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Renal failure - care of the neonate with severe renal failure at birth

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Should renal replacement therapy be offered to all neonates?

Long term peritoneal dialysis of newborn infants may be undertaken in the majority of patients who have isolated renal failure. However, the ethics of offering or not such treatment is vigorously debated. In newborns with co-existing congenital abnormalities, the prognosis is often poor especially when there is a major neurological or cardiopulmonary abnormality present and palliative care may be more appropriate.

It is important each case is discussed early with the paediatric nephrology service to decide whether long term dialysis is a viable option.

How will these newborns present?

Newborn infants with renal failure severe enough to need dialysis therapy occur in two situations:

  • Acute insult (sepsis, perinatal hypoxic ischaemic injury). This is a common cause for acute renal failure in newborns. The acute renal failure is usually reversible and the need for acute dialysis is uncommon, but may be required for a short period to support renal function in expectation of recovery. This is usually started after appropriate discussion between the neonatologist and the nephrologist but where there is severe brain injury long term dialysis may not be appropriate. 
  • Bilateral chronic kidney disease. This is usually due to an obstructive congenital abnormality of the urinary tract resulting in severe damage to both kidneys with renal failure detected shortly after birth. Many of these would have been detected on antenatal ultrasonography, while others will present within the first week or two of life with failure to thrive. The renal disease may be an isolated problem in an otherwise normal baby or associated with other congenital abnormalities. Where other organ systems are also involved such as major cardiac lesions, significant brain abnormality, severe pulmonary hypoplasia, major abdominal organ involvement, dialysis therapy would generally not be offered due to poor outcome.

When severe kidney abnormalities are detected in-utero, the paediatric nephrology and urology services should be involved as early as possible. Ideally discussion should take place antenatally so as to provide appropriate information on possible treatment and outcome.

How often does this occur?

In a recent survey performed in 2014, of all infants starting chronic dialysis between 2000 and 2011, only 264 newborns less than one month of age were recorded to have commenced dialysis in Europe, Japan and Australia and New Zealand. In New Zealand, there were only 5 neonates who started chronic dialysis before age 30 days in the period 2004-17.

What determines outlook?

  • The presence of oliguria indicates poor residual renal function and is the most important predictor of outcome.
  • Non renal co-morbidities such as neurological insults, cardiac problems, and other malformations also contribute to mortality.

Dialysis indications

  • Biochemical abnormalities that cannot be controlled by medication and nutritional support
  • Poor growth
  • Fluid overload

Most infants with chronic renal failure have polyuric chronic kidney disease due to congenital anomalies of the kidney and urinary tract (CAKUT); hence hyperkalemia, fluid overload, and hypertension are uncommon despite very low GFR (renal function). Unless the newborn is anuric, there is generally no urgency to commence dialysis in an infant with severe renal failure as with careful supportive care, acid base and electrolyte abnormalities will usually stabilise.  If the newborn remains severely oliguric, dialysis may be required to support nutrition and growth.

Outcome of those infants who survive

An international study combining multiple registry databases examined 264 infants who started dialysis within the first month of life from 2000-2011. With a median follow up of 7months, 219/264 (83%) had survived with an estimated 2 year survival of 81%, and 76% at 5 years. Of the 45 infants who had died, infection occurred in 16 (36%), cardiac arrest in 4 (9%), pulmonary hypoplasia/oedema in 7 (16%). The secondary effects of end stage renal failure were present in most; namely poor growth (63%), hypertension (57%) and anaemia (55%)

60-80% of children attend full time school in appropriate classes. Neuropsychological impairment has been diagnosed in 20-40% of these patients

What should be considered when presented with a newborn with severe renal failure?

For those infants who have isolated severe chronic kidney disease, where the possibility of dialysis is being considered, the following issues should be considered and discussed:

  • Attitude and wishes of the parents, and relatives to undertake long term dialysis for their baby after full presentation and discussion of current data available.
  • Assessment by the paediatric nephrology multidisciplinary team as to suitability and appropriateness of long term treatment.
  • During the discussion it should be made clear to the parents that appropriateness of treatment will be regularly reviewed and withdrawal of treatment would be recommended if in the treating team's opinion that ongoing therapy is causing unnecessary suffering with no reasonable possibility of a quality long term outcome.
  • The agreement to offer long term dialysis care to a newborn is a partnership between the parents and treatment team.
  • A decision not treat or withdraw treatment is made by the nephrology multidisciplinary team in discussion with the parents.
  • Discussion and advice from the ADHB clinical ethics committee can be sought.

The paediatric nephrology multidisciplinary team

A team of medical, nursing and allied health professionals is essential to manage a neonate with severe chronic renal failure.

Table 1: Options for management

Option 1 No treatment with palliative care support
This is a decision which parents may choose after full and detailed discussions with the nephrology team and the wider multidisciplinary team. 
Option 2 Full treatment with full support
An agreed treatment regimen between the parents and the nephrology team that includes long term dialysis and nutritional support as a bridge to renal transplantation when the child reaches 10kg body weight.
Option 3 "Wait and see" 
This is not a recommended option as during the "wait and see" period, the infant will inevitably develop significant failure to thrive, severe metabolic bone disease, anaemia and other complications. If parents change their minds and request active treatment, the infant has already incurred significant morbidity and renders the subsequent management more difficult. The recommended management in this setting is to treat the complications of chronic renal failure. A decision to offer chronic dialysis is deferred pending the response to conservative medical treatment.

References

  1. Rees L, Renal replacement therapy in neonates: issues and ethics Semin in Fetal and Neonat Med 2017 (22) 104-108
  2. Misurac J. Chronbic kidney disease in the neonate, etiologies, management and outcomes. Semin in Fetal and Neonat Med 2017 (22) 98-103
  3. Van Stralen et al Survival and clinical outcomes of children starting renal replacement therapy in the neonatal period Kidney Int 2014, 86 168-174
  4. Warady, BA, Schaefer F, Alexander SR. Pediatric Dialysis, Springer 2014
  5. Sanderson K, Yu Y, Hongying D, Willig D, Warady BA. Outcomes of infants receiving chronic dialysis: an analysis of the USRDS registry. Pediatr Nephrol 2018 August https://doi.org/10.1007/s00467-018-4056
  6. Carey WA, Talley LI, Sehring SA, Jaskula JM, Mathias RS. Outcome of dialysis initiated during the neonatal period for treatment of end stage renal disease. A North American Pediatric Renal Trials and Collaborative Studies Special Analysis. Pediatrics 2007:119;e468-e473

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Document Control

  • Date last published: 28 September 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology, Paediatric Nephrology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years