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Brunson C, House TR, Noone D, Wightman A. Management dilemmas in pediatric nephrology: moving from friction to flourishing in "challenging" cases. Pediatr Nephrol 2024; 39:3363-3371. [PMID: 38668777 DOI: 10.1007/s00467-024-06384-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/14/2024] [Accepted: 04/05/2024] [Indexed: 09/20/2024]
Abstract
BACKGROUND The circumstances surrounding chronic kidney disease and its impact on families can be complex and difficult to navigate, leading to these cases being labeled "challenging." CASE PRESENTATION We present the case of an adolescent with kidney failure due to unremitting systemic illness and multiple complications ultimately resulting in the family's request to forgo dialysis. Medical team members wrestled with meeting the family's needs among internal and external constraints. CONCLUSION Past experiences, systemic inequities, differing perspectives, and consequential decision-making within individual belief systems can lead to friction between and among medical team members and families. As pediatric nephrologists, we must shift our focus from the "challenging" patient or family to addressing what is challenging their ability to flourishing.
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Affiliation(s)
- Celina Brunson
- Department of Pediatrics, George Washington University, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, USA
| | - Taylor R House
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin Madison, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Damien Noone
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, M5G 1X8, Canada
| | - Aaron Wightman
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA
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2
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Munshi R, Turner K, Berrettini A, Weiss EM. Now what: navigating care of maternal/fetal dyads with bilateral renal agenesis after RAFT. A physician and parent point of view. Pediatr Nephrol 2024:10.1007/s00467-024-06460-z. [PMID: 39043966 DOI: 10.1007/s00467-024-06460-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 07/25/2024]
Affiliation(s)
- Raj Munshi
- Department of Pediatric Nephrology, Seattle Children's and University of Washington, Seattle, WA, USA.
| | - Kirsten Turner
- Department of Pediatric Nephrology, Seattle Children's and University of Washington, Seattle, WA, USA
| | - Alfredo Berrettini
- Department of Pediatric Urology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elliott Mark Weiss
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Department of Pediatrics, University of Washington, Seattle, WA, USA
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3
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Cleto-Yamane TL, Gomes CLR, Koch-Nogueira PC, Suassuna JHR. Acute kidney injury requiring dialysis in children: a multicentric, emerging country perspective. Pediatr Nephrol 2024; 39:2253-2262. [PMID: 38446208 DOI: 10.1007/s00467-024-06305-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Acute kidney injury (AKI) is a life-threatening condition, especially in extreme age groups and when kidney replacement therapy (KRT) is necessary. Studies worldwide report mortality rates of 10-63% in pediatric patients undergoing KRT. METHODS Over 13 years, this multicenter study analyzed data from 693 patients with AKI, all receiving KRT, across 74 hospitals and medical facilities in Rio de Janeiro, Brazil. RESULTS The majority were male (59.5%), under one year old (55.6%), and treated in private hospitals (76.5%). Sixty-six percent had comorbidities. Pneumonia and congenital heart disease were the most common admission diagnoses (21.5% and 20.2%, respectively). The mortality rate was 65.2%, with lower rates in patients over 12 years (50%). Older age was protective (HR: 2.35, IQR [1.52-3.62] for neonates), and primary kidney disease had a three-fold lower mortality rate. ICU team experience (HR: 0.74, IQR [0.60-0.91]) correlated with lower mortality, particularly in hospitals treating 20 or more patients. Among the deceased, 40% died within 48 h of KRT initiation, suggesting possible late referral or treatment futility. CONCLUSIONS This study confirms the high mortality in pediatric dialytic AKI in middle-income countries, underlining early mortality and offering critical insights for improving outcomes.
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Affiliation(s)
- Thais Lira Cleto-Yamane
- Clinical and Academic Unit of Nephrology, Pedro Ernesto University Hospital, Faculty of Medical Sciences, Rio de Janeiro State University, Rio de Janeiro, Brazil.
