Chronic Kidney Disease in Children: Overview of Management

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Official reprint from UpToDate®

www.uptodate.com © 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Chronic kidney disease in children: Overview of

management
Authors: Tarak Srivastava, MD, Bradley A Warady, MD
Section Editor: Tej K Mattoo, MD, DCH, FRCP
Deputy Editor: Laurie Wilkie, MD, MS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2023. | This topic last updated: Jan 13, 2021.
INTRODUCTION
Chronic kidney disease (CKD) refers to a state of irreversible kidney damage and/or reduction of
kidney function that is associated with progressive loss of kidney function over time.
An overview of the management of CKD in children will be reviewed here. The etiology,
epidemiology, natural course, presentation, and evaluation of CKD in children are discussed
separately. (See "Chronic kidney disease in children: Definition, epidemiology, etiology, and
course" and "Chronic kidney disease in children: Clinical manifestations and evaluation".)
DEFINITIONS AND DIAGNOSIS
CKD is defined as the presence of structural or functional kidney damage that persists over a
minimum period of three months. Functional damage is characterized by sustained reduction
of estimated glomerular filtration rate (GFR), persistent elevation of urinary protein excretion, or
both.
Based on this definition, clinical practice guidelines from Kidney Disease: Improving Global
Outcomes (KDIGO) in 2012 published criteria for diagnosis and staging of pediatric CKD [1]. The
KDIGO diagnosis criteria and staging classification are the standard used in clinical practice,
research, and public health in the care of children with CKD and will be used throughout this
topic.
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The KDIGO diagnosis of pediatric CKD is based on fulfilling one of the following clinical criteria
[1]:
● GFR of less than 60 mL/min per 1.73 m2 for greater than three months with implications
for health regardless of whether other CKD markers are present.
● GFR greater than 60 mL/min per 1.73 m2 that is accompanied by evidence of structural
damage or other markers of functional kidney abnormalities including proteinuria,
albuminuria, renal tubular disorders, or pathologic abnormalities detected by histology or
inferred by imaging. This category also includes patients with functioning kidney
transplants.
The KDIGO CKD staging for children older than two years of age stratifies the risk for
progression of CKD and its complications based on GFR and is used to guide management
( table 1):
● G1 – Normal GFR (≥90 mL/min per 1.73 m2)

● G2 – GFR between 60 and 89 mL/min per 1.73 m2
● G3a – GFR between 45 and 59 mL/min per 1.73 m2
● G3b – GFR between 30 and 44 mL/min per 1.73m2
● G4 – GFR between 15 and 29 mL/min per 1.73 m2
● G5 – GFR of <15 mL/min per 1.73 m2 also referred to as kidney failure [2]
Children under two years of age do not fit within the above classification system because they
normally have a low GFR even when corrected for body surface area. In these patients,
calculated GFR based upon serum creatinine can be compared with normative age-appropriate
values to detect kidney impairment ( table 2). The KDIGO guideline suggests that a GFR value
more than one standard deviation below the mean should raise concern and prompt more
intensive monitoring. (See "Chronic kidney disease in children: Definition, epidemiology,
etiology, and course", section on 'Estimated glomerular filtration rate'.)
MANAGEMENT APPROACH
The general management of the patient with CKD includes the following components:
● Routine health maintenance

● Prevent or slow the progression of kidney disease
● Prevent or treat the complications of CKD
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● Preparation for kidney replacement therapy when approaching kidney failure (stage G5,
previously referred to as end-stage kidney disease)
Our practice is consistent with recommendations in the Kidney Disease: Improving Global
Outcome (KDIGO) Clinical Practice Guideline and the National Kidney Foundation's Kidney
Disease Outcomes Quality Initiative (KDOQI) guidelines [1,3]. Routine health care is provided to
all children with CKD. The timing of implementation of the other components of care vary
primarily based on the severity of CKD. (See "Society guideline links: Chronic kidney disease in
children".)
● Early asymptomatic CKD: Stages G1 and G2 – Children with stages G1 and G2 disease
are asymptomatic and should be closely followed for deterioration of kidney function.
Although not frequent, metabolic derangements may be seen in stage G1 and G2. For
these children, there may be an opportunity to treat any reversible cause of kidney
dysfunction, and prevent or slow the progression of chronic kidney disease. Educational
outreach is initiated so the child and family can understand and implement care to avoid
risk factors that can accelerate the progression of CKD (eg, avoidance of nephrotoxic
drugs, recurrent infections, dehydration, obesity, and smoking in adolescents) and
incorporate measures (eg, strict blood pressure control and/ or reducing proteinuria) that
may slow the process. (See 'Prevent or slow progression of kidney disease' below.)
● Mild to moderate CKD: Stages G3a and G3b – Children who progress to stages G3a and
G3b may begin to display CKD-associated complications. These include disorders of fluid
and electrolytes, anemia, hypertension, dyslipidemia, endocrine abnormalities, growth
impairment, mineral and bone disorder (MBD), and decreased clearance of substances
normally excreted from the body by the kidney (uremia). In these patients, management is
focused on preventing and treating these complications. In addition, avoidance of risk
factors as outlined above should be maintained to slow CKD progression. (See "Chronic
kidney disease in children: Complications".)
● Severe CKD and end-stage kidney failure: Stages G4 and G5 – Patients who continue to
have progressive disease need to be identified well in advance of the time that kidney
replacement therapy is required so that adequate preparation and education can be
provided to both the patient and family. The preparation for kidney replacement therapy
generally starts with stage G4 CKD when GFR falls below 30 mL/min per 1.73 m2. (See
'Preparation for end-stage kidney disease' below.)
ROUTINE HEALTH MAINTENANCE

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Components — As CKD progresses children are at increased risk for developing complications
such as poor growth, elevated blood pressure (BP), increased cardiovascular risk (eg,
dyslipidemia), anemia, vitamin D deficiency, and fluid and electrolyte abnormalities (see
"Chronic kidney disease in children: Complications"). As a result, routine health maintenance in
addition to the care provided normally to all children requires more intense monitoring of
kidney function, growth, and nutritional status, with intervention as needed and screening for
associated complications as CKD progresses. The following parameters are closely monitored
[3-12]:
● Growth, including measurements of weight and height. For patients who are three years
of age and younger, head circumference is also monitored.
● Nutritional status.
● BP.
● Neurodevelopment assessment.
● Laboratory tests to monitor kidney function and detect associated complications,

including serum creatinine, electrolytes, calcium and phosphorus, alkaline phosphatase,
25-hydroxyvitamin D, parathyroid hormone level, hemoglobin, iron, total iron binding
capacity, ferritin, lipid profile, urinalysis, and urinary protein-to-creatinine ratio. The
frequency of assessment is based on the severity of kidney dysfunction.
● Immunizations.
Nutrition — Appetite and nutritional intake decrease with progression of CKD in children

[13,14]. As a result, malnutrition is common in children with CKD because of poor appetite,
decreased intestinal absorption of nutrients, and metabolic acidosis affecting physical growth,
neurocognitive development, and overall health status (ie, fragility) [15]. Weight loss primarily
occurs when the GFR decreases to <35 mL/min per 1.73 m2, and this weight loss is associated
with a higher risk for renal failure (previously referred to as end-stage kidney disease) [16]. In
our practice, ongoing assessment and follow-up for growth and nutrition is based on the 2008
Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline (CPG) for
Nutrition in Children with Chronic Kidney Disease: Update 2008 ( table 3) and the
recommendations from the Pediatric Renal Nutrition Taskforce [17-21]. These guidelines
provide a schedule for health and nutritional surveillance in children with CKD based on severity
of kidney function and age. More frequent assessments are recommended in younger children
and in children with severe impairment of kidney function regardless of age (ie, stages G4 and
G5). At each of the scheduled visits, in addition to the growth measurements, the dietary intake
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is assessed using either a three-day diet record or three 24-hour dietary recall in children who
are at increased risk.
Nutritional therapy based upon growth parameters is developed for each child with CKD and
should ideally be coordinated by a dietician with expertise in pediatrics and renal nutrition.
Nutritional management should address the energy, protein, vitamin, mineral, and electrolyte
needs of the individual patient.
● Energy – The initial prescribed energy (calorie) intake for children with CKD is based upon
the estimated energy requirement (EER) for chronological age ( table 4) [18,22]. Further
supplementation should be considered when the initial intake fails to meet the child's EER
and they are not achieving expected rates of weight gain and/or growth. Although
supplementation by the oral route is preferred, one may have to resort to tube feedings
with a gastrostomy, transpyloric tube, or nasogastric tube to ensure adequate energy
intake [19] (see "Overview of enteral nutrition in infants and children"). A trial of
intradialytic parenteral nutrition may be considered in children undergoing chronic
hemodialysis therapy. (See "Hemodialysis for children with chronic kidney disease", section
on 'Inadequate nutrition'.)
● Protein – Protein intake should be between 100 and 140 percent of the Dietary Reference
Intake (DRI) based upon age and gender for children with CKD stage G3 and between 100
and 120 percent for those with CKD stages G4 and G5 ( table 5) [18,22]. For patients on
peritoneal dialysis, protein intake should be higher (additional average 0.15 to 0.3 g/kg
per day) to compensate for dialytic protein loss. Protein supplementation should be
considered if the oral and/or enteral protein intake is inadequate [22-24].
Protein restriction is not recommended in children as it has not been shown to influence
the decrease in kidney function in children with CKD and may impair growth [23,25,26].
● Vitamins and minerals – Children with CKD should receive 100 percent of the DRIs for the
following vitamins: thiamine (B1); riboflavin (B2); pyridoxine (B6); vitamins B12, A, C, E, K;
and folic acid ( table 6 and table 7) and the following minerals: copper and zinc [22].
Vitamin D deficiency is common in children with CKD and the formulation of vitamin D
supplementation is dependent on the severity of kidney function, as discussed separately.
(See "Pediatric chronic kidney disease-mineral and bone disorder (CKD-MBD)", section on
'Vitamin D deficiency'.)
In children with advanced CKD (ie, stage G5), the loss of kidney clearance of vitamin A
metabolites places them at risk for developing hypervitaminosis A; these children should
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receive a water-soluble vitamin supplement with the addition of vitamin A only if they have
very low dietary intake of vitamin A.
Blood pressure and targeted goals — Office BP measurement should be performed at each

