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Chronic Kidney Disease


 a state of irreversible kidney damage and/or

reduction of kidney function, which can lead to
future decreases in kidney function.
Stages of chronic kidney disease

Stage Description GFR (mL/min/1.73 m2)

1 Kidney damage with normal or ↑ GFR ≥ 90

2 Kidney damage with mild ↓ GFR 60-89

3 Moderate ↓ GFR 30-59

4 Severe ↓ GFR 15-29

5 Kidney failure <15 (or dialysis)

Chronic kidney disease is defined as either kidney damage or GFR <60 mL/min/1.73 m2 for 3 months. Kidney
damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine
tests or imaging studies.
 Normal levels of GFR vary with age, gender,
and body size.

 A reduction in GFR implies a decrease in the

number of functioning nephrons
Normal GFR in children and young adults
Mean GFR ± SD
Age (gender)c Schwartz equation mL/min/1.73m2
GFR=0.33*(Length/SCr) in
1 week (males and females) 40.6 ± 14.8
GFR=0.45*(Length/SCr) in
2-8 weeks (males and
GFR=0.45*(Length/SCr) 65.8 ± 24.8

>8 weeks (males and females) GFR=0.45*(Length/SCr) 95.7 ± 21.7

2-12 years (males and

GFR=0.55*(Length/SCr) 133.0 ± 27.0

13-21 years (males) GFR=0.70*(Length/SCr) 140.0 ± 30.0

13-21 years (females) GFR=0.55*(Length/SCr) 126.0 ± 22.0

SCr: serum creatinine in mg/dL

Distribution of the etiology of chronic kidney disease (CKD) in children based
upon age
 Congenital renal anomalies were present in 57
percent of cases.
 Glomerular disease was present in 17 percent of
 Other causes accounted for approximately 25
percent of cases.
 Early stages of CKD  asymptomatic.
 Direct kidney injury or disease.
 Incidental findings of an elevation in the serum
creatinine concentration and/or abnormalities on
 Detection of congenital or structural anomalies by
imaging studies.
 Poor growth.
 Symptoms and/or signs of severe renal impairment.
 Systemic symptoms and findings due to a concurrent
systemic disease
 Disorders of fluid and electrolytes
 Renal Osteodystrophy
 Anemia
 Hypertension
 Dyslipidemia
 Endocrine abnormalities
 Growth impairment
 Decreased clearance of renally excreted substances
from the body (uremia).
Fluid and electrolyte abnormalities
Fluid and electrolyte abnormalities
Sodium and water balance
Usually is maintained untill GFR <10-15
CKD 2-3 are less able to respond to rapid infusions
of sodium & are prone to fluid overload

 Hyperkalemia
Reduced GFR  inadequate potassium excretion &
decreased delivery of sodium to DT.
Metabolic acidosis
CKD 3 
1. Ammonium excretion begins to fall.
2. Reduction in titratable acid excretion (primarily
as phosphate).
3. Decreased bicarbonate reabsorption.
4. Body utilizes bone to buffer the excess
hydrogen ions.
Renal Osteodystrophy:
 Decreased renal clearance of phosphorus resulting in
retention of phosphate and elevation of serum
parathyroid hormone (PTH)
 Decreased production of Calcitriol.
 CKD2  reduced calcitriol level & elevated PTH
 CKD3  Subtle signs of bone.
 bone pain, difficulty in walking, and/or skeletal
deformities with more advanced disease.
 Normochromic, normocytic. Due to reduced renal
erythropoietin production
 Microcytosis may reflect iron deficiency or
aluminum excess
 Macrocytosis may be associated with vitamin B12 or
folate deficiency.
 Occurs at a GFR of 30-58ml/min/1.73m².
 Volume expansion
 Activation of the renin-angiotensin system.
 May be due to medications used to treat the
underlying renal disease.
 can be present in the earliest stages of CKD and its
prevalence increases with progressive declines in
Dyslipidemia and atherosclerosis:
 Young adults (25 to 34 years) with CKD have at least a 100-
fold higher risk for CVD related mortality compared to the
general population.
 40 to 50 % of patients with CKD have triglyceride levels
greater than 200 mg/dL (2.26 mmol/L).
 20 to 30% have total cholesterol levels greater than 240
mg/dL (6.2 mmol/L), 10 to 45 % have LDL cholesterol
levels greater than 130 mg/dL (3.4 mmol/L).
Dyslipidemia and atherosclerosis:
 lipoprotein lipase activity is reduced in advanced
renal failure; the increase in parathyroid hormone
secretion may play a contributory role.
 A circulating lipase inhibitor also may be retained in
renal failure.
Endocrine Dysfunction:

