Responding to the workforce crisis: consensus recommendations from the Second Workforce Summit of the American Society of Pediatric Nephrology.

IMPORTANCE: Pediatric patients with complex medical problems benefit from pediatric sub-specialty care; however, a significant proportion of children live greater than 80 mi. away from pediatric sub-specialty care. OBJECTIVE: To identify current knowledge gaps and outline concrete next steps to make progress on issues that have persistently challenged the pediatric nephrology workforce. EVIDENCE REVIEW: Workforce Summit 2.0 employed the round table format and methodology for consensus building using adapted Delphi principles. Content domains were identified via input from the ASPN Workforce Committee, the ASPN's 2023 Strategic Plan survey, the ASPN's Pediatric Nephrology Division Directors survey, and ongoing feedback from ASPN members. Working groups met prior to the Summit to conduct an organized literature review and establish key questions to be addressed. The Summit was held in-person in November 2023. During the Summit, work groups presented their preliminary findings, and the at-large group developed the key action statements and future directions. FINDINGS: A holistic appraisal of the effort required to cover inpatient and outpatient sub-specialty care will help define faculty effort and time distribution. Most pediatric nephrologists practice in academic settings, so work beyond clinical care including education, research, advocacy, and administrative/service tasks may form a substantial amount of a faculty member's time and effort. An academic relative value unit (RVU) may assist in creating a more inclusive assessment of their contributions to their academic practice. Pediatric sub-specialties, such as nephrology, contribute to the clinical mission and care of their institutions beyond their direct billable RVUs. Advocacy throughout the field of pediatrics is necessary in order for reimbursement of pediatric sub-specialist care to accurately reflect the time and effort required to address complex care needs. Flexible, individualized training pathways may improve recruitment into sub-specialty fields such as nephrology. CONCLUSIONS AND RELEVANCE: The workforce crisis facing the pediatric nephrology field is echoed throughout many pediatric sub-specialties. Efforts to improve recruitment, retention, and reimbursement are necessary to improve the care delivered to pediatric patients.

Child Health Needs and the Pediatric Nephrology Subspecialty Workforce: 2020-2040.

Pediatric nephrology is dedicated to caring for children with kidney disease, a unique blend of acute care and chronic longitudinal patient relationships. Though historically a small field, trainee interest has declined over the past 2 decades. This has led to growing alarm about the health of the pediatric nephrology workforce, although concerns have been hampered by a lack of available data to enable feasible projections. This article is part of a supplement that anticipates the future pediatric subspecialty workforce supply. It draws on existing literature, data from the American Board of Pediatrics, and findings from a model that estimates the future supply of pediatric subspecialists developed by the Carolina Health Workforce Research Center at the University of North Carolina Chapel Hill's Cecil G. Sheps Center for Health Services Research and Strategic Modeling Analytics & Planning Ltd. The workforce projections from 2020 to 2040 incorporate population growth, clinical effort, and geographic trends and model alternate scenarios adjusting for changes in trainee interest, clinical efforts, and workforce attrition. The baseline model predicts growth of clinical work equivalents by 26% by 2040, but further widening geographic disparities worsen the existing mismatch between supply, clinical need, and market demand. The worst-case scenario projects 13% growth by 2040 which, at best, maintains the status quo of an already strained workforce. The models do not account for many factors expected to heighten demand over the coming decades. Urgent reforms are necessary now. Proposed solutions require multipronged changes in education and training pathways, remuneration, clinical practice models, and government policy.

The first randomized controlled trial in pediatric nephrology: the history of the International Study of Kidney Disease in Children (ISKDC).

The International Study of Kidney Disease in Children (ISKDC), begun in 1966, conducted the first international collaborative randomized blinded controlled trial in pediatric nephrology and one of the first in either pediatrics or nephrology. For this trial, the ISKDC developed the criteria, such as those for response and relapse, used today to describe the clinical course of the nephrotic syndrome, and the trial generated the nephropathologic terminology and criteria which largely remain the current standards. Over an approximately 20-year span, the ISKDC followed the natural history and evaluated the therapeutic effectiveness of therapies in over 500 children with the nephrotic syndrome from three continents. It published 14 peer-reviewed studies and several reports and commentaries, many of which helped create current standards of practice for therapy of childhood nephrotic syndrome and consequently remain highly cited today. The ISKDC continues to be an important model for subsequent collaborative studies and was the impetus for the development of regional and national pediatric nephrology societies leading to the recognition and growth of pediatric nephrology as a separate subspecialty. A higher resolution version of the Graphical abstract is available as Supplementary information.

