Growth and nutrition in children with chronic kidney disease

The Role of Growth Hormone in Chronic Kidney Disease

Growth hormone (GH) has become a critical therapy for treating growth delay and failure in pediatric chronic kidney disease. Recombinant human GH treatment is safe and significantly improves height and height velocity in these growing patients and improved growth outcomes are associated with decreased morbidity and mortality as well as improved quality of life. However, the utility of recombinant human GH in adults with chronic kidney disease and end-stage renal disease for optimization of body habitus and reducing frailty remains uncertain. Semin Nephrol 41:x-xx © 2021 Elsevier Inc. All rights reserved.

Using videoconsultations to deliver dietary advice to children with chronic kidney disease: a qualitative study of parent and child perspectives

BACKGROUND

Children with chronic kidney disease require specialist renal paediatric dietetic care, regardless of disease severity or geographical location; however, under-resourcing makes this challenging. Videoconsultation may offer a solution but research exploring its acceptability is limited. The present study explored parent/carer and child perspectives of videoconsultation as an alternative or supplement to existing regional dietetic care.

METHODS

Children and families using a regional paediatric nephrology service were recruited through purposeful sampling techniques. Renal paediatric dietitians used existing hospital software to host videoconsultations with families. Perspectives were subsequently explored in telephone interviews with the children, their parents and separately with the renal dietitians. Data were transcribed verbatim and an inductive framework analysis conducted.

RESULTS

Twelve families took part in the study, comprising 13 parents and five children (aged 9 months to 14 years). Two renal dietitians were also interviewed. Six themes emerged which were 'Logistics', 'Understanding Information', 'Family Engagement', 'Establishing Trust', 'Willingness to Change' and 'Preferences'. Satisfaction with the videoconsultations was high, with no data security fears and only minor privacy concerns. Parents reported that screen-sharing software enhanced their understanding, generating greater discussion and engagement compared to clinic and telephone contacts. Parents praised efficiencies and  improved access to specialist advice, requesting that videoconsultations supplement care. Children preferred videoconsultations outright.

CONCLUSIONS

Dietetic videoconsultations were acceptable to families and perceived to be a feasible, high-quality complement to regional specialist dietetic care. Enhanced understanding and engagement might improve self-care in adolescents. The acceptability and feasibility of videoconsultations could address inequitable regional service provision.

Validity of Bioelectrical Impedance Analysis to Estimation Fat-Free Mass in the Army Cadets

Background: Bioelectrical Impedance Analysis (BIA) is a fast, practical, non-invasive, and frequently used method for fat-free mass (FFM) estimation. The aims of this study were to validate predictive equations of BIA to FFM estimation in Army cadets and to develop and validate a specific BIA equation for this population. Methods: A total of 396 males, Brazilian Army cadets, aged 17–24 years were included. The study used eight published predictive BIA equations, a specific equation in FFM estimation, and dual-energy X-ray absorptiometry (DXA) as a reference method. Student’s t-test (for paired sample), linear regression analysis, and Bland–Altman method were used to test the validity of the BIA equations. Results: Predictive BIA equations showed significant differences in FFM compared to DXA (p < 0.05) and large limits of agreement by Bland–Altman. Predictive BIA equations explained 68% to 88% of FFM variance. Specific BIA equations showed no significant differences in FFM, compared to DXA values. Conclusion: Published BIA predictive equations showed poor accuracy in this sample. The specific BIA equations, developed in this study, demonstrated validity for this sample, although should be used with caution in samples with a large range of FFM.

Anthropometric and biochemical profile of children and adolescents with chronic kidney disease in a predialysis pediatric interdisciplinary program

This is longitudinal retrospective observational cohort study that evaluated anthropometric and biochemical variables of children and adolescents admitted to a Predialysis Interdisciplinary Management Program (PDIMP) responsible for the follow-up of children and adolescents at stages 2 to 4 of chronic kidney disease (CKD) at a tertiary center. One hundred thirty-eight patients with CKD on predialysis treatment with median age at admission of 9 years and the median follow-up time of 5 years were evaluated. Seventy-four (53%) had CKD stage 3 at admission and 70 (51%) reached CKD stage 5 at the end of the follow-up. There was no significant difference between the mean initial and final hemoglobin and serum albumin. However, the final serum bicarbonate presented a significant improvement. Analyses stratified according to clinical variables of interest showed a significant improvement in body mass index (BMI) Z score, especially in the subgroup of children admitted under two years of age. In relation to stature-for-age Z score, data show a significant improvement in stature SD at the end of the study. In conclusion, the present study showed improvement of nutritional status of CKD patients and that the deterioration of renal function was not correlated with BMI-for-age Z score.