supervised health visit. As noted below, strict BP control has shown a beneficial effect on
slowing CKD progression in children. (See 'Strict BP control' below.)
It remains unclear what optimal target BP goals should be for children with CKD. Guidelines
from several professional societies have been published using both office BP measurement and
ambulatory blood pressure monitoring (ABPM) [27-29]. We use the following target BP goals for
office measurements ( table 8). These targets represent the thresholds for normal BP for
pediatric patients with CKD, as defined by the 2017 American Academy of Pediatrics and
American Heart Association (AAP/AHA). The AAP/AHA BP guidelines are based on normal-
weight children and exclude overweight/obese children in their normative data. guidelines [27]:
● In children with CKD (<13 years of age), we use target systolic and diastolic BPs of less
than the 90th percentile of normative data for age, gender, and height ( table 9 and
table 10).
● In adolescents (≥13 years of age), we use a target BP of ≤120/80 mmHg.
If ABPM is performed, we use a target goal of a 24-hour mean arterial BP (MAP) below the 50th
percentile based on pediatric ABPM normative data for gender and height as recommended by
the 2017 AAP guidelines ( table 11 and table 12 and table 13 and table 14) [27].
We recommend strict BP control in all children with CKD, as aggressive BP control slows the
progression of CKD. Treatment of hypertension (defined as BP greater than the BP targeted
goal on three separate occasions) should be initiated using nonpharmacologic therapy, and if
needed, antihypertensive therapy. (See "Chronic kidney disease in children: Complications",
section on 'Hypertension'.)
Additional studies include the following:
● Ambulatory blood pressure monitoring (ABPM) – In accordance with the AAP/AHA

guidelines, we perform ABPM in children with CKD periodically in the following settings:
• To evaluate for the presence of masked hypertension (defined as normal office BP but
elevated BP on ABPM)
• When consistent blood pressure data are difficult to obtain with office measurements
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• To evaluate the efficacy of antihypertensive therapy, especially when hypertension is

difficult to control
• If the patient is symptomatic with complaints that could be attributed to adverse

effects from antihypertensive therapy
• To detect white coat hypertension (defined as elevated office BP but normal BP on

ABPM)
The AAP/AHA guidelines recommend that ABPM should be used to identify any child
suspected to have white coat hypertension, and children with CKD should be periodically
evaluated with ABPM to evaluate for the presence of masked hypertension [30-32]. The
AAP/AHA recommendations do not change for a child with CKD if overweight/obese. (See
"Ambulatory blood pressure monitoring in children".)
● Echocardiogram – We obtain echocardiograms in patients with CKD and elevated BP as

these children are at risk for left ventricular hypertrophy (LVH), which is associated with
adverse cardiovascular disease [33]. We suggest echocardiogram be performed annually
especially in children with CKD, especially for those with uncontrolled hypertension and/or
documented end-organ damage. ECG is not recommended for evaluation of LVH in
children as it is not a sensitive tool [27]. Detection of LVH is an indication that efforts
should be made to improve BP control. (See "Nonemergent treatment of hypertension in
children and adolescents", section on 'Cardiovascular disease'.)
Neurodevelopment assessment — CKD is associated with impairment in neurodevelopment.

As a result, routine health maintenance includes early developmental surveillance and
screening to identify children with or at-risk for neurodevelopmental delay, and formal
assessment for older children, especially if they have poor school performance. Assessment
should include identifying modifiable risk factors (eg, anemia, poor nutrition, and uremia),
which can negatively impact on neurodevelopmental performance. For patients with impaired
neurodevelopmental function, referral to early intervention programs or special educational
services may be beneficial. (See "Chronic kidney disease in children: Complications", section on
'Neurodevelopmental impairment' and "Developmental-behavioral surveillance and screening
in primary care" and "Specific learning disorders in children: Educational management".)
Laboratory testing — Laboratory testing is used to monitor kidney function and detect

associated-CKD complications. Tests include serum creatinine, urea, electrolytes, bicarbonate,
calcium, phosphorus and alkaline phosphatase, hemoglobin, indices of iron status, fasting lipid
profile, 25-hydroxyvitamin D, parathyroid hormone level, urinalysis, and urinary protein-to-
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creatinine ratio. The frequency of assessment is based on the severity of kidney dysfunction
( table 15).
Immunization — All childhood vaccinations should be administered in children with CKD with

the caveat that live-attenuated vaccines should not be administered to children who are
immunosuppressed. As an example, live-attenuated influenza vaccine should not be given to
children with nephrotic syndrome or those receiving immunosuppressive therapy post-kidney
transplantation [1]. After receiving a live-attenuated vaccine, a mandatory minimum waiting
period of four weeks is necessary prior to using immunosuppression for kidney transplantation.
Management for specific vaccinations include:
● Pneumococcal vaccine should be given to all children with nephrotic syndrome and those
with CKD.
● Hepatitis B vaccination should be provided to all children with CKD or undergoing

dialysis.
● Human papillomavirus (HPV) vaccine should be given to individuals based on the normal
schedule. Limited data have shown a robust and sustained response to human
papillomavirus (HPV) vaccination in children with predialysis CKD and children on dialysis,
but a less robust response was observed in kidney transplant recipients [34,35].
● Varicella vaccine should be given to all children with CKD [36,37]. However, since it is a live
attenuated vaccine, it is contraindicated in patients with severe immunocompromise,
including children receiving high doses of corticosteroids. It is ideally administered as a
two-dose regimen when the child is on low-dose regimen of corticosteroids (eg, less than
2 mg/kg of body weight on alternate days) or off of corticosteroid therapy. (See
"Vaccination for the prevention of chickenpox (primary varicella infection)", section on
'Immunocompromised hosts' and "Symptomatic management of nephrotic syndrome in
children", section on 'Varicella'.)
● Tuberculosis in endemic countries is prevented by the universal administration of the

Bacillus Calmette-Guérin (BCG) vaccine at birth. In some countries with a low incidence of
tuberculosis, BCG is administered to children with CKD prior to kidney transplantation [38].
PREVENT OR SLOW PROGRESSION OF KIDNEY DISEASE
Treat underlying cause of kidney disease — In some cases, identifying and treating the
underlying primary kidney disease can prevent or slow the progression of disease. Examples
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include:
● Correction of obstructive uropathy or high-grade vesicoureteral reflux [39-41]. (See

"Management of vesicoureteral reflux", section on 'Grades III to V'.)
● Immunosuppressive therapy for primary nephrotic syndrome and primary and secondary
glomerulonephritis (eg, lupus nephritis). (See "Treatment of idiopathic nephrotic
syndrome in children", section on 'Long-term outcome of SSNS' and "C3 glomerulopathies:
Dense deposit disease and C3 glomerulonephritis" and "Lupus nephritis: Initial and
subsequent therapy for focal or diffuse lupus nephritis" and "C3 glomerulopathies: Dense
deposit disease and C3 glomerulonephritis", section on 'Prognosis'.)
Avoid subsequent kidney injury — Episodes of acute kidney injury can result in a faster
decline in kidney function in children with CKD [42]. Decreased kidney perfusion or the
administration of nephrotoxic agents are two common conditions that may result in further
kidney injury in children with CKD.
● Avoid acute episodes of kidney hypoperfusion – A subset of children with CKD have
impaired tubular sodium reabsorption (salt losers) and urinary concentrating ability, which
increases their risk for hypovolemia and hypoperfusion with minor illnesses. At-risk
patients should be identified at the onset of an intercurrent illness associated with
hypovolemia or hypotension so that fluid repletion can be provided prior to a significant
decrease in kidney blood flow.
Kidney hypoperfusion is caused by hypotension (eg, septic shock), administration of drugs

that lower the kidney perfusion (such as nonsteroidal anti-inflammatory drugs,
angiotensin-converting enzyme [ACE] inhibitors, and angiotensin II receptor blockers
[ARBs]), and volume depletion from vomiting, diarrhea, diuretic use, burns, major
surgeries (eg, cardiac surgery performed on cardiopulmonary bypass, orthopedic spine
surgeries), and/or bleeding. (See "Etiology and diagnosis of prerenal disease and acute
tubular necrosis in acute kidney injury in adults", section on 'Causes of prerenal disease'
and "Acute kidney injury in children: Clinical features, etiology, evaluation, and diagnosis".)
● Avoid nephrotoxic drugs – Common nephrotoxic drugs include nonsteroidal anti-

inflammatory agents, diagnostic agents (eg, radiographic contrast materials),
aminoglycosides, amphotericin B, cyclosporine, and tacrolimus. The administration of
such drugs should be avoided or used with caution in patients with underlying CKD, with
the assistance of therapeutic drug level monitoring. When drugs that have a narrow
therapeutic index are used and precision in dosing is critical (eg, cisplatinum in bone
marrow transplant induction protocol) based on kidney function, measurement of
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glomerular filtration rate (GFR) should be made using iohexol or one of the radioisotopes
(51Cr-EDTA, 125Iothalamate, or 99Tc-DTPA). In this situation, drug dosing ideally should not
be based on an estimated GFR using a regression equation. (See "Manifestations of and
risk factors for aminoglycoside nephrotoxicity" and "NSAIDs: Acute kidney injury" and
"Contrast-associated and contrast-induced acute kidney injury: Clinical features, diagnosis,
and management" and "Assessment of kidney function".)
Certain drugs, such as cimetidine, trimethoprim, ciprofloxacin, and flucytosine, lead to an

elevation in serum creatinine but not blood urea nitrogen (BUN), as they interfere with
either the tubular secretion of creatinine or the laboratory assay for creatinine [43]. As a
result, they do not directly impact on kidney function.
Slow progression of CKD — Reported interventions to slow CKD progression include BP

