Long term outcome of chronic renal failure

1
Long term outcome of chronic renal failure

• Dr Nick Plant,
• Consultant Paediatric Nephrologist,
• RMCH

2
Overview

• Causes of CRF
• Nutrition
• Acidosis
• Renal osteodystrophy
• Hypertension
• Proteinuria

3
Overview

• Hyperlipidaemia
• Anaemia
• Growth
• Education
• Social psychosocial support
• Summary

4
Causes of CRF
5
Nutrition

• If untreated, CRF leads to malnutrition and
  growth failure (Chantler. Clin Nephrol 73)
• Nutritional therapy can ameliorate effects of
  CRF, improve well being growth (Shaw. Paed
  Nursing 99)
• Can it slow rate of progression of disease?
• Calorie supplements
• NGT / gastrostomy feeds

6
Nutrition

• Low phosphate intake (binders)
• Protein intake
• Animal models reduced intake slows progression.
  Cochrane death down 31
• In children restriction leads to inferior growth
  (Wingen et al. Lancet 97) no slowing of
  disease progression (Uauy et al. Pediatr Nephrol
  94)
• Only reduce to keep urea 20mmol/l

7
Acidosis

• Associated with
• failure to thrive
• muscle degradation
• bone demineralisation
• hyperkalaemia
• Thus treat (with sodium bicarbonate not protein
  restriction).

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Renal osteodystrophy

• Covered by later speaker. But
• PTH ? with pGFR of 50-80ml/min/1.73m²
• Control phosphate to improve PTH
• Reduce dietary intake
• Phosphate binders
• Compliance
• CaCO3, Ca acetate, AlOH3, sevelamer
• Choice Binder pack
• Dose, route, frequency type of vitamin D?
• Monitor with care adynamic bone disease

9
Hypertension

• Primary disease or secondary to salt water
  retention in advanced CRF
• gt90th centile for age/height then treat
• ABPM (annual?) 24 vs. 48 hours
• Control of hypertension retards progression of
  CRF (Hebert et al. Kidney Int 01)
• Drugs which agent? Weight loss? Reduce salt
  compliance?

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Control of proteinuria

• Proteinuric patients urine contains
• complement
• inflammatory lipoproteins
• Fe species inducing free O2-radical formation
• Vicious cycle
• ACEI are renoprotective in both diabetic and
  non-diabetic nephropathies (Taal et al. Kidney
  Int 2000)

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Control of proteinuria

• ACEI independent of their effect on blood
  pressure
• GISEN group, REIN studies late 90s
• Which ACEI?
• First dose?

12
Hyperlipidaemia

• Controversial area with concerns re. safety
• Statins
• Work well and tolerated in children
• Safe in short term in children
• Cochrane insufficient evidence re. long term
  benefit currently in adults on dialysis
• Fibrates
• Adverse effects preclude use?
• Very little good evidence base

13
Anaemia

• Contributed to by
• reduced erythropoetin production
• reduced RBC survival, blood loss GI tract
• marrow inhibition, esp. by PTH
• Fe ? folate ? B12 deficiency
• Causes
• reduced quality of life
• need for transfusions, poor growth
• reduced exercise tolerance

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Anaemia

• Improved by
• Fe, folate, B12, nutrition, correction of
  secondary hyperPTism
• EPO (IV vs. PO Fe) carefully monitored
• EPO
• Good evidence for its use re. quality of life,
  CVar function, etc. but no good evidence re.
  progression of renal disease

15
Growth

• GH tackled by Prof Clayton
• Most sensitive marker of adequacy of CRF
  treatment
• Factors contributing to growth failure
• inadequate energy/protein intake
• salt deficiency (Haycock. Pediatr Nephrol 93),
  acidosis, renal bone disease
• anaemia, infection, hypertension
• steroids, hormonal abnormalities, psychosocial
  factors

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Education

• Full explanation at all times
• See dialysis/transplantation coming
• Talk about PD vs. HD, cad vs. LRD
• Consider bladder function
• Meet other families
• See Dialysis Unit, transplant team, etc
• Get immunised

17
Social/psychosocial support

• Good medical team
• Time in OPD building rapport
• Good nursing team
• Good education team
• Social worker
• Psychologist/child psychiatrist
• Play therapist
• Parent support group

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Summary

• CRF is difficult to manage well
• Bread and butter
• Many different issues to consider
• medical and non-medical
• Team approach required
• Think ahead