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  Figure 8.1 Adjusted all-cause rehospitalization rates in pediatric patients 30 days after live hospital discharge
  Figure 8.2 Unadjusted rates of hospitalization for any infection in pediatric patients, by modality, age, & race, 2007–2010
  Figure 8.3 Unadjusted rates of hospitalization for infection due to internal device in pediatric patients, by modality, age, & race, 2007–2010
  Figure 8.4 Unadjusted rates of hospitalization for bacteremia/septicemia in pediatric patients, by modality, age, & race, 2007–2010
  Figure 8.5 Unadjusted rates of hospitalization for respiratory infection ( including pneumonia) in pediatric patients, by modality, age, & race, 2007-2010
  Figure 8.6 Infections in pediatric patients by vascular access use, July–December, 2010
  Figure 8.7 Influenza vaccination rates in pediatric patients, by modality, age, & race, 2007–2010
  Figure 8.8 Pneumovax vaccination rates in pediatric patients, by modality, age, & race, 2007–2010
  Figure 8.9 Prevnar vaccination rates in pediatric patients, by modality, age, & race, 2007–2010
  Figure 8.10 One-year adjusted all-cause hospitalization rates in pediatric patients (from day 90), by age & modality
  Figure 8.11 One-year adjusted cardiovascular hospitalization rates in pediatric patients (from day 90), by age & modality
  Figure 8.12 One-year adjusted rates of hospitalization for infection in pediatric patients (from day 90), by age & modality
  Figure 8.13 One-year adjusted all-cause mortality rates in pediatric patients (from day one), by age & modality
  Figure 8.14 One-year adjusted cardiovascular mortality rates in pediatric patients (from day one), by age & modality
  Figure 8.15 One-year adjusted rates of mortality due to infection in pediatric patients (from day one), by age & modality
  Figure 8.16 Adjusted five-year survival in pediatric patients (from day one), by age & modality, 2001–2005
  Figure 8.17 Incident rates of pediatric ESRD in the United States & Canada, by age
  Figure 8.18 Incident rates of pediatric ESRD in the United States & Canada, by gender
  Figure 8.19 Incident rates of pediatric ESRD in the United States & Canada, by race
  Figure 8.20 Incident rates of pediatric ESRD in the United States & Canada, by primary diagnosis
  Figure 8.21 Incident rates of pediatric ESRD in the United States & Canada, by modality
  Figure 8.22 Prevalent rates of pediatric ESRD in the United States & Canada, by age
  Figure 8.23 Prevalent rates of pediatric ESRD in the United States & Canada, by gender
  Figure 8.24 Prevalent rates of pediatric ESRD in the United States & Canada, by race
  Figure 8.25 Prevalent rates of pediatric ESRD in the United States & Canada, by primary diagnosis
  Figure 8.26 Prevalent rates of pediatric ESRD in the United State & Canada, by modality
  Figure 8.27 Pediatric first transplant rates in the United States & Canada, by donor type
  Figure 8.28 Use of injectables & oral medications in pediatric dialysis patients, by age
  Table 8.a Distribution of reported incident ESRD pediatric patients, by primary diagnosis, 2001–2005 (period A) & 2006–2010 (period B)
  Table 8.b Antihypertensive medication use in pediatric patients with ESRD, by age & modality (column %)
  Table 8.c Average dose per week of injectable medications in pediatric dialysis patients, by age
  Table 8.d Top 25 drugs used in pediatric ESRD patients, sorted by total days supply, 2009–2010
  Table 8.e Top 25 drugs used in pediatric ESRD patients, sorted by percentage of patients with at least one fill, 2009–2010
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Chapter 8

Pediatric ESRD

Introduction

Pediatric end-stage renal disease patients pose unique challenges to parents, providers, and the healthcare system, which must address not only the disease itself, but the many extra-renal manifestations that affect patients’ lives and families. On the next spread we detail the causes of kidney failure in children, using data from the Medical Evidence form (2728). The leading causes are cystic/hereditary and congenital disorders, which account for 32 percent of pediatric ESRD cases, while 26 percent are caused by glomerular diseases, and 11 percent by secondary causes of glomerulonephritis, including vasculitis.

