Opinion

VIEWPOINT

KDIGO 2024 Guidelines—Key Points for Pediatricians

Anna Francis, MBBS, PhD; Rukshana Shroff, MD, PhD; Amy Earley, BS; Bethany J. Foster, MD, MSCE

Chronic kidney disease (CKD) care in childhood presents unique Use of a cystatin C–based eGFR equation is recommended in chil-
challenges, including age-based assessments of kidney function, un- dren with low muscle mass (eg, neuromuscular conditions or se-
derstanding disease trajectories, and supporting growth. Here, we vere malnutrition), as creatinine-based equations may give falsely
summarize key takeaways for pediatricians from the Kidney Dis- high eGFR values.
ease: Improving Global Outcomes (KDIGO) 2024 update of the Clini-
cal Practice Guideline for the Evaluation and Management of CKD.1 Proteinuria
Proteinuria should be assessed using a first-morning midstream
Estimating Glomerular Filtration Rate and Proteinuria sample to avoid detecting orthostatic proteinuria, which affects 2%
Glomerular Filtration Rate to 5% of adolescents. Exercise, menstruation, and intercurrent in-
It is important to estimate glomerular filtration rate (GFR) in children fection can cause transient proteinuria.
using validated equations developed or validated in comparable popu- Both protein to creatinine (PCR) and albumin creatinine (ACR)
lations (Figure). Many pediatric nephrologists will use the Chronic Kid- ratios should be included in initial screening, which will capture glo-
ney Disease in Children Under 25 (CKIDU25) estimated GFR (eGFR) merular (ACR) and glomerular and tubular (PCR) proteinuria. A high
equation,2 an update of the modified Schwartz equation.3 This equa- PCR and low ACR points to tubular proteinuria. Subsequently, PCR or
tion was developed and validated in pediatric and young adult CKD ACR can be monitored, noting that PCR is cheaper than ACR and more
populations, increasing accuracy in estimating GFR in children with reference data exist for PCR than ACR in neonates and children.5
CKD. The development cohort included Black, Hispanic, and White Urine PCR varies with age and body size. Neonates have high
children and was validated in European populations. The CKIDU25 glomerular and tubular protein losses with high urine PCR (1000-
equation has lower accuracy and/or higher bias in very low (<15 mL/ 3000 mg/g [100-300 mg/mmol]) in the first few days of life. With
min/1.73 m2) and high GFR (>90 mL/min/1.73 m2) ranges and in the tubular maturity and increase in muscle mass, urine PCR decreases
very young (<5 years). Another commonly used pediatric eGFR equa- to less than 500 mg/g (50 mg/mmol) by 6 months and further de-
tion,theEuropeanKidneyFunctionConsortium(EKFC)equation,4 was creases by 2 years to less than 200 mg/g (20 mg/mmol).5
developed using a European general pediatric cohort, with a smaller
proportion of children with CKD. The EKFC equation has the advan- Definition of Low eGFR Creatinine in Children
tage of not requiring height, but accuracy was poorer when vali- An eGFR creatinine of less than 90 mL/min/1.73 m2 can be flagged
dated in an external multiethnic CKD population. as low in children older than 2 years. This new recommendation em-

Figure. Screening Algorithm for Diagnosis and Staging of Chronic Kidney Disease (CKD) in Pediatrics

Identify children aged >2 y at risk of CKD

Test for GFR, ACR, and PCR with or without other markers of kidney damage

GFR <60 mL/min/1.73 m2, ACR ≥30 mg/g (3 mg/mmol)

or PCR >200 mg/g (20 mg/mmol), or other markers
of kidney damage

Test for GFR or for ACR or PCR if not performed and exclude AKI and AKD
Acute kidney disease (AKD) is
defined by the abnormalities of
kidney function or structure with
GFR <60 mL/min/1.73 m2, AKI or AKD present: GFR ≥60 mL/min/1.73 m2,
ACR ≥30 mg/g (3 mg/mmol), follow AKI or AKD guidance ACR <30 mg/g (3 mg/mmol), implications for health and with
or PCR >200 mg/g (20 mg/mmol) or PCR <200 mg/g (20 mg/mmol) a duration of 3 months or less.
after 3 mo or earlier if evidence and no other markers of kidney Please also see the Kidney Disease:
of chronicity damage
Improving Global Outcomes (KDIGO)
Clinical Practice Guideline for Acute
Stage according to GFR and ACR, For children <2 y substitute CKD not present but high risk in those Kidney Injury.1 ACR indicates albumin
establish underlying cause, age-appropriate eGFR and with GFR <90 mL/min/1.73 m2, to creatinine ratio; AKI, acute kidney
estimate risk of progression, proteinuria thresholds timing of retesting based on individual injury; eGFR, estimated glomerular
and initiate treatment characteristics, such as risk of progression
filtration rate; PCR, protein to
creatinine ratio.

