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Chronic Kidney Disease in Children Clinical Presentation

  • Author: Sanjeev Gulati, MD, MBBS, DNB(Peds), DM, DNB(Neph), FIPN(Australia), FICN, FRCPC(Canada); Chief Editor: Craig B Langman, MD  more...
 
Updated: Jan 21, 2015
 

History and Physical Examination

Chronic kidney disease (CKD) is asymptomatic in its earliest stages (stage I and stage II), although urinalysis findings or blood pressure may be abnormal. As chronic kidney disease progresses to more advanced stages, signs and symptoms greatly increase.

Polydipsia and nocturia (secondary to a reduced capacity to concentrate the urine) may be one of the earliest symptoms that indicate a diagnosis of chronic kidney disease in an otherwise healthy-looking child who has tubulointerstitial kidney disease.

The signs and symptoms in advanced chronic kidney disease may include the following:

  • Volume overload
  • Hyperkalemia
  • Metabolic acidosis
  • Hypertension
  • Anemia
  • Bone disease (termed osteodystrophy)
  • Cardiovascular disease
  • Anorexia, nausea, vomiting

The absolute serum levels of blood urea nitrogen (BUN) or creatinine do not directly correlate with the development of these symptoms; however, estimated glomerular filtration rate (eGFR) seems to be associated with a stronger correlation.

The physical findings vary depending on the severity of kidney failure and can range from an absence of any physical findings to the presence of one or more of the following:

  • Anemia
  • Short stature
  • Hypertension
  • Osteodystrophy
  • Cardiac abnormalities (eg, left ventricular hypertrophy [LVH], pericarditis)
  • Peripheral neuropathy
  • Central nervous system (CNS) abnormalities (eg, ranging from loss of concentration and lethargy to seizures, coma)

Approximately 50-100% of patients with end-stage renal disease (ESRD) also have at least one dermatologic condition. In addition, uremia and conditions associated with renal replacement therapy often give rise to numerous and, often, relatively unique cutaneous disorders. These dermatologic manifestations of renal disease may be divided into 3 general associated with ESRD, uremia, or renal transplantation. Discussion of the common cutaneous disorders in renal disease is beyond the scope of this article; see Dermatologic Manifestations of Renal Disease.

The image below illustrates several uremia-related cutaneous disorders.

Hands of a transfusion-dependent patient on long-t Hands of a transfusion-dependent patient on long-term hemodialysis. Several uremia-related cutaneous disorders are visible. The pigmentary alteration results from retained urochromes and hemosiderin deposition. The large bullae are consistent with either porphyria cutanea tarda or the bullous disease of dialysis. All nails show the distal brown-red and proximal white coloring of half-and-half nails.

A population-based, case-control study with 1994 patients with childhood CKD and 20,032 controls sought to determine the association of childhood CKD with prenatal risk factors, including birth weight, maternal diabetes mellitus, and maternal overweight/obesity. The prevalence of CKD was 126.7 cases per 100,000 births. The study concludes that low birth weight, maternal gestational diabetes mellitus, and maternal overweight/obesity associated significantly with obstructive uropathy. The data suggested that prenatal factors may impact the risk of CKD. The authors add that future studies are needed to determine if modification of these factors could reduce the risk of childhood CKD.[11]

Staging

The Kidney Disease Outcomes Quality Initiative (KDOQI) recommended the following classification of chronic renal disease by stage[4, 12] :

  • Stage I disease is defined by a normal glomerular filtration rate (GFR) (> 90 mL/min per 1.73 m 2) and persistent albuminuria
  • Stage II disease is characterized by a GFR of 60-89 mL/min per 1.73 m 2 and persistent albuminuria
  • Stage III disease is characterized by a GFR of 30-59 mL/min per 1.73 m 2
  • Stage IV disease is characterized by a GFR of 15-29 mL/min per 1.73 m 2
  • Stage V disease is characterized by a GFR of less than 15 mL/min per 1.73 m 2 or end-stage renal disease (ESRD)
 
