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Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 64-66

Nutritional and metabolic issues in children with chronic kidney disease

Dietitian, Department of Dietetics, B. Y. L. Nair Hospital, Mumbai, Maharashtra, India

Date of Web Publication23-Apr-2019

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrnm.jrnm_6_19

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How to cite this article:
Palekar A. Nutritional and metabolic issues in children with chronic kidney disease. J Renal Nutr Metab 2018;4:64-6

How to cite this URL:
Palekar A. Nutritional and metabolic issues in children with chronic kidney disease. J Renal Nutr Metab [serial online] 2018 [cited 2020 Feb 21];4:64-6. Available from: http://www.jrnm.in/text.asp?2018/4/3/64/256824

Growth spurts and development since conception, infancy, childhood, to adolescence mark the attainment of physical, cognitive, and emotional milestones. Nutrition plays an instrumental role in achieving these milestones to the fullest. A hindrance in this phenomenon at any stage can have a significant and long-term impact on the nutritional status of a child.

Chronic kidney diseases (CKDs) in children result in irreversible renal damage that progresses to end-stage renal diseases. The declining renal function in pediatric patients results in protein–energy malnutrition, stunting of linear growth.[1] The International Society of Renal Nutrition and Metabolism has proposed the term protein–energy wasting defined by complex metabolic syndrome associated with an underlying chronic illness and characterized by a loss of muscle, with or without the loss of fat. Protein–energy wasting is associated with impaired growth and development and an increased incidence of cardiovascular diseases, infection, and death.[2] Along with poor nutrient intake, systemic inflammation, endocrine disturbances, and abnormal neuropeptide signaling are linked to wasting in CKD.

Poor nutrient intake in CKD pediatric patients may be associated with altered taste sensation, anorexia, nausea, vomiting, dietary restrictions, palatability of diet, emotional distress, loss of nutrients through renal replacement therapy, presence of uremia, and abdominal fullness due to peritoneal dialysis. Hence, to attain growth milestones in the presence of electrolyte imbalance such as hyperkalemia, hyperphosphatemia, fluid restriction, anemia, altered calcium metabolism, sodium restriction, or chronic sodium depletion, metabolic acidosis is extremely challenging.

Dietary objectives for the nutritional management of children with CKD focus on optimizing growth and development milestones, preserving renal function, meeting the increased losses occurred through renal replacement therapy, maintaining fluid and electrolyte balance, ascertaining micronutrient sufficiency, preventing or reducing long-term complications and morbidity, and delivering enteral nutrition to maintain nutritional status. These objectives should be fulfilled keeping in mind the palatability, food preferences, and socioeconomic background of patients.

Nutritional care process steps should be followed by a registered renal pediatric dietitian initiating with nutritional assessment. Anthropometric assessment such as height, height-for-age percentile, weight, weight-for-age percentile, BMI-for-age percentile, and head circumference for children up to 36 months of age should be documented. Dietary intake assessment can be done by using 24-h diet recall, food diary maintained with time, and meal type and quantity of meal on weekdays and weekends.[3] Based on these data, macronutrients and disease-specific micronutrients should be calculated to identify and correct the dietary cause of electrolyte changes or protein insufficiency. Percent deficit can be calculated by comparing the assessed macronutrients and energy with reference values. Other factors such as biochemical parameters, blood pressure, fluid and electrolyte balance, presence of edema, medical history, present medications, history of nausea and vomiting, taste changes, presence of stressors, and clinical signs should be documented. These findings should be used critically to formulate nutritional diagnosis.

In 2008, the Kidney Diseases Outcome Qualitative Initiative (KDOQI) guidelines have developed evidence-based pediatric nutrition clinical practice guidelines. Nutritional intervention should be individualized, based on present oral intake, activity pattern, age, stress of disease, and weight loss changes on the background of these guidelines.

