Wait list status of pediatric dialysis patients in North America

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.

Gender and kidney transplantation

Kidney transplantation provides the best form of kidney replacement therapy with improvement in quality of life and longevity. However, disparity exists in its availability, utilisation and outcomes, not only due to donor availability or financial constraints but also arising from the influence of biological sex and its sociocultural attribute i.e., Gender. Women make up the majority of kidney donors but are less likely to be counselled regarding transpantation, be waitlisted or receive living/deceased donor kidney. Biological differences also contribute to differences in kidney transplantation among the sexes. Women are more likely to be sensitised owing to pregnancy, especially in multiparous individuals, complicating donor compatibility. A heightened immune system in women, evidenced by more autoimmune illnesses, increases the risk of allograft rejection and loss. Differences in the pharmacokinetics of transplant drugs owing to biological variances could also contribute to variability in outcomes. Transgender medicine is also increasingly becoming a relevant topic of study, providing greater challenges in the form of hormonal manipulations and anatomic changes. It is thus important to determine and study transplantation and its nuances in this backdrop to be able to provide relevant sex and gender-specific interventions and design better practices for optimum kidney transplant utilisation and outcomes.

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.

Kidney Transplantation in Small Children: Association Between Body Weight and Outcome-A Report From the ESPN/ERA-EDTA Registry

BACKGROUND

Many centers accept a minimum body weight of 10 kg as threshold for kidney transplantation (Tx) in children. As solid evidence for clinical outcomes in multinational studies is lacking, we evaluated practices and outcomes in European children weighing below 10 kg at Tx.

METHODS

Data were obtained from the European Society of Paediatric Nephrology/European Renal Association and European Dialysis and Transplant Association Registry on all children who started kidney replacement therapy at <2.5 y of age and received a Tx between 2000 and 2016. Weight at Tx was categorized (<10 versus ≥10 kg) and Cox regression analysis was used to evaluate its association with graft survival.

RESULTS

One hundred of the 601 children received a Tx below a weight of 10 kg during the study period. Primary renal disease groups were equal, but Tx <10 kg patients had lower pre-Tx weight gain per year (0.2 versus 2.1 kg; P < 0.001) and had a higher preemptive Tx rate (23% versus 7%; P < 0.001). No differences were found for posttransplant estimated glomerular filtration rates trajectories (P = 0.23). The graft failure risk was higher in Tx <10 kg patients at 1 y (graft survival: 90% versus 95%; hazard ratio, 3.84; 95% confidence interval, 1.24-11.84), but not at 5 y (hazard ratio, 1.71; 95% confidence interval, 0.68-4.30).

CONCLUSIONS

Despite a lower 1-y graft survival rate, graft function, and survival at 5 y were identical in Tx <10 kg patients when compared with Tx ≥10 kg patients. Our results suggest that early transplantation should be offered to a carefully selected group of patients weighing <10 kg.

Sex disparities in dialysis initiation, access to waitlist, transplantation and transplant outcome in German patients with renal disease-A population based analysis

Background

Renal transplantation access and outcome differ between men and women, but no analysis has considered all transition phases and transplant outcome using the same data set. We analyzed sex disparities in all phases of patients’ clinical path (progression to dialysis, waitlisting, transplantation, graft failure/death).

Methods

In a population based approach using health insurance data (2005–2013) we examined patients’ risk of changing from one phase to another applying Cox Proportional Hazards model.

Results

After adjusting for age and comorbidities, women had a 16% lower risk of progression to ESRD (HR/95%-CI: 0.84/0.79–0.88). Access to the waitlist was lowered by 18% in women compared to men (HR/95%-CI: 0.82/0.70–0.96). An age stratified analysis did not reveal differences in any age group. Once waitlisted, the chance to receive a transplant was identical (HR/95%-CI: 0.96/0.81–1.15). The risk of transplant failure/death was identical for both sexes (HR/95%-CI: 0.99/0.73–1.35), but the effect was modified by age: in younger women (18–45 years) the risk was twice as high compared to men (HR/95%-CI: 2.08/1.04–4.14), whereas the risk in elderly women (> 65 years) was only half the risk of men (HR/95%-CI: 0.47/0.24–0.93).

Conclusion

Sex disparities occurred at different steps in the history of patients with renal disease and affected progression to dialysis, waitlisting and transplantation outcome in a population with equal access to medical treatment.

