Pediatric Nephrology at a Crossroads: Workforce Challenges to Ensure Access to Kidney Disease Care.

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Learn more: PMC Disclaimer | PMC Copyright Notice editorial J Am Soc Nephrol . 2025 May 7;36(6):1011–1013. doi: 10.1681/ASN.0000000730 Pediatric Nephrology at a Crossroads Workforce Challenges to Ensure Access to Kidney Disease Care Leonela Villegas 1, ✉ , Zubin J Modi 2, 3 Author information Article notes Copyright and License information 1 Division of Pediatric Nephrology, Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut 2 Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan 3 Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan ✉ Correspondence: Dr. Leonela Villegas, email: Lvillegas@connecticutchildrens.org ✉ Corresponding author. Issue date 2025 Jun. Keywords: CKD, kidney transplantation, outcomes, pediatric kidney transplantation, pediatric nephrology, USRDS (United States Renal Data System) Copyright © 2025 by the American Society of Nephrology PMC Copyright notice PMCID: PMC12147956  PMID: 40334692 See " Pediatric Nephrology Workforce and Access of Children with Kidney Failure to Transplantation in the United States " on page 1164. Children are not little adults—their needs and treatments differ in ways that make pediatric nephrologists indispensable in managing the growth and development of children with kidney diseases. Yet, an underlying sense of uncertainty looms over the future of this essential field. As advances in medicine extend the survival and complexity of children with chronic conditions, the number of children with AKI and CKD continues to rise, driving an increasing demand for pediatric nephrology care. Adding to this is the ongoing childhood obesity epidemic, leading to an increasing incidence of both pediatric kidney diseases and hypertension—ultimately increasing the need for pediatric nephrology care. Unfortunately, significant barriers remain in cultivating and sustaining the workforce necessary to meet the needs of future generations of children in the United States. We face a critical moment where the projected production of pediatric nephrologists is insufficient to meet the growing demand for care among children with kidney diseases. 1 The workforce growth rate between 2020 and 2040 is expected to be approximately 26%, increasing from 0.5 to 0.63 nephrologists per 100,000 children per state, remaining the fifth smallest pediatric subspecialty. This has the potential to exacerbate further inequities and potentially suboptimal care based on geographic location, as most pediatric nephrologists work in academic centers. 1 In 2023, 46% of pediatric nephrology fellowship positions remained unfilled, placing the field among the bottom subspecialties in recruitment. 2 Barriers such as financial burden, poor compensation, limited exposure during training, and high attrition rates continue to challenge the field, which is further compounded by inadequate data on the current system. Notably, the estimated opportunity cost of pursuing pediatric nephrology over general pediatrics is approximately $1.2 million over the course of a career. 3 Understanding and addressing these issues are crucial, especially as the population of children with CKD continues to grow—driven by innovation and advancements in neonatology, cardiac intensive care, solid organ transplants, and cancer therapies. The multifaceted nature of the commonly reported causes of workforce stagnation underscores the need for systemic solutions in health systems, governing boards, and training organizations, as well as state and federal reimbursement policies. Given the importance of delaying or stopping CKD progression to mitigate poor outcomes in children, it is critical to have pediatric nephrologists involved across the entire spectrum of kidney disease, from early-stage CKD to transplant, ensuring timely and comprehensive care. Both large prospective cohort studies and clinical trials have demonstrated the benefits of goal-oriented therapy for BP and proteinuria in delaying CKD progression. 4 , 5 In addition, current advances in therapies, such as sodium-glucose transport protein 2 inhibitors, are anticipated to provide further benefits to children. To achieve this, a sustainable and systematic approach is needed to build a sufficient workforce, ensuring that children have access to specialized care from pediatric nephrologists. 6 In this issue of JASN , the results of Acceta Rojas et al. emphasize the importance of pediatric nephrologists in facilitating access to kidney transplantation for children. 