Assessment of dietary intake of children with chronic kidney disease

Predictors of hyperkalemia in pediatric patients on dialysis: international prospective observational study

BACKGROUND

Hyperkalemia is an important issue in kidney failure. The aim of the study was to investigate the predictors of hyperkalemia in children receiving maintenance dialysis.

METHODS

This was an international prospective cross-sectional observational study involving patients < 18 years receiving chronic hemodialysis or peritoneal dialysis. Hyperkalemia was defined as serum potassium (sK+) ≥ 5 mEq/L based on the Pediatric Renal Nutrition Taskforce recommendations. We recorded age, dialysis vintage, urine output (24-h urine collection); dietary K+, energy, protein and sodium intake (three-day diaries); office blood pressure (BP) in children < 5 years and 24-h ABPM in older patients; biochemistry (creatinine, urea, sodium, bicarbonate, hemoglobin, phosphate, albumin) and antihypertensive drugs.

RESULTS

Forty-one patients were enrolled (10 peritoneal dialysis, 31 hemodialysis), median age 13.3 (IQR 10.6-15.8) years; 15 of them (36.6%) showed hyperkalemia, and median sK+ was 4.7 (4.4-5.0) mEq/L. Renin-angiotensin-aldosterone system inhibitors (RAASi) were prescribed in 9/15 patients with hyperkalemia (60%) and 7/26 (26.9%) without hyperkalemia (p = 0.04). Patients with hyperkalemia were older and had higher urea and creatinine than those with normal sK+. A backward stepwise multivariable model showed that the only predictors of hyperkalemia were age (b = 0.53, p = 0.01), urea (b = 0.02, p = 0.03) and treatment with RAASi (b = 2.75, p = 0.021).

CONCLUSIONS

While higher age, higher urea levels and treatment with RAASi independently predicted the occurrence of hyperkalemia, K+ intake was not associated with sK+ in children on dialysis. This emphasizes the importance of considering non-dietary causes of hyperkalemia and considering the bioavailability of K+ more than the total dietary K+ intake.

Patient, Parental, and Health Professional Perspectives on Growth in Children With CKD

RATIONALE & OBJECTIVE

Growth failure is a common problem among children with chronic kidney disease (CKD). Reduced height is associated with psychosocial burden, social stigma, and impaired quality of life. This study describes the aspects of growth impairment that are most impactful from the perspectives of children with CKD, their parents, and health professionals.

STUDY DESIGN

Qualitative study.

SETTINGS & PARTICIPANTS

120 children with CKD (aged 8-21 years), 250 parents, and 445 health professionals from 53 countries who participated in 16 focus groups, 2 consensus workshops, and a Delphi survey.

ANALYTICAL APPROACH

A thematic analysis of all qualitative data concerning growth from the Standardized Outcomes in Nephrology-Children and Adolescents (SONG-Kids) initiative.

RESULTS

We identified 5 themes: diminishing psychological well-being (compared to and judged by peers, tired of explaining to others, damaging self-esteem), constrained life participation and enjoyment (deprived of normal school experiences, excluded from sports or competing at a disadvantage, impaired quality of life in adulthood); grappling with impacts of symptoms and treatment (difficulty understanding short stature and accessing help, lack of appetite, uncertainty regarding bone pains, medication side effects, burden of growth hormone treatment); facilitating timely interventions and optimizing outcomes (early indicator of disease, assessing management, maximizing transplant outcomes, minimizing morbidity); and keeping growth and health priorities in perspective (quality of life and survival of utmost priority, achieved adequate height).

LIMITATIONS

Only English-speaking participants were included.

CONCLUSIONS

Impaired growth may diminish psychological well-being, self-esteem, and participation in daily activities for children with CKD. Balancing different treatments that can affect growth complicates decision making. These findings may inform the psychosocial support needed by children with CKD and their caregivers to address concerns about growth.

PLAIN-LANGUAGE SUMMARY

Children with chronic kidney disease (CKD) are often much shorter than their peers and may experience poorer mental health and quality of life. To understand the specific important issues on how growth impairment affects these children, we collected qualitative data from the Standardized Outcomes in Nephrology-Children and Adolescents (SONG-Kids) initiative and analyzed perspectives on growth from patients, parents, and health professionals. These data revealed impaired psychological health, reduced enjoyment during school and sports, difficulty dealing with medication side effects and growth hormone treatment, and concerns related to tracking health status and kidney transplant outcomes. These findings may inform the psychosocial support needed by children with CKD and their caregivers to address concerns about growth and overall health.

