1
|
Ross LF, Gallo A, Hester DM. Achieving Live Birth is Not an Endpoint but a Steppingstone. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:115-117. [PMID: 39283371 DOI: 10.1080/15265161.2024.2388722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/20/2024]
Affiliation(s)
| | | | - D Micah Hester
- University of Arkansas for Medical Sciences (UAMS), Arkansas Children's Hospital
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Claes DJ, Richardson T, Harer MW, Keswani M, Neu A, Mahon ACR, Somers MJ, Traum AZ, Warady BA. Survival of neonates born with kidney failure during the initial hospitalization. Pediatr Nephrol 2023; 38:583-591. [PMID: 35655038 DOI: 10.1007/s00467-022-05626-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/10/2022] [Accepted: 05/10/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Survival to hospital discharge in neonates born with kidney failure has not been previously described. METHODS This was a retrospective, observational analysis of the Pediatric Health Information System (PHIS) database from 2005 to 2019. Primary outcome was survival at discharge; secondary outcomes were hospital and ICU length of stay (LOS). Univariate analysis was performed to describe the population by birth weight (BW) and characterize survival; multivariable generalized liner mixed modeling assuming a binomial distribution and logit link was performed to identify mortality risk factors. RESULTS Of 213 neonates born with kidney failure (median BW 2714 g; GA 35 weeks; 68% male), 4 (1.9%) did not receive dialysis or peritoneal dialysis (PD) catheter placement, 152 (72.9%) received PD only, 49 (23.4%) received PD plus extracorporeal dialysis (ECD), and 8 (3.4%) were treated with an undocumented dialysis modality. Median age at dialysis initiation was 7 days; median hospital LOS and ICU LOS were 84 and 69 days, respectively. One-hundred and sixty-two patients (76%) survived to discharge. Non-survivors (n = 51) were more likely to have received ECD and mechanical ventilation, and had a longer duration of mechanical ventilation. Every day of mechanical ventilation increased the mortality odds by 2% (n = 189; adjusted OR 1.02; 1.01, 1.03); in addition, the odds of mortality were 2 times higher in those who received ECD vs. only PD (adjusted OR 2.25; 1.04, 4.86). CONCLUSIONS Survival to initial hospital discharge occurs in the majority of neonates born with kidney failure. Predictors of increased mortality included longer duration of mechanical ventilation, as well as the requirement for ECD. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Donna J Claes
- Division of Pediatric Nephrology, Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA.
| | | | - Matthew W Harer
- Division of Neonatology, Department of Pediatrics, University of Wisconsin, Madison, WI, USA
| | - Mahima Keswani
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Alicia Neu
- Division of Pediatric Nephrology, The John's Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allison C Redpath Mahon
- Division of Pediatric Nephrology, Department of Pediatrics, University of Wisconsin, Madison, WI, USA
| | - Michael J Somers
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
| | - Avram Z Traum
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
| |
Collapse
|
6
|
Abstract
The most severe forms of congenital anomalies of the kidney and urinary tract present in fetal life with early pregnancy renal anhydramnios and are considered lethal due to pulmonary hypoplasia without fetal therapy. Due to the high rate of additional structural anomalies, genetic abnormalities, and associated syndromes, detailed anatomic survey and genetic testing are imperative when stratifying which pregnancies are appropriate for fetal intervention. Restoring amniotic fluid around the fetus is the principal goal of prenatal treatment. The ongoing multi-center Renal Anhydramnios Fetal Therapy (RAFT) trial is assessing the safety and efficacy of serial amnioinfusions to prevent pulmonary hypoplasia so that the underlying renal disease can be addressed.
Collapse
|
7
|
McCulloch MI, Adabayeri VM, Goka S, Khumalo TS, Lala N, Leahy S, Ngubane-Mwandla N, Nourse PJ, Nyann BI, Petersen KL, Levy CS. Perspectives: Neonatal acute kidney injury (AKI) in low and middle income countries (LMIC). Front Pediatr 2022; 10:870497. [PMID: 36120656 PMCID: PMC9471194 DOI: 10.3389/fped.2022.870497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/13/2022] [Indexed: 11/22/2022] Open
Abstract
Neonatal AKI (NAKI) remains a challenge in low- and middle-income countries (LMICs). In this perspective, we address issues of diagnosis and risk factors particular to less well-resourced regions. The conservative management pre-kidney replacement therapy (pre-KRT) is prioritized and challenges of KRT are described with improvised dialysis techniques also included. Special emphasis is placed on ethical and palliation principles.
Collapse
Affiliation(s)
- Mignon I McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Selasie Goka
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Tholang S Khumalo
- Nelson Mandela Children's Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Nilesh Lala
- Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Shannon Leahy
- Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Peter J Nourse
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Beatrice I Nyann
- Department of Paediatrics, University of Ghana Medical Centre, Accra, Ghana
| | - Karen L Petersen
- Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Cecil S Levy
- Nelson Mandela Children's Hospital, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
8
|
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.
