Association between timing of dialysis initiation and clinical outcomes in the paediatric population: an ESPN/ERA-EDTA registry study

Abstract

Background There is no consensus regarding the timing of dialysis therapy initiation for end-stage kidney disease (ESKD) in children. As studies investigating the association between timing of dialysis initiation and clinical outcomes are lacking, we aimed to study this relationship in a cohort of European children who started maintenance dialysis treatment. Methods We used data on 2963 children from 21 different countries included in the European Society of Pediatric Nephrology/European Renal Association–European Dialysis and Transplant Association Registry who started renal replacement therapy before 18 years of age between 2000 and 2014. We compared two groups according to the estimated glomerular filtration rate (eGFR) at start: eGFR ≥8 mL/min/1.73 m2 (early starters) and eGFR <8 mL/min/1.73 m2 (late starters). The primary outcomes were patient survival and access to transplantation. Secondary outcomes were growth and cardiovascular risk factors. Sensitivity analyses were performed to account for selection- and lead time-bias. Results The median eGFR at the start of dialysis was 6.1 for late versus 10.5 mL/min/1.73 m2 for early starters. Early starters were older [median: 11.0, interquartile range (IQR): 5.7–14.5 versus 9.4, IQR: 2.6–14.1 years]. There were no differences observed between the two groups in mortality and access to transplantation at 1, 2 and 5 years of follow-up. One-year evolution of height standard deviation scores was similar among the groups, whereas hypertension was more prevalent among late initiators. Sensitivity analyses resulted in similar findings. Conclusions We found no evidence for a clinically relevant benefit of early start of dialysis in children with ESKD. Presence of cardiovascular risk factors, such as high blood pressure, should be taken into account when deciding to initiate or postpone dialysis in children with ESKD, as this affects the survival.

Prescribing peritoneal dialysis for high-quality care in children

“…1 A recent registry report from the European Society of Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry examined dialysis initiation in 2963 children from 21 countries. 2 There were no clinically relevant benefits noted among those who started dialysis at an eGFR more than or less than 8 mL/min/1.73 m 2 in terms of survival, growth, or access to transplantation; however, hypertension was more prevalent among late initiators. 2 While these studies are registry reports only and must be interpreted with caution, the accuracy of eGFR estimation in late stages of CKD must also be interpreted with caution.…”

“…2 There were no clinically relevant benefits noted among those who started dialysis at an eGFR more than or less than 8 mL/min/1.73 m 2 in terms of survival, growth, or access to transplantation; however, hypertension was more prevalent among late initiators. 2 While these studies are registry reports only and must be interpreted with caution, the accuracy of eGFR estimation in late stages of CKD must also be interpreted with caution. 3 The Schwartz bedside formula, which can be used to estimate GFR in children, was developed in the CKD in children study and is most valid in the GFR range of 15-75 ml/min/1.73 m 2 and with the use of standardized serum creatinine methods traceable to the isotope dilution mass spectrometry technique.…”

Renal replacement therapy and conservative management: NICE guideline (NG 107) October 2018

“…In the paediatric population, it is common practice to commence RRT based on symptoms, electrolyte balance, poor growth and fluid control but not an absolute eGFR. Recent data from the European renal registry-based study7 observed no difference in outcomes including mortality or access to transplantation in early (eGFR >8 mL/min/1.73 m 2 ) versus late (eGFR <8 mL/min/1.73 m 2 ) starters of dialysis.…”

Commentary on the NICE guideline on renal replacement therapy and conservative management

“…In infants and children there are no data to support starting dialysis on the basis of eGFR alone [ 1 ]. Decisions to start dialysis should be on the basis of symptoms which include those listed in the NICE guidance but also include poor growth and nutrition which are critical in this early stage of life [ 2 ].…”