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Ku E, McCulloch CE, Bicki A, Lin F, Lopez I, Furth SL, Warady BA, Grimes BA, Amaral S. Association Between Dialysis Facility Ownership and Mortality Risk in Children With Kidney Failure. JAMA Pediatr 2023; 177:1065-1072. [PMID: 37669042 PMCID: PMC10481326 DOI: 10.1001/jamapediatrics.2023.3414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/13/2023] [Indexed: 09/06/2023]
Abstract
Importance In adults, treatment at profit dialysis facilities has been associated with a higher risk of death. Objective To determine whether profit status of dialysis facilities is associated with the risk of death in children with kidney failure treated with dialysis and whether any such association is mediated by differences in access to transplant. Design, Setting, and Participants This retrospective cohort study reviewed US Renal Data System records of 15 359 children who began receiving dialysis for kidney failure between January 1, 2000, and December 31, 2019, in US dialysis facilities. The data analysis was performed between May 2, 2022, and June 15, 2023. Exposure Time-updated profit status of dialysis facilities. Main Outcomes and Measures Adjusted Fine-Gray models were used to determine the association of time-updated profit status of dialysis facilities with risk of death, treating kidney transplant as a competing risk. Cox proportional hazards regression models were also used to determine time-updated profit status with risk of death regardless of transplant status. Results The final cohort included 8465 boys (55.3%) and 6832 girls (44.7%) (median [IQR] age, 12 [3-15] years). During a median follow-up of 1.4 (IQR, 0.6-2.7) years, with censoring at transplant, the incidence of death was higher at profit vs nonprofit facilities (7.03 vs 4.06 per 100 person-years, respectively). Children treated at profit facilities had a 2.07-fold (95% CI, 1.83-2.35) higher risk of death compared with children at nonprofit facilities in adjusted analyses accounting for the competing risk of transplant. When follow-up was extended regardless of transplant status, the risk of death remained higher for children treated in profit facilities (hazard ratio, 1.47; 95% CI, 1.35-1.61). Lower access to transplant in profit facilities mediated 67% of the association between facility profit status and risk of death (95% CI, 45%-100%). Conclusions and Relevance Given the higher risk of death associated with profit dialysis facilities that is partially mediated by lower access to transplant, the study's findings indicate a need to identify root causes and targeted interventions that can improve mortality outcomes for children treated in these facilities.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine and Pediatrics, University of California, San Francisco, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Alexandra Bicki
- Division of Nephrology, Department of Medicine and Pediatrics, University of California, San Francisco, San Francisco
| | - Feng Lin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Isabelle Lopez
- Division of Nephrology, Department of Medicine and Pediatrics, University of California, San Francisco, San Francisco
| | - Susan L. Furth
- Division of Pediatric Nephrology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Bradley A. Warady
- Children’s Mercy Kansas City, Division of Nephrology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Barbara A. Grimes
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Sandra Amaral
- Division of Pediatric Nephrology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Practice patterns and outcomes of maintenance dialysis in children < 2 years of age: a report of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS). Pediatr Nephrol 2022; 37:1117-1124. [PMID: 34648058 DOI: 10.1007/s00467-021-05287-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/19/2021] [Accepted: 09/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Peritoneal dialysis (PD) is the preferred mode of kidney replacement therapy (KRT) in infants and young children with kidney failure. Hemodialysis (HD) is used less often due to the technical challenges and risk of complications in smaller patients. There are limited data on chronic HD in this patient population. METHODS This was a retrospective