Pediatric Chronic Kidney Disease

What Is Pediatric Chronic Kidney Disease?

Pediatric chronic kidney disease, usually shortened to pediatric CKD, means that a child’s kidneys have been damaged or have worked below their normal capacity for a prolonged period — generally defined as three months or more. It is a long-term condition rather than a single illness. It affects infants, children and adolescents whose kidneys carry structural damage, leak protein or blood into the urine, or filter waste less efficiently than they should. Treatment does not centre on one procedure; it is an ongoing programme of monitoring and adjustment designed to slow further damage, treat complications early and support normal childhood development.

To understand why the diagnosis matters, it helps to know what the kidneys actually do. They remove waste products and extra fluid from the blood. They balance minerals and salts such as sodium, potassium, calcium and phosphorus. They help control blood pressure, support red blood cell production and contribute to healthy bone development. When kidney function falls, the effects are not confined to the urinary system. They can reach the heart, the bones, the blood, the appetite, the child’s energy levels and — critically in childhood — growth itself.

Children are not simply small adults, and pediatric chronic kidney disease cannot be managed the way adult kidney disease is managed. A kidney problem in a growing child touches nutrition, bone development, blood pressure, puberty, school life, emotional wellbeing and family routines all at once. That is why care is led by pediatric nephrologists working within a broader pediatrics structure, supported by renal dietitians, specialist nurses, radiologists, urologists, transplant teams and other pediatric experts as the child’s needs change.

Pediatric chronic kidney disease behaves differently from child to child. It may remain stable for years, progress slowly, or worsen more quickly depending on the underlying cause and how the child responds to treatment. The goals of care are consistent throughout: slow further kidney damage, treat complications before they become entrenched, protect growth and development as far as possible, and prepare thoughtfully for dialysis or kidney transplantation if kidney failure develops. With structured monitoring and timely intervention, many children continue school, sports within agreed limits, and age-appropriate daily life while receiving ongoing medical care.

What are the different stages of pediatric chronic kidney disease (CKD)?

Pediatric chronic kidney disease is divided into five stages based on the estimated glomerular filtration rate (eGFR) — a calculation of how well the kidneys filter, adjusted for the child’s body size — together with evidence of kidney damage such as protein in the urine or abnormal kidney structure on imaging.

• Stage 1: kidney function is normal (eGFR of 90 or above), but there is evidence of kidney damage — for example, persistent protein in the urine or a structural abnormality on ultrasound.
• Stage 2: mildly reduced function (eGFR roughly 60 to 89) alongside signs of kidney damage.
• Stage 3: moderately reduced function (eGFR roughly 30 to 59). Complications such as anemia, growth concerns and bone-mineral changes become more likely and are actively screened for.
• Stage 4: severely reduced function (eGFR roughly 15 to 29). This is the stage at which detailed planning for dialysis or transplantation usually begins, well before either is needed.
• Stage 5: kidney failure (eGFR below 15, or the child is receiving dialysis). The kidneys can no longer do enough of their work on their own.

Two caveats matter in children. First, in infants under about two years of age, normal eGFR is naturally lower than in older children, so staging is applied cautiously and interpreted alongside growth, imaging and the underlying diagnosis. Second, the stage describes current function, not destiny. A child in stage 2 may remain there for many years with good blood pressure and proteinuria control; another child’s function may change faster. The stage mainly determines how closely the child is monitored and which complications the team looks for.

What Causes Chronic Kidney Disease in Children?

The causes of CKD in childhood differ sharply from the adult pattern. In adults, diabetes and long-standing high blood pressure dominate. In children, structural problems present from birth and inherited conditions account for a large share of cases, which is why the diagnostic work-up often reaches back to pregnancy scans and family history.

What are the most common causes of chronic kidney disease in children?

Congenital anomalies of the kidney and urinary tract — often abbreviated CAKUT — are the most common causes of chronic kidney disease in children. These are problems in how the kidneys and urinary tract formed before birth. They include kidney dysplasia (kidney tissue that did not develop normally), hypoplasia (kidneys that are too small), obstruction of urine flow, posterior urethral valves in boys, and vesicoureteral reflux — urine flowing backwards from the bladder towards the kidneys, which can scar kidney tissue over time. Many of these conditions are first suspected on a prenatal ultrasound, and some belong to the wider family of congenital disease that pediatric teams follow from birth.

