Non-Medical Risk Factors as Avoidable Determinants of Excess Mortality in Children with Chronic Kidney Disease. A Prospective Cohort Study in Nicaragua, a Model Low Income Country

Longitudinal associations between socioeconomic position and overall health of children with chronic kidney disease and their carers

BACKGROUND

Disadvantaged socioeconomic position (SEP) is an important predictor of poor health in children with chronic kidney disease (CKD). The time course over which SEP influences the health of children with CKD and their carers is unknown.

METHODS

This prospective longitudinal study included 377 children, aged 6-18 years with CKD (stages I-V, dialysis, and transplant), and their primary carers. Mixed effects ordinal regression was performed to assess the association between SEP and carer-rated child health and carer self-rated health over a 4-year follow-up.

RESULTS

Adjusted for CKD stage, higher family household income (adjusted odds ratio (OR) (95% CI) 3.3, 1.8-6.0), employed status of primary carers (1.7, 0.9-3.0), higher carer-perceived financial status (2.6, 1.4-4.8), and carer home ownership (2.2, 1.2-4.0) were associated with better carer-rated child health. Household income also had a differential effect on the carer's self-rated health over time (p = 0.005). The predicted probabilities for carers' overall health being 'very good' among lower income groups at 0, 2, and 4 years were 0.43 (0.28-0.60), 0.34 (0.20-0.51), and 0.25 (0.12-0.44), respectively, and 0.81 (0.69-0.88), 0.84 (0.74-0.91), and 0.88 (0.76-0.94) for carers within the higher income group.

CONCLUSIONS

Carers and their children with CKD in higher SEP report better overall child and carer health compared with those in lower SEP. Carers of children with CKD in low-income households had poorer self-rated health compared with carers in higher-income households at baseline, and this worsened over time. These cumulative effects may contribute to health inequities between higher and lower SEP groups over time. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.

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.

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.

Paediatric nephrology in under-resourced areas

BACKGROUND

Nearly 50% of the world population and 60% of children aged 0 to 14 years live in low- or lower-middle-income countries. Paediatric nephrology (PN) in these countries is not a priority for allocation of limited health resources. This article explores advancements made and persisting limitations in providing optimal PN services to children in such under-resourced areas (URA).

METHODS

Medline, PubMed and Google Scholar online databases were searched for articles pertaining to PN disease epidemiology, outcome, availability of services and infrastructure in URA. The ISN and IPNA offices were contacted for data, and two online questionnaire surveys of IPNA membership performed. Regional IPNA members were contacted for further detailed information.

RESULTS

There is a scarcity of published data from URA; where available, prevalence of PN diseases, managements and outcomes are often reported to be different from high income regions. Deficiencies in human resources, fluoroscopy, nuclear imaging, immunofluorescence, electron microscopy and genetic studies were identified. Several drugs and maintenance kidney replacement therapy are inaccessible to the majority of patients. Despite these issues, regional efforts with support from international bodies have led to significant advances in PN services and infrastructure in many URA.

CONCLUSIONS

Equitable distribution and affordability of PN services remain major challenges in URA. The drive towards acquisition of regional data, advocacy to local government and non-government agencies and partnership with international support bodies needs to be continued. The aim is to optimise and achieve global parity in PN training, investigations and treatments, initially focusing on preventable and reversible conditions.

Social Deprivation Is Associated With Lower Access to Pre-emptive Kidney Transplantation and More Urgent-Start Dialysis in the Pediatric Population

Introduction

Socioeconomic status (SES) is recognized as an important determinant of kidney health. We aimed to evaluate the association of social deprivation with different indicators at kidney replacement therapy (KRT) initiation in the French pediatric metropolitan population.

Methods

All patients with end-stage kidney disease (ESKD) who started KRT before 20 years old in France between 2002 and 2015 were included. We investigated different indicators at KRT initiation, which are as follows: KRT modality (dialysis vs. pre-emptive transplantation), late referral to a nephrologist, and dialysis modality (hemodialysis [HD] vs. peritoneal dialysis [PD], urgent vs. planned start of dialysis, use of catheter vs. use of fistula for HD vascular access). An ecological index (European Deprivation Index [EDI]) was used as a proxy for social deprivation.

Results

A total of 1115 patients were included (males 59%, median age at dialysis 14.4 years, glomerular/vascular diseases 36.8%). The most deprived group represented 38.7% of the patients, suggesting pediatric patients with ESKD come from a more socially deprived background. The most deprived group was more likely to initiate KRT with dialysis versus kidney transplantation. Among patients on HD, the odds of starting treatment in emergency with a catheter was >2-fold higher for the most deprived compared with the least deprived children (adjusted odds ratio [aOR] 2.35, 95% CI 1.16-4.78).

Conclusion

Children from the most deprived area have lower access to pre-emptive transplantation, have lower access to PD, tend to be late referred to a nephrologist, and have more urgent initiation of HD with a catheter.

The incidence of and risk factors for late presentation of childhood chronic kidney disease: A systematic review and meta-analysis

BACKGROUND

When detected early, inexpensive measures can slow chronic kidney disease progression to kidney failure which, for children, confers significant morbidity and impacts growth and development. Our objective was to determine the incidence of late presentation of childhood chronic kidney disease and its associated risk factors.

METHODS

We searched MEDLINE, Embase, PubMed, Web of Science, Cochrane Library and CINAHL, grey literature and registry websites for observational data describing children <21 years presenting to nephrology services, with reference to late presentation (or synonyms thereof). Independent second review of eligibility, data extraction, and risk of bias was undertaken. Meta-analysis was used to generate pooled proportions for late presentation by definition and investigate risk factors. Meta-regression was undertaken to explore heterogeneity.

