Treatment Methods for Kidney Failure in
Children
Kidneys play an important part in a child's growth and
health. They
- remove wastes and extra water from the blood
- regulate blood pressure
- balance chemicals like sodium and potassium
- make a hormone that signals bone marrow to make red
blood cells
- make a hormone to help bones grow and keep them strong
Kidney failure can lead directly to more health problems,
like swelling of the body, bone deformities, and growth
failure. A successful kidney transplant can give a child
with chronic kidney failure the best chance to grow normally
and lead a full, active life. Dialysis can help a child to
survive an acute episode of kidney failure or to stay
healthy until a donated kidney becomes available.
Families caring for a child with kidney disease often
need help—not just from doctors and nurses, but from a whole
team of pediatric specialists, including dietitians, social
workers, and family counselors. Learning about treatments
for kidney disease and getting to know the entire team can
make life easier for your child and your entire family.
[Top]
Problems Specific to Children
Everyone who has kidney failure, adults and children
alike, will experience medical complications, which may
include extreme fatigue, inability to concentrate, weak
bones, nerve damage, depression, and sleep problems.
Additional problems for children can include effects on
their growth and development. Children may fall behind on
the growth chart and in school.
The isolation people feel because of kidney failure is
especially a problem in children and adolescents because of
the importance of making friends and fitting in at this age.
Finding the best treatment for a child takes on special
significance to ensure that the child with kidney failure
can become an active, productive, well-adjusted adult.
[Top]
Treatment Choices for Kidney Failure
in Children
Children usually have a range of treatment options for
kidney failure. In most cases, the goal is to have a
successful transplant that allows your child to lead the
most normal life possible. But viable kidneys are not always
readily available, and not all children can have a
transplant. Many children begin with dialysis to stay
healthy until a suitable kidney becomes available.
Sometimes, a transplant itself may stop working, and the
child may need to return to dialysis. Knowing about
transplantation and dialysis will prepare you and your child
for any circumstance.
[Top]
Transplantation
Transplantation means that a healthy kidney from a donor
is placed inside a child's body to take over the job of
filtering wastes and extra fluid from the blood. The donor
may be a stranger who has just died or a living family
member or friend.
Once kidneys fail because of chronic kidney disease,
function cannot be restored, so transplantation is the
closest thing to a cure we have. A child with a transplant
will still need to take medicines every day, follow a
restricted diet, and get regular checkups to make sure the
new kidney is accepted and functioning in the body.
In adults, most transplanted kidneys come from people who
have just died. However, about half of the kidney
transplants in children come from a living donor, usually a
parent or other close family member.
Deceased Donor Kidneys
To receive a deceased donor kidney, your child will be
placed on a waiting list. Every person who needs an organ
from a deceased donor is registered with the national
organisation e.g. in UK it is UK Transplant, which maintains
a centralized computer network linking all regional organ
gathering organizations and transplant centers.
How long your child will have to wait for a transplant
depends on many things but is determined primarily by how
good the match is between your child and a donor. When a
kidney becomes available, the hospital that has obtained the
kidney reports to national organisation, where the central
computer generates a list of compatible recipients.
Candidates' ages and length of time they have waited are
factors in the point system. Children 18 and under get extra
points compared with adults because they are likely to
receive the greatest benefit from a donated kidney.
Living Donor Kidneys
About half of the kidneys transplanted into children are
donated by family members—usually a parent—or a family
friend. Potential donors need to be tested for matching
factors and to make sure that donating a kidney will not
endanger their health. Most people can donate a kidney with
little risk.
A kidney from a living donor often has advantages over a
kidney from a person who has just died.
- A kidney from a parent is guaranteed to match on at
least three of six proteins; mismatched proteins may cause
rejection.
- Living donation allows for greater preparation and for
the operation to be scheduled.
- A kidney from a living donor may be in better
condition because it does not have to be transported from
one site to another.
Preemptive Transplantation
Preemptive transplantation means that the child receives a
donated kidney before dialysis is needed. Some studies
indicate that preemptive transplantation reduces the chances
of rejecting the new kidney and improves the chances that it
will function for a long time. Other studies show little or
no survival advantage in preemptive transplants, although
some families may feel that avoiding dialysis is an
advantage in itself.
