Division of Nephrology,
Departments of Pediatrics.
J Am Soc Nephrol. 2019 Aug;30(8):1505-1513. doi: 10.1681/ASN.2018111130. Epub 2019 Jul 18.
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.
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) versus lower eGFR (eGFR≤10 ml/min per 1.73 m).
Of 15,170 children, 4327 (29%) had a higher eGFR (median eGFR, 12.8 ml/min per 1.73 m) at dialysis initiation. Compared with children with a lower eGFR (median eGFR, 6.5 ml/min per 1.73 m), 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 (<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).
In children with ESRD, a higher eGFR at dialysis initiation is associated with lower survival, particularly among children whose initial treatment modality is hemodialysis.
研究结果表明，在终末期肾病（ESRD）患者中，以较高的肾小球滤过率（eGFR）开始透析并不能改善生存率。在患有慢性肾脏病（CKD）的儿童中，以较高的 eGFR 开始透析是否与生存获益相关尚不清楚。
为了研究这个问题，我们对美国肾脏数据系统（US Renal Data System）记录的 1995 年至 2015 年间开始透析的 1 至 18 岁儿科患者进行了回顾性队列研究。主要预测因素是透析开始时的 eGFR，分为较高（eGFR＞10ml/min per 1.73 m）和较低（eGFR≤10ml/min per 1.73 m）两组。
在 15170 名儿童中，4327 名（29%）在透析开始时的 eGFR 较高（中位数 eGFR 为 12.8ml/min per 1.73 m）。与 eGFR 较低的儿童（中位数 eGFR 为 6.5ml/min per 1.73 m）相比，透析开始时 eGFR 较高的儿童更常见于白人、女孩、体重不足或肥胖，且更可能因肾小球肾炎（GN）而导致 ESRD。在透析开始时 eGFR 较高（与较低）的儿童中，死亡风险高 1.36 倍（95%置信区间，1.24 至 1.50）。透析时机与生存率之间的关系因治疗方式（血液透析与腹膜透析）而异（交互作用 P＜0.001），且在最初接受血液透析治疗的儿童中更为明显（危险比，1.56，95%置信区间，1.39 至 1.75；与危险比，1.07，95%置信区间，0.91 至 1.25）。
在 ESRD 患儿中，透析开始时较高的 eGFR 与生存率降低相关，尤其是在初始治疗方式为血液透析的患儿中。
