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Background End stage renal disease (ESRD) remains the terminology most often used by Paediatricians in the UK to describe irreversible Kidney failure. However, the international Nephrology community now describe irreversible Kidney failure as Stage 5 Chronic Kidney Disease ( CKD 5 ) End stage renal failure ( Chronic Kidney Disease stage 5) Defined by the National Kidney Foundation (US) Kidney Disease Quality Outcome initiative (KDOQI) Clinical Practice guidelines as either - a Glomerular Filtration rate (GFR) of less than 15 mL/min/1.73 m2, which is accompanied in most cases by signs and symptoms of uraemia, or - a need for initiation of kidney replacement therapy (dialysis or transplantation) for treatment for complications of decreased GFR, which would otherwise result in an increased risk of mortality and morbidity. Rather than ask respondents to calculate an estimated GFR to decide if their case was reportable, the study uses a serum creatinine of equal to, or greater then 120 micromols/l as the cut-off for inclusion. This will give an estimated Glomerular filtration rate of less than 15 mL/min/1.73 m2 for most infants in this population. This will also allow for maximal ascertainment. We are aware that the case definition may result in the reprting of cases with reversible renal impairment but these cases who recover native renal function will be identified through the 1 year follow-up questionnaire. Section 1- Clinicians details Name Job title Address Email address  Page 1 of 7 Consultant name Job title Delete as appropriateNephrologist / Neonatologist / General PaediatricianEmail address  Date of Completion DDMMYYYY Section 2- Childs details 2.1 BPSU I.D 2.2Hospital number  2.3NHS number  2.4DOB  D  D M M Y Y Y Y 1.31111111111112222 2.42222 2.5Birth gestation ( in completed weeks )  2.6Sex  MALE  FEMALE 2.7Birth weight ( Kg)  % 2.8Home postcode at birth First part only 2.9County of birth If born in Irish Republic 2.10 Ethnicity Enter tick in relevant box i.White?BritishOther white background Please describe ii.Mixed race ?White & Black CaribbeanWhite & Black AfricanWhite & AsianOther mixed background. Please describe iii.Asian or Asian British?IndianPakistaniBangladeshiOther Asian background Please describe iv. Black or Black British?CaribbeanAfricanOther black background Please describe v.Chinese or Other ethnic groupChineseAny other Please describe  Section 3- Mode of presentation 3.1When was the diagnosis of ESRD made? Definition- Presumed irreversible renal failure with a serum creatinine of greater than, or equal to 120 micromol/l D D M M Y Y Y Y 3.2What was the Serum Creatinine at diagnosis? ( umol/l)  3.3Weight at diagnosis ( kg)  % 3.4 Length at diagnosis (cm)  3.5What was the primary renal diagnosis? Please tick the appropriate box(es) Renal dysplasiaObstructive uropathy Please describeCongential nephropathies Please describe Renal cystic diseasePrune belly syndrome Renal Vein thrombosis Wilms tumour Other Please describe Diagnosis not yet known 3.6Was the primary diagnosis made ante-natally?YNNot knownIf Yes, please state the diagnosis made  What was the gestational age at diagnosis? in completed weeksWas foetal intervention performed?YNNot knownIf yes, please describe  Section 4 Management following the diagnosis of ESRD 4.1Was the patient referred to a Paediatric Nephrologist?YN If yes, please complete the following Name of Nephrologist- ________________________ Hospital- _____________________ 4.2Please tick all treatments used and major changes subsequent to the diagnosis of ESRD? Please tick the appropriate box & enter the date of commencement. If the same treatment was used more than once, please enter the information in column 2 of the appropriate section. 