Risk Factors and Rate of Progression of CKD in Children

Pediatric kidney replacement therapies in low-to-middle income countries: a review and white paper

Acute kidney injury (AKI) disproportionately impacts children in low- and middle-income countries (LMICs), where up to 85% of AKI cases occur. As for pediatric chronic kidney disease (CKD), the true burden in LMICs remains unclear, as many cases go undiagnosed early, and other children succumb without adequate treatment. Unfortunately, these disparities result from limited access to kidney replacement therapy (KRT), kidney laboratory and imaging resources, healthcare provider shortages, and financial barriers. Pediatric kidney disease in LMICs often remains undiagnosed until advanced stages, magnified by limited access to lifesaving KRT, leading to significantly higher mortality rates compared to high-income countries. Additional challenges include community-acquired AKI from preventable causes such as infections and dehydration, compounded by the use of nephrotoxic remedies, poor healthcare seeking behavior, and lack of monitoring. Pediatric data for this vulnerable population is lacking. For children with CKD, barriers to sustained treatment-including dialysis and transplantation-further worsen outcomes. Socioeconomic inequalities, geographic barriers, and cultural factors additionally exacerbate outcomes. Efforts to address these disparities include implementing affordable, resource-efficient peritoneal dialysis (PD) programs, enhancing healthcare worker training, and adopting innovative diagnostic technologies. Successful international collaborations, such as the Sister Renal Program, Saving Young Lives, and the Affordable Dialysis Project, have demonstrated the potential for improving access and outcomes. Advocacy for sustainable government policies, resource allocation, and integration of community-based approaches is critical. This paper highlights global inequities in pediatric nephrology care and proposes targeted strategies to enhance diagnostics, treatment, and management of AKI and CKD in LMICs. A call to action is issued to foster international collaboration and prioritize the needs of resource-limited regions.

Economic burden of inpatient hospitalizations for pediatric chronic kidney disease in the US

BACKGROUND

Children with chronic kidney disease (CKD) face extensive healthcare needs, leading to substantial financial strain on both families and healthcare systems due to costly kidney replacement therapies and associated comorbidities. Limited research on inpatient healthcare utilization is available for the individual stages of pediatric CKD.

METHODS

This retrospective cohort study included inpatient encounters for pediatric patients (≤ 18 years) using the Pediatric Health Information System Database (PHIS) between January 2016 and December 2022, with an ICD-10 code for any CKD stage (1-5). Hospitalization cost, length of stay (LOS), morbidity, and mortality data were collected.

RESULTS

We identified 23,980 pediatric CKD cases [stage 1: 5,059, stage 2: 6,763, stage 3: 7,012, stage 4: 3,102, and stage 5: 2,044] across 49 different children's hospitals in the United States. Mortality rates were observed to increase with increasing CKD severity, but no clear trend was observed for surgical, medical, and infection rates by CKD stage. The LOS for patients with CKD stage 4 and CKD stage 5 was 56% and 71% longer relative to the LOS of a typical hospitalization for a patient without CKD, and the billed charges for these hospitalizations were 92% and 147% higher than those of a typical hospitalization.

CONCLUSIONS

LOS and hospitalization costs were significantly higher for patients with CKD than for patients without CKD. Furthermore, pediatric patients with stage 5 CKD had significantly higher in-patient costs and all-cause hospitalization LOS compared to those with CKD stages 1-4.

Framework for Kidney Health Follow-Up Among Neonates With Critical Cardiac Disease: A Report From the Neonatal Kidney Health Consensus Workshop

