Survival Analysis of Pediatric Dialysis Patients in Taiwan
Hsin-Hung Lin1,5, Ching-Wei Tsai2, Pao-Hsuan Lin3, Kuang-Fu Cheng3,
Hong-Dar Wu3, I-Kwan Wang1,5, Ching-Yuang Lin4,5, Walter Chen4,
Chiu-Ching Huang1,5
1The
Kidney Institute and Division of Nephrology, China Medical University
Hospital; 2Division of Nephrology, National Taiwan University Hospital,
3Biostatistic
Center, China Medical University; 4Children Medical Center,
China Medical University Hospital, 5Graduate Institute of Clinical Medical
Science, College of medicine, China Medical University
Correspondence: Chiu-Ching Huang, M.D., The Kidney Institute and Division
of Nephrology , China Medical University and Hospital, 2
Yu-Der Road, Taichung, Taiwan
Telephone: +886-4-2205-2121 Ext.2902
Fax: +886-4-2207-6863
E-mail: cch@mail.cmuh.org.tw
Key Words: Pediatric ESRD patient survival, stroke, Taiwan
Running title: Survival of pediatric dialysis patients
1
ABSTRACT
The long-term survival of Taiwanese children with end-stage renal disease
(ESRD) has not been reported before. This study aimed to determine the
long-term survival, mortality hazards, and causes of death in pediatric patients
receiving dialysis. Pediatric patients (age 19 and younger) with incident ESRD
who were reported to the Taiwan Renal Registry from 1995 to 2004 were
included. A total of 319 incident hemodialysis (HD) and 156 peritoneal dialysis
(PD) patients formed the database. The annual pediatric ESRD incidence rate
was 8.12 per million of age-related populations. The survival analysis showed
no significant difference between HD and PD patients during the follow-up
period. The adjusted survival rates revealed that older patients had better
survival than younger patients. The death rate for pediatric ESRD patients was
24.66 per 1000 dialysis patient-years. The three major causes of death were
infection, cardiovascular disease, and cerebrovascular disease. Compared
with adult ESRD patients, pediatric patients were more susceptible to
cerebrovascular deaths (17.8% vs. 7.8%, P =0.021). Hemorrhagic stroke was
the main type of cerebrovascular death.
2
INTRODUCTION
In 2000, the prevalence and incidence of children on renal replacement
therapy (RRT) in the European Renal Association - European Dialysis and
Transplant Association (ERA-EDTA) Registry was 62.1 per million and 9.9 per
million, respectively, of age-related populations [1]. The latest data of the 2007
report [2] from the European Society for Paediatric Nephrology/European
Renal
Association-European
Dialysis
and
Transplant
Association
(ESPN/ERA-EDTA) revealed lower prevalence (33.6 per million) and incidence
(6.5 per million) of age-related populations. The Australia/New Zealand
(ANZDATA) Registry reported end-stage renal disease (ESRD) occurring in
about 5 to 10 children per million of age-related populations each year [3].
Nonetheless, long-term survival of ESRD children has improved in the last 20
years [4] as shown in the survival data reported from various study groups,
including the ERA-EDTA Registry [1], the Australia/New Zealand Registry [3],
the United States Renal Data System (USRDS) [5], the Dutch cohort study [6],
the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS)
[7], the UK Renal Registry [8], and the Japanese Registry [9]. However, data
has not been reported for the Chinese ethnic children and adolescents. Since
96% of children and adolescents are Chinese descendants in Taiwan, this
3
study may represent the first report of survival analysis of Chinese pediatric
dialysis population.
Mortality rates among children on chronic dialysis therapy are 150 times
greater than those in the general pediatric population [5]. Most studies enroll
both patients on dialysis and those who received renal transplantation.
However, the survival and causes of death are quite different between these
two groups of patients [3, 10, 11]. Moreover, up to present, there are no data
published comparing the survival of Chinese ethnic pediatric patients who
received either peritoneal dialysis (PD) or hemodialysis (HD).
