Chronic Kidney Disease in Children Clinical Presentation: History and Physical Examination (original) (raw)

History and Physical Examination

Chronic kidney disease (CKD) is asymptomatic in its earliest stages (stage I and stage II), although urinalysis findings or blood pressure may be abnormal. As chronic kidney disease progresses to more advanced stages, signs and symptoms greatly increase.

Polydipsia and nocturia (secondary to a reduced capacity to concentrate the urine) may be one of the earliest symptoms that indicate a diagnosis of chronic kidney disease in an otherwise healthy-looking child who has tubulointerstitial kidney disease.

The signs and symptoms in advanced chronic kidney disease may include the following:

The absolute serum levels of blood urea nitrogen (BUN) or creatinine do not directly correlate with the development of these symptoms; however, estimated glomerular filtration rate (eGFR) seems to be associated with a stronger correlation.

The physical findings vary depending on the severity of kidney failure and can range from an absence of any physical findings to the presence of one or more of the following:

Approximately 50-100% of patients with end-stage renal disease (ESRD) also have at least one dermatologic condition. In addition, uremia and conditions associated with renal replacement therapy often give rise to numerous and, often, relatively unique cutaneous disorders. These dermatologic manifestations of renal disease may be divided into 3 general associated with ESRD, uremia, or renal transplantation. Discussion of the common cutaneous disorders in renal disease is beyond the scope of this article; see Dermatologic Manifestations of Renal Disease.

The image below illustrates several uremia-related cutaneous disorders.

Hands of a transfusion-dependent patient on long-t

Hands of a transfusion-dependent patient on long-term hemodialysis. Several uremia-related cutaneous disorders are visible. The pigmentary alteration results from retained urochromes and hemosiderin deposition. The large bullae are consistent with either porphyria cutanea tarda or the bullous disease of dialysis. All nails show the distal brown-red and proximal white coloring of half-and-half nails.

A population-based, case-control study with 1994 patients with childhood CKD and 20,032 controls sought to determine the association of childhood CKD with prenatal risk factors, including birth weight, maternal diabetes mellitus, and maternal overweight/obesity. The prevalence of CKD was 126.7 cases per 100,000 births. The study concludes that low birth weight, maternal gestational diabetes mellitus, and maternal overweight/obesity associated significantly with obstructive uropathy. The data suggested that prenatal factors may impact the risk of CKD. The authors add that future studies are needed to determine if modification of these factors could reduce the risk of childhood CKD. [18]

Staging

The Kidney Disease Outcomes Quality Initiative (KDOQI) recommended the following classification of chronic renal disease by stage [7, 19] :

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Author

Sanjeev Gulati, MD, MBBS, DNB(Peds), DM, DNB(Neph), FIPN(Australia), FICN, FRCPC(Canada) Additional Professor, Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences; Senior Consultant in Pediatric Nephrology and Additional Director, Department of Nephrology and Transplant Medicine, Fortis Institute of Renal Sciences Transplantation, India

Sanjeev Gulati, MD, MBBS, DNB(Peds), DM, DNB(Neph), FIPN(Australia), FICN, FRCPC(Canada) is a member of the following medical societies: American Society of Pediatric Nephrology, International Society of Nephrology, Royal College of Physicians and Surgeons of Canada, Indian Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Frederick J Kaskel, MD, PhD Director of the Division and Training Program in Pediatric Nephrology, Vice Chair, Department of Pediatrics, Montefiore Medical Center and Albert Einstein School of Medicine

Frederick J Kaskel, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, Eastern Society for Pediatric Research, Renal Physicians Association, American Academy of Pediatrics, American Pediatric Society, American Physiological Society, American Society of Nephrology, American Society of Pediatric Nephrology, American Society of Transplantation, Federation of American Societies for Experimental Biology, International Society of Nephrology, National Kidney Foundation, New York Academy of Sciences, Sigma Xi, The Scientific Research Honor Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Craig B Langman, MD Tenured Professor of Pediatrics, The First Isaac A Abt, MD, Professor of Kidney Diseases (Emeritus), Northwestern University, The Feinberg School of Medicine; Staff Nephrologist, The Ann and Robert H Lurie Children’s Hospital of Chicago

Craig B Langman, MD is a member of the following medical societies: American Academy of Pediatrics, American Federation for Clinical Research, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Pediatric Nephrology, Association of Clinical Scientists, Cochrane Collaboration, International Bone and Mineral Society, International Conferences on Calcium Regulating Hormones, International Pediatric Nephrology Association, International Society of Nephrology, International Society of Renal Nutrition and Metabolism, Midwest Society for Pediatric Research, Pediatric Academic Societies, ROCK (Research on Calculus Kinetics) Society, Society for Pediatric Research

Disclosure: Received income in an amount equal to or greater than $250 from: Alexion Pharmaceuticals; Horizon Pharmaceuticals); Dicerna Pharmaceuticals
Incyte Pharmaceuticals; Eli Lilly for: Federation bio; Dicerna pharmaceuticals.

Additional Contributors

Laurence Finberg, MD Clinical Professor, Department of Pediatrics, University of California, San Francisco, School of Medicine and Stanford University School of Medicine

Laurence Finberg, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.