Acute kidney injury is common among neonates with critical cardiac disease. Risk factors and associations with kidney-related outcomes are heterogeneous and distinct from other neonates. As survival of children with critical cardiac disease increases to adulthood, the burden of chronic kidney disease is increasing. Thirty percent to 50% of adults with congenital heart disease have impaired kidney function, even in the absence of prior kidney injury episodes. This may be related to the current standardized acute kidney injury criteria, which may not fully capture clinically meaningful kidney injury and long-term kidney health risks. An improved understanding of which neonates with critical cardiac disease should undergo kidney health follow-up is imperative. During the National Institutes of Health-supported Neonatal Kidney Health Consensus Workshop to Address Kidney Health meeting conducted in February 2024, a panel of 51 neonatal nephrology experts focused on at-risk groups: (1) preterm infants, (2) critically ill infants with acute kidney injury, and (3) infants with critical cardiac disease. The critical cardiac disease subgroup, comprising multidisciplinary experts, used a modified Delphi process to achieve consensus on recommendations for kidney health follow-up. In this report, we review available data on kidney health follow-up in critical cardiac disease and summarize the 2 consensus-based recommendations. We introduce novel diagnostic and risk-stratification tools for acute kidney injury diagnosis in neonates with cardiac disease to guide follow-up recommendations. Finally, we identify important knowledge gaps, representing areas of focus for future research. These should be prioritized to understand and improve long-term kidney health in critical cardiac disease.

Longitudinal progression trajectory of estimated glomerular filtration rate in children with chronic kidney disease: results from the KNOW-Ped CKD (KoreaN cohort study for Outcomes in patients With Pediatric Chronic Kidney Disease)

BACKGROUND

The natural course of chronic kidney disease (CKD) progression in children varies according to their underlying conditions. This study aims to identify different patterns of subsequent decline in kidney function and investigate factors associated with different patterns of estimated glomerular filtration rate (eGFR) trajectories.

METHODS

We analyzed data from the KNOW-Ped CKD (KoreaN cohort study for Outcomes in patients With Pediatric Chronic Kidney Disease), which is a longitudinal, prospective cohort study. A latent class linear mixed model was applied to identify the trajectory groups.

RESULTS

In a total of 287 patients, the median baseline eGFR (mL/min/1.73 m2) was 63.3, and the median age was 11.5 years. The eGFR decline rate was -1.54 during a 6.0-year follow-up. The eGFR trajectory over time was classified into four groups. Classes 1 (n = 103) and 2 (n = 11) had a slightly reduced eGFR at enrollment with a stable trend (ΔeGFR, -0.2/year) and a rapid decline eGFR over time (ΔeGFR, -10.5/year), respectively. Class 3 had a normal eGFR (n = 16), and class 4 had a moderately reduced eGFR (n = 157); both these chasses showed a linear decline in eGFR over time (ΔeGFR, -4.1 and -2.4/year). In comparison with classes 1 and 2, after adjusting for age, causes of primary renal disease, and baseline eGFR, nephrotic-range proteinuria was associated with a rapid decline in eGFR (odds ratio, 8.13).

CONCLUSION

We identified four clinically relevant subgroups of kidney function trajectories in children with CKD. Most children showed a linear decline in eGFR; however, there are different patterns of eGFR trajectories.

Chronic kidney disease

Chronic kidney disease (CKD) is defined by persistent abnormalities of kidney function or structure that have consequences for the health. A progressive decline of excretory kidney function has effects on body homeostasis. CKD is tightly associated with accelerated cardiovascular disease and severe infections, and with premature death. Kidney failure without access to kidney replacement therapy is fatal - a reality in many regions of the world. CKD can be the consequence of a single cause, but CKD in adults frequently relates rather to sequential injuries accumulating over the life course or to the presence of concomitant risk factors. The shared pathomechanism of CKD progression is the irreversible loss of kidney cells or nephrons together with haemodynamic and metabolic overload of the remaining nephrons, leading to further loss of kidney cells or nephrons. The management of patients with CKD focuses on early detection and on controlling all modifiable risk factors. This approach includes reducing the overload of the remaining nephrons with inhibitors of the renin-angiotensin system and the sodium-glucose transporter 2, as well as disease-specific drug interventions, if available. Hypertension, anaemia, metabolic acidosis and secondary hyperparathyroidism contribute to cardiovascular morbidity and reduced quality of life, and require diagnosis and treatment.

Catastrophic healthcare expenditure and caregiver burden in pediatric chronic kidney disease - a mixed methods study from a low resource setting

BACKGROUND

Caregivers of children with chronic kidney disease (CKD) in low resource settings must provide complex medical care at home while being burdened by treatment costs often paid out-of-pocket. We hypothesize that caregiver burden in our low resource setting is greater than reported from high income countries and is associated with frequent catastrophic healthcare expenditure (CHE).

