Impact of Global Economic Disparities on Practices and Outcomes of Chronic Peritoneal Dialysis in Children: Insights from the International Pediatric Peritoneal Dialysis Network Registry

Abstract

♦ Background, Objectives, and Methods: The number of patients on chronic peritoneal dialysis (CPD) is increasing rapidly on a global scale. We analyzed the International Pediatric Peritoneal Dialysis Network (IPPN) registry, a global database active in 33 countries spanning a wide range in gross national income (GNI), to identify the impact of economic conditions on CPD practices and outcomes in children and adolescents. ♦ Results: We observed close associations of GNI with the fraction of very young patients on dialysis, the presence and number of comorbidities, the prevalence of patients with unexplained causes of end-stage kidney disease, and the rate of culture-negative peritonitis. The prevalence of automated PD increased with GNI, but was 46% even in the lowest GNI stratum. The GNI stratum also affected the use of biocompatible peritoneal dialysis fluids, enteral tube feeding, calcium-free phosphate binders, active vitamin D analogs, and erythropoiesis-stimulating agents (ESAs). Patient mortality was strongly affected by GNI (hazard ratio per $10 000: 3.3; 95% confidence interval: 2.0 to 5.5) independently of young patient age and the number of comorbidities present. Patients from low-income countries tended to die more often from infections unrelated to CPD (5 of 9 vs 15 of 61, p = 0.1). The GNI was also a strong independent predictor of standardized height (p < 0.0001), adding to the impact of congenital renal disease, anuria, age at PD start, and dialysis vintage. Patients from the lower economic strata (GNI < $18 000) had higher serum parathyroid hormone (PTH) and lower serum calcium, and achieved lower hemoglobin concentrations. No impact of GNI was observed with regard to CPD technique survival or peritonitis incidence. ♦ Conclusions: We conclude that CPD is practiced successfully, albeit with major regional variation related to economic differences, in children around the globe. The

Peritoneal Dialysis Access Revision in Children: Causes, Interventions, and Outcomes

“…CAKUT is the predominant cause of childhood ESRD, and patients with this disorder often require complicated urologic procedures, which can be associated with a higher risk for infectious and mechanical complications and associated catheter malfunction. Because there are major regional differences in PD practice and outcome associated with economic welfare, we speculated that GNI might have an effect on the risk of access revision (19). The unexpected finding that high GNI was associated with a higher risk of access revision was not explained by differences in the patient age distribution or kidney disease spectrum, which differed by GNI and showed independent associations with access revision risk by multivariate analysis.…”

Outcome of Patients Initiating Chronic Peritoneal Dialysis During the First Year of Life

“…This new temporal pattern of mortality may reflect improvements in surgical and medical management at the time of dialysis initiation, or it may be a reflection of a more select patient population with less frequent use of chronic dialysis in those neonates/infants with significant potentially life-threatening comorbidities. 22,26 Termination characteristics also improved among infants who initiated chronic PD during 2000 to …”

Inequalities in access to pediatric ESRD care: a global health challenge

“…In a hospital-based study of children presenting with ESRD in Nigeria, 80 % of whom started dialysis, the median survival was less than 2 months and there was virtually no one alive 6 months after presentation in the hospital in the absence of chronic RRT [25]. Even in developing countries where chronic dialysis is available, mortality is strongly associated with country income, which further reduces RRT prevalence [26].…”