Strategy to Enable and Accelerate Kidney Transplant in Small Children and Results of the First 130 Transplants in Children ≤15 kg in a Single Center

BACKGROUND

Proper care of young children in need of kidney transplant (KT) requires many skilled professionals and an expensive hospital structure. Small children have lesser access to KT.

METHODS

We describe a strategy performed in Brazil to enable and accelerate KT in children ≤15 kg based on the establishment of one specialized transplant center, focused on small children, and cooperating with distant centers throughout the country. Actions on 3 fronts were implemented: (a) providing excellent medical assistance, (b) coordinating educational activities to disseminate expertise and establish a professional network, and (c) fostering research to promote scientific knowledge. We presented the number and outcomes of small children KT as a result of this strategy.

RESULTS

Three hundred forty-six pediatric KTs were performed in the specialized center from 2009 to 2017, being 130 in children ≤15 kg (38%, being 41 children ≤10 kg) and 216 in >15 kg (62%). Patient survival after 1 and 5 years of the transplant was 97% and 95% in the "small children" group, whereas, in the "heavier children" group, it was 99% and 96% (P = 0.923). Regarding graft survival, we observed in the "small children" group, 91% and 87%, whereas in the "heavier children" group, 94% and 87% (P = 0.873). These results are comparable to the literature data. Groups were similar in the incidence of reoperation, vascular thrombosis, posttransplant lymphoproliferative disease, and estimated glomerular filtration rate.

CONCLUSIONS

The strategy allowed an improvement in the number of KT in small children with excellent results. We believe this experience may be useful in other locations.

Equally Interchangeable? How Sex and Gender Affect Transplantation

Organ transplantation as an option to overcome end-stage diseases is common in countries with advanced healthcare systems and is increasingly provided in emerging and developing countries. A review of the literature points to sex- and gender-based inequity in the field with differences reported at each step of the transplant process, including access to a transplantation waiting list, access to transplantation once waitlisted, as well as outcome after transplantation. In this review, we summarize the data regarding sex- and gender-based disparity in adult and pediatric kidney, liver, lung, heart, and hematopoietic stem cell transplantation and argue that there are not only biological but also psychological and socioeconomic issues that contribute to disparity in the outcome, as well as an inequitable access to transplantation for women and girls. Because the demand for organs has always exceeded the supply, the transplant community has long recognized the need to ensure equity and efficiency of the organ allocation system. In the spirit of equity and equality, the authors call for recognition of these inequities and the development of policies that have the potential to ensure that girls and women have equitable access to transplantation.

Sex and Glomerular Filtration Rate Trajectories in Children

BACKGROUND AND OBJECTIVES

Differences in CKD progression by sex have been hypothesized to explain disparities in access to kidney transplantation in children. This study aims to identify distinct trajectories of eGFR decline and to investigate the association of sex with eGFR decline.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used data from the CKD in Children study. Latent class mixed models were used to identify eGFR trajectories and patient characteristics were compared between trajectories. Progression was studied to two outcomes: ESKD (dialysis or transplantation) and a combined outcome of ESKD or 50% eGFR decline from baseline, using multivariable parametric failure time models.

RESULTS

Among 888 patients, 613 with nonglomerular and 275 with glomerular diseases, we observed four and two distinct GFR trajectories, respectively. Among patients with nonglomerular diseases, there was a higher proportion of males in the group with a low baseline GFR. This group had an increased risk of ESKD or 50% GFR decline, despite a similar absolute decline in GFR. Eight patients with nonglomerular diseases, mostly males with obstructive uropathies, had a more rapid absolute GFR decline. However, the association between male sex and rapid absolute GFR decline was NS after adjustment for age, baseline GFR, and proteinuria. Among patients with glomerular diseases, a subgroup including mostly females with systemic immunologic diseases or crescentic GN had a rapid absolute GFR decline.

CONCLUSIONS

This study identifies different trajectories of CKD progression in children and found a faster progression of CKD in females in patients with glomerular diseases, but no significant sex difference in patients with nonglomerular diseases. The differences in progression seem likely explained by sex differences in the underlying primary kidney disease and in baseline GFR rather than by a direct effect of sex on progression.

Is Preoperative Preparation Time a Barrier to Small Children Being Ready for Kidney Transplantation?

BACKGROUND

Small children are less frequently transplanted when compared with older. The objective of the present study was to compare the preparation time for transplantation in children of different weights and to identify factors associated with a delay in the workup of small children.

