Children may present to the ED with previously undiagnosed CKD Life-threatening electrolyte and acid–base disturbances may be present on presentation requiring emergent intervention Management must focus on restoring homeostasis while treating any potential underlying causes Patients may require emergent RRT Current Evidence The definition of CKD is based upon persistent structural or functional abnormalities, which may be associated with reduced or normal GFR It may be due to congenital or acquired pathologies The natural history of CKD is variable and depends upon the severity of the underlying kidney damage A significant insult or progressive loss of functioning nephron mass may lead to ESRD In 2002, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative published diagnostic criteria and a classification scheme to define the stages of CKD in patients older than years ( Table 100.15 ) Goals of Treatment Emphasis is placed on early detection and intervention as measures to inhibit the progression of renal dysfunction include treating hypertension and reducing significant proteinuria For children who progress to ESRD, therapies include chronic hemodialysis, peritoneal dialysis, and renal transplantation Renal transplantation is recognized as the preferred treatment for children with ESRD, as restoration of normal renal physiologic function can greatly improve the child’s quality of life Clinical Considerations Clinical recognition The clinical presentation of CKD will depend upon the severity of the renal dysfunction and the underlying cause Children with mild CKD (stage and 2) and no other comorbidities may be asymptomatic Children with more severe CKD are at increased likelihood for associated signs and symptoms such as fatigue, anorexia, and poor growth Furthermore, these children may present for emergent care with a