Clinical characteristics at the renal replacement therapy initiation of Japanese pediatric patients: a nationwide cross-sectional study

  • Daishi HiranoEmail author
  • Eisuke Inoue
  • Mayumi Sako
  • Akira Ashida
  • Masataka Honda
  • Shori Takahashi
  • Kazumoto Iijima
  • Motoshi Hattori
  • the Japanese Society of Pediatric Nephrology
Original article



Although there is debate regarding the timing of initiation of renal replacement therapy (RRT) in adults with end-stage renal disease, there is a paucity of reliable epidemiological data on pediatric patients. The present study was performed to investigate current practice in Japan with regard to the timing of initiation of RRT in children based on estimated glomerular filtration rate (eGFR).


A total of 649 pediatric patients < 20 years old with eGFR at the initiation of RRT between 1 January 2006 and 31 December 2013 were included in the study. Baseline eGFR was calculated for each patient using the Schwartz formula.


eGFR at the start of RRT was 12.1 mL/min/1.73 m2 [interquartile range (IQR) 8.4–16.3]. A total of 209 children (32.2%) had high eGFR (eGFR > 15 mL/min/1.73 m2) at the initiation of RRT. Initiation of RRT was more likely in those undergoing preemptive transplantation (PEKT) with high eGFR [odds ratio (OR) 4.16; 95% confidence interval (CI) 1.95–8.90, P < 0.001]. There were 31 deaths of various causes during follow-up, with infections representing the leading causes of death.


The median eGFR at the initiation of RRT in children showed a wide range of variation. Further studies are needed to investigate the impact of the decision regarding when to initiate RRT in individual pediatric patients.


Renal replacement therapy Children eGFR Initiation Timing Dialysis 



This work was funded by the Japanese Society for Pediatric Nephrology (JSPN). The authors thank all patients, families, physicians, and institutes who contributed to the JSPN ESRD Survey. The authors also thank Drs. Akira Matsunaga, Toru Igarashi, Toshiyuki Ota, Takao Konomoto, Naoko Ito, Ryoko Harada, Takuya Fujimaru, and Kenichi Satomura as members of the JSPN ESRD Survey Committee, and Drs. Yuko Akioka, Kenji Ishikura, Yuko Hamasaki, Yoshitomo Itami, Yoshimitsu Goto, Yoshihiko Ueda, Misako Hiramatsu, Shuich Ito, Osamu Uemura, Satoshi Sasaki, Ken Hatae, Hiroshi Hataya, Mikiya Fujieda, and Hiroshi Yoshimura and the members of the JSPN, the Japanese Society for Dialysis Therapy (JSDT), and the Japanese Society for Clinical Renal Transplantation (JSCRT) for their contributions to data collection. The authors also thank Prof. Yasuo Ohashi, Mr. Tetsuji Kaneko, Mr. Masaaki Kurihara, Ms. Chie Matsuda, and Ms. Takako Arai for their help with data management [Japan Clinical Research Support Unit (Tokyo), and Ever Progressing Clinical Research Support Unit (Tokyo, Japan)].

Author contributions

DH and MH designed the study; DH and EI carried out statistical analyses; DH, MS, AA, EI, MH, ST, and MH analyzed the data; DH and MH made the figures; DH, MS, AA, EI, MH, ST, and MH drafted and revised the paper; all authors approved the final version of the manuscript.

Compliance with ethical standards

Conflict of interest

The authors have no conflicts of interest to declare.


