INTERVIEW WITH DR. STEFANO PICCA FROM THE NEPHROLOGY AND DIALYSIS UNIT AT BAMBIN GESU' HOSPITAL IN ROME

Dr. Picca, what exactly does the term "dialysis" mean?

Dialysis is a form of therapy that has been in use for nearly 50 years. It is a way to replace kidney function in a system that displays some sort of dysfunction. This procedure is performed in order to filter blood, by eliminating the waste produced by the body when the kidneys are no longer able to serve this purpose. This treatment can allow the patient to live for an extended period of time, and with regard to children, it constitutes the first phase leading up to a kidney transplant.

 

What is the difference between hemodialysis and peritoneal dialysis?

In hemodialysis, blood is withdrawn from a vascular access and moved through a device to a filter that cleanses it and pumps it back into the patient after the waste has been removed. The process takes 2-5 hours and is performed 2-4 times a week.

In peritoneal dialysis, on the other hand, a small tube is inserted permanently in the intestines, which are flushed out with a sterile solution making use of the peritoneum as the membrane for dialysis. This generally takes all night and is carried out with special equipment.

Generally, the parents are the ones to carry out the procedure on the child at home, after taking a 2-month training course. Once they have been properly trained, the parents can bring the equipment supplied by the local health care authority (ASL) to their own home (upon authorization) and begin treatment.

The parents become the child's personal medical staff, ensuring that he/she receives dialysis at home during the night, and the next morning he/she can go about a more or less normal life.

The parents of these children are truly exceptional people. If it's true that a mother knows her own child better than anyone else ever could, then in this type of case, she may also be the best one to provide medical care for her child.

What causes can lead to kidney malfunction un in children?

The main difference from forms of nephropathy in an adult is that in most cases involving children, the causes of chronic kidney disease are congenital and, therefore, derive from malformations that may be either genetic or embryonic, and which are often related to other more complex syndromes or diseases affecting the children.

How can you tell if a child is affected by kidney disease? When and how can action be taken?

In the earliest forms, or rather, congenital forms, there are generally other conditions indicative of a more complex condition. Once a disorder or syndrome is observed, tests are also performed on the kidneys to see if they are also compromised.

There are also a number of other symptoms relating to kidney dysfunction which dialysis alone cannot address, for example, growth deficit. Today we have various means allowing us to aid the growth of a child undergoing dialysis through forms of growth hormone therapy. There are also serious cardiovascular issues, especially in the case of hypertension, which dialysis is only able to address partially.

Today many forms of infant nephropathy, which entail congenital malformations in the urinary tract, can be detected in utero through prenatal ultrasounds, thus making it possible to identify kidney malformations in the child even before it is born.

Often times, the malformations cannot be corrected due to the very fact that they are congenital. In this case, there are conservative forms of therapy that can be applied, including pharmacological and dietary treatment; given that the kidney is not able to carry out its functions properly, the kidney functions need to be replaced either artificially, via dialysis, or biologically, via transplant.

What results can be expected from these treatments and how long does it take to see them?

With regard to pediatric dialysis, the only true cure allowing the patient to overcome these issues and achieve a good quality of life is a kidney transplant.

Generally speaking, the time it takes to have this result depends on the wait for a transplant to be performed.

At our hospital, the average wait for a kidney from a deceased donor is 12 months; however there are exceptions, such as rare cases in which the children have to wait for years, or another case in particular, when the child only had to wait 48 hours.

What are the risks for children affected by kidney disorders and undergoing dialysis?

There are two categories of risk relating strictly to dialysis: chronic and acute.

Chronic, in that the dialysis may not be able to replace all of the kidney functions. The child may have a chronic bone disease which may lead to a deficiency of calcium in the bones, then in turn leading to a growth deficit or anemia.

In recent years, the quality of life for these children has shown general improvement but the risks are still present for the most part.

There are also acute risks which are connected to the treatment itself. In fact, during dialysis, the patient has to take anticoagulants to prevent the blood from coagulating inside of the device, which would increase the risk of internal bleeding with serious consequences.

Dialysis can also cause high blood pressure, so patients who are at risk of hypertension could have cardiac or cerebral issues. In young children, dialysis can also cause imbalanced water to solutes ratios, electrolytes in this case, which lead to alterations in the central nervous system. So, if a young child receives dialysis improperly, it could cause convulsions.

Approximately what percentage of patients actually fall victim to these risks?

There are a number of rules and measures that are implemented and through which all of these issues can be avoided, so the occurrence of these problems and acute side effects of dialysis is actually very rare. In our hospital's 27 years of experience, there have been no dialysis incidents resulting in the death of a patient. Acute kidney disease is a different story; this type of case is much more critical with much more urgent treatment provided in intensive care. For this category of patients, the risk relating to dialysis is higher by definition, because the patient's overall condition is more critical.

What have you been able to do through the help of the Ginevra Caltagirone Foundation?

We are extremely grateful to the Foundation for donating a defibrillator to the dialysis center, both because there was a real need, and because a defibrillator is a device that can truly save lives. In fact, patients receiving dialysis are more exposed to risks regarding cardiac activity, so it unthinkable that a dialysis center could go without this type of equipment. We would like to thank you on behalf of the ward and all the children.

How does a defibrillator work?

A defibrillator is a device that delivers a therapeutic dose of electrical energy which is adjusted based on the patient's needs and essentially resets atrioventricular transmission so that it will start over again. Naturally, it is used in situations where the cardiac transmission is not functioning properly and the heart stops. A defibrillator essentially makes the heart start working again.


Interview conducted by
Lorenza Aquilani