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  • 1. T SIX Pediatric ESRD There is always one moment in childhood when the door opens and lets the future in. Graham Greene, The Power and the Glory
  • 2. 9 8 ž 2 0 0 0 A T LA S O F E S R D I N T H E U N I T E D S TAT E S In pediatric ESRD patients of all age groups both sis patients than for children who have received incident and prevalent rates have increased mod- transplants (fig 6.22). Patient and graft survival erately since 1990 (table 6.1). Rates continue to curves for both cadaver and living donor trans- be highest in the 15–19 age group, with particu- plants show generally equivalent rates in females larly high rates—three times those of whites— compared to males, but lower rates, in many age seen in black children of both genders (fig 6.2). groups, for black children compared to white (figs 6.23–26). Survival in black children also shows Among pediatric dialysis patients the most com- the most variation by patient age. mon causes of renal failure are glomerulonephri- tis and cystic/hereditary/congenital kidney dis- Infection is more frequent in peritoneal dialysis ease, with the latter disease occurring almost twice patients, and occurs with much higher rates in as often in male children as in females (fig 6.7). the youngest children (figs 6.28–30). With the Glomerulonephritis is more common in children exception of admissions for respiratory infections of color, and the rate of secondary glomerulone- in transplant patients, admission rates for over- phritis/vasculitis is twice as high in Asian chil- all and respiratory infections are higher in girls at dren than in the other populations (fig 6.8). The most stages of ESRD than in boys; the rate of res- most frequent primary diagnosis among pediat- piratory infections in female dialysis patients, in ric transplant patients is cystic/hereditary/con- fact, increases steadily for these patients the longer genital kidney disease; the number of boys with they have ESRD (figs 6.32–37). this diagnosis is almost three times as high as the number of girls (fig 6.10). Causes of death were generally similar between genders, with the exception of cardiac arrest and While the numbers of living donor and cadav- cardiac “other” causes in peritoneal dialysis pa- eric first transplants were similar between 1995 tients; deaths attributed to these causes were at and 1997, the number of transplants from living least three times more common in girls (figs 6.38– donors has begun to increase once again (a total 40). Twice as many white children on hemodi- of 30% since 1994), while the number of cadav- alysis died from infection; more black children eric donations continues to decline (fig 6.19). on peritoneal dialysis, in contrast, died from the Transplant rates are highest in children aged 5–9, same cause, and cardiac arrest was more frequent and while cadaver transplants are slightly more in this group as well (figs 6.41–42). frequent in older children, children aged 0–4 are All data underlying the almost twice as likely to receive a kidney from a Future analyses will examine how regional dif- living donor (fig 6.20). ferences in socio-economic factors and in the figures in this chapter, availability of pediatric nephrologists may be as- When examined in terms of race, transplants sociated with outcomes