CHRONIC

KIDNEY
DISEASE IN
CHILDREN
Presented by
Chanchal Dinodiya -07
Zufa Fangiri-08
 Definition
Irreversible loss of the renal
function seen for more than 3
months to an extent that the
kidney cannot filter blood and
waste builds up in the body which
require renal replacement
therapy.

https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/what-is-chronic-kidney-disease
Patient has CKD if either of the following
Criteria is present:

kidney damage for Abnormalities in the

≥3 months as composition of the
defined by structural blood or urine
or functional
abnormalities of the Abnormalities in
kidney with or imaging tests
without decreased
GFR, manifested by
one or more of the Abnormalities on kidney
following features biopsy

GFR <60 ml/min/1.73 m² for ≥3 months, with or without the A healthy newborn can have a
other sign of kidney damage GFR which is between 40-60
ml/min/1.73m2

https://doi.org/10.1111/j.1523-1755.2005.00365.x
 Stages of Chronic Kidney Disease

Stage Description GFR Symptoms

Kidney damage with normal or

1 increased GFR
≥90 No symptoms

Kidney damage with mild decrease in

2 GFR
60-89 Anemia

Anemia,
3 Moderate decrease in GFR 30-59
fatigue,Edema

4 Severe decrease in GFR 15-29 HD or PD needed

5 Kidney failure <15 or on dialysis RRT needed

 Etiology of CKD in children

Birth
defects/Congenital Hereditary diseases Other Conditions
Abnormalities

Chromosome Abnormalities Polycystic Kidney Disease Nephrotic syndrome- diseases

disorder that causes cysts to grow that affect the glomeruli
Single-Gene Abnormalities in the kidneys
Conditions During Pregnancy Systemic diseases- Lupus
Alport Syndrome Nephritis
That Affect The Baby a condition that affects the outer
lining of the cells in the kidneys Trauma- Dehydration ,low BP
Combination of Genetic and
Environmental Problems Urine blockage or
reflux-blockage between the
kidneys and the urethra
https://www.healthychildren.org/English/health-issues/conditions/developmental-disabilities/Pages/Congenital-Abnormalities.aspx
 Clinical Features and future Implications

Growth impairment Mineral and Bone disorder

● Degree of growth impairment increases as
GFR declines which results into stunted
height ● Presence of one or a combination of the
● In children with CKD the risk factors that following is seen : abnormalities in calcium,
contribute to impaired growth include: phosphorus, parathyroid hormone (PTH) or
malnutrition, metabolic acidosis, mineral vitamin D metabolism; abnormalities in
and bone disorders, anaemia, and fluid and bone histology, linear growth, or strength;
electrolyte abnormalities vascular or other soft tissue calcifications
● Growth failure is mainly due to ● Changes in calcium and phosphorus
disturbances in growth hormone (GH) metabolism can significantly altered bone
metabolism and its main mediator, remodelling and somatic growth
insulin-like growth factor-I (IGF-I
● Inadequate nutrition (due to anorexia or
vomiting) appears to be the most important
factor contributing to growth impairment
 Anemia
Metabolic Acidosis
● Anaemia is a common complication in
children with CKD causing many adverse ● Retention of phosphate or sulfate as acids
clinical consequences, including poor may lead to metabolic acidosis.
quality of life, depressed neurocognitive ● Treatment consists primarily of
ability, reduced exercise capacity and supplemental bicarbonate or citrate
progression of cardiovascular risk factors, solutions.
such as left ventricular hypertrophy ● Treatment of metabolic acidosis in children
● Liver produces a peptide called Hepcidin in is important for ensuring growth and bone
CKD which inhibits the iron from getting health
absorbed in the blood
● Also the lifespan of RBC is shortened which
leads to further complications
 Clinical Features and future Implications

High Blood Pressure Cardiovascular diseases

● Early markers of cardiomyopathy, such
● Strict blood pressure control is the only as left ventricular hypertrophy and
intervention which has been shown to slow dysfunction, and early markers of
the progression of Chronic Kidney Disease atherosclerosis, such as increased
in children. carotid artery intima-media thickness,
● Agents such as ACE-I or Angiotensin carotid arterial wall stiffness, and
Receptor Blockade (ARB) are to be used as coronary artery calcification, are
preferred agents in children with CKD and frequently present in these children,
hypertension. especially those on maintenance dialysis
● Side effects from these medications in
children with CKD include hyperkalemia
(high potassium) and worsening of renal
function due to less plasma in the blood.
 Goals of Medical Nutrition Therapy

