Nephrology••

Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study

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Abstract

Background Ocular disorders can arise in the advanced stages of chronic kidney disease (CKD) for various reasons, including uraemia, biochemical abnormalities, hypertension and inadequate haemodialysis treatment.

Methods We conducted a cross-sectional study at the Pediatric Nephrology Department, both inpatient and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.

Results The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p<0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p<0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p<0.001).

Conclusion This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings.

What is already known on this topic

Ocular manifestations are prevalent among paediatric patients with chronic kidney disease (CKD), especially with advancing stages. The spectrum of ocular symptoms can be extensive and permanent visual impairment may result from failure to detect and treat the disease in an expedient manner.

What this study adds

In the context of Bangladesh, this is the first study to investigate the ocular manifestations of paediatric CKD patients in relation to potential clinical and biochemical risk factors. Ocular manifestations were most prevalent among children in the final stages of CKD. In advanced CKD, hypertensive retinopathy was prevalent and significantly associated with elevated serum phosphate and calcium phosphate products as well as a decline in estimated glomerular filtration rate and haemoglobin levels.

How this study might affect research, practice or policy

Due to the paucity of prior research, this study sheds light on a relatively neglected but critical aspect of the paediatric CKD population in Bangladesh. The results indicate that ocular manifestations are relatively prevalent among paediatric patients with CKD. It also emphasises the significance of clinical vigilance, routine screening and additional research into the prevention and early treatment of this condition.

Introduction

Chronic kidney disease (CKD) is a significant global public health issue associated with considerable morbidity and mortality.1 CKD often goes undetected and undiagnosed until it reaches an advanced stage and leads to kidney failure. The prevalence of CKD among children under the age of 16 is between 1.5 and 3.0 cases per million children,2 which can result in multiorgan dysfunction, including various ocular complications.3 In advanced CKD stages, ocular problems may result from uraemia, biochemical abnormalities, hypertension or inadequate haemodialysis treatment.4

The ocular manifestation of advanced CKD results from interactions of multiple factors including underlying risk factors, metabolic aberrations, uraemia and anaemia and treatment induced.5 Hypertensive retinopathy (HR) is the most frequent cause of visual disturbance in these patients, which may initially be asymptomatic but can progress to permanent visual loss if not promptly diagnosed and treated (Ignat et al., 1999; Bajracharya et al., 2008 Contrarily, in CKD with severe anaemia (hemoglobin≤5 gm/dL), retinal arterioles may be pale and optic disc pallor (ischaemic optic neuropathy) may occur.6 In patients with poorly regulated blood pressure, CKD further worsens retinopathy. Thus, treating hypertension in end-stage renal failure may stabilise vision and reduce cataracts.7 Among the biochemical parameters, hypercalcemia and secondary hyperparathyroidism may cause corneal and conjunctival calcifications.8 On the other hand, chronic dialysis patients may develop subsequent cataract due to lens fluid variations,9 whereas inadequate haemodialysis can result in ocular manifestation due to alteration of lacrimal secretion.10 There has also been reported instances of posterior subcapsular cataracts in patients receiving steroid therapy for chronic glomerulonephritis.9 Urea accumulation in lens can also cause chronic water buildup, resulting in osmotic cataract. Furthermore, severe optic nerve injury can result from high intraocular pressure.11

While it is established that individuals with CKD are at higher risk for ocular issues, these complications vary across CKD stages and depend on multiple factors. For instance, while Nusinovici et al5 found that ocular complications significantly increase as CKD progresses to end stage, leading to prominent visual impairment, Bajracharya et al12 identified maculopathy as the predominant issue in a different cohort. These discrepancies in findings underscore the complexity of CKD-related ocular manifestations and highlight the need for further investigation. The data are particularly sparse regarding the paediatric population, with very few studies exploring the prevalence and potential contributing factors of ocular complications in children.13 Given the lack of comprehensive studies focused on paediatric patients, especially in South Asia, our study aims to address this gap by systematically evaluating the ophthalmological changes in paediatric CKD patients in Bangladesh. This study seeks to provide a clearer understanding of the prevalence, severity and underlying mechanisms of these ocular complications, thereby emphasising the importance of regular screening and early intervention to improve the quality of life for these patients.6–10 10–12

