Medical management of the child with chronic renal failure

Elisabeth Hodson

Centre for Kidney Research, The Children's Hospital at Westmead Westmead, NSW 2145, Australia

The goals of the management of children with chronic renal failure (CRF), defined as glomerular filtration rate below 30ml/min/1.73m2, are to achieve normal growth and development while minimising the complications of uraemia. The most important part of medical management is to ensure an adequate intake of energy and protein. Children with CRF ingest 10-20% less energy than healthy children; requirements are not increased. The initial energy and protein intake should be 100% of that recommended for healthy children of the same chronological age. If growth velocity falls and/or energy intake is low, supplements of high energy foods should be given orally or enterally by naso-gastric tube or gastrostomy. Most infants have CRF due to dysplastic kidneys with polyuria allowing a large fluid intake, which makes it easier to achieve the energy requirements using standard infant formulae. However vomiting associated with gastrointestinal dysfunction and gastro-oesphageal reflux may impair intake. Maintaining energy intake at 100% is associated with improvement or stabilisation of growth rates especially in infants. Infants with polyuria may require supplements of 4-7mmol/kg of sodium chloride since sodium chloride excretion may exceed the input obtained from standard infant formulae or breast milk. Supplements of water-soluble vitamins to achieve 100% of recommended are needed for those children, who are not receiving oral or enteral nutritional supplements which contain adequate vitamins. Growth should be monitored by regular measurements of weight, length and head circumference. Nutritional assessment and counselling should be undertaken regularly especially in infants. Other measures include correction of metabolic acidosis, treatment of anaemia with erythropoietin and iron supplements to achieve a haemoglobin of 100-110 g/L, and prevention and treatment of renal osteodystrophy by maintaining normal calcium and phosphorus levels and reducing PTH levels with vitamin D, phosphate restriction and phosphate binders. The success of this programme depends on adequate family support and massive input from physicians, dietitians, social workers and occupational therapists among others.

Invited lecture at the 6th annual convention of Pediatric Nephrology of the Philippines, Manila, July 2001

Correspondence
Elisabeth Hodson
ElisaH@chw.edu.au