study of children younger than 24 months on HD and PD in the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry between January 1992 and December 2018. We compared demographic, clinical, and laboratory data and outcomes, including patient survival and kidney transplantation. RESULTS We identified 1125 infants and toddlers younger than 2 years of age who initiated KRT from January 1992 to December 2018. Of those, 1011 (89.8%) initiated peritoneal dialysis and 114 (10.2%) initiated hemodialysis. Median (IQR) age at HD onset was 12 (5.6-18.7) months compared to 4.6 (0.8-11.7) months at PD onset (p < 0.001). The primary cause of kidney failure with replacement therapy was congenital anomalies of the kidney and urinary tract (56.2% of PD versus 39.5% of HD group). Patients on HD had superior growth and nutrition markers than those on PD. Patient survival was similar between the two groups. CONCLUSIONS While HD may not be the modality of choice for chronic KRT in younger children, 10% of children younger than 24 months of age receive maintenance HD and the numbers have increased over time. Patient survival on dialysis is similar irrespective of dialysis modality. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Iorember FM, Bamgbola OF. Structural Inequities and Barriers to Accessing Kidney Healthcare Services in the United States: A Focus on Uninsured and Undocumented Children and Young Adults. Front Pediatr 2022; 10:833611. [PMID: 35450110 PMCID: PMC9016185 DOI: 10.3389/fped.2022.833611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
The population of children living in poverty and lacking healthcare insurance has increased in the United States of America in the last decade. Several factors have been responsible for this trend including illegal immigration, socioeconomic deprivation, young age, racial segregation, environmental degradation, and discriminatory housing policies. These systemic barriers have contributed to the exclusion of families from essential healthcare services. They are also contributory to the development of chronic illnesses (such as dialysis-dependent kidney disease) that are debilitating and frequently require considerable therapeutic resources. This unfortunate scenario creates a never-ending vicious cycle of poverty and diseases in a segment of society. For pediatric nephrologists, the challenges of caring for uninsured children with chronic kidney disease are all too familiar. Federally funded healthcare programs do not cover this patient population, leaving them the option of seeking care in emergency healthcare settings. Presentation with a critical illness often necessitates urgent placement of vascular catheters and the choice of acute hemodialysis. Adverse social environment influences the need for protracted chronic hemodialysis and a delay in kidney transplantation. Consequently, there is greater comorbidity, recurrent hospitalization, and a higher mortality rate. New policies should address the deficit in health insurance coverage while promoting social programs that will remove structural barriers to health care resources for undocumented children and young adults.
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Affiliation(s)
- Franca M Iorember
- Division of Pediatric Nephrology, Baylor College of Medicine, Children's Hospital of San Antonio, San Antonio, TX, United States
| | - Oluwatoyin F Bamgbola
- Division of Pediatric Nephrology, SUNY Downstate Medical Center, Brooklyn, NY, United States
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Policy in pediatric nephrology: successes, failures, and the impact on disparities. Pediatr Nephrol 2021; 36:2177-2188. [PMID: 32968856 DOI: 10.1007/s00467-020-04755-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/10/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
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.
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Resident foreign patients receive adequate dialysis but fewer preemptive transplantations: data from the Italian pediatric dialysis registry. Pediatr Nephrol 2021; 36:639-647. [PMID: 32914248 DOI: 10.1007/s00467-020-04730-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/15/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
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.
