COMMENTARY

Does Childhood Kidney Disease Lead to Adult ESRD?

William T. Basco, Jr., MD, MS

Disclosures

June 13, 2018

Outcomes of Childhood Renal Disease

What is the risk for future end-stage renal disease (ESRD) among adolescents with normal renal function but a history of childhood kidney disease? A recent population-based study[1] of young adults (aged 16-25 years) who were being evaluated for entry into the Israeli army sought to answer this question. Those with chronic diseases that are associated with later risk for ESRD (eg, diabetes, lupus) were excluded. Data from the army medical evaluations were then merged with national registry data on ESRD to determine outcomes for those in the dataset.

The study sample was large, including 1.5 million adults with no childhood kidney disease, compared with 18,592 adults with a history of childhood kidney disease. Another 22,596 individuals who had a chronic condition that increased risk for ESRD were excluded.

Among the participants with a history of childhood kidney disease, 3198 had a congenital anomaly of the kidney or urinary tract, 7231 had pyelonephritis (at least one episode, with or without documented kidney scarring), and 8611 had resolved glomerular disease.

Overall, 2490 participants developed ESRD, producing an incidence of 5.39/100,000 person-years. ESRD occurred in 0.16% of the adults with no childhood kidney disease compared with 0.75% of those who had childhood kidney disease. In a regression model adjusted for age, sex, body mass index, and systolic blood pressure, as well as a few demographic variables, a history of any childhood kidney disease presented a hazard ratio of 4.19 (95% confidence interval, 3.52-4.99) for ESRD. When looking at the individual types of childhood kidney disease, the hazard ratios for subsequent ESRD were fairly similar (Table).

Table. Risk for ESRD

Childhood Renal Disease Hazard Ratio for ESRD
Any renal disease 5.19
Congenital malformation 5.19
Pyelonephritis 4.03
Glomerular disease 3.85

The investigators concluded that a history of childhood kidney disease, even if glomerular function was normal during the medical screening process, conveyed a greater risk for ESRD in adulthood.

Viewpoint

This is an example of the importance of looking at percentages rather than risk. The good news is that the risk for ESRD, even among those with transient childhood kidney disease, is still less than 1%. However, it is approximately four times more common in that group compared with the general population.

The historical nature of the data may mean that some of the children diagnosed with pyelonephritis may also have had undiagnosed congenital abnormalities. It is also important to note that the data and analyses do not attempt to account for the severity of the childhood kidney condition (meaning that participants with a single episode of "mild" pyelonephritis were lumped with patients with a history of multiple or severe episodes of pyelonephritis).

What should a general practitioner do with these data? First, they are helpful when talking with parents about risks. Second, they are a reminder to follow the American Academy of Pediatrics guidelines for evaluation of urinary tract infections in children, which calls for an evaluation for genitourinary or functional abnormalities after a first or repeated UTI.

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