control, reducing protein excretion, correcting anemia and maintaining normal 25-
hydroxyvitamin D levels [44-46]. However, BP control has been the only intervention that has
been shown to have a beneficial effect on slowing CKD progression in children. (See "Chronic
kidney disease in children: Definition, epidemiology, etiology, and course", section on
'Interventions'.)
Strict BP control — We suggest that blood pressure (BP) be strictly controlled to reach
targeted BP goals ( table 8), including the use of antihypertensive therapy in children with
CKD when necessary, based on evidence that strict BP control reduced the rate of progression
of CKD in children [47-49].
For children who require antihypertensive therapy, our preferred agents are an ACE inhibitor or
ARB consistent with 2017 AAP Clinical Practice Guideline for screening and management of high
BP in children and adolescents [27]. There is good evidence that these agents are more
protective than other antihypertensive drugs in slowing the progression of CKD as they control
BP and also decrease proteinuria, even in children with advanced CKD [27,47,48,50-53]. The
management of hypertension in children with CKD is discussed in more detail below. (See
"Chronic kidney disease in children: Definition, epidemiology, etiology, and course", section on
'Blood pressure control' and "Chronic kidney disease in children: Complications", section on
'Hypertension' and "Overview of hypertension in acute and chronic kidney disease".)
Reduction of proteinuria — Data in both patients and animal models provide evidence that
angiotensin blockade using either an ACE inhibitor or ARB may also slow CKD progression in
patients with hereditary nephritis without elevated BP. (See "Clinical manifestations, diagnosis,
and treatment of Alport syndrome (hereditary nephritis)", section on 'Renin-angiotensin
blockade'.)
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Other interventions with insufficient evidence — Additional interventions that have been

studied in adults with CKD include dietary protein restriction, lipid-lowering therapy, acidosis,
and correction of anemia. However, results are inconclusive with respect to the impact of these
interventions upon delaying the progression of pediatric CKD.
In particular, data have not shown a benefit of a low-protein diet upon the progression of
kidney disease in children [23]. The current consensus in pediatric nephrology is to provide
children with CKD the age-appropriate recommended daily allowance for protein. (See
'Nutrition' above.)
Hyperuricemia, which is due to decreases in urinary excretion, has been proposed to contribute
to CKD progression, in part by decreasing kidney perfusion via stimulation of afferent arteriolar
vascular smooth muscle cell proliferation. In addition to adult data that suggest an association
between hyperuricemia and progressive CKD, an observational study reported that a serum
uric acid level greater than 7.5 mg/dL was an independent risk factor for accelerated
progression of CKD in children and adolescents [54]. However, there are no recommendations
for intervention or monitoring of serum uric acid in children or adults with CKD. Whereas the
Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline for
Evaluation and Management of Chronic Kidney Disease acknowledges the growing body of
evidence regarding the association of hyperuricemia and CKD, they also acknowledge the lack
of reliable evidence to warrant intervention to lower serum uric acid in order to slow the rate of
GFR decline among both adult and pediatric patients with CKD [1]. (See "Secondary factors and
progression of chronic kidney disease", section on 'Hyperuricemia'.)
COMPLICATIONS OF CKD
Complications due to kidney impairment become more prevalent with decreasing glomerular
filtration rate (GFR) in children as CKD advances from stages G3 to G5 ( table 1). They include:
● Fluid and electrolytes abnormalities

● Mineral and bone disorder (see "Pediatric chronic kidney disease-mineral and bone
disorder (CKD-MBD)")
● Anemia
● Hypertension
● Dyslipidemia
● Endocrine abnormalities
● Growth impairment
● Uremia (decreased clearance of substances excreted by the kidneys):
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• Uremic pericarditis
• Uremic bleeding
These complications and their management are discussed in greater detail separately. (See
"Chronic kidney disease in children: Complications".)
PREPARATION FOR END-STAGE KIDNEY DISEASE
In children with CKD, kidney replacement therapy (KRT) will generally be needed when the
glomerular filtration rate (GFR) falls below 15 mL/min per 1.73 m² (stage G5 CKD, kidney failure)
and in some circumstances prior to that. Thus, once the estimated GFR declines to <30 mL/min
per 1.73 m² (stage G4), it is time to start preparing the child and the family for KRT [3]. The
family and patient should be provided information related to the timing and choice of KRT
(preemptive kidney transplantation, peritoneal dialysis, and hemodialysis).
When, on a rare occasion, parents of a child with stage G5 CKD elect conservative management
and death over a lifetime of dialysis and transplantation for their child, this should be
considered a choice that may, on occasion, be medically, ethically, and legally acceptable. A host
of factors need to be considered by the family, the health care providers, and often the
institution's ethics committee. When a decision to forego KRT is deemed acceptable, the family
should be supported emotionally and provided with whatever care is necessary to maintain the
child in a pain-free state [55]. (See "Kidney palliative care: Principles, benefits, and core
components" and "Kidney palliative care: Withdrawal of dialysis".)
The timing and choice of KRT for children are discussed in greater detail separately. (See
"Overview of kidney replacement therapy (KRT) for children with chronic kidney disease".)
LONG-TERM OUTCOME
Kidney failure
Pediatric mortality — Children with kidney failure (previously referred to as end-stage kidney

disease) have a shortened life expectancy compared with children without CKD. Kidney
transplantation remains the treatment of choice to maximize survival, growth, and
development. (See "Overview of kidney replacement therapy (KRT) for children with chronic
kidney disease", section on 'KRT options'.)
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Almost three-quarters of children diagnosed with renal failure undergo dialysis in the United
States, and the mortality rate for these children is reported to be at least 30 times higher than
in the general pediatric population [56]. However, data from the United States Renal Data
System (USRDS) and the North American Pediatric Renal Trials and Collaborative Studies
(NAPRTCS) database have shown a decrease in mortality for children who received chronic
dialysis [57-59]. The 2018 USRDS Annual Data Report, which includes all children who receive
KRT (both kidney transplant and dialysis), found that the one-year adjusted all-cause mortality
had decreased from 49 to 39 per 1000 patient years between 2006 to 2010 and 2011 to 2015
[60]. Based on the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS)
database, survival of infants who initiate chronic peritoneal dialysis in the first year of life has
improved over time from 2000 to 2012 compared with an earlier cohort from 1992 to 1999 [61].
The leading causes of death are cardiovascular disease and infection. The authors speculate
that the reduction in mortality is probably due to improved predialysis care, advances in dialysis
technology, and increased clinical experience in caring for these patients.
Adulthood outcome — Patients placed on KRT before 15 years of age have a greater mortality
and morbidity risk than age-matched controls. This was illustrated in a long-term Dutch follow-
up study (median time 25.5 years) that observed 30 times greater mortality risk for adults who
began pediatric KRT (median time of KRT 25.5 years) than age-matched peers [62]. These
individuals were more likely to have motor disabilities, skin cancer, and severe fatigue when
they were >40 years old.
QUALITY OF LIFE
CKD, as is true for any chronic condition, impacts the quality of life (QOL) for both the child and
family [13,63-66]. In particular, psychological (eg, depression) and social stresses are found in
children with CKD and their families [65,66]. The normal progression of the child to
independence is impeded, and concerns about body composition and image are greatly
magnified in children whose growth and pubertal development are delayed or altered,
especially those who undergo chronic dialysis [65]. The prospect of a lifetime with kidney
replacement therapy (dialysis and/or transplant) and the potential for catastrophic
complications and/or death makes it difficult to achieve normal childhood and adolescent
developmental goals.
This difficulty continues into adulthood. Compared with age-matched population normative
data, patients who had renal failure were more likely to be unemployed and to have lower
income and scores on QOL surveys [67-70]. Whereas many adults with childhood renal failure
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are able to attain social autonomy, employment remains challenging due to an inability to work
because of medical issues and a lack of understanding among teachers and employers about
the medical burden of CKD/dialysis that these young adults have to deal with [70,71]. This
results in loss of self-esteem, social isolation, fatigue, and low mood [70].
The negative impact of chronic disease on the emotional status of the patient's siblings is also
well recognized [72]. These siblings frequently feel "neglected" because the parents must
provide substantial physical and psychological support to the sick child. Furthermore, the well
child may simultaneously feel jealous of the attention provided to the sick child, as well as guilt
about being well while the sibling is severely ill.
Optimal comprehensive management of these issues involves a multidisciplinary approach that

proactively addresses these concerns. Key members of the team include social workers and
mental health specialists.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Chronic kidney disease
in children" and "Society guideline links: Chronic kidney disease-mineral and bone disorder".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
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sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Chronic kidney disease (The Basics)" and "Patient
education: Bone problems caused by kidney disease (The Basics)" and "Patient education:
3/29/23, 11:01 PM 6085
Medicines for chronic kidney disease (The Basics)")
SUMMARY AND RECOMMENDATIONS
● The general management of children with chronic kidney disease (CKD) includes routine
health maintenance, measures to prevent or slow progression of CKD, treatment of the
complications associated with CKD, and identifying and preparing patients with advancing
CKD and their families for kidney replacement therapy (KRT). (See 'Management approach'
above.)
● In addition to care measures provided to all children, routine health maintenance for
children with CKD requires more intense monitoring of kidney function and potential
complications ( table 15), growth, nutrition ( table 3) and diet, neurodevelopment,
blood pressure (BP) control and immunization. (See 'Routine health maintenance' above.)
● Prevention and slowing progression of CKD includes:
• Treatment of the underlying primary kidney disease if possible. (See 'Treat underlying
cause of kidney disease' above.)
• Prevention of subsequent kidney injury by avoiding episodes of decreased kidney

perfusion or the administration of nephrotoxic agents. (See 'Avoid subsequent kidney
injury' above.)
• Strict BP control has been the only intervention shown to slow the progression of
kidney disease in children. In children with CKD, we suggest that BP be strictly
controlled to reach targeted BP goals, including through the use of antihypertensive
therapy if needed ( table 8) (Grade 2B). For children with CKD who require
antihypertensive therapy, we suggest an agent that blocks the renin-angiotensin
system (angiotensin-converting enzyme [ACE] inhibitors, and angiotensin II receptor
blockers [ARB]) versus other classes of antihypertensive drugs (Grade 2B). (See 'Strict
BP control' above and 'Blood pressure and targeted goals' above.)
• In children with CKD, there is no evidence that a low-protein diet slows the progression
of kidney disease. There is also concern that such a diet may impair growth. We
suggest that children with CKD be given a daily diet containing at least 100 percent of
the dietary reference intake for protein based upon age and gender ( table 5) (Grade
2C). (See 'Other interventions with insufficient evidence' above and 'Nutrition' above.)
3/29/23, 11:01 PM 6085
● Complications due to kidney impairment become more prevalent as CKD progresses (see
"Chronic kidney disease in children: Complications"). They include:
• Fluid and electrolytes abnormalities

