Outcomes of dialysis in neonates with anuric end-stage renal disease at birth: ethical considerations

Journal of Perinatology (2022) 42:920–924. doi:10.1038/s41372-022-01328-2

Daniel S. Han , Margret E. Bock, Jacqueline J. Glover and Vijaya M. Vemulakonda

Reviewed by: Daniel Helfgott and Shanthy Sridhar

Background:

Congenital bilateral renal agenesis is typically a lethal diagnosis. However, amnioinfusion has led to improved pulmonary development which has increased potential survivability to birth. While the potential of aminioinfusion is currently being studied in multiple other etiologies, little research has focused on this population. These patients would require Renal replacement therapy (RRT) immediately after delivery as a bridge to renal transplantation with multiple potential peri- and post-operative complications.

What was the purpose of the study?

The goal of the study was to report on 5 cases who initiated RRT within one week of life due to anuric End Stage Renal Disease (ESRD). Additionally, ethical implications of RRT in these patients were discussed to help guide pre-and postnatal counseling.

What were the study design and methods?

A Retrospective review of patients who initiated RRT within 1 week of life due to anuric ESRD from 2009–2019 at a single tertiary center was performed. Primary outcomes were receipt of renal transplant (RT), one-year survival, and overall survival.

What are the results?

5 Patients were identified and their cases were reviewed (1 male 4 female). Two patients had bilateral renal agenesis and received serial amnioinfusions. The other patients were diagnosed with autosomal recessive polycystic kidney disease, renal tubular dysgenesis, and renal dysplasia.

  • The initial mode of RRT (median age of initiation was 3 days) was peritoneal dialysis in 3 patients and Continued renal replacement/ hemodialysis in 2 patients. However, all the patient ended up receiving both methods as those with PD had complications requiring HD.
  • Three patient had peritonitis from PD
  • All were initially intubated due to pulmonary hypoplasia
  • The median length of the initial hospital stay from birth was 133 days (range: 73–367). All patients had pulmonary hypoplasia and initially required intubation, but all could eventually be extubated.
  • Two patients received a renal transplant at 43 months of age.
  • Four patients survived to one year.
  • Two patients in total did not survive One from recurrent Necrotizing enterocolitis (NEC) and the other from cardiopulmonary complication of renal transplantation.

What was the conclusion?

This study highlights the feasibility of survivorship with bilateral renal agenesis and eventual renal transplantation. However, the significant comorbidities and high mortality raise significant ethical considerations on whether RRT should be offered. Ethical principles such a futility and more specifically Qualitative futility (any treatment that merely preserves permanent unconsciousness or that fails to end total dependence on intensive medical care should be regarded as non-beneficial and, therefore, futile) can be applied to this case.  Moreover, the quality of life of the parents/caregivers should be considered as well.

Why is this important?

The study shows that RRT in patients with bilateral renal agenesis is not completely non-beneficial. However, prenatal counseling for congenital renal anomalies should consider the significant morbidity and mortality of the disease. If appropriate, they should receive consultation with maternal-fetal medicine along with extensive interdisciplinary care at a fetal intervention center. The parents should receive an accurate description of the potential postnatal course as this study highlights.