Management of children with CKD in a DGH

M ShenoyConsultant Paediatric Nephrologist

RMCH

Nephrology for the General Paediatrician Meeting

Manchester

CKD in a DGH

• CKD

• Tubulopathy

• Peritoneal dialysis

• Renal transplant recipient

CKD

eGFR Calculation

• Schwartz formula

40 * ht (cm)/Pcreatinine

Schwartz GJ, Haycock GB et al Pediatrics 1976

1. Child with CKD Stage III

• 4 yr old, male child

• Diagnosed to have dysplastic kidneys

• Creatinine 95umol/l (eGFR 42ml/min/1.73m2)

• Medications: Enalapril, one aphacalcidol

• Admitted with febrile illness, poor intake

• Diagnosis: Tonsillitis

• Creatinine 144umol/l, eGFR now 27ml/min/1.73m2

What are the possible reasons for deterioration in kidney

function in this child?• Infection

• Dehydration

• Medications– Captopril– Ibuprofen

Management

• Prevent dehydration

• Omit ACEi during episodes of dehydration

• Avoid nephrotoxic drugs– NSAID’s– Gentamicin, vancomycin,

aciclovir

• Adjust drug dose for eGFR

Tubulopathy

• RTA– Proximal

• Cystinosis• Drug induced

• Bartter syndrome

• Nephrogenic DI

2. Child with tubulopathy

• 12 year old boy with cystinosis

• Admitted for tonsillectomy

• Pre-op bloods– Na 134, K 3.5, HCO3 19, U 4.2, Cr 124, Ca

2.4, PO4 1.1

• Post op bloods– Na 136, K 2.8, HCO3 11, U 7.8, Cr 210, Ca

2.3, PO4 0.7

Tubulopathy

• Fluids: not ‘maintenance’

• Continue regular medications and electrolyte supplements

• Need 8-12 hourly bloods

• Avoid nephrotoxic drugs

Dialysis

• Around 30 children on dialysis– Home PD 20, 6-7

nights/week– In centre 3-4/week HD 10

• Oliguric and non-oliguric

• Dialysis access

3. Child on PD

• 12 year old girl on PD, anuric

• Admitted with abdominal pain

• Mother reports cloudy effluent

Fluids in an anuric child

• Ask how much is their fluid allowance

• Usually 600 – 1000ml/day

• Excess fluids leads to hypertension and need for more dialysis

Complications of PD catheter

• Peritonitis– < 1 episode/14 patient months averaged over 3 years– Diagnosis: PD fluid WCC >100– Treated with IP antibiotics for 2 weeks

• Exit site infection

• Catheter migration

• Catheter blockage

Renal Transplant

• UK 125 paediatric transplants per year– Manchester ~15

• 75% living donor

• ~60 children attending transplant clinic

Renal transplant

• Immunosuppression– Used to be ciclosporin,

azathioprine and prednisolone

– Now tacrolimus and mycophenolate mofetil

Graft survival following first paediatric kidney only transplant

% g

raf t

sur

viva

l

0

10

20

30

40

50

60

70

80

90

100

years post-transplant0 5 10 15 20

5 yr survival 10 yr survival 20 yr survival

Living 88 (85 - 91) 71 (65 - 76) 48 (38 - 58)(n=714) p<0.0001 p<0.0001 p<0.0001

DBD 72 (70 - 74) 59 (57 - 61) 37 (33 - 40)(n=2009)

Am J Transplant 2004; 4: 384-389

4. Child with kidney transplant

• 6 year old boy with kidney transplant 2 years back

• Admitted with febrile illness

• Bloods:– Creat 135 (usually ~60)

Reasons for reduced graft function

• Infection– Bacterial, viral, PTLD

• Rejection– Late rejection, usually compliance issues

• Drug toxicity– Tacrolimus, NSAIDs

• Obstruction

Summary

• Child with CKD – Attention to fluid balance and electrolytes

– Avoid drug toxicity

– Dialysis access is precious

– Infection, rejection and drug toxicity in a transplant recipient

– Discuss with Nephrologist