1. Recognizing Chronic Kidney Disease in Children

2. Goals Know the epidemiology of kidney disease in children
Identify chronic kidney disease when you see it
Know how to screen for kidney disease

3. “Real Goals”
Add “renal disease” to your differential for 5 common pediatric complaints
Be able to name the #1 cause of pediatric end-stage renal disease
Name 1 way to stop progression of kidney disease
Use the Schwartz Formula to calculate GFR every time you see a creatinine

4. Glomerular Filtration Rate (GFR):
How much plasma is filtered per minute
Normalized to body surface area (1.73 m2)
Reaches BSA-corrected adult levels by
2 months of age

5. Normal GFR
100 mL/min/1.73m2

6. How much kidney do you need to lose before your creatinine increases?

8. What’s an abnormal creatinine?

9. Who’s Got an Abnormal Creatinine ?
VS.
10 mo/o boy
Cr = 0.6
16 y/o boy
Cr = 1.0

10. VS. Who’s Got an Abnormal Creatinine ? 4 y/o boy 15 y/o girl Cr = 0.8

11. = K * height (cm) ------------------- GFR Creatinine (ml/min/1.73m2)
The Schwartz Formula
K * height (cm)
Creatinine
GFR
(ml/min/1.73m2) =
Babies
Kids
Teenage Girl
Teenage Boy K
0.45
0.55
0.7
Schwartz, 1976.

12. 53 = K * ht 0.45 * 70 -------- ------------- Cr 0.6 (ml/min/1.73m2)
10 month old boy
Length = 70 cm
Cr = 0.6
K * ht Cr =
0.45 * 70
0.6 53
(ml/min/1.73m2)

13. 126 = K * ht 0.70 * 180 -------- ------------- Cr 1.0 (ml/min/1.73m2)
16 year old boy
Ht = 180 cm
Cr = 1.0
K * ht Cr =
0.70 * 180
1.0
126
(ml/min/1.73m2)

14. 73 = K * ht 0.55 * 107 -------- ------------- Cr 0.8 (ml/min/1.73m2)
4 year old boy
Ht = 107 cm
Cr = 0.8
K * ht Cr =
0.55 * 107
0.8 73
(ml/min/1.73m2)

15. 91 = K * ht 0.55 * 150 -------- ------------- Cr 0.9 (ml/min/1.73m2)
15 year old girl
Ht = 150 cm
Cr = 0.9
K * ht Cr =
0.55 * 150
0.9 91
(ml/min/1.73m2)

16. Other Ways to Measure GFR
Timed Urine
Collection
Nuclear
Medicine
Scan
Cystatin C

17. How accurate do you need to be?

18. Stages of Chronic Kidney Disease
CKD Stage
Severity
GFR ml/min/1.73m2 1
Minimal
>90 + evidence of damage 2
Mild
60-89 3
Moderate
30-59 4
Severe
15-29 5
Kidney failure
<15
Pause – what are the functions of the kidney? Lytes, fluids, bp control, toxin(uremia buildup), acid/base, epo, vit D

19. Clinical Manifestations of Kidney Disease and Stage

20. U.S. Adult Population with Kidney Disease
Stage 5 4 3 2 1
300k
400,000
8,000,000
12,000,000
25 million

21. U.S. Pediatric Population with Kidney Disease
Stage 5 4 3 2 1
5000
Estimate 400,000 GFR < 80
(NHANES III)

22. When did he start getting kidney disease?

23. Internists are seeing what we’re not..
Trans-
plant PD HD

24. Top 5 Causes of Pediatric Kidney Disease
Top 2 comprise 70+%

26. Seven Red Flags for Kidney Disease
Failure to Thrive

27. Seven Red Flags for Kidney Disease
Failure to Thrive
Elevated Blood Pressure

28. Seven Red Flags for Kidney Disease
Failure to Thrive
Elevated Blood Pressure
Chronic Anemia

29. Seven Red Flags for Kidney Disease
Failure to Thrive
Elevated Blood Pressure
Chronic Anemia
Voiding Problems

30. Seven Red Flags for Kidney Disease
Failure to Thrive
Elevated Blood Pressure
Chronic Anemia
Voiding Problems
Unusual Bone Disease

31. Seven Red Flags for Kidney Disease
Failure to Thrive
Elevated Blood Pressure
Chronic Anemia
Voiding Problems
Unusual Bone Disease
Proteinuria

32. Seven Red Flags for Kidney Disease
Failure to Thrive
Elevated Blood Pressure
Chronic Anemia
Voiding Problems
Unusual Bone Disease
Proteinuria
Pre-Existing Diseases

33. Why bother identifying kidney disease in kids?

34. Slow Progression…
HTN, proteinuria, BMI, high uric acid, smoking (not etoh), avoiding nephrotoxins, avoiding dehydration, ApoE, lipids, ?birth weight/preemie, ?homocystine,

35. ACE Inhibitors slow Progression of Renal Disease
REIN 1993

36. Improve Quality of Life…
School attendance, hospitalization, teasing

37. Percentage of Children starting renal replacement therapy before 15 years of age who are < 2 SD below mean adult height
Rizzoni, 1985
Hokken-Koelega, 1994

38. Adults at -2 SD for Height
5’ 5”
4’ 11”
60-77 % of boys end up shorter than Woody Allen
40-71 % of girls end up shorter than Lil’ Kim

39. Anticipate and Treat Complications…

42. Index cards