Children with end-stage renal disease (ESRD) who initiate dialysis at a higher estimated glomerular filtration rate (eGFR) have worse survival than those who start dialysis at lower eGFRs, according to investigators.

Erica Winnicki, MD, of the University of California, San Francisco, and colleagues studied outcomes of 15,170 patients 18 years old and younger from the US Renal Data System during 1995 to 2015. Of these, 4327 (29%) started dialysis at an eGFR higher than 10 mL/min/1.73 m2 (median 12.8 mL/min/1.73 m2) and 10,843 (71%) at an eGFR of 10 mL/min/1.73 m2 or lower (median 6.5 mL/min/1.73 m2). The team observed a trend toward dialysis initiation at higher eGFRs over time, from approximately 17% in 1995 to 41% in 2015.

Children initiating dialysis at a higher vs lower eGFR had a 36% increased risk for death, the investigators reported in the Journal of the American Society of Nephrology. “Early” initiators tended to be white, female, underweight or obese, and have glomerular nephropathy.

The risk for death differed by dialysis modality. Among patients initiating hemodialysis, those starting with a high eGFR had a significant 56% increased risk for death compared with those starting with a low eGFR. In contrast, a high vs low eGFR among patients initiating peritoneal dialysis was associated with a nonsignificant 7% increased risk for death.

In children, any dialysis exposure before transplantation has been associated with worse survival and worse allograft outcomes, according to the researchers. In this study, 20% of children starting dialysis received a kidney transplant within 6 months. The study lacked information on patients’ indications for dialysis initiation.

“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,” according to Dr Winnicki and her collaborators.

Nicholas G. Larkins, MBBS, PhD, of Perth Children’s Hospital, and Jonathan C. Craig, M Med, PhD, of Flinders University, both in Australia, commented into an accompanying editorial: “Although more research is clearly needed to address this question, including prospective cohort studies with information on pediatric specific outcomes such as growth and development, until then the implications are clear. Time’s up. Start dialysis later, except in the context of a trial.”

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Winnicki E, Johansen KL, Cabana MD, et al. Higher eGFR at dialysis initiation is not associated with a survival benefit in children. J Am Soc Nephrol. 2019. doi:10.1681/ASN.2018111130

Larkins NG and Craig JC. Time’s up! Start dialysis later in children. J Am Soc Nephrol. 2019. doi:10.1681/ASN.2019040429