Higher Ultrafiltration Rate Is Associated with Longer Dialysis Recovery Time in Patients Undergoing Conventional Hemodialysis.

BACKGROUND: Increased mortality and morbidity are reported in association with high ultrafiltration rate (UFR) and with long dialysis recovery time (DRT). We studied the association between UFR and DRT. METHODS: This is a cross-sectional, observational study was conducted. Patients on thrice-weekly hemodialysis (HD) with self-reported DRT between August and December 2014 were included. We examined the association of 30-day average UFR with recovery time. RESULTS: The total number of patients included in this study was 2,689. DRT in categories of immediate recovery, >0-≤2, >2-≤6, >6-≤12, and >12 h, were reported in 27, 28, 17, 9, and 20% of the patients respectively. In multivariable analysis, longer DRT was associated with female gender, non-black race, higher body weight, lower serum albumin, chronic heart failure, cerebrovascular disease, missed dialysis sessions, higher pre-dialysis systolic blood pressure, and larger UF volume. Compared to UFR of <10, UFR ≥13 mL/kg/h was associated with longer DRT, OR of 1.16 (95% CI 0.99-1.36), and 1.28 (95% CI 1.06-1.54) in the unadjusted and the adjusted analyses respectively. Intradialytic hypotension was also associated with longer DRT in the unadjusted (per 10% higher frequency, OR 1.04 [95% CI 1.01-1.07]) and adjusted analyses (OR 1.03 [95% CI 1.00-1.07]). CONCLUSION: Long recovery time is common after HD. Rapid fluid removal is associated with longer DRT.

The chronic disease self-management program--A pilot study in patients undergoing hemodialysis.

A strong emphasis on self-management for health maintenance in a variety of chronic diseases has been shown to benefit patients' outcomes and quality of life. However, little has been published on such programs in patients with chronic kidney disease. We studied the feasibility and effectiveness of the Chronic Disease Self-Management Program (CDSMP) in 14 patients with ESRD undergoing conventional hemodialysis. This program is designed to enhance skills in the areas of medical, emotional, and role management. Outcome measures in health status, self-management behaviors, self-efficacy, and health care utilization were evaluated through use of questionnaires at baseline and after six months.

Predicting transfer to haemodialysis using the peritoneal dialysis surprise question.

BACKGROUND: People on peritoneal dialysis (PD) at risk of transfer to haemodialysis (HD) need support to remain on PD or ensure a safe transition to HD. Simple point-of-care risk stratification tools are needed to direct limited dialysis centre resources. In this study, we evaluated the utility of collecting clinicians' identification of patients at high risk of transfer to HD using a single point of care question. METHODS: In this prospective observational study, we included 1275 patients undergoing PD in 35 home dialysis programmes. We modified the palliative care 'surprise question' (SQ) by asking the registered nurse and treating nephrologist: 'Would you be surprised if this patient transferred to HD in the next six months?' A 'yes' or 'no' answer indicated low and high risk, respectively. We subsequently followed patient outcomes for 6 months. Cox regression model estimated the hazard ratio (HR) of transfer to HD. RESULTS: Patients' mean age was 59 ± 16 years, 41% were female and the median PD vintage was 20 months (interquartile range: 9-40). Responses were received from nurses for 1123 patients, indicating 169 (15%) as high risk and 954 (85%) as low risk. Over the next 6 months, transfer to HD occurred in 18 (11%) versus 29 (3%) of the high and low-risk groups, respectively (HR: 3.92, 95% confidence interval (CI): 2.17-7.05). Nephrologist responses were obtained for 692 patients, with 118 (17%) and 574 (83%) identified as high and low risk, respectively. Transfer to HD was observed in 14 (12%) of the high-risk group and 14 (2%) of the low-risk group (HR: 5.56, 95% CI: 2.65-11.67). Patients in the high-risk group experienced higher rates of death and hospitalisation than low-risk patients, with peritonitis events being similar between the two groups. CONCLUSIONS: The PDSQ is a simple point of care tool that can help identify patients at high risk of transfer to HD and other poor clinical outcomes.

A randomized trial comparing gentamicin/citrate and heparin locks for central venous catheters in maintenance hemodialysis patients.

