Associations between Deprivation, Geographic Location, and Access to Pediatric Kidney Care in the United Kingdom

Abstract

Background and objectivesPre-emptive kidney transplantation is advocated as best practice for children with kidney failure who are transplant eligible; however, it is limited by late presentation. We aimed to determine whether socioeconomic deprivation and/or geographic location (distance to the center and rural/urban residence) are associated with late presentation, and to what degree these factors could explain differences in accessing pre-emptive transplantation.Design, setting, participants, & measurementsA cohort study using prospectively collected United Kingdom Renal Registry and National Health Service Blood and Transplant data from January 1, 1996 to December 31, 2016 was performed. We included children aged >3 months to ≤16 years at the start of KRT. Multivariable logistic regression models were used to determine associations between the above exposures and our outcomes: late presentation (defined as starting KRT within 90 days of first nephrology review) and pre-emptive transplantation, with a priori specified covariates.ResultsAnalysis was performed on 2160 children (41% females), with a median age of 3.8 years (interquartile range, 0.2–9.9 years) at first nephrology review. Excluding missing data, 478 were late presenters (24%); 565 (26%) underwent pre-emptive transplantation, none of whom were late presenting. No association was seen between distance or socioeconomic deprivation with late presentation, in crude or adjusted analyses. Excluding late presenters, greater area affluence was associated with higher odds of pre-emptive transplantation, (odds ratio, 1.20 per quintile greater affluence; 95% confidence interval, 1.10 to 1.31), with children of South Asian (odds ratio, 0.52; 95% confidence interval, 0.36 to 0.76) or Black ethnicity (odds ratio, 0.31; 95% confidence interval, 0.12 to 0.80) less likely to receive one. A longer distance to the center was associated with pre-emptive transplantation on crude analyses; however, this relationship was attenuated (odds ratio, 1.02 per 10 km; 95% confidence interval, 0.99 to 1.05) in the multivariable model.ConclusionsSocioeconomic deprivation or geographic location are not associated with late presentation in children in the United Kingdom. Geographic location was not independently associated with pre-emptive transplantation; however, children from more affluent areas were more likely to receive a pre-emptive transplant.

Social Deprivation Is Associated With Lower Access to Pre-emptive Kidney Transplantation and More Urgent-Start Dialysis in the Pediatric Population

“…While no association was found in Australia (contrary to remoteness) 21 , a study found such disparities in the UK for access to pre-emptive kidney transplantation but not for late referral. 12 In the US, a better access to pre-emptive transplantation was found for white children. 9,22 Regarding modality of dialysis initiation, Schaefer et al found that the use of nightly intermittent PD at a country level increased with growth national income contrary to continuous ambulatory PD.…”

“…These results raise questions about the barriers leading to social inequality since pre-emptive kidney transplantation has been shown to improve kidney transplant outcomes. 36 Plumb et al recently showed in the UK that the association between social deprivation and access to pediatric kidney care could be mediated by the access to living donor transplant, 12 but the reasons explaining this social gradient are certainly more complex (psychosocial decision, role of clinicians' perspective…) and require further investigation.…”

“…In Australia and New-Zealand, lower SES was associated with poorer parent-rated children's clinical conditions in early stages CKD but not in dialysis. 11 In the US and Canada, African American children had higher mortality and lower access to transplant within one year of dialysis initiation 13 , and SES partly explained their observed faster progression to endstage kidney disease (ESKD) 12 . In the United Kingdom (UK), social deprivation was not associated with late referral, but strongly associated with access to pre-emptive kidney transplantation 12 .…”

“… 13 In the United Kingdom, social deprivation was not associated with late referral, but it strongly associated with access to pre-emptive kidney transplantation. 14 …”

Mind the Gap

“…In this issue of CJASN, Plumb et al (1) published their analysis of the associations between deprivation, geographic location, and access to pediatric kidney care in the United Kingdom. Over a 20-year period, they examined a cohort of children who started KRT between the ages of 3 months and 16 years of age.…”