Search

There have been no studies in pediatric dialysis patients to evaluate the impact of higher estimated glomerular filtration rate (eGFR) at dialysis initiation on clinical outcomes. Baseline clinical and demographic information was collected for children aged 1-18 years undergoing incident dialysis from 1995-2002 within the United States Renal Data System. Baseline eGFRs calculated by the Schwartz formula were categorized as high (>15 ml/min/1.73 [m.sup.2]) or low ( Keywords Residual kidney function * End-stage renal disease * Pediatric * Morbidity * Hospitalization, Introduction Dialysis initiation in children is typically based on clinical manifestations of end-stage renal disease (ESRD) or complications such as inadequate growth or poor nutrition. Standard practice is that children [...]

Background: Medical provider assessment of nonadherence is known to be inaccurate. Researchers have suggested using a multimethod assessment approach; however, no study has demonstrated how to integrate different measures to improve accuracy. This study aimed to determine if using additional measures improves the accurate identification of nonadherence beyond provider assessment alone.Methods: Eighty-seven adolescents and young adults (AYAs), age 11-19 years, with chronic kidney disease (CKD) [stage 1-5/end-stage renal disease (ESRD)] and prescribed antihypertensive medication, their caregivers, and 17 medical providers participated in the multisite study. Five adherence measures were obtained: provider report, AYA report, caregiver report, electronic medication monitoring (MEMS), and pharmacy refill data [medication possession ratio (MPR)]. Concordance was calculated using kappa statistic. Sensitivity, specificity, positive predictive power, and negative predictive power were calculated using MEMS as the criterion for measuring adherence.Results: There was poor to fair concordance (kappas = 0.12-0.54), with 35-61% of AYAs classified as nonadherent depending on the measure. While both providers and MEMS classified 35% of the AYAs as nonadherent, sensitivity (0.57) and specificity (0.77) demonstrated poor agreement between the two measures on identifying which AYAs were nonadherent. Combining provider report of nonadherence and MPR < 75% resulted in the highest sensitivity for identifying nonadherence (0.90) and negative predictive power (0.88).Conclusions: Nonadherence is prevalent in AYAs with CKD. Providers inaccurately identify nonadherence, leading to missed opportunities to intervene. Our study demonstrates the benefit to utilizing a multimethod approach to identify nonadherence in patients with chronic disease, an essential first step to reduce nonadherence. [ABSTRACT FROM AUTHOR]

Objective: To investigate longitudinal associations of health beliefs, which included self-efficacy, outcome expectancies, and perceived barriers, and demographic risk factors (i.e., age, gender, race, and family income) with antihypertensive medication adherence in adolescents with chronic kidney disease (CKD) over 24 months.Method: The sample included 114 adolescents (M age = 15.03 years, SD = 2.44) diagnosed with CKD. Adolescents reported their self-efficacy for taking medications, medication outcome expectancies, and barriers to adherence at baseline and 12 and 24 months after baseline. Antihypertensive medication adherence was assessed via electronic monitoring for 2 weeks at baseline and 6, 12, 18, and 24 months after baseline.Results: Adherence increased and then decreased over the 2-year study period (inverted U-shape). Self-efficacy, outcome expectancies, and barriers did not change over time. Older adolescent age, female gender, African American race, <$50,000 annual family income, and public health insurance were associated with lower adherence. However, family income was the primary demographic risk factor that predicted adherence over time (≥$50,000 annual family income was longitudinally associated with higher adherence). Higher self-efficacy and more positive and less negative outcome expectancies across time were also associated with higher antihypertensive medication adherence across time.Conclusions: Clinical interventions should be developed to target medication self-efficacy and outcome expectancies to improve long-term antihypertensive medication adherence in adolescents with CKD. Family income may be considered when conceptualizing contextual factors that likely contribute to adolescents' consistent challenges with medication adherence over time. [ABSTRACT FROM AUTHOR]

