Version May 2024
INTRODUCTION — Chronic kidney disease (CKD) refers to a state of irreversible kidney damage and/or reduction of kidney function that is associated with progressive loss of kidney function over time.
The clinical manifestations, diagnosis, and evaluation of CKD in children will be reviewed here. The etiology, epidemiology, natural course, management, and complications of CKD in children are discussed separately. (See "Chronic kidney disease in children: Definition, epidemiology, etiology, and course" and "Chronic kidney disease in children: Overview of management" and "Chronic kidney disease in children: Complications".)
DEFINITIONS AND DIAGNOSIS — Chronic kidney disease (CKD) is defined as the presence of structural or functional kidney damage that persists over a minimum period of three months. Functional damage is characterized by sustained reduction of estimated glomerular filtration rate (GFR), persistent elevation of urinary protein excretion, or both.
Based on this definition, clinical practice guidelines from Kidney Disease: Improving Global Outcomes (KDIGO) in 2012 included criteria for the diagnosis and staging of pediatric CKD [1]. The KDIGO diagnosis criteria and staging classification are the standard used in clinical practice, research, and public health in the care of children with CKD and will be used throughout this topic.
The KDIGO diagnosis of pediatric CKD is based on fulfilling one of the following clinical criteria [1]:
●GFR of less than 60 mL/min per 1.73 m2 for greater than three months with implications for health regardless of whether other CKD markers are present.
●GFR greater than 60 mL/min per 1.73 m2 that is accompanied by evidence of structural damage or other markers of functional kidney abnormalities including proteinuria, renal tubular disorders, or pathologic abnormalities detected by histology or inferred by imaging. This category also includes patients with functioning kidney transplants.
The KDIGO CKD staging for children older than two years of age stratifies the risk for progression of CKD and its complications based on GFR and is used to guide management (table 1):
●G1 – Normal GFR (≥90 mL/min per 1.73 m2)
●G2 – GFR between 60 and 89 mL/min per 1.73 m2
●G3a – GFR between 45 and 59 mL/min per 1.73 m2
●G3b – GFR between 30 and 44 mL/min per 1.73m2
●G4 – GFR between 15 and 29 mL/min per 1.73 m2
●G5 – GFR of less than 15 mL/min per 1.73 m2 (kidney failure)
Children under two years of age do not fit within the above classification system, because they normally have a low GFR even when corrected for body surface area. In these patients, estimated GFR based on serum creatinine can be compared with normative age-appropriate values to detect kidney impairment (table 2). The KDIGO guidelines suggest that a GFR value >1 standard deviation below the mean should raise concern and prompt more intensive monitoring. (See "Chronic kidney disease in children: Definition, epidemiology, etiology, and course", section on 'Estimated glomerular filtration rate'.)
CLINICAL MANIFESTATIONS — The clinical findings of CKD depend on the underlying disorder (nonglomerular versus glomerular disease) and the severity of kidney impairment. Patients may present with dysmorphic features or physical manifestations representing features of genetic disorders that are associated with kidney anomalies and CKD (eg, hereditary nephritis [Alport syndrome] and cystinosis). (See "Chronic kidney disease in children: Definition, epidemiology, etiology, and course", section on 'Etiology'.)
Nonglomerular disease — Nonglomerular causes of CKD affect the tubulointerstitial space and are primarily comprised of congenital anomalies of the kidney and urinary tract (CAKUT) and cystic kidney diseases. Approximately 60 percent of childhood cases of CKD are due to congenital anomalies. (See "Overview of congenital anomalies of the kidney and urinary tract (CAKUT)".)
Generally, CKD in this population will be associated with subtle signs of kidney dysfunction early in its course and are most often identified by imaging including routine antenatal ultrasonography that detects structural abnormalities. Clinical findings include:
●Polyuria may be an early presenting finding because many CAKUT (eg, obstructive uropathy, bilateral renal dysplasia), inherited disorders (eg, nephronophthisis), and tubulointerstitial disorders are associated with reduced concentrating ability (ie, arginine vasopressin resistance [previously called nephrogenic diabetes insipidus]). In these conditions, the impairment in concentrating capacity of the kidneys generally precedes a significant reduction in glomerular filtration rate (GFR). Such patients are at a high risk of acute kidney injury with an acute episode of dehydration as may occur with gastroenteritis. (See "Chronic kidney disease in children: Overview of management", section on 'Avoid subsequent kidney injury'.)
