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Kids and Kidney Disease. Catherine Picarelli, RN, BSN, CNN Hackensack University Medical Center Hackensack, NJ. Objectives. List common causes of kidney disease in children. Name two differences in caring for children as compared to adults with kidney disease.

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kids and kidney disease

Kids and Kidney Disease

Catherine Picarelli, RN, BSN, CNN

Hackensack University Medical Center

Hackensack, NJ

  • List common causes of kidney disease in children.
  • Name two differences in caring for children as compared to adults with kidney disease.
  • Describe treatment options for children with stage 5 Chronic Kidney Disease.
common kidney diseases in children
Common Kidney Diseases in Children
  • Nephrotic Syndrome
  • Cystic/Hereditary/Congenital
  • Glomerulonephritis
  • Vasculitis
  • Acquired Diseases
nephritis nephrosis

Glomerular inflammation



RBC casts


Renal Insufficiency



↑ Glomerular capillary wall permeability






Nephritis /Nephrosis
nephrotic syndrome
Nephrotic Syndrome
  • Applicable to any condition with heavy proteinuria, hypoalbuminemia, and edema
  • Disorder of the glomerular filtration system
  • May be primary or secondary to systemic disease
minimal change disease
Minimal Change Disease
  • 90% respond to steroids
  • Remission achieved in 1-4 weeks
  • Relapse when proteinuria and hypoalbuminemia recur
  • Frequent relapses
    • 2 or more episodes in 6 months
    • 4 or more episodes in 12 months
minimal change disease8
Minimal Change Disease
  • Treatment
    • Steroids: Prednisone 2 mg/Kg/Day
    • Cyclophosphimide
    • Prograf
    • Cellcept
    • Rituximab
steroid resistant nephrotic syndrome
Due to



Steroid-resistant MCD

Alport Disease

Diagnosis by kidney biopsy

Known progression to ESRD

50% or more after 10 year follow-up

Steroid-Resistant Nephrotic Syndrome
steroid resistant nephrotic syndrome10
Steroid-Resistant Nephrotic Syndrome
  • Treatment: Combined immunosuppression
    • Prednisone
    • Cytoxan/Cellcept
    • Prograf/Cyclosporin
    • ACE/ARB: decreases proteinuria to slow progression of disease
steroid resistant nephrotic syndrome11
Steroid-Resistant Nephrotic Syndrome
  • End- Stage Renal Disease (ESRD)
    • Hemodialysis
    • Peritoneal Dialysis
    • Kidney Transplant
      • Recurrence of FSGS with graft loss about 30-40%
      • Recurrence of MPGN, type I, with graft loss about 30%
causes of renal failure in children
Causes of Renal Failure in Children
  • Age 0-4:Genetic Causes, Congenital Defects
  • Age 5-9: Dysplastic Kidneys, Hypoplastic Kidneys, Triad Kidneys
  • Age 10-19:Glomerulonephritis
  • Very rare for cause to be diabetes or hypertension
effects of renal failure on children
Effects of Renal Failure on Children
  • Growth Problems
  • School/Cognitive Problems
  • Cardiovascular
  • Infectious Complications
  • Social Isolation
  • Family/Financial Stress
goals in caring for children
Goals in Caring for Children
  • Maximize growth and development potential
  • Diminish behavioral, social, and family dysfunction
  • Insure child has age appropriate equipment
growth issues

Behavioral aversion



Renal failure at times of growth spurts

Supplement nutrition

Monitor closely

Correct acidosis

Calcium/Phos control

Growth hormone therapy

Growth Issues
school cognitive development
Behind peers cognitively

Missed school days

Failing grades

Coping skills limited

Decreased social skills

Treatment (anemia, uremia, sleep)

Encourage school attendance (IEP, 504)

Peer activities

Summer camp

School/Cognitive Development
Hypertension (LVH, Microvascular damage)