Materials and methods

This cross-sectional study was conducted over a period of 1 year, from June 2020 to July 2021 at Department of Pediatric Nephrology of a tertiary-level hospital in Bangladesh. @@@This site was selected since it is situated in the capital city and serves patients from across the entire country.

Study participants

Paediatric patients aged 5–18 of both sexes with advanced CKD (stage III, IV, V and VD dialysis dependent) and consenting parents/legal guardians were included in the study. Acute or chronic eye disorders, ocular trauma within 3 months, CKD owing to cystinosis, oxalosis, Alport syndrome and non-co-operative children were excluded from the study. Each paediatric patient with advanced CKD who visited the department during the study period was consecutively assessed for eligibility. A total of 196 patients were assessed for eligibility and 92 patients were included in final analysis (figure 1).

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Figure 1

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) diagram of flow of participants at different stages of the study.

Study procedure

After obtaining consent from the patients’ parents/legal guardians, a semistructured questionnaire was filled out for each case containing detailed history, clinical examination and lab report findings. Blood obtained through aseptic precautions was transported to the institution’s Clinical Pathology Laboratory and Biochemistry Department for measurement. Alport syndrome was ruled out by checking for familial hematuria, sensorineural deafness, anterior lenticonus, macular and perimacular retinopathy and corneal erosion. CKD diagnosis was based on patients’ previous prescription. Allergic conjunctivitis was ruled out during eye examination. To rule out cystinosis, corneal cystine crystal was inspected with slit lamp examination, and retinal pigmentation for oxalate crystal was checked for oxalosis exclusion.

CKD occurs when there is gradual decline in renal function, causing a progressive decrease in glomerular filtration rate (GFR). It also comprises a range of pathophysiologic processes that are linked to abnormal kidney function.14 Grading of CKD was done following KDIGO guidelines 2012. Estimated GFR (eGFR) was calculated by revised Schwartz formula as follows—eGFR=0.413 × (height/S. creatinine), where height was expressed in centimetre and serum creatinine in mg/dL.15 After measurement of eGFR, each patient was categorised as stage I, II, III, IV, V and V(D).15 16

An experienced ophthalmologist performed the ophthalmological examination. Visual acuity was measured with a Snellen chart.17 Schirmer tear test strips measured dry eye; Schirmer I: <10 mm in 5 min.18 Slit lamp bio microscopy (Appasamy, India) examined eyelids, cornea, conjunctiva and lens. L-5110 applanation tonometer (Inami & Co, Japan) assessed intraocular pressure. For posterior segment eye examination, pupils were dilated with tropicamide eye drops (trophen–tropicamide 0.8% and phenylephrine HCL) with fundus evaluation using (a) direct ophthalmoscopy (HEINE Beta-200, HEINE Optotechnik GmbH & Co KG, Germany) and (b) indirect ophthalmoscopy+20 diopter lens. Colour fundus photography was done for HR patients and graded according to Keith and Wagener classification.19 Visual acuity that was measured by using Snellen chart converted to quantitative variable with LogMAR visual acuity conversion chart.20 The patient was diagnosed with visual impairment if their VA LogMAR was <0.50, according to WHO guidelines.21 The parameters for biochemical testing included the possible associated factors, which has been shown to influence the ocular manifestation in CKD patients, including haemoglobin,6 urea,5 triglyceride and cholesterol,22 blood sugar,22 calcium and phosphate and parathyroid hormone.8

Statistical analysis

After data collection, it was thoroughly checked for inaccuracies and analysed using Stata V.16. Categorical data were displayed by frequency and relative percentage, whereas continuous variables were shown by mean and SD. Pearson’s χ² test, two independent sample t-test and Analysis of Variance(ANOVA) were used to examine two variables’ correlations. A two-tailed p<0.05 considered statistically significant.

