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Timing and Modality of Kidney Replacement Therapy in Children and Adolescents
Julia Thumfart1, Steffen Wagner2, Marietta Kirchner3
1Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité Universitätsmedizin, Berlin, Germany.
Insights
Kidney replacement therapy (KRT) choices in children depend on kidney function decline, disease type, and patient factors. Center-specific elements also influence KRT timing and modality decisions for pediatric patients.
Area of Science:
- Pediatric Nephrology
- Renal Replacement Therapy
- Chronic Kidney Disease
Background:
- Kidney replacement therapy (KRT) is crucial for pediatric patients with end-stage renal disease.
- Decisions regarding KRT initiation, timing, and modality are complex, influenced by multiple clinical and patient-related factors.
Purpose of the Study:
- To analyze factors influencing the choice and timing of KRT in a large, multinational pediatric cohort.
- To identify predictors for initiating dialysis versus preemptive transplantation in children with chronic kidney disease (CKD).
Main Methods:
- Prospective investigation of 695 pediatric patients (age 6-17) with CKD in the Cardiovascular Comorbidity in Children with CKD (4C) study.
- Competing risk regression analysis to determine associations between clinical/laboratory parameters and KRT initiation (dialysis or preemptive transplantation).
Main Results:
- Nearly half (49%) of patients initiated KRT within 8 years; 200 started dialysis, 142 received preemptive transplantation.
- Lower eGFR, steeper eGFR decline, and higher systolic blood pressure SDS predicted KRT initiation.
- Glomerulopathies, lower BMI SDS, and lower hemoglobin were linked to higher dialysis likelihood, while CAKUT was associated with lower dialysis likelihood.
Conclusions:
- The rate of kidney function loss, primary kidney diagnosis, and patient's nutritional and hematological status significantly impact KRT decisions in children.
- Center-specific factors play a role, highlighting the need for standardized approaches in pediatric KRT management.
Introduction:
The choice and timing of kidney replacement therapy (KRT) is influenced by clinical factors, laboratory features, feasibility issues, family preferences, and clinicians' attitudes. We analyzed the factors associated with KRT modality and timing in a multicenter, multinational prospective pediatric cohort study.
Methods:
A total of 695 pediatric patients with chronic kidney disease (CKD) enrolled into the Cardiovascular Comorbidity in Children with CKD (4C) study at age 6 to 17 years with estimated glomerular filtration rate (eGFR) of 10 to 60 ml/min per 1.73 m2 were investigated. Competing risk regression was performed to identify factors associated with initiation of dialysis or preemptive transplantation (Tx), including primary renal diagnosis, demographics, anthropometrics, and laboratory parameters.
Results:
During the 8-year observation period, 342 patients (49%) started KRT. Of these, 200 patients started dialysis, whereas 142 patients underwent preemptive Tx. A lower eGFR at enrolment (Hazard ratio [HR]: 0.76 [95% confidence interval: 0.74-0.78]), a steeper eGFR slope (HR: 0.90 [0.85-0.95], and a higher systolic blood pressure SD score (SDS) (HR: 2.07 [1.49-2.87]) increased the likelihood of KRT initiation. Patients with glomerulopathies were more likely to start dialysis than children with congenital anomalies of the kidneys and urinary tracts (CAKUT) (HR: 3.81 [2.52-5.76]). Lower body mass index (BMI) SDS (HR: 0.73 [0.6-0.89]) and lower hemoglobin (HR: 0.8 [0.72-0.9]) were associated with higher likelihood of dialysis. A significant center effect was observed, accounting for 6.8% (dialysis) to 8.7% (preemptive Tx) of explained variation.
Conclusion:
The timing and choice of KRT in pediatric patients is influenced by the rate of kidney function loss, the underlying kidney disease, nutritional status, blood pressure, anemia and center-specific factors.
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