Chronic Kidney Disease in Children

Nephrology

Clinicals - History

Fact Explanation
Asymptomatic Initial stages of CKD are asymptomatic and only a routine blood or urine investigation may point towards the diagnosis. Asymptomatic
Initial stages of CKD are asymptomatic and only a routine blood or urine investigation may point towards the diagnosis.
Antenatal history of oligohydroamnios The low volume of amniotic fluid during antenatal period suggests that the production of urine in the fetus is impaired and usually suggests a renal anomaly Antenatal history of oligohydroamnios
The low volume of amniotic fluid during antenatal period suggests that the production of urine in the fetus is impaired and usually suggests a renal anomaly
Respiratory difficulties, distended abdomen with weak musculature, and facial anomalies in a neontate These are usually features of a syndrome called "Potter syndrome" due to bilateral renal agenesis and the lung hypoplasia causes respiratory difficulties. These neonates usually die soon after birth. Respiratory difficulties, distended abdomen with weak musculature, and facial anomalies in a neontate
These are usually features of a syndrome called "Potter syndrome" due to bilateral renal agenesis and the lung hypoplasia causes respiratory difficulties. These neonates usually die soon after birth.
Polyuria, Nocturia and Nocturnal eneuresis Passage of large volumes of urine (Polyuria), Awakening at night to pass urine (Nocturia), and bed wetting usually suggest decrease in urine concentrating ability and could be an early sign of chronic kidney disease in children. Polyuria, Nocturia and Nocturnal eneuresis
Passage of large volumes of urine (Polyuria), Awakening at night to pass urine (Nocturia), and bed wetting usually suggest decrease in urine concentrating ability and could be an early sign of chronic kidney disease in children.
History of febrile episodes with Frequency, urgency, dysuria, hesitancy, hematuria These features usually suggest Urinary tract infection which can cause kidney damage in children and later progress to CKD if untreated. History of febrile episodes with Frequency, urgency, dysuria, hesitancy, hematuria
These features usually suggest Urinary tract infection which can cause kidney damage in children and later progress to CKD if untreated.
History of abdominal or flank pain These features usually suggest acute pyelonephritis, urinary calculi, trauma to kidney or bladder which can cause CKD later History of abdominal or flank pain
These features usually suggest acute pyelonephritis, urinary calculi, trauma to kidney or bladder which can cause CKD later
Abdominal mass It usually suggests hydronephrosis, multicystic, dysplastic or polycystic kidney disease, renal vein thrombosis, and Wilms tumor or neuroblastoma which can cause CKD Abdominal mass
It usually suggests hydronephrosis, multicystic, dysplastic or polycystic kidney disease, renal vein thrombosis, and Wilms tumor or neuroblastoma which can cause CKD
Shortness of breath on exertion, easy fatiguability These features suggest anemia which occurs due to inadequate Erythropoietin production from the kidney which is needed for red blood cell synthesis Shortness of breath on exertion, easy fatiguability
These features suggest anemia which occurs due to inadequate Erythropoietin production from the kidney which is needed for red blood cell synthesis
Ankle swelling This is due to volume overload due to renal impairment. Reduced glomerular filtration of sodium, activation of the Renin-Angiotensin-Aldosterone system causes sodium and water retention Ankle swelling
This is due to volume overload due to renal impairment. Reduced glomerular filtration of sodium, activation of the Renin-Angiotensin-Aldosterone system causes sodium and water retention
Anorexia and other gastrointestinal disturbances, bleeding Anorexia in CKD is due to decreased taste and smell of food, early satiety, dysfunctional hypothalamic membrane adenylate cyclase, increased brain tryptophan, and increased cytokine production. As well as GI bleeding is common and is thought to be due to increased association with angiodysplasia in these patients with CKD Anorexia and other gastrointestinal disturbances, bleeding
Anorexia in CKD is due to decreased taste and smell of food, early satiety, dysfunctional hypothalamic membrane adenylate cyclase, increased brain tryptophan, and increased cytokine production. As well as GI bleeding is common and is thought to be due to increased association with angiodysplasia in these patients with CKD
Chest pain, shortness of breath on exertion Atherosclerosis is common in CKD. This can cause myocardial ischemia and ischemic heart disease with angina, myocardial infarction, and sudden cardiac death. Additionally cardiomyopathy is also common due to pressure and volume overload. Chest pain, shortness of breath on exertion
Atherosclerosis is common in CKD. This can cause myocardial ischemia and ischemic heart disease with angina, myocardial infarction, and sudden cardiac death. Additionally cardiomyopathy is also common due to pressure and volume overload.