• Mineral and bone disorder (see "Pediatric chronic kidney disease-mineral and bone
disorder (CKD-MBD)")
• Anemia
• Hypertension
• Dyslipidemia
• Endocrine abnormalities
• Growth impairment
• Uremia including uremic pericarditis and bleeding
● Preparations for the child and family are initiated for KRT when the estimated glomerular
filtration rate (GFR) declines to less than 30 mL/min per 1.73 m2 (stage G4 CKD). The
patient (if appropriate) and family should be provided with information related to timing
and choice of KRT (preemptive kidney transplantation, peritoneal dialysis, and
hemodialysis). (See 'Preparation for end-stage kidney disease' above.)
● For children with renal failure (stage G5, previously referred to as end-stage kidney
disease), there is a significant increased risk for morbidity and mortality that persists
through adulthood. (See 'Long-term outcome' above.)
● CKD impacts on the quality of life for both the child and family and includes psychological
(eg, depression) and social stresses for both. Comprehensive management of these issues
involves a multidisciplinary approach that proactively addresses these concerns. (See
'Quality of life' above.)
Use of UpToDate is subject to the Terms of Use.
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33:779.
Topic 6085 Version 57.0
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GRAPHICS
Stages of chronic kidney disease for children based on the KDIGO 2012
clinical practice guideline
GFR
GFR category Terms
(mL/min/1.73 m 2 )
G1 ≥90 Normal or high
G2 60 to 89 Mildly decreased*
G3a 45 to 59 Mildly to moderately decreased
G3b 30 to 44 Moderately to severely decreased
G4 15 to 29 Severely decreased
G5 <15 Kidney failure
In the absence of evidence of kidney damage, neither GFR category G1 nor G2 fulfill the criteria for
CKD.
KDIGO: Kidney Disease: Improving Global Outcomes; GFR: glomerular filtration rate; CKD: chronic
kidney disease.
* Relative to young adult level.
Reprinted with permission from: Macmillan Publishers Ltd: Kidney International Supplements. KDIGO 2012 Clinical Practice
Guideline for the Evaluation and Management of Chronic Kidney Disease. Chapter 1: Definition and classification of CKD.
Kidney Int Suppl 2013; 3:19. Copyright © 2013. www.nature.com/kisup.
Graphic 89808 Version 2.0
3/29/23, 11:01 PM 6085
Plasma pediatric creatinine reference intervals (2.5 th to 97.5 th percentiles)
Enzymatic creatinine Jaffe creatinine
Age group mg/dL micromol/L Age group mg/dL micromol/L
0 to 14 days 0.32 to 0.92 28 to 81 0 to 14 days 0.42 to 1.05 37 to 93
15 days to <2 0.10 to 0.36 9 to 32 15 days to <1 0.31 to 0.53 27 to 47

years year
2 to <5 years 0.20 to 0.43 18 to 38 1 to <4 years 0.39 to 0.55 34 to 49
5 to <12 years 0.31 to 0.61 27 to 54 4 to <7 years 0.44 to 0.65 39 to 57
12 to <15 0.45 to 0.81 40 to 72 7 to <12 years 0.52 to 0.69 46 to 61

years
15 to 19 years 0.62 to 1.08 55 to 95 12 to 15 years 0.57 to 0.80 50 to 71

(male)
15 to <19 0.49 to 0.84 43.3 to 74 15 to <17 0.65 to 1.04 57 to 92

years (female) years (male)
15 to <17 0.59 to 0.86 52 to 76

years (female)
17 to <19 0.69 to 1.10 61 to 97

years (male)
17 to <19 0.60 to 0.88 53 to 78

years (female)
Creatinine pediatric reference values measured by two different laboratory assays: enzymatic
reaction by isotope dilution mass spectrometry (IDMS) and the Jaffe reaction. Creatinine values are
based on age; and for adolescent patients, reference values are also based on sex.
Data from: Colantonio DA, Kyriakopoulou L, Chan MK, et al. Closing the gaps in pediatric laboratory reference intervals: a
CALIPER database of 40 biochemical markers in a healthy and multiethnic population of children. Clin Chem 2012; 58:854.
3/29/23, 11:01 PM 6085
Recommended parameters and frequency of nutritional assessment for

children with CKD stages 2 to 5 and 5D
Minimum interval (month)
Age 0 to <1 year Age 1 to 3 years Age >3 years

Measure
CKD CKD CKD CKD CKD
CKD CKD CKD CKD CKD
2 or 4 or 2 or 4 or 4 or
5D 5D 2 3 5D
3 5 3 5 5
Dietary intake 0.5 0.5 0.5 1 to 1 to 1 to 6 to 6 3 to 3 to

to 3 to 3 to 2 3 3 3 12 4 4
Height or length-for- 0.5 0.5 0.5 1 to 1 to 1 3 to 3 to 1 to 1 to

age percentile or SDS to to to 1 3 2 6 6 3 3
1.5 1.5
Height or length 0.5 0.5 0.5 1 to 1 to 1 to 6 6 6 6

velocity-for-age to 2 to 2 to 1 6 3 2
percentile or SDS
Estimated dry weight 0.5 0.5 0.25 1 to 1 to 0.5 3 to 3 to 1 to 1 to

and weight-for-age to to to 1 3 2 to 1 6 6 3 3
percentile or SDS 1.5 1.5
BMI-for-height-age 0.5 0.5 0.5 1 to 1 to 1 3 to 3 to 1 to 1 to

percentile or SDS to to to 1 3 2 6 6 3 3
1.5 1.5
Head circumference- 0.5 0.5 0.5 1 to 1 to 1 to N/A N/A N/A N/A

for-age percentile or to to to 1 3 2 2
SDS 1.5 1.5
nPCR N/A N/A N/A N/A N/A N/A N/A N/A N/A 1*
CKD: chronic kidney disease; SDS: standard deviations score; BMI: body mass index; N/A: not
applicable; nPCR: normalized protein catabolic rate.
* Only applies to adolescents receiving hemodialysis.
Reproduced with permission from: National Kidney Foundation. Recommendation 1: Evaluation of Growth and Nutritional
Status. Am J Kid Dis 2009; 53:S16. Illustration used with permission of Elsevier Inc. All rights reserved.
3/29/23, 11:01 PM 6085
Equations to estimate energy requirements for children with chronic kidney

disease at healthy weights
Estimated energy requirement (EER) (kcal/day) = total energy

Age
expenditure + energy deposition
0 to 3 EER = [89 x weight (kg) - 100] + 175

months
4 to 6 EER = [89 x weight (kg) - 100] + 56

months
7 to 12 EER = [89 x weight (kg) - 100] + 22

months
13 to 35 EER = [89 x weight (kg) - 100] + 20

months
3 to 8 years Boys: EER = 88.5 - 61.9 x age (years) + PA x [26.7 x weight (kg) + 903 x height (m)] + 20
Girls: EER = 135.3 - 30.8 x age (years) + PA x [10 x weight (kg) + 934 x height (m)] + 20
9 to 18 years Boys: EER = 88.5 - 61.9 x age (years) + PA x [26.7 x weight (kg) + 903 x height (m)] + 25
Girls: EER = 135.3 - 30.8 x age (years) + PA x [10 x weight (kg) + 934 x height (m)] + 25
CKD: chronic kidney disease; PA: physical activity coefficient.
Reproduced with permission from: National Kidney Foundation. KDOQI Clinical Practice Guideline for Nutrition in Children
with CKD: 2008 update. Executive summary. Am J Kidney Dis 2009; 53:S11. Illustration used with the permission of Elsevier
Inc. All rights reserved.
3/29/23, 11:01 PM 6085
Recommended dietary protein intake in children with chronic kidney

disease*
Dietary reference intake (DRI)
Recommended
Recommended
for CKD stages
Age for CKD stage Recommended Recommended
DRI 4 or 5
3 (g/kg/day) for HD for PD
(g/kg/day) (g/kg/day)
(100 to 140 (g/kg/day) ¶ (g/kg/day) Δ
(100 to 120
percent DRI)
percent DRI)
0 to 6 1.5 1.5 to 2.1 1.5 to 1.8 1.6 1.8

months
7 to 12 1.2 1.2 to 1.7 1.2 to 1.5 1.3 1.5

months
1 to 3 1.05 1.05 to 1.5 1.05 to 1.25 1.15 1.3

years
4 to 13 0.95 0.95 to 1.35 0.95 to 1.15 1.05 1.1

years
14 to 0.85 0.85 to 1.2 0.85 to 1.05 0.95 1

18
years
CKD: chronic kidney disease; HD: hemodialysis; PD: peritoneal dialysis.
* Children with chronic kidney disease stages 3 to 5.
¶ DRI + 0.1 g/kg/day to compensate for dialytic losses.
Δ DRI + 0.15 to 0.3 g/kg/day depending on patient age to compensate for peritoneal losses.
Reproduced with permission from: National Kidney Foundation. KDOQI Clinical Practice Guideline for Nutrition in Children
with CKD: 2008 update. Executive summary. Am J Kidney Dis 2009; 53:S11. Illustration used with the permission of Elsevier
Inc. All rights reserved.
3/29/23, 11:01 PM 6085
Dietary reference intake (DRI) for water-soluble vitamins
Pantothenic
Life Thiamine Riboflavin Niacin Vitamin B6 Bio
acid
stage (mg/day) (mg/day) (mg/day)* (mg/day) (mcg
(mg/day)
group
RDA/AI UL RDA/AI UL RDA/AI UL RDA/AI UL RDA/AI UL RDA/A
Infants
0 to 6 0.2 ¶ ND 0.3 ¶ ND 2¶ ND 1.7 ¶ ND 0.1 ¶ ND 5¶

months
7 to 12 0.3 ¶ ND 0.4 ¶ ND 4¶ ND 1.8 ¶ ND 0.3 ¶ ND 6¶

months
Children
1 to 3 0.5 ND 0.5 ND 6 10 2¶ ND 0.5 30 8¶

years
4 to 8 0.6 ND 0.6 ND 8 15 3¶ ND 0.6 40 12 ¶

years
Males
9 to 13 0.9 ND 0.9 ND 12 20 4¶ ND 1 60 20 ¶
years
14 to 1.2 ND 1.3 ND 16 30 5¶ ND 1.3 80 25 ¶