Nutritional management of the child with chronic kidney disease and on dialysis

While it is widely accepted that the nutritional management of the infant with chronic kidney disease (CKD) is paramount to achieve normal growth and development, nutritional management is also of importance beyond 1 year of age, particularly in toddlers, to support the delayed infantile stage of growth that may extend to 2-3 years of age. Puberty is also a vulnerable period when nutritional needs are higher to support the expected growth spurt. Inadequate nutritional intake throughout childhood can result in failure to achieve full adult height potential, and there is an increased risk for abnormal neurodevelopment. Conversely, the rising prevalence of overweight and obesity among children with CKD underscores the necessity for effective nutritional strategies to mitigate the risk of metabolic syndrome that is not confined to the post-transplant population. Nutritional management is of primary importance in improving metabolic equilibrium and reducing CKD-related imbalances, particularly as the range of foods eaten by the child widens as they get older (including increased consumption of processed foods), and as CKD progresses. The aim of this review is to integrate the Pediatric Renal Nutrition Taskforce (PRNT) clinical practice recommendations (CPRs) for children (1-18 years) with CKD stages 2-5 and on dialysis (CKD2-5D). We provide a holistic approach to the overall nutritional management of the toddler, child, and young person. Collaboration between physicians and pediatric kidney dietitians is strongly advised to ensure comprehensive and tailored nutritional care for children with CKD, ultimately optimizing their growth and development.

Does the Nutritional Intake and Diet Quality of Children With Chronic Kidney Disease Differ From Healthy Controls? A Comprehensive Evaluation

OBJECTIVE

Children with chronic kidney disease (CKD) experience many obstacles to achieving optimal dietary intake. Dietary intake patterns remain unexplored or poorly described. This study compares nutritional intake and diet quality of Australian children with CKD to controls.

METHODS

A food frequency questionnaire captured intake data and was compared to controls. Nutritional intake was determined using individualized nutrient reference values, and diet quality described using the Australian Guide to Healthy Eating and the Australian Child and Adolescent Recommended Food Score.

RESULTS

Children with CKD (n = 36) and controls (n = 82) were studied. Children with CKD had lower weight and height z scores, but higher body mass index (P < .0001 for all parameters). Children with CKD had adequate energy intake, and excessive protein and sodium intake (336% and 569%). They were significantly less likely to meet requirements for vitamin A (P < .001), thiamine (P = .006), folate (P = .01), vitamin C (P = .008), calcium (P < .0001), iron (P = .01), magnesium (P = .0009), and potassium (P = .002). No child met recommended vegetable intake; however, less than half of children with CKD met fruit (44%), grains (31%), and dairy serves (31%). They were also less likely to meet recommended fruit and dairy serves (P = .04 and P = .01, respectively). Non-core foods provided 36% of energy, and although comparable to controls, was contributed more by takeaway foods (P = .01).

CONCLUSION

Children with CKD have reduced nutritional intake of key nutrients and consume more takeaways than controls. Attention to increasing core foods, limiting sodium intake, and managing restrictions while promoting nutrient density appears necessary.

Role of Nutrients in Pediatric Non-Dialysis Chronic Kidney Disease: From Pathogenesis to Correct Supplementation

Nutrition management is fundamental for children with chronic kidney disease (CKD). Fluid balance and low-protein and low-sodium diets are the more stressed fields from a nutritional point of view. At the same time, the role of micronutrients is often underestimated. Starting from the causes that could lead to potential micronutrient deficiencies in these patients, this review considers all micronutrients that could be administered in CKD to improve the prognosis of this disease.

The medium-term impact of a micronutrient powder intervention on anemia among young children in Rural China

BACKGROUND

Poor development of young children is a common issue in developing countries and it is well established that iron deficiency anemia is one of the risk factors. Research has shown that iron deficiency is a common micronutrient deficiency among children in rural China and can result in anemia. A previous paper using data from the same trial as those used in the current study, but conducted when sample children were younger, found that after 6 months of providing caregivers of children 6-11 months of age free access to iron-rich micronutrient powder (MNP) increased the hemoglobin concentrations (Hb) of their children. However, no effects were found 12 and 18 months after the intervention. The current study followed up the children four years after the start of the original intervention (when the children were 4-5 years old) and aims to assess the medium-term impacts of the MNP program on the nutritional status of the sample pre-school-aged children, including their levels of Hb, the prevalence of anemia, and the dietary diversity of the diets of the children.

METHODS

At baseline, this study sampled 1,802 children aged 6-11 months in rural Western China. The intervention lasted 18 months. In this medium-term follow-up study that successfully followed 81% (n = 1,464) of children (aged 49-65 months) from the original study population 4 years after the start of the intervention, we used both intention-to-treat (ITT) effect and average treatment on the treated effect (ATT) analyses to assess the medium-term impacts of the MNP distribution program on the nutritional status of sample children.