Breastmilk is the preferred choice for infants. However, if breastmilk is not available, an infant formula with lower potential renal solute load and low electrolytes should be selected. This formula or breastmilk can be calorically densed with carbohydrates and fats. Increasing the concentration of the infant formula with water should be avoided to prevent electrolyte overload.[4] The nutritional requirement should be 100% of the estimated energy requirement for children with CKD. Additional nutrition support in the form of nutritional supplements is essential for the group of children failing to achieve or catch up their growth milestones. However, energy restriction may be needed in children with preexisting obesity. Enteral nutrition support may be necessary to provide aggressive nutrition support in children who are not able to meet their energy requirements orally. In children receiving peritoneal dialysis, energy derived from dialysate glucose concentration should be added in total caloric intake. Peritoneal glucose absorption increases total caloric intake by 7–10 kcal/kg/day.[5]

The protein requirement of pediatric group should be 100%–140% of the dietary reference intake (DRI) for CKD Stage 3 and 100%–120% of DRI for Stages 4 and 5. The requirement is increased by 0.1 g/kg body weight and 0.2–0.3 g/kg body weight for patients on hemodialysis (HD) and peritoneal dialysis, respectively, to account for dialysate protein and amino acid losses. Adequate energy intake at all stages is needed for protein-soaring action. Protein requirement may further vary in children with proteinurea and acute illness and obese or stunted children. While focusing on increasing protein intake, attention should be given to prevent increased phosphorus intake.

Presence of dyslipidemia (hypertriglyceridemia, low high-density lipoprotein cholesterol, and increased small dense low-density lipoprotein cholesterol) in children with CKD and 5D imposes an increased risk of cardiovascular disease. Dietary guidelines focusing on restricting saturated fat, total dietary cholesterol, and total fat and choosing complex carbohydrate should be the initial nonpharmacological management.[6] Increased intake of dietary fiber and omega 3 fatty acid should be encouraged.

Electrolyte management makes diet planning the most challenging in this group. The dietitian should skillfully manage sodium, potassium, phosphorus, and fluid restriction while maintaining palatability and variety of foods. Fluid intake should be restricted in children with CKD Stages 3–5 and 5D who are oligoanuric to prevent the complications of fluid overload (KDOQI, 2008).

Patients with renal disease are always advised sodium restriction. However, the primary cause of CKD should be ruled out before advising fluid restriction. Infants and children with obstructive uropathy or renal dysplasia present with polyuria, polydypsia, and diffi culty conserving sodium chloride and often develop salt-wasting and, therefore, require salt supplementation.[7]

Dietary sodium intake should be restricted to <1500 mg–2400 mg/day in children with hypertension or prehypertension (KDOQI, 2008). Infants with kidney diseases should be weaned with low sodium foods with limited-to-no use of salt while cooking. Use of salt substitute should not be discouraged, and flavor of foods should be enhanced through spices and herbs. Low sodium snacks should be designed to be carried at school, outing, and picnics. Children with salt-wasting syndrome or peritoneal dialysis may require sodium supplementation.

Hyperkalemia is a common and life-threatening electrolyte abnormality in children with CKD. Fall in glomerular filtration rate below 10–15 mL/min/1.73 m2 increases the risk of hyperkalemia. Other conditions such as metabolic acidosis and medications such as angiotensin-converting enzyme inhibitors and potassium-sparing diuretics increase the risk of hyperkalemia. It can affect the activities of muscles, especially the heart and cardiac arrhythmias. Therefore, children at risk of hyperkalemia should be counseled along with caretaker to prefer low-potassium foods. For infants and young children, the KDOQI guidelines recommend 40–120 mg (1–3 mmol/kg/day) of potassium. Older children can be prescribed <30–40 mg/kg/day (0.8–1 mmol/kg/day). On the contrary, children receiving HD or peritoneal dialysis rarely need potassium restritction and may require supplementation. Hence, regular monitoring of potassium is recommended.[8]

Phosphorus restriction is critical in preventing hyperphosphatemia-induced bone disease and cardiovascular diseases.[9] Dietary phosphorus restriction has shown to reduce increased parathyroid level.[10] The present guidelines recommend restriction of phosphorus intake to 100% of DRI for age in children with Stages 3–5 and 5D with raised serum parathyroid hormone level and normal serum phosphorus range. However, when levels of both serum parathyroid and phosphorus increase, dietary phosphorus level should be restricted further to 80% of DRI. Follow-up of serum phosphorus every 3 months in children with Stages 3–4 and monthly for children with CKD Stage 5 and 5D is recommended.[11]

Calcium plays a crucial role in skeletal development in childhood for attainment of peak bone mass during adolescence. Decreased Vitamin D production with progression of CKD impairs calcium absorption. The KDOQI guidelines recommend that total oral and enteral calcium intake from dietary sources and phosphate binders should be in the range of 100% to 200% of the DRI for calcium for age in children with CKD Stages 2–5 and 5D. The safe upper limit of dietary calcium intake in healthy individuals older than 1 year is 2500 mg/day.

