Variation in estimated glomerular filtration rate at dialysis initiation in children

Dart, Allison; Zappitelli, Michael; Sood, Manish M.; Alexander, R. Todd; Arora, Sourabh; Erickson, Robin L.; Kroeker, Kristine; Soo, Andrea; Manns, Braden; Samuel, Susan

doi:10.1007/s00467-016-3483-5

Cited by 11 publications

(9 citation statements)

References 34 publications

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“…Awaiting a pre-emptive transplant is also an important factor that can delay the decision to start dialysis. These findings shed important light on the reasons for variability in practice across Canada previously reported by our group [ 2 , 3 ].…”

Section: Discussionsupporting

confidence: 73%

“…Our group also reported, utilizing the Canadian Organ Replacement Register (CORR) data, that 30 % of children in Canada are started on dialysis with an eGFR ≥10.5 ml/min/1.73 m 2 . This study showed considerable practice variation across the country, with a range of 12–70 % of children started with an eGFR >10.5 ml/min/1.73 m 2 by treatment facility [ 3 ]. The limitation of these previous studies is a lack of information that may have influenced clinical decision-making, such as the clinical indication for dialysis and the presence of uremic symptoms at the time of dialysis initiation.…”

Section: Discussionmentioning

confidence: 99%

“…Early initiation of dialysis was defined as initiating dialysis with an eGFR ≥10.5 ml/min/1.73 m 2 , and late dialysis initiation was defined as an eGFR <10.5 ml/min/1.73 m 2 based on thresholds utilized in previous observational studies in adults and children [ 2 , 3 , 14 ].…”

Section: Methodsmentioning

confidence: 99%

“…The decision as to when to start a child on renal replacement therapy for individual pediatric nephrologists is therefore a relatively rare, yet important and complex decision. Our group has previously shown significant practice variation across the country with respect to timing of dialysis initiation based on the estimated glomerular filtration rate (eGFR) [ 2 , 3 ]. However, indications for dialysis were not available for this previous study; therefore, an understanding of the factors driving this practice variation remains unknown.…”

Section: Introductionmentioning

confidence: 99%

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Perceptions of Pediatric Nephrologists regarding Timing of Dialysis Initiation in Children in Canada

Saban

Zappitelli

Samuel

et al. 2016

Can J Kidney Health Dis

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BackgroundSignificant practice variation exists in Canada with respect to timing of dialysis initiation in children. In the absence of evidence to guide practice, physicians’ perceptions may significantly influence decision-making.ObjectiveThe objectives of this study are to (1) evaluate Canadian pediatric nephrologists’ perceptions regarding dialysis initiation in children with chronic kidney disease (CKD) and (2) determine the factors guiding practice that may contribute to practice variation across Canada.DesignThis study was a cross-sectional online survey.SettingThis study was done in academic pediatric nephrology centers in Canada.ParticipantsThe participants of this study are pediatric nephrologists.Measurements and methodsAn anonymous web-based survey was administered to pediatric nephrologists in Canada to evaluate perspectives and practice patterns regarding timing of dialysis initiation. We also explored the importance of estimated glomerular filtration rate (eGFR) vs. symptoms and the role of patient and provider factors influencing decisions.ResultsThirty-five nephrologists (59 %) completed the survey. Most respondents care for advanced CKD patients in a multidisciplinary clinic (86 %) and no centers have a formal policy on timing of dialysis initiation. Seventy-five percent of centers follow <20 stage 4–5 CKD patients, and 9 % follow >30 patients. Discussions about dialysis initiation are generally informal (75 %) and the decision to start is made by the nephrologist (37 %) or a team (57 %). Fifty percent agreed GFR was important when deciding when to initiate dialysis, 41 % were neutral, and 9 % disagreed. Variability exists in the threshold that nephrologists considered early (vs. late) dialysis initiation: >20 (21 %), >15 (38 %), >12 (26 %), and >10 ml/min/1.73 m2 (12 %). Practitioners however typically start dialysis in asymptomatic patients at eGFRs of 7–9 (9 %), 10–11 (41 %), 12–14 (38 %), and 15–19 (6 %) ml/min/1.73 m2. Patient factors important in the decision to start dialysis for >90 % of nephrologists were fatigue, >10 % weight loss, nausea, increasing missed school, and awaiting a pre-emptive transplant. Age was only a factor for 56 %.LimitationsThis study has a 59 % response rate.ConclusionsVariability exists in Canada regarding the importance and threshold of eGFR guiding the decision as to when to start dialysis in children, whereas patient symptoms are almost universally important to pediatric nephrologists’ decision-making. Additional studies evaluating outcomes of children starting dialysis earlier vs. later are needed to standardize decision-making and care for children with kidney failure.Electronic supplementary materialThe online version of this article (doi:10.1186/s40697-016-0123-8) contains supplementary material, which is available to authorized users.

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Section: Discussionsupporting

confidence: 73%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Perceptions of Pediatric Nephrologists regarding Timing of Dialysis Initiation in Children in Canada

Saban

Zappitelli

Samuel

et al. 2016

Can J Kidney Health Dis

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“…In Canada, there has been a trend over the last two decades to starting dialysis at higher GFRs, with one third of the children initiating dialysis with an eGFR ≥ 10.5 ml/min/1.73 m 2 . The differences seem to be centre specific without any other clearly identifiable factor [13]. The majority of paediatric nephrologists believe that transplantation is the best form of RRT and would try to avoid dialysis altogether, so that waiting on the transplant list may contribute to the lower GFRs at start of dialysis seen in some patients.…”

Section: When Should Dialysis Be Started?mentioning

confidence: 99%

Assessment of dialysis adequacy: beyond urea kinetic measurements

Rees

2018

Pediatr Nephrol

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Adequacy of dialysis is a term that has been used for many years based on measurement of small solute clearance using urea and creatinine. This has been shown in some but not all studies in adults to correlate with survival. However, small solute clearance is just one minor part of the effectiveness of dialysis and in fact ‘optimum’ dialysis, rather than ‘adequate’ dialysis is what most paediatric nephrologists would want for their patients. Additional ways to assess the success of dialysis in children would include dialysis access complications and longevity, preservation of residual kidney function, body composition, biochemical and haematological control, nutrition and growth, discomfort during the dialysis process and psychosocial adjustment including hospitalisation and school attendance. These criteria need to be balanced against a dialysis programme that has the least possible adverse effects on quality of life.

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