Outcomes of Dialysis Initiated During the Neonatal Period for Treatment of End-Stage Renal Disease: A North American Pediatric

Renal Trials and Collaborative Studies Special Analysis William A. Carey, Lynya I. Talley, Sally A. Sehring, Janet M. Jaskula and Robert S. Mathias Pediatrics 2007;119;e468-e473; originally published online Jan 15, 2007; DOI: 10.1542/peds.2006-1754

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/119/2/e468

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2007 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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ARTICLE

Outcomes of Dialysis Initiated During the Neonatal Period for Treatment of End-Stage Renal Disease: A North American Pediatric Renal Trials and Collaborative Studies Special Analysis
William A. Carey, MDa, Lynya I. Talley, PhDb, Sally A. Sehring, MDa, Janet M. Jaskula, RNc, Robert S. Mathias, MDc Divisions of aNeonatal-Perinatal Medicine and cPediatric Nephrology, University of California San Francisco Childrens Hospital, University of California, San Francisco, California; bEMMES Corporation, Rockville, Maryland
The authors have indicated they have no nancial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVE. We sought to determine the outcomes of initiating long-term dialysis of

neonates and children aged 1 to 24 months with end-stage renal disease.

PATIENTS AND METHODS. By querying the North American Pediatric Renal Trials and

www.pediatrics.org/cgi/doi/10.1542/ peds.2006-1754 doi:10.1542/peds.2006-1754

Key Words neonate, end-stage renal disease, dialysis, renal transplantation, survival Abbreviations ESRD end-stage renal disease NAPRTCSNorth American Pediatric Renal Trials and Collaborative Studies ARPKDautosomal recessive polycystic kidney disease CNS congenital nephrotic syndrome CI condence interval
Accepted for publication Aug 14, 2006 Address correspondence to William A. Carey, MD, Division of Neonatal-Perinatal Medicine, UCSF Childrens Hospital, University of California San Francisco, 3333 California St, Suite 150K, San Francisco, CA 94118-1245. E-mail: william.carey@ucsf.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2007 by the American Academy of Pediatrics

Collaborative Studies database, we obtained information on 193 neonates (1 month of age) and 505 children (124 months of age) with a presumptive diagnosis of end-stage renal disease who initiated long-term dialysis. Dialysis characteristics and likelihood of hospitalization were compared using the 2 test, and duration of hospitalization was compared using the Wilcoxon 2-sample test. Product limit methods were implemented, and the log rank test was used to compare time-to-event analyses. Multivariate analyses were performed using Cox proportional hazards models.
RESULTS. Neonates with end-stage renal disease were more likely to receive perito-

neal dialysis versus hemodialysis than older children with end-stage renal disease. Moreover, neonates who initiated dialysis during the rst month of life were just as likely to terminate dialysis as were the older children. Rates of renal transplantation were signicantly lower in the neonates compared with the older children, but neonates were more likely to recover function of the native kidney. Although neonates were more often hospitalized, their overall risk of mortality was similar to that observed in older children.
CONCLUSIONS. Neonates with a presumptive diagnosis of end-stage renal disease may

initiate long-term dialysis during the rst month of life with outcomes comparable to those of patients who initiate dialysis later in infancy.

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quently during the rst month of life, but its implications for the patients and their families are substantial.1,2 Morbidities and mortality related to the disease and its treatment are common,3,4 and the growth and development of surviving infants are often suboptimal.57 For families, providing care to a chronically ill child can be overwhelming, in terms of both emotional and capital resources. Thus, the decision to initiate longterm dialysis in neonates with a presumptive diagnosis of ESRD is complex and may present an ethical dilemma for physicians and family members alike. Although dialysis has been used to treat neonatal renal failure for decades,8 there are limited data regarding the outcomes of initiating long-term dialysis for treatment of ESRD during the rst month of life. This lack of information is attributable, in part, to the diverse etiologies of neonatal ESRD and to the small numbers of patients who are available for analysis.912 Because of these limitations, the neonatal dialysis experience has been lost in studies that describe the outcomes of infants of a broader age range, often spanning birth to 24 months.1,4,5 This scarcity of published data also may account for the variability of attitudes displayed by those who provide primary and specialty care for neonates with ESRD. In a worldwide survey of pediatric nephrologists, nearly all who responded would offer treatment to some neonates with ESRD, whereas less than half would offer such treatment for all neonates.13 Likewise, many neonatologists consider unfavorable the prospect of initiating dialysis as a bridge to renal transplant for their patients, whereas others would be willing to treat their patients through transplantation.14 To provide further insight into this complex issue, we conducted the following study to determine the frequency of key outcomes of initiating long-term dialysis for treatment of presumptive ESRD during the rst month of life. PATIENTS AND METHODS Since January 1, 1992, the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) has maintained a voluntary dialysis registry database that includes information on thousands of pediatric patients requiring long-term dialysis.15 For this study, we queried the NAPRTCS database to obtain information about children who initiated long-term dialysis for treatment of ESRD within the rst 24 months of life during the calendar years 1992 to 2005. Specically, we analyzed data regarding patient gender and race, primary renal diagnosis and type of dialysis at the time of initiation, likelihood of and reason for termination of dialysis, time to transplantation, patient mortality, and likelihood and duration of hospitalization. Primary renal diagnoses were entered in the database as renal a-/hypo-/dysplasia (dysplasia), obstructive uropa-

