Pretransplant Management

If dialysis is necessary, the method of dialysis (hemodialysis vs peritoneal) must be discussed and an access catheter placed. Peritoneal dialysis (PD), either continuous cycling or continuous ambulatory, is the preferred method and requires a peritoneal dialysis catheter.3 The catheter of choice is a coiled, swan-neck, tunneled, double cuffed catheter. At operation, the coil is placed in the pelvis and an omentectomy preformed. Postoperative complications include tunnel infections, peritonitis, and catheter malfunction. The coil (vs. straight) catheter decreases discomfort associated with dialysate infusion. The swan neck, a permanent, 180° bend in the catheter, prevents outward catheter migration and assists in maintaining the catheter in the pelvis. The tunneling and double cuff (vs. nontunneled, single cuffed) decreases the incidence of peritonitis and tract infections. The omentectomy decreases catheter occlusion.

Hemodialysis (HD) is an option for older children. The catheter of choice is a double lumen, tunneled, cuffed catheter.3At operation, the catheter is placed in the right internal jugular vein (IJ) and the tip positioned at the superior vena cava/right atrial junction. Postoperative complications include infection, thrombosis, catheter malfunction, and venous stenosis. Tunneling and cuff(s) decrease infection. Right IJ catheters have the lowest incidence of vascular stenosis. Catheter malfunction due to thrombosis or a fibrin sheath is treated with intraluminal urokinase (74% successful) or fibrin sheath removal (95% successful), respectively.3 All PD and HD patients are screened for nasal Stapholcoccus aureus and treated with intranasal Mupirocin if positive.

Medical management of ESRD children is aimed at preventing growth retardation, malnutrition, anemia, and renal osteodystrophy.4 The etiology of growth retardation is multifactorial and related to age of ESRD onset, duration of ESRD, and glomerulofiltration rate. Other important factors include anorexia, malnutrition, anemia, chronic acidosis, and uremia. Malnourished or anorectic children are treated with enteral feedings by either a nasoenteric feeding tube or gastrostomy. Unlike adults, ESRD children are not protein restricted but rather receive additional protein due to their greater lean body mass/weight ratio and poor protein utilization. Growth hormone (0.05 mg/kg/day) is a safe and effective treatment for growth retardation. Anemia is due to lack of erythropoietin and iron deficiency. Potential recipients with long waiting time should receive eryth-ropoietin (50-100 |i/kg 3 times per week), oral iron, and be followed to insure resolution of anemia. Renal osteodystrophy is the result of elevations in parathyroid hormone levels, hypocalcemia, hyperphosphatemia, and altered vitamin D metabolism. The result is an increase in bone resorption and poor bone mineralization. Treatment consist of a low phosphate diet, the use of phosphate binders (calcium carbonate, 10-20 mg calcium/kg/day) and vitamin D supplementation (calcitriol, 20-60 ng/kg/day).

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