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Chronic Kidney Disease (CKD) in Children

General Information


  • chronic kidney disease in children is characterized by abnormalities of kidney structure or function that are present for > 3 months and have implications for health (criteria for duration > 3 months does not apply to infants ≤ 3 months old)2,5

Also called

  • CKD
  • chronic renal failure (CRF)
  • chronic renal insufficiency (CRI)
  • end-stage renal disease (ESRD) if renal replacement therapy required


  • Kidney Disease Improving Global Outcomes (KDIGO) defines CKD as either of the following present for > 3 months (criteria for duration > 3 months does not apply to infants ≤ 3 months old)2
    • reduced glomerular filtration rate (GFR)
      • in patients ≥ 2 years old < 60 mL/minute/1.73 m2
      • in patients < 2 years old, > 1 standard deviation (SD) below mean age-appropriate GFR
      • GFR in children can be calculated using Pediatric GFR Calculators available at National Kidney Foundation
    • kidney damage as evidenced by ≥ 1 of
      • urinary total protein or albumin excretion rate above age normative value
      • urine sediment abnormalities
      • electrolyte or other abnormalities due to tubular disorders (as defined in light of age normative values)
      • abnormal histology
      • abnormal structure detected by imaging
      • history of kidney transplant
  • KDIGO CKD staging based on cause, GFR category, and albuminuria category (KDIGO Level 1, Grade B)2,3,5
    • cause assignment based on presence or absence of systemic disease and location in the kidney of observed or presumed pathologic-anatomic findings
    • GFR categories
      • GFR categories for patients ≥ 2 years old
        • G1 - GFR > 90 mL/minute/1.73 m2 (normal or high)
        • G2 - GFR 60-89 mL/minute/1.73 m2 (mildly decreased compared to young adult level)
        • G3a - GFR 45-59 mL/minute/1.73 m2 (mild-to-moderately decreased)
        • G3b - GFR 30-44 mL/minute/1.73 m2 (moderate-to-severely decreased)
        • G4 - GFR 15-29 mL/minute/1.73 m2 (severely decreased)
        • G5 - GFR < 15 mL/minute/1.73 m2 (kidney failure)
        • D - on dialysis
        • T - post transplant
      • CKD staging in children < 2 years old based on GFR category
        • normal GFR ≤ 1 SD below mean for age
        • moderately reduced GFR > 1 SD below mean
        • severely reduced GFR > 2 SDs below mean
    • proteinuria categories
      • pediatric considerations in CKD staging with abnormal urinary protein excretion (by any marker)
      • proteinuria/albuminuria categories generally applicable to children > 2 years old without demonstrable orthostatic proteinuria
        • A1 - normal to mildly increased proteinuria or albuminuria as seen by any of the following
          • protein to creatinine ratio (PCR) < 150 mg/g (< 15 mg/mmol)
          • albumin to creatinine ratio (ACR) < 30 mg/g (3 mg/mmol)
          • protein excretion rate (PER) < 150 mg/24 hours
          • albumin excretion rate (AER) < 30 mg/24 hours
        • A2 - moderately increased proteinuria or albuminuria as seen by any of the following
          • PCR 150-500 mg/g (15-50 mg/mmol)
          • ACR 30-300 mg/g (3-30 mg/mmol)
          • PER 150-500 mg/24 hours
          • AER 30-300 mg/24 hours
        • A3 - severely increased (including nephrotic syndrome) as seen by any of the following
          • PCR > 500 mg/g (> 50 mg/mmol)
          • ACR > 300 mg/g (30 mg/mmol)
          • PER > 500 mg/24 hours
          • AER > 300 mg/24 hours
      • see Urine studies section for additional information


General references used

  1. Harambat J, van Stralen KJ, Kim JJ, Tizard EJ. Epidemiology of chronic kidney disease in children. Pediatr Nephrol. 2012 Mar;27(3):363-73full-text
  2. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. KDIGO 2013 Jan PDF
  3. KDOQI Work Group. KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 update. Executive summary. Am J Kidney Dis. 2009 Mar;53(3 Suppl 2):S11-104PDF
  4. Bunchman, TE. Pediatric Chronic Kidney Disease: Lack of Overt Symptoms Makes Diagnosis Challenging. Nephrology Times. 2008 Apr;1(4):13
  5. Hogg RJ, Furth S, Lemley KV, et al. National Kidney Foundation's Kidney Disease Outcomes Quality Initiative clinical practice guidelines for chronic kidney disease in children and adolescents: evaluation, classification, and stratification. Pediatrics. 2003 Jun;111(6 Pt 1):1416-21