in pediatric patients. as well as additional related from living donors are most common in white Included in this chapter Included in this chapter and female Native American children, and least ¨ Graphs and maps of incident and prevalent rates; graphs of pa- tient distribution by modality, primary diagnosis, gender, race, data, may be viewed & likely to occur in black and Asian children (fig and age; and graphs showing causes of renal failure by age group and by race 6.21). The rates of cadaveric transplantation, ¨ Graphs of first and repeat transplant rates, and Kaplan-Meier downloaded at however, are highest in children of Asian descent. survival curves of patient and graft survival Overall survival rates echo those of adult patients, ¨ Graphs and maps of hospitalization rates by modality and by primary diagnosis; graphs of heart disease by age and race www.usrds.org. with rates dramatically lower for pediatric dialy- ¨ Causes of death by race and modality
  • 3. C H A P T E R 6 ž P E D I A T R I C E S R D ž 99 Table 6.1 Incident & prevalent counts & rates unadjusted Includes only white, black, Native 1990-1992 1993-1995 1996-1998 American, and Asian patients. Counts Incident Prevalent Incident Prevalent Incident Prevalent 0- 4 391 941 479 1,163 552 1,180 5- 9 338 1,838 419 2,053 409 2,241 10-14 618 3,182 740 3,715 820 4,124 15-19 1,332 6,329 1,548 7,212 168 7,803 Rates per million population 0- 4 6.8 16.2 8.1 19.8 9.6 20.7 5- 9 6.2 33.6 7.4 36.2 6.9 37.7 10-14 11.7 59.3 13.2 66.0 14.3 72.0 15-19 25.5 121.8 29.0 133.6 28.2 134.5 Figure 6.1 Incident rates per million population, unadjusted 35 Ages 0-4 Ages 5-9 30 Ages 10-14 Ages 15-19 25 20 15 10 5 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 Figure 6.2 Incident rates by race, gender, & age group per million population, 1996– Ages 0-4 Ages 5-9 Ages 10-14 Ages 15-19 1998 combined, unadjusted 80 Male 70 Female 60 50 40 30 20 10 0 White Black N. Am. Asian White Black N. Am. Asian White Black N. Am. Asian White Black N. Am. Asian
  • 4. 1 0 0 ž 2 0 0 0 A T LA S O F E S R D I N T H E U N I T E D S TAT E S Ages 0–4 White 11.4 + 11.9 + 9.4 to 11.4 10.8 to 11.9 7.9 to 9.4 10.1 to 10.8 6.0 to 7.9 8.0 to 10.1 below 6.0 below 8.0 Ages 5–9 Black 8.6 + 33.5 + 6.7 to 8.6 27.0 to 33.5 5.4 to 6.7 24.0 to 27.0 4.8 to 5.4 15.3 to 24.0 below 4.8 below 15.3 Ages 10–14 Native American 14.9 + 11.6 + 13.3 to 14.9 10.3 to 11.6 12.0 to 13.3 8.7 to 10.3 8.5 to 12.0 7.8 to 8.7 below 8.5 below 7.8 Ages 15–19 Asian 32.3 + 11.9 + 27.6 to 32.3 5.7 to 11.9 23.2 to 27.6 5.1 to 5.7 19.5 to 23.2 3.3 to 5.1 below 19.5 below 3.3 Figure 6.3 Figure 6.4 Incident rates by age group Incident rates by race per million population, 1994–1998 combined, by state, unadjusted per million population, 1994–1998 combined, by state, unadjusted
  • 5. C H A P T E R 6 ž P E D I A T R I C E S R D ž 1 0 1 Male Female 16.6 + 14.5 + 14.6 to 16.6 12.7 to 14.5 13.4 to 14.6 11.2 to 12.7 12.0 to 13.4 7.9 to 11.2 below 12.0 below 7.9 Diabetes Hypertension 0.4 + 1.1 + 0.3 to 0.4 0.7 to 1.1 0.2 to 0.3 0.4 to 0.7 0.1 to 0.2 0.1 to 0.4 below 0.1 below 0.1 Glomerulonephritis Cystic kidney 5.3 + 4.1 + 4.5 to 5.3 3.3 to 4.1 4.0 to 4.5 2.9 to 3.3 3.2 to 4.0 2.4 to 2.9 below 3.2 below 2.4 Other urologic Unknown cause 1.7 + 2.7 + 1.1 to 1.7 2.3 to 2.7 1.0 to 1.1 1.9 to 2.3 0.8 to 1.0 1.6 to 1.9 below 0.8 below 1.6 Figures 6.5 & 6.6 Incident rates by gender & primary diagnosis per million population, 1994–1998 combined, by state, unadjusted
