Cost analysis of substitutive renal therapies in children

Candidacy Decisions for Long-term Ventilation

Decisions to initiate long-term ventilation (LTV) in children with severe neurologic impairment have recently been subject to candidacy determinations by home ventilation teams that exclude patients based on their neurologic status alone. Determinations of whether decisions are inappropriate require careful analysis of specific clinical circumstances and attention to the family's values. In this Ethics Rounds, we present a case of a previously healthy child who sustained an acute severe anoxic brain injury and was assessed by the medical team to have a high likelihood of remaining minimally conscious or unconscious. It was determined that he was not a candidate for LTV based on the severity of neurologic impairment. The family disagreed and declined withdrawal of ventilatory support. Drawing upon our backgrounds in intensive care, pulmonology, and bioethics, we offer commentary on utilizing a candidacy-based approach for LTV decisions in children with severe neurologic impairment from variable perspectives, including clinical determinations of inappropriate care, ablest biases and discrimination, and obligations to maintain a just process.

Cost Analysis of End-Stage Renal Disease in Pediatric Patients in Greece

BACKGROUND/OBJECTIVES

The cost resulting from peritoneal dialysis (PD), conventional hemodialysis (HD) and online hemodiafiltration (OL-HDF) in pediatric patients with end-stage renal disease (ESRD) has not been estimated to date in Greece. The present single-center retrospective study aimed to estimate the mean annual cost of the above methods, as well as the individual components of this cost.

METHODS

Twenty pediatric patients undergoing the three different methods of renal replacement therapy were included in this study. Their mean total annual cost was estimated by the method of micro-costing and the bottom-up approach.

RESULTS

The mean total annual cost for PD patients (n = 7) was estimated at EUR 56,676.04; for conventional HD patients (n = 9), it was EUR 39,786.86; and for OL-HDF patients (n = 4), it was EUR 43,894.73. The PD method was found to be more expensive than the other two methods (p < 0.001 vs. conventional HD and p = 0.024 vs. OL-HDF). PD consumables used for daily application had the greatest contribution to the total annual cost. The total mean annual cost in the groups of patients undergoing HD and OL-HDF did not differ significantly (p = 0.175). The total operating cost of the renal dialysis unit had the greatest contribution to the total mean annual costs of both the conventional HD and OL-HDF techniques.

CONCLUSIONS

This cost analysis provides useful information to healthcare policymakers who make decisions about the treatment of children with ESRD.

Structural Inequities and Barriers to Accessing Kidney Healthcare Services in the United States: A Focus on Uninsured and Undocumented Children and Young Adults

The population of children living in poverty and lacking healthcare insurance has increased in the United States of America in the last decade. Several factors have been responsible for this trend including illegal immigration, socioeconomic deprivation, young age, racial segregation, environmental degradation, and discriminatory housing policies. These systemic barriers have contributed to the exclusion of families from essential healthcare services. They are also contributory to the development of chronic illnesses (such as dialysis-dependent kidney disease) that are debilitating and frequently require considerable therapeutic resources. This unfortunate scenario creates a never-ending vicious cycle of poverty and diseases in a segment of society. For pediatric nephrologists, the challenges of caring for uninsured children with chronic kidney disease are all too familiar. Federally funded healthcare programs do not cover this patient population, leaving them the option of seeking care in emergency healthcare settings. Presentation with a critical illness often necessitates urgent placement of vascular catheters and the choice of acute hemodialysis. Adverse social environment influences the need for protracted chronic hemodialysis and a delay in kidney transplantation. Consequently, there is greater comorbidity, recurrent hospitalization, and a higher mortality rate. New policies should address the deficit in health insurance coverage while promoting social programs that will remove structural barriers to health care resources for undocumented children and young adults.

The impact of multiple donor renal arteries on perioperative complications and allograft survival in paediatric renal transplantation

BACKGROUND

The impact of using allografts with multiple renal arteries in paediatric kidney transplantation has not been clearly established. The aim of this study was to determine whether kidney grafts with multiple arteries pose any adverse effects upon perioperative surgical outcomes, and graft survival up to 12 months post-transplant.

OBJECTIVE

The objective of this study was to perform a comparative analysis of a minimum of 12-month graft survival and transplant renal function in paediatric renal transplant recipients receiving single versus multiple donor arteries, and to assess perioperative and early post-operative surgical outcomes.

STUDY DESIGN

A retrospective divisional chart review of 379 transplants performed (2000-2018), of which 90 (23.7%) contained multiple donor arteries. The number of arteries of the graft, donor type, vascular reconstruction technique, occurrence of urological and vascular complications, estimated GFR and graft survival up to 12 months post-transplantation, graft loss and mortality were analysed. Comparisons in baseline characteristics and outcome measures were made between both groups.