- UDA de Nefrologia, Hospital Universitário Pedro Ernesto, Boulevard Vinte e Oito de Setembro 77, 3º Andar, Rio de Janeiro, RJ, 20551-030, Brazil.
| | - Conrado Lysandro R Gomes
- Clinical and Academic Unit of Nephrology, Pedro Ernesto University Hospital, Faculty of Medical Sciences, Rio de Janeiro State University, Rio de Janeiro, Brazil
- Kidney Assistance LLC, Rio de Janeiro, Brazil
| | | | - José Hermógenes Rocco Suassuna
- Clinical and Academic Unit of Nephrology, Pedro Ernesto University Hospital, Faculty of Medical Sciences, Rio de Janeiro State University, Rio de Janeiro, Brazil
- Kidney Assistance LLC, Rio de Janeiro, Brazil
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4
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Claes D, Markham KB, Cortezzo DE. An Ethical Analysis of Therapy for Severe Congenital Kidney and Urinary Tract Anomalies. Pediatrics 2024; 153:e2023064720. [PMID: 38784992 DOI: 10.1542/peds.2023-064720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 05/25/2024] Open
Abstract
Technological advancements before and after delivery have greatly altered the counseling of pregnant patients facing a fetal diagnosis of severe oligohydramnios or anhydramnios secondary to congenital anomalies of the kidneys and urinary tract. Once considered a nearly uniformly lethal abnormality, long-term survival may now be possible secondary to prenatal innovations aimed at restoring the amniotic fluid volume and the availability of more advanced neonatal dialysis techniques. However, these available therapies are far from perfect. The procedures are onerous for pregnant patients without a guarantee of success, and families must prepare themselves for the complex life-long medical care that will be necessary for surviving individuals. Multidisciplinary counseling is imperative to help pregnant individuals understand the complexity of these conditions and assist them in exercising their right to informed decision-making. Moreover, as with any developing field of medicine, providers must contend with ethical questions related to the treatment options, including questions regarding patient-hood, distributive justice, and the blurred lines between research, innovation, and standard care. These ethical questions are best addressed in a multidisciplinary fashion with consideration of multiple points of view from various subspecialties. Only by seeing the entirety of the picture can we hope to best counsel patients about these highly complex situations and help navigate the most appropriate care path.
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Affiliation(s)
- Donna Claes
- Divisions of Nephrology
- Departments of Pediatrics
| | - Kara B Markham
- Cincinnati Children's Fetal Care Center
- Obstetrics and Gynecology and Division of Maternal Fetal Medicine
| | - DonnaMaria E Cortezzo
- Cincinnati Children's Fetal Care Center
- Neonatal and Pulmonary Biology
- Pain and Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Departments of Pediatrics
- Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Divisions of Neonatology
- Pain and Palliative Care
- Fetal Care Program, Connecticut Children's Medical Center, Hartford, Connecticut
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut
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5
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Sanderson KR, Shih WV, Warady BA, Claes DJ. Severe Fetal CAKUT (Congenital Anomalies of the Kidneys and Urinary Tract), Prenatal Consultations, and Initiation of Neonatal Dialysis. Am J Perinatol 2024; 41:e156-e162. [PMID: 35554891 PMCID: PMC9734282 DOI: 10.1055/a-1850-4429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Pediatric nephrology prenatal consultations for congenital anomalies of the kidney and urinary tract (CAKUT) and criteria for kidney replacement therapy initiation in neonatal end-stage kidney disease (ESKD) are not well described. We evaluated pediatric nephrology approaches to prenatal CAKUT counseling and neonatal dialysis initiation. METHODS A 35-question Qualtrics survey was distributed via the North American Pediatric Renal Trials and Collaborative Studies email list between January and March 2021. Thirty-nine pediatric nephrology centers completed the survey. RESULTS All but one responding center (n = 38) provide prenatal CAKUT consultations and neonatal dialysis, with wide variability in reported multispecialty involvement. Nearly half (47%) of centers utilize written/unwritten criteria for offering neonatal dialysis. The most common contraindications to neonatal dialysis were parental refusal (61%), contraindication to access placement by surgeons (55%), and birth weight (BW) contraindication (55%, with < 1,500 g being the most common BW contraindication). Overall, 79% of centers reported caring for < 5 neonates with ESKD in the past year, 61% use hemodialysis therapies prior to peritoneal dialysis in neonates requiring dialysis, and 100% transition to peritoneal dialysis by hospital discharge. CONCLUSION Many pediatric nephrology programs provide prenatal CAKUT consultations and neonatal dialysis, but with variability in practice approach. Further multicenter research regarding prenatal consultations and neonatal dialysis outcomes is necessary to further improve care delivery to this population.
