Mortality risk in European children with end-stage renal disease on dialysis

Abstract

We aimed to describe survival in European pediatric dialysis patients and compare the differential mortality risk between patients starting on hemodialysis (HD) and peritoneal dialysis (PD). Data for 6473 patients under 19 years of age or younger were extracted from the European Society of Pediatric Nephrology, the European Renal Association, and European Dialysis and Transplant Association Registry for 36 countries for the years 2000 through 2013. Hazard ratios (HRs) were adjusted for age at start of dialysis, sex, primary renal disease, and country. A secondary analysis was performed on a propensity score-matched (PSM) cohort. The overall 5-year survival rate in European children starting on dialysis was 89.5% (95% confidence interval [CI] 87.7%-91.0%). The mortality rate was 28.0 deaths per 1000 patient years overall. This was highest (36.0/1000) during the first year of dialysis and in the 0- to 5-year age group (49.4/1000). Cardiovascular events (18.3%) and infections (17.0%) were the main causes of death. Children selected to start on HD had an increased mortality risk compared with those on PD (adjusted HR 1.39, 95% CI 1.06-1.82, PSM HR 1.46, 95% CI 1.06-2.00), especially during the first year of dialysis (HD/PD adjusted HR 1.70, 95% CI 1.22-2.38, PSM HR 1.79, 95% CI 1.20-2.66), when starting at older than 5 years of age (HD/PD: adjusted HR 1.58, 95% CI 1.03-2.43, PSM HR 1.87, 95% CI 1.17-2.98) and when children have been seen by a nephrologist for only a short time before starting dialysis (HD/PD adjusted HR 6.55, 95% CI 2.35-18.28, PSM HR 2.93, 95% CI 1.04-8.23). Because unmeasured case-mix differences and selection bias may explain the higher mortality risk in the HD population, these results should be interpreted with caution.

Long-term all-cause mortality and cardiovascular outcomes in Scottish children after initiation of renal replacement therapy: a national cohort study

“…Mortality rates in children receiving RRT are much higher than in the age and sex-matched general population [4]. Cardiovascular disease (CVD) is the leading cause of death in these children, responsible for 23-60% of all deaths [4][5][6][7]. Several factors are known to be associated with mortality risk.…”

“…These include modality at start of RRT, with children who started RRT with dialysis having an almost seven times higher risk of mortality compared to those who received a pre-emptive kidney transplant (HR 6.6, 95% CI 2.9-14.8) [8]. Younger age at start of RRT [4][5][6][7][8][9][10][11], female sex [5] and primary renal disease (PRD) other than congenital anomalies of kidney and urinary tract (CAKUT) [4,5,12] have also been found to be associated with increased risk of mortality among children receiving RRT. Studies so far have generally reported 5-year survival [6,8,13].…”

“…Younger age at start of RRT [4][5][6][7][8][9][10][11], female sex [5] and primary renal disease (PRD) other than congenital anomalies of kidney and urinary tract (CAKUT) [4,5,12] have also been found to be associated with increased risk of mortality among children receiving RRT. Studies so far have generally reported 5-year survival [6,8,13]. Only limited data exist about longer-term survival [4,14,15] and incidence of nonfatal CVD events [9,11] in individuals who start RRT in childhood.…”

Long‐term outcomes of pediatric kidney transplant recipients with a pretransplant malignancy

“…Albeit uncommon, the development of ESRD after cancer treatment (surgery or chemotherapy‐induced nephrotoxicity) in pediatric patients is associated with high mortality rates and severe cardiovascular morbidity . A recent European registry analysis estimated the 5‐year mortality for children on HD to be 11%, with the highest mortality rates in the first year of HD and in the youngest patients . KT is considered the most effective treatment for pediatric patients with ESRD with a 5‐year patient survival rate of 96.6% and a graft survival rate of 78.6% …”

“…immunosuppression, nephrotoxicity, pediatric kidney transplantation, pretransplant malignancy the 5-year mortality for children on HD to be 11%, with the highest mortality rates in the first year of HD and in the youngest patients. 6 KT is considered the most effective treatment for pediatric patients with ESRD with a 5-year patient survival rate of 96.6% and a graft survival rate of 78.6%. 7 Previous work analyzing outcomes in patients with a pretransplant malignancy after pediatric KT has primarily focused on earlystage Wilms' tumor patients.…”