Shortness of breath, hemoptysis Volume overload causes pulmonary edema which causes acute left ventricular failure and this causes dyspnea and blood stained sputum Shortness of breath, hemoptysis
Volume overload causes pulmonary edema which causes acute left ventricular failure and this causes dyspnea and blood stained sputum
Headache, visual disturbances, altered level of consciousness Hypertension is mainly due to voulme overload in renal impairment and hypertensive encephalopathy may lead to these symptoms Also uremic encephalopathy can lead to altered level of consciousness. Headache, visual disturbances, altered level of consciousness
Hypertension is mainly due to voulme overload in renal impairment and hypertensive encephalopathy may lead to these symptoms Also uremic encephalopathy can lead to altered level of consciousness.
Itching of the body Many factors contribute to itching in CKD. Skin of patients with chronic renal failure becomes atrophic and dry and pruritogenic cytokines may be produced in the dermis. As well as mast cells are high in number and this is thought to be due to the raised parathyroid hormone level due to secondary hyperparathyroidism.However in chronic dialysis patients with itching is due to increased level of calcium, magnesium and phosphate. Plasma histamine level is also higher in uraemic patients. Additionally there's an imbalance in the expression of the opioid receptor subtypes in uremia which can cause itching. Itching of the body
Many factors contribute to itching in CKD. Skin of patients with chronic renal failure becomes atrophic and dry and pruritogenic cytokines may be produced in the dermis. As well as mast cells are high in number and this is thought to be due to the raised parathyroid hormone level due to secondary hyperparathyroidism.However in chronic dialysis patients with itching is due to increased level of calcium, magnesium and phosphate. Plasma histamine level is also higher in uraemic patients. Additionally there's an imbalance in the expression of the opioid receptor subtypes in uremia which can cause itching.
Weight loss anorexia leads to cachexia as well as protein calorie malnutrition is seen in these children Weight loss
anorexia leads to cachexia as well as protein calorie malnutrition is seen in these children
Poor growth This is multifactorial. The underlying disease, metabolic bone disease, acid base disturbances, anemia, protein-calorie malnutrition are some of contributing factors. Alterations is gonadotrophic and somatotrophic axis es are also seen Poor growth
This is multifactorial. The underlying disease, metabolic bone disease, acid base disturbances, anemia, protein-calorie malnutrition are some of contributing factors. Alterations is gonadotrophic and somatotrophic axis es are also seen
Increased incidence of fractures Kidneys excrete phophorous and 1-α-hydroxylation of vitamin D. Inadequate 1, 25 dihydroxy-vitamin D levels cause serum calcium levels to fall in turn causing secondary hyperparathyroidism. Parathyroid hormone has a phosphaturic effect, as well as cause bone resorption and renal osteodystrophy results Increased incidence of fractures
Kidneys excrete phophorous and 1-α-hydroxylation of vitamin D. Inadequate 1, 25 dihydroxy-vitamin D levels cause serum calcium levels to fall in turn causing secondary hyperparathyroidism. Parathyroid hormone has a phosphaturic effect, as well as cause bone resorption and renal osteodystrophy results

Clinicals - Examination

Fact Explanation
No signs Initial stages of CKD are asymptomatic and there are usually no signs on examination, only a routine blood or urine investigation may point towards the diagnosis. No signs
Initial stages of CKD are asymptomatic and there are usually no signs on examination, only a routine blood or urine investigation may point towards the diagnosis.