RESULTS

No significant differences were found in age (p = 0.42), BMI (p = 0.39), estimated intraoperative blood loss (p = 0.14), overall (p = 0.63) or warm ischaemic time (p = 0.37). 51.3% patients with multiple donor arteries underwent an ex vivo reconstruction. There were no differences in the site of arterial anastomosis (aorta, external iliac, internal iliac), or anastomotic type (end-side; end-end). Whilst there was a significantly higher post-operative lymphocoele rate in the multiple vessel cohort (p = 0.024), there was no increase in post-transplant urine leaks, rejection episodes, graft loss (1.1% multiple vs 2.1% single), perioperative complications (p = 0.68), or estimated GFR at 1 month (p = 0.9) or at 1 year (p = 0.67).

DISCUSSION

We demonstrated in this study that there was no significant difference in postoperative complications up to 3 months, eGFR and renal function up to 1 year, and graft survival up to 4 years post transplantation irrespective of allograft type or reconstruction technique. There was however, a higher rate of lymphocoeles in the multiple artery cohort. The results seen here broadly mirror trends seen in adult studies, however, there is little data available from paediatric series.

CONCLUSION

Our study demonstrates that multiple renal artery allografts - previously been considered to carry a high complication risk - can be safely used for paediatric renal transplantation with equivalent perioperative complications and graft outcomes to single artery allografts.

Preemptive Kidney Transplantation is Associated With Transplantation Outcomes in Children: Results From the French Kidney Replacement Therapy Registry

BACKGROUND

Kidney transplantation (KT) is the optimal treatment for children with end-stage kidney disease (ESKD). The aim of this study was to evaluate the impact of PKT and of pretransplant dialysis duration on graft survival among French pediatric kidney transplant recipients.

METHODS

We analyzed all first pediatric kidney-only transplantations performed in France between 1993 and 2012. A Cox multivariable model was used to investigate the association of PKT and pretransplant dialysis time with the hazard of graft failure defined as death, return to dialysis or retransplant, whichever occurred first.

RESULTS

1911 patients were included, of which 380 (19.8%) received a PKT. Median time of follow-up was 7.0 years. PKT was associated with a 55% reduction of the hazard of graft failure at any time after KT compared to patients transplanted after dialysis (HR 0.45; 95%CI 0.33-0.62), after adjustment for recipient sex and age, primary kidney disease, donor age and type (living or deceased donor), number of HLA mismatches, cold ischemia time and year of transplantation. A reduction of the hazard of graft failure was found in PKT whatever the compared duration of dialysis, even when less than 6 months and whatever the dialysis modality. Results were similar in multiple sensitivity analyses.

CONCLUSIONS

In France, PKT among pediatric patients is associated with a better graft survival when compared to KT after dialysis, even when less than 6 months. Based on these findings, we suggest that PKT should be considered as the treatment of choice for children with ESKD.

Acute rejection in pediatric renal transplantation: Retrospective study of epidemiology, risk factors, and impact on renal function

AR is a major relevant and challenging topic in pediatric kidney transplantation. Our objective was to evaluate cumulative incidence of AR in pediatric kidney transplant patient, risk factors for this outcome, and impact on allograft function and survival. A retrospective cohort including pediatric patients that underwent kidney transplantation between 2011 and 2015 was designed. Risk factors for AR were tested by competing risk analysis. To estimate its impact, graft survival and difference in GFR were evaluated. Two hundred thirty patients were included. As a whole, the incidence of AR episodes was 0.16 (95% CI = 0.12-0.20) per person-year of follow-up. And cumulative incidence of AR was 23% in 1 year and 39% in 5 years. Risk factors for AR were number of MM (SHR 1.36 CI 1.14-1.63 P = .001); ISS with CSA, PRED, and AZA (SHR 2.22 CI 1.14-4.33 P = .018); DGF (SHR 2.49 CI 1.57-3.93 P < .001); CMV infection (SHR 5.52 CI 2.27-11.0 P < .001); and poor adherence (SHR 2.28 CI 1.70-4.66 P < .001). Death-censored graft survival in 1 and 5 years was 92.5% and 72.1%. Risk factors for graft loss were number of MM (HR 1.51 CI 1.07-2.13 P = .01), >12 years (HR 2.66 CI 1.07-6.59 P = .03), and PRA 1%-50% (HR 2.67 CI 1.24-5.73 P = .01). Although occurrence of AR did not influence 5-year graft survival, it negatively impacted GFR. AR was frequent in patients assessed and associated with number of MM, ISS regimen, DGF, CMV infection, and poor adherence, and had deleterious effect on GFR.

Relationship between antithymocyte globulin, T cell phenotypes, and clinical outcomes in pediatric kidney transplantation

Depletional induction using antithymocyte globulin (ATG) reduces rates of acute rejection in adult kidney transplant recipients, yet little is known about its effects in children. Using a longitudinal cohort of 103 patients in the Immune Development in Pediatric Transplant (IMPACT) study, we compared T cell phenotypes after ATG or non-ATG induction. We examined the effects of ATG on the early clinical outcomes of alloimmune events (development of de novo donor specific antibody and/or biopsy proven rejection) and infection events (viremia/viral infections). Long-term patient and graft outcomes were examined using the Scientific Registry of Transplant Recipients. After ATG induction, although absolute counts of CD4 and CD8 T cells were lower, patients had higher percentages of CD4 and CD8 memory T cells with a concomitant decrease in frequency of naïve T cells compared to non-ATG induction. In adjusted and unadjusted models, ATG induction was associated with increased early event-free survival, with no difference in long-term patient or allograft survival. Decreased CD4⁺ naïve and increased CD4⁺ effector memory T cell frequencies were associated with improved clinical outcomes. Though immunologic parameters are drastically altered with ATG induction, long-term clinical benefits remain unclear in pediatric patients.

