more likely to receive a kidney transplant within 1 year of starting dialysis. African-American race and lower household-income are associated with decreased access to PKT.

Race and Mortality in CKD and Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

RATIONALE & OBJECTIVES

Few studies have investigated racial disparities in survival among dialysis patients in a manner that considers risk factors and mortality during the phase of kidney disease before maintenance dialysis. Our objective was to explore racial variations in survival among dialysis patients and relate them to racial differences in comorbid conditions and rates of death in the setting of kidney disease not yet requiring dialysis therapy.

STUDY DESIGN

Retrospective cohort study.

SETTINGS & PARTICIPANTS

3,288 black and white participants in the Chronic Renal Insufficiency Cohort (CRIC), none of whom were receiving dialysis at enrollment.

EXPOSURE

Race.

OUTCOME

Mortality.

ANALYTIC APPROACH

Cox proportional hazards regression was used to examine the association between race and mortality starting at: (1) time of dialysis initiation and (2) entry into the CRIC.

RESULTS

During 7.1 years of median follow-up, 678 CRIC participants started dialysis. Starting from the time of dialysis initiation, blacks had lower risk for death (unadjusted HR, 0.67; 95% CI, 0.51-0.87) compared with whites. Starting from baseline CRIC enrollment, the strength of the association between some risk factors and dialysis was notably stronger for whites than blacks. For example, the HR for dialysis onset in the presence (vs absence) of heart failure at CRIC enrollment was 1.30 (95% CI, 1.01-1.68) for blacks versus 2.78 (95% CI, 1.90-4.50) for whites, suggesting differential severity of these risk factors by race. When we included deaths occurring both before and after dialysis, risk for death was higher among blacks (vs whites) starting from CRIC enrollment (HR, 1.41; 95% CI, 1.22-1.64), but this finding was attenuated in adjusted models (HR, 1.08; 95% CI, 0.91-1.28).

LIMITATIONS

Residual confounding.

CONCLUSIONS

The apparent survival advantage among blacks over whites treated with dialysis may be attributed to selected transition of a subset of whites with more severe comorbid conditions onto dialysis.

High Rate of Living Kidney Donation to Immigrant Children Despite Disparities-An Epidemiological Paradox?

Background: Kidney transplantation is the preferred treatment modality for children with end-stage renal disease. In the adult population, migration-related modifiable factors were associated with low living donation rates; no such data are available on the pediatric population. This pilot study therefore compares donation modality, communication, knowledge, and attitudes/beliefs between families of immigrant and non-immigrant descent. Methods: Demographic and clinical characteristics of a cohort of children from 77 families of immigrant (32; 42%) and non-immigrant (45; 58%) descent who had undergone renal transplantation were assessed and related to donation modality at the Medical University of Vienna. In a representative subset, modifiable migration-related factors were assessed in a questionnaire-based study. Results: In immigrant families, information delay, limited communication, low knowledge levels, and self-reported conflicting beliefs were significantly more prevalent than in non-immigrants. The living kidney donation rate to children was high in both populations (immigrants: 63%, non-immigrants: 44%; p = 0.12). Living donation to children on dialysis was even significantly higher in immigrant families (immigrants: 13 out of 20; 57%, non-immigrants: 9 out of 33; 27%; p = 0.03). Conclusion: Contrary to expectations, migration-related disparities did not translate into decreased living donation rates in immigrant families, in particular to children on dialysis. Certain factors might therefore be less important for the living donation process in pediatric care structures and/or might be overcome by yet undefined protective factors. Larger pediatric studies including qualitative and quantitative methods are required to validate and refine current conceptual frameworks integrating the perspective of affected families.

Emergency department use among kidney transplant recipients in the United States

Patients with end-stage renal disease use the emergency department (ED) at a 6-fold higher rate than do other US adults. No national studies have described ED use rates among kidney transplant (KTx) recipients, and the factors associated with higher ED use. We examined a cohort of 132 725 adult KTx recipients in the United States Renal Data System (2005-2013). Data on ED visits, hospitalization, and outpatient nephrology visits were obtained from Medicare claims databases. Nearly half (46.1%) of KTx recipients had at least one ED visit (1.61 ED visits/patient-year [PY]), and 39.7% of ED visits resulted in hospitalization in the first year posttransplantation. ED visit rate was high in the first 30 days (5.26 visits/PY) but declined substantially thereafter (1.81 visits/PY in months 1-3; 1.13 visits/PY in months 3-12 posttransplantation). ED visit rates were higher in the first 30 days versus rates for dialysis patients but less than half the rate thereafter. Female sex, public insurance, medical comorbidities, longer pretransplantation dialysis vintage, and delayed graft function were associated with higher ED use in the first year post-KTx. Policies and strategies addressing potentially preventable ED visits should be promoted to help improve patient care and increase efficient use of ED resources.