Charasteristic facies, protuberant abdomen These are usually features of a syndrome called "Potter syndrome/ Prune belly syndrome" due to bilateral renal agenesis and the lung hypoplasia results. These neonates usually die soon after birth. Charasteristic facies, protuberant abdomen
These are usually features of a syndrome called "Potter syndrome/ Prune belly syndrome" due to bilateral renal agenesis and the lung hypoplasia results. These neonates usually die soon after birth.
Ear tags and ear anomalies This is a feature of branchiootorenal (BOR) syndrome which is an autosomal dominant condition resulting in congenital abnormal development of the first and second branchial arches and urinary tract. Therefore ear anomalies are found in these children Ear tags and ear anomalies
This is a feature of branchiootorenal (BOR) syndrome which is an autosomal dominant condition resulting in congenital abnormal development of the first and second branchial arches and urinary tract. Therefore ear anomalies are found in these children
Pallor This suggests anemia which occurs due to inadequate Erythropoietin production from the kidney which is needed for red blood cell synthesis Pallor
This suggests anemia which occurs due to inadequate Erythropoietin production from the kidney which is needed for red blood cell synthesis
Hyper pigmentation of the skin and other skin changes such as Xerosis/Icthyosis This characteristic hyper pigmentation is due to an increase in melanin as a result of fai­lure of the kidneys to execrete B-melanocyte­stimulating hormone (B-MSH). Hyper pigmentation of the skin and other skin changes such as Xerosis/Icthyosis
This characteristic hyper pigmentation is due to an increase in melanin as a result of fai­lure of the kidneys to execrete B-melanocyte­stimulating hormone (B-MSH).
Cachexia anorexia leads to cachexia as well as protein calorie malnutrition is seen in these children Cachexia
anorexia leads to cachexia as well as protein calorie malnutrition is seen in these children
Reduced growth parameters This is multifactorial. The underlying disease, metabolic bone disease, acid base disturbances, anemia, protein-calorie malnutrition are some of contributing factors. Alterations is gonadotrophic and somatotrophic axis es are also seen Reduced growth parameters
This is multifactorial. The underlying disease, metabolic bone disease, acid base disturbances, anemia, protein-calorie malnutrition are some of contributing factors. Alterations is gonadotrophic and somatotrophic axis es are also seen
Half and half nails./Leukonychia of nails It's not clearly known but is thought due to melanin pigment in the nail plate. another theory postulated explains that it's due to the capillary density in the nail bed, and thickening of the capillary walls which forms the discolored band. Leukonychia is due to proteinuria in Nephrotic syndrome Half and half nails./Leukonychia of nails
It's not clearly known but is thought due to melanin pigment in the nail plate. another theory postulated explains that it's due to the capillary density in the nail bed, and thickening of the capillary walls which forms the discolored band. Leukonychia is due to proteinuria in Nephrotic syndrome
Arterio-venous fistula at the wrist These children with chronic renal failure are usually on dialysis therefore iatrogenic A-V fistula may be seen Arterio-venous fistula at the wrist
These children with chronic renal failure are usually on dialysis therefore iatrogenic A-V fistula may be seen
Bilateral pitting ankle oedema Reduced glomerular filtration of sodium, activation of the Renin-Angiotensin-Aldosterone system causes sodium and water retention and this volume overload causes edema. Bilateral pitting ankle oedema
Reduced glomerular filtration of sodium, activation of the Renin-Angiotensin-Aldosterone system causes sodium and water retention and this volume overload causes edema.
