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

Abstract

Background: Nephrology is one of the pediatric subspecialties with the largest workforce shortage in the US. Waitlist registration is one of the first steps towards 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 <18 years who developed kidney failure between 2016-2020 according to the US 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 4,497 children, of whom 3,198 (71%) were waitlisted and 2,691 (60%) received transplantation. Children residing in states with pediatric nephrologist density >1 had 33% (HR 1.33; 95%CI 1.07-1.66) and 22% (HR 1.22; 95%CI 1.02-1.45) better access to waitlisting compared to 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 (adjusted OR 1.56; 95% CI 1.02-2.41). The adjusted HR was 1.25 (95% CI 1.00-1.55, p=0.046) for deceased donor transplantation and 1.24 (95% CI 0.85-1.82) for living donor transplantation for children residing in states with pediatric nephrologist density > 1 compared to 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.