When Good Kidneys Go Bad

Perhaps the diagnosis surprised the family. A previously healthy child became more and more fatigued, ultimately resulting in a trip to the doctor and some blood tests. Perhaps it was the long-anticipated-but-dreaded progression of a known condition. Either way, a child’s kidneys have reached the point of  no return. What now?

What level of kidney function requires treatment?

Current dialysis achieves 10-15% of normal kidney function. In the case of a patient with a progressing kidney disorder, planning for replacement of kidney function should begin when estimated glomerular filtration rate reaches 20-30% of normal.

What is dialysis?

Dialysis treatment removes excess fluid and chemicals from the blood by filtering it. The trick is removing enough of things like sodium, potassium, magnesium, phosphorus, and acid without removing too much. Two methods of dialysis exist at this time, hemodialysis and peritoneal dialysis.

Click to enlarge

Click to enlarge

Hemodialysis

In this form of dialysis, the patient’s blood is taken out of their body, run through an artificial kidney machine, and then returned. Typical treatments take 3 to 4 hours and are performed in a dialysis center 3 days each week. Blood can be accessed using a large intravenous tube in the neck veins or, in adults and larger children, a fistula. A surgeon creates a fistula by connecting an artery to a vein, usually in a forearm. After several weeks, the connecting vessel becomes enlarged. Needles can be inserted and used with the same level of blood flow as the plastic tube. Fistula’s provide better dialysis and have fewer risks of infection than the large intravenous tube.

Some dialysis centers now offer home hemodialysis. Patients’ and their families must learn to stick a fistula and perform the treatments themselves. There are many advantages to this situation, although many centers will not accept children for this treatment option.

Peritoneal dialysis

Peritoneal dialysis involves placement of a plastic tube into the tummy of the patient, the peritoneal space around the bowls. Lots of tiny blood vessels flow through this membrane. By putting fluid in and out of the peritoneal space, fluid and chemicals can be removed from the patient. In children we often use a cycler to do this job. This small machine sits by the patient’s bed and runs fluid in and out while the child sleeps. In another form of peritoneal dialysis, the fluid is changed 4 to 6 times each day over 24 hours.

This type of dialysis is performed by the patient and family at home, so it interferes less with school or work. Monthly lab monitoring and doctor visits are necessary.

What is transplantation?

Ultimately, the goal of nephrologists is to transplant every patient with permanent kidney failure, especially children. A new kidney can be obtained from a healthy relative or other volunteer, or it may be donated by a deceased person. Surgeons can attach the new kidney into the patient, most often in one of the groins. The non-functioning “native” kidneys can almost always remain in place.

Kidney transplant can provide a very normal quality of life, but it is not a complete cure. Patients must take medications to prevent rejection as long as they have the kidney.
These medications can make the patient more susceptible to infections and cancers since they tone down the immune system. Patients with transplants require life-long monitoring of kidney function, medication levels, and other potential side-effects. Despite this list of problems, transplantation is the best therapy for kidney failure and should be the goal for most patients.

A new information sheet about dialysis and transplantation is available on the Information Page of this web site.

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