Ethics

The Institutional Review Board at BSMMU granted ethical approval for this study; reference number: BSMMU/2020/4108. Wherever possible, adherence to the 1964 Declaration of Helsinki and its revisions, as well as similar ethical principles, was ensured. Each participant or their guardians have provided informed consent.

Patient and public involvement

Members of the public were involved in several stages of the study including design and conduct. We received input from children and their parents during the pilot and implemented them in our study design. We intend to disseminate the main results to study participants and will seek public involvement in the development of an appropriate method of dissemination.

Results

Out of 92 patients, 61 were men and 31 women. Male to female ratio in CKD was 1.97:1, with a mean age of 12.1±3.68 years. The highest prevalence was 41.3% for CKD stage VD. Hypoplastic kidney was the predominant cause of CKD, comprising 39.13% of the cases (table 1). Table 2 highlights CKD stage correlations with clinical and laboratory parameters. CKD progression led to a substantial increase in average systolic blood pressure (SBP) and diastolic blood pressure (DBP) (p<0.05). As CKD advanced, serum creatinine, urea, phosphate, Ca × PO4, and parathyroid levels increased. Conversely, the average eGFR, haemoglobin and serum calcium decreased. All indicators showed statistical significance (p<0.05), with CKD V and VD showing displaying the most pronounced shift. At advanced CKD, the eGFR dropped significantly and serum urea nearly doubled. The average intraocular pressure in stage VD chronic renal disease patients was 12.8±2.5 mm Hg. 29 (31.5%) patients had impaired vision, 9 in CKD V and 20 in stage VD. Lid oedema (12 in CKD V, 3 in VD), conjunctival pallor (21 in V, 18 in VD) and dry eyes (nine in VD) were also more common in later stages. 15 (16.30%) patients had HR, 1 in CKD V and 14 in VD. Each of these correlations was statistically significant and suggests that worsening CKD increases ophthalmological symptoms. Patients with HR had raised mean serum phosphate and Ca × PO4 levels. These patients also had decreased mean haemoglobin and eGFR. In contrast, conjunctival congestion patients had significantly higher serum phosphate and calcium phosphate products (table 3).

Table 1

Background characteristics of the study participants (n=92)

Table 2

Clinical parameters of study subjects at different stages of CKD (n=92)

Table 3

Comparison of laboratory parameters in relation to retinopathy and conjunctival congestion in the study subjects (N=92)

Discussion

To the researchers’ knowledge, this is Bangladesh’s first comprehensive research evaluating ophthalmological changes of paediatric CKD patients. Since the study institution was a specialist tertiary care hospital, 22.8% and 41.3% of patients sent from other hospitals had stage V and stage VD CKD. The most common cause of CKD was congenital abnormalities of the kidney and urinary tracts (CAKUT), which includes hypoplastic kidneys and obstructive uropathies. Our findings support the global consensus that infections and CAKUT cause most paediatric CKD.23 We also found that CAKUT is the leading cause of CKD in children in South Asia also, including India,24 Pakistan25 and Nepal.26 Due to a lack of diagnostic facilities, CAKUT was less common in Bhutan.27

Our research used clinical and laboratory parameters to correlate with CKD classifications. SBP and DBP increased significantly with CKD progression. Hypertension is the primary clinical indicator of CKD, and higher levels suggest a worse prognosis.28 Mean haemoglobin, eGFR, serum creatinine, urea, calcium, phosphate, calcium-phosphate product and parathyroid hormone correlated significantly with CKD advancement. Value changes in our study indicate accelerating CKD and may indicate deteriorating prognosis.29 30

