Hemodialysis (HD) dose and ultrafiltration rate are associated with survival in pediatric and adolescent patients on chronic HD—a large observational study with follow-up to young adult age

Abstract

Background Hemodialysis (HD) dose targets and ultrafiltration rate (UFR) limits for pediatric patients on chronic HD are not known and are derived from adults (spKt/V>1.4 and <13 ml/kg/h). We aimed to characterize how delivered HD dose and UFR are associated with survival in a large cohort of patients who started HD in childhood. Methods Retrospective analysis on a cohort of patients <30 years, on chronic HD since childhood (<19 years), having received thrice-weekly HD 2004–2016 in outpatient DaVita centers. Outcome: Survival while remaining on HD. Predictors: (I) primary analysis: mean delivered dialysis dose stratified as spKt/V ≤1.4/1.4–1.6/>1.6 (Kaplan–Meier analysis), (II) secondary analyses: UFR and alternative dialysis adequacy measures [eKt/V, body-surface normalized Kt/BSA] on continuous scale (Weibull regression model). Results A total of 1780 patients were included (age at the start of HD: 0–12y: n=321, >12–18y: n=1459; median spKt/V=1.55, eKt/V=1.31, Kt/BSA=31.2 L/m2, UFR=10.6 mL/kg/h). (I) spKt/V<1.4 was associated with lower survival compared to spKt/V>1.4–1.6 (P<0.001, log-rank test), and spKt/V>1.6 (P<0.001), with 10-year survival of 69.3% (59.4–80.9%) versus 83.0% (76.8–89.8%) and 84.0% (79.6–88.5%), respectively. (II) Kt/BSA was a better predictor of survival than spKt/V or eKt/V. UFR was additionally associated with survival (P<0.001), with increased mortality <10/>18 mL/kg/h. Associations did not alter significantly following adjustment for demographic characteristics (age, etiology of kidney disease, and ethnicity). Conclusions Our results suggest usefulness of targeting Kt/BSA>30 L/m2 for best long-term outcomes, corresponding to spKt/V>1.4 (>12 years) and >1.6 (<12 years). In contrast to adults, higher UFR of 10–18 ml/kg/h was not associated with greater mortality in this population.

A Deep Variational Approach to Clustering Survival Data

“…Additionally, dialysis dose in terms of spKt/V and fluid balance in terms of ultrafiltration (UF) rate prove to be crucial in classifying the data into high-risk (cluster 1) and low-risk (cluster 2) groups. By analysing the cluster-wise distributions, we notice that the high-risk cluster is characterised by lower values of albumin, dialysis dose, and ultrafiltration, in agreement with previous studies (Gotta et al, 2020(Gotta et al, , 2021Movilli et al, 2007).…”

“…We now investigate qualitatively the clustering obtained by VaDeSC when applied to the Hemodialysis dataset. The true structure of this data is unknown, however several studies have suggested a stratification of patients according to age and dialysis doses (Gotta et al, 2021). We compute the optimal number of clusters using grid-search by measuring the timeto-event prediction performance.…”

“…Hemodialysis As a fourth clinical dataset, we include an observational cohort of patients from the DaVita Kidney Care (DaVita Inc., Denver, CO, USA) dialysis centres (Gotta et al, 2018(Gotta et al, , 2019a(Gotta et al, ,b, 2020(Gotta et al, , 2021. The cohort is composed of patients who started chronic hemodialysis (HD) in childhood and have then received thrice-weekly HD between 05/2004 and 03/2016, with a maximum follow-up until < 30 years of age.…”

“…The scientific use of the deidentified standardised electronic medical records was approved by DaVita (DaVita Clinical Research®, Minneapolis, MN); IRB approval was not required since retrospective analysis was performed on the deidentified dataset. A complete description of the variables and measurements used is provided by Gotta et al (2021) in the Methods section.…”

Myopericarditis Associated with COVID-19 in a Pediatric Patient with Kidney Failure Receiving Hemodialysis

“…Echocardiography revealed moderate/severe systolic dysfunction of the left ventricle, impaired diastolic dysfunction (pseudonormal transmitral pattern), low-normal right ventricle systolic function, moderate pulmonary systolic pressure, and a large amount of pericardial fluid. The clinical picture maintained despite supplemental daily hemodialysis sessions performed with maximal ultrafiltration (13 mL/kg/h) [16,17]. She was transferred to a COVID-19 designated hospital for isolation and specific treatment.…”