Published data on the comparative achievement of The Kidney Disease Dialysis Outcome Quality Initative (KDOQI) recommended clinical performance targets between children and young adults on dialysis are scarce. To characterize the achievement of KDOQI targets among children (<18 years) and young adults (18-24 years) with prevalent end stage renal disease (ESRD), we performed a cross-sectional analysis of data collected by the Mid-Atlantic Renal Coalition, in conjunction with the 2007 and 2008 ESRD Clinical Performance Measures Projects. Data on all enrolled pediatric dialysis patients, categorized into three age groups (0-8, 9-12, 13-17 years), and on a random sample of 5% of patients ≥18 years in ESRD Network 5 were examined for two study periods: hemodialysis (HD) data were collected from October to December 2006 and from October to December 2007 and peritoneal dialysis (PD) data were collected from October 2006 to March 2007 and from October 2007 to March 2008. In total, 114 unique patients were enrolled the study, of whom 41.2% (47/114) were on HD and 58.8% (67/114) on PD. Compared to the pediatric patients, young adults were less likely to achieve the KDOQI recommended serum phosphorus levels and serum calcium × phosphorus product values, with less than one-quarter demonstrating values at or below each goal. Multivariate analysis revealed that both young adults and 13- to 17-year-olds were less likely to achieve target values for phosphorus [young adults: odds ratio (OR) 0.04, 95% confidence interval (95% CI) 0.01-0.19, p < 0.001; 13- to 17-year-olds: OR 0.17, 95% CI 0.04-0.77, p = 0.02] and calcium × phosphorus product (young adults: OR 0.01, 95% CI 0.002-0.09, p < 0.001; 13- to 17-year-olds: OR 0.09, 95% CI 0.02-0.56, p = 0.01) than younger children. In summary, there are significant differences in clinical indices between pediatric and young adult ESRD patients. [ABSTRACT FROM AUTHOR]

Urologic disorders are the most common cause of chronic kidney disease in children. To determine whether children with urologic etiology of end-stage renal disease (ESRD) fare better than children with ESRD from other causes while on dialysis, we conducted a cross-sectional study of children <18 years receiving peritoneal and hemodialysis in the United States using data from the Centers for Medicare & Medicaid Services 2005 ESRD CPM Project. We compared baseline demographics and the study groups. In multivariate logistic regression analysis of 1,286 subjects, we assessed whether children with urologic disorders had a higher odds of meeting adult KDOQI targets for hemoglobin levels ≥11 g/dl and albumin ≥3.5 BCG/3.2 BCP g/dl. We conducted a subset analysis of 1,136 patients to examine the impact of erythropoietin on hemoglobin targets. Our results did not reveal differences in achievement of adult hemoglobin targets (adjusted OR: 1.27; p value 0.09; CI: 0.97-1.66) or in the subset analysis with erythropoietin (adjusted OR: 1.32; p value 0.06; CI: 0.98-1.78) or albumin targets (adjusted OR: 1.22; p value 0.21; CI: 0.90-1.65) in adjusted analyses. Due to our study's limitations, it is difficult to determine whether this may result from treatment prior to dialysis initiation or treatment effect of dialysis rather than underlying diagnosis. [ABSTRACT FROM AUTHOR]

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that can cause significant kidney disease. Our goal was to assess the relative mortality risk associated with SLE in pediatric and adult populations with end-stage renal disease (ESRD) maintained on hemodialysis (HD). We performed Kaplan-Meier survival analysis from data collected by the United States Renal Data System (USRDS) in strata of pediatric and adult patients. This file includes data on all Medicare-reimbursed renal replacement patients. Cox proportional hazard models were used to assess mortality after adjusting for race and gender. Subjects were censored at transplantation or at end of follow-up. Pediatric patients with ESRD secondary to SLE had a 2-fold increased risk of death compared with other pediatric patients with ESRD (hazard ratio [HR]: 2.4, 95% confidence interval [CI]: 1.5-3.7). Adult patients with ESRD secondary to SLE were also at increased risk of death compared with other adult patients (HR: 1.7, 95% CI: 1.2-2.7). The most common causes of death in both pediatric and adult patients with SLE were cardiovascular disease and cardiac arrest. Our study demonstrates that there is a significant increase in mortality secondary to cardiovascular disease in pediatric and adult patients with ESRD secondary to SLE. Patients with ESRD secondary to SLE may need aggressive monitoring for traditional risk factors for atherosclerosis and the diagnosis of SLE alone may be an independent risk factor for death in patients with ESRD. [ABSTRACT FROM AUTHOR]

