Chronic Kidney Disease in Children


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Overview of CKD in children

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Chronic Kidney Disease in Children

  1. 1. Chronic kidney disease (CKD) in children: an overview <ul><ul><li>KHARTOUM - February 2009 </li></ul></ul><ul><ul><li>Eltigani M A. A Ali </li></ul></ul><ul><ul><li>Consultant Paediatrician & Nephrologist, U. of K </li></ul></ul><ul><ul><li>Head of Paediatric Kidney Unit </li></ul></ul><ul><ul><li>Soba U. Hospital </li></ul></ul>
  2. 2. Background <ul><li>CKD has emerged as serious health problem worldwide. </li></ul><ul><li>CKD is about 10 times common in adults than children, </li></ul><ul><li>( Collins AJ, Kasiske B, Herzog C et al, 2003 Am J Kidney Dis ), </li></ul><ul><li>But children have additional problems, e.g slow growth and delayed development, that need special attention. </li></ul>
  3. 3. Background <ul><li>Therefore, evidence-based clinical practice to guidelines support; </li></ul><ul><li>Early recognition and treatment of CKD and related complications in children to improve these problems and, ultimately, the quality of their life. </li></ul><ul><li>[Guidelines] Kopple JD. National Kidney Foundation K/DOQI clinical practice guidelines for nutrition in chronic renal failure (2001), Am J Kidney Dis. </li></ul>
  4. 4. Definition <ul><li>KDOQI defined CKD as “evidence of structural or functional kidney abnormalities (abnormal urinalysis, imaging studies, or histology) that persists for at least 3 months, with or without a decrease in GFR, as defined by a GFR of <60 ml/min per 1.73 m 2” </li></ul><ul><li>However, this is not applicable to children <2 years of age (GFR usually low). Calculated GFR based on serum creatinine is used in this age group. </li></ul><ul><li>[Guideline] Kopple JD. National Kidney Foundation K/DOQI clinical practice guidelines for CKD: evaluation, classification, and stratification. (2002), Am J Kidney Dis. </li></ul>
  5. 5. <ul><li>Prevalence of CKD European data (62.1 per million children require RRT). Van der Heijden et al, (2004) Pediatr Nephrol. In Sudan – difficult to determine (lack of of national database). Table showing children on HD (2005-2009) Nora Ped. Kid. Unit </li></ul>52 42 33 29 36 No of HD patients 2009 2008 2007 2006 2005
  6. 6. Mortality / Morbidity <ul><li>About 70% of children with CKD develop ESRF by age 20 years (10 years survival rate of ≈ 80%). </li></ul><ul><li>Age specific mortality is ≈ 10 times that in children without ESRF. </li></ul><ul><li>The most common cause of death was CVD followed by infection </li></ul><ul><li>Craven AM, Hawley CM, et al, (2007)Perit Dial Int. </li></ul><ul><li>In Sudan mortality was about 24%. The majority had inadequate dialysis. </li></ul><ul><li>EL-tigani Ali, Moh. B. Abdelraheem et al, (2009) Pediatr Nephrol </li></ul>
  7. 7. Aetiology of CKD <ul><li>Chief causes of CKD in children include: </li></ul><ul><li>Obstructive uropathy </li></ul><ul><li>Hypoplastic or dysplastic kidneys </li></ul><ul><li>Reflux nephropathy </li></ul><ul><li>Glomerular diseases mainly FSGS </li></ul><ul><li>Polycystic kidney disease </li></ul>
  8. 8. Aetiology of CKD (stage II or < )in children in Sudan (EL-tigani Ali, Moh. B. Abdelraheem et al, 2009, Pediatr Nephrol) Percentage of total % frequency Primary renal disease 100% 205 Total 39.1 80 Cause Unknown 2 4 Multisystem Disease 6.8 14 Hereditary Nephropathy 9.3 19 Urolithiasis / stones 17.5 36 Congenital Urologic Malformation 25.4 52 Glomerulopathy
  9. 9. Aetiology of CKD (stage II or < )in Sudanese Children : Comparison with International Data 2 8.4 1.7 26 39.1 Cause Unknown ------ ------ ----- 28.9 53.3 Nigeria 2005 % of T 5.6 6.6 3.5 ----- 2 Multisystem Disease 17.6 21.1 21 29 6.8 Hereditary Nephropathy 5.4 ----- ----- 9.3 Urolithiasis / stone 55.1 47 61.9 13 17.5 Congenital Urologic Malformation 10.3 10.2 5.2 19 25.4 Glomerolupathy UK 2006 % of Iran 2001 % of T Kuwait 2004 % of T Tunisia 2004 % of T Sudan 2008 % of T Aetiology
