chronic kidney disease in children , definition , criteria of ckd , stages of ckd , etiology, management .

1. Chronic kidney disease in children
Dr Ahmed Mohamed Adan

2. 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 function over time.
DEFINITIONS AND CLASSIFICATIONS

3. There are two pediatric exceptions:
(1) the criteria for duration longer than 3 months does not apply to
infants younger than 3 months, and
(2) the glomerular filtration rate (GFR) criteria of less than 60
mL/min/1.73 m2 cannot be used in children under 2 years of age since
developmental immaturity in this age group is associated with mean GFR
of less than this value. Thus, the diagnostic criteria for reduced GFR in
this particular population must be compared to age-matched normative
values.
• Modified Schwartz = 0.413 × length in cm
Serum creatinine in mg/d
The normal GFR in children is 90 - 130 ml/min/1.73m
2

4. CKD is divided into 5 stages according to GFR ( NKF KDOQI GIUDELINES )
GFR
mL/min/1.73 m2DescriptionStage
More than 90
Slight kidney damage with
normal or increased filtration
G 1
60-89
Kidney damage with Mild decrease in
GFR
2
30-59Moderate decrease in GFR3
15-29Severe decrease in GFR4
Less than 15 or in dailysis
Kidney failure; requiring
dialysis or transplantation
5

5. CKD is divided into 5 stages according to GFR:
GFR
mL/min/1.73 m2DescriptionStage
More than 90
Slight kidney damage with
normal or increased filtration
G 1
60-89
Kidney damage with Mild decrease in
GFR
2
30-59Moderate decrease in GFR3
15-29Severe decrease in GFR4
Less than 15 or in dailysis
Kidney failure; requiring
dialysis or transplantation
5

6. ETIOLOGY
 in children <5 yr old is most commonly a
result of congenital abnormalities of the
kidney and urinary (CAKUT) such as renal
hypoplasia, dysplasia, or obstructive
uropathy
Additional causes include :-
congenital nephrotic syndrome, prune belly
syndrome, cortical necrosis, focal segmental
glomerulosclerosis,
autosomal recessive PCKD , HUS.
renal vein thrombosis,
 After 5 yr of age, acquired diseases (various
forms of glomerulonephritis – FSGS -lupus
nephritis) and inherited disorders (familial
juvenile nephronophthisis, Alport
syndrome).
CKD
related to metabolic disorders
(cystinosis, hyperoxaluria)

7. Copyrights apply

9. Pathophysiology of CKD
MECHANISMSMANIFESTATION
Decrease in glomerular filtration rateAccumulation of nitrogenous waste
products
Impaired bicarbonate reabsorption
Impaired ammonia synthesis
Decreased net acid excretion
Metabolic Acidosis – Normal AG or
ed AG
Excessive renin production
Oliguria
Sodium retention
Solute diuresis
Tubular damage
Sodium wasting
Solute diuresis
Tubular damage
Urinary concentrating defect

10. MECHANISMSMANIFESTATION
Decrease in glomerular filtration rate
Metabolic acidosis- extracellular shift of K+
Excessive potassium intake
Hyporeninemic hypoaldosteronism
Hyperkalemia
Impaired renal production of 1,25-
dihydroxycholecalciferol
Hyperphosphatemia
Hypocalcemia
Secondary hyperparathyroidism
Renal osteodystrophy – high turnover
most common 2 to hyperparathyroidism
Inadequate caloric intake
Renal osteodystrophy
Metabolic acidosis
Anemia
Growth hormone resistance
Growth retardation

12. MECHANISMSMANIFESTATION
Decreased erythropoietin production- stage 3-4
Iron deficiency
Folate deficiency
Vitamin B12 deficiency
Decreased erythrocyte survival
Chronic blood loss from uremia-induced platelet
dysfunction .
Chronic inflammation
Secondary hyperparathyroidism- BM fibrosis
Accumulation of inhibitors of erythropoiesis
Anemia- normocytic normochromic anemia with
no reticulocyte response
Defective granulocyte function
Impaired cellular immune functions
Indwelling dialysis catheters
Infection

14. MECHANISMSMANIFESTATION
Gastroesophageal reflux
Decreased gastrointestinal motility
Serositis to uremia
Gastrointestinal symptoms (feeding intolerance,
abdominal pain)
Volume overload
Excessive renin production
Hypertension
Decreased plasma lipoprotein lipase activity-
uremia inhibits lipoprotein lipase and hepatic lipase leads to lack od
degradation of lipids .
Hyperlipidemia
Uremic factor(s)
Hypertension
Fluid overload
Pericarditis, cardiomyopathy
Tissue insulin resistanceGlucose intolerance

