1. Management of children with CKD in a DGH M Shenoy Consultant Paediatric Nephrologist RMCH Nephrology for the General Paediatrician Meeting Manchester

2. CKD in a DGH CKD Tubulopathy Peritoneal dialysis Renal transplant recipient

3. CKD

4. eGFR Calculation Schwartz formula 40 * ht (cm)/Pcreatinine Schwartz GJ, Haycock GB et al Pediatrics 1976

5. 1. Child with CKD Stage III 4 yr old, male child Diagnosed to have dysplastic kidneys Creatinine 95umol/l (eGFR 42ml/min/1.73m 2 ) Medications: Enalapril, one aphacalcidol Admitted with febrile illness, poor intake Diagnosis: Tonsillitis Creatinine 144umol/l, eGFR now 27ml/min/1.73m 2

6. What are the possible reasons for deterioration in kidney function in this child? Infection Dehydration Medications –Captopril –Ibuprofen

7. Management Prevent dehydration Omit ACEi during episodes of dehydration Avoid nephrotoxic drugs –NSAID’s –Gentamicin, vancomycin, aciclovir Adjust drug dose for eGFR

8. Tubulopathy RTA –Proximal Cystinosis Drug induced Bartter syndrome Nephrogenic DI

9. 2. Child with tubulopathy 12 year old boy with cystinosis Admitted for tonsillectomy Pre-op bloods –Na 134, K 3.5, HCO3 19, U 4.2, Cr 124, Ca 2.4, PO4 1.1 Post op bloods –Na 136, K 2.8, HCO3 11, U 7.8, Cr 210, Ca 2.3, PO4 0.7

10. Tubulopathy Fluids: not ‘maintenance’ Continue regular medications and electrolyte supplements Need 8-12 hourly bloods Avoid nephrotoxic drugs

11. Dialysis Around 30 children on dialysis –Home PD 20, 6-7 nights/week –In centre 3-4/week HD 10 Oliguric and non-oliguric Dialysis access

12. 3. Child on PD 12 year old girl on PD, anuric Admitted with abdominal pain Mother reports cloudy effluent

13. Fluids in an anuric child Ask how much is their fluid allowance Usually 600 – 1000ml/day Excess fluids leads to hypertension and need for more dialysis

14. Complications of PD catheter Peritonitis –< 1 episode/14 patient months averaged over 3 years –Diagnosis: PD fluid WCC >100 –Treated with IP antibiotics for 2 weeks Exit site infection Catheter migration Catheter blockage

15. Renal Transplant UK 125 paediatric transplants per year –Manchester ~15 75% living donor ~60 children attending transplant clinic

16. Renal transplant Immunosuppression –Used to be ciclosporin, azathioprine and prednisolone –Now tacrolimus and mycophenolate mofetil

17. Graft survival following first paediatric kidney only transplant 5 yr survival 10 yr survival 20 yr survival Living 88 (85 - 91) 71 (65 - 76) 48 (38 - 58) (n=714) p<0.0001 p<0.0001 p<0.0001 DBD 72 (70 - 74) 59 (57 - 61) 37 (33 - 40 ) (n=2009)

18. Am J Transplant 2004; 4: 384-389

19. 4. Child with kidney transplant 6 year old boy with kidney transplant 2 years back Admitted with febrile illness Bloods: –Creat 135 (usually ~60)

20. Reasons for reduced graft function Infection –Bacterial, viral, PTLD Rejection –Late rejection, usually compliance issues Drug toxicity –Tacrolimus, NSAIDs Obstruction

21. Summary Child with CKD –Attention to fluid balance and electrolytes –Avoid drug toxicity –Dialysis access is precious –Infection, rejection and drug toxicity in a transplant recipient –Discuss with Nephrologist