773 that for patients on PD for more than 8 years, the therapy can be continued under certain condi tions, specifically if there is a stable D/P Cr on PET test, no development of a high transport memb[.]
39 Long-Term Outcome of Chronic Dialysis in Children that for patients on PD for more than 8 years, the therapy can be continued under certain conditions, specifically if there is a stable D/P Cr on PET test, no development of a high-transport membrane status or requirement for the frequent use of hypertonic solutions, clinical stability with a good appetite and stable body weight, no signs of overhydration, stable serum CRP, and the absence of recurrent episodes of peritonitis [92] Earlier discontinuation of PD may be considered for the patient who has been on PD for 5 years or more with an increased D/P Cr or worsening UF capacity/development of UF failure 773 studies performed in children [171–173] Impaired schooling and cognition appear to have been induced by a long period of dialysis during youth The LERIC study found no difference in intellectual performance between patients who were on dialysis and those who were transplanted at the time of the investigation [171], which is in line with comparable outcomes of recent IQ studies in ESKD. Most deficits were found in tasks requiring memory, concentration, and general knowledge [171] In contrast to the finding of the LERIC study, pediatric transplanted patients with a median age of 25.7 years in a Swedish study reached the Cognitive Functioning same level of academic achievement as in the Impaired neurocognitive development and func- general population The limitation of this study tioning are important, but not well-understood was that 40% of the overall cohort did not particicomplications of pediatric CKD. There is evi- pate and no information about the characteristics dence that dialysis treatment is a prominent of these non-participants was provided [174] determinant Many have found evidence of sevOther studies on cognition in pediatric patients eral neuropsychological deficits in children with with CKD suggest that toddlers and young chilESKD, including impairment in IQ, academic dren with CKD are at greatest risk for impaired achievement, memory, and executive functioning neurocognitive development [175] In a large [167–169] This may not be completely revers- North American study from the Chronic Kidney ible after transplantation and can result in cogni- Disease in Children (CKiD) cohort, of the 386 tive dysfunction in adulthood Cognitive and children with CKD stages 2–4 (mean glomerular learning impairment is more prevalent in middle- filtration rate 41 mL/min/1.73 m2) studied, the aged adult patients with childhood ESKD than in overall neurocognitive functioning was within the age-matched population [170, 171] the average range for the entire group, but 21% to These issues have been uniquely addressed in 40% of participants scored at least one SD below the aforementioned longitudinal Dutch initiative, the mean on measures of IQ, academic achieveLERIC study [171] As noted previously, the ment, attention regulation, or executive functionLERIC study comprises all Dutch patients who ing A higher glomerular filtration rate was started RRT at age 0–15 years between 1972 and associated with a lesser risk for poor performance 1992 Information was obtained by reviewing all on measures of executive function [176] available charts from all patients in 2000 and Early detection of neurocognitive impairment in 2010 and inviting all living patients to return for children on long-term dialysis is of extreme cross-sectional investigation While the LERIC importance; an individualized adapted school study is predominantly an analysis of long-term program may significantly improve academic RRT with a functioning kidney transplant, because performance and lead to greater autonomy and a these patients began RRT as children, the study skilled job as an adult that better matches the suboffers important insights into the future for chil- ject’s capabilities and expectations dren who have received long-term dialysis In the LERIC study, the mean IQ scores of adults aged 20–40 years with childhood ESKD Quality of Life were on average ten points lower than in the agedmatched Dutch population, which is in line with In the LERIC study, patients aged 20–40 years the results of recent intelligence quotient (IQ) with pediatric onset of ESKD and who were on 774 dialysis at the time of assessment indicated the presence of an impaired quality of life more often than the general population in all physical domains: in activities that require good physical condition (physical functioning), in social activities that require a good physical condition (role physical), in social functioning, and in general health perception These same patients, however, reported equally or even less often an impaired quality of life for mental domains [177] compared to age-matched Dutch citizens This was sharply in contrast with data from dialysis patients of the same age with onset of ESKD in adulthood, who scored substantially lower on all physical and mental domains compared to healthy individuals [178–180] The high mental health scores in LERIC are in line with data from other studies in adolescents and adults with chronic illness since childhood, including cystic fibrosis, sickle cell disease, and asthma [181–183] Different life expectations and coping strategies between children and adults may explain the different mental status of patients with adult and those with pediatric onset of disease Health-related quality of life reflects the difference between health experiences and health expectations; children may be far superior to adults in successfully using coping strategies [184, 185] Although transplanted patients showed the most favorable outcomes with respect to the physical domains, “early” aging seems to become a problem after more than 30 years of RRT. Finally, consideration of the sociodemographic variables is also important, and being employed appeared to be associated with a lower risk of impaired QoL in the domains of physical functioning, vitality, and general health perception Having offspring was also associated with a lower risk of impaired QoL [186] Social Outcome Employment In the LERIC study, social outcome was assessed in 2000 (mean age 30) and 2010 (mean age 40) In 2000 and 2010, 67.4% and 61.8%, respectively, of subjects were M Honda et al employed, 85% (81.8% in 2010) for more than 50% time equivalent [187, 188] Involuntary unemployment occurred in 19.1% vs 6.4% in the Dutch population at large Low-skilled professions were most prevalent (53%); only 10% of patients had high-skilled professions [187, 188] In 2010, there was a very significant difference between patients on dialysis, of whom only 31.3% were still employed, and transplanted patients Dialysis as the RRT modality and having motor disabilities were the most important risk factors for unemployment Increasing chronic fatigue was also often mentioned as a reason for becoming unemployed Others, however, reported that their employment contract was not renewed as a direct result of the disclosure of their dialysis patient status to the employer Unemployment was more often related to the patients’ low subjective health perception, rather than to their objective physical condition, or to whether they were transplanted or on dialysis Between 2000 and 2010, there was a trend toward more highly educated occupations and an increase in the educational level within the cohort In 2010, 22.1% of subjects had completed a high vocational training or scientific degree, compared to 31.2% in the general Dutch population (P > 0.05) 34.8% of the patients had an income equal to or above the national modal income of €2500 (about US$ 3200) gross per month, a significantly smaller proportion compared to the general population (61.1%) [188] In a French outcome study on 624 patients transplanted at childhood, fewer subjects than expected had a high-level degree (14.8% vs 30.2% general population) and fewer women had a baccalaureate degree (49.2% vs 76.5%), but these differences were less marked than in LERIC [170] Mean incomes were much lower than in the overall French population and more patients were unemployed (18.5% vs 10.4%, p 0.05) and 64.8% (P