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Key Points

Essentials of Diagnosis

  1. Congenital or inherited disorders are the most common causes of renal failure in children.

  2. The etiology of renal failure plays a very important role in the management of patients with ESRD.

Essentials of Management

  1. RRT includes hemodialysis, peritoneal dialysis, and renal transplantation.

  2. The decision of the modality to be used is multifactorial and based on the individual patient.

  3. For long-term dialysis, an arteriovenous fistula or graft is preferable to a hemodialysis catheter.

  4. Peritoneal dialysis catheters are preferred in small children with small caliber vessels.

  5. Renal transplantation is ultimately the best treatment for children with ESRD.


The surgical management of pediatric patients with end-stage renal disease (ESRD) is generally focused on providing means for renal replacement therapy (RRT), namely dialysis or renal transplantation. Many patients with ESRD will alternate between the various modalities of renal replacement therapies throughout their lifetime. Initiation of RRT is usually based on the presence of complications such as fluid overload, acidosis, symptomatic uremia, electrolyte abnormalities, failure to thrive, profound bone disease, or developmental delay. The decision regarding the most suitable RRT modality for each patient is based on a number of factors such as the acuity of renal failure, etiology of renal disease, patient size, anatomy, and family support. Currently, kidney transplantation is the treatment of choice for children with ESRD since it provides several advantages when compared to long-term dialysis. Such transplant-related benefits include improvements in quality of life, improved growth and development, and avoidance of the morbidity and mortality associated with long-term dialysis.

Pediatric kidney transplantation should be performed at specialized centers with a dedicated multidisciplinary team to achieve optimal long-term graft and patient survival.

The surgeon is intimately involved in the care of pediatric patients with ESRD to address such challenges as creation and maintenance of dialysis access, construction of urinary conduits, native nephrectomy, and transplantation. This chapter focuses on surgical decision making and techniques that are used in the care of the pediatric patient with ESRD.

Patient Characteristics and Pathophysiology of Children with ESRD

The most common etiologies of renal failure in children who have undergone kidney transplantation are listed in Table 98-1. Congenital or inherited disorders are the most common causes in younger children. The leading cause of renal failure is related to abnormalities of renal genesis closely followed by conditions resulting in obstructive uropathy. In older children, acquired renal disease becomes more common.

Table 98-1Diagnoses and Demographics of Pediatric Patients Undergoing Renal Transplantation Based on Data from North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS)

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