Management of Chronic Kidney Disease in Children

Abstract

The practice of clinical pediatric nephrology encompasses a wide variety of diseases and conditions affecting the kidneys. Yet, these activities fall under a common umbrella in terms of screening, identification, and management of childhood chronic kidney disease (CKD). The Kidney Disease Improving Global Outcomes (KDIGO) initiative defines CKD as abnormalities of kidney structure or function for greater than 3 months with implications for health [1]. In its reference to “implications for health,” distinctions are made between benign kidney conditions (such as a solitary cortical cyst or a duplicated collecting system) and more severe disorders (such as autosomal dominant polycystic kidney disease or focal segmental glomerulosclerosis) that cause CKD. Compared to adults in whommost cases of CKD are caused by diabetes and hypertension, the disorder in children is predominantly the result of congenital and inherited anomalies of the urinary tract. Common to both adults and children, the diagnosis of CKD is linked with an ever present risk for CKD progression, a steady decline in kidney function over time to the point of failure. Clinically, children with CKD may be asymptomatic in the initial stages of the disorder with subclinical complications, which might be undiagnosed and untreated. However, as kidney function declines, various signs and symptoms (e.g., volume overload, hypertension, fatigability, growth failure) become more evident. Concurrently, there is a heighted awareness for further complications of CKD compromising the overall well-being of the child and demanding early identification and management. The clinical management of pediatric CKD is comprised of determining CKD severity, ameliorating risk factors for CKD progression, and detecting/treating comorbid complications that are the result of reduced kidney function [1]. In pediatrics, the management of CKD is not only directed toward the primary cause of CKD but also encompasses a multidisciplinary team approach to assure normal growth, nutrition, neurocognitive development, educational progress, and transition to adulthood. The primary focus of this chapter is on the management of the stages of CKD prior to the initiation of dialysis or kidney transplantation.