Glomerular diseases form the second major group. These conditions inflame or scar the kidney’s filtering units and typically announce themselves through protein in the urine, blood in the urine, swelling, high blood pressure or declining kidney function on blood tests. Examples include focal segmental glomerulosclerosis, IgA nephropathy, lupus nephritis and membranoproliferative patterns of injury. Treatment often involves medication that dampens inflammation or modifies immune activity, alongside strict blood pressure and proteinuria control.

Inherited kidney disorders are the third group. Polycystic kidney diseases, Alport syndrome, nephronophthisis and cystinosis are among the genetic conditions that can lead to CKD in childhood or adolescence. A confirmed genetic diagnosis matters beyond the label: it can shape treatment, prompt screening of siblings and parents, trigger hearing or eye evaluations in conditions such as Alport syndrome, and inform long-term planning for the whole family.

Other causes include reflux nephropathy after repeated kidney infections, haemolytic uraemic syndrome following certain infections, autoimmune conditions affecting the kidneys, kidney injury that complicates other serious illness, and damage from medicines that are toxic to kidney tissue. In some children, more than one factor contributes, and in a minority the cause remains uncertain even after thorough evaluation — which is itself useful information, because it changes how the team monitors and treats.

What is the most common kidney disorder in children?

Urinary tract infections are the most common kidney and urinary problem in children overall — far more common than chronic kidney disease itself, and in most children they resolve with treatment and leave no lasting damage. The distinction matters. Among conditions that lead to long-term loss of kidney function, congenital anomalies of the kidney and urinary tract are the most common, while nephrotic syndrome is the most common glomerular disorder of childhood. So the answer depends on what is being asked: the most frequent kidney-related complaint a pediatrician sees is infection; the most frequent driver of pediatric chronic kidney disease is a structural abnormality present from birth. Repeated kidney infections combined with reflux can, however, bridge the two — which is why recurrent infections in a young child are investigated rather than simply treated and forgotten.

Signs and Symptoms of Kidney Disease in Children

What are the first signs of kidney disease in children?

Often there are no obvious first signs at all. Early pediatric CKD is frequently silent, discovered through a urine test, a blood test or a blood pressure reading taken for another reason, or through a prenatal scan before the child is even born. When early signs do appear, they tend to be subtle and easy to attribute to something else: puffiness around the eyes, particularly in the morning; swelling of the ankles or feet; urine that looks foamy or contains visible blood; a child who was dry at night starting to wet the bed again; urinating unusually often or unusually little; poor growth compared with siblings or peers; pale skin; persistent tiredness; and a poor appetite.

As kidney function falls further, symptoms usually become harder to miss. Children with more advanced CKD may experience fatigue that limits play, nausea and vomiting, itching, headaches, bone pain, delayed growth, delayed puberty, difficulty concentrating at school and reduced tolerance for exercise. High blood pressure is common at this stage and may itself cause headaches or remain entirely unnoticed without measurement.

The most important point for parents is that a child can look and feel well while carrying significant protein in the urine, high blood pressure or reduced kidney function on blood testing. This is why routine medical care — and careful interpretation of even mildly abnormal blood and urine results — matters so much in childhood. Symptoms are a late messenger in kidney disease; the laboratory usually speaks first.

How Pediatric Chronic Kidney Disease Is Diagnosed

Diagnosis begins with a detailed history and physical examination. The physician asks about the pregnancy and birth, growth patterns since infancy, previous infections, urinary symptoms, family history of kidney disease or deafness, medication use, prior blood pressure readings and any other medical conditions. Growth charts are reviewed carefully, because a child’s height and weight trajectory can reveal problems that a single visit cannot. From there, the work-up typically follows a stepwise sequence:

1. Blood tests. Creatinine — and cystatin C in selected cases — is used to estimate kidney filtration. Urea, sodium, potassium, bicarbonate, calcium, phosphorus, parathyroid hormone, vitamin D, albumin, hemoglobin and iron stores map out both function and complications. Immune and inflammatory markers are added when glomerular disease is suspected.
2. Urine tests. The protein-to-creatinine ratio and albumin measurement quantify protein leakage. The urine is also examined for blood, infection and concentrating ability.
3. Kidney and bladder ultrasound. This is usually the first imaging step because it is non-invasive and involves no radiation. It shows kidney size, structure, scarring, cysts, obstruction, hydronephrosis and bladder abnormalities.
4. Further imaging when needed. Selected children need studies of urinary reflux, drainage or blood flow to clarify how urine moves and where it is being held up.
5. Kidney biopsy. When glomerular disease or another complex diagnosis is suspected, a small sample of kidney tissue is taken under image guidance and examined under the microscope. Sedation or anaesthesia is adapted to the child’s age and medical condition, and the result frequently changes treatment.
6. Genetic testing. This is considered when an inherited condition is suspected, when the family history points that way, or when the diagnosis remains unclear after standard evaluation.

Blood pressure itself is measured with more care than many families expect. In children, an accurate reading depends on a cuff sized correctly for the arm, repeated measurements taken at rest, and comparison against reference values for the child’s age, sex and height rather than adult thresholds. When clinic readings are borderline or inconsistent, 24-hour ambulatory blood pressure monitoring — a small wearable device that records pressure through a normal day and night — can distinguish true hypertension from clinic nervousness, and can also reveal the opposite problem: pressure that looks normal in clinic but runs high at home or during sleep.

Not every child needs every step. A toddler with a clear structural abnormality on ultrasound follows a different path from a teenager with heavy proteinuria and normal-looking kidneys. The purpose of the sequence is to establish two things with confidence: why the kidneys are damaged, and how much function remains — because both determine everything that follows.

Who May Need Specialist Pediatric Kidney Care

Children reach a pediatric nephrology team by several routes. Some are identified before birth, when a prenatal ultrasound shows kidney or urinary tract abnormalities. Others are referred after urinary tract infections, abnormal urine tests at a routine check, unexplained high blood pressure, poor growth, swelling, or blood results that show reduced kidney function found incidentally during another illness.

Families with an established diagnosis may also seek specialist review — for a second opinion, when kidney function is worsening, when blood pressure or proteinuria has proved difficult to control, when growth has fallen behind, or when dialysis or transplant planning has been recommended and the family wants the reasoning examined carefully.

How Pediatric Chronic Kidney Disease Is Treated

There is no single operation or medicine that treats pediatric CKD. Treatment is an individualised plan built around the cause, the stage, the child’s age and size, laboratory results, blood pressure, urine findings and the family’s circumstances. The process usually begins with a structured review of the child’s existing medical records, laboratory results, imaging, biopsy reports, growth charts and medication lists, so the team knows what is established, what needs confirmation and which additional tests are genuinely worth doing.

At the initial clinical evaluation, the child’s blood pressure, height, weight, growth velocity, physical development, fluid status and general health are assessed. Growth deserves emphasis: in pediatric kidney disease it is one of the most sensitive overall markers, because faltering height or weight can reveal nutritional shortfall, metabolic acidosis, hormonal effects of CKD or simply the total burden of the disease. The team also reviews diet, appetite, school activities, sleep, vaccinations and the family’s own concerns before writing a single prescription.

Blood pressure control

Blood pressure control is one of the most important tools for slowing CKD progression in children. Persistent hypertension both strains the heart and accelerates kidney damage, so targets are set individually according to age, sex, height, the kidney diagnosis and the degree of proteinuria. Treatment combines lifestyle measures — chiefly sodium moderation and activity — with medication where needed, and families are often taught to measure blood pressure at home so the team can see the real pattern rather than a snapshot. Doses are calculated carefully for a child’s size and remaining kidney function, and any change to medication is a decision for the treating doctor, made against fresh laboratory results.

Reducing proteinuria and protecting remaining kidney function

Protein leaking into the urine is both a marker of kidney injury and a contributor to further scarring, so reducing it — where medically possible — is a central goal. Depending on the diagnosis, the plan may include medications that lower pressure within the kidney’s filters, immune-modifying treatment for selected glomerular diseases, and correction of urinary tract problems such as obstruction or reflux, which may involve pediatric surgery or urological procedures to protect the kidney tissue that remains. Protection also means avoidance: keeping the child away from medicines that harm the kidneys, and paying attention to hydration during vomiting or diarrhoeal illness, when an already vulnerable kidney can take additional injury.