● Maintenance of an optimal nutritional status that is achievement of

a normal pattern of growth and body composition by intake of
appropriate amounts and types of nutrients
● Avoidance of uremic toxicity, metabolic abnormalities and
malnutrition
● Reduction of the risk of chronic morbidity and mortality
● Control the dietary potassium, sodium, phosphate, fluid intake to
maintain fluid balance
Anthropometric Assessment

Height, weight, head circumference (up

to 36 months of age), and body mass
index. These parameters should be
plotted on the appropriate percentile
charts to evaluate the health status

https://www.niddk.nih.gov/health-information/kidney-disease/child
ren/caring-child-kidney-disease/nutrition-chronic-kidney-disease#
protein
 Biochemical Assessment
● Urine tests to check how well your child’s kidneys are
filtering blood and to look for proteins in the urine blood
tests to test the glomerular filtration rate and to look for
underlying diseases imaging tests, to see the size and
shape of the kidneys and identify any abnormalities
● Kidney biopsy, to check for kidney damage and help identify
the cause of the kidney disease genetic tests to look for
specific gene mutations

https://www.niddk.nih.gov/health-information/kidney-disease/children#diagnose
 Clinical Signs and Symptoms

Classical Symptoms Other Symptoms

● Swelling in the feet, legs, hands, or face, called ● Decreased appetite
edema. ● Feeling tired
● Increased or decreased urine output. Some ● Fever
children may have to urinate more often and ● High blood pressure
may wet the bed at night. ● Itchy skin
● Foamy urine due to too much protein in the ● Nausea or vomiting
urine, called proteinuria. ● Shortness of breath
● Pink or cola-colored urine caused by blood in ● Trouble concentrating
the urine, called hematuria. ● Weakness
● Weight loss
● stunted growth
https://www.niddk.nih.gov/health-information/kidney-disease/children#symptoms
Inadequate food intake is due to:
● Anorexia
● Altered taste sensation
● Nausea and vomiting
● Emotional distress
● Intercurrent illness

PEW is due to:

● Chronic inflammatory state
● Catabolic response to illness
● Accumulation of endogenously formed uremic toxins
● Removal of nutrients during dialysis
● Resistance to action of insulin , hyperglucagonemia, hyperparathyroidism
Nutritional Therapy
Energy
• Patients with CKD need the same caloric intake as healthy children of the same chronological
age. The energy requirements for each child are determined by body size, physical activity, and
other attributes.
• If the patient has a higher stage , catabolism would be high thus energy requirements would be
high therefore 30-35kcal/day is recommended, if obese 25-30 kcal/day can be given

Protein:
• Protein intake is often limited in these patients. However, children with CKD who have reached
the point of needing dialysis will have increased protein needs due to losses during haemodialysis
and peritoneal dialysis.
• The current Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend
supplying children with stages 2-3 CKD with 100–140% of the RDA of protein for ideal body
weight, while children with more advanced CKD should receive 100–120% of the RDA
• For Stage 1 the recommendation would be 0.6-0.8g/kg BW

Carbohydrates:
• 50-60% of Energy should be coming from Carbohydrates. Complex carbohydrates should be
considered, different grains and millets should be considered
Fats
● Different children with CKD have very different sodium needs

● Thus the recommendation would be 20-25% of total energy.