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Wallace EL, Lea J, Chaudhary NS, Griffin R, Hammelman E, Cohen J, Sloand JA. Home Dialysis Utilization Among Racial and Ethnic Minorities in the United States at the National, Regional, and State Level. Perit Dial Int 2016; 37:21-29. [PMID: 27680759 DOI: 10.3747/pdi.2016.00025] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/05/2016] [Indexed: 11/15/2022] Open
Abstract
♦ BACKGROUND: United States Renal Data System (USRDS) data from 2014 show that African Americans (AA) are underrepresented in the home dialysis population, with 6.4% versus 9.2% utilization in the general populace. This racial disparity may be inaccurately ascribed to the nation as a whole if regional and inter-state variability exists. This investigation sought to examine home dialysis utilization by minority Medicare beneficiary populations across the US nationally, regionally, and by individual state. ♦ METHODS: The 2012 Medicare 100% Outpatient Standard Analytic File was used to identify all Medicare fee-for-service (FFS) patients, with state of residence and race, receiving an outpatient dialysis facility bill type. Peritoneal dialysis (PD) and home hemodialysis (HHD) patients were identified using revenue and condition codes and were defined by having at least one claim during the year that met criteria for the category. Beneficiaries were counted once for each modality used that year. A home dialysis utilization ratio (UR) was calculated as the ratio of the proportion of a minority on PD or HHD within a geographic division to the proportion of Caucasians on PD or HHD within the same geographic division. A UR less than 1.00 indicated under-representation while a UR over 1.00 indicated over-representation. Utilization ratios were compared using a Poisson regression model. ♦ RESULTS: A total of 369,164 Medicare FFS dialysis patients were identified. Within the total cohort, AA were the most underrepresented minority on PD (UR 0.586; 95% confidence interval [CI]: 0.585 - 0.586; p < 0.0001), followed by Hispanics (UR 0.744; 95% CI 0.743 - 0.744; p < 0.0001). The underutilization of PD by AA and Hispanics could not be ascribed to any region of the US, as all regions of the US had UR < 1.00. Only Massachusetts had a UR > 1.00 for AA on PD. Peritoneal dialysis UR values for Asians and those self-identified as Other were 0.954; 95% CI 0.953 - 0.954 and 0.932; 95% CI 0.931 - 0.932, respectively. Nationally, all minorities utilized HHD less than Caucasians. However, more variability existed, with Asians utilizing more HHD than Caucasians in the Midwest. ♦ CONCLUSIONS: Although regional and interstate variability exists, there is near universal under-representation of AA and Hispanics in the home dialysis population, while Asians and Other demonstrate more interregional and interstate variability.
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Affiliation(s)
- Eric L Wallace
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Ninad S Chaudhary
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Russell Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - James A Sloand
- Baxter Healthcare Corporation, Deerfield, IL, United States
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Hidalgo G, Ng DK, Moxey-Mims M, Minnick ML, Blydt-Hansen T, Warady BA, Furth SL. Association of income level with kidney disease severity and progression among children and adolescents with CKD: a report from the Chronic Kidney Disease in Children (CKiD) Study. Am J Kidney Dis 2013; 62:1087-94. [PMID: 23932090 PMCID: PMC3840111 DOI: 10.1053/j.ajkd.2013.06.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 06/12/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Among adults, lower socioeconomic status (SES) is a risk factor for chronic kidney disease (CKD), progression to end-stage renal disease, and poor health outcomes; but its impact on young people with CKD is not established. STUDY DESIGN Prospective cohort study. SETTINGS & PARTICIPANTS 572 children and adolescents aged 1-16 years with mild to moderate CKD residing in the United States and Canada who were enrolled in the Chronic Kidney Disease in Children (CKiD) Study. PREDICTOR Self-reported annual household income category as a proxy measure for SES: ≥$75,000 (high income), $30,000 to <$75,000 (middle income) and <$30,000 (low income). OUTCOMES & MEASUREMENTS Clinical characteristics and CKD severity at baseline (glomerular filtration rate [GFR] and comorbid conditions related to disease severity and management) and longitudinally (GFR decline and changes in blood pressure z scores and height z scores per year). RESULTS At baseline, low and middle household incomes, compared to high income, were associated with minority race (39% and 20% vs. 7%), lower maternal education (28% and 5% vs. 1%), abnormal birth history (34% and 32% vs. 21%), and having at least one clinical comorbid condition (66% and 64% vs. 55%). Baseline median GFRs were similar across income categories (43-45 mL/min/1.73 m2). After adjusting for baseline differences, average GFR declines per year for the low-, middle-, and high-income categories were -2.3%, -2.7%, and -1.9%, respectively, and were not statistically significantly different among groups. Blood pressure control tended to improve in all groups (z score, -0.10 to -0.04) but higher income was associated with a faster improvement. Each group showed similar deficits in height at baseline. Height deficits diminished over time for participants from high-income families, but not among those from low-income families (z scores for height per year, 0.05 and -0.004, respectively; P = 0.03 for comparison of high and low income). LIMITATIONS Income is an imperfect measure for SES; CKiD participants are not representative of children and adolescents with CKD who are uninsured or not receiving care; statistical power to detect associations by income level is limited. CONCLUSIONS GFR decline was similar across income groups but better improvement in BP was observed among those with high income. Children and adolescents with CKD from lower income households are at higher risk of impaired growth.