METHODS

We report on a retrospective cohort comprising all children referred for renal transplantation (RTx) workup between 2009 and 2017. The main outcome was transplantation workup time, defined as the time elapsed between the first consultation and when the child became ready for the surgery.

RESULTS

A total of 389 children (63.5% males) were selected, with a median weight of 18 kg (interquartile range, 11-32). Patients were categorized into 2 groups: group A (study group): ≤15 kg (n = 165) and group B (control group): >15 kg (n = 224). The probability of being ready for RTx was comparable between groups A and B. The cumulative incidence rate difference between groups is -0.05 (95% confidence interval, -0.03 to 0.02). The median time for RTx workup was 5.4 (2.4-9.4) in group A and 4.3 (2.2-9.0) months in group B (P = 0.451). Moreover, the presence of urinary tract malformation was associated with the need for longer transplantation workup time (P < 0.001).

CONCLUSIONS

In children >7 kg, the workup time for transplantation is not related to body weight. In a specialized center, children weighing 7-15 kg became ready within the same timeframe as children weighing >15 kg, despite the smaller children had greater difficulty being nourished, dialyzed, and a greater need for surgical correction of the urinary tract pretransplant.

Gender Disparities in Access to Pediatric Renal Transplantation in Europe: Data From the ESPN/ERA-EDTA Registry

Inequalities between genders in access to transplantation have been demonstrated. We aimed to validate this gender inequality in a large pediatric population and to investigate its causes. This cohort study included 6454 patients starting renal replacement therapy before 18 years old, in 35 countries participating in the European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry. We used cumulative incidence competing risk and proportional hazards frailty models to study the time to receive a transplant and hierarchical logistic regression to investigate access to preemptive transplantation. Girls had a slower access to renal transplantation because of a 23% lower probability of receiving preemptive transplantation. We found a longer follow-up time before renal replacement therapy in boys compared with girls despite a similar estimated glomerular filtration rate at first appointment. Girls tend to progress faster toward end-stage renal disease than boys, which may contribute to a shorter time available for pretransplantation workup. Overall, medical factors explained only 70% of the gender difference. In Europe, girls have less access to preemptive transplantation for reasons that are only partially related to medical factors. Nonmedical factors such as patient motivation and parent and physician attitudes toward transplantation and organ donation may contribute to this inequality. Our study should raise awareness for the management of girls with renal diseases.

Repeat Kidney Transplantation After Failed First Transplant in Childhood: Past Performance Informs Future Performance

BACKGROUND AND OBJECTIVES

Kidney transplant graft survival is almost uniformly superior for initial transplants compared to repeat transplants. We investigate the association between first second kidney transplant graft survival in patients who underwent initial transplant during their pediatric years whether age at second transplant is associated with outcome.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

This is a retrospective analysis of Organ Procurement and Transplantation Network data from October 1987 to May 2009 examining second kidney graft survival in 2281 patients who received their first transplant at younger than 18 years using Kaplan-Meier statistics. Factors associated with second graft survival were identified using a multivariable Cox proportional hazards model.

RESULTS

Patients with first kidney graft survival of less than 5 years had better second graft survival compared to patients with first graft survival of 30 days to 5 years (P < 0.01). Patients with first kidney graft survival less than 30 days had similar second kidney graft outcomes(P = 0.50) as those with longer than 5 years first kidney graft survival, demonstrating that very early first graft loss is not associated with poor second transplant outcome. Patients 15 to 20 years of age at second transplant have lower second graft survival compared to other age groups; P less than 0.01, regardless of other recipient/donor characteristics and recurrent disease.

CONCLUSIONS

Poor second transplant outcomes are identified among patients with previous pediatric kidney transplant with first graft survival longer than 30 days, but shorter than 5 years, and those receiving second transplants at a high-risk age category (15-20 years). These groups may benefit from increased attention both before and after transplantation.

Outcome of Patients Initiating Chronic Peritoneal Dialysis During the First Year of Life

BACKGROUND AND OBJECTIVE

Among children with end-stage renal disease (ESRD), those who abstract initiated chronic dialysis during the first year of life historically were less likely to survive or receive a kidney transplant compared with those who initiated dialysis later in childhood.We hypothesized that recently treated infants have experienced improved outcomes.