ND-STAGE RENAL DISEASE (ESRD) occurs infre-

thy, autosomal recessive polycystic kidney disease (ARPKD), congenital nephrotic syndrome (CNS), and other. Dialysis modalities were characterized as peritoneal dialysis or hemodialysis. The reasons for termination of dialysis included renal transplant, change of dialysis modality, death, recovery of native kidney function, or other (eg, peritonitis, pancreatitis, change of medical center, and family choice). To describe the outcomes of children with ESRD who initiated long-term dialysis during the neonatal period, patients were categorized on the basis of age as neonates (1 month) or older children (124 months). Patient characteristics, dialysis characteristics, termination characteristics, overall mortality, and hospitalization were compared using the 2 test. Duration of hospitalization was compared using the Wilcoxon 2-sample test. Product limit analyses of termination, time to transplant, and time to death were performed, and data were compared using the log rank test. All of the tests of signicance were 2-sided with at .05. To determine whether outcomes had improved over time for neonates with ESRD who initiated dialysis during the rst month of life, neonates were subcategorized on the basis of the date on which dialysis was initiated. Specically, we compared neonates who initiated longterm dialysis during the calendar years 19921998 (past) with those who had initiated during the calendar years 1999 2005 (recent). Plots depicting time to transplant and time to death were created using Kaplan-Meier methods. For analyses involving time to transplant, time to transplant was dened as the interval from the date of the rst registryreported initiation of dialysis until the date of transplant. Those patients who were still on the initial dialysis at the last date of contact or those who terminated dialysis for a reason other than transplantation (eg, death) were censored at the last date of contact or at the date of termination or death. For survival analyses, time to death was dened as the interval from the date of the rst registry-reported initiation of dialysis until the date of death, irrespective of whether transplantation, modality changes, or recovery of native kidney function had occurred. Multivariate analyses were performed using Cox proportional hazards models. Confounding factors taken into consideration include: gender, race, primary renal diagnosis, type of dialysis, and center size. To categorize centers based on size, the total number of subjects enrolled in the NAPRTCS registry was computed for each center and then summed. The median value was chosen as the cut point. For analysis purposes, centers that had enrolled 40 patients were categorized as large, whereas those that had enrolled 40 were categorized as small. In all, 98 centers contributed data that were analyzed in this study, each center following the requirements of its
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local institutional review board for participation in NAPRTCS. RESULTS NAPRTCS data were available for 193 patients who initiated long-term dialysis during the rst month of life and for 505 patients who initiated between 1 and 24 months of age. Given the mean populations of the United States and Canada during the study period,16,17 NAPRTCS reported an incidence of 0.045 cases of dialysis-treated neonatal ESRD per million population per year. Given the mean number of annual live births in the United States and Canada during the rst 12 years of the study period,18,19 NAPRTCS reported an incidence of 0.32 cases per 100 000 live births. The gender and race characteristics of the neonates were similar to those of the older children (Table 1). Table 2 details the distribution of primary renal diagnoses and the type of dialysis of each age group. Neonates were more likely to be diagnosed with renal dysplasia or ARPKD, whereas older children were much more likely to suffer from CNS (P .001). Nearly all of the neonates were treated with peritoneal dialysis (98%), whereas 9% of older children received hemodialysis (P .001). As shown in Table 3, neonates were as likely to terminate dialysis during the study period as were older children (81% vs 83%). However, the reason for terminating dialysis differed signicantly between the 2 age groups (P .001). Neonates were more likely to terminate because of death, and they were less likely to terminate because of transplantation. On the other hand, neonates were more likely to recover native kidney function, and they were less likely to require a change in the type of dialysis. As shown in Fig 1, there also was a signicant difference in the time to transplant between the 2 age groups. Over the 5 years after initiation of dialysis, older children were transplanted more quickly than were neonates (P .001). However, the percentage of neonates receiving transplantation more closely approximated that of the older children within 3 years of the initiation of dialysis. After adjusting for confounding factors, multivariate analysis also revealed that older

