Get documents about "06
Shared by: huanghengdong
-
Stats
- views:
- 2
- posted:
- 12/16/2011
- language:
- pages:
- 10
Document Sample
Q Q u i ck l y t a ke m e u p
i n t o t h e b r i g h t ch i l d
of yo u r m i n d .
E.E. CUMMINGS,
The Enormous Room
mSIX
PEDIATrIC ESrD
108 2 0 0 1 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
I
ncident rates of ESRD in chil- received a transplant. Some of these are more likely to receive a cadaveric
dren have risen two to three disparities may be partially explained organ (fig 6.11). Pediatric patients
percent over the past decade, by the availability of organs for renal younger than five have a 93% sur-
and the odds of developing ESRD transplants, as demonstrated in vival rate after transplantation in
are as much as 2.2 times greater in Chapter Seven (figs 7.1 and 7.3). Since contrast to a 69% rate for children
some states than in others (fig 6.2). ESRD incidence rates are two to three of the same age on dialysis (fig 6.12).
times higher for black children than Other pediatric age groups have
The primary causes of ESRD in pedi- for whites, the organ donation rates five-year survivals on dialysis of
atric patients are glomerulonephri- from the general population would greater than 81% (fig 6.12).
tis and cystic/congenital/hereditary need to be at a comparable rate for
diseases. Boys have a higher likeli- there to be a similar proportion of Hospitalizations for children are di-
hood of renal failure from these lat- transplants. The ability to match an rectly related to age (figs 6.15–17) and
ter causes than do girls (fig 6.4). organ immunologically may also be are dominated by infectious compli-
different in black children compared cations. Although the number of
The modalities for treatment of pe- to whites. prevalent deaths is low, female chil-
diatric ESRD vary with patient age dren are generally at a greater risk
and particularly with race (figs 6.9– Most young patients with a first than males regardless of modality
10). White pediatric patients are more renal transplant receive that trans- (figs 6.18–20). The reasons for these
likely to receive a renal transplant plant from a living donor, a pattern differences have not been explored,
than patients in other racial groups, opposite to that in the adult but may be related to a higher degree
and non-whites are twice as likely to population. Children with of anemia in girls than in boys. At
be on hemodialysis as whites. After a repeat renal trans- initiation of dialysis children have
1999 t
two years on ESRD treatment black plant, in con- 1997-revAlen6 lower hematocrits than adults (fig
children have an almost equal chance trast, P 1,21 2.39), with female children having the
ent
of being treated with either dialysis ncid 29
I 5 2,58
1
lowest levels. These findings are
-1996lent 12
or transplant whereas more 1994 evA 2 423 4,8
7
present even though children are the
than 60% of white t Pr 1,26 0 8,74 most likely to receive EPO before
iden 68 84
children Inc 502 2,4 6 ESRD, as documented on the Medical
3 3 1,61
have 199 1-199evAlent 45 2 4,45
1
21.0 Evidence form 2728 (fig 2.25). These
Pr 1,165 8,22 42.4
nt 785 9.1 associations suggest that girls may be
cide 3
In 49 2,25
8
4 81.1 iron deficient to a greater degree than
nts 08 1,64 7.0 .1
Cou 380 3,7 21.3 4.2 144 boys or adults. Also, the prolonged
0- 4 7, 104 42.0
1
686 8.4 26.5 and more severe anemia may predis-
5- 9 3 tio n 76.9 pose these children to a greater risk
0-1
4 1,42 opulA .6 7.7 .2
1 np 19
13.4 144 Table 6.1 of myocardial hypertrophy and sub-
1 5-1
9 illio3
m . 4 0.1 Incident & prevalent counts & rates
per 8 28.4 sequent fibrosis, which could place
RAte
s
6.8 66.8 For patients younger than ten there was little them at risk for arrhythmic disorders.
.7
0- 4
12 .5 133 variation in incident and prevalent rates per million Further investigations are needed to
5- 9 26.3
population through the 1990s. For older pediatric patients, in
more completely understand the
4 contrast, prevalent rates have risen, possibly a reflection of improved
1 0-1 pathobiology of these patients.
19 survival after transplantation (see Chapter Seven).
15-
C H A P T E R 6 P E D I A T R I C E S R D 1 0 9
15-19
30
25
RAte per million populAtion
0-4
20
10-14
15 1999
1998
5-9 1997 Figure 6.1
1996 Incident rates, by age
10 1995 per million population, adjusted
1994 for gender & race
1993
1992 Incident rates of ESRD for pediatric patients aged
199 1 0–4 increased slightly from 1990 to 1999, as did the rates
5 1990 for children aged 10–14.