15. The goals of therapy in children with CKD are:
1. Treat reversible kidney disease
2. Slow progression to ESRD
3. Manage complications
4. Prepare for RRT- in whom renal replacement therapy will be required
MANAGEMENT
Multidisciplinary Services : Medical , Nursing , Social service Nutritional
Psychological

16. Slowing the progression of kidney dysfunction
1) Optimum Control of Hypertension
2) Control of proteinuria
3) Serum Phosphorus within normal range
4) Serum Calcium-Phosphorus Product < 5 mmol2
/l2
5) Prompt treatment of infectious complications and dehydration
6) Correction of anemia
7) Avoidance of cigarette smoking
8) Minimization of regular use of NSAIDs
9) Control of hyperlipidemia
10)Dietary Protein restriction

17. Dietary Management
Goals –
a) Reduce nitrogen intake
b) Maintain nitrogen balance
c) Cover essential amino acid requirement
d) Supply enough calories
Energy: Intake equivalent to the RDA of healthy children of the same age
• Infant : 100 – 120 kCal/kg/day
• Children : 80 – 100 kCal/kg/day
• 55 – 60% from carbohydrates
• 30% from fats
• 10% from proteins Proteins of high biological value or ‘good quality’ are preferred (are
metabolized primarily to usable aminoacids rather than to nitrogenous wastes) and are found
mainly in eggs, milk, meat, fish and poultry.
Nutrition

20. Anemia become manifested at a GFR less than 35 ml/min/1.73 m2
ESA- Recombinant Human Erythropoietin((Epogen, Procrit, Eprex) is
usually initiated when the patient's Hb concentration falls bellow 10 g/dL ,
at a dose of 50 – 100 unit/kg S.C. one to three times weekly.
An alternative option to rHuEPO is darbepoetin alfa (Aranesp), a longer-
acting agent administered at a dose of 0.45 μg/kg/wk. The chief advantage
of this agent is that it may be dosed once weekly to once monthly because
of its extended duration of action.
• Iron supplementation :- Oral or Intravenous.
oral : 3 – 5 mg/kg/day of elemental iron(max 150 – 300 mg/day)
ANAEMIA

21. • Control of levels of blood phosphate – most important factor in
prevention & treatment of secondary hyperparathyroidism .
• The target phosphorus level for adolescents is between 3.5 and 5.5 mg/ dL,
children 1-12 yr of age it is 4-6 mg/dL ,
Children and adolescents should follow a low-phosphorus diet .
The cornerstone of therapy for renal osteodystrophy is vitamin D administration.
– Therapy may be initiated with 0.01-0.05 µg/kg/24 hr of calcitriol.
– Phosphate binders: • Calcium salts [calcium carbonate & calcium acetate]
• Sevelamer hydrochloride
CKD - MBD

22. Hypertension
ACE inhibitors are the antihypertensive medication of choice in all children with proteinuric
renal disease.
Angiotensin-II blockers have been shown to be effective in controlling BP and in slowing
disease progression in patients with diabetic nephropathy.

23. –Sodium bicarbonate tablets ( 650mg =8meq ) is used to maintain the
serum bicarbonate level above 22 mEq/L.
– Growth problems (especially short stature) are very commen in CKD
children.
– CKD children have an apparent growth hormone resistant state with
elevated GH levels but decreased insuline-like growth factor-I (IGF-I).
Acidosis
Growth problems

26. Long-term Follow Up
close monitoring of a patient's clinical and laboratory status
 Blood studies to be followed routinely include:
 serum electrolytes
 blood urea nitrogen (BUN)
 creatinine
 calcium
 phosphorus
 albumin
 alkaline phosphatase
 Hb and Htc
 Periodic measurement of intact parathyroid hormone (PTH) levels and
roentgenographic studies of bone may be of value in detecting early evidence of
renal osteodystrophy
 Echocardiography should be performed periodically to identify left ventricular
hypertrophy and cardiac dysfunction that can occur as a consequence of the
complications of CKD

28. • Nelson TEXTBOOK of PEDIATRICS EDITION 20
• Clinical Pediatric Tmephrology Third Edition
• Uptodate 22 version
References