Kidney Diseases in Children

By – Dr. V. Narayanan Unni, Senior Consultant – Nephrology, Aster Medcity, Kochi

Kidney diseases in children cause a lot of mental agony and grief to parents. Today, there are effective treatment modalities for many kidney diseases. Early diagnosis and appropriate treatments are essential to cure or delay the occurrence of end stage kidney failure.

The usual symptoms of kidney diseases are swelling of feet and face, frothy urine, blood staining of urine, reduced quantity of urine, loss of appetite or vomiting, failure of growth in children. High blood pressure (hypertension), low haemoglobin levels (anaemia), bony deformities, poor scholastic performance in school can be the presentations of poor kidney function; repeated urinary tract infections may be due to congenital abnormalities of kidney and urinary tract; kidney stones in children may be due to inherited metabolic disorders or obstruction to urine flow.

It is important to have the child seen by a doctor and appropriate tests done to make a diagnosis of kidney disease / kidney failure. Simple and inexpensive tests like urine examination for proteins and red blood cells and blood test for serum creatinine would indicate the presence of a significant kidney disease. If there is a suspicion of a kidney disease, the child needs to be shown to a Nephrologist ( kidney specialist) who can advise on further tests and the treatment that is needed.

If kidney diseases are diagnosed in the initial stages, effective treatment with medicines and dietary restrictions can be undertaken. Good control of blood pressure protects the kidneys form further damage. Excessive body weight (obesity) is known to lead on to kidney diseases in future.

If the kidney disease progresses on to severe degree of kidney failure, the child would need to undergo dialysis or later kidney transplantation. There are two types of dialysis – haemodialysis and peritoneal dialysis. Haemodialysis is usually done in hospitals, while peritoneal dialysis can be done at home by parents. The definitive and curative treatment for end stage kidney failure is kidney transplantation. Kidney is usually donated by parents, grandparents, or siblings above the age of 20 years. Kidney transplantation for children can be done very successfully in hospitals which have the necessary infrastructure, equipment, and the medical personnel experienced in performing kidney transplantations in children. Kidney transplantation gives a second lease of life to these children with permanent kidney failure.

Kidney transplantation is considered the treatment of choice for end stage renal disease (ESRD) in children, as it provides a much better quality of life, productivity, growth and longer patient survival than what can be achieved with any modality of dialysis. Graft survival has improved significantly in recent years, mainly due to improved immunosuppressive strategies.

Chronic Kidney Disease (CKD) in children

There are distinct geographic differences in the reported causes of CKD in children ; this isdue to environmental, racial, genetic, and cultural (consanguinity) differences. A substantial proportion of children who develop CKD early in life have congenital anomalies of the kidney and urinary tract – obstructive uropathy , aplasia, hypoplasia, or dysplasia of kidneys . Although the best treatment modality for ESRD in children is renal transplantation, lack of high quality health care resources and expertise in many countries limits the widespread use of renal transplantation in young children.

Although the number of children with ESRD in need for renal transplantation is small compared with adults, the advantages associated with renal transplant in children are numerous and varied. Children and adolescents with ESRD would be able to achieve normal growth, normal cognitive and psychological development following successful kidney transplantation.

Preemptive Transplantation

Preemptive transplantation (PET), which denotes transplantation prior to the initiation of dialysis, has recently been growing in popularity, as it is seen that transplanting children before they develop symptoms of severe uremia avoids many of the associated long -term complications of ESRD and dialysis. Avoiding dialysis and all its hazards is one of the most important advantages of PET. Moreover, PET is also more cost effective. Therefore, decreasing the period on dialysis or even avoiding dialysis altogether whenever appropriate, has a significant effect on the cost of care in children with ESRD.

Types of Kidney Transplantation in Children

a) Deceased donor transplantation – The child can get a kidney from a healthy person who has suffered a brain death. To obtain a deceased donor kidney, the child must be registered with the Kerala Network for Organ Sharing (KNOS) and be on the waiting list.
b) Living donor renal transplantation – A healthy relative can donate one of his/herkidneys to the child. Donors for children are often their parents, siblings, or grandparents. Parents of a child with kidney disease are usually the best donors,because they often have the same blood group and are a good tissue match with the recipient.
Immunosuppression

Steroid-free regimens may be tried in children to avoid steroid related adverse effects, especially related to growth and mineral metabolism.

Robot Assisted Kidney Transplantation

Renal transplantation is the treatment of choice for children and adults who have been diagnosed to have end stage renal failure (ESRD). All patients who have ESRD have to either undergo dialysis lifelong or undergo kidney transplantation surgery. Renal transplantation provides a much better quality of life and a better survival rate

Introduction of the surgical robot was a landmark development. The use of Robot assistance in renal transplantation has these clear advantages: less chances of bleeding and lower needs for blood transfusions, short incision, less pain, less hospital stays, faster return to activity, less wound infection and better cosmesis. The results of graft survival and patient survival for open and robot assisted transplantation are not different.

ABO Incompatible Kidney Transplantation

Previously it was believed that the kidney donor and recipient have to have matching blood groups for a successful kidney transplantation. However, for the past few years, it has been established that kidney transplantation can be successfully done even if donor and recipient have incompatible blood groups. In these cases , the recipient would need to undergo some procedures to remove antibodies from his blood and receive certain medicines to reduce further antibody production. Although the success of an incompatible transplant is slightly lower than a blood group compatible transplant, this is a viable option for patients who have a close relative to donate a kidney , but the blood groups are incompatible.