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.

由於透析和腎移植被視為長期腎替代療法的緣故，使到兒童終末期腎衰竭的預後與 20 年前相比已經完全改變。在腎小球濾過率 10-15 ml/min/1.73 m² BSA 並且有生長遲緩和明顯症狀時，透析或者腎移植就應該予以考慮。對於年齡較小的透析病童來講，腹膜透析是一個較好的選擇，自動腹膜透析優於持續性非卧床腹膜透析，因為前者提供了更好的生活質量和更能切合透析上不同的需要。足夠的透析療法能夠降低發病率與病死率，這對於長期的透析治療是重要的。現在，長期透析已經在嬰兒中取得高的成功率，這樣亦証明它可以應用於新生兒的終末期腎衰竭，除非其合併有胸、心和肺等疾病。血液透析是較大兒童和青少年腎替代療法的其中一個選擇。其面對的主要問題就是血管通路、血栓形成和狹窄對於已應用血透析多年的病者來講並不少見，腎移植是腎替代療法中最好的方式，亦可以成功地在較小的兒童中應用，這取決於專門技術和醫療中心，在應用有力的免疫抑制劑之下，排斥現象已經少見，而且也有良好的遠期效果。我們討論瑪嘉烈醫院兒童腎病中心在腎替代療法所取得的經驗與結果，自 1996 年共有24 位需要腹膜透析的病童應用了自動腹膜透析。透析量亦超過了建議的目標，並且腹膜類的發生率亦低至 1/87.5 病人/月。有 15 名病人是通過永久性中心導管或者動靜脈瘻作為血管通路來進行長期血液透析。在年齡較小的兒童中其重要問題是阻塞、血栓形式和狹窄。有 19 名兒童進行了腎移植，共用了 20 個腎移植物，其中 13 個來自屍體供者，7 個來自活體，有一個兒童進行第二次的移植術。對於屍供腎移植，移植物的一年和三年的成活率分別為 92% 和 81%；對於活體移植，一年和三年移植物成活率均為 100%。這些結果可以較好地與(NAPRTCS)北美洲兒童腎移植協作研究發表的報告相比。這些結果只有通過服務的再組織從而積累病人和專門技術才能達至。