Dialysis and Transplantation in Youth Bradley A. Warady, M.D. Professor of Pediatrics University of Missouri - Kansas City Director, Division of Nephrology Director, Dialysis and Transplantation The Children’s Mercy Hospital ©2013 Children's ©2013 Children's Mercy. All Mercy. RightsAll Reserved. Rights Reserved. 09/13 09/13 Incident & Prevalent Counts for Pediatric ESRD Patients USRDS, 2014 Dialysis Patients in U.S. N = 415,013 Pediatric <1% Adult 99% Anemia Solute & Fluid Control Nutrition Bone Optimization of Pediatric Dialysis Care Cardiovascular Growth Infection HRQOL Primary Renal Diagnosis Aplasia/hypoplasia/ dysplasia N=10632 15% Other 49% Polycystic 3% NAPRTCS, 2011 Reflux 5% FSGS 12% Obstructive uropathy 15% Dialysis Modalities ■ Peritoneal Dialysis ■ Hemodialysis Patients (%) Dialysis Modality by Age 100 90 80 70 60 50 40 30 20 10 0 PD HD 0-1 2-5 6-12 Age NAPRTCS, 2011 >13 http://www.baxter.com/patients_and_caregivers/therapies/renal/home_dialysis/peritoneal_dialysis.html http://www.baxter.com/patients_and_caregivers/therapies/renal/incenter_dialysis/hemodialysis_therapies.html Dialysis Access Infectious Events Incident hemodialysis patients, age 0-19; ESRD CPM data. USRDS, 2009 Comparison of HRQOL Across Chronic Illness Groups (PedsQL youth self-report data) 85 CKD CKD (CKiD data, n=283) (CKiD data, n=283) 80 Dialysis Dialysis (Gerson et al, 2007 data, n=234) (Gerson et al, 2007, n=234) 75 70 65 60 Total Physical Healthy Diabetes Cardiac Asthma Mild to Moderate CKD Cancer Rheumatology CP ESRD Standardized Height Distribution of the Pediatric Hemodialysis Population, as Compared to the U.S. General Pediatric Population USRDS, 2008 The Impact of Height Dissatisfaction on Quality of Life 40 ■ Mean adult height SDS score: –1.56 ± 1.55 Percent of individuals dissatisfied with adult height 35 ■ Height satisfaction correlated significantly with height SDS score (r = 0.42; P = .006) 30 25 20 15 10 5 0 Adults with childhoodonset ESRD Healthy age-matched controls ■ Quality of life correlated significantly with height satisfaction (r = 0.41; P = .008) Rosenkranz J, et al. Pediatr Nephrol. 2005 Growth and CKD conservative treatment Dialysis transplantation -2 * ## Height [SDS] * * Start GH -3 # # * * * Start GH -4 * * Start GH 11 12 13 14 15 16 Age [years] Nissel, R. et al. J Clin Endocrinol Metab 2008;93:1359-1365 Copyright ©2008 The Endocrine Society 17 18 19 Kidney Transplantation Adjusted Five-Year Survival in Pediatric Patients (from day one), by Age & Modality, 2001–2005 Incident dialysis & transplant pts defined on the onset of dialysis or transplant day 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. USRDS, 2012 Etiologies of End-Stage Renal Disease in Children % Aplasia/hypoplasia/dysplasia 15.8 Obstructive uropathy 15.3 Focal segmental glomerulosclerosis 11.7 Reflux nephropathy 5.1 Chronic glomerulonephritis 3.1 Polycystic kidney disease 3.0 NAPRTCS, 2014 Recipient Characteristics NAPRTCS, 2014 Donor Source Deceased 50% Living 50% N = 12,116 NAPRTCS, 2014 Donor Source Parent 40% Sibling 3% NAPRTCS, 2014 Deceased 49% Other related 5% Unrelated 3% N = 12,116 Organs Made to Order It won't be long before surgeons routinely install replacement body parts created in the laboratory Read more: http://www.smithsonianmag.com/specialsections/40th-anniversary/OrgansMade-to-Order.html#ixzz2UtB6DC3i Initial Hospitalization Days NAPRTCS, 2014 Immunosuppressive Therapy NAPRTCS, 2014 Transplant-Related Challenges ■ Infection ■ Rejection Vaccinations Pre-Transplant Killed Vaccines  DPT  Pneumovax  Hib  Influenza  Hepatitis  Polio Live Vaccines  Varicella (do not give within 8 weeks of transplant  MMR (do not give within 8 weeks of transplant) Post-Transplant Killed Vaccines  Influenza Vaccine (give yearly)  Pneumovax  Polio Live Vaccines (contraindicated)  Give VZG for varicella exposure  Give IgG for measles exposure Influenza Vaccination Rates in Pediatric Patients, by Modality, Age, & Race, 2008–2011 USRDS, 2013 Pneumococcal Vaccination Rates in Pediatric Patients, by Modality, Age, & Race, 2008–2011 USRDS, 2013 NAPRTCS, 2014 Time to First Rejection for Index Transplants NAPRTCS, 2014 Time to First Rejection for Index Transplants NAPRTCS, 2014 The Brain of the Adolescent Look How Many Attributes Could Contribute to Nonadherence! Age and Graft Failure Young Kidney Transplant Recipients Foster et al., Transplantation, 2011 The Patient’s Perspective “I know why I lost my kidney. It was because I didn’t take my medicine all the time. I didn’t do it on purpose. I usually forgot it when I was sleeping over at my friends. I guess I was just excited about staying with my friends and I felt like a normal person not being held down by taking medicine.” http://www.medactionplan.com/ Graft Survival Rates NAPRTCS, 2014 Graft Survival by Transplant Era NAPRTCS, 2014 Cause of Graft Failure N = 2,702 Death 9% CAN 37% NAPRTCS, 2014 Recurrent Disease 7% Other 25% Acute Rejection 13% Vascular Thrombosis 9% END