Growth failure and nutrition considerations in chronic childhood wasting diseases

Growth failure is a common problem in many children with chronic diseases. This article is an overview of the most common causes of growth failure/growth retardation that affect children with a number of chronic diseases. We also briefly review the nutrition considerations and treatment goals. Growth failure is multifactorial in children with chronic conditions, including patients with cystic fibrosis, chronic kidney disease, chronic liver disease, congenital heart disease, human immunodeficiency virus, inflammatory bowel disease, short bowel syndrome, and muscular dystrophies. Important contributory factors to growth failure include increased energy needs, increased energy loss, malabsorption, decreased energy intake, anorexia, pain, vomiting, intestinal obstruction, and inflammatory cytokines. Various metabolic and pathologic abnormalities that are characteristic of chronic diseases further lead to significant malnutrition and growth failure. In addition to treating disease-specific abnormalities, treatment should address the energy and protein deficits, including vitamin and mineral supplements to correct deficiencies, correct metabolic and endocrinologic abnormalities, and include long-term monitoring of weight and growth. Individualized, age-appropriate nutrition intervention will minimize the malnutrition and growth failure seen in children with chronic diseases.

Development of a measure of caregiver burden in paediatric chronic kidney disease: The Paediatric Renal Caregiver Burden Scale

To inform the development of a measure of caregiver burden for carers of children with chronic kidney disease, interviews were conducted with 16 caregivers and 10 renal healthcare professionals. A pool of 97 items generated from interviews was reduced to 60 items following review. A piloting exercise provided evidence for the usability, readability and relevance of items and informed further adaptations resulting in the 51-item Paediatric Renal Caregiver Burden Scale. Further to assessment of its psychometric properties, it is hoped that that the Paediatric Renal Caregiver Burden Scale will serve as a useful measure of caregiver burden in paediatric chronic kidney disease.

Long-term experience of steroid-free pediatric renal transplantation: effects on graft function, body mass index, and longitudinal growth

Increased focus on the potential negative side effects of steroid usage in pediatric transplantation has led to steroid minimization or steroid-free transplantation. In this study, we report results after complete steroid avoidance in renal transplantation in the period 1994-2009. We evaluate the effects of complete steroid avoidance on allograft function, BMI, and linear growth. The majority of transplanted children were induced with antithymocyte globulin and immunosuppressed with a calcineurin inhibitor and mycophenolate mofetil. Steroids were given only when rejection occurred or due to comorbidities. Anthropometric data were collected from 65 transplantations in 60 children. Patient survival was 93%; graft survival was 81% after five yr (N = 42) and 63% after 10 yr (N = 16). Acute rejection within the first year of transplantation was 9%. The distribution of the children's BMI before transplantation was normal; the mean BMI-SDS was 0.21 before transplantation, and this value remained stable during the next five yr. Post-transplantation the children demonstrated significant improved growth as the mean height-SDS increased significantly from -1.7 to -1.1. Catch-up growth was most pronounced in the youngest (< six yr). Steroid-free immunosuppression in pediatric renal transplantation is safe and protects against steroid-induced obesity and short stature.

Improvement in growth after 1 year of growth hormone therapy in well-nourished infants with growth retardation secondary to chronic renal failure: results of a multicenter, controlled, randomized, open clinical trial

BACKGROUND AND OBJECTIVES

Our aim was to evaluate the growth-promoting effect of growth hormone (GH) treatment in infants with chronic renal failure (CRF) and persistent growth retardation despite adequate nutritional and metabolic management.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The study design included randomized, parallel groups in an open, multicenter trial comparing GH (0.33 mg/kg per wk) with nontreatment with GH during 12 months. Sixteen infants who had growth retardation, were aged 12+/-3 months, had CRF (GFR<or=60 ml/min per 1.73 m2), and had adequate nutritional intake and good metabolic control were recruited from eight pediatric nephrology departments from Spain and Portugal. Main outcome measures were body length, body weight, bone age, biochemical and hormonal analyses, renal function, bone mass, and adverse effects.

