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Published on: July 19, 2021
Timing of Kidney Replacement Therapy among Children and Young Adults
Nicholas G Larkins1,2, Wai Lim2,3, Carrie Goh1
1Department of Nephrology and Hypertension, Perth Children's Hospital, Nedlands, Western Australia, Australia.
Insights
Pediatric patients are starting kidney replacement therapy (KRT) earlier, particularly those receiving peritoneal dialysis or preemptive transplants. This earlier initiation of KRT does not impact patient survival rates.
Area of Science:
- Pediatric Nephrology
- Renal Replacement Therapy
- Epidemiology
Background:
- No randomized trials guide the timing of kidney replacement therapy (KRT) initiation in children.
- Understanding trends and predictors of KRT initiation is crucial for pediatric kidney care.
Purpose of the Study:
- To define trends and predictors of estimated glomerular filtration rate (eGFR) at KRT initiation in children and young adults.
- To assess center-related clinical practice variation in KRT initiation.
- To determine the association between eGFR at KRT initiation and patient survival.
Main Methods:
- Analysis of data from the Australia and New Zealand Dialysis and Transplant Registry (1995-2018) for patients aged 1-25 years starting KRT.
- Quantile regression to estimate associations between eGFR and covariates.
- Cox and logistic regression to assess eGFR's impact on survival and quantify clinical practice variation.
Main Results:
- Median eGFR at KRT initiation increased from 7 to 9 ml/min/1.73 m² over the study period.
- Earlier KRT initiation was more pronounced for preemptive kidney transplants and peritoneal dialysis.
- No association was found between eGFR at KRT initiation and patient survival (HR 1.01; 95% CI, 0.98-1.04).
- Center variation accounted for 6-10% of the variance in KRT initiation timing.
Conclusions:
- Children and young adults are commencing KRT at an earlier stage of kidney disease.
- The timing of KRT initiation, even when earlier, is not linked to improved patient survival.
- Significant variation in KRT initiation practices exists between centers, highlighting a need for standardized care guidelines.
Background:
No randomized trials exist to guide the timing of the initiation of KRT in children. We sought to define trends and predictors of the eGFR at initiation of KRT, center-related clinical practice variation, and any association with patient survival.
Methods:
Children and young adults (1-25 years) commencing KRT (dialysis or kidney transplantation) between 1995 and 2018 were included using data from the Australia and New Zealand Dialysis and Transplant Registry. The associations between eGFR on commencing KRT and covariates were estimated using quantile regression. Cox regression was used to estimate the association between eGFR and patient survival. Logistic regression, categorizing eGFR about a value of 10 ml/min per 1.73 m 2 , was used in conjunction with a random effect by center to quantify clinical practice variation.
Results:
Overall, 2274 participants were included. The median eGFR at KRT initiation increased from 7 to 9 ml/min per 1.73 m 2 over the study period and the 90th centile from 11 to 17 ml/min per 1.73 m 2 . The effect of era on median eGFR was modified by modality, with a greater increase among those receiving a preemptive kidney transplant (1.0 ml/min per 1.73 m 2 per 5 years; 95% confidence interval [CI], 0.6 to 1.5) or peritoneal dialysis (0.7 ml/min per 1.73 m 2 per 5 years; 95% CI, 0.4 to 0.9) compared with hemodialysis (0.1 ml/min per 1.73 m 2 per 5 years; 95% CI, -0.1 to 0.3). There were 252 deaths (median follow-up 8.5 years, interquartile range 3.7-14.2) and no association between eGFR and survival (hazard ratio, 1.01 per ml/min per 1.73 m 2 ; 95% CI, 0.98 to 1.04). Center variation explained 6% of the total variance in the odds of initiating KRT earlier. This rose to over 10% when comparing pediatric centers alone.
Conclusions:
Children and young adults progressively commenced KRT earlier. This change was more pronounced for children starting peritoneal dialysis or receiving a preemptive kidney transplant. Earlier initiation of KRT was not associated with any difference in patient survival. A substantial proportion of clinical practice variation was due to center variation alone.
Podcast:
This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_08_08_CJN0000000000000204.mp3.
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