Scratch marks Many factors contribute to itching in CKD. Skin of patients with chronic renal failure becomes atrophic and dry and pruritogenic cytokines may be produced in the dermis. As well as mast cells are high in number and this is thought to be due to the raised parathyroid hormone level due to secondary hyperparathyroidism.However in chronic dialysis patients with itching is due to increased level of calcium, magnesium and phosphate. Plasma histamine level is also higher in uraemic patients. Additionally there's an imbalance in the expression of the opioid receptor subtypes in uremia which can cause itching Scratch marks
Many factors contribute to itching in CKD. Skin of patients with chronic renal failure becomes atrophic and dry and pruritogenic cytokines may be produced in the dermis. As well as mast cells are high in number and this is thought to be due to the raised parathyroid hormone level due to secondary hyperparathyroidism.However in chronic dialysis patients with itching is due to increased level of calcium, magnesium and phosphate. Plasma histamine level is also higher in uraemic patients. Additionally there's an imbalance in the expression of the opioid receptor subtypes in uremia which can cause itching
Elevated Jugular Venous Pressure Volume overload and ultimate cardiac failure both cause JVP to be elevated Elevated Jugular Venous Pressure
Volume overload and ultimate cardiac failure both cause JVP to be elevated
Elevated blood pressure Volume overload causes hypertension Elevated blood pressure
Volume overload causes hypertension
Cardiomegaly Heart failure causes cardiomegaly. Cardiomegaly is due to increased work load due to volume overload Cardiomegaly
Heart failure causes cardiomegaly. Cardiomegaly is due to increased work load due to volume overload
Gallop rhythm Heart failure due to volume overload causes gallop rhythm Gallop rhythm
Heart failure due to volume overload causes gallop rhythm
Bilateral end inspiratory crepitations Volume overload causes heart failure and pulmonary edema due to venous congestion in the lungs cause bilateral end inspiratory crepitations Bilateral end inspiratory crepitations
Volume overload causes heart failure and pulmonary edema due to venous congestion in the lungs cause bilateral end inspiratory crepitations
Ballotable kidneys It usually suggests hydronephrosis, multicystic, dysplastic or polycystic kidney disease, renal vein thrombosis, and Wilms tumor or neuroblastoma which can cause CKD Ballotable kidneys
It usually suggests hydronephrosis, multicystic, dysplastic or polycystic kidney disease, renal vein thrombosis, and Wilms tumor or neuroblastoma which can cause CKD
Altered level of consciousness, Confusion, Coma This is usually due to uremic encephalopathy but hypertensive encephalopathy too can cause this Altered level of consciousness, Confusion, Coma
This is usually due to uremic encephalopathy but hypertensive encephalopathy too can cause this
Bowing of legs, widening of the wrists, frontal bossing, Rachitic rossary These are features of rickets due to inadequate active form of vitamin D due to renal impairment. Therefore characteristic skeletal changes and clinical features of Rickets appear Bowing of legs, widening of the wrists, frontal bossing, Rachitic rossary
These are features of rickets due to inadequate active form of vitamin D due to renal impairment. Therefore characteristic skeletal changes and clinical features of Rickets appear
Tenderness and stiffness in joints This is due to metabolic bone disease in these children. It can also produce spontaneous tendon rupture, predisposition to fracture, and proximal muscle weakness. Tenderness and stiffness in joints
This is due to metabolic bone disease in these children. It can also produce spontaneous tendon rupture, predisposition to fracture, and proximal muscle weakness.

Investigations - Diagnosis

Fact Explanation
Full blood count and blood picture Low Hemoglobin is seen in CKD and blood picture may show normochromic normocytic anemia Full blood count and blood picture
Low Hemoglobin is seen in CKD and blood picture may show normochromic normocytic anemia
Blood urea nitrogen This is elevated and this is due to reduced excretory capacity of the kidneys. Blood urea nitrogen
This is elevated and this is due to reduced excretory capacity of the kidneys.
Serum creatinine This is elevated and this is due to reduced excretory capacity of the kidneys. Serum creatinine
This is elevated and this is due to reduced excretory capacity of the kidneys.
