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Shaw V, Anderson C, Desloovere A, Greenbaum LA, Haffner D, Nelms CL, Paglialonga F, Polderman N, Qizalbash L, Renken-Terhaerdt J, Stabouli S, Tuokkola J, Vande Walle J, Warady BA, Shroff R. Nutritional management of the infant with chronic kidney disease stages 2-5 and on dialysis. Pediatr Nephrol 2023; 38:87-103. [PMID: 35378603 PMCID: PMC9747855 DOI: 10.1007/s00467-022-05529-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 01/10/2023]
Abstract
The nutritional management of children with chronic kidney disease (CKD) is of prime importance in meeting the challenge of maintaining normal growth and development in this population. The objective of this review is to integrate the Pediatric Renal Nutrition Taskforce clinical practice recommendations for children with CKD stages 2-5 and on dialysis, as they relate to the infant from full term birth up to 1 year of age, for healthcare professionals, including dietitians, physicians, and nurses. It addresses nutritional assessment, energy and protein requirements, delivery of the nutritional prescription, and necessary dietary modifications in the case of abnormal serum levels of calcium, phosphate, and potassium. We focus on the particular nutritional needs of infants with CKD for whom dietary recommendations for energy and protein, based on body weight, are higher compared with children over 1 year of age in order to support both linear and brain growth, which are normally maximal in the first 6 months of life. Attention to nutrition during infancy is important given that growth is predominantly nutrition dependent in the infantile phase and the growth of infants is acutely impaired by disruption to their nutritional intake, particularly during the first 6 months. Inadequate nutritional intake can result in the failure to achieve full adult height potential and an increased risk for abnormal neurodevelopment. We strongly suggest that physicians work closely with pediatric renal dietitians to ensure that the infant with CKD receives the best possible nutritional management to optimize their growth and development.
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Affiliation(s)
- Vanessa Shaw
- University College London Great Ormond Street Hospital Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Caroline Anderson
- grid.430506.40000 0004 0465 4079University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - An Desloovere
- grid.410566.00000 0004 0626 3303University Hospital Ghent, Ghent, Belgium
| | | | - Dieter Haffner
- grid.10423.340000 0000 9529 9877Children’s Hospital, Hannover Medical School, Hannover, Germany
| | | | - Fabio Paglialonga
- grid.414818.00000 0004 1757 8749Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nonnie Polderman
- grid.414137.40000 0001 0684 7788British Columbia Children’s Hospital, Vancouver, Canada
| | - Leila Qizalbash
- grid.459561.a0000 0004 4904 7256Great North Children’s Hospital, Newcastle upon Tyne, UK
| | - José Renken-Terhaerdt
- grid.417100.30000 0004 0620 3132Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stella Stabouli
- grid.4793.900000001094570051st Department of Pediatrics, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Jetta Tuokkola
- grid.7737.40000 0004 0410 2071Children’s Hospital and Clinical Nutrition Unit, Internal Medicine and Rehabilitation, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Johan Vande Walle
- grid.410566.00000 0004 0626 3303University Hospital Ghent, Ghent, Belgium
| | - Bradley A. Warady
- grid.239559.10000 0004 0415 5050Children’s Mercy Kansas City, Kansas City, MO USA
| | - Rukshana Shroff
- grid.83440.3b0000000121901201University College London Great Ormond Street Hospital Institute of Child Health, 30 Guilford Street, London, WC1N 1EH UK
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Desloovere A, Renken-Terhaerdt J, Tuokkola J, Shaw V, Greenbaum LA, Haffner D, Anderson C, Nelms CL, Oosterveld MJS, Paglialonga F, Polderman N, Qizalbash L, Warady BA, Shroff R, Vande Walle J. The dietary management of potassium in children with CKD stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2021; 36:1331-1346. [PMID: 33730284 PMCID: PMC8084813 DOI: 10.1007/s00467-021-04923-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/18/2020] [Accepted: 01/05/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
| | - José Renken-Terhaerdt
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jetta Tuokkola
- Children's Hospital and Clinical Nutrition Unit, Internal Medicine and Rehabilitation, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Vanessa Shaw
- UCL Great Ormond Street Institute of Child Health, London, UK.
- University of Plymouth, Plymouth, UK.
| | - Larry A Greenbaum
- Emory University, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Dieter Haffner
- Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Caroline Anderson
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Michiel J S Oosterveld
- Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Fabio Paglialonga
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | | | - Rukshana Shroff
- UCL Great Ormond Street Institute of Child Health, London, UK
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Nelms CL. Optimizing Enteral Nutrition for Growth in Pediatric Chronic Kidney Disease (CKD). Front Pediatr 2018; 6:214. [PMID: 30116725 PMCID: PMC6083216 DOI: 10.3389/fped.2018.00214] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/12/2018] [Indexed: 12/25/2022] Open
Abstract
Growth in pediatric Chronic Kidney Disease is important for long-term outcomes including final adult height and cognitive function. However, there are many barriers for children with chronic kidney disease to achieve adequate nutritional intake to optimize growth. This review highlights these unique concerns, including route of nutrition, dialysis contributions and biochemical indices. Fitting the enteral feeding to the patients' needs involves choosing an appropriate product or products, limiting harmful nutrients in excess, notably aluminum, and altering for electrolyte and micronutrient needs. Unique adjustments to the enteral regimen include accommodating volume needs, optimizing macronutrient ratios, specific electrolyte adjustments, the blending of products together, and adjustments made to consider patient and family psychosocial needs. When a holistic approach to medical nutrition therapy is applied, taking the above factors into consideration, adequate intake for growth of the child with CKD is achievable.