According to the information contained in the USRDS 2006 Report,
Taiwanese patients of age older than 45 years have the highest ESRD
incidence and prevalence rates in the world [5]. However, this is not the case
for pediatric group. Renal replacement therapy has been used for children with
ESRD in Taiwan since 1990. In 1995, National Health Insurance of Taiwan was
implemented. All patients with end stage renal disease are eligible for dialysis
therapy under the financial coverage of Catastrophic Program. The Taiwan
Renal Registry has collected data on all of these patients since 1995 [12]. This
study examined the long-term survival and outcome in children and
4
adolescents treated for ESRD in Taiwan by comparing the PD and HD groups
from the registry data.
5
METHODS
Study population, data collection, and definitions
The long-term survival of all children and adolescents in Taiwan aged <20
years for whom dialysis therapy was started from 1995 to 2004, was examined
using data from the Taiwan Renal Registry. The Registry collected information
every year from all dialysis units of all patients receiving dialysis with the
diagnosis of end stage renal disease (ESRD). The registry began in 1987 with
funding from Department of Health, Taiwan. The registry is a nationwide,
non-government system. It is supervised by Taiwan Society of Nephrology
(TSN). The coverage is as high as 95% of all dialysis patients in Taiwan. Data
collections are on voluntary basis. However, dialysis centers not reporting their
data were inquired repeatedly by TSN personnel. Finally, about 95% of all
centers reported their data. These data included a patient identifier, date of
birth, gender, primary renal disease, year and age at start of dialysis, history of
dialysis modalities, total duration of peritoneal dialysis (PD) or hemodialysis
(HD), age at death, modality of dialysis at time of death, co-morbidities at start
of dialysis, and date and cause of death. There were nine types of
co-morbidities, including diabetes mellitus (defined as oral anti-hyperglycemic
agents or insulin ever used), hypertension (defined as highblood pressure
6
required anti-hypertensive medication ever used), congestive heart failure
(defined as New York Heart Association Classification for congestive heart
failure functional class III and IV), ischemic heart disease (defined by typical
presentation or cardiac catheterization), cerebrovascular disease (ischemic or
hemorrhagic stroke, defined by clinical presentation and computer tomography
(CT) or magnetic resonance imaging (MRI) study), chronic liver disease or liver
cirrhosis (defined by Child-Turcotte-Pugh criteria and abdominal echogram),
malignancy, tuberculosis (defined as ever anti-TB medicine used) and others.
There were seven causes of death with six major categories and another
category as unknown cause. They included cardiovascular (pericarditis,
pulmonary edema, acute myocardial infarction, heart failure, arrhythmia and
sudden death related or unrelated to hyperkalemia), cerebrovascular
(ischemic or hemorrhagic stroke by clinical presentation and CT or MRI study),
infection, gastrointestinal or hepatic disorder (gastrointestinal bleeding,
pancreatitis and hepatic failure etc.), malignancy, others (including lung
disease, massive bleeding excluding gastrointestinal bleeding, self-withdrawal
from dialysis, suicide and accidents) and unknown cause. These data by no
means complete in each individual patient except age, gender, modality of
dialysis and date of dialysis commencement.
7
Each patient of the study was followed until death, receipt of a renal
transplant, or until the end of the study period (December 31, 2006). Only
patients who survived their first 90 days on dialysis were included. For patients
with one switch of dialysis modality (HD to PD, or PD to HD), they were
classified into the previous dialysis modality if the death event occurred when
the transfer time was shorter than 3 months after switch. The patients with
multiple switches between PD and HD were excluded. The HD and PD
patients formed the database for dialysis survival analysis. Dialysis patients
who received renal transplants during the study period were also included up
to the time point of transplantation for survival analysis
Statistical analysis
Statistical analyses were performed using the SAS/STAT software,
Version 9.1.3 (SAS Institute Inc., Cary, NC, USA). The chi-square test was
used to test differences in the characteristics of HD and PD patients. Stratified
analysis was used throughout the study when HD/PD treatment was used as a
stratification variable. Survival curves were displayed and compared by
Kaplan-Meier estimates and Wilcoxon tests. The multivariate Cox proportional
hazards model was used to offer relative risk (RR) for death estimate along
with 95% confidence intervals.