Based on visual acuity, 29 patients (31.5%) in our study exhibited visual impairment, with 20 (69.0%) having CKD V. This association was statistically significant and suggests advanced-stage patients with CKD experience greater vision impairment. A complete assessment of ocular health requires consideration of the cornea, lens and retina as well as decreasing visual acuity.31 15 of 29 visually impaired patients had HR as their primary cause. This group had 14 (93.3%) stage VD patients. This finding supports Nusinvoici et al’s5 finding that retinopathy severity is correlated with renal impairment. Additionally, eGFR values below 30 mL/min/1.73/m² triple the risk of retinopathy.5 Furthermore, CKD resulting from chronic glomerulonephritis caused a posterior subcapsular cataract in one patient, impairing vision. Another research of adult patients with CKD identified maculopathy to be the main cause of visual impairment.12

Progression in CKD cause increasingly severe ophthalmological symptoms. Most (15, 79.0%) of the 19 patients with eyelid oedema were in CKD V and VD stages. Our findings match Mansour et al’s,4 who found eyelid oedema in 56.8% of end-stage renal disease (ESRD) patients. 56 patients (60.9%) had conjunctival pallor, indicating clinically evident anaemia and low haemoglobin. These findings align with Thulasidas and Amin,32 who found conjunctival pallor in 56.9% of patients with CKD. 9 (9.98%) stage VD patients reported dry eyes. Dry, red and irritated eyes are common in ESRD patients due to an altered blink reflex, shortened tear breakup times and decreased goblet cell density. CKD’s high vitamin A levels further accelerate the transition from secretory conjunctival mucosa to non-secreting keratinised epithelium.33 Akinci et al34 observed 15.8% of paediatric CKD patients had dry eye symptoms, matching our findings. In addition, El-Ghany et al13 identified dry eyes in 6.7% of haemodialysis patients compared with early CKD. One patient with chronic glomerulonephritis-related CKD stage VD and long-term steroid therapy had a posterior subcapsular cataract. A study also found 4.7% cataracts in paediatric ESRD patients with CKD VD due to CKD and dialysis complications.35 Stage VD CKD patients had an average intraocular pressure (IOP) of 12.8 mm Hg and an SD of 2.5. This measurement is within the usual 12-to-22-mm Hg IOP range. The finding matches with other studies. Both Mansour et al4 and Thulasidas and Amin32 found that the IOP of the study populations was 12.68±1.92 mm Hg and 13.4±2.2 mm Hg, respectively.

Conjunctival congestion was strongly correlated with serum phosphate and calcium phosphate levels in seven individuals (7.6%), six of whom were in stage VD. Calcium phosphate product buildup in the cornea and conjunctiva surpasses their solubility limit and causes persistent inflammatory changes, resulting in conjunctival congestion.9 36 In 2016, Malleswari and Rahmathunnisa37 found conjunctival congestion in 25.6% of haemodialysis patients with CKD. The medical goal for dialysis patients is to keep calcium-phosphate below 55 mg/dL .9

The most important results that potentially threaten vision in advanced CKD are posterior segment abnormalities. 45.7% of our patients had hypertension, and 16.3% had HR. All HR cases were in CKD VD patients. HR is rarer in children than adults, although renal insufficiency considerably increases it.38 The possible explanation for the connection between retinopathy and kidney function could be that retinal microvascular abnormalities resulting from hypertension, inflammation, and other processes may share a common pathophysiological link in the development and progression of CKD.37 In a study by El-Ghany et al,13 13.3% of Egyptian paediatric patients with CKD developed retinal abnormalities. Diabetes was common in ESRD adult research populations.4 However, none of the study participants had diabetes.