Even more striking are the simplest measures of outcomes in the first year of therapy. Thirty-eight percent of patients receive a transplant in the first year, while 4 percent die; neither of these rates has altered over the past decade. Considerable progress, however, has been made in the first-year mortality rate among patients with primary glomerular diseases, falling from 2.1 to 1.1 percent. But both the transplant and mortality rates among patients with congenital/hereditary/cystic diseases — the most common diagnoses — remain unchanged.

In this chapter we highlight the considerable degree of morbidity in pediatric patients, manifested not only in overall hospitalization rates, but in rates of repeated hospitalizations. Almost 35 percent of children with ESRD are rehospitalized within 30 days of discharge. As with the adult population (discussed in Chapter Three), this rate has not changed in a decade. Rates of hospitalization related to infection are highest in the youngest patients and in those on peritoneal dialysis, while hospitalizations due to bacteremia/sepsis are most frequent in the youngest patients on hemodialysis — an area of major concern. Hospitalizations due to pneumonia are greatest in transplant patients younger than ten, a finding which suggests that the low rates of pneumonia vaccinations may be an area to target.

Next we compare rates over time, allowing us to focus providers’ attention on areas which may need to be prioritized for greater prevention efforts. Between the periods of 2000–2004 and 2005–2010, overall hospitalization rates rose 29 percent for children younger than ten, and 17 percent for those age 15–19; hospitalizations in the hemodialysis and peritoneal dialysis populations rose 18–19 percent. Hospitalizations for cardiovascular causes rose 38 percent in the youngest children, and 47 percent in the oldest. Cardiovascular hospitalizations have increased the most in patients on hemodialysis and in those with a transplant, rising 49 and 56 percent, respectively, compared to 10 percent among those treated with peritoneal dialysis. And rates of hospitalization due to infection have increased 32 percent among patients younger than 10.

In similar analyses of mortality, adjusted rates show small increases in mortality in those younger than ten and those age 15–19, in contrast to a 31 percent decline among those age 10–14. These overall changes, however, are not reflected in rates of cardiovascular mortality, which have increased across all age groups in the hemodialysis population, and risen 17 percent for those on peritoneal dialysis; the rate among transplant patients, in contrast, has fallen 24 percent. More detailed analyses need to be developed on the specific causes of hospitalization, including congestive heart failure and arrhythmias. These complications are of particular concern in pediatric patients, in whom fluid overload and hypertension are major clinical problems. Also needed are analyses of medication use specific to these areas of morbidity.

Influenza and pneumococcal pneumonia can, of course, lead to increased hospitalization rates and higher risks of mortality. Rates of vaccination against these diseases have improved in the pediatric population, but still remain far below recommended levels, at less than half the rates seen in the adult population. There also continue to be disparities in vaccination rates by modality, with hemodialysis patients more likely to be vaccinated than children on peritoneal dialysis. This year we present new data on the various types of pneumococcal pneumonia vaccines.

Data on trends in incidence and prevalence are presented later in this year’s chapter, as we wanted to ensure that data on hospitalization were given high priority by providers, policy makers, and regulators. There are a few trends that merit particular attention. Rates of incidence due to cystic/hereditary/congenital diseases, for instance, appear to be increasing. This trend, which may be related to earlier diagnosis and better treatment (allowing children to survive to ESRD), needs to be investigated, but the small numbers pose many challenges. There also appears to be a real decline in ESRD due to glomerular disease, a trend noted in adults as well. The high use of kidney protective medications needs to be assessed to provide insight into this area. And the decrease in incidence among black/African American patients is parallel to a rise in rates among patients of other races, suggesting that reclassification may have occurred.

Overall, the most striking findings related to pediatric ESRD patients continue to center on the extreme vulnerability of patients younger than ten. Issues of infection control, which could lower the rate of complications, need to be addressed. This year we also show that cardiovascular mortality has increased, and should be addressed as well. In past ADRs we have noted issues of uncontrolled hypertension and heart failure, and of sudden death, which remain issues of concern. None of these are new challenges, but the community will need to assess them and develop new approaches to improving outcomes in this vulnerable population. ESRD patients age 0–19. Adjusted: gender/race/primary diagnosis; reference: discharges in 2005.

