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 • 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 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

Management of children with CKD in a DGH