chronic kidney disease in pediatric

1. CHRONIC KIDNEY
DISEASE
By Saba Sadeghpour

2. Definition
Chronic kidney disease is characterized by an irreversible
deterioration of renal function that gradually progresses to end-
stage renal disease.

3. Evidence of structural or functional kidney abnormalities (abnormal
urinalysis, imaging studies, histology) that persist for at least 3 months,
with or without a decreased GFR, as defined by a GFR of less than 60
mL/min per 1.73 m2.
Definition

4. ✔This definition is not applicable to children younger than 2 years. (they
normally have a low GFR, even when corrected for body surface area)
✔In these patients, calculated GFR based on serum creatinine can be
compared with normative age-appropriate values to detect renal
impairment.
Definition

6. Etiology
◦ <10 yo, CAKU )congenital anomalies of the kidney and urinary tract(
◦ >10 yo ,acquired diseases (focal segmental glomerulosclerosis and
glomerulonephritis)
*The risk of progression to ESRD is related to the underlying cause and severity of CKD.

7. ✎Obstructive uropathy
✎Hypoplastic dysplastic kidneys
✎Reflux nephropathy
✎Focal segmental glomerulosclerosis (as a variant of childhood
nephritic syndrome)
✎Polycystic kidney disease, autosomal-recessive, autosomal-dominant
varieties
Etiology

8. STAGE GFR (ml/min/1.73 m2) DESCRIPTION
1 >90 Minimal kidney damage
2 60-89 Kidney damage with mild reduction of
GFR
3 40-59 Moderate reduction of GFR
4 15-29 Severe reduction of GFR
5 <15 (dialysis) End-stage renal disease

9. • Most complications of CKD do not manifest until at least stage 3
CKD.
• In stage 4 CKD, the complications become more numerous and
severe.
• Children with stage 5 CKD (ESRD) are typically treated with either
dialysis or renal transplantation.

11. Clinical Manifestations
It related to both the underlying diagnosis and complications of CKD.
CAKUT may have polyuria, polydipsia, and recurrent urinary
tract infections.
Glomerular disease may have hematuria, proteinuria, edema,
and hypertension.

12. COMPLICATION
Common Complications and Treatments
of CKD
1. Poor growth
Increased caloric intake, treat acidosis, treat renal
osteodystrophy, recombinant GH
2. Anemia Erythropoietin, iron supplementation
3. Renal osteodystrophy/ secondary
hyperparathyroidism
1,25-Dihydroxyvitamin D supplementation, calcium
supplementation, dietary phosphorous restriction,
phosphate binders
4. Cardiovascular
4a. Hypertension
4b. Left ventricular hypertrophy
Antihypertensive medications Volume control
5. Electrolyte abnormalities
5a. Hyperkalemia
5b. Hyponatremia
5c. Metabolic acidosis
Low K diet, furosemide, sodium polystyrene sulfonate
Sodium supplementation Alkali replacement

13. *Most of these complications are multifactorial in etiology.
*Learning and school performance may also be impaired in CKD.

14. Growth failure (complication):
Poor nutrition
Renal osteodystrophy (ROD)
Metabolic acidosis
Hormonal abnormalities
Resistance to growth hormone

15. Anemia (complication):
Failure to produce adequate erythropoietin
Iron deficiency

16. ROD (complication):
Secondary hyperparathyroidism (as a result of diminished 1,25-
dihydroxyvitamin D production in the kidney)
Hypocalcemia
Hyperphosphatemia (from decreased renal excretion)
Rickets and bone deformities (prolonged / severe, ROD)

17. HTN & LVH(complication):
Aaltered gonadotropin secretion
Feedback patterns

18. Other sign & symptoms
⚠Anorexia
⚠Nausea
⚠Vomiting
⚠Volume overload
⚠Hyperkalemia
⚠Uremia

20. Diagnosis
Initial testing in a child with suspected CKD must include:
✧UA
✧Estimation of the GFR
✧CBC (in the initial evaluation and the subsequent follow-up in affected
children)