BACKGROUND: Central venous catheters (CVCs) are used for vascular access in hemodialysis patients who have no alternative access or are awaiting placement or maturation of a permanent access. The major complications of CVCs are catheter-related bloodstream infection and clotting in the catheter lumen. STUDY DESIGN: Parallel-group, randomized, multicenter clinical trial, with patients blinded to study intervention. SETTING & PARTICIPANTS: 16 free-standing dialysis facilities in Northern California belonging to a single provider. 303 adult maintenance hemodialysis patients who were using a tunneled cuffed CVC for vascular access. INTERVENTION: The treatment group received an antibiotic lock containing gentamicin 320 µg/mL in 4% sodium citrate, whereas the control group received the standard catheter lock containing heparin 1,000 U/mL. Both groups received triple-antibiotic ointment on the catheter exit site during dressing changes at each dialysis treatment. OUTCOMES: Catheter-related bloodstream infection and catheter clotting. MEASUREMENTS: Catheter-related bloodstream infection was defined as the occurrence of symptoms consistent with bacteremia together with positive blood culture results in the absence of another obvious source of infection. Catheter clotting was measured as the rate of thrombolytic agent use required to maintain adequate blood flow. A single patient could contribute more than one infection or clotting episode. RESULTS: The rate of catheter-related bloodstream infection was 0.91 episodes/1,000 catheter-days in the control group and 0.28 episodes/1,000 catheter-days in the treatment group (P = 0.003). The time to the first episode of bacteremia was significantly delayed (P = 0.005). The rates of tissue plasminogen activator use were similar in the treatment and control groups: 2.36 versus 3.42 events/1,000 catheter-days, respectively (P = 0.2). LIMITATIONS: The requirement for dialysis facility staff to prepare the treatment intervention prevented a completely blinded study. CONCLUSION: Gentamicin 320 µg/mL in 4% sodium citrate used as a routine catheter lock in CVCs in patients on maintenance hemodialysis therapy markedly decreases the incidence of catheter-related bloodstream infection and is as effective as heparin 1,000 U/mL in preventing catheter clotting.

Changes in patient activation in people starting dialysis: A prospective longitudinal, observational study.

INTRODUCTION: Increased patient activation is associated with improved health outcomes; however, little is known about patient activation in people with end-stage kidney disease at the start of their dialysis journey. This study aimed to measure activation status changes over the first 4 months of dialysis. METHODS: Prospective, longitudinal, and observational study. Incident patients initiating dialysis at 25 in-center hemodialysis and 17 home dialysis programs across three US states managed by the same dialysis provider completed the 13-item Patient Activation Measure (PAM-13) survey at baseline (month 1 after commencement of dialysis) and follow-up (month 4). The survey yields a score (0-100) that corresponds to four levels (1-4), with higher scores or levels indicating higher activation. FINDINGS: One hundred eighty-two participants (139 center, 43 home) completed both baseline and follow-up surveys. Mean age was 60 ± 15 years, 40% female. Mean PAM-13 scores were 65.1 ± 16.8 and 64.8 ± 17.8 at baseline and follow-up, respectively; mean intraindividual change: -0.3 ± 17.3. The proportions of patients at levels 1-4 at baseline were 11%, 23%, 35%, and 31% respectively. At follow-up, 50%, 64%, 52%, and 37% of participants at levels 1-4, respectively, changed to a different PAM level (Spearman correlation = 0.47; p < 0.001). Home dialysis was associated with higher PAM scores when compared to in-center hemodialysis in multivariable analyses, adjusted for sociodemographic variables, comorbidities, and predialysis nephrology care (ß = 5.74, 95% confidence intervals [CI]: 0.11-11.37 and 9.02, 95% CI: 3.03-15.02, at baseline and follow-up, respectively). DISCUSSION: Although aggregated group scores and levels remained stable, intra-individual patient activation changed significantly during the first 4 months of dialysis. This novel finding is foundational to future projects aiming to design interventions to improve patient activation.

Patient Activation Among Prevalent Hemodialysis Patients: An Observational Cross-Sectional Study.

Patient activation is the product of knowledge, skills, and confidence that enables a person to manage their own healthcare. It is associated with healthy behaviors and improved patient outcomes. We surveyed prevalent hemodialysis (HD) patients at 10 centers using the Patient Activation Measure 13-item instrument (PAM-13). Activation was reported as scores (0-100) and corresponding levels (1-4). Of 1149 eligible patients, surveys were completed by 925 patients (92% response rate). Mean age was 62 ± 14 years, 40% were female, median vintage was 41 (IQR 19-77) months, and 66% had diabetes. Mean PAM score was 56 ± 13, with 14%, 50%, 25%, and 10% in levels 1 to 4, respectively. In adjusted analysis, older age and having diabetes were associated with lower activation, whereas higher educational levels and female gender were associated with higher scores. Significant variation in activation was observed among participants from different centers even after adjustment for other variables. In conclusion, low activation is common among prevalent HD patients.