Keeping a Healthy Kidney
Health professionals use the term "noncompliance" or "nonadherence"
to describe a patient's failure or refusal to take
prescribed medicines or follow a doctor's directions.
Teenagers with transplanted organs are often noncompliant
because the immunosuppressive drugs they must take change
their appearance in unflattering ways. A child psychologist
may be able to suggest techniques that reinforce desired
behaviors. But communicating clearly about the reasons for
treatment and the importance of following the regimen is an
important part of helping all patients, including children.
Children who understand that their decisions can affect
their health are more likely to take responsibility for
their actions.
[Top]
Dialysis
The kidneys remove waste products and extra water from
the blood. If the kidneys fail before transplantation is
possible, your child may need some form of dialysis to do
this job. Each type of dialysis will affect your family's
lifestyle. Your doctor will help you choose the one that is
best for your child. Each situation is different.
Peritoneal Dialysis
Peritoneal dialysis uses the lining of your child's abdomen,
called the peritoneal membrane, to filter blood. A mixture
of minerals and sugar dissolved in water, called dialysis
solution, is inserted into your child's abdomen through a
soft tube. The sugar, called dextrose, draws wastes,
chemicals, and extra water from the tiny blood vessels in
the peritoneal membrane into the dialysis solution. After
some time, the used solution—now loaded with the wastes and
extra fluid that the kidneys would have filtered out—is
drained from your child's abdomen through the tube. The
period that dialysis solution is in the abdomen is called
the dwell time. The abdomen is filled again with fresh
dialysis solution, and the cycle repeats. The process of
emptying and refilling the abdomen is called an exchange and
takes about 30 to 40 minutes.
Before the first treatment, a surgeon will place a small,
soft tube called a catheter into your child's abdomen. The
catheter tends to work better if the insertion site has
time—usually from 10 days to 3 weeks—to heal. The catheter
stays there to help transport dialysis solution to and from
the abdomen and is removed only after a successful
transplant is in place.
Peritoneal dialysis can be done with or without a cycling
machine.
- Continuous ambulatory peritoneal dialysis (CAPD).
CAPD requires no machine and can be done in any clean,
well-lit place. With CAPD, your child's blood is always
being cleaned. The dialysis solution passes from a plastic
bag through the catheter and into the abdomen, where it
stays for several hours with the catheter sealed. After
the dwell time, the child drains the dialysis solution
into a drain bag for disposal. Then the same catheter is
used to refill the abdomen with fresh solution so the
cleaning process can begin again. With CAPD, the dialysis
solution stays in the abdomen for 4 to 6 hours or more.
Most people change the dialysis solution at least four
times a day and sleep with solution in their abdomen at
night. With CAPD, it is not necessary to perform an
exchange during the night.
- Continuous cycling peritoneal dialysis (CCPD).
CCPD uses a machine called a cycler to fill and empty your
child's abdomen many times at night during sleep. In the
morning, the child begins one exchange with a dwell time
that lasts the entire day. An additional exchange without
the cycler may be added in the middle of the afternoon to
increase the amount of waste removed and to reduce the
amount of fluid left behind.
Both types of peritoneal dialysis can be performed in the
home without help from a nurse or doctor. If your child is
very young, you will need to help with the exchanges or set
up the cycler. Older children can do it themselves. You and
your child will receive detailed instructions and extensive
training so you feel confident when you perform the
exchanges.
The most common problem with peritoneal dialysis is
peritonitis, a serious abdominal infection that can occur if
the opening where the catheter enters the body becomes
infected or if contamination occurs as the catheter is
connected or disconnected from the bags. Peritonitis
requires antibiotic treatment prescribed by your child's
nephrologist.
To avoid peritonitis, you must be careful to follow the
correct procedures exactly and learn to recognize the early
signs—fever, unusual color or cloudiness of the used fluid,
and redness or pain around the catheter. Report these signs
to your child's doctor immediately so treatment for
infection can begin promptly.
Hemodialysis
In hemodialysis, your child’s blood is sent through a filter
to remove harmful wastes, extra salt, and extra water.
Hemodialysis helps control blood pressure and keep the
proper balance of potassium, sodium, calcium, and
bicarbonate.
Hemodialysis uses a special filter called a dialyzer.
