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Background: Comprehensive training of children on peritoneal dialysis (PD) and their caregivers is crucial to minimize peritonitis risk. Few studies have evaluated the impact of training on infection, so many published recommendations rely on expert opinion. This study uses data from the SCOPE collaborative to examine the impact of compliance with 4 components of PD training on the risk for peritonitis., Methods: A retrospective cohort study of children enrolled in the SCOPE collaborative between 2011 and 2021 who received training prior to initiating PD. Compliance with 4 training components were assessed: performance of a home visit, 1:1 training, delaying training ≥ 10 days after PD catheter insertion and average individual training session length ≤ 3 h. Univariate and multivariable generalized linear mixed modeling were used to assess relationships between peritonitis ≤ 90 days after PD training and median days to peritonitis and compliance with each component as well as all-or-none compliance., Results: Among 1450 trainings, 51.7% had median session length ≤ 3 h, 67.1% delayed training ≥ 10 days after catheter insertion, 74.3% had a home visit and 94.6% had 1:1 training. Only 333 trainings (23%) were compliant with all 4 training components. There was no statistically significant association between compliance with individual components, or all-or-none compliance and either the percentage of catheters with peritonitis ≤ 90 days after training end or median days to peritonitis., Conclusion: No associations between 4 PD training components and risk for peritonitis were found. SCOPE requires monthly review of PD catheter practices which may have decreased the impact of training non-compliance. A higher resolution version of the Graphical abstract is available as Supplementary information., (© 2023. The Author(s), under exclusive licence to International Pediatric Nephrology Association.)

Purpose of Review: This manuscript details the development and execution of a quality improvement (QI) initiative aimed at standardizing blood pressure (BP) measurement practices in pediatric hemodialysis (HD) units across a national dialysis collaborative., Recent Findings: Although there are recommendations for the detection and treatment of hypertension in the pediatric population, currently there is no data or recommendations specific to the methodology of measuring blood pressure in a pediatric hemodialysis setting. In 2016, the Standardizing Care to Improve Outcomes in Pediatric End Stage Kidney Disease (SCOPE) Collaborative assembled a dedicated working group to thoroughly examine BP measurement practices across participating pediatric HD centers and, drawing from current research, to establish a standardized best practice for BP measurement in pediatric HD patients both in-center and at home. Employing QI methodology, the working group devised a standardized "BP Bundle" and implemented it throughout the SCOPE Collaborative. This work led to successful practice improvement by establishing a consistent approach to BP measurement in pediatric HD patients cared for in SCOPE centers. With a standard best practice now in place and over 85% compliance with the BP Bundle across the SCOPE Collaborative, researchers and healthcare professionals can more accurately study and ultimately enhance the cardiovascular health of pediatric HD patients., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Studies regarding hemodialysis (HD) arteriovenous fistula (AVF) cannulation in adults indicate a higher risk of infection with the buttonhole (BH) technique compared to the rope-ladder (RL) technique. Pediatric data on this issue is sparse., Methods: We compared infection rates within the Standardizing Care to Improve Outcomes in Pediatric End stage kidney disease (SCOPE) centers performing BH cannulation versus RL cannulation of AVF. Generalized linear mixed modeling was used to assess differences in access-related blood stream infection (BSI) and access site infection (ASI) rates between the centers., Results: Data was available from 211 AVF enrollments among 210 children. There were 61 AVF enrollments at 6 BH centers and 150 enrollments at 13 RL centers. Demographics were similar between the two groups. There were 12 total infections in 3383 patient months. BH centers had 3 infections (0 BSI, 3 ASI) and RL centers had 9 infections (5 BSI, 3 ASI). Mean [95% confidence interval] infection rates per 1000 patient months were not different between BH and RL centers (BH: 3.1 [0.6,15.6], RL: 3.2 [1.3,9.4], p = 0.947). A survey was also completed by the BH centers to describe their BH practices. The BH procedure at the majority of sites was characterized by a small patient/nurse ratio and strict antiseptic protocols., Conclusions: This data provides evidence of a low BSI rate associated with BH cannulation in pediatric HD patients. Further studies are needed to better delineate the differences in the pediatric and adult experience with the BH cannulation technique., (© 2021. IPNA.)

Rationale & Objective: Research on pediatric kidney replacement therapy (KRT) has primarily focused on Europe and North America. In this study, we describe the mortality risk of children treated with maintenance peritoneal dialysis (MPD) in different parts of the world and characterize the associated demographic and macroeconomic factors., Study Design: Prospective cohort study., Setting & Participants: Patients younger than 19 years at inclusion into the International Pediatric Peritoneal Dialysis Network registry, who initiated MPD between 1996 and 2017., Exposure: Region as primary exposure (Asia, Western Europe, Eastern Europe, Latin America, North America, and Oceania). Other demographic, clinical, and macroeconomic (4 income groups based on gross national income) factors also were studied., Outcome: All-cause MPD mortality., Analytical Approach: Patients were observed for 3 years, and the mortality rates in different regions and income groups were calculated. Cause-specific hazards models with random effects were fit to calculate the proportional change in variance for factors that could explain variation in mortality rates., Results: A total of 2,956 patients with a median age of 7.8 years at the start of KRT were included. After 3 years, the overall probability of death was 5%, ranging from 2% in North America to 9% in Eastern Europe. Mortality rates were higher in low-income countries than in high-income countries. Income category explained 50.1% of the variance in mortality risk between regions. Other explanatory factors included peritoneal dialysis modality at start (22.5%) and body mass index (11.1%)., Limitations: The interpretation of interregional survival differences as found in this study may be hampered by selection bias., Conclusions: This study shows that the overall 3-year patient survival on pediatric MPD is high, and that country income is associated with patient survival., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: In its first 3 years, the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative demonstrated a statistically significant increase in the likelihood of compliance with a standardized follow-up care bundle and a significant reduction in peritonitis. We sought to determine if compliance with care bundles and low peritonitis rates could be sustained in centers continuously participating for 84 months., Methods: Centers that participated from collaborative launch through the 84-month study period and provided pre-launch peritonitis rates were included. Children on maintenance peritoneal dialysis were eligible for enrollment. Changes in bundle compliance were assessed using a logistic regression model or a generalized linear mixed model (GLMM). Changes in average annualized peritonitis rates over time were modeled using GLMMs., Results: Nineteen centers contributed 1055 patients with 1268 catheters and 17,247 follow-up encounters. The likelihood of follow-up compliance increased significantly over the study period (OR 1.05 95% confidence interval (CI) 1.03, 1.07; p < 0.001). Centers achieved ≥ 80% follow-up bundle compliance by 28 months and maintained a mean compliance of 84% between 28 and 84 months post-launch. Average monthly peritonitis rates decreased from 0.53 (95% CI 0.37, 0.70) infections per patient-year pre-launch to 0.30 (95% CI 0.23, 0.43) at 84 months post-launch, p < 0.001., Conclusions: Centers participating in the SCOPE Collaborative for 84 months achieved and maintained a high level of compliance with a standardized follow-up care bundle and demonstrated a significant and continued reduction in average monthly peritonitis rates.

