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The management of chronic kidney disease is complex. With disease management being the responsibility of parents in the paediatric renal clinic, the responsibility is gradually shifted to adolescents and young adults during the transition to adult care. This multi-perspective qualitative study aimed to explore the experiences of adolescents and young adults, their parents and health professionals to gain an insight into transitional care. Focussing on the transition process and transfer to adult care, 18 adolescents and young adults and eight mothers participated in individual semi-structured interviews. Additionally, three focus groups were conducted with 20 multidisciplinary health professionals. Data were transcribed verbatim and analysed thematically. Similar responses from adolescents and young adults and mothers included the reluctance to leave the paediatric health service. Mothers found the transition to adult care more challenging than the adolescents and young adults. While health professionals acknowledged that engaging adolescents and young adults in their own care was challenging, they believed parents had an important role in facilitating their child's independence. This study highlights that health professionals in both paediatric and adult health services need to work collaboratively. However, importantly, health professionals need to be mindful that parents require an equal amount of engagement as adolescents and young adults, if not more, to mitigate parental barriers in achieving a successful transfer.Copyright © The Author(s) 2021.

AIM: Cardiovascular death is a leading cause of mortality in paediatric end stage kidney disease (ESKD). There is however little known about clinically relevant vascular disease in this population. We aimed to describe the incidence of new onset vascular disease and vascular death in Australian children receiving renal replacement therapy (RRT). We also aimed to identify demographic or childhood risk factors for these endpoints, and whether vascular disease predicts mortality. METHOD(S): Data on Australian patients who commenced RRT at <18years of age from 1991-2017 was extracted from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). Multivariable competing risks regression was used to identify factors associated with vascular events. RESULT(S): A cohort of 1268 patients were followed up for a median of 10.31years. Vascular disease was reported in 5.4%, and vascular death in 4.1%. The cumulative incidence of any vascular event, i.e. disease or death, at 10 and 20years was 5.5% and 12.8% respectively. Childhood vascular events were associated with non-Caucasian, non-Indigenous ethnicity, and for the 804 patients followed-up after 18years of age, vascular events were associated with lack of childhood transplantation, longer childhood dialysis duration and Indigenous ethnicity. Vascular disease was only reported for 25.49% of patients who had a vascular death, and although a significant risk factor for mortality, it had limited ability to predict mortality. CONCLUSION(S): Cumulative incidence of vascular events is significant after commencing RRT during childhood and is associated with ethnicity, longer childhood dialysis duration and lack of childhood transplantation.Copyright This article is protected by copyright. All rights reserved.

Aim: We aimed to describe the incidence of new onset vascular disease and vascular death in Australian children receiving renal replacement therapy (RRT). We also aimed to evaluate whether demographic or childhood clinical factors predict these endpoints, and whether vascular disease predicts mortality. Background(s): Cardiovascular death is a leading cause of mortality in paediatric end stage kidney disease (ESKD). There is however relatively little known about clinically relevant vascular disease in this population. Method(s): Data on Australian patients who commenced RRT at <18 years of age from 1991-2017 were extracted from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). The association of variables with outcomes were evaluated using Fine and Gray competing risk models. Result(s): A cohort of 1268 patients were followed up for a median of 10.31 years. Vascular disease was reported in 5.4%, and vascular death in 4.1%. The cumulative incidence of any vascular event, i.e. disease or death, at 10 and 20 years was 5.5% and 12.8% respectively. Vascular events were predicted by non-Caucasian (especially Indigenous) ethnicity. For the 804 patients who were followed-up after 18 years of age, vascular disease was predicted by longer childhood dialysis duration and vascular mortality by lack of transplantation during childhood. Whilst vascular disease was only reported for 15.4% of patients who had a vascular death, it was predictive of mortality. Conclusion(s): Cumulative incidence of vascular events is significant after commencing RRT during childhood. Vascular events are associated with ethnicity, longer childhood dialysis duration and lack of transplantation during childhood.

Aim: To understand antibody mediated rejection (AMR) surveillance and management among paediatric nephrologists. Background(s): Little high-quality evidence exists to guide AMR management in kidney transplantation. A recent consensus statement from The Transplantation Society provides recommendations based on expert opinion. In paediatrics there may be challenges that lead physicians to vary practice from such recommendations. Method(s): Members of the Australian and New Zealand Paediatric Nephrology Association (ANZPNA) were emailed an electronic survey in June 2020. Scenarios were presented of non-ABOI, non-pre-sensitized patients with AMR. Result(s): Of 34 ANZPNA nephrologists, 11 responded with 80% survey completion rate. Whilst the majority (66%) do not perform protocol biopsies, the majority do undertake routine DSA surveillance (66%), mostly at yearly intervals, starting at 6 months post-transplant. AT1R antibody testing is performed by 90%, most commonly in DSA negative AMR or with past early graft thrombosis. For a 10-week indication biopsy demonstrating PTC1 and linear C4d, 81% used a combination of methylprednisolone, IVIG and plasma exchange before DSA status was known. There was some variation dependent on presence of vascular access, concomitant T-cell rejection and degree of creatinine rise. There were 3 respondents who added rituximab with a subsequent finding of a Class 1 or 2 DSA with MFI 2200. IVIG prescription was highly variable. Plasma exchange with IVIG was used by 66% in late DSA+ AMR at 18 months. Where chronic active AMR at 6 years is associated with 25% IFTA and an eGFR drop to 30, plasma exchange with IVIG was used by 44% and IVIG/Rituximab combination by 44%. Conclusion(s): Considerable variation exists in paediatric AMR management. Physicians are more aggressive in chronic active AMR management than published recommendations.

