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

Responding to ethical dilemmas in pediatric nephrology: a framework for clinicians in varied practice settings

Around the world, pediatric nephrologists encounter challenging clinical situations when decision-making is difficult. Ethical dilemmas occur when the best treatment choice is uncertain or when the nephrologist is constrained from providing a clearly superior treatment option due to conflict or a scarcity of resources. These include decision-making regarding burdensome treatments, disagreements between the nephrologist and parents or other healthcare providers, and inequities in access to therapies. While useful in providing grounding and a starting point, the traditional models of pediatric decision-making are challenged in pediatric nephrology. These limitations can contribute to further conflict and distress. This review will highlight the key ethical principles in ethical dilemmas encountered in clinical pediatric nephrology. We propose a stepwise decision-making framework, consisting of 5 questions, to respond using an ethically defensible process. Using case-based examples, we show how the framework will guide pediatric nephrologists in different practice settings to recognize an ethical dilemma, analyze it systematically, and reach a morally acceptable solution recognizing that this may vary by geographic location, availability of resources, and local cultural practices.

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.

Monitoring and maintaining quality in the paediatric haemodialysis unit

Chronic kidney disease in children is being increasingly recognised and reported worldwide, and the focus of paediatric dialysis planning has changed from acute care alone to encompass chronic care. In many parts of the world, haemodialysis for children is performed in adult units and is based on standards established for adults. This review proposes standards for paediatric haemodialysis, incorporating special requirements for children while simultaneously drawing from the adult experience. We discuss the optimum requirements, including space utilisation, equipment needed, water treatment facilities, disposables, safety standards, staffing needs, monitoring and maintenance, infection prevention, waste disposal and quality indicators. We also review recent advancements in the field that should be incorporated into future dialysis units and the steps required for achieving carbon neutrality and protecting the environment.

International equity in access to home dialysis

PURPOSE OF REVIEW

Discussion of inequalities and inequities in global distribution of and access to home dialysis.

RECENT FINDINGS

The majority of patients receiving home dialysis receive peritoneal dialysis, but these are concentrated in few countries across the globe. Peritoneal dialysis as the most common form of home dialysis has many advantages in terms of individual freedoms, similar outcomes to haemodialysis, being less costly in some countries, and more scalable than in-centre haemodialysis. Despite this there are many inequities in access at the patient, clinician, health system and geopolitical levels. Poverty, discrimination and lack of support at home are important drivers of inequities at the patient level. At the clinician and health systems level lack of experience in home dialysis, lack of resources and lack of time drive patients towards in-centre dialysis. At the geopolitical level, high costs associated with procurement and distribution of peritoneal dialysis solutions exacerbate inequities in access.

SUMMARY

The challenge of reducing global inequities in access to home dialysis in low- and middle-income countries are vast and would require training of the doctors, nurses, families, patients, leaders and community partners. Once this is achieved, dealing with costs and logistics of supplies is crucial to improve and sustain equitable access.

Management dilemmas in pediatric nephrology: moving from friction to flourishing in "challenging" cases

BACKGROUND

The circumstances surrounding chronic kidney disease and its impact on families can be complex and difficult to navigate, leading to these cases being labeled "challenging."

CASE PRESENTATION

We present the case of an adolescent with kidney failure due to unremitting systemic illness and multiple complications ultimately resulting in the family's request to forgo dialysis. Medical team members wrestled with meeting the family's needs among internal and external constraints.

CONCLUSION

Past experiences, systemic inequities, differing perspectives, and consequential decision-making within individual belief systems can lead to friction between and among medical team members and families. As pediatric nephrologists, we must shift our focus from the "challenging" patient or family to addressing what is challenging their ability to flourishing.

An Ethical Analysis of Therapy for Severe Congenital Kidney and Urinary Tract Anomalies

Technological advancements before and after delivery have greatly altered the counseling of pregnant patients facing a fetal diagnosis of severe oligohydramnios or anhydramnios secondary to congenital anomalies of the kidneys and urinary tract. Once considered a nearly uniformly lethal abnormality, long-term survival may now be possible secondary to prenatal innovations aimed at restoring the amniotic fluid volume and the availability of more advanced neonatal dialysis techniques. However, these available therapies are far from perfect. The procedures are onerous for pregnant patients without a guarantee of success, and families must prepare themselves for the complex life-long medical care that will be necessary for surviving individuals. Multidisciplinary counseling is imperative to help pregnant individuals understand the complexity of these conditions and assist them in exercising their right to informed decision-making. Moreover, as with any developing field of medicine, providers must contend with ethical questions related to the treatment options, including questions regarding patient-hood, distributive justice, and the blurred lines between research, innovation, and standard care. These ethical questions are best addressed in a multidisciplinary fashion with consideration of multiple points of view from various subspecialties. Only by seeing the entirety of the picture can we hope to best counsel patients about these highly complex situations and help navigate the most appropriate care path.

Stress Factors for the Paediatric and Adult Palliative Care Multidisciplinary Team and Workplace Wellbeing Solutions

BACKGROUND

Palliative care is a challenging specialty, especially when it comes to caring for children with serious life-limiting conditions and supporting their families. Workers face significant challenges and experience major impacts on their wellbeing. We conducted a qualitative study to understand the sources of stress in the palliative care team, their work expectations, and how they can cope with the demands.

METHODS

We used an online questionnaire about the causes of stress, the impact of the COVID-19 pandemic and the ways in which support is needed in the workplace.

