We thank Preka et al. for their comments regarding our analysis using the US Renal Data System to investigate the association between higher versus lower eGFR at dialysis initiation in children and survival.1 We concur that postponing chronic dialysis in children in every clinical setting would be inappropriate and not supported by the current literature, and we do not suggest adoption of such practice based on our study results. We acknowledge there are limitations to the conclusions that can be drawn from our study given its observational nature and the lack of more granular data surrounding the reasons for dialysis initiation. Certainly, a causal relationship between higher eGFR at dialysis initiation in children and increased risk of mortality are not established with such a study design. We also thank the authors for highlighting their recent findings.2 As noted in their letter, in this European cohort of pediatric patients with CKD, no clinical benefit was found to be associated with earlier initiation of dialysis. The fact that no benefit to earlier initiation of dialysis in children has been identified in multiple observational studies,1–3 coupled with the trend toward initiation of dialysis at higher levels of kidney function in children with CKD over time,1,3 raises concerns regarding the recent changes in national practice patterns in the United States. A clinical trial would indeed be informative in this regard. However, we do note that timing of dialysis initiation is one of the areas where the observational evidence has agreed with clinical trial results,4 at least in adults. In the meantime, we agree that many clinical criteria, and certainly not eGFR alone, should be taken into account when deciding whether chronic dialysis therapy should be initiated. Regardless, efforts to increase living kidney donation and pre-emptive kidney transplantation rates should continue to provide children with CKD the best long-term health outcomes.
Disclosures
None.
Funding
Dr. Ku is supported by National Institutes of Health (NIH) grant R01 DK115629. Dr. McCulloch is supported by the National Center for Advancing Translational Sciences, NIH, through University of California, San Francisco Clinical and Translational Science Institute (UCSF-CTSI) grant KL2 TR001870.
Footnotes
Published online ahead of print. Publication date available at www.jasn.org.
References
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