Serum Sodium/ Potassium/ Calcium/ Magnesium/ Phophorous Serum electrolytes are important as electrolyte imbalances are common with high Potassium, Low Sodium, Calcium and Magnesium and high phosphorous. Serum Sodium/ Potassium/ Calcium/ Magnesium/ Phophorous
Serum electrolytes are important as electrolyte imbalances are common with high Potassium, Low Sodium, Calcium and Magnesium and high phosphorous.
Serum Alkaline Phosphatase (ALP) With secondary hyper parathyroidsm, ALP is elevated Serum Alkaline Phosphatase (ALP)
With secondary hyper parathyroidsm, ALP is elevated
Serum Parathyroid hormone This is elevated due to secondary hyper parathyroidsm Serum Parathyroid hormone
This is elevated due to secondary hyper parathyroidsm
Serum cholesterol Blood lipid levels are elevated in CKD Serum cholesterol
Blood lipid levels are elevated in CKD
Estimated glomerular filtration rate This is the most important investigation to diagnose and stage the disease. This uses serum creatinine concentration, either the Cockcroft-Gault or the Modification of Diet in Renal Disease (MDRD) Study estimating equations Estimated glomerular filtration rate
This is the most important investigation to diagnose and stage the disease. This uses serum creatinine concentration, either the Cockcroft-Gault or the Modification of Diet in Renal Disease (MDRD) Study estimating equations
Arterial blood gas analysis Acid base disturbances with metabolic acidosis is seen in CKD therefore this is important Arterial blood gas analysis
Acid base disturbances with metabolic acidosis is seen in CKD therefore this is important
Urine full report This may show proteins, red blood cells, white blood cells, red cell casts aid in making a diagnosis Urine full report
This may show proteins, red blood cells, white blood cells, red cell casts aid in making a diagnosis
Urine for microalbuminuria This identifies the earliest abnormality that is filtration of microalbumin before manifestation of proteinuria Urine for microalbuminuria
This identifies the earliest abnormality that is filtration of microalbumin before manifestation of proteinuria
Ultrasound kidney-ureter-bladder It's cheap. widely available and easy to use and chronic renal parenchymal changes can be identified as well as etiology such as ureteric stones, congenital anomalies Ultrasound kidney-ureter-bladder
It's cheap. widely available and easy to use and chronic renal parenchymal changes can be identified as well as etiology such as ureteric stones, congenital anomalies
Radionuclide studies DMSA, MCUG scans are important in determining scarring in CKD Radionuclide studies
DMSA, MCUG scans are important in determining scarring in CKD
Skeletal x-rays The changes seen are osteitis fibrosa cystica, osteomalacia, adynamic bone disorder and mixed osteodystrophy. This is important in ruling out the presence of changes due to secondary hyper parathyroidism Skeletal x-rays
The changes seen are osteitis fibrosa cystica, osteomalacia, adynamic bone disorder and mixed osteodystrophy. This is important in ruling out the presence of changes due to secondary hyper parathyroidism
Renal biopsy This is mainly to identify the etiology but will not be of use in end stage renal disease in which the whole kidney is scarred Renal biopsy
This is mainly to identify the etiology but will not be of use in end stage renal disease in which the whole kidney is scarred

Investigations - Management

Fact Explanation
Full blood count and blood picture Low Hemoglobin is seen in CKD and Low platelet count maybe observed with iron repletion therapy. Blood picture may show normochromic normocytic anemia and this is important in follow up of the patient with treatment Full blood count and blood picture
Low Hemoglobin is seen in CKD and Low platelet count maybe observed with iron repletion therapy. Blood picture may show normochromic normocytic anemia and this is important in follow up of the patient with treatment
Blood urea nitrogen Reduced excretory capacity of the kidneys causes elevation and usually done in follow up. Blood urea nitrogen
Reduced excretory capacity of the kidneys causes elevation and usually done in follow up.