8
After stratification by dialysis modality (HD or PD), multivariate Cox
proportional-hazards model was constructed with age, sex, and co-morbidity
as predictive variables. Inclusion in the final model was determined by a
backward stepwise process using the likelihood ratio to evaluate the effect of
omitting variables. Age was analyzed by five-year categories. We performed
subgroup analyses by stratifying patients according to gender and age
differences.
Data on the proportions of causes of death among adult ESRD patients
between 1995 and 2004 in the Taiwan Renal Registry database were used for
comparison with the pediatric cohort data. Statistical tests were two-tailed and
differences were considered to be statistically significant when the P-value was
<0.05.
9
RESULTS
Demographic characteristics
Between 1995 and 2004, 528 children and adolescents aged <20 years
started RRT in Taiwan. The average annual pediatric ESRD incidence rate was
8.12 per million of age-related populations (1995-2004). Totally 40 patients
ever switched the dialysis modality, including single switch from PD to HD
(n=27, because of severe peritonitis, ultrafiltration failure or family burn-out),
single switch from HD to PD (n=10, because of intra-dialytic hypotension or
vascular access problems), and multiple switches between PD and HD (n=3).
Fifty patients who survived less than 90 days after the start of dialysis and
three patients with multiple dialysis modality switches were excluded. Finally, a
total of 475 patients (319 HD and 156 PD) formed the database for dialysis
survival analysis. There were more males (58.3%) than females (41.7%) in
these
dialysis
patients
(n=475),
101
patients
who
received
renal
transplantation (55 HD and 46 PD patients) during the follow-up period were as
the transplantation group. The median age of transplanted patients was 20.00
years for HD patients and 17.50 years for PD patients. The median waiting
time for transplantation was 2.01 years for HD patients and 3.02 years for PD
patients. The median follow-up time was 6.32 years (6.85 years for HD and
10
5.44 years for PD patients). Their demographic and clinical characteristics
were summarized in Table 1.
Dialysis modality differed significantly depending on age (P<0.001). Near
fifty percent (9/19) of patients <5 years of age received HD, while up to 79.6%
(214/283) of patients aged 15 to 19 years received HD. 18.7% (89/475) of
patients had one co-morbidity and 6.5% (39/475) of patients had more than
two co-morbidities (Table 1). At the initiation of RRT, the incidence of
hypertension was 14.42% (46/319) in HD patients and 16.67% (26/156) in PD
patients. The follow up status of hypertension after dialysis was not required to
report.
Mode of treatment
The median survival time of patients who died during follow-up period was
2.78 years (HD 2.55 years, PD 3.59 years). Unadjusted comparisons of
survival status (P=0.105) and survival years (P=0.611) showed no differences
between HD and PD treatments. No significant difference was observed
between the two groups in terms of gender (P=0.693) and number of
co-morbidities (P=0.852) (Table 1). The long-term survival of RRT patients is
shown in Figure 1. The overall 1-, 3-, 5-,7- and 10-year survival rates for PD
patients were 98.1%, 91.9%, 88.0%, 77.7% and 68.4% respectively, and were
11
96.9%, 89.9%, 87.3%, 84.3%,78.5% for HD patients. The PD and HD
treatment groups had multiple crossings in survivals during the follow-up, but
the difference was hot significant. (P=0.4878). The adjusted survival rates from
multivariable Cox proportional-hazard analysis, which was stratified by age
groups, are shown in Figure 2. The survival rates of the four age groups
showed a trend of favorable outcome with increasing age. Older ESRD
patients had better survival than younger ESRD patients (P<0.0001).