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Affiliation(s)
- Guillermo Hidalgo
- Department of Pediatrics, East Carolina University School of Medicine, Greenville, NC
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Watson AR, Hayes WN, Vondrak K, Ariceta G, Schmitt CP, Ekim M, Fischbach M, Edefonti A, Shroff R, Holta T, Zurowska A, Klaus G, Bakkaloglu S, Stefanidis CJ, Van de Walle J. Factors influencing choice of renal replacement therapy in European paediatric nephrology units. Pediatr Nephrol 2013; 28:2361-8. [PMID: 23843162 DOI: 10.1007/s00467-013-2555-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 05/28/2013] [Accepted: 06/18/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many factors may impact upon choice of renal replacement therapy (RRT) for children and adolescents, including patient and family choice, patient size and distance from the renal centre as well as logistic issues such as facilities and staffing at the unit. We report a survey of factors influencing treatment choice in 14 European paediatric nephrology units. METHODS A questionnaire was developed by consensus and completed by 14 members of the European Paediatric Dialysis Working Group on facilities, staffing and family assessments impacting on choice of therapy as well as choice of therapy for 97 patients commencing initial RRT in 2011. RESULTS All units offered all modalities of RRT, but there were limitations for pre-emptive transplantation (PET) and largely adult surgical dependence for creation of arteriovenous fistulae and transplantation. The average waiting time for a deceased donor kidney was 18.5 (range 3-36) months. Full time dietetic support was available in six of the 14 units. There was no social worker, psychology, play therapy or teaching support in three, two, seven and four units, respectively. Assessment by other members of the multidisciplinary team and home visits before choice of therapy was carried out in 50 % of units, and although all patients were discussed at team meetings, the medical opinion predominated. In terms of types of RRT, 50 % of patients were commenced on chronic peritoneal dialysis (PD), 34 % on haemodialysis (HD) and 16 % underwent pre-emptive transplantation (PET). Chronic PD predominated in patients aged <5 years and HD predominated in those aged >10 years. Patient and family choice and age or size of patient were predominant factors in choice of therapy with a predictable decline in renal function favouring PET and social factors HD. CONCLUSIONS Chronic peritoneal dialysis predominated as primary choice of RRT, especially in younger children. The PET rates remain low. The influence of surgeons predominanted, and national transplant rules may be significant. Most units had insufficient multiprofessional support, which may impact upon initial choice of therapy as well as sustaining families through RRT.