Pre-emptive Intestinal Transplant: The Surgeon's Point of View

Pre-emptive transplantation is a well-established practice for certain types of end-organ failure such as in the use of kidney transplantation. For irreversible intestinal failure, total parenteral nutrition (TPN) remains the gold standard, due to the suboptimal long-term results of intestinal transplantation. As such, the only role for pre-emptive transplantation, if at all, will be for patients identified to be at high risk of complications and mortality while on definitive long-term TPN. In these patients, the timing of early listing and transplantation could become life-saving, taking into account that mortality on the waiting list is still the highest for intestinal candidates. The development of simulation models or pre-transplant scoring systems could help in selecting patients based on potential outcome on TPN or with transplantation, and recent reports from high-volume centers identify few underlying pathologic conditions and some TPN complications as at higher risk of increased morbidity and mortality. A pre-emptive transplant could be used as a rehabilitative procedure in a well-selected case-by-case scenario, among TPN patients at risk of liver failure, repeated central line infections, mesenteric infarction, short bowel syndrome (SBS) <50 cm or with end stoma, congenital mucosal disease, desmoid tumors: These conditions must be carefully evaluated, not to underestimate the clinical stage nor to over-estimate the impact of a temporary situation. At the present time, diseases with a variable and unpredictable course, such as intestinal dysmotility disorders, or quality of life and financial issues are still far from being considered as indications for a pre-emptive transplant.

The pervasive crisis of diminishing radiation therapy access for vulnerable populations in the United States, part 1: African-American patients

Introduction

African Americans experience the highest burden of cancer incidence and mortality in the United States and have been persistently less likely to receive interventional care, even when such care has been proven superior to conservative management by randomized controlled trials. The presence of disparities in access to radiation therapy (RT) for African American cancer patients has rarely been examined in an expansive fashion.

Methods and materials

An extensive literature search was performed using the PubMed database to examine studies investigating disparities in RT access for African Americans.

Results

A total of 55 studies were found, spanning 11 organ systems. Disparities in access to RT for African Americans were most prominently study in cancers of the breast (23 studies), prostate (7 studies), gynecologic system (5 studies), and hematologic system (5 studies). Disparities in RT access for African Americans were prevalent regardless of organ system studied and often occurred independently of socioeconomic status. Fifty of 55 studies (91%) involved analysis of a population-based database such as Surveillance, Epidemiology and End Result (SEER; 26 studies), SEER-Medicare (5 studies), National Cancer Database (3 studies), or a state tumor registry (13 studies).

Conclusions

African Americans in the United States have diminished access to RT compared with Caucasian patients, independent of but often in concert with low socioeconomic status. These findings underscore the importance of finding systemic and systematic solutions to address these inequalities to reduce the barriers that patient race provides in receipt of optimal cancer care.

Race, Income, and Disease Outcomes in Juvenile Dermatomyositis

OBJECTIVE

To determine the relationships among race, income, and disease outcomes in children with juvenile dermatomyositis (JDM).

STUDY DESIGN

Data from 438 subjects with JDM enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Legacy Registry were analyzed. Demographic data included age, sex, race, annual family income, and insurance status. Clinical outcomes included muscle strength, presence of rash, calcinosis, weakness, physical function, and quality of life measures. Disease outcomes were compared based on race and income.

RESULTS

Minority subjects were significantly more likely to have low annual family income and significantly worse scores on measures of physical function, disease activity, and quality of life measures. Subjects with lower annual family income had worse scores on measures of physical function, disease activity, and quality of life scores, as well as weakness. Black subjects were more likely to have calcinosis. Despite these differences in outcome measures, there were no significant differences among the racial groups in time to diagnosis or duration of disease. Using calcinosis as a marker of disease morbidity, black race, annual family income <$50 000 per year, negative antinuclear antibody, and delay in diagnosis >12 months were associated with calcinosis.

