Decision factors for pediatric kidney replacement therapies may differ from guidelines
Click Here to Manage Email Alerts
Key takeaways:
- Starting dialysis was more likely for children with glomerulopathies compared with congenital renal anomalies.
- Preemptive transplant was more likely for those with tubulointerstitial diseases.
Level of kidney function, rate of decline and type of renal disease are key factors influencing the decision to initiate kidney replacement therapy, whether dialysis or transplantation, for pediatric patients, according to study data.
“The kidney replacement option more frequently available in the pediatric CKD population is preemptive transplantation. It is associated with better patient survival and reduced cardiovascular comorbidity but advances the need for maintenance immunosuppressive therapy and also causes various long-term sequelae,” Julia Thumfart, MD, deputy clinic director and head of the nephrology section in the department of pediatric gastroenterology, nephrology and metabolic diseases at Charité Universitätsmedizin in Berlin, Germany, and colleagues wrote in study background. “International guidelines and recommendations propose to base the decision to initiate kidney replacement therapy primarily on clinical signs and symptoms, such as hypertension, malnutrition, growth retardation and impaired physical performance, rather than a specific level of kidney function.”
Thumfart and colleagues assessed data from 695 participants in the Cardiovascular Comorbidity in Children with Chronic Kidney Disease (4C) Study, conducted from 2010 to 2018 at 55 study sites in Europe and Turkey. Participants with data in the current study were aged 6 to 17 years (mean age, 12.3 years; 35% girls) and had CKD with an eGFR of 10 mL/min per 1.73 m2 to 60 mL/min per 1.73 m2 and at least two study visits before initiating any kidney replacement therapy. Among the cohort, 68.6% had congenital anomalies of the kidneys and urinary tracts (CAKUT), 13.5% had tubulointerstitial diseases, 8.5% had a glomerulopathy, 4.9% had post-AKI CKD and 4.5% had other/unknown primary renal diagnosis. Researchers analyzed the relationship between diagnosis and disease progression and time to treatment.
Almost half of the cohort — 342 participants — initiated kidney replacement therapy:
101 had a preemptive transplant with a kidney from a living donor and 41 with a kidney from a deceased donor, 107 started hemodialysis and 93 started peritoneal dialysis, with 12 of these receiving a kidney transplantation within 3 months.
Median eGFR was of 11 mL/min per 1.73 m2 for those who started dialysis and10.7 mL/min per 1.73 m2 for those proceeding right to transplantation.
Initiating any type of kidney replacement therapy was more likely for those with a lower eGFR (HR = 0.76; 95% CI, 0.74-0.78), a more rapid decline in eGFR (HR = 0.90; 95% CI, 0.85-0.95) and a higher systolic blood standard deviation score (HR = 2.07; 95% CI, 1.49-2.87).
Starting dialysis was more likely for those with glomerulopathies compared with CAKUT (HR = 5.39; 95% CI, 3.29-8.82) and for those with lower BMI standard deviation score (HR = 0.73; 95% CI, 0.6-0.89) and lower hemoglobin (HR = 0.8; 95% CI, 0.72-0.9).
Preemptive kidney transplantation was more likely for participants with tubulointerstitial diseases compared with CAKUT (HR = 1.79; 95% CI, 1.11-2.88) and for those with a lower eGFR (HR = 0.74; 95% CI, 0.71-0.77) and higher systolic blood pressure standard deviation score (HR = 2.02; 95% CI, 1.23-3.32).
Researchers noted that practices at individual centers significantly influenced the decision to initiate kidney replacement therapy.
“[After eGFR level], the second most important determinant of kidney replacement start was the rate of GFR loss,” the researchers wrote. “At a given eGFR, children with a more rapid eGFR decline were more likely to initiate kidney replacement therapy. ... Notably, the association was highly significant for initiation of dialysis, but not for preemptive transplantation. ... [T]he greater flexibility of timing when a transplant donor is available facilitates the initiation of kidney replacement therapy primarily according to absolute eGFR level, with less dependence on the rate of eGFR deterioration.”
Collapse
Click Here to Manage Email Alerts