  • 6. 1 02 ž 2 0 0 0 A T L A S O F E S R D I N T H E U N I T E D S TAT E S Figure 6.7 Number of patients, by gender, within primary diagnosis group dialysis patients, 1994–1998 combined 800 Male 700 Female 600 Number of patients 500 400 300 200 100 0 Diabetes Glomerulo- Secondary GN/ Interstitial Hypertension Cystic/hereditary/ Neoplasm/ nephritis (GN) vasculitis nephritis congenital cancer Figure 6.8 Distribution of primary diagnosis within racial group dialysis patients, 1994–1998 combined 60 Diabetes Glomerulonephritis 50 Percent of patients with diagnosis Secondary GN/vasculitis Interstitial nephritis/pyelonephritis 40 Hypertension Cystic/hereditary/congenital Neoplasms/tumors 30 20 10 0 White Black Native American Asian Figure 6.9 Mean & median age within primary diagnosis group dialysis patients, 1994–1998 combined 20 Mean age Median age 15 Age in years 10 5 0 Diabetes Glomerulo- Secondary GN/ Interstitial Hypertension Cystic/hereditary/ Neoplasm/ nephritis (GN) vasculitis nephritis congenital cancer
  • 7. C H A P T E R 6 ž P E D I A T R I C E S R D ž 1 0 3 Figure 6.10 Number of patients, by gender, within primary diagnosis group transplant patients, 1994–1998 280 combined Male 240 Female 200 Number of patients 160 120 80 40 0 Diabetes Glomerulo- Secondary GN/ Interstitial Hypertension Cystic/hereditary/ Neoplasm/ nephritis (GN) vasculitis nephritis congenital cancer Figure 6.11 Distribution of primary diagnosis within racial group transplant patients, 1994–1998 40 Diabetes combined Glomerulonephritis 35 Secondary GN/vasculitis Percent of patients with diagnosis Interstitial nephritis/pyelonephritis 30 Hypertension Cystic/hereditary/congenital 25 Neoplasms/tumors 20 15 10 5 0 White Black Native American Asian Figure 6.12 Mean & median age within primary diagnosis group transplant patients, 1994–1998 20 combined Mean age Median age 15 Age in years 10 5 0 Diabetes Glomerulo- Secondary GN/ Interstitial Hypertension Cystic/hereditary/ Neoplasm/ nephritis (GN) vasculitis nephritis congenital cancer
  • 8. 1 0 4 ž 2 0 0 0 A T L A S O F E S R D I N T H E U N I T E D S TAT E S Figure 6.13 Racial distribution within primary diagnosis group dialysis patients, 1994–1998 combined 100 90 White Black 80 Native American 70 Asian Percent of patients 60 50 40 30 20 10 0 Diabetes Glomerulo- Secondary GN/ Interstitial Hypertension Cystic/hereditary/ Neoplasm/ nephritis (GN) vasculitis nephritis congenital cancer Figure 6.14 Racial distribution within primary diagnosis group transplant patients, 1994–1998 combined 100 White 90 Black 80 Native American Asian 70 Percent of patients 60 50 40 30 20 10 0 Diabetes Glomerulo- Secondary GN/ Interstitial Hypertension Cystic/hereditary/ Neoplasm/ nephritis (GN) vasculitis nephritis congenital cancer Figure 6.15 Gender distribution within primary diagnosis group 1994–1998 combined Dialysis Transplant 100 Diabetes, glomerulonephritis, Male secondary glomerulonephritis, 90 interstitial nephritis/pyelone- Female phritis, hypertension, cystic kid- 80 ney/hereditary/congenital, and 70 Percent of patients neoplasms/tumors are abbrevi- ated along the x-axis. 60 50 40 30 20 10 0 DM GN SGN Inst. HTN Cyst. Neopl. DM GN SGN Inst. HTN Cyst. Neopl.