Figure 8.1 Adjusted all-cause rehospitalization rates in pediatric patients 30 days after live hospital discharge

ESRD diagnosis in the pediatric population

Table 8.a Distribution of reported incident ESRD pediatric patients, by primary diagnosis, 2001–2005 (period A) & 2006–2010 (period B)

Indections

Figure 8.2 Unadjusted rates of hospitalization for any infection in pediatric patients, by modality, age, & ;race, 2007–2010 (see page 442 for analytical methods)

For pediatric hemodialysis and peritoneal dialysis (PD) patients prevalent in 2007–2010, unadjusted rates of hospitalization for infection are highest in those age 0–4, at 1,130 per 1,000 patient years; in all age groups the lowest rates occur in pediatric patients with a transplant. By race, overall rates are highest in blacks/African Americans and lowest in whites, at 560 and 429, respectively; unadjusted.

Figure 8.3 Unadjusted rates of hospitalization for infection due to internal device in pediatric patients, by modality, age, & race, 2007–2010 (see page 442 for analytical methods)

Hemodialysis patients age 0–9 have higher rates of admission for infection due to an internal device then do PD patients, and infection is more common in younger patients. For blacks/African Americans on dialysis, admission rates due to infection from an internal device are higher compared to whites, at 272 and 234, respectively. Period prevalent dialysis patients; “infection due to internal device” includes those related to a vascular access device or peritoneal dialysis catheter.

Figure 8.4 Unadjusted rates of hospitalization for bacteremia/septicemia in pediatric patients, by modality, age, & race, 2007–2010 (see page 442 for analytical methods)

Rates of hospitalization for bacteria/ septicemia are highest in hemodialysis patients. By race, they tend to be higher in blacks/African Americans compared to whites or patients of other races. Period prevalent ESRD patients; unadjusted.

Figure 8.5 Unadjusted rates of hospitalization for respiratory infection ( including pneumonia) in pediatric patients, by modality, age, & race, 2007-2010 (see page 442 for analytical methods)

Rates of admission for respiratory infection (including pneumonia) overall are highest in patients age 0–4, at 161, and in patients of race other than white or black/African American, at 124. Period prevalent ESRD patients unadjusted.

For pediatric hemodialysis and peritoneal dialysis (PD) patients prevalent in 2007–2010, unadjusted rates of hospitalization for infection are highest in those age 0–4, at 1,130 per 1,000 patient years; in all age groups the lowest rates occur in pediatric patients with a transplant. By race, overall rates are highest in blacks/African Americans and lowest in whites, at 560 and 429, respectively.

Hemodialysis patients age 0–9 have higher rates of admission for infection due to an internal device then do PD patients, and infection is more common in younger patients. For blacks/African Americans on dialysis, admission rates due to infection from an internal device are higher compared to whites, at 272 and 234, respectively.

Rates of hospitalization for bacteria/ septicemia are highest in hemodialysis patients. By race, they tend to be higher in blacks/African Americans compared to whites or patients of other races.

The rate of vascular access infections in children on hemodialysis is higher in those using a catheter compared to those using an AV fistula or graph, at 1.7 vs. 14.6 percent.Period prevalent ESRD (8.2, 8.4–5) & dialysis (8.3) patients, & point prevalent hemodialysis patients (8.6), age 0–19; rates for 8.2–5 are unadjusted. In Figure 8.3,“infection due to internal device” includes those related to a vascular access device or peritoneal dialysis catheter.

Figure 8.6 Infections in pediatric patients by vascular access use, July–December, 2010 (see page 442 for analytical methods)

The rate of vascular access infections in children on hemodialysis is higher in those using a catheter compared to those using an AV fistula or graph, at 1.7 vs. 14.6 percent. Point prevalent hemodialysis patients.

Vaccinations

Figure 8.7 Influenza vaccination rates in pediatric patients, by modality, age, & race, 2007–2010

Rates of vaccination against influenza in the pediatric ESRD population have improved, but remain below recommended levels. In 2007–2010, approximately one-third of children age 14 or younger received a vaccination. Rates are highest in those age 15–19, at nearly 40 percent, and vary little by race. In older patients, rates are generally higher in those on hemodialysis compared to those on peritonal dialysis or with a transplant. Point prevalent ESRD patients age 0–19 prior to January 1 of the two-year study period & alive through December 31 of the second year, 2007–2008 & 2009–2010.

Figure 8.8 Pneumovax vaccination rates in pediatric patients, by modality, age, & race, 2007–2010

In 2007–2010, pneumovax vaccination rates were highest overall in children age 15–19, at 17 percent, and were just 8 percent or below in those 14 and younger. When compared to white children, rates in blacks/African Americans tend to be higher, at 11.2 versus 15.9 percent, respectively. Point prevalent ESRD patients age 0–19 prior to January 1 of the two-year study period &alive through December 31 of the second year, 2007–2008 & 2009–2010.