Ahsan et al39 found a strong link between low haemoglobin, high blood pressure, severe eGFR decline, and retinopathy risk. We also found that stage VD haemodialysis patients had high blood pressure, low haemoglobin and low eGFR. Comparing patients in different stages of CKD, these differences were significant (p<0.001). Most patients with HR were among haemodialysis group. Moreover, retinopathy patients had substantially low haemoglobin and eGFR. A strong correlation (p<0.001) was found between serum phosphate and calcium-phosphate product in HR patients. Increased blood phosphate levels may cause calcification in medium and large blood vessels, causing endothelial dysfunction and vascular disease in CKD patients. Retinopathy severity in CKD patients was independently associated to blood phosphate levels.40 Serum calcium and phosphate are also predictive markers for chronic renal disease-related ocular symptoms.39 CKD often causes secondary hyperthyroidism, which is exacerbated by mineral metabolism disruption. Therefore, these issues must be monitored routinely.

Limitations

This study had some limitations. It was a hospital-based study with no national sample. Due to COVID-19, sample size was limited. Additionally, the study did not assess intraobserver variation. Patients’ ophthalmological changes could not be assessed more extensively due to the study’s cross-sectional nature. Another limitation of our study is that Snellen’s criterion was translated to logMAR for visual acuity measurements. Scientifically, this conversion is imperfect since the two scales lack equivalent steps. This may have incorporated flaws into our data, affecting the precision of our visual acuity findings. Future study should consider using a single, uniform visual acuity test to avoid such differences. Expressing blood pressure in z-scores would have provided a more standardised comparison across different age groups. As a result, the observed increase in blood pressure may partially reflect the fact that advanced CKD stages are more common in older children, who naturally have higher normal blood pressure values.

Conclusion

Paediatric CKD patients often had ophthalmological symptoms, which increased with disease progression. Patients with CKD VD had the highest HR prevalence. Conjunctival congestion and HR were strongly linked to serum and calcium phosphate levels. If neglected, these disorders can cause permanent visual impairment, thus ophthalmological awareness and routine exams can help to detect and prevent them.