●Elevation in the serum creatinine concentration for age. It should be emphasized that patients with spina bifida, lower limb paralysis, or other disorders associated with a reduction in muscle mass may be at risk for underdiagnosis of CKD because of their lower creatinine levels that overestimate GFR. (See 'Serum creatinine and glomerular filtration rate' below.)
●Poor growth [2]. (See "Growth failure in children with chronic kidney disease: Risk factors, evaluation, and diagnosis".)
Glomerular disorders — Children with a glomerular disorder as the cause for CKD often present with more prominent signs and symptoms of kidney disease.
●Tea-colored or "Coca-Cola"-colored urine may be the presenting symptom. In these patients, red blood cell casts are generally indicative of glomerulonephritis. In other cases, microscopic hematuria may be an incidental finding.
●Proteinuria is a strongly associated biomarker of CKD and is a possible sign of underlying glomerular disease or tubular dysfunction. Persistent (≥3 months) increased excretion of urinary protein in a nonorthostatic pattern is indicative of CKD [3]. (See "Evaluation of proteinuria in children".)
●Edema may be present secondary to nephrotic-range proteinuria or fluid overload (a complication of CKD). (See "Chronic kidney disease in children: Complications", section on 'Sodium and water homeostasis'.)
●Elevated creatinine concentration for age.
●Elevated blood pressure (BP) for age. (See "Chronic kidney disease in children: Complications", section on 'Hypertension'.)
●Systemic symptoms and findings associated with secondary glomerulonephritis that affects kidney function resulting in CKD, such as lupus nephritis or granulomatosis with polyangiitis. Clinical manifestations may include fever, arthralgias/arthritis, rash, and/or pulmonary symptoms. (See "Childhood-onset systemic lupus erythematosus (SLE): Clinical manifestations and diagnosis", section on 'Clinical manifestations' and "Granulomatosis with polyangiitis and microscopic polyangiitis: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)
Clinical presentation by stage of chronic kidney disease — Clinical findings vary depending on the severity of kidney dysfunction (table 1):
●In the early stages of CKD (G1 and G2), patients are often asymptomatic unless there are signs and/or symptoms that result directly from underlying structural kidney abnormalities or systemic diseases with kidney involvement. Asymptomatic patients may be identified by elevated serum creatinine for age, abnormalities on urinalysis (proteinuria, hematuria, or concentrating defect), or detection of kidney disease by imaging studies, including prenatal ultrasonography. Patients may have evidence of anemia and vitamin D deficiency [4,5]. (See "Chronic kidney disease in children: Complications", section on 'Screening and evaluation of anemia' and "Pediatric chronic kidney disease-mineral and bone disorder (CKD-MBD)", section on 'Clinical manifestations'.)
●In moderate stages of CKD (G3a and G3b), patients not only have symptoms found in the early stages of CKD but may also exhibit poor growth, acidosis, elevated BP, and mineral bone disorder. (See "Chronic kidney disease in children: Complications".)
●With severe CKD or kidney failure (G4 and G5, respectively), the symptoms found in the earlier stages of CKD are more likely to be present and may be more severe. The presence of severe electrolyte derangements and acidosis may manifest as weakness, fatigue, anorexia, or vomiting. (See "Chronic kidney disease in children: Complications", section on 'Uremia' and "Chronic kidney disease in children: Complications", section on 'Neurodevelopmental impairment'.)