Figure 6.2
Incident rates, ages 0–19
per million population, 1995–1999
combined, adjusted for age, gender, &
race, by state
The mean incident rate varies by 118%
between the lowest and highest
15.7+ (20.3)
14.3 to <15.7 quintiles.
13.2 to <14.3
11.6 to <13.2
below 11.6 (9.3)
Included in tHis cHApter ¨ A graph of incident rates, and graphs of patient distribution by modality, primary diagnosis, gender, race, and
age ¨ Graphs showing treatment modality two years following the onset of ESRD ¨ A graph of the number of first and repeat transplants, and Kaplan-Meier survival
curves ¨ Graphs of hospital admissions for infection, by modality, age, and gender ¨ Graphs of causes of death by gender and race
110 2 0 0 1 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 6.3
Incident rates, by race, age, &
gender
1997–1999 combined, unadjusted
Ages 0-4 Ages 5-9 Ages 10-14 Ages 15-19
Black pediatric patients across 70
all age groups have higher inci- Male
dent rates of end-stage renal 60
Female
disease compared to patients in
Rate per million population
other racial groups, with the
50
highest incident rates among
pediatric patients occurring in
blacks aged 15–19. 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
Figure 6.4
Number of patients within
primary diagnosis group, by
gender: dialysis
incident patients aged 0–19, 900
1995–1999 combined Male
800 Female
Glomerulonephritis and cystic/
hereditary/congenital diseases 700
are the most frequent primary
diagnoses in the pediatric ESRD 600
Number of patients
population, with both occur-
ring more in boys than girls. 500
400
300
200
100
0
Diabetes Glomerulo- Secondary GN/ Interstitial Hypertension Cystic/hereditary/ Neoplasm/
nephritis (GN) vasculitis nephritis congenital cancer
Figure 6.5
Number of patients within
primary diagnosis group, by
gender: transplant
incident patients aged 0–19, 320
1995–1999 combined Male
280 Female
In the pediatric patients who re-
ceive a transplant as their initial
modality, cystic/hereditary/ 240
Number of patients
congenital diseases are the pri-
mary cause of ESRD, and occur 200
in more than twice as many
boys as girls. 160
120
80
40
0
Diabetes Glomerulo- Secondary GN/ Interstitial Hypertension Cystic/hereditary/ Neoplasm/
nephritis (GN) vasculitis nephritis congenital cancer
C H A P T E R 6 P E D I A T R I C E S R D 1 1 1
Figure 6.6
Distribution of primary
diagnosis within racial group:
dialysis
60 incident patients aged 0–19,
Diabetes Hypertension 1995–1999 combined
Glomerulonephritis Cystic/hereditary/congenital
50 Glomerulonephritis is the most
Percent of patients with diagnosis
Secondary GN/vasculitis Neoplasms/cancer
frequent primary diagnosis in
Interstitial nephritis/pyelonephritis black, Native American, and
40 Asian pediatric patients. Cystic/
hereditary/congenital diseases
occur most often in young
30 white and Native American
patients, while Asian children
are almost twice as likely than
20 children of other races to have
a primary diagnosis of second-
ary glomerulonephritis/vasculi-
10 tis.
0
White Black Native American Asian
Figure 6.7
Distribution of primary
diagnosis within racial group:
transplant
Diabetes Hypertension incident patients aged 0–19,
80 1995–1999 combined
Glomerulonephritis Cystic/hereditary/congenital
Secondary GN/vasculitis Neoplasms/tumors Cystic/hereditary/congenital
70 disease is by far the most fre-
Interstitial nephritis/pyelonephritis
Percent of patients with diagnosis
quent diagnosis among pedi-
60 atric patients who receive a
transplant at the beginning of
50 ESRD. No Native American or
Asian patients with diabetes,
40 secondary glomerulonephritis/
vasculitis, interstitial nephritis/
pyelonephritis, or neoplasms/
30
tumors were reported.
20
10
0
White Black Native American Asian
Figure 6.8
Gender distribution within
primary diagnosis group
incident patients aged 0–19,
1995–1999 combined
Dialysis Transplant Diabetes, glomerulonephritis,
80
secondary glomerulonephritis,
Male interstitial nephritis/pyelone-
70 Female phritis, hypertension, cystic/he-
Percent of patients with diagnosis
reditary/congenital diseases,
60 and neoplasms/tumors are
abbreviated along the axis.
50 Distribution within primary
diagnosis categories differs
40 greatly between the modalities.
Girls account for 61% of diabetic
30 children on dialysis, and 68% of
those with secondary glomeru-
20 lonephritis. Among transplant
patients, however, boys account
for 75% of diabetics, and the
10
population with secondary
glomerulonephritis is split
0 evenly between the genders.
