Care of the Neonate with
|Reviewed by William Wong, Max Morris, Tonya Kara, Jane Ronaldson, Sarah Farrell and Malcolm Battin|
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
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.
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.
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.
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.
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.
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.
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
A team of medical, nursing and allied health professionals is essential to manage a neonate with severe chronic renal failure.
No treatment with palliative care support.
Full treatment with full support
“Wait and see”
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.
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