Nutrition and growth support

Nutrition in pediatric CKD is not simply restriction, and this is where children differ most from adults. A growing child needs calories and protein for brain development, immune function, bones, muscles and ordinary play — while the kidneys may struggle with sodium, potassium, phosphorus or fluid. A pediatric renal dietitian balances these competing demands and adjusts the plan as the child grows and as laboratory results change. In infants and in children with poor appetite, the strategy may include specialised formulas, calorie enrichment or structured feeding support when medically appropriate, because undernutrition in early childhood compounds every other problem CKD causes.

Managing complications: anemia, bone health and acidosis

Reduced kidney function produces a predictable set of complications, and treating them is not secondary care — it is central to keeping the child well. Anemia, which drives fatigue and poor concentration, is managed with iron therapy and specific medication when indicated. Metabolic acidosis, which quietly interferes with growth and muscle health, is corrected. Bone and mineral disorders are addressed through phosphate management, vitamin D and monitoring of parathyroid hormone, protecting the developing skeleton. Electrolyte abnormalities and fluid overload are watched for and treated as they arise. Each of these threads is followed at every visit, because complications caught early are far easier to manage than complications allowed to establish themselves.

Renal Replacement Therapy: Dialysis and Kidney Transplantation

Renal replacement therapy refers to treatments that take over part of the kidneys’ work when kidney failure develops: peritoneal dialysis, hemodialysis and kidney transplantation. The defining principle in pediatric care is that planning starts early — usually during stage 4 — so that the child never faces an emergency start with a temporary catheter and a frightened family. Early planning creates time to compare options, prepare dialysis access properly, evaluate transplant possibilities and support the child emotionally.

Peritoneal dialysis

Peritoneal dialysis uses the lining of the child’s own abdomen to remove waste products and excess fluid. After a soft catheter is placed and caregivers complete structured training, it is performed at home — often overnight while the child sleeps — which is one reason it suits many younger children and school routines. Its practicality depends on the child’s medical condition and on the family’s capacity to carry out the technique consistently and hygienically, both of which are assessed and supported before a decision is made.

Hemodialysis

Hemodialysis filters the blood through a dialysis machine and requires reliable vascular access, created and maintained with the child’s small vessels in mind. It typically takes place in a dialysis centre or specialised setting several times a week. The choice between peritoneal dialysis and hemodialysis is never generic: it weighs the child’s age and size, the medical picture, the family’s circumstances, the distance to a suitable centre and — importantly — the transplant plan, since dialysis in childhood is usually a bridge rather than a destination.

Kidney transplantation for children

Kidney transplantation is considered for children with advanced kidney failure who are medically suitable, and for many it is the preferred long-term form of renal replacement therapy. Evaluation is thorough: detailed medical testing, infection screening, immunology testing, surgical assessment and structured family education. When a living donor is being considered, the donor undergoes an equally rigorous evaluation under strict medical and ethical standards. Some children are candidates for preemptive transplantation — receiving a kidney before long-term dialysis is ever required — when timing, donor availability and medical factors allow. Transplantation is a treatment, not an endpoint: it brings its own lifelong medication and follow-up requirements, which the team explains honestly from the first conversation.

Why Acting Early Matters

Kidney tissue that has already scarred generally cannot be restored. What early, active management can do is slow further injury: controlling blood pressure, reducing proteinuria, correcting obstruction or reflux when indicated, treating immune-mediated kidney disease, preventing dehydration-related injury and keeping nephrotoxic medicines away from vulnerable kidneys. The earlier this work begins, the more function there is to protect.

Delay lets complications entrench. Untreated hypertension strains the heart while it accelerates kidney damage. Anemia saps energy and concentration during the school years. Bone and mineral disorders can distort skeletal development at exactly the age when the skeleton is being built. Metabolic acidosis quietly blunts growth. Poor nutrition compounds all of it and weakens the child’s resilience during infections and procedures.

In advanced disease, delayed planning has a specific and avoidable cost: emergency dialysis through temporary access, which is more stressful and medically more complex than a planned start. Families lose the time they needed to learn a dialysis technique, complete transplant evaluation, arrange logistics and prepare the child emotionally. Early preparation converts a crisis into a scheduled step.

Acting early also matters for the child who looks perfectly well. Significant proteinuria and high blood pressure produce no complaints in many children; they are found by measuring, not by asking. Regular monitoring and timely specialist review identify these patterns before the child ever feels ill — and for families already in treatment, an early second look can confirm that the current approach is sound or reveal that additional testing deserves consideration.