Recommendation grading systems used

  • American Diabetes Association (ADA) evidence grading system for clinical practice recommendations
    • Grade A
      • clear evidence from well-conducted, generalizable, randomized controlled trials (RCTs) that are adequately powered, including evidence from well-conducted multicenter trial or meta-analysis that incorporated quality ratings in analysis
      • compelling nonexperimental evidence, specifically, "all or none" rule developed by Center for Evidence Based Medicine at Oxford
      • supportive evidence from well-conducted RCTs that are adequately powered, including evidence from well-conducted trial at ≥ 1 institution or meta-analysis that incorporated quality ratings in analysis
    • Grade B
      • supportive evidence from well-conducted cohort studies, including evidence from well-conducted prospective cohort study, registry, or meta-analysis of cohort studies
      • supportive evidence from well-conducted case-control study
    • Grade C
      • supportive evidence from poorly controlled or uncontrolled studies
        • evidence from randomized clinical trials with ≥ 1 major or ≥ 3 minor methodologic flaws that could invalidate results
        • evidence from observational studies with high potential for bias (such as case series with comparison to historical controls)
        • evidence from case series or case reports
      • conflicting evidence with weight of evidence supporting recommendation
    • Grade E - expert consensus or clinical experience
    • PubMed31862741Diabetes careDiabetes Care2020010143Suppl 1S1-S2S1Reference - ADA 2020 standards of medical care in diabetes: introduction (Diabetes Care 2020 Jan;43(Suppl 1):S1)
  • Canadian Society of Transplantation (CST) uses Canadian Task Force on Preventive Health Care (CTFPHC) grades of recommendation
    • Grade A - good evidence to support clinical preventive action
    • Grade B - fair evidence to support clinical preventive action
    • Grade C
      • existing evidence conflicts
      • other factors may influence decision making
    • Grade D - fair evidence to recommend against clinical preventive action
    • Grade E - good evidence to recommend against clinical preventive action
    • Reference - CST consensus guidelines on eligibility for kidney transplantation (16275969CMAJ 2005 Nov 8;173(10):1181full-text), supporting details can be found in 16275956CMAJ 2005 Nov 8;173(10):S1full-text
  • American College of Radiology (ACR) rating scale
    • Rating 1, 2, and 3 - usually not appropriate
    • Rating 4, 5, and 6 - may be appropriate
    • Rating 7, 8, and 9 - usually appropriate
    • Reference - ACR appropriateness criteria on renal failure (ACR 2013 PDF)
  • Kidney Disease: Improving Global Outcomes (KDIGO)
    • strength of recommendation
      • Level 1 ("we recommend") - most patients should receive recommended course of action
      • Level 2 ("we suggest") - different choices appropriate for different patients, based on patient's values and preferences
      • Not Graded - topic does not allow adequate application of evidence, not meant to be interpreted as being stronger recommendations than Level 1 or 2
    • quality of evidence
      • Grade A - high-quality evidence, true effect lies close to that of estimate of effect
      • Grade B - moderate-quality evidence, true effect likely to be close to estimate of effect, but there is possibility it is substantially different
      • Grade C - low-quality evidence, true effect may be substantially different from estimate of effect
      • Grade D - very low-quality evidence, estimate of effect very uncertain and often far from truth
  • National Kidney Foundation (NKF) strengths of recommendation
    • Grade A
      • strongly recommended that clinicians routinely follow guideline for eligible patients
      • strong evidence that practice improves health outcomes
    • Grade B
      • recommended that clinicians routinely follow guideline for eligible patients
      • moderately strong evidence that practice improves health outcomes
    • Clinical Practice Recommendations (Grade CPR)
      • consider following guideline for eligible patients
      • based on weak evidence or opinions of Work Group and reviewers that practice might improve health outcomes
    • Reference - NKF clinical practice guideline on chronic kidney disease in children and adolescents: evaluation, classification, and stratification (12777562Pediatrics 2003 Jun;111(6 Pt 1):1416)

Synthesized Recommendation Grading System for DynaMed Content

  • The DynaMed Team systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed content, we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
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DynaMed Editorial Process

  • DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
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Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
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    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T908705, Chronic Kidney Disease (CKD) in Children; [updated 2018 Nov 30, cited place cited date here]. Available from Registration and login required.

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