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Affiliation(s)
- Keia R. Sanderson
- Department of Medicine-Nephrology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Weiwen V. Shih
- Department of Pediatrics-Nephrology, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado, United States
| | - Bradley A. Warady
- Division of Nephrology, Children’s Mercy Kansas City, Kansas City, Missouri, United States
| | - Donna J. Claes
- Department of Pediatrics, Division of Nephrology and Hypertension, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
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6
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Glover J, Bock M, Reynolds R, Zaretsky M, Vemulakonda V. Prenatally-diagnosed renal failure: an ethical framework for decision-making. J Perinatol 2024; 44:333-338. [PMID: 37735209 DOI: 10.1038/s41372-023-01779-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 08/31/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
The Children's Hospital Working Group has developed an ethical framework to guide patient care and research for prenatally diagnosed severe renal anomalies. It identifies ethical challenges in communication, timing of decisions and scarce resources. Key elements include shared decision-making, establishing a trusting relationship, and managing disagreement. The ethical framework will be used to develop a clinical pathway that operationalizes the key values of trust, honesty, transparency, beneficence, nonmaleficence, respecting parental authority, professional integrity, and justice.
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Affiliation(s)
- Jacqueline Glover
- Pediatrics, Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA.
| | - Margret Bock
- Pediatrics, Nephrology, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Regina Reynolds
- Pediatrics, Neonatology, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael Zaretsky
- OB, GYN, Maternal-Fetal Medicine, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Vijaya Vemulakonda
- Surgery, Pediatric Urology, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
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7
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Butler CR, Wightman AG. Beyond Autonomy: Ethics of Decision Making About Treatments for Kidney Failure at the Extremes of Age. Am J Kidney Dis 2023; 82:360-367. [PMID: 37028637 PMCID: PMC10524142 DOI: 10.1053/j.ajkd.2023.01.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/18/2023] [Indexed: 04/08/2023]
Abstract
Decisions around initiating and forgoing treatments for kidney failure are complex, and contemporary approaches to medical decision making are designed to uphold patients' own preferences and values when there are multiple clinically reasonable treatment options. When patients do not have cognitive capacity to make their own decisions, these models can be adapted to support the previously expressed preferences of older adults and to promote open futures as autonomous persons for young children. Nonetheless, an autonomy-focused approach to decision making may not align with other overlapping values and needs of these groups. Dialysis profoundly shapes life experience. Values framing decisions about this treatment extend beyond independence and self-determination and vary between life stages. Patients at the extremes of age may place a strong emphasis on dignity, caring, nurturing, and joy. Models of decision making tailored to support an autonomous individual may also discount the role of family as not only surrogate decision makers but stakeholders whose lives and experience are interwoven with a patient's and will be shaped by their treatment decisions. These considerations underline a need to more flexibly incorporate a diversity of ethical frameworks to support medical decisions, especially for the very young and old, when facing complex medical decisions such as initiating or forgoing treatments for kidney failure.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, and the Kidney Research Institute, School of Medicine, University of Washington, Seattle; Nephrology Section, Hospital and Specialty Medicine and Seattle-Denver Health Services Research and Development Center of Innovation, Veterans Affairs Puget Sound Health Care System, Seattle.
