Renal replacement therapies in neonates: issues and ethics

Chronic irreversible kidney disease requiring dialysis is rare in the neonate. Many such neonates are diagnosed following antenatal ultrasound with congenital abnormalities of the kidneys and urinary tract. There is an increased incidence of prematurity and infants that are small for gestational age. Given the natural improvement in renal function that occurs in the neonatal period, some with extremely poor renal function may, with careful management of fluid and electrolytes, be kept off dialysis until the creatinine reaches a nadir when a definitive plan can be made. There is a very high incidence of comorbidity and this affects survival, which for those on dialysis is about 80% at five years. The multiple and complex ethical issues surrounding the management of these very young children are discussed.