|Year : 2019 | Volume
| Issue : 1 | Page : 7-9
Translating growth and nutrition guidelines for children with chronic renal failure and chronic kidney disease Stages 2–5 and 5D into practice
Associate Professor, Department of Nephrology, Kasturba Medical College and Hospital, Manipal Academy of Higher Education, Manipal, Karnataka, India
|Date of Web Publication||15-Nov-2019|
Dr. Dharshan Rangaswamy
Department of Nephrology, Kasturba Medical College and Hospital, Manipal Academy of Higher Education, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
There is a remarkable lack of published data available for the topic of nutrition in children in all stages of CKD. Kidney Disease Outcomes Quality Initiative (KDOQI) published their guidelines for children on maintenance dialysis in the year 2000 to address the concerns of malnutrition and growth failure in them. In the 2008 update, they included infants, children, and adolescents with chronic kidney disease (CKD) stage 2 to 5 and also children on long term dialysis or renal transplant. The quality of evidence in the guidelines involving pediatric nephrology studies are frequently low due to small sample size, the lack of randomized control trials and the lack of information for long and short term clinical outcomes. With the current available data the article address the practical key components for nutritional management of children with CKD and thus reduce the risk of chronic morbidities in adulthood.
Keywords: Chronic kidney disease, KDOQI guidelines, nutrition in children
|How to cite this article:|
Rangaswamy D. Translating growth and nutrition guidelines for children with chronic renal failure and chronic kidney disease Stages 2–5 and 5D into practice. J Renal Nutr Metab 2019;5:7-9
|How to cite this URL:|
Rangaswamy D. Translating growth and nutrition guidelines for children with chronic renal failure and chronic kidney disease Stages 2–5 and 5D into practice. J Renal Nutr Metab [serial online] 2019 [cited 2019 Dec 11];5:7-9. Available from: http://www.jrnm.in/text.asp?2019/5/1/7/271042
| Introduction|| |
Malnutrition and growth failure are the major concerns in children with chronic kidney disease. The key components for management of children with chronic kidney disease (CKD) are regular monitoring of nutritional status, evaluation of physical growth, and development and adequate nutrition. The aim of nutritional surveillance is to prevent the development of protein–energy malnutrition. Thus, the focus of nutritional care for children with CKD is on the achievement of the following goals: (1) maintenance of an optimal nutritional status (i.e., achievement of a normal pattern of growth and body composition by intake of appropriate amounts and types of nutrients), (2) prevention of uremic toxicity, metabolic abnormalities, and malnutrition, and (3) reducing the risk of chronic morbidities in adulthood.
Following international guidelines for management of these children is therefore essential. This article highlights the salient features of recommendations of clinical practice guideline for nutrition in children with CKD.
Evaluation of growth and nutritional status
In clinical practice, nutritional status and growth of children with CKD Stages 2–5 and 5D should be evaluated periodically [Table 1]. The frequency of monitoring depends on the stage of CKD. In children with CKD, assessments should be done at least twice as frequently as they would be performed in a healthy child of the same age.
|Table 1: Parameters for evaluation of nutritional status and growth in children with chronic kidney disease|
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| Growth Monitoring for Chronic Kidney Disease Stages 2–5 and 5d, Short Stature, and Potential for Linear Growth Failure|| |
In children with short stature (height standard deviation score <−1.88 or height-for-age <3rd percentile), existing nutritional deficiencies and metabolic abnormalities must be identified and treated more aggressively. Serum bicarbonate level should be maintained at 22 mmol/L. Treatment with recombinant human growth hormone should be considered if low height velocity persists beyond 3 months despite treatment of nutritional deficiencies and metabolic abnormalities.
| Nutritional Management and Counseling for Chronic Kidney Disease Stages 2–5 and 5d, Short Stature, and Potential for Linear Growth Failure|| |
Nutrition counseling should be individualized and should take into consideration cultural preferences. The frequency of re-evaluation is given in [Table 1]. nutrition plan should be modified as per the needs based on dietary recall and biochemical parameters. Acute illness negatively impacts on nutritional status. Nutritional management should be done by a pediatric renal nutritionist and should involve family closely.