 Growth hormone metabolism

changes in the plasma concentration of GH, its
release, and its end-organ responsiveness due to
insulin growth factor binding proteins.
Endocrine Dysfunction:

 Thyroid function
alterations in the production, distribution, and
excretion of thyroid hormones.
Sick euthyroid syndrome: low T4 and T3, a normal
TSH level, normal or decreased TBG levels or TRH
stimulation test results.
Endocrine Dysfunction:
 Gonadal hormones
Delayed puberty ( average delay 2.5 years)
 In males, reduced levels of free testosterone,
dihydrotestosterone, adrenal androgens, and
increases LH & FSH
 Postpubertal females low estrogen, elevated LH and
FSH, and loss of the LH pulsatile pattern. These
disturbances result in anovulation.
Growth impairment:
 Metabolic acidosis

 Decreased caloric intake

 Renal osteodystrophy

 Alterations in GH metabolism
Uremia: With the onset of ESRD
Uremic state:
 anorexia
 nausea,
 vomiting
 growth retardation
 platelate dysfunction
 pericardial disease
 peripheral neuropathy
 central nervous system abnormalities ranging from
loss of concentration and lethargy to seizures,
coma and death.
 Neurologic findings range from seizures and severe
mental retardation to subtle deficits resulting in poor
school performance.
 Uremia, malnutrition & Aluminum.
Frequency by CKD stage* (GFR mL/min 1.73 m2)
Assessment/tests CKD stage 5 (GFR <15 or
CKD stage 2 (GFR 60 to 89) CKD stage 3 (GFR 30 to 59) CKD stage 4 (GFR 15 to 29)
replacement therapy)

Kidney replacement therapy

Assessment of GFR[1] 6-12 months 3-6 months 1-3 months
(if uremia present)

Height/length; Height z-
3-6 months 3-6 months 3-4 months 1-3 months

Weight (dry wt if on dialysis)[2,3] 3-6 months 3-6 months 3-4 months 1 monthly

Head circumference (until 36

1-3 months 1-3 months 1-2 months 1-2 months
months of age)[2,3]

Weight/height index[2,3] 3-6 months 3-6 months 3-4 months 1-3 months
Dietary interview[2,3] 6-12 months 6 months 3-4 months 1-3 months
Serum electrolytes and
6-12 months 6 months 1-3 months 1-3 months

Blood pressure measurement[5] Performed at each health encounter

Performed within 3 months of

At presentation for new patients with hypertension. At least yearly in patients
Echocardiogram[4,6] who are on antihypertensive medications.
6-12 months commencing dialysis; and yearly

For adolescent patients, evaluate on

presentation (when patient is stable);
Screen for dyslipidemia[7,8] at 2-3 months after a change in
For adolescent patients, screening at presentation with CKD and annually
treatment or other conditions
(cholesterol, LDL, HDL and
modifying serum lipid levels; and
triglycerides) every 6-12 months thereafter

Targeted screening recommended for children older than 2 years of age

6-12 months 6-12 months 3-6 months 1-3 months

Screen for anemia[9]
Monthly in patients on erythropoietic stimulating agents

Serum calcium, phosphorus, and

6-12 months 3-6 months 1-3 months 1-3 months
total CO2[10,11]

PTH and alkaline

6-12 months 3-6 months 1-3 months 1-3 months
 Treat reversible renal dysfunction

 Prevent or slow the progression of renal disease

 Treat the complications of CKD

 Identify and adequately prepare the child/family

in whom renal replacement therapy will be

reversible renal dysfunction

 Decreased renal perfusion

 Nephrotoxic drugs
Slowing CKD progression
 progression of CKD is greatest during the two
periods of rapid growth: infancy and puberty.
 strict blood pressure control

 Proteinuria reduction

 Dietary protein restriction, lipid lowering

therapy, and correction of anemia.
CKD Complications
1.Sodium & water retention:
dietary sodium restriction and diuretic therapy
 Sodium intake 1.2 – 1.5 g/day

 Diuretics: furosemide, thiazide diuretics.

Fluid & sodium supplementation

CKD Complications
2. hyperkalemia:
 Low potassium diet.
 Administration of a loop diuretics.
 correct acidosis.
 formula can be mixed with kayexalate
 Renal replacement therapy must be considered if
conservative management fails to control
CKD Complications
3. Metabolic acidosis:
 guidelines by the K/DOQI working group are
to maintain the serum bicarbonate level at or
above 22 mEq/L
 Sodium bicarbonate is started at 1-2 meq/kg/d
CKD Complications
4.renal osteodystrophy :
 Low phosphate diet.

 Administration of phosphate binders.

