2011 USRDS Annual Data Report
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Figure 8.1 ESRD patients age 019. Adj: age/gender/race; ref: 2005 ESRD patients.
Figure 8.2 Unadjusted rates of hospitalization for bacteremia/ septicemia, by modality, age, & race, 20062009
Figure 8.3 Unadjusted rates of hospitalization for pneumonia, by modality, age, & race, 20062009
Figure 8.4 Unadjusted rates of hospitalization for respiratory infection (excluding pneumonia), by modality, age, & race, 20062009
Figure 8.5 Influenza vaccination rates, by modality, age, & race, 20062009
Figure 8.6 Pneumococcal pneumonia vaccination rates, by modality, age, & race, 20062007 & 20082009
Figure 8.7 Adjusted all-cause hospitalization rates in the first months of ESRD, by age & modality, 20012008
Figure 8.8 Adjusted cardiovascular hospitalization rates in the first months of ESRD, by age & modality, 20012008
Figure 8.9 Adjusted rates of hospitalization for infection in the first months of ESRD, by age & modality, 20012008
Figure 8.10 Adjusted all-cause mortality rates in the first months of ESRD (from day one), by age & modality, 20012008
Figure 8.11 Adjusted cardiovascular mortality rates in the first months of ESRD (from day one), by age & modality, 20012008
Figure 8.12 Adjusted rates of mortality due to infection in the first months of ESRD (from day one), by age & modality, 20012008
Figure 8.13 Adjusted five-year survival (from day one), by age & modality, 20002004>
Table A Distribution of reported incident ESRD pediatric patients, by primary diagnosis, 20002004 (period A) & 20052009 (period B)

Chapter Eight

Pediatric End-Stage Renal Disease

Sections this chapter: 

Introduction

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, and as shown on the next page, incidence due to glomerular disease has been declining gradually 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.

This year we have included a table showing the full range of diseases that cause ESRD in children, and covering the years 20002004 and 20052009. The total number of children beginning ESRD therapy grew nearly 4 percent between the two periods. Cystic/hereditary/congenital diseases accounted for 35 percent of new cases in 20052009, while 23 percent were caused by glomerular disease; focal glomerular sclerosis accounted for half of these reported cases. The third leading cause was secondary glomerular diseases, at 11 percent (54 percent of these patients had a primary diagnosis of lupus nephritis). In many disease groups males account for close to 60 percent of cases not a surprising number, as congenital diseases such as posterior urethral valves occur only in males. For other diseases such as lupus nephritis, in contrast, males account for just one in five cases.

In 2005-2009, close to 40 percent of children received a kidney transplant in the first year of ESRD, up from 37 percent in 20002004. And in both periods, 4.2 percent of children died in the first year of ESRD treatment.

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 complications from infection 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 the initiation of ESRD therapy. The pattern of hospitalization is different in children compared to adults, with rates in children increasing steadily over the first 15 months. Among patients younger than 10, rates of hospitalization for infection rise 31 percent between month three and months 1215; similar increases are noted for older children. By modality, these rates increase a striking 40 percent for hemodialysis patients, and 54 percent for those treated with peritoneal dialysis.

In contrast to patterns in hospitalization, those of mortality rates are similar to what is 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. In the early months of therapy, the youngest children are at the highest risk of both hospitalization and death.

The most striking findings related to pediatric ESRD patients continued to 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 remain issues of concern as well. 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 390 for analytical methods. ESRD patients age 0-19. Adj: age/gender/race; ref: 2005 ESRD patients.)

Table 8.a Distribution of reported incident ESRD pediatric patients, by primary diagnosis, 20002004 (period A) & 20052009 (period B) (see page 390 for analytical methods. Incident ESRD patients age 019. *Values for cells with ten or fewer patients are suppressed. "." Zero values in this cell.)

Infections | Vaccinations Top

Figure 8.2 Unadjusted rates of hospitalization for bacteremia/ septicemia, by modality, age, & race, 20062009 (see page 390 for analytical methods. Period prevalent ESRD patients age 019, 2006-2009; unadjusted.)
Figure 8.3 Unadjusted rates of hospitalization for pneumonia, by modality, age, & race, 20062009 (see page 390 for analytical methods. Period prevalent ESRD patients age 019, 2006-2009; unadjusted.)
Figure 8.4 Unadjusted rates of hospitalization for respiratory infection (excluding pneumonia), by modality, age, & race, 20062009 (see page 390 for analytical methods. Period prevalent ESRD patients age 019, 2006-2009; unadjusted.)

For pediatric ESRD patients prevalent in 20062009, unadjusted rates of hospitalization for bacteremia/septicemia are highest in those age 04, at 51 per 1,000 patient years at risk, and lowest in those age 1014, at 19. By race, overall rates are highest in African Americans and lowest in whites, at 45 and 31, respectively. Patients on hemodialysis have higher rates of admission for bacteremia/septicemia than do those on peritoneal dialysis or with a transplant.

Overall rates of admission for pneumonia are also greatest in patients age 04, at 91 per 1,000 patient years at risk. By modality, pneumonia admissions for transplant patients age 04 reach 96, compared to 29 for those of the same age on hemodialysis, and 84 for those treated with peritoneal dialysis.

Rates of admission for respiratory infection (excluding pneumonia) range from 2425 per 1,000 patient years at risk for patients age 1019 to 83 for those age 04. Rates differ less by race than they do by age.

Figure 8.5 Influenza vaccination rates, by modality, age, & race, 20062009 (see page 390 for analytical methods. Point prevalent ESRD patients age 0-19 prior to January 1 of each year, initiating therapy 90 days prior to September 1, & living through December 31 of each year, 2006-2009.)
Figure 8.6 Pneumococcal pneumonia vaccination rates, by modality, age, & race, 2006-2007 & 2008-2009 (see page 390 for analytical methods. Point prevalent ESRD patients age 0-19 prior to January 1 of the first year of the two-year study period & living through December 31 of the second year, 2006-2007 & 2008-2009.)