Specifically, the median two groups (5-9 and 10-14 years) showed no
significant difference (P=0.383), while other paired groups showed significant
differences (Figure 2). Stratifying by treatment modality (HD/PD) and by using
the Cox proportional hazards model, only age was significant in predicting
survival (Table 2). Using “15-19 years” as a reference group, the relative risk
(RR) of the youngest group (0-4 years) was 6.60 (95% CI: 2.50-17.38) for HD,
and 5.03 (95% CI: 1.23-20.67) for PD. Co-morbidity affected mortality in HD
children (HR: 2.02, 95% CI: 1.12-3.64), but did not affect PD children (HR: 0.62,
95% CI: 0.24-1.62).
Cause of death
Of the 475 patients in the cohort, 77 died. The death rate for pediatric
dialysis patients was 24.66 per 1000 patient-years. The causes of death are
12
listed in Table 3. The three major causes of death were infection,
cardiovascular disease, and cerebrovascular disease. The causes of death of
PD patients were not different from HD patients: cardiovascular (12.0% vs. HD
13.5%, P=1.000), cerebrovascular disease (16.0% vs. HD 7.7%, P=0.426) and
infection (16.0% vs. HD 13.5%, P=0.741). No death was caused by
malignancy. It is noteworthy that major causes of death of these patients were
slightly different during follow up period. For initial 5 years, cardiovascular
(11.11%), infection (11.11%) and cerebrovascular (14.81%) diseases were
major causes of death. However, after 5 years of dialysis, cardiovascular
disease (17.39%) and infection (21.74%) remained major causes of death, but
not the cerebrovascular disease (0%). In another words, the lethal
cerebrovascular events all occurred during the initial 5 years of dialysis.
Table 4 compares the proportions of causes of death between this study’s
pediatric cohort data and the cohort data of adult dialysis patients from 1995 to
2004. Compared with adult dialysis patients, pediatric dialysis patients had
similar cardiovascular death (22.2% vs. 32.3%, P=0.200) and infection death
(24.4% vs. 22.5%, P=0.722). However, more pediatric dialysis patients died
from cerebrovascular disease (17.8% vs. 7.8%, P=0.021). The types of
cerebrovascular diseases were not different between pediatric and adult
13
patients (87.5% of death due to cerebral hemorrhage in pediatric group vs.
82.3% in adult group, p= 0.99). Hemorrhagic stroke is the major type of
cerebrovascular disease in both adult and pediatric patients.
14
DISCUSSION
According to the USRDS 2006, Taiwanese patients of age older than 45
years have the highest ESRD incidence rates in the world [5]. However, this is
not the case in pediatric group. The average annual pediatric ESRD incidence
rate is 8.12 per million of age-related populations (1995-2004) .This is similar
to 9.9 per million reported by 2000 ERA-EDTA Registry and other developed
countries [1]. Why such difference of ESRD incidence exists between adult
and pediatric populations from Taiwan? We speculate this is related to the
successful implementation of two public health policies. First, since 1991,
Department of Health and Department of Education have established a
nationwide urine screening program for children and adolescents from
elementary schools through middle schools at grade 1, 4 and 7, with an
interval of every 3 years. Those with abnormal urinalysis will be referred to
local clinics or hospitals for further work-up. In addition, since 1994, all
pregnant women with ≥20 weeks of gestation may have up to two free
abdominal ultrasound examinations, in order to screen for fetal congenital
structure anomalies. These two programs succeed in early detection and early
intervention for pediatric patients with congenital urinary tract anomalies and
kidney diseases. As a matter of fact, our society expresses a strong supportive
15
attitude towards any issue related to health and welfare of children. On the
contrary, the adult urine screening program and CKD prevention program was
not implemented until 2003.