Collapse
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.
| |
Collapse
|
9
|
End-stage kidney disease in infancy: an educational review. Pediatr Nephrol 2020; 35:229-240. [PMID: 30465082 PMCID: PMC6529305 DOI: 10.1007/s00467-018-4151-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/05/2018] [Accepted: 11/12/2018] [Indexed: 12/15/2022]
Abstract
An increasing number of infants with end-stage kidney disease (ESKD) are surviving and receiving renal replacement therapy (RRT). Unique clinical issues specific to this age group of patients influence their short- and long-term outcomes. This review summarizes current epidemiology, clinical characteristics, ethical dilemmas, management concerns, and outcomes of infants requiring chronic dialysis therapy. Optimal care during infancy requires a multidisciplinary team working closely with the patient's family. Nutritional management, infection prevention, and attention to cardiovascular status are important treatment targets. Although mortality rates remain higher among infants on dialysis compared to older pediatric dialysis patients, outcomes have improved over time. Most importantly, infants who subsequently receive a kidney transplant are now experiencing graft survival rates that are comparable to older pediatric patients.
Collapse
|
10
|
Noh ES, Kim HH, Kim HS, Han YS, Yang M, Ahn SY, Sung SI, Chang YS, Park WS. Continuous Renal Replacement Therapy in Preterm Infants. Yonsei Med J 2019; 60:984-991. [PMID: 31538434 PMCID: PMC6753340 DOI: 10.3349/ymj.2019.60.10.984] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/23/2019] [Accepted: 08/07/2019] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Despite the increasing use of continuous renal replacement therapy (CRRT) in the neonatal intensive care unit (NICU), few studies have investigated its use in preterm infants. This study evaluated the prognosis of preterm infants after CRRT and identified risk factors of mortality after CRRT. MATERIALS AND METHODS A retrospective review was performed in 33 preterm infants who underwent CRRT at the NICU of Samsung Medical Center between 2008 and 2017. Data of the demographic characteristics, predisposing morbidity, cardiopulmonary function, and CRRT were collected and compared between surviving and non-surviving preterm infants treated with CRRT. Univariable and multivariable analyses were performed to identify factors affecting mortality. RESULTS Compared with the survivors, the non-survivors showed younger gestational age (29.3 vs. 33.6 weeks), lower birth weight (1359 vs. 2174 g), and lower Apgar scores at 1 minute (4.4 vs. 6.6) and 5 minutes (6.5 vs. 8.6). At the initiation of CRRT, the non-survivors showed a higher incidence of inotropic use (93% vs. 40%, p=0.017) and fluid overload (16.8% vs. 4.0%, p=0.031). Multivariable analysis revealed that fluid overload >10% at CRRT initiation was the primary determinant of mortality after CRRT in premature infants, with an adjusted odds ratio of 14.6 and a 95% confidence interval of 1.10-211.29. CONCLUSION Our data suggest that the degree of immaturity, cardiopulmonary instability, and fluid overload affect the prognosis of preterm infants after CRRT. Preventing fluid overload and earlier initiation of CRRT may improve treatment outcomes.
Collapse
Affiliation(s)
- Eu Seon Noh
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Hyun Ho Kim
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Hye Seon Kim
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Yea Seul Han
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Misun Yang
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - So Yoon Ahn
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Se In Sung
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea.
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| |
Collapse
|
11
|
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.
Collapse
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,
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Sanderson KR, Yu Y, Dai H, Willig LK, Warady BA. Outcomes of infants receiving chronic peritoneal dialysis: an analysis of the USRDS registry. Pediatr Nephrol 2019; 34:155-162. [PMID: 30141177 PMCID: PMC6289046 DOI: 10.1007/s00467-018-4056-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Outcome data for infants on chronic peritoneal dialysis (CPD) is limited and has been based primarily on the analyses of voluntary entry registry data. In contrast, the United States Renal Data Systems (USRDS) collects data on all infants with end-stage kidney disease (ESKD) on chronic dialysis in the USA. We aimed to describe the clinical characteristics of this population and to determine the associated patient mortality. METHODS The USRDS database was reviewed retrospectively for data on infants who initiated CPD at ≤ 12 months of age from 1990 to 2014. Infants were categorized into four groups, CPD initiation age (≤ 1 month of age or neonates and > 1-12 months of age or older infants) and initiation era (1990-1999 and 2000-2014). RESULTS A total of 1723 infants (574 neonates and 1149 older infants) were identified. Overall, 20.9% of infants (147 neonates and 213 older infants) died on dialysis during the follow-up. The most commonly identified causes of death on dialysis were cardiorespiratory disease (25.8%) and infection (22.8%). There was an increased risk for mortality in all infants who initiated CPD in the earlier initiation era (1990-1999) vs the later era (2000-2014) (aHR of 1.95), for females vs males (aHR 1.43), and for those with a primary diagnosis of cystic kidney diseases vs congenital anomalies of the kidney and urinary tract (CAKUT) (aHR 1.84). In 2000-2014, patient survival at 1 and 5 years was 86.8% and 74.6% for those who initiated CPD as neonates and 89.6% and 79.3% for those who did so as older infants. CONCLUSIONS In this large cohort of infants who received chronic peritoneal dialysis over more than two decades, the probability of survival after initiating CPD in the first year of life has significantly improved. There is no difference in the probability of death for neonates compared to older infants. However, the mortality rate remains substantial in association with multiple risk factors.
