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Factors influencing choice of renal replacement therapy in European paediatric nephrology units
Alan R Watson1, Wesley N Hayes, Karel Vondrak
1Children's Renal & Urology Unit, Nottingham Children's Hospital, QMC Campus, Derby Road, Nottingham, NG7 2UH, UK, judith.hayes@nuh.nhs.uk.
Insights
Pediatric renal replacement therapy choices vary, with peritoneal dialysis favored for younger children and hemodialysis for older ones. Insufficient multidisciplinary support impacts treatment decisions and family care.
Area of Science:
- Pediatric Nephrology
- Renal Replacement Therapy
- Treatment Modalities
Background:
- Factors influencing renal replacement therapy (RRT) choice in children include patient/family preferences, physical characteristics, and logistical constraints.
- A survey of 14 European centers investigated these influencing factors in pediatric RRT selection.
Purpose of the Study:
- To survey factors influencing treatment choice in European pediatric nephrology units.
- To identify common RRT modalities and influencing factors for children and adolescents.
Main Methods:
- A consensus-developed questionnaire was administered to 14 European Paediatric Dialysis Working Group members.
- Data collected included unit facilities, staffing, family assessments, and RRT choices for 97 new patients in 2011.
Main Results:
- All units offered hemodialysis (HD), peritoneal dialysis (PD), and pre-emptive transplantation (PET), but PET had limitations.
- Chronic PD was the primary RRT for 50% of patients (predominant in <5 years), HD for 34% (>10 years), and PET for 16%.
- Patient/family choice and age/size were key factors; social factors favored HD, while declining renal function favored PET. Multidisciplinary support was often insufficient.
Conclusions:
- Chronic peritoneal dialysis is the predominant initial RRT choice for young children, while pre-emptive transplantation rates remain low.
- Surgical influence and national transplant rules significantly impact choices.
- Inadequate multiprofessional support across units may affect initial RRT selection and ongoing family support.
Background:
Many factors may impact upon choice of renal replacement therapy (RRT) for children and adolescents, including patient and family choice, patient size and distance from the renal centre as well as logistic issues such as facilities and staffing at the unit. We report a survey of factors influencing treatment choice in 14 European paediatric nephrology units.
Methods:
A questionnaire was developed by consensus and completed by 14 members of the European Paediatric Dialysis Working Group on facilities, staffing and family assessments impacting on choice of therapy as well as choice of therapy for 97 patients commencing initial RRT in 2011.
Results:
All units offered all modalities of RRT, but there were limitations for pre-emptive transplantation (PET) and largely adult surgical dependence for creation of arteriovenous fistulae and transplantation. The average waiting time for a deceased donor kidney was 18.5 (range 3-36) months. Full time dietetic support was available in six of the 14 units. There was no social worker, psychology, play therapy or teaching support in three, two, seven and four units, respectively. Assessment by other members of the multidisciplinary team and home visits before choice of therapy was carried out in 50 % of units, and although all patients were discussed at team meetings, the medical opinion predominated. In terms of types of RRT, 50 % of patients were commenced on chronic peritoneal dialysis (PD), 34 % on haemodialysis (HD) and 16 % underwent pre-emptive transplantation (PET). Chronic PD predominated in patients aged <5 years and HD predominated in those aged >10 years. Patient and family choice and age or size of patient were predominant factors in choice of therapy with a predictable decline in renal function favouring PET and social factors HD.
Conclusions:
Chronic peritoneal dialysis predominated as primary choice of RRT, especially in younger children. The PET rates remain low. The influence of surgeons predominanted, and national transplant rules may be significant. Most units had insufficient multiprofessional support, which may impact upon initial choice of therapy as well as sustaining families through RRT.
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