RESULTS

The ITT analysis shows that the MNP intervention decreased the prevalence of anemia of young children in the medium run by 8% (4 percentage points, p < 0.1). The ATT analysis shows that consuming 100 (out of 540) MNP sachets during the initial intervention led to a decrease in anemia of 4% (2 percentage points, p < 0.1). Among children with moderate anemia at baseline (Hb < 100 g/L), the intervention reduced the probability of anemia by 45% (9 percentage points, p < 0.1), and, for those families that complied by consuming 100 (out of 540) sachets, a 25% (5 percentage points, p < 0.05) reduction in the anemia rate was found. The MNP intervention also led to a persistent increase in dietary diversity among children that were moderately anemic at baseline. The results from the quantile treatment effect analysis demonstrated that children with lower Hb levels at baseline benefited relatively more from the MNP intervention.

CONCLUSIONS

The findings of the current study reveal that the MNP intervention has medium-term effects on the nutritional status of children in rural China. The impacts of the MNP program were relatively higher for children that initially had more severe anemia levels. Hence, the implications of this study are that programs that aim to increase caregiver knowledge of nutrition and improve their feeding practices should be encouraged across rural China. Families, policymakers, and China's society overall need to continue to pay more attention to problems of childhood anemia in rural areas. This is particularly crucial for families with moderately anemic children at an early age as it can significantly contribute to improving the anemia status of children across rural areas of China.

TRIAL REGISTRATION

ISRCTN44149146 (15/04/2013).

Sodium intake and urinary losses in children on dialysis: a European multicenter prospective study

BACKGROUND

Sodium (Na) balance is unexplored in dialyzed children. We assessed a simplified sodium balance (sNaB) and its correlates in pediatric patients receiving maintenance dialysis.

METHODS

Patients < 18 years old on hemodialysis (HD) or peritoneal dialysis (PD) in six European Pediatric Dialysis Working Group centers were recruited. sNaB was calculated from enteral Na, obtained by a 3-day diet diary, Na intake from medications, and 24-h urinary Na (uNa). Primary outcomes were systolic blood pressure and diastolic blood pressure standard deviation scores (SBP and DBP SDS), obtained by 24-h ambulatory blood pressure monitoring or office BP according to age, and interdialytic weight gain (IDWG).

RESULTS

Forty-one patients (31 HD), with a median age of 13.3 (IQR 5.2) years, were enrolled. Twelve patients (29.3%) received Na-containing drugs, accounting for 0.6 (0.7) mEq/kg/day. Median total Na intake was 1.5 (1.1) mEq/kg/day, corresponding to 60.6% of the maximum recommended daily intake for healthy children. Median uNa and sNaB were 0.6 (1.8) mEq/kg/day and 0.9 (1.7) mEq/kg/day, respectively. The strongest independent predictor of sNaB in the cohort was urine output. In patients receiving HD, sNaB correlated with IDWG, pre-HD DBP, and first-hour refill index, a volume index based on blood volume monitoring. sNaB was the strongest predictor of IDWG in multiple regression analysis (β = 0.63; p = 0.005). Neither SBP SDS nor DBP SDS correlated with sNaB.

CONCLUSIONS

Na intake is higher than uNa in children on dialysis, and medications may be an important source of Na. sNaB is best predicted by urine output in the population, and it is a significant independent predictor of IDWG in children on HD. A higher resolution version of the Graphical abstract is available as Supplementary information.

Development of a semi-quantitative food frequency questionnaire for dietary intake of elementary school children: data from the Seventh Korea National Health and Nutrition Examination Survey

BACKGROUND/OBJECTIVES

In Korea, studies of diet in elementary school children are hindered by the need for a comprehensive dietary assessment tool. Thus, the aim of this study was to develop a semi-quantitative food frequency questionnaire (FFQ) for Korean elementary school children.

SUBJECTS/METHODS

The 24-h recall data for 1,624 subjects aged 6-11 yrs from the seventh Korea National Health and Nutrition Examination Survey were used to extract the items included in the questionnaire. The FFQ items were developed by selecting major dishes based on the results of nutritional contribution and between-person variability for energy and 14 nutrients (carbohydrate, protein, fat, crude fiber, calcium, phosphorous, iron, sodium, potassium, vitamin A, thiamin, riboflavin, niacin, and vitamin C). We selected the major dishes with over 90% of the total contribution to each nutrient and with over 90% of the accumulated R² for each nutrient. Among the 452 dishes, we selected 248 dishes contributing more than 1% of the total consumption.

RESULTS

Finally, the FFQ included 107 items combined from 248 dishes based on nutrient profile and recipe. The FFQ items accounted for an average of 88.6% of the energy, 14 nutrient intakes, and 91.4% of the between-person variability. Quantities of dietary intake were assessed by 9 categories of frequency and 3 categories of portion size. Percentages of coverage for energy, protein, fat, carbohydrate, and calcium were 90.2%, 87.8%, 89.9%, 90.8%, and 88.7%, respectively.

CONCLUSIONS

We developed a dish-based, semi-quantitative FFQ comprising 107 items for Korean elementary school children aged 6 to 11. Further studies are needed to evaluate the reproducibility and validity of this FFQ for elementary school children.