Ethnicity information was collected for all pediatric peritoneal dialysis patients from the End-Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project for the period October 2004 through March 2005. Associations between intermediate outcomes and Hispanic ethnicity were determined. Thirty percent (207/696) of patients in the final cohort were Hispanic, 24% (165/696) non-Hispanic black, and 46% (324/696) non-Hispanic white. Hispanics were more likely to be female, older, and have a lower mean height standard deviation score (SDS). There were no significant differences among ethnic/racial groups regarding clearance parameters. More Hispanics had a mean hemoglobin ≥ 11 g/dl compared with non-Hispanic blacks and non-Hispanic whites (77% vs. 55% and 70%, P < 0.0001). More Hispanics compared with non-Hispanic blacks and non-Hispanic whites had a mean serum albumin ≥ 4.0/3.7 g/dl [bromcresol green/bromcresol purple laboratory method (BCG/BCP)] (50% vs. 24% and 27%, respectively, P < 0.0001). In multivariate analyses, Hispanics remained significantly more likely to achieve a mean serum albumin ≥ 4.0/3.7 g/dl (BCG/BCP) compared with non-Hispanic whites (referent) and were as likely to achieve clearance and hemoglobin targets. Pediatric Hispanic peritoneal dialysis patients experience equivalent or better intermediate outcomes of dialytic care compared with non-Hispanics. Further study is needed to understand associations of Hispanic ethnicity with outcomes such as hospitalization, transplantation, and mortality. [ABSTRACT FROM AUTHOR]

Current formulas that estimate the delivered dose of hemodialysis rely upon pre- and post-treatment blood urea nitrogen (BUN) concentrations for calculation. Single-pool kinetic modeling (spKt/V) uses a convenient 30-s post-dialysis BUN sample but does not take urea rebound into account. Double-pool modeling (eKt/V) uses an equilibrated BUN (eqBUN) and is the best reflection of the true urea mass removed by hemodialysis but is inconvenient for patients and costly to the dialysis unit to wait to obtain an eqBUN sample. We compared simple spKt/V and eKt/V estimation formulas using data obtained from the Centers for Medicare & Medicaid Services (CMS) End Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project to determine how frequently these two results would lead to different prescription management. We set an expected difference Kt/V (spKt/V−eKt/V) of 0.20 based on results of the Hemodialysis (HEMO) Study; 1,513 paired spKt/V and estimated eKt/V results were available for comparison. For patients with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) ( n=720), mean spKt/V and estimated eKt/V were 1.62±0.30 and 1.37±0.26, respectively. For patients with a catheter ( n=793), mean spKt/V and estimated eKt/V were 1.53±0.32 and 1.33±0.29, respectively. Examination of the different spKt/V and estimated eKt/V pairings revealed a greater adequacy discordance rate between a 0.20 difference in spKt/V and estimated eKt/V at higher Kt/V values, but Kt/V discordance rates only varied from 0.3 to 5.5% depending on the paired Kt/V values used. [ABSTRACT FROM AUTHOR]