Studies indicate that dietary trans fats not only

PUFAs might delay the contribute to raising the
Since CKD can lead to onset of CKD and alleviate amount of bad cholesterol
dyslipidemia so omega 3 CVD as kidney disease (LDL) in the body, but they
should be included which progresses . Higher plasma also have been shown to
lower LDL and increase PUFA levels were linked to a
lower the amount of good
HDL lower risk of CKD in a
cholesterol in the blood
three-year follow-up study of
(HDL).
the elderly
Micronutrients
Sodium Potassium Phosphorus
● Potassium also plays a ● Generally, phosphate levels
● Sodium requirements major role in many are elevated in CKD.
directly depend on the important cellular ● Hyperphosphatemia and
cause of CKD functions, such as muscle other factors play major
● The KDOQI recommends contraction and nerve roles in the development of
less than 1500 - conduction cardiovascular events.
2400 mg/day including ● Patients with CKD are at ● Therefore, the general
prioritising fresh over risk of both hypokalemia approach to manage
refined food and hyperkalemia, hyperphosphatemia is to
depending on many restrict phosphate intake,
factors. which should, however, be
● The KDOQI recommends adequate for normal bone
restricting potassium in mineralisation and to
infants and young children prevent mineral and bone
to 40–120 mg/kg/day and disorders
to 30–40 mg/kg/day in ● Intake should be between
older children. 8000-1000 mg/day
Calcium Iron Fluid Intake
● In advanced CKD, calcitriol ● In CKD patients there are ● Fluid intake in patients with
production decreases, low levels of Erythropoietin CKD, especially those on
which may affect the hormone (EPO). dialysis, should be carefully
intestinal absorption of ● EPO stimulates bone monitored because
calcium, causing marrow to produce RBCs intravascular fluid imbalance
hypocalcemia and ● When low levels of EPO is can lead to cardiovascular
secondary present in CKD, less complications, which will
hyperparathyroidism. production of RBC takes directly increase morbidity
● Therefore, the KDOQI place leading to anemia. and mortality risks
recommends that the child ● To correct the anemia, IV ● While fluid overload is
should receive up to or oral iron harmful, aggressive fluid
100–200% of the supplementation is restriction may be toxic to the
age-appropriate DRI with a recommended. child’s myocardium.
maximum dose of ● 2-6mg/kg of oral iron per ● In all cases, fluid intake must
2500 mg/day, including from day till the levels are be balanced and carefully
food containing calcium, normal. IV iron can be assessed and managed.
medications such as given at a dose of ● Recommended intake would
phosphate binders, and 1500mg/year. be = Urine output+ 500ml
calcium supplementation
Ways to Observe Fluid Restrictions

1 2 3
Use small glasses, such as Limit the amount of salt in Keep a supply of hard
juice glasses, at meals. If your diet. Salt makes your candy, like mints, lemon
you use larger glasses, body hold on to water. Limiting drops, or sour balls. They
don’t fill them up completely. salt helps control your thirst. lubricate your mouth and
help decrease thirst

4 5
Take sips, not gulps. Try
Divide your fluid allowance 6 Use a refreshing
into manageable parts. For
to savor whatever liquid mouthwash daily, and be
example, if you can have 32
you’re drinking and make sure to brush your tongue,
ounces per day, you could
it an experience, not just a since good oral hygiene
drink 8 ounces at 4 different
thirst quencher. habits also help get rid of
times of the day, at 10 a.m., 2
that “dry mouth” feeling.
p.m., 6 p.m. and 10 p.m.
Hemodialysis
● During hemodialysis, your blood
goes through a filter, called a
dialyzer, outside your body. A
dialyzer is sometimes called an
“artificial kidney.”
● The dialysis machine pumps
blood through the filter and
returns the blood to your body.
During the process, the dialysis
machine checks your blood
pressure and controls how quickly
➢ blood flows through the filter
➢ fluid is removed from your body
Renal Transplantation Peritoneal dialysis

A kidney transplant is a surgery that involves Dialysis which uses the peritoneum in a person's abdomen as the
taking a healthy kidney from a donor and membrane through which fluid and dissolved substances are
placing it into a person whose kidneys are no exchanged with the blood. It is used to remove excess fluid, correct
longer working properly. electrolyte problems, and remove toxins in those with kidney failure
 References

● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8526268/
● https://www.niddk.nih.gov/health-information/kidney-disease/children/caring-chi
ld-kidney-disease/nutrition-chronic-kidney-disease#protein
● https://kidshealth.org/en/parents/chronic-kidney-disease.html#:~:text=Children
%20with%20chronic%20kidney%20failure,lungs%2C%20and%20high%20bloo
d%20pressure
● https://www.niddk.nih.gov/health-information/kidney-disease/children#diagnose
● https://www.healthychildren.org/English/health-issues/conditions/developmenta
l-disabilities/Pages/Congenital-Abnormalities.aspx
● https://bmcnephrol.biomedcentral.com/track/pdf/10.1186/s12882-016-0297-4
THANK YOU!
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