CONCLUSION

Minority race and lower family income are associated with worse morbidity and outcomes in subjects with JDM. Calcinosis was more common in black subjects. Further studies are needed to examine these associations in more detail, to support efforts to address health disparities in subjects with JDM and improve disease outcomes.

Barriers to live donor kidney transplants in the pediatric population: A single-center experience

A decrease in live donor pediatric kidney transplants has occurred in the United States. This study investigates barriers that may influence access to live donor kidney transplants in children. Retrospective chart review was conducted for 91 children (69% male, mean age 11.9 years) who underwent pretransplant workup from 2005 to 2015 at an urban pediatric hospital. Fifty-four percent were African American, 32% Caucasian, 8% Arabic, 3% Hispanic, and 3% Others. Government-sponsored insurance (Medicaid/Medicare) was utilized by 73%, and 54% had dual caregivers. Only nine of 68 kidney transplants were live donor transplants. Live donor transplants (11%) were significantly (P=.008) lower than deceased donor transplants (59%) in African Americans. Private insurance was reported by 56% of live donor recipients and 25% of deceased donor recipients. Among live donor recipients, 78% were from dual caregiver families. Caregiver, health-related, financial, and religious/cultural barriers to live donor transplants were reported, several of which may be amenable to positive intervention.

Racial and Ethnic Disparities in Survival of Children with ESRD

Observational studies have reported that black and Hispanic adults receiving maintenance dialysis survive longer than non-Hispanic white counterparts. Whether there are racial disparities in survival of children with ESRD is not clear. We compared mortality risk among non-Hispanic black, Hispanic, and non-Hispanic white children who started RRT between 1995 and 2011 and were followed through 2012. We examined all-cause mortality using adjusted Cox models. Of 12,123 children included for analysis, 1600 died during the median follow-up of 7.1 years. Approximately 25% of children were non-Hispanic black, and 26% of children were of Hispanic ethnicity. Non-Hispanic black children had a 36% higher risk of death (95% confidence interval [95% CI], 1.21 to 1.52) and Hispanic children had a 34% lower risk of death (95% CI, 0.57 to 0.77) than non-Hispanic white children. Adjustment for transplant as a time-dependent covariate abolished the higher risk of death in non-Hispanic black children (hazard ratio, 0.99; 95% CI, 0.88 to 1.12) but did not attenuate the finding of a lower risk of death in Hispanic children (hazard ratio, 0.59; 95% CI, 0.51 to 0.68). In conclusion, Hispanic children had lower mortality than non-Hispanic white children. Non-Hispanic black children had higher mortality than non-Hispanic white children, which was related to differences in access to transplantation by race. Parity in access to transplantation in children and improvements in strategies to prolong graft survival could substantially reduce disparities in mortality risk of non-Hispanic black children treated with RRT.

Preemptive kidney transplantation is associated with survival benefits among pediatric patients with end-stage renal disease

Kidney transplantation is the preferred treatment for pediatric end-stage renal disease (ESRD). Preemptive transplantation avoids the increased morbidity and mortality of dialysis. Yet, previous studies have not demonstrated significant graft or patient survival benefits for children undergoing transplantation preemptively versus nonpreemptively. These previous studies were limited by small samples sizes and low rates of adverse events. Here we compared graft failure and mortality rates using Kaplan-Meier methods and Cox regression among a large national cohort of children with ESRD undergoing preemptive versus nonpreemptive kidney transplantation between 2000 and 2012. Among 7527 pediatric kidney transplant recipients in the United States Renal Data System, 1668 underwent preemptive transplantation. Over a median 4.8 years follow-up, 1314 experienced graft failure, and over a median 5.2 years of follow-up, 334 died. Dialysis exposure versus preemptive transplantation conferred a higher risk of graft failure (hazard ratio 1.32; 95% confidence interval: 1.10-1.56) and a higher risk of death (hazard ratio 1.69; 95% confidence interval: 1.22-2.33) in multivariable analysis. Compared with children undergoing preemptive transplantation, children on dialysis for >1 year had a 52% higher risk of graft failure and those on dialysis >18 months had an 89% higher risk of death, regardless of donor source. Thus, preemptive transplantation is associated with substantial benefits in allograft and patient survival among children with ESRD, particularly when compared with children who receive dialysis for >1 year. These findings support policies to promote early access to transplantation and avoidance of dialysis for children with ESRD whenever feasible.