DM GN SGN Inst. HTN Cyst. Neopl. DM GN SGN Inst. HTN Cyst. Neopl.
1 1 2 2 0 01 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 6.9
Treatment modality two years
following ESRD onset, within
age group
incident patients aged 0–19, 100
1995–1997 combined Hemodialysis
90
At two years following the on- Peritoneal dialysis
set of ESRD, transplant is by far 80 Transplant
the most frequent modality Death
70
Percent of patients
among all pediatric age groups.
Among patients aged 5–9, 72% 60
have received a transplant; that
number is 47%, however, 50
among patients aged 15–19,
40
and 36% of patients in this age
group are on hemodialysis two 30
years after beginning ESRD.
20
10
0
0-4 5-9 10-14 15-19
Figure 6.10
Treatment modality two years
following ESRD onset, within
race group
incident patients aged 0–19, 100
1995–1997 combined Hemodialysis
90
White children are most likely Peritoneal dialysis
to have received a transplant by 80 Transplant
the end of their second year of Death
70
Percent of patients
ESRD, followed by Native
Americans. The percentage of 60
black and Asian children with a
transplant at two years is only 50
slightly higher than that of their
40
peers on hemodialysis.
30
20
10
0
White Black Native American Asian
Figure 6.11
Total first & repeat transplants,
by donor source
incident patients aged 0–19 First transplants Repeat transplants
500 150
Includes patients not eligible
for Medicare enrollment. The 450 Living (365, 22.7%)
number of transplants in 1994, 125
and the percent change be- 400
tween 1994 and 1999, are indi-
Number of transplants
350
cated next to the lines. Cadaver (380, -5.5%) 100
First transplantation rates 300 Cadaver (109, -24.8%)
among pediatric patients have 250 75
been relatively steady for trans-
plants from living donors, while 200
the rate of cadaveric transplants 50
declined from 1994 to 1998. 150
Both rates increased in 1999. Living (28, -3.6%)
100
The number of living unrelated 25
transplants in pediatric patients 50
is extremely small, and reduced
organ availability limits the 0
number of repeat transplants in 1994 1995 1996 1997 1998 1999 1994 1995 1996 1997 1998 1999
these patients.
C H A P T E R 6 P E D I A T R I C E S R D 1 1 3
Figure 6.12
Kaplan-Meier five-year patient
survival, by age
Dialysis First transplant incident dialysis & transplant
100 patients, 1993–1994 combined
By five years after the start of
ESRD, 69% of children whose
ESRD began between birth and
90 age 4 are still alive on dialysis,
compared to 82% of children in
Percent surviving
other age groups. For patients
who receive their first trans-
80 plant, survival is best for those
aged 10–14 years and lowest
for those aged 0–4 years. All age
groups, however, have over 93%
Ages 0-4
70 survival at five years.
Ages 5-9
Ages 10-14
Ages 15-19
60
0 12 24 36 48 60 0 12 24 36 48 60
Months of survival
Figure 6.13
Kaplan-Meier five-year patient
survival after first transplanta-
White Black tion, by race & gender:
100 cadaveric transplants
1993–1994 combined
Because of the small number of
90 Ages 0-4
patients, data are not shown for
Ages 5-9
Native American or Asian
Ages 10-14 patients.
Percent surviving
Ages 15-19
80 The lowest five-year survival
probabilities for cadaveric
Male Female transplants occur in black and
100
male patients aged 0–4. Overall,
children aged 10–14 have the
highest probabilities of survival
90 across racial and gender
groups.
80
0 12 24 36 48 60 0 12 24 36 48 60
Months of survival
Figure 6.14
Kaplan-Meier five-year patient
survival after first transplanta-
White Black tion, by race & gender: living
100 donor transplants
1993–1994 combined
Because of the small number of
90 Ages 0-4
patients, data are not shown for
Ages 5-9
Native American or Asian
Ages 10-14 patients.
Percent surviving
Ages 15-19
80 Survival probabilities for pedi-
atric patients receiving trans-
Male Female plants from living donors are
100
similar across age groups for
whites and for males.
90
80
0 12 24 36 48 60 0 12 24 36 48 60
Months of survival
1 1 4 2 0 0 1 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 6.15
Admissions for infection
(overall), by age, gender, &
time on ESRD: hemodialysis
incident & prevalent 140 Age Gender
hemodialysis patients,1997– < 1 year
Admissions per 100 patient years at risk
1999 combined 120 1 to < 2 years
The rates of admissions for in- 2 to <5 years
fection vary little between the 100 5+ years
genders. Among age groups,
however, rates are highest for
80
children younger than ten years
of age who have had ESRD for
less than one year, and for chil- 60
dren aged 5–9 who have had
ESRD less than five years. 40
20
0
0-4 5-9 10-14 15-19 Male Female
Figure 6.16
Admissions for infection
(overall), by age, gender, &
time on ESRD: peritoneal
dialysis 140 Age Gender
incident & prevalent peritoneal < 1 year
Admissions per 100 patient years at risk
dialysis patients, 1997–1999 120 1 to < 2 years
combined 2 to <5 years
In all age and gender groups 100 5+ years
except ages 5–9, pediatric
patients on peritoneal dialysis
80
have higher rates of admission
for infection than their counter-
parts on hemodialysis. Rates are 60
highest for the youngest
patients (ages 0–4), and for chil- 40
dren aged 5–9 who have had
ESRD for more than five years.
