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Evgenia Preka1, Marjolein Bonthuis2, Jerome Harambat3, Kitty J. Jager2, Jaap W. Groothoff4, Sergey Baiko5, Aysun K. Bayazit6, Michael Boehm7, Mirjana Cvetkovic8, Vidar O. Edvardsson9, Svitlana Fomina10, James G. Heaf11, Tuula Holtta12, Eva Kis13, Gabriel Kolvek14, Linda Koster-Kamphuis15, Elena A. Molchanova16, Marina Munoz17, Gisela Neto18, Gregor Novljan19, Nikoleta Printza20, Emilija Sahpazova21, Lisa Sartz22, Manish D. Sinha23, Enrico Vidal24, Karel Vondrak25, Isabelle Vrillon26, Lutz T. Weber27, Marcus Weitz28, Ilona Zagozdzon29, Constantinos J. Stefanidis30 and Sevcan A. Bakkaloglu31

1 - Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
2 - ESPN/ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam, The Netherlands,
3 - Department of Pediatrics, Bordeaux University Hospital, Bordeaux, France
4 - Amsterdam UMC, University of Amsterdam, Department of Paediatric Nephrology, Emma Children’s Academic Medical Center, Amsterdam, The Netherlands
5 - Department of Pediatrics, Belarusian State Medical University, Minsk, Belarus
6 - Department of Pediatric Nephrology, School of Medicine, Cukurova University, Adana, Turkey
7 - Department of Pediatric Nephrology, University Children’s Hospital, Vienna, Austria,
8 - Nephrology Department, University Children’s Hospital, Belgrade, Serbia,
9 - Children’s Medical Center, Landspitali–The National University Hospital of Iceland, and Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland,
10 - Department of Pediatric Nephrology, National Academy of Medical Sciences of Ukraine, Kiev, Ukraine,
11 - Department of Medicine, Zealand University Hospital, Roskilde, Denmark,
12 - Children’s Hospital, University of Helsinki, Helsinki, Finland,
13 - Gottsegen Gyo ̈rgy Hungarian Institute of Cardiology, Budapest, Hungary,
14 - Pediatric Department, Faculty of Medicine, Safarik University, Kosice, Slovakia,
15 - Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Nijmegen, The Netherlands,
16 - Department of Kidney Transplantation, Russian Children’s Clinical Hospital, Moscow, Russia,
17 - Department of Pediatric Nephrology, University Hospital Vall d’Hebron, Barcelona, Spain,
18 - Paediatric Nephrology Unit, Hospital de Dona Estefânia, Lisbon, Portugal,
19 - Department of Pediatric Nephrology, University Medical Center Ljubjana, Faculty of Medicine, University of Ljubjana, Slovenia,
20 - 1st Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece,
21 - University Pediatric Clinic, Skopje, FYR of Macedonia,
22 - Department of Clinical Sciences, Pediatric Nephrology, Skane University Hospital, Lund University, Lund, Sweden,
23 - Department of Paediatric Nephrology, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK,
24 - Pediatric Nephrology, Dialysis and Transplantation Unit, Department of Woman’s and Child’s Health, University Hospital of Padua, Padua, Italy,
25 - Department of Pediatrics, University Hospital Motol, Prague, Czech Republic,
26 - Pediatric Nephrology Department, Nancy University Hospital, Nancy, France,
27 - Pediatric Nephrology, Childrens and Adolescents Hospital, University Hospital of Cologne, Cologne, Germany,
28 - Pediatric Nephrology, University Children’s Hospital Zurich, Zurich, Switzerland,
29 - Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland,
30 - Department of Pediatric Nephrology, “Mitera” Children’s Hospital, Athens, Greece
31 - Department of Pediatric Nephrology, Gazi University, Ankara, Turkey

- Abstract published Nephrology Dialysis Transplant (2019) 34; 1932-1949

Background: There is no consensus regarding the timing of di- alysis therapy initiation for end-stage kidney disease (ESKD) in children. As studies investigating the association between tim- ing of dialysis initiation and clinical outcomes are lacking, we aimed to study this relationship in a cohort of European chil- dren who started maintenance dialysis treatment.
Methods: We used data on 2963 children from 21 different countries included in the European Society of Pediatric Nephrology/European Renal Association–European Dialysis and Transplant Association Registry who started renal replace- ment therapy before 18 years of age between 2000 and 2014. We compared two groups according to the estimated glomerular fil- tration rate (eGFR) at start: eGFR ?8 mL/min/1.73 m2 (early starters) and eGFR <8 mL/min/1.73 m2 (late starters). The pri- mary outcomes were patient survival and access to transplanta- tion. Secondary outcomes were growth and cardiovascular risk factors. Sensitivity analyses were performed to account for se- lection- and lead time-bias.
Results: The median eGFR at the start of dialysis was 6.1 for late versus 10.5 mL/min/1.73 m2 for early starters. Early starters were older [median: 11.0, interquartile range (IQR): 5.7–14.5 versus 9.4, IQR: 2.6–14.1 years]. There were no differences ob- served between the two groups in mortality and access to trans- plantation at 1, 2 and 5 years of follow-up. One-year evolution of height standard deviation scores was similar among the groups, whereas hypertension was more prevalent among late initiators. Sensitivity analyses resulted in similar findings.
Conclusion: We found no evidence for a clinically relevant benefit of early start of dialysis in children with ESKD. Presence of cardiovascular risk factors, such as high blood pressure, should be taken into account when deciding to initiate or post- pone dialysis in children with ESKD, as this affects the survival.

Keywords: access to transplantation, cardiovascular complication, children, chronic kidney disease, timing of dialysis initiation