Timing and Modality of Kidney Replacement Therapy in Children and Adolescents

Abstract

IntroductionThe choice and timing of kidney replacement therapy (KRT) is influenced by clinical factors, laboratory features, feasibility issues, family preferences and clinicians´ attitudes. We analyzed the factors associated with KRT modality and timing in a multicenter, multinational prospective pediatric cohort study. Methods695 pediatric chronic kidney disease patients enrolled into the 4C study at age 6 to 17 years with estimated glomerular filtration rate (eGFR) 10 to 60 ml/min/1.73 m2 were investigated. Competing risk regression was performed to identify factors associated with initiation of dialysis or pre-emptive transplantation (Tx), including primary renal diagnosis, demographics, anthropometrics and laboratory parameters. ResultsDuring the 8-year observation period, 342 patients (49%) started KRT. Of these, 200 patients started dialysis whereas 142 patients underwent pre-emptive Tx. A lower eGFR at enrolment (HR (hazard ratio) 0.76 [95% confidence interval 0.74-0.78], a steeper eGFR slope (HR 0.90 [0.85-0.95] and a higher systolic blood pressure standard deviation score (SDS) (HR 2.07 [1.49-2.87]) increased the likelihood of KRT initiation. Patients with glomerulopathies were more likely to start dialysis than children with CAKUT (HR 3.81 [2.52-5.76]). Lower BMI SDS (HR 0.73 [0.6-0.89]) and lower hemoglobin (HR 0.8 [0.72-0.9]) were associated with higher likelihood of dialysis. A significant center effect was observed, accounting for 6.8% (dialysis) to 8.7% (pre-emptive Tx) of explained variation. ConclusionThe timing and choice of KRT in pediatric patients is influenced by the rate of kidney function loss, the underlying kidney disease, nutritional status, blood pressure, anemia and center-specific factors.