Nutrition Management for Chronic Kidney Disease: Differences and Special Needs for Children and Adults

Common goals of nutritional therapy across the spectrum of pediatric and adult chronic kidney disease (CKD) include maintaining normal body mass and composition and reducing associated morbidity and mortality. Adult nephrologists caring for children and adolescents may be challenged by the existing complexities in identifying and interpreting the nutritional status and growth in children. Pediatric nephrologists may face situations that call for a sound knowledge of assessing nutritional status and providing nutrition therapy for adolescents and young adults. One important additional nutrition goal in children is to achieve normal growth and development. Children are growing and therefore need more calories and nutrients than just maintaining their body weight and composition. Lack of weight and height gain actually is considered failure to thrive in children. Some fundamental differences in approaches to nutritional therapy in CKD are necessitated based on the etiology of CKD. A large proportion of adults with CKD are diabetics, so the approach would be a low-carbohydrate diet. Children with CKD, especially young ones, often are anorexic, so calorie supplements that could include quite a lot of carbohydrates often are prescribed. More adults with CKD have hypertension and atherosclerotic comorbidities, which result in recommendations for low-salt and low-fat diets. Children with CKD often have salt and electrolyte wasting disease states and would require normal- or even high-salt diets, and fats often are included in supplements to bolster calorie intake. Low-protein diets often are recommended in adults with predialysis CKD to slow disease progression. Children are growing and have a higher protein daily requirement. Low-protein diets have not been found to be efficacious in children with CKD, in achieving normal growth, or in slowing disease progression. Adult nephrologists caring for children and adolescents may be challenged by the existing complexities in identifying and interpreting nutritional status and growth in children. Pediatric nephrologists may face situations that call for a sound knowledge of assessing nutritional status and providing nutrition therapy for adolescents and young adults. This article discusses the differences in the assessment of nutritional status between children and adults, as well as provides a comprehensive approach to nutritional management for CKD across the age spectrum. Semin Nephrol 43:x-xx © 2023 Elsevier Inc. All rights reserved.

Assessment of Dietary Phosphorus Intake and Implementation of Parental Phosphate Education in Pediatric Chronic Kidney Disease

Introduction

Management of dietary phosphorus intake is a challenge in children with chronic kidney disease and is governed by regional food sources and culinary practices. The aim of this study was to evaluate dietary intake of phosphorus in these children and assess the utility of parental phosphate education for control of hyperphosphatemia.

Methods

This prospective study included children aged 2-18 years with CKD stages 2-5D. Phosphorus intake was assessed by 24-hour dietary recall, analyzed using food processor software, and interpreted based on dietary reference intake (DRI) and suggested dietary intake (SDI). Parents of those with hyperphosphatemia were subjected to a structured phosphate education, and serum phosphate was monitored every 2 months for 6 months.

Results

Seventy children were recruited (mean age 9.4 ± 3.4 years, CKD5/5D: 51% (n = 36)) with median duration of CKD being 3.8 (IQR2,6) years. In the overall cohort, 50% (35/70) had phosphorus intake exceeding DRI with no significant difference between groups [CKD 5/5D,52.7% (n = 19) vs CKD2-4 47% (n = 16), P = 0.63]. Mean daily phosphorus intake was comparable between children with and without hyperphosphatemia [908 ± 279 mg vs 814 ± 302 mg, P = 0.1]. Based on DRI, 44% of children with normal serum phosphate and 58% with hyperphosphatemia had increased dietary intake of phosphorus (P = 0.15). Based on SDI, 26% with normal serum phosphate and 94% with hyperphosphatemia had increased dietary phosphorus intake (P < 0.001). Hyperphosphatemia was observed in 51% (CKD 2-4); 33% CKD5-5D 66%, P = 0.6). Among 29 children completing 6 months of follow up, there was a significant reduction in mean serum phosphate levels (P = 0.001) which was independent of age, stage of CKD or intake of phosphate binders. At end of the study, hyperphosphatemia persisted in 34%.

Conclusion

Compared to DRI, dietary assessment of phosphorus intake based on SDI was significantly associated with hyperphosphatemia in children with CKD 2-5D. In the majority, repeated parental structured phosphate education over 6 months was useful in managing hyperphosphatemia.