Poor energy intake, restriction of certain foods to maintain electrolyte balance may affect the intake of vitamins and minerals. However, supplementation of B-complex Vitamin C, Vitamin E, folic acid, copper, and zinc should only be given in the presence of signs of deficiency, low blood level, or failure to meet 100% DRI for age of these nutrients through dietary sources. Supplementation of B-complex is recommended for children on dialysis.

Progression of CKD may lead to the development of anemia with gradual loss of erythropoetin production. Diet-related deficiency of iron may be present due to restriction of various foods. For all pediatric CKD patients with anemia not on iron or erythropoetin-stimulating agent (ESA) therapy, oral iron (or intravenous [IV] iron in CKD and HD patients) administration is recommended when transferrin saturation (TSAT) is <20% and ferritin is <100 ng/ml (<100 lg/L). For all pediatric CKD patients on ESA therapy who are not receiving iron supplementation, oral iron (or IV iron in CKD and HD patients) administration to maintain TSAT 420% and ferritin 4100 ng/ml (4100 lg/L) is recommended. In all pediatric CKD patients receiving ESA therapy, the hemoglobin concentration should be maintained in the range of 11.0–12.0 g/dl (110–120 g/L).

Monitoring of prescribed intervention should be done at regular intervals by repeating thorough nutrition assessment and evaluating changes in the affected parameters. Measurement and plotting of the anthropometric parameters at follow-up indicates growth and development trend in this group. Maintenance of a diet diary ensures regular monitoring of dietary intake. This enables timely modifications in diet to correct the altered parameters. Changes in dietary pattern should be done at every stage as the infant develops into adolescence.

Thus, a skilled pediatric renal dietitian is an integral part of a multidisciplinary team. Planning a practical diet keeping in mind the disease- and age-specific metabolic and nutritional changes is a huge challenge as well as a responsibility.

  References Top

Kopple JD, Massry SG, editors. Kopple and Massry's Nutritional Management of Renal Disease. 3rd edition: Lippincott Williams & Wilkins; 2004:836.  Back to cited text no. 1
Ingulli EG, Mak RH. Growth in children with chronic kidney disease: Role of nutrition, growth hormone, dialysis, and steroids. Curr Opin Pediatr 2014;26:187-92.  Back to cited text no. 2
KDOQI Work Group. KDOQI clinical practice guideline for nutrition in children with CKD: 2008 update. Executive summary. Am J Kidney Dis 2009;53:S11-104.  Back to cited text no. 3
Nguyen L, Levitt R, Mak RH. Practical nutrition management of children with chronic kidney disease. Clin Med Insights Urol 2016;9. Available from: https://doi.org/10.4137/CMU.S13180.  Back to cited text no. 4
Broyer M, Niaudet P, Champion G, Jean G, Chopin N, Czernichow P. Nutritional and metabolic studies in children on continuous ambulatory peritoneal dialysis. Kidney Int Suppl 1983;15:S106-10.  Back to cited text no. 5
Kavey RE, Allada V, Daniels SR, Hayman LL, McCrindle BW, Newburger JW, et al. Cardiovascular risk reduction in high-risk pediatric patients: A Scientific Statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: Endorsed by the American Academy of Pediatrics. Circulation 2006;114:2710-38.  Back to cited text no. 6
Rodriguez-Soriano J, Arant BS, Brodehl J, Norman ME. Fluid and electrolyte imbalances in children with chronic renal failure. Am J Kidney Dis 1986;7:268-74.  Back to cited text no. 7
Factor KF. Potassium management in pediatric peritoneal dialysis patients: Can a diet with increased potassium maintain a normal serum potassium without a potassium supplement? Adv Perit Dial 2007;23:167-9.  Back to cited text no. 8
Oh J, Wunsch R, Turzer M, Bahner M, Raggi P, Querfeld U, et al. Advanced coronary and carotid arteriopathy in young adults with childhood-onset chronic renal failure. Circulation 2002;106:100-5.  Back to cited text no. 9
Llach F, Massry SG. On the mechanism of secondary hyperparathyroidism in moderate renal insufficiency. J Clin Endocrinol Metab 1985;61:601-6.  Back to cited text no. 10
Rees L. 3.21 Nutritional management in children with chronic kidney disease. In: Pediatric Nutrition in Practice. Vol. 113. Karger Publishers; 2015. p. 254-8.  Back to cited text no. 11


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