This can provide a valuable assessment of the renal parenchyma and the urologic tract Ultrasound can detect such disorders as renal dysplasia, renal cortical thinning consistent with reflux nephropathy, cystic kidney disease, urinary tract obstruction, and screen for renal vascular disease Kidneys that appear relatively normal in architecture but enlarged, are suggestive of an acute or reversible process Small kidneys would be consistent with a chronic process and parenchymal scarring Imaging requiring IV contrast including gadolinium may worsen renal injury and should be avoided when possible or used in conjunction with consultation of a pediatric nephrologist or radiologist Management The treatment of children with CKD can range from routine care to intensive management If a child with CKD presents to the ED with a significant illness, treatment should be coordinated with a pediatric nephrologist when possible The initial approach should identify reversible causes of decreased renal function, such as intravascular volume depletion and use of nephrotoxic medications (i.e., NSAIDs) Children who have decreased effective circulating volume should be provided IV isotonic fluid if oral hydration is expected to be insufficient or not well tolerated Bolus IV fluid can be provided at 10 mL/kg and should be followed by repeated assessment to determine if further IV fluid is warranted Patients presenting in shock may require more aggressive fluid resuscitation Subsequent fluid rates should be provided on the basis of ongoing losses and urine flow to ensure adequate perfusion and avoid volume excess With severe decline in GFR, sodium and water retention may develop and lead to clinical signs of volume overload Diuretic therapy should be trialed for treatment of clinical volume overload, although it may not be adequately effective Furosemide at a dose of 0.5 to mg/kg may be given intravenously, recognizing that higher doses may be required to achieve the desired effect for those with more severe renal dysfunction For children with sustained hypertension, therapy will depend on the degree and the chronicity of elevation Severe hypertension with end organ dysfunction or concern for impending end organ dysfunction should be treated with shortacting IV antihypertensive medications such as hydralazine, β-blockers such as esmolol and labetalol, or calcium channel blockers The goal of therapy is to lower the blood pressure by 20% to 30% or to a range that is not acutely dangerous within the first to hours Blood pressure can then