18
years
19 to 1.2 ND 1.3 ND 16 35 5¶ ND 1.3 100 30 ¶

30
years
31 to 1.2 ND 1.3 ND 16 35 5¶ ND 1.3 100 30 ¶

50
years
51 to 1.2 ND RDA ND 16 35 5¶ ND 1.7 100 30 ¶

70
years
>70 1.2 ND 1.3 ND 16 35 5¶ ND 1.7 100 30 ¶

years
Females
9 to 13 0.9 ND 0.9 ND 12 20 4¶ ND 1 60 20 ¶
years
3/29/23, 11:01 PM 6085
14 to 1 ND 1 ND 14 30 5¶ ND 1.2 80 25 ¶
18
years
19 to 1.1 ND 1.1 ND 14 35 5¶ ND 1.3 100 30 ¶

30
years
31 to 1.1 ND 1.1 ND 14 35 5¶ ND 1.3 100 30 ¶

50
years
51 to 1.1 ND 1.1 ND 14 35 5¶ ND 1.5 100 30 ¶

70
years
>70 1.1 ND 1.1 ND 14 35 5¶ ND 1.5 100 30 ¶

years
Pregnancy
14 to 1.4 ND 1.4 ND 18 30 6¶ ND 1.9 80 30 ¶

18
years
19 to 1.4 ND 1.4 ND 18 35 6¶ ND 1.9 100 30 ¶

30
years
31 to 1.4 ND 1.4 ND 18 35 6¶ ND 1.9 100 30 ¶

50
years
Lactation
14 to 1.4 ND 1.6 ND 17 30 7¶ ND 2 80 35 ¶
18
years
19 to 1.4 ND 1.6 ND 17 35 7¶ ND 2 100 35 ¶

30
years
31 to 1.4 ND 1.6 ND 17 35 7¶ ND 2 100 35 ¶

50
years
Dietary reference intakes (DRIs) include the following measures describing optimal nutrient intake:
Recommended dietary allowance (RDA) – The level of dietary intake that is sufficient to meet
the daily nutrient requirements of 97% of the individuals in a specific life stage group.
Adequate intake (AI) – An approximation of the average nutrient intake that sustains a
defined nutritional state, based on observed or experimentally determined values in a defined
3/29/23, 11:01 PM 6085
population.
Upper tolerable level (UL) – The maximum level of daily nutrient intake that is likely to pose
no risk of adverse health effects in almost all individuals in the specified life stage or gender
group.
RDAs and AIs may both be used as goals for individual intake. The AI is used when there are
insufficient data to determine the RDA for a given nutrient.
* Niacin is dosed as niacin equivalents (NE), where 1 mg niacin = 60 mg of tryptophan. Infants 0 to 6

months: only preformed niacin (not NE).
¶ As AI.
Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Otten JJ, Hellwig JP, Meyers LD (Eds), The National
Academies Press, Washington, DC 2006. pp.530-541. Reprinted and expanded with permission from the National Academies
Press, Copyright © 2006, National Academy of Sciences.
Sources: Dietary reference intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Panthothenic acid, Biotin,
and Choline (1998); Dietary reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000). These reports may
be accessed via www.nap.edu.
3/29/23, 11:01 PM 6085
Dietary reference intakes for fat-soluble vitamins
Adverse
¶ Δ
Nutrient Age group RDA*/AI UL effects of
excess
Vitamin A
1 mcg retinol Micrograms Micrograms Ataxia, alopecia,

activity daily daily hyperlipidemia,
equivalent = hepatotoxicity,
Infants
3.3 unit bone and muscle
vitamin A 0 to 6 months 400 ¶ 600 pain; teratogenic
7 to 12 months 500 ¶ 600
Children
1 to 3 years 300 600
4 to 8 years 400 900
Males
9 to 13 years 600 1700
14 to 18 years 900 2800
≥19 years 900 3000
Females
9 to 13 years 600 1700
14 to 18 years 700 2800
≥19 years 700 3000
Pregnancy
<18 years 750 2800
≥19 years 770 3000
Lactation
<18 years 1200 2800
≥19 years 1300 3000
Vitamin D
(calciferol) Micrograms Micrograms Hypercalcemia,

daily daily hypercalciuria,
1 mcg
polydipsia,
calciferol = 40 Infants
polyuria,
int. unit
3/29/23, 11:01 PM 6085
0 to 12 months 10 (400 int. unit) ¶ 0 to 6 months: 25 confusion,

(1000 int. unit) anorexia,
vomiting, bone
6 to 12 months: demineralization
37.5 (1500 int.
unit)
Children and adolescents
1 to 18 years 15 (600 int. unit) 1 to 3 years: 62.5

(2500 int. unit)
4 to 8 years: 75
(3000 int. unit)
9 to 18 years: 100
(4000 int. unit)
Males and females (including pregnancy and lactation)
19 to 50 years 15 (600 int. unit) 100 (4000 int.

unit)
50 to 70 years 15 100
>70 years 20 (800 int. unit) 100
Vitamin E
(alpha- Milligrams daily Milligrams daily Increased risk of

tocopherol) bleeding; possibly
Infants
increased risk of
1 mg = 1.47
0 to 6 months 4¶ ND necrotizing
int. unit
enterocolitis in
"natural 7 to 12 months 5¶ ND
infants
source"
Children
vitamin E or
2.2 int. unit 1 to 3 years 6 200
synthetic
4 to 8 years 7 300
vitamin E
Males and females (including pregnancy)
9 to 13 years 11 600
14 to 18 years 15 800
>18 years 15 1000
Lactation
≤18 years 19 800
>19 years 19 1000
Vitamin K
3/29/23, 11:01 PM 6085
Micrograms Micrograms No adverse

daily daily effects associated
with vitamin K
Infants
consumption
0 to 6 months 2¶ ND from food or
supplements
7 to 12 months 2.5 ¶ ND
have been
Children reported;
1 to 3 years 30 ¶ ND however, data are
limited
4 to 8 years 55 ¶ ND
Males
>19 years 120 ¶ ND
Females (including pregnancy and lactation)
>19 years 90 ¶ ND
Vitamin A doses given as RAE. 1 RAE = 1 mcg retinol, 12 mcg beta-carotene, 14 mcg alpha-carotene,
or 24 mcg beta-cryptoxanthin.
RDA: recommended dietary allowance; AI: adequate intake; UL: upper tolerable level; int. unit:
international units; ND: not determined; RAE: retinol activity equivalents.
* Values in this column represent the RDA unless otherwise indicated. The RDA is the level of dietary
intake that is sufficient to meet the daily nutrient requirements of 97% of the individuals in a specific
life stage group.
¶ These values represent an AI. The AI represents an approximation of the average nutrient intake
that sustains a defined nutritional state, based on observed or experimentally determined values in
a defined population.
Δ The UL is the maximum level of daily nutrient intake that is likely to pose no risk of adverse health
effects in almost all individuals in the specified life stage or gender group.
Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Otten JJ, Hellwig JP, Meyers LD (Eds), The National
Academies Press, Washington, DC 2006. pp.530-541. Modified with permission from the National Academies Press,
Copyright © 2006, National Academy of Sciences.
Sources: Dietary reference intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Panthothenic acid, Biotin,
and Choline (1998); Dietary reference intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference
3/29/23, 11:01 PM 6085
Intake reports of the Food and Nutrition Board, Institute of Medicine (2010). These reports may be accessed via
www.nap.edu.
3/29/23, 11:01 PM 6085
Target blood pressure goals for children with chronic kidney disease
Age Targeted blood pressure goals
Office blood pressure*
Children <13 years of age Systolic and diastolic BPs <90 th percentile for
age, sex, and height ¶
Children ≥13 years of age BP ≤120/80 mmHg
Ambulatory blood pressure monitoring (ABPM)
All ages 24-hour mean arterial BP <50 th percentile based

on ABPM normative data for age, sex, and height
BP: blood pressure.
* BP values are based on auscultatory office measurements using aneroid sphygmomanometers

and appropriate size cuff and placement.
¶ Normative BP values are based on the 2017 the American Academy of Pediatrics (AAP) published
revised guidelines for screening and managing high BP for children and adolescents.
3/29/23, 11:01 PM 6085
Blood pressure levels for males by age and height percentile
Systolic BP (mmHg) Diastolic BP (m

BP
Height percentile or measured height Height percentile or m
(percentile)
5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50%
1 year
Height (in) 30.4 30.8 31.6 32.4 33.3 34.1 34.6 30.4 30.8 31.6 32.4
Height 77.2 78.3 80.2 82.4 84.6 86.7 87.9 77.2 78.3 80.2 82.4
(cm)
50 th 85 85 86 86 87 88 88 40 40 40 41
90 th 98 99 99 100 100 101 101 52 52 53 53
95 th 102 102 103 103 104 105 105 54 54 55 55
95 th + 12 114 114 115 115 116 117 117 66 66 67 67

mmHg
2 years
Height (in) 33.9 34.4 35.3 36.3 37.3 38.2 38.8 33.9 34.4 35.3 36.3
Height 86.1 87.4 89.6 92.1 94.7 97.1 98.5 86.1 87.4 89.6 92.1
(cm)
50 th 87 87 88 89 89 90 91 43 43 44 44
90 th 100 100 101 102 103 103 104 55 55 56 56
95 th 104 105 105 106 107 107 108 57 58 58 59
95 th + 12 116 117 117 118 119 119 120 69 70 70 71

mmHg
3 years
Height (in) 36.4 37.0 37.9 39.0 40.1 41.1 41.7 36.4 37.0 37.9 39.0
Height 92.5 93.9 96.3 99.0 101.8 104.3 105.8 92.5 93.9 96.3 99.0
(cm)
50 th 88 89 89 90 91 92 92 45 46 46 47
90 th 101 102 102 103 104 105 105 58 58 59 59
95 th 106 106 107 107 108 109 109 60 61 61 62
95 th + 12 118 118 119 119 120 121 121 72 73 73 74