During treatment, blood travels from the child's body
through tubes into the dialyzer, which filters out wastes
and extra water. Then the cleaned blood flows through
another set of tubes back into the child's body. The
dialyzer is connected to a machine that monitors blood flow
and disposes of the wastes.
Hemodialysis usually takes place in a clinic three times
a week, but it may be required more often in smaller
children. Each treatment lasts from 3 to 4 hours. Some
clinics offer home hemodialysis, which allows more
flexibility in scheduling but requires the caregiver to take
weeks of training. During treatment, the child can do
homework, read, write, sleep, talk, or watch TV.
If you choose hemodialysis, the doctor will need to
create an access to the bloodstream (vascular access)
several months before the first treatment. The child may be
able to complete the procedure for the vascular access in
one day or may need to stay overnight in the hospital.
When a child starts hemodialysis, problems can be caused
by rapid changes in the body's water and chemical balance
during treatment. Muscle cramps and a sudden drop in blood
pressure are two common side effects. Low blood pressure,
called hypotension, can make a child feel weak, dizzy, or
nauseated.
Most children need a few months to adjust to hemodialysis.
Side effects can often be treated quickly and easily, so you
should always report them to your doctor and dialysis staff.
You can avoid many side effects by making sure your child
gets a proper diet, limits liquid intake, and takes all
medicines as directed. .
[Top]
Role of the Health Care Team
Because the treatments for kidney failure involve
complicated procedures with a number of steps, many skilled
professionals must work together to ensure that your child
gets the best possible care. As a parent or guardian, you
are the most important member of your child's team. You may
need to speak for your child or ask questions when
instructions are not clear. Knowing the roles of the
different team members can help you ask the right questions
and contribute to your child's care.
Pediatrician
A pediatrician is a doctor who treats children. Your child's
pediatrician is likely to be the first to recognize a kidney
problem—either during a routine physical exam or while
treating an ailment. Depending on how well the kidneys are
working, the doctor may decide to monitor your child or
advise you to see a specialist. (Your health insurance plan
may require a written referral from the pediatrician in
order for you to make an appointment with a specialist.) As
your child's regular doctor, the pediatrician should talk
with any specialists who become involved. A referral for
consultation should optimally occur soon after chronic
kidney disease is diagnosed, even if dialysis and
transplantation are still a long way off.
Nephrologist
A nephrologist is a doctor who treats kidney diseases and
kidney failure. If possible, your child should see a
pediatric nephrologist because they are specifically trained
to take care of kidney problems in children. In many areas
of the country, pediatric nephrologists are in short supply,
so you and your child may need to travel. If traveling is
not possible, some nephrologists who treat adults can also
treat children in consultation with a pediatric
nephrologist.
The nephrologist may prescribe treatments to slow disease
progression and will determine when referral to a transplant
center or to a dialysis clinic is appropriate.
Dialysis Nurse
If your child needs dialysis, a nurse with special training
will make sure all procedures are followed carefully. If you
and your child choose peritoneal dialysis, the dialysis
nurse will train you so you feel comfortable doing the
exchanges at home. For hemodialysis in a clinic, the
dialysis nurse will make sure that all needles are placed
correctly and watch for any problems. The dialysis nurse can
talk to you about the advantages and disadvantages of the
different types of dialysis and explain the laboratory
reports that indicate how well the treatments are working.
Transplant Coordinator
A coordinator at the transplantation center will be your
main contact. He or she will schedule any required
examinations and procedures and make sure your child's
medical information is complete and properly placed on the
UNOS national waiting list. The transplant coordinator will
make sure that every member of the child's health care team
has all the necessary information and paperwork.
Social Worker
Every dialysis clinic and transplant center has a social
worker who can help you locate financial assistance and
social services like transportation or family counseling and
help with applications for Medicare. The social worker can
tell you about support groups in your community and ways to
reduce the stress that caring for a child with a chronic
illness can cause.
Psychologist, Psychiatrist, or Counselor
Kidney disease can disrupt a child's life and create
emotional turmoil. A psychologist or counselor can help your
child find ways to express emotions constructively. Adults
and siblings may also find that counseling helps them with
the conflicts and stresses they face. For example, medical
bills can strain family finances. A parent or guardian may
need to give up work to care for the child full-time.
