title: Perceptions of pediatric nephrologists regarding timing of dialysis initiation in children in Canada.
abstract: BACKGROUND
  Significant practice variation exists in Canada with respect to timing of dialysis initiation in children. In the absence of evidence to guide practice, physicians' perceptions may significantly influence decision-making.
  
  
  OBJECTIVE
  The objectives of this study are to (1) evaluate Canadian pediatric nephrologists' perceptions regarding dialysis initiation in children with chronic kidney disease (CKD) and (2) determine the factors guiding practice that may contribute to practice variation across Canada.
  
  
  METHODS
  This study was a cross-sectional online survey.
  
  
  METHODS
  This study was done in academic pediatric nephrology centers in Canada.
  
  
  METHODS
  The participants of this study are pediatric nephrologists.
  
  
  METHODS
  An anonymous web-based survey was administered to pediatric nephrologists in Canada to evaluate perspectives and practice patterns regarding timing of dialysis initiation. We also explored the importance of estimated glomerular filtration rate (eGFR) vs. symptoms and the role of patient and provider factors influencing decisions.
  
  
  RESULTS
  Thirty-five nephrologists (59 %) completed the survey. Most respondents care for advanced CKD patients in a multidisciplinary clinic (86 %) and no centers have a formal policy on timing of dialysis initiation. Seventy-five percent of centers follow <20 stage 4-5 CKD patients, and 9 % follow >30 patients. Discussions about dialysis initiation are generally informal (75 %) and the decision to start is made by the nephrologist (37 %) or a team (57 %). Fifty percent agreed GFR was important when deciding when to initiate dialysis, 41 % were neutral, and 9 % disagreed. Variability exists in the threshold that nephrologists considered early (vs. late) dialysis initiation: >20 (21 %), >15 (38 %), >12 (26 %), and >10 ml/min/1.73 m(2) (12 %). Practitioners however typically start dialysis in asymptomatic patients at eGFRs of 7-9 (9 %), 10-11 (41 %), 12-14 (38 %), and 15-19 (6 %) ml/min/1.73 m(2). Patient factors important in the decision to start dialysis for >90 % of nephrologists were fatigue, >10 % weight loss, nausea, increasing missed school, and awaiting a pre-emptive transplant. Age was only a factor for 56 %.
  
  
  CONCLUSIONS
  This study has a 59 % response rate.
  
  
  CONCLUSIONS
  Variability exists in Canada regarding the importance and threshold of eGFR guiding the decision as to when to start dialysis in children, whereas patient symptoms are almost universally important to pediatric nephrologists' decision-making. Additional studies evaluating outcomes of children starting dialysis earlier vs. later are needed to standardize decision-making and care for children with kidney failure.
authors.affiliation: McGill University, Montreal, Canada.
authors.forename: Jeremy A
authors.initials: JA
authors.lastname: Saban
authors.affiliation: McGill University, Montreal, Canada ; Canadian Kidney Knowledge Translation and Generation Network (CANN-NET), Calgary, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Zappitelli
authors.affiliation: University of Calgary, Calgary, Canada ; Canadian Kidney Knowledge Translation and Generation Network (CANN-NET), Calgary, Canada.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Samuel
authors.affiliation: University of Ottawa, Ottawa, Canada ; Canadian Kidney Knowledge Translation and Generation Network (CANN-NET), Calgary, Canada.
authors.forename: Manish M
authors.initials: MM
authors.lastname: Sood
authors.affiliation: University of Alberta, Edmonton, Canada ; Canadian Kidney Knowledge Translation and Generation Network (CANN-NET), Calgary, Canada.
authors.forename: R Todd
authors.initials: RT
authors.lastname: Alexander
authors.affiliation: McMaster University, Hamilton, Canada ; Canadian Kidney Knowledge Translation and Generation Network (CANN-NET), Calgary, Canada.
authors.forename: Steven
authors.initials: S
authors.lastname: Arora
authors.affiliation: University of Saskatchewan, Saskatoon, Canada ; Canadian Kidney Knowledge Translation and Generation Network (CANN-NET), Calgary, Canada.
authors.forename: Robin L
authors.initials: RL
authors.lastname: Erickson
authors.affiliation: University of Manitoba, Winnipeg, Canada.
authors.forename: Kristine
authors.initials: K
authors.lastname: Kroeker
authors.affiliation: University of Calgary, Calgary, Canada ; Canadian Kidney Knowledge Translation and Generation Network (CANN-NET), Calgary, Canada.
authors.forename: Braden J
authors.initials: BJ
authors.lastname: Manns
authors.affiliation: University of Manitoba, Winnipeg, Canada ; Canadian Kidney Knowledge Translation and Generation Network (CANN-NET), Calgary, Canada ; Department of Pediatrics and Child Health, Section of Nephrology, Health Sciences Centre, Children's Hospital of Winnipeg, FE009 - 840 Sherbrook Street, Winnipeg, MB R3A 1S1 Canada.
authors.forename: Allison B
authors.initials: AB
authors.lastname: Dart