The impact of socioeconomic status and geographic remoteness on access to pre-emptive kidney transplantation and transplant outcomes among children

BACKGROUND

Low socioeconomic status (SES) and geographic disparity have been associated with worse outcomes and poorer access to pre-emptive transplantation in the adult end-stage kidney disease (ESKD) population, but little is known about their impact in children with ESKD. The aim of our study was to determine whether access to pre-emptive transplantation and transplant outcomes differ according to SES and geographic remoteness in Australia.

METHODS

Using data from the Australia and New Zealand Dialysis and Transplant Registry (1993-2012), we compared access to pre-emptive transplantation, the risk of acute rejection and graft failure, based on SES and geographic remoteness among Australian children with ESKD (≤ 18 years), using adjusted logistic and Cox proportional hazard modelling.

RESULTS

Of the 768 children who commenced renal replacement therapy, 389 (50.5%) received living donor kidney transplants and 28.5% of these (111/389) were pre-emptive. There was no significant association between SES quintiles and access to pre-emptive transplantation, acute rejection or allograft failure. Children residing in regional or remote areas were 35% less likely to receive a pre-emptive transplant compared to those living in major cities [adjusted odds ratio (OR) 0.65, 95% confidence interval (CI) 0.45-1.0]. There was no significant association between geographic disparity and acute rejection (adjusted OR 1.03, 95% CI 0.68-1.57) or graft loss (adjusted hazard ratio 1.05, 95% CI 0.74-1.41).

CONCLUSIONS

In Australia, children from regional or remote regions are much less likely to receive pre-emptive kidney transplantation. Strategies such as improved access to nephrology services through expanding the scope of outreach clinics, and support for regional paediatricians to promote early referral may ameliorate this inequity.

Nephrologists' likelihood of referring patients for kidney transplant based on hypothetical patient scenarios

Background

There is wide variation in referral for kidney transplant and preemptive kidney transplant (PKT). Patient characteristics such as age, race, sex and geographic location have been cited as contributing factors to this disparity. We hypothesize that the characteristics of nephrologists interplay with the patients' characteristics to influence the referral decision. In this study, we used hypothetical case scenarios to assess nephrologists' decisions regarding transplant referral.

Methods

A total of 3180 nephrologists were invited to participate. Among those interested, 252 were randomly selected to receive a survey in which nephrologists were asked whether they would recommend transplant for the 25 hypothetical patients. Logistic regression models with single covariates and multiple covariates were used to identify patient characteristics associated with likelihood of being referred for transplant and to identify nephrologists' characteristics associated with likelihood of referring for transplant.

Results

Of the 252 potential participants, 216 completed the survey. A nephrologist's affiliation with an academic institution was associated with a higher likelihood of referral, and being ‘>10 years from fellowship’ was associated with lower likelihood of referring patients for transplant. Patient age <50 years was associated with higher likelihood of referral. Rural location and smoking history/chronic obstructive pulmonary disease were associated with lower likelihood of being referred for transplant. The nephrologist's affiliation with an academic institution was associated with higher likelihood of referring for preemptive transplant, and the patient having a rural residence was associated with lower likelihood of being referred for preemptive transplant.

Conclusions

The variability in transplant referral is related to patients' age and geographic location as well as the nephrologists' affiliation with an academic institution and time since completion of training. Future educational interventions should emphasize the benefits of kidney transplant and PKT for all population groups regardless of geographic location and age and should target nephrologists in non-academic settings who are 10 or more years from their fellowship training.

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.

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.

An overview of disparities and interventions in pediatric kidney transplantation worldwide

Despite the stated goals of the transplant community and the majority of organ allocation systems, persistent racial disparities in pediatric kidney transplantation exist throughout the world. These disparities are evident in both living and deceased donor kidney transplantation and are independent of any clinical differences between racial groups. The reasons for these persistent disparities are multifactorial, reflecting both patient and provider barriers to care. In this review, we examine the most current findings regarding disparities in pediatric kidney transplantation and consider interventions which may help reduce those disparities.