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Affiliation(s)
- Christina L. Nelms
- PedsFeeds, Kearney, NE, United States
- Department of Family Studies, University of Nebraska System, Kearney, NE, United States
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Acute Hypocalcemia and Metabolic Alkalosis in Children on Cation-Exchange Resin Therapy. Case Rep Nephrol 2017; 2017:6582613. [PMID: 28959498 PMCID: PMC5556615 DOI: 10.1155/2017/6582613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/03/2017] [Indexed: 11/18/2022] Open
Abstract
Background Sodium polystyrene sulfonate (SPS) is a chelating agent used for the treatment of hyperkalemia. SPS has a wide range of exchange capacity requiring close monitoring of serum electrolytes. We observed two patients who developed acute hypocalcemia and increased metabolic alkalosis after initiating SPS therapy. We report these cases to draw attention to the potential risk of this medication in pediatric patients. Case Diagnosis/Treatment Two children with chronic kidney disease on dialysis were started on SPS for hyperkalemia. Within a week after initiation of the medication, both patients developed hypocalcemia on routine labs without overt clinical manifestations. The hypocalcemia was rapidly corrected with oral supplementation and discontinuation of SPS. Conclusions Severe hypocalcemia can develop after SPS therapy. The metabolic alkalosis in these patients associated with the hypocalcemia put them at increased risk for complications. Hence, careful attention must be paid to the state of calcium metabolism in all patients receiving SPS. Often calcium supplementation is required to maintain normal calcium levels.
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Thompson K, Flynn J, Okamura D, Zhou L. Pretreatment of formula or expressed breast milk with sodium polystyrene sulfonate (Kayexalate(®)) as a treatment for hyperkalemia in infants with acute or chronic renal insufficiency. J Ren Nutr 2013; 23:333-9. [PMID: 23707305 DOI: 10.1053/j.jrn.2013.02.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Revised: 02/05/2013] [Accepted: 02/07/2013] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To evaluate the effect on serum potassium of treating infant formula or expressed breast milk (EBM) with sodium polystyrene sulfonate (SPS) before patient consumption. DESIGN AND SETTING Retrospective cohort study of patients at Seattle Children's Hospital who received SPS-treated formula or EBM. SUBJECTS AND INTERVENTION Thirteen patients less than 2 years of age with a diagnosis of hyperkalemia and acute kidney injury or chronic kidney disease that had received formula or EBM pretreated with SPS between September 2009 and May 2012 were identified. Hyperkalemia was defined as a serum potassium concentration greater than 5.5 mEq/L. MAIN OUTCOME MEASURE The primary endpoint was the mean change in serum potassium 48 hours after receiving pretreated formula or EBM. Serum potassium levels before and after patient consumption were averaged and compared using a paired t test. RESULTS Pretreatment of formula or EBM with SPS resulted in a 24% decrease in serum potassium levels (6.3 mEq/L to 4.8 mEq/L; P < .0001). There was a significant difference in before and after calcium and creatinine levels (P < .05), and no significant differences in blood urea nitrogen, sodium, magnesium, phosphorus, chloride, or bicarbonate levels. CONCLUSION Pretreatment of formula or EBM with SPS before consumption is an effective treatment for hyperkalemia in infants. Caution needs to be taken in patients who have sodium restrictions because the exchange for potassium produces a sodium-rich formula.
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Bunchman TE. Nutritional delivery in infants with CKD: techniques to avoid hyperkalemia. J Ren Nutr 2013; 23:387-8. [PMID: 23706704 DOI: 10.1053/j.jrn.2013.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 03/26/2013] [Indexed: 11/11/2022] Open
Affiliation(s)
- Timothy E Bunchman
- Department of Pediatric Nephrology, Virginia Commonwealth University School of Medicine, Children's Hospital of Richmond, Richmond, VA 23298, USA.