Figure 8.9 Prevnar vaccination rates in pediatric patients, by modality, age, & race, 2007–2010

The use of Prevnar is most common in children age 0–4 who are on peritoneal dialysis. Use varies little by race, at 1.0 and 0.7 percent, respectively, in whites and blacks/African Americans. Point prevalent ESRD patients age 0–19 prior to January 1 of the two-year study period & alive through December 31 of the second year, 2007–2008 & 2009–2010.

Figure 8.10 One-year adjusted all-cause hospitalization rates in pediatric patients (from day 90), by age & modality
(see page 442 for analytical methods)

Hospitalization &mortality

Between 2000–2004 and 2005–2009, one-year adjusted all-cause hospitalization rates per 1,000 patient years increased 29 and 17 percent, respectively, in patients age 0–9 and 15–19; in patients age 10–14, in contrast, rates fell one percent. By modality, rates rose 18–19 percent for dialysis patients and remained stable in those with a transplant; overall, all-cause hospitalization rates increased 16 percent between the two time periods. Incident ESRD patients age 0–19, 2000–2009. Adjusted for gender, race, & primary diagnosis. Reference: incident ESRD patients age 0–19, 2004–2005. Included patients survived the first 90 days after ESRD initiation &are followed from day 90.

Figure 8.11 One-year adjusted cardiovascular hospitalization rates in pediatric patients (from day 90), by age & modality
(see page 442 for analytical methods)

Cardiovascular hospitalization rates increased 38 and 47 percent, respectively, in children age 0–9 and 15–19, but fell 6 percent in those age 10–14. Rates rose 49 and 56 percent in hemodialysis and transplant patients, but just 10 percent in patients on peritoneal dialysis. Overall, rates increased 36 percent between the two periods. Incident ESRD patients age 0–19, 2000–2009. Adjusted for gender, race, & primary diagnosis. Ref: incident ESRD patients age 0–19, 2004–2005. Included patients survived the first 90 days after ESRD initiation & are followed from day 90.

Figure 8.12 One-year adjusted rates of hospitalization for infection in pediatric patients (from day 90), by age & modality
(see page 442 for analytical methods)

Rates of hospitalization for infection increased 32 and 9 percent in patients age 0–9 and 15–19, and fell 9 percent in those age 10–14. By modality, rates increased 12, 8, and 15 percent, respectively, for hemodialysis, peritoneal dialysis, and transplant patients; the overall rate rose 12 percent. Incident ESRD patients age 0–19, 2000–2009. Adjusted for gender, race, & primary diagnosis. Ref: incident ESRD patients age 0–19, 2004–2005. Included patients survived the first 90 days after ESRD initiation & are followed from day 90.

Figure 8.13 One-year adjusted all-cause mortality rates in pediatric patients (from day one), by age & modality

The one-year adjusted all-cause mortality rate in children age 0–9 was 89.8 per 1,000 patient years in 2005–2009, nearly six times higher than the rate in patients age 10–14, and slightly more than three times higher than for patients age 15–19. The rate for children on hemodialysis was 58.2, compared to 48.0 and 11.9, respectively, for those on peritoneal dialysis or with a transplant. Incident dialysis & transplant patients defined at the onset of dialysis or the day of transplant without the 60-day rule; followed to December 31, 2010. Adjusted for age, gender, race, Hispanic ethnicity, & primary diagnosis. Ref: incident ESRD patients age 0–19, 2004–2005.

Figure 8.14 One-year adjusted cardiovascular mortality rates in pediatric patients (from day one), by age & modality

In 2005–2009, the one-year adjusted cardiovascular mortality rate in children age 0–9 was 28.5 per 1,000 patient years, 4.8 and 2.5 times higher, respectively, than for ages 10–14 and 15–19. Children on hemodialysis have higher cardiovascular mortality than those on peritoneal dialysis, at 23.2 versus 17.5, while children with a transplant have the greatest survival advantage, with a mortality rate of 2.3. Incident dialysis & transplant patients defined at the onset of dialysis or the day of transplant without the 60-day rule; followed to December 31, 2010. Adjusted for age, gender, race, Hispanic ethnicity, &primary diagnosis. Ref: incident ESRD patients age 0–19, 2004–2005.

