Fetal management of advanced chronic kidney disease: Fetal Genitourinary...
With Dr. Jan Scober · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Video
Fetal urological aspect: Fetal Genitourinary Disease 2015
59 min · Published Jul 2017
Video
Fetal Diagnostic Imaging: Cincinnati Fetal Center
10 min · Published Nov 2018
Video
Prenatal diagnosis of fetal lower urinary tract obstruction: Fetal...
40 min · Published Jul 2017
Video
Overview of Prenatal Diagnosis: Cincinnati Fetal Center
40 min · Published Nov 2018
Video
Urologic Fetal Intervention: Cincinnati Fetal Center
61 min · Published Nov 2018
Video
Cloaca - Urologic Concerns
25 min · Published Nov 2018
Only a few other public items share this expert — go deeper there →
Video
Pediatric Surgical Oncology Research Collaborative (PSORC): Studying Rare Pediatric Tumors
56 s · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Pooling Patients to Study Rare Pediatric Tumors: An Introduction to PSORC
56 s · Published May 2026
Video
The fetal frontier: A review of current and emerging fetal therapies for genetic diseases
44 s · Published May 2026
Video
Indocyanine green assists with sentinel lymph node mapping in pediatric and adolescent patients
1 min · Published May 2026
What the experts said
In fetal genitourinary disease, pulmonary survival is the critical first question that determines whether renal outcomes matter, yet it is frequently overlooked in discussions focused on kidney function.
When amniotic fluid levels are restored to normal through shunting or amnioinfusion, the likelihood of pulmonary survival increases significantly to approximately 80%.
If amniotic fluid levels are not returned to normal despite intervention, pulmonary outcomes are poor.
Determining pulmonary survivor status after delivery is complex because multiple postnatal factors can affect outcomes: sepsis-related lung injury, nutritional status affecting lung growth, and ventilator-induced barotrauma.
Being a pulmonary survivor does not mean normal respiratory function; many infants have reduced lung reserve similar to reduced renal reserve and can rapidly decompensate with additional injury.
Some infants with prenatal renal problems who had amniotic fluid replacement and normal fluid levels still developed chronic lung disease after delivery, demonstrating they are not respiratory-normal.
Any kind of urine output, even poor-quality urine that is mostly water without cleared metabolites, is much better than no urine for both prenatal and postnatal management.
Infants with obstructive uropathy often have a concentrating defect and produce large volumes of urine, which may be poor quality but is still beneficial as fluid.
At this center, infants are typically transplantable at a size between 8 and 10 kg, which usually occurs in the second year of life.
Lower urinary tract management in infants with obstructive uropathy requires collaboration with pediatric urologists and includes antibiotic prophylaxis, bladder irrigations, and bladder pressure management with anticholinergics and catheterization programs.
Obstructive uropathy bladders can have very high pressure and can change over time, requiring regular urodynamic studies and potentially changing management strategies.
Infants with chronic kidney disease from obstructive uropathy typically do not have significant hypertension because they have high urine output and are not volume overloaded, and they lose sodium due to tubular dysfunction.
Chronic kidney disease management in infants requires supplementation of erythropoietin and iron to prevent anemia, which has negative cognitive, energy, and quality-of-life effects.
Untreated secondary hyperparathyroidism from advanced CKD impairs bone and skeletal health, which is especially problematic in growing children.
Advanced chronic kidney disease not requiring dialysis often causes metabolic acidosis, which is harmful to growth and well-being and requires buffering with citrate supplementation.
Specialized nutrition management in infant CKD includes formula modification and pre-treatment with potassium-binding resins to prevent hyperkalemia.
Infants with advanced CKD have feeding and swallowing difficulties and require occupational therapy, physical therapy, and feeding team involvement for developmental support.
Standard chronic kidney disease staging based on GFR does not apply to children under 2 years of age because normal infants spend their first year developing normal kidney function, with GFR rising from about 50 at one month to about 100 by one year.
The decision to initiate dialysis is based on failed chronic kidney disease management—inability to support growth (including head circumference) or medically manage hyperkalemia or metabolic acidosis—not on creatinine level alone.
Peritoneal dialysis is the modality of choice for infant dialysis because it is the technically least difficult approach in small children.
Peritoneal dialysis introduces a major additional layer of complexity and quality-of-life burden for parents, who are typically taught to perform dialysis at home.
When counseling parents about infant dialysis, the focus should be on the length of time it may be needed (until the child reaches transplantable size at 8-10 kg, typically in the second year of life) and the complexity of the therapy package.
Parents typically report that when their baby requires complex care including dialysis, one parent usually stops working and caring for the baby becomes their full-time job.
Residual urine output is a major advantage in managing fluid balance during dialysis; it is very difficult to manage fluid balance with dialysis alone without some residual diuresis.
It is difficult to justify placing a patient on chronic dialysis without some prospect of transplantation, as this creates a never-ending one-way street that becomes very challenging.
For aggressive pulmonary care in infants with genitourinary disease, whatever respiratory support is needed should be provided for at least the first 3 to 4 days, as many infants requiring high levels of support (including oscillator or pulmonary vasodilators) will begin to improve after this period.
If an infant is not showing signs of stabilizing and improving by 3 to 4 days of life, discussion with parents about the reality that the infant is likely not a pulmonary survivor is necessary.
The question of pulmonary survival may need to be revisited later, most frequently in the setting of sepsis, where infants on peritoneal dialysis who develop infection can progress from room air to ventilator dependence and never be weaned.
When peritoneal dialysis is not available due to peritonitis, short-term hemodialytic strategies can be attempted but are challenging because they require blood priming of circuits and very large catheters in small blood vessels.
Aquaphoresis (ultrafiltration with convective clearance) using slightly smaller catheters than hemodialysis has been successfully used to maintain anuric babies with intraperitoneal problems or those requiring major abdominal surgeries.
Temporary hemodialysis catheters in newborns are difficult to maintain because there is limited catheter design for small children, resulting in excess extravascular catheter length that moves despite securing attempts.
Hemodialysis catheters in newborns are 8 French in size and are limited to jugular vein placement; even tunneled catheters are likely to cause local thrombosis or central circulation stenosis.
Nutrition management is easier in infants with urine output compared to oliguric or anuric infants because formula does not need to be as concentrated.
High-output infants with CKD lose electrolytes including potassium and phosphorus, requiring supplementation of electrolytes that are typically restricted in older CKD patients.
Formula density for infants with CKD is inversely related to urine output volume.
Dietitians calculate required calories for growth and required protein intake while ensuring BUN does not reach dangerously high levels; the inability to provide adequate protein without excessive BUN may necessitate dialysis.
It is relatively unusual to expect infants with advanced CKD to drink spontaneously in amounts sufficient to supply required nutrition.
Breast milk from motivated mothers can be incorporated into specialized formulas that meet the infant's specific nutritional needs; this is typically pumped breast milk.
The majority of infants with advanced CKD have either an NG tube or gastrostomy tube for feeding, which is maintained even around transplant time for medication administration.
Guideline writers accept that GFR criteria for CKD staging don't apply to children less than 2 years of age; these children can only be categorized as having normal, moderately reduced, or very severely reduced age-adjusted GFR.
Dialysis for small children remains challenging but has improved in outcomes and feasibility and should be discussed with families on an individualized basis.