Malnutrition Patterns in Children with Chronic Kidney Disease

Malnutrition is frequent in children with chronic kidney disease (CKD). Apart from undernutrition and protein energy wasting (PEW), overnutrition prevalence is rising, resulting in fat mass accumulation. Sedentary behavior and unbalanced diet are the most important causal factors. Both underweight and obesity are linked to adverse outcomes regarding renal function, cardiometabolic risk and mortality rate. Muscle wasting is the cornerstone finding of PEW, preceding fat loss and may lead to fatigue, musculoskeletal decline and frailty. In addition, clinical data emphasize the growing occurrence of muscle mass and strength deficits in patients with fat mass accumulation, attributed to CKD-related wasting processes, reduced physical activity and possibly to obesity-induced inflammatory diseases, leading to sarcopenic obesity. Moreover, children with CKD are susceptible to abdominal obesity, resulting from high body fat distribution into the visceral abdomen compartment. Both sarcopenic and abdominal obesity are associated with increased cardiometabolic risk. This review analyzes the pathogenetic mechanisms, current trends and outcomes of malnutrition patterns in pediatric CKD. Moreover, it underlines the importance of body composition assessment for the nutritional evaluation and summarizes the advantages and limitations of the currently available techniques. Furthermore, it highlights the benefits of growth hormone therapy and physical activity on malnutrition management.

Utility of muscle ultrasound in nutritional assessment of children with nephrotic syndrome

BACKGROUND

Nutritional status assessment in children with nephrotic syndrome (NS) is critical for identifying patients who are at risk of protein-energy wasting (PEW) and for determining their nutritional needs and monitoring nutritional intervention outcomes.

METHODS

In a case-control study, we enrolled 40 children (age range: 2-16 years) with NS and 40 apparently healthy children (age and sex-matched) as a control group. Anthropometric data, as well as demographic, clinical, and laboratory data, were collected. A dietary intake assessment using a 3-day food intake record was done, and the quadriceps rectus femoris thickness (QRFT) and quadriceps vastus intermedius thickness (QVIT) were assessed using B-mode ultrasound and compared between both groups.

RESULTS

Children with NS had lower QRFT and QVIT measurements than control groups (p < 0.001). Inadequacy in protein intake occurred in 62.5% and 27.5% of the NS and control groups, respectively (p = 0.002). The thickness of the rectus and vastus muscles by ultrasound was significantly associated with the percentage of protein intake (p < 0.001). The ROC curve revealed that the best cutoff value of QRFT for the prediction of the patient at risk of malnutrition was ≤ 1.195 with an area under curve of 0.907, with p < 0.001.

CONCLUSION

In children with NS, skeletal muscle ultrasound is a simple and easy-to-use bedside technique for the identification of patients at risk of malnutrition. A higher resolution version of the Graphical abstract is available as Supplementary information.

Urine Uromodulin Is Not Associated With Blood Pressure in the Chronic Kidney Disease in Children Cohort

BACKGROUND

Uromodulin regulates activity of the sodium-potassium-two-chloride transporter in the loop of Henle. In adults, higher urine uromodulin levels are associated with greater rise in blood pressure (BP) in response to salt intake. We hypothesized that higher urine uromodulin levels would be associated with higher BP in children with chronic kidney disease, and that there would be an interaction of dietary sodium on this association.

METHODS

In the chronic kidney disease in children Cohort, we utilized univariable and multivariable linear regression models to evaluate the relationship between baseline spot urine uromodulin levels indexed to urine creatinine (Umod/Cr mg/g) and 24-hour mean systolic and diastolic BP, as well as baseline clinic BP. We also tested whether sodium intake (g/day) modified these relationships.

RESULTS

Among 436 participants, the median age was 12.4 years (8.9-15.2), median estimated glomerular filtration rate was 50 mL/min per 1.73 m2 (36-62), and median 24-hour mean systolic BP was 112 mm Hg (104-119). The etiology of chronic kidney disease was glomerular disease in 27%. In univariable models, each 2-fold higher Umod/Cr ratio was associated with a 1.66 mm Hg (95% CI, -2.31 to -1.00) lower 24-hour mean systolic and a 1.71 mm Hg (-2.45 to -0.97) lower clinic systolic BP. However, there was no statistically significant association between Umod/Cr and either 24-hour or clinic BP in multivariable models. We did not find a significant interaction between uromodulin and sodium intake in their effect on BP (P>0.05 in all models).

CONCLUSIONS

Urine uromodulin levels are not associated with BP in the chronic kidney disease in children cohort. Further studies are needed to confirm this finding in healthy pediatric cohorts.

Scoping review of the dietary intake of children with chronic kidney disease

BACKGROUND

Adequate nutrition is integral to optimal health outcomes for children with chronic kidney disease. However, no studies to date have summarised the existing knowledge base on the dietary intake of this patient group.

OBJECTIVE

Analyse and summarise evidence regarding the dietary intake of children with chronic kidney disease and identify areas that require further research or clarification.

METHODS

A scoping review of English language articles using four bibliographic databases and a predefined search term strategy. Weighted mean intake for each nutrient was calculated.