Effect of lowering dialysate sodium concentration on interdialytic weight gain and blood pressure in patients undergoing thrice-weekly in-center nocturnal hemodialysis: a quality improvement study.

BACKGROUND: Patients on in-center nocturnal hemodialysis therapy typically experience higher interdialytic weight gain (IDWG) than patients on conventional hemodialysis therapy. We determined the safety and effects of decreasing dialysate sodium concentration on IDWG and blood pressure in patients on thrice-weekly in-center nocturnal hemodialysis therapy. STUDY DESIGN: Quality improvement, pre-post intervention. SETTINGS & PARTICIPANTS: 15 participants in a single facility. QUALITY IMPROVEMENT PLAN: Participants underwent three 12-week treatment phases, each with different dialysate sodium concentrations, as follows: phase A, 140 mEq/L; phase B, 136 or 134 mEq/L; and phase A(+), 140 mEq/L. Participants were blinded to the exact timing of the intervention. OUTCOMES: IDWG, IDWG/dry weight (IDWG%), and blood pressure. MEASUREMENTS: Outcome data were obtained during the last 2 weeks of each phase and compared with mixed models. The fraction of sessions with adverse events (eg, cramping and hypotension) also was reported. RESULTS: IDWG, IDWG%, and predialysis systolic blood pressure decreased significantly by 0.6 ± 0.6 kg, 0.6% ± 0.8%, and 8.3 ± 14.9 mm Hg, respectively, in phase B compared with phase A (P < 0.05 for all comparisons). No differences in predialysis diastolic and mean arterial or postdialysis blood pressures were found (P > 0.05 for all comparisons). The proportion of treatments with intradialytic hypotension was low and similar in each phase (P = 0.9). In phase B compared with phase A, predialysis plasma sodium concentration was unchanged (P > 0.05), whereas postdialysis plasma sodium concentration decreased by 3.7 ± 1.9 mEq/L (P < 0.05). LIMITATIONS: Modest sample size. CONCLUSION: Decreasing dialysate sodium concentrations in patients undergoing thrice-weekly in-center nocturnal hemodialysis resulted in a clinical and statistically significant decrease in IDWG, IDWG%, postdialysis plasma sodium concentration, and predialysis systolic blood pressure without increasing adverse events. Prolonged exposure to higher than required dialysate sodium concentrations may drive IDWG and counteract some of the purported benefits of "go-slow" (longer session length) hemodialysis.

Dialysate sodium and sodium gradient in maintenance hemodialysis: a neglected sodium restriction approach?

BACKGROUND: A higher sodium gradient (dialysate sodium minus pre-dialysis plasma sodium) during hemodialysis (HD) has been associated with sodium loading; however, its role is not well studied. We hypothesized that a sodium dialysate prescription resulting in a higher sodium gradient is associated with increases in interdialytic weight gain (IDWG), blood pressure (BP) and thirst. METHODS: We conducted a cross-sectional study on 1084 clinically stable patients on HD. A descriptive analysis of the sodium prescription was performed and clinical associations with sodium gradient were analyzed. RESULTS: The dialysate sodium prescription varied widely across dialysis facilities, ranging from 136 to 149 mEq/L, with a median of 140 mEq/L. The mean pre-HD plasma sodium was 136.7 ± 2.9 mEq/L, resulting in the majority of subjects (n = 904, 83%) being dialyzed against a positive sodium gradient, while the mean sodium gradient was 4.6 ± 4.4 mEq/L. After HD, the plasma sodium increased in nearly all patients (91%), reaching a mean post-HD plasma sodium of 141.3 ± 2.5 mEq/L. We found a direct correlation between IDWG and sodium gradient (r = 0.21, P < 0.0001). After adjustment for confounders and clustering by facilities, the sodium gradient was independently associated with IDWG (70 g/mEq/L, P < 0.0001). There were no significant associations among sodium gradient and BP, whether measured as pre-HD systolic (r = -0.02), diastolic (r = -0.06) or mean arterial pressure (r = -0.04). Post-HD thirst was directly correlated with sodium gradient (r = 0.11, P = 0.02). CONCLUSION: Sodium gradient is associated with statistically significant and clinically meaningful differences in IDWG in stable patients on HD.