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Cameron JCF, Kennedy D, Feber J, Wong E, Geier P, Vaillancourt R. Pretreatment of infant formula with sodium polystyrene sulfonate : focus on optimal amount and contact time. Paediatr Drugs 2013; 15:43-8. [PMID: 23329388 DOI: 10.1007/s40272-012-0003-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND In pediatric patients at risk of hyperkalemia there are limited treatment or preventive alternatives for this electrolyte imbalance. Oral or rectal sodium polystyrene sulfonate (SPS) has several potential adverse effects, and dietary potassium restriction may compromise nutrition. Pretreatment of infant formula with SPS has been previously studied with promising efficacy. The optimal dosing and contact time has not been fully elucidated for this practice, nor have brand and generic products been compared. OBJECTIVE The present study aimed to evaluate the effectiveness of varying amounts of brand and generic SPS for the removal of potassium from formula after 1 and 24 hours. METHODS SPS was added to infant formula in four different amounts measured in milliliters to reflect how a parent or caregiver would measure this product at home. After 1 and 24 hours samples were withdrawn and potassium and sodium levels were measured. RESULTS Potassium decreased in all samples, with the greatest reduction after the addition of 10 mL of SPS. Sodium levels increased in all pretreated samples to a greater extent than the potassium reduction. Contact time of either 1 or 24 hours did not impact the amount of potassium removed or the increase in sodium concentration. There were also no differences found between generic and brand SPS products. CONCLUSION The effectiveness of SPS for formula pretreatment appears to have a plateau effect beyond the addition of 20 mL (16.47 g of brand name product, 19.5 g of generic product). This study demonstrates an effective protocol for pretreatment of formula.
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Nutrition in infants and very young children with chronic kidney disease. Pediatr Nephrol 2012; 27:1427-39. [PMID: 21874586 DOI: 10.1007/s00467-011-1983-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 07/19/2011] [Accepted: 07/20/2011] [Indexed: 12/16/2022]
Abstract
Provision of adequate nutrition is a cornerstone of the management of infants and very young children with chronic kidney disease (CKD). Very young children with CKD frequently have poor spontaneous nutritional intake. Because growth depends strongly on nutrition during early childhood, growth in very young children with CKD is often suboptimal. In this review we will consider the mechanisms and manifestations of inadequate nutritional status in very young children with CKD, mechanisms mediating inadequate nutritional intake, and the optimal nutritional management of this special population. In addition, we suggest an approach to the assessment of nutritional status, including the use of body mass index in infants. Five major nutritional components are considered: energy, macronutrients, fluids and electrolytes, micronutrients, and calcium/phosphorus/vitamin D. The use of adjunctive therapies, including appetite stimulants, treatment of gastroesophageal reflux and gastric dysmotility, enhanced dialytic clearance, and growth hormone, is also briefly discussed.
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Jadeja YP, Kher V. Protein energy wasting in chronic kidney disease: An update with focus on nutritional interventions to improve outcomes. Indian J Endocrinol Metab 2012; 16:246-251. [PMID: 22470862 PMCID: PMC3313743 DOI: 10.4103/2230-8210.93743] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Protein-energy wasting (PEW) is common in patients with chronic kidney disease (CKD). PEW is one of the strongest predictors of mortality in patients with CKD. The International Society of Renal Nutrition and Metabolism (ISRNM) expert panel has defined PEW as a, "state of decreased body stores of protein and energy fuels (body protein and fat masses)". The ISRNM panel has also proposed diagnostic criteria of PEW with four categories. Cachexia is a severe form of PEW. The proposed causes of PEW are multi-factorial and include nutritional and non-nutritional mechanisms. The literature indicates that PEW can be mitigated or corrected with an appropriate diet and enteral nutritional support that targets dietary protein intake. Dietary requirements and enteral nutritional support must also be considered in patients with CKD and diabetes mellitus and in children with CKD, in addition to dialysis patients. Features of ideal dietary supplement have also been discussed. Dietary interventions such as enteral feeding with high-protein meals or supplements might improve the nutritional status and outcomes in dialysis patients.
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Affiliation(s)
- Yashpal P. Jadeja
- Medical Advisor, Cadila Healthcare Limited, Ahmedabad, Gujarat, India
| | - Vijay Kher
- Chairman, Medanta Kidney and Urology Institute, Medanta - The Medicity, Gurgaon (Haryana), India
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Abstract
Protein-energy wasting (PEW), which is manifested by low serum levels of albumin or prealbumin, sarcopenia and weight loss, is one of the strongest predictors of mortality in patients with chronic kidney disease (CKD). Although PEW might be engendered by non-nutritional conditions, such as inflammation or other comorbidities, the question of causality does not refute the effectiveness of dietary interventions and nutritional support in improving outcomes in patients with CKD. The literature indicates that PEW can be mitigated or corrected with an appropriate diet and enteral nutritional support that targets dietary protein intake. In-center meals or oral supplements provided during dialysis therapy are feasible and inexpensive interventions that might improve survival and quality of life in patients with CKD. Dietary requirements and enteral nutritional support must also be considered in patients with CKD and diabetes mellitus, in patients undergoing peritoneal dialysis, renal transplant recipients, and in children with CKD. Adjunctive pharmacological therapies, such as appetite stimulants, anabolic hormones, and antioxidative or anti-inflammatory agents, might augment dietary interventions. Intraperitoneal or intradialytic parenteral nutrition should be considered for patients with PEW whenever enteral interventions are not possible or are ineffective. Controlled trials are needed to better assess the effectiveness of in-center meals and oral supplements.
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