TABLE 2 Dialysis Characteristics of Those Infants Who Initiated Dialysis at Age <1 Month or >124 Months
1 mo (n 193) Diagnosis, n (%) Renal dysplasia Obstructive uropathy ARPKD CNS Other Type of dialysis, n (%) Peritoneal dialysis Hemodialysis
aP

124 mo (n 505) 129 (25.5) 89 (15.8) 40 (7.9) 54 (10.7) 202 (40.0)

P .001a

72 (37.3) 39 (20.2) 23 (11.9) 3 (1.5) 56 (29.0) 189 (97.9) 4 (2.1)

.001a 457 (90.7) 48 (9.5)

is by 2 test.

TABLE 3 Termination Characteristics of Those Infants Who Initiated Dialysis at Age <1 Month or >124 Months
1 mo (n 193) Terminated, n (%) Yes No Reason terminated, n (%) Renal transplant Change of modality Death Recovery of native kidney Other
aP

124 mo (n 505) 418 (82.8) 87 (17.2)

P .659a

157 (81.3) 36 (18.7) 73 (46.5) 21 (13.4) 17 (10.8) 23 (14.6) 23 (14.6)

.001a 241 (57.7) 81 (19.4) 33 (7.9) 17 (4.1) 46 (11.0)

is by 2 test.

TABLE 1 Characteristics of Those Infants Who Initiated Dialysis at Age <1 Month or >124 Months
1 mo (n 193) Gender, n (%) Male Female Race, n (%) White Black Hispanic Other
aP

FIGURE 1 Time to transplant: neonates versus older children. Neonates (n 193) transitioned to renal transplantation less quickly than did older children (n 505). Log rank test, P .001.

124 mo (n 505) 329 (65.2) 176 (34.8)

P .418a

132 (68.4) 61 (31.6) 129 (66.8) 28 (14.5) 24 (12.4) 12 (6.2)

.324a 306 (60.5) 83 (16.4) 88 (17.4) 28 (5.4)

is by 2 test.

children have a relative hazard of termination because of transplantation that is 1.55 times that of neonates (95% condence interval [CI]: 1.19 2.02; Table 4). For survival analyses, the median follow-up times were 17.8 months for neonates and 14.6 months for older children. Overall, 46 (24%) of 193 neonates and 100 (20%) of 505 older children expired during the study period (P .192). Seventeen (9%) neonates died during their initial dialysis course, whereas 26 (15%)

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TABLE 4 Multivariate Analyses: Time to Termination, Time to Transplant, and Time to Death
Termination HR Transplant HR (95% CI) (95% CI) Age group 124 vs 1 mo Gender Male vs female Cohort era 19921998 vs 19992005 Center size 40 vs 40 patients Diagnosis Dysplasia vs all others Obstruction vs all others Death HR (95% CI)

1.15 (0.951.39) 1.55 (1.192.02) 0.80 (0.561.14) 1.02 (0.851.22) 1.15 (0.891.47) 1.07 (0.751.52) 1.16 (0.971.39) 0.80 (0.631.01) 1.30 (0.881.91) 1.14 (0.881.47) 0.89 (0.651.24) 1.00 (0.611.65) 0.82 (0.680.99) 0.77 (0.591.01) 0.67 (0.450.98) 0.69 (0.540.88) 0.77 (0.571.05) 0.47 (0.280.81)

Hazard ratios (HR) are adjusted for variables shown.

