Symptoms
The symptoms of autosomal recessive polycystic kidney disease (ARPKD) can vary significantly, even within the same family.
Generally, however, the main symptoms of ARPKD differ, depending on when the condition first becomes apparent.
Before and soon after birth
In many cases, potential signs of ARPKD can be detected before birth during routine ultrasound scans.
If your baby has the condition, an ultrasound scan may show that:
- they have enlarged kidneys
- their lungs are underdeveloped
- there's a lack of amniotic fluid surrounding your baby
When your baby is born, there may be clearer signs that suggest they have ARPKD, such as:
- significant breathing difficulties – this is caused by the lungs being underdeveloped
- a swollen tummy (abdomen) – caused by enlargement of the kidneys
- Potter's syndrome – where a lack of amniotic fluid leads to deformities of the limbs, face and ears; Potter's syndrome is a possibility in severe cases of ARPKD
Underdeveloped lungs is the biggest problem immediately after birth, and breathing assistance with a ventilator is often needed. A ventilator is a machine that moves air in and out of the lungs.
Unfortunately, even with treatment around 1 in every 3 babies with ARPKD who develop breathing difficulties soon after birth will die within a few weeks or months.
If a baby survives this stage, the chance of long-term survival is much better and around 90% of those who survive these early stages will live for 10 years.
But about a third of these children will need treatment for kidney failure.
Infants and children
ARPKD tends to be less immediately life-threatening in infants and older children, although the condition can still cause a wide range of serious problems.
Some of the main problems infants and children with ARPKD experience are described below.
High blood pressure
High blood pressure (hypertension) is a common problem for children with ARPKD.
If your child has high blood pressure, they'll usually need to take medication to lower it and prevent long-term damage to their heart and blood vessels.
Liver problems and internal bleeding
For children with ARPKD, a number of problems affecting the liver can also develop.
For example, the small tubes called bile ducts that allow a digestive fluid called bile to flow out of the liver may develop abnormally and cysts may grow inside them.
Over time, the liver can also develop fibrosis, a process similar to scarring. This restricts the blood flow through the liver and increases the pressure in its delicate blood vessels (portal hypertension).
When this occurs, blood bypasses the liver and is diverted into veins. These veins then become swollen, particularly in the lower gullet (oesophagus). They can bleed if they get too big.
Portal hypertension also diverts blood to the spleen, causing it to become enlarged. This can affect the spleen's normal functions, such as removing old or damaged blood cells from the blood.
An enlarged spleen may remove too many of these cells, including platelets, which can increase the risk of internal bleeding, particularly from any varices that have developed.
Platelets are tiny cells that cause the blood to thicken (clot) if a blood vessel is damaged.
Internal bleeding can be rapid and severe, causing your child to vomit blood or pass stools that are very dark or tar-like.
Excessive peeing and thirst
In ARPKD, the small tubes (tubules) that make up the kidneys can develop abnormally, causing bulges and fluid-filled sacs) called cysts to form within them.
The tubules are important in regulating how much water is held in the body. This is disrupted in ARPKD, which is why small children lose excessive amounts of body fluid as urine.
This can lead to:
- polyuria – where your child will need to pee frequently and may wet the bed
- polydipsia – an excessive and prolonged thirst
These symptoms increase the risk of dehydration, particularly if the child also has a high temperature, is vomiting, or has diarrhoea.
Signs and symptoms of dehydration can include:
Contact your child's kidney specialist if you think your child may be becoming dehydrated, as regular dehydration treatments, including oral rehydration treatments such as Dioralyte, may not be suitable for them.
Feeding problems
Your child may have problems feeding because their enlarged kidneys take up most of the space in their abdomen.
They may vomit after eating, and may only be able to eat small amounts at a time.
If this leads to malnourishment, your child may need to be fed through a tube inserted into their stomach, either through the nose or abdomen.
Faltering growth
Some children with ARPKD do not grow at a normal rate. Doctors call this faltering growth or failure to thrive, and it's usually caused by a combination of factors.
Children with ARPKD are usually under the care of a dietitian, who may recommend a high-calorie and high-protein diet to boost their weight.
Some children may also need to be fed through a tube if they're having feeding problems.
Chronic kidney disease and kidney failure
Most people with ARPKD lose a significant amount of kidney function. Loss of kidney function caused by kidney damage is called chronic kidney disease (CKD).
CKD doesn't usually cause any symptoms until it's reached an advanced stage.
The most advanced stage of CKD is known as kidney failure or end-stage renal disease. This occurs when the kidneys have lost almost all of their ability to function.
Symptoms of kidney failure can include:
- poor appetite and weight loss
- swollen ankles, feet or hands (oedema)
- shortness of breath
- an increased need to urinate, particularly at night (nocturia)
- itchy skin
- feeling sick
Most children with ARPKD will develop kidney failure by the time they're 15 to 20 years old.