According to our data from 1995 to 2004, the mortality of pediatric dialysis
patients was 24.66 per 1000 patient-years. The USRDS of 2006 [5] reported a
mortality rate of 56.5 per 1000 patient-years for pediatric dialysis patients who
started treatment between 1995 and 1999. The overall mortality rate was
22.8% per 1000 patient-years for pediatric dialysis patients in the Italian study
[13] and the rate was 15.7 per 1000 patient-years in another cohort study from
the Netherlands [6]. Besides, the mortality rates in the NAPTRCS study
(deaths/1000 patient-years) varied with age, from 13.6 in infants to 2.2 in
adolescents [14]. Taiwan’s mortality rate was simlar to Italian. We all know that
key determinants of ESRD care are costs and resources. In Taiwan, dialysis
costs are covered 100% by National Health Insurance since 1995. In most
areas, dialysis units are not far from patients’ residences, usually within 10
kilometers. In addition, by government regulation, nephrologists have to see
HD patients every shift and see PD patients every month. With abundant
resources for dialysis care, dialysis patients in Taiwan generally have
acceptable long-term survivals when compared to other developed countries.
16
The trend of long-term survival in the current study is similar to that
reported previously [3, 8, 13, 14, 15] when the study population was stratified
by age. The younger patients, especially those aged 4 years or younger, had a
lower probability of survival. The reason for the higher mortality rate in infants
and younger children undergoing dialysis may have been due to several
factors, such as the presence of other congenital anomalies and the presence
of oliguria or anuria, which are more common in infants [16, 17]. In our registry,
we did not have specific co-morbidity codes for pediatric patients. This may
explain why co-morbidity was not a separate predictor for lower survival in the
entire group.
In Taiwan, by national standards, HD patients usually are dialyzed for 4
hours, three times a week by targeting Kt/V >
which will be examined
every three months. Hemodiafiltration (HDF) is rarely performed in pediatric
dialysis. The PD patients are usually dialysed by continuous ambulatory
peritoneal dialysis (CAPD) or automatic peritoneal dialysis (APD) with day
dwells, targeting weekly Kt/V >2.0 and weekly CCr > 60 L. The adequacy
indices are required to report every six months. Like USA and Holland, in
Taiwan, the liklihood of acceptance for pediatric HD is universal, as financially
all treatments are covered by National health Insurance. PD is suggested first
17
for the pediatric dialysis patients by renal physician if there is no
contraindication. The reason of higher penetration of pediatric HD in Taiwan
may be due to high density of HD center for patients and family preference.
Young parents are usually reluctant to do PD for very young children. In adult
ESRD patients, Two large-scale studies reveal that PD is generally associated
with equal or better survival among non-diabetic and younger diabetic patients
[18,19]. Furthermore, several studies have shown a time-dependent trend that
PD is generally associated with equivalent or better survival during the first
year or two of dialysis [20, 21]. On the other hand, few studies have compared
survival between PD and HD in pediatric patients [3, 14]. Recently, a
multi-national registry study among pediatric patients showed preliminary data
of lower mortality associated with PD in the first 12 months after RRT for all
age groups. No significant difference in survival between PD and HD was
found after 12 months except in children younger than 4 years of age [8, 22]. In
this study, Taiwanese pediatric PD and HD patients had similar survival rates
during the follow-up period.
Cardiovascular diseases (CVD), including hypertension, atherosclerosis,
myocardial infarction, and cerebrovascular accidents, constitute an important
cause of morbidity and mortality in both adults and children with ESRD.
18
Studies in the United States and Europe have shown that CVD is the leading
cause of death among young adults diagnosed with ESRD in childhood [10, 11,
23, 24, 25]. The rate of cardiovascular death in pediatric ESRD patients varies
from different databases: 45% in ANZDATA [3], 37% in USRDS [5] and 21% in
NAPRTCS [7, 11]. However, the rate varies, partly due to different coding
systems
used.
Some
studies
include
cerebrovascular
death
within
cardiovascular death [1, 3], while other studies count cerebrovascular death
separately [6, 15].