End-stage renal disease (ESRD) causes growth retardation in children, and poor growth has been linked to worse outcomes. Recombinant human growth hormone (rhGH) can increase growth velocity and final adult height in pediatric ESRD patients. We aimed to identify clinical predictors of short stature (height standard deviation score (Ht SDS) <−1.88) and rhGH use in short stature pediatric hemodialysis patients. In 2002, the Centers for Medicare & Medicaid Services (CMS) Clinical Performances Measures (CPM) ESRD Project collected demographic, clinical and laboratory data as well as rhGH use on all in-center hemodialysis patients in the US aged <18 years. The odds ratios (OR) of short stature and rhGH use for individual predictors were determined by multivariate logistic regression modeling. Six-hundred and fifty-one (92%) of 710 eligible patients were included for analysis. Of these, 266 (41%) had Ht SDS <−1.88. After adjustment, short stature was predicted by congenital / urologic causes of ESRD ((OR 5.4; 95% confidence interval [CI], 2.1–13.8; p <0.001) in patients aged 10–14 years; (OR 2.8; 95% CI, 1.5–5.4; p<0.01) in patients aged 15–18 years) and increasing years on dialysis ((OR 1.2; 95% CI, 1.1–1.4; p <0.01) in patients aged 10–14 years; (OR 1.2; 95% CI, 1.1–1.4; p <0.001) in patients aged 15–18 years). Of 266 short stature patients, 214 (80.5%) had data on rhGH use. Of these, 80 (37%) had been prescribed rhGH. After adjustment, use of rhGH in short-stature patients was predicted by white race (OR 2.1; 95% CI, 1.1–4.0; p <0.05), increasing years on dialysis (OR 1.13; 95% CI, 1.05–1.22; p <0.01) and patients with BMI <16.6 kg/m2 (OR 3.1; 95% CI, 1.2–8.4; p <0.05). Increasing age and level of intact parathyroid hormone were not associated with rhGH use among short stature patients. A significant proportion of pediatric hemodialysis patients have short stature. The majority of short-stature patients are not receiving rhGH. Patients with short stature who are white, have longer durations on dialysis and have lower BMI are more likely to receive rhGH. [ABSTRACT FROM AUTHOR]

The Centers for Medicare & Medicaid Services’ (CMS) end-stage renal disease (ESRD) Clinical Performance Measures (CPM) Project has collected data on all adolescent hemodialysis patients since 2000. Thus, by 2002 data were available on all adolescents on hemodialysis in the USA for 3 consecutive years. Possible associations between clinical parameters and linear growth in this cohort were evaluated. Ninety-four adolescents were on hemodialysis for the 3 study years. The mean height standard deviation score (ht SDS) fell from −1.97 to −2.36 over the 3 study years. Compared with patients with ht SDS ≥−1.88, patients with ht SDS <−1.88 in the 2002 study year ( n =53) were more likely to be male (66% vs 44%, p <0.05), on dialysis longer (6.9±4.5 years vs 4.1±2.3 years, p <0.001), and had lower height SDS in the 2000 study year (−2.90±1.31 vs −0.772±1.10, p <0.001). Patients with a ht SDS <−1.88 had a lower mean hemoglobin (11.4±1.6 g/dl vs 12.0±1.1 g/dl, p <0.05), but there were no differences in other clinical parameters. Among patients with ht SDS <−1.88, 38.8% ( n =20) were prescribed recombinant human growth hormone (rhGH) in the 2002 study year. There were no differences in demographic or clinical parameters between rhGH treated and untreated patients. Many adolescents who remain on hemodialysis have poor linear growth. Further evaluation is needed to delineate contributory factors and the possible underutilization of rhGH. [ABSTRACT FROM AUTHOR]

To identify demographic and clinical characteristics associated with failure to achieve hemoglobin levels ≥11 g/dl in prevalent pediatric end-stage renal disease (ESRD) patients, a cross-sectional analysis of patient clinical data collected by the Mid-Atlantic Renal Coalition in conjunction with the 2000 and 2001 ESRD Clinical Performance Measures Projects was performed. Ninety-nine patients (mean age 12.6 years, SD 5.4) contributed 119 observations to this analysis. Of patients on hemodialysis, 36.6% were anemic, and 39.5% of patients on peritoneal dialysis (PD) were anemic. Associations between age, race, gender, assigned cause of ESRD, Kt/V, transferrin saturation, time on dialysis, serum albumin, dialysis modality, and the achievement of target hemoglobin were examined. In multivariate logistic regression analyses examining age, dialysis modality, time on dialysis, and serum albumin, each 1-year increase in age was significantly associated with hemoglobin levels <11 g/dl [adjusted odds ratio (OR) 1.18, 95% confidence interval (CI) 1.06–1.32] and PD patients were more than twice as likely to have hemoglobin levels <11 g/dl (adjusted OR 2.62, 95% CI 0.98–7.04). Patients on dialysis for 6 months or more were less likely to be anemic than those on dialysis for less than 6 months (adjusted OR 0.39, 95% CI 0.16–0.99). In conclusion, increasing age, dialysis for less than 6 months, and treatment with PD were predictive of anemia in this population. [ABSTRACT FROM AUTHOR]