  1. 1.
    Jungers P, Zingraff J, Albouze G, Chauveau P, Page B, Hannedouche T, Man NK. Late referral to maintenance dialysis: detrimental consequences. Nephrol Dial Transplant. 1993;8:1089–93.PubMedGoogle Scholar
  2. 2.
    Sesso R, Belasco AG. Late diagnosis of chronic renal failure and mortality on maintenance dialysis. Nephrol Dial Transplant. 1996;11:2417–20.CrossRefPubMedGoogle Scholar
  3. 3.
    Crews DC, Scialla JJ, Liu J, Guo H, Bandeen-Roche K, Ephraim PL, Jaar BG, Sozio SM, Miskulin DC, Tangri N, Shafi T, Meyer KB, Wu AW, Powe NR, Boulware LE, Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Patient Outcomes in End Stage Renal Disease Study Investigators. Predialysis health, dialysis timing, and outcomes among older United States adults. J Am Soc Nephrol. 2014;25:370–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Pan Y, Xu XD, Guo LL, Cai LL, Jin HM. Association of early versus late initiation of dialysis with mortality: systematic review and meta-analysis. Nephron Clin Pract. 2012;120:c121–c131131.CrossRefPubMedGoogle Scholar
  5. 5.
    Rosansky SJ, Eggers P, Jackson K, Glassock R, Clark WF. Early start of hemodialysis may be harmful. Arch Intern Med. 2011;171:396–403.PubMedGoogle Scholar
  6. 6.
    Wright S, Klausner D, Baird B, Williams ME, Steinman T, Tang H, Ragasa R, Goldfarb-Rumyantzev AS. Timing of dialysis initiation and survival in ESRD. Clin J Am Soc Nephrol. 2010;5:1828–35.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Hwang SJ, Yang WC, Lin MY, Mau LW, Chen HC, Taiwan Society of Nephrology. Impact of the clinical conditions at dialysis initiation on mortality in incident haemodialysis patients: a national cohort study in Taiwan. Nephrol Dial Transplant. 2010;25:2616–24.CrossRefPubMedGoogle Scholar
  8. 8.
    Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Johnson DW, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA, IDEAL Study. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010;363:609–19.CrossRefPubMedGoogle Scholar
  9. 9.
    Wong MG, Pollock CA, Cooper BA, Branley P, Collins JF, Craig JC, Kesselhut J, Luxton G, Pilmore A, Harris DC, Johnson DW. Association between GFR estimated by multiple methods at dialysis commencement and patient survival. Clin J Am Soc Nephrol. 2014;9:135–42.CrossRefPubMedGoogle Scholar
  10. 10.
    Dart AB, Zappitelli M, Sood MM, Alexander RT, Arora S, Erickson RL, Kroeker K, Soo A, Manns BJ, Samuel SM. Variation in estimated glomerular filtration rate at dialysis initiation in children. Pediatr Nephrol. 2017;32:331–40.CrossRefPubMedGoogle Scholar
  11. 11.
    van Stralen KJ, Tizard EJ, Jager KJ, Schaefer F, Vondrak K, Groothoff JW, Podracká L, Holmberg C, Jankauskiené A, Lewis MA, van Damme-Lombaerts R, Mota C, Niaudet P, Novljan G, Peco-Antic A, Sahpazova E, Toots U, Verrina E. Determinants of eGFR at start of renal replacement therapy in pediatric patients. Nephrol Dial Transplant. 2010;25:3325–32.CrossRefPubMedGoogle Scholar
  12. 12.
    Seikaly MG, Salhab N, Browne R. Patterns and time of initiation of dialysis in US children. Pediatr Nephrol. 2005;20:982–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Atkinson MA, Oberai PC, Neu AM, Fivush BA, Parekh RS. Predictors and consequences of higher estimated glomerular filtration rate at dialysis initiation. Pediatr Nephrol. 2010;25:1153–61.CrossRefPubMedGoogle Scholar
  14. 14.
