Kidney Outcomes for First Nations Children Lalji, Rowena; Sinka, Victoria; Craig, Jonathan C.
Kidney international reports,
06/2021, Letnik:
6, Številka:
6
Journal Article
Paediatric hypertension predisposes to hypertension and cardiovascular disease in adult life. Despite clear guidelines, there remains a lack of screening. Diagnosis remains challenging given the high ...rate of false-positive high blood pressure (BP) readings at a single visit; thus, multiple visits are required to confirm the diagnosis. Depending on the normative data sets used, hypertension in overweight and obese children can be underestimated by up to 20%. Specific BP targets are required for subgroups such as adolescents, children with chronic kidney disease (CKD) and type 1 diabetes. High dietary salt intake is a risk factor for cardiovascular disease. Given the rise in processed food consumption, children in developed nations are likely to benefit from salt restriction at a population-based level.
Children requiring long-term kidney replacement therapy are a “rare disease” cohort. While the basic technical requirements for hemodialysis (HD) are similar in children and adults, key aspects of ...the child’s cardiovascular anatomy and hemodynamic specifications must be considered. In this article, we describe the technical requirements for long-term HD therapy for children and the devices that are currently available around the world. We highlight the characteristics and major technical shortcomings of permanent central venous catheters, dialyzers, dialysis machines, and software available to clinicians who care for children. We show that currently available HD machines are not equipped with appropriately small circuits and sensitive control mechanisms to perform safe and effective HD in the youngest patients. Manufacturers limit their liability, and health regulatory agencies permit the use of devices, only in children according to the manufacturers’ pre-specified weight limitations. Although registries show that 6–23% of children starting long-term HD weigh less than 15 kg, currently, there is only one long-term HD device that is cleared for use in children weighing 10 to 15 kg and none is available and labelled for use in children weighing less than 10 kg anywhere in the world. Thus, many children are being treated “off-label” and are subject to interventions delivered by medical devices that lack pediatric safety and efficacy data. Moreover, recent improvements in dialysis technology offered to adult patients are denied to most children. We, in turn, advocate for concerted action by pediatric nephrologists, industry, and health regulatory agencies to increase the development of dedicated HD machines and equipment for children.
Background
Data on sex‐based disparities in children with kidney failure and outcomes after kidney transplantation are relatively sparse. This study examined the association between sex differences ...and the odds of receiving a pre‐emptive living donor kidney transplantation, and post‐transplant outcomes in children and adolescents.
Methods
We studied all patients (aged <20 years) who commenced kidney replacement therapy (KRT) between 2002 and 2017 using data from the ANZDATA Registry. Factors associated with graft loss and acute rejection after transplantation were assessed using multivariable Cox regression model. Differences in the odds of receiving a pre‐emptive live donor transplant between sexes were assessed using adjusted logistic regression.
Results
Of the 757 children transplanted during the study period, 497 (65.7%) received a live donor kidney (163, 21.5% pre‐emptive). In total, 168 (22.2%) patients experienced graft loss and 213 (28.1%) patients experienced a first episode of acute rejection during the median follow‐up period of 6.9 years (IQR 3.5–11.5 years). There were no differences in the rates of graft loss or acute rejection by sex. Compared with boys, the adjusted hazard ratios (aHR) (95% confidence interval) for graft loss and acute rejection in girls were 0.97 (0.71–1.33) and 1.09 (0.82–1.44), respectively. Among children who received living donor kidney transplants, there were no sex differences in the odds of receiving a pre‐emptive transplant (adjusted odds ratio (aOR) 0.90 (95% CI 0.56–1.45)).
Conclusions
No sex differences were observed in the odds of receiving a pre‐emptive living donor kidney transplant or outcomes after kidney transplantation.
The incidence and outcomes of kidney replacement therapy (KRT) have been well-studied in adults, but much less so in children. This study aimed to investigate the epidemiology and outcomes of KRT in ...children in Australia and New Zealand from 2000 to 2020.
Children aged <18 years initiating KRT in Australia and New Zealand between January 1, 2000 and December 31, 2020 and reported to the Australia and New Zealand Dialysis and Transplant Registry were included. Patient survival, technique-survival, and graft survival were analyzed by Cox regression analyses.
Overall, 1058 children (median interquartile range (IQR) age 11 5–15 years, 41% female, 66% White) were followed-up with for a median period of 12.3 years. First KRT modalities were peritoneal dialysis (PD; 48%), hemodialysis (HD; 34%), and kidney transplantation (KT; 18%). Pre-emptive KT incidence was highest in Caucasian children (80.4%) and lowest in the Indigenous population (3.2%). There was no difference in 5-year patient survival rates between 2011 and 2020 (96.9%, 95% confidence interval CI 93.8–98.4) and the preceding decade, 2000–2010 (94.5%, 95% CI 90.4–96.8) (P = 0.79). There was no difference in 5-year death-censored technique survival between 2011 and 2020 (51.2%, 95% CI 39.1–62) and 2000–2010 (48.8%, 95% CI 40.5–56.6) (P = 0.27). However, 5-year derath-censored graft survival was significantly higher in 2011–2020 (88.4%, 95% CI 84.6–91.4) than in 2000–2010 (84.3%, 95% CI 80.4–87.5) (P < 0.001).
PD is the most commonly prescribed KRT modality for children in Australia and New Zealand. Patient-survival, technique-survival, and graft survival rates are excellent and graft survival has improved over the last 2 decades.
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