21. Imaging studies help in confirming the diagnosis of CKD and may also
provide clues to its etiology. such as:
✦Ultrasonography
✦Radionuclide studies
Diagnosis

22. Differential diagnoses
✈Rapidly progressive glomerulonephritis
✈Acute kidney injury
✈Chronic glomerulonephritis
✈Diabetic nephropathy
✈Nephrosclerosis

23. Treatment
☕Nutrition should be provided. (if this requires dietary supplements and
tube feedings)
☕In infants a low-solute formula maybe indicated.
☕Unless a child is oliguric, fluid restriction is not necessary.

24. ☕Supplemental salt in CAKUT (urine Na wasting)
☕Retain sodium and may become hypertensive or edematous in GN (if
given excess salt)
Treatment

25. COMPLICATION
Common Complications and Treatments
of CKD
1. Poor growth
Increased caloric intake, treat acidosis, treat renal
osteodystrophy, recombinant GH
2. Anemia Erythropoietin, iron supplementation
3. Renal osteodystrophy/ secondary
hyperparathyroidism
1,25-Dihydroxyvitamin D supplementation, calcium
supplementation, dietary phosphorous restriction,
phosphate binders
4. Cardiovascular
4a. Hypertension
4b. Left ventricular hypertrophy
Antihypertensive medications Volume control
5. Electrolyte abnormalities
5a. Hyperkalemia
5b. Hyponatremia
5c. Metabolic acidosis
Low K diet, furosemide, sodium polystyrene sulfonate
Sodium supplementation Alkali replacement

26. ✍Measures to preserve kidney function slow down the progression
✍HTN & proteinuria treat with ACE inhibitorsangiotensin receptor blockers
✍Avoid potentially nephrotoxic medications (when feasible) & medication
adjustment (for reduced kidney function)
✍Protein intake is typically not restricted in pediatric CKD.
Treatment

27. ✍Maintenance dialysis is effective for a child awaiting renal transplantation or
for whom renal transplantation is not possible.
✍Peritoneal dialysis is done at home by the family.
✍Hemodialysis is typically done three times a week at a dialysis facility.
Treatment

28. Treatment
✍The optimal treatment of ESRD : transplantation
✍Both deceased and living donors can be used for renal
transplantation, but living donors are preferred.

29. Major indications for dialysis
ACUTE AND/OR CHRONIC DIALYSIS
Volume overload
Metabolic acidosis
Electrolyte abnormalities
Uremia
ACUTE DIALYSIS
Certain ingestions
Hyperammonemia
CHRONIC DIALYSIS
Poor growth
Stage 5 chronic kidney disease (end-stage
renal disease)

31. Prognosis
☺In mild CKD (stages 1 & 2) may do well but need to be monitored (for
progressive loss of kidney function)
☺In stages 3 & 4 CKD have a high likelihood of progressing to ESRD at
some point, although the timing can vary.

32. Children with kidney transplants generally do well but have to take
immunosuppressive medications associated with a variety of side
effects, including:
✘Infections
✘Nephrotoxicity
✘Cardiovascular complications
✘Increased risk for certain malignancies
Prognosis

33. ♻Unfortunately most transplanted kidneys fail over time but can last for
several years.
♻Children on maintenance dialysis have the highest morbidity &
mortality, especially with longer time spent on dialysis. (Thus, their
primary goal is to receive a kidney transplant)
Prognosis

34. Preventions
Manage blood pressure
Manage blood sugar
Active life style
Drink enough water
Don’t smoke and drink alcohol

37. References
✆Nelson Textbook of Pediatrics, 21th edition 2020
✆Essentials of pediatrics, 7th edition 2020
✆https://www.freepik.com/
✆https://www.medindia.net/
✆https://knowpathology.com.au//
✆https://www.healthgrades.com/
✆https://www.dreamstime.com/
✆medscape