Management of children with ckd in a dgh
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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

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Management of children with CKD in a DGH

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Management of children with ckd in a dgh

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 in a DGH

  • CKD

  • Tubulopathy

  • Peritoneal dialysis

  • Renal transplant recipient


Management of children with ckd in a dgh

CKD


Egfr calculation

eGFR Calculation

  • Schwartz formula

    40 * ht (cm)/Pcreatinine

Schwartz GJ, Haycock GB et al Pediatrics 1976


1 child with ckd stage iii

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

What are the possible reasons for deterioration in kidney function in this child?

  • Infection

  • Dehydration

  • Medications

    • Captopril

    • Ibuprofen


Management

Management

  • Prevent dehydration

  • Omit ACEi during episodes of dehydration

  • Avoid nephrotoxic drugs

    • NSAID’s

    • Gentamicin, vancomycin,

      aciclovir

  • Adjust drug dose for eGFR


Tubulopathy

Tubulopathy

  • RTA

    • Proximal

      • Cystinosis

      • Drug induced

  • Bartter syndrome

  • Nephrogenic DI


2 child with tubulopathy

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


Tubulopathy1

Tubulopathy

  • Fluids: not ‘maintenance’

  • Continue regular medications and electrolyte supplements

  • Need 8-12 hourly bloods

  • Avoid nephrotoxic drugs


Dialysis

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

3. Child on PD

  • 12 year old girl on PD, anuric

  • Admitted with abdominal pain

  • Mother reports cloudy effluent


Fluids in an anuric child

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

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

Renal Transplant

  • UK 125 paediatric transplants per year

    • Manchester ~15

  • 75% living donor

  • ~60 children attending transplant clinic


Renal transplant1

Renal transplant

  • Immunosuppression

    • Used to be ciclosporin, azathioprine and prednisolone

    • Now tacrolimus and mycophenolate mofetil


Graft survival following first paediatric kidney only transplant

Graft survival following first paediatric kidney only transplant

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)


Management of children with ckd in a dgh

Am J Transplant 2004; 4: 384-389


4 child with kidney transplant

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

Reasons for reduced graft function

  • Infection

    • Bacterial, viral, PTLD

  • Rejection

    • Late rejection, usually compliance issues

  • Drug toxicity

    • Tacrolimus, NSAIDs

  • Obstruction


Summary

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


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