  10. 10. Treatment of children with CKD <ul><li>Specific therapy based on diagnosis </li></ul><ul><li>Evaluation and management of reversible causes of renal dysfunction (e.g volume depletion, drugs,infection) </li></ul><ul><li>Prevention and treatment of complications (e.g. anaemia, bone disease, CVD, hypertension, growth failure) </li></ul><ul><li>Evaluation and management of co-morbid conditions </li></ul><ul><li>Slowing the loss of kidney functions </li></ul><ul><li>Preparation of ESRF therapy </li></ul><ul><li>Replacement of kidney function with dialysis and transplantation </li></ul>
  11. 11. Complexity of care for children with CKD: an example; <ul><li>A child born with prune belly syndrome. </li></ul><ul><li>First week of life –had cutaneous ureter-ostomies. U Tract repair was unsuccessful. </li></ul><ul><li>Further evaluation showed severe renal dysplasia. </li></ul><ul><li>R. function deteriorated-PD was started at 6 months. </li></ul><ul><li>At 21 months had LD renal transplant. </li></ul><ul><li>The child grew and developed well and his vesicostomy was converted to an ileal loop. </li></ul>
  12. 12. Complexity of care for children with CKD: <ul><li>At 12 years had chronic rejection -> slow growth rate -> improved with rhGH therapy. </li></ul><ul><li>At 18 years he was started on HD. </li></ul><ul><li>He had reconstruction of his UT and intensive nutritional treatment. </li></ul><ul><li>At 19 years – had a successful LD renal transplant, s creatinine was 0.9 mg/ld </li></ul>
  13. 13. Complexity of care for children with CKD <ul><li>These children with CKD can only do well if care is consistently provided an by a multi-disciplinary team including; </li></ul><ul><li>Paediatric nephrologists </li></ul><ul><li>Dialysis and transplant nurses </li></ul><ul><li>Paediatric urologists </li></ul><ul><li>Transplant surgeons </li></ul><ul><li>Nutritionists </li></ul><ul><li>Social workers </li></ul><ul><li>Psychologist. </li></ul>
  14. 14. Treatment designed to slow progression of CKD; <ul><li>Interventions proven to be effective in adults include; </li></ul><ul><li>1-Strict BP control </li></ul><ul><li>2-ACE inhibitors ± angiotensin II receptor-blockers (ARBS). </li></ul><ul><li>3- Lipid – lowering therapy + dietary interventions </li></ul><ul><li>4- correction of anaemia. </li></ul><ul><li>*In children, prevention of kidney damage by obstruction and infection should be also considered. </li></ul><ul><li>*The main gaols are BP control and reduction of proteinuria </li></ul>
  15. 15. Progression through ESRF <ul><li>Children with CKD inevitably progress to ESRF that needs treatment. </li></ul><ul><li>Treatment choices for children and their families; </li></ul><ul><li>1- Dialysis or renal transplant? </li></ul><ul><li>2- If dialysis; PD or HD? </li></ul><ul><li>3- If transplant; PEM or after dialysis. </li></ul><ul><li>No choice is final (patients may switch between modalities). </li></ul>
  16. 16. Treatment choices <ul><li>PD versus HD </li></ul><ul><li>Advantages of PD : </li></ul><ul><li>1- Technically easy (used for very small patients) </li></ul><ul><li>2- Better fluid and metabolites balance. </li></ul><ul><li>3- Less disruptive to daily schedules (home dialysis) </li></ul><ul><li>4- No dietary restrictions. </li></ul><ul><li>Advantages of HD; </li></ul><ul><li>1- Appropriate for those with no home support </li></ul><ul><li>2- Better small molecule clearance. </li></ul>
  17. 17. Treatment choices <ul><li>Transplant versus dialysis </li></ul><ul><li>Transplantation is the preferred modality of treatment for most children with ESRF (risk of death from dialysis is 4 times higher). </li></ul><ul><li>(National Kidney Foundation. K/DOQI clinical practice guide-lines for CKD: Am J Kidney Dis 2002) </li></ul><ul><li>1- Patient and graft survival is longer </li></ul><ul><li>2- Quality of life is better </li></ul><ul><li>3- Vascular and peritoneal access sites will be preserved for future use </li></ul><ul><li>4- No risks of vascular calcifications or CVS events. </li></ul><ul><li>5- Improved well-being, growth and development. </li></ul>
  18. 18. Treatment choices <ul><li>Transplantation before dialysis (PEM) or after? </li></ul><ul><li>Transplantation should be performed before the need for dialysis (PEM) because; </li></ul><ul><li>1- Dialysis is disruptive to lifestyle </li></ul><ul><li>2- Dietary and fluid restrictions are needed on dialysis </li></ul><ul><li>3- Mortality is higher on dialysis than post transplant </li></ul><ul><li>Up to 25% of children with ESRD are currently transplanted pre-emptively. (NAPRTCS data 1999) </li></ul><ul><li>In the Sudan only 2 out of 28 (7%) transplanted children had pre-emptive renal transplant </li></ul>