METHODS

We conducted a mixed-methods study of primary caregivers of children with advanced CKD (stage 3b-5) in our private-sector referral hospital in a low resource setting. We assessed caregiver burden using the Pediatric Renal Caregiver Burden Scale (PRCBS) and measured financial burden by calculating the proportion of caregivers who experienced CHE (monthly out-of-pocket healthcare expenditure exceeding 10% of total household monthly expenditure). We performed a qualitative reflexive thematic analysis of caregiver interviews to explore sources of burden.

RESULTS

Of the 45 caregivers included, 35 (78%) had children on maintenance dialysis (25 PD, 10 HD). Mean caregiver burden score was 141 (± 17), greater than previously reported. On comparative analysis, PRCBS scores were higher among caregivers of children with kidney failure (p = 0.005), recent hospitalization (p = 0.03), non-earning caregivers (p = 0.02), caring for > 2 dependents (p = 0.009), and with high medical expenditure (p = 0.006). CHE occurred in 43 (96%) caregivers of whom 37 (82%) paid out-of-pocket. The main themes derived relating to caregiver burden were severe financial burden, mental stress and isolation, and perpetual burden of concern.

CONCLUSION

Parents of children with CKD experienced severe caregiver burden with frequent CHE and relentless financial stress indicating an imminent need for social support interventions.

Renal impairment is prevalent in pediatric NAFLD/MASLD and associated with disease severity

OBJECTIVES

Renal impairment is prevalent in adults with nonalcoholic fatty liver disease (NAFLD/metabolic dysfunction associated steatotic liver disease [MASLD]) and is associated with increased mortality. Pediatric data are limited. Our objective was to determine the prevalence of hyperfiltration or chronic kidney disease (CKD) in children with NAFLD/MASLD and determine links with liver disease severity.

METHODS

Data from children who had previously participated in prospective, multicenter, pediatric studies by the Nonalcoholic Steatohepatitis Clinical Research Network (NASH-CRN) were collected. Renal function was determined using the calculated glomerular filtration rate (cGFR). Hyperfiltration was defined as cGFR > 135 mL/min/1.73m2, while CKD stage 2 or higher as cGFR < 90 mL/min/1.73 m2. Renal dysfunction progression was defined as transition from normal to hyperfiltration or to CKD stage ≥ 2, or change in CKD by ≥1 stage. Multinomial logistic regression models were used to determine the prevalence of CKD and independent associations between CKD and liver disease severity.

RESULTS

The study included 1164 children (age 13 ± 3 years, 72% male, 71% Hispanic). The median cGFR was 121 mL/min/1.73 m2; 12% had CKD stage 2-5, while 27% had hyperfiltration. Hyperfiltration was independently associated with significant liver fibrosis (odds ratio: 1.45). Baseline renal function was not associated with progression in liver disease over a 2-year period (n = 145). Renal dysfunction worsened in 19% independently of other clinical risk factors. Progression of renal impairment was not associated with change in liver disease severity.

CONCLUSIONS

Renal impairment is prevalent in children with NAFLD/MASLD and hyperfiltration is independently associated with significant liver fibrosis. Almost 1/5 children have evidence of progression in renal dysfunction over 2 years, not associated with change in liver disease severity. Future assessments including additional renal impairment biomarkers are needed.

Prevalence and associated factors of impaired kidney functions among children and adolescents in India: insights from the Comprehensive National Nutrition Survey (CNNS) 2016-18

BACKGROUND

Chronic kidney disease (CKD) is a significant public health problem. The burden of CKD in children and adolescents in India is not well described. We used data from the recent Comprehensive National Nutrition Survey (CNNS) to estimate the prevalence of impaired kidney function (IKF) and its determinants in children and adolescents between the ages of 5 and 19.

