Policy in pediatric nephrology: successes, failures, and the impact on disparities

Krissberg, Jill R; Sutherland, Scott M.; Chamberlain, Lisa; Wise, Paul H.

doi:10.1007/s00467-020-04755-5

Cited by 21 publications

(14 citation statements)

References 84 publications

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“…There is a wide disparity in the availability of pediatric dialysis ( 32 , 33 ). In high income countries (HIC) pediatric dialysis is easily accessible and financially supported by the government.…”

Section: Inequity In Access To Dialysismentioning

confidence: 99%

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

Pais

Wightman

2022

Front. Pediatr.

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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.

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Section: Inequity In Access To Dialysismentioning

confidence: 99%

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

Pais

Wightman

2022

Front. Pediatr.

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“…Assessing the 2014 KAS policy change does not address racial and ethnic disparities that occur throughout the transplant listing process. The pediatric nephrology community needs to remain diligent in considering all aspects of kidney failure care, steps to transplantation, and consequences of systemic racism and provider biases in this process to truly address racial and ethnic disparities: from early identification of CKD to access to subspecialty care, activation, and preemptive and living related donors (22). A study found that with adherence being equal, referral to transplantation varied by race and ethnicity (23).…”

Section: Discussionmentioning

confidence: 99%

Racial Disparities in Pediatric Kidney Transplantation under the New Kidney Allocation System in the United States

Krissberg

Kaufmann

Gupta

et al. 2021

CJASN

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Background and objectivesIn December 2014, the Kidney Allocation System (KAS) was implemented to improve equity in access to transplantation, but preliminary studies in children show mixed results. Thus, we aimed to assess how the 2014 KAS policy change affected racial and ethnic disparities in pediatric kidney transplantation access and related outcomes.Design, setting, participants, & measurementsWe performed a retrospective cohort study of children <18 years of age active on the kidney transplant list from 2008 to 2019 using the Scientific Registry of Transplant Recipients. Log-logistic accelerated failure time models were used to determine the time from first activation on the transplant list and the time on dialysis to deceased donor transplant, each with KAS era or race and ethnicity as the exposure of interest. We used logistic regression to assess odds of delayed graft function. Log-rank tests assessed time to graft loss within racial and ethnic groups across KAS eras.ResultsAll children experienced longer wait times from activation to transplantation post-KAS. In univariable analysis, Black and Hispanic children and other children of color experienced longer times from activation to transplant compared with White children in both eras; this finding was largely attenuated after multivariable analysis (time ratio, 1.16; 95% confidence interval, 1.01 to 1.32; time ratio, 1.13; 95% confidence interval, 1.00 to 1.28; and time ratio, 1.17; 95% confidence interval, 0.96 to 1.41 post-KAS, respectively). Multivariable analysis also showed that racial and ethnic disparities in time from dialysis initiation to transplantation in the pre-KAS era were mitigated in the post-KAS era. There were no disparities in odds of delayed graft function. Black and Hispanic children experienced longer times with a functioning graft in the post-KAS era.ConclusionsNo racial and ethnic disparities from activation to deceased donor transplantation were seen before or after implementation of the KAS in multivariable analysis, whereas time on dialysis to transplantation and odds of short-term graft loss improved in equity after the implementation of the KAS, without compromising disparities in delayed graft function.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_12_07_CJN06740521.mp3

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“…Socioeconomic inequities in health are mediated by complex and multifactorial pathways from disadvantaged SEP to health, including increased exposure and vulnerability to adverse material, psychosocial, behavioral, biological, and healthcare factors (mechanisms ii-iii in Figure 3 ), often referred to as “intermediary determinants of health.” 4 , 5 , 21 As illustrated in Figure 4 , adapted from the Commission on Social Determinants of Health conceptual framework 21 and its adaptations by Bell, 77 all of these domains may be hypothesized to play a role in socioeconomic inequities in pediatric CKD. 44 , 78 As discussed earlier, these factors are driven by upstream “structural determinants of health,” including SEP, social stratification, and broader social, economic and political factors ( Figure 4 , mechanism i in Figure 3 ). 4 , 21 Importantly, as shown in Figure 4 , even the intermediary determinants can be ordered from more upstream (material) to more midstream (psychosocial) and downstream (behavioral, biological, and healthcare) factors that are more proximal to the individual.…”

Section: Aimsmentioning

confidence: 91%

“…Much research has focused on access to and outcomes of KRT, 44 primarily using the area-level SEP measures that are often available in kidney registries, with somewhat conflicting findings. Regarding preemptive transplantation, the optimal treatment for kidney failure, children from socioeconomically disadvantaged areas were less likely to receive a preemptive kidney transplant in analyses from the French REIN registry, 34 UK Renal Registry, 45 a New Zealand national clinical database, 46 and the CKiD study in North America.…”

Section: Aimsmentioning

confidence: 99%

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

van Zwieten,

Kim,

Dominello

et al. 2024

Kidney International Reports

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Policy in pediatric nephrology: successes, failures, and the impact on disparities

Cited by 21 publications

References 84 publications

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

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

Racial Disparities in Pediatric Kidney Transplantation under the New Kidney Allocation System in the United States

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

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