Starting Dialysis at Higher EGFR in Kids Linked to Worse Survival

By Will Boggs MD

July 26, 2019

NEW YORK (Reuters Health) - Starting dialysis in children with higher estimated glomerular filtration rate (eGFR) is associated with worse survival, according to a retrospective study of pediatric patients registered in the U.S. Renal Data System (USRDS).

Earlier initiation of dialysis - i.e., at a higher eGFR - in adults has not yielded a survival benefit, but it has been unclear whether the timing of dialysis initiation in children is associated with mortality.

Dr. Erica Winnicki of the University of California, San Francisco, and colleagues used USRDS data from more than 15,000 children treated with dialysis to evaluate trends in the timing of dialysis initiation and determine whether initiation at higher eGFR (>10 mL/min/1.73m2) is associated with a survival benefit.

Overall, 29.0% of these children had higher eGFR at dialysis initiation, the researchers report in the Journal of the American Society of Nephrology, online July 16.

Between 1995 and 2015, there was a 0.18 mL/min/1.73m2 annual increase in eGFR at dialysis initiation, and the fraction of children with higher eGFR at dialysis initiation increased from 16.6% to 40.7%.

The unadjusted one-year survival for children with higher eGFR at dialysis initiation was 95.6% compared to 97.7% in those with lower eGFR at dialysis initiation.

In the authors' adjusted model, the risk of mortality was 36% higher for children with higher versus lower eGFR at dialysis initiation (P<0.001), and there was an increasing hazard of death with progressively higher categories of eGFR.

The mortality risk was 56% higher with higher eGFR at initiation of hemodialysis (P<0.001), whereas the risk was nonsignificantly higher with higher eGFR at initiation of peritoneal dialysis.

Median time to transplant for children who underwent renal transplantation did not differ significantly between those with higher and lower eGFR at dialysis initiation.

"Because of the limitations and potential for residual confounding in observational studies, confirmation of our findings with prospective trials in children with chronic kidney disease (CKD) should be considered," the researchers note. "Based on our findings, we conclude that while the decision to initiate dialysis should be based on the individual patient, consideration of delaying dialysis initiation in asymptomatic children may be prudent."

Dr. Nicholas G. Larkins from Perth Children's Hospital, in Australia, who co-authored an accompanying editorial, told Reuters Health by email, "There are now data to support the translation of evidence among adult populations, which indicate that early initiation of dialysis is associated with increased mortality, to children."

"We need to consider why children are starting dialysis substantially earlier," he said. "There remains no evidence to support the initiation of dialysis based on eGFR alone, and there are important psychosocial and physical consequences associated with initiating dialysis. Therapy should be delayed in children without uremic or other clinical indications."

Dr. Evgenia Preka from Great Ormond Street Hospital, in London, U.K., who also recently reported a lack of clinically relevant benefit of early dialysis timing in children with end-stage renal disease (ESRD), told Reuters Health by email, "Interestingly, this is the third big publication this year showing that early dialysis initiation is of no benefit regarding overall survival in pediatric ESRD patients."

"The take-home-message from all recent studies on that topic is that pediatric nephrologists should reassess their management regarding dialysis initiation and postpone - whenever possible - starting dialysis," she said.

"With the current available literature, there is no preferred GFR at which dialysis becomes necessary and no benefit to starting dialysis early in CKD in terms of mortality, morbidity, or economics, both in adults and children," Dr. Preka said.

Dr. Winnicki did not respond to a request for comments.


J Am Soc Nephrol 2019.