2010 USRDS Annual Data Report
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Figure List
Figure 8.1Incident &prevalent counts &adjusted rates in the pediatric ESRD population, by primary diagnosis
Figure 8.2Incident patient counts, by age &primary diagnosis
Figure 8.3Incident counts &adjusted rates, by race
Figure 8.4Incident counts &adjusted rates, by modality
Figure 8.5Prevalent patient counts, by age &primary diagnosis
Figure 8.6Prevalent counts &adjusted rates, by race
Figure 8.7Prevalent counts &adjusted rates, by modality
Figure 8.8Hospital admissions for bacteremia/septicemia, by modality, age, &race, 20052008
Figure 8.9Hospital admissions for pneumonia, by modality, age, &race, 20052008
Figure 8.10Hospital admissions for respiratory infection (excluding pneumonia), by modality, age, &race, 20052008
Figure 8.11Influenza vaccination rates, by modality, age, &race, 20052008
Figure 8.12Pneumococcal pneumonia vaccination rates, by modality, age, &race, 20052006 &20072008
Figure 8.13Adjusted all-cause admissions in the first months of dialysis, by age &race, 20002007
Figure 8.14Adjusted cardiovascular admissions in the first months of dialysis, by age &race, 20002007
Figure 8.15Adjusted admissions for infection in the first months of dialysis, by age &race, 20002007
Figure 8.16Adjusted rates of all-cause mortality in the first months of dialysis, by age &race, 20002007
Figure 8.17Adjusted rates of cardiovascular mortality in the first months of dialysis, by age &race, 20002007
Figure 8.18Adjusted rates of mortality due to infection in the first months of dialysis, by age &race, 20002007
Figure 8.19Adjusted five-year survival for dialysis patients, by age &race, 19992003

Chapter OnEight
Pediatric end-stage renal disease  Top

Sections this chapter: 

Pediatric end-stage renal disease patients pose unique challenges to 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. To determine what progress may have been made in slowing the development of ESRD, we this year revisit trends in the incidence and prevalence of ESRD among children.

The overall incidence of ESRD in the pediatric population rose slowly between 1984 and 1990, a period when expertise in pediatric dialysis and transplantation was growing. Consistent with findings in the adult population, incidence due to glomerular disease has been declining slowly since 1990, and the number of patients has remained remarkably consistent. Both the incidence of ESRD due to cystic kidney disease and the number of children with this diagnosis, however, have been rising, a finding that merits investigation to determine whether the disease is truly increasing or if earlier recognition and treatment have led to more children coming to ESRD.

Racial disparities in rates of ESRD in children are similar to those noted in adults, but occur to a lesser degree. In adults, for example, the incidence of ESRD is nearly four times greater in African Americans compared to whites. Among children, in contrast, the difference is almost two-fold. These variations have been explored in prior ADRs, and will be addressed again in 2011.

High rates of hospitalization for bacteremia/sepsis in the hemodialysis population, particularly for children age four and younger, is a major concern. Due to the challenges of internal access placement in children, hemodialysis is performed through a dialysis catheter, creating the same risk of infectious complications faced by adult patients. Infection control procedures developed for adults may, with some modification, be applicable for children, and should be investigated.

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 both recommended levels and the levels seen in the adult population. There also continue to be discrepancies in vaccination rates by modality, with hemodialysis patients more likely to be vaccinated than children on peritoneal dialysis.

We next present data on hospitalizations after dialysis initiation. The pattern of hospitalization is different in children compared to adults, with rates increasing steadily over the first 15 months. Cardiovascular hospitalizations appear to have a bimodal distribution, with rates peaking in the fourth month, declining slightly in months 57, then rising again in months 1215. Rates of hospitalization for infection rise 61 percent between month three and months 1215. By race, rates are consistently higher among African American children than in their white counterparts.

In contrast to patterns in hospitalization, patterns in mortality rates are similar to those seen in the adult population, with rates peaking in the second month after initiation of treatment, then slowly declining through the rest of the first year. The youngest children are at the highest risk of both hospitalization and death.

The most striking findings related to pediatric ESRD patients center on the extreme vulnerability of patients younger than ten. And issues of infection control, which could lower the rate of complications, need to be addressed. In past ADRs we have also noted issues of uncontrolled hypertension and heart failure, and of sudden death, which still need to be addressed as well. In the 2011 ADR we will investigate the use of cardiovascular medications under the Medicare Part D prescription medication benefit, examining levels of treatment in the pediatric population.

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.

