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Larkins NG, Lim W, Goh C, Francis A, McCarthy H, Kim S, Wong G, Craig JC. Timing of Kidney Replacement Therapy among Children and Young Adults. Clin J Am Soc Nephrol 2023; 18:1041-1050. [PMID: 37279903 PMCID: PMC10564350 DOI: 10.2215/cjn.0000000000000204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/23/2023] [Indexed: 06/08/2023]
Abstract
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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Affiliation(s)
- Nicholas G. Larkins
- Department of Nephrology and Hypertension, Perth Children's Hospital, Nedlands, Western Australia, Australia
- School of Medicine, University of Western Australia, Australia, Crawley, Western Australia, Australia
| | - Wai Lim
- School of Medicine, University of Western Australia, Australia, Crawley, Western Australia, Australia
- Department of Nephrology, Sir Charles Gardiner Hospital, Nedlands, Western Australia, Australia
| | - Carrie Goh
- Department of Nephrology and Hypertension, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Anna Francis
- Department of Nephrology, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Hugh McCarthy
- Department of Nephrology, Sydney Children's Hospital, Randwick, New South Wales, Australia
- Nephrology Department, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Centre for Kidney Research, Westmead, New South Wales, Australia
| | - Siah Kim
- Nephrology Department, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Centre for Kidney Research, Westmead, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Germaine Wong
- Centre for Kidney Research, Westmead, New South Wales, Australia
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Jonathan C. Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Preka E, Bonthuis M, Harambat J, Jager KJ. Think Twice before Postponing Chronic Dialysis in Children. J Am Soc Nephrol 2019; 30:2473-2474. [PMID: 31649099 DOI: 10.1681/asn.2019090895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Evgenia Preka
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, United Kingdom;
| | - Marjolein Bonthuis
- Department of Medical Informatics, Amsterdam Public Health Research Institute, European Society of Paediatric Nephrology/European Renal Association and European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and
| | - Jérôme Harambat
- Department of Pediatrics, Bordeaux University Hospital, Bordeaux, France
| | - Kitty J Jager
- Department of Medical Informatics, Amsterdam Public Health Research Institute, European Society of Paediatric Nephrology/European Renal Association and European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and
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