Antibiotic use is necessary in the outpatient hemodialysis setting because patients receiving hemodialysis are at increased risk for infections and sepsis. However, inappropriate antibiotic use can lead to adverse drug events, including adverse drug reactions and infections with Clostridioides difficile and antibiotic-resistant bacteria. Optimizing antibiotic use can decrease adverse events and improve infection cure rates and patient outcomes. The American Society of Nephrology and the US Centers for Disease Control and Prevention created the Antibiotic Stewardship in Hemodialysis White Paper Writing Group, comprising experts in antibiotic stewardship, infectious diseases, nephrology, and public health, to highlight strategies that can improve antibiotic prescribing for patients receiving maintenance hemodialysis. Based on existing evidence and the unique patient and clinical setting characteristics, the following strategies for improving antibiotic use are reviewed: expanding infection and sepsis prevention activities, standardizing blood culture collection processes, treating methicillin-susceptible Staphylococcus aureus infections with β-lactams, optimizing communication between nurses and prescribing providers, and improving data sharing across transitions of care. Collaboration among the Centers for Disease Control and Prevention; American Society of Nephrology; other professional societies such as infectious diseases, hospital medicine, and vascular surgery societies; and dialysis provider organizations can improve antibiotic use and the quality of care for patients receiving maintenance hemodialysis., (Copyright © 2020 National Kidney Foundation, Inc. All rights reserved.)

The recently published 2020 International Society for Peritoneal Dialysis (ISPD) practice recommendations regarding prescription of high-quality goal-directed peritoneal dialysis differ fundamentally from previous guidelines that focused on "adequacy" of dialysis. The new ISPD publication emphasizes the need for a person-centered approach with shared decision making between the individual performing peritoneal dialysis and the clinical care team while taking a broader view of the various issues faced by that individual. Cognizant of the lack of strong evidence for the recommendations made, they are labeled as "practice points" rather than being graded numerically. This commentary presents the views of a work group convened by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) to assess these recommendations and assist clinical providers in the United States in interpreting and implementing them. This will require changes to the current clinical paradigm, including greater resource allocation to allow for enhanced services that provide a more holistic and person-centered assessment of the quality of dialysis delivered., (Copyright © 2020. Published by Elsevier Inc.)

Objective: The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative seeks to reduce hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) by increasing implementation of standardized HD catheter care bundles. We report HD catheter care practices and HD CA-BSI rates from SCOPE., Methods: Catheter care practices and infection events were collected prospectively during the study period, from collaborative implementation in June 2013 through May 2017. For comparative purposes, historical data, including patient demographics and HD CA-BSI events, were collected from the 12 months prior to implementation. Catheter care bundle compliance in 5 care bundle categories was monitored across the post-implementation reporting period at each center via monthly care observation forms. CA-BSI rates were calculated monthly, and reported as number of infections per 100 patient months. Changes in CA-BSI rates were assessed using generalized linear mixed model (GLMM) techniques., Results: Three hundred twenty-five patients with tunneled HD catheters [median (IQR) age 12 years (6, 16), M 53%, F 47%] at 15 centers were included. A total of 3996 catheter care observations over 4170 patient months were submitted with a median (IQR) 5 (2, 14) observations per patient. Overall bundle compliance was high at 87.6%, with a significant and progressive increase (p < 0.001) in compliance for 4/5 bundle categories over the 48-month study period. The adjusted CA-BSI rate significantly decreased over time from 3.3/100 patient months prior to implementation of the care bundles to 0.8/100 patient months 48 months after care bundle implementation (p < 0.001)., Conclusions: Using quality improvement methodology, SCOPE has demonstrated a significant increase in compliance with a majority of HD catheter care practices and a significant reduction in the rate of CA-BSI among children maintained on HD.

HLA eplet mismatch load has been suggested as an improvement to HLA antigen mismatch determination for organ selection. Given that eplet mismatches are determined based on amino acid sequence difference among HLA alleles, and that the frequency of HLA alleles varies between racial groups, we investigated the correlation between eplet mismatch load and allograft outcomes in 110 pediatric kidney transplant recipients who received their first organ from a donor of the same race (SRT) versus a donor of a different race (DRT). Adjusted modified Poisson regression was used to assess the interaction between eplet mismatch load and race mismatch and its effect on outcome. Caucasians and living donor recipients had lower eplet mismatched loads against their donors compared with non-Caucasian and deceased donor recipients. Overall, for the entire population, the risk of de novo HLA-DSA development was significantly increased with higher eplet loads (p < 0.001). Compared with the SRT group, the DRT group had higher eplet loads when compared with their donor, for HLA class I but not HLA class II molecules; however, there was no significant difference in the incidence of de novo HLA-DSA between the 2 groups. The risk of rejection increased significantly for DRT compared with SRT, only when class I eplet load was ≥ 70 (p = 0.04). Together this data show that eplet mismatch load analysis is an effective tool for alloimmune risk assessment. If considered for donor selection, acceptable eplet mismatch loads determined from studies in homogenous populations may restrict transplantation across racially diverse donor and patient groups with no evidence of poor outcome. Therefore, an acceptable eplet mismatch load threshold must consider the heterogeneity of the transplant population.