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Affiliation(s)
- Alan R Watson
- Children's Renal & Urology Unit, Nottingham Children's Hospital, QMC Campus, Derby Road, Nottingham, NG7 2UH, UK,
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Practice patterns and outcomes in retransplantation among pediatric kidney transplant recipients. Transplantation 2013; 95:1360-8. [PMID: 23549198 DOI: 10.1097/tp.0b013e31828c6d64] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND More than 25% of pediatric kidney transplants are lost within 7 years, necessitating dialysis or retransplantation. Retransplantation practices and the outcomes of repeat transplantations, particularly among those with early graft loss, are not clear. METHODS We examined retransplantation practice patterns and outcomes in 14,799 pediatric (ages <18 years) patients between 1987 and 2010. Death-censored graft survival was analyzed using extended Cox models and retransplantation using competing risks regression. RESULTS After the first graft failure, 50.4% underwent retransplantation and 12.1% died within 5 years; after the second graft failure, 36.1% underwent retransplantation and 15.4% died within 5 years. Prior preemptive transplantation and graft loss after 5 years were associated with increased rates of retransplantation. Graft loss before 5 years, older age, non-Caucasian race, public insurance, and increased panel-reactive antibody were associated with decreased rates of retransplantation. First transplants had lower risk of graft loss compared with second (adjusted hazard ratio [aHR], 0.72; 95% confidence interval [CI], 0.64-0.80; P<0.001), third (aHR, 0.62; 95% CI, 0.49-0.78; P<0.001), and fourth (aHR, 0.44; 95% CI, 0.24-0.78; P=0.005) transplants. However, among patients receiving two or more transplants (conditioned on having lost a first transplant), second graft median survival was 8.5 years despite a median survival of 4.5 years for the first transplant. Among patients receiving three or more transplants, third graft median survival was 7.7 years despite median survivals of 2.1 and 3.1 years for the first and second transplants. CONCLUSIONS Among pediatric kidney transplant recipients who experience graft loss, racial and socioeconomic disparities exist with regard to retransplantation, and excellent graft survival can be achieved with retransplantation despite poor survival of previous grafts.
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Disparities in dialysis treatment and outcomes for Dutch and Belgian children with immigrant parents. Pediatr Nephrol 2012; 27:1369-79. [PMID: 22434424 PMCID: PMC3382654 DOI: 10.1007/s00467-012-2135-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 02/10/2012] [Accepted: 02/13/2012] [Indexed: 11/03/2022]
Abstract
BACKGROUND In Belgium and the Netherlands, up to 40% of the children on dialysis are children with immigrant parents of non-Western European origin (non-Western). Concerns exist regarding whether these non-Western patients receive the same quality of care as children with parents of Western European origin (Western). We compared initial dialysis, post-initial treatment, and outcomes between non-Western and Western patients on dialysis. METHODS All children <19 years old on chronic dialysis in the Netherlands and Belgium between September 2007 and May 2011 were included in the study. Non-Western patients were defined as children of whom one or both parents were born in non-Western countries. RESULTS Seventy-nine of the 179 included patients (44%) were non-Western children. Compared to Western patients, non-Western patients more often were treated with hemodialysis (HD) instead of peritoneal dialysis (PD) as first dialysis mode (52 vs. 37%, p = 0.046). Before renal transplantation, non-Western patients were on dialysis for a median (range) of 30 (5-99) months, vs. 15 (0-66) months in Western patients (p = 0.007). Renal osteodystrophy was diagnosed in 34% of non-Western vs. 18% of Western patients (p = 0.028). The incidence rate ratio [95% confidence interval] for acute peritonitis was 2.44 [1.43-4.17] (p = 0.032) for non-Western compared to Western patients. CONCLUSIONS There are important disparities between children on chronic dialysis with parents from Western European origin and those from non-Western European origin in the choice of modality, duration, and outcomes of dialysis therapy.