mmHg
4 years
3/29/23, 11:01 PM 6085
Height (in) 38.8 39.4 40.5 41.7 42.9 43.9 44.5 38.8 39.4 40.5 41.7
Height 98.5 100.2 102.9 105.9 108.9 111.5 113.2 98.5 100.2 102.9 105.9
(cm)
50 th 90 90 91 92 93 94 94 48 49 49 50
90 th 102 103 104 105 105 106 107 60 61 62 62
95 th 107 107 108 108 109 110 110 63 64 65 66
95 th + 12 119 119 120 120 121 122 122 75 76 77 78

mmHg
5 years
Height (in) 41.1 41.8 43.0 44.3 45.5 46.7 47.4 41.1 41.8 43.0 44.3
Height 104.4 106.2 109.1 112.4 115.7 118.6 120.3 104.4 106.2 109.1 112.4
(cm)
50 th 91 92 93 94 95 96 96 51 51 52 53
90 th 103 104 105 106 107 108 108 63 64 65 65
95 th 107 108 109 109 110 111 112 66 67 68 69
95 th + 12 119 120 121 121 122 123 124 78 79 80 81

mmHg
6 years
Height (in) 43.4 44.2 45.4 46.8 48.2 49.4 50.2 43.4 44.2 45.4 46.8
Height 110.3 112.2 115.3 118.9 122.4 125.6 127.5 110.3 112.2 115.3 118.9
(cm)
50 th 93 93 94 95 96 97 98 54 54 55 56
90 th 105 105 106 107 109 110 110 66 66 67 68
95 th 108 109 110 111 112 113 114 69 70 70 71
95 th + 12 120 121 122 123 124 125 126 81 82 82 83

mmHg
7 years
Height (in) 45.7 46.5 47.8 49.3 50.8 52.1 52.9 45.7 46.5 47.8 49.3
Height 116.1 118.0 121.4 125.1 128.9 132.4 134.5 116.1 118.0 121.4 125.1
(cm)
50 th 94 94 95 97 98 98 99 56 56 57 58
90 th 106 107 108 109 110 111 111 68 68 69 70
95 th 110 110 111 112 114 115 116 71 71 72 73
3/29/23, 11:01 PM 6085
95 th + 12 122 122 123 124 126 127 128 83 83 84 85

mmHg
8 years
Height (in) 47.8 48.6 50.0 51.6 53.2 54.6 55.5 47.8 48.6 50.0 51.6
Height 121.4 123.5 127.0 131.0 135.1 138.8 141.0 121.4 123.5 127.0 131.0
(cm)
50 th 95 96 97 98 99 99 100 57 57 58 59
90 th 107 108 109 110 111 112 112 69 70 70 71
95 th 111 112 112 114 115 116 117 72 73 73 74
95 th + 12 123 124 124 126 127 128 129 84 85 85 86

mmHg
9 years
Height (in) 49.6 50.5 52.0 53.7 55.4 56.9 57.9 49.6 50.5 52.0 53.7
Height 126.0 128.3 132.1 136.3 140.7 144.7 147.1 126.0 128.3 132.1 136.3
(cm)
50 th 96 97 98 99 100 101 101 57 58 59 60
90 th 107 108 109 110 112 113 114 70 71 72 73
95 th 112 112 113 115 116 118 119 74 74 75 76
95 th + 12 124 124 125 127 128 130 131 86 86 87 88

mmHg
10 years
Height (in) 51.3 52.2 53.8 55.6 57.4 59.1 60.1 51.3 52.2 53.8 55.6
Height 130.2 132.7 136.7 141.3 145.9 150.1 152.7 130.2 132.7 136.7 141.3
(cm)
50 th 97 98 99 100 101 102 103 59 60 61 62
90 th 108 109 111 112 113 115 116 72 73 74 74
95 th 112 113 114 116 118 120 121 76 76 77 77
95 th + 12 124 125 126 128 130 132 133 88 88 89 89

mmHg
11 years
Height (in) 53.0 54.0 55.7 57.6 59.6 61.3 62.4 53.0 54.0 55.7 57.6
Height 134.7 137.3 141.5 146.4 151.3 155.8 158.6 134.7 137.3 141.5 146.4
(cm)
50 th 99 99 101 102 103 104 106 61 61 62 63
3/29/23, 11:01 PM 6085
90 th 110 111 112 114 116 117 118 74 74 75 75
95 th 114 114 116 118 120 123 124 77 78 78 78
95 th + 12 126 126 128 130 132 135 136 89 90 90 90

mmHg
12 years
Height (in) 55.2 56.3 58.1 60.1 62.2 64.0 65.2 55.2 56.3 58.1 60.1
Height 140.3 143.0 147.5 152.7 157.9 162.6 165.5 140.3 143.0 147.5 152.7
(cm)
50 th 101 101 102 104 106 108 109 61 62 62 62
90 th 113 114 115 117 119 121 122 75 75 75 75
95 th 116 117 118 121 124 126 128 78 78 78 78
95 th + 12 128 129 130 133 136 138 140 90 90 90 90

mmHg
13 years
Height (in) 57.9 59.1 61.0 63.1 65.2 67.1 68.3 57.9 59.1 61.0 63.1
Height 147.0 150.0 154.9 160.3 165.7 170.5 173.4 147.0 150.0 154.9 160.3
(cm)
50 th 103 104 105 108 110 111 112 61 60 61 62
90 th 115 116 118 121 124 126 126 74 74 74 75
95 th 119 120 122 125 128 130 131 78 78 78 78
95 th + 12 131 132 134 137 140 142 143 90 90 90 90

mmHg
14 years
Height (in) 60.6 61.8 63.8 65.9 68.0 69.8 70.9 60.6 61.8 63.8 65.9
Height 153.8 156.9 162.0 167.5 172.7 177.4 180.1 153.8 156.9 162.0 167.5
(cm)
50 th 105 106 109 111 112 113 113 60 60 62 64
90 th 119 120 123 126 127 128 129 74 74 75 77
95 th 123 125 127 130 132 133 134 77 78 79 81
95 th + 12 135 137 139 142 144 145 146 89 90 91 93

mmHg
15 years
Height (in) 62.6 63.8 65.7 67.8 69.8 71.5 72.5 62.6 63.8 65.7 67.8
3/29/23, 11:01 PM 6085
Height 159.0 162.0 166.9 172.2 177.2 181.6 184.2 159.0 162.0 166.9 172.2
(cm)
50 th 108 110 112 113 114 114 114 61 62 64 65
90 th 123 124 126 128 129 130 130 75 76 78 79
95 th 127 129 131 132 134 135 135 78 79 81 83
95 th + 12 139 141 143 144 146 147 147 90 91 93 95

mmHg
16 years
Height (in) 63.8 64.9 66.8 68.8 70.7 72.4 73.4 63.8 64.9 66.8 68.8
Height 162.1 165.0 169.6 174.6 179.5 183.8 186.4 162.1 165.0 169.6 174.6
(cm)
50 th 111 112 114 115 115 116 116 63 64 66 67
90 th 126 127 128 129 131 131 132 77 78 79 80
95 th 130 131 133 134 135 136 137 80 81 83 84
95 th + 12 142 143 145 146 147 148 149 92 93 95 96

mmHg
17 years
Height (in) 64.5 65.5 67.3 69.2 71.1 72.8 73.8 64.5 65.5 67.3 69.2
Height 163.8 166.5 170.9 175.8 180.7 184.9 187.5 163.8 166.5 170.9 175.8
(cm)
50 th 114 115 116 117 117 118 118 65 66 67 68
90 th 128 129 130 131 132 133 134 78 79 80 81
95 th 132 133 134 135 137 138 138 81 82 84 85
95 th + 12 144 145 146 147 149 150 150 93 94 96 97

mmHg
The 50 th , 90 th , and 95 th percentiles were derived by using quantile regression on the basis of
normal-weight children (BMI <85 th percentile). BP stages are defined as elevated BP ≥90 th
percentile but <95 th percentile; stage 1 HTN: ≥95 th percentile or 130/80 to 139/89 mmHg; and stage
2 HTN: ≥95 th percentile + 12 mmHg or >140/90 mmHg.
BP: blood pressure; BMI: body mass index; HTN: hypertension.
Reproduced with permission from: Pediatrics, Vol. 140, doi: 10.1542/peds.2017-1904. Copyright © 2017 by the AAP.
3/29/23, 11:01 PM 6085
Blood pressure levels for females by age and height percentile
Systolic BP (mmHg) Diastolic BP (m

BP
Height percentile or measured height Height percentile or m
(percentile)
5% 10% 25% 50% 75% 90% 95% 5% 10% 25% 50%
1 year
Height (in) 29.7 30.2 30.9 31.8 32.7 33.4 33.9 29.7 30.2 30.9 31.8
Height 75.4 76.6 78.6 80.8 83.0 84.9 86.1 75.4 76.6 78.6 80.8
(cm)
50 th 84 85 86 86 87 88 88 41 42 42 43
90 th 98 99 99 100 101 102 102 54 55 56 56
95 th 101 102 102 103 104 105 105 59 59 60 60
95 th + 12 113 114 114 115 116 117 117 71 71 72 72

mmHg
2 years
Height (in) 33.4 34.0 34.9 35.9 36.9 37.8 38.4 33.4 34.0 34.9 35.9
Height 84.9 86.3 88.6 91.1 93.7 96.0 97.4 84.9 86.3 88.6 91.1
(cm)
50 th 87 87 88 89 90 91 91 45 46 47 48
90 th 101 101 102 103 104 105 106 58 58 59 60
95 th 104 105 106 106 107 108 109 62 63 63 64
95 th + 12 116 117 118 118 119 120 121 74 75 75 76

mmHg
3 years
Height (in) 35.8 36.4 37.3 38.4 39.6 40.6 41.2 35.8 36.4 37.3 38.4
Height 91.0 92.4 94.9 97.6 100.5 103.1 104.6 91.0 92.4 94.9 97.6
(cm)
50 th 88 89 89 90 91 92 93 48 48 49 50
90 th 102 103 104 104 105 106 107 60 61 61 62
95 th 106 106 107 108 109 110 110 64 65 65 66
95 th + 12 118 118 119 120 121 122 122 76 77 77 78