 
Contributor Information and Disclosures
Author

Sanjeev Gulati, MD, MBBS, DNB(Peds), DM, DNB(Neph), FIPN(Australia), FICN, FRCPC(Canada) Additional Professor, Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences; Senior Consultant in Pediatric Nephrology and Additional Director, Department of Nephrology and Transplant Medicine, Fortis Institute of Renal Sciences Transplantation, India

Sanjeev Gulati, MD, MBBS, DNB(Peds), DM, DNB(Neph), FIPN(Australia), FICN, FRCPC(Canada) is a member of the following medical societies: American Society of Pediatric Nephrology, International Society of Nephrology, Royal College of Physicians and Surgeons of Canada, Indian Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Frederick J Kaskel, MD, PhD Director of the Division and Training Program in Pediatric Nephrology, Vice Chair, Department of Pediatrics, Montefiore Medical Center and Albert Einstein School of Medicine

Frederick J Kaskel, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, Eastern Society for Pediatric Research, Renal Physicians Association, American Academy of Pediatrics, American Pediatric Society, American Physiological Society, American Society of Nephrology, American Society of Pediatric Nephrology, American Society of Transplantation, Federation of American Societies for Experimental Biology, International Society of Nephrology, National Kidney Foundation, New York Academy of Sciences, Sigma Xi, Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Craig B Langman, MD The Isaac A Abt, MD, Professor of Kidney Diseases, Northwestern University, The Feinberg School of Medicine; Division Head of Kidney Diseases, The Ann and Robert H Lurie Children's Hospital of Chicago

Craig B Langman, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Nephrology, International Society of Nephrology

Disclosure: Received income in an amount equal to or greater than $250 from: Alexion Pharmaceuticals; Raptor Pharmaceuticals; Eli Lilly and Company; Dicerna<br/>Received grant/research funds from NIH for none; Received grant/research funds from Raptor Pharmaceuticals, Inc for none; Received grant/research funds from Alexion Pharmaceuticals, Inc. for none; Received consulting fee from DiCerna Pharmaceutical Inc. for none.

Additional Contributors

Laurence Finberg, MD Clinical Professor, Department of Pediatrics, University of California, San Francisco, School of Medicine and Stanford University School of Medicine

Laurence Finberg, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

References
  1. US Renal Data System (USRDS). 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, Md: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2010. Available at http://www.usrds.org/adr.htm. Accessed: June 13, 2011.

  2. [Guideline] Kopple JD. National kidney foundation K/DOQI clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis. 2001 Jan. 37(1 Suppl 2):S66-70. [Medline].

  3. [Guideline] National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002 Feb. 39(2 Suppl 1):S1-266. [Medline].

  4. [Guideline] KDOQI. KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 update. Executive summary. Am J Kidney Dis. 2009 Mar. 53(3 Suppl 2):S11-104. [Medline].

  5. Seikaly MG, Ho PL, Emmett L, et al. Chronic renal insufficiency in children: the 2001 Annual Report of the NAPRTCS. Pediatr Nephrol. 2003 Aug. 18(8):796-804. [Medline].

  6. Gulati S, Mittal S, Sharma RK, Gupta A. Etiology and outcome of chronic renal failure in Indian children. Pediatr Nephrol. 1999 Sep. 13(7):594-6. [Medline].

  7. Ardissino G, Dacco V, Testa S, et al. Epidemiology of chronic renal failure in children: data from the ItalKid project. Pediatrics. 2003 Apr. 111(4 Pt 1):e382-7. [Medline].

  8. Choi AI, Rodriguez RA, Bacchetti P, Bertenthal D, Hernandez GT, O''Hare AM. White/black racial differences in risk of end-stage renal disease and death. Am J Med. 2009 Jul. 122(7):672-8. [Medline]. [Full Text].

  9. Craven AM, Hawley CM, McDonald SP, et al. Predictors of renal recovery in Australian and New Zealand end-stage renal failure patients treated with peritoneal dialysis. Perit Dial Int. 2007 Mar-Apr. 27(2):184-91. [Medline].