    Bakkaloğlu SA, Kandur Y, Serdaroğlu E, Noyan A, Bayazıt AK, Sever L, Özlü SG, Özçelik G, Dursun İ, Alparslan C. Effect of the timing of dialysis initiation on left ventricular hypertrophy and ınflammation in pediatric patients. Pediatr Nephrol. 2017;32:1595–602.CrossRefPubMedGoogle Scholar
  15. 15.
    Watson AR, Gartland C, European Pediatric Peritoneal Dialysis Working Group. Guidelines by an Ad Hoc European Committee for Elective Chronic Peritoneal Dialysis in Pediatric Patients. Perit Dial Int. 2001;21:240–4.PubMedGoogle Scholar
  16. 16.
    National Kidney Foundation. NKF KDOQI guidelines. Clinical practice guidelines and clinical practice recommendations 2006 updates. 2006. Accessed 18 Aug 2019.
  17. 17.
    Hattori M, Sako M, Kaneko T, Ashida A, Matsunaga A, Igarashi T, Itami N, Ohta T, Gotoh Y, Satomura K, Honda M, Igarashi T. End-stage renal disease in Japanese children: a nationwide survey during 2006–2011. Clin Exp Nephrol. 2015;19:933–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Schwartz GJ, Haycock GB, Edelmann CM Jr, Spitzer A. A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. Pediatrics. 1976;58:259–63.PubMedGoogle Scholar
  19. 19.
    Schwartz GJ, Brion LP, Spitzer A. The use of plasma creatinine concentration for estimating glomerular filtration rate in infants, children, and adolescents. Pediatr Clin N Am. 1987;34:571–90.CrossRefGoogle Scholar
  20. 20.
    Traynor JP, Simpson K, Geddes CC, Deighan CJ, Fox JG. Early initiation of dialysis fails to prolong survival in patients with end-stage renal failure. J Am Soc Nephrol. 2002;13:2125–32.CrossRefPubMedGoogle Scholar
  21. 21.
    Sawhney S, Djurdjev O, Simpson K, Macleod A, Levin A. Survival and dialysis initiation: comparing British Columbia and Scotland registries. Nephrol Dial Transplant. 2009;24:3186–92.CrossRefPubMedGoogle Scholar
  22. 22.
    Evans M, Tettamanti G, Nyrén O, Bellocco R, Fored CM, Elinder CG. No survival benefit from early-start dialysis in a population-based, inception cohort study of Swedish patients with chronic kidney disease. J Intern Med. 2011;269:289–98.CrossRefPubMedGoogle Scholar
  23. 23.
    Scialla JJ, Liu J, Crews DC, Guo H, Bandeen-Roche K, Ephraim PL, Tangri N, Sozio SM, Shafi T, Miskulin DC, Michels WM, Jaar BG, Wu AW, Powe NR, Boulware LE, DEcIDE Network Patient Outcomes in End Stage Renal Disease Study Investigators. An instrumental variable approach finds no associated harm or benefit with early dialysis initiation in the United States. Kidney Int. 2014;86:798–809.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Nesrallah GE, Mustafa RA, Clark WF, Bass A, Barnieh L, Hemmelgarn BR, Klarenbach S, Quinn RR, Hiremath S, Ravani P, Sood MM, Moist LM, Canadian Society of Nephrology. Canadian Society of Nephrology. clinical practice guideline for timing the initiation of chronic dialysis. CMAJ. 2014;2014(186):112–7.CrossRefGoogle Scholar
  25. 25.
    Fischbach M, Dheu C, Seuge L, Orfanos N. Hemodialysis and nutritional status in children: malnutrition and cachexia. J Ren Nutr. 2009;19:91–4.CrossRefPubMedGoogle Scholar
  26. 26.
    Warady BA, Neu AM, Schaefer F. Optimal care of the infant, child, and adolescent on dialysis: 2014 update. Am J Kidney Dis. 2014;64:128–42.CrossRefPubMedGoogle Scholar
  27. 27.
