In the Journals

Higher eGFR at dialysis initiation associated with increased mortality risk for pediatric patients

Children and adolescents who begin dialysis therapy with higher eGFRs may be at greater risk for mortality compared with those who have lower eGFRs at initiation, according to a published study.

“A number of observational studies have shown an association between higher eGFR at dialysis therapy initiation and higher mortality in adult patients with ESRD,” Yusuke Okuda, MD, PhD, of the Harold Simmons Center for Kidney Disease Research and Epidemiology in the division of nephrology and hypertension at the University of California Irvine, School of Medicine, and colleagues wrote. “Moreover, some of these studies have also suggested an association between lower eGFRs and lower mortality risk. Contrary to the growing body of research in adult dialysis patients, there is little research investigating eGFRs and dialysis therapy timing in children receiving dialysis.”

To examine the relationship between eGFR at dialysis therapy initiation and risk for mortality in the pediatric population, researchers used data from the U.S. Renal Data System to conduct a retrospective cohort study of 9,963 patients aged between 1 year and 17 years (median eGFR at dialysis-initiation, 7.8 mL/min/1.73 m2; median age, 13 years).

Researchers then divided eGFRs into categories of less than 5 mL/min/1.73 m2, 5 to at least 7 mL/min/1.73 m2, 7 mL/min/1.73 m2 to less than 9 mL/min/1.73 m2, 9 mL/min/1.73 m2 to less than 12 mL/min/1.73 m2 and 12 mL/min/1.73 m2 or greater, considering the association of mortality with the highest and lowest eGFR categories.

The primary outcome of the study was all-cause mortality with follow-up lasting a median of 1.4 years. During this time, 696 deaths occurred.

Researchers found an association between eGFR at dialysis therapy initiation and mortality, with a higher mortality risk observed across higher eGFRs (for eGFR 12 mL/min/1.73 m2, HR = 1.31) and a lower mortality risk observed across lower eGFRs (for eGFR <5 mL/min/1.73 m2, HR = 0.57).

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Children and adolescents who begin dialysis therapy with higher eGFRs may be at greater risk for mortality compared with those who have lower eGFRs at initiation.
Source: Adobe Stock

After stratifying for age, researchers found this eGFR-mortality relationship was attenuated among patients younger than 6 years but remained consistent among patients 6 years or older.

“We observed an increased and linear association between eGFRs at dialysis therapy initiation and mortality, such that higher eGFRs at dialysis therapy initiation were associated with higher risk for mortality,” the researchers wrote. “Further studies are needed to elucidate the association between eGFR and mortality, especially among patients younger than 6 years. Moreover, additional studies are needed to evaluate the benefit of dialysis therapy initiation at lower eGFRs in children. Other relevant outcomes, including cardiovascular complications, access to transplantation, and growth, should also be examined.”

In a related editorial, Edward Nehus, MD, MS, and Mark M. Mitsnefes, MD, MS, both of the division of nephrology and hypertension at Cincinnati Children’s Hospital Medical Center, University of Cincinnati in Ohio, wrote: “Despite improvements in the care of pediatric patients with end-stage kidney disease, children receiving dialysis continue to have unacceptably high mortality, with an average lifespan that is 30 to 40 years shorter compared with individuals matched for age and ethnicity ... Based on the results of this study, the pediatric nephrology community may need to reevaluate the current recommendation of dialysis initiation when eGFR decreases to just [less than] 10 mL/min/1.73 m2 and adopt a practice that is more closely aligned with the most recent KDIGO (Kidney Disease: Improving Global Outcomes) recommendations. However, particular attention must be given to the growth and development of children approaching end-stage kidney disease, and dialysis should not be withheld in the presence of significant delays in these parameters despite a relatively high eGFR. Most importantly, the timing of dialysis initiation should balance the risks and benefits of the procedure while incorporating a patient-centered approach that encourages caregiver participation in the decision-making process.” – by Melissa J. Webb

Disclosures: Okuda reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Children and adolescents who begin dialysis therapy with higher eGFRs may be at greater risk for mortality compared with those who have lower eGFRs at initiation, according to a published study.

