Association between timing of dialysis initiation and clinical outcomes in the paediatric population: An ESPN/ERA-EDTA registry study

PubMedID: 31038179Background: There is no consensus regarding the timing of dialysis therapy initiation for end-stage kidney disease (ESKD) in children. As studies investigating the association between timing of dialysis initiation and clinical outcomes are lacking, we aimed to study this relationship in a cohort of European children who started maintenance dialysis treatment. Methods: We used data on 2963 children from 21 different countries included in the European Society of Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry who started renal replacement therapy before 18 years of age between 2000 and 2014. We compared two groups according to the estimated glomerular filtration rate (eGFR) at start: eGFR ?8 mL/min/1.73 m2 (early starters) and eGFR <8 mL/min/1.73 m2 (late starters). The primary outcomes were patient survival and access to transplantation. Secondary outcomes were growth and cardiovascular risk factors. Sensitivity analyses were performed to account for selection-and lead time-bias. Results: The median eGFR at the start of dialysis was 6.1 for late versus 10.5 mL/min/1.73 m2 for early starters. Early starters were older [median: 11.0, interquartile range (IQR): 5.7-14.5 versus 9.4, IQR: 2.6-14.1 years]. There were no differences observed between the two groups in mortality and access to transplantation at 1, 2 and 5 years of follow-up. One-year evolution of height standard deviation scores was similar among the groups, whereas hypertension was more prevalent among late initiators. Sensitivity analyses resulted in similar findings. Conclusions: We found no evidence for a clinically relevant benefit of early start of dialysis in children with ESKD. Presence of cardiovascular risk factors, such as high blood pressure, should be taken into account when deciding to initiate or postpone dialysis in children with ESKD, as this affects the survival. © 2019 The Author(s).Háskóli Íslands Aristotle University of Thessaloniki Behavioural Science institute, Radboud University Academisch Medisch Centrum Universitair Medisch Centrum Utrecht Helsingin Yliopisto Lunds Universitet Belarusian State University National Academy of Sciences of Ukraine Gazi Üniversitesi Universiteit van Amsterdam National Institute for Health Research Sjællands Universitetshospital Great Ormond Street Hospital for Children1Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK, 2ESPN/ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam, The Netherlands, 3Department of Pediatrics, Bordeaux University Hospital, Bordeaux, France, 4Amsterdam UMC, University of Amsterdam, Department of Paediatric Nephrology, Emma Children’s Academic Medical Center, Amsterdam, The Netherlands, 5Department of Pediatrics, Belarusian State Medical University, Minsk, Belarus, 6Department of Pediatric Nephrology, School of Medicine, Cukurova University, Adana, Turkey, 7Department of Pediatric Nephrology, University Children’s Hospital, Vienna, Austria, 8Nephrology Department, University Children’s Hospital, Belgrade, Serbia,9Children’s Medical Center, Landspitali–The National University Hospital of Iceland, and Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland, 10Department of Pediatric Nephrology, National Academy of Medical Sciences of Ukraine, Kiev, Ukraine, 11Department of Medicine, Zealand University Hospital, Roskilde, Denmark, 12Children’s Hospital, University of Helsinki, Helsinki, Finland, 13Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary, 14Pediatric Department, Faculty of Medicine, Safarik University, Kosice, Slovakia, 15Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Nijmegen, The Netherlands, 16Department of Kidney Transplantation, Russian Children’s Clinical Hospital, Moscow, Russia, 17Department of Pediatric Nephrology, University Hospital Vall d’Hebron, Barcelona, Spain, 18Paediatric Nephrology Unit, Hospital de Dona Estefânia, Lisbon, Portugal, 19Department of Pediatric Nephrology, University Medical Center Ljubjana, Faculty of Medicine, University of Ljubjana, Slovenia, 201st Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece, 21University Pediatric Clinic, Skopje, FYR of Macedonia, 22Department of Clinical Sciences, Pediatric Nephrology, Skåne University Hospital, Lund University, Lund, Sweden, 23Department of Paediatric Nephrology, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK, 24Pediatric Nephrology, Dialysis and Transplantation Unit, Department of Woman’s and Child’s Health, University Hospital of Padua, Padua, Italy, 25Department of Pediatrics, University Hospital Motol, Prague, Czech Republic, 26Pediatric Nephrology Department, Nancy University Hospital, Nancy, France, 27Pediatric Nephrology, Childrens and Adolescents`Hospital, University Hospital of Cologne, Cologne, Germany, 28Pediatric Nephrology, University Children’s Hospital Zurich, Zurich, Switzerland, 29Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland, 30Department of Pediatric Nephrology, “Mitera” Children’s Hospital, Athens, Greece and 31Department of Pediatric Nephrology, Gazi University, Ankara, Turke