The Kidney Allocation System (KAS) has resulted in fewer pediatric kidneys being allocated to pediatric deceased donor kidney transplant (pDDKT) recipients. This had prompted concerns that post-pDDKT outcomes may worsen. To study this, we used SRTR data to compare the outcomes of 953 pre-KAS pDDKT (age <18 years) recipients (December 4, 2012-December 3, 2014) with the outcomes of 934 post-KAS pDDKT recipients (December 4, 2014-December 3, 2016). We analyzed mortality and graft loss by using Cox regression, delayed graft function (DGF) by using logistic regression, and length of stay (LOS) by using negative binomial regression. Post-KAS recipients had longer pretransplant dialysis times (median 1.26 vs 1.07 years, P = .02) and were more often cPRA 100% (2.0% vs 0.1%, P = .001). Post-KAS recipients had less graft loss than pre-KAS recipients (hazard ratio [HR]: 0.35 0.54 0.83 , P = .005) but no statistically significant differences in mortality (HR: 0.29 0.72 1.83 , P = .5), DGF (odds ratio: 0.93 1.32 1.93 , P = .2), and LOS (LOS ratio: 0.96 1.06 1.19 , P = .4). After adjusting for donor-recipient characteristics, there were no statistically significant post-KAS differences in mortality (adjusted HR: 0.37 1.04 2.92 , P = .9), DGF (adjusted odds ratio: 0.94 1.41 2.13 , P = .1), or LOS (adjusted LOS ratio: 0.93 1.04 1.16 , P = .5). However, post-KAS pDDKT recipients still had less graft loss (adjusted HR: 0.38 0.59 0.91 , P = .02). KAS has had a mixed effect on short-term posttransplant outcomes for pDDKT recipients, although our results are limited by only 2 years of posttransplant follow-up., (© 2019 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Pediatric kidney transplant candidates often have multiple potential living donors (LDs); no evidence-based tool exists to compare potential LDs, or to decide between marginal LDs and deceased donor (DD) kidney transplantation (KT). We developed a pediatric living kidney donor profile index (P-LKDPI) on the same scale as the DD KDPI by using Cox regression to model the risk of all-cause graft loss as a function of living donor characteristics and DD KDPI. HLA-B mismatch (adjusted hazard ratio [aHR] per mismatch =  1.04 1.27 1.55 ), HLA-DR mismatch (aHR per mismatch =  1.02 1.23 1.49 ), ABO incompatibility (aHR =  1.20 3.26 8.81 ), donor systolic blood pressure (aHR per 10 mm Hg =  1.01 1.07 1.18 ), and donor estimated GFR (eGFR; aHR per 10 mL/min/1.73 m 2 = 0.88 0.94 0.99 ) were associated with graft loss after LDKT. Median (interquartile range [IQR]) P-LKDPI was -25 (-56 to 12). 68% of donors had P-LKDPI <0 (less risk than any DD kidney) and 25% of donors had P-LKDPI >14 (more risk than median DD kidney among pediatric KT recipients during the study period). Strata of LDKT recipients of kidneys with higher P-LKDPI had a higher cumulative incidence of graft loss (39% at 10 years for P-LDKPI ≥20, 28% for 20> P-LKDPI ≥-20, 23% for -20 > P-LKDPI ≥-60, 19% for P-LKDPI <-60 [log rank P < .001]). The P-LKDPI can aid in organ selection for pediatric KT recipients by allowing comparison of potential LD and DD kidneys., (© 2019 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background: Peritoneal dialysis (PD) is the preferred chronic dialysis modality amongst pediatric patients. Peritonitis is a devastating complication of PD. Adult data demonstrates early onset peritonitis (EP) is associated with higher rates of subsequent peritonitis and technique failure. Limited data exists regarding EP in the pediatric population, here defined as peritonitis occurring within 60 days of catheter insertion., Methods: PD catheter insertion practices and EP episodes were examined from the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative database., Results: There were 98 episodes of EP amongst 1106 PD catheters inserted. Multivariable analysis demonstrated a significant association between early use of the PD catheter and EP (P = 0.001). Age less than 1 year at the time of catheter insertion (P < 0.001), first catheter placed (P < 0.001) for the patient, use of a plastic adapter (P = 0.003), placement of sutures at the exit site (ES) (P = 0.032), and dressing change prior to 7 days post-operatively (P < 0.001) were all significantly associated with early PD catheter use. Concurrent placement of a hemodialysis catheter was associated with a decreased risk for early PD catheter use (P = 0.010)., Conclusions: In this large cohort of pediatric PD recipients, 8.4% of PD catheters were associated with the development of EP. The finding of an association between early use of the PD catheter and EP represents a potentially modifiable risk factor to reduce infection rates within this patient population.

Background: The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative is a quality improvement initiative to reduce dialysis-associated infections. The frequency of peritoneal dialysis (PD) catheter exit site infection (ESI) and variables influencing its development and end result are unclear. We sought to determine ESI rates, to elucidate the epidemiology, risk factors, and outcomes for ESI, and to assess for association between provider compliance with care bundles and ESI risk., Methods: We reviewed demographic, dialysis and ESI data, and care bundle adherence and outcomes for SCOPE enrollees from October 2011 to September 2014. ESI involved only the exit site, only the subcutaneous catheter tunnel, or both., Results: A total of 857 catheter insertions occurred in 734 children over 10,110 cumulative months of PD provided to these children. During this period 207 ESIs arose in 124 children or 0.25 ESIs per dialysis year. Median time to ESI was 392 days, with 69% of ESIs involving exit site only, 23% involving the tunnel only, and 8% involving both sites. Peritonitis developed in 6%. ESI incidence was associated with age (p = 0.003), being the lowest in children aged < 2 years and highest in those aged 6-12 years, and with no documented review of site care or an exit site score  of > 0 at prior month's visit (p < 0.001). Gender, race, end stage renal disease etiology, exit site orientation, catheter cuff number or mobilization, and presence of G-tube, stoma, or vesicostomy were unassociated with ESI incidence. Of the ESIs reported, 71% resolved with treatment, 24% required hospitalization, and 9% required catheter removal, generally secondary to tunnel infection., Conclusions: Exit site infections occur at an annualized rate of 0.25, typically well into the dialysis course. Younger patient age and documented review of site care are associated with lower ESI rates. Although most ESIs resolve, hospitalization is frequent, and tunnel involvement/catheter loss complicate outcomes.

Background: Fungal peritonitis is a serious complication among peritoneal dialysis (PD) patients. The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative is a North American multicenter quality improvement initiative with the primary aim to reduce catheter-related infections in children on chronic dialysis., Objective: To describe the epidemiology of fungal peritonitis and outcomes of affected patients among pediatric subjects receiving chronic PD and enrolled in SCOPE., Methods: Data pertaining to PD characteristics, peritonitis episodes and patient outcome were collected between October 2011 and September 2015 from 30 pediatric dialysis centers participating in the SCOPE collaborative. Peritonitis-related data were stratified by etiology, fungal versus bacterial/culture-negative peritonitis. Differences among groups were assessed by Chi-square analysis., Results: Of 994 patients enrolled in the registry, there were 511 peritonitis episodes of which 41 (8.0%) were fungal. Thirty-six individual patients with 39 unique catheters accounted for the fungal peritonitis episodes. Twenty-three (59%) of the episodes occurred in patients aged < 2 years (p = 0.03). Fungal peritonitis was the initial episode of peritonitis in 48.8% of affected patients, and only 17.1% of these patients had had a previous peritonitis episode within 30 days of the fungal infection. Insertion of the PD catheter at < 2 years of age was associated with an adjusted odds ratio of 2.8 (95% confidence interval 1.24, 6.31) for development of fungal peritonitis compared to older children (p = 0.01). Fungal peritonitis was associated with an increased rate of hospitalization (80.5 vs. 63.4%; p = 0.03), increased length of hospitalization (median of 8 vs. 5 days; p < 0.001) and increased rates of catheter removal (84.6 vs 26.9%; p = 0.001) and technique failure (68.3 vs. 8%; p = 0.001) compared to other causes of peritonitis., Conclusion: Fungal infections were responsible for 8.0% of peritonitis episodes in the SCOPE collaborative, with the majority of fungal peritonitis episodes occurring in children aged < 2 years. Although no risk factors for infection other than young age were identified, fungal peritonitis was associated with an increased risk of hospitalization, longer hospital stay and an increased frequency of technique failure.

