Pediatric chronic renal failure (PCRF) is a progressive disease caused by several factors that impair kidney functions until it is necessary to undergo a replacement therapy called dialysis or a kidney transplant. When PCRF is present in a patient, the following are the most common complications: retention of toxins in the blood, hypertension, water retention, electrolyte disequilibrium (mainly sodium, potassium, calcium, phosphorus, and magnesium), malnutrition, anemia, failure to thrive, and adverse neurocognitive outcome.Dr. Rotundo, one of my teachers, studied in 1982 at the University of Minnesota the neurological development in PCRF (1). He observed significant neurodevelopmental impairment in children with advanced PCRF during the first year of life, characterized by mental retardation, microcephaly, and seizure disorders (1). More recently in 2007, Gipson and colleagues suggested that those consequences were related to an early onset of PCRF (2). Furthermore, in 2010, Icard and colleagues demonstrated that better kidney function was associated with improved neurocognitive study results (i.e. spelling task) (3), and it has been well established that compromised cognitive functions in adults with renal failure have a childhood onset (4).
Johnson and Warady recently published that ESRD drastically impacts infants’ brain development and therefore possibly lead to a poor neurological outcome (5). The researchers reinforced that transplantation improves kidney function, promotes brain development in childhood, as well as neurological functions (5).
Thirty years ago, when I was beginning to study Pediatric Nephrology in a third world country of South America, I was astonished to see so many pediatric patients in need of either dialysis and/or kidney transplant. Several factors including weighing less than 10 Kg, immunological reproducible diseases, very young patients, absence of a possible living-related donor, antigen blood sensitization, and profound neurological damage, made it nearly impossible to consider replacement therapy. It was an extremely challenging task to decide who should be recommended for these treatments and who was not-even more so in a country with social and economic health difficulties. Not only patients with real possibilities to have somatic recuperation will be considered first, but also patients who will be able to be completely immersed in schooling and societal activities.
Almost 45 years ago, Reinhart and more recently Cohen in 1987 established the doubt of the real benefits of dialysis and transplant surgery to very young patients with renal failure. They pointed out the necessity to balance the parent’s desires vs. the success of these treatments offering considerable pain and suffering in these patients (6,7). Therefore, there are ethical implications that should always be considered: palliative care vs. complete therapy. Lantos and Warady stated: “… it is not a therapy that doctors feel to be morally obligatory in most cases. (8).” The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Bio-behavioral Research in 1983 summarized three categories related to the topic: 1-Clear beneficial treatment; 2-Clear futile treatment; 3-An ambiguous or uncertain outcome (8). Only 1 and 3 give options to proceed, but there are some others factors to be considered: a-Burden on families: Peritoneal dialysis is done at home and requires an active and committed parent; b-Renal replacement therapy is very expensive; c-Associated co-morbidities to PCRF are around 30%, and the neurocognitive development restrain the decision to go further with the treatments (8).
Finally the recommendation for replacement therapy for infants in ESRD is difficult and brings legal and ethical consequences that should always be very well discussed before, considering the particular characteristics of patients and their families.