| | - Aaron G Wightman
- Department of Pediatrics, School of Medicine, University of Washington, Seattle; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington
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8
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Pais P, Wightman A. Addressing the Ethical Challenges of Providing Kidney Failure Care for Children: A Global Stance. Front Pediatr 2022; 10:842783. [PMID: 35359883 PMCID: PMC8963107 DOI: 10.3389/fped.2022.842783] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/10/2022] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Priya Pais
- Department of Pediatric Nephrology, St. John's Medical College, St. John's National Academy of Health Sciences, Bangalore, India
| | - Aaron Wightman
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States
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9
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Chan EYH, Yap DYH, Wong WHS, Ho TW, Tong PC, Lai WM, Chan TM, Ma ALT. Demographics and long-term outcomes of children with end-stage kidney disease: A 20-year territory-wide study. Nephrology (Carlton) 2021; 27:171-180. [PMID: 34837272 DOI: 10.1111/nep.14007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/12/2021] [Accepted: 11/10/2021] [Indexed: 01/23/2023]
Abstract
AIM To evaluate the demographics and long-term patient outcomes of children with end-stage kidney disease in Hong Kong. METHODS We conducted a cohort study at the Paediatric Nephrology Centre, the designated site providing kidney replacement therapy (KRT) for children in Hong Kong. The clinical characteristics and outcomes of all children who initiated chronic KRT before 19 years, between 2001 and 2020, were analysed. RESULTS One hundred forty-seven children (50% male) received KRT at a mean age of 11.4 ± 5.7 years. The incidence of ESKD was 6.28 per million age-related population (pmarp). The leading cause of ESKD was congenital anomalies (33%). Ten children (7%) had pre-emptive kidney transplants, 104 (71%) and 33 (22%) patients received automated peritoneal dialysis and haemodialysis as initial KRT. The incidence of ESKD increased over time, and were 4.38, 5.07, 6.15 and 9.17 pmarp during 2001-2005, 2006-2010, 2011-2015 and 2016-2020, respectively (p = .005). Ninty-seven patients (66%) received kidney transplants and the median time to receive a kidney graft was 3.7 years (95% CI 3.1-4.3). Only 10 patients had pre-emptive kidney transplants. The mortality rate was 9.1 deaths per 1000-patient-years (95%CI 4.6-16.2). The survival probabilities at 1-, 5-, 10- and 15-year were 100%, 94.8% (95%CI 90.7-98.9%), 89.7% (95% CI 83.4%-95.9%), 87.1% (95% CI 79.3%-94.9%), respectively. Standardised mortality ratio was 54.5. 72% of deaths were due to infections. Young infants and those without kidney transplants were associated with worse survival (p < .01). Multivariate analysis demonstrated that dialysis was the only factor associated with significantly increased risk of death (HRadj 12.9, 95% CI 2.7-63.2, p = .002). CONCLUSION We observed an increasing incidence of paediatric ESKD in Hong Kong with considerable waiting time to kidney transplant. Mortality risk is comparable to other developed countries and is highest among dialysis population. Efforts should be made to facilitate early access to paediatric kidney transplantation in Hong Kong.
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Affiliation(s)
- Eugene Yu Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong SAR
| | - Desmond Yat Hin Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Wilfred Hing Sang Wong
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Tsz Wai Ho
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong SAR
| | - Pak Chiu Tong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong SAR
| | - Wai Ming Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong SAR
| | - Tak Mao Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Alison Lap Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong SAR
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10
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Roizenblatt A, Henriques C, Carvalho MF, Takihi FA, Koch Nogueira PC. Children on chronic hemodialysis before the first year of age in Brazil: A 3-year survival analysis. Semin Dial 2021; 35:66-70. [PMID: 34405466 DOI: 10.1111/sdi.13015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 07/15/2021] [Accepted: 07/29/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The limited data on survival rates of small children undergoing hemodialysis preclude comparison with other countries. The goal of this study was to determine the mortality rate and its risk factors in children starting hemodialysis during their first year of life. METHODS We performed a retrospective cohort study, based on data from a reference dialysis center in São Paulo city. Data from 47 (8 females) children who underwent chronic hemodialysis before the first year of age were analyzed. Survival was characterized using Kaplan-Meier methods and log-rank tests, followed by a multivariable Cox regression model. RESULTS The survival rates were 93%, 75%, and 64% at 1, 2, and 3 years, respectively. Only cardiovascular comorbidity was significantly associated with the mortality outcome (HR = 5.7, 95% CI = 1.7-19.6, p = 0.006). CONCLUSION The survival rate among children who started hemodialysis in their first year of life was reasonable, similar to international standards.
