Mode of initial renal replacement therapy and transplant outcomes in the chronic kidney disease in children (CKiD) study

Abstract

Background: Kidney transplant is the renal replacement therapy (RRT) of choice for children with end stage kidney disease (ESKD). Only 21.3% of children who initiate RRT receive a preemptive kidney transplant (PKT). We characterized the transition to RRT in children in the CKiD cohort including the prevalence of dialysis as first RRT vs. PKT and graft survival.

Methods: 258 children enrolled in CKiD have initiated RRT, and 202 had post-RRT initiation data collected through phone or in-person follow-up. Characteristics by first RRT modality were compared using Chi-square and Kruskal-Wallis tests. Parametric-accelerated failure time models were fit for transplantation. Graft failure was characterized using Kaplan-Meier methods and log rank tests.

Results: Sixty-one percent received dialysis as first RRT modality and 39% PKT. Those with PKT were less likely to have glomerular disease and to be African-American, and had higher household-income. African-American subjects were nearly twice as likely to undergo dialysis prior to transplant. Those with a living donor and a college-educated mother had 40%-decreased odds of being dialysis experienced. Children with PKT were more likely to receive a living donor transplant. Only 5% of PKT subjects had graft failure by 4 years compared to 16% of those initially treated with dialysis (p = 0.092); however, after adjustment the effect of dialysis exposure was attenuated (p = 0.206).

Conclusion: CKiD subjects undergo PKT more often compared to nationally-reported rates, and are more likely to receive a kidney transplant within 1 year of starting dialysis. African-American race and lower household-income are associated with decreased access to PKT.

Keywords: Graft loss; Hemodialysis; Pediatrics; Peritoneal dialysis; Preemptive.

Conflict of interest statement

Conflict of interest The authors declare that they have no conflict of interest

Figures

Figure 1.

Cumulative incidence of transplantation (solid lines) following dialysis as first RRT event in 123 CKiD subjects. The black lines represent the 81 HD participants of whom 50% were transplanted by 11 months after initiating dialysis. The gray lines are the 42 PD participants of whom 50% were transplanted 13 months after initiating dialysis. The dashed lines represent the generalized gamma curves yielding a likelihood ratio statistic with a p-value= 0.028.

Figure 2.

Cumulative incidence of transplant failure following transplant event in 170 CKiD subjects. Solid lines depict unadjusted functions and dash-dotted lines represent adjusted functions using inverse probability weights. The gray lines are the 79 PKT participants of whom only 5% had transplant failure by 48 months. The black lines represent the 91 dialysis-experienced participants of whom 16% had transplant failure by 48 months. Incidence of transplant failure marginally differs between dialysis-experienced and PKT when unadjusted (p=0.092), but attenuates when adjusted by inverse probability weights (p=0.206).