Renal disease in a child: Chronic Renal Failure Flashcards
Define chronic renal failure.
Characterized by decreased GFR, persistently increased urea and increased creatinine concentration.
What are causes of chronic renal failure in a child <5 years old?
Congenital abnormalities
Hypoplasia
Dysplasia
Obstruction (posterior urethral valve)
Malformations
What are causes of chronic renal failure in a child >5 years old?
Hereditary disorders: Alport syndrome (thickened glomerular basement membrane), autosomal recessive polycystic disease.
All causes of GN and tubulointerstitial nephritis may result in CRF
Vesicoureteral reflux (VUR)
Systemic disease (HSP, SLE)
What is the pathophysiology of chronic renal failure?
Progressive fibrosis of the glomeruli, tubules and small vessels which leads to renal scarring
Summarise the epidemiology of chronic renal failure.
CRF prevalence not known but prevalence of end-stage renal failure (ESRF) 14-40/million (UK); more common in Asian children.
What are symptoms of chronic renal failure?
Antenatal diagnosis
Failure to thrive
Delayed puberty
Malaise
Anorexia
Anaemia
Incidental (blood test/urinalysis).
What are signs of chronic renal failure?
Examine flanks for palpable kidneys (polycystic disease)
Pallor
Oedema
Pigmentation
Scratch marks
Hypertension
Growth retardation and rickets
What are appropriate investigations for chronic renal failure?
Bloods: Decreased Hb, MCV (usually normcytic) decreased Na+, Increased K+, increased urea, increased creatinine, decreased Ca2+, increased phosphate, increased ALP, increased PTH (secondary hyperparathyroidism).
Urine: 24-hour collection for protein and creatinine clearance
X-rays: For signs of osteomalacia and hyperparathyroidism.
Renal USS: For anatomical/hereditary abnormalities, measure size (small shrunken kidneys consistent with CRF), exclude obstruction/stones.
Renal biopsy: For changes specific to the underlying disease, contraindicated in shrunken kidneys.
What should be monitored in the management of chronic renal failure?
Child’s clinical (physical examination, growth, BP) and biochemical status.
What are factors to treat in chronic renal failure?
- Anaemia
- BP control
- Ca2+ maintenance: 1-hydroxylated vitamin D analogues, e.g. alfacalcidol
- Diet: high-energy intake with enteral/parenteral nutrition if oral intake is poor, restrict K+ in hyperkalaemia or acidosis, restriction of phosphate intake combine with use of phosphate binders to prevent secondary hyperparathyroidism
- Drugs: Avoid nephrotoxic drugs, adjust doses of other drugs, e.g. frusemide in oedema
What are potential solutions for chronic renal failure?
Continuous ambulatory peritoneal dialysis: Dialysate is introduced and exchanged through a catheter, inserted via a SC tunnel into the peritoneum. Preferred method in children.
Haemodialysis: Blood is removed via an arteriovenous fistula surgically
Transplantation: In end-stage renal failure. Requires long-term immunosuppressants to decreased rejection
What are complications associated with chronic renal failure?
Haematological: Anaemia, abnormal platelet activity (bruising, epistaxis)
CVS: Accelerated atherosclerosis, increased BP and pericarditis
Neuro: Peripheral and autonomic neuropathy, proximal myopathy
Renal osteodystrophy: Osteoporosis, osteomalacia, secondary and tertiary hyperparathyroidism
Endocrine: Amenorrhoea
What are complications associated with the treatment of chronic renal failure?
Peritoneal dialysis: Peritonitis (e.g. Staphyloccocus epidermidis)
Haemodialysis:
- Acute: Hypotension due to excessive removal of extracellular fluid
- Long-term: Atherosclerosis, sepsis (secondary to peritonitis with staph aureus infection)
- Amyloidosis: Periarticular deposition, arthralgia (e.g. shoulder) and carpal tunnel syndrome
Transplantation/immunosuppression: Opportunistic infections (e.g. Pneumocystis carinii), malignancies (lymphomas and skin), and side effects of immunosuppressant drugs
What is the prognosis of chronic renal failure?
Depends on complications.
Timely dialysis/transplantation improves survival.