RESULTS

Eighteen studies were identified (1407 children and 118 healthy controls). Data on socioeconomic status, underreporting of intake and binder use was sparse. Most studies collected dietary information using food records or 24-h recalls. Nutrient data was missing for many subgroups especially transplant and dialysis patients. Protein intake was excessive in all groups where data was reported and varied from 125.7 ± 33% of the recommended dietary allowance in the severe disease group to 391.3 ± 383% in the group with mild kidney disease. Fibre, calcium, iron and vitamin C intake was inadequate for all groups. For children undertaking dialysis, none met the recommended dietary allowance for vitamins C, B1, B2, B3, B5 and B6. Sodium intake was excessive in all groups (> 220% of the recommended dietary allowance). Limited data suggests diet quality is poor, particularly fruit and vegetable intake.

CONCLUSIONS

This review has identified important subgroups of children with kidney disease where nutrient intake is suboptimal or not well described. Future studies should be conducted to describe intake in these groups. A higher-resolution version of the graphical abstract is available as Supplementary information.

Low variability of plant protein intake in the CKiD cohort does not demonstrate changes in estimated GFR nor electrolyte balance

BACKGROUND

Vegetable or plant-based sources of protein may confer health benefits in children with progressive kidney disease. Our aims were to understand the effect of the proportion of vegetable protein intake on changes in estimated GFR and to understand the effect of the proportion of vegetable protein intake on serum levels of bicarbonate, phosphorus, and potassium.

METHODS

Children with baseline eGFR between 30 and 90 mL/min/1.73 m² were recruited from 59 centers across North America as part of the chronic kidney disease in children (CKiD) study. The percentage of dietary vegetable protein (VP%) was gathered from annual Food Frequency Questionnaires. We performed longitudinal linear mixed models to determine the effect of VP% on eGFR and longitudinal logistic mixed models to determine the effect of VP% on electrolyte balance (potassium, phosphorus, bicarbonate).

RESULTS

Two thousand visits from 631 subjects. Across all dichotomized groups of children (sex, African American race, Hispanic ethnicity, glomerular etiology of CKD, hypertension, anemia, hyperkalemia, hyperphosphatemia, acidosis, BMI < 95th percentile), the median VP% was 32-35%. The longitudinal mixed model analysis did not show any effect of VP% on eGFR electrolyte (bicarbonate, phosphorus, and potassium) abnormalities (p > 0.1).

CONCLUSIONS

A diverse cohort of children with CKD has a narrow and homogeneous intake of vegetable protein. Due to the low variability of plant-based protein in the cohort, there were no associations between the percentage of plant protein intake and changes in eGFR nor electrolyte balance. A higher resolution version of the Graphical abstract is available as Supplementary information.

Managing the Nutritional Requirements of the Pediatric End-Stage Kidney Disease Graduate

The pediatric patient with end-stage kidney disease who transitions to the adult dialysis unit or nephrology center requires a unique nutritional focus. Clinicians in the adult center may be faced with complex issues that have often been part of the patient's journey since early childhood. The causes of kidney disease in children are often quite different than those which affect the adult population and may require different nutritional priorities. Abnormal growth including severe short stature, underweight, overweight or obesity, and poor musculature may affect the long-term health and psychosocial well-being of these patients. Nutritional assessment of these patients should include a focus on past growth and anthropometric data, dietary information, including appetite, quality of diet, and assessment of biochemical data through a pediatric lens. This review discusses the unique factors that must be considered when transitioning pediatric patients and notes major recommendations from a compilation of pediatric guideline statements.

Nocturnal Dipping and Left Ventricular Mass Index in the Chronic Kidney Disease in Children Cohort

BACKGROUND AND OBJECTIVES

The physiologic nocturnal BP decline is often blunted in patients with CKD; however, the consequences of BP nondipping in children are largely unknown. Our objective was to determine risk factors for nondipping and to investigate if nondipping is associated with higher left ventricular mass index in children with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a cross-sectional analysis of ambulatory BP monitoring and echocardiographic data in participants of the Chronic Kidney Disease in Children study. Multivariable linear and spline regression analyses were used to evaluate the relationship of risk factors with dipping and of dipping with left ventricular mass index.

RESULTS

Within 552 participants, mean age was 11 (±4) years, mean eGFR was 53 (±20) ml/min per 1.73 m2, and 41% were classified as nondippers. In participants with nonglomerular CKD, female sex and higher sodium intake were significantly associated with less systolic and diastolic dipping (P≤0.05). In those with glomerular CKD, Black race and greater proteinuria were significantly associated with less systolic and diastolic dipping (P≤0.05). Systolic dipping and diastolic dipping were not significantly associated with left ventricular mass index; however, in spline regression plots, diastolic dipping appeared to have a nonlinear relationship with left ventricular mass index. As compared with diastolic dipping of 20%-25%, dipping of <20% was associated with 1.41-g/m2.7-higher left ventricular mass index (95% confidence interval, -0.47 to 3.29), and dipping of >25% was associated with 1.98-g/m2.7-higher left ventricular mass index (95% confidence interval, -0.77 to 4.73), although these relationships did not achieve statistical significance.