talized, neonates had a greater mean number of hospital days than older children (54 vs 39; P .001). Data were available for 130 neonates who initiated dialysis during 1992-1998 and for 63 neonates who initiated dialysis during 1999-2005. Overall, neonates in the recent and past cohorts transitioned to renal transplantation at similar rates (Fig 3). However, within 3 years of initiating dialysis, 80% of the recent cohort had undergone transplantation, in contrast to only 60% of the past cohort. Similarly, the recent cohort of neonates tended to have better survival during the 3 years after the initiation of dialysis (P .111); application of the Wilcoxon 2-sample test indicated that this survival advantage was statistically signicant (P .036; Fig 4). DISCUSSION For physicians and parents alike, the decision to initiate long-term dialysis for a neonate with presumptive ESRD poses a complex ethical quandary.1,2 This dilemma derives, at least in part, from the paucity of published reports describing the outcomes of infants who initiate dialysis during the rst month of life. Using the NAPRTCS database, the goals of our study were to gain further insight into the outcome of neonates with ESRD and to provide information to physicians and families that would assist in the decision-making process. The age at which dialysis was initiated had no effect on the likelihood of dialysis termination over time, because the neonates in our study were just as likely to terminate dialysis as were older children. Among those infants who initiated dialysis during the rst month of life, 1 in 8 neonates recovered native kidney function. Furthermore, by 5 years postinitiation, 80% of neonates in this study had transitioned to renal transplantation. These ndings indicate that a signicant propor-

died having terminated their initial dialysis course for another reason (eg, transplantation, change of modality, or recovery of native kidney function). As shown in Fig 2, there was no signicant difference in time to death between the neonates and older children (P .401). Furthermore, after adjusting for confounding factors, multivariate analysis revealed no signicant difference in time to death between the 2 age groups (hazard ratio: 0.80; 95% CI: 0.56-1.14; Table 4). Multivariate analyses also indicated that gender, cohort era, and center size had no inuence on the time to termination, time to transplant, or time to death of the patients in this study (Table 4). However, a primary renal diagnosis of either dysplasia or obstruction was signicantly associated with a reduction in the relative hazard for time to termination and time to death and tended toward a reduced relative hazard for time to transplant (Table 4). After the initiation of dialysis, the vast majority of both neonates and older children required hospitalization (80% vs 73%; P .034). Among those ever hospi-

FIGURE 2 Time to death: neonates versus older children. Neonates (n 193) and older children (n 505) had similar survival within 5 years of initiating dialysis. Log rank test, P .401 (not signicant).

FIGURE 3 Time to transplant: past versus recent cohorts. Neonates who initiated dialysis between 1999 and 2005 (n 63) were as likely to transition to renal transplantation as were neonates who initiated between 1992 and 1998 (n 130). Log rank test, P .325 (not signicant).

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FIGURE 4 Time to death: past versus recent cohorts. Neonates who initiated dialysis between 1999 and 2005 (n 63) had more favorable survival than did neonates who initiated between 1992 and 1998 (n 130). Wilcoxon test, P .036.

