Pediatric emergency medicine trisk 2912 2912

Triage considerations. Patients with CKD may present in extremis due to
fluid or electrolyte imbalances. Cardiopulmonary function may be severely
compromised due to volume excess. Patients may demonstrate lifethreatening dysrhythmias due to electrolyte disturbances. Altered mental
status may be secondary to azotemia, electrolyte, or acid–base
abnormalities. Triage will depend on the patient’s clinical status at the time
of presentation.
Clinical assessment. Though many children with CKD who present for
emergent care have a known history of renal disease, some will present with
previous unknown CKD. For those with a new diagnosis, the physician
should inquire about previous episodes of urinary tract infections as well as
signs of concentrating defects or urologic disease, such as polyuria,
polydipsia, and enuresis. To evaluate for signs consistent with chronic
glomerulonephritis, history of gross hematuria, edema, rashes, or evidence
of systemic inflammation should be sought. A review of family history
should include inquiries of urologic disease, vesicoureteral reflux,
progressive kidney disease, cystic kidney disease, and early-onset
hypertension.
The physical evaluation of a child with CKD must include accurate
assessment of blood pressure, cardiopulmonary examination, volume status,
and growth parameters. Initial laboratory studies should be guided by the
presenting complaint and history, though assessment of blood counts,
electrolytes (including calcium and phosphorus), acid–base status, and renal
function should be performed. The GFR may be estimated by using the
Schwartz formula ( Table 100.13 ), which takes into account the serum
creatinine and the patient’s height and gender. However, it must be
acknowledged that this formula overestimates GFR especially at levels of
decreased function. Urinalysis should also be performed. Most patients with
congenital dysplasia or reflux nephropathy will have bland urine sediments
and modest amounts of proteinuria. Significant hematuria, heavy
proteinuria, and active urine sediment with glomerular hematuria and
cellular casts would be consistent with glomerular disease. Further

laboratory studies should be guided by the presentation of illness and
clinical suspicion.
For all children with newly diagnosed CKD of unknown etiology and for
many children with known urologic disease, a renal ultrasound is indicated.