World Kidney Day 2016: Kidney Disease & Children World Kidney Day 2016: Kidney Disease & Children. Act Early to Prevent It!

World Kidney Day 2016: Kidney Disease & Children World Kidney Day 2016: Kidney Disease & Children. Act Early to Prevent It! Kidney disease affects millions of people worldwide, including many children who may be at risk at an early age. It is therefore crucial that we encourage and facilitate education, early detection and a healthy life style in children, to fight the increase of preventable kidney diseases and to treat children with inborn and acquired disorders of the kidneys worldwide.

Pediatric Kidney Disease – An Update Edited by the ASPN Clinical Affairs Committee

Renal Replacement Therapy (Dialysis) Michael Somers, MD Boston Children’s Hospital, Harvard Medical School

Pediatric Dialysis in 2016 Although transplantation remains the preferred treatment for ESRD in children and adolescents, pre-emptive transplants occur in only about 20% of children so the overwhelming majority of incident ESRD children receive dialysis United States Renal Data System. 2015 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2015. About 1500 pediatric patients develop ESRD each year in the US, a number that has been stable for some time Of the 1200 who start dialysis each year, two-thirds start on hemodialysis (HD) and one-third start peritoneal dialysis (PD)

Pediatric Dialysis in 2016 Although either dialysis modality is effective, younger and smaller children are more likely to receive PD whereas older and larger children are more likely to receive HD Pre-emptive transplants are less common with young adults United States Renal Data System. 2015 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2015.

Pediatric Dialysis in 2016 Pediatric patients with ESRD compose only 1.5% of the entire US ESRD population – children may be lost in the flood of adults Access to pediatric-specific dialysis care is limited Pediatric dialysis units number in the dozens and are usually based at or affiliated with tertiary care pediatric centers Average census at a pediatric dialysis unit is 11 patients vs. hundreds in typical adult units Specialized pediatric multidisciplinary team is optimal and team members should include physicians, nurses, dietitians, social workers, child life specialists, psychologists, pharmacists – all with pediatric expertise Pediatric dialysis care is labor intensive and very costly, especially in comparison to adult dialysis care with its economy of volume Only about half of American children on dialysis receive care at pediatric-specific centers, making children on dialysis potentially a very vulnerable population for optimal care provision

Pediatric Dialysis in 2016 Recent advances in pediatric hemodialysis include: More widespread availability of HD equipment capable of very low blood flow rates with tubing requiring small extracorporeal volumes and with ability to precisely measure small volumes of ultrafiltration Development of home HD equipment that is easier and safer to use in adolescents and larger children Development of specialized HD equipment for infants Recent advances in pediatric peritoneal dialysis include: More widespread availability of automated PD machines (“cyclers”) with specialized PD tubing requiring smaller volumes, yielding less dead space during each cycle and minimizing recirculation of dialysate Development of cyclers that allow low volume flow rates without triggering alarms

Pediatric Dialysis in 2016 Survival by Treatment Modality Outcomes are better but still suboptimal: One year survival in children who initiate dialysis < 1 y.o. is 82%, approaching the 92% survival in children 2-to-5 y.o. Mortality rates between dialysis modalities is similar: HD: 4.8 deaths/100 pt-yrs PD: 5.9 deaths/100 pt-yrs Risk of death on dialysis is still 30-times greater than age-matched children, with a distinct survival advantage to transplantation Cause of death most often is from infection or cardiovascular complication United States Renal Data System. 2015 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2015. Survival by Treatment Modality

Pediatric Dialysis in 2016 Increasing focus on improving outcomes using multicenter collaboration The SCOPE Collaborative is an example of such an endeavor, reducing infection rates across the collaborative and saving an estimated $2.8 million in care costs to date

Dialysis: Summary Dialysis in children continues to be a life-saving therapy, though risks and complications are significant. Optimal dialysis in children requires a multidisciplinary team with expertise and specialization in pediatrics. Large-scale, multi-centered collaboration is required to improve outcomes for children requiring dialysis.

Happy World Kidney Day 2016! Your pediatric nephrology community continues to work hard to improve clinical care, foster education, and advance the science regarding kidney disease in children! We appreciate your support and all you do for children’s health care!