In our country, the ESRD patients are supported by health ministry and “foundation of special disease” and most parents tend to follow their children's treatment. In our study only 7.8% of parents refused treatment. In study of Gulati in 1999, in India[13
] 40% and in Vietnam[10
] 50% of parents refused from further therapy because of financial problems.
Initial modality of dialysis varies among nephrology centers depending on technical and nursing facilities. Peritoneal dialysis (PD) is the most common modality in most European countries and North America for dialysis of children.[5
] Also in some developing countries such as Tunisia and Jordan, PD was used in most of children needed RRT.[14
] While in our study HD was initial RRT modality in 82% of patients. In an Iranian multicenter national study, 93.5% of all dialysis patients (including children and adults) received HD and only 6.5% received PD.[12
] Also in a single-center study in Tehran/Iran, HD was the predominant form of RRT in children.[16
] The higher use of HD in our patients may be explained by nephrologist bias, lack of adequate nursing and technical support and noncompliant families. Automated PD (APD) which is the most frequently used form of PD in children in developed countries[5
] has led to considerable reduction of peritonitis rate. In our study, CAPD (instead of APD) was the sole modality of PD due to lack of cycler machines. Similar to our results, CAPD was the initial PD modality of choice in 92.6% of Turkish children as reflected in the report of the Turkish Pediatric Peritoneal Dialysis registry.[17
In this study, 34% of patients and in an 8-year study in Tehran/Iran, 32.5% of ESRD children underwent transplantation.[16
] According to the report of Turkish Pediatric Peritoneal Dialysis registry,[17
] only 15.4% of Turkish ESRD children were transplanted that is less than our study. While in an 11-year study in Kuwait,[18
] a country with high level of treatment facilities, 76% of pediatric ESRD patients underwent renal transplantation. In a study in the United Kingdom, 56% of ESRD children younger than 2 years received transplant at mean age of 2.6 years and 87% were transplanted between 1 and 4 years.[19
] While in our study, from 14 patients younger than 4 years, no one was transplanted before 4 years of age. Lower rate of transplantation in this study in comparison with some countries may be attributed to lack of cadaver donors and high cost of living unrelated donors.
Preemptive transplantation is optimal treatment of pediatric ESRD for maintaining growth and development of children. In a report from North America[5
] 16% and in Kuwait[18
] 26% of ESRD children underwent preemptive transplantation. Contrary to these reports, relative frequency of preemptive transplantation was only 1.4% in Turkey[20
] and 2.5% in our study. The less number of preemptive transplantation in this study may be explained by late referral. Most of our patients (58.5%) presented at terminal stage, so needed dialysis before preparing for transplantation. Similar findings have been reported from other developing countries.[9
] In Vietnam[11
] 85%, in India[13
] 54% and in Paraguay[21
] over 60% of ESRD children were already in ESRD before first admission. Late referral indicates the failure of primary healthcare systems to diagnose CKD and conditions leading to ESRD in early stages.
Survival rate of children younger than 20 years on chronic RRT has increased over the past years and varies from 79% to 82% at 10 years in developed countries.[5
] In this study that included children younger than 16 years, only 67% of patients were alive at the end of study period. It should be noted that a younger age at onset of RRT is a considerable mortality risk factor in all studies.[22
] Moreover, higher mortality in our study may be attributed to prolonged stay on dialysis and some socioeconomic factors. In some countries such as Jamaica[22
] and Nigeria,[23
] mortality rate of ESRD children is even higher than our results and is about 44.4% and 47%, respectively.
Cardiovascular disease is the most common cause of death in ESRD children and is responsible for 21.5–50% of mortalities in different studies followed by infections that account for 20% of mortalities.[24
] In accordance to other studies, heart failure and infections were the most frequent causes of death in our study.