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A prospective cohort study of incident maintenance dialysis in children: an NAPRTC study
Mary B Leonard1, Lynn A Donaldson, Martin Ho
1Department of Pediatrics, The Children's Hospital of Philadelphia, and Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. leonard@email.chop.edu
Insights
This study of pediatric end-stage renal disease (ESRD) patients found significant variability in dialysis practices and outcomes, highlighting the need for further research into optimal care for children on dialysis.
Area of Science:
- Pediatric Nephrology
- Renal Replacement Therapy
- End-Stage Renal Disease (ESRD) Management
Background:
- Previous studies on pediatric dialysis have limitations due to varied patient cohorts and disease durations.
- This research focuses on an incident cohort to better understand dialysis in children.
Purpose of the Study:
- To evaluate dialysis characteristics, complications, practices, and outcomes in a newly diagnosed pediatric end-stage renal disease (ESRD) cohort.
- To identify variations in management and outcomes across different pediatric centers.
Main Methods:
- Analysis of 1992 subjects from the North American Pediatric Renal Transplant Cooperative Study registry initiating hemodialysis (HD) or peritoneal dialysis (PD) between 1992-1998.
- Inclusion criteria: no prior dialysis or transplantation.
Main Results:
- Peritoneal dialysis (PD) was predominant in infants (97%), while hemodialysis (HD) use increased with age.
- Significant racial disparities in PD initiation were observed (Blacks less likely than Whites).
- Anemia prevalence exceeded 40% after six months; transplantation intervals varied by race, age, and sex, with higher mortality in younger patients.
Conclusions:
- Considerable variability exists in pediatric dialysis patient management across centers.
- Further prospective studies are essential to define optimal dialysis care and identify at-risk pediatric populations.
Background:
Prior studies of dialysis practices and outcomes have included children with varied duration of end-stage renal disease (ESRD). This study evaluated dialysis characteristics, complications, practices, and outcomes in an incident pediatric cohort.
Methods:
The cohort was limited to 1992 subjects enrolled in the North American Pediatric Renal Transplant Cooperative Study registry, starting hemodialysis (HD) or peritoneal dialysis (PD) between 1992 and 1998, without prior dialysis or transplantation.
Results:
At dialysis initiation, the median glomerular filtration rate (GFR; Schwartz formula) was 6 to 11 mL/min/1.73 m2, and 90th percentile was 14 to 25 mL/min/1.73 m2. GFR was not associated with age or race. PD was used in 97% of infants, 70 to 80% of children and 59% of adolescents. Blacks were significantly less likely to be started on PD than whites. Twenty percent of patients switched dialysis modality, largely due to infection, inadequate access or family choice. Younger children received HD almost exclusively through percutaneous catheters, while 57% of children more than six years old were dialyzed with fistula or graft after six months on HD. The prevalence of anemia (Hct <33%) still exceeded 40% after six months of dialysis. The median interval to transplantation was 1.4 years, and was significantly greater in non-white, young, and female patients. Mortality rates (deaths/1000 patient-years) varied with age, from 13.6 in infants to 2.2 in adolescents.
Conclusion:
These data demonstrate considerable variability in patient management across pediatric centers. Prospective studies are needed to determine the optimum adequacy of care among children on dialysis and to identify populations at risk.