Nutritional management of the infant with chronic kidney disease stages 2–5 and on dialysis

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.

Clearance and Nutrition in Neonatal Continuous Renal Replacement Therapy (CRRT) Using the CARPEDIEM™ System

“…Sensitivity analysis found sustained weight gain was a delayed response occurring 14 days after start of CARPEDIEM TM which supports the growth trends reported by Sutherland et al of 7 ESKD infants (86% CAKUT) who either primarily started on RRT with continuous ultra ltration therapy or rst failed a trial of PD [23]. Given di culties performing accurate length measurements in this population, failure to gain weight can be more sensitive for poor overall growth, especially when occurring in the rst few months of life [24]. Infants are most sensitive to weight failure in their rst 3 months of life: if they do not experience weight gain for 2 weeks they can lose 1 weight centile, and if this persists for 4 weeks they can lose 2 weight centiles [25].…”

“…Factors affecting linear growth were likely similar to those contributing to delays in sustained weight gain. Additionally, neonates with CKD may experience unique factors such as growth hormone insensitivity and a delayed infantile phase, leading to a notable reduction in their height potential [24,[26][27][28][29][30].…”

“…However, given infants with CAKUT demonstrate variable degrees of renal dysfunction, it would be di cult and likely inaccurate to develop CAKUT-speci c growth charts. The Pediatric Renal Nutrition Taskforce currently recommends the use of worldwide standard growth charts at this time as the goal is to obtain growth that is as close to normal as possible [24]. Interpretation of relative growth is challenging when disease-speci c growth charts do not exist as growth velocity slower than the growth chart population will progressively lead to worsening discrepancy and declining z-score.…”

Sodium zirconium cyclosilicate pretreatment for formula in vitro reduces potassium intake in infants with chronic kidney disease

“…To manage hyperkalemia, dietary potassium intake restrictions is the most convenient, safe, and effective treatment. Kidney Disease Outcomes Quality Initiative (KDOQI) guideline recommends that the general restriction of potassium is 40 to 120 mg·kg −1 ·day −1 for infants and 30 to 40 mg·kg −1 ·day −1 for older children with CKD [1] . Thus, commercial infant formulas as the main alternative source of nutrition for infants are not suitable for infants with CKD, because of their high potassium content, which may initiate or further aggravate hyperkalemia of them.…”

“…Kidney Disease Outcomes Quality Initiative (KDOQI) guideline recommends that the general restriction of potassium is 40 to 120 mg·kg −1 ·day −1 for infants and 30 to 40 mg·kg −1 ·day −1 for older children with CKD. [ 1 ] Thus, commercial infant formulas as the main alternative source of nutrition for infants are not suitable for infants with CKD, because of their high potassium content, which may initiate or further aggravate hyperkalemia of them. Sodium polystyrene sulfonate (SPS) as a non-selective