METHODS

We queried the North American Pediatric Renal Trials and Collaborative Studies database, obtaining information on 628 children who initiated maintenance peritoneal dialysis for treatment of ESRD at ,1 year of age. We further subcategorized these children by age(neonates, #31 days and infants, 32–365 days) and date of dialysis initiation (past,1992–1999, and recent, 2000–2012).

RESULTS

Survival while on dialysis and overall survival were significantly better among neonates and infants in the recent cohort. Overall survival at 3 years after dialysis initiation was 78.6%and 84.6% among the recently treated neonates and infants, respectively. Neonates and infants in the recent cohort also were more likely to terminate dialysis for transplantation, and graft survival was improved among recently transplanted infants (3-year graft survival 92.1%).

CONCLUSIONS

Among children who initiate chronic peritoneal dialysis for treatment of ESRD in the first year of life, survival has improved in recent years. Graft survival also has improved for the subset of these patients who received a kidney transplant.

Vascular access for chronic hemodialysis in children: arteriovenous fistula or central venous catheter?

BACKGROUND

The choice of vascular access (VA) for hemodialysis (HD) in end-stage renal disease (ESRD) is arteriovenous fistula (AVF) or central venous catheter (CVC). Whereas clinical practice guidelines suggest AVF to preserve the vascular bed, pediatric nephrologists tend to favor CVC for shorter-term dialysis. Our objective was to determine whether pediatric priority allocation policies for deceased-donor kidneys affect VA planning.

METHODS

Pediatric priority for deceased-donor kidneys was instituted in Quebec in 2004. We retrospectively compared clinical practice on AVF, CVC, wait time on transplant list, HD duration in pre-policy (group A) and post-policy (group B) from 1997-2011.

RESULTS

We identified 78 patients with a median age of 14.7 years (range, 0.7-20.5 years) and weight of 46 kg (12.5-95 kg); AVF decreased from 76 % in group A to 41 % in group B (p = 0.002). Wait times on transplant list were significantly reduced: median 413.5 days (range, 2-1,910 days) in group A vs. 89 days (range, 18-692 days) in group B (p = 0.003). Time on HD for deceased-donor recipients was shorter: 705 (range, 51-1,965 days) group A vs. 349.5 days (range, 158-1,060 days) group B (p = 0.01).

CONCLUSIONS

This is the first study to document VA changes related to pediatric priority allocation policy. Our fistula-first center saw a shift toward CVC-first.

Disparities, race/ethnicity and access to pediatric kidney transplantation

PURPOSE OF REVIEW

Kidney transplantation remains the optimal treatment for children with end-stage renal disease; yet, in the United States, profound differences in access to transplant persist, with black children experiencing significantly reduced access to transplant compared with white children. The reasons for these disparities remain poorly understood. Several recent studies provide new insights into the interplay of socioeconomic status, racial/ethnic disparities and access to pediatric kidney transplantation.

RECENT FINDINGS

New evidence suggests that disparities are more pronounced in access to living vs. deceased donors. National allocation policies have mitigated racial differences in pediatric deceased donor kidney transplant (DDKT) access after waitlisting. However, disparities in access to DDKT are stark for minority emerging adults, who lose pediatric priority allocation. Although absence of health insurance poses an important barrier to transplant, even after adjustment for insurance status and neighborhood poverty, disparities persist. Differential access to care and unjust social structures are posited as important modifiable barriers to achieving equity in pediatric transplant access.

SUMMARY

Future approaches to overcome disparities in pediatric kidney transplant access must focus on the continuum of the transplant process, including equitable health care access. Public health advocacy efforts to promote national policies that address disparate multilevel socioeconomic factors are essential.

Likelihood of children with end-stage kidney disease in Europe to live with a functioning kidney transplant is mainly explained by nonmedical factors

BACKGROUND

Registry data can be used to assess associations between medical and health-policy factors and the likelihood of children on renal replacement therapy (RRT) to live with a functioning kidney transplant in Europe.

METHODS

A survey questionnaire was distributed among renal registry representatives in 38 European countries, and additional data was obtained from the European Society for Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) registry.

RESULTS

Thirty-two countries with a pediatric RRT program responded. The median percentage of children by country on RRT with a functioning transplant was 62 % (interquartile range 39-77). One per million population increase in donation rate from deceased donors was associated with a 5 % increase in the percentage of functioning transplants; the existence of an intermediate and high pediatric priority policy doubled and tripled this percentage, respectively, compared with no priority, whereas an increase in living donor pediatric kidney transplant rate of one per million children was associated with a 14 % higher percentage of functioning transplants. The percentage of functioning transplants was also strongly associated with the gross domestic product (GDP).