Serum creatinine Reduced excretory capacity of the kidneys causes elevation and usually done in follow up. Serum creatinine
Reduced excretory capacity of the kidneys causes elevation and usually done in follow up.
Serum Sodium/ Potassium/ Calcium/ Magnesium/ Phophorous Serum electrolytes are important as electrolyte imbalances are common with high Potassium, Low Sodium, Calcium and Magnesium and high phosphorous. Serum Sodium/ Potassium/ Calcium/ Magnesium/ Phophorous
Serum electrolytes are important as electrolyte imbalances are common with high Potassium, Low Sodium, Calcium and Magnesium and high phosphorous.
Serum cholesterol Blood lipid levels are elevated in CKD and done in the follow up Serum cholesterol
Blood lipid levels are elevated in CKD and done in the follow up
Estimated glomerular filtration rate This is the most important investigation to diagnose and stage the disease. This uses serum creatinine concentration, either the Cockcroft-Gault or the Modification of Diet in Renal Disease (MDRD) Study estimating equations Estimated glomerular filtration rate
This is the most important investigation to diagnose and stage the disease. This uses serum creatinine concentration, either the Cockcroft-Gault or the Modification of Diet in Renal Disease (MDRD) Study estimating equations
Skeletal x-rays As renal osteodystrophy occurs inadequate active form of Vitamin D production, rickets changes, osteopenia, osteoprorois can be identified. Skeletal x-rays
As renal osteodystrophy occurs inadequate active form of Vitamin D production, rickets changes, osteopenia, osteoprorois can be identified.
2D echocardiography As these patients have high cardiovascular risk due to pressure overload due to long standing hypertension it's important to do a cardiac echo and look for left ventricular hypertrophy 2D echocardiography
As these patients have high cardiovascular risk due to pressure overload due to long standing hypertension it's important to do a cardiac echo and look for left ventricular hypertrophy
Blood pressure As hypertension develops as a complication, it's important to monitor blood pressure long term Blood pressure
As hypertension develops as a complication, it's important to monitor blood pressure long term
Growth parameters As growth impairment is seen in these children, it's important to monitor height and weight during follow up Growth parameters
As growth impairment is seen in these children, it's important to monitor height and weight during follow up
Full blood count To exclude any anemia and low platelet count prior to surgery (Renal transplant). Low platelet count maybe observed in iron repletion therapy Full blood count
To exclude any anemia and low platelet count prior to surgery (Renal transplant). Low platelet count maybe observed in iron repletion therapy
Coagulation studies To exclude any coagulopathy before surgical management Coagulation studies
To exclude any coagulopathy before surgical management
Renal function tests- Serum creatinine, Blood urea nitrogen As these patients have impaired renal function, it's important to determine the severity prior to anesthesia Renal function tests- Serum creatinine, Blood urea nitrogen
As these patients have impaired renal function, it's important to determine the severity prior to anesthesia
HLA typing This is important to be done prior to renal transplant as HLA should be matched between donor and recipient for a better outcome HLA typing
This is important to be done prior to renal transplant as HLA should be matched between donor and recipient for a better outcome
Estimated glomerular filtration rate This is the most important investigation to diagnose and stage the disease. This uses serum creatinine concentration, either the Cockcroft-Gault or the Modification of Diet in Renal Disease (MDRD) Study estimating equations. The staging is done as below.
Stage 1-normal eGFR ≥ 90 mL/min per 1.73 m2 and persistent albuminuria, Stage 2-eGFR between 60 to 89 mL/min per 1.73 m2, Stage 3- eGFR between 30 to 59 mL/min per 1.73 m2, Stage 4- eGFR between 15 to 29 mL/min per 1.73 m2, Stage 5- eGFR of < 15 mL/min per 1.73 m2 or end-stage renal disease
Estimated glomerular filtration rate
This is the most important investigation to diagnose and stage the disease. This uses serum creatinine concentration, either the Cockcroft-Gault or the Modification of Diet in Renal Disease (MDRD) Study estimating equations. The staging is done as below.
