Article of the Month - Mar 2020

The decision as to whether to offer neonates and infants chronic dialysis has been a challenging one for many years, with data limited on survival and ongoing receipt of transplantation. This article helps to provide neonatologists and nephrologists with the outcomes from a large data registry demonstrating that outcomes have improved over the last two decades.

Outcomes of infants receiving chronic peritoneal dialysis: an analysis of the USRDS registry

Pediatr Nephrol. 2019 Jan;34(1):155-162. doi: 10.1007/s00467-018-4056-6. Epub 2018 Aug 23.

Sanderson KR, Yu Y, Dai H, Willig LK, Warady BA

Reviewed by Erin Rademacher

Purpose: To define the demographic features and mortality of all infants in the United States diagnosed with ESRD and started on chronic peritoneal dialysis (CPD) in the first year of life. Previous reports on infants’ mortality while on CPD have come from single centers or voluntary registries. This study aimed to provide a more complete picture by using the United States Renal Data System (USRDS). In the U.S. pediatric nephrologists are required to submit a form to Centers for Medicaid and Medicare on all patients initiating outpatient dialysis. This data, as well as data at time of death and transplantation, are recorded in the USRDS./

Study Design: Retrospective cohort study of infants < 12 months at time of initiation of CPD with a diagnosis of ESRD during the time period of January 1, 1990-December 31, 2014 as recorded in the USRDS database. Subjects were divided into 2 categories based on age at initiation of CPD: ≤ 1 month and > 1-12 months of age. The 2 age categories were compared against each other in 2 different eras: 1990-1999 and 2000-2014. This was done based on the publication of pediatric specific recommendations for PD published in the year 2000.

Sample Characteristics: 1723 infants were included. The majority were white (77%), non-Hispanic (73%) and male (68%). Congenital anomalies of the kidney and urinary tract was the most common reason for CPD (55%) followed by cystic kidney diseases (12%).

Results: 32% and 28% of neonates and older infants died on dialysis in the older era. In the modern era, these numbers improved to 22% and 14%. Cardiorespiratory failure and infection were the most common causes of death in both eras. 1- and 5- year survival by era showed significant improved in both groups (see table). In a competing risk model (competing risk equaled transplantation), initiation era and female sex were found to be significant predictors of mortality.

  2000-2014 1990-1999
  < 1 m (n = 372) 1-12 m (n = 808) <1 m (n = 202) 1-12 m (n = 341)
1 year survival 86.8% 89.6% 76.9% 80.8%
5 year survival 74.6 % 79.3% 63.8% 61.6%

Implications: Survival of even the youngest infants on CPD has improved over time. This data can help neonatologists and nephrologists counsel families about expected outcomes.