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Affiliation(s)
- Arnaldo Roizenblatt
- Department of Pediatrics, Pediatric Nephrology Division, Universidade Federal de São Paulo (UNIFESP-EPM), São Paulo, Brazil
| | - Cristina Henriques
- Department of Pediatrics, Pediatric Nephrology Division, Hospital Samaritano Higienópolis-Americas Serviços Médicos, São Paulo, Brazil
| | - Maria Fernanda Carvalho
- Department of Pediatrics, Pediatric Nephrology Division, Hospital Samaritano Higienópolis-Americas Serviços Médicos, São Paulo, Brazil
| | - Fabio Akio Takihi
- Department of Pediatrics, Pediatric Nephrology Division, Universidade Federal de São Paulo (UNIFESP-EPM), São Paulo, Brazil
| | - Paulo C Koch Nogueira
- Department of Pediatrics, Pediatric Nephrology Division, Universidade Federal de São Paulo (UNIFESP-EPM), São Paulo, Brazil.,Department of Pediatrics, Pediatric Nephrology Division, Hospital Samaritano Higienópolis-Americas Serviços Médicos, São Paulo, Brazil
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11
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Larkins NG, Wong G, Alexander SI, McDonald S, Prestidge C, Francis A, Le Page AK, Lim WH. Survival and transplant outcomes among young children requiring kidney replacement therapy. Pediatr Nephrol 2021; 36:2443-2452. [PMID: 33649894 DOI: 10.1007/s00467-021-04945-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/22/2020] [Accepted: 01/11/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Young children starting kidney replacement therapy (KRT) suffer high disease burden with unique impacts on growth and development, timing of transplantation and long-term survival. Contemporary long-term outcome data and how these relate to patient characteristics are necessary for shared decision-making with families, to identify modifiable risk factors and inform future research. METHODS We examined outcomes of all children ≤ 5 years enrolled in the Australia and New Zealand Dialysis and Transplant Registry, commencing KRT 1980-2017. Primary outcomes were patient and graft survival. Final height attained was also examined. We used generalized additive modelling to investigate the relationship between age and graft loss over time post-transplant. RESULTS In total, 388 children were included, of whom 322 (83%) received a kidney transplant. Cumulative 1-, 5- and 10-year patient survival probabilities were 93%, 86% and 83%, respectively. Death censored graft survival at 1, 5 and 10 years was 93%, 87% and 77%, respectively. Most children were at least 10 kg at transplantation (n = 302; 96%). A non-linear relationship between age at transplantation and graft loss was observed, dependent on time post-transplant, with increased risk of graft loss among youngest recipients both initially following transplantation and subsequently during adolescence. Graft and patient survival have improved in recent era. CONCLUSIONS Young children commencing KRT have good long-term survival and graft outcomes. Early graft loss is no reason to postpone transplantation beyond 10 kg, and among even the youngest recipients, late graft loss risk in adolescence remains one of the greatest barriers to improving long-term outcomes.
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Affiliation(s)
- Nicholas G Larkins
- Department of Nephrology and Hypertension, Perth Children's Hospital, 15 University Ave, Nedlands, WA, 6009, Australia.
- School of Medicine, University of Western Australia, Perth, WA, Australia.
- Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia.
| | - Germaine Wong
- Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, Westmead Hospital, Sydney, NSW, Australia
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Stephen I Alexander
- School of Public Health, University of Sydney, Sydney, NSW, Australia
- Department of Nephrology, Westmead Children's Hospital, Westmead, NSW, Australia
| | - Stephen McDonald
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, Royal Adelaide Hospital, Adelaide, SA, Australia
- Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | | | - Anna Francis
- Child and Adolescent Renal Service, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Amelia K Le Page
- Department of Nephrology, Monash Children's Hospital, Clayton, VIC, Australia
| | - Wai H Lim
- School of Medicine, University of Western Australia, Perth, WA, Australia
- Department of Nephrology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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12
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Chishiki M, Go H, Endo K, Ueda NK, Takehara H, Namai Y. Response: Treatment Strategy for Severe Sepsis in Newborns. TOHOKU J EXP MED 2021; 254:143-144. [PMID: 34193766 DOI: 10.1620/tjem.254.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Mina Chishiki
- Department of Pediatrics, Ohta Nishinouchi Hospital.,Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Hayato Go
- Department of Pediatrics, Ohta Nishinouchi Hospital.,Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Kisei Endo
- Department of Pediatrics, Fukushima Medical University School of Medicine
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13
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Brewer ED. ESRD Policies and the Delivery of Pediatric Long-term Dialysis Care in the United States. Am J Kidney Dis 2020; 77:264-267. [PMID: 32920156 DOI: 10.1053/j.ajkd.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 08/03/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Eileen D Brewer
- Pediatric Renal Section, Department of Pediatrics, Baylor College of Medicine and Renal Service, Texas Children's Hospital, Houston, TX.