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 Opinion Viewpoint

phasizes that children and adolescents should have excellent kid- tension, kidney stones, kidney outflow obstruction or anomalies
ney function. A large study found children with a sustained eGFR of of the kidney and urinary tract, known or suspected CKD, or recur-
60 to 90 mL/min/1.73 m2 had a 10% to 40% risk of a 50% decline rent urinary tract infections.
in eGFR or reaching kidney failure within 10 years, with risk highest
among those with glomerular kidney disease.6 Blood Pressure
Children with CKD stage 3 to 5 should have annual BP monitoring
Thoroughly Assessing Children for Cause of CKD by ambulatory blood pressure monitoring (ABPM) and office BP,
Medical history should include birth weight, gestational age, ante- measured manually by auscultation following standardized proto-
natal course, nephrotoxic medications, hematuria, polyuria, and uri- cols, every 3 to 6 months. Where ABPM is not available, manual
nary tract infections. Blood pressure (BP), growth, development, and auscultatory office systolic BP measurements can be used.
volume status (edema or volume depletion) should also be evalu- A randomized clinical trial (RCT)7 reported that intensive BP
ated. A history of consanguinity and a family history of kidney dis- control delayed the progression of CKD in children. There were low
eases and hypertension must be sought. Children with a genetic risks of adverse effects in intensive BP lowering.7,8 We suggest
disorder affecting 1 organ system may have associated kidney in- that in children with CKD and 24-hour mean arterial pressure by
volvement and must be investigated appropriately. ABPM should be lowered to the 50th centile (or office systolic BP
in the range of the 50th to 75th percentile) for age, sex, and height,
Monitoring for Disease Progression unless achieving this target is limited by signs or symptoms of hy-
The kidneys of children with limited nephron mass may have low potension. Renin-angiotensin system inhibitors (RASi) can be used.
potential to adapt to rapid increases in body size and filtration re-
quirements. During periods of rapid growth (such as puberty), chil- Diet
dren with low GFR may show rapid decline in kidney function and An RCT9 in children showed a low protein diet leads to growth im-
should be monitored closely. A trajectory of preserved GFR or even pairment, so protein restriction is not recommended. The target pro-
hyperfiltration is common during childhood because of excellent re- tein and energy intake in children with CKD should be 100% to 140%
nal reserves, but these reserves may be exhausted during adoles- of the dietary reference intake (DRI) for ideal body weight in chil-
cence or young adulthood. Adolescents with low eGFR should con- dren with CKD3 and at 100% to 120% of the DRI in children with
tinue to have close monitoring in adulthood for evolution of CKD. CKD stage 4 or 5.

Referral to Specialist Kidney Care Services Conclusions

We suggest children and adolescents be referred to pediatric spe- The 2024 iteration of the KDIGO CKD guideline provides an evidence-
cialist kidney care services if they have a sustained early morning PCR informed approach to the evaluation and care of children and young
of 200 mg/g (20 mg/mmol) or greater or ACR of 30 mg/g (3 mg/ adults with CKD. Refinements to estimating GFR, BP targets, and ap-
mmol) or greater when well, persistent hematuria, any sustained de- proaches to advanced CKD care will improve outcomes for the young
crease in eGFR (ie, greater than expected from variability), hyper- people we care for.

ARTICLE INFORMATION serving as Chair of the Women in Transplantation of pooled data. Ann Intern Med. 2021;174(2):183-191.
Author Affiliations: Department of Nephrology, Initiative of The Transplantation Society. No other doi:10.7326/M20-4366
Queensland Children’s Hospital, Brisbane, disclosures were reported. 5. Filler G, Ferris M, Gattineni J. Assessment of
Queensland, Australia (Francis); School of Medicine, Additional Contributions: We thank the Kidney kidney function in children, adolescents, and young
University of Queensland, Brisbane, Queensland, Disease: Improving Global Outcomes Chronic adults. In: Emma F, Goldstein SL, Bagga A, Bates
Australia (Francis); Division of Pediatric Nephrology, Kidney Disease (KDIGO CKD) Work Group, KDIGO CM, Shroff R, eds. Pediatric Nephrology. Springer;
2022:145-171. doi:10.1007/978-3-030-52719-8_87
University College London Great Ormond Street staff, and the Johns Hopkins Evidence Review
Hospital and Institute of Child Health, London, Team who made this guideline possible. 6. Gluck CA, Forrest CB, Davies AG, et al. Evaluating
United Kingdom (Shroff); Kidney Disease: kidney function decline in children with chronic
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Corresponding Author: Anna Francis, MBBS, PhD, for the evaluation and management of chronic
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Conflict of Interest Disclosures: Dr Earley reported
Furth SL, Schwartz GJ. Age- and sex-dependent multicentre, randomised, controlled trial. Lancet
personal fees from Kidney Disease: Improving Global clinical equations to estimate glomerular filtration Child Adolesc Health. 2023;7(1):26-36. doi:10.1016/
Outcomes. Dr Shroff reports consultancy fees (paid rates in children and young adults with chronic S2352-4642(22)00302-9
to institution) from AstraZeneca and Fresenius kidney disease. Kidney Int. 2021;99(4):948-956. 9. Uauy RD, Hogg RJ, Brewer ED, Reisch JS,
Medical Care, research support (paid to institution) doi:10.1016/j.kint.2020.10.047 Cunningham C, Holliday MA. Dietary protein and
from Fresenius Medical Care and Vitaflo, and speaker
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honoraria from Amgen and Fresenius Medical Care. a report from the Southwest Pediatric Nephrology
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Dr Foster reports receiving research support (paid spectrum creatinine-based equation to estimate Study Group and the University of California,
to institution) from the Canadian Institutes of Health glomerular filtration rate: a cross-sectional analysis San Francisco. Pediatr Nephrol. 1994;8(1):45-50.
Research and the National Institutes of Health and doi:10.1007/BF00868260

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