Figure 8.15 One-year adjusted rates of mortality due to infection in pediatric patients (from day one), by age & modality

The rate of mortality due to infection is highest in patients age 0–9, at 18.9 per 1,000 patient years in 2005–2009, compared to 1.4 and 2.5, respectively, in children age 10–14 and 15–19. And by modality, rates for children on hemodialysis and peritoneal dialysis are similar, at 9.0 and 8.4 — three times higher than those found in children with a transplant. Incident dialysis & transplant patients defined at the onset of dialysis or the day of transplant without the 60-day rule; followed to December 31, 2010. Adjusted for age, gender, race, Hispanic ethnicity, & primary diagnosis. Ref: incident ESRD patients age 0–19, 2004–2005.

Figure 8.16 Adjusted five-year survival in pediatric patients (from day one), by age & modality, 2001–2005

For patients beginning ESRD therapy in 2001–2005, the overall probability of surviving five years was 0.89. By age, the five-year survival probability ranged from 0.80 for ages 0–4 to 0.92 in those age 5–14; in children age 15–19, the survival probability was 0.89. By modality, the highest five-year survial probability occurs in children with a transplant, at 0.95 compared to 0.75 and 0.81, respectively, in those treated with hemodialysis or peritoneal dialysis. Incident dialysis &transplant patients defined at the onset of dialysis or the day of transplant without the 60-day rule; followed to December 31, 2010. Adjusted for age, gender, race, Hispanic ethnicity, &primary diagnosis. Ref: incident ESRD patients age 0–19, 2004–2005.

Pediatric ESRD in the Untied States & Canada

Figure 8.17 Incident rates of pediatric ESRD in the United States & Canada, by age

Here we present data graciously sent by CORR, the Canadian Organ Replacement Register. Together with U.S. data, these data provide a perspective on pediatric ESRD in North America, and allow comparisons of incidence, prevalence, patient characteristics, and modalities of therapy. The USRDS sincerely thanks the Canadian registry and providers for their efforts. In 2010, the incident rate of ESRD per million population was 16.0 for U.S. children compared to 9.2 for children in Canada. In both countries the rate is higher for adolescents age 15–19 compared to younger children; in the U.S., however, the rate for adolescents is 51 percent greater than for their Canadian counterparts, at 27 per million population. Incident ESRD patients age 0–19; unadjusted.

Figure 8.18 Incident rates of pediatric ESRD in the United States & Canada, by gender

Incident ESRD patients age 0–19; unadjusted.

Figure 8.19 Incident rates of pediatric ESRD in the United States & Canada, by race

By race, incident rates for whites are 35 and 16, respectively in Canada and the U.S., and 32 and 18 in children of other races. The extremely low rate of 5 per million among black children in Canada, compared to 15 per million in black/African American children in the U.S., likely reflects differences in ethnic group composition between the two countries. Incident ESRD patients age 0–19; unadjusted.

Figure 8.20 Incident rates of pediatric ESRD in the United States & ;Canada, by primary diagnosis

In the U.S., cystic kidney disease is the most common cause of ESRD in children, with a rate that has increased to 5.3 per million population; in Canada, in contrast, the rate is only 0.1, the lowest rate by primary diagnosis. Incident ESRD patients age 0–19; unadjusted.

Figure 8.21 Incident rates of pediatric ESRD in the United States & Canada, by modality

By modality, hemodialysis is the most common therapy for pediatric patients in both countries, with an incident rate of 8.0 per million population in the U.S. and 4.8 in Canada. Use of peritoneal dialysis among incident pediatric patients in Canada has been declining over the past decade. Incident ESRD patients age 0–19; unadjusted.

Figure 8.22 Prevalent rates of pediatric ESRD in the United States & Canada, by age

The prevalent rate of ESRD per million population in 2010 reached 86.0 for U.S. children and 68.3 for children in Canada. December 31 point prevalent patients age 0–19, unadjusted.

Figure 8.23 Prevalent rates of pediatric ESRD in the United States & Canada, by gender

As seen with incident rates, rates of prevalent ESRD are highest in children age 15–19 and in males compared to females. December 31 point prevalent patients age 0–19.

Figure 8.24 Prevalent rates of pediatric ESRD in the United States & Canada, by race

The prevalent rate of ESRD per million population in 2010 is four times higher in white children in Canada than in their U.S. counterparts. December 31 point prevalent patients age 0–19, unadjusted.