Longitudinal analysis of living donor kidney transplant rates in pediatric candidates in the United States.

Among adults, living donor kidney transplant rates began declining in the United States after 2004 but whether a similar decline is occurring in the pediatric candidates has not been well studied. Share 35, a change in allocation rules implemented in October of 2005, may also have influenced rates of living donation. We sought to determine whether a decline in rates was occurring in pediatric candidates and whether the Share 35 program was the cause of the decline. All children listed for a kidney transplant or transplanted with a living donor without listing between 1996 and 2011 were identified in the United States (N=14 911) of which 6046 had received a living donor transplant during follow-up. Kaplan-Meier analysis showed a decline in living donor rates in candidates listed after 2001. Logistic regression analysis for living donor kidney transplantation confirmed the timing of the drop but also showed that changes in candidate demographics and center listing practices were impacting rates. A large drop in parental donation was the main cause for the drop. The rate of living donor transplant among pediatric candidates declined after 2001 predating by 4 years the implementation of Share 35, suggesting that factors other than changes in allocation rules are responsible for the decline.

Surgical outcomes analysis of pediatric peritoneal dialysis catheter function in a rural region.

PURPOSE: The purpose of this study was to analyze the experience with peritoneal dialysis (PD) at a high-volume, single center institution that supports a rural population. METHODS: From 2000 to 2010, 88 children (median age: 1.98 years, [range: 2 days-20.2 years]) received 134 PD catheters for the management of acute and chronic renal failure. The primary outcome of interest was the incidence of primary PD catheter failure (replacement or revision within 60 days). Operative technique, longitudinal outcomes, and time intervals to transplantation were analyzed. RESULTS: Median time to transplant from the institution of dialysis was 1.4 years [range: 0.3-6.4 years]. Primary catheter failure occurred in 24.6% of cases. Infants less than 6 months of age demonstrated an increased incidence of primary catheter failure (p = 0.02). The operative technique for catheter placement was not associated with the incidence of primary failure. Postoperative complications included peritonitis (22.7%), omental plugging (11.9%), pericatheter drainage (9.0%), and exit site infection (3.0%). CONCLUSION: Peritoneal dialysis provides a safe and effective renal replacement therapy for regional pediatric centers that serve a rural population. However, primary catheter failure rates remain high at 24.6%. The surgical technique for placement had no effect on this failure rate in our patient population. Infants less than 6 months of age are at increased risk for primary catheter failure and warrant intensive surveillance.

Patient recruitment into a multicenter randomized clinical trial for kidney disease: report of the focal segmental glomerulosclerosis clinical trial (FSGS CT).

We describe the experience of the focal segmental glomerulosclerosis clinical trial (FSGS CT) in the identification and recruitment of participants into the study. This National Institutes of Health funded study, a multicenter, open-label, randomized comparison of cyclosporine versus oral dexamethasone pulses plus mycophenolate mofetil, experienced difficulty and delays meeting enrollment goals. These problems occurred despite the support of patient advocacy groups and aggressive recruitment strategies. Multiple barriers were identified including: (1) inaccurate estimates of the number of potential incident FSGS patients at participating centers; (2) delays in securing one of the test agents; (3) prolonged time between IRB approval and execution of a subcontract (mean 7.5 ± 0.8 months); (4) prolonged time between IRB approval and enrollment of the first patient at participating sites (mean 19.6 ± 1.4 months); and (5) reorganization of clinical coordinating core infrastructure to align resources with enrollment. A Web-based anonymous survey of site investigators revealed site-related barriers to patient recruitment. The value of a variety of recruitment tools was of marginal utility in facilitating patient enrollment. We conclude that improvements in the logistics of study approval and regulatory start-up and testing of promising novel agents are important factors in promoting enrollment into randomized clinical trials in nephrology.

Paediatric acid-base disorders: A case-based review of procedures and pitfalls.

Acid-base disorders occur frequently in paediatric patients. Despite the perception that their analysis is complex and difficult, a straightforward set of rules is sufficient to interpret even the most complex disorders - provided certain pitfalls are avoided. Using a case-based approach, the present article reviews the fundamental concepts of acid-base analysis and highlights common mistakes and oversights. Specific topics include the proper identification of the primary disorder; distinguishing compensatory changes from additional primary disorders; use of the albumin-corrected anion gap to generate a differential diagnosis for patients with metabolic acidosis; screening for mixed disorders with the delta-delta formula; recognizing the limits of compensation; use of the anion gap to identify 'hidden' acidosis; and the importance of using information from the history and physical examination to identify the specific cause of a patient's acid-base disturbance.