Background: Maintenance peritoneal dialysis (PD) is the dialysis modality of choice for infants and young children. However, there are limited outcome data for those who undergo PD catheter insertion and initiate maintenance PD within the first year of life., Methods: Using data from the Children's Hospital Association's Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (ESRD) Collaborative (SCOPE), we examined peritonitis rates and patient survival in 156 infants from 29 North American pediatric dialysis centers who had a chronic PD catheter placed prior to their first birthday., Results: In-hospital and overall annualized rates of peritonitis were 1.73 and 0.76 episodes per patient-year, respectively. Polycystic kidney disease was the most frequent renal diagnosis and pulmonary hypoplasia the most common co-morbidity in infants with peritonitis. Multivariable regression models demonstrated that nephrectomy at or prior to PD catheter placement and G-tube insertion after catheter placement were associated with a nearly sixfold and nearly threefold increased risk of peritonitis, respectively. Infants with peritonitis had longer initial hospital stays and lower overall survival (86.3 vs. 95.6%, respectively; P < 0.02) than those without an episode of peritonitis., Conclusions: In this large cohort of infants with ESRD, the frequency of peritonitis was high and several risk factors associated with the development of peritonitis were identified. Given that peritonitis was associated with a longer duration of initial hospitalization and increased mortality, increased attention to the potentially modifiable risk factors for infection is needed.

Peritonitis is a leading cause of hospitalizations, morbidity, and modality change in pediatric chronic peritoneal dialysis (CPD) patients. Despite guidelines published by the International Society for Peritoneal Dialysis aimed at reducing the risk of peritonitis, registry data have revealed significant variability in peritonitis rates among centers caring for children on CPD, which suggests variability in practice. Improvement science methods have been used to reduce a variety of healthcare-associated infections and are also being applied successfully to decrease rates of peritonitis in children. A successful quality improvement program with the goal of decreasing peritonitis will not only include primary drivers directly linked to the outcome of peritonitis, but will also direct attention to secondary drivers that are important for the achievement of primary drivers, such as health literacy and patient and family engagement strategies. In this review, we describe a comprehensive improvement science model for the reduction of peritonitis in pediatric patients on CPD.

The Standardizing Care to improve Outcomes in Pediatric End stage renal disease (SCOPE) Collaborative aims to reduce peritonitis rates in pediatric chronic peritoneal dialysis patients by increasing implementation of standardized care practices. To assess this, monthly care bundle compliance and annualized monthly peritonitis rates were evaluated from 24 SCOPE centers that were participating at collaborative launch and that provided peritonitis rates for the 13 months prior to launch. Changes in bundle compliance were assessed using either a logistic regression model or a generalized linear mixed model. Changes in average annualized peritonitis rates over time were illustrated using the latter model. In the first 36 months of the collaborative, 644 patients with 7977 follow-up encounters were included. The likelihood of compliance with follow-up care practices increased significantly (odds ratio 1.15, 95% confidence interval 1.10, 1.19). Mean monthly peritonitis rates significantly decreased from 0.63 episodes per patient year (95% confidence interval 0.43, 0.92) prelaunch to 0.42 (95% confidence interval 0.31, 0.57) at 36 months postlaunch. A sensitivity analysis confirmed that as mean follow-up compliance increased, peritonitis rates decreased, reaching statistical significance at 80% at which point the prelaunch rate was 42% higher than the rate in the months following achievement of 80% compliance. In its first 3 years, the SCOPE Collaborative has increased the implementation of standardized follow-up care and demonstrated a significant reduction in average monthly peritonitis rates., (Copyright © 2016 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: There is a disproportionate burden of human papillomavirus (HPV) -related genital tract disease in patients with CKD and kidney transplantation; therefore, the potential effect of the quadrivalent HPV vaccine (Gardasil; Merck GmbH, Darmstadt, Germany) is profound. Immune abnormalities associated with CKD and immunosuppression may prevent optimal vaccine response. Our objective was to determine antibody response to the HPV vaccine in adolescent girls with CKD., Design, Setting, Participants, & Measurements: This cohort study conducted from 2008 to 2012 included 57 girls aged 9-21 years old with CKD (n=25), on dialysis (n=9), or with status postkidney transplantation (n=23) who received the standard three-dose vaccine series of the HPV vaccine recruited from two pediatric nephrology clinics. Antibody levels to HPV genotypes 6, 11, 16, and 18 were measured before vaccine dose 1 (baseline), <12 months after vaccine dose 3 (blood draw 2), and ≥12 months after vaccine dose 3 (blood draw 3). Seropositivity was defined as antibody level above an established threshold for each HPV genotype. Not all participants completed three blood draws., Results: Antibody response to all four HPV genotypes was 100% in the CKD and dialysis groups with samples drawn at <12 and ≥12 months after dose 3 of the HPV vaccine. Among patients with transplants, the percentages of patients achieving seropositivity were significantly lower at blood draw 2 for HPV genotypes 6 (63.6%; P=0.003), 11 (63.6%; P=0.003), and 18 (72.7%; P=0.02) and blood draw 3 for HPV genotypes 6 (62.5%; P=0.02), 11 (50%; P=0.001), 16 (75%; P=0.04), and 18 (50%; P=0.001)., Conclusions: Antibody response to the quadrivalent recombinant HPV vaccine was robust and sustained in girls and young women with CKD and on dialysis. A less robust response to the vaccine was observed among those with a kidney transplant. Additional study is needed to determine if vaccination before kidney transplantation or an alternative vaccination regimen would benefit transplant recipients., (Copyright © 2016 by the American Society of Nephrology.)

Background: Clinical practice guidelines for management of anemia in children with end-stage kidney disease (ESKD) remain largely opinion-based. In this study, we evaluated the risk of mortality and hospitalization by hemoglobin (Hb) level in a large prevalent population of U.S. children on peritoneal dialysis (PD)., Methods: Hemoglobin levels in prevalent PD patients from the 2005 End Stage Renal Disease Clinical Performance Measures Project were linked with 5-year mortality and 4-year hospitalization records from the United States Renal Data System., Results: Of the 468 patients included in the study, the mean age was 11 years, 55 % were male, 67 % were white, 254 (54 %) were hospitalized, and 23 (5 %) died. Median (interquartile range) Hb levels were 11.7 (10.7-12.6) g/dl, and 30 % had Hb levels of <11 g/dl. In adjusted survival analysis, Hb thresholds of 10, 11, or 12 g/dl were not associated with a significant difference in risk of death. The incidence rate ratio (IRR) of hospitalization for patients with a mean Hb of ≥11 g/dl was 0.56 (95 % CI 0.43-0.73). Compared to a reference range of Hb of 11 to <12, Hb of ≥12 g/dl was not associated with a significant difference in hospitalization risk (IRR 0.88; 95 % CI 0.61-1.25). Using age- and sex specific cut-offs for anemia, children who were not anemic had a 27 % decreased risk of hospitalization compared to those with anemia (IRR 0.73; 95 % CI 0.55-0.97). Compared to the first erythropoiesis stimulating agent (ESA) dosing quartile, higher ESA doses were associated with an increased risk of both hospitalization and mortality., Conclusions: U.S. children on PD with Hb levels of ≥11 g/dl were less likely to be hospitalized but had no observed difference in mortality. Children who were not anemic were also less likely to be hospitalized. Further study is necessary to elucidate whether a single optimal Hb level or a range applies to the pediatric ESKD population.