Siblings may feel resentment over the huge amount of
attention given to their sibling and guilt over thinking bad
thoughts about the sick child. Couples sometimes report
increased tension in their marriage when a child is sick. A
counselor can help families deal with conflicts that may
arise, and social workers or financial counselors can help
families meet the financial obligations that chronic illness
creates.
Dietitian
When the kidneys stop working, wastes and excess fluid build
up in the body and create chemical and hormonal imbalances.
In children, however, these problems are especially
troublesome because they can interfere with physical growth
and mental development. Avoiding certain foods can help
minimize the buildup of wastes and prevent chemical
imbalance, but it can also lead to nutritional deficiencies.
The buildup of wastes often makes children lose their
appetite, causing further nutritional problems. These
complications are the reason your clinic's dietitian is so
important.
Proper nutrition is extremely important for children with
chronic kidney disease. Every dialysis clinic has a
dietitian to help patients understand how the food they eat
affects their health. The dietitian can help you develop
meal plans that will fit your child's restricted diet and
will talk with you about laboratory reports that may show
nutritional deficiencies caused by your child's kidney
disease. They may recommend special dietary supplements or
formulas so that your child receives the best nutrition
possible.
[Top]
Vaccinations and Immunosuppression
The wastes and toxins that build up in the bloodstream of
a child with kidney disease can weaken the immune system and
make the child vulnerable to infections and the kinds of
diseases that vaccines are designed to prevent. Children
with kidney failure should receive the standard vaccinations
recommended for all children, plus additional vaccinations
for pneumonia and influenza.
Children who take immunosuppressive medication to treat
an autoimmune disease or to prevent rejection of a
transplanted kidney, however, should not receive vaccines
containing live viruses, that is, the oral polio vaccine,
the measles, mumps, and rubella (MMR) vaccine, or the
varicella (chicken pox) vaccine. Children who are likely to
need a transplant may benefit from early immunization with
these vaccines before immunosuppressive drugs are needed.
The body's immune system protects against foreign
substances like bacteria and viruses that can cause disease.
But the immune system also attacks transplanted organs, and
the medicines that recipients must take to prevent rejection
leave them vulnerable to infections. Children need
relatively higher doses of immunosuppressive drugs than
adults because their immune systems are more active. But
these high doses can slow down growth and development. Over
a long period of time, immunosuppression may lead to
malignant growths. Immunosuppressive drugs can also have
side effects such as weight gain, unusual hair growth, and
acne. Children, especially teenagers, cite these side
effects as the reason they do not take their pills, a
problem that contributes to the high rate of organ rejection
in children.
[Top]
Medical Complications of Kidney
Failure
The kidneys not only clean waste and extra fluid from the
blood, they also help make red blood cells and balance
nutrients needed for strong bones and growth. In addition,
the kidneys may play a role in the metabolism of growth
hormone (somatotropin). Chronic kidney disease can make
children feel more tired, limit physical growth, and
interfere with their ability to concentrate in school.
Anemia
Diseased kidneys do not make enough of a hormone called
erythropoietin, or EPO, which stimulates the bone marrow to
produce the red blood cells needed to carry oxygen to vital
organs. Anemia is a shortage of red blood cells, and it is
common in children with kidney disease. A child with anemia
may tire easily and look pale. Anemia may also contribute to
heart problems. A genetically engineered form of EPO
injected under the skin one or more times a week can treat
this form of anemia.
Bone Problems and Growth Failure
The kidneys help keep bones healthy by balancing
phosphorus and calcium levels in the blood. When the kidneys
stop working normally, phosphorus levels in the blood can
become high and interfere with bone formation and normal
growth.
Your child's doctor may recommend dietary changes and
food supplements to treat growth failure. Dietary changes
may include limiting foods that contain large amounts of
phosphorus, such as milk, cheese, cola, dried beans, peas,
and nuts. Since avoiding all of these foods is impossible,
caregivers will need to work with a dietitian to find a
healthy way to limit the phosphorus in the child's diet
while maintaining a desirable intake of the calories,
protein, and other nutrients necessary to maintain growth
and general health. In addition to dietary restrictions,
most children will need to take specific medications called
phosphate binders to lower their blood phosphorus levels.
[Top] |