CONCLUSIONS

Black race, female sex, and greater proteinuria and sodium intake were significantly associated with blunted dipping in children with CKD. We did not find a statistically significant association between dipping and left ventricular mass index.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_12_20_CJN09810721.mp3.

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

Obesity and metabolic syndrome (O&MS) due to the worldwide obesity epidemic affects children at all stages of chronic kidney disease (CKD) including dialysis and after kidney transplantation. The presence of O&MS in the pediatric CKD population may augment the already increased cardiovascular risk and contribute to the loss of kidney function. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. We present CPRs for the assessment and management of O&MS in children with CKD stages 2-5, on dialysis and after kidney transplantation. We address the risk factors and diagnostic criteria for O&MS and discuss their management focusing on non-pharmacological treatment management, including diet, physical activity, and behavior modification in the context of age and CKD stage. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT.

Nutritional Assessment and Management in Paediatric Chronic Kidney Disease

Nutrition in paediatrics has always been one of the most important factors for optimal growth. Children with chronic kidney disease (CKD) need special consideration for better long-term outcomes, including nutritional status, optimal height, and cognitive function. Nonetheless, there are many obstacles to overcome to attain optimal linear growth and nutritional status in children with CKD. This review highlights the need for tools to assess the growth parameters in CKD. In addition, recommendations for dietary intake play a major role in controlling electrolyte disturbances in patients with CKD. For example, it is still unclear whether it is better to restrict phosphate sources in inorganic, organic, or food additives. The review also summarises different factors such as fluid intake, route of feeding, and essential nutrients that require particular attention in paediatric patients with CKD. In summary, a multidisciplinary team is needed to devise individual nutritional plans to achieve the best outcome and improve the quality of life of patients.

Growth in children on kidney replacement therapy: a review of data from patient registries

Growth retardation is a major complication in children with chronic kidney disease (CKD) and on kidney replacement therapy (KRT). Conversely, better growth in childhood CKD is associated with an improvement in several hard morbidity-mortality endpoints. Data from pediatric international registries has demonstrated that improvements in the overall conservative management of CKD, the search for optimal dialysis, and advances in immunosuppression and kidney transplant techniques have led to a significant improvement of final height over time. Infancy still remains a critical period for adequate linear growth, and the loss of stature during the first years of life influences final height. Preliminary new original data from the European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry confirm an association between the final height and the height attained at 2 years in children on KRT.

The dietary management of potassium in children with CKD stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Dyskalemias are often seen in children with chronic kidney disease (CKD). While hyperkalemia is common, with an increasing prevalence as glomerular filtration rate declines, hypokalemia may also occur, particularly in children with renal tubular disorders and those on intensive dialysis regimens. Dietary assessment and adjustment of potassium intake is critically important in children with CKD as hyperkalemia can be life-threatening. Manipulation of dietary potassium can be challenging as it may affect the intake of other nutrients and reduce palatability. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPRs) for the dietary management of potassium in children with CKD stages 2-5 and on dialysis (CKD2-5D). We describe the assessment of dietary potassium intake, requirements for potassium in healthy children, and the dietary management of hypo- and hyperkalemia in children with CKD2-5D. Common potassium containing foods are described and approaches to adjusting potassium intake that can be incorporated into everyday practice discussed. Given the poor quality of evidence available, a Delphi survey was conducted to seek consensus from international experts. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs, based on the clinical judgment of the treating physician and dietitian. These CPRs will be regularly audited and updated by the PRNT.

Assessment of nutritional status in children with kidney diseases-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

In children with kidney diseases, an assessment of the child's growth and nutritional status is important to guide the dietary prescription. No single metric can comprehensively describe the nutrition status; therefore, a series of indices and tools are required for evaluation. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. Herein, we present CPRs for nutritional assessment, including measurement of anthropometric and biochemical parameters and evaluation of dietary intake. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Audit and research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT.

Energy and protein requirements for children with CKD stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Dietary management in pediatric chronic kidney disease (CKD) is an area fraught with uncertainties and wide variations in practice. Even in tertiary pediatric nephrology centers, expert dietetic input is often lacking. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, was established to develop clinical practice recommendations (CPRs) to address these challenges and to serve as a resource for nutritional care. We present CPRs for energy and protein requirements for children with CKD stages 2-5 and those on dialysis (CKD2-5D). We address energy requirements in the context of poor growth, obesity, and different levels of physical activity, together with the additional protein needs to compensate for dialysate losses. We describe how to achieve the dietary prescription for energy and protein using breastmilk, formulas, food, and dietary supplements, which can be incorporated into everyday practice. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgment. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT.