Energy requirements for children with CKD Stages 2–5 and 5D should be considered to be 100% of the estimated energy requirement for chronological age, individually adjusted for physical activity level and body size (i.e., body mass index). Energy intake should be adjusted according to the rate of weight gain or loss. If daily intake of a child is insufficient to meet energy requirements, nutritional support should be considered. Supplements should be energy dense. If through oral nutritional supplement energy requirements cannot be met, tube feeding should be considered. Intradialytic parenteral nutrition should be considered in malnourished children if oral and tube feeds cannot supplement energy and protein requirements. Calories should be supplied from carbohydrate and unsaturated fats. In overweight or obese children, dietary and lifestyle modifications may be considered.
| Protein Requirements for Children|| |
The dietary protein intake (DPI) should be maintained at 100%–140% of the dietary reference intake (DRI) for ideal body weight in children with CKD Stage 3 and at 100%–120% of the DRI in children with CKD Stages 4–5. In children with CKD Stage 5D, DPI at 100% of the DRI for ideal body weight plus an allowance for dialytic protein and amino acid losses should be maintained. As for energy, protein supplements to provide protein should be resorted to in case of inadequate oral and/or enteral administration of protein.
| Vitamin and Trace Element for Children With Chronic Kidney Disease Stages 2–5 and 5d|| |
The dietician should ensure 100% of the DRI for thiamine (B1), ribofiavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), biotin (B8), cobalamin (B12), ascorbic acid (C), retinol (A), tocopherol (E), Vitamin K, folic acid, copper, and zinc. However, if dietary intake alone does not meet 100% of the DRI or deficiency is documented, vitamins and trace element supplements and water-soluble vitamin supplements for CKD children are recommended by the international guidelines. Total oral and/or enteral calcium intake from nutritional sources and phosphate binders should be in the range of 100%–200% of the DRI for calcium for age. The serum 25-hydroxyvitamin D levels should be tested once a year. If the serum level of 25-hydroxyvitamin D is <30 ng/mL, supplementation with Vitamin D2 (ergocalciferol) or Vitamin D3 (cholecalciferol) is suggested. In the repletion phase, serum levels of corrected total calcium and phosphorus should be measured/checked at 1 month after initiation or change in dose of Vitamin D and thereafter every 3 months. After Vitamin D repletion, Vitamin D should be supplemented continuously and serum levels of 25-hydroxyvitamin D should be monitored yearly. In all children, serum phosphorus concentrations both above and below the normal reference range for age should be avoided. When the serum parathyroid hormone level is above the target range for CKD stage and the serum phosphorus concentration is within the normal reference range for age, dietary phosphorus intake of the DRI for age in children with CKD Stages 3–5D should be reduced to 100%, but if phosphorus is above the normal reference range for age, dietary phosphorus intake of the DRI for age should be reduced to 80%. After restricting dietary phosphorus, serum phosphorus concentration should be maintained every 3 months.
To avoid chronic intravascular depletion and to promote optimal growth, free water and sodium supplements should be considered for children with CKD stages, especially in children with polyuria. Sodium supplements should be considered for all infants with CKD Stage 5D on peritoneal dialysis. Sodium intake in children who have hypertension (systolic and/or diastolic blood pressure >95th percentile) or prehypertension (systolic and/or diastolic blood pressure >90th percentile and <95th percentile) must be restricted. To prevent the complications of fiuid overload in oligo-anuric children, fiuid intake must be restricted. In hyperkalemic patients or children who are at risk of hyperkalemia, intake of potassium intake should be limited.
Financial support and sponsorship
Confiicts of interest
There are no confiicts of interest.
| References|| |
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.