METHODS

CNNS 2016-18 adopted a multi-stage sampling design using probability proportional to size sampling procedure after geographical stratification of urban and rural areas. Serum creatinine was tested once in 24,690 children and adolescents aged 5-19 years. The estimated glomerular filtration rate (eGFR) was derived using the revised Schwartz equation. The eGFR value below 60 ml/min/1.73 m2 is defined as IKF. Bivariate analysis was done to depict the weighted prevalence, and multivariable logistic regression examined the predictors of IKF.

RESULTS

The mean eGFR in the study population was 113.3 + 41.4 mL/min/1.73 m2. The overall prevalence of IKF was 4.9%. The prevalence in the 5-9, 10-14, and 15-19 year age groups was 5.6%, 3.4% and 5.2%, respectively. Regression analysis showed age, rural residence, non-reserved social caste, less educated mothers, Islam religion, children with severe stunting or being overweight/obese, and residence in Southern India to be predictors of IKF.

CONCLUSIONS

The prevalence of IKF among children and adolescents in India is high compared to available global estimates. In the absence of repeated eGFR-based estimates, these nationally representative estimates are intriguing and call for further assessment of socio-demographic disparities, genetics, and risk behaviours to have better clinical insights and public health preparedness.

Socioeconomic Position and Health Among Children and Adolescents With CKD Across the Life-Course

Children and adolescents in families of lower socioeconomic position (SEP) experience an inequitable burden of reduced access to healthcare and poorer health. For children living with chronic kidney disease (CKD), disadvantaged SEP may exacerbate their considerable disease burden. Across the life-course, CKD may also compromise the SEP of families and young people, leading to accumulating health and socioeconomic disadvantage. This narrative review summarizes the current evidence on relationships of SEP with kidney care and health among children and adolescents with CKD from a life-course approach, including impacts of family SEP on kidney care and health, and bidirectional impacts of CKD on SEP. It highlights relevant conceptual models from social epidemiology, current evidence, clinical and policy implications, and provides directions for future research. Reflecting the balance of available evidence, we focus primarily on high-income countries (HICs), with an overview of key issues in low- and middle-income countries (LMICs). Overall, a growing body of evidence indicates sobering socioeconomic inequities in health and kidney care among children and adolescents with CKD, and adverse socioeconomic impacts of CKD. Dedicated efforts to tackle inequities are critical to ensuring that all young people with CKD have the opportunity to live long and flourishing lives. To prevent accumulating disadvantage, the global nephrology community must advocate for local government action on upstream social determinants of health; and adopt a life-course approach to kidney care that proactively identifies and addresses unmet social needs, targets intervening factors between SEP and health, and minimizes adverse socioeconomic outcomes across financial, educational and vocational domains.

Understanding Similarities and Differences in CKD and Dialysis Care in Children and Adults

In lower-income settings there is often a dearth of resources and nephrologists, especially pediatric nephrologists, and individual physicians often find themselves caring for patients with chronic kidney diseases and end-stage kidney failure across the age spectrum. The management of such patients in high-income settings is relatively protocolized and permits high-volume services to run efficiently. The basic principles of managing chronic kidney disease and providing dialysis are similar for adults and children, however, given the differences in body size, causes of kidney failure, nutrition, and growth between children and adults with kidney diseases, nephrologists must understand the relevance of these differences, and have an approach to providing quality and safe dialysis to each group. Prevention, early diagnosis, and early intervention with simple therapeutic and lifestyle interventions are achievable goals to manage symptoms, complications, and reduce progression, or avoid kidney failure in children and adults. These strategies currently are easier to implement in higher-resource settings with robust health systems. In many low-resource settings, kidney diseases are only first diagnosed at end stage, and resources to pay out of pocket for appropriate care are lacking. Many barriers therefore exist in these settings, where specialist nephrology personnel may be least accessible. To improve management of patients at all ages, we highlight differences and similarities, and provide practical guidance on the management of children and adults with chronic kidney disease and kidney failure. It is important that children are managed with a view to optimizing growth and well-being and maximizing future options (eg, maintaining vein health and optimizing cardiovascular risk), and that adults are managed with attention paid to quality of life and optimization of physical health.