RESULTS

Length gain in infants who were treated with GH was statistically greater (P<0.05) than that of nontreated children (14.5 versus 9.5 cm/yr; SD score 1.43 versus -0.11). The GH-induced stimulation of growth was associated with no undesirable effects on bone maturation, renal failure progression, or metabolic control. In addition, GH treatment improved forearm bone mass and increased serum concentrations of total and free IGF-I and IGF-binding protein 3 (IGFBP-3), whereas IGF-II, IGFBP-1, IGFBP-2, GH-binding protein, ghrelin, and leptin were not modified.

CONCLUSIONS

Infants with CRF and growth retardation despite good metabolic and nutritional control benefit from GH treatment without adverse effects during 12 months of therapy.

Blood pressure in children with chronic kidney disease: a report from the Chronic Kidney Disease in Children study

To characterize the distribution of blood pressure (BP), prevalence, and risk factors for hypertension in pediatric chronic kidney disease, we conducted a cross-sectional analysis of baseline BPs in 432 children (mean age 11 years; 60% male; mean glomerular filtration rate 44 mL/min per 1.73 m(2)) enrolled in the Chronic Kidney Disease in Children cohort study. BPs were obtained using an aneroid sphygmomanometer. Glomerular filtration rate was measured by iohexol disappearance. Elevated BP was defined as BP >or=90th percentile for age, gender, and height. Hypertension was defined as BP >or=95th percentile or as self-reported hypertension plus current treatment with antihypertensive medications. For systolic BP, 14% were hypertensive and 11% were prehypertensive (BP 90th to 95th percentile); 68% of subjects with elevated systolic BP were taking antihypertensive medications. For diastolic BP, 14% were hypertensive and 9% were prehypertensive; 53% of subjects with elevated diastolic BP were taking antihypertensive medications. Fifty-four percent of subjects had either systolic or diastolic BP >or=95th percentile or a history of hypertension plus current antihypertensive use. Characteristics associated with elevated BP included black race, shorter duration of chronic kidney disease, absence of antihypertensive medication use, and elevated serum potassium. Among subjects receiving antihypertensive treatment, uncontrolled BP was associated with male sex, shorter chronic kidney disease duration, and absence of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use. Thirty-seven percent of children with chronic kidney disease had either elevated systolic or diastolic BP, and 39% of these were not receiving antihypertensives, indicating that hypertension in pediatric chronic kidney disease may be frequently under- or even untreated. Treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may improve BP control in these patients.

Parent perspectives of health related quality of life in adolescents with chronic kidney disease due to underlying urological disorders: an assessment using the Child Health Questionnaire-Parent Form 50

PURPOSE

Little is known about health related quality of life in adolescents with chronic kidney disease due to urological anomalies. We assessed generic health related quality of life in this population using a validated parent proxy instrument.

MATERIALS AND METHODS

In this multicenter prospective cohort study the Child Health Questionnaire-Parent Form 50, a generic health related quality of life parent proxy instrument, was administered to 92 parents of adolescents 10 to 18 years old with chronic kidney disease. Mean summary measure and scale scores in adolescents with urological anomalies were compared to scores in those with other causes of kidney disease and in a representative American population sample.

RESULTS

The cohort included 35 adolescents with an underlying diagnosis of congenital urological anomaly and 57 with another cause of kidney disease. There were no significant differences in mean scale or summary measure scores between the 2 diagnostic groups. When compared to a representative population sample, adolescents with congenital urological anomalies scored significantly worse on the questionnaire physical summary measure (44.5, 95% CI 39.9-49.1 vs 52.0, 95% CI 51.1-52.9, p = 0.002), and on the Child Health Questionnaire scales physical functioning, role physical, general health perceptions, family activities and parental emotional impact.

CONCLUSIONS

As assessed by Child Health Questionnaire-Parent Form 50, parents reported that adolescents with chronic kidney disease due to urological disorders scored lower on the physical summary measure than a population based reference sample and they reported a negative effect on family activities and parental emotional well-being. These findings suggest that the Child Health Questionnaire-Parent Form 50 could provide a family based assessment of generic health related quality of life in adolescents with urological disorders.