Collapse
Affiliation(s)
- Keia R. Sanderson
- University of North Carolina Department of Medicine-Nephrology, 7024 Burnett-Womack, CB 7155, Chapel Hill, NC 27599, USA
| | - Yichun Yu
- University of North Carolina Department of Medicine-Nephrology, 7024 Burnett-Womack, CB 7155, Chapel Hill, NC 27599, USA
| | - Hongying Dai
- Children’s Mercy Hospitals and Clinics, Kansas City, Kansas City, MO, USA
| | - Laurel K. Willig
- Children’s Mercy Hospitals and Clinics, Kansas City, Kansas City, MO, USA
| | - Bradley A. Warady
- Children’s Mercy Hospitals and Clinics, Kansas City, Kansas City, MO, USA
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Mehler K, Gottschalk I, Burgmaier K, Volland R, Büscher AK, Feldkötter M, Keller T, Weber LT, Kribs A, Habbig S. Prenatal parental decision-making and postnatal outcome in renal oligohydramnios. Pediatr Nephrol 2018; 33:651-659. [PMID: 29075889 DOI: 10.1007/s00467-017-3812-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/13/2017] [Accepted: 09/11/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Previous studies on renal oligohydramnios (ROH) report highly variable outcome and identify early onset of ROH and presence of extrarenal manifestations as predictors of adverse outcome in most cases. Data on termination of pregnancy (TOP) and associated parental decision-making processes are mostly missing, but context-sensitive for the interpretation of these findings. We provide here a comprehensive analysis on the diagnosis, prenatal decision-making and postnatal clinical course in all pregnancies with ROH at our medical centre over an 8-year period. METHODS We report retrospective chart review data on 103 consecutive pregnancies from 2008 to 2015 with a median follow-up of 554 days. RESULTS After ROH diagnosis, 38 families opted for TOP. This decision was associated with onset of ROH (p < 0.001), underlying renal disease (p = 0.001) and presence of extrarenal manifestations (p = 0.02). Eight infants died in utero and 8 cases were lost to follow-up. Of the 49 liveborn children, 11 received palliative and 38 underwent active care. Overall survival of the latter group was 84.2% (n = 32) corresponding to 31% of all pregnancies (32 out of 103) analysed. One third of the surviving infants needed renal replacement therapy during the first 6 weeks of life. CONCLUSIONS Over one third of pregnancies with ROH were terminated and the parental decision was based on risk factors associated with adverse outcome. Neonatal death was rare in the actively treated infants and the overall outcome promising. Our study illustrates that only careful analysis of the whole process, from prenatal diagnosis via parental decision-making to postnatal outcome, allows sensible interpretation of outcome data.
Collapse
Affiliation(s)
- Katrin Mehler
- Neonatology and Pediatric Intensive Care, Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Ingo Gottschalk
- Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital of Cologne, Cologne, Germany
| | - Kathrin Burgmaier
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Ruth Volland
- Pediatric Oncology and Hematology, Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Anja K Büscher
- Clinic for Pediatrics II, Pediatric Nephrology, University of Essen, Essen, Germany
| | | | - Titus Keller
- Neonatology and Pediatric Intensive Care, Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Lutz T Weber
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Angela Kribs
- Neonatology and Pediatric Intensive Care, Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Sandra Habbig
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany.
| |
Collapse
|
16
|
Hogan J, Bacchetta J, Charbit M, Roussey G, Novo R, Tsimaratos M, Terzic J, Ulinski T, Garnier A, Merieau E, Harambat J, Vrillon I, Dunand O, Morin D, Berard E, Nobili F, Couchoud C, Macher MA. Patient and transplant outcome in infants starting renal replacement therapy before 2 years of age. Nephrol Dial Transplant 2018; 33:1459-1465. [DOI: 10.1093/ndt/gfy040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/21/2018] [Indexed: 01/16/2023] Open
Affiliation(s)
- Julien Hogan
- Pediatric Nephrology Department, Robert Debré University Hospital, APHP, Paris, France
- Agence de la Biomédecine, La Plaine Saint-Denis, France
| | - Justine Bacchetta
- Pediatric Nephrology Department, HFME, Lyon University Hospital, Bron, France
| | - Marina Charbit
- Pediatric Nephrology Department, Necker University Hospital, APHP, Paris, France
| | - Gwenaelle Roussey
- Pediatric Nephrology Department, Nantes University Hospital, Nantes, France
| | - Robert Novo
- Pediatric Nephrology Department, Jeanne de Flandre University Hospital, Lille, France
| | - Michel Tsimaratos
- Pediatric Nephrology Department, La Timone University Hospital, Marseille, France
| | - Joelle Terzic
- Pediatric Nephrology Department, Hautepierre University Hospital, Strasbourg, France
| | - Tim Ulinski
- Pediatric Nephrology Department, Armand Trousseau University Hospital, APHP, Paris, France
| | - Arnaud Garnier
- Pediatric Nephrology Department, Children University Hospital, Toulouse, France
| | - Elodie Merieau
- Pediatric Nephrology Department, Tours University Hospital, Tours, France
