Treatment options for children with

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Treatment options for children with End Stage
Renal Failure
David V Milford Birmingham Childrens Hospital
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Regional context
Renal Unit established by Mike Winterbon October
1979 288 children treated for ESRF to date
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Age at start of RRT Birmingham Childrens
Hospital
age
20
died
15
10
5
0
1980
1982
1984
1986
1988
1990
1992
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Peritoneal dialysis

• CCPDgtCAPD
• Advantages
• nocturnal therapy (CCPD)
• relative preservation of daily routine
• easy(ish) to learn
• Disadvantages
• less efficient than HD
• requires strict attention to technique
• pressure on carers
• infections are (relatively) common
• not possible in some patients

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Haemodialysis

• Hospital HD, home HD
• Advantages
• less pressure on carers
• efficient, requires less time
• frequent hospital reviews
• Disadvantages
• disruptive of routine
• access problems
• hospital dependant
• requires special equipment,fluids

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Kidney transplantation

• Cadavaric, live donor
• Before/after dialysis
• Advantages
• restores normal renal functions
• improved growth, development, educational
  progress
• Disadvantages
• lifelong immunosuppression (infections,
  neoplasia)
• sensitisation
• graft loss

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Pre-emptive renal transplantation
transplantation prior to dialysis LRD or CAD
kidneys Advantages avoids stress of
dialysis better for growth and development Disadv
antages timing is difficult for CAD risk of
transplanting unnecessarily
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Transplantation

• Developments
• better immunosuppressive regimens
• less nephrotoxic immunosuppressive drugs
• less steroids
• reduced incidence of rejection
• improved graft survival
• acceptance of pre-emptive grafting
• improved bladder management
• ABO and HLA incompatible grafts

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1 year graft survival (UNOS)
LRD
cadavaric
Hariharan et al NEJM 2000 342605-12
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Transplantation

• Limitations
• inadequate supply of cadavaric organs
• compliance issues

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Transplant numbers
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Patients on Waiting list 2000- Dec 2006
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Transplant losses gt3 months after
Tx 1.1.1995-31.12.2004
Graft survival (yrs) Age graft loss (yrs)
SH 3.5 17
DF 3.6 18
DP 3.2 18
MG 4.75 17
NN 2.2 17
WH ? 17
DR 3 16
KE 9.1 16
SM 1.4 16
HL 3.1 15
SS 3.6 16
HS 2.1 14