Chronic kidney disease: treatment

2021-03-03 12:00 AM

There should be an 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.

  • The estimated average requirement (EAR) should be worked out.

often require supplements to achieve this;

NG/gastrostomy feeds.

  • Minimum protein intake of the 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/PO4binders.
  • Calcitriol (vitamin D) 15ng/kg/day.
  • Monitor PTH.

Anaemia

  • Assess iron status: oral iron supplements.
  • Subcutaneous erythropoietin.
  • Hypertension.

Preservation of renal function

  • Control of 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)

  • The 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 the 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.
  • Preemptive 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 a lifelong treatment.
  •  Focus on the prevention of cardiovascular disease, which is a major cause of mortality and morbidity in adult life.