  • 9. C H A P T E R 6 ž P E D I A T R I C E S R D ž 105 Figure 6.16 Causes of renal failure within age group incident patients, 1994–1998 60 Diabetes combined Glomerulonephritis Secondary GN/vasculitis 50 Interstitial nephritis/pyelonephritis Percent of patients with diagnosis Hypertension 40 Cystic/hereditary/congenital Neoplasms/tumors 30 20 10 0 0-4 5-9 10-14 15-19 Figure 6.17 Treatment modality two years following ESRD onset, within race group 100 incident patients, 1994–1996 Hemodialysis combined 90 Peritoneal dialysis 80 Transplant Percent of patients on modality Death 70 Unknown 60 50 40 30 20 10 0 White Black Native American Asian Figure 6.18 Treatment modality two years following ESRD onset, within age group 100 incident patients, 1994–1996 Hemodialysis combined 90 Peritoneal dialysis 80 Transplant Percent of patients on modality Death 70 Other 60 50 40 30 20 10 0 0-4 5-9 10-14 15-19
  • 10. 1 0 6 ž 2 0 0 0 A T LA S O F E S R D I N T H E U N I T E D S TAT E S Figure 6.19 Total first transplants by donor source & year Includes patients not eligible for 250 Medicare enrollment. The num- ber of transplants in 1994, and the percent change between 1994 and 1998, are indicated in the legend. Number of transplants 200 150 Cadaver (247, -31%) Living (154, 30%) 100 1994 1995 1996 1997 1998 Figure 6.20 First transplant rates by age group & gender, 1996– 1998 combined Ages 0-4 Ages 5-9 Ages 10-14 Ages 15-19 30 Cadaver Transplants per 100 patient years on dialysis Living donor 25 20 15 10 5 0 Male Female Male Female Male Female Male Female Figure 6.21 First transplant rates by race & gender, 1996–1998 combined 30 White Black Native American Asian Cadaver Transplants per 100 patient years on dialysis Living donor 25 20 15 10 5 0 Male Female Male Female Male Female Male Female
  • 11. C H A P T E R 6 ž P E D I A T R I C E S R D ž 1 0 7 Figure 6.22 Kaplan-Meier 5-year patient survival Dialysis First transplant incident dialysis & transplant 100 patients, 1992–1993 combined 90 80 70 Percent surviving 60 50 40 30 Ages 0-4 Ages 5-9 20 Ages 10-14 10 Ages 15-19 0 0 12 24 36 48 60 0 12 24 36 48 60 Months of survival Figure 6.23 Kaplan-Meier 5-year patient survival after first transplanta- White Black tion 100 cadaveric transplants,1992–1993 combined 90 Because of the small number of Ages 0-4 Ages 5-9 patients, data are not shown for 80 Ages 10-14 Native American or Asian pa- tients. Ages 15-19 Percent surviving 70 Male Female 100 90 80 70 0 12 24 36 48 60 0 12 24 36 48 60 Months of survival Figure 6.24 Kaplan-Meier 5-year patient survival after first transplanta- White Black tion 100 living donor transplants, 1992– 1993 combined Ages 0-4 Because of the small number of 90 patients, data are not shown for Ages 5-9 Ages 10-14 Native American or Asian pa- tients. Percent surviving Ages 15-19 80 Male Female 100 90 80 0 12 24 36 48 60 0 12 24 36 48 60 Months of survival
  • 12. 108 ž 2 0 0 0 A T L A S O F E S R D I N T H E U N I T E D S TAT E S Figure 6.25 Kaplan-Meier 5-year graft survival after first transplanta- tion White Black cadaveric transplants, 1992– 100 1993 combined 80 Because of the small number of 60 Ages 0-4 patients, data are not shown for Ages 5-9 Native American or Asian pa- 40 Ages 10-14 tients. Percent surviving Ages 15-19 20 Male Female 100 80 60 40 20 0 12 24 36 48 60 0 12 24 36 48 60 Months of survival Figure 6.26 Kaplan-Meier 5-year graft survival after first transplanta- tion White Black living donor transplants, 1992– 100 1993 combined 80 Because of the small number of Ages 0-4 patients, data are not shown for 60 Native American or Asian pa- Ages 5-9 tients. Ages 10-14 40 Percent surviving Ages 15-19 Male Female 100 80 60 40 0 12 24 36 48 60 0 12 24 36 48 60 Months of survival Figure 6.27 Total repeat transplants by donor source & year The number of repeat trans- 60 plants in 1994, and the percent change from 1994 to 1998, are shown in the legend. Includes patients not eligible for Medicare enrollment. Number of transplants 40 Cadaver (53, -28%) Living (11, -55%) 20 0 1994 1995 1996 1997 1998