  19. 19. Treatment choices <ul><li>Sudan paediatric HD programme (2005-2010) </li></ul><ul><li>223 ESRF children were on HD in Nora kid. Unit; 58 referred to other centres. Out of the remaining165 patients: </li></ul><ul><li>52 (31.5%) remained active on HD </li></ul><ul><li>18 (10.9%) changed to CAPD </li></ul><ul><li>9 ( 5.5%) transplanted </li></ul><ul><li>69 (41.8%) died </li></ul><ul><li>17 (10.3%) lost of follow up </li></ul>
  20. 21. Treatment choices <ul><li>Sudan paediatric PD programme (2006-2010) </li></ul><ul><li>Out of 114 children (73 Nora Kid. centre, 21 G.I. Oaf Hospital) who opted initially for CAPD:- </li></ul><ul><li>24 (21.1%) remained active on CAPD </li></ul><ul><li>30 (26.3%) changed to HD </li></ul><ul><li>9 ( 7.9%) transplanted </li></ul><ul><li>21 (18.4%) died </li></ul><ul><li>30 (26.3%) lost to follow up </li></ul>
  21. 23. Paediatric Renal transplant in the Sudan <ul><li>No specialised centre for children </li></ul><ul><li>A newly established centre is due to start shortly </li></ul><ul><li>Total number transplanted children-28 (age range 4.5-17 years) </li></ul><ul><li>PEM transplantation 2/28 (7%) </li></ul><ul><li>Male: Female ratio 1.33: 1 </li></ul><ul><li>17 (61%) done in the Sudan </li></ul><ul><li>Donor source; (92% LRD, 8% LURD) </li></ul><ul><li>1 year survival (patient 90%, graft 86.4%) </li></ul><ul><li>Death rate (17%), mainly infection and bleeding </li></ul>
  22. 25. International links <ul><li>Previous ; Manchester Paediatric Nephrology Unit (2001-2005)- Dr. Mc Malcolm Lewis and his nurses group </li></ul><ul><li>Current ; Nottingham City Hospital-Paediatric Nephrology Unit (since 2006)- Prof. Alan R Watson and his group </li></ul><ul><li>Fields of support; </li></ul><ul><li>Training of Doctors (IPNA Fellowship programmes) </li></ul><ul><li>Training of Nurses (dialysis, transplantation) </li></ul><ul><li>Training of Renal Dieticians </li></ul><ul><li>In-service training </li></ul><ul><li>Collaboration in research </li></ul>
  23. 26. Conclusions <ul><li>CKD in paediatric patients in the Sudan </li></ul><ul><li>Number is increasing, but no national registry to determine the prevalence </li></ul><ul><li>Aetiology is unknown in ≈ 40% because of late referral. </li></ul><ul><li>Is associated with high mortality among those on dialysis. </li></ul><ul><li>Transplant is the best choice, but available for only a limited number of patients. </li></ul>
  24. 27. Recommendation <ul><li>Establishment of a national database </li></ul><ul><li>Early detection of CKD cases </li></ul><ul><li>Improvement of dialysis adequacy by recruiting and training of more staff </li></ul><ul><li>Establishment of paediatric renal transplant services </li></ul>
  25. 28. Early detection of CKD <ul><li>Suspect CKD in any child with; </li></ul><ul><li>Bilateral renal defects on antenatal scans. </li></ul><ul><li>Bilateral renal defects on scans e.g. for UTI. </li></ul><ul><li>Some kindred with a family history of CKD. </li></ul><ul><li>Persistent proteinuria. </li></ul><ul><li>Plasma creatinine above the normal range for age. </li></ul><ul><li>Previous ARF. </li></ul><ul><li>Hypertension. </li></ul>
  26. 31. <ul><ul><li>THANK YOU </li></ul></ul>
  27. 33. Treatment choices <ul><li>Re-transplantation versus chronic dialysis </li></ul><ul><li>Re-transplantation is the treatment of choice for children whose grafts have failed. </li></ul><ul><li>But patients may prefer chronic dialysis in ; </li></ul><ul><li>1-Reccurrence of FSGS. </li></ul><ul><li>2-Familial HUS. </li></ul>
  28. 34. Treatment choices <ul><li>LD versus DD renal transplantation </li></ul><ul><li>Most PET come from LD </li></ul><ul><li>Advantages of LD transplant; </li></ul><ul><li>Planned and performed electively </li></ul><ul><li>Better 1 and 5 years graft survival (91% and 80%) compared to (93% and 65%) for CD. </li></ul><ul><li>No difference in patient survival except in infants (79% in CD versus 90% in LRD) </li></ul><ul><li>NAPRTCS 2001 </li></ul>