Higher eGFR at Dialysis Initiation Is Not Associated with a Survival Benefit in Children

Significance Statement Although observational studies suggest that dialysis initiation at higher levels of eGFR is not associated with survival benefit in adults with ESRD, the issue is not well studied in children. In a retrospective cohort study of the timing of dialysis initiation and survival in children who (according to the US Renal Data System) began dialysis in 1995–2015, the authors found a trend toward increased initiation of dialysis at higher eGFR over that period. Higher eGFR at dialysis initiation was associated with an increased risk of death, particularly for children who initiated treatment with hemodialysis rather than peritoneal dialysis. These findings may have important implications for the care of children with ESRD; a more concerted effort to delay dialysis initiation in asymptomatic children may reduce exposure to dialysis. Background Study findings suggest that initiating dialysis at a higher eGFR level in adults with ESRD does not improve survival. It is less clear whether starting dialysis at a higher eGFR is associated with a survival benefit in children with CKD. Methods To investigate this issue, we performed a retrospective cohort study of pediatric patients aged 1–18 years who, according to the US Renal Data System, started dialysis between 1995 and 2015. The primary predictor was eGFR at the time of dialysis initiation, categorized as higher (eGFR>10 ml/min per 1.73 m 2 ) versus lower eGFR (eGFR≤10 ml/min per 1.73 m 2 ). Results Of 15,170 children, 4327 (29%) had a higher eGFR (median eGFR, 12.8 ml/min per 1.73 m 2 ) at dialysis initiation. Compared with children with a lower eGFR (median eGFR, 6.5 ml/min per 1.73 m 2 ), those with a higher eGFR at dialysis initiation were more often white, girls, underweight or obese, and more likely to have GN as the cause of ESRD. The risk of death was 1.36 times higher (95% confidence interval, 1.24 to 1.50) among children with a higher (versus lower) eGFR at dialysis initiation. The association between timing of dialysis and survival differed by treatment modality—hemodialysis versus peritoneal dialysis ( P <0.001 for interaction)—and was stronger among children initially treated with hemodialysis (hazard ratio, 1.56, 95% confidence interval, 1.39 to 1.75; versus hazard ratio, 1.07, 95% confidence interval, 0.91 to 1.25; respectively). Conclusions In children with ESRD, a higher eGFR at dialysis initiation is associated with lower survival, particularly among children whose initial treatment modality is hemodialysis.