Chronic Kidney Disease and Dietary Measures to Improve Outcomes

Chronic kidney disease is an ongoing deterioration of renal function that often progresses to end-stage renal disease. Management goals in children include slowing disease progression, prevention and treatment of complications, and optimizing growth, development, and quality of life. Nutritional management is critically important to achieve these goals. Control of blood pressure, proteinuria, and metabolic acidosis with dietary and pharmacologic measures may slow progression of chronic kidney disease. Although significant progress in management has been made, further research is required to resolve many outstanding controversies. We review recent developments in pediatric chronic kidney disease, focusing on dietary measures to improve outcomes.

Assessment and management of fluid overload in children on dialysis

Dysregulation of intravascular fluid leads to chronic volume overload in children with end-stage kidney disease (ESKD). Sequelae include left ventricular hypertrophy and remodeling and impaired cardiac function. As a result, cardiovascular complications are the commonest cause of mortality in the pediatric dialysis population. The clinical need to optimize intravascular volume in children with ESKD is clear; however, its assessment and management is the most challenging aspect of the pediatric dialysis prescription. Minimizing chronic fluid overload is a key priority; however, excessive ultrafiltration is toxic to the myocardium and can precipitate intradialytic symptoms. This review outlines emerging objective techniques to enhance the assessment of fluid overload in children on dialysis and outlines evidence for current management strategies to address this clinical problem.

Hypertension in Pediatric Dialysis Patients: Etiology, Evaluation, and Management

PURPOSE OF REVIEW

Review epidemiology, pathophysiology, and management of hypertension in the pediatric dialysis population.

RECENT FINDINGS

Interdialytic blood pressure measurement, especially with ambulatory blood pressure monitoring, is the gold standard to assess for hypertension. Tools to assess dry weight aid in achievement of euvolemia, the primary therapy for management of hypertension. Persistent hypertension should be treated with antihypertensive medications and potentially with native nephrectomies. Cardiovascular disease continues to be the primary cause of morbidity and mortality in the dialysis population with hypertension as an important modifiable factor. Achievement on dry weight and limiting both aggressiveness of interdialytic weight gain and ultrafiltration rate underlie the best approach. Tools to assess volume status beyond clinical assessment have shown promise in achieving euvolemia. When hypertension persists despite achievement of euvolemia, antihypertensive medications may be required and in some cases native nephrectomies. Future studies in children are needed to determine the best antihypertensive class and ideal rate of ultrafiltration on hemodialysis towards achievement of normotension and reduction of cardiovascular risk.

Blood pressure management in children on dialysis

Hypertension is a leading cause of cardiovascular complications in children on dialysis. Volume overload and activation of the renin-angiotensin-aldosterone system play a major role in the pathophysiology of hypertension. The first step in managing blood pressure (BP) is the careful assessment of ambulatory BP monitoring. Volume control is essential and should start with the accurate identification of dry weight, based on a comprehensive assessment, including bioimpedance analysis and intradialytic blood volume monitoring (BVM). Reduction of interdialytic weight gain (IDWG) is critical, as higher IDWG is associated with a worse left ventricular mass index and poorer BP control: it can be obtained by means of salt restriction, reduced fluid intake, and optimized sodium removal in dialysis. Optimization of peritoneal dialysis and intensified hemodialysis or hemodiafiltration have been shown to improve both fluid and sodium management, leading to better BP levels. Studies comparing different antihypertensive agents in children are lacking. The pharmacokinetic properties of each drug should be considered. At present, BP control remains suboptimal in many patients and efforts are needed to improve the long-term outcomes of children on dialysis.

Health-related quality of life of children with pre-dialysis chronic kidney disease

BACKGROUND

The goal of this study was to evaluate the quality of life (QOL) of Asian children with pre-dialysis chronic kidney disease (CKD) and to reveal the factors influencing the QOL of children with CKD.

METHODS

We performed a cross-sectional study of the PedsQL 4.0 Generic Core Scale Module in the KNOW-PedCKD (KoreaN cohort study for Outcome in patients with Pediatric Chronic Kidney Disease) cohort, and compared the child self-reported and parent proxy-reported QOL of the pediatric cohort. From 2011 through 2016, a total of 376 children with CKD were enrolled after informed consent was obtained from parents or caregivers in seven pediatric nephrology centers.

RESULTS

In parent proxy-reports, male patients had a better QOL than female patients in the Physical Functioning category. In child self-reports, male patients had better QOL than female patients in the Physical, Emotional, and School Functioning categories. According to CKD stage, there were significant differences in the QOL score in all categories of parent proxy-reports, and patients with higher CKD stage (lower glomerular filtration rate) had a worse QOL. Growth parameters showed a significantly positive correlation with the QOL score in all categories.

CONCLUSIONS

The QOL of children with predialysis CKD is affected by various factors, including sex, glomerular filtration rate (GFR), socio-economic status, existence of co-morbidities, anemia, growth retardation, and behavioral disorders. To improve their QOL, it is important to objectively understand the respective effects of these factors and attempt early intervention.