Renal Failure, Chronic

Renal Failure, Chronic: Excerpt from The 5-Minute Pediatric Consult

Lawrence Copelovitch, MD

Renal Failure, Chronic - BASICS

Renal Failure, Chronic - description

• Chronic kidney disease (CKD): The Kidney Disease Outcomes Quality Initiative (K/DOQI) of the National Kidney Foundation (NKF) defines chronic kidney disease (CKD) as either kidney damage or a decreased kidney glomerular filtration rate (GFR) of <60 mL/min/1.73 m² for 3 or more months
• Kidney damage is defined as pathological abnormalities or markers of kidney injury, including abnormalities in the composition of the blood or urine, or abnormalities in imaging tests.
• CKD is stratified from stages I–V with CKD stage 1 representing patients with a normal GFR but some evidence of kidney damage to CKD stage V which represent patients with end-stage renal failure (ESRF) and a GFR <15.
• Chronic renal failure (CRF) refers to the destruction and progressive loss of nephron function (decreased GFR).

Renal Failure, Chronic - epidemiology

Renal Failure, Chronic - incidence

~3–8 new cases of ESRF are reported per 1 million children per year.

Renal Failure, Chronic - prevalence

• Among children in the US with chronic renal insufficiency entered into the North American Pediatric Renal Transplant Cooperative Study, 65.9% are boys and 63.9% are white.
• Prevalence of CRF has been reported to be 32.4 per 1 million children in western Europe, with 6% <3 years of age, 30% between 3–9 years of age, and 64% between 9–15 years of age.

Renal Failure, Chronic - risk factors

Renal Failure, Chronic - genetics

Several hereditary diseases can cause CRF, including:

• Alport disease (partially X-linked dominant)
• Polycystic kidney disease (autosomal recessive or dominant)
• Familial juvenile nephronophthisis (autosomal recessive)
• Cystinosis (autosomal recessive)
• Hyperoxaluria (autosomal recessive)
• Congenital nephrotic syndrome (autosomal recessive)
• Nail patella syndrome (autosomal dominant)
• Sickle cell disease (autosomal recessive)

Renal Failure, Chronic - pathophysiology

• Infants <2 years of age develop CRF due to either obstructive uropathy or renal hypodysplasia.
• Children 2–5 years of age develop CRF secondary to neonatal vascular accidents and hemolytic-uremic syndrome, obstructive uropathy, or renal hypodysplasia.
• More common causes of CRF in older children and adolescents include various types of glomerulonephritis (e.g., focal segmental glomerulosclerosis, crescentic glomerulonephritis, lupus nephritis), reflux nephropathy, or hereditary causes (e.g., Alport syndrome).

Renal Failure, Chronic - etiology

Growth failure may be secondary to poor nutrition, bone disease, acidosis, or a direct effect on the growth hormone-IGF-1 axis.

Renal Failure, Chronic - DIAGNOSIS

Renal Failure, Chronic - signs & symptoms

• Malaise
• Poor appetite
• Vomiting
• Bone pain
• Headache (if hypertensive)
• Polyuria
• Polydipsia

Renal Failure, Chronic - history

• Past history:
  • Perinatal complications
  • Oligohydramnios
  • Single umbilical artery
  • Recurrent UTIs
  • Enuresis
• Familial history:
  • Renal disease
  • Hearing impairment

Renal Failure, Chronic - physical exam

• General:
  • Short stature
  • Retarded weight gain
  • Dermatologic pallor
  • Fetid breath
• Head, ears, eyes, nose, and throat:
  • Retinal changes
  • Presence of preauricular sinus
  • Hearing deficit
• Chest:
  • Rales
• Heart:
  • Flow murmur
  • Gallop
  • Rub
• Abdomen:
  • Palpable kidneys
  • Suprapubic mass
• Extremities:
  • Rachitic changes
  • Edema
  • Absent patella
• Neurologic system:
  • Developmental delay
  • Altered mental status
  • Hypotonia
  • Irritability

Renal Failure, Chronic - tests

Renal Failure, Chronic - lab

• Serum chemistries: Azotemia, hyperkalemia (if advanced), acidemia, hypocalcemia, hyperphosphatemia, elevated alkaline phosphatase (Onset of these electrolyte abnormalities is CKD stage 4, GFR <30.)
• CBCs: Normocytic anemia with low reticulocyte count (CKD stage 3, GFR <60)
• Urinalysis: Isosthenuria, mild proteinuria
• Intact parathyroid hormone: Elevated
• 24-hour (1,440-minute) urine collection: GFR can be estimated with concomitant blood sampling by calculating the creatinine clearance: Ucreat × (volume voided/1,440)/Pcreat × 1.73/body surface area. The resultant value is expressed as mL/min/1.73 m². Normal range is 80–120 mL/min/1.73 m².
• A simpler and more commonly used method to estimate GFR is the Schwartz formula. The calculation is already corrected for surface area and does not require a urine collection: Height (cm) × 0.55/ Pcreat.
• The correction factor (0.55) is applicable to most children 1 year of age. A lower factor (0.45) is suggested for infants <1 year of age and a higher one (0.7) for adolescent boys.
• Plotting the reciprocal of the serum creatinine versus time can approximate the rate of decline of renal function. This may be useful in determining when renal replacement therapy will be necessary.