Complications of chronic kidney disease — Complications due to kidney impairment become more prevalent with decreasing GFR in children as CKD advances from stage G3 to stage G5 (table 1). They include:
●Fluid and electrolyte abnormalities (see "Chronic kidney disease in children: Complications", section on 'Fluid and electrolyte abnormalities')
●Mineral and bone disorder (see "Pediatric chronic kidney disease-mineral and bone disorder (CKD-MBD)")
●Anemia (see "Chronic kidney disease in children: Complications", section on 'Anemia')
●Hypertension (see "Chronic kidney disease in children: Complications", section on 'Hypertension')
●Dyslipidemia (see "Chronic kidney disease in children: Complications", section on 'Dyslipidemia')
●Endocrine abnormalities (see "Chronic kidney disease in children: Complications", section on 'Endocrine dysfunction')
●Growth impairment (see "Growth failure in children with chronic kidney disease: Prevention and management")
●Decreased clearance of substances excreted by the kidneys (uremia) (see "Chronic kidney disease in children: Complications", section on 'Uremia')
EVALUATION AT PRESENTATION
Who should be evaluated — Providers should consider an evaluation for CKD with a child who has any of the following symptoms or risk factors [6]:
●Family history of kidney disease
●Poor linear growth
●Polyuria, polydipsia, or secondary enuresis
●Previous history of acute kidney injury
●Elevated blood pressure (BP)
●Congenital anomalies of the kidney or urinary tract (CAKUT) including a solitary kidney
●Urologic abnormalities
●Recurrent renal calculi or nephrocalcinosis
●Recurrent urinary tract infection
●Unexplained anemia
●Fluid and electrolyte disorders
●Conditions associated with CKD, including diabetes mellitus, cardiac disease, multisystem disease (eg, systemic lupus erythematosus), and preterm birth
●Incidental detection of hematuria or proteinuria
Components of the evaluation
Additional history — Other additional important historical findings (beyond the initial history determining whether the child should be evaluated for CKD) include age at onset of symptoms, duration of symptoms, and identification of additional CKD risk factors (eg, family history of CKD in a child who presents with unexplained anemia).
Physical examination — Because the initial presentation of CKD can be nonspecific, a comprehensive physical examination is necessary to determine if the child has findings compatible with CKD. For example, BP measurement is important in a child who presents with gross hematuria as an elevated BP would be indicative of glomerulonephritis, whereas gross hematuria due to urethritis or trauma is less likely to be associated with a high BP value. The physical examination of any child suspected of having CKD should include:
●Measurement of growth parameters (height, weight, and, for patients ≤3 years of age, head circumference) as these children are at risk for growth impairment.
●BP measurement as hypertension often occurs in children with CKD due to underlying kidney pathology, hypervolemia due to impaired salt and water excretion, or certain medications. BP values are compared with normative BP percentiles based on sex, age, and height from the National Health and Nutrition Examination Survey and other population-based studies (table 3 and table 4). (See "Definition and diagnosis of hypertension in children and adolescents" and "Chronic kidney disease in children: Overview of management", section on 'Blood pressure and targeted goals' and "Chronic kidney disease in children: Complications", section on 'Hypertension'.)
●Assessment for any sign of hypervolemia by noting the presence/absence of edema, rales, hepatic enlargement/tenderness, or cardiac gallop. However, these signs appear late as >5 percent body weight fluid retention is needed for these signs to appear. (See "Chronic kidney disease in children: Complications", section on 'Sodium and water homeostasis'.)
●Cardiac auscultation to detect a pericardial rub due to pericarditis or diminished heart sounds secondary to a pericardial effusion. (See "Chronic kidney disease in children: Complications", section on 'Uremic pericarditis'.)
●Pallor as an indication of anemia should be assessed for by examining sites where capillary beds are visible through the mucosa (eg, conjunctiva, palm, and nail beds). (See "Chronic kidney disease in children: Complications", section on 'Anemia'.)
●Examination of the extremities for edema as an indication of nephrotic syndrome or fluid retention, or any deformity as an indication of chronic kidney disease-mineral and bone disorder (CKD-MBD). The site and type of deformity of the extremities due to CKD-MBD depend on the age of the child and the weight-bearing patterns in the limbs and are similar to those found in children with rickets. (See "Pediatric chronic kidney disease-mineral and bone disorder (CKD-MBD)" and "Overview of rickets in children".)
•In infants, findings include deformities of the forearms and posterior bowing of the distal tibia.
•In toddlers who have started to walk, a characteristic finding is an exaggeration of the normal physiological bowing of the legs (genu varum).
•In older children, valgus deformities of the legs or a windswept deformity (valgus deformity of one leg and varus deformity of the other) may be apparent.
Imaging — Imaging may be useful in identifying the underlying cause of CKD and assessing renal parenchymal structure.
Ultrasound — Ultrasonography (US) of the kidneys is widely available, safe, and noninvasive, making it the initial imaging modality when CKD is suspected. US assesses the dimensions and the structure of the kidneys. It may be diagnostic for some underlying causes of CKD, such as detecting cystic kidney disease or hypoplasia. Antenatal ultrasonography may identify neonates at risk for CKD, especially if there are abnormalities of both kidneys.