Providing optimal care to the infant, child, and adolescent patient who is treated with long-term dialysis therapy mandates that attention be directed to a variety of clinical issues in addition to those related to solute removal and fluid management. Therapeutic plans must be formulated by a multidisciplinary team of pediatric specialists to address the clinical parameters of growth, anemia and osteodystrophy management, cardiovascular health, nutritional adequacy, education, cognitive development, quality of life, preparation for transplantation, and transition to adult care. This review highlights key components of current management recommendations based on a combination of published guidelines, pediatric registry data, and the combined clinical experience of the authors. Whereas some components of this review reflect a modification of the content and recommendations contained in the original publication from more than a decade ago, the contrast emphasizes the advances in understanding and therapeutics of many aspects of pediatric dialysis care that have taken place in the interim. In turn, the content of this article should provide the reader with valuable guidance toward the goal of providing optimal care to patients receiving dialysis., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Unlabelled: BACKGROUND, OBJECTIVES, AND METHODS: Hospitalization and mortality rates in pediatric dialysis patients remain unacceptably high. Although studies have associated the presence of comorbidities with an increased risk for death in a relatively small number of pediatric dialysis patients, no large-scale study had set out to describe the comorbidities seen in pediatric dialysis patients or to evaluate the impact of those comorbidities on outcomes beyond the newborn period. In the present study, we evaluated the prevalence of comorbidities in a large international cohort of pediatric chronic peritoneal dialysis (CPD) patients from the International Pediatric Peritoneal Dialysis Network registry and began to assess potential associations between those comorbidities and hospitalization rates and mortality., Results: Information on comorbidities was available for 1830 patients 0 - 19 years of age at dialysis initiation. Median age at dialysis initiation was 9.1 years [interquartile range (IQR): 10.9], median follow-up for calculation of hospitalization rates was 15.2 months (range: 0.2 - 80.9 months), and total follow-up time in the registry was 2095 patient-years. At least 1 comorbidity had been reported for 602 of the patients (32.9%), with 283 (15.5%) having cognitive impairment; 230 (12.6%), motor impairment; 167 (9.1%), cardiac abnormality; 76 (4.2%), pulmonary abnormality; 212 (11.6%), ocular abnormality; and 101 (5.5%), hearing impairment. Of the 150 patients (8.2%) that had a defined syndrome, 85% had at least 1 nonrenal comorbidity, and 64% had multiple comorbidities. The presence of at least 1 comorbidity was associated with a higher hospitalization rate [hospital days per 100 observation days: 1.7 (IQR: 5.8) vs 1.2 (IQR: 3.9), p = 0.001] and decreased patient survival (4-year survival rate: 73% vs 90%, p < 0.0001)., Conclusions: Nearly one third of pediatric CPD patients in a large international cohort had at least 1 comorbidity, and multiple comorbidities were frequently reported among patients with a defined syndrome. Preliminary analysis suggests an association between comorbidity and poor outcome in those patients. As this powerful international registry matures, further multivariate analyses will be important to more clearly define the impact of comorbidities on hospitalization rates and mortality in pediatric CPD patients.

Kidney transplantation is the treatment of choice for the majority of pediatric patients with end-stage kidney disease. Previous studies demonstrating racial or gender disparities in access to the deceased donor transplant list could not evaluate the impact of medical concerns or patient preference on waitlist status. We undertook a retrospective cohort study using the NAPRTCS registry to begin to determine barriers to wait list registration for kidney transplantation among pediatric dialysis patients. Clinical and demographic factors were compared in listed vs. non-listed patients. Reasons cited for not listing patients were examined by clinical and demographic factors. At dialysis initiation, 88.7% of pediatric dialysis patients were not on the renal transplant wait list. Twelve months after dialysis initiation, 67.1% of pediatric dialysis patients were not on the wait list. The groups least likely to be on the wait list were infants (adjusted OR 0.23, 95% CI 0.16, 0.32) and girls (adjusted OR 0.78, 95% CI 0.67, 0.90) after adjusting for multiple confounders. The reason most often cited for not listing was medical reason for young infants and that the transplant workup was pending for girls. Further study is needed to identify barriers to wait list registration., (© 2011 John Wiley & Sons A/S.)

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.

Purpose: We describe a cohort of children with chronic kidney disease due to vesicoureteral reflux. We compared the rate of progression to end stage renal disease in those patients to the rate in children with another cause of chronic kidney disease and identified potential risk factors for progression., Materials and Methods: We performed a retrospective cohort study using data from the North American Pediatric Renal Trials and Collaborative Studies Registry. Patients with vesicoureteral reflux as a cause of chronic kidney disease were compared to 2 other diagnostic cohorts. The 3 groups were compared with respect to baseline characteristics and progression to end stage renal disease based on diagnostic category. Multivariate analysis was performed to identify risk factors for progression to end stage renal disease using Cox proportional hazards regression model., Results: Data on 6,981 patients were available for analysis. Patients with vesicoureteral reflux as a cause of chronic kidney disease had a significantly slower rate of progression to end stage renal disease than patients with renal aplasia, hypoplasia or dysplasia and all other causes (log rank p <0.0001). On multivariate analysis of risk factors for progression to end stage renal disease in patients with vesicoureteral reflux as the cause of chronic kidney disease we found that, in addition to older age and more advanced chronic kidney disease stage, a history of urinary tract infection at registration was significantly associated with an increased risk of progression., Conclusions: Children with vesicoureteral reflux had a slower rate of progression to end stage renal disease than children with another cause of chronic kidney disease even after controlling for multiple possible confounders. In children with vesicoureteral reflux as the cause of chronic kidney disease older age, higher chronic kidney disease stage and history of urinary tract infection are significantly associated with the risk of progression to end stage renal disease.

Although prospective randomized trials have provided important information and allowed the development of evidence-based guidelines in adult hemodialysis (HD) patients, with approximately 800 prevalent pediatric HD patients in the United States, such studies are difficult to perform in this population. Observational data obtained through the Center for Medicare & Medicaid Services' (CMS') End Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project have allowed description of the clinical care provided to pediatric HD patients as well as identification of risk factors for failure to reach adult targets for clinical parameters such as hemoglobin, single-pool Kt/V (spKt/V) and serum albumin. In addition, studies linking data from the ESRD CPM Project and the United States Renal Data System have allowed evaluation of associations between achievement of those targets and the outcomes of hospitalization and death. The results of those studies, while unable to prove cause and effect, suggest that the adult ESRD CPM targets may assist in identifying pediatric HD patients at risk for poor outcomes.