Annual reports of the USRDS and NAPRTCS indicate that CVD remains
the most common cause of death in children on chronic dialysis or after
transplantation [26]. Arrhythmia is the most common cardiac event in the
USRDS database [27]. CVD is the most common cause (41%) in the Dutch
study [5, 27, 28] as well, in which cerebrovascular accidents (24%) account for
most of CVD death. Recently, we conduct a population-based study
(unpublished observation) using Taiwan National Health Insurance claim data
of one million patients. The multivariate logistic regression of pediatric
population revealed ESRD patients has the highest risk of stroke (odds ratio
(OR) = 46.3, 95% confidence interval (CI) 5.88-365, P=0.0003), followed by
chronic kidney disease (OR 33), hypertension (OR 29.5) and hyperlipidemia
19
(OR 8).The current study reports 17.8% fatal cerebrovascular accidents, which
is lower than the 24% reported in the LERIC study [6] but much higher than the
6% reported by the USRDS [5].
The incidence of stroke in adult ESRD patients, between 13.2 and 37.8
strokes/1000 person-years in patients on long-term HD therapy, is much higher
than in the general population. Adult patients who undergo a relatively long
period of dialysis have more than a 15-fold higher risk of cerebrovascular
death compared to those who live relatively long with a renal graft [12]. The
USRDS reported that the incidence of ischemic stroke for adult ESRD patients
was 5.3 fold greater than that for hemorrhagic stroke. In contrast, studies [30,
31] from Japan have shown that hemorrhagic stroke is more frequent than
ischemic stroke. In this study, we have similar findings as Japanese study. In
our adult patients with mortality, hemorrhagic stroke was 4.6 fold greater than
that for ischemic stroke. In our pediatric patients, the chance of hemorrhagic
stroke was even higher, 7 fold (87.5% vs 12.5%) greater than that of ischemic
stroke. The above studies [12, 30, 31] evaluating stroke in dialysis patients are
all in adults. There is no similar study available that look strictly at children. Our
study is the first one to point out that hemorrhagic stroke (87.5%) was more
common than that for ischemic stroke (12.5%) in pediatric dialysis patients. In
20
addition, all lethal strokes occurred during the initial 5 years of dialysis.
Hypertension is prevalent and difficult to control in children on dialysis,
especially when they just started dialysis therapy. Unfortunately, we did not
have blood pressure measurement of each individual patient. We speculate
the relatively high cerebrovascular death due to hemorrhagic stroke occurring
in the initial 5 years of dialysis might be due to poor control of hypertension in
young children on dialysis. Future prospectively designed studies are
required to confirm this observation.
This study has a number of limitations. First, the total number of patients is
relatively small despite the nationwide scope. Second, comparisons based on
observational data of current study may be subject to several biases, including
selection bias between HD and PD (e.g. type of dialysis was not randomly
assigned) and having incomplete reporting of causes of death and the
absence of any information on patients’ hypertension control during the
dialysis treatment. In addition, the data of our registry do not provide detailed
clinical characteristics, such as blood pressure control and residual renal
function etc.
In summary, this cohort study is the first in Taiwanese children and
adolescents that focuses on long-term survival of pediatric ESRD patients on
21
RRT. Taiwanese pediatric PD and HD patients have similar survivals. Age at
initiation of dialysis is an important factor affecting survival since the highest
mortality rate is in the youngest patients (0-4 years). Infection, cardiovascular
diseases and cerebrovascular diseases are the most common causes of death
in children on chronic dialysis in Taiwan. Higher proportion of pediatric dialysis
patients suffered from cerebrovascular death than adult dialysis population.
Hemorrhagic stroke is the main type of cerebrovascular disease.
22
ACKNOWLEDGMENTS
This study was supported by a grant from Bureau of Health Promotion,
Department of Health, Taiwan (DOH97-HP-1103) and another grant from
China Medical University Hospital, Taiwan (DMR-98-018). We appreciated
hundreds of people in renal units throughout Taiwan who collect data for
Taiwan Renal Registry.
23
Disclosures
None.
24
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Murakami M, Hamasaki T, Kimura S, Maruyama D, Kakita K (2004)
Clinical features and management of intracranial hemorrhage in
patients undergoing maintenance dialysis therapy. Neurol Med Chir
(Tokyo) 44: 225-232; discussion 233
FIGURE LEGENDS
Figure 1. Survival rates among children and adolescents with ESRD in Taiwan
according to different treatment modality- hemodialysis (HD) and peritoneal
dialysis (PD). The numbers of patients at each time point were showed.