“A number of observational studies have shown an association between higher eGFR at dialysis therapy initiation and higher mortality in adult patients with ESRD,” Yusuke Okuda, MD, PhD, of the Harold Simmons Center for Kidney Disease Research and Epidemiology in the division of nephrology and hypertension at the University of California Irvine, School of Medicine, and colleagues wrote. “Moreover, some of these studies have also suggested an association between lower eGFRs and lower mortality risk. Contrary to the growing body of research in adult dialysis patients, there is little research investigating eGFRs and dialysis therapy timing in children receiving dialysis.”

To examine the relationship between eGFR at dialysis therapy initiation and risk for mortality in the pediatric population, researchers used data from the U.S. Renal Data System to conduct a retrospective cohort study of 9,963 patients aged between 1 year and 17 years (median eGFR at dialysis-initiation, 7.8 mL/min/1.73 m2; median age, 13 years).

Researchers then divided eGFRs into categories of less than 5 mL/min/1.73 m2, 5 to at least 7 mL/min/1.73 m2, 7 mL/min/1.73 m2 to less than 9 mL/min/1.73 m2, 9 mL/min/1.73 m2 to less than 12 mL/min/1.73 m2 and 12 mL/min/1.73 m2 or greater, considering the association of mortality with the highest and lowest eGFR categories.

The primary outcome of the study was all-cause mortality with follow-up lasting a median of 1.4 years. During this time, 696 deaths occurred.

Researchers found an association between eGFR at dialysis therapy initiation and mortality, with a higher mortality risk observed across higher eGFRs (for eGFR 12 mL/min/1.73 m2, HR = 1.31) and a lower mortality risk observed across lower eGFRs (for eGFR <5 mL/min/1.73 m2, HR = 0.57).

#
Children and adolescents who begin dialysis therapy with higher eGFRs may be at greater risk for mortality compared with those who have lower eGFRs at initiation.
Source: Adobe Stock

After stratifying for age, researchers found this eGFR-mortality relationship was attenuated among patients younger than 6 years but remained consistent among patients 6 years or older.

“We observed an increased and linear association between eGFRs at dialysis therapy initiation and mortality, such that higher eGFRs at dialysis therapy initiation were associated with higher risk for mortality,” the researchers wrote. “Further studies are needed to elucidate the association between eGFR and mortality, especially among patients younger than 6 years. Moreover, additional studies are needed to evaluate the benefit of dialysis therapy initiation at lower eGFRs in children. Other relevant outcomes, including cardiovascular complications, access to transplantation, and growth, should also be examined.”

In a related editorial, Edward Nehus, MD, MS, and Mark M. Mitsnefes, MD, MS, both of the division of nephrology and hypertension at Cincinnati Children’s Hospital Medical Center, University of Cincinnati in Ohio, wrote: “Despite improvements in the care of pediatric patients with end-stage kidney disease, children receiving dialysis continue to have unacceptably high mortality, with an average lifespan that is 30 to 40 years shorter compared with individuals matched for age and ethnicity ... Based on the results of this study, the pediatric nephrology community may need to reevaluate the current recommendation of dialysis initiation when eGFR decreases to just [less than] 10 mL/min/1.73 m2 and adopt a practice that is more closely aligned with the most recent KDIGO (Kidney Disease: Improving Global Outcomes) recommendations. However, particular attention must be given to the growth and development of children approaching end-stage kidney disease, and dialysis should not be withheld in the presence of significant delays in these parameters despite a relatively high eGFR. Most importantly, the timing of dialysis initiation should balance the risks and benefits of the procedure while incorporating a patient-centered approach that encourages caregiver participation in the decision-making process.” – by Melissa J. Webb

Disclosures: Okuda reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.