Chronic Kidney Disease

Question 1

What is the difference between AKI and Chronic Kidney Disease?

Answer 1

• in AKI, decline in kidney function occurs acutely i.e. in less than 3 months
• in CKD, decline in kidney function occurs more gradually over a period greater than 3 months

Question 2

What causes CKD in children?

Answer 2

congenital abnormalities of the kidney and urinary tract:

• reflux nephropathy
• dysplasia

Question 3

What should you consider if a congenital abnormality of the kidneys and urinary tract are found?

Answer 3

it may not be isolated - it may be a part of a syndrome e.g. Turner, Down’s

Question 4

Stage 1 CKD.

Answer 4

normal or high GFR (90-120ml/min/1.73m2)

Question 5

Stage 2 CKD.

Answer 5

GFR 60-89ml/min/1.73m2

Question 6

Stage 3 CKD.

Answer 6

GFR 30-59ml/min/1.73m2

Question 7

Stage 4 CKD.

Answer 7

GFR 15-29ml/min/1.73m2

Question 8

Stage 5 (end stage) CKD.

Answer 8

GFR <15ml/min/1.73m2

Question 9

What metabolic/ endocrine functions does the kidney have?

Answer 9

• production of renin
• activation of vitamin D
• production of erythropoietin

Question 10

How can CKD present?

Answer 10

• bladder dysfunction
• high blood urea or creatinine
• electrolyte imbalance e.g. hyperkalemia
• hypocalcaemia
• proteinuria
• metabolic acidosis
• anaemia

Question 11

What would be a hallmark that there may be ureteric/bladder dysfunction?

Answer 11

UTI

Question 12

What are suggestive tests of UTI?

Answer 12

• dipstix i.e. nitrites, leucocyte esterase activity
• urine microscopy
• culture >10 to power of 5 colony forming units e.g. E.coli

Question 13

Why should we worry about UTIs?

Answer 13

UTI, vesicoureteric reflux and kidney dysplasia can interplay and lead to scarring of kidney and progress to CKD

Question 14

What would you do to investigate cause of UTI?

Answer 14

imaging:

• US looks at structure
• DMSA looks for scarring/function kidneys
• micturating cystourethrogram or MAG 3 scan to look at dynamics of kidneys and lower urinary tract

Question 15

Which children with UTI would you want to image?

Answer 15

• those with upper tract UTI
• younger
• recurrent UTI

Question 16

How would you treat a lower tract UTI?

Answer 16

3 days of oral antibiotic - from 3 months of age either trimethoprim, co-amoxiclav or cephalosporin

Question 17

How would you treat an upper tract/pyelonephritis UTI?

Answer 17

• antibiotics for 7-10 days (oral if systemically well)

- IV co-amoxiclav

Question 18

How would you prevent further UTI?

Answer 18

• fluids, hygiene, constipation

- treat voiding dysfunction

Question 19

What are the 2 main factors affecting the progression of CKD?

Answer 19

• hypertension

- proteinuria

Question 20

How can you determine the prognosis of CKD?

Answer 20

base it on GFR (decreasing) and albuminuria (increasing)

Question 21

How should CKD be monitored?

Answer 21

monitor blood pressure (Hypertension if greater than 95th centile on 3 separate occasions)

Question 22

What complications are there of CKD?

Answer 22

• metabolic bone disease as the hypocalcamia and high phosphate as a result of failing kidney means increase in PTH and bone resorption
• anaemia
• cardiovascular risk - hypertension

Question 23

How should the complications be managed?

Answer 23

• hypertension with ramipril
• metabolic bone disease with low phosphate diet, phosphate binders and active vitamin D to control PTH
• if ongoing growth poor then growth hormone may be considered

Question 24

To summarise, from the paediatric perspective, what is the cause of or important in:

1. Proteinuria/haematuria?
2. AKI?
3. CKD?

Answer 24

1. glomerular disease (nephrotic or nephritic syndromes)
2. Haemolytic Uraemic Syndrome
3. developmental anomalies (reflux nephropathy)