Use of a gentamicin-citrate lock leads to lower catheter-related bloodstream infection rates and reduced cost of care in hemodialysis patients.

INTRODUCTION: Central venous catheters (CVC) are a major contributor to infections in hemodialysis (HD) patients, leading to high morbidity and mortality. Gentamicin-citrate (GC) lock is used as standard of care at centers belonging to a mid-size dialysis organization. Four outpatient HD centers acquired by the organization continued to use heparin for catheter locks for a period of time before converting to the provider's standard of using GC lock. METHODS: In this retrospective observational study, we included patients receiving HD by CVC at these four centers. We report rates of CVC-related bloodstream infections (CVC-BSI) during the heparin lock and the GC lock periods; crude rate ratios and adjusted rate ratios using Cox survival analyses adjusting for potential confounders; microbiology patterns; safety signals (gentamicin resistance, hospitalizations and deaths); and financial impact on payer. FINDINGS: A total of 220 and 281 patients used tunneled CVCs, accounting for 25,245 and 44,550 catheter days in the heparin and the GC lock periods, respectively. CVC-BSI event rates were 66% lower in the GC lock period (CVC-BSI event rate: 0.20 per 1000 catheter-days) than the heparin lock period (rate: 0.59 per 1000 catheter days); rate ratio 0.34 (95% confidence interval (CI) 0.15-0.78, P = 0.01). In the fully adjusted multivariable Cox model, use of GC lock was associated with 70% reduction in CVC-BSI events (HR 0.30, 95% CI 0.12-0.72, P = 0.01). No increased risk of gentamicin resistance, hospitalizations, or death associated with use of GC lock were observed. Use of GC lock was associated with an estimated saving of $1533 (95% CI: $259-$4882) per patient per year. DISCUSSION: Use of GC lock led to significant reductions in CVC-BSIs with no signal for harm, and is associated with significant cost savings in dialysis care.

COVID19 vaccine type and humoral immune response in patients receiving dialysis.

Background: Patients on dialysis vaccinated with the attenuated adenovirus SARS-CoV-2 vaccine might mount an impaired response to vaccination. Methods: We evaluated the humoral vaccination response among 2,099 fully vaccinated patients receiving dialysis. We used commercially available assays (Siemens) to assess prevalence of no response or diminished response to COVID-19 vaccination by vaccine type. We defined "no seroconversion" as lack of change from negative to positive in total RBD Ig antibody, no detectable response on semiquantitative RBD IgG antibody (index value <1) as "no RBD IgG response", and a semiquantitative RBD IgG index value <10 as "diminished RBD IgG response". Results: Of the 2,099 fully vaccinated patients on dialysis, the proportion receiving the mRNA1273, BNT162b2, and Ad26.COV2.S were 62% (n=1316), 20% (n=416) and 18% (n=367), respectively. A third (33.3%) of patients receiving the attenuated adenovirus Ad26.COV2.S vaccine failed to seroconvert and an additional 36% had no detectable or diminished IgG response even 28-60 days post vaccination. Conclusion: One in three fully vaccinated patients receiving dialysis had evidence of an impaired immune response to the attenuated adenovirus Ad26.COV2.S vaccine.

The Mobile Health Readiness of People Receiving In-Center Hemodialysis and Home Dialysis.

BACKGROUND AND OBJECTIVES: Mobile health is the health care use of mobile devices, such as smartphones. Mobile health readiness is a prerequisite to successful implementation of mobile health programs. The aim of this study was to examine the status and correlates of mobile health readiness among individuals on dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A cross-sectional 30-item questionnaire guided by the Khatun mobile health readiness conceptual model was distributed to individuals on dialysis from 21 in-center hemodialysis facilities and 14 home dialysis centers. The survey assessed the availability of devices and the internet, proficiency, and interest in using mobile health. RESULTS: In total, 949 patients (632 hemodialysis and 317 home dialysis) completed the survey. Of those, 81% owned smartphones or other internet-capable devices, and 72% reported using the internet. The majority (70%) reported intermediate or advanced mobile health proficiency. The main reasons for using mobile health were appointments (56%), communication with health care personnel (56%), and laboratory results (55%). The main reported concerns with mobile health were privacy and security (18%). Mobile health proficiency was lower in older patients: compared with the 45- to 60-years group, respondents in age groups <45, 61-70, and >70 years had adjusted odds ratios of 5.04 (95% confidence interval, 2.23 to 11.38), 0.39 (95% confidence interval, 0.24 to 0.62), and 0.22 (95% confidence interval, 0.14 to 0.35), respectively. Proficiency was lower in participants with Hispanic/Latinx ethnicity (adjusted odds ratio, 0.49; 95% confidence interval, 0.31 to 0.75) and with less than college education (adjusted odds ratio for "below high school," 0.09; 95% confidence interval, 0.05 to 0.16 and adjusted odds ratio for "high school only," 0.26; 95% confidence interval, 0.18 to 0.39). Employment was associated with higher proficiency (adjusted odds ratio, 2.26; 95% confidence interval, 1.18 to 4.32). Although home dialysis was associated with higher proficiency in the unadjusted analyses, we did not observe this association after adjustment for other factors. CONCLUSIONS: The majority of patients on dialysis surveyed were ready for, and proficient in, mobile health. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER DIALYSIS MHEALTH SURVEY,: NCT04177277.

