Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Overview of renal replacement therapy (RRT) for children with chronic kidney disease

Lesley Rees, MD, FRCPCH
Bradley A Warady, MD
Section Editor
Tej K Mattoo, MD, DCH, FRCP
Deputy Editor
Melanie S Kim, MD


Pediatric chronic kidney disease (CKD) is a chronic, progressive disorder. However, the rate of decline varies with age, underlying etiology, and clinical findings. An improvement in renal function is often seen in the first two years of life, and this may be followed by a period of stability until puberty, when declining function develops [1]. Children with glomerular disease, proteinuria, and/or hypertension are more likely to have a progressive fall in renal function regardless of age [2]. Nevertheless, as the estimated glomerular filtration rate (GFR) declines to less than 30 mL/min per 1.73 m2 (CKD stage 4), preparations for renal replacement therapy (RRT) are needed [3]. The family and, if appropriate, the child should be provided with information related to preemptive kidney transplantation, peritoneal dialysis (PD), and hemodialysis (HD).

The choice and timing of RRT for children with CKD are reviewed here. Topic reviews that include more comprehensive descriptions of the different forms of RRT for pediatric CKD, including complications and outcome, are discussed separately. (See "Hemodialysis for children with chronic kidney disease" and "Chronic peritoneal dialysis in children" and "General principles of renal transplantation in children" and "Complications of renal transplantation in children".)


A classification schema for CKD in children is based upon the level of kidney function (defined by glomerular filtration rate [GFR]) as follows (table 1) [4]:

G1 − Normal GFR (≥90 mL/min per 1.73 m2)

G2 − GFR between 60 and 89 mL/min per 1.73 m2

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jul 13, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. González Celedón C, Bitsori M, Tullus K. Progression of chronic renal failure in children with dysplastic kidneys. Pediatr Nephrol 2007; 22:1014.
  2. Warady BA, Abraham AG, Schwartz GJ, et al. Predictors of Rapid Progression of Glomerular and Nonglomerular Kidney Disease in Children and Adolescents: The Chronic Kidney Disease in Children (CKiD) Cohort. Am J Kidney Dis 2015; 65:878.
  3. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002; 39:S1.
  4. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl 2013; 3:1.
  5. Srivastava T, Alon US, Althahabi R, Garg U. Impact of standardization of creatinine methodology on the assessment of glomerular filtration rate in children. Pediatr Res 2009; 65:113.
  6. Schwartz GJ, Muñoz A, Schneider MF, et al. New equations to estimate GFR in children with CKD. J Am Soc Nephrol 2009; 20:629.
  7. Harambat J, van Stralen KJ, Kim JJ, Tizard EJ. Epidemiology of chronic kidney disease in children. Pediatr Nephrol 2012; 27:363.
  8. United States Renal Data System, 2016 Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2016. www.usrds.org/adr.aspx (Accessed on July 26, 2016).
  9. Harambat J, Bonthuis M, Groothoff JW, et al. Lessons learned from the ESPN/ERA-EDTA Registry. Pediatr Nephrol 2016; 31:2055.
  10. Pruthi R, Hamilton AJ, O’Brien C, et al. UK Renal Registry 17th Annual Report: Chapter 4 Demography of the UK Paediatric Renal Replacement Therapy. Population in 2013. https://www.renalreg.org/wp-content/uploads/2014/12/04-Chap-04.pdf https://www.renalreg.org/wp-content/uploads/2014/12/04-Chap-04.pdf (Accessed on February 18, 2015).
  11. Chesnaye NC, Schaefer F, Groothoff JW, et al. Mortality risk in European children with end-stage renal disease on dialysis. Kidney Int 2016; 89:1355.
  12. McDonald SP, Craig JC, Australian and New Zealand Paediatric Nephrology Association. Long-term survival of children with end-stage renal disease. N Engl J Med 2004; 350:2654.
  13. Chesnaye NC, Schaefer F, Bonthuis M, et al. Mortality risk disparities in children receiving chronic renal replacement therapy for the treatment of end-stage renal disease across Europe: an ESPN-ERA/EDTA registry analysis. Lancet 2017; 389:2128.
  14. US Renal Data System. The Concise 2009 Annual Data Report: Atlas of Chronic kidney disease and End-stage Renal Disease in the US. National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, MD 2009.
  15. Lewis MA, Shaw J, Sinha M, et al. UK Renal Registry 11th Annual Report (December 2008): Chapter 13 Demography of the UK paediatric renal replacement therapy population. Nephron Clin Pract 2009; 111 Suppl 1:c257.
  16. NAPRTCS: 2008 Annual Report, Rockville, MD. http://www.emmes.com/study/ped/annlrept/Annual%20Report%20-2008.pdf (Accessed on March 14, 2011).
  17. North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) 2014 Annual Transplant Report. Emmes Corp., Rockville, MD. https://web.emmes.com/study/ped/annlrept/annualrept2014.pdf (Accessed on July 05, 2016).
  18. Pediatric ESRD. United States Renal Data System 2015 Annual Data Report. https://www.usrds.org/2015/view/v2_08.aspx (Accessed on July 05, 2016).
  19. ANZDATA Annual Report 2014. www.anzdata.org.au/anzdata/AnzdataReport/37thReport/c11_paediatric_print_20150929.pdf (Accessed on July 05, 2016).
  20. Gillen DL, Stehman-Breen CO, Smith JM, et al. Survival advantage of pediatric recipients of a first kidney transplant among children awaiting kidney transplantation. Am J Transplant 2008; 8:2600.
  21. Kramer A, Stel VS, Tizard J, et al. Characteristics and survival of young adults who started renal replacement therapy during childhood. Nephrol Dial Transplant 2009; 24:926.
  22. Kennedy S, Briggs N, Dent, H et al. Chapter 11: Paediatric in Australia and New Zealand Dialysis and Transplant Registry. http://www.anzdata.org.au/anzdata/AnzdataReport/35thReport/2012c11_paediatric_v1.9.pdf (Accessed on February 26, 2015).
  23. Sadowski RH, Harmon WE, Jabs K. Acute hemodialysis of infants weighing less than five kilograms. Kidney Int 1994; 45:903.
  24. Carey WA, Talley LI, Sehring SA, et al. Outcomes of dialysis initiated during the neonatal period for treatment of end-stage renal disease: a North American Pediatric Renal Trials and Collaborative Studies special analysis. Pediatrics 2007; 119:e468.
  25. Ma A, Shroff R, Hothi D, et al. A comparison of arteriovenous fistulas and central venous lines for long-term chronic haemodialysis. Pediatr Nephrol 2013; 28:321.
  26. Baracco R, Mattoo T, Jain A, et al. Reducing central venous catheters in chronic hemodialysis--a commitment to arteriovenous fistula creation in children. Pediatr Nephrol 2014; 29:2013.
  27. Clinical practice recommendation 8: vascular access in pediatric patients. Am J Kidney Dis 2006; 48 Suppl 1:S274.
  28. Warady BA, Bakkaloglu S, Newland J, et al. Consensus guidelines for the prevention and treatment of catheter-related infections and peritonitis in pediatric patients receiving peritoneal dialysis: 2012 update. Perit Dial Int 2012; 32 Suppl 2:S32.
  29. North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) 2011 Annual Dialysis Report. Emmes Corp., Rockville, MD. https://web.emmes.com/study/ped/annlrept/annualrept2011.pdf (Accessed on July 05, 2016).