Halle MP, Takongue C, Kengne AP, et al. Epidemiological profile of patients with end stage renal disease in a referral hospital in Cameroon. BMC Nephrol 2015; 16.
doi:10.1186/s12882-015-0044-2•Google Scholar •PubMed
Meena J, Sinha A, Hari P, et al. Pediatric Kidney Transplantation: Experience over Two Decades. Asian J Pediatr Nephrol 2018; 1:22–8.
doi:10.4103/AJPN.AJPN_20_18•Google Scholar
Gao B, Zhu L, Pan Y, et al. Ocular fundus pathology and chronic kidney disease in a Chinese population. BMC Nephrol 2011; 12.
doi:10.1186/1471-2369-12-62•Google Scholar •PubMed
Mansour DE, El-Bayomi AM, El-Azab AM, et al. Abnormal Ocular Findings in Chronic Renal Failure Patients on Hemodialysis. The Egyp J Hosp Med 2018; 72:5640–6.
doi:10.21608/ejhm.2018.11540•Google Scholar
Nusinovici S, Sabanayagam C, Teo BW, et al. Vision Impairment in CKD Patients: Epidemiology, Mechanisms, Differential Diagnoses, and Prevention. Am J Kidney Dis 2019; 73:846–57.
doi:10.1053/j.ajkd.2018.12.047•Google Scholar •PubMed
Leys AM. Eye fundus of the diabetic patient with nephropathy and hypertensive retinopathy Macroangiopathic complications. Bull Soc Belge Ophtalmol 1995; 256:49–59.
Google Scholar •PubMed
Schmechel H, Heinrich U. Retinopathy and nephropathy in 772 insulin-treated diabetic patients in relation to the type of diabetes. Diabete Metab 1993; 19:138–42.
Google Scholar •PubMed
Resende LAL, Caramori JCT, Kimaid PAT, et al. Blink reflex in end-stage-renal disease patients undergoing hemodialysis. J Electromyogr Kinesiol 2002; 12:159–63.
doi:10.1016/S1050-6411(02)00007-X•Google Scholar •PubMed
Evans RD, Rosner M. Ocular abnormalities associated with advanced kidney disease and hemodialysis. Semin Dial 2005; 18:252–7.
doi:10.1111/j.1525-139X.2005.18322.x•Google Scholar •PubMed
Friberg TR, Eller AW. Serous retinal detachment resembling central serous chorioretinopathy following organ transplantation. Graefe's Arch Clin Exp Ophthalmol 1990; 228:305–9.
doi:10.1007/BF00920052•Google Scholar
Berlyne GM, Ari JB, Danovitch GM, et al. Cataracts of chronic renal failure. Lancet 1972; 1:509–11.
doi:10.1016/s0140-6736(72)90175-4•Google Scholar •PubMed
Bajracharya L, Shah DN, Raut KB, et al. Ocular evaluation in patients with chronic renal failure--a hospital based study. Nepal Med Coll J 2008; 10:209–14.
Google Scholar •PubMed
El-Ghany SMA, El-Salam MA, Farag MM, et al. Ocular Changes in Egyptian Children on Regular Hemodialysis. IJCM 2019; 10:353–62.
doi:10.4236/ijcm.2019.106028•Google Scholar
Thomas R, Kanso A, Sedor JR, et al. Chronic kidney disease and its complications. Prim Care 2008; 35:329–44.
doi:10.1016/j.pop.2008.01.008•Google Scholar •PubMed
Tamm ER, Ethier CR, Dowling JE, et al. Biological aspects of axonal damage in glaucoma: A brief review. Exp Eye Res 2017; 157:5–12.
doi:10.1016/j.exer.2017.02.006•Google Scholar •PubMed
Stevens PE, Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med 2013; 158:825–30.
doi:10.7326/0003-4819-158-11-201306040-00007•Google Scholar •PubMed
Azzam D, Ronquillo Y. Snellen chart. 2024;
Google Scholar
Schwartz GJ, Muñoz A, Schneider MF, et al. New equations to estimate GFR in children with CKD. J Am Soc Nephrol 2009; 20:629–37.
doi:10.1681/ASN.2008030287•Google Scholar •PubMed
Vitali C, Moutsopoulos HM, Bombardieri S, et al. The European Community Study Group on diagnostic criteria for Sjögren’s syndrome. Sensitivity and specificity of tests for ocular and oral involvement in Sjögren’s syndrome. Ann Rheum Dis 1994; 53:637–47.
doi:10.1136/ard.53.10.637•Google Scholar •PubMed
Holladay JT. Visual acuity measurements. J Cataract Refract Surg 2004; 30:287–90.
doi:10.1016/j.jcrs.2004.01.014•Google Scholar •PubMed
Mashige KP, Ramklass SS. Prevalence and causes of visual impairment among older persons living in low-income old age homes in Durban, South Africa. Afr J Prim Health Care Fam Med 2020; 12:e1–7.