RESULTS

Of the 56 palliative care professionals who participated in the survey, 57.1% considered the main causes of stress to be high workload, difficult emotional burdens (55.4%) affecting their outlook on life (61.2%), the death of patients (46.4%), and communication with patients' families (26.8%). The COVID-19 pandemic increased stress levels for the majority of respondents (89.3%). The need for specialised training (53.6%), support groups, psychological counselling and adapted organisational policies was highlighted.

CONCLUSIONS

The study demonstrates the importance of understanding the needs of both paediatric and adult palliative care staff in order to provide optimal care and support their balance in this demanding area of the healthcare system.

Analyzing the composition of the editorial boards in high-impact medical ethics journals: a survey study

BACKGROUND

The underrepresentation of scholarly works from low- and middle-income countries (LMICs) in academic literature is a documented concern, attributed partly to editorial biases. This trend, prevalent across various disciplines, has been less explored in the context of medical ethics journals. This study aimed to examine the composition of editorial board members (EBM) in high-impact medical ethics journals and to evaluate the extent of international diversity within these editorial teams.

METHODS

This study incorporated an analysis of 16 high-impact medical ethics journals. Information regarding the EBM of these journals was systematically gathered and categorized based on the World Bank's country income classifications. An in-depth examination of the editorial board compositions was then conducted.

RESULTS

The study identified 669 EBM across the selected journals. A predominant 89.84% (601) of these members were from high-income countries (HICs), with upper-middle-income countries contributing 7.47% (50) and lower-middle-income countries 2.69% (18). No EBM were associated with low-income countries. A regional breakdown indicated that North America was the most represented area, accounting for 48.88% (327), followed by Europe & Central Asia (27.50%, 184), East Asia & Pacific (13.45%, 90), Latin America & Caribbean (4.63%, 31), Sub-Saharan Africa (4.19%, 28), Middle East & North Africa (0.75%, 5), and South Asia (0.60%, 4). In total, these EBMs hailed from 46 different countries, with the United States representing the largest proportion (43.80%, 293), followed by the United Kingdom (13.15%, 88), Australia (7.92%, 53), Germany (6.73%, 45), and Canada (5.08%, 34).

CONCLUSIONS

There is a significant lack of international representation within the EBM of high-impact medical ethics journals. The majority of editors in this field are affiliated with HICs, leading to a severe underrepresentation of LMICs within the editorial boards.

Disparity in organ distribution in Gauteng province in South Africa: Challenges and solutions

BACKGROUND

Despite South Africa's rich heritage as pioneers in organ transplantation, access to organs remains a major issue in the Gauteng province. This is secondary to an array of socioeconomic and political factors that have implications for organ distribution. Our aim was to assess the contribution of the public sector to solid organ transplantation in Gauteng province and compare the distribution of solid organs between the recipient groups.

METHODS

This was a retrospective registry review of consented brain-dead donors from the public sector within Gauteng from January 1, 2016, to June 30, 2021, coordinated at Charlotte Maxeke Johannesburg Academic Hospital, a tertiary academic hospital.

RESULTS

Records of 49 deceased donors were analyzed. Mean donor age was 31.5 years with the age group 30-39 years constituting the majority of deceased donors at 15/49 (30.6%); 10/49 (16%) were from pediatric donors. There was a significant discrepancy in allocation between public and private sector in cardiac (p = .012) and liver allocation (p < .001) and adult and pediatric recipients for all solid organs (p < .001). There was a significant increase in the rate and number (p = .0026) of pediatric kidney transplants occurring after March 1, 2020, when there was a transition to a public sector-mandated kidney transplant waitlist.

CONCLUSION

Current disparities in organ distribution have a significant impact on public sector recipients, especially pediatric patients. This is likely secondary to paucity of legislation and resource limitations which would benefit from improved governmental policies and explicit pediatric prioritization policies in transplant units.

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.

Social, political and legal determinants of kidney health: Perspectives from lower- and middle-income countries with a focus on India

The social determinants of health (SDoH) are the non-medical factors that influence kidney health outcomes directly or indirectly in a substantial manner and include conditions in which people are born, grow, work, live, and age. Many such challenges in lower- and middle- income countries have an unfavourable impact on kidney health. These conditions potentially influence economic policies and systems, development agendas, social norms, social policies, and political systems. In addition, many political and legal factors also determine and modify the ultimate outcome in patients with kidney disease. Legal factors that ensure universal health care, promote gender and racial equality, prevent malpractices and regulate strict laws in the field of kidney transplantation are the paramount determinants for the provision of necessary kidney care. Converging lines of evidence have supported the impact of social variables such as socioeconomic resources, social inclusion, housing conditions, educational attainment, and financial status on kidney health, particularly affect vulnerable and disadvantaged groups and result in challenges in kidney care delivery. Furthermore, the climate is an important SDoH that plays a crucial role in the occurrence, prevalence, and progression of kidney diseases as highlighted by the presence of higher prevalence of chronic kidney disease in hot tropical countries. The rising incidence of water and vector-borne diseases causing acute kidney injury is another consequence of disruptive environmental and climate change which is detrimental to kidney health. Political risk factors such as conflict also have a devastating influence on kidney health. The relationship between SDoH and kidney health outcomes requires more clarity. Gaps in the current knowledge need to be identified to inform the development of appropriate interventions to address upstream socio-economic risk factors for kidney disease.