Renal Failure, Chronic - imaging

• Chest x-ray: Pulmonary edema, cardiomegaly
• Bone films: Delayed bone age, rickets, osteomalacia, osteitis fibrosa
• Renal ultrasound: Significance—small echogenic kidneys, cystic kidneys, hydronephrosis
• EKG, in hyperkalemic patients: Significance—peaked T waves

Renal Failure, Chronic - differencial diagnosis

• Differentiate acute from CRF.
• Usually, CRF is insidious and associated with poor growth, delayed puberty, rickets, polyuria, and anemia. The kidneys may be smaller on renal ultrasound. A renal biopsy may be indicated to determine the cause of renal failure if genetic causes are suspected (for family counseling) or if treatment is being considered.

Renal Failure, Chronic - TREATMENT

Renal Failure, Chronic - general measures

Renal Failure, Chronic - diet

Restrictions mandated by condition:

• Protein (not less than RDA in children)
• Phosphate
• Potassium
• Sodium (indicated if patient swollen)
• Fluid (indicated in conditions related to oliguria)

Renal Failure, Chronic - special therapy

Dialysis: Indications similar to those for acute renal failure or when GFR <10 mL/min/1.73 m² and patient is experiencing fatigue, poor school performance, or weight loss due to severe dietary restrictions.

During episodes of gastroenteritis, infants with CRF may be prone to dehydration because they have obligatory polyuria due to a concentrating defect. Do not use urine output level or specific gravity of urine as indices for hydration. If hospitalized, fluid levels considered “maintenance” may be insufficient due to polyuria.

Renal Failure, Chronic - medication

• Phosphate binders (e.g., calcium carbonate, calcium acetate, sevelamer; avoid aluminum if possible)
• 1,25-dihydroxy vitamin D
• Alkali therapy (e.g., sodium bicarbonate/citrate)
• Antihypertensive therapy
• ACE inhibitors (renoprotection)
• Recombinant erythropoietin
• Recombinant human growth hormone

Renal Failure, Chronic - surgery

Transplantation: In some cases, a preemptive transplant may be offered instead of dialysis.

Renal Failure, Chronic - FOLLOW UP

Renal Failure, Chronic - disposition

Renal Failure, Chronic - issues for referral

Pediatric primary care physicians should observe patients with CRF in consultation and with assistance from a pediatric nephrologist.

Renal Failure, Chronic - prognosis

Depends on underlying cause, child’s age, degree of renal insufficiency, and need for dialysis or transplantation

Renal Failure, Chronic - complications

• Growth retardation is particularly severe when CRF develops in the 1st year of life.
• Renal osteodystrophy may be seen early in association with CRF, taking the form of growth failure, bowing of the lower extremities, and slipped epiphysis. Vitamin D deficiency and secondary hyperparathyroidism are the major factors leading to bone disease.
• Anemia develops secondary to decreased erythropoietin secretion and decreased erythrocyte survival. The anemia is a normocytic variant associated with a low reticulocyte count.
• Cardiovascular disease including LVH, and coronary artery disease often develops in early adulthood. Uncontrolled hypertension, anemia, hyperlipidemia, and hyperparathyroidism all contribute to this leading cause of death in adults with ESRD.
• Neurodevelopmental delay increases in children with CRF. This is probably due to uremic effects on the development of the brain.
• Hypertension may be seen in some patients with CRF, due either to hyperreninemia or hypervolemia.
• Platelet abnormalities, protein-calorie malnutrition, and immunologic disturbances are also seen in patients with uremia.

Renal Failure, Chronic - bibliography

1. Benfield MR, McDonald R, Sullivan EK, et al. The 1997 Annual Renal Transplantation in Children Report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Pediatr Transplant. 1999;3:152–167.
2. Dabbagh S. Renal osteodystrophy. Curr Opin Pediatr. 1998;10;190–196.
3. Friedman AL. Etiology, pathophysiology, diagnosis, and management of chronic renal failure in children. Curr Opin Pediatr. 1996;8:148–151.
4. Seidman A, Freidman A, Boineau F, et al. Nutritional management of the child with mild to moderate chronic renal failure. J Pediatr. 1996;129:13–18.

Renal Failure, Chronic - CODES

Renal Failure, Chronic - icd9

585.0 Chronic renal failure

Renal Failure, Chronic - FAQ

• Q: Which OTC medications should be avoided in children with CRF?
• A: NSAIDs, pseudoephedrine (if patient hypertensive), enemas containing phosphate, and antacids containing magnesium or aluminum should not be taken.
• Q: Can children with CRF receive immunizations?
• A: Children with CRF should especially receive all necessary immunizations, because some vaccines are contraindicated after transplantation. In some cases, booster immunizations are necessary because of an inadequate response to the initial series (e.g., hepatitis B virus, measles, mumps, rubella; varicella).
• Q: When is recombinant human erythropoietin indicated?
• A: Generally, this medication should be considered when the hematocrit level is <33% (hgb <11.0 g/gL).

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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