CONCLUSION

Considerable variations exist in the percentages of prevalent pediatric RRT populations with functioning renal transplants across Europe. A macroeconomic indicator such as GDP is the most important determinant of these international differences. Efforts should be made for living donation programs and pediatric allocation priority to increase access to kidney transplantation for children.

Disparities in policies, practices and rates of pediatric kidney transplantation in Europe

We aimed to provide an overview of kidney allocation policies related to children and pediatric kidney transplantation (KTx) practices and rates in Europe, and to study factors associated with KTx rates. A survey was distributed among renal registry representatives in 38 European countries. Additional data were obtained from the ESPN/ERA-EDTA and ERA-EDTA registries. Thirty-two countries (84%) responded. The median incidence rate of pediatric KTx was 5.7 (range 0-13.5) per million children (pmc). A median proportion of 17% (interquartile range 2-29) of KTx was performed preemptively, while the median proportion of living donor KTx was 43% (interquartile range 10-52). The median percentage of children on renal replacement therapy (RRT) with a functioning graft was 62%. The level of pediatric prioritization was associated with a decreased waiting time for deceased donor KTx, an increased pediatric KTx rate, and a lower proportion of living donor KTx. The rates of pediatric KTx, distribution of donor source and time on waiting list vary considerably between European countries. The lack of harmonization in kidney allocation to children raises medical and ethical issues. Harmonization of pediatric allocation policies should be prioritized.

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

Preemptive kidney transplantation is the optimal treatment for pediatric end stage renal disease patients to avoid increased morbidity and mortality associated with dialysis. It is unknown how race/ethnicity and poverty influence preemptive transplant access in pediatric. We examined the incidence of living donor or deceased donor preemptive transplantation among all black, white, and Hispanic children (<18 years) in the United States Renal Data System from 2000 to 2009. Adjusted risk ratios for preemptive transplant were calculated using multivariable-adjusted models and examined across health insurance and neighborhood poverty levels. Among 8,053 patients, 1117 (13.9%) received a preemptive transplant (66.9% from LD, 33.1% from DD). In multivariable analyses, there were significant racial/ethnic disparities in access to LD preemptive transplant where blacks were 66% (RR = 0.34; 95% CI: 0.28-0.43) and Hispanics 52% (RR = 0.48; 95% CI: 0.35-0.67) less likely to receive a LD preemptive transplant versus whites. Blacks were 22% less likely to receive a DD preemptive transplant versus whites (RR = 0.78, 95% CI: 0.57-1.05), although results were not statistically significant. Future efforts to promote equity in preemptive transplant should address the critical issues of improving access to pre-ESRD nephrology care and overcoming barriers in living donation, including obstacles partially driven by poverty.

Gender differences in questions asked in an online preoperative patient education program

BACKGROUND

Although osteoarthritis more commonly affects women than men, women are 3 times less likely to undergo hip or knee replacement surgery compared with men. Disparity in the appropriate utilization of surgery between men and women is a complex subject that must take into account the willingness of a patient to proceed with the operation. Adequately addressing patient concerns before surgery may influence such willingness.

OBJECTIVE

We examined if a gender difference can be identified in the frequency and types of questions submitted by patients scheduled for total hip or total knee arthroplasty.

METHODS

Patients completed an online interactive preoperative educational program and a database was created containing deidentified information on surgical procedure, sex, year of birth, and any questions that were submitted. Data were also available regarding the total number of patients issued the program, the number of patients who started the program, and the number of patients who completed the program. The results were analyzed by Wilcoxon rank sum test. P values ≤0.05 were considered statistically significant.

RESULTS

Among the 2770 women and 1708 men included in the study, 935 (34%) and 462 (27%) asked at least 1 question, respectively. Compared with men, women asked a significantly greater number of questions overall (P < 0.001). Women also asked a significantly greater number of questions in the categories Your Condition (P = 0.031), Your Procedure (P < 0.001), and Risks and Benefits (P < 0.001).

CONCLUSIONS

Gender differences in concerns and physicians' ability to adequately address these concerns may contribute to disparity in use of hip and knee replacement surgery between men and women. Effective preoperative counseling for women may require additional resources to address their higher level of questions.