Background: Young children starting kidney replacement therapy (KRT) suffer high disease burden with unique impacts on growth and development, timing of transplantation and long-term survival. Contemporary long-term outcome data and how these relate to patient characteristics are necessary for shared decision-making with families, to identify modifiable risk factors and inform future research. Method(s): We examined outcomes of all children <= 5 years enrolled in the Australia and New Zealand Dialysis and Transplant Registry, commencing KRT 1980-2017. Primary outcomes were patient and graft survival. Final height attained was also examined. We used generalized additive modelling to investigate the relationship between age and graft loss over time post-transplant. Result(s): In total, 388 children were included, of whom 322 (83%) received a kidney transplant. Cumulative 1-, 5- and 10-year patient survival probabilities were 93%, 86% and 83%, respectively. Death censored graft survival at 1, 5 and 10 years was 93%, 87% and 77%, respectively. Most children were at least 10 kg at transplantation (n = 302; 96%). A non-linear relationship between age at transplantation and graft loss was observed, dependent on time post-transplant, with increased risk of graft loss among youngest recipients both initially following transplantation and subsequently during adolescence. Graft and patient survival have improved in recent era. Conclusion(s): Young children commencing KRT have good long-term survival and graft outcomes. Early graft loss is no reason to postpone transplantation beyond 10 kg, and among even the youngest recipients, late graft loss risk in adolescence remains one of the greatest barriers to improving long-term outcomes.Copyright © 2021, Crown.

Background: In this 30-year national review, we describe trends in DD transplantation for paediatric recipients, assess the impact of paediatric allocation bonuses and identify outstanding areas of need for this population. Method(s): A retrospective review of all DD kidney only transplants to paediatric recipients (<18 years old) in Australia between 1989 and 2018 was conducted using deidentified extracts from the ANZDATA. Result(s): Of the 1011 kidney only transplants performed in paediatric recipients during the study period, 426 (42%) were from deceased donors. Paediatric candidates on the DD waiting list had consistently higher rates of transplantation and shorter time from dialysis initiation to transplantation compared with adult candidates (median 372 vs 832 days in 2018, for example). Donor characteristics remained more favourable for paediatric recipients, despite a decline in the overall quality of the donor pool. The mean number of HLA antigen mismatches for paediatric recipients of DD transplants increased each decade (2.86 [1989-1998], 3.85 [1999-2008], 4.01 [2009-2018]). Both patient and graft survival have improved for paediatric DD transplant recipients in the most recent era (5-year graft and patient survival 85% vs 65% and 99% vs 94%, respectively, for 2009-2018 vs 1999-2008). Conclusion(s): The current DD kidney allocation system in Australia provides rapid access to high-quality organs for paediatric recipients, and early graft loss has decreased significantly in recent years; however, additional targeted interventions to address HLA matching may improve long-term outcomes in this population.Copyright © 2021 The Authors. Pediatric Transplantation published by Wiley Periodicals LLC.

Aim: Cardiovascular death is a leading cause of mortality in paediatric end-stage kidney disease (ESKD). There is however little known about the clinically relevant vascular disease in this population. We aimed to describe the incidence of new onset vascular disease and vascular death in Australian children receiving renal replacement therapy (RRT). We also aimed to identify demographic or childhood risk factors for these endpoints, and whether vascular disease predicts mortality. Method(s): Data on Australian patients who commenced RRT at <18 years of age from 1991 to 2017 were extracted from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). Multivariable competing risks regression was used to identify factors associated with vascular events. Result(s): A cohort of 1268 patients were followed up for a median of 10.31 years. Vascular disease was reported in 5.4%, and vascular death in 4.1%. The cumulative incidence of any vascular event, that is, disease or death, at 10 and 20 years was 5.5% and 12.8%, respectively. Childhood vascular events were associated with non-Caucasian, non-Indigenous ethnicity, and for the 804 patients followed up after 18 years of age, vascular events were associated with lack of childhood transplantation, longer childhood dialysis duration and Indigenous ethnicity. Vascular disease was only reported for 25.49% of patients who had a vascular death, and although a significant risk factor for mortality, it had limited ability to predict mortality. Conclusion(s): Cumulative incidence of vascular events is significant after commencing RRT during childhood and is associated with ethnicity, longer childhood dialysis duration and lack of childhood transplantation.Copyright © 2021 Asian Pacific Society of Nephrology.

