1. Kids and Kidney Disease
Catherine Picarelli, RN, BSN, CNN
Hackensack University Medical Center
Hackensack, NJ

2. 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.

3. Common Kidney Diseases in Children
Nephrotic Syndrome
Cystic/Hereditary/Congenital
Glomerulonephritis
Vasculitis
Acquired Diseases

4. Nephritis /Nephrosis ‘itis ‘osis Glomerular inflammation Hematuria
Proteinuria
RBC casts
Hypertension
Renal Insufficiency
Edema
‘osis
↑ Glomerular capillary wall permeability
Proteinuria
Hypoalbuminemia
Edema
Hyperlipidemia
Lipiduria

5. 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

6. 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

8. Minimal Change Disease
Treatment
Steroids: Prednisone 2 mg/Kg/Day
Cyclophosphimide
Prograf
Cellcept
Rituximab

9. 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

10. Steroid-Resistant Nephrotic Syndrome
Treatment: Combined immunosuppression
Prednisone
Cytoxan/Cellcept
Prograf/Cyclosporin
ACE/ARB: decreases proteinuria to slow progression of disease

11. 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%

12. 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

13. Effects of Renal Failure on Children
Growth Problems
School/Cognitive Problems
Cardiovascular
Infectious Complications
Social Isolation
Family/Financial Stress

14. Goals in Caring for Children
Maximize growth and development potential
Diminish behavioral, social, and family dysfunction
Insure child has age appropriate equipment

15. 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

16. 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

17. Cardiovascular Hypertension (LVH, Microvascular damage) Dyslipidemias
Long-term mortality risk
Keep BP <90th %ile
Echocardiograms/ ABPM
Low sodium/Low fat diet
Regular exercise

18. 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

19. Gastrointestinal Constipation/ diarrhea Anorexia/nausea
Feeding problems
High fiber diet
Regular bowel program
PPI’s
High incidence of G-tubes

20. Social Issues Child and family can become isolated Financial stress
Insurance coverage
Job instability
Social work and Child life therapy involvement
School support
Prescribe covered medications
FMLA

21. Treatment Options Hemodialysis Peritoneal Dialysis Transplantation
No Treatment

22. 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

23. Prime
Normal Saline
5% Albumin
Blood

24. 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

25. Blood Flow Rate 3-5 cc/kg per minute Access is the driver in rate
Central venous catheters
Grafts
Fistulas

26. Monitoring Signs often subtle Watch closely Irritability Yawning
Fidgeting
Heart rate may change before BP drops

27. 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

28. Peritoneal Dialysis CCPD CAPD Manual
Machine programmed with prescription
Maintain a running tabulation of UF
CAPD
Backup for power outages, vacations
Manual
Used in infants with fill volumes < 50mL

29. Renal Transplant Definitive form of RRT for children
Preemptive transplant when possible

30. Transplantation Recipient 6 months/10kg
Pt/Family able to comply with meds and follow-up
Stable social/home situation

31. Donors Living Donor Deceased Donor Shorter waiting time/ischemic time
Closer matches
Better graft survival/overall outcomes
Deceased Donor
Advantage given to pediatric patients on waiting list

32. Bladder/Urology
Many pediatric diseases are associated with bladder dysfunction
Posterior urethral valves
Severe vesico-ureteral reflux
Other obstructions
Dysfunctional voiding
Inadequate bladder emptying

33. Bladder/Urology
Collaborative evaluation and care between the Pediatric Urologist and Nephrologist
Minimally invasive approach
Bladder augmentation
CIC, mitrofanoff
Native nephrectomy

34. 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

35. Additional Transplants
Goal is to keep transplant as long as possible.
Most children will require additional transplants.

36. 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.

37. 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.

38. 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.

39. 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.

40. 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!