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Hiraki LT, Lu B, Alexander SR, Shaykevich T, Alarcón GS, Solomon DH, Winkelmayer WC, Costenbader KH. End-stage renal disease due to lupus nephritis among children in the US, 1995-2006. ACTA ACUST UNITED AC 2011; 63:1988-97. [PMID: 21445963 DOI: 10.1002/art.30350] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify predictors of wait-listing for kidney transplantation, kidney transplantation, and mortality among children with lupus nephritis-associated end-stage renal disease (ESRD). METHODS Children ages 5-18 years with new-onset lupus nephritis-associated ESRD were identified in the US Renal Data System (1995-2006). Demographic and clinical characteristics, causes of death, and predictors of wait-listing for kidney transplantation, kidney transplantation, and mortality during the first 5 years of ESRD were investigated. Cox proportional hazards models were used. RESULTS A total of 583 children had incident lupus nephritis-associated ESRD. The mean ± SD age of the patients at the time of ESRD onset was 16.2 ± 2.4 years; 49% were African American, and 24% were Hispanic. During the 5-year period after the onset of ESRD, 292 (49%) were wait-listed, 193 (33%) received a kidney transplant, and 131 (22%) died. The main causes of death were cardiopulmonary (31%) and infectious (16%). Children living in the northeast and west were more than twice as likely as children in the south to be wait-listed and were >50% more likely than children in the south to undergo transplantation. There were fewer kidney transplants among older versus younger patients (odds ratio [OR] 0.59, P = 0.009), African American versus white patients (OR 0.48, P < 0.001), Hispanic versus non-Hispanic patients (OR 0.63, P = 0.03), and those with Medicaid versus those with private insurance (OR 0.70, P = 0.03). Mortality among African American children was almost double that among white children (OR 1.83, P < 0.001). CONCLUSION Among US children with lupus nephritis-associated ESRD, age, race, ethnicity, type of medical insurance, and geographic region were associated with significant variation in 5-year wait-listing for kidney transplantation, kidney transplantation, and mortality.
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Affiliation(s)
- Linda T Hiraki
- Harvard School of Public Health and Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Minnick ML, Boynton S, Ndirangu J, Furth S. Sex, race, and socioeconomic disparities in kidney disease in children. Semin Nephrol 2010; 30:26-32. [PMID: 20116645 DOI: 10.1016/j.semnephrol.2009.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Racial and gender differences in the prevalence and treatment of chronic kidney disease in US children have been reported. Girls have lower rates of kidney transplantation than boys. Incidence of end-stage renal disease is twice as high among black patients compared with whites. African Americans are less likely than white patients to achieve hemoglobin targets on dialysis, are more likely to be treated with hemodialysis, and to wait longer for a transplant. Reasons for these disparities in disease burden and treatment choices are not known, but possible causes include genetic factors and socioeconomic and sociocultural influences on accessing medical care.
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Affiliation(s)
- Maria Lourdes Minnick
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
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Abstract
OBJECTIVE This technical report reviews and synthesizes the published literature on racial/ethnic disparities in children's health and health care. METHODS A systematic review of the literature was conducted for articles published between 1950 and March 2007. Inclusion criteria were peer-reviewed, original research articles in English on racial/ethnic disparities in the health and health care of US children. Search terms used included "child," "disparities," and the Index Medicus terms for each racial/ethnic minority group. RESULTS Of 781 articles initially reviewed, 111 met inclusion criteria and constituted the final database. Review of the literature revealed that racial/ethnic disparities in children's health and health care are quite extensive, pervasive, and persistent. Disparities were noted across the spectrum of health and health care, including in mortality rates, access to care and use of services, prevention and population health, health status, adolescent health, chronic diseases, special health care needs, quality of care, and organ transplantation. Mortality-rate disparities were noted for children in all 4 major US racial/ethnic minority groups, including substantially greater risks than white children of all-cause mortality; death from drowning, from acute lymphoblastic leukemia, and after congenital heart defect surgery; and an earlier median age at death for those with Down syndrome and congenital heart defects. Certain methodologic flaws were commonly observed among excluded studies, including failure to evaluate children separately from adults (22%), combining all nonwhite children into 1 group (9%), and failure to provide a white comparison group (8%). Among studies in the final database, 22% did not perform multivariable or stratified analyses to ensure that disparities persisted after adjustment for potential confounders. CONCLUSIONS Racial/ethnic disparities in children's health and health care are extensive, pervasive, and persistent, and occur across the spectrum of health and health care. Methodologic flaws were identified in how such disparities are sometimes documented and analyzed. Optimal health and health care for all children will require recognition of disparities as pervasive problems, methodologically sound disparities studies, and rigorous evaluation of disparities interventions.
