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American Journal of Kidney Diseases

Estimating Time to ESRD in Children With CKD

Published:April 10, 2018DOI:https://doi.org/10.1053/j.ajkd.2017.12.011

      Rationale & Objective

      The KDIGO (Kidney Disease: Improving Global Outcomes) guideline for chronic kidney disease (CKD) presented an international classification system that ranks patients’ risk for CKD progression. Few data for children informed guideline development.

      Study Design

      Observational cohort study.

      Settings & Participants

      Children aged 1 to 18 years enrolled in the North American Chronic Kidney Disease in Children (CKiD) cohort study and the European Effect of Strict Blood Pressure Control and ACE Inhibition on the Progression of CRF in Pediatric Patients (ESCAPE) trial.

      Predictor

      Level of estimated glomerular filtration rate (eGFR) and proteinuria (urine protein-creatinine ratio [UPCR]) at study entry.

      Outcome

      A composite event of renal replacement therapy, 50% reduction in eGFR, or eGFR < 15 mL/min/1.73 m2. eGFR was estimated using the CKiD-derived “bedside” equation.

      Analytical Approach

      Accelerated failure time models of the composite outcome using a conventional generalized gamma distribution. Likelihood ratio statistics of nested models were used to amalgamate levels of similar risk.

      Results

      Among 1,232 children, median age was 12 (IQR, 8-15) years, median eGFR was 47 (IQR, 33-62) mL/min/1.73 m2, 60% were males, and 13% had UPCRs > 2.0 mg/mg at study entry. 6 ordered stages with varying combinations of eGFR categories (60-89, 45-59, 30-44, and 15-29 mL/min/1.73 m2) and UPCR categories (<0.5, 0.5-2.0, and >2.0 mg/mg) described the risk continuum. Median times to event ranged from longer than 10 years for eGFRs of 45 to 90 mL/min/1.73 m2 and UPCRs < 0.5 mg/mg to 0.8 years for eGFRs of 15 to 30 mL/min/1.73 m2 and UPCRs > 2 mg/mg. Children with glomerular disease were estimated to have a 43% shorter time to event than children with nonglomerular disease. Cross-validation demonstrated risk patterns that were consistent across the 10 subsample validation models.

      Limitations

      Observational study, used cross-validation rather than external validation.

      Conclusions

      CKD staged by level of eGFR and proteinuria characterizes the timeline of progression and can guide management strategies in children.

      Index Words

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      Linked Article

      • Erratum Regarding “Estimating Time to ESRD in Children With CKD” (Am J Kidney Dis. 2018;71(6):783-792)
        American Journal of Kidney DiseasesVol. 74Issue 1
        • Preview
          In the Original Investigation entitled “Estimating Time to ESRD in Children With CKD” that appeared in the June 2018 issue of AJKD (Furth et al, volume 71, issue 6, pages 783-792), there was an error in the description of the analysis shown in Figure S2. On page 787, the last sentence of the Results, “Figure S2 shows standardized times, wi, derived from the cross-validation superimposed on the survival function of the standard lognormal LN[0,1],” should instead read “Figure S2 shows standardized times, wi, derived from the cross-validation superimposed on the survival function e−t of the standard exponential,” as was specified in the Methods.
        • Full-Text
        • PDF
      • More Realistic Estimation of Time to ESRD in Children
        American Journal of Kidney DiseasesVol. 71Issue 6
        • Preview
          It is the job of the pediatric nephrologist to slow the progression of chronic kidney disease (CKD) and provide realistic estimates for the time to end-stage kidney disease. On average, estimated glomerular filtration rate (eGFR) decreases by ∼4.0 mL/min/1.73 m2 per year in children with CKD.1 This can be improved with a programmatic multidisciplinary approach, potentially to as little as 0.5 mL/min/1.73 m2 per year.1,2 Based on the very large Annual Health Exam Participants in Japan study, the attrition of eGFR is 0.36 mL/min/1.73 m2 per year in healthy adult individuals and presumably the same in children.
        • Full-Text
        • PDF