It Takes a Village: Barriers to Optimal Pediatric ESKD Care

Background: Kidney transplantation (KT) is the preferred method of treatment for children with end stage kidney disease (ESKD). Pre-emptive KT (PKT) is associated with improved patient and graft survival. The effect of social isolation due to insufficient family support (IFS) or underlying psychosocial conditions have not been evaluated as a potential additional influential factor in the pediatric ESKD population. Methods: Single-center, retrospective chart review of 177 children who received ESKD care (dialysis only (D), dialysis followed by KT (D-KT), and PKT only) in our center from 2010 to 2020. Based on patient addresses, neighborhood disadvantage was categorized using the Child Opportunity Index (COI). Pediatric pre-KT psychology evaluations of all patients referred for KT during the study period were reviewed to identify additional barriers to PKT based on 4 standardized questions: AK=adequate knowledge about transplant, AT=ability to adhere to the treatment based on previous history, Psych= relevant mental health issues likely impacting on transplant success in the parents or in the child and evidence of IFS. Groups were compared based on race (R), modalities, and COI groups. Differences in characteristics between groups were determined by the chi-square test. Multinomial logistic regression analysis was conducted to identify the most significant factors influencing receipt of PKT. Results: PKT was more likely among white children (p=0.037) but was not associated with COI (p=0.095). Only IFS and Psych in child correlated with a decreased likelihood of PKT;. Subjects were more likely to remain on D if they had IFS (p<0.001) or had a Psych in child (p= 0.002). IFS was more likely among non-white (p=0.003), and families who lived in low COI areas (p<0.001). However, Psych in child did not correlate with R (p=0.54) or COI (0.67). Multinomial logistic regression was conducted using 4 variables (COI, R, Psych in child and IFS) to evaluate the likelihood of receiving a PKT: with only having no psychiatric illness in the child (LR=8.69, p=0.013, OR:0.15 95% CI: 0.032-0.698) and sufficient family support (LR=16.965, p<0.001, OR: 5.98, 95% 0.728-49.17) were significant contributing factors to receive a PKT. Conclusion: Psychosocial issues appear to play a significant role in access to transplant care, with social support from family being a significant predictor for PKT. Funding: Clinical Revenue Support