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. 2019 Aug;30(8):1505-1513.
doi: 10.1681/ASN.2018111130. Epub 2019 Jul 18.

Higher eGFR at Dialysis Initiation Is Not Associated with a Survival Benefit in Children

Erica Winnicki  1   2 , Kirsten L Johansen  3   4 , Michael D Cabana  2   5 , Bradley A Warady  6 , Charles E McCulloch  5 , Barbara Grimes  5 , Elaine Ku  7   2   5   8
Affiliations

Higher eGFR at Dialysis Initiation Is Not Associated with a Survival Benefit in Children

Erica Winnicki et al. J Am Soc Nephrol. 2019 Aug.

Abstract

Background: Study findings suggest that initiating dialysis at a higher eGFR level in adults with ESRD does not improve survival. It is less clear whether starting dialysis at a higher eGFR is associated with a survival benefit in children with CKD.

Methods: To investigate this issue, we performed a retrospective cohort study of pediatric patients aged 1-18 years who, according to the US Renal Data System, started dialysis between 1995 and 2015. The primary predictor was eGFR at the time of dialysis initiation, categorized as higher (eGFR>10 ml/min per 1.73 m2) versus lower eGFR (eGFR≤10 ml/min per 1.73 m2).

Results: Of 15,170 children, 4327 (29%) had a higher eGFR (median eGFR, 12.8 ml/min per 1.73 m2) at dialysis initiation. Compared with children with a lower eGFR (median eGFR, 6.5 ml/min per 1.73 m2), those with a higher eGFR at dialysis initiation were more often white, girls, underweight or obese, and more likely to have GN as the cause of ESRD. The risk of death was 1.36 times higher (95% confidence interval, 1.24 to 1.50) among children with a higher (versus lower) eGFR at dialysis initiation. The association between timing of dialysis and survival differed by treatment modality-hemodialysis versus peritoneal dialysis (P<0.001 for interaction)-and was stronger among children initially treated with hemodialysis (hazard ratio, 1.56, 95% confidence interval, 1.39 to 1.75; versus hazard ratio, 1.07, 95% confidence interval, 0.91 to 1.25; respectively).

Conclusions: In children with ESRD, a higher eGFR at dialysis initiation is associated with lower survival, particularly among children whose initial treatment modality is hemodialysis.

Keywords: ESRD; dialysis; pediatric nephrology.

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Figures

None
Graphical abstract
Figure 1.
Figure 1.
Derivation of the cohort results in 15,170 children being included in the study. Chart shows the inclusion and exclusion criteria for the cohort included in our analysis.
Figure 2.
Figure 2.
There was a trend toward dialysis initiation at higher eGFR over time for both dialysis modalities. This figure shows the proportion of children initiated on dialysis at higher eGFR (eGFR>10 ml/min per 1.73 m2) by calendar year of initiation and dialysis type.
See this image and copyright information in PMC

Comment in

  • Time's Up! Start Dialysis Later in Children.
    Larkins NG, Craig JC. Larkins NG, et al. J Am Soc Nephrol. 2019 Aug;30(8):1344-1345. doi: 10.1681/ASN.2019040429. Epub 2019 Jul 18. J Am Soc Nephrol. 2019. PMID: 31366694 Free PMC article. No abstract available.
  • Think Twice before Postponing Chronic Dialysis in Children.
    Preka E, Bonthuis M, Harambat J, Jager KJ. Preka E, et al. J Am Soc Nephrol. 2019 Dec;30(12):2473-2474. doi: 10.1681/ASN.2019090895. Epub 2019 Oct 24. J Am Soc Nephrol. 2019. PMID: 31649099 Free PMC article. No abstract available.

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