| | - Jérôme Harambat
- Pediatric Nephrology Department, Pellegrin University Hospital, Bordeaux, France
| | - Isabelle Vrillon
- Pediatric Nephrology Department, Nancy University Hospital, Nancy, France
| | - Olivier Dunand
- Pediatric Nephrology Department, Felix Guyon University Hospital, Saint-Denis de la Réunion, France
| | - Denis Morin
- Pediatric Nephrology Department, Montpellier University Hospital, Montpellier, France
| | - Etienne Berard
- Pediatric Nephrology Department, Lenval University Hospital, Nice, France
| | - Francois Nobili
- Pediatric Nephrology Department, Saint Jacques University Hospital, Besançon, France
| | | | - Marie-Alice Macher
- Pediatric Nephrology Department, Robert Debré University Hospital, APHP, Paris, France
- Agence de la Biomédecine, La Plaine Saint-Denis, France
| | | |
Collapse
|
17
|
Willig L, Paquette E, Hester DM, Warady BA, Lantos JD. Parents Refusing Dialysis for a 3-Month-Old With Renal Failure. Pediatrics 2018; 141:peds.2017-2096. [PMID: 29490907 DOI: 10.1542/peds.2017-2096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 11/24/2022] Open
Abstract
A 3-month-old boy with failure to thrive was referred to a nephrology clinic after a diagnostic workup for failure to thrive revealed a serum urea nitrogen level of 95 mg/dL and creatinine level of 3.6 mg/dL. A renal ultrasound revealed marked bilateral hydronephrosis with little remaining renal cortex in either kidney. A voiding cystourethrogram revealed evidence of posterior urethral valves. The child had no evident comorbidities. Fulguration of the valves was successfully performed but did not lead to improvement in kidney function. The nephrologists recommended the initiation of dialysis with the hope that the child would be able to receive a kidney transplant in the future. After careful consideration, the family stated that they did not want this child to suffer with a lifetime of dialysis and transplant care. They were also concerned about the impact of this child's illness on their other 2 children and their family. They requested that their son be provided with palliative care only. Experts in nephrology, bioethics, and critical care discuss the ethical issues raised by this parental request.
Collapse
Affiliation(s)
| | - Erin Paquette
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois; and
| | - D Micah Hester
- Division of Medical Humanities, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - John D Lantos
- Children's Mercy Bioethics Center, Children's Mercy Kansas City, Kansas City, Missouri;
| |
Collapse
|
18
|
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
| |
Collapse
|
19
|
Abstract
Chronic irreversible kidney disease requiring dialysis is rare in the neonate. Many such neonates are diagnosed following antenatal ultrasound with congenital abnormalities of the kidneys and urinary tract. There is an increased incidence of prematurity and infants that are small for gestational age. Given the natural improvement in renal function that occurs in the neonatal period, some with extremely poor renal function may, with careful management of fluid and electrolytes, be kept off dialysis until the creatinine reaches a nadir when a definitive plan can be made. There is a very high incidence of comorbidity and this affects survival, which for those on dialysis is about 80% at five years. The multiple and complex ethical issues surrounding the management of these very young children are discussed.
Collapse
Affiliation(s)
- Lesley Rees
- Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, UK.
| |
Collapse
|
20
|
Twichell SA, Fiascone J, Gupta M, Prendergast M, Rodig N, Hansen A. A Regional Evaluation of Survival of Infants with End-Stage Renal Disease. Neonatology 2017; 112:73-79. [PMID: 28359062 PMCID: PMC5931204 DOI: 10.1159/000456647] [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: 09/08/2016] [Accepted: 01/16/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Information regarding morbidity and mortality of infants born with end-stage renal disease (ESRD) requiring dialysis early in life is critical to optimize patient care and better counsel families. OBJECTIVE We evaluated outcomes of infants born regionally with ESRD, and those within our broader catchment area referred for dialysis. STUDY DESIGN We screened deaths at 5 regional referral hospitals, identifying infants with ESRD who did not survive to transfer for dialysis. We also screened all infants <8 weeks old seen at our institution over a 7-year period with ESRD referred for dialysis. We evaluated factors associated with survival to dialysis and transplant. RESULTS We identified 14 infants from regional hospitals who died prior to transfer and 12 infants at our institution who were dialyzed. Because of the large burden of lethal comorbidities in our regional referral centers, overall survival was low, with 73% dying at birth hospitals. Amongst dialyzed infants, 42% survived to transplant. CONCLUSION This study is unusual in reporting survival of infants with ESRD including those not referred for dialysis, which yields an expectedly lower survival rate than reported by dialysis registries.