12Conservative management (Pre-dialysis) DD MM YYYYDD MM YYYYPeritoneal Dialysis DD MM YYYYDD MM YYYYHaemodialysis DD MM YYYYDD MM YYYYPalliative care DD MM YYYYDD MM YYYYRecovered native renal function DD MM YYYYDD MM YYYYRenal transplantation DD MM YYYYDD MM YYYY 4.3If the patient is deceased, please state the date and cause of death Date of death DD MM YYYYCause of death  Section 5- Additional medical problems Has the child ever had any of the following? If so, please provide details. Details 5.1Urinary Tract Infection YN5.2Hypertension YNDont know5.3Congenital Heart Disease YNDont know5.4Other Cardiovascular Disease YNDont know5.5Chronic Lung Disease YNDont know5.6Other Respiratory Disease YNDont know5.7Liver Disease YNDont know5.8Gastro-intestinal Disease YNDont know5.9Cerebral haemorrhage YNDont know5.10Seizures YNDont know5.11Visual impairment YNDont know5.12Hearing impairment YNDont know5.13Hypoxic-ischaemic Encephalopathy YNDont know5.14Other Neurological disease YNDont know5.15 Other, please give details YNDont know 5.16 Does the child have any syndromic abnormalities?YNDont know 5.17Nutrition. Please indicate which of the following feeding modalities have been used and state which is the current method of feeding.Naso-gastric/Naso-jejunal feeds (NG/NJ) YNGastrostomy feeds ( GF)YNTotal Parenteral nutrition (TPN) YNHow is the patient currently fed ? Please tick boxOral NG/NJGFTPN Section 6- Surgical history Please tick the appropriate box to describe the patients surgical history 6.1.1Has the child had surgery?YNNot known If Yes, please answer Questions 6.1.2 to 6.1.4 6.1.2 Surgical procedures Please detail the patients surgical history Procedure Yes?No?Not Known?Date(s) of Procedure(s)Access surgery Insertion of Peritoneal dialysis ( PD) catheter  DD MM YYYYInsertion of Central venous catheter (CVC) DD MM YYYYRemoval of PD catheter DD MM YYYYRemoval of CVC DD MM YYYYInsertion of Gastrostomy DD MM YYYYUrology Insertion of Nephrostomy DD MM YYYYPartial Nephrectomy DD MM YYYYComplete Nephrectomy DD MM YYYYNephroureteretomy DD MM YYYYFashioning of Cystostomy/ Vesicotomy DD MM YYYYInse  ACDST[\^_δkXE2%hC5CJOJQJ^JaJnH tH %h P5CJOJQJ^JaJnH tH $jhNhUmHnHtH u4jhh5CJOJQJU^JaJnH tH 4j5h Ph5CJOJQJU^JaJnH tH %h5CJOJQJ^JaJnH tH +h]h$65CJOJQJ^JaJnH tH h Pjhh PU$jhNhUmHnHtH uhCmHnHtH uhmHnHtH u  )$$d%d&d'dNOPQa$gdA6&$d%d&d'dNOPQgdA6gd-igd@&gdw ;@&`;gd P   ƲpaTG<1<1<h-i6CJ]aJhi6CJ]aJh-ihiOJQJ^JhihiOJQJ^JhpF5CJOJQJ^JaJ#hihpF5CJOJQJ^JaJh-i5CJOJQJ^JaJhrAP5CJOJQJ^JaJ#h-ihrAP5CJOJQJ^JaJ&hih5CJ aJ mHnHtH u&hihi5CJ aJ mHnHtH uh-imHnHtH uhQImHnHtH uhZ.5CJOJQJ^JaJ   1 : ; F K Y Z   1 ; [ \ ] ^ _ j ķĪķĪĝѪxkZLh-ih#5OJQJ^J h]hA6CJOJQJ^JaJh-ih-iOJQJ^JhA6OJQJ^Jh-ih!gOJQJ^Jh-ih5OJQJ^Jh-ih;OJQJ^Jh-ihgOJQJ^Jh-ihPIPOJQJ^Jh-ihOJQJ^Jh-ihA6OJQJ^J#h]hi5CJOJQJ^JaJh5CJOJQJ^JaJ ] ^ _ j { | ~SS* $d%d&d'dNOPQgd-i* $d%d&d'dNOPQgdA6)$$d%d&d'dNOPQa$gdA6gdPIP&$d%d&d'dNOPQgd-ij { D J \'wfWhi5CJOJQJ^JaJ h]hA6CJOJQJ^JaJ h]hp^CJOJQJ^JaJ h]hPIPCJOJQJ^JaJh-ih!gCJ^JaJh-ihPIPCJH*^JaJh-ihA6CJ^JaJh-ihp^CJ^JaJh-ihp^5CJ^JaJh-iCJ^JaJh-ihPIPCJ^JaJh-ih;CJ^JaJ! 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