Background: Arteriovenous fistulas (AVFs) and grafts (AVGs) have been associated with improved clinical outcomes in children and adults with end-stage renal disease (ESRD) on maintenance hemodialysis (HD) therapy, but use of vascular catheters is high. Identifying the reasons for the high prevalence of vascular catheters in children on HD therapy is necessary to assess whether targeted interventions may increase the prevalence of AVFs/AVGs., Study Design: Retrospective cohort study., Setting & Participants: Children younger than 18 years on HD therapy in the 2001 to 2003 ESRD Clinical Performance Measures (CPM) Projects followed up in the US Renal Data System transplant files through December 31, 2004., Predictor: Vascular access type and reasons for use of a vascular catheter., Outcomes & Measurements: Demographic/clinical characteristics, including the reason provided for use of a vascular catheter, and the association of type of vascular access and (1) patient size and (2) time to kidney transplantation., Results: Of 1,284 prevalent pediatric CPM patients examined, 529 (41%) had an AVF/AVG and 755 (59%) had a vascular catheter. Of 755 children with a catheter, "small body size" was a commonly listed reason (N = 142); 49% of these children weighed 20 kg or more. Of 53 patients with catheters described as having an "AVF/AVG maturing" and present in the consecutive ESRD CPM project year, 64% had a functioning AVF/AVG the following year. For those with "transplantation scheduled" listed as a reason for a vascular catheter (N = 83), 69% underwent transplantation within 1 year, and median time to transplantation was 115 days. Of all children with vascular catheters (N = 755), 32.2% underwent transplantation within 1 year, and median time to transplantation was 264 days compared with 21.7% and 347 days for those with AVFs/AVGs, respectively (N = 529). Of the 445 incident children in this cohort, 89% had a vascular catheter at dialysis therapy initiation., Limitations: Because of study design, only associations can be described., Conclusions: Vascular catheter use in children on HD therapy is high. This is partially explained by expeditious transplantation and technical barriers to AVF/AVG placement in small children; however, only one-third of patients with a vascular catheter underwent transplantation within 1 year. Interventions to decrease vascular catheter use in this population may be necessary.

Associations between achievement of adult Kidney Disease Outcomes Quality Initiative (KDOQI) targets for hemoglobin, adequacy and albumin, and race and gender were determined for pediatric peritoneal dialysis patients from the End-Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) project for the period October 2004-March 2005. Fifty-six percent (427/761) of patients were male. Sixty-six percent (500/761) of patients were White. There were no differences in achievement of targets for adults by gender, and no differences in adequacy parameters by race. Blacks had lower mean hemoglobin levels than did Whites (11.1 +/- 1.6 g/dl vs 11.8 +/- 1.4 g/dl, P < 0.0001). Blacks were more likely to have mean hemoglobin levels < 10 g/dl (24% vs 11%, P < 0.0001) and less likely to achieve mean hemoglobin > 11 g/dl (56% vs 72%, P < 0.0001). Whites were more likely to achieve mean serum albumin levels > 4.0/3.7 g/dl [bromocresol green/bromocresol purple (BCG/BCP)] than Blacks were (35% vs 26%, P = 0.0376). In multivariate logistic regression models, White race was associated with mean hemoglobin levels > 11 g/dl [adjusted odds ratio (adj OR) 2.7, 95% confidence interval (CI) 1.7, 4.3] and mean serum albumin > 4.0/3.7 g/dl (BCG/BCP) (adj OR 1.9, 95% CI 1.3, 2.9]. Further study is needed of factors associated with anemia on peritoneal dialysis and barriers to its correction.

Growth is an important outcome in pediatric kidney disease. We aimed to identify factors associated with growth in pediatric hemodialysis (HD) patients. Height standard deviation scores (Ht SDS) of pediatric HD patients with consecutive height measurements in the ESRD Clinical Performance Measures Project were calculated. Multiple linear regression determined the effect of factors on Ht SDS change/year. Four hundred and seven patients were included. Median age was 15.2 years (interquartile range 13.2-16.5 years); 44% were girls, and 27% were black. Of patients observed, 66% had growth hormone (GH) data, and of those, 29% were prescribed GH. Mean change in Ht SDS/year was -0.10+/-0.71. After adjustment, decreasing Ht SDS was associated with younger age (-0.2/year for <13 vs. >or=13 years; p<0.0001), longer duration on dialysis (-0.03/year for >or=6 months vs. <6 months; p<0.01), and higher normalized protein catabolic rate (nPCR) (-0.02/year per 0.1; p<0.05). Improved growth was seen in girls (0.10/year; p<0.01) and in those with lower Ht SDS (0.03/year per 0.5 decrease; p<0.001). Hemoglobin, GH use, and adequacy were associated with neither positive nor negative changes in Ht SDS. Growth retardation while on HD was most pronounced in patients who were young, male, had longer durations on HD, had higher nPCR, and had higher baseline Ht SDS.

Background: The Centers for Medicare & Medicaid Services End-Stage Renal Disease Clinical Performance Measures (CPM) Project contains one of the largest databases of prevalent pediatric dialysis patients in the United States. Since 2005, the CPM Project has included not only children on long-term hemodialysis (HD) therapy, but also those on long-term peritoneal dialysis (PD) therapy. This study describes demographic and clinical characteristics and compares them between patients on HD and PD therapy., Study Design: Cross-sectional., Setting & Participants: Children aged 0 to younger than 18 years included within the 2005 End-Stage Renal Disease CPM Project., Predictor: Demographic and clinical characteristics, with emphasis on dialysis modality., Outcomes & Measurements: Achievement of values for hemoglobin, dialysis adequacy, and serum albumin as recommended by recent National Kidney Foundation-Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines and Recommendations., Results: Of 1,453 patients examined, 692 received HD and 761 received PD. There was no significant difference by dialysis modality in the likelihood of having a mean hemoglobin level of 11 g/dL or greater; however, HD patients were significantly more likely to have a mean hemoglobin level less than 10 g/dL (19% versus 14% of PD patients; P = 0.02). Although statistically significant, the absolute difference in mean hemoglobin levels between patients receiving HD versus PD was small (11.4 versus 11.6 g/dL). Eighty-nine percent of patients receiving HD and 87% of patients receiving PD achieved the recommended modality-specific Kt/V (P = 0.4). Children receiving HD were more likely than those receiving PD to have a mean serum albumin level of 4.0/3.7 g/dL or greater (bromcresol green/bromcresol purple laboratory method): 46% versus 33% (P < 0.001)., Limitations: Because of study design, only associations can be described., Conclusions: A significant number of children had hemoglobin, serum albumin, and/or Kt/V values outside the recommended targets. Future research is needed to better define the risk relationships of these predictors with morbidity and mortality in children on dialysis therapy, evaluate the benefit of treating to certain treatment targets, and understand reasons for failing to reach treatment targets in individual patients or patient groups.

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 > or = 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 > or = 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 > or = 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.