Females have slightly higher 20
admission rates than males, and
these rates increase with longer 0
patient vintages. 0-4 5-9 10-14 15-19 Male Female
Figure 6.17
Admissions for infection
(overall), by age, gender, &
time on ESRD: transplant
incident & prevalent transplant 80 Age Gender
patients, 1997–1999 combined
Admissions per 100 patient years at risk
70
Transplant-related admissions < 1 year
for infection in pediatric
60 1 to < 2 years
patients are the lowest within
2 to <5 years
all modalities, at about half of
those of the other dialytic thera- 50 5+ years
pies. Age is a significant factor,
with transplant patients 40
younger than ten having higher
infectious hospitalization rates 30
than their older counterparts.
20
10
0
0-4 5-9 10-14 15-19 Male Female
C H A P T E R 6 P E D I A T R I C E S R D 1 1 5
Figure 6.18
Causes of death, by gender:
hemodialysis
prevalent patients aged 0–19,
14 1997–1999 combined
Male The “other known” category ac-
Deaths per 1,000 patient years at risk
12 Female counts for the highest number
of deaths in pediatric patients
10 on hemodialysis. Death rates
are higher for females than for
males in this category, “cardiac
8 other,” and infectious death.
6
4
2
0
Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown
disease
Figure 6.19
Causes of death, by gender:
peritoneal dialysis
prevalent patients aged 0–19,
20 1997–1999 combined
Male
Female Female patients on peritoneal
Deaths per 1,000 patient years at risk
dialysis have a more than four-
16 fold difference in rates of death
due to cardiac arrest compared
to their male counterparts.They
12 also have higher rates of death
due to infection and to other
cardiac and other known
causes.
8
4
0
Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown
disease
Figure 6.20
Causes of death, by gender:
transplant
prevalent patients aged 0–19,
4 1997–1999 combined
Male While mortality rates for pedi-
Female atric patients with transplants
Deaths per 1,000 patient years at risk
are low, girls again have higher
3 rates than boys in many catego-
ries. Males do have higher rates
of mortality due to infection
and other known causes.
2
Transplant centers frequently
do not receive notification
about the deaths of patients
who are followed by the pri-
1 mary care doctors. Because
graft survival is longest in pedi-
atric patients, causes of death
for these patients are frequently
0 unreported.
Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown
disease
116 2 0 01 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 6.21
Causes of death, by race:
hemodialysis
prevalent patients aged 0–19,
1997–1999 combined 15
White
Because of the small number of Black
Deaths per 1,000 patient years at risk
patients, data are not shown for
Native American or Asian 12
patients.
The rate of mortality due to car-
diac arrest is almost three times 9
higher among black pediatric
patients on hemodialysis than
in their white counterparts. 6
White patients, however, have
slightly higher rates of death
due to infection and to other 3
cardiac and other known
causes.
0
Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown
disease
Figure 6.22
Causes of death, by race:
peritoneal dialysis
prevalent patients aged 0–19,
1997–1999 combined 15
White
Because of the small number of Black
Deaths per 1,000 patient years at risk
patients, data are not shown for
Native American or Asian 12
patients.
In contrast to rates in the hemo-
dialysis population, rates of 9
mortality due to cardiac arrest
show little difference between
the races for pediatric patients 6
on peritoneal dialysis. Mortality
due to infection or to other
known causes is more frequent 3
among black patients, while
deaths related to cerebrovascu-
lar disease or to other cardiac
events occur more often in 0
white patients. Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown
disease
Figure 6.23
Causes of death, by race:
transplant
prevalent patients aged 0–19,
1997–1999 combined 4
White
Because of the small number of Black
Deaths per 1,000 patient years at risk
patients, data are not shown for
Native American or Asian
3
patients.
Black patients have higher mor-
tality rates on transplant for all
causes of death except “other 2
known;” in several categories
(cardiac other, cerebrovascular
disease, and infection) rates for
blacks are more than twice as
1
high as those for whites.
0
Cardiac arrest Cardiac other Cerebrovascular Infection Malignancy Other known Unknown
disease
