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Estimated GFR at Dialysis Initiation and Mortality in Children and Adolescents.
Am J Kidney Dis. 2019 06; 73(6):797-805.AJ

Abstract

RATIONALE & OBJECTIVE

The association of estimated glomerular filtration rate (eGFR) at dialysis therapy initiation with mortality among adult dialysis patients has been greatly debated, with some studies showing no benefit from early dialysis therapy initiation. However, this association has not been well investigated in pediatric dialysis patients. The objective of this study was to evaluate the mortality risk associated with eGFR at dialysis therapy initiation in children and adolescents with kidney failure.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

9,963 incident dialysis patients aged 1 to 17 years in the US Renal Data System registry (1995-2016).

PREDICTOR

eGFRs at dialysis therapy initiation calculated using the pediatric-specific bedside Schwartz equation (<5, 5-<7, 7-<9, 9-<12, and ≥12mL/min/1.73m2).

OUTCOME

Time to all-cause death.

ANALYTICAL APPROACH

Cox proportional hazards regression adjusted for case-mix variables, height, body mass index, hemoglobin level, and serum albumin level.

RESULTS

Median eGFR was 7.8 (IQR, 5.6-10.5) mL/min/1.73m2 and median age was 13 (IQR, 9-16) years. 696 deaths were observed during the median follow-up of 1.4 (IQR, 0.7-2.7) years, and overall crude mortality rate was 31 per 1,000 patient-years. There appeared to be a trend toward higher mortality risk across higher eGFRs at dialysis therapy initiation. Compared with eGFRs of 7 to <9mL/min/1.73m2, eGFRs <5 and ≥12mL/min/1.73m2 were associated with lower and higher mortality, with adjusted HRs of 0.57 (95% CI, 0.43-0.74) and 1.31 (95% CI, 1.05-1.65), respectively. In age-stratified analysis, there were consistent relationships among patients 6 years and older while the eGFR-mortality association was attenuated among patients younger than 6 years (Pinteraction = 0.002).

LIMITATIONS

Possible errors in eGFRs due to methods for serum creatinine measurement. Unmeasured confounders related to eGFR at dialysis therapy initiation.

CONCLUSIONS

Higher eGFR at dialysis therapy initiation was associated with higher mortality risk. Further studies of eGFR at initiation are needed in pediatric dialysis patients, especially among those younger than 6 years.

Authors+Show Affiliations

Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA.Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA.Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Department of Pediatric Nephrology, Shengjing Hospital of China Medical University, Shenyang, China.Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA.David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Pediatric Nephrology, Mattel Children's Hospital at UCLA, Los Angeles, CA.Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA.Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA.Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA. Electronic address: kkz@uci.edu.

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

30833086

Citation

Okuda, Yusuke, et al. "Estimated GFR at Dialysis Initiation and Mortality in Children and Adolescents." American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation, vol. 73, no. 6, 2019, pp. 797-805.
Okuda Y, Soohoo M, Tang Y, et al. Estimated GFR at Dialysis Initiation and Mortality in Children and Adolescents. Am J Kidney Dis. 2019;73(6):797-805.
Okuda, Y., Soohoo, M., Tang, Y., Obi, Y., Laster, M., Rhee, C. M., Streja, E., & Kalantar-Zadeh, K. (2019). Estimated GFR at Dialysis Initiation and Mortality in Children and Adolescents. American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation, 73(6), 797-805. https://doi.org/10.1053/j.ajkd.2018.12.038
Okuda Y, et al. Estimated GFR at Dialysis Initiation and Mortality in Children and Adolescents. Am J Kidney Dis. 2019;73(6):797-805. PubMed PMID: 30833086.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Estimated GFR at Dialysis Initiation and Mortality in Children and Adolescents. AU - Okuda,Yusuke, AU - Soohoo,Melissa, AU - Tang,Ying, AU - Obi,Yoshitsugu, AU - Laster,Marciana, AU - Rhee,Connie M, AU - Streja,Elani, AU - Kalantar-Zadeh,Kamyar, Y1 - 2019/03/02/ PY - 2018/09/18/received PY - 2018/12/17/accepted PY - 2019/3/6/pubmed PY - 2020/3/12/medline PY - 2019/3/6/entrez KW - Children KW - dialysis timing KW - early dialysis initiation KW - end-stage kidney disease (ESKD) pediatric KW - end-stage renal disease (ESRD) KW - estimated glomerular filtration rate (eGFR) KW - hemodialysis KW - mortality KW - peritoneal dialysis KW - renal failure KW - survival SP - 797 EP - 805 JF - American journal of kidney diseases : the official journal of the National Kidney Foundation JO - Am J Kidney Dis VL - 73 IS - 6 N2 - RATIONALE & OBJECTIVE: The association of estimated glomerular filtration rate (eGFR) at dialysis therapy initiation with mortality among adult dialysis patients has been greatly debated, with some studies showing no benefit from early dialysis therapy initiation. However, this association has not been well investigated in pediatric dialysis patients. The objective of this study was to evaluate the mortality risk associated with eGFR at dialysis therapy initiation in children and adolescents with kidney failure. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 9,963 incident dialysis patients aged 1 to 17 years in the US Renal Data System registry (1995-2016). PREDICTOR: eGFRs at dialysis therapy initiation calculated using the pediatric-specific bedside Schwartz equation (<5, 5-<7, 7-<9, 9-<12, and ≥12mL/min/1.73m2). OUTCOME: Time to all-cause death. ANALYTICAL APPROACH: Cox proportional hazards regression adjusted for case-mix variables, height, body mass index, hemoglobin level, and serum albumin level. RESULTS: Median eGFR was 7.8 (IQR, 5.6-10.5) mL/min/1.73m2 and median age was 13 (IQR, 9-16) years. 696 deaths were observed during the median follow-up of 1.4 (IQR, 0.7-2.7) years, and overall crude mortality rate was 31 per 1,000 patient-years. There appeared to be a trend toward higher mortality risk across higher eGFRs at dialysis therapy initiation. Compared with eGFRs of 7 to <9mL/min/1.73m2, eGFRs <5 and ≥12mL/min/1.73m2 were associated with lower and higher mortality, with adjusted HRs of 0.57 (95% CI, 0.43-0.74) and 1.31 (95% CI, 1.05-1.65), respectively. In age-stratified analysis, there were consistent relationships among patients 6 years and older while the eGFR-mortality association was attenuated among patients younger than 6 years (Pinteraction = 0.002). LIMITATIONS: Possible errors in eGFRs due to methods for serum creatinine measurement. Unmeasured confounders related to eGFR at dialysis therapy initiation. CONCLUSIONS: Higher eGFR at dialysis therapy initiation was associated with higher mortality risk. Further studies of eGFR at initiation are needed in pediatric dialysis patients, especially among those younger than 6 years. SN - 1523-6838 UR - https://www.unboundmedicine.com/medline/citation/30833086/Estimated_GFR_at_Dialysis_Initiation_and_Mortality_in_Children_and_Adolescents_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0272-6386(19)30080-0 DB - PRIME DP - Unbound Medicine ER -