Timing and Modality of Kidney Replacement Therapy in Children and Adolescents

Julia Thumfart; Steffen Wagner; Marietta Kirchner; Karolis Azukaitis; Aysun K Bayazit; Lukasz Obrycki; Nur Canpolat; Ipek Kaplan Bulut; Ali Duzova; Ali Anarat; Lucie Bessenay; Rukshana Shroff; Dusan Paripovic; Lale Sever; Cengiz Candan; Francesca Lugani; Alev Yilmaz; Fatos Yalcinkaya; Klaus Arbeiter; Aysel Kiyak; Aleksandra Zurowska; Matthias Galiano; Uwe Querfeld; Anette Melk; Franz Schaefer; 4C Study Group

doi:10.1016/j.ekir.2024.06.009

Timing and Modality of Kidney Replacement Therapy in Children and Adolescents

Kidney Int Rep. 2024 Jun 12;9(9):2750-2758. doi: 10.1016/j.ekir.2024.06.009. eCollection 2024 Sep.

Authors

Julia Thumfart¹, Steffen Wagner², Marietta Kirchner³, Karolis Azukaitis⁴, Aysun K Bayazit⁵, Lukasz Obrycki⁶, Nur Canpolat⁷, Ipek Kaplan Bulut⁸, Ali Duzova⁹, Ali Anarat⁵, Lucie Bessenay¹⁰, Rukshana Shroff¹¹, Dusan Paripovic¹², Lale Sever⁷, Cengiz Candan¹³, Francesca Lugani¹⁴, Alev Yilmaz¹⁵, Fatos Yalcinkaya¹⁶, Klaus Arbeiter¹⁷, Aysel Kiyak¹⁸, Aleksandra Zurowska¹⁹, Matthias Galiano²⁰, Uwe Querfeld¹, Anette Melk²¹, Franz Schaefer²²; 4C Study Group

Collaborators

4C Study Group:
G Cortina, K Arbeiter, J Dusek, J Harambat, B Ranchin, M Fischbach, U Querfeld, S Habbig, M Galiano, R Büscher, C Gimpel, M Kemper, A Melk, D Thurn, F Schaefer, A Doyon, E Wühl, M Pohl, S Wygoda, N Jeck, B Kranz, M Wigger, G Montini, F Lugani, S Testa, E Vidal, C Matteucci, S Picca, A Jankauskiene, K Azukaitis, A Zurowska, D Drodz, M Tkaczyk, T Urasinski, M Litwin, M Szczepanska, A Texeira, A Peco-Antic, B Bucher, G Laube, A Anarat, A K Bayazit, F Yalcinkaya, E Basin, N Cakar, O Soylemezoglu, A Duzova, Y Bilginer, H Erdogan, O Donmez, A Balat, A Kiyak, S Caliskan, N Canpolat, C Candan, M Civilibal, S Emre, G Ozcelik, S Mir, B Sözeri, O Yavascan, Y Tabel, P Ertan, E Yilmaz, R Shroff

Affiliations

¹ Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité Universitätsmedizin, Berlin, Germany.
² BHT Berliner Hochschule für Technik, Berlin, Germany.
³ Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany.
⁴ Clinic of Pediatrics, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania.
⁵ Department of Pediatric Nephrology, School of Medicine, Cukurova University, Adana, Türkiye.
⁶ Department of Nephrology, Kidney Transplantation and Hypertension, Children`s Memorial Health Institute, Warsaw, Poland.
⁷ Division of Pediatric Nephrology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Türkiye.
⁸ Department of Pediatric Nephrology, Ege University Faculty of Medicine, Izmir, Türkiye.
⁹ Division of Pediatric Nephrology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Türkiye.
¹⁰ Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France.
¹¹ UCL Great Ormond Street Hospital and Institute of Child Health, London, UK.
¹² Department of Pediatric Nephrology, University Children's Hospital, Belgrade, Serbia.
¹³ Department of Pediatric Nephrology, Istanbul Medeniyet University, Istanbul, Türkiye.
¹⁴ Division of Nephrology and Transplantation, IRCCS Istituto G. Gaslini, Genova, Italy.
¹⁵ Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye.
¹⁶ Department of Pediatrics, Ankara University Medical School, Ankara, Türkiye.
¹⁷ Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria.
¹⁸ Department of Pediatric Nephrology, Yenimahalle Egitim ve Arastirma Hastanesi Bakirkoy, Istanbul, Türkiye.
¹⁹ Department of Pediatric Nephrology, Medical University of Gdansk, Gdansk, Poland.
²⁰ Department of Pediatrics and Adolescent Medicine, University of Erlangen-Nürnberg, Erlangen, Germany.
²¹ Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany.
²² Center for Pediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany.

Abstract

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.

Keywords: dialysis initiation; pediatric risk factors; progression kidney disease.