Severe Chronic Kidney Disease Presenting as Asymptomatic Normocytic Anemia in a Child.

Anemia is a common finding in pediatric practice and is most often attributed to nutritional deficiency; however, it may also represent the earliest manifestation of underlying systemic disease. We describe the case of a six-year-old girl who presented for a routine well-child visit and was found to have severe normocytic, normochromic anemia despite appearing clinically asymptomatic. Subsequent laboratory evaluation revealed profound renal dysfunction with metabolic acidosis and electrolyte abnormalities. Renal imaging demonstrated bilaterally small kidneys without hydronephrosis, consistent with advanced chronic kidney disease (CKD) likely due to congenital renal hypoplasia. The patient required emergent initiation of hemodialysis and was later transitioned to long-term renal replacement therapy. This case underscores the importance of maintaining a broad differential diagnosis when evaluating unexplained anemia in children and highlights that CKD may remain clinically silent until late stages, with anemia serving as a critical early diagnostic clue.