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End-stage renal disease (ESRD) is characterized by kidney failure that requires either chronic dialysis or kidney transplant. According to the US Renal Data System (USRDS) 2016 Annual Report, at the end of December 2014, 9721 children were receiving care for management of ESRD; of these, 1398 children represented incident cases of ESRD. Etiologies of pediatric ESRD can be divided into 4 main categories: congenital abnormalities of the kidney and urinary tract (CAKUT), primary glomerular diseases, secondary glomerular diseases, and hereditary/cystic kidney disease (Table 474-1). The degree of renal failure is characterized along a continuum and defined by chronic kidney disease (CKD) staging. The Kidney Disease Outcomes Quality Initiative (KDOQI) provides recommendations for follow-up and management based on CKD staging.


Renal transplantation is recognized as the better form of treatment for pediatric ESRD when compared to chronic dialysis as it offers the possibility of restoring normal kidney function, eliminating morbidity associated with renal impairment, and allowing for maximal cognitive, psychomotor, and physical development. However, preemptive transplantation is not always an option, and dialytic therapy often needs to be initiated. Timing of initiation of chronic dialysis therapy typically involves integration of laboratory data, clinical parameters, and psychosocial issues. There is no defined blood urea nitrogen (BUN) or creatinine value that serves as an absolute indication for the initiation of dialysis. Dialysis should be considered in children who are CKD stage 5 (glomerular filtration rate [GFR] < 15 mL/min/1.73 m2) and should be initiated in children who have uncontrolled hypertension, volume overload, metabolic derangements (hyperkalemia, acidosis, or hyperphosphatemia), malnutrition or poor growth, or uremic symptoms despite medical therapy with appropriate medication management and dietary modifications. There are 2 main modalities available in a dialysis program for infants, children, and adolescents: peritoneal dialysis (PD) and hemodialysis (HD). Selection of the appropriate modality is individualized to the needs of each patient and family. Patient size, age, lifestyle choices, parental preferences, and psychosocial assessments all play key roles in evaluating the choice of modality for chronic renal replacement therapy. Hence, the need for dialysis care should be anticipated as CKD progresses ...

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