Collapse
Affiliation(s)
- Sarah A Twichell
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | | | | | | | | | | |
Collapse
|
21
|
Vidal E, van Stralen KJ, Chesnaye NC, Bonthuis M, Holmberg C, Zurowska A, Trivelli A, Da Silva JEE, Herthelius M, Adams B, Bjerre A, Jankauskiene A, Miteva P, Emirova K, Bayazit AK, Mache CJ, Sánchez-Moreno A, Harambat J, Groothoff JW, Jager KJ, Schaefer F, Verrina E. Infants Requiring Maintenance Dialysis: Outcomes of Hemodialysis and Peritoneal Dialysis. Am J Kidney Dis 2016; 69:617-625. [PMID: 27955924 DOI: 10.1053/j.ajkd.2016.09.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 09/01/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND The impact of different dialysis modalities on clinical outcomes has not been explored in young infants with chronic kidney failure. STUDY DESIGN Cohort study. SETTING & PARTICIPANTS Data were extracted from the ESPN/ERA-EDTA Registry. This analysis included 1,063 infants 12 months or younger who initiated dialysis therapy in 1991 to 2013. FACTOR Type of dialysis modality. OUTCOMES & MEASUREMENTS Differences between infants treated with peritoneal dialysis (PD) or hemodialysis (HD) in patient survival, technique survival, and access to kidney transplantation were examined using Cox regression analysis while adjusting for age at dialysis therapy initiation, sex, underlying kidney disease, and country of residence. RESULTS 917 infants initiated dialysis therapy on PD, and 146, on HD. Median age at dialysis therapy initiation was 4.5 (IQR, 0.7-7.9) months, and median body weight was 5.7 (IQR, 3.7-7.5) kg. Although the groups were homogeneous regarding age and sex, infants treated with PD more often had congenital anomalies of the kidney and urinary tract (CAKUT; 48% vs 27%), whereas those on HD therapy more frequently had metabolic disorders (12% vs 4%). Risk factors for death were younger age at dialysis therapy initiation (HR per each 1-month later initiation, 0.95; 95% CI, 0.90-0.97) and non-CAKUT cause of chronic kidney failure (HR, 1.49; 95% CI, 1.08-2.04). Mortality risk and likelihood of transplantation were equal in PD and HD patients, whereas HD patients had a higher risk for changing dialysis treatment (adjusted HR, 1.64; 95% CI, 1.17-2.31). LIMITATIONS Inability to control for unmeasured confounders not included in the Registry database and missing data (ie, comorbid conditions). Low statistical power because of relatively small number of participants. CONCLUSIONS Despite a widespread preconception that HD should be reserved for cases in which PD is not feasible, in Europe, we found 1 in 8 infants in need of maintenance dialysis to be initiated on HD therapy. Patient characteristics at dialysis therapy initiation, prospective survival, and time to transplantation were very similar for infants initiated on PD or HD therapy.
Collapse
Affiliation(s)
- Enrico Vidal
- Department of Women's and Children's Health, University-Hospital of Padova, Padova, Italy
| | | | | | - Marjolein Bonthuis
- ESPN/ERA-EDTA Registry, Academic Medical Center, Amsterdam, the Netherlands.
| | - Christer Holmberg
- Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - Aleksandra Zurowska
- Department of Nephrology and Hypertension for Children and Adolescents, Medical University of Gdańsk, Gdańsk, Poland
| | | | | | - Maria Herthelius
- Karolinska Institutet-Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Brigitte Adams
- Queen Fabiola Children's University Hospital, Brussels, Belgium
| | - Anna Bjerre
- Department of Pediatrics, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | | | - Polina Miteva
- University Hospital for Active Treatment of Pediatric Diseases, Sofia Medical University, Sofia, Bulgaria
| | - Khadizha Emirova
- Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Aysun K Bayazit
- Department of Pediatric Nephrology, Çukurova University, Adana, Turkey
| | | | | | - Jérôme Harambat
- Department of Pediatrics, Bordeaux University Hospital, Bordeaux, France
| | - Jaap W Groothoff
- Departmnent of Pediatric Nephrology, Emma Children's Hospital AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Kitty J Jager
- ESPN/ERA-EDTA Registry, Academic Medical Center, Amsterdam, the Netherlands; ERA-EDTA Registry, Academic Medical Center, Amsterdam, the Netherlands
| | - Franz Schaefer
- Division of Pediatric Nephrology, University of Heidelberg, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | | | | |
Collapse
|
22
|
Sakai T, Murakami Y, Okuda Y, Hamada R, Hamasaki Y, Ishikura K, Hataya H, Honda M. Prolonged respiratory disorder predicts adverse prognosis in infants with end-stage kidney disease. Pediatr Nephrol 2016; 31:2127-36. [PMID: 27271033 DOI: 10.1007/s00467-016-3430-5] [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: 12/25/2015] [Revised: 04/27/2016] [Accepted: 05/16/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Among comorbidities, pulmonary hypoplasia (PH) is known as a significant risk factor for mortality in infants with end-stage kidney disease (ESKD). However, the final outcomes of infants with both ESKD and PH are still not well defined, as the diagnosis modality, and definition of PH severity remain ambiguous. METHODS Children initiating peritoneal dialysis during infancy from 1990 to 2015 were followed until death, date of last contact, or the end of 2015. We examined the long-term outcome of children with congenital pulmonary disorders by studying infants with prolonged respiratory disorders of greater than 28 days duration after birth and evaluated risk factors for mortality. RESULTS Forty-six children were followed (median follow-up, 9.23 years), and classified as children without (n = 38; Group A) or with (n = 8; Group B) a prolonged respiratory disorder. Overall actuarial 5 year survival rate in this cohort was 79.5 %. The survival curve in Group B showed a significant decline compared with Group A. Prolonged respiratory disorder was significantly associated with mortality by multivariate analysis (hazard ratio, 8.32). CONCLUSIONS Infants who initiate peritoneal dialysis complicated by prolonged respiratory disorders have increased adverse risk factors for mortality; therefore, withholding aggressive treatment should be considered.