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14
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Wightman A. Caregiver burden in pediatric dialysis. Pediatr Nephrol 2020; 35:1575-1583. [PMID: 31435726 DOI: 10.1007/s00467-019-04332-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/08/2019] [Accepted: 08/06/2019] [Indexed: 12/28/2022]
Abstract
In spite of improvements in expected survival, neurodevelopmental outcome, and quality of life, decision-making in neonatal dialysis remains controversial in high-resource countries. In part, this may be based upon the significant burdens experienced by the child, and also those experienced by the parents as caregivers. Emerging research offers a clearer description of the burdens experienced by dialysis caregivers worldwide. Caregiver burden represents an important area for nephrologists to advocate for patients and their families; however, nephrologists must also recognize the realities caregivers currently experience. Incorporation of caregiver burden into medical decision-making for children with end-stage kidney disease is necessary, but raises several ethical concerns.
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Affiliation(s)
- Aaron Wightman
- Divisions of Nephrology, Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA. .,Division of Nephrology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98115, USA. .,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA, USA.
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15
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Broenen E, Ranchin B, Besmond C, Freychet C, Fouilhoux A, Perouse de Montclos T, Ville D, Bacchetta J. RMND1 mutations in two siblings: Severe renal hypoplasia but different levels of extrarenal abnormality severity: The ethics of decision making. Arch Pediatr 2019; 26:377-380. [PMID: 31506229 DOI: 10.1016/j.arcped.2019.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/15/2019] [Accepted: 08/02/2019] [Indexed: 10/26/2022]
Abstract
Mutations in the RMND1 gene, causing defects in the mitochondrial respiratory chain, result in a very heterozygous phenotype. Currently there are 36 cases reported in the literature. We report two siblings from a non-consanguineous family who were severely affected by a compound heterozygous RMND1 mutation that had not been described previously and were treated differently for their end-stage renal disease. We summarize all previous published cases and focus on the importance of extrarenal comorbidities in the context of therapeutic decision making (renal replacement therapy) and its ethical relevance.
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Affiliation(s)
- E Broenen
- Centre de référence des maladies rénales rares, hôpital femme-mère-enfant, hospices civils de Lyon, 69677 Bron cedex, France
| | - B Ranchin
- Centre de référence des maladies rénales rares, hôpital femme-mère-enfant, hospices civils de Lyon, 69677 Bron cedex, France
| | - C Besmond
- Inserm UMR1163, institut imagine, génétique translationnelle, université de Paris, 75015 Paris, France
| | - C Freychet
- Centre de référence des maladies rénales rares, hôpital femme-mère-enfant, hospices civils de Lyon, 69677 Bron cedex, France
| | - A Fouilhoux
- Centre de référence des maladies métaboliques héréditaires, hôpital femme-mère-enfant, hospices civils de Lyon, 69677 Bron cedex, France
| | - T Perouse de Montclos
- Service de cardiologie pédiatrique, hôpital Louis-Pradel, hospices civils de Lyon, 69677 Bron cedex, France
| | - D Ville
- Service de neurologie pédiatrique, hôpital femme-mère-enfant, hospices civils de Lyon, 69677 Bron cedex, France
| | - J Bacchetta
- Centre de référence des maladies rénales rares, hôpital femme-mère-enfant, hospices civils de Lyon, 69677 Bron cedex, France; Faculté de médecine Lyon Est, université Lyon 1, 69373 Lyon cedex 08, France.
