Pediatric Nephrology Workforce and Access of Children with Kidney Failure to Transplantation in the United States

Key Points Pediatric nephrologists play a critical role in evaluating children with kidney failure for transplant candidacy. Nephrology is one of the pediatric subspecialties with the greatest workforce shortage in the United States. Children residing in states with the highest density of pediatric nephrologists had better access to waitlisting and deceased donor transplantation. Background Nephrology is one of the pediatric subspecialties with the largest workforce shortage in the United States. Waitlist registration is one of the first steps toward kidney transplantation and is facilitated by pediatric nephrologists. The objective of this study was to determine whether state-level density of pediatric nephrologists is associated with access to waitlisting (primary outcome) or kidney transplantation (secondary outcome) in children with kidney failure. Methods Using Cox proportional hazards and logistic regression analyses, we studied children younger than 18 years who developed kidney failure between 2016 and 2020 according to the United States Renal Data System, the national kidney failure registry. The density of pediatric nephrologists (determined by the count of pediatric nephrologists per 100,000 children in each state) was estimated using workforce data from the American Board of Pediatrics and categorized into three groups: >1, 0.5–1, and <0.5. Results We included 4497 children, of whom 3198 (71%) were waitlisted and 2691 (60%) received transplantation. Children residing in states with pediatric nephrologist density >1 had 33% (hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.07 to 1.66) and 22% (HR, 1.22; 95% CI, 1.02 to 1.45) better access to waitlisting compared with those residing in states with <0.5 pediatric nephrologist density (reference group) in unadjusted and adjusted analysis, respectively. Pediatric nephrologist density was particularly important for the odds of preemptive waitlisting comparing the highest versus lowest workforce density (adjusted odds ratio, 1.56; 95% CI, 1.02 to 2.41). The adjusted HR was 1.25 (95% CI, 1.00 to 1.55; P = 0.046) for deceased donor transplantation and 1.24 (95% CI, 0.85 to 1.82) for living donor transplantation for children residing in states with pediatric nephrologist density >1 compared with the reference group. Conclusions Children residing in states with higher pediatric nephrologist density had better access to waitlist registration, especially preemptively, and deceased donor transplantation.