Background: HLA epitope-based matching offers the potential to improve immunological risk prediction and management in children receiving renal allografts; however, studies demonstrating the association between systems for defining epitope mismatches and clinical end-points are lacking in this population. Method(s): We conducted a pragmatic, retrospective, registry-based study of pediatric recipients of primary renal allografts in Victoria, Australia between 1990 and 2014 to determine the association between HLA EpMM and clinical outcomes including graft failure, re-transplantation and dnDSA formation. Result(s): A total of 196 patients were included in the analysis with a median age of 11 years. Median follow-up period was 15 years during which time 108 (55%) primary grafts failed and 72 patients were re-transplanted. HLA class I but not class II EpMM was a significant predictor of graft failure on univariate analysis but not in adjusted models. EpMM was associated with reduced likelihood of re-transplantation in univariate but not adjusted analysis. Within the limitations of the study, class-specific EpMM was a strong predictor of dnDSA formation. Associations were stronger when considering only the subset of antibody-verified EpMM. Conclusion(s): Associations between HLA EpMM and clinical outcomes in pediatric renal allograft recipients seen on univariate analysis were attenuated following adjustment for confounders. These findings are inconclusive but suggest that HLA EpMM may provide one tool for assessing long-term risk in this population while highlighting the need for further clinical studies.Copyright © 2020 Wiley Periodicals LLC

Background: Phenobarbitone (PB) is the first-line anti-convulsant for neonatal seizures. The use of peritoneal dialysis (PD) to enhance drug elimination in cases of neonatal PB overdose has not been reported. Objective(s): To report a case of neonatal severe PB toxicity and review the elimination of PB by PD. Method(s): Assessment of PD drug clearance. Result(s): A neonate with prolonged seizures was administered PB. Encephalopathy and myocardial failure developed, which were initially suspected to be secondary to hypoxia. At 42 h of age, the serum PB concentration was in the toxic range at 131 mg/L. Despite supportive care, the infant's condition deteriorated with escalating inotropes and the need for CPR. Enhanced PB elimination via multiple-dose activated charcoal and exchange transfusion were considered too risky. Hourly PD cycles via Tenckhoff catheter were commenced, based on reports suggesting that PD enhances PB clearance. The clinical state of the infant then improved. PD administration was continued for 60 h, recovering 20% of the estimated total PB body load. The infant survived and there were no PD complications. Conclusion(s): PD increased PB clearance in this neonate, correlating with clinical recovery. Where other techniques are not possible, PD may have a role to play in enhancing PB elimination.Copyright © 2017 S. Karger AG, Basel.

Aim: To evaluate the association between evidence based targets of haemoglobin (Hb), phosphate and calcium in young (age <25yrs) dialysis patients with demographic and clinical variables, and explore the impact of these categories on time to transplant and survival on dialysis. Background(s): Hb and phosphate are associated with mortality on dialysis in adult patients. Whether these relationships hold in young patients with less comorbidities is unclear. Off-target indices may also be associated with transplantation delay given postulated links to nonadherence. Method(s): All incident young Australian dialysis patients (N=789) within ANZDATA from 2003 to 2015 were assessed. First reported uncorrected calcium, haemoglobin (Hb) and phosphate at 3-15 months were categorized according to evidence based targets. Multivariate Cox models with age stratification were developed to examine associations between categories with time to transplant and mortality. Result(s): Low calcium and phosphate were significantly more common in those with diabetic kidney disease (42.9%, 30.8% respectively) compared with glomerulonephritis (14.66%, 15%). High phosphate was associated with older age, and high calcium with younger age. Hb>120 was more common in regional/remote (25.2% versus 19% cities) or low socioeconomic postcodes (27.3% lowest SES, 13.9% highest SES). Time to transplant did not associate with Hb, phosphate or calcium categories in the multivariate analysis. Mortality was significantly associated with Hb>120 for those starting dialysis at 20-25 years (HR 4.1 95%CI 1.64-10.1). Low calcium was associated with mortality for the 15-20 year age group (HR 12.4 95%CI 1.7-91). Conclusion(s): Age, remoteness, SES, race, and ESKD cause were associated with off-target calcium, phosphate and Hb. These indices did not associate with time to transplant, however high Hb was associated with increased mortality on dialysis.

DD kidney allocation protocols may influence timing of transplantation and graft quality for pediatric recipients. This study aimed to evaluate the effects of these protocols, including pediatric priority, on waiting time on dialysis, transplant type, donor age, and HLA matching according to state of transplant in Australia. De-identified information on patients <15 yr of age who commenced RRT in NSW, Qld, and Victoria from 2002 to 2011 was retrieved from the ANZDATA. Transplant type, donor age, and HLA mismatching were compared between states, with competing risk regression used to examine the time to transplant. There were significant differences in waiting time to DD transplantation between the three states. Children in NSW and Qld waited a median of 14 and 11 months vs. 21 months in Victoria. The ratio of LD to DD transplants was lower in NSW and Qld. Differences correlated with DD pediatric priority in NSW and Qld. DDs in NSW were older than in the other states. HLA matching did not differ. DD kidney allocation protocols with pediatric priority in Australian states were associated with shorter waiting times and increased DD proportion.Copyright © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.