Youngest en-bloc kidney transplant recipient in India: defying the barriers and challenges with teamwork

We received a call from a transplant coordinator about the availability of a consented deceased donor. En-bloc kidneys with the aorta and IVC (inferior vena cava) were harvested from a toddler weighing 8 kg. The recipient was of early childhood weighing 14 kg who had been on haemodialysis for the last 3 years for end-stage kidney disease. He received anti-thymocyte globulin as an induction immunosuppressant. The kidneys were transplanted en bloc in the right lower quadrant retroperitoneal region; an anastomosis was performed to the recipient's aorta and IVC, and two separate neocystoureterostomies were created. His serum creatinine reached 0.5 mg/dL on the seventh postoperative day, following a few days of delayed graft function. In this study, we describe the surgical and non-surgical challenges that we faced while performing en-bloc kidney transplant to the youngest recipient and how a multidisciplinary team approach helped us overcome them.

Risk factors for progression of chronic kidney disease: An investigation in prepubertal children

AIM

Previous studies on progression of chronic kidney disease (CKD) in children have included older post-pubertal subjects. This study attempted to evaluate risk factors for progression of CKD in pre-pubertal children.

METHODS

An observational study of children aged 2-10 years with an eGFR within the limits of >30 and <75 mL/min/1.73 m² was performed. Presenting clinical and biochemical risk factors, as well as diagnosis, were analysed for their association with progression to kidney failure, time to kidney failure and for the rate of decline of kidney function.

RESULTS

One hundred and twenty-five children were studied of whom 42 (34%) had progressed to CKD stage 5 during the median period of follow up of 3.1 (IQR = 1.8-6) years. Hypertension, anaemia and acidosis at entry were associated with progression but they did not predict reaching the end point. Only glomerular disease, proteinuria and stage 4 kidney disease were independent predictors of kidney failure and the time to kidney failure. The rate of kidney function decline was greater in patients with glomerular than non-glomerular disease.

CONCLUSIONS

Common modifiable risk factors, when present at initial evaluation, were not independently associated with CKD progression to kidney failure in prepubertal children. Only non-modifiable risk factors and proteinuria predicted eventual stage 5 disease. The physiological changes of puberty may be the major precipitator of kidney failure during adolescence.

Fatigue assessment and its predictors in pediatric patients with chronic kidney disease stages III to V

Background

Chronic fatigue is an intense subjective feeling of mental or physical exhaustion. It influences patients’ daily functioning and quality of life, delays recovery, and increases mortality, especially in chronic kidney disease (CKD) patients. The aim of this study is to assess and determine predictors of chronic fatigue in children with ESRD, dialysis, and pre-dialysis stages that can affect the patients’ quality of life (QOL).

Methods

We conducted a cross-sectional study on 114 patients diagnosed with CKD stages III to V, following at the nephrology outpatient clinic and hemodialysis (HD) unit of Cairo University Children’s Hospital during the period September 2020 till April 2021. Demographic and laboratory data of patients were gathered, and dialytic analysis in the form of frequency, duration of dialysis sessions, and adequacy of hemodialysis was calculated. The fatigue severity score (FSS) questionnaire was used to assess fatigue’s effects on daily functions, querying its relationship to motivation, physical activity, work, family, and social life.

Results

The mean age in the current study was (8.8 ± 1.8) years, with 62% being males. The median FSS score was 5.8, with a higher FSS score in stage V CKD patients. High e-GFR, serum sodium, folic acid, and L-carnitine supplementation all reduced the intensity of fatigue, while prolonged HD duration, acidosis, hypertension, and non-compliance to vitamin D replacement increased tiredness severity.

Conclusion

Routine fatigue assessment and measures to reduce it is a fundamental issue in pediatric CKD patients for better QOL.

Etiology, Comorbidities, and Rate of Progression of Pediatric Chronic Kidney Disease: A Cohort Study

OBJECTIVES

To evaluate the etiology of pediatric chronic kidney disease (CKD), assess comorbidities, and identify rate of progression of CKD and its risk factors.