mmHg
4 years
3/29/23, 11:01 PM 6085
Height (in) 38.3 38.9 39.9 41.1 42.4 43.5 44.2 38.3 38.9 39.9 41.1
Height 97.2 98.8 101.4 104.5 107.6 110.5 112.2 97.2 98.8 101.4 104.5
(cm)
50 th 89 90 91 92 93 94 94 50 51 51 53
90 th 103 104 105 106 107 108 108 62 63 64 65
95 th 107 108 109 109 110 111 112 66 67 68 69
95 th + 12 119 120 121 121 122 123 124 78 79 80 81

mmHg
5 years
Height (in) 40.8 41.5 42.6 43.9 45.2 46.5 47.3 40.8 41.5 42.6 43.9
Height 103.6 105.3 108.2 111.5 114.9 118.1 120.0 103.6 105.3 108.2 111.5
(cm)
50 th 90 91 92 93 94 95 96 52 52 53 55
90 th 104 105 106 107 108 109 110 64 65 66 67
95 th 108 109 109 110 111 112 113 68 69 70 71
95 th + 12 120 121 121 122 123 124 125 80 81 82 83

mmHg
6 years
Height (in) 43.3 44.0 45.2 46.6 48.1 49.4 50.3 43.3 44.0 45.2 46.6
Height 110.0 111.8 114.9 118.4 122.1 125.6 127.7 110.0 111.8 114.9 118.4
(cm)
50 th 92 92 93 94 96 97 97 54 54 55 56
90 th 105 106 107 108 109 110 111 67 67 68 69
95 th 109 109 110 111 112 113 114 70 71 72 72
95 th + 12 121 121 122 123 124 125 126 82 83 84 84

mmHg
7 years
Height (in) 45.6 46.4 47.7 49.2 50.7 52.1 53.0 45.6 46.4 47.7 49.2
Height 115.9 117.8 121.1 124.9 128.8 132.5 134.7 115.9 117.8 121.1 124.9
(cm)
50 th 92 93 94 95 97 98 99 55 55 56 57
90 th 106 106 107 109 110 111 112 68 68 69 70
95 th 109 110 111 112 113 114 115 72 72 73 73
3/29/23, 11:01 PM 6085
95 th + 12 121 122 123 124 125 126 127 84 84 85 85

mmHg
8 years
Height (in) 47.6 48.4 49.8 51.4 53.0 54.5 55.5 47.6 48.4 49.8 51.4
Height 121.0 123.0 126.5 130.6 134.7 138.5 140.9 121.0 123.0 126.5 130.6
(cm)
50 th 93 94 95 97 98 99 100 56 56 57 59
90 th 107 107 108 110 111 112 113 69 70 71 72
95 th 110 111 112 113 115 116 117 72 73 74 74
95 th + 12 122 123 124 125 127 128 129 84 85 86 86

mmHg
9 years
Height (in) 49.3 50.2 51.7 53.4 55.1 56.7 57.7 49.3 50.2 51.7 53.4
Height 125.3 127.6 131.3 135.6 140.1 144.1 146.6 125.3 127.6 131.3 135.6
(cm)
50 th 95 95 97 98 99 100 101 57 58 59 60
90 th 108 108 109 111 112 113 114 71 71 72 73
95 th 112 112 113 114 116 117 118 74 74 75 75
95 th + 12 124 124 125 126 128 129 130 86 86 87 87

mmHg
10 years
Height (in) 51.1 52.0 53.7 55.5 57.4 59.1 60.2 51.1 52.0 53.7 55.5
Height 129.7 132.2 136.3 141.0 145.8 150.2 152.8 129.7 132.2 136.3 141.0
(cm)
50 th 96 97 98 99 101 102 103 58 59 59 60
90 th 109 110 111 112 113 115 116 72 73 73 73
95 th 113 114 114 116 117 119 120 75 75 76 76
95 th + 12 125 126 126 128 129 131 132 87 87 88 88

mmHg
11 years
Height (in) 53.4 54.5 56.2 58.2 60.2 61.9 63.0 53.4 54.5 56.2 58.2
Height 135.6 138.3 142.8 147.8 152.8 157.3 160.0 135.6 138.3 142.8 147.8
(cm)
50 th 98 99 101 102 104 105 106 60 60 60 61
3/29/23, 11:01 PM 6085
90 th 111 112 113 114 116 118 120 74 74 74 74
95 th 115 116 117 118 120 123 124 76 77 77 77
95 th + 12 127 128 129 130 132 135 136 88 89 89 89

mmHg
12 years
Height (in) 56.2 57.3 59.0 60.9 62.8 64.5 65.5 56.2 57.3 59.0 60.9
Height 142.8 145.5 149.9 154.8 159.6 163.8 166.4 142.8 145.5 149.9 154.8
(cm)
50 th 102 102 104 105 107 108 108 61 61 61 62
90 th 114 115 116 118 120 122 122 75 75 75 75
95 th 118 119 120 122 124 125 126 78 78 78 78
95 th + 12 130 131 132 134 136 137 138 90 90 90 90

mmHg
13 years
Height (in) 58.3 59.3 60.9 62.7 64.5 66.1 67.0 58.3 59.3 60.9 62.7
Height 148.1 150.6 154.7 159.2 163.7 167.8 170.2 148.1 150.6 154.7 159.2
(cm)
50 th 104 105 106 107 108 108 109 62 62 63 64
90 th 116 117 119 121 122 123 123 75 75 75 76
95 th 121 122 123 124 126 126 127 79 79 79 79
95 th + 12 133 134 135 136 138 138 139 91 91 91 91

mmHg
14 years
Height (in) 59.3 60.2 61.8 63.5 65.2 66.8 67.7 59.3 60.2 61.8 63.5
Height 150.6 153.0 156.9 161.3 165.7 169.7 172.1 150.6 153.0 156.9 161.3
(cm)
50 th 105 106 107 108 109 109 109 63 63 64 65
90 th 118 118 120 122 123 123 123 76 76 76 76
95 th 123 123 124 125 126 127 127 80 80 80 80
95 th + 12 135 135 136 137 138 139 139 92 92 92 92

mmHg
15 years
Height (in) 59.7 60.6 62.2 63.9 65.6 67.2 68.1 59.7 60.6 62.2 63.9
3/29/23, 11:01 PM 6085
Height 151.7 154.0 157.9 162.3 166.7 170.6 173.0 151.7 154.0 157.9 162.3
(cm)
50 th 105 106 107 108 109 109 109 64 64 64 65
90 th 118 119 121 122 123 123 124 76 76 76 77
95 th 124 124 125 126 127 127 128 80 80 80 81
95 th + 12 136 136 137 138 139 139 140 92 92 92 93

mmHg
16 years
Height (in) 59.9 60.8 62.4 64.1 65.8 67.3 68.3 59.9 60.8 62.4 64.1
Height 152.1 154.5 158.4 162.8 167.1 171.1 173.4 152.1 154.5 158.4 162.8
(cm)
50 th 106 107 108 109 109 110 110 64 64 65 66
90 th 119 120 122 123 124 124 124 76 76 76 77
95 th 124 125 125 127 127 128 128 80 80 80 81
95 th + 12 136 137 137 139 139 140 140 92 92 92 93

mmHg
17 years
Height (in) 60.0 60.9 62.5 64.2 65.9 67.4 68.4 60.0 60.9 62.5 64.2
Height 154.4 154.7 158.7 163.0 167.4 171.3 173.7 154.4 154.7 158.7 163.0
(cm)
50 th 107 108 109 110 110 110 111 64 64 65 66
90 th 120 121 123 124 124 125 125 76 76 77 77
95 th 125 125 126 127 128 128 128 80 80 80 81
95 th + 12 137 137 138 139 140 140 140 92 92 92 93

mmHg
The 50 th , 90 th , and 95 th percentiles were derived by using quantile regression on the basis of
normal-weight children (BMI <85 th percentile). BP stages are defined as elevated BP ≥90 th
percentile but <95 th percentile; stage 1 HTN: ≥95 th percentile or 130/80 to 139/89 mmHg; and stage
2 HTN: ≥95 th percentile + 12 mmHg or >140/90 mmHg.
BP: blood pressure; BMI: body mass index; HTN: hypertension.
Reproduced with permission from: Pediatrics, Vol. 140, doi: 10.1542/peds.2017-1904. Copyright © 2017 by the AAP.
3/29/23, 11:01 PM 6085
24-hour ambulatory blood pressure (BP) levels for boys based on age
Average 24-hour BP Average

Age Average day BP (percentile)
(percentile) (perce
(years)
50th 75th 90th 95th 50th 75th 90th 95th 50th 75th
5 105/65 109/69 113/72 116/74 111/72 116/76 120/79 123/81 95/55 99/59
6 106/66 110/69 115/73 118/75 112/72 116/76 121/79 124/81 96/55 100/59
7 106/66 111/70 116/73 119/75 112/73 117/76 122/80 125/82 96/56 101/60
8 107/66 112/70 117/73 120/75 112/73 117/76 122/80 125/82 97/56 102/60
9 108/67 113/70 118/73 121/75 113/72 118/76 123/80 126/82 97/56 103/60
10 109/67 114/70 119/73 123/75 113/72 119/76 124/80 127/82 98/56 104/60
11 110/67 116/71 121/74 125/76 115/72 121/76 126/80 129/82 99/56 105/60
12 113/67 118/71 124/74 127/76 117/72 123/76 128/80 132/82 101/56 107/60
13 115/67 121/71 126/74 130/76 120/72 126/76 131/80 135/82 103/56 109/60
14 118/68 124/71 129/75 133/77 122/73 129/77 134/80 138/82 106/57 112/61
15 121/68 127/72 132/75 136/77 125/73 132/77 137/81 141/83 108/57 114/61
16 123/69 129/72 135/76 138/78 128/74 135/78 140/81 144/84 111/57 117/61
The values are in mmHg and are the average BP based on 24-hour ambulatory BP monitoring.
From: Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al. 2016 European Society of Hypertension guidelines for the management
of high blood pressure in children and adolescents. J Hypertens 2016; 34:1887. DOI: 10.1097/HJH.0000000000001039.
Copyright © 2016 International Society of Hypertension and European Society of Hypertension. Reproduced with permission
from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.
3/29/23, 11:01 PM 6085
24-hour ambulatory blood pressure (BP) levels for boys based on height

