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Part 3: Chronic Kidney Disease

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Chronic Kidney Disease

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INTRODUCTION

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Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for ≥ 3 months. The chief markers of kidney damage include either decreased glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 or albuminuria. Additional markers are the presence of urine sediment abnormalities, electrolyte disturbances due to tubular disorder, abnormalities detected either by imaging or kidney biopsy, or a history of kidney transplantation. In addition, a defined staging system has evolved to classify the severity of CKD and guide clinical management, as certain manifestations and complications of CKD arise at specific GFR levels irrespective of the etiology of CKD. In 2012, Kidney Disease Improving Global Outcome (KDIGO) guidelines modified this staging system to include albuminuria, as the relative risk of mortality, cardiovascular complications, and disease progression is influenced independently by both GFR and albuminuria (Table 473-1). There are a number of caveats with respect to applying this classification system to pediatrics. First, the staging of CKD excludes patients younger than 2 years whose renal function improves markedly in the first 2 years of life; therefore, a GFR < 90 mL/min/1.73 m2 in a 6-month-old child may not represent any abnormality of renal function. Second, the duration of ≥ 3 months to define CKD cannot be applied to newborns and infants younger than 3 months of age. Finally, in children, urinary protein excretion can be used instead of albumin excretion.

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TABLE 473-1STAGES OF CHRONIC KIDNEY DISEASE (CKD)
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TABLE 473-1STAGES OF CHRONIC KIDNEY DISEASE (CKD)
Stage Description Glomerular Filtration Rate (GFR) (mL/min/1.73 m2)
1 Kidney damage with normal or ↑ GFR ≥ 90
2 Kidney damage with mild ↓ GFR 60–89
3a Mild to moderate ↓ GFR 45–59
3b Moderate to severe ↓ GFR 30–44
4 Severe ↓ GFR 15–29
5 Kidney failure < 15 (or dialysis)
Proteinuria Category Protein Excretion Rate (mg/24 h) Protein/Creatinine Ratio (mg/g) Terms
A1 < 30 < 30 Normal to mildly increased
A2 30–300 30–300 Moderately increased
A3 > 300 > 300 Severely increased

 

 

 

GFR Categories

 Risk for Progression and Complications
Proteinuria Categories
A1 A2 A3
1 Low risk Moderately increased risk High risk
2 Low risk Moderately increased risk High risk
3a Moderately increased risk High risk Very high risk
3b High risk Very high risk Very high risk
4 Very high risk Very high risk Very high risk
5 Very high risk Very high risk Very high risk

Chronic kidney disease is defined as either kidney damage or GFR < 60 mL/min/1.73 m2 for 3 months or longer. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies.

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CAUSES OF CHRONIC KIDNEY DISEASE IN CHILDREN

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The causes of CKD in children are very different from those in adults. In younger children, the most common causes are congenital abnormalities of the kidney and urinary tract (CAKUT) ...

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