doi:10.4102/phcfm.v12i1.2159•Google Scholar •PubMed
Wong CW, Wong TY, Cheng C-Y, et al. Kidney and eye diseases: common risk factors, etiological mechanisms, and pathways. Kidney Int 2014; 85:1290–302.
doi:10.1038/ki.2013.491•Google Scholar •PubMed
Warady BA, Chadha V. Chronic kidney disease in children: the global perspective. Pediatr Nephrol 2007; 22:1999–2009.
doi:10.1007/s00467-006-0410-1•Google Scholar •PubMed
Kanitkar M. Chronic Kidney Disease in Children: An Indian Perspective. Med J Armed Forces India 2009; 65:45–9.
doi:10.1016/S0377-1237(09)80055-5•Google Scholar •PubMed
Amanullah F, Malik AA, Zaidi Z, et al. Chronic kidney disease causes and outcomes in children: Perspective from a LMIC setting. PLoS ONE 2022; 17.
doi:10.1371/journal.pone.0269632•Google Scholar •PubMed
Kansakar P, Anjum MF, Daha SK, et al. Changing pattern of renal disease in children at pediatric nephrology clinic of a tertiary teaching hospital, Nepal: 10-year review. J Patan Acad Health Sci 2021; 8:94–100.
doi:10.3126/jpahs.v8i3.28870•Google Scholar
Sonam -, Lhadon T, Choden T, et al. Pattern and short-term outcome of pediatric kidney disease at national referral hospital in Bhutan: an observational study. Bhutan Health J 2022; 8:20–6.
doi:10.47811/bhj.133•Google Scholar
Flynn JT, Mitsnefes M, Pierce C, et al. Blood Pressure in Children With Chronic Kidney Disease. Hypertension 2008; 52:631–7.
doi:10.1161/HYPERTENSIONAHA.108.110635•Google Scholar
Furth SL, Abraham AG, Jerry-Fluker J, et al. Metabolic abnormalities, cardiovascular disease risk factors, and GFR decline in children with chronic kidney disease. Clin J Am Soc Nephrol 2011; 6:2132–40.
doi:10.2215/CJN.07100810•Google Scholar •PubMed
Pontoriero G, Cozzolino M, Locatelli F, et al. CKD patients: the dilemma of serum PTH levels. Nephron Clin Pract 2010; 116:c263–8.
doi:10.1159/000318787•Google Scholar •PubMed
Dahal P, Gouli S. Ocular findings in the chronic renal failure. J Coll Med Sci Nepal 2015; 10:18–26.
doi:10.3126/jcmsn.v10i2.12949•Google Scholar
Thulasidas M. Ocular Evaluation in Patients with Chronic Kidney Disease- A Hospital Based Study. OAJO 2018; 3.
doi:10.23880/OAJO-16000164•Google Scholar
Mullaem G, Rosner MH. Ocular problems in the patient with end-stage renal disease. Semin Dial 2012; 25:403–7.
doi:10.1111/j.1525-139X.2012.01098.x•Google Scholar •PubMed
Akinci A, Cakar N, Kara N, et al. Ocular findings in children with chronic renal failure. Cornea 2009; 28:5–6.
doi:10.1097/ICO.0b013e318181f9f0•Google Scholar •PubMed
Abdelrazek NI, Sallam DE. Ocular Findings in Pediatric Patients with Chronic Kidney Disease Stage 5 on Regular Hemodialysis. Med J Cairo Univ 2022; 90:1671–8.
doi:10.21608/mjcu.2022.272088•Google Scholar
Manjula B, Khadari MH, Velampalli S, et al. A Clinical Study of Retinal Changes in Chronic Renal Failure Patients. IOSR J D M S 2017; 16:31–4.
doi:10.9790/0853-1604063134•Google Scholar
Malleswari B, Rahmathunnisa I. Eye Findings in Chronic Renal Failure Patients Undergoing Hemodialysis. Int J Contemp Med Res 2016; 3.
Available: here
Google Scholar
Chakraborty K, Bhattacharya D, Kanwar P, et al. Sudden-Onset Blindness in a Child With Hypertensive Emergency: Unmasking of Chronic Kidney Disease. Cureus 2022; 14.
doi:10.7759/cureus.29233•Google Scholar •PubMed
Ahsan MK, Alam MR, Khanam A, et al. Ocular Fundus Abnormalities in Pre-Dialytic Chronic Kidney Disease Patients. JBM 2019; 07:20–35.
doi:10.4236/jbm.2019.711003•Google Scholar
Mehta R, Hodakowski A, Cai X, et al. Serum Phosphate and Retinal Microvascular Changes: The Multi-Ethnic Study of Atherosclerosis and the Beaver Dam Eye Study. Ophthalmic Epidemiol 2017; 24:371–80.
doi:10.1080/09286586.2017.1304562•Google Scholar •PubMed

Overview

Abstract
Introduction
Materials and methods
Results
Discussion
Conclusion
References

Footnotes
Publication history
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