Infant Dialysis: Is The Price Still High?
The recent paper in Pediatric Nephrology Journal by Lantos and Warady takes you smoothly through the whole story of infant dialysis and renal replacement therapy that started in the sixties of the last century .
The authors echo the concerns of many doctors and nurses working in the field of infant dialysis questioning the appropriateness of this aggressive approach to what had been considered as a uniformly fatal disease.
On one end of the spectrum in an early study in 1978, Hodson and colleagues report 21 patients in which dialysis started in the neonatal period and transplantation performed at a mean age of 3 years. Four children died, 5 lost their initial graft, and the overall patient survival at 4 years of age was 76% .
Despite of all the ethical concerns and the seemingly insurmountable hurdles, more and more centers began to offer dialysis to the increasing numbers of diagnosed and referred infants as a direct result of enhanced perinatal care and antenatal diagnosis of kidney diseases, primarily Congenital Anomalies of the Kidney and Urinary Tract (CAKUT).
With gained experience and careful study, the outcome partially improved. In 2007, Rees reported Great Ormond Street Hospital (GOSH) in that respect. In 20 infants on PD, 14% had developmental delay; 7%, congenital heart disease; 3%, gut problems; 2%, hypothyroidism; 2%, respiratory problems; and 2%, blindness and deafness .
So, is RRT justified in infants?
Whether to initiate RRT in an infant is one of the most difficult questions facing pediatric nephrologists. Moreover, the ethics surrounding withdrawing or withholding treatment have been extensively discussed. That decision is even more complex for infants with other co-existing congenital anomalies ; approximately one third of the infant renal failure population .
Whereas some families opt for intensive management of their infant, with dialysis and early transplantation, other families may decide that they do not wish to inflict further pain and suffering on their infant, and they choose conservative management rather than RRT. Having said that, down the road parental bonding with an infant could be an issue and can lead to reversal of a decision for conservative management, by which time irreversible damage to growth and development may have occurred .
For infant dialysis to achieve the best possible outcomes, attention must be paid to nutrition, growth and development, prevention of renal bone disease, preservation of dialysis access sites and the peritoneal membrane (major issue in many centers), and above all provision of utmost support to the families of these infant who will endure considerable suffering in this journey.
In 1970, Reinhart wrote "I feel that programs of chronic dialysis and renal transplantation in children should be carefully evaluated, not in terms of gross survival but in parameters of meaningful growth and development-living. We may find the price the child pays too great at present" 
The question remains, is the price still high?
1. Lantos JD, Warady BA. The evolving ethics of infant dialysis. Pediatr Nephrol. 2013 Oct;28(10):1943-7. doi: 10.1007/s00467-012-2351-1. Epub 2012 Nov 7
2. Hodson EM, Najarian JS, Kjellstrand CM, Simmons RL, Mauer SM. Renal transplantation in children ages 1 to 5 years. Pediatrics. 1978;61(3):458-64
3. Rees L. Long-term peritoneal dialysis in infants. Perit Dial Int. 2007;27 Suppl 2:S180-4
4. Shooter M, Watson A. The ethics of withholding and withdrawing dialysis therapy in infants. Pediatr Nephrol 2000 ; 14:347 -51
5. Reinhart JB. The doctor's dilemma: whether or not to recommend continuous renal dialysis or renal homotransplantation for the child with end-stage renal disease. J Pediatr. 1970;77(3):505-7