  • 13. C H A P T E R 6 ž P E D I A T R I C E S R D ž 1 0 9 Figure 6.28 First hospital admission rates all dialysis, 1996–1998 combined 80 Ages 0-4 70 Ages 5-9 Ages 10-14 Admissions per 100 patient years 60 Ages 15-19 50 40 30 20 10 0 Cardiovascular overall Infection overall Figure 6.29 First hospital admission rates hemodialysis, 1996–1998 combined 100 Ages 0-4 90 Ages 5-9 80 Ages 10-14 Admissions per 100 patient years Ages 15-19 70 60 50 40 30 20 10 0 Cardiovascular overall Infection overall Infection, vascular access Vascular access overall Figure 6.30 First hospital admission rates peritoneal dialysis, 1996–1998 combined 100 Ages 0-4 90 Ages 5-9 80 Ages 10-14 Ages 15-19 Admissions per 100 patient years 70 60 50 40 30 20 10 0 Cardiovascular overall Infection overall Infection, peritonitis Catheter complication
  • 14. 110 ž 2 0 0 0 A T L A S O F E S R D I N T H E U N I T E D S TAT E S Hemodialysis, cardiovascular overall Peritoneal dialysis, cardiovascular overall Network 1 Network 1 Network 16 Network 16 Network 11 Network 11 Network 2 Network 2 Network 4 Network 4 Network 3 Network 3 Network 10 Network 9 Network 10 Network 9 Network 12 Network 5 Network 12 Network 5 Network Network Network 15 Network 15 17 and 18 17 and 18 Network 13 Network 6 Network 13 Network 6 Network 8 Network 8 19 + 6+ 18 to 19 5 to 6 Network 14 Network 14 11 to 18 4 to 5 Network 7 7 to 11 Network 7 2 to 4 below 7 below 2 Hemodialysis, infection overall Peritoneal dialysis, infection overall Network 1 Network 1 Network 16 Network 16 Network 11 Network 11 Network 2 Network 2 Network 4 Network 3 Network 4 Network 3 Network 12 Network 10 Network 9 Network 12 Network 10 Network 9 Network Network 5 Network Network 5 Network 15 Network 15 17 and 18 17 and 18 Network 13 Network 6 Network 13 Network 6 Network 8 57 + Network 8 106 + 48 to 57 86 to 106 Network 14 45 to 48 Network 14 76 to 86 37 to 45 67 to 76 Network 7 Network 7 below 37 below 67 Hemodialysis, vascular access overall Peritoneal dialysis, peritonitis Network 1 Network 1 Network 16 Network 16 Network 11 Network 11 Network 2 Network 2 Network 4 Network 3 Network 4 Network 3 Network 10 Network 9 Network 12 Network 10 Network 9 Network 12 Network 5 Network 5 Network Network Network 15 Network 15 17 and 18 17 and 18 Network 13 Network 13 Network 6 Network 6 Network 8 Network 8 22 + 34 + Network 14 19 to 22 Network 14 24 to 34 18 to 19 22 to 24 Network 7 14 to 18 Network 7 18 to 22 below 14 below 18 Hemodialysis, vascular access infection Peritoneal dialysis, catheter complication Network 1 Network 1 Network 16 Network 16 Network 11 Network 11 Network 2 Network 2 Network 4 Network 3 Network 4 Network 3 Network 10 Network 9 Network 10 Network 9 Network 12 Network 5 Network 12 Network Network Network 5 Network 15 Network 15 17 and 18 17 and 18 Network 13 Network 6 Network 13 Network 6 Network 8 31 + Network 8 26 + 24 to 31 21 to 26 Network 14 Network 14 19 to 24 18 to 21 Network 7 13 to 19 Network 7 12 to 18 below 13 below 12 Figure 6.31 Admission rates for hemodialysis & peritoneal dialysis patients rates per 100 patient years at risk, by principal diagnosis or procedure category, 1996– 1998 combined, by network Alaska is included in Network 16, Hawaii in Network 17.
