MC Chiu, KC Tse, WM Lai

Abstract

With dialysis and renal transplantation as long-term renal replacement therapy (RRT), the prognosis of end-stage renal failure in children has been completely changed as compared with 20 years ago. Either dialysis or tranplantation should be considered when glomerular filtration rate (GRF) is reduced to 10-15 ml/min/1.73m² BSA in the presence of growth failure and significant symptoms. For dialysing small children, peritoneal dialysis is the preferred mode; and automated peritoneal dialysis (APD) is better than continuous ambulatory peritoneal dialysis (CAPD) in that it allows a better quality of life and sees to the different requirements of dialysis. Adequate dialysis is correlated with less morbidities and mortalities, and thus is important in long term dialysis. Nowadays, chronic dialysis in infants has a high success rate, which justifies its implementation even in end-stage renal failure neonates, unless there are significant non-renal co-morbidities of the brain, heart or lung. Haemdialysis is an option of RRT especially for bigger children and adolescents. The main problem is vascular access. Thrombosis and stenosis are complications not uncommonly encountered when patients have been put on haemodialysis for some years. Renal transplantation is the best modality of RRT and can be successfully done in small children, depending on expertise and centres. With the use of potent immunosuppressants, rejections are few and good long-term results can be achieved. The experience and results of the RRT programme of the Paediatric Nephrology Centre at Princess Margaret Hospital are discussed. Since 1996, all children requiring peritoneal dialysis were put on automated peritoneal dialsysis (APD), and there were 24 of them altogether. Dialysis adequacy exceeded the recommended targets, and the peritonitis rate was recorded to be very low, 1 in 87.5 patient-months. There were 15 patients on long-term haemodialysis, and either permanent central catheter or arteriovenous fistula (AVF) had been used as the vascular access. The main problems were blockage, thrombosis and stenosis in small children. Renal transplantation was done in 19 children with 20 kidney grafts, 13 from cadaver donors and 7 from living donors. One child had a second transplant. For cadaveric transplants, the graft survival rates at 1 and 3 years were 92% and 81%; and for living transplants, the graft survival rates at 1 and 3 years were 100%. These results compared favourably with those reported by the North American Pediatric Renal Tranplant Co-operative Study (NAPRTCS). Such results could only be achieved through re-organization of services to allow accumulation of patients and expertise.