Height Average day BP (percentile)
(percentile) (perce
(cm)
120 105/66 109/70 114/74 117/77 111/72 116/77 122/80 125/82 94/54 99/58
125 105/66 110/70 115/74 118/77 111/72 117/76 122/80 125/82 95/55 100/58
130 106/66 111/70 116/74 119/77 112/72 117/76 122/80 126/82 96/55 101/59
135 107/66 112/70 117/74 120/77 112/72 117/76 123/80 126/82 97/56 102/59
140 108/67 113/71 118/75 121/77 113/72 118/76 123/80 126/82 98/56 104/60
145 110/67 115/71 120/75 123/77 114/72 119/76 124/79 127/81 99/56 105/60
150 111/67 116/71 121/75 124/77 115/72 120/76 125/79 128/81 100/56 106/60
155 113/67 118/71 123/75 126/77 117/72 122/76 127/79 130/81 101/56 107/60
160 114/67 120/71 124/75 127/77 119/72 124/76 129/79 133/81 103/56 108/60
165 116/68 121/71 126/75 129/78 121/72 126/76 132/80 135/82 104/57 110/60
170 118/68 123/72 128/75 131/78 123/73 128/77 134/80 138/82 106/57 112/61
175 120/68 125/72 130/75 133/78 124/73 130/77 136/81 140/83 107/57 113/61
180 122/68 127/72 131/76 134/78 126/73 132/77 138/81 142/83 109/57 115/61
185 123/68 128/72 133/76 136/78 128/73 134/78 140/81 144/84 110/57 116/61
3/29/23, 11:01 PM 6085
24-hour ambulatory blood pressure (BP) levels for girls based on age

Age Average day BP (percentile)
(percentile) (perce
(years)
5 103/66 108/69 112/72 115/74 108/73 114/77 118/80 121/82 95/56 100/61
6 104/66 109/69 114/72 116/74 110/73 115/77 120/80 122/82 96/56 101/61
7 105/66 110/69 115/72 118/74 111/72 116/77 121/80 123/82 96/56 102/60
8 107/66 112/69 116/72 119/74 112/72 117/76 122/80 124/82 97/55 103/60
9 108/66 113/70 117/73 120/74 112/72 118/76 122/80 125/82 98/55 103/59
10 109/66 114/70 118/73 121/75 113/72 119/76 123/79 126/81 98/55 104/59
11 110/66 115/70 119/73 122/75 114/72 120/76 124/79 127/81 99/54 105/59
12 111/67 116/70 120/74 123/76 115/72 121/76 125/80 128/82 100/54 105/59
13 112/67 117/71 121/74 124/76 116/72 122/77 126/80 129/82 101/54 106/59
14 113/67 118/71 122/74 125/76 118/73 123/77 127/80 130/82 101/55 106/59
15 114/68 118/71 123/75 125/77 119/73 124/77 128/80 130/82 102/55 107/59
16 115/68 119/71 123/75 126/77 120/74 124/77 129/80 131/82 103/55 107/59
3/29/23, 11:01 PM 6085
24-hour ambulatory blood pressure (BP) levels for girls based on height

Height Average day BP (percentile)
(percentile) (perce
(cm)
120 104/66 108/69 112/71 114/72 110/73 114/77 118/80 120/82 95/55 99/60
125 105/66 109/69 113/71 116/73 111/73 115/77 119/80 121/82 96/55 100/60
130 106/66 110/69 114/72 117/73 111/72 116/76 120/80 122/82 96/55 101/59
135 107/66 111/70 115/72 118/74 112/72 116/76 120/80 123/82 97/55 102/59
140 108/66 112/70 116/73 119/75 112/72 117/76 121/80 124/82 98/55 103/59
145 109/66 113/70 117/73 120/75 113/72 118/76 123/80 125/82 98/54 103/59
150 110/67 115/70 119/74 121/76 114/72 119/76 124/80 127/82 99/54 104/59
155 111/67 116/71 120/74 123/76 116/72 121/76 125/80 128/82 100/54 106/59
160 112/67 117/71 121/74 123/76 117/72 122/76 126/80 129/82 101/55 106/59
165 114/67 118/71 122/74 124/76 118/73 123/77 127/80 130/82 102/55 107/59
170 115/68 119/71 123/74 125/76 120/74 124/77 128/80 131/82 103/55 108/61
175 116/69 120/72 124/75 126/76 121/75 125/78 129/81 131/82 105/55 109/59
3/29/23, 11:01 PM 6085
Laboratory tests and frequency for children with CKD stages 2 to 5
Frequency of testing
Laboratory test
CKD stage 2 CKD stage 3 CKD stage 4 CKD stage 5
Electrolytes 12 months 6 to 12 months 3 to 6 months 1 to 3 months
Calcium/phosphorus 12 months 6 to 12 months 3 to 6 months 1 to 3 months
PTH 6 months 6 to 12 months 3 to 6 months
ALP 12 months 12 months
25-hydroxy vitamin 6 to 12 months 6 to 12 months 6 to 12 months 6 to 12 months

D
Lipid profile 12 months 12 months 12 months 12 months
Hemoglobin 12 months Every 6 months Every 6 months
CKD: chronic kidney disease; PTH: parathyroid hormone; ALP: alkaline phosphatase.
3/29/23, 11:01 PM 6085
Contributor Disclosures
Tarak Srivastava, MD Grant/Research/Clinical Trial Support: Apellis Pharmaceuticals [MPGN]; Bristol-
Myers Squibb [Nephrotic syndrome]; Roche [Nephrotic syndrome]; Travere Therapeutics [FSGS]. All of the
relevant financial relationships listed have been mitigated. Bradley A Warady, MD Consultant/Advisory
Boards: Amgen [Bone/mineral]; Bayer [Chronic kidney disease]; Covis Pharma [Hyperkalemia]; Fibrogen
[Anemia]; Roche [Anemia]. Other Financial Interest: National Kidney Foundation [Board of Directors]. All of
the relevant financial relationships listed have been mitigated. Tej K Mattoo, MD, DCH,
FRCP Consultant/Advisory Boards: Alnylam Pharmaceuticals [Primary hyperoxaluria]. All of the relevant
financial relationships listed have been mitigated. Laurie Wilkie, MD, MS No relevant financial
relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

Chronic Kidney Disease in Children: Overview of Management

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Official reprint from UpToDate®

Chronic kidney disease in children: Overview of

DEFINITIONS AND DIAGNOSIS

● G1 – Normal GFR (≥90 mL/min per 1.73 m2)

● Routine health maintenance

ROUTINE HEALTH MAINTENANCE

● Laboratory tests to monitor kidney function and detect associated complications,

Nutrition — Appetite and nutritional intake decrease with progression of CKD in children

Blood pressure and targeted goals — Office BP measurement should be performed at each

● In adolescents (≥13 years of age), we use a target BP of ≤120/80 mmHg.

Additional studies include the following:

● Ambulatory blood pressure monitoring (ABPM) – In accordance with the AAP/AHA

• To evaluate the efficacy of antihypertensive therapy, especially when hypertension is

• If the patient is symptomatic with complaints that could be attributed to adverse

• To detect white coat hypertension (defined as elevated office BP but normal BP on

● Echocardiogram – We obtain echocardiograms in patients with CKD and elevated BP as

Neurodevelopment assessment — CKD is associated with impairment in neurodevelopment.

Laboratory testing — Laboratory testing is used to monitor kidney function and detect

Immunization — All childhood vaccinations should be administered in children with CKD with

Management for specific vaccinations include:

● Hepatitis B vaccination should be provided to all children with CKD or undergoing

● Tuberculosis in endemic countries is prevented by the universal administration of the

PREVENT OR SLOW PROGRESSION OF KIDNEY DISEASE

● Correction of obstructive uropathy or high-grade vesicoureteral reflux [39-41]. (See

Kidney hypoperfusion is caused by hypotension (eg, septic shock), administration of drugs

● Avoid nephrotoxic drugs – Common nephrotoxic drugs include nonsteroidal anti-

Certain drugs, such as cimetidine, trimethoprim, ciprofloxacin, and flucytosine, lead to an

Slow progression of CKD — Reported interventions to slow CKD progression include BP

Other interventions with insufficient evidence — Additional interventions that have been

● Fluid and electrolytes abnormalities

PREPARATION FOR END-STAGE KIDNEY DISEASE

Pediatric mortality — Children with kidney failure (previously referred to as end-stage kidney

Optimal comprehensive management of these issues involves a multidisciplinary approach that

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

Medicines for chronic kidney disease (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Prevention and slowing progression of CKD includes:

• Prevention of subsequent kidney injury by avoiding episodes of decreased kidney

• Fluid and electrolytes abnormalities

Use of UpToDate is subject to the Terms of Use.

evaluation, classification, and stratification. Am J Kidney Dis 2002; 39:S1.

51. Trachtman H, Gauthier B. Effect of angiotensin-converting enzyme inhibitor therapy on

Nephrol 2017; 32:2319.

G1 ≥90 Normal or high

G3a 45 to 59 Mildly to moderately decreased

G3b 30 to 44 Moderately to severely decreased

G5 <15 Kidney failure

* Relative to young adult level.

Graphic 89808 Version 2.0

Plasma pediatric creatinine reference intervals (2.5 th to 97.5 th percentiles)

Enzymatic creatinine Jaffe creatinine

Age group mg/dL micromol/L Age group mg/dL micromol/L

0 to 14 days 0.32 to 0.92 28 to 81 0 to 14 days 0.42 to 1.05 37 to 93

15 days to <2 0.10 to 0.36 9 to 32 15 days to <1 0.31 to 0.53 27 to 47

2 to <5 years 0.20 to 0.43 18 to 38 1 to <4 years 0.39 to 0.55 34 to 49

5 to <12 years 0.31 to 0.61 27 to 54 4 to <7 years 0.44 to 0.65 39 to 57

12 to <15 0.45 to 0.81 40 to 72 7 to <12 years 0.52 to 0.69 46 to 61

15 to 19 years 0.62 to 1.08 55 to 95 12 to 15 years 0.57 to 0.80 50 to 71

15 to <19 0.49 to 0.84 43.3 to 74 15 to <17 0.65 to 1.04 57 to 92

15 to <17 0.59 to 0.86 52 to 76

17 to <19 0.69 to 1.10 61 to 97