Abstract
Keywords
The present paper narrates the experience of dealing with children with renal failure at the Children's Kidney Care Center, St. John's Medical College Hospital, Bangalore, India. Strategies to possibly improve the outcomes of children with renal failure in developing countries are discussed.
Patients and Methods
We reviewed and analyzed the case records of children requiring dialysis therapy over the past 20 months at the Children's Kidney Care Center, St. John's Medical College Hospital, Bangalore, India. A total of 50 children received acute dialysis therapy during the period. Of those 50 children, 36 children received peritoneal dialysis (PD), 7 received hemodialysis (HD), and 7 received both PD and HD. The male:female ratio was 4:1. The mean age of the children who received PD was 6.7 years (range: 1 month to 15 years), and of those who received HD, 9.2 years (range: 4 – 17 years).
Two children were dialyzed for severe metabolic acidosis owing to an inborn error of metabolism. The rest had renal failure: acute renal failure (ARF) in 47.9%; end-stage renal failure (ESRF) in 35.4%; and acute on chronic renal failure in 16.7%. In the cases of acute on chronic renal failure, the main causes for acute worsening of renal function were volume depletion and drug nephrotoxicity. The causes of ARF and chronic renal failure (CRF) are depicted in Tables 1 and 2.
Causes of Acute Renal Failure
ATN = acute tubular necrosis; NS = nephrotic syndrome.
Causes of End-Stage Renal Failure
The main reasons for dialyzing the children were fluid overload (20%), hyperkalemia (14%), severe metabolic acidosis (8%), encephalopathy (18%), and biochemical azotemia (40%). The mean pre-dialysis levels of blood urea and serum creatinine were 204.9 mg/dL and 6.76 mg/dL respectively.
Acute PD was performed using acute PD catheters and available standard PD solutions containing 1.5% dextrose. The volume of dialysate infused per cycle was 20 – 50 mL/kg, as tolerated. Hypertonic solutions were used to achieve additional negative balance if fluid overload was a problem. The PD catheters were removed after each PD session. The problems encountered during PD were predominantly mechanical: for example, poor flow or blockage necessitating change of the acute PD catheter.
For acute HD, temporary double-lumen internal jugular catheters were used. Depending on the weight of the child, F3 or F4 Fresenius hemodialyzers were used. Because pediatric HD blood tubing was not available, regular adult HD tubing was cut to size and tailored to reduce the volume of the extracorporeal circuit. The main problems encountered during HD were poor flow, blockage, and bleeding from the catheter site.
Table 3 depicts the outcomes of the children who presented with ARF. Among those children, 60% made a complete recovery, with no residual renal deficits. Two children with atypical hemolytic uremic syndrome progressed to CRF. The children with acute on chronic renal failure with residual renal deficits are being followed up.
Outcomes in Acute Renal Failure
Six children underwent continuous ambulatory peritoneal dialysis (CAPD). One child was initiated on CAPD at another center. She had developed multiple adhesions secondary to Candida peritonitis and hence CAPD could not be continued. In 2 children, CAPD was discontinued by request of the parents, owing to financial constraints. In the other 3 children, CAPD was used as a renal replacement therapy for a few weeks until transplantation could be arranged. Of all the children with ESRF, only 3 could undergo transplantation. In the others, maintenance dialysis could not be continued beyond a few weeks or months owing to financial constraints and passive, negative attitudes.
Discussion
Few studies in children compare the outcome of ARF when various types of renal replacement therapies (RRTs) are used for treatment (1). A survey of North American pediatric nephrologists by Warady et al regarding dialytic management of childhood ARF (2) showed that hemofiltration was the initial choice for RRT among the nephrologists (median: 40%; range: 0% – 100%), followed by PD (median: 30%; range: 0% – 85%) and HD (median: 20%; range: 0% – 50%). Many factors, including the age and size of the child, cause of renal failure, rapidity of onset of renal failure, degree of metabolic derangement, blood pressure, and need for nutrition are considered in deciding when to initiate RRT and which modality to use (2).
Acute PD has been a major modality of therapy for ARF in children for several years (2-4). The advantages of PD are that it is relatively easy to perform and does not require heparinization, and that the child need not be hemodynamically stable to undergo treatment. The disadvantages include a slower correction of metabolic parameters and a potential risk of peritonitis. Relative contraindications include recent abdominal surgery, massive organomegaly or intra-abdominal masses, and existence of ostomies (which may increase the risk of peritonitis).
