The optimal treatment of ESRD is renal transplantation.Both deceased and living donors can be used for renal transplantation, but living donors are preferred when available. Maintenance dialysis is effective for a child awaiting renal transplantation or for whom renal transplantation is not possible. Indications for chronic dialysis are given in Table 165-3. Peritoneal dialysis is done at home by the family. Hemodialysis is typically done three times a week at a dialysis facility.
Children with mild CKD (stages 1 and 2) may do well but needto be monitored for progressive loss of kidney function. Childrenwith stages 3 and 4 CKD have a high likelihood of progressing toESRD at some point, although the timing can vary. Children withkidney transplants generally do well but have to take immunosuppressive medications associated with a variety of side effects,including infections, nephrotoxicity, cardiovascular complications, and increased risk for certain malignancies. Unfortunatelymost transplanted kidneys fail over time but can last for severalyears. Children on maintenance dialysis have the highest morbidity and mortality, especially with longer time spent on dialysis. Thus, their primary goal is to receive a kidney transplant.
In children, hypertension (HTN) is defined as blood pressure (BP) greater than the 95th percentile for age, gender, and height on at least three different occasions. The context of the BP measurement (e.g., cuff size, pain, anxiety) is important. The staging of HTN is given in Table 166-1. Hypertensive emergency is defined as severe elevation in BP associated with target organ damage (encephalopathy, heart failure).
Pediatric HTN has many causes (Table 166-2) that are either primary (essential) or secondary. Essential HTN is the most common cause of HTN in adolescents. Obese children are more likelyto develop essential HTN. Secondary HTN should be suspectedwith younger age and more severely elevated BP. Renal disease is the most common cause of secondary HTN in children.
Available @ StudentConsult.com <90th Prehypertension *90th to 95th Stage 1 hypertension 95th to (99th + 5 mm Hg) Stage 2 hypertension >99th + 5 mm Hg *If 90th % is >120/80, use 120/80 as the lower limit.
Congenital anomalies (renal dysplasia, obstructive uropathy) Structural disorders (Wilms tumor, polycystic kidney disease) Glomerulonephritis Acquired injury (renal scarring, acute tubular necrosis)
Catecholamine-secreting tumors (pheochromocytoma, neuroblastoma) Hypercortisolism (Cushing syndrome) Hyperaldosteronism Hyperthyroidism
Increased sympathetic activity (stress, anxiety, pain) Dysautonomia Increased intracranial pressure
Coarctation of the aorta Renal artery embolism (from umbilical artery catheter) Renal vein thrombosis Renal artery stenosis Vasculitis
Obstructive sleep apnea Medications, illicit drugs