METHODS

Children aged 2-18 y with the Kidney Disease Improving Global Outcome (KDIGO) CKD stages 2-4 were enrolled. The etiology of CKD and its comorbidities were recorded. Kaplan-Meier survival curves were used to analyze the time to progression of CKD.

RESULTS

Of the 131 patients enrolled, CKD stages 2, 3a, 3b, and 4 constituted 62 (47.3%), 17 (13%), 26 (19.8%), and 26 (19.8%), respectively. At the last follow-up [at median (IQR) 24 (12, 30) mo], the number of children in CKD stages 2, 3a, 3b, 4 and 5 were 48 (36.6%), 16 (12.2%), 23 (17.6%), 28 (21.4%), and 16 (12.2%), respectively. Etiologies of CKD included obstructive uropathy [48 (36.6%)], chronic glomerular disease [19 (14.5%)], reflux nephropathy [14 (10.7%)] and cystic renal disease [11 (8.3%)]. Comorbidities during follow-up included CKD-MBD [87 (66.4%)], metabolic acidosis [95 (72.5%)], hypertension [88 (67.1%)], growth retardation [69 (52.6%)], and anemia [63 (48.1%)]. The number of patients with metabolic acidosis, hypertension, MBD and anemia in CKD stage 2 were 27 (56%), 26 (54.2%), 24 (50%), 15 (30%), respectively. The median (IQR) rate of decline in eGFR was 3.3 (2, 4.6) mL/min/1.73 m²/y. On multivariable analysis, proteinuria [hazard ratio 3.5 (95% CI 1.4, 8.8) p = 0.01] and hyperphosphatemia [hazard ratio 2.2 (95% CI 1.1, 4.3) p = 0.03] were significant predictors for progression of CKD.

CONCLUSIONS

Even the earlier stages of CKD had significant comorbidities. The median decline in eGFR was 3.3 mL/min/1.73 m²/y. Proteinuria and hyperphosphatemia were the risk factors for progression of CKD.

Paediatric nephrology in under-resourced areas

BACKGROUND

Nearly 50% of the world population and 60% of children aged 0 to 14 years live in low- or lower-middle-income countries. Paediatric nephrology (PN) in these countries is not a priority for allocation of limited health resources. This article explores advancements made and persisting limitations in providing optimal PN services to children in such under-resourced areas (URA).

METHODS

Medline, PubMed and Google Scholar online databases were searched for articles pertaining to PN disease epidemiology, outcome, availability of services and infrastructure in URA. The ISN and IPNA offices were contacted for data, and two online questionnaire surveys of IPNA membership performed. Regional IPNA members were contacted for further detailed information.

RESULTS

There is a scarcity of published data from URA; where available, prevalence of PN diseases, managements and outcomes are often reported to be different from high income regions. Deficiencies in human resources, fluoroscopy, nuclear imaging, immunofluorescence, electron microscopy and genetic studies were identified. Several drugs and maintenance kidney replacement therapy are inaccessible to the majority of patients. Despite these issues, regional efforts with support from international bodies have led to significant advances in PN services and infrastructure in many URA.

CONCLUSIONS

Equitable distribution and affordability of PN services remain major challenges in URA. The drive towards acquisition of regional data, advocacy to local government and non-government agencies and partnership with international support bodies needs to be continued. The aim is to optimise and achieve global parity in PN training, investigations and treatments, initially focusing on preventable and reversible conditions.

Addressing the Ethical Challenges of Providing Kidney Failure Care for Children: A Global Stance

Children with kidney failure require kidney replacement therapy (KRT), namely maintenance dialysis and kidney transplant. Adequate kidney failure care consists of KRT or conservative treatment with palliative care. In the context of kidney failure, children depend on parents who are their surrogate decision-makers, and the pediatric nephrology team for taking decisions about KRT or conservative care. In this paper, we discuss the ethical challenges that arise relating to such decision-making, from a global perspective, using the framework of pediatric bioethics. While many ethical dilemmas in the care of children with KRT are universal, the most significant ethical dilemma is the inequitable access to KRT in low & middle income countries (LMICs) where rates of morbidity and mortality depend on the family's ability to pay. Children with kidney failure in LMICs have inadequate access to maintenance dialysis, timely kidney transplant and palliative care compared to their counterparts in high income countries. Using case vignettes, we highlight how these disparities place severe burdens on caregivers, resulting in difficult decision-making, and lead to moral distress among pediatric nephrologists. We conclude with key action points to change this status-quo, the most important being advocacy by the global pediatric nephrology community for better access to affordable kidney failure care for children.

