A comparative analysis of the starting modality of kidney replacement therapy amongst UK children and young adults and the association with all-cause mortality

BACKGROUND: Few studies have compared the long-term survival of children by their first modality of kidney replacement therapy (KRT). This study aimed to compare the mortality outcomes of children starting dialysis as their first KRT modality to those who received a pre-emptive kidney transplant (PKT). METHODS: Historical cohort analyses of UK children starting KRT between 1997-2020 were undertaken, using data from the UK Renal Registry linked to Hospital Episodes Statistics. Crude and multivariable Cox proportional hazards regression analyses were performed to compare mortality amongst children with complete records who received (i) haemodialysis (HD) and (ii) peritoneal dialysis (PD) for ≥ 3 months with those receiving PKT, stratified by the time-period of KRT initiation. Mortality estimates were adjusted for sociodemographic, time-period, primary kidney disease and comorbidity-related covariates. RESULTS: 242 deaths were recorded amongst 2440 children included in complete-case analyses. Adjusted mortality amongst children was highest (HR 3.70, 95% CI: 1.41-9.74), when compared to PKT) for those starting HD in 1997-2008. Evidence for a difference in mortality amongst children receiving HD (compared to PKT) was weak in later time-periods (2009-14, 2015-20). Mortality did not differ amongst children receiving PD first compared to those who had been pre-emptively transplanted. CONCLUSIONS: Whilst adjusted mortality was highest for children starting HD at KRT onset in the earliest time-period, there were no differences in long-term survival amongst those starting dialysis (HD or PD) to those pre-emptively transplanted in more recent years.