Les troubles de l'équilibre acido-basique sont fréquents chez les patients d'âge pédiatrique. Même si on les croit difficiles et complexes à analyser, des règles simples suffsent pour interpréter même les troubles les plus complexes, pourvu qu'on évite certains écueils.Au moyen d'une approche fondée sur des cas, le présent article contient les concepts fondamentaux de l'analyse acido-basique et fait ressortir des erreurs et des omissions courantes. Les thèmes abordés incluent la bonne détermination du trouble primaire, la distinction entre les changements compensatoires et d'autres troubles primaires, l'utilisation du trou anionique corrigé par l'albumine pour produire un diagnostic différentiel chez les patients ayant une acidose métabolique, le dépistage de troubles mixtes au moyen de la formule delta-delta, la détermination des limites de compensation, l'utilisation du trou anionique pour dépister une acidose « cachée ¼ et l'importance d'utiliser l'information tirée de l'anamnèse et de l'examen physique pour déterminer la cause précise de la perturbation acido-basique du patient.

Predictors of Retention and BMI Loss or Stabilization in Obese Youth Enrolled in a Weight Loss Intervention.

OBJECTIVE: To evaluate predictors for intervention dropout and successful reduction of metabolic syndrome risk factors among obese children enrolled in a short-term, clinic-based weight-loss intervention. DESIGN, SETTING, SUBJECTS: Retrospective database review of 1080 children 8 months-17 y.o. seen a a pediatric obesity clinic. INTERVENTIONS: Behavior modification counseling to induce change in dietary and exercise choices. MAIN OUTCOME MEASURES: 1). Pre-/post-intervention change in body mass index (BMI), waist circumference, blood pressure, glucose, insulin, and cholesterol (LDL, HDL, & total). 2) Predictors of successful decrease in BMI and clinic drop-out. ANALYSIS: Paired t-tests for pre-/post-intervention comparisons. Linear regression to assess predictors of success and predictors of drop-out, with adjustment for age, gender, race, insurance status, and service area. RESULTS: Among children evaluated, adolescent females were most likely to achieve successful decrease in BMI, insulin level, and LDL cholesterol post-intervention. Nearly 40% of children dropped out early in the intervention. Predictors of drop out included age <6y, public insurance status, follow-up scheduled during summer months, and residence in a tertiary service area. CONCLUSIONS: Clinic-based weight loss interventions can lead to successful improvements in BMI and other metabolic parameters in pediatric populations and may be more likely among adolescent females than in younger children or males. Drop-out is common, particularly among younger children, children with public insurance and children scheduled for follow-up in the summer. Identification of these drop-out predictors in individual patients may help in targeting children likely to succeed in short-term, clinic-based, weight-loss interventions.

Council of Pediatric Subspecialties (CoPS): the first five years.

The Council of Pediatric Subspecialties (CoPS) was founded in September 2006 largely due to concerns about the nonuniformity of the fellowship application process. Working with the pediatric subspecialty community, CoPS has been successful in promoting a uniform process with many more pediatric fellowship programs now using a matching program and the Electronic Residency Application Service. More important, the organization has created a bidirectional network of communication among the pediatric subspecialties and has used this to accomplish a great deal more than improving the entry of residents into subspecialty training. CoPS has provided a united voice for the subspecialties in response to the Institute of Medicine's Duty Hours report, participated in the development of educational conferences geared toward the subspecialist, promoted careers in the subspecialties, and worked with other pediatric organizations to advocate for improved health care for children. This article highlights CoPS' many achievements and describes the methods it used to accomplish them, illustrating how pediatric subspecialists can develop a communication network and use this to work together to achieve common goals.

Sport-related kidney injury among high school athletes.