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16
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O'Hare EM, Jelin AC, Miller JL, Ruano R, Atkinson MA, Baschat AA, Jelin EB. Amnioinfusions to Treat Early Onset Anhydramnios Caused by Renal Anomalies: Background and Rationale for the Renal Anhydramnios Fetal Therapy Trial. Fetal Diagn Ther 2019; 45:365-372. [PMID: 30897573 DOI: 10.1159/000497472] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/31/2019] [Indexed: 11/19/2022]
Abstract
Anhydramnios caused by early anuria is thought to be universally fatal due to pulmonary hypoplasia. Bilateral renal agenesis and early fetal renal failure leading to anhydramnios constitute early pregnancy renal anhydramnios (EPRA). There have been successful reports of amnioinfusions to promote lung growth in the setting of EPRA. Some of these successfully treated EPRA fetuses have survived the neonatal period, undergone successful dialysis, and subsequently received a kidney transplant. Conversely, there are no reports of untreated EPRA survivors. This early success of amnioinfusions to treat EPRA justifies a rigorous prospective trial. The objective of this study is to provide a review of what is known about fetal therapy for EPRA and describe the Renal Anhydramnios Fetal Therapy trial. We review the epidemiology, pathophysiology, and genetics of EPRA. Furthermore, we have performed systematic review of case reports of treated EPRA. We describe the ethical framework, logistical challenges, and rationale for the current single center (NCT03101891) and planned multicenter trial.
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Affiliation(s)
| | - Angie C Jelin
- Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jena L Miller
- Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rodrigo Ruano
- Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ahmet A Baschat
- Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eric B Jelin
- Pediatric Surgery, Johns Hopkins University, Baltimore, Maryland, USA, .,Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA,
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17
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Wightman A, Zimmerman CT, Neul S, Lepere K, Cedars K, Opel D. Caregiver Experience in Pediatric Dialysis. Pediatrics 2019; 143:peds.2018-2102. [PMID: 30696758 DOI: 10.1542/peds.2018-2102] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric dialysis is thought to be burdensome on caregivers given their need to assume dual responsibilities of parental and medical management of their child's chronic illness. In this study, we seek to describe the experience of parental caregivers of children receiving chronic dialysis for end-stage kidney disease. METHODS We performed semistructured interviews of primary caregivers of children with end-stage kidney disease receiving chronic peritoneal dialysis or hemodialysis for at least 8 weeks from March 2016 to April 2017 at 3 pediatric dialysis centers in the United States. We performed a thematic analysis to inductively derive and identify themes and subthemes related to positive and negative caregiver experiences. RESULTS Thirty-five caregivers completed interviews. Four major themes were identified, each with several subthemes: (1) caregiver medicalization (subthemes: diagnosis and initiation, disease management, and the future), (2) emotional adjustment (initial and/or acute phase, acceptance, personal growth, and medical stress and psychological burden), (3) pragmatic adaptation (disruption, adaptation of life goals and/or sense of self, and financial impact), and (4) social adjustment (relationship opportunity, relationship risk, advocacy, family functioning, and intimate relationships). These themes and subthemes reflected a broad range of experiences from positive to severely burdensome. CONCLUSIONS Caregivers of patients on dialysis report a broad range of positive and burdensome experiences. These results reveal a need for continued advocacy to support families with a child on dialysis and can be used to develop targeted measures to study and improve caregiver experience in this population.
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Affiliation(s)
- Aaron Wightman
- Divisions of Nephrology, .,Bioethics and Palliative Care, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | - Cortney Taylor Zimmerman
- Section of Psychology, Nephrology Service, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Shari Neul
- Division of Hematology and Oncology, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee; and
| | - Katherine Lepere
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | - KristiLynn Cedars
- Division of Psychology, Department of Psychiatry and Behavioral Medicine, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Douglas Opel
- Bioethics and Palliative Care, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
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18
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Levy CS, Mudi A, Venter B, Geel J. Challenges Facing Children on Chronic Peritoneal Dialysis in South Africa. Perit Dial Int 2018; 38:402-404. [DOI: 10.3747/pdi.2017.00275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Cecil Steven Levy
- Division of Paediatric Nephrology Department of Paediatrics and Child Health Nelson Mandela Children's Hospital and the University of the Witwatersrand Johannesburg, South Africa
| | - Abdullahi Mudi
- Department of Paediatrics Bayero University, Kano Nigeria
| | - Bonnie Venter
- Steve Biko Centre for Bioethics Faculty of Health Sciences, University of Witwatersrand Johannesburg, South Africa
| | - Jennifer Geel
- Division of Paediatric Haematology and Oncology Department of Paediatrics and Child Health Charlotte Maxeke Johannesburg Academic Hospital and the University of the Witwatersrand Johannesburg, South Africa
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19
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Wong AY, John RM. Diagnosis and primary care management of focal segmental glomerulosclerosis in children. Nurse Pract 2018; 43:28-37. [PMID: 30134435 DOI: 10.1097/01.npr.0000544275.97385.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Focal segmental glomerulosclerosis (FSGS) is a pattern of kidney damage that can occur in individuals at any age, including children. Pediatric patients with FSGS require medication monitoring, growth, and psychological health. This article discusses the NP's role in the clinical presentation, diagnostic workup, and treatment of FSGS in pediatric patients.