With the use of data from the Centers for Medicare & Medicaid Services' ESRD Clinical Performance Measures Project (October through December 1999 and 2000) linked with US Renal Data System hospitalization and mortality records, whether achieving adult target hemoglobin (Hb) levels in adolescents who are on hemodialysis (HD) was associated with decreased risk for death or hospitalization was assessed. Of 677 adolescents, 238 were hospitalized and 54 died. In bivariate analysis, 11.7% with Hb <11 g/dl at study entry died versus 5% of those with initial Hb > or =11 g/dl (P = 0.001); 40.3% with baseline Hb <11 g/dl were hospitalized versus 31.1% with initial Hb > or =11 g/dl (P = 0.013). In multivariate analysis, Hb > or =11 g/dl was associated with decreased risk for death (hazard ratio [HR] 0.38; 95% confidence interval [CI] 0.20 to 0.72) but did not show a statistically significant association with decreased risk for hospitalization (HR 0.87; 95% CI 0.66 to 1.15). When Hb was recategorized as Hb <10, > or =10 and <11, > or =11 and < or =12, and >12 g/dl, risk of mortality declined as Hb level increased. At Hb 11 to 12 g/dl (versus Hb <10 g/dl), mortality risk decreased by 69% (HR 0.31; 95% CI 0.14 to 0.65). Risk for mortality was similar for Hb 11 to 12 and >12 g/dl. For hospitalization, no statistically significant difference in risk between Hb categories was found. This observational study of adolescents who are on HD is consistent with adult literature showing decreased mortality in patients who have ESRD and meet adult Hb targets. Further studies in the form of randomized, clinical trials are needed to assess optimal Hb levels for adolescents who are on HD.

Limited research has described clinical outcomes that are associated with the type of vascular access in pediatric patients who receive maintenance hemodialysis. This retrospective cohort study examined prevalent pediatric patients who were aged 12 to <18 yr and identified in the 2000 ESRD Clinical Performance Measures Project as receiving in-center hemodialysis. Vascular access type as of December 31, 1999, was identified. These patients were linked with 1 yr of data (January 1, 2000, through December 31, 2000) from US Renal Data System standard analytic files that allow for the comparison of rates of hospitalizations and access complications by access type. Of the 418 patients who met inclusion criteria, the mean age was 15.6 yr, 53% were male, 49% were white, the mean time on dialysis was 22 mo, and 42% had a structural/urologic cause of ESRD; 42% of patients had an arteriovenous graft or fistula, and 58% had a vascular catheter. Patients with a vascular catheter as compared with those with a graft or fistula had the following adjusted relative risks (95% confidence interval): 1.84 (1.38 to 2.44) for hospitalization for any cause, 4.74 (2.02 to 11.14) for hospitalization as a result of infection, and 2.72 (2.00 to 3.69) for a complication of vascular access. Vascular catheters are the predominant access type in adolescent patients who receive maintenance hemodialysis and are associated with significantly more hospitalizations and complications.

Background: There is limited information regarding outcomes of dialytic care for Hispanic adolescent hemodialysis patients., Methods: Ethnicity information was collected for all adolescent in-center hemodialysis patients for the Centers for Medicare & Medicaid Services 2000 End-Stage Renal Disease (ESRD) Clinical Performance Measures Project. Associations between intermediate outcomes and Hispanic ethnicity were determined. Associations of ethnicity and other demographic/clinical variables with hospitalization and transplantation during the 12-month follow-up period were examined., Results: Twenty-two percent of patients were identified as Hispanic; 40%, as non-Hispanic black; and 32%, as non-Hispanic white. Hispanic patients were younger and more likely to have congenital/urological causes of ESRD. More Hispanic patients had a mean single-pool Kt/V of 1.2 or greater compared with non-Hispanic blacks and non-Hispanic whites (87% versus 73% and 79%; P = 0.036). More Hispanic patients had a mean serum albumin level of 3.5/3.2 g/dL (bromcresol green/bromcresol purple method) or greater (> or = 35/32 g/L; 91% versus 82% and 76%; P = 0.017). More Hispanic patients compared with non-Hispanic blacks and non-Hispanic whites were dialyzed with a catheter for 90 days or longer (30% versus 21% and 23%; P = 0.027). In the final multivariate Cox proportional hazard models, Hispanic patients were at a slightly decreased risk for hospitalization compared with non-Hispanics (adjusted hazard ratio [adjHR], 0.63; P = 0.031) and were as likely to undergo a first transplantation as non-Hispanic whites (adjHR, 0.56; P = 0.099)., Conclusion: Adolescent Hispanic hemodialysis patients experience equivalent or better intermediate outcomes of dialytic care than non-Hispanics. They experienced a decreased risk for subsequent hospitalization and are as likely to undergo transplantation within 12 months as non-Hispanic whites.

Background: The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative guidelines recommend that adult hemodialysis (HD) patients receive a minimum dialysis dose by single-pooled Kt/V (spKt/V) of 1.2 or greater. There are no data to support a minimum spKt/V dose for children on HD therapy. We aim to determine the association of spKt/V with mortality and hospitalization in adolescents., Methods: Clinical characteristics of adolescent HD patients aged 12 to 18 years old included in the 2000/2001 End-Stage Renal Disease Clinical Performance Measures Project were linked to US Renal Data System data from October 1, 1999, to October 15, 2001. Hospitalization risks after adjustment for time on dialysis therapy, access, hemoglobin level, albumin level, and height were determined by means of Poisson regression. spKt/V was analyzed by the adult target (< versus > or = 1.2) and by intervals., Results: There were 613 patients with 477 patient-years of follow-up, during which there were 14 deaths and 185 hospitalizations covering 1,108 days. After adjustment, patients with an spKt/V less than 1.2 had increased hospitalization risk (1.59; 95% confidence interval, 0.98 to 2.56; P = 0.06) compared with those with an spKt/V of 1.2 or greater. Compared with patients with an spKt/V of 1.2 to 1.4, patients with an spKt/V less than 1.2 had increased adjusted risk for hospitalization (2.46; 95% confidence interval, 1.23 to 4.94; P = 0.01). Increases in spKt/V beyond 1.4 were not associated with improved outcomes., Conclusion: Applying the current adequacy guideline to adolescent HD patients is justified by the increased hospitalization risk of those who fail to attain an spKt/V of 1.2 or greater. However, attaining an spKt/V in excess of 1.4 was not associated with greater benefit.

Background: Children with end-stage renal disease (ESRD) receiving hemodialysis may have their care overseen primarily by a pediatric nephrologist or internal medicine (IM) nephrologist., Methods: To examine specific clinical outcomes by nephrologist specialization, a cross-sectional analysis of demographic and clinical data collected in the 2002 ESRD Clinical Performance Measures Project was performed., Results: Of 653 pediatric patients meeting inclusion criteria, 27% were cared for by IM nephrologists, and 73%, by pediatric nephrologists. Pediatric nephrologists were significantly more likely than IM nephrologists to care for patients who were younger and of Hispanic ethnicity. Patients of pediatric compared with IM nephrologists also were more likely to have a congenital cause of ESRD, smaller body mass index, and longer time on dialysis therapy. No significant differences in achieving a mean Kt/V of 1.2 or greater or mean hemoglobin level of 11 g/dL or greater (> or =110 g/L) according to nephrologist specialization were observed. After adjustment for patient clinical characteristics, no significant difference in use of arteriovenous fistulae was observed. Patients cared for by pediatric nephrologists were less likely to achieve a mean serum albumin level of 4.0/3.7 g/dL (40/37 g/L; bromcresol green laboratory method/bromcresol purple laboratory method; adjusted odds ratio, 0.60; 95% confidence interval, 0.42 to 0.86). Patients cared for by pediatric nephrologists had significantly greater serum calcium levels, lower serum phosphate levels, and lower intact parathyroid hormone levels., Conclusion: Using adult-focused clinical care targets, care provided by pediatric and IM nephrologists to pediatric patients receiving hemodialysis in the United States is similar. However, differences exist, and the significance of these differences requires further study.