RESULTS

Forty-five sources containing data from 30 countries were included, comprising 19,339 children. Most studies (37, n = 15,772) described children first presenting in kidney failure as a proportion of the chronic kidney disease population (mean proportion 0.43, 95% CI 0.34-0.54). Using this definition, the median incidence was 2.1 (IQR 0.9-3.9) per million age-related population. Risk associations included non-congenital disease and older age. Studies of hospitalised patients, or from low- or middle-income countries, that had older study populations than high-income countries, had higher proportions of late presentation.

CONCLUSIONS

Late presentation is a global problem among children with chronic kidney disease, with higher proportions seen in studies of hospitalised children or from low/middle-income countries. Children presenting late are older and more likely to have non-congenital kidney disease than timely presenting children. A consensus definition is important to further our understanding and local populations should identify modifiable barriers beyond age and disease to improve access to care.

Paediatric emergencies and related mortality in Nicaragua: results from a multi-site paediatric emergency registry

BACKGROUND

We aim to describe the characteristics and outcomes of the severe spectrum of paediatric emergency visits using a multi-site registry developed as part of an international cooperation project.

METHODS

This observational registry-based study presented descriptive statistics of clinical and outcome data on urgent-emergency paediatric visits from 7 Nicaraguan hospitals, including the national referral paediatric hospital, between January and December 2017. Extensive piloting to ensure data collection feasibility, sustainability and accuracy was carried out in 2016 with substantial input and feedback from local stakeholders.

RESULTS

Overall, 3521 visits of patients <15 years of age, of whom two-thirds <5 years, met predefined inclusion criteria of urgent-emergency visits. Respiratory (1619/3498; 46%), gastrointestinal (407/3498; 12%) and neurological (368/3498; 11%) complaints were the most common symptoms. Malnutrition was reported in 18% (610/3448) of presentations. Mortality was 7% (233/3521); 52% (120/233) of deaths occurred in the <1-year subgroup; 32% (71/3521) of deaths occurred within the first 24 hours of presentation. The most common immediate causes of death were septic shock (99/233; 43%), respiratory failure (58/233; 25%) and raised intracranial pressure (24/233; 10%).

CONCLUSIONS

The mortality rate of urgent-emergency paediatric visits in Nicaragua is high, with younger children being most at risk and the majority of deaths being eventually caused by septic shock or respiratory failure. Our data provide useful information for the development of a Paediatric Emergency Care network to help direct training efforts, resources and logistic/organisational interventions to improve children's health in an emergency setting in Nicaragua.

Challenges of access to kidney care for children in low-resource settings

Kidney disease is a global public health concern across the age spectrum, including in children. However, our understanding of the true burden of kidney disease in low-resource areas is often hampered by a lack of disease awareness and access to diagnosis. Chronic kidney disease (CKD) in low-resource settings poses multiple challenges, including late diagnosis, the need for ongoing access to care and the frequent unavailability of costly therapies such as dialysis and transplantation. Moreover, children in such settings are at particular risk of acute kidney injury (AKI) owing to preventable and/or reversible causes - many children likely die from potentially reversible kidney disease because they lack access to appropriate care. Acute peritoneal dialysis (PD) is an important low-cost treatment option. Initiatives, such as the Saving Young Lives programme, to train local medical staff from low-resource areas to provide care for AKI, including acute PD, have already saved hundreds of children. Future priorities include capacity building for both educational purposes and to provide further resources for AKI management. As local knowledge and confidence increase, CKD management strategies should also develop. Increased awareness and advocacy at both the local government and international levels will be required to continue to improve the diagnosis and treatment of AKI and CKD in children worldwide.

A systematic review of reasons for and against asking patients about their socioeconomic contexts

Background

People’s social and economic circumstances are important determinants of their health, health experiences, healthcare access, and healthcare outcomes. However, patients’ socioeconomic circumstances are rarely asked about or documented in healthcare settings. We conducted a systematic review of published reasons for why patients’ socioeconomic contexts (including education, employment, occupation, housing, income, or wealth) should, or should not, be enquired about.

Methods

Systematic review of literature published up to and including 2016. A structured literature search using databases of medicine and nursing (pubmed, embase, global health), ethics (Ethicsweb), social sciences (Web of Science), and psychology (PsychINFO) was followed by a ‘snowball’ search. Eligible publications contained one or more reasons for: asking patients about socioeconomic circumstances; collecting patients’ socioeconomic information; ‘screening’ patients for adverse socioeconomic circumstances; or linking other sources of individual socioeconomic data to patients’ healthcare records. Two authors conducted the screening: the first screened all references, the second author screened a 20% sample with inter-rater reliability statistically confirmed. ‘Reason data’ was extracted from eligible publications by two authors, then analysed and organised.

Results

We identified 138 eligible publications. Most offered reasons for why patients’ should be asked about their socioeconomic circumstances. Reasons included potential improvements in: individual healthcare outcomes; healthcare service monitoring and provision; population health research and policies. Many authors also expressed concerns for improving equity in health. Eight publications suggested patients should not be asked about their socioeconomic circumstances, due to: potential harms; professional boundaries; and the information obtained being inaccurate or unnecessary.

Conclusions

This first summary of literature on the subject found many published reasons for why patients’ social and economic circumstances should be enquired about in healthcare settings. These reasons include potential benefits at the levels of individuals, health service provision, and population, as well as the potential to improve healthcare equity. Cautions and caveats include concerns about the clinician’s role in responding to patients’ social problems; the perceived importance of social health determinants compared with biomedical factors; the use of average population data from geographic areas to infer the socioeconomic experience of individuals. Actual evidence of outcomes is lacking: our review suggests hypotheses that can be tested in future research.