Collapse
Affiliation(s)
- Tomoyuki Sakai
- Department of Pediatrics, Shiga University of Medical Science, Tsukinowa, Seta, Otsu, Shiga, 520-2192, Japan.
| | - Yoshitaka Murakami
- Department of Medical Statistics, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yusuke Okuda
- Department of Pediatrics, Shiga University of Medical Science, Tsukinowa, Seta, Otsu, Shiga, 520-2192, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Pediatric Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| |
Collapse
|
23
|
Severe congenital anomalies of the kidney and urinary tract: epidemiology can inform ethical decision-making. J Perinatol 2016; 36:954-959. [PMID: 27467564 DOI: 10.1038/jp.2016.107] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/08/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Decision-making for pregnancies complicated by severe congenital anomalies of the kidneys and urinary tract (CAKUT) are ethically challenging, partly because the outcomes are not well studied. STUDY DESIGN Retrospective cohort study of severe cases of CAKUT over 14 years. RESULTS Seventy-one of the 108 cases could be completely analyzed. Forty-six percent (n=33) infants were live-born; one-third (n=11) survived to 12 months. Twice as many non-surviving infants received a trial of therapy vs comfort care only. Two-thirds of non-survivors who received a trial of therapy died within the first 9 h of life. Live-born infants faced morbidities such as pneumothorax and neonatal dialysis. CONCLUSIONS Over half of pregnancies complicated by severe CAKUT ended in termination or stillbirth, but one-third of live-born infants survived to 12 months and the majority of non-survivors died within hours. This may allay concerns about prolonged and futile intensive care for parents considering a trial of therapy.
Collapse
|
24
|
Wightman AG, Freeman MA. Update on Ethical Issues in Pediatric Dialysis: Has Pediatric Dialysis Become Morally Obligatory? Clin J Am Soc Nephrol 2016; 11:1456-1462. [PMID: 27037272 PMCID: PMC4974893 DOI: 10.2215/cjn.12741215] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Improvements in pediatric dialysis over the past 50 years have made the decision to proceed with dialysis straightforward for the majority of pediatric patients. For certain groups, however, such as children with multiple comorbid conditions, children and families with few social and economic resources, and neonates and infants, the decision of whether to proceed with dialysis remains much more controversial. In this review, we will examine the best available data regarding the outcomes of dialysis in these populations and analyze the important ethical considerations that should guide decisions regarding dialysis for these patients. We conclude that providers must continue to follow a nuanced and individualized approach in decision making for each child and to recognize that, regardless of the decision reached about dialysis, there is a continued duty to care for patients and families to maximize the remaining quality of their lives.
Collapse
Affiliation(s)
- Aaron G Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington; and
| | - Michael A Freeman
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| |
Collapse
|
25
|
Maizlin II, Shroyer MC, Perger L, Chen MK, Beierle EA, Martin CA, Anderson SA, Mortellaro VE, Rogers DA, Russell RT. Outcome assessment of renal replacement therapy in neonates. J Surg Res 2016; 204:34-8. [DOI: 10.1016/j.jss.2016.04.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 03/26/2016] [Accepted: 04/15/2016] [Indexed: 11/28/2022]
|
26
|
Rees L. The dilemmas surrounding the decision to start chronic dialysis in the neonate. Kidney Int 2016; 86:18-20. [PMID: 24978378 DOI: 10.1038/ki.2014.12] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In this issue of Kidney International, van Stralen et al. have analyzed four registries to look at outcomes over up to 5 years of neonates who commenced chronic dialysis. The work provides valuable data that will help pediatric teams to counsel families with such newborns. This Commentary addresses the dilemmas surrounding the decision to start chronic dialysis in the neonate.
Collapse
Affiliation(s)
- Lesley Rees
- Renal Office, Department of Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| |
Collapse
|
27
|
Carey WA, Martz KL, Warady BA. Outcome of Patients Initiating Chronic Peritoneal Dialysis During the First Year of Life. Pediatrics 2015; 136:e615-22. [PMID: 26304827 DOI: 10.1542/peds.2015-0980] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Among children with end-stage renal disease (ESRD), those who abstract initiated chronic dialysis during the first year of life historically were less likely to survive or receive a kidney transplant compared with those who initiated dialysis later in childhood.We hypothesized that recently treated infants have experienced improved outcomes. METHODS We queried the North American Pediatric Renal Trials and Collaborative Studies database, obtaining information on 628 children who initiated maintenance peritoneal dialysis for treatment of ESRD at ,1 year of age. We further subcategorized these children by age(neonates, #31 days and infants, 32–365 days) and date of dialysis initiation (past,1992–1999, and recent, 2000–2012). RESULTS Survival while on dialysis and overall survival were significantly better among neonates and infants in the recent cohort. Overall survival at 3 years after dialysis initiation was 78.6%and 84.6% among the recently treated neonates and infants, respectively. Neonates and infants in the recent cohort also were more likely to terminate dialysis for transplantation, and graft survival was improved among recently transplanted infants (3-year graft survival 92.1%). CONCLUSIONS Among children who initiate chronic peritoneal dialysis for treatment of ESRD in the first year of life, survival has improved in recent years. Graft survival also has improved for the subset of these patients who received a kidney transplant.