 Vitamine D replacement therapy .

CKD Complications
5. Hypertension:
 The K/DOQI guidelines recommend a target
blood pressure of less than 90th percentile for
age, gender, and height, or less than 120/80
mmHg, whichever is lower.
 Non pharmacologic therapy
 Pharmacological therapy: diuretics, ACE
inhibirors, ARBs
CKD Complications
6. Anemia:
Screening and evaluation of anemia
 Annual testing regardless of stage or cause of CKD
 Dx is made when Hgb level is below the 5th % of normal
adjusted for age & sex.
 Once detected:
* Red blood cell indices
* Reticulocyte count
* Iron parameters (serum iron, total iron binding capacity, percent
transferrin saturation [TSAT] and serum ferritin)
*Test for occult blood in stool
CKD Complications
6. Anemia:
Treatment of anemia
1. K/DOQI guidelines recommend a target Hb between 11 and 12
g/dL, FDA recommend a Hb of 10-12
2. Iron therapy: targeted to maintain a TSAT ≥20 percent and serum ferritin
≥100 ng/dL.
Iron status should be monitored every 1-3 mon.
3. Erythropoiesis stimulating agent
• initial EPO dose in older children not receiving dialysis is 80 to 120 u/kg per
• Children < 5 years or receiving dialysis require higher doses (300 u/kg per
• Hb should be monitored
CKD Complications
6. Anemia:
Failure to respond to therapy
 Infection or inflammation
 Chronic blood loss
 Osteitis fibrosa /secondary hyperparathyroidism
 Aluminum toxicity
 Folate or vitamin B12 deficiency
 Malnutrition
 Hemoglobinopathies
 Hemolysis
 Carnitine deficiency (rare)
 Copper deficiency (rare)
CKD Complications
7. Dyslipidemia:
 Evaluation is performed at presentation, and annually thereafter
or two to three months following a change in treatment.
Lipid disorders
Lifestyle intervention for BMI <85th percentile for age and sex
Decrease intake of simple sugars
Fasting TG >150 Evaluate for secondary causes such as diabetes, thyroid disease, renal disease, and
mg/dl alcohol abuse
For TG >700 - 1000 mg/dL, consider gemfibrozil or fenofibrate if >10 years old to
prevent pancreatitis

Lifestyle intervention for BMI <85th percentile for age and sex
HDL <35 mg/dl Moderate to vigorous physical activity 60 minutes daily
Pharmacologic intervention not currently recommended for isolated low HDL

Nutrition training & life style changes

LDL ≥ 100 mg/dl Repeat LDL measurement
Start statin therapy if >10 years, goal LDL 130 mg/dL
CKD Complications
8. Nutrition:
K/DOQI pediatric guidelines for nutrition recommend that the
nutritional status of children with CKD should be monitored on
a monthly basis for children younger than two years and every
three to four months for children older than two years of age
CKD Complications
8. Nutrition:
 Dietary interview
 Weight
 Height or length
 Weight / height index & BMI`
 Mid-arm circumference and muscle circumference or area
 Skin fold thickness
 Head circumference for patients younger than three years of age.
CKD Complications
8. Nutrition:
 The initial prescribed energy (calorie) for children with CKD
should be the recommended dietary allowance (RDA) for
chronological age.
 Protein restriction is not recommended in children.
 100 % of the RDA should be the goal for vitamins A, B, C, E,
K, and the minerals, copper and zinc
 Tube feedings
CKD Complications
9. Growth:
criteria for initiating rHuGH in children with CKD
include all of the following:
 Height SDS that is more negative than -1.88 and/or a
height velocity SDS that is more negative than -2.
 Growth potential that is documented by open
 There are no contraindications for rHuGH
CKD Complications
9. Growth:
rHuGH is continued until the child reaches
the 50th percentile for mid-parental height,
achieves a final adult height with closed
epiphyses, or receives a kidney transplant.
CKD Complications
10. Uremic bleeding
If undergoing a procedure or actively
 Desmopressin (0.3 mcg/kg)
 Cryoprecipetate (1 to 2 units/10 kg);
 Estrogen (0.6 mg/kg per day for 5 days)
 Correct anemia
CKD Complications

10. Uremic pericarditis

 Seen in late stages of CKD

 Indicates the need for dialysis
Renal replacement
Renal replacement therapy
The registry of the North American Pediatric Renal
Trials and Collaborative Studies (NAPRTCS)
 One quarter of children underwent preemptive
renal transplantation
 One half were started on peritoneal dialysis
 One quarter were started on hemodialysis
The choice among renal replacement
options is dictated by technical, social,
and compliance issues, and family
preference .