The successful use of acute peritoneal dialysis (APD) in infants and children with ARF was first reported in 1961 and 1962 by Segar et al (5) and Etteldorf et al (6). Acute PD catheters are straight, relatively rigid conduits about 1.5 – 3.0 mm in diameter and 25 – 35 mm in length. They were first introduced by Westin and Roberts in 1965 (7). With prolonged use, the catheter design is associated with a significant risk of peritonitis, malfunction, and bowel perforation. Therefore, the recommendation is that these catheters not be left in place for longer than 3 days. The use of safer, long-term catheters is recommended.
Few centers use the acute catheters (8). In the circumstances pertaining in India, where facilities and expertise for HD are not available in remote areas and where HD centers exclusively for pediatric patients are essentially nonexistent, acute PD is a useful procedure. It is not only lifesaving, it also helps to buy time for planning investigations and definitive treatment. In our patients with ARF, acute PD was the primary modality of dialysis treatment.
Although early problems arose with the application of a complex extracorporeal technique for HD in children and small infants, the availability of sophisticated equipment, together with skilled nursing, makes the technique applicable to even the smallest or sickest of children (9). Hemodialysis has the advantage of quick correction of metabolic abnormalities and rapid correction of hypervolemia by ultrafiltration. The disadvantages of HD include the requirement for vascular access and the need for heparinization, purified water, sophisticated equipment, infrastructure, and skilled personnel. Those disadvantages, pertaining to India, preclude the routine use of HD as a modality of RRT, especially in smaller children.
Over the past several years, RRT with hemofiltration has become increasingly popular in the treatment of ARF in children (10,11). However, in India, hemofiltration as a modality of RRT is not commonly considered for the same reasons that HD is seldom used. In India, acute PD remains the mainstay of dialysis treatment for children with ARF.
The causes of ARF vary in the various parts of India. Acute intravascular hemolysis in glucose-6-phosphate dehydrogenase (G-6PD)–deficient subjects, snakebites and Falciparum malaria are important causes of ARF in some areas of the country. The incidence of ARF following streptococcal glomerulonephritis and acute gastroenteritis, and hemolytic uremic syndrome (HUS) following Shigella have been on the decline. Infection caused by verotoxin-producing Escherichia coli appears to be rare (12). The causative spectrum in our patients with ARF is wide, as depicted in Table 1.
The long-term goal of ESRF care for children is to provide the longest possible life span with minimum morbidity, and an opportunity for maximal growth and development. As compared with adults, children are excellent candidates for all types of ESRF care (13). The consensus is that renal transplantation is the preferred mode of treatment for most children with ESRF (14). In children in India, CRF carries a poor prognosis owing to late referral and limited availability and high cost of RRT (15). Provision of RRT is constrained by socioeconomic factors. Chronic dialysis is usually undertaken only if renal transplantation is an option.
Pediatric renal transplantation in India has lagged. No transplant registry exists in the country. So far, hardly 100 transplants have been performed in children in the country (12). The reasons cited for poor growth of pediatric renal transplantation in India include lack of awareness, passive attitudes, financial constraints, inadequate facilities, and an ill-developed cadaveric transplant program (16).
Most of our ESRF children presented for the first time with an acute crisis requiring emergency dialysis. Out of 17 children with ESRF, only 3 could undergo transplantation. The others ultimately succumbed owing to discontinuation of dialysis therapy for one or more of the reasons mentioned earlier.
Conclusions and Recommendations
In a developing country such as India, the emphasis should be on prevention. Education about kidney diseases in children for the medical profession, the paramedical professions, and society at large would play an important role. Early diagnosis and quick referral would improve the outcomes of children with renal failure.
Neither the government nor the insurance companies cover treatment expenses. Hence, the “cost issues” need to be addressed by developing financial supports from the private corporate and industrial sectors.
Acute PD should be promoted to take care of children with uncomplicated ARF and to stabilize children with ESRF before they are referred to specialized tertiary care centers. A dedicated social worker should form an integral part of the team taking care of children with renal failure. Preemptive transplantation should be encouraged, so that the cost of RRT therapy is reduced. All efforts should be made to promote the cadaveric transplant program.
The International Pediatric Nephrology Association and the International Society for Peritoneal Dialysis should make united efforts to see how the cost of CAPD can be reduced in developing countries and help to run a CAPD program to keep children with ESRF alive and fit to undergo transplantation.