Care of the Neonate with Severe
Renal Failure at Birth
 

 

Reviewed by William Wong, Max Morris, Tonya Kara, Jane Ronaldson, Sarah Farrell and Malcolm Battin
July 2009
Clinical Guidelines Back Newborn Services Home Page
Incidence Presentation Outlook
Considerations Options For Management References

Should renal replacement therapy be offered to all neonates?

Long term peritoneal dialysis of newborn infants has been successfully undertaken in the majority of patients who have isolated renal failure. For many developed countries in 2009, chronic dialysis of newborns has become the standard of clinical care. However, in newborns with co-existing congenital abnormalities, the prognosis may be poor. In these circumstances, palliative care can be discussed with the family and within the multidisciplinary environment.

It is important that the neonatologist/general paediatrician discusses each individual case with the paediatric nephrology service. This will give the parents and referring doctor an opportunity to discuss the relevant issues with the paediatric nephrology team and decide whether long term dialysis is a viable option.

How often does this occur?

The incidence of chronic dialysis from birth is very low; UK figures are 3 per million population per year. In the US, it is 6 per million. These figures are only of those who are offered chronic dialysis. In New Zealand, there have been 3 neonates who started chronic dialysis before age 30 days in the period 2004-9.

There is an increased incidence of prematurity in neonates with chronic renal failure. In a study of infants with GFR < 20ml/min/1.73m2 at the end of the first year of life, (normal at least >60) 26% were preterm; of these 18% were also low birth weight.
 

How will these newborns present?

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

In the second scenario, were severe kidney abnormalities are detected in-utero, the paediatric nephrology and urology services should be involved as early as possible so as provide appropriate information on possible treatment and outcome. Ideally discussion should take place antenatally with the opportunity for nephro-urological input at the fetal medicine panel.

What determines outlook?

Dialysis indications

Most infants with chronic renal failure have polyuric chronic kidney disease; hence hyperkalemia, fluid overload, and hypertension are uncommon despite very low GFR (renal function). On the other hand, if the baby is oliguric, dialysis is likely to be required to enable adequate nutrition support and growth.

Mortality

Survival of infants on long term dialysis is less than that of older children. Most deaths occur in first year of life. The North American Pediatric Renal Trials Collaborative Study (NAPRTCS) 2007 reported patient survival was 82% at 12 months and 73% at 24 months. For infants in whom treatment has never been started, most will have died before one year and the majority of these deaths are in infants with co-morbidity. The most common causes of death are cardiopulmonary and sepsis.

Outcome of those infants who survive

In the study by Warady, 28 of 34 (79%) infants who were dialysed before 3 months of age, one had significant developmental delay, 15 of the 16 who had reached 5 years of age were attending normal school. In the UK series of 105 children old enough to assess, 91(87%) attended normal school. 85% of children dialysed as infants had developmental scores within the normal range, but 50% had borderline abnormal psychosocial adjustment.

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

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.

Options for management

Option  
1

No treatment with palliative care support.

  • This is a decision which the parent may wish to choose after full and detailed discussions with the nephrology team and the wider multidisciplinary team. The newborn would be given usual cares such as feeding, analgesia as required but no invasive treatment that would prolong life.
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.
3 “Wait and see”
  • Some health professionals and parents may elect to adopt a “wait and see approach” to see what the infant will do on its own in the belief the strongest will survive and the weaker ones will perish. 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. As the infant survives the ensuing weeks, parents become more attached to the baby and may change their minds, requesting the nephrology team provide active treatment. By the time this occurs, the infant has 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.
     

Summary

Newborn infants with isolated severe renal failure may be offered long term dialysis but only after careful consideration of a variety of issues which include ethics of initiating or withdrawing such a treatment, resource availability, wishes of the family and expectations of society in general. Each case should be considered on a case by case basis in the nephrology multidisciplinary team.

References

1 Coulthard MG, Crosier J. Outcome of reaching ESRF in children under 2 years of age. Arch Dis Child 2002;87:511-7
2 UK Renal Registry. The ninth annual report;2006, chapter 13, 228. Renal Association
3 Kari J, Gonzales C, Lederman SE, Shaw V, Rees L. Outcome and growth of infants with chronic renal failure. Kidney Int 2000;57:1681-7
4 Lederman SE, Scanes ME, Fernando ON, Duffy PG, Madden SJ, et al Long term outcome of peritoneal dialysis in infants. J Pediatr 2000;136:24-9
5 Wood EG, Hand M, Briscoe DM, et al. Risk factors for mortality in infants and young children on dialysis. Am J Kid Dis 2001;37:373-9
 
6 Warady BA, Belden B, Kohaut E. Neurodevelopmental outcome of children initiating PD in early infancy. Pediatr Nephrol 1999;13:759-65
7 Madden SJ, Lederman SE, Trompeter RS et al. Cognitive and psychosocial outcome of infants dialysed in infancy. Child Care Health Dev 2003;29:55-61
 
8 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
9 Rees L. Management of the neonate with chronic renal failure. Semin Fetal & Neonatal Med 2008;13:181-188