Figure 8.1 Incident &prevalent counts &adjusted rates in the pediatric ESRD population, by primary diagnosis (see page 481 for analytical methods. Incident ESRD patients age 019. Adj: age/gender/race; ref: 2005 ESRD patients)

Incident &prevalent counts  Top

Figure 8.2 Incident patient counts, by age &primary diagnosis (see page 481 for analytical methods. Incident ESRD patients age 019)

The total number of children initiating ESRD therapy with a primary diagnosis of glomerulonephritis fell 5.1 percent between the 19992003 and 20042008 periods, from 1,635 to 1,552, while the numbers with ESRD caused by secondary glomerulonephritis or cystic/hereditary/congenital disease rose 6.4 and 11.9 percent, respectively, to 727 and 2,152.

Figure 8.3 Incident counts &adjusted rates, by race (see page 481 for analytical methods. Inc. ESRD pts age 019. Adj: age/gender/primary diag.; ref: 2005)

Between 2000 and 2008, the number of children starting ESRD therapy rose 9 percent, to 1,277; the rate per million population rose 5.9 percent, to 15. By race, the rate of new cases is generally highest among African Americans, although a sharp rise in the number of Asian patients in 2007 accounts for a parallel spike in the rate for patients of other races, which reached 27.7 in 2008.

Figure 8.4 Incident counts &adjusted rates, by modality (see page 481 for analytical methods. Incident ESRD patients age 019. Adj: age/gender/race/primary diagnosis; ref: 2005 ESRD patients)

The number of children beginning ESRD therapy with a transplant has remained quite stable since 2000, reaching 189 in 2008, while the population starting on peritoneal dialysis has increased just 2 percent, to 405. The number initiating on hemodialysis, in contrast, has grown nearly 17 percent, to 673, with a rate per million population of 7.7

Figure 8.5 Prevalent patient counts, by age &primary diagnosis (see page 481 for analytical methods. December 31 point prevalent ESRD patients age 019)

Between 2003 and 2008, the total number of children being treated for ESRD caused by glomerulonephritis fell nearly 5 percent, to 1,488. The prevalent populations with a primary diagnosis of secondary glomerulonephritis or cystic/hereditary/congenital disease, in contrast, rose 16 and 19 percent, respectively, to 582 and 3,303.

Figure 8.6 Prevalent counts &adjusted rates, by race (see page 481 for analytical methods. December 31 point prevalent ESRD patients age 019. Adj: age/gender/primary diagnosis; ref: 2005 ESRD patients)

In 2008, the prevalent pediatric ESRD population reached 7,216, nearly 15 percent larger than in 2000. The overall rate per million population rose 11.9 percent in this period, to 85. Growth since 2006 of 36 percent in the number of patients of other races accounts for a corresponding rise in the prevalent rate for this population.

Figure 8.7 Prevalent counts &adjusted rates, by modality (see page 481 for analytical methods. Dec. 31 point prev. ESRD pts age 019. Adj: age/gender/race/primary diagnosis; ref: 2005 ESRD patients)

The number of children receiving hemodialysis therapy has increased nearly 11 percent since 2000, to 1,248 in 2008, while the adjusted rate for this population has grown 7.6 percent, to 14.1 per million population. The transplant population, in contrast, has grown nearly 19 percent in the same period, to 5,092; the rate of 60.6 is 16 percent higher than in 2000.

Hospitalization &preventive care  Top

Figure 8.8 Hospital admissions for bacteremia/septicemia, by modality, age, &race, 20052008

For pediatric ESRD patients prevalent in 20052008, overall rates (unadjusted) of hospital admissions for bacteremia/septicemia are highest in the youngest patients, at 4048 admissions per 1,000 patient years at risk in those age 09. Rates are lowest in those age 1014, at 22. By race, overall rates are greatest in African Americans and lowest in whites, at 45 and 28, respectively. Patients on hemodialysis generally have higher rates of admission for bacteremia/septicemia than do those on peritoneal dialysis or with a transplant.

Figure 8.9 Hospital admissions for pneumonia, by modality, age, &race, 20052008

Overall rates of admission for pneumonia are also greatest in the youngest patients, reaching 93 per 1,000 patient years at risk for those age 04. By modality, pneumonia admission rates for transplant patients age 04 reach 106, compared to 51 for those of the same age on hemodialysis, and 75 for those treated with peritoneal dialysis.

Figure 8.10 Hospital admissions for respiratory infection (excluding pneumonia), by modality, age, &race, 20052008

Rates of admission for respiratory infection excluding pneumonia range from 1819 per 1,000 patient years at risk for patients age 1019 to 80 for those age 04. Rates differ less by race than they do by age.