Stage 1-normal eGFR ≥ 90 mL/min per 1.73 m2 and persistent albuminuria, Stage 2-eGFR between 60 to 89 mL/min per 1.73 m2, Stage 3- eGFR between 30 to 59 mL/min per 1.73 m2, Stage 4- eGFR between 15 to 29 mL/min per 1.73 m2, Stage 5- eGFR of < 15 mL/min per 1.73 m2 or end-stage renal disease
Urine full report for protein This might help to detect albuminuria and this is thought to be associated with high cardiovascular risk. Urine full report for protein
This might help to detect albuminuria and this is thought to be associated with high cardiovascular risk.
Urine dipstick for protein Urine dipstick for protein may help to identify early CKD and can be done as mass screening Urine dipstick for protein
Urine dipstick for protein may help to identify early CKD and can be done as mass screening
Antenatal ultrasound scan The low volume of amniotic fluid during antenatal period suggests that the production of urine in the fetus is impaired and usually suggests a renal anomaly and other congenital anomalies can be identified Antenatal ultrasound scan
The low volume of amniotic fluid during antenatal period suggests that the production of urine in the fetus is impaired and usually suggests a renal anomaly and other congenital anomalies can be identified

Management - Supportive

Fact Explanation
Patient and parental education This is a chronic disease, therefore patient education plays a major role. The parents are educated on etiology, nature, course, prognosis, available treatment options and importance of follow up. It's important to improve their quality of life. Patient and parental education
This is a chronic disease, therefore patient education plays a major role. The parents are educated on etiology, nature, course, prognosis, available treatment options and importance of follow up. It's important to improve their quality of life.
Diet and nutrition Anorexia and malnutrition is common , therefore calorie supplementation is necessary. Severe anorexia may indicate nasogastric or gastrostomy feeding. Protein intake should be sufficient. Phosphorous containing food such as milk products, Potassium containing fruits should be restricted. Salt restriction may be necessary. Diet and nutrition
Anorexia and malnutrition is common , therefore calorie supplementation is necessary. Severe anorexia may indicate nasogastric or gastrostomy feeding. Protein intake should be sufficient. Phosphorous containing food such as milk products, Potassium containing fruits should be restricted. Salt restriction may be necessary.
Acute management of hyperkalemia When the child presents with hyperkalemia, management is crucial as it can cause cardiac arrest if not treated. Ca gluconate is given if there are any ECG changes followed by insulin with glucose, intravenous or nebulized salbutamol. Sodium polystyrene sulphonate which is a gut potassium binding resin can be given as well. Dialysis is the definitive management. Acute management of hyperkalemia
When the child presents with hyperkalemia, management is crucial as it can cause cardiac arrest if not treated. Ca gluconate is given if there are any ECG changes followed by insulin with glucose, intravenous or nebulized salbutamol. Sodium polystyrene sulphonate which is a gut potassium binding resin can be given as well. Dialysis is the definitive management.
Acute management of metabolic acidosis Intravenous bicarbonate may be necessary Acute management of metabolic acidosis
Intravenous bicarbonate may be necessary
Acute management of acute pulmonary edema High flow oxygen followed with intravenous Furosemide, Nitrates are used. Acute management of acute pulmonary edema
High flow oxygen followed with intravenous Furosemide, Nitrates are used.
Management of anemia Oral and intravenous iron supplementation is done. But recombinant erythropoietin is usually necessary. The target Hemoglobin level is 11-12 g/dl. Management of anemia
Oral and intravenous iron supplementation is done. But recombinant erythropoietin is usually necessary. The target Hemoglobin level is 11-12 g/dl.
