Practical Procedures in Pediatric Nephrology Subal Kumar Pradhan, Rajiv Sinha
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Setting-up Pediatric Nephrology ServicesCHAPTER 1

Kishore Phadke
It is quite challenging to initiate pediatric nephrology services in the regions where they were earlier nonexistent. Expansion of existent services also requires dedication to the field of pediatric nephrology, hard work and patience.
The first step would be to identify your mission and draw carefully your mission statement. Your mission should tally with the mission of the organization or the institution where you work. You and your activities will need support and encouragement from your institution. For example, if the aim of your institution is to make profits (as it is usually in case of a corporate structure); then your activities in areas of patient care, training, education and research will have to translate into funds generation. If your institution supports “service”; you may be able to pursue a lot of educational, academic and community oriented activities.
It is desirable to set up an “Identity” for pediatric nephrology within your institution. It will then become easier to focus on your activities in pediatric nephrology and develop resources (people, equipment, library, research projects etc.). Also, this may facilitate your having to spend less time in day-to-day activities of areas other than pediatric nephrology (in departments of pediatrics or adult nephrology as the case may be). You may want to name the entity as a “kidney center for children” or think of any other suitable name. At some stage, you may be able to form a separate division of pediatric nephrology and later, a separate department. While doing this, you need to take care of maintaining good relationships with your colleagues in general pediatrics, pediatric surgery/urology and adult nephrology and participate in joint activities of mutual interest.
You should have a “step up” approach. Start with outpatient services in the form of a pediatric renal clinic once a week. Later, as the load increases, you may want to make it 2–3 times a week. When appropriate, think of a joint outpatient service with pediatric surgery/urology (pediatric nephrourology clinic) and a specialized clinic such as a CKD (chronic kidney disease) clinic. Initially, the inpatient service patient beds may be dispersed within other pediatric beds.2 When the load increases, you may think of a separate pediatric nephrology ward.
The procedures in pediatric nephrology such as acute peritoneal dialysis, central line insertions, continuous ambulatory peritoneal dialysis (CAPD), acute hemodialysis, plasmapheresis, sustained low efficiency dialysis (SLED), continuous renal replacement therapy (CRRT) may be established, in the order mentioned. Ensure that the required consumables are available and the support systems such as pediatric intensive care and neonatal care are geared up to take care of sick patients. If there is a good functioning hemodialysis unit for adults; initially you may dialyze your children in that unit until you have enough manpower, resources and personnel to be able to independently handle a pediatric hemodialysis unit. Renal transplantation can be considered only if all above are established and an interested surgical team, tissue matching facilities, reliable high quality diagnostics, radiological services and other hospital support systems are available.
You will need support of a resident pediatrician who may initially be shared with the department of pediatrics. As the load increases, that person may be dedicated to pediatric nephrology. You need to spend a lot of time with him/her, educating him/her and getting him/her involved with patient care. If you are able to start a training course in pediatric nephrology, the trainees should be able to participate in day-to-day patient care. Additional senior faculties in pediatric nephrology may be added, depending on the workload and on the relationships you have developed with the administration. A shared or dedicated social worker, a dietician, a dialysis technician and a nurse are other personnel who will increase the quality of patient care. A team approach should develop with pediatricians, pediatric surgeons/urologists, adult nephrologists, pathologists, radiologists and others with whom you work.
You will have to tackle the issue of “affordability” while delivering optimum patient care since most patients do not have financial support from the government or insurance companies. Your elite patients, NGOs, individual philanthropists, philanthropic organizations in your area and the corporate sector could be the sources you want to approach. If possible, you may want to set up an independent transparent structure or a trust (may be a kidney foundation), mostly consisting of non-controversial citizens of the region.
You should get into a habit of setting up a “good data base” of the patients you see and manage. This is not easy but efforts towards it, from the beginning itself are worth. You may want to develop relevant clinical studies by asking simple research questions. You may later be able to write research proposals, to apply for funding to agencies such as Indian Council of Medical Research and get financial and personnel support to conduct research studies. Basic science research is beyond the scope of most clinicians unless they have genuine interest, they have exposure and have institutional support in the form of a basic science research lab.
You must spend a lot of time with each patient and their families, aiming at state of the art patient care and counsel them so that they understand and get involved with the patient care. You must get back to the referring doctors3 (pediatricians, family practitioners and others) who refer cases to you (by telephone, letter, email, etc.), discuss cases with them and make them part of the team delivering comprehensive care to the child. Let the non-renal care be delivered by them as much as possible while you focus on the renal care of the patients. A good personal and professional rapport with the referring doctors goes a long way. Also, give feedback to the laboratories, pathologists and radiodiagnostics and discuss with them specific issues related to individual patients.
You need to make active efforts to update yourself, keeping pace with recent developments in the field of pediatric nephrology. Journal subscription to “Pediatric Nephrology” and active participation in local, state level, national level meetings of pediatricians, general practitioners and pediatric nephrologists are essential. Do not lose opportunities in making paper presentations and delivering talks wherever possible. This is an important part of your “learning and image building”.
Most of your activities will be geared to the patients who reach you. There may be a lot more who are undetected and hence never reach you or other facilities or they may reach you late. With educational activities, you may want to adopt “Reaching out strategies” to help children with renal diseases far and wide. Creating awareness about kidney diseases is important. Educating pediatricians and other child health care workers about prevention, early detection, appropriate early management and timely referral are important components of improving outcomes of children with renal diseases.