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/m(2) (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.

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 > or =-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.

Chronic renal failure is, fortunately, an unusual occurrence in children; however, many children with various underlying illnesses develop acute renal failure, and transiently require renal replacement therapy - peritoneal dialysis, intermittent hemodialysis (IHD), or continuous renal replacement therapy (CRRT). As children with acute and chronic renal failure often have multiple comorbid conditions requiring drug therapy, generalists, intensivists, nephrologists, and pharmacists need to be aware of the issues surrounding the management of drug therapy in pediatric patients undergoing renal replacement therapy. This article summarizes the pharmacokinetics and dosing of many drugs commonly prescribed for pediatric patients, and focuses on the management of drug therapy in pediatric patients undergoing IHD and CRRT in the intensive care unit setting. Peritoneal dialysis is not considered in this review. Finally, a summary table with recommended initial dosages for drugs commonly encountered in pediatric patients requiring IHD or CRRT is presented.

In 2000 and 2001, The Centers for Medicare & Medicaid Services (CMS) End-Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) project collected data on all in-center hemodialysis (HD) patients in the United States aged >or=12 and <18 years. There were 433 of 486 (89%) patients and 435 of 516 (84%) patients who had the minimum required data submitted and were included in the 2000 and 2001 study years, respectively. There were 188 patients (43%) who had data submitted in both study years, providing longitudinal data on this cohort. A comparison of clinical parameters on these 188 patients in the 2000 and 2001 study years reveals significant improvement in mean calculated spKt/V (1.50+/-0.36 vs. 1.58+/-0.30, P<0.01), mean hemoglobin (11.0+/-1.6 g/dl vs. 11.5+/-1.3 g/dl, P<0.001), mean ferritin (286+/-278 ng/ml vs. 460+/-353 ng/ml, P<0.001), mean transferrin saturation (27.8+/-15.1% vs. 31.3+/-15.0%, P<0.05), mean serum albumin as measured by the bromocresol green method (3.83+/-0.54 g/dl vs. 3.95+/-0.42 g/dl, P<0.01), and mean height standard deviation score (-1.814+/-1.756 vs. -1.699+/-1.657, P<0.05). In addition, 20 of 29 (69%) patients who had a spKt/V <1.2 in the 2000 study year had a spKt/V >1.2 in the 2001 study year. Of 68 (44%) patients who had a catheter as their HD access in the 2000 study year, 30 had an arteriovenous fistula or graft in the 2001 study year and 49 of 80 (61%) patients who had a mean hemoglobin <11 g/dl in the 2000 study year had a hemoglobin >11 g/dl in the 2001 study year. In summary, these longitudinal data demonstrate significant improvements in nearly all clinical parameters studied in these adolescent HD patients.

The 2001 annual report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) registry includes data on 4,546 dialysis patients. Important trends in dialysis care include a significant increase in the use of peritoneal dialysis catheters with two cuffs (51.6% vs. 36.2%, P<0.001), a Swan neck tunnel (34.1% vs. 20.9%, P<0.001), and a downward pointing exit site (34.9% vs. 29.5%, P<0.001) in patients who initiated dialysis between 1997 and 2000 compared with 1992-1996. Most hemodialysis patients continued to have an external percutaneous catheter as their access at the time of initiation of dialysis (1,550/1,971 patients, 78.6%), but the odds of using a jugular rather than a subclavian vein for these catheters increased by 24% each year between 1992 and 2000. There was a significant trend for increasing use of erythropoietin and by 1996, 96% of patients were prescribed this medication at initiation of dialysis. There was also a modest, but significant, increase in hematocrit in the dialysis registry, as the median hematocrit at 6 months of follow-up was 31% in patients who started dialysis between 1997 and 2000 ( P<0.001).

Growth failure remains a significant problem for children with chronic renal insufficiency and end-stage renal disease (ESRD). We examined whether growth failure is associated with more-frequent hospitalizations or higher mortality in children with kidney disease. We studied data on prevalent United States pediatric patients with ESRD in 1990 who were followed through 1995. Patients were categorized according to the standard deviation score (SDS) of their incremental growth during 1990: severe (<-3 SDS), moderate growth failure (>-3 and <-2 SDS), and normal growth (>-2 SDS). Among 1,112 prevalent pediatric dialysis and transplant patients (<17 years, Tanner I-IV), those with severe and moderate growth failure had higher hospitalization rates [relative risk (RR) 1.14 [95% confidence interval (CI) 1.1, 1.2] and 1.24 [95% CI 1.2, 1.3]] respectively than those with normal growth after adjustment for age, gender, race, cause and duration of ESRD, and treatment modality (dialysis or transplant) in 1990. Kaplan-Meier survival analysis showed 5-year survival of 85% and 90% for patients with severe and moderate growth failure, respectively, compared with 96% for patients with normal growth ( P<0.001, log-rank). Cox proportional hazards analysis revealed that those with severe (RR 2.9, 95% CI 1.6, 5.3) and moderate growth failure (RR 2.01, 95% CI 1.1, 3.6) had an increased risk of death compared with youths with normal growth, after adjustment. A higher proportion of deaths in the severe and moderate growth failure groups were attributed to infectious causes (22% and 18.7%, respectively) than in the normal growth group (15.6%). We conclude that growth failure is associated with a more-complicated clinical course and increased risk of death for children with kidney failure.

In 2000, the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA) 2000 ESRD Clinical Performance Measures (CPM) Project, was expanded to obtain demographic characteristics and clinical information on all adolescent (age > or =12 years, <18 years) patients receiving in-center hemodialysis on 31 December, 1999. Of the 486 patients identified, 433 (89%) had the minimum required data submitted. Demographic characteristics included mean age of 15.8 years (+/-1.6 years). Forty-nine percent were white, 42% black; 21% were Hispanic. Congenital/urologic disease and focal and segmental sclerosis were the leading causes of end-stage renal disease. Forty-one percent had a catheter as their dialysis access, while 37% had an AV fistula and 22% an AV graft in place. The mean Kt/V was 1.47 (+/-0.38) and 79% had a mean calculated Kt/V> or =1.2, although residual renal function was not included in this measurement. After multivariate logistic regression, male gender and black race were among the factors predictive of mean calculated Kt/V<1.2. The mean serum albumin was 3.85 g/dl (+/-0.51) in patients with bromcresol green measurements and 3.62 mg/dl (+/-0.52) in patients with bromcresol purple measurements. The mean hemoglobin was 10.99 g/dl (+/-1.6) and 55% had a mean hemoglobin > or =11 g/dl. After multivariate logistic regression, lower epoetin dose and mean serum albumin > or =3.5/3.2 g/dl (BCG/BCP) remained predictive of mean hemoglobin > or =11 g/dl. These data provide important information about the clinical status of adolescent hemodialysis patients in the United States. Continued data collection and analyses are planned to identify areas for potential improvement in patient care.