In the Journals

Early dialysis initiation linked to lower survival in pediatric patients

As the initiation of dialysis at an eGFR greater than 10 mL/min/1.732 was associated with lower survival in children and adolescents, it may be beneficial to delay dialysis until further eGFR decline, according to a published study.

“The trend toward earlier initiation of dialysis is concerning given that observational studies in adults with ESRD have not shown a survival benefit to starting dialysis at higher levels of eGFR,” Erica Winnicki, MD, of the University of California, San Francisco, and colleagues wrote. “The Initiating Dialysis Early and Late (IDEAL) trial in adult patients with [chronic kidney disease] CKD, which randomized patients to earlier (defined as an eGFR 10 [mL/min/1.73m2] to 14 mL/min/1.73m2) vs. later (defined as an eGFR 5 [mL/min/1.73m2] to 7 mL/min/1.73m2) initiation of dialysis did not find a survival benefit to the planned initiation of dialysis at higher eGFR. Fewer studies have focused on how the timing of dialysis initiation in children with CKD has changed over time and the extent to which the timing of dialysis initiation is associated with mortality.”

Using the United States Renal Data System, researchers conducted a retrospective cohort study of 15,170 patients aged between 1 year and 18 years who began dialysis between 1995 and 2015. Researchers categorized patients according to eGFR at time of dialysis initiation as higher (eGFR > 10 mL/min/m2; median, 12.8 mL/min/m2) or lower (eGFR  10 mL/min/m2; median, 6.5 mL/min/m2).

Patients who had a higher eGFR at dialysis initiation were more often white, female, and either underweight or obese. They were also more likely to have glomerulonephritis as the cause of ESRD and to live further from the dialysis center.

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It may be beneficial to delay dialysis in children.
Source: Adobe Stock

Researchers found that, during the past 20 years, pediatric patients have been beginning dialysis at higher eGFRs (16.6% in 1995 vs. 40.7% in 2015; increase of 0.18 mL/min/m2 annually). Compared with patients who initiated dialysis at a lower eGFR, the risk of mortality was 36% greater for those who began the therapy at a higher eGFR. In addition, researchers observed that this mortality risk was higher among those initially treated with hemodialysis (HR = 1.56) than those treated with peritoneal dialysis (HR = 1.07).

“Our findings have important implications for clinical practice, as we found that pediatric nephrologists are initiating children on dialysis with higher levels of kidney function during the contemporary time period even though our findings do not support the presence of any associated mortality benefit,” the researchers wrote. “While we do not have granular data on the reasons why a child started dialysis, those children with higher eGFR at dialysis initiation could theoretically have reduced or avoided dialysis exposure altogether if they had been initiated on dialysis at lower eGFR. This is evidenced by the fact that 20% of those starting dialysis received a kidney transplant within 6 months of initiating renal replacement therapy. We speculate that deferring dialysis in asymptomatic children may allow for more transplants to be performed preemptively and for vascular access sites to be preserved.”

In a related editorial, Nicholas Larkins, MD, of Perth Children’s Hospital, and Jonathan Craig, PhD, of Flinders University, wrote: “That the proportion of children starting dialysis with an eGFR [greater than] 10 mL/min/1.73m2 has more than doubled in the last 20 years is concerning given the absence of any benefit found in this study, and in adult studies. There appears to be no trade-off. The direct, immediate and incontrovertible deleterious financial, psychosocial, and physical impacts of dialysis are experienced on a daily basis by clinicians, children and their families. Although more research is clearly needed to address this question, including prospective cohort studies with information on pediatric specific outcomes such as growth and development, until then the implications are clear. Start dialysis later.” – by Melissa J. Webb

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

As the initiation of dialysis at an eGFR greater than 10 mL/min/1.732 was associated with lower survival in children and adolescents, it may be beneficial to delay dialysis until further eGFR decline, according to a published study.

“The trend toward earlier initiation of dialysis is concerning given that observational studies in adults with ESRD have not shown a survival benefit to starting dialysis at higher levels of eGFR,” Erica Winnicki, MD, of the University of California, San Francisco, and colleagues wrote. “The Initiating Dialysis Early and Late (IDEAL) trial in adult patients with [chronic kidney disease] CKD, which randomized patients to earlier (defined as an eGFR 10 [mL/min/1.73m2] to 14 mL/min/1.73m2) vs. later (defined as an eGFR 5 [mL/min/1.73m2] to 7 mL/min/1.73m2) initiation of dialysis did not find a survival benefit to the planned initiation of dialysis at higher eGFR. Fewer studies have focused on how the timing of dialysis initiation in children with CKD has changed over time and the extent to which the timing of dialysis initiation is associated with mortality.”

Using the United States Renal Data System, researchers conducted a retrospective cohort study of 15,170 patients aged between 1 year and 18 years who began dialysis between 1995 and 2015. Researchers categorized patients according to eGFR at time of dialysis initiation as higher (eGFR > 10 mL/min/m2; median, 12.8 mL/min/m2) or lower (eGFR  10 mL/min/m2; median, 6.5 mL/min/m2).

Patients who had a higher eGFR at dialysis initiation were more often white, female, and either underweight or obese. They were also more likely to have glomerulonephritis as the cause of ESRD and to live further from the dialysis center.

#
It may be beneficial to delay dialysis in children.
Source: Adobe Stock

Researchers found that, during the past 20 years, pediatric patients have been beginning dialysis at higher eGFRs (16.6% in 1995 vs. 40.7% in 2015; increase of 0.18 mL/min/m2 annually). Compared with patients who initiated dialysis at a lower eGFR, the risk of mortality was 36% greater for those who began the therapy at a higher eGFR. In addition, researchers observed that this mortality risk was higher among those initially treated with hemodialysis (HR = 1.56) than those treated with peritoneal dialysis (HR = 1.07).

“Our findings have important implications for clinical practice, as we found that pediatric nephrologists are initiating children on dialysis with higher levels of kidney function during the contemporary time period even though our findings do not support the presence of any associated mortality benefit,” the researchers wrote. “While we do not have granular data on the reasons why a child started dialysis, those children with higher eGFR at dialysis initiation could theoretically have reduced or avoided dialysis exposure altogether if they had been initiated on dialysis at lower eGFR. This is evidenced by the fact that 20% of those starting dialysis received a kidney transplant within 6 months of initiating renal replacement therapy. We speculate that deferring dialysis in asymptomatic children may allow for more transplants to be performed preemptively and for vascular access sites to be preserved.”

In a related editorial, Nicholas Larkins, MD, of Perth Children’s Hospital, and Jonathan Craig, PhD, of Flinders University, wrote: “That the proportion of children starting dialysis with an eGFR [greater than] 10 mL/min/1.73m2 has more than doubled in the last 20 years is concerning given the absence of any benefit found in this study, and in adult studies. There appears to be no trade-off. The direct, immediate and incontrovertible deleterious financial, psychosocial, and physical impacts of dialysis are experienced on a daily basis by clinicians, children and their families. Although more research is clearly needed to address this question, including prospective cohort studies with information on pediatric specific outcomes such as growth and development, until then the implications are clear. Start dialysis later.” – by Melissa J. Webb

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