Box 2 The management in the NDCP on chronic kidney disease in children

1

Maintain height and head circumference growth according to age-related curves, which implies:

Correct acidosis by limiting excess protein and prescribing sodium bicarbonate to achieve an alkaline reserve of > 22 mmol/L

Counteract the usual electrolyte imbalance in uropathy: free sodium diet and supplementation if necessary

Note that potassium retention is rare in malformative uropathies, allowing normal potassium intake even in advanced stages of renal failure

In patients with a GFR < 60 mL/min/1.73 m², where growth remains retarded despite nutritional optimization, treatment with growth hormone injection may be indicated

2

Management of anemia to obtain a normal hemoglobin level for age: correction of iron deficiency, folates and if necessary, treatment with erythropoiesis stimulating agents

3

Management of bone and mineral metabolism disorders: these disorders increase with decreasing GFR and include hyperphosphatemia, hypocalcemia, vitamin D deficiency and hyperparathyroidism. The role of the dietician is essential in reducing phosphate intake and ensuring normal calcium intake. Vitamin D supplementation (ergocalciferol or cholecalciferol) is systematic and adapted to the age of the child with the 25-OH level maintained within recommended targets. When renal insufficiency is advanced, active derivatives of vitamin D (Un-alfa^©) are used and the addition of phosphorus binders becomes necessary

4

Cardiovascular prevention: Blood pressure measurement should be part of the clinical examination. The cuff should be appropriate for the size of the child. In CKD, the target blood pressure is in the 50 th percentile of the norms for age and height. In PUV, hypertension is uncommon due to the usual sodium depletion and only occurs in the later stages of renal failure. It may sometimes occur earlier in cases of renal scarring secondary to pyelonephritis. A conversion enzyme inhibitor (CEI) or an angiotensin II antagonist should be used as a first-line treatment, regardless of the level of associated proteinuria, subject to monitoring of the blood chemistry and a cautious and gradual dose increase. In parallel, a healthy lifestyle is recommended with regular physical activity, fighting against obesity and information about the harmful effects of smoking

5

Preservation of renal function. Avoid UTIs, episodes of dehydration (prompt medical consultation in case of digestive disorders) and nephrotoxic drugs (NSAIDs) or limit their use (aminoglycosides). Adapt drug doses to the level of GFR and check blood tests if available to detect the appearance of pathological microalbuminuria and, if necessary, propose treatment with CEI

6

Preparation for renal transplantation (RT). In the event of renal failure, renal replacement therapies will inevitably be needed with dialysis and RT at an age that can vary from the first year of life to adulthood, depending on the degree of damage. In any case, it is important to anticipate this deadline from the neonatal period:

By preserving the child’s venous and arterial capital as it may be necessary to create an arteriovenous fistula for hemodialysis one day. Arm punctures should be avoided, and blood samples should be taken on the back of the hands. If frequent injections are needed for antibiotic therapy or episodes of dehydration, or in the event of frequent ionic controls, particularly in infants with severe renal insufficiency, an implantable central line catheter should be discussed

By limiting transfusions as much as possible. This can immunize the child in the HLA system and thus reduce his access to a renal transplant

Anticipating vaccinations and the specific pre-transplant assessment