Long-term mortality risk

Keep BP <90th %ile

Echocardiograms/ ABPM

Low sodium/Low fat diet

Regular exercise

Decreased immunity in ESRD

Access infections

Second most common morbidity in children after CV

Good nutrition

Teach good hand washing

Prompt recognition and treatment of infections

Constipation/ diarrhea


Feeding problems

High fiber diet

Regular bowel program


High incidence of G-tubes

social issues
Child and family can become isolated

Financial stress

Insurance coverage

Job instability

Social work and Child life therapy involvement

School support

Prescribe covered medications


Social Issues
treatment options
Treatment Options
  • Hemodialysis
  • Peritoneal Dialysis
  • Transplantation
  • No Treatment
  • Small volume dialyzers/extracorporeal circuit
    • Calculate prime / rinse volume
  • Program machine in pediatric mode
  • Adjust blood pump segment according to prescribed extracorporeal circuit
    • Small amounts of fluid make a big difference
    • Need precise weights
  • Bicarbonate dialysate
  • Normal Saline
  • 5% Albumin
  • Blood
extracorporeal blood volume
Extracorporeal Blood Volume
  • Blood volume of child is 80cc/kg body weight
  • No more than 10% of blood volume should be in circuit during treatment
  • Example-10kg child: 80cc x 10kg= 800cc blood volume
    • No more than 80cc out during treatment
blood flow rate
Blood Flow Rate
  • 3-5 cc/kg per minute
  • Access is the driver in rate
    • Central venous catheters
    • Grafts
    • Fistulas
  • Signs often subtle
  • Watch closely
    • Irritability
    • Yawning
    • Fidgeting
    • Heart rate may change before BP drops
peritoneal dialysis
Peritoneal Dialysis
  • Treatment of choice for infants and small children
  • Peritoneal membrane in children is very large in relation to their BSA
    • Usually high transporters
  • Initial fluid volumes are 10-20mL/kg, then up to 40mL/kg
peritoneal dialysis28
Peritoneal Dialysis
  • CCPD
    • Machine programmed with prescription
    • Maintain a running tabulation of UF
  • CAPD
    • Backup for power outages, vacations
  • Manual
    • Used in infants with fill volumes < 50mL
renal transplant
Renal Transplant
  • Definitive form of RRT for children
  • Preemptive transplant when possible
  • Recipient
    • 6 months/10kg
    • Pt/Family able to comply with meds and follow-up
    • Stable social/home situation
  • Living Donor
    • Shorter waiting time/ischemic time
    • Closer matches
    • Better graft survival/overall outcomes
  • Deceased Donor
    • Advantage given to pediatric patients on waiting list
bladder urology
  • Many pediatric diseases are associated with bladder dysfunction
    • Posterior urethral valves
    • Severe vesico-ureteral reflux
    • Other obstructions
  • Dysfunctional voiding
  • Inadequate bladder emptying
bladder urology33
  • Collaborative evaluation and care between the Pediatric Urologist and Nephrologist
    • Minimally invasive approach
    • Bladder augmentation
    • CIC, mitrofanoff
    • Native nephrectomy
immunizations viral surveillance
Immunizations/Viral Surveillance
  • Assure pre-transplant immunizations
  • No live-virus vaccines post transplant
    • MMR
    • Varicella
    • Oral polio
  • Determine pre-transplant viral exposure and antibody response
    • EBV, CMV, HIV, Hepatitis, VZV
additional transplants
Additional Transplants
  • Goal is to keep transplant as long as possible.
  • Most children will require additional transplants.
tips in caring for children
Tips in Caring for Children
  • Need a basic knowledge of developmental milestones and capabilities of the age child you are caring for.
  • Explanations and teaching should be age appropriate.
tips in caring for children37
Tips in Caring for Children
  • Set limits and stick to them.
  • Be firm- don’t let a child manipulate you.
  • Consider having parents assist in getting a child to cooperate.
  • Avoid patient/parent/staff power struggles.
tips in caring for children38
Tips in Caring for Children
  • Don’t feel sorry for them because they have renal failure.
  • Don’t treat them as if they are sick.
  • Treat them as much like their peers as possible.
  • Expect them to behave as their peers would.
tips in caring for children39
Tips in Caring for Children
  • Expect cooperation- they will rise to the occasion and meet your expectations.
  • Never lie!
  • Telling a lie destroys trust with you.
  • Determine activities and interactions based on developmental age- not chronological age.
tips in caring for children40
Tips in Caring for Children
  • Children like consistent routines.
  • Explain what you are doing- before you do it.
  • Don’t offer a choice if none are available.
  • Treat each child as you would want your own child treated!