Global Variation of Nutritional Status in Children Undergoing Chronic Peritoneal Dialysis: A Longitudinal Study of the International Pediatric Peritoneal Dialysis Network

Abstract

While children approaching end-stage kidney disease (ESKD) are considered at risk of uremic anorexia and underweight they are also exposed to the global obesity epidemic. We sought to investigate the variation of nutritional status in children undergoing chronic peritoneal dialysis (CPD) around the globe. The distribution and course of body mass index (BMI) standard deviation score over time was examined prospectively in 1001 children and adolescents from 35 countries starting CPD who were followed in the International Pediatric PD Network (IPPN) Registry. The overall prevalence of underweight, and overweight/obesity at start of CPD was 8.9% and 19.7%, respectively. Underweight was most prevalent in South and Southeast Asia (20%), Central Europe (16.7%) and Turkey (15.2%), whereas overweight and obesity were most common in the Middle East (40%) and the US (33%). BMI SDS at PD initiation was associated positively with current eGFR and gastrostomy feeding prior to PD start. Over the course of PD BMI SDS tended to increase on CPD in underweight and normal weight children, whereas it decreased in initially overweight patients. In infancy, mortality risk was amplified by obesity, whereas in older children mortality was markedly increased in association with underweight. Both underweight and overweight are prevalent in pediatric ESKD, with the prevalence varying across the globe. Late dialysis start is associated with underweight, while enteral feeding can lead to obesity. Nutritional abnormalities tend to attenuate with time on dialysis. Mortality risk appears increased with obesity in infants and with underweight in older children.

Summary of Expert Opinion on the Management of Children With Chronic Kidney Disease and Growth Failure With Human Growth Hormone

“…It is also assumed that nutrition adequacy is essential to promote growth and development of children with CKD. However, it has been demonstrated that aggressive enteral feeding in infants with CKD stage 5 on peritoneal dialysis may result in excessive weight gain with rather limited effects on longitudinal growth (26,27).…”

“…Chronic Kidney Disease (CKD) in pediatric and adult patients is characterized by a progressive decline in kidney function, classified according to the Kidney Disease: Improving Global Outcomes (KDIGO) in a system based primarily on glomerular filtration rate (eGFR, ml/min/1.73 m 2 ) and on proteinuria (1). The classification consists of 5 stages based on a decreasing of eGFR: G1 normal or high (≥ 90); G2 mildly decreased (60-89); G3a mildly to moderately decreased (45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57)(58)(59); G3b moderately to severely decreased (30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44); G4 severely decreased (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29) and G5 kidney failure (≤ 15, or dialysis) (1). According to these Guidelines, CKD should be established based on kidney function and damage expressed as eGFR, irrespective of...…”

Delivery of a nutritional prescription by enteral tube feeding in children with chronic kidney disease stages 2–5 and on dialysis—clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

“…There is no evidence that gastrostomy placement can induce GER and, in fact, there is some evidence that gastrostomy feeding may reduce or prevent vomiting [4]. An NG tube may stent open the gastro-esophageal junction, increasing any tendency to vomiting and GERD [3].…”

“…For example, in a study from the International Pediatric Peritoneal Dialysis Network (IPPN) of growth in children under 2 years of age on peritoneal dialysis (PD), tube feeding was predominantly used in North America and Europe, with very little usage elsewhere in the world [3]. Similarly, in a second IPPN study in older children, enteral tube feeding was rarely applied in Central Europe, Turkey, India, South East Asia, and China [4]. KDOQI did not guide readers in the type of enteral feeding device to choose.…”

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

“…Malnutrition is also associated with worsening uremic symptoms and can lead to protein-energy wasting and increased mortality. Conversely, obesity is a worldwide problem that is also increasingly affecting the CKD population (2).…”