Strategy to Enable and Accelerate Kidney Transplant in Small Children and Results of the First 130 Transplants in Children ≤15 kg in a Single Center

BACKGROUND

Proper care of young children in need of kidney transplant (KT) requires many skilled professionals and an expensive hospital structure. Small children have lesser access to KT.

METHODS

We describe a strategy performed in Brazil to enable and accelerate KT in children ≤15 kg based on the establishment of one specialized transplant center, focused on small children, and cooperating with distant centers throughout the country. Actions on 3 fronts were implemented: (a) providing excellent medical assistance, (b) coordinating educational activities to disseminate expertise and establish a professional network, and (c) fostering research to promote scientific knowledge. We presented the number and outcomes of small children KT as a result of this strategy.

RESULTS

Three hundred forty-six pediatric KTs were performed in the specialized center from 2009 to 2017, being 130 in children ≤15 kg (38%, being 41 children ≤10 kg) and 216 in >15 kg (62%). Patient survival after 1 and 5 years of the transplant was 97% and 95% in the "small children" group, whereas, in the "heavier children" group, it was 99% and 96% (P = 0.923). Regarding graft survival, we observed in the "small children" group, 91% and 87%, whereas in the "heavier children" group, 94% and 87% (P = 0.873). These results are comparable to the literature data. Groups were similar in the incidence of reoperation, vascular thrombosis, posttransplant lymphoproliferative disease, and estimated glomerular filtration rate.

CONCLUSIONS

The strategy allowed an improvement in the number of KT in small children with excellent results. We believe this experience may be useful in other locations.

Results in the ESPN/ERA-EDTA Registry suggest disparities in access to kidney transplantation but little variation in graft survival of children across Europe

One of the main objectives of the European health policy framework is to ensure equitable access to high-quality health services across Europe. Here we examined country-specific kidney transplantation and graft failure rates in children and explore their country- and patient-level determinants. Patients under 20 years of age initiating kidney replacement therapy from January 2007 through December 2015 in 37 European countries participating in the ESPN/ERA-EDTA Registry were included in the analyses. Countries were categorized as low-, middle-, and high-income based on gross domestic product. At five years of follow-up, 4326 of 6909 children on kidney replacement therapy received their first kidney transplant. Overall median time from kidney replacement therapy start to first kidney transplantation was 1.4 (inter quartile range 0.3-4.3) years. The five-year kidney transplantation probability was 48.8% (95% confidence interval: 45.9-51.7%) in low-income, 76.3% (72.8-79.5%) in middle-income and 92.3% (91.0-93.4%) in high-income countries and was strongly associated with macro-economic factors. Gross domestic product alone explained 67% of the international variation in transplantation rates. Compared with high-income countries, kidney transplantation was 76% less likely to be performed in low-income and 58% less likely in middle-income countries. Overall five-year graft survival in Europe was 88% and showed little variation across countries. Thus, despite large disparities transplantation access across Europe, graft failure rates were relatively similar. Hence, graft survival in low-risk transplant recipients from lower-income countries seems as good as graft survival among all (low-, medium-, and high-risk) graft recipients from high-income countries.

Is Preoperative Preparation Time a Barrier to Small Children Being Ready for Kidney Transplantation?

BACKGROUND

Small children are less frequently transplanted when compared with older. The objective of the present study was to compare the preparation time for transplantation in children of different weights and to identify factors associated with a delay in the workup of small children.

METHODS

We report on a retrospective cohort comprising all children referred for renal transplantation (RTx) workup between 2009 and 2017. The main outcome was transplantation workup time, defined as the time elapsed between the first consultation and when the child became ready for the surgery.

RESULTS

A total of 389 children (63.5% males) were selected, with a median weight of 18 kg (interquartile range, 11-32). Patients were categorized into 2 groups: group A (study group): ≤15 kg (n = 165) and group B (control group): >15 kg (n = 224). The probability of being ready for RTx was comparable between groups A and B. The cumulative incidence rate difference between groups is -0.05 (95% confidence interval, -0.03 to 0.02). The median time for RTx workup was 5.4 (2.4-9.4) in group A and 4.3 (2.2-9.0) months in group B (P = 0.451). Moreover, the presence of urinary tract malformation was associated with the need for longer transplantation workup time (P < 0.001).

CONCLUSIONS

In children >7 kg, the workup time for transplantation is not related to body weight. In a specialized center, children weighing 7-15 kg became ready within the same timeframe as children weighing >15 kg, despite the smaller children had greater difficulty being nourished, dialyzed, and a greater need for surgical correction of the urinary tract pretransplant.