Recognizing Chronic Kidney Disease in Children

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. Who’s Got an Abnormal Creatinine ? VS. 4 y/o boy Cr = 0.8 15 y/o girl Cr = 0.9

11. The Schwartz Formula K * height (cm) ------------------- Creatinine GFR (ml/min/1.73m2) = Schwartz, 1976.

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

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

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

15. K * ht -------- Cr 0.55 * 150 ------------- 0.9 = = • 15 year old girl • Ht = 150 cm • Cr = 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. 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 Stages of Chronic Kidney Disease

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

26. Failure to Thrive Seven Red Flags for Kidney Disease

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…

35. ACE Inhibitors slow Progression of Renal Disease REIN 1993

36. Improve Quality of Life…

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…