BACKGROUND: There is no consensus regarding the timing of dialysis therapy initiation for end-stage kidney disease (ESKD) in children. As studies investigating the association between timing of dialysis initiation and clinical outcomes are lacking, we aimed to study this relationship in a cohort of European children who started maintenance dialysis treatment. METHODS: We used data on 2963 children from 21 different countries included in the European Society of Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry who started renal replacement therapy before 18 years of age between 2000 and 2014. We compared two groups according to the estimated glomerular filtration rate (eGFR) at start: eGFR ≥8 mL/min/1.73 m2 (early starters) and eGFR <8 mL/min/1.73 m2 (late starters). The primary outcomes were patient survival and access to transplantation. Secondary outcomes were growth and cardiovascular risk factors. Sensitivity analyses were performed to account for selection- and lead time-bias. RESULTS: The median eGFR at the start of dialysis was 6.1 for late versus 10.5 mL/min/1.73 m2 for early starters. Early starters were older [median: 11.0, interquartile range (IQR): 5.7-14.5 versus 9.4, IQR: 2.6-14.1 years]. There were no differences observed between the two groups in mortality and access to transplantation at 1, 2 and 5 years of follow-up. One-year evolution of height standard deviation scores was similar among the groups, whereas hypertension was more prevalent among late initiators. Sensitivity analyses resulted in similar findings. CONCLUSIONS: We found no evidence for a clinically relevant benefit of early start of dialysis in children with ESKD. Presence of cardiovascular risk factors, such as high blood pressure, should be taken into account when deciding to initiate or postpone dialysis in children with ESKD, as this affects the survival.

1st Pediatric Department Aristotle University of Thessaloniki Thessaloniki Greece

Amsterdam UMC University of Amsterdam Department of Paediatric Nephrology Emma Children's Academic Medical Center Amsterdam The Netherlands

Children's Hospital University of Helsinki Helsinki Finland

Children's Medical Center Landspitali The National University Hospital of Iceland and Faculty of Medicine School of Health Sciences University of Iceland Reykjavik Iceland

Department of Clinical Sciences Pediatric Nephrology Skåne University Hospital Lund University Lund Sweden

Department of Kidney Transplantation Russian Children's Clinical Hospital Moscow Russia

Department of Medicine Zealand University Hospital Roskilde Denmark

Department of Paediatric Nephrology Evelina London Children's Hospital Guy's and St Thomas' NHS Foundation Trust London UK

Department of Paediatric Nephrology Great Ormond Street Hospital for Children NHS Foundation Trust London UK

Department of Pediatric Nephrology Gazi University Ankara Turkey

Department of Pediatric Nephrology Mitera Children's Hospital Athens Greece

Department of Pediatric Nephrology National Academy of Medical Sciences of Ukraine Kiev Ukraine

Department of Pediatric Nephrology Radboud University Medical Center Radboud Institute for Molecular Life Sciences Amalia Children's Hospital Nijmegen The Netherlands

Department of Pediatric Nephrology School of Medicine Cukurova University Adana Turkey

Department of Pediatric Nephrology University Children's Hospital Vienna Austria

Department of Pediatric Nephrology University Hospital Vall d'Hebron Barcelona Spain

Department of Pediatric Nephrology University Medical Center Ljubjana Faculty of Medicine University of Ljubjana Slovenia

Department of Pediatrics Belarusian State Medical University Minsk Belarus

Department of Pediatrics Bordeaux University Hospital Bordeaux France

Department of Pediatrics Nephrology and Hypertension Medical University of Gdansk Gdansk Poland

Department of Pediatrics University Hospital Motol Prague Czech Republic

ESPN ERA EDTA Registry Amsterdam UMC University of Amsterdam Department of Medical Informatics Amsterdam Public Health research institute Amsterdam The Netherlands

Gottsegen György Hungarian Institute of Cardiology Budapest Hungary

Nephrology Department University Children's Hospital Belgrade Serbia

Paediatric Nephrology Unit Hospital de Dona Estefânia Lisbon Portugal

Pediatric Department Faculty of Medicine Safarik University Kosice Slovakia

Pediatric Nephrology Childreńs and Adolescents` Hospital University Hospital of Cologne Cologne Germany

Pediatric Nephrology Department Nancy University Hospital Nancy France

Pediatric Nephrology Dialysis and Transplantation Unit Department of Woman's and Child's Health University Hospital of Padua Padua Italy

Pediatric Nephrology University Children's Hospital Zurich Zurich Switzerland

University Pediatric Clinic Skopje FYR of Macedonia

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