  • 15. C H A P T E R 6 ž P E D I A T R I C E S R D ž 1 1 1 Figure 6.32 Admissions for infection (overall) by time on ESRD By age group By gender dialysis patients, 1996–1998 140 combined < 1 year 120 1 -< 2 years 2 -<5 years 100 5+ years Admissions per 100 patient years at risk 80 60 40 20 0 0-4 5-9 10-14 15-19 Male Female Figure 6.33 Admissions for infection (overall) by time on ESRD hemodialysis patients, 1996– 140 By age group By gender 1998 combined < 1 year 120 1 -< 2 years 2 -<5 years 5+ years Admissions per 100 patient years at risk 100 80 60 40 20 0 0-4 5-9 10-14 15-19 Male Female Figure 6.34 Admissions for infection (overall) by time on ESRD By age group peritoneal dialysis patients, 140 By gender 1996–1998 combined < 1 year 120 1 -< 2 years 2 -<5 years 5+ years Admissions per 100 patient years at risk 100 80 60 40 20 0 0-4 5-9 10-14 15-19 Male Female
  • 16. 1 1 2 ž 2 0 0 0 A T LA S O F E S R D I N T H E U N I T E D S TAT E S Figure 6.35 Admissions for infection (overall) by time on ESRD transplant patients, 1996–1998 By age group 60 By gender combined < 1 year 1 -< 2 years 50 2 -<5 years Admissions per 100 patient years at risk 5+ years 40 30 20 10 0 0-4 5-9 10-14 15-19 Male Female Figure 6.36 Admissions for respiratory infections by time on ESRD dialysis patients, 1996–1998 By age group By gender combined 10 < 1 year 1 -< 2 years Admissions per 100 patient years at risk 8 2 -<5 years 5+ years 6 4 2 0 0-4 5-9 10-14 15-19 Male Female Figure 6.37 Admissions for respiratory infections by time on ESRD transplant patients, 1996–1998 By age group combined 14 By gender < 1 year 12 1 -< 2 years Admissions per 100 patient years at risk 2 -<5 years 10 5+ years 8 6 4 2 0 0-4 5-9 10-14 15-19 Male Female
  • 17. C H A P T E R 6 ž P E D I A T R I C E S R D ž 1 1 3 Figure 6.38 Causes of death by gender prevalent hemodialysis patients, 1996–1998 combined 12 Male Female Deaths per 1,000 patient years at risk 10 8 6 4 2 0 Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown disease Figure 6.39 Causes of death by gender prevalent peritoneal dialysis patients, 1996–1998 combined 12 Male Female Deaths per 1,000 patient years at risk 10 8 6 4 2 0 Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown disease Figure 6.40 Causes of death by gender prevalent transplant patients, 1996–1998 combined 12 Male Female Deaths per 1,000 patient years at risk 10 8 6 4 2 0 Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown disease
  • 18. 1 1 4 ž 2 0 0 0 A T L A S O F E S R D I N T H E U N I T E D S TAT E S Figure 6.41 Causes of death by race prevalent hemodialysis patients, 1996–1998 combined 15 Because of the small number of patients, data are not shown for White Native American or Asian pa- Black Deaths per 1,000 patient years at risk tients. 12 9 6 3 0 Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown disease Figure 6.42 Causes of death by race prevalent peritoneal dialysis patients, 1996–1998 combined 15 Because of the small number of patients, data are not shown for White Native American or Asian pa- Black Deaths per 1,000 patient years at risk tients. 12 9 6 3 0 Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown disease Figure 6.43 Causes of death by race prevalent transplant patients, 1996–1998 combined 15 Because of the small number of patients, data are not shown for White Native American or Asian pa- Black Deaths per 1,000 patient years at risk tients. 12 9 6 3 0 Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown disease

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