BACKGROUND AND OBJECTIVE: The American Academy of Pediatrics recommends a "qualified yes" for participation by athletes with single kidneys in contact/collision sports. Despite this recommendation, most physicians continue to discourage participation in contact/collision sports for patients with single kidneys. A major concern is the lack of prospective data quantifying the incidence of sport-related kidney injury. The objective was to quantify the incidence of sport-related kidney injury among high school varsity athletes and compare it with sport-related injuries of other organ systems. METHODS: Data from the National Athletic Trainers' Association High School Injury Surveillance Study, an observational cohort study collected during the 1995-1997 academic years, were used. Incidence rates for sport-specific injuries to select organs were computed and compared. RESULTS: Over 4.4 million athlete-exposures, defined as 1 athlete participating in 1 game or practice, and 23,666 injuries were reported. Eighteen kidney injuries, none of which were catastrophic or required surgery, were reported compared with 3450 knee, 2069 head/neck/spine, 1219 mild traumatic brain, 148 eye, and 17 testicle injuries. Student athletes incurring kidney injuries were most often playing football (12 injuries) or girls' soccer (2 injuries). Sport-specific rates of kidney injury were significantly lower than sport-specific rates of mild traumatic brain, head/neck/spine, and knee injuries for all sports as well as rates of baseball- and basketball-specific eye injuries (P < .01). CONCLUSIONS: Kidney injuries occur significantly less often than other injuries during sport. These data do not support limiting sport participation by athletes with single kidneys.

Evolution of the urinary proteome during human renal development and maturation: variations with gestational and postnatal age.

BACKGROUND: Low birth weight is associated with deficits in nephron number in the infant kidney and increased risk of adulthood hypertension and renal dysfunction. Urinary biomarkers may be potential indicators of renal reserve, but little is known about the influence of gestational and postnatal age on the expression of urinary proteins. The aims of this study were to determine the relationships between selected urinary proteins and renal maturation. We hypothesized that urinary protein patterns would change over time during late nephrogenesis and renal maturation. METHODS: Urine samples were collected at birth and over 12 mo from preterm (33-35 wk) and term (38-40 wk) infants. Candidate urinary proteins were identified by antibody array and quantified with enzyme-linked immunosorbent assay. RESULTS: Preterm infants at birth were found to have relatively elevated levels of insulin-like growth factor binding protein-1, -2, and -6, monocyte chemotactic protein-1, CD14, and sialic acid-binding Ig-like lectin 5. These markers gradually decline to levels similar to those of full-term infants by 2-6 mo of life. In contrast, many urinary markers in healthy full-term infants remain stable over the first year of life. CONCLUSION: Gestational and postnatal age must be considered when evaluating the utility of urinary biomarkers.

A clinical approach to paediatric acid-base disorders.

Acid-base disorders are common in pediatric patients. We present a simple methodology for assessing both simple and complex acid-base disorders that is applicable to patients of all ages, and focus specifically on the usefulness of this approach in the pediatric patient. The application of four simple rules in sequence will define even the most complicated acid-base disturbance. However, because acid-base disorders are manifestations of systemic disorders, the primary value of characterizing them is that each generates a unique differential diagnosis. For each of the cardinal acid base disorders, the common and clinically-relevant causes in pediatric patients are explored. Additional diagnostic tools (including the serum anion gap, the delta-delta, the alveolar-arterial gradient, urine anion gap, and urine chloride), certain easily-recalled mnemonics, and empiric rules of thumb are also useful in specific situations. The treatment of acid-base disturbances is also considered, though treatment is generally best directed at the underlying disorder.

Predictors of retention and BMI loss or stabilization in obese youth enrolled in a weight loss intervention.

OBJECTIVE: To evaluate predictors for intervention dropout and successful reduction of metabolic syndrome risk factors among obese children enrolled in a short-term, clinic-based weight-loss intervention. DESIGN, SETTING, SUBJECTS: Retrospective database review of 1080 children 8 months to 17 years. seen a pediatric obesity clinic. INTERVENTIONS: Behavior modification counseling to induce change in dietary and exercise choices. MAIN OUTCOME MEASURES: (1) Pre-/post-intervention change in body mass index (BMI), waist circumference, blood pressure, glucose, insulin, and cholesterol (LDL, HDL, & total). (2) Predictors of successful decrease in BMI and clinic drop-out. ANALYSIS: Paired t-tests for pre-/post-intervention comparisons. Linear regression to assess predictors of success and predictors of drop-out, with adjustment for age, gender, race, insurance status, and service area. RESULTS: Among children evaluated, adolescent females were most likely to achieve successful decrease in BMI, insulin level, and LDL cholesterol post-intervention. Nearly 40% of children dropped out early in the intervention. Predictors of drop out included age <6 years, public insurance status, follow-up scheduled during summer months, and residence in a tertiary service area. CONCLUSIONS: Clinic-based weight loss interventions can lead to successful improvements in BMI and other metabolic parameters in pediatric populations and may be more likely among adolescent females than in younger children or males. Drop-out is common, particularly among younger children, children with public insurance and children scheduled for follow-up in the summer. Identification of these drop-out predictors in individual patients may help in targeting children likely to succeed in short-term, clinic-based, weight-loss interventions.