They'll need either a kidney transplant or dialysis (where a machine is used to replicate many of the functions of the kidneys).
Treatment
There's currently no cure for autosomal recessive polycystic kidney disease (ARPKD).
But treatments are available to manage the condition's associated symptoms and any complications that may occur, such as:
Breathing difficulties
If there's a significant risk your baby will be born with underdeveloped lungs (pulmonary hypoplasia), particularly if your baby is premature, treatment can begin before they're born.
You may be injected with a medication called betamethasone during your pregnancy.
This stimulates the development of your baby's lungs and helps them work more efficiently if they're born prematurely.
After birth, it's likely your baby will be immediately admitted to an intensive care unit (ICU), where they'll be placed on a ventilator to assist their breathing.
They may also be given a type of medication called a surfactant, which helps prevent tiny air sacs inside the lungs known as alveoli collapsing.
The more working alveoli your baby has, the better their ability to breathe.
Breathing difficulties can be made worse if your baby's enlarged kidneys press on their diaphragm, the sheet of muscle in the abdomen that helps with breathing.
In a few cases, the doctor treating your baby may recommend removing one of their kidneys to relieve the pressure.
Despite advances in treatment, pulmonary hypoplasia is a very difficult condition to manage in babies with ARPKD.
In some cases, your baby may need to stay in hospital for weeks or months.
Even with the best efforts of the medical team, around 1 in every 3 babies will die as a result of the condition.
High blood pressure
An angiotensin-converting enzyme (ACE) inhibitor is the most widely used treatment for babies and children with high blood pressure.
ACE inhibitors reduce blood pressure by reducing the pressure across the filtering units of the kidney (glomeruli).
Possible side effects of ACE inhibitors can include:
Most of these side effects should pass in a few days, although some people have a dry cough for longer.
A similar group of blood pressure medicines are angiotensin 2 receptor blockers (ARBs), which work in a similar way to ACE inhibitors, but do not cause a cough.
As well as ACE inhibitors and ARBs, there are lots of other medications that may also be used to control blood pressure in children with ARPKD, such as calcium channel blockers, beta blockers and diuretics.
Read more about treating high blood pressure.
Liver problems
Many children with ARPKD also have problems affecting their liver, such as swelling and scarring.
Scarring in the liver can make it difficult for blood to flow through it, and this can mean that blood is forced through blood vessels in your child's stomach or gullet (oesophagus) instead.
These blood vessels, known as varices, are smaller and more fragile than the blood vessels in the liver and can burst under high blood pressure.
If your child has bleeding from these varices, urgent treatment will be needed to stop the bleeding.
This will usually involve passing a thin, flexible tube called an endoscope down their mouth and oesophagus, and either placing a small band around the base of the varices or injecting a special medication "superglue" to make the blood clot.
If your child has particularly severe liver problems, they may need a liver transplant.
If they also need a kidney transplant, both procedures may be combined into a single operation.
Chronic kidney disease
If your child's condition progresses to a stage where their kidney function is significantly affected, they'll usually need a number of different treatments to manage the various problems this can cause.
For example, your child may need treatment for the following problems:
- a lack of iron in the body, which leads to a decreasing number of red blood cells (anaemia) – this can be treated with iron supplements, injections of erythropoietin, the hormone the kidneys produce to stimulate red blood cell production, or blood transfusions in severe cases
- high phosphate levels, which can affect bone health – this can be treated with a medication called a phosphate binder, which is taken with meals
- growth problems – which can be treated with injections of human growth hormone (HGH), a synthetic version of the hormones used by the body to stimulate growth
Read more about treating chronic kidney disease.
Kidney failure
Most people with ARPKD will eventually develop kidney failure at some point in their life.
More than half of all children who survive the early stages of ARPKD after birth will eventually experience kidney failure by the time they're 15 to 20 years old.
When kidney failure occurs, your child will need to have their kidneys replaced or treatment to compensate for their loss of kidney function.
There are currently 2 effective treatments that can be used on a long-term basis:
- dialysis – where a machine replicates many functions of the kidneys
- kidney transplant – where a kidney is removed from a living or recently deceased donor and implanted into a person with kidney failure
A person only needs 1 kidney to survive, so unlike many other types of organ donation, a living person can donate a kidney.
Close relatives usually make the best match, so you may want to consider getting yourself tested to see if you're a suitable candidate for donation.
You could also ask your relatives if they'd consider having themselves tested to see if they could donate one of their kidneys.
Avoiding injury
If your child has ARPKD, their kidneys will be vulnerable to injury. A sudden knock or blow to their kidneys could cause bleeding, leading to severe and intense pain.
Your child may therefore be advised to avoid playing contact sports, such as football and rugby.
Some over-the-counter medicines, such as non-steroidal anti-inflammatory drug (NSAID) painkillers, can also be harmful if your child has ARPKD.
Make sure you check with your doctor before giving your child any new medication.