tion of neonatal dialysis patients will successfully transition off long-term dialysis. The likelihood of mortality was considerable for all of the children in our study, with 1 in 4 neonates expiring after the initiation of dialysis. However, this overall mortality risk was only marginally higher than that observed in older children, and it did not reach statistical signicance. Furthermore, product limit analysis revealed no difference in survival between the 2 age groups, even after adjusting for confounding factors. These data suggest that the long-term survival rates of neonates and older infants with ESRD are similar. In our study, the majority of infants who initiated long-term dialysis during the rst 24 months of life required hospitalization. Only 1 in 5 neonates escaped inpatient treatment after the initiation of dialysis. The duration of hospitalization also was longer for neonates, because they spent 8 weeks in the hospital compared with 6 weeks for older children. Because the likelihood and duration of hospitalization were substantially different between the 2 age groups, these ndings indicate that neonates with ESRD (and their families) incur signicant human and scal costs of long-term dialysis. When we designed this study, we hypothesized that neonates who initiated long-term dialysis in recent years would have better outcomes than those who initiated dialysis 1 decade ago. Indeed, we found that a greater percentage of neonates in the more recent cohort had transitioned to transplantation within 3 years of initiating dialysis. Furthermore, these same neonates enjoyed better survival in comparison with those treated in the earlier cohort. We speculate that the improvement in outcomes in the more recent cohort is attributable, in part, to the advancement of medical and surgical techniques over time, as well as to the accrual of experience by medical centers that provide care for these infants. One potential limitation of this study is the difference
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between the 2 age cohorts in the frequency of each primary renal diagnosis. We found that neonates were more likely to be diagnosed with renal dysplasia or obstructive uropathy, whereas older children were more likely to suffer from CNS. The associated morbidities of these conditions are quite different (ie, respiratory insufciency versus infection and thrombosis), so each could uniquely impact the likelihood of transplantation and long-term survival. To address this possible confounding factor, we performed multivariate analyses taking into consideration, among other factors, primary renal diagnosis. Although these analyses revealed that dysplasia and obstruction were associated with better survival outcomes, the relative frequency of these primary renal diagnoses were taken into consideration in our comparisons of age group-specic termination and survival outcomes. Selection bias also may have been introduced into this study by the difference between the 2 age cohorts in the frequency of each primary renal diagnosis. Neonates with renal dysplasia or obstructive uropathy are at risk for associated congenital anomalies, either true malformations or deformations, because of severe oligohydramnios. In such cases, the presence of signicant comorbid conditions may preclude long-term dialysis as a bridge to renal transplantation, thus excluding these neonates from the NAPRTCS database. Hence, the ndings presented in this report reect the outcomes of those neonates whose associated anomalies (if any) were judged to be insufcient to preclude long-term dialysis. The voluntary nature of the NAPRTCS database is another limitation of this study. Although it is reasonable to speculate that some medical centers may report only their successful cases, such bias likely would be applied equally to both age groups in this study. Furthermore, the calculated rate of dialysis-treated neonatal ESRD in our study is very similar to that reported in Britain and Ireland.1 Moreover, the survival data presented in our study closely resemble that reported for young dialysis patients in Australia and New Zealand, countries in which the outcome of every dialysis patient is recorded in a registry biannually.20 Because the NAPRTCS database seems to be in accord with other published studies and registries, we believe that is it a valid tool to describe the outcomes of long-term dialysis initiated during the rst month of life in North America. The fact that NAPRTCS is a volunteer registry also may have limited our ability to determine the effect of center size on termination and survival outcomes. It is conceivable that some of the centers considered small in this study are actually large institutions that care for many infants with ESRD but lack data entry support for the enrollment of patients in the NAPRTCS database. The converse also may have occurred: a truly small center may have been able to register each of its patients

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with NAPRTCS, thereby leading us to classify this center as large. If 1 assumes a priori that high-volume centers would achieve better outcomes because of their greater experience, the misclassication of center size could have contributed to our nding that termination and survival outcomes did not vary according to center size. Finally, this is the largest study designed to determine the outcomes of long-term dialysis initiated in the neonatal period. Based on the results of our analyses, we conclude that the initiation of long-term dialysis during the rst month of life is an acceptable option for the parents and clinicians who care for these infants. Recent advances in automated peritoneal dialysis have reduced the rates of peritonitis in young infants while reducing the burden of care imposed on their parents.21 In addition, the introduction of comprehensive enteral feeding programs and growth hormone therapy has improved the growth of these infants considerably.22 With these and other improvements in pretransplant care, many young and small infants are successfully surviving to renal transplant with excellent allograft and patient survival.23,24 Further studies are necessary, however, to determine the inuence of the primary etiology of ESRD or attendant comorbid conditions on the outcomes of longterm dialysis in this very select population. ACKNOWLEDGMENTS We thank the North American Pediatric Renal Trials and Collaborative Studies for supporting this special analysis. This study was also supported as by a grant from the National Institutes of Health (HD-07162). REFERENCES
1. Coulthard MG, Crosier J. Outcome of reaching end stage renal failure in children under 2 years of age. Arch Dis Child. 2002; 87:511517 2. Bunchman TE. The ethics of infant dialysis. Perit Dial Inter. 1996;16(suppl 1):3 6 3. Ledermann SE, Scanes ME, Fernando ON, Duffy PG, Madden SJ, Trompeter RS. Long-term outcome of peritoneal dialysis in infants. J Pediatr. 2000;136:24 29 4. Shroff R, Wright E, Ledermann S, Hutchinson C, Rees L. Chronic hemodialysis in infants and children under 2 years of age. Pediatr Nephrol. 2003;18:378 383 5. Kari JA, Gonzalez C, Ledermann SE, Shaw V, Rees L. Outcome and growth of infants with severe chronic renal failure. Kidney Int. 2000;57:16811687 6. Madden SJ, Ledermann SE, Guerrero-Blanco M, Bruce M, Trompeter RS. Cognitive and psychosocial outcome of infants dialysed in infancy. Child Care Health Dev. 2003;29:55 61 7. Warady BA, Belden B, Kohaut E. Neurodevelopmental outcome of children initiating peritoneal dialysis in early infancy. Pediatr Nephrol. 1999;13:759 765