Experiences of parents who have children with chronic kidney disease: a systematic review of qualitative studies

OBJECTIVE

The objective of this study was to describe the experiences of parents who have children with chronic kidney disease.

METHODS

We conducted a systematic review and meta-ethnography of studies that had used in-depth interviews or focus groups to explore experiences of parents with children who have chronic kidney disease (predialysis, hemodialysis, peritoneal dialysis, or after kidney transplantation). We searched 5 electronic databases (through to August 2005), Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Sociofile/Sociological Abstract, and reference lists of relevant articles.

RESULTS

Sixteen articles that reported the experiences of parents of 358 children with chronic kidney disease were included. Ten themes emerged, which we grouped into 3 interrelated clusters: intrapersonal (living with constant uncertainty, stress, and maintaining vigilance despite experiencing fatigue), interpersonal (medicalization of the parental role, dependence on and conflict with staff, and disrupted peer relationships), and external issues (management of the medical regimen, pursuit of information, organizing transportation, accommodation and finances, adhering to the child's liquid and diet restrictions, and balancing medical care with domestic responsibilities).

CONCLUSIONS

In addition to "normal" parental roles, being a parent of a child with chronic kidney disease demands a high-level health care provider, problem solving, information seeking, and financial and practical skills at a time when the capacity to cope is threatened by physical tiredness, uncertainty, and disruption to peer support within and outside the family structure. Parents of children with chronic kidney disease need multidisciplinary care, which may lead to improved outcomes for their children.

An Assessment of Health Related Quality of Life Using the Child Health and Illness Profile-Adolescent Edition in Adolescents With Chronic Kidney Disease Due to Underlying Urological Disorders

PURPOSE

We examined health related quality of life in adolescents with congenital urological disease causing kidney disease using a generic health related quality of life instrument. We then compared the results to those in adolescents with medical kidney disease and to population based norms.

MATERIALS AND METHODS

The Child Health and Illness Profile-Adolescent Edition was administered to 113 patients 10 to 18 years old with chronic kidney disease. Mean domain and subdomain scores for adolescents with urological disease were compared to those of adolescents with medical kidney disease and to population based norms.

RESULTS

The cohort included adolescents with an underlying diagnosis of congenital urological anomaly (37 patients) or other causes of kidney disease (76). Compared to adolescents with kidney disease caused by other factors, those with congenital urological disease scored statistically significantly better in the Child Health and Illness Profile-Adolescent Edition subdomain of Limitations of Activity (mean 22.3 [SD 2.5] vs 20.4 [SD 5.0], p = 0.04). Compared to population norms, adolescents with congenital disorders scored lower in the Disorders domain (mean 16.5, 95% CI 14.2 to 18.9) but better in the Risks domain (mean 25.9, 95% CI 25.1 to 26.6) and in the Home Safety and Health subdomain (mean 25.2, 95% CI 23.7 to 26.6).

CONCLUSIONS

As assessed by the Child Health and Illness Profile-Adolescent Edition generic health status questionnaire, adolescents with kidney disease due to underlying congenital urological disease had fewer limitations of activity compared to those with underlying medical kidney disease. Except for low scores in the Disorders domain, children with underlying urological disease did not have significant impairments in any other domain compared to population based norms.

Lipoprotein metabolism in chronic renal insufficiency

Chronic renal insufficiency (CRI) is associated with a characteristic dyslipidemia. Findings in children with CRI largely parallel those in adults. Moderate hypertriglyceridemia, increased triglyceride-rich lipoproteins (TRL) and reduced high-density lipoproteins (HDL) are the most usual findings, whereas total and low-density lipoprotein cholesterol (LDL-C) remain normal or modestly increased. Qualitative abnormalities in lipoproteins are common, including small dense LDL, oxidized LDL, and cholesterol-enriched TRL. Measures of lipoprotein lipase and hepatic lipase activity are reduced, and concentrations of apolipoprotein C-III are markedly elevated. Still an active area of research, major pathophysiological mechanisms leading to the dyslipidemia of CRI include insulin resistance and nonnephrotic proteinuria. Sources of variability in the severity of this dyslipidemia include the degree of renal impairment and the modality of dialysis. The benefits of maintaining normal body weight and physical activity extend to those with CRI. In addition to multiple hypolipidemic pharmaceuticals, fish oils are also effective as a triglyceride-lowering agent, and the phosphorous binding agent sevelamer also lowers LDL-C. Emerging classes of hypolipidemic agents and drugs affecting sensitivity to insulin may impact future treatment. Unfortunately, cardiovascular benefit has not been convincingly demonstrated by any trial designed to study adults or children with renal disease. Therefore, it is not possible at this time to endorse general recommendations for the use of any agent to treat dyslipidemia in children with chronic kidney disease.