Collapse
Affiliation(s)
- William A. Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Bradley A. Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri
| |
Collapse
|
28
|
Wightman A, Kett J. Has neonatal dialysis become morally obligatory? Lessons from Baby Doe. Acta Paediatr 2015; 104:748-50. [PMID: 25982939 DOI: 10.1111/apa.13042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/12/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Aaron Wightman
- Division of Nephrology; Department of Pediatrics; University of Wisconsin School of Medicine and Public Health; Madison WI USA
| | - Jennifer Kett
- University of Washington School of Medicine; Seattle WA USA
| |
Collapse
|
29
|
Abstract
An increased emphasis has been placed on the early identification of chronic kidney disease (CKD) in the neonatal population, given the long-term health consequences that can accompany this diagnosis. The definition of CKD in neonates and young infants differs from that of children older than 2 years and, if severe, treatment may mandate dialysis with appropriate ethical considerations. Special attention must also be directed to optimal nutrition because of its impact on height, weight, and brain development in the young child experiencing impaired kidney function. There has been steady improvement in patient survival over the last decade.
Collapse
Affiliation(s)
- Joshua J Zaritsky
- Department of Pediatrics, Nemours/A.I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA.
| | - Bradley A Warady
- Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| |
Collapse
|
30
|
Evaluation of quality of life by young adult survivors of severe chronic kidney disease in infancy. Pediatr Nephrol 2014; 29:1387-93. [PMID: 24609826 DOI: 10.1007/s00467-014-2785-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 01/27/2014] [Accepted: 02/05/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The health related quality of life (HRQoL) of young adults treated for chronic kidney disease (CKD) stage 4/5 from infancy is unknown. METHODS A HRQoL questionnaire was sent to all 41 patients aged >16 years from a previously characterised cohort of infants with CKD stage 4/5 born between 1986 and 1997. Patient scores were compared with a previously reported cohort of patients who needed renal replacement therapy (RRT) in mid childhood and in the normal population. RESULTS All patients (11 women) completed the questionnaire at a median (range) age of 19.2 (16.3-23.4) years. At the time of the survey, 5 (12.5 %) were on dialysis, 35 (85.5 %) had a functioning kidney transplant, one (2 %) was still conservatively treated and 22 (54 %) had comorbidities; 68 % were either studying or in paid employment, with 17 % actively seeking employment. Although patients described a lower HRQoL than a healthy, age-matched UK group, in some aspects, scores were comparable with patients needing RRT in later childhood. Lower scores were associated with comorbidities, dialysis at last follow-up, more than one treatment modality change and short stature. CONCLUSIONS Our survey demonstrates very encouraging results for long-term HRQoL of infants with severe CKD and highlights the negative impact of comorbidities. These data will help clinicians to counsel and inform families.
Collapse
|
31
|
|
32
|
Survival and clinical outcomes of children starting renal replacement therapy in the neonatal period. Kidney Int 2014; 86:168-74. [DOI: 10.1038/ki.2013.561] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 11/20/2013] [Accepted: 11/21/2013] [Indexed: 01/06/2023]
|
33
|
Wightman AG, Oron AP, Symons JM, Flynn JT. Pediatric nephrologists' beliefs regarding randomized controlled trials. J Investig Med 2014; 62:84-7. [PMID: 24379023 DOI: 10.2310/jim.0000000000000019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pediatrics and pediatric nephrology lag behind adult medicine in producing randomized controlled trials (RCTs). Physician attitudes have been shown to play a significant role in RCT enrollment. METHODS We surveyed members of the American Society of Pediatric Nephrology regarding beliefs about RCTs and factors influencing decisions to recommend RCT enrollment. Regression analyses were used to identify the effects of variables on an aggregate score summarizing attitudes toward RCTs. RESULTS One hundred thirty replies were received. Sixty-six percent had enrolled patients in RCTs. Respondents in practice for more than 15 years were more likely to have recruited a patient to an RCT than those in practice for less than 5 years. Respondents were more willing to recommend RCT enrollment if the study was multicenter, patients were sicker or had a poorer prognosis, or if the parent or participant received a financial incentive versus the provider. In multiple regression analysis, history of enrolling patients in an RCT was the only significant predictor of higher aggregate RCT-friendly attitude. CONCLUSIONS Many pediatric nephrologists have never enrolled a patient in an RCT, particularly those in practice for less than 5 years. Respondents who have not enrolled patients in RCTs have a less RCT-friendly attitude. Provision of improved training and resources might increase participation of junior providers in RCTs.
Collapse
Affiliation(s)
- Aaron G Wightman
- From the *Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine; †Division of Nephrology, Seattle Children's Hospital; and ‡Core for Biomedical Statistics, Seattle Children's Hospital, Seattle, WA
| | | | | | | |
Collapse
|
34
|
Lantos JD, Warady BA. The evolving ethics of infant dialysis. Pediatr Nephrol 2013; 28:1943-7. [PMID: 23131864 PMCID: PMC3626731 DOI: 10.1007/s00467-012-2351-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/02/2012] [Accepted: 10/03/2012] [Indexed: 11/28/2022]
Abstract
In this paper, we review ethical issues that arise when families and doctors face clinical decisions about renal replacement therapy for an infant with end-stage renal disease (ESRD). Over the last 20 years, many centers have begun to routinely offer renal replacement therapy. However, doctors and nurses both continue to view such therapy as optional, rather than mandatory. We speculate that the burdens of therapy on the family, and the uncertainties about satisfactory outcomes have led to a situation in which renal replacement therapy remains desirable, but non-obligatory. We discuss the reasons why this is likely to remain so, and the ways in which renal replacement therapy for infants with ESRD is similar to, or different from, other clinical situations in pediatrics. Finally, we propose a research agenda to answer questions that are crucial to making good ethical decisions about infant dialysis.
