Download Management of children with CKD in a DGH 2

Management of children
with CKD in a DGH
M Shenoy
Consultant 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
100
90
% graft survival
80
70
5 yr survival
60
50
10 yr survival
20 yr survival
48 (38 - 58)
p<0.0001
Living
(n=714)
88 (85 - 91)
p<0.0001
71 (65 - 76)
p<0.0001
DBD
72 (70 - 74)
59 (57 - 61)
40
30
(n=2009)
20
10
0
0
5
10
15
years post-transplant
20
37 (33 - 40)
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