Figures 8.810; see page 481 for analytical methods. Period prevalent ESRD patients age 019, 20052008; unadjusted.

Figure 8.11 Influenza vaccination rates, by modality, age, &race, 20052008

Rates of vaccination against influenza in the pediatric population remain far from the Healthy People 2010 goal of 90 percent, with overall rates highest in those age 1519 and in whites, at 34.8 and 32.5 percent, respectively.

Figure 8.12 Pneumococcal pneumonia vaccination rates, by modality, age, &race, 20052006 &20072008

Pneumococcal pneumonia vaccination rates are highest overall in whites and African Americans, at 12.9 and 12.4 percent, respectively. Older children on hemodialysis are more likely to be vaccinated than their counterparts on peritoneal dialysis or with a transplant, while hemodialysis patients of other races are the most likely by race to receive vaccinations.

Figures 8.1112; see page 481 for analytical methods. Point prevalent ESRD patients, 20052008 (8.11) &20052006 &20072008 (8.12).

First-year hospitalization &mortality  Top

Figure 8.13 Adjusted all-cause admissions in the first months of dialysis, by age &race, 20002007

In the 315 months following initiation, adjusted all-cause admission rates for patients age 09 are 1.6 times greater than those of their counterparts age 1019, increasing from 1,835 admissions per 1,000 patient years at risk in months 3< 4 to 2,776 in months 12< 15. By race, rates are consistently greatest among African American patients, rising from 1,637 to 2,474. (Follow-up starts at month three after ESRD initiation in order to obtain complete admissions data, as in-center hemodialysis patients younger than 65 cannot bill Medicare for hospitalizations in the first 90 days.)

Figure 8.14 Adjusted cardiovascular admissions in the first months of dialysis, by age &race, 20002007

Across age and race groups, rates of cardiovascular admissions peak in months 4< 5, fall slightly, and then increase again in the later months of the period. At 12< 15 months following initiation, rates reach 396 per 1,000 patient years at risk for patients age 09, 1.4 times greater than the rate of 284 found among those age 1014. The rate among African American patients reaches 447, 1.4 times greater than that of their white counterparts, and 1.8 times higher than that of patients of other races.

Figure 8.15 Adjusted admissions for infection in the first months of dialysis, by age &race, 20002007

Patterns in admissions for infection are similar to those seen with all-cause admissions, rising quite steadily between months 3< 4 and months 12< 15.

Figures 8.1315; see page 481 for analytical methods. Incident dialysis patients age 019, 20002007. Adj: by age: gender/race/primary diagnosis; by race, age/gender/primary diagnosis. Ref: incident dialysis patients age 019, 20042005.

Figure 8.16 Adjusted rates of all-cause mortality in the first months of dialysis, by age &race, 20002007

As with hospital admission rates, adjusted all-cause mortality rates for children age 09 are noticeably higher than those found in their older counterparts. In the first month of therapy, for example, mortality in younger children is nearly five-fold higher, reaching 103.8 per 1,000 patient years at risk compared to 23.3 in older children. White children appear to have a slight survival advantage over African American children during the early course of therapy; rates then tend to converge at six months, and at months 912 are 34.1 and 54.1, respectively.

Figure 8.17 Adjusted rates of cardiovascular mortality in the first months of dialysis, by age &race, 20002007

Cardiovascular mortality rates in the first three months of dialysis reach 4244 per 1,000 patient years at risk in children age 09, compared to 1318 in older children. By race, cardiovascular mortality rates in African American children are 36 percent higher at initiation, and remain higher throughout the first year's course of treatment.

Figure 8.18 Adjusted rates of mortality due to infection in the first months of dialysis, by age &race, 20002007

As is the case with all-cause and cardiovascular mortality, rates of mortality due to infection are highest in the younger pediatric population, ranging from 14.624.0 per 1,000 compared to 1.66.1 in those age 1019. Rates by race tend to be similar in white and African American children.

Figure 8.19 Adjusted five-year survival for dialysis patients, by age &race, 19992003

The probability of a child surviving five years on dialysis was 0.8 for those starting therapy in 19992003. Patients age 04 have the lowest probability of five-year survival, at 0.72 compared to 0.820.83 among those age 519. Whites have a slight survival advantage over African Americans, at 0.81 and 0.77, respectively.

Figures 8.1619; see page 481 for analytical methods. Incident dialysis patients age 019, 20002007. Adj: by age: gender/race/primary diagnosis; by race, age/gender/primary diagnosis; overall: age, gender, race, &primary diagnosis. Ref: ESRD patients age 019, 20042005.