Figure 8.25 Prevalent rates of pediatric ESRD in the United States & Canada, by primary diagnosis

The rate of ESRD due to cystic kidney disease is ten times greater in the U.S. Rates of ESRD due to glomerulonephritis and secondary glomerulonephritis are higher in the U.S. as well, at 16.9 versus 12.4 and 7.1 versus 3.9 per million population. December 31 point prevalent patients age 0–19, unadjusted.

Figure 8.26 Prevalent rates of pediatric ESRD in the United State & Canada, by modality

Figure 8.27 Pediatric first transplant rates in the United States & Canada, by donor type

Kidney transplantation is the most common mode of therapy for both U.S. and Canadian children with ESRD. Living donor transplant rates for U.S. children in 2006–2010 were 4.3 per million population, compared to 3.5 in Canadian children; rates of deceased donor transplants were 6.3 and 4.2 per million, respectively. December 31 point prevalent patients age 0–19, unadjusted. First transplant rates in Figure 8.27 include cases in which a kidney was simultaneously transplanted in combination with another organ.

Use of medications and injectables

Table 8.b Antihypertensive medication use in pediatric patients with ESRD, by age & modality (column %)

Because data have been unavailable, use of prescription medications in children with ESRD has received little attention. As of 2006, however, medication use can now be assessed in children covered by Medicare based on their Part D prescription drug use. Reported comorbidity and complications in children include persistent hypertension, left ventricular hypetrophy (LVH), and heart failure with cardiomyopathy, and are far too common. The use of cardio-protective medications, however, appears to be similar to that of the adult population. In 2010, 40 percent of children were using ACEI/ARBs compared to 45 percent of adults; 35 percent of children on dialysis used beta blockers, compared to 52–56 percent of their adult counterparts (see Table 4.c in Chapter Four). Despite comparable use of cardiovascular drugs, and declining rates of hospitalization in adults, hospitalization rates for children are on the rise (Figure 8.11), findings which may suggest inadequate treatment of CVD in children. Period prevalent ESRD patients with Medicare Part D, 2009–2010.

Table 8.c Average dose per week of injectable medications in pediatric dialysis patients, by age

Use of injectables &oral medications in pediatric dialysis patients, by age

Figure 8.28 Use of injectables & oral medications in pediatric dialysis patients, by age

Children appear to receive less intranvenous anemia treatment than adults, with more than 85 percent of adult patients receiving IV iron, compared to 61 percent of children. Vitamin D therapy appears to be a combination of IV vitamin D analogs and oral therapy, and may reflect the fact that peritoneal dialysis patients receive oral medications and those on hemodialysis receive them by IV. Growth hormone therapy, an area reported previously by the USRDS and others, is used in less than 30 percent of children under age 6, and by only one in five of those age 6–14. These rates stand out sharply in light of the very high prevalence of short stature and poor growth in children with kidney disease, as shown in the USRDS 2009 Annual Data Report (Volume Two, Figure 8.1). Period prevalent ESRD patients with Medicare Part D, 2009–2010. IV vitamin D dose in paricalcitol-equivalent units.

Table 8.d Top 25 drugs used in pediatric ESRD patients, sorted by total days supply, 2009–2010
(see page 443 for analytical methods)

Table 8.e Top 25 drugs used in pediatric ESRD patients, sorted by percentage of patients with at least one fill, 2009–2010
(see page 443 for analytical methods)

Sevelamer (carbonate or hydrochloride), a drug to treat high phosphorus levels, was used by 47.9 percent of pediatric dialysis patients who had at least one prescription fill in 2009–2010; amlodipine, calcitriol, calcium acetate and cinacalcet were used by 33.2, 31.1, 27.7, and 24.6 of patients, respectively.In children with a transplant, sulfamethoxazole-trimethoprim, an antibacterial, is used in nearly three of four patients, while more than 50 percent of patients had at least one fill of valgancidovir, or prednisone or prednisolone. Amlodipine, and amoxicillin round out the top five medications used by pediatric transplant recipients. Period prevalent ESRD patients with Medicare Part D, 2009–2010. For Table 8.d, each prescription drug is disbursed with sufficient quantity to administer for a set number of days, so long as instructions are followed (i.e., so long as adherence is perfect). Total days supplied equals the cumulative number of days supplied through all fills of a particular medication in a population.