The effect of blood flow rate on dialysis recovery time in patients undergoing maintenance hemodialysis: A prospective, parallel-group, randomized controlled trial.

INTRODUCTION: A majority of patients with end-stage renal disease (ESRD) on in-center hemodialysis (HD) require several hours to recover from an HD session. Patients and caregivers identify fatigue as a high priority for improvement. However, evidence for practical interventions to improve recovery time from conventional in-center HD is lacking. The effect of blood flow rate reduction on dialysis recovery time (DRT) is unknown. METHODS: Multicenter, single-blinded, randomized, parallel-design controlled trial of blood flow rate reduction vs. usual care. One-hundred two patients with ESRD undergoing maintenance HD in 18 centers with baseline DRT of greater than 6 hours were included as subjects. The intervention was a blood flow rate reduction of 100 mL/min, to a minimum of 300 mL/min. The primary outcome was the between-group difference in change in DRT. Secondary outcomes were changes in London Evaluation of Illness (LEVIL) survey responses from baseline. FINDINGS: Baseline median DRT was 720 (IQR 360-1013) minutes in controls and 720 (IQR 360-1106) minutes in the intervention group. DRT decreased in both groups. Mean change from baseline (95% confidence interval) at Week 4 in the study was -324 (-473, -175) minutes in the control group and -120 (-329, 90) minutes in the intervention group. The change from baseline was more profound in the control group (P = 0.05). Secondary outcomes of measures of quality of life reported on the LEVIL survey showed more improvement in patients' feelings of general well-being in the control group (P = 0.01). Differences between groups in pain, feeling washed out or drained, sleep quality, shortness of breath, and appetite were not statistically significant. DISCUSSION: Blood flow rate reduction did not improve DRT over usual care. Though more work needs to be done to address patient-reported fatigue, a significant positive impact may not be achieved without substantial changes in dialysis prescription.

Patient education and care for peritoneal dialysis catheter placement: a quality improvement study.

BACKGROUND AND OBJECTIVES: Peritoneal dialysis catheter (PDC) complications are an important barrier to peritoneal dialysis (PD) utilization. Practice guidelines for PDC placement exist, but it is unknown if these recommendations are followed. We performed a quality improvement study to investigate this issue. ♢ METHODS: A prospective observational study involving 46 new patients at a regional US PD center was performed in collaboration with a nephrology fellowship program. Patients completed a questionnaire derived from the International Society for Peritoneal Dialysis (ISPD) catheter guidelines and were followed for early complications. ♢ RESULTS: Approximately 30% of patients reported not being evaluated for hernias, not being asked to visualize their exit site, or not receiving catheter location marking before placement. After insertion, 20% of patients reported not being given instructions for follow-up care, and 46% reported not being taught the warning signs of PDC infection. Directions to manage constipation (57%), immobilize the PDC (68%), or leave the dressing undisturbed (61%) after insertion were not consistently reported. Nearly 40% of patients reported that their PDC education was inadequate. In 41% of patients, a complication developed, with 30% of patients experiencing a catheter or exit-site problem, 11% developing infection, 13% needing PDC revision, and 11% requiring unplanned transfer to hemodialysis because of catheter-related problems. ♢ CONCLUSIONS: There were numerous deviations from the ISPD guidelines for PDC placement in the community. Patient satisfaction with education was suboptimal, and complications were frequent. Improving patient education and care coordination for PDC placement were identified as specific quality improvement needs.