The ultrasound examination should compare the measured length of each kidney with normative age-appropriate values (figure 1) [7-9]. Kidneys that are smaller than normal indicate a decrease in kidney mass due to CAKUT (eg, renal hypoplasia), poor growth, or loss of renal parenchyma associated with an underlying disorder or injury.
Children with a congenital solitary kidney are at risk for a decreased glomerular filtration rate (GFR). Risk factors for a decreased GFR for a solitary kidney include additional anomalies of the kidney and urinary tract and a kidney length not consistent with expected compensatory hypertrophy (defined as a kidney length that is at least 10 percent less than predicted for a solitary kidney) [10]. Children with a solitary kidney without CKD typically have a kidney with a length greater than the 95th percentile due to compensatory kidney hypertrophy [11].
Other modalities
●Voiding cystourethrogram (VCUG) – A VCUG is obtained to detect vesicoureteral reflux in a patient with hydronephrosis or recurrent urinary tract infection. Additionally, the VCUG can diagnose the presence of posterior urethral valves and provide other information regarding the structure and function of the bladder and urethra.
●Renal scans – Renal scans are used to assess differential kidney function and to detect focal kidney abnormalities and urinary tract obstruction and its location. The choice of isotope and the addition of adjunctive medication (eg, furosemide) are based on the clinical setting and the underlying goal of the study. (See "Evaluation of congenital anomalies of the kidney and urinary tract (CAKUT)", section on 'Dynamic renal scan' and "Evaluation of congenital anomalies of the kidney and urinary tract (CAKUT)", section on 'Static renal scan' and "Urinary tract infections in infants older than one month and children less than two years: Acute management, imaging, and prognosis", section on 'Kidney scintigraphy' and "Postnatal evaluation and management of hydronephrosis", section on 'Diuretic renography'.)
●Other imaging studies include computed tomography (CT), and magnetic resonance imaging (MRI), which are used in specific clinical settings or when better resolution or visualization is required than that provided by ultrasonography. Imaging studies such as angiography, intravenous pyelogram, and functional MRI are used to clarify or delineate abnormalities found on standard imaging studies.
Ionic and nonionic contrast agents used for some of the above imaging studies may be nephrotoxic and cause acute kidney injury. Guidelines recommend the use of isotonic saline before and after the administration of iodinated contrast for CT scan in patients with CKD to prevent contrast-associated acute kidney injury [12]. Gadolinium-based contrast agents (GBCA) for MRI and magnetic resonance angiography have been associated with nephrogenic fibrosing dermopathy and sometimes fatal nephrogenic systemic fibrosis in both children and adults with CKD [13,14]. (See "Contrast-associated and contrast-induced acute kidney injury: Clinical features, diagnosis, and management".)
Laboratory testing — Blood and urine studies are often used to support the diagnosis, assess the severity of CKD, and detect associated complications. Abnormalities in these assessments may not be readily apparent during the early stages of CKD but will become increasingly prevalent as the glomerular filtration rate (GFR) decreases. Whereas there is no single pattern of laboratory abnormalities that characterizes pediatric CKD, there are some abnormalities that are commonly present and that are indicative of underlying chronic kidney dysfunction, as discussed in the following sections.
Serum creatinine and glomerular filtration rate — The serum creatinine is the most commonly used test to estimate the GFR. In children with CKD, the formula used to calculate estimated GFR (eGFR) depends on the child's height measured in cm, serum creatinine (mg/dL), and a constant "k" that is based on the creatinine assay (Jaffe or enzymatic) used by the clinical laboratory performing the test [15] (calculator 1). (See "Chronic kidney disease in children: Definition, epidemiology, etiology, and course", section on 'Calculated glomerular filtration rate'.)
eGFR = "k" × Height in cm / Serum creatinine in mg/dL
●If the Jaffe method is used, the Schwartz equation is used where the value of "k" is directly proportional to the muscle component of body, and varies with age, and in adolescents, with the sex of the patient [16-18].
