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Treatment options for children with End Stage Renal Failure. David V Milford Birmingham Children’s Hospital. Regional context. Renal Unit established by Mike Winterbon October 1979 288 children treated for ESRF to date. Age at start of RRT Birmingham Children’s Hospital. age. 20. died.

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Treatment options for children with End Stage Renal Failure

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Treatment options for children with end stage renal failure

Treatment options for children with

End Stage Renal Failure

David V Milford

Birmingham Children’s Hospital


Treatment options for children with end stage renal failure

Regional context

Renal Unit established by Mike Winterbon October 1979

288 children treated for ESRF to date


Treatment options for children with end stage renal failure

Age at start of RRT

Birmingham Children’s Hospital

age

20

died

15

10

5

0

1980

1982

1984

1986

1988

1990

1992


Peritoneal dialysis

Peritoneal dialysis

  • CCPD>CAPD

  • Advantages

    • nocturnal therapy (CCPD)

    • relative preservation of daily routine

    • easy(ish) to learn

  • Disadvantages

    • less efficient than HD

    • requires strict attention to technique

    • pressure on carers

    • infections are (relatively) common

    • not possible in some patients


Haemodialysis

Haemodialysis

  • Hospital HD, home HD

  • Advantages

    • less pressure on carers

    • efficient, requires less time

    • frequent hospital reviews

  • Disadvantages

    • disruptive of routine

    • access problems

    • hospital dependant

    • requires special equipment,fluids


Kidney transplantation

Kidney transplantation

  • Cadavaric, live donor

  • Before/after dialysis

  • Advantages

    • restores normal renal functions

    • improved growth, development, educational progress

  • Disadvantages

    • lifelong immunosuppression (infections, neoplasia)

    • sensitisation

    • graft loss


Treatment options for children with end stage renal failure

Pre-emptive renal transplantation

transplantation prior to dialysis

LRD or CAD kidneys

Advantages

avoids stress of dialysis

better for growth and development

Disadvantages

timing is difficult for CAD

risk of transplanting unnecessarily


Transplantation

Transplantation

  • Developments

    • better immunosuppressive regimens

      • less nephrotoxic immunosuppressive drugs

      • less steroids

      • reduced incidence of rejection

      • improved graft survival

    • acceptance of pre-emptive grafting

    • improved bladder management

    • ABO and HLA incompatible grafts


Treatment options for children with end stage renal failure

1 year graft survival (UNOS)

LRD

cadavaric

Hariharan et al NEJM 2000; 342:605-12


Treatment options for children with end stage renal failure

Birmingham Children’s Hospital

Kaplan Meier Actuarial Survival Curve (excluding deaths

with a functioning graft) n=80 Graft Survival (days)

1.0

0.8

0.6

Cumulative Survival

0.4

0.2

0.0

0.00

1000.00

2000.00

3000.00

4000.00

5000.00

Graft survival (days)


Transplantation1

Transplantation

  • Limitations

    • inadequate supply of cadavaric organs

    • compliance issues


Treatment options for children with end stage renal failure

Transplant numbers


Treatment options for children with end stage renal failure

Patients on Waiting list 2000- Dec 2006


Treatment options for children with end stage renal failure

Transplant losses >3 months after Tx

1.1.1995-31.12.2004


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