Thrombocytopenia absent radius (TAR) syndrome, associated with small, echogenic kidneys and subsequent end-stage renal disease, was seen in a full-term newborn. In this infant, renal insufficiency may have increased the known risk of bleeding that is associated with TAR syndrome. Renal abnormalities and dysfunction are unusual in TAR syndrome. When they are present, however, treatment with frequent transfusions and early dialysis may he necessary to prevent serious and life-threatening hemorrhagic episodes. [ABSTRACT FROM AUTHOR]

Objective: Among adolescents and young adults (AYAs) with chronic illness, effective provider communication is essential for patient-centered care during a sensitive developmental period. However, communication in chronic illness care for AYAs is not well studied. Our objectives were to describe the provider communication skills in pediatric chronic kidney disease (CKD) care visits; and determine if communication skills differ by AYA characteristics.Methods: We adapted a global consultation rating system for pediatric subspecialty care using audiotaped clinic encounters of 18 pediatric nephrologists with 99 AYAs (age M(SD) = 14.9(2.6)) with CKD stages 1-5 and 96 caregivers. We hypothesized that provider communication skills would differ by AYA characteristics (age, gender, and race).Results: The strongest provider skills included initiating the session and developing rapport; lowest rated skills were asking patient's perspective and checking understanding. Communication scores did not consistently differ by AYA age or race, but were rated higher with female AYAs in several domains (ps<0.05).Conclusions: Pediatric providers generally had adequate or good communication scores with AYAs, but improvement in certain skills, particularly with male AYAs, may further support patient-centered care.Practice Implications: To achieve consistent, patient-centered communication with AYAs, an observation-based global assessment may identify areas for provider improvement. [ABSTRACT FROM AUTHOR]

ABSTRACT. Context. Renal transplantation is the treatment of choice for pediatric patients with end-stage renal disease (ESRD). Black patients wait longer for kidney transplants than do white patients. Objective. To determine whether the increased time to transplantation for black pediatric patients is attributable not only to a shortage of suitable donor organs, but also to racial differences in the time from a child's first treatment for ESRD until activation on the cadaveric kidney transplant waitlist. Design. National longitudinal cohort study. Setting. US Medicare-eligible, pediatric ESRD population. Patients. Children and adolescents is less than or equal to 19 years old at the time of their first dialysis for ESRD between 1988 and 1993, followed through 1996. Patients who received living donor renal transplants were excluded from study. Main Outcome Measures. Time from first dialysis for ESRD until activation on the kidney transplant waiting list, relative hazard of activation on the waiting list for black compared with white pediatric patients. Results. Comparisons of the time from first dialysis for ESRD to waitlisting among the 2162 white (60.7%) and 1122 black (31.5%) patients studied using survival analysis revealed that blacks were less likely to be waitlisted at any given time in follow-up. In multivariate analysis, even after controlling for patient age, gender, socioeconomic status, geographic region, incident year of renal failure, and cause of ESRD, blacks were 12% less likely to be waitlisted than were whites at any point in time (relative hazard: .88: 95% confidence interval: .79-.97). Conclusions. Racial disparities in access to the renal transplant waiting list exist in pediatrics. Whether these disparities are attributable to differences in time of presentation to a nephrologist, physician bias in identification of transplant candidates, or patient preferences warrants further study. Pediatrics 2000;106:756-761; children, race, renal ... [ABSTRACT FROM AUTHOR]