Background: In the family-centered care model used in the pediatric setting, the decision to initiate renal replacement therapy (RRT) and the modality of choice are major decisions made by the health care team and family. Medical indications for RRT are widely described in literature; however, this primarily adult data is not easily transferrable to pediatric populations. Pediatric recommendations include individualized interpretation of clinical symptoms as part of the decision-making process; however, pediatric clinical factors have not been studied in detail. 

Objective: This study aims to describe the factors influencing (1) the timing of initiation of RRT and (2) the choice of modality in children with ESRD. We have organized the factors into four categories: medical indicators, quality of life factors, contextual or social factors, and patient/family preference. 

Design/Methods: We conducted a retrospective chart review of all children, up to 19 year of age, who progressed to ESRD and underwent RRT including hemodialysis (HD), peritoneal dialysis (PD), and preemptive renal transplant (PT) between 2004 and 2014, in a single pediatric renal tertiary care center in Canada. 

Results: Between 2004 and 2014, 92 patients progressed to ESRD, with a mean age of 11.9 years at initiation of RRT. Renal diagnoses include renal dysplasias (32%), glomerulonephritis (27%), cystic disease (14%), and other (27%). RRT was started urgently for 26 patients and electively for 66 patients. Overall, 43 patients started PD, 23 started HD, and 26 had a PT. The mean eGFR for urgent and elective initiation was 9.7 and 10.8 mL/min/1.73 m2 respectively. The mean eGFR at initiation of RRT for PD, HD, and PT was 9.5, 10.5, and 12.0 mL/min/1.73 m2 respectively. Medical factors were of primary importance for initiation of dialysis in urgent start patients. In elective RRT, medical and quality of life factors influence the timing of RRT initiation. Level and rapidity of decline in renal function, fatigue, nutritional status, and concentration were most important. Choice of modality was influenced by medical factors such as patient size or rate of decline of renal function, but also by the patient/family’s preference, and location of residence. 

Conclusion(s): The timing of initiation of RRT depends primarily on medical and quality of life factors, whereas the choice of modality depends on medical and social factors, and patient/family preference.

Factors influencing the timing of initiation of renal replacement therapy and choice of modality in children with end-stage renal disease&#8232