Paediatric Nephrology
At first such treatment was only offered to older children; acceptance of infants began in the 1980s. Indeed RRT is still not available everywhere in the world: 80% of children who receive RRT live in Europe, North America or Japan. Even within Europe there are differences that are principally related to economic factors, prejudicing against younger children who are more costly to treat.
The incidence of CKD increases with age: in the UK 3% of children on RRT are under two years of age, 28% are aged two to eight, 28% are 8 to 12, and 40% are 12 to 16 years. The prevalence of RRT ranges from 18 to 100 per million age-related population. Prevalence has increased over the years due to a combination of inclusion of younger children and those with comorbidities, and improved survival.
As well as advances in surgical techniques and technology for RRT, our therapeutic toolkit continues to expand and we take for granted many treatments that are now in routine use. A large number of important developments took place in the 1980s.
To name but a few: ACE inhibitors revolutionised the treatment of hypertension alongside our understanding of their role in the attenuation of the progression of CKD; ciclosporine improved outcomes for patients post-transplant, for whom immunosuppression had before been just steroids and azathioprine; and prevention of anaemia with erythropoietin rather than blood transfusion has improved the health, wellbeing and future chances of transplantation for thousands of patients.
Despite these advances, three major complications of CKD remain and continue to adversely affect the outcome of our patients: poor growth, bone disease and cardiovascular disease (CVD).
Height prognosis has improved considerably during the last decades. There are two studies from the US of the growth of children with CKD: in 2006, one third of children were below the third centile for height; whereas between 2005 and 2013, this figure was only 12%.
This improvement applies to children on RRT as well. Between 1985 and 1988 the European Dialysis and Transplant Association (EDTA) Registry reported that the mean height standard deviation score (HtSDS) was −3.0. In Germany between 1998 and 2009, mean HtSDS improved to −1.8. Puberty had been a time when growth was particularly badly affected: EDTA data showed that the pubertal growth spurt was delayed by as much as two years and the overall height gain was significantly reduced.
These developments are likely to be due to better understanding and management of the complications of CKD such as nutrition (particularly in infants), anaemia, acidosis, bone disease, derangements of the GH IGF-1 axis, and of dialysis machines and programmes, and parallels an improvement in the survival of our patients. Reduction of steroid use post-transplant has also contributed, and the use of rhGH.
References:
Rees L, Schaefer F, Schmitt C, Shroff R, Warady B (2017) Chronic dialysis in children and adolescents: challenges and outcomes. Lancet Child Adolesc Health 1: 68–77
Rees, L (2016) Growth hormone therapy in children with CKD after more than two decades of practice. Pediatr Nephrol 31:1421-35.
