Definition (Pediatr Rev 2008;29:335)
• CKD now classified as any kidney damage or GFR <60 mL/min/1.73 m2 for >3 mo
• KDOQI Group classified CKD into 5 stages. Stage 1: Kidney damage w/ nml/↑ GFR (>90). Stage 2: ↓ GFR to 60–89. Stage 3: ↓ GFR to 30–59. Stage 4: ↓ GFR to 15–29. Stage 5: Kidney failure w/ GFR <15. All GFR in mL/min/1.73 m2 and for pts >2 yo
Etiology (Pediatr Rev 2008;29:335)
• ∼30–33% w/ urologic anomalies, 25–27% w/ glomerulopathies, 16% w/ hereditary nephropathies and ∼11% w/ renal hypoplasia and dysplasia
Complications (Pediatr Rev 2008;29:335; Pediatr Nephrol 2003;18:796)
• Infections prompt 45% of hospital admissions in one series
• Other complications include: Anemia (keep Hgb 11–12 mg/dL w/ Fe & Epo), HTN, bone disease (rx’d w/ Vit D), electrolyte abn (met acidosis rx’d w/ NaBicarb, hyperK)
• Growth retardation is a major complication; degree matches age of onset of CKD, likely 2/2 effect on GH & IGF-1 axis; treatment w/ nutritional support +/− GH therapy
Prognosis (Pediatr Nephrol 2008;23:705; J Am Soc Nephrol 2005;16:2796)
• CKiD is large prospective cohort study of pts aged 1–16 yr to identify risk factors for progression and the effect of ↓ GFR on cognition, growth, behavior, cardiovasc risk factors (Clin J Am Soc Nephrol 2006;1:1006)
• Intensive (50th percentile) BP control w/ ACE-I slows GFR ↓ (N Engl J Med 2009;361:1639)
• Proteinuria, low Hct, hypoalbuminemia, hypoCa, hyperphos, hyperPTH all assoc w/ rate of progress to ESRD, as is age at dx and the dx itself
• Rx of anemia, hypoCa, and hyperphos leads to improved outcomes in the short term
• Glomerular disorders, including FSGS, increase risk of progression to ESRD
• Cardiac and vascular abn (LVH, diastolic dysfxn, ↑ carotid intima-media thickness, Mönckeberg sclerosis) are progressive and may be related to ↑ calcium–phosphorus product (Nat Rev Nephrol 2011;7:624)
Management (N Engl J Med 2009;361:1639; Curr Opin Pediatr 2010;22:170)
• ESCAPE trial, fixed-dose ACE-inhibitor + additional anti-hypertensives to ↓ BP 3–4 mm Hg
• R-A blockade may also benefit by ↓ proteinuria, correction of acidosis, hyperuricemia
• W/ Stage V CKD ultimate management is renal transplantation