RENAL FAILURE: MEDICAL AND ETHICAL ASPECTS

Renal failure: medical and ethical aspects

Jochen H.H. Ehrich

Children's Hospital, Medical School, Hannover, Germany

End stage renal failure (ESRF) may occur very early in life and infants may require renal replacement therapy (RRT) even shortly after birth. The main causes for kidney failure in young children are renal dysplasias and urinary tract malformations affecting more boys than girls (2:1 ratio). During a symposium held in 1998 at the Charité Hospital in Berlin 40 European paediatric nephrologists wrote a memorandum on medical and ethical issues in RRT in young children. It was agreed that the decisions about offering or withholding RRT must not be left to the parents. A competent medical team including a paediatric nephrologist, neonatologist, obstetrician paediatric surgeon or urologist and a psychologist should be involved in the decision making process which may result in life long therapy. Once the decision has been made in favour of RRT the start of dialysis should follow the rules which also apply for older children with ESRF, well knowing that RRT in young children is usually associated with a higher rate of complications disabilities. Peritoneal dialysis was regarded as initial treatment of choice for infants. It was agreed that any such decision to institute or withhold RRT is not a "one-way street". If infants develop life limiting extrarenal complications, the decision may be taken by the parents and the caregivers to stop RRT. There was some debate if renal transplantation should be performed early or only above a certain age and weight limit. It was agreed that children above two years of age should not be withheld from transplantation. Adequate nutritional support (e.g. via PEG or nasogastric tube) should be given during dialysis. Some experts reported the special need for an adequate control of renal bone disease in infants with ESRF requiring high doses of 1,25 vitamin D3 and adequate phosphate supplementation. There was a general agreement that growth hormone is not a treatment of first choice in very young children. In summary, RRT should be offered to infants with ESRF if there is no additional extrarenal life limiting disease. RRT in this age group is high-tech care, cost-effective and not without risks for the patient, thus requiring a highly specialised team of care givers.