CHIU MC, Department of Paediatrics &
Adolescent Medicine, Princess Margaret Hospital, HONG KONG
Dialysis and renal transplantation (RT) has completely changed the outlook of children with end-stage renal disease (ESRD). While 20 years ago, these children had no hope of living, now with successful dialysis and transplantation as means of renal recplacement therapy (RRT), they are able to lead a normal life.
There are many problems with chronic renal failure, e.g. fluid & electrolyte disturbances, hypertension, anaemia, growth failure, renal osteodystrophy, which can be managed conservatively with diet and drugs until GFR falls below 10 ml/min/m2. Other complications may set in, like cardiomyopathy, encephalopathy and neuropathy. Dialysis or transplantation will need to be introduced to avoid such complications & for better control of the disturbances.
For dialysis, it can be either peritoneal (PD) or haemodialysis (HD). The former is often preferable in young children for its easy delivery; as in the latter, vascular access can be sometimes difficult in small kids. Peritoneal dialysis can be delivered by APD (automated PD using a PD machine), or CAPD or IPD. APD is a better choice for it can be delivered at night while the child is asleep, allowing better quality of life in the daytime for educaton and social activity. HD needs the child to come to hospital 3 times a week for dialysis. The procedure requires trained staff for safe delivery of service.
Transplantation can now be done in small children. However, results of those done below 3 are less favourable than those above. Thus, for young infants with ESRD, dialysis can be maintained for the first few years to allow better results to be achieved by RT done later.
In reviewing 20 children put on AutomatedPD in our Department for mean duration of 33.6 ± 14 mons, the incidence of peritonitis was only 1 in 67 patient mons (annualized rate of 0.178). The dialysis adequacy as assessed by Kt/V was 2.67 ± 0.78 and weekly creatinine clearance was 64.6 ± 26.9 litre/1.73 m2. It has proved to be a safe and efficient renal replacement modality with low complication rate.
In 12 children put on chronic HD, mean age 12.3 yrs (4.2 – 19.1yrs) for a mean duration of 23 mons (3-58), Kt/V was 1.35 (cf <1.2 as recommended). There were no major complications, and most problems were catheter related. It was an effective mode of therapy (RRT).
In 15 children (16 grafts) who were transplanted (RT), 7 were living related and 9 cadaveric. The mean duration of follow-up was 2.2 ± 2.4 yrs (0.1 – 8.8 yrs). Actuarial patient survival and graft survival rate were 100% & 93.8% respectively (up to 8.8 yrs). There were 8 episodes of rejection and grafts were able to be salvaged by anti-rejection therapy except one. Three had chronic graft dysfunction despite intensive therapy. There were no other major complications, and infective episodes (mainly of urinary tract) responded to treatment.
Dialysis and tranplantation are effective means of managing children going into ERSD. They are not without problems. Careful management is essential for dialysis patients to have successful long term result, which is important when there is shortage in source of kidneys for transplant.