Rates of vaccination against influenza in the pediatric population remained alarmingly low in 20062009, with fewer than one in three patients age 14 or younger receiving a vaccination. Rates are highest in those age 1519, at 37 percent, vary little by race, and are generally higher in patients on hemodialysis.

In 2006-2007 and 2008-2009, pneumococcal pneumonia vaccination rates were highest overall in children age 1519, at 15 percent, and were just 7 percent in those 14 and younger. By race, rates are highest in African Americans, at 15.4 percent compared to 10.6 and 8.2 percent in whites and individuals of other races. And older children on hemodialysis are more likely to receive pneumoccal pneumonia vaccinations than their counterparts on peritoneal dialysis or with a transplant.

Hospitalization & Mortality Top

Figure 8.7 Adjusted all-cause hospitalization rates in the first months of ESRD, by age & modality, 20012008 (see page 390 for analytical methods. Incident ESRD patients age 019, 20012008. Adj.: rates by age, gender/race/primary diagnosis; rates by modality, age/gender/race/primary diagnosis. Ref: incident ESRD patients age 0-19, 2004-2005.)
Figure 8.8 Adjusted cardiovascular hospitalization rates in the first months of ESRD, by age & modality, 20012008 (see page 390 for analytical methods. Incident ESRD patients age 019, 20012008. Adj.: rates by age, gender/race/primary diagnosis; rates by modality, age/gender/race/primary diagnosis. Ref: incident ESRD patients age 019, 2004-2005.)
Figure 8.9 Adjusted rates of hospitalization for infection in the first months of ESRD, by age & modality, 20012008 (see page 390 for analytical methods. Incident ESRD patients age 019, 20012008. Adj.: rates by age, gender/race/primary diagnosis; rates by modality, age/gender/race/primary diagnosis. Ref: incident ESRD patients age 019, 2004-2005.)

In the 315 months following initiation of ESRD therapy, adjusted all-cause admission rates for patients age 09 are 1.61.7 times greater than those of their counterparts age 1019, increasing from 2,025 admissions per 1,000 patient years at risk in months 3<6 to 2,525 in months 12<15. By modality, admissions are lowest in transplant patients, and decline slightly over time, in contrast to the increase seen for both dialysis modalities. (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.)

Rates of cardiovascular admissions are greatest by age in patients age 09 and 1519, and reach 324334 per 1,000 patient years at months 12<15. Transplant patients have the lowest rates by modality, at just 22 in months 3<6, compared to 340 and 278 for hemodialysis and peritoneal dialysis patients, respectively.

For each age group, admissions for infection rise between months 3<6 and 6<9, then level out; the highest rates occur among the youngest patients. By modality, rates are lowest for transplant patients, and similar over time in both the hemodialysis and peritoneal dialysis populations.

Figure 8.10 Adjusted all-cause mortality rates in the first months of ESRD (from day one), by age & modality, 20012008 (see page 390 for analytical methods. Incident patients age 0-19, 2001-2008 (8.1012) & 2000-2004 (8.13). Adj: age/gender/race/primary diagnosis. Ref: incident ESRD patients age 019, 2004-2005.)
Figure 8.11 Adjusted cardiovascular mortality rates in the first months of ESRD (from day one), by age & modality, 20012008 (see page 390 for analytical methods. Incident patients age 0-19, 2001-2008 (8.1012) & 2000-2004 (8.13). Adj: age/gender/race/primary diagnosis. Ref: incident ESRD patients age 019, 2004-2005.)
Figure 8.12 Adjusted rates of mortality due to infection in the first months of ESRD (from day one), by age & modality, 20012008 (see page 390 for analytical methods. Incident patients age 0-19, 2001-2008 (8.1012) & 2000-2004 (8.13). Adj: age/gender/race/primary diagnosis. Ref: incident ESRD patients age 019, 2004-2005.)
Figure 8.13 Adjusted five-year survival (from day one), by age & modality, 2000-2004 (see page 390 for analytical methods. Incident patients age 0-19, 2001-2008 (8.1012) & 2000-2004 (8.13). Adj: age/gender/race/primary diagnosis. Ref: incident ESRD patients age 019, 2004-2005.)

Adjusted all-cause mortality rates for children age 04 are noticeably higher than those found in their older counterparts. In the first month of therapy, for example, mortality in younger children reaches 153 deaths per 1,000 patient years at risk, compared to 24 in those age 59, and 5.3 in those age 1014.

Overall, the all-cause mortality rate in pediatric patients reaches 48 in the first month after initiation, peaks at 57 in the next two months, then falls to 28 in months 9<12. Rates are highest in patients treated with hemodialysis, and lowest in those with a transplant.

Rates of mortality due to cardiovascular disease show similar patterns. For the youngest patients, the rate falls from 65 deaths per 1,000 patient years in the first month to 19 at the end of the year; rates for patients age five and older remain lower than 20 throughout the year. The overall rate of cardiovascular mortality is 19 in the first month, and declines to 7.9.

For most age groups, the rate of mortality due to infection peaks in months 1<3, reaching 38 for the youngest patients. The overall rate is 11.3 during this period, and falls to 5.4 in months 9<12.

For patients beginning ESRD therapy in 2000-2004, the overall probability of surviving five years was 0.88. By age, this ranges from a low of 0.78 among patients age 04 to 0.92 for ages 10-14. By modality, the highest probability is found in patients with a transplant, at 0.95, compared to 0.74 for those treated with hemodialysis.