8. Rennie ID, Cameron JS. Peritoneal dialysis for traumatic renal failure in a three-week-old infant. Guys Hosp Rep. 1966;115: 449 454 9. Haycock GB. Management of acute and chronic renal failure in the newborn. Semin Neonatol. 2003;8:325334 10. Feldenberg LR, Siegel NJ. Clinical course and outcome for children with multicystic dysplastic kidneys. Pediatr Nephrol. 2000;14:1098 1101 11. Bajpai M, Dave S, Gupta DK. Factors affecting outcome in the management of posterior urethral valves. Pediatr Surg Int. 2001; 17:1115 12. Roy S, Dillon MJ, Trompeter RS, Barratt TM. Autosomal recessive polycystic kidney disease: long-term outcome of neonatal survivors. Pediatr Nephrol. 1997;11:302306 13. Geary DF. Attitudes of pediatric nephrologists to management of end-stage renal disease in infants. J Pediatr. 1998;133: 154 156 14. Burguet A, Abraham-Lerat L, Cholley F, Champion G, Bouissou F, Andre JL. Terminal and pre-terminal chronic renal insufciency in newborns in French neonatal intensive care units: survey of the French pediatric nephrologic society of resuscitation and emergency [in French]. Arch Pediatr. 2002;9: 489 494 15. Alexander SR, Beneld MR, Fine RN, Warady BA. Renal transplantation, chronic dialysis, and chronic renal insufciency: the 2004 annual report of the North American Pediatric Renal Transplant Coo perative Study. Available at: http://spitre. emmes.com/study/ped/resources/annlrept2004.pdf. Accessed July 13, 2005 16. US Census Bureau. People: population data programs/ products; estimates. population estimates; popular tables. Available at: www.census.gov/popest/estimates.php. Accessed June 27, 2005 17. Statistics Canada. Estimated population of Canada, 1605 to present. Available at: www.statcan.ca/english/freepub/98187-XIE/pop.htm. Accessed July 13, 2005 18. National Center for Health Statistics. Health, United States, 2005: with chartbook on trends in health in Americans. Available at: www.cdc.gov/nchs/data/hus/hus05.pdf. Accessed August 6, 2006 19. Statistics Canada. Pregnancy outcomes, by age group, Canada, provinces and territories, annual, 1974 to 2003. Available at: http://cansim2.statcan.ca. Accessed August 6, 2006 20. McDonald SP, Craig JC. Long-term survival of children with end-stage renal disease. N Engl J Med. 2004;350:2654 2662 21. Fine RN, Ho, M. The role of APD in the management of pediatric patients: a report of the North American Pediatric Renal Transplant Coo perative Study. Semin Dial. 2002;15: 427 429 22. Ledermann SE, Shaw V, Trompeter RS. Long-term enteral nutrition in infants and young children with chronic renal failure. Pediatr Nephrol. 1999;13:870 875 23. Humar A, Arrazola L, Mauer M, Matas AJ, Najarian JS. Kidney transplantation in young children: should there be a minimum age? Pediatr Nephrol. 2001;16:941945 24. Millan MT, Sarwal MM, Lemley KV, et al. A 100% 2-year graft survival can be attained in high-risk 15-kg or smaller infant recipients of kidney allografts. Arch Surg. 2000;135:10631069

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PEDIATRICS Volume 119, Number 2, February 2007

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Outcomes of Dialysis Initiated During the Neonatal Period for Treatment of End-Stage Renal Disease: A North American Pediatric Renal Trials and Collaborative Studies Special Analysis William A. Carey, Lynya I. Talley, Sally A. Sehring, Janet M. Jaskula and Robert S. Mathias Pediatrics 2007;119;e468-e473; originally published online Jan 15, 2007; DOI: 10.1542/peds.2006-1754
Updated Information & Services References including high-resolution figures, can be found at: http://www.pediatrics.org/cgi/content/full/119/2/e468 This article cites 19 articles, 3 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/119/2/e468#BIBL This article has been cited by 5 HighWire-hosted articles: http://www.pediatrics.org/cgi/content/full/119/2/e468#otherarticl es This article, along with others on similar topics, appears in the following collection(s): Genitourinary Tract http://www.pediatrics.org/cgi/collection/genitourinary_tract Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtml Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml

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