Management of CKD in Infancy



Management of CKD in Infancy





Infant CKD is a complex condition requiring intensive, specialized management to avoid the many complications of renal insufficiency and promote normal growth and development. Management can be generally divided into two categories—conservative management, which encompasses
all of the medical therapies short of dialysis and transplantation, and renal replacement therapy, which include both dialysis and transplantation. Table 42-13 summarizes the many problems encountered in infants with CKD and the usual approaches to management of each problem.








TABLE 42-12 DIAGNOSES OF CHILDREN WHO REACHED END STAGE RENAL FAILURE BEFORE THE AGE OF 2 YEARS DURING THE 10 YEARS 1988-97 INCLUSIVE1










































































Diagnosis Treated Not Treated Antenatal Diagnosis (%)
Renal dysplasia 57 7 40
Posterior urethral valves 44 0 84
Finnish congenital nephrotic syndrome 26 2 8
Cortical necrosis 12 1
Diffuse mesangial sclerosis and nephrotic syndrome 8 1
Recessively inherited polycystic kidney disease 6 2 25
Prune belly syndrome 4 0 50
Renal vein thrombosis 4 0
Nephronophthisis 3 0
Hemolytic uremic syndrome 3 0
Hyperoxaluria type I 2 2
Interstitial nephritis 2 0
Wilms tumor 2 1
Cloaca, aortic thrombosis, glomerular fibrosis, glomerulonephritis 1 each 0
Total 177 15
1 Reprinted with permission from Reference 640.

The most crucial aspect of managing an infant with CKD is ensuring adequate nutrition. As mentioned previously, most infants with CKD have underlying structural renal disease as the etiology of their CKD. These conditions are characterized by tubular dysfunction leading to salt and water wasting, which in turn produces unique requirements not only for adequate caloric intake, but also for adequate intake of sodium and water to achieve normal growth rates (see the earlier discussion on sodium balance). A recent report demonstrated that infants and young children with CKD who were fed with dilute, sodium-supplemented feedings had superior growth compared to similar patients who were fed with high caloric density formulas (640).
Most infants with CKD will require placement of a feeding gastrostomy to maintain adequate intake of fluid, formula, and medications.








TABLE 42-13 CONSERVATIVE MANAGEMENT OF INFANTS WITH CKD








































Problem Usual Therapy Comment
Acidosis Alkali (Na citrate, NaHCO3) Correction of acidosis necessary to maintain anabolism and promote normal growth
Anemia Recombinant erythropoietin Iron supplementation always necessary during erythropoietin treatment
Anorexia Nasogastric or gastrostomy feeds Nearly all infants with CKD require supplemental feedings
Hyperphosphatemia Low-phosphate formula; phosphate binders CaCO3 most commonly used phosphate binder in infancy; avoid aluminum containing binders
Secondary hyperparathyroidism Vitamin D analogues (DHT, calcitriol) Maintain serum intact PTH in normal range in pre-dialysis CKD patients; avoid calcium*phosphorous product >70
Uremia Low-protein diet Do not restrict protein intake below RDA for age; infants with CNS require increased protein intake
Growth failure Supplemental feedings; rHGH Correction of all above problems must be achieved prior to instituting rHGH treatment
Neurodevelopmental delay “Early intervention” services Most infants require some combination of physical, occupational and speech/feeding therapies
Abbreviations used in table:
CaCO3, calcium carbonate; CKD, chronic kidney disease; CNS, congenital nephrotic syndrome; DHT, dihydrotachysterol; Na, sodium; NaHCO3, sodium bicarbonate; RDA, recommended daily allowance; rHGH, recombinant human growth hormone.

Other aspects of the management of CKD in infants and children have been reviewed elsewhere (641,642,643,644,645). It should be noted that common complications of acute renal failure, such as hyperkalemia and hypertension as a result of fluid overload, are uncommon in infants with CKD because of the polyuria that accompanies the structural forms of renal disease that occur in infancy (645). No matter what the underlying etiology, infants with CKD require the services of a multidisciplinary team consisting of pediatric nephrologists, pediatric renal dietitians, pediatric surgeons and other medical personnel geared toward meeting their unique needs.

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Jul 1, 2016 | Posted by in OBSTETRICS | Comments Off on Management of CKD in Infancy

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