•Preterm infants up to one year of age – The value for "k" is 0.33
•Term infants up to one year of age – The value for "k" is 0.45
•Children greater than two years of age, including adolescent females – The value for "k" is 0.55
•Adolescent males – The value for "k" is 0.77
●If the enzymatic method is used, the value of "k" is equal to 0.413 [19]. This formula has only been validated for a range of GFR between 15 and 75 mL/min per 1.73 m2 in children <18 years of age.
●The measurement of serum cystatin C is clinically available and standardized against International Federation of Clinical Chemistry (IFCC)-approved reference material. Newer and more precise GFR-estimating equations based on enzymatic creatinine and IFCC-standardized cystatin C have been published by the Chronic Kidney Disease in Children (CKiD) study [10]. These newer equations developed by CKiD include age- and sex-dependent values for "k" for children and young adults with CKD up to age 25 years old.
Other diagnostic laboratory tests — Other tests obtained in the evaluation of a child with CKD include the following:
●Urinalysis – A urinalysis is a useful screening test for abnormalities of the kidney and urinary tract and as an aid in identifying the underlying cause of CKD. The urinary dipstick makes it possible to test for protein, pH, concentration (specific gravity), glucose, red blood cells, and white blood cells. The different patterns of urinary findings associated with both acute and chronic kidney disease are discussed separately. (See "Urinalysis in the diagnosis of kidney disease".)
●Proteinuria is an indicator of underlying glomerular and/or tubulointerstitial disease, and is an important biomarker strongly associated with CKD. Persistent high-grade proteinuria (2+ protein or greater by dipstick evaluation) usually warrants a prompt evaluation including detection of orthostatic proteinuria (benign condition) and for signs of kidney dysfunction. Lower levels of protein detected by urinary dipstick can usually be followed with repeated measurements to determine if there is resolution of proteinuria. The presence of persistent proteinuria by dipstick evaluation should be quantified by determination of the first morning urine protein/creatinine ratio. Ongoing urinary protein excretion may contribute to the progression of CKD. The severity of kidney disease is generally associated with the amount and duration of proteinuria. (See "Evaluation of proteinuria in children".)
●Kidney biopsy – Kidney biopsy is often done in patients with glomerular causes for CKD. However, kidney biopsy in patients near kidney failure (G5 stage, previously referred to as end-stage kidney disease) may not identify the etiology of CKD, because of the presence of diffuse global sclerosis of the glomeruli and severe tubulointerstitial fibrosis. Tissue samples obtained via kidney biopsy are typically evaluated by light microscopy, immunofluorescence staining, and electron microscopy. Data from these studies may be useful in providing a diagnosis for the cause of CKD and guiding therapeutic choices. If a specific diagnosis is not possible, it often serves to exclude other disease entities in the differential diagnosis. The biopsy results also provide information about disease severity, including whether any abnormalities may be reversible and the degree of interstitial fibrosis, which is generally not reversible.
Testing for chronic kidney disease complications — Testing is performed to detect associated complications of CKD. (See "Chronic kidney disease in children: Complications".)
●Electrolytes – To detect electrolyte abnormalities, particularly metabolic acidosis, hyperkalemia, hypokalemia, hyperphosphatemia, and hypocalcemia. (See "Chronic kidney disease in children: Complications", section on 'Fluid and electrolyte abnormalities'.)
●Complete blood count to detect anemia and evidence of systemic diseases. If the red blood cell indices are not consistent with a normocytic and normochromic anemia, which usually characterizes the anemia of CKD, then other causes of anemia should be considered and the following tests may be helpful:
•Reticulocyte count
•Tests to determine iron status (serum iron, total iron-binding capacity, percent transferrin saturation, serum ferritin)
•Serum vitamin B12 and folate levels
●Serum calcium, phosphorus, 25-hydroxyvitamin D, and parathyroid hormone level to detect any abnormalities in bone and mineral metabolism. (See "Pediatric chronic kidney disease-mineral and bone disorder (CKD-MBD)".)
●Lipid profile that includes total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides to detect the presence of dyslipidemia. (See "Chronic kidney disease in children: Complications", section on 'Dyslipidemia'.)
Referral — For children with established CKD, consultation with a pediatric nephrologist would be helpful to guide additional testing and evaluation.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic kidney disease in children".)
SUMMARY AND RECOMMENDATIONS
●Definition – Chronic kidney disease (CKD) is defined as a state of irreversible kidney damage and/or reduction of kidney function, which persists over a minimum period of three months and can lead to a progressive decrease in kidney function. (See 'Definitions and diagnosis' above.)