29
Figure 2. Adjusted survival rates among children and adolescents with ESRD
in Taiwan from 1995 to 2004 according to age at dialysis initiation. All
models were adjusted for gender, dialysis modality, and co-morbidity.
30
Table 1. Comparisons of characteristics between HD and PD patients
HD treatment
Age at dialysis initiation
(Yr)
0~4
5~9
10~14
15~19
Gender
Female
Male
Total
Survival Status
Survival
Death
Survival Time (Year)
0~1
1~2
2~3
3~4
4~5
5+
Number of Comorbidity
0
1
2+
PD treatment
P-value
(χ2-test)
N
%
N
%
9
19
77
214
(2.8%)
(6.0%)
(24.1%)
(67.1%)
10
22
55
69
(6.4%)
(14.1%)
(35.3%)
(44.2%)
<0.001*
135
184
319
(42.3%)
(57.7%)
63
93
156
(40.4%)
(59.6%)
0.693
267
52
(83.7%)
(16.3%)
131
25
(84.0%)
(16.0%)
0.105
10
11
10
(19.2%)
(21.2%)
(19.2%)
3
6
3
(12.0%)
(24.0%)
(12.0%)
0.611
5
2
14
(9.6%)
(3.9%)
(26.9%)
1
3
9
(4.0%)
(12.0%)
(36.0%)
197
58
22
(71.1%)
(20.9%)
(7.9%)
99
31
9
(71.2%)
(22.3%)
(6.5%)
The categorical variables were compared by Fisher exact test.
*p<0.05 was considered statistically significant.
31
0.852
Table 2. Cox proportional hazards model for pediatric ESRD patients after
stratification with dialysis modality (HD/PD)
HD treatment
HR
(95%CI)
Age at dialysis
initiation(yr)
0~4 vs 15~19
5~9 vs 15~19
10~14 vs 15~19
Sex
Male vs Female
Comorbidity
1+ vs 0
6.60
(2.50~17.38)
2.03
P-value
<0.001*
0.190
(0.70~5.85)
1.52
(0.78~2.98)
0.221
PD treatment
HR
(95%CI)
5.03
(1.23~20.67)
2.30
(0.57~9.28)
2.01
(0.71~5.74)
P-value
0.025*
0.240
0.191
0.83
(0.46~1.49)
0.529
1.45
(0.57~3.67)
0.436
2.02
(1.12~3.64)
0.020*
0.62
(0.24~1.62)
0.329
CI, confidence interval.
*p<0.05 was considered statistically significant.
32
Table 3. Causes of death in pediatric HD and PD patients
Cause (disease)
HD(%)
PD(%)
p-value*
Cardiovascular
disease
Cerebrovascular
disease
Infection
G-I and hepatic
disease
Malignancy
7 (13.5%)
3 (12.0%)
1.000
4(7.7%)
4 (16.0%)
0.426
7(13.5%)
0 (0.0%)
4 (16.0%)
1(4.0%)
0.741
0.327
0(0.0%)
0(0.0%)
Others
Unknown
Total
14 (26.9%)
20 (38.4%)
52 (100%)
1 (4.0%)
12(48.0%)
25(100%)
*Fisher’s Exact test
33
0.028
0.466
Table 4. Comparison of causes of death between pediatric and adult ESRD
patients
Cause (disease)
Pediatric N(%)
Adult N(%)
p-value*
Non-cardiovascular
cardiovascular
35 (77.8%)
10 (22.2%)
9906 (67.7%)
4720 (32.3%)
0.200
Non-cerebrovascular
cerebrovascular
37 (82.2%)
8 (17.8%)
13493 (92.3%)
1133 (7.8%)
0.021
Non-infectious
infectious
34 (75.6%)
11 (24.4%)
11337 (77.5%)
3289 (22.5%)
0.722
*Fisher’s Exact test
34
Figure 1.
35
Figure 2.
36