  10. Mak RH. Chronic kidney disease in children: state of the art. Pediatr Nephrol. 2007 Oct. 22(10):1687-8. [Medline].

  11. Hsu CW, Yamamoto KT, Henry RK, De Roos AJ, Flynn JT. Prenatal risk factors for childhood CKD. J Am Soc Nephrol. 2014 Sep. 25(9):2105-11. [Medline]. [Full Text].

  12. [Guideline] Hogg RJ, Furth S, Lemley KV, et al. National Kidney Foundation's Kidney Disease Outcomes Quality Initiative clinical practice guidelines for chronic kidney disease in children and adolescents: evaluation, classification, and stratification. Pediatrics. 2003 Jun. 111(6 Pt 1):1416-21. [Medline].

  13. Eknoyan G. The importance of early treatment of the anaemia of chronic kidney disease. Nephrol Dial Transplant. 2001. 16 Suppl 5:45-9. [Medline].

  14. Sanchez CP. Secondary hyperparathyroidism in children with chronic renal failure: pathogenesis and treatment. Paediatr Drugs. 2003. 5(11):763-76. [Medline].

  15. [Guideline] Noordzij M, Korevaar JC, Boeschoten EW, Dekker FW, Bos WJ, Krediet RT. The Kidney Disease Outcomes Quality Initiative (K/DOQI) Guideline for Bone Metabolism and Disease in CKD: association with mortality in dialysis patients. Am J Kidney Dis. 2005 Nov. 46(5):925-32. [Medline].

  16. Seeherunvong W, Abitbol CL, Chandar J, Zilleruelo G, Freundlich M. Vitamin D insufficiency and deficiency in children with early chronic kidney disease. J Pediatr. 2009 Jun. 154(6):906-11.e1. [Medline].

  17. Salusky IB. A new era in phosphate binder therapy: what are the options?. Kidney Int Suppl. 2006 Dec. (105):S10-5. [Medline].

  18. Saland JM, Ginsberg H, Fisher EA. Dyslipidemia in pediatric renal disease: epidemiology, pathophysiology, and management. Curr Opin Pediatr. 2002 Apr. 14(2):197-204. [Medline].

  19. Soergel M, Schaefer F. Effect of hypertension on the progression of chronic renal failure in children. Am J Hypertens. 2002 Feb. 15(2 Pt 2):53S-56S. [Medline].

  20. Swinford RD, Portman RJ. Measurement and treatment of elevated blood pressure in the pediatric patient with chronic kidney disease. Adv Chronic Kidney Dis. 2004 Apr. 11(2):143-61. [Medline].

  21. Haffner D, Schaefer F, Nissel R, et al. Effect of growth hormone treatment on the adult height of children with chronic renal failure. German Study Group for Growth Hormone Treatment in Chronic Renal Failure. N Engl J Med. 2000 Sep 28. 343(13):923-30. [Medline].

  22. Hodson EM, Willis NS, Craig JC. Growth hormone for children with chronic kidney disease. Cochrane Database of Systematic Reviews. 2012.

  23. Fogo AB. Mechanisms of progression of chronic kidney disease. Pediatr Nephrol. 2007 Jul 24. [Medline].

  24. Muscheites J, Wigger M, Drueckler E, Fischer DC, Kundt G, Haffner D. Cinacalcet for secondary hyperparathyroidism in children with end-stage renal disease. Pediatr Nephrol. 2008 Oct. 23(10):1823-9. [Medline].

 
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Major clinical predictors to be used for the perioperative management of a patient with chronic renal failure. CHF = congestive heart failure.
Intermediate clinical predictors to be used for the perioperative management of a patient with chronic renal failure. CHF = congestive heart failure; METs = metabolic equivalents of task; MI = myocardial infarction.
Minor clinical predictors to be used for the perioperative management of a patient with chronic renal failure. ECG = electrocardiogram; METs = metabolic equivalents of task.
Hands of a transfusion-dependent patient on long-term hemodialysis. Several uremia-related cutaneous disorders are visible. The pigmentary alteration results from retained urochromes and hemosiderin deposition. The large bullae are consistent with either porphyria cutanea tarda or the bullous disease of dialysis. All nails show the distal brown-red and proximal white coloring of half-and-half nails.
 
 
 
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