Benefits of Structured Pediatric CKD Care

Effective pediatric CKD care is designed to protect kidney function, support development and prepare the family for each stage before it arrives.

Benefit	What It Means for You
Slowing kidney damage	Careful blood pressure control, proteinuria management and treatment of the underlying cause may help preserve kidney function for as long as possible.
Better growth and nutrition support	A pediatric renal nutrition plan helps children receive adequate calories and nutrients while managing kidney-related restrictions.
Management of complications	Treatment addresses anemia, mineral imbalance, acidosis, swelling and other effects of CKD before they become more difficult to control.
Clear planning for dialysis or transplant	If kidney failure is likely, families learn the options early, prepare access or transplant evaluation, and reduce the risk of urgent decision-making.
Coordinated pediatric expertise	Children benefit from care that considers kidney health together with development, school life, emotional needs and family routines.

Recovery and Ongoing Care Timeline

Recovery in pediatric CKD does not usually mean the kidneys return to normal. In most cases the realistic goal is disease control: stabilising kidney function, improving symptoms, correcting complications, protecting growth and preparing safely for the next stage if one is needed. The timeline depends on the diagnosis and stage, but families can generally expect a phased approach.

Time Period	What Patients Can Expect
Day 1	The team reviews medical history, symptoms, growth, blood pressure, medications, previous tests and family concerns. Initial blood and urine testing may begin.
First Week	Additional laboratory tests, imaging, specialist consultations, medication adjustments and nutrition planning may be completed. Some children need biopsy or urology review.
First Month	The care plan is refined based on test results and response to treatment. Families receive guidance on home monitoring, diet, medications and follow-up schedules.
Several Months	Growth, kidney function, blood pressure, urine protein, anemia and bone-mineral markers are reassessed. Treatment is adjusted as the child changes or grows.
Longer Term	Ongoing care focuses on maintaining stability, preventing complications, supporting school and development, and planning dialysis or transplantation if advanced kidney failure develops.

Visit frequency follows stability, not the calendar alone. A child with early, stable CKD may be reviewed periodically through the year, while a child with active glomerular inflammation, difficult blood pressure, advanced disease or dialysis needs is seen far more often. The care plan is written so that routine testing and monitoring between visits can be carried out close to home and the results interpreted consistently at each review.

Factors That Influence Outcomes

The underlying diagnosis is one of the strongest influences. Some congenital kidney conditions remain stable for years and only decline as the child’s body outgrows the kidney tissue available; others progress earlier. Certain glomerular diseases respond well to treatment in some children yet prove resistant in others with the same label. Genetic conditions vary in timing and severity even among siblings with related diagnoses — which is why the team resists giving a single confident prediction and instead monitors the child’s own trajectory.

The stage at diagnosis matters. Children identified early have more time for blood pressure control, proteinuria reduction, nutritional support and complication prevention to do their work. Children who present in advanced kidney failure still benefit from structured care, but the emphasis shifts more quickly towards dialysis and transplant preparation.

Blood pressure and proteinuria are the two levers most consistently linked to kidney protection. Persistent hypertension accelerates damage to the kidneys, the heart and the blood vessels; sustained protein leakage marks — and contributes to — ongoing scarring. Keeping both under control, where medically possible, is the daily substance of slowing progression.

Growth and nutrition shape resilience and quality of life. Children with CKD contend with poor appetite, nausea, dietary limits, inflammation and increased metabolic demands, and consistent nutritional care supports height gain, weight stability, immune health and readiness for procedures if they become necessary.

Medication adherence and follow-up are decisive over the years. Pediatric CKD care typically involves daily medicines, periodic laboratory checks, home blood pressure monitoring and continual dose adjustment as the child grows. Families need instructions that are practical rather than idealised, and adolescents need the plan explained to them directly — not only to their parents — as they gradually take responsibility for their own health.

Infections deserve particular respect in this population. Children with reduced kidney function, and especially those on dialysis or immunosuppressive treatment, are more vulnerable to infections and to their consequences, so vaccination review, sensible precautions and prompt treatment — with infectious diseases input in complex cases — form a quiet but important strand of long-term care. Vaccination is reviewed early and deliberately, because some live vaccines cannot be given after transplantation or during immunosuppressive treatment, so completing them in good time protects options later.