Sex and gender differences in chronic kidney disease and access to care around the globe

The difference between sex, the biological construct, and gender, the social construct, may be most evident in settings of vulnerability. Globally, chronic kidney disease is more prevalent among women, but the prevalence of end-stage kidney failure, and especially receipt of kidney replacement therapy, is higher in men. These differences likely reflect a combination of physiological and social/structural risk factors that independently modulate kidney disease and/or its progression. The distribution of the most common risk factors such as hypertension and obesity differ between men and women and may impact disease risk differentially. Social and structural gender-related inequities remain stark across the globe. More women live in poverty, receive less education, and are more dependent on others for health care decision making, but men may have a higher risk of injury, occupational exposures, and less access to screening, prevention, and primary care. In this article, we explore how social determinants of health affect kidney disease risk and access to care differentially across genders, and differently across the globe. We also describe specific challenges experienced by boys and girls with kidney disease, how culture and geography may impact kidney care in places where resources are particularly limited such as sub-Saharan Africa, and give examples of social and structural circumstances that place young men and women at high risk of kidney disease in Mexico and Central America, illustrated by case vignettes. The coronavirus disease-2019 pandemic has raised awareness of pervasive gender-based inequities within all societies. This applies to kidney disease and is not new. The nephrology community must add its voice to the calls for action, for a more just society overall, and for the recognition of the roles of sex and gender as modulators of kidney disease risk and access to care.

Paediatric kidney transplantation in under-resourced regions-a panoramic view

Kidney transplantation is the ideal choice of kidney replacement therapy in children as it offers a low risk of mortality and a better quality of life. A wide variance in the access to kidney replacement therapies exists across the world with only 21% of low- and low-middle income countries (LLMIC) undertaking kidney transplantation. Pediatric kidney transplantation rates in these under-resourced regions are reported to be as low as < 4 pmcp [per million child population]. A robust kidney failure care program forms the cornerstone of a transplant program. Even the smallest transplant program entails a multidisciplinary workforce and expertise besides ensuring family commitment towards long-term care and economic burden. In general, the short-term graft survival rates from under-resourced regions are comparable to most high-income countries (HIC) and the challenge lies in the long-term outcomes. This review focuses on specific issues relevant to kidney transplants in children in under-resourced regions by highlighting limitations in the capacity and health workforce, regulatory norms, medical issues, economic burden, factors beyond financial hardship and ethical considerations relevant to these regions. Finally, the perspective of strengthening transplant programs in these regions should factor in the bigger challenges that exist in achieving the health-related sustainable development goals by 2030.

Challenges of access to kidney care for children in low-resource settings

Kidney disease is a global public health concern across the age spectrum, including in children. However, our understanding of the true burden of kidney disease in low-resource areas is often hampered by a lack of disease awareness and access to diagnosis. Chronic kidney disease (CKD) in low-resource settings poses multiple challenges, including late diagnosis, the need for ongoing access to care and the frequent unavailability of costly therapies such as dialysis and transplantation. Moreover, children in such settings are at particular risk of acute kidney injury (AKI) owing to preventable and/or reversible causes - many children likely die from potentially reversible kidney disease because they lack access to appropriate care. Acute peritoneal dialysis (PD) is an important low-cost treatment option. Initiatives, such as the Saving Young Lives programme, to train local medical staff from low-resource areas to provide care for AKI, including acute PD, have already saved hundreds of children. Future priorities include capacity building for both educational purposes and to provide further resources for AKI management. As local knowledge and confidence increase, CKD management strategies should also develop. Increased awareness and advocacy at both the local government and international levels will be required to continue to improve the diagnosis and treatment of AKI and CKD in children worldwide.