Collapse
Affiliation(s)
- John D Lantos
- Children's Mercy Hospital, University of Missouri, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | | |
Collapse
|
35
|
Johnson RJ, Warady BA. Long-term neurocognitive outcomes of patients with end-stage renal disease during infancy. Pediatr Nephrol 2013; 28:1283-91. [PMID: 23553044 DOI: 10.1007/s00467-013-2458-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Revised: 02/27/2013] [Accepted: 03/01/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND End-stage renal disease (ESRD) during infancy has been associated with poor short-term neurocognitive outcomes. Limited information exists regarding long-term outcomes. METHODS Neurocognitive outcomes for 12 patients diagnosed with ESRD during the first 16 months of life were assessed. Nine patients (mean age: 11 years) were compared to their healthy siblings (mean age: 10 years) on measures of intellectual and executive functioning, memory, and academic achievement using paired-samples t tests. RESULTS Patients' Full Scale IQ (FSIQ) scores (M = 78, SD = 16.1) were significantly lower than sibling controls (M = 94, SD = 18.9; p < 0.03). For patients, FSIQ negatively correlated with total months on dialysis (r = -0.6, p < 0.04), as did WISC-IV Processing Speed (r = -0.6, p < 0.05). Patients' scores on the Metacognition Index of the BRIEF (M = 61.4, SD = 16.3) were significantly higher (indicating greater risk for dysfunction) than siblings (M = 46.7, SD = 6.4; p < 0.04). Patients' scores (M = 84, SD = 19) on the WIAT-II-A Total Achievement were significantly lower than siblings (M = 103, SD = 20, p < 0.01). Younger age at transplant was associated with higher scores on measures of Processing Speed (r = -0.7, p < 0.05), as well as higher scores on measures of executive functioning, memory, and academic achievement. CONCLUSIONS In summary, patients diagnosed with ESRD as infants had intellectual and metacognitive functioning significantly lower than sibling controls. Fewer months on dialysis and younger age at transplant were associated with better outcomes.
Collapse
Affiliation(s)
- Rebecca J Johnson
- Developmental & Behavioral Sciences, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64113, USA.
| | | |
Collapse
|
36
|
Alexander RT, Foster BJ, Tonelli MA, Soo A, Nettel-Aguirre A, Hemmelgarn BR, Samuel SM. Survival and transplantation outcomes of children less than 2 years of age with end-stage renal disease. Pediatr Nephrol 2012; 27:1975-83. [PMID: 22673972 DOI: 10.1007/s00467-012-2195-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 04/04/2012] [Accepted: 04/05/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Young children with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT) have traditionally experienced high rates of morbidity and mortality; however, detailed long-term follow-up data is limited. METHODS Using a population-based retrospective cohort with data from a national organ failure registry and administrative data from Canada's universal health care system, we analysed the outcomes of 87 children starting RRT (before age 2 years) and followed them until death or date of last contact [median follow-up 4.7 years, interquartile range (IQR) 1.4-9.8). We assessed secular trends in survival and the influence of: (1) age at start of RRT and (2) etiology of ESRD with survival and time to transplantation. RESULTS Patients were mostly male (69.0 %) with ESRD predominantly due to renal malformations (54.0 %). Peritoneal dialysis was the most common initial RRT (83.9 %). Fifty-seven (65.5 %) children received a renal transplant (median age at first transplant: 2.7 years, IQR 2.0-3.3). During 490 patient-years of follow-up, there were 23 (26.4 %) deaths, of which 22 occurred in patients who had not received a transplant. Mortality was greater for patients commencing dialysis between 1992 and 1999 and among the youngest children starting RRT (0-3 months). Children with ESRD secondary to renal malformations had better survival than those with ESRD due to other causes. Among the transplanted patients, all but one survived to the end of the observation period. CONCLUSION Children who start RRT before 3 months of age have a high risk of mortality. Among our paediatric patient cohort, mortality rates were much lower among children who had received a renal transplant.
Collapse
Affiliation(s)
- R Todd Alexander
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
| | | | | | | | | | | | | | | |
Collapse
|
37
|
Abstract
Although end-stage renal disease is rare in infants and young children, its development can be associated with significant morbidity and mortality and only through the provision of experienced, multidisciplinary care can a favorable outcome be anticipated. Peritoneal dialysis is the renal replacement modality of choice for this age group and serves as an essential bridge until successful renal transplantation can occur. In this review, we discuss the practice of peritoneal dialysis in infants including the unique ethical and technical considerations facing pediatric nephrologists and caregivers. In addition, we review current guidelines concerning nutrition, growth, and adequacy, as well as the literature on complications and outcomes.
Collapse
Affiliation(s)
- Joshua Zaritsky
- Department of Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | | |
Collapse
|