Association of Body Mass Index with Patient-Centered Outcomes in Children with ESRD

Obesity is associated with less access to transplantation among adults with ESRD. To examine the association between body mass index at ESRD onset and survival and transplantation in children, we performed a retrospective analysis of children ages 2-19 years old beginning RRT from 1995 to 2011 using the US Renal Data System. Among 13,172 children, prevalence of obesity increased from 14% to 18%, whereas prevalence of underweight decreased from 12% to 9% during this period. Over a median follow-up of 7.0 years, 10,004 children had at least one kidney transplant, and 1675 deaths occurred. Risk of death was higher in obese (hazard ratio [HR], 1.17; 95% confidence interval [95% CI], 1.03 to 1.32) and underweight (HR, 1.26; 95% CI, 1.09 to 1.47) children than children with normal body mass indices. Obese and underweight children were less likely to receive a kidney transplant (HR, 0.92; 95% CI, 0.87 to 0.97; HR, 0.83; 95% CI, 0.78 to 0.89, respectively). Obese children had lower odds of receiving a living donor transplant (odds ratio, 0.85; 95% CI, 0.74 to 0.98) if the transplant occurred within 18 months of ESRD onset. Adjustment for transplant in a time-dependent Cox model attenuated the higher risk of death in obese but not underweight children (HR, 1.09; 95% CI, 0.96 to 1.24). Lower rates of kidney transplantation may, therefore, mediate the higher risk of death in obese children with ESRD. The increasing prevalence of obesity among children starting RRT may impede kidney transplantation, especially from living donors.

Racial and ethnic disparities in pediatric renal allograft survival in the United States

This study was undertaken to describe the association of patient race/ethnicity and renal allograft survival among the national cohort of pediatric renal allograft recipients. Additionally, we determined whether racial and ethnic differences in graft survival exist among individuals living in low or high poverty neighborhoods and those with private or public insurance. Among 6,216 incident, pediatric End Stage Renal Disease patients in the United States Renal Data System (kidney transplant from 2000 through September, 2011) 14.4% experienced graft failure, with a median follow-up time of 4.5 years. After controlling for multiple covariates, black race, but not Hispanic ethnicity, was significantly associated with a higher rate of graft failure for both deceased and living donor transplant recipients. Disparities were particularly stark by 5 years post-transplant, when black living donor transplant recipients experienced only 63.0% graft survival compared with 82.8% and 80.8% for Hispanics and whites, respectively. These disparities persisted among high and low poverty neighborhoods and among both privately- and publicly-insured patients. Notably profound declines in both deceased and living donor graft survival rates for black, compared to white and Hispanic, children preceded the 3-year mark when transplant Medicare eligibility ends. Further research is needed to identify the unique barriers to long-term graft success among black pediatric transplant recipients.

Association of U.S. Dialysis facility neighborhood characteristics with facility-level kidney transplantation

BACKGROUND

Improving access to optimal healthcare may depend on the attributes of neighborhoods where patients receive healthcare services. We investigated whether the characteristics of dialysis facility neighborhoods--where most patients with end-stage renal disease are treated--were associated with facility-level kidney transplantation.

METHODS

We examined the association between census tract (neighborhood)-level sociodemographic factors and facility-level kidney transplantation rate in 3,983 U.S. dialysis facilities where kidney transplantation rates were high. Number of kidney transplants and total person-years contributed at the facility level in 2007-2010 were obtained from the Dialysis Facility Report and linked to the census tract data on sociodemographic characteristics from the American Community Survey 2006-2010 by dialysis facility location. We used multivariable Poisson models with generalized estimating equations to estimate the link between the neighborhood characteristics and transplant incidence.

RESULTS

Dialysis facilities in the United States were located in neighborhoods with substantially greater proportions of black and poor residents, relative to the national average. Most facility neighborhood characteristics were associated with transplant, with incidence rate ratios (95% CI) for standardized increments (in percentage) of neighborhood exposures of: living in poverty, 0.88 (0.84-0.92), black race, 0.83 (0.78-0.89); high school graduates, 1.22 (1.17-1.26); and unemployed, 0.90 (0.85-0.95).

CONCLUSION

Dialysis facility neighborhood characteristics may be modestly associated with facility rates of kidney transplantation. The success of dialysis facility interventions to improve access to kidney transplantation may partially depend on reducing neighborhood-level barriers.