    Manns B, Barrett B, Evans M, Garg A, Hemmelgarn B, Kappel J, Klarenbach S, Madore F, Parfrey P, Samuel S, Soroka S, Suri R, Tonelli M, Wald R, Walsh M, Zappitelli M, CAnadian KidNey KNowledge TraNslation, and GEneration NeTwork. Establishing a national knowledge translation and generation network in kidney disease: the CAnadian KidNey KNowledge TraNslation and GEneration NeTwork. Can J Kidney Health Dis. 2014;1:2.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Tromp WF, Schoenmaker NJ, van der Lee JH, Adams B, Bouts AH, Collard L, Cransberg K, Van Damme-Lombaerts R, Godefroid N, van Hoeck K, Koster-Kamphuis L, Lilien MR, Raes A, Offringa M, Groothoff JW. Important differences in management policies for children with end-stage renal disease in the Netherlands and Belgium–report from the RICH-Q study. Nephrol Dial Transplant. 2012;27:1984–92.CrossRefPubMedGoogle Scholar
  29. 29.
    Hattori M, Mieno M, Aikawa A, Ohsima S, Shishido S, Takahashi K, Hasegawa A, Yoshimura N. Japanese Pediatric Kidney Transplant Study Group, on behalf of the Japanese Society for Transplantation and the Japanese Society for Clinical Renal Transplantation. Ishoku. 2016;51:452–63 (In Japanese).Google Scholar
  30. 30.
    Kennedy SE, Mackie FE, Rosenberg AR, McDonald SP. Waiting time and outcome of kidney transplantation in adolescents. Transplantation. 2006;82:1046–50.CrossRefPubMedGoogle Scholar
  31. 31.
    Watson AR, Hayes WN, Vondrak K, Ariceta G, Schmitt CP, Ekim M, Fischbach M, Edefonti A, Shroff R, Holta T, Zurowska A, Klaus G, Bakkaloglu S, Stefanidis CJ, Van de Walle J, European Paediatric Dialysis Working Group. Factors influencing choice of renal replacement therapy in European paediatric nephrology units. Pediatr Nephrol. 2013;28:2361–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Warady BA, Chadha V. Chronic kidney disease in children: the global perspective. Pediatr Nephrol. 2007;12:1999–2009.CrossRefGoogle Scholar
  33. 33.
    Harambat J, Ekulu PM. Inequalities in access to pediatric ESRD care: a global health challenge. Pediatr Nephrol. 2016;31:353–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Schaefer F, Borzych-Duzalka D, Azocar M, Munarriz RL, Sever L, Aksu N, Barbosa LS, Galan YS, Xu H, Coccia PA, Szabo A, Wong W, Salim R, Vidal E, Pottoore S, Warady BA, IPPN investigators. Impact of global economic disparities on practices and outcomes of chronic peritoneal dialysis in children: insights from the International Pediatric Peritoneal Dialysis Network Registry. Perit Dial Int. 2012;32:399–409.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Japanese Society of Nephrology 2019

Authors and Affiliations

  • Daishi Hirano
    • 1
    Email author
  • Eisuke Inoue
    • 2
  • Mayumi Sako
    • 3
  • Akira Ashida
    • 4
  • Masataka Honda
    • 5
  • Shori Takahashi
    • 6
  • Kazumoto Iijima
    • 7
  • Motoshi Hattori
    • 8
  • the Japanese Society of Pediatric Nephrology
  1. 1.Department of PediatricsThe Jikei University School of MedicineTokyoJapan
  2. 2.Medical InformaticsSt. Marianna University School of MedicineKawasakiJapan
  3. 3.Division for Clinical Trials, Department of Clinical Research Promotion, Clinical Research CenterNational Center for Child Health and DevelopmentTokyoJapan
  4. 4.Department of PediatricsOsaka Medical CollegeOsakaJapan
  5. 5.Department of NephrologyTokyo Metropolitan Children’s Medical CenterTokyoJapan
  6. 6.Department of Pediatrics and Child HealthNihon University School of MedicineTokyoJapan
  7. 7.Department of PediatricsKobe University Graduate School of MedicineKobeJapan
  8. 8.Department of Pediatric Nephrology, School of MedicineTokyo Women’s Medical UniversityTokyoJapan

Personalised recommendations