●CKD staging – The standard definition and staging of pediatric CKD used in clinical practice, research, and public health are derived from the 2012 practice guidelines from Kidney Disease: Improving Global Outcomes (KDIGO) (table 1).
The diagnosis of pediatric CKD is based on fulfilling one of the following clinical criteria (see 'Definitions and diagnosis' above):
•Glomerular filtration rate (GFR) of less than 60 mL/min per 1.73 m2 for greater than three months with implications for health regardless of whether other CKD markers are present.
•GFR greater than 60 mL/min per 1.73 m2 that is accompanied by evidence of structural damage or other markers of functional kidney abnormalities including proteinuria, albuminuria, renal tubular disorders, or pathologic abnormalities detected by histology or inferred by imaging.
●Clinical manifestations – The clinical findings of CKD vary based on the underlying disorder (nonglomerular versus glomerular disease).
•Children with nonglomerular disease are most often identified by imaging studies that detect structural abnormalities. These children are often asymptomatic or have clinical findings that include polyuria (reduced renal concentrating ability), elevated serum creatinine, and poor growth. (See 'Nonglomerular disease' above.)
•Children with a glomerular disorder typically present with more prominent signs and symptoms of kidney disease than those with nonglomerular disease. These include gross hematuria, proteinuria, edema, hypertension, and elevated serum creatinine. Those with secondary glomerulonephritis may also present with findings consistent with the underlying systemic disease such as fever, arthralgias/arthritis, rash, and/or pulmonary symptoms.
●Clinical presentation – The clinical presentation of CKD depends on the severity of kidney impairment (table 1). (See 'Clinical presentation by stage of chronic kidney disease' above.)
•Early stage – Patients in the early stages of CKD are often asymptomatic unless there are signs and/or symptoms that result directly from underlying structural kidney abnormalities or systemic diseases with kidney involvement.
Asymptomatic patients may be identified by elevated serum creatinine for age, abnormalities on urinalysis, or detection of kidney disease by imaging studies, particularly prenatal ultrasonography.
•Moderate CKD – Patients with moderate CKD (stage 3 CKD) may present with poor growth.
•Severe CKD – Patients with severe kidney impairment or failure (stages 4 and 5 CKD) may present with signs and symptoms of uremia, such as weakness, fatigue, anorexia, or vomiting.
●Complications – Loss of kidney function is associated with a number of comorbid complications. These include fluid and electrolytes abnormalities, mineral and bone disorders (chronic kidney disease-mineral and bone disorder) (figure 2), anemia, hypertension, cardiovascular risk factors, endocrine abnormalities, growth impairment, and uremia. (See 'Complications of chronic kidney disease' above and "Chronic kidney disease in children: Complications".)
●Evaluation
•Who should be evaluated – Evaluation is considered for all children who have an underlying risk factor for CKD. Additional important aspects of the history include age at onset of symptoms, duration of symptoms, and additional features of CKD (eg, hypertension or poor growth) or risk factors for CKD (eg, family history or congenital anomalies of the kidney and urinary tract [CAKUT]). (See 'Who should be evaluated' above and 'Additional history' above.)
•Physical examination – The examination of the child with suspected CKD should include measurement of growth parameters and blood pressure (BP), assessment for pallor, cardiovascular examination, and examination of the extremities for bony deformities and edema. (See 'Physical examination' above.)
•Renal imaging – Imaging may be useful in identifying the underlying cause of CKD and assessing renal parenchymal structure. Typically, ultrasonography is the preferred initial modality as it is widely available, safe, and noninvasive. (See 'Imaging' above.)
•Laboratory tests – Laboratory testing determines the severity of kidney impairment and detects the presence of associated complications. Tests include serum creatinine, electrolytes including serum bicarbonate, complete blood count, urinalysis, and quantification of urinary protein by a urine protein-to-creatinine ratio. Other tests to consider include serum calcium, phosphorus, 25-hydroxyvitamin D, and parathyroid hormone. (See 'Laboratory testing' above.)
•Referral – For children who are diagnosed with CKD, consultation with a pediatric nephrologist is desirable to guide additional testing and evaluation. (See 'Referral' above.)
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