Beck Depression Inventory-Fast Screen (BDI-FS): an efficient tool for depression screening in patients with end-stage renal disease.

Depression is common in patients suffering from end-stage renal disease (ESRD). Various screening tools for depression in ESRD patients are available. This study aimed to validate the Beck Depression Inventory-Fast Screen (BDI-FS) with the Beck Depression Inventory-II (BDI-II) as depression screening tool in conventional hemodialysis (CHD) patients. One hundred sixty two CHD patients were studied with both screening questionnaires. We used the Pearson Correlation Coefficient to measure the agreement between BDI-II and BDI-FS scores from 134 patients who responded to both questionnaires. Receiver operating characteristics curve and area under the curve were constructed to determine a valid BDI-FS cutoff score to identify ESRD patients at risk for depression. BDI-II and BDI-FS scores strongly correlated (Pearson r = 0.85, p < 0.0001). At a BDI-II cutoff ≥16, receiver operating characteristics showed the best balance between sensitivity and specificity for the BDI-FS cutoff value of ≥4 with a sensitivity of 97.2% (95% confidence interval [CI]: 85.5%, 99.9%) and a specificity of 91.8% (95% CI: 84.5%, 96.4%). When applying the above cutoff scores, prevalence of depressive symptoms in all completed questionnaires was found to be 28.7% (BDI-II) and 30.1% (BDI-FS), respectively. The BDI-FS was found to be an efficient and effective tool for depression screening in ESRD patients which can be easily implemented in routine dialysis care.

Individualized reduction in dialysate sodium in conventional in-center hemodialysis.

Recent studies have focused on the association between dialysate sodium (Na(+)) prescriptions and interdialytic weight gain (IDWG). We report on a case series of 13 patients undergoing conventional, thrice-weekly in-center hemodialysis with an individualized dialysate Na(+) prescription. Individualized dialysate Na(+) was achieved in all patients through a stepwise weekly reduction of the standard dialysate Na(+) prescription (140 mEq/L) by 2-3 mEq/L until reaching a Na(+) gradient of -2 mEq/L (dialysate Na(+) minus average plasma Na(+) over the preceding 3 months). Interdialytic weight gain, with and without indexing to dry weight (IDWG%), blood pressure, and the proportion of treatments with cramps, intradialytic hypotension (drop in systolic blood pressure >30 mmHg) and intradialytic hypotension requiring an intervention were reviewed. At the beginning of the observation period, the pre-hemodialysis (HD) plasma Na(+) concentration ranged from 130 to 141 mEq/L. When switched from the standard to the individualized dialysate Na(+) concentration, IDWG% decreased from 3.4% ± 1.6% to 2.5% ± 1.0% (P = 0.003) with no change in pre- or post-HD systolic or diastolic blood pressures (all P > 0.05). We found no significant change in the proportion of treatments with cramps (6% vs. 13%), intradialytic hypotension (62% vs. 65%), or intradialytic hypotension requiring an intervention (29% vs. 33%). Individualized reduction of dialysate Na(+) reduces IDWG% without significantly increasing the frequency of cramps or hypotension.

Underuse of effective measures to prevent and manage pediatric tuberculosis in the United States.

OBJECTIVE: To characterize problems with prevention and management of pediatric tuberculosis (TB) and latent TB infection (LTBI). DESIGN: A multisite, cross-sectional study using data from medical records and public health logs to categorize and define use of routine prevention practices in managing pediatric TB and LTBI. SETTING: Four areas of the United States. PARTICIPANTS: Children younger than 5 years diagnosed with TB from January 1, 2002, through December 31, 2004, and children with LTBI reported during a continuous 12-month period in 2003 to 2004. Main Exposure Mycobacterium tuberculosis. MAIN OUTCOME MEASURES: Underuse or nonuse of standard medical and public health interventions. RESULTS: Almost 40% of children had a TB risk factor related to their country of birth, parental origin, or travel to a country with a high incidence of TB. Children having LTBI were less likely than those having TB to complete treatment (53.7% vs 88.6%, respectively). Almost half (46.3%) of the children with TB came to medical attention late in their course when they already had symptoms. Among 63 adult source patients, 19 (30.2%) previously had LTBI but were not treated, and none of the 40 foreign-born source patients were known to have been evaluated for TB before entry into the United States. CONCLUSIONS: Prevention efforts are unsatisfactory to prevent TB in children. Effective interventions such as treatment of LTBI and TB evaluation of adult immigrants remain less than optimal.