What is the comprehensive management plan for a child with chronic kidney disease (CKD)?

Comprehensive Management of Chronic Kidney Disease in Children

Preemptive kidney transplantation is the treatment of choice for children with progressive and irreversible CKD, typically pursued when eGFR reaches 5-15 ml/min per 1.73 m², with living or deceased donor options prioritized to optimize long-term outcomes and quality of life. 1

Detection and Initial Assessment

• Test all at-risk children using both urine albumin measurement and eGFR assessment to enable early detection and intervention 1
• Monitor children with CKD more frequently than adults at the same CKD stage due to unique developmental needs and higher risk for adverse outcomes 1

Nutritional Management and Growth Optimization

Protein and Energy Intake

• Do NOT restrict protein intake in children with CKD due to risk of growth impairment—target protein and energy intake at the upper end of normal range for healthy children to promote optimal growth 2, 3
• Screen children with CKD G4-G5 or those with poor growth twice annually for malnutrition using validated assessment tools 1
• Refer all children to renal dietitians or accredited nutrition providers for individualized medical nutrition therapy addressing sodium, phosphorus, potassium, and protein intake 1, 3

Growth Hormone Therapy

• Once nutrition is optimized, initiate growth hormone therapy as an effective strategy to improve terminal height in children with growth failure 4
• Poor growth refractory to optimized nutrition, growth hormone, and medical management is a specific indication for initiating kidney replacement therapy in children (not applicable to adults) 1

Dietary Recommendations

• Advise adoption of plant-based predominant diets with reduced ultraprocessed food consumption 5, 2, 3
• Limit sodium intake to <2 g per day (equivalent to <90 mmol/day or <5 g sodium chloride/day) 5, 3

Physical Activity and Lifestyle

• Encourage children with CKD to undertake physical activity aiming for WHO-advised levels (≥60 minutes daily) and achieve a healthy weight 2
• Advise children to avoid sedentary behavior as a distinct intervention beyond exercise prescription 3

Cardiovascular and Blood Pressure Management

• Target blood pressure <130/80 mmHg in patients with albuminuria ≥30 mg/24 hours and <140/90 mmHg in those without albuminuria 5
• Initiate ACE inhibitors or ARBs as first-line therapy at maximum tolerated dose, particularly when hypertension or albuminuria is present 5, 2

Mineral and Bone Disorder Management

• Monitor for abnormalities in calcium, phosphorus, and parathyroid hormone levels regularly 4
• Implement dietary phosphorus restriction, phosphorus binders, and inactive vitamin D or active vitamin D sterols as needed 4
• Effective treatment reduces risk for bone deformities, growth abnormalities, fractures, cardiovascular disease, and mortality 4

Anemia Management

• Control anemia aggressively to prevent neurocognitive sequelae 4
• For pediatric patients with CKD, initiate erythropoietin treatment only when hemoglobin is <10 g/dL 6
• If hemoglobin approaches or exceeds 12 g/dL, reduce or interrupt erythropoietin dose 6
• Recommended starting dose for pediatric patients (ages 1 month or older) is 50 Units/kg three times weekly intravenously or subcutaneously 6

Metabolic Complications

• Provide pharmacological treatment with or without dietary intervention when serum bicarbonate <18 mmol/L 5
• Control of metabolic acidosis with dietary and pharmacologic measures may slow CKD progression 7

Neurocognitive Function Preservation

• Direct prevention of cognitive sequelae toward improved blood pressure control 4
• Provide augmented school support for children with CKD who suffer from cognitive difficulties 4
• Decrease exposure to heavy metals via dialysate and dietary binding agents 4

Multidisciplinary Team-Based Care

• Enable access to patient-centered multidisciplinary care team consisting of dietary counseling, medication management, education about KRT modalities, transplant options, dialysis access surgery, and ethical, psychological, and social care 1
• Establish referrals to specialized providers including psychologists, renal dietitians, pharmacists, physical/occupational therapy, and smoking cessation programs 3
• Education programs should involve care partners to promote informed, activated patients with CKD 1

Symptom Assessment and Quality of Life

• Ask children with progressive CKD about uremic symptoms (reduced appetite, nausea, fatigue/lethargy) at each consultation using standardized validated assessment tools 1
• Use evidence-informed management strategies to support children to live well with CKD and improve health-related quality of life 1
• Screen for and treat depression, which affects approximately 26.5% of patients with CKD stages 1-4 5

Timing of Kidney Replacement Therapy

Indications for Initiating Dialysis

• Initiate dialysis based on composite assessment of symptoms, signs, quality of life, preferences, level of GFR, and laboratory abnormalities 1
• Pediatric-specific indication: Poor growth refractory to optimized nutrition, growth hormone, and medical management 1
• Adult indications also apply: uremic symptoms, pericarditis, anorexia, medically resistant acid-base or electrolyte abnormalities, intractable pruritus, inability to control volume status or blood pressure, progressive nutritional deterioration 1
• Dialysis often occurs when GFR is between 5-10 ml/min per 1.73 m² 1

Preemptive Kidney Transplantation

• Pursue living or deceased donor preemptive kidney transplantation as the treatment of choice for children with progressive and irreversible CKD 1
• The eGFR at which preemptive transplantation should be undertaken depends on age, size of child, and rate of progression but will usually be between eGFR 5-15 ml/min per 1.73 m² 1

Transition to Adult Care (Adolescents)

Pediatric Provider Responsibilities

• Prepare adolescents and families for transfer to adult-oriented care starting at 11-14 years of age using checklists to assess readiness and guide preparation 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 and cognitive abilities/social support 1
• Transfer young people during times of medical and social stability where possible 1

Adult Provider Responsibilities

• Recognize that young people under 25 years of age with CKD are at high risk for adverse outcomes due to physiologic incomplete brain maturation 1
• Encourage young people to informally visit the adult care clinic before the first appointment 1
• Assess young people with CKD more frequently than older people with same CKD stage, including caregivers or significant others in care (with patient agreement) for at least 1-3 years following transfer 1

Medication Management

• Adjust all medication dosages according to kidney function 5
• Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 2

Referral to Specialist Nephrology Care

• Refer when ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol) confirmed on repeat first morning void sample 1, 2
• Refer with persistent hematuria, any sustained decrease in eGFR, hypertension, kidney outflow obstruction or anomalies, known or suspected CKD, or recurrent urinary tract infection 1, 2

Critical Pitfalls to Avoid

• Never restrict protein intake in children with CKD without proper nutritional counseling—this risks malnutrition, protein-energy wasting, and growth impairment 2, 3
• Do not delay growth hormone therapy once nutrition is optimized, as it is effective but underutilized 4
• Avoid focusing solely on protein restriction while neglecting overall diet quality 3