Recommended reading:
Delivery of a nutritional prescription by enteral tube feeding in children with chronic kidney disease stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce, 2021 🔓
Assessment and management of obesity and metabolic syndrome in children with CKD stages 2-5 on dialysis and after kidney transplantation-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce, 2022 🔓
Nutritional management of the infant with chronic kidney disease stages 2-5 and on dialysis, 2022 🔓
Recombinant Growth Hormone (rhGH): Children with CKD are at risk for growth failure/deficiency as part of their disease
Growth Hormone (various brands) starting at 0.35mg/kg/week, DAILY injections.
Targeting at least 50th %ile or mid-parental height. It’s an expensive drug, so some people suggest just going to whichever is lower.
Workup prior to starting GH can include: bone age (L wrist XR), XR hips/pelvis, TSH/FT4, ***
Monitor for/Contra-indicated in:
Increased ICP (headaches, fundoscopic exam)
Neoplasia
Severe hyperPTH (PTH > 800ng/mL)
Closed epiphyses
AVN or SCFE (hip pain)
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Growth failure due to congenital CKD
Major part of growth happens during the first 3 years of life: 50 cm
U-shaped mortality: cardiac death, infection-related death, malignancy-related death
Factors that contribute to growth failure in CKD:
[***] Nature Reviews Nephrology 2019 (Drube et al)
GH in well-nourhished infants with CKD
[***] see: clin J am soc nephrol 2010
Age dependent efficacy of GH treatment
Earlier initiation leads to improvement
Change in growth
Adult height below 3rd percentile in approximatley 40% of European patients with ESKD
Short stature impairs quality of life, self-esteem and social rehabilitiation, and is associated with increased mortality in children with ESKD
Uremia is a state of GH insensitivity which can be overcome by supraphysiological doses of recombinant human growth hormone
The efficacy and safety of GH has been studied in several controlled, uncontrolled and open-label studies during the last 30 yers
GH treatment is licensed for CKD-induced growth failurei n Europe, NA and many other high0-incoming countries
2018 consensus statement
Work up before initiation of GH treatment:
Height or supine length should be regularly measured
Height velocity should be calculated over a minimum period of six months, and both height and height velocity should be plotted on standardized growth charts
Assessment intervals for statural growth in CKD [*** table with intervals]
Growth potential should be assessed by genetic target height, based on parental height and the extent to which the epiphysis of the left wrist is open on radiography
Factors need to be addressed before initiation: protein-calorie malnutrition, metabolic acidosis, [*** list factors]
Labs:
Serum creatinine, urea, calcium,p phosphorus, ALP, bicarbonate, PTH, 25(OH) vitamin D, albumin, fasting glucose and HbA1c levels
Serum thyroid hormone (TSH, free t3) and IGF1 concentrations
Funduscopic examination
Radiography of the left wrist
Pubertal status according to Tanner
Discuss pros and cons with family
Must give it every day
Particularly important for immobilized patients (being larger and heavier may complicate their care) and syndromic kidney diseases
Candidates: stage 3-5 CKD
[***] criteria
For transplants, wait 1 year after the transplant
Ideally, use steroid free immunosuppression
May have spontaneous catch up growth after transplant without the use of exogenous growth hormone
Nephropathic cystinosis: if persistent growth failure (height <3%ile for age & sex + height velocity <25%ile)
GH therapy should be considered at all stages of CKD
GH should NOT be started if:
Close epiphyses
Known hypersensitivity to the active substance or to any of the excipients
In case of unwillingness of the patient or the family
Patients with severe secondary hyperparathyroidism (PTH >500 pg/mL)
During the first year after renal transplantation
Acute critical illness
Active malignancy
Cost-benefit ratio should be considered
Dosing
0.045 to 0.05 mg/kg body weight day, given every evening, by subcutaneous injection
Encourage children from 8-10 years of age to do the GH injections on their own if adequate training and adherence is ensured (should be supervised by parents)
3-6 months, more frequently in young patients in young patients or
Monitor: height velocity, pubertal development, skeletal maturation on wrist radiography, kidney function, thyroid hormone levels, serum glucose, calcium, phosphorus, bicarbonate, PTH
Side effects:
NO increased risk for: acceleration of CKD progression, acute rejection after KTx, malignancy
Promotes insulin resistance, check glucose intolerance (cystinosis)
2ndary hyperparathyroidism
Hypothyroidism may occur
Peripheral edema (usually transient)
Benign intracranial hypertension: if repeatedly complaining of headaches, should have fundoscopic exam
Adherence:
If height velocity in first year of GH treatment is less than 2 cm/year over baseline, assess adherence, measure IGF1, weight adjust doses, assess nutrition and metabolic factors
Some companies provide a pen that has a microchip that records the dose, and some will even verify the skin is consistent with human skin before the dose is administered
Discontinue if:
Epiphyseal closure
Renal transplantation
ICH
Persistent severe secondary hyperparathyroidism
SCFE
Inadequate response despite optimal nutritional and metabolic control
If unexplained decreased in eGFR and treatment is suspected as a possible cause
Consider if accelerated bone maturation
Consider if:
Patient has reached genetic target height percentile
Can be reinstituted if catch-down growth occurs
When patients reaches genetic target height
Barriers to optimizing growth and nutritional status
Metabolic acidosis
Anemia
Fluid and electrolyte imbalances
Long term use of corticosteroids
Alterations in bone metabolism leading to bone diseases
