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.
• Describe treatment options for
children with stage 5 Chronic Kidney
Disease.
Common Kidney Diseases in
Children
• Nephrotic Syndrome
• Cystic/Hereditary/Congenital
• Glomerulonephritis
• Vasculitis
• Acquired Diseases
Nephritis /Nephrosis
• ‘itis
– Glomerular
inflammation
– Hematuria
– Proteinuria
– RBC casts
– Hypertension
– Renal Insufficiency
– Edema
• ‘osis
– ↑ Glomerular
capillary wall
permeability
– Proteinuria
– Hypoalbuminemia
– Edema
– Hyperlipidemia
– Lipiduria
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
• 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 Disease
• Treatment
– Steroids: Prednisone 2 mg/Kg/Day
– Cyclophosphimide
– Prograf
– Cellcept
– Rituximab
Steroid-Resistant Nephrotic
Syndrome
• Due to
– FSGS
– MPGN
– 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
• Treatment: Combined
immunosuppression
– Prednisone
– Cytoxan/Cellcept
– Prograf/Cyclosporin
– ACE/ARB: decreases proteinuria to slow
progression of disease
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
• 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
• Growth Problems
• School/Cognitive Problems
• Cardiovascular
• Infectious Complications
• Social Isolation
• Family/Financial Stress
Goals in Caring for Children
• Maximize growth and development
potential
• Diminish behavioral, social, and
family dysfunction
• Insure child has age appropriate
equipment
Growth Issues
•
•
•
•
•
Anorexia
Behavioral aversion
Acidosis
Anemia
Renal failure at
times of growth
spurts
• Supplement
nutrition
• Monitor closely
• Correct acidosis
• Calcium/Phos
control
• Growth hormone
therapy
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
Cardiovascular
• Hypertension (LVH,
Microvascular
damage)
• Dyslipidemias
• Long-term
mortality risk
• Keep BP <90th %ile
• Echocardiograms/
ABPM
• Low sodium/Low
fat diet
• Regular exercise
Infection
• 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
Gastrointestinal
• Constipation/
diarrhea
• Anorexia/nausea
• Feeding problems
• High fiber diet
• Regular bowel
program
• PPI’s
• High incidence of
G-tubes
Social Issues
• Child and family
• Social work and
can become
Child life therapy
isolated
involvement
• Financial stress
• School support
• Insurance coverage • Prescribe covered
medications
• Job instability
• FMLA
Treatment Options
• Hemodialysis
• Peritoneal Dialysis
• Transplantation
• No Treatment
Hemodialysis
• 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
Prime
• Normal Saline
• 5% Albumin
• Blood
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
• 3-5 cc/kg per minute
• Access is the driver in rate
– Central venous catheters
– Grafts
– Fistulas
Monitoring
• Signs often subtle
• Watch closely
– Irritability
– Yawning
– Fidgeting
– Heart rate may change before BP drops
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 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
• Definitive form of
RRT for children
• Preemptive
transplant when
possible
Transplantation
• Recipient
– 6 months/10kg
– Pt/Family able to comply with meds and
follow-up
– Stable social/home situation
Donors
• 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/Urology
• Collaborative evaluation and care
between the Pediatric Urologist and
Nephrologist
– Minimally invasive approach
– Bladder augmentation
– CIC, mitrofanoff
– Native nephrectomy
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
• Goal is to keep transplant as long as
possible.
• Most children will require additional
transplants.
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 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 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 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 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!