Nutrition assessment and hormonal influences on body composition in children with chronic kidney disease

Malnutrition is a serious complication of chronic kidney disease (CKD) in the pediatric population. Management of the nutritional status of children presents the challenge of ensuring sufficient energy to promote linear growth, development of brain and organs, and maintenance of appropriate fat and muscle stores, while preventing excess protein intake and controlling electrolytes. Aggressive nutrition intervention in the early stages of CKD may be critical in the prevention of more serious complications further in the disease process. Nutrition assessment involves analysis of dietary intake, anthropometric parameters, and laboratory data. Currently, no guidelines are available for nutritional management of pediatric patients with CKD before the onset of dialysis. The content and algorithms in this article are intended to serve as a guide in the management of the nutritional status of children with CKD. Although adequate calorie and protein intake is critical in prevention of malnutrition, it is only part of a complex mechanism in the development of cachexia in CKD. Research suggests that the effects of inflammatory cytokines and hormones such as leptin and ghrelin play a role in the development of malnutrition in CKD. As a more thorough understanding of this mechanism emerges, new treatments aimed at inhibiting cachexia can be developed.

Growth hormone treatment of non-growth hormone-deficient growth disorders

Although a large body of data on efficacy and safety of growth hormone (GH) treatment for various non-growth hormone-deficient (GHD) growth disorders has accumulated from a combination of clinical trial and postmarketing sources in the last 20 years or more, there remain limitations. Clinical trial data have the advantage of direct comparison of well-matched, randomized patient groups receiving treatment (or not) under comparable conditions and, as such, provide the highest quality evidence of efficacy. Clinical trials, however, are typically too small for any statistically valid assessment for safety, which is more comprehensively addressed using postmarketing data. Consequently, while the efficacy of GH treatment in children with non-GHD growth disorders has been solidly established and, based on the combination of the rigor of the clinical trial data and numerical power of the postmarketing data, no major concerns exist regarding safety, additional long-term data are required.

Neurocognitive outcomes in children with chronic kidney disease: Current findings and contemporary endeavors

Given the rise in chronic kidney disease (CKD) in both children and adults, CKD has recently been targeted as a public health priority. Childhood onset kidney disease is generally a noncurable and progressive condition that leads to kidney failure by early adulthood. Fortunately, improved identification of kidney problems allows for early intervention, which is thought to slow progression toward end-stage renal disease. In addition, medical interventions for pediatric end-stage renal disease have also improved, allowing children to take advantage of lifesaving renal replacement treatments such as dialysis and kidney transplantation. In spite of improvements in identification and treatment, CKD causes both direct and indirect insults to a variety of organ systems. This paper reviews recently published studies pertaining to the neurocognitive and psychosocial impact of CKD on children of various ages and at various stages of kidney failure. Specific attention is focused on summarizing peer reviewed research that describes associations between kidney functioning and cognitive functioning, language acquisition, visual spatial abilities, memory, and executive functioning. In addition, peer reviewed research describing psychosocial outcomes associated with CKD related to academic achievement, social-behavioral functioning, and quality of life are summarized. The authors also identified disease-specific factors that likely mediate neurocognitive outcomes (e.g., anemia, hypertension, cardiovascular) and endorse the importance of continued interdisciplinary research collaborations that will provide a better understanding of the mechanisms responsible for improved neurocognitive functioning after transplantation. The authors conclude this review by describing a multicenter, prospective, longitudinal, National Institutes of Health funded study that is currently examining the developmental outcomes of children with mild to moderate CKD. The authors speculate that the Chronic Kidney Disease in Children Prospective Cohort Study (CKiD) findings will provide additional evidence-based guidance for clinicians and researchers working with children and adolescents with deteriorating kidney function to improve medical and developmental outcomes.