Finally, access to genuinely multidisciplinary expertise shapes the quality of every decision. Over the course of childhood, a child with CKD may need pediatric nephrology, urology, cardiology, endocrinology, hematology, nutrition, transplant surgery, psychology, radiology and intensive care support at different moments. Outcomes are best supported when these services communicate as one team, review decisions together and keep the family inside the conversation rather than at the end of it.

Living With Pediatric CKD: School, Sport and Growing Up

A treatment plan that ignores ordinary childhood tends to fail, so pediatric CKD care deliberately addresses school, activity and independence. Most children with CKD can attend school, and the team’s role is to make that workable: scheduling dialysis around lessons where possible, managing the fatigue and concentration effects of anemia, and giving schools clear, simple information about medication timing, hydration and what genuinely requires attention versus what does not.

Sport and activity are discussed case by case rather than banned by default. Physical activity supports bone health, blood pressure, mood and weight, and for most children some form of it belongs in the plan. Specific guidance depends on the diagnosis, on dialysis access that must be protected, and — after transplantation — on the position of the transplanted kidney. The aim is agreed limits, not blanket restriction.

Adolescence brings its own medical work. Puberty may be delayed by CKD and is monitored deliberately. Teenagers begin managing their own medicines and appointments, a handover that is planned rather than assumed, because this is the age at which adherence most often slips. Transition to adult nephrology services is prepared over time — with the young person increasingly leading their own consultations — rather than announced on an eighteenth birthday.

The emotional dimension is treated as part of the medicine. A long-term diagnosis changes family routines, affects siblings and asks a great deal of children who mostly want to be like their friends. Psychological support, honest age-appropriate explanation and attention to the parents’ own strain are legitimate components of pediatric CKD care, not extras to be added when something goes wrong.

How Acibadem Organises Pediatric CKD Care

At Acibadem, pediatric CKD care is delivered by pediatric nephrology teams working within the wider hospital structure, drawing on urology, transplant surgery, radiology, pathology, nutrition and intensive care as each child’s situation requires. Complex cases — biopsy findings, urologic reconstruction, dialysis planning, transplant suitability, immune-mediated kidney disease — are discussed across specialties, so that recommendations reflect the full clinical picture rather than a single test result.

Diagnostic depth carries the same purpose. Advanced laboratory testing, pediatric imaging, interventional radiology support and pathology review of biopsy specimens exist not to generate data but to reduce uncertainty: to clarify why the kidneys are damaged, to guide safer treatment and to show whether the child is responding. Where a diagnosis remains genuinely unclear, the team says so and explains what monitoring will resolve it.

The evaluation itself is organised as a single coordinated pathway: review of existing records and imaging, consultations with the relevant specialists, and — at the end — documentation written so that the child’s referring physicians can continue the plan without ambiguity. For children whose disease is approaching kidney failure, the pathway includes structured education about peritoneal dialysis, hemodialysis and transplantation, with the timing of transplant evaluation individualised and held to strict medical and ethical standards.

Personalised planning is the constant. A toddler with congenital kidney disease, a school-aged child with nephrotic-range proteinuria and a teenager preparing for transplant need very different things from the same specialty. The plan is written for the actual child: medication dosing for their size and function, diet for their growth stage, school and sports guidance for their life, vaccination timing for their treatment, and — for adolescents — a mapped transition towards adult care.

Moving Forward With a Clear Pediatric Kidney Care Plan

For most families, the hardest part of pediatric CKD is not any single treatment — it is uncertainty. Not knowing how quickly the disease may progress, whether the current medicines are the right ones, or when dialysis or transplantation should realistically enter the conversation. A structured evaluation replaces much of that uncertainty with something usable: a confirmed diagnosis, a defined stage, an honest account of what can be protected and what cannot, and a monitoring plan that tells the family what will be measured, when, and why.

Kidney disease in childhood is a long road, but it is a mapped one. The stages are defined, the complications are known and screened for, the decision points around dialysis and transplantation can be anticipated years in advance, and the child’s own results — growth, blood pressure, urine protein, filtration — show at every visit whether the plan is working. Families who understand that map, and clinicians who keep them on it, give a child with CKD the best conditions medicine can currently offer: preserved function for as long as possible, complications caught early, and each next step taken by choice rather than by emergency.