7 Acceta Rojas et al. examine whether the state-level density of pediatric nephrologists is associated with waitlist registration and kidney transplantation for children with kidney failure. Using data from the United States Renal Data System, the study included 4497 children who initiated KRT between 2016 and 2020. The authors found that children residing in states with the highest density of pediatric nephrologists, defined as number of American Board of Pediatrics–certified nephrologists per 100,000 children, had higher odds of waitlist registration and access to deceased donor kidney transplants compared with states with the lowest density of pediatric nephrologists. Disparities in waitlist access were observed among adolescents (12–17 years) at the time of kidney failure onset and Black children. However, no significant association was found between pediatric nephrology density and living donor transplantation. In line with previous reports on pediatric kidney failure, the study population is older, more likely to have glomerular disease, and more likely to be publicly insured compared with the overall pediatric CKD population. However, the study did not distinguish between Medicare and Medicaid coverage. Although children with kidney failure can be eligible for Medicare, the coverage landscape for children is more complex than for adults. Children's eligibility depends on their parents' Social Security contributions. Even if children apply for and enroll in Medicare, logistical challenges arise in accessing non-nephrology medical care, specifically routine primary care, as most pediatric clinicians outside of nephrology do not accept Medicare. This creates additional barriers to a multidisciplinary team approach for some of the most medically complex pediatric patients. 8 The findings by Acceta Rojas et al. provide valuable insight into the potential connection between the health care workforce and access to appropriate clinical care within a national cohort. This study is among the first to link pediatric nephrology density to a specific outcome facilitated by nephrologists. As integral members of the transplant team and process, pediatric nephrologists are uniquely positioned to enable transplant referrals and evaluate children with impending kidney failure. However, it is essential to note that pediatric nephrologist density alone does not fully capture the availability of the health care workforce. Several factors must be considered, including ( 1 ) geographic distribution, ( 2 ) workforce utilization, ( 3 ) quality of care ( i.e ., multidisciplinary clinics), ( 4 ) complexity of health care systems, and ( 5 ) patient demand. In addition, most pediatric nephrologists work in academic centers and commonly hold diverse academic and nonacademic roles. Thus, the study's estimate of density is likely overestimating the actual clinical workforce present in each state. Understanding the broader implications of these findings is challenging. There is a severe lack of data on the proportion and demographics of pediatric patients seen by adult nephrologists and in adult dialysis units, which is particularly critical given the study's identification of adolescents as a high-risk group. Although adult-trained nephrologists have significant expertise, they have less familiarity with the specific nuances of pediatric kidney disease, including congenital anomalies, which account for 50% of CKD in children. In addition, there are multiple rate-limiting factors for being placed on a kidney transplant waitlist, many of which are not solely dependent on the availability of pediatric nephrologists. These factors include transplant center requirements, proximity to the transplant center, and the infrastructure necessary to address the multiple subspecialty clearances required for this complex patient population. The study found that children residing in states with a pediatric nephrology density >1 had 1.56 times higher odds of preemptive waitlist registration and better access to waitlist registration compared with children in states with a pediatric nephrology density of <0.5. States with a pediatric nephrology density of 0.5 and 1.0 did not show statistical significance, potentially because of variability in state sizes. This underscores the complexity of state-level policies, specifically variations in Medicaid eligibility, reimbursement, and the provision of children's special health care programs, which directly affect care before need for KRT for children. The Centers for Medicare & Medicaid Services has acknowledged the unique needs of pediatric patients by implementing the Transitional Pediatric ESRD Add-on Payment Adjustment in 2024. However, this measure is far from sufficient to improve reimbursement as it covers only a small fraction of pediatric nephrology patients and remains a temporary measure. These disparities between states influence not only the ability to maintain a robust workforce and ensure multidisciplinary care in preparation for transplant but also the interpretation of the authors' findings on a national level. 9 Subgroups disproportionately affected by waitlist registration include adolescent-onset kidney failure and Black children, reflecting similar disparities observed in studies examining transplant outcomes among these vulnerable groups. 