Management of bone disease Gut phosphate binders are used to reduce phosphate and these are either calcium or aluminum based. But calcium-free, phosphate have been developed, such as the nonabsorbable agent sevelamer which neither has calcium or aluminum. Vitamin D is given as well as calcimimetics, agents which increase the calcium sensitivity of the calcium receptor in the parathyroid gland, down-regulating parathyroid hormone secretion and reducing hyperplasia of the parathyroid gland Management of bone disease
Gut phosphate binders are used to reduce phosphate and these are either calcium or aluminum based. But calcium-free, phosphate have been developed, such as the nonabsorbable agent sevelamer which neither has calcium or aluminum. Vitamin D is given as well as calcimimetics, agents which increase the calcium sensitivity of the calcium receptor in the parathyroid gland, down-regulating parathyroid hormone secretion and reducing hyperplasia of the parathyroid gland
Management of hypertension According to KDOQI guidelines target blood pressure is less than 130/85 mm Hg for all patients with kidney disease and less than 125/75 mmHg for patients with urinary protein excretion greater than 1g/24h. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers, are the first-line agents Management of hypertension
According to KDOQI guidelines target blood pressure is less than 130/85 mm Hg for all patients with kidney disease and less than 125/75 mmHg for patients with urinary protein excretion greater than 1g/24h. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers, are the first-line agents
Management of hyperlipidemia Life style changes and Drugs may be used as Statins according to blood cholesterol level. Management of hyperlipidemia
Life style changes and Drugs may be used as Statins according to blood cholesterol level.
Management of hormonal abnormalities Recombinant human growth hormone is effective as well as safe for the treatment of growth failure in CKD children along with good nutrition Management of hormonal abnormalities
Recombinant human growth hormone is effective as well as safe for the treatment of growth failure in CKD children along with good nutrition
Patient identification These patients should be provided with a diagnosis card stating that they are having CKD. This is important especially when they go to other doctors and seek medication for other illnesses because certain drugs are contraindicated in CKD Patient identification
These patients should be provided with a diagnosis card stating that they are having CKD. This is important especially when they go to other doctors and seek medication for other illnesses because certain drugs are contraindicated in CKD

Management - Specific

Fact Explanation
Pharmacological therapy for the underlying disease If the underlying cause is an auto immune disease such as Lupus nephritis management with immunosupressants are necessary such as steroids. Alternatively recurrent Urinary tract infections should be treated with proper antibiotic therapy Pharmacological therapy for the underlying disease
If the underlying cause is an auto immune disease such as Lupus nephritis management with immunosupressants are necessary such as steroids. Alternatively recurrent Urinary tract infections should be treated with proper antibiotic therapy
Surgical interventions for the underlying disease If the underlying cause is obstructive uropathy, congenital anomalies corrective surgery is necessary to reverse the course Surgical interventions for the underlying disease
If the underlying cause is obstructive uropathy, congenital anomalies corrective surgery is necessary to reverse the course
Dialysis This is a form of renal replacement therapy. Usually dialysis is indicated when the glomerular filtration rate (GFR) is <15 mL/min and there is one or more of the following such as symptoms or signs of uraemia, inability to control hydration status or blood pressure or a progressive deterioration in nutritional status. Dialysis should be started before the GFR has fallen to 6 mL/min/1.73m2 even if asymptomatic. Hemodialysis is commonly done Dialysis
This is a form of renal replacement therapy. Usually dialysis is indicated when the glomerular filtration rate (GFR) is <15 mL/min and there is one or more of the following such as symptoms or signs of uraemia, inability to control hydration status or blood pressure or a progressive deterioration in nutritional status. Dialysis should be started before the GFR has fallen to 6 mL/min/1.73m2 even if asymptomatic. Hemodialysis is commonly done
Renal transplantation This is the ultimate management option as a form of replacement therapy. But finding a matched donor is crucial and following the transplantation, complications can occur. The child is usually on immunosuppressants life long. Renal transplantation
This is the ultimate management option as a form of replacement therapy. But finding a matched donor is crucial and following the transplantation, complications can occur. The child is usually on immunosuppressants life long.

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