Growth
Postnatal growth:
infancy (birth-18 months): growth hormone, nutrition
Childhood (18 months-12 years): growth dependent on growth hormone, thyroid hormone, good overall health
Pubertal growth: growth hormone, testosterone, estrogen, good overall health
[***] nutrition loss
If weight is static for 2 weeks in the first 3 months of life, there is a loss of 1 %ile of maximum height
Calories and relation to growth velocity
>80% DRI: normal growth
<80% DRI: reduced growth velocity
<40% DRI: cessation of growth velocity
Growth assessment frequency: [*** KDOQI guidelines]
Measure:
Weight infant scale <2 years, standing scale >2 years
Recumbent length <2 years, standing height >2 years
Head circumference up to 36 months
Example: gain of 200 grams should take 6 week old
at 6 weeks: 1 week
7 years: 1 month
14 years: 2-3 weeks
Treating growth failure
Metabolic abnormalities should be corrected and nutrition optimized prior to starting growth hormone
Ensure optimal energy intake prior to starting growth hormone
When possible, should be initiated pre-transplantation and pre-puberty
Overnourishment: Obesity rates increasing
Peaked at ~30% in adolescents
Rate of metabolic syndrome also on the rise, 15-30% in CKD
Other tools: MUAC is validated at a marker of nutrition status
[***] other measurements
Renal modifications
There is no one renal diet; each needs to be tailored to the individual
CPR: Pediatric Renal Nutrition Taskforce (PRNT) 2017: link
Calories: Aim for initial target of 100% of estimated energy requirement (EER) for a healthy child of the same chronological age, with adjustments based on individual weight gain/loss
Protein: aim for DRI, and adjust for dialysate losses (add 0.1 mg/kg HD, add 0.15-0.3 g/kg for PD)
Estimated to be higher in CKRT: up to 2.5 g/kg/day
Sodium: 1-2 mmol/kg/day
Sodium awareness should be taught in early stages of CKD
More than 25% of adolescents take in >2x the upper limit of recommended intake
Must also account for kidney medications (e.g., sodium polystyrene sulfonate [Kayexalate], sodium bicarbonate)
Fluids: individualized
Depends on method of dialysis, residual function, and primary kidney disease
Must be continually assessed, especially with changes in urine output
Polyuria and Na wasting: [*** slide]
Fluid allowance needs to be clearly documented and regularly discussed
Certain amount of fluid is necessary to ensure adequate calories
Must be very clear to patients/families about what this entails [***]
Potassium: initial target of 1-3 mmol/kg/day in infants and young children
Plant based levels, widely considered to be good from CV standpoint, but can be high in potassium
May take 3-7 full days to appreciate full effect of any dietary change on serum potassium
Natural potassium
50-60% absorbed
Fiber ↓ absorption
Fruits/vegetables
Milk, milk products
Meat, chicken, fish
Beans, lentils, nuts
Added potassium
100% absorbed
Flavor agent
Sodium substitutes (e.g., Mrs. Dash)
Potassium may not be on the nutrition label: look for the ingredients list
Examples: potassium sorbate, potassium benzoate, potassium nitrate, potassium propionate, potassium acetate, potassium lactate, potassium citrate, potassium phosphate, potassium chloride, potassium carbonate, potassium sulphate, potassium gluconate, etc.
Calcium, phosphorus and vitamin D
KDOQI:
Ca: DRI and no more than 2x DRI
Phos: DRI
Vitamin D: individualized
Bones:
Lower GFR can cause disorders in calcium and phosphorus metabolism
Lower/higher serum calcium
higher phosphorus
Higher PTH levels
Inadequate activation of vitamin D
Lower levels of 1,25 dihydroxyvitamin D
[***] tables:
NKF, AJKD 2009 KDOQI; McAlister (2019) Ped Neph
Phosphorus:
Natural phosphorus: 40-60% absorbed
Phytates ↓ absorption
Found in:
Dairy products
Meat, poultry, fish
Soy (milk, tofu)
Nuts, seeds
Dried beans and peas
Whole grains
Added phosphorus: >90% absorbed
Food additives
Used to improve texture, taste, shelf life of processed foods
Dietary supplements
Calcium fortification
Also not always on nutrition label, so check ingredients list for anything with "phos" in the name
Vitamin D
Other vitamins and minerals:
[***]
Zinc: commonly low on dialysis
Copper: can be high or low
Selenium: commonly low on dialysis
If energy requirements not being met:
Formula prescription tailored: volume, electrolytes, nutrients, mixture of products
No magic renal formula
BC children's hospital formula calculator
Standard infant options:
Expressed breast milk
Lower in protein, sodium, potassium, and phosphorus
Can be fortified with Duocal to increase calories or mixed with renal formula to reduce electrolytes
[***]
Renal formula liquid (Suplena, Novasource)
Lower in K
Predialysis: lower in protein
Dialysis: higher in protein
Intended for use in adults
Concentrated calories, good for controlled fluids
Renal formula powders (Nephea kid, renastart, PM 60/40)
Electrolyte/mineral reduced supplement intended for use in children with CKD
Short term use, not sole source of nutrition
Can be used in combination with other formulas to reduce electrolytes
Decanting and pretreatment:
Hyperkalemia may require treatment
SPS: sodium based cation exchange
Patiromer: calcium based cation exchange
Provided by mouth or feeding tube: not in infants due to increased risk of NEC
May need to pretreat formula for babies/children
6 g/L max dose SPS [***]
Medical nutrition therapy:
Take "shots" of nutrition supplement a few times a day
Home blenderized tube feeds
[***]
Benefits:
Improvement in GI symptoms
Firmer stools, decrease in emesis
Decreased retching and gagigng
Can tailor recipe to meet patients' needs
[***]
intradialytic parenteral nutrition (IDPN)
Noninv asive method to provie carbohydrates, protein and fat to undernourished HD patients
Not sole source of nutrition; addiotoin to oral or enteral nutrition
Provided during HD via venous access distal to hemolyzer
[***]
[AMA formatted citations]
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