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Affiliation(s)
- Angela Y Wong
- Angela Y. Wong is a pediatric NP at Maimonides Children's Hospital, Brooklyn, N.Y. Rita Marie John is a PNP program director and associate professor of nursing at Columbia University Medical Center, Columbia University School of Nursing, New York, N.Y
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20
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Wightman A, Goldberg A, Diekema D. Fairness, severe intellectual disability, and the special case of transplantation. Pediatr Transplant 2018; 22:e13228. [PMID: 29785805 DOI: 10.1111/petr.13228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2018] [Indexed: 11/27/2022]
Abstract
Children with severe intellectual disability have historically been excluded from solid organ transplantation. The purpose of this article was to review the arguments for excluding this population, including claims of poorer recipient and graft survival, a lower QoL as pediatric recipients become adults, and poorer outcomes for other, more deserving pediatric transplant candidates, and make the case that these arguments are no longer persuasive. We will argue that pediatric transplant centers for reasons of social justice, value of relationships, power differential, and fairness should generally not consider intellectual ability or disability as a criterion when making decisions regarding organ transplant eligibility.
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Affiliation(s)
- Aaron Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA
| | - Aviva Goldberg
- Department of Pediatrics, University of Manitoba College of Medicine, Winnipeg, MB, Canada
| | - Douglas Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA
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21
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Reusz GS, Molnar MZ. Are kidney transplantation outcomes improved in children weighting 15 kilograms or less in the last decades? Transpl Int 2018; 31:703-705. [PMID: 29341248 DOI: 10.1111/tri.13113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/10/2018] [Indexed: 11/28/2022]
Affiliation(s)
- George S Reusz
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Miklos Z Molnar
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
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22
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Wightman A. Management dilemmas in pediatric nephrology: time-limited trials of dialysis therapy. Pediatr Nephrol 2017; 32:615-620. [PMID: 27942955 DOI: 10.1007/s00467-016-3545-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/24/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Time-limited trials of dialysis have been proposed as a third option in addition to initiation of treatment and comfort-care only in the setting of high uncertainty or discordance between the treating team and child/family or among the treating team. CASE-DIAGNOSIS/TREATMENT The index case was noted antenatally to have severe kidney disease and pulmonary hypoplasia. In light of the guarded, but uncertain prognosis and a lack of consensus among the treating team, as well as between the treating team and the family, a time-limited trial of dialysis was initiated. Six days later the child developed bacteremia due to infection of the dialysis catheter. The treating team felt this was a failure of the trial and that future dialysis should be withheld, the family disagreed. CONCLUSION A time-limited trial is a problematic option. Providers may be better suited by returning to the dichotomous choice of withholding or initiating treatment. KEY MANAGEMENT POINTS • Time-limited trials offer potential benefits in terms of alleviating the burden of decision-making in the setting of uncertainty, offering an opportunity to forecast a poor prognosis, help avoid interprofessional conflict, and providing support for patients, their families, and staff. • Time-limited trials have important limitations, including the use of time limits, difficulty in determining clear, meaningful endpoints, and different interpretations of a trial of therapy between parents and providers. • Decisions regarding the initiation, withholding, and withdrawal of dialysis should be made based on regular assessments of the benefits and burdens of the intervention for the child. • Pediatric nephrologists are better served to abandon the concept of time-limited trials.
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Affiliation(s)
- Aaron Wightman
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
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