Perspectives on obesity programs at children's hospitals: insights from senior program administrators.

OBJECTIVE: The obesity epidemic has resulted in an increasing number of children needing multidisciplinary obesity treatment. To meet this need, pediatric obesity programs have arisen, particularly in children's hospitals. In 2008, the National Association of Children's Hospitals and Related Institutions (NACHRI) convened FOCUS on a Fitter Future, a group drawn from NACHRI member institutions, to investigate the needs, barriers, and capacity-building in these programs. METHODS: Senior administrators of the 47 NACHRI member hospitals that completed an application to participate in the FOCUS group were invited to complete a Web-based survey. The survey targeted 4 key areas: (1) perceived value of the obesity program; (2) funding mechanisms; (3) administrative challenges; and (4) sustainability of the programs. RESULTS: Nearly three-quarters of the respondents reported that their obesity programs were integrated into their hospitals' strategic plans. Obesity programs added value to their institutions because the programs met the needs of patients and families (97%), met the needs of health care providers (91%), prevented future health problems in children (85%), and increased visibility in the community (79%). Lack of reimbursement (82%) and high operating costs (71%) were the most frequently cited challenges. Respondents most frequently identified demonstration of program effectiveness (79%) as a factor that is necessary for ensuring program sustainability. CONCLUSIONS: Hospital administrators view tackling childhood obesity as integral to their mission to care for children. Our results serve to inform hospital clinicians and administrators as they develop and implement sustainable pediatric obesity programs.

Factors influencing pediatric nephrology trainee entry into the workforce.

BACKGROUND AND OBJECTIVES: Emerging needs in pediatric nephrology (PN) have made the number of nephrologists entering the workforce of critical importance. This study aimed to discern factors that influence PN fellows to choose their career path and decide to enter the PN workforce. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A survey was sent to the American Society of Pediatric Nephrology list of PN fellows (n = 103) in 2008. The 57 fellows (55%) who completed the survey were representative of the group. RESULTS: The majority decided on a career in PN as senior residents, most commonly due to their interest in renal physiology and academics. They felt residents chose other fields due to lack of interest/exposure to PN, financial constraints, and perceived PN workload. Fellows identified workload and their perception of faculty dissatisfaction as important concerns with PN. None of the respondents planned to leave fellowship, but 21% have considered this. Twenty-eight percent knew a PN fellow who resigned, thought to be due to workload, personal conflicts, and perceived faculty dissatisfaction. CONCLUSIONS: Exposing residents to PN earlier in training and emphasizing positive features may create greater interest in PN. PN programs should be cognizant of workload and the influence of faculty dissatisfaction. Ongoing evaluation of PN fellow perceptions can assist in efforts to enhance recruitment and retention.

The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours.

In December 2008, the Institute of Medicine published new recommendations regarding duty hours and supervision of residents' training in the United States. These recommendations evoked immediate concerns from program directors and leadership in all surgical and medical disciplines, including pediatrics. To address these concerns, the Accreditation Council for Graduate Medical Education convened a Duty Hours Congress in Chicago, Illinois, on June 11 and 12, 2009. This report summarizes the opinions and testimony of the organizations (American Academy of Pediatrics, Association of Pediatric Program Directors, and Council of Pediatric Specialties) that were invited to represent pediatrics at the Duty Hours Congress. The American Academy of Pediatrics, the Association of Pediatric Program Directors, and the Council of Pediatric Specialties supported the basic principles of the Institute of Medicine report regarding patient safety, resident supervision, resident safety, and the importance of effective "hand-offs"; however, the organizations opposed additional reductions in resident duty hours given the potential unintended adverse effects on the competency of trainees, the costs of graduate medical education, and the future pediatric workforce. These organizations agreed that additional changes in graduate medical education must be data driven and consider residents within the broader system of health care. The costs and benefits must be carefully analyzed before implementing the Institute of Medicine recommendations.