How to manage the increasing incidence of Chronic Kidney Disease (CKD) in young individuals?

Managing the Increasing Incidence of CKD in Young Individuals

Young people under 25 years with CKD require more intensive monitoring and multidisciplinary care than older adults with the same CKD stage, with structured transition programs starting at age 11-14 years to prevent the high-risk period of adverse outcomes during emerging adulthood. 1

Recognition of Young People as High-Risk Population

The 2024 KDIGO guidelines explicitly recognize that young people under 25 years with CKD represent a unique, high-risk population for adverse outcomes, attributed in part to physiologically incomplete brain maturation. 1 This biological vulnerability necessitates a fundamentally different management approach compared to older adults with equivalent kidney function.

Key principle: Assess young people with CKD more frequently than older people with the same CKD stage. 1

Structured Transition from Pediatric to Adult Care

Pediatric Provider Responsibilities (Ages 11-14 Years)

The transition preparation must begin early to prevent the documented high-risk period during emerging adulthood:

• Start transition preparation at 11-14 years of age using standardized checklists to assess readiness and guide the process 1
• Conduct part of each visit without the parent/guardian present to foster independence 1
• Provide comprehensive written transfer summary AND ideally oral handover to receiving providers, including medical information, cognitive abilities, and social support details 1
• Transfer only during times of medical and social stability when possible 1

Adult Provider Responsibilities (Ages 18-25 Years)

The critical "emerging adulthood" period (roughly ages 18-25) represents the highest risk for adverse outcomes:

• Encourage informal pre-visit to the adult clinic before formal transfer 1
• See emerging adults more frequently than older adults with the same CKD stage for at least 1-3 years following transfer 1
• Include caregivers or significant others in patient visits with the young person's permission during this vulnerable period 1

Multidisciplinary Team-Based Care Structure

Enable access to a patient-centered multidisciplinary care team that must include: 1

• Dietary counseling with renal dietitians 1
• Medication management 1, 2
• Education about kidney replacement therapy (KRT) modalities 1, 2
• Transplant options counseling 1, 2
• Dialysis access surgery planning 1, 2
• Psychological and social care services 1, 2

Education programs should involve care partners to promote informed, activated patients with CKD. 1, 2

Technology-Enhanced Care Delivery

Consider telehealth technologies including web-based platforms, mobile applications, virtual visiting, and wearable devices for education and care delivery, particularly valuable for young people comfortable with digital health tools. 1

Symptom Assessment and Nutritional Monitoring

Screen systematically at each consultation using validated assessment tools:

• Ask about uremic symptoms (reduced appetite, nausea, fatigue/lethargy) at every visit using standardized validated tools 1, 2
• Screen twice annually for malnutrition in those with CKD G4-G5, poor growth (pediatrics), or symptoms of involuntary weight loss, frailty, or poor appetite 1
• Provide medical nutrition therapy under supervision of renal dietitians when malnutrition is identified 1

Pediatric-Specific Considerations for Advanced CKD

Dialysis Initiation in Children

In addition to standard adult indications (uremic symptoms, volume overload, refractory electrolyte abnormalities), poor growth refractory to optimized nutrition, growth hormone, and medical management is an indication for initiating KRT in children. 1

Preemptive Transplantation Priority

Pursue living or deceased donor preemptive kidney transplantation as the treatment of choice for children with progressive and irreversible CKD. 1 The eGFR threshold for preemptive transplantation depends on:

• Age and size of the child 1
• Rate of CKD progression 1
• Typically occurs between eGFR 5-15 ml/min per 1.73 m² 1

Early Detection and Prevention Strategies

The broader context of managing increasing CKD incidence requires systematic early detection:

• Screen individuals with diabetes, hypertension, cardiovascular disease, age ≥60 years, family history of kidney disease, previous acute kidney injury, or preeclampsia 3
• Use eGFR calculated with CKD-EPI creatinine equation without race variable 3
• Assess albuminuria in at-risk populations, as early detection when GFR is normal may delay need for KRT by up to 3 decades 4
• Implement the ABCDE approach (Albuminuria, Blood pressure, Cholesterol, Diabetes, Estimated GFR) for early detection and treatment of cardiovascular-kidney-metabolic risk 4

Common Pitfalls to Avoid

Critical error: Treating young adults with CKD the same as older adults. The evidence clearly demonstrates that emerging adults require more intensive monitoring and support during the high-risk transition period. 1

Transition failure: Transferring during medical or social instability. This significantly increases risk of loss to follow-up and adverse outcomes. 1

Inadequate preparation: Starting transition discussions too late. Beginning at age 11-14 years allows adequate time for readiness development. 1