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Chapter: Paediatrics: Nephrology

Paediatrics: Chronic kidney disease: treatment

There should be early liaison with and referral to a regional paediatric nephrology centre.

Chronic kidney disease: treatment

 

There should be early liaison with and referral to a regional paediatric nephrology centre.

 

Urgent life-threatening abnormalities

   High/low plasma K+.

   Low plasma Na+/acidosis/low Ca2+/high. PO43–.

   High/low BP.

 

Nutrition

 

Early involvement of the paediatric dietician is needed.

   Estimated average requirement (EAR) should be worked out.

often require supplements to achieve this;

NG/gastrostomy feeds.

   Minimum protein intake of EAR for age.

   Vitamin supplements (but not vitamin A).

 

Fluid and electrolyte balance

·  Avoid high K+-containing foods (e.g. banana, chocolate).

   Many causes of chronic renal failure (CRF) cause polyuria and Na+ wasting; therefore, Na+ supplements are needed.

   If clinical fluid overload, Na+ restriction and diuretics.

 

Acid–base balance sodium bicarbonate supplements.

 

Renal osteodystrophy

   Control of plasma PO4. Restrict dietary intake/PO4 binders.

   Calcitriol (vitamin D) 15ng/kg/day.

   Monitor PTH.

 

Anaemia

 

   Assess iron status: oral iron supplements.

 

   Subcutaneous erythropoietin.

 

   Hypertension.

 

Preservation of renal function

 

   Control hypertension.

 

   Reduce proteinuria: e.g. angiotensin-converting enzyme (ACE) inhibitor/ angiotensin receptor blocker therapy.

 

   ‘Statin’ therapy: evidence of benefit from adult CRF trials.

Growth

 

Optimize nutrition, acid–base balance, electrolyte balance.

 

If failing height velocity (HV –2 SD or below) or short stature (Ht –2 SD or below) despite correction of above, treatment with recombinant human growth hormone is indicated.

 

Education and preparation for dialysis/transplantation

 

Information provision.

 

Meet team.

 

Meet other families.

 

Dialysis

 

Peritoneal dialysis (PD)

 

Preferred choice is automated peritoneal dialysis (APD) performed in

 

patient’s home (with mobile machines); therefore minimal disruption.

 

Main risks: peritonitis and catheter blockage.

 

Needs family and social support.

 

Haemodialysis (HD)

 

Extracorporeal circuit.

 

Vascular access by jugular venous catheter.

 

Increasingly, long-term vascular access is by AV fistula (wrist or elbow). Therefore, avoid non-dominant arm for venepuncture and IV.

 

Usually 4hr session, 3 times/wk in hospital.

 

Home HD possible if there is a family member to support this.

 

Renal transplantation

 

This is the ultimate goal in CRF.

 

Minimum 10kg (or when immunizations complete).

 

Deceased donor vs. living-related donor (LRD) source.

 

Pre-emptive transplantation before dialysis required is ideal.

 

LRD by laparoscopic donor nephrectomy is now standard.

 

Graft survival 85% after 2yrs.

 

Lifelong immunosuppression is required.

 

Psychosocial support

 

For patient and family this is crucial as CRF is lifelong treatment.

 

Focus on prevention of cardiovascular disease, which is a major cause of mortality and morbidity in adult life.

 

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Paediatrics: Nephrology : Paediatrics: Chronic kidney disease: treatment |


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