10 Black children are less likely to receive a preemptive or living donor transplant, both of which are associated with better outcomes and long-term graft survival. Adolescents are particularly important as they benefit most from early waitlisting due to pediatric priority. However, if they are not waitlisted because of pediatric nephrology access, it creates upstream delays, further delaying transplant and increasing dialysis exposure. Adolescents also face unique challenges, including psychologic readiness, treatment nonadherence, a greater need for social support, and impending transition to adult nephrology care. The potential for care discoordination between pediatric and adult facilities, coupled with the need for a multidisciplinary approach, complicates care coordination and contributes to delays in waitlisting and transplantation. In conclusion, the future of pediatric nephrology as a field—and the care it provides for children with CKD and kidney failure—depends on our ability to address both present and impending workforce challenges effectively and sustainably. It requires ongoing granular data collection, including specific characteristics of transplant centers, the clinical components of care, and more robust data on children with ESKD, regardless of the insurance provider. Acceta Rojas et al. provide an essential analysis to focus the community on these research questions to improve the current landscape. Pediatric nephrologists must have the time, resources, and support to deliver evidence-based, high-quality care that can delay disease progression before children require a transplant and ensure continued care during kidney failure. This issue's investigation highlights the importance of establishing a comprehensive system that ensures access to specialized care, reduces medical inequities, and secures a sustainable future for pediatric nephrologists and the children they care for. Acknowledgments The content of this article reflects the personal experience and views of the authors and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or JASN . Responsibility for the information and views expressed herein lies entirely with the authors. Footnotes See related article, “Pediatric Nephrology Workforce and Access of Children with Kidney Failure to Transplantation in the United States,” on pages 1164–1172. Disclosures Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/JSN/F177 . Funding None. Author Contributions Conceptualization: Zubin J. Modi, Leonela Villegas. Writing – original draft: Leonela Villegas. Writing – review & editing: Zubin J. Modi. References 1. Weidemann DK, Orr CJ, Norwood V, Brophy P, Leonard MB, Ashoor I. Child health needs and the pediatric nephrology subspecialty workforce: 2020-2040. Pediatrics. 2024;153(suppl 2):e2023063678P. doi: 10.1542/peds.2023-063678P [ DOI ] [ PubMed ] [ Google Scholar ] 2. National Academies of Sciences, Engineering, and Medicine. The Future Pediatric Subspecialty Physician Workforce: Meeting the Needs of Infants, Children, and Adolescents. National Academies Press; 2023. doi: 10.17226/27207 [ DOI ] [ PubMed ] [ Google Scholar ] 3. Catenaccio E, Rochlin JM, Simon HK. Differences in lifetime earning potential for pediatric subspecialists. Pediatrics. 2021;147(4):e2020027771. doi: 10.1542/peds.2020-027771 [ DOI ] [ PubMed ] [ Google Scholar ] 4. Vincent CL, Poehling KA, Rigdon J, Schaich CL, South AM, Downs SM. Cost-effectiveness of intensive blood pressure control in youth with chronic kidney disease. Hypertension. 2025;82(2):393–401. doi: 10.1161/HYPERTENSIONAHA.124.23437 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 5. Atkinson MA, Ng DK, Warady BA, Furth SL, Flynn JT. The CKiD study: overview and summary of findings related to kidney disease progression. Pediatr Nephrol. 2021;36(3):527–538. doi: 10.1007/s00467-019-04458-6 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 6. Soranno DE Amaral S Ashoor I, et al. Responding to the workforce crisis: consensus recommendations from the second workforce summit of the American Society of Pediatric Nephrology. Pediatr Nephrol. 2024;39(12):3609–3619. doi: 10.1007/s00467-024-06410-9 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 7. Accetta Rojas G McCulloch CE Copeland TP, et al. Pediatric nephrology workforce and access of children with kidney failure to transplantation in the United States. J Am Soc Nephrol. 2025;36(6):1164–1172. doi: 10.1681/ASN.0000000586 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 8. Brewer ED. ESRD policies and the delivery of pediatric long-term dialysis care in the United States. Am J Kidney Dis. 2021;77(2):264–267. doi: 10.1053/j.ajkd.2020.08.006 [ DOI ] [ PubMed ] [ Google Scholar ] 9. Warady BA Feldman DL Bell LE, et al. Improving clinical care for children with CKD: a report from a national kidney foundation scientific workshop. Am J Kidney Dis. 2023;81(4):466–474. doi: 10.1053/j.ajkd.2022.09.017 [ DOI ] [ PubMed ] [ Google Scholar ] 10. Maclay LM Yu M Amaral S, et al. Disparities in access to timely waitlisting among pediatric kidney transplant candidates. Pediatrics. 2024;154(3):e2024065934. doi: 10.1542/peds.2024-065934 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Articles from Journal of the American Society of Nephrology : JASN are provided here courtesy of American Society of Nephrology ACTIONS View on publisher site PDF (111.3 KB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

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