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Fadrowski JJ, Frankenfield D, Amaral S, Brady T, Gorman GH, Warady B, Furth SL, Fivush B, Neu AM. Children on Long-Term Dialysis in the United States: Findings From the 2005 ESRD Clinical Performance Measures Project. Am J Kidney Dis 2007; 50:958-66. [DOI: 10.1053/j.ajkd.2007.09.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Accepted: 09/10/2007] [Indexed: 11/11/2022]
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Gorman GH, Furth SL. Clinical research in pediatric nephrology: state of the art. Pediatr Nephrol 2005; 20:1382-7. [PMID: 15942788 DOI: 10.1007/s00467-005-1924-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2004] [Revised: 02/18/2005] [Accepted: 02/22/2005] [Indexed: 11/29/2022]
Abstract
The goals of clinical research include comparing new and standard treatments, establishing treatment efficacy, defining risk factors for disease, elucidating pathophysiologic mechanisms of disease, and establishing causation. Although the randomized clinical trial has been the "gold standard" in clinical research and is the strongest study design to establish causation for many clinical research questions, an interventional study or "experiment" such as a randomized trial is often not possible. Observational study designs also demonstrate associations between exposures and outcome. To determine whether these associations are likely to be causal, one can assess a number of qualities, first outlined by the British epidemiologist Sir Austin Bradford Hill. These qualities include analogy to what is known; the plausibility, strength and specificity of the association; consistency and coherence across studies; the temporality of the putative cause and effect; and the presence of a biological gradient. The presence of these factors adds weight to the probability that a given association is causal. Systematic reviews and meta-analyses use these factors in combining studies to assess whether associations are cause and effect. Additionally, new methods in the analysis of longitudinal data collected in observational studies can help to determine causation. In this review, we will use recent literature and contemporary topics in pediatric nephrology to illustrate state-of-the-art research methods using classic epidemiological elements needed to establish causation.
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Affiliation(s)
- Gregory H Gorman
- Pediatric Nephrology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Park 335, Baltimore, MD 21287-2535, USA
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Affiliation(s)
- Neil R Powe
- Johns Hopkins University School of Medicine, Baltimore, Maryland 21205-2223, USA.
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Leonard MB, Donaldson LA, Ho M, Geary DF. A prospective cohort study of incident maintenance dialysis in children: an NAPRTC study. Kidney Int 2003; 63:744-55. [PMID: 12631143 DOI: 10.1046/j.1523-1755.2003.00788.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Prior studies of dialysis practices and outcomes have included children with varied duration of end-stage renal disease (ESRD). This study evaluated dialysis characteristics, complications, practices, and outcomes in an incident pediatric cohort. METHODS The cohort was limited to 1992 subjects enrolled in the North American Pediatric Renal Transplant Cooperative Study registry, starting hemodialysis (HD) or peritoneal dialysis (PD) between 1992 and 1998, without prior dialysis or transplantation. RESULTS At dialysis initiation, the median glomerular filtration rate (GFR; Schwartz formula) was 6 to 11 mL/min/1.73 m2, and 90th percentile was 14 to 25 mL/min/1.73 m2. GFR was not associated with age or race. PD was used in 97% of infants, 70 to 80% of children and 59% of adolescents. Blacks were significantly less likely to be started on PD than whites. Twenty percent of patients switched dialysis modality, largely due to infection, inadequate access or family choice. Younger children received HD almost exclusively through percutaneous catheters, while 57% of children more than six years old were dialyzed with fistula or graft after six months on HD. The prevalence of anemia (Hct <33%) still exceeded 40% after six months of dialysis. The median interval to transplantation was 1.4 years, and was significantly greater in non-white, young, and female patients. Mortality rates (deaths/1000 patient-years) varied with age, from 13.6 in infants to 2.2 in adolescents. CONCLUSION These data demonstrate considerable variability in patient management across pediatric centers. Prospective studies are needed to determine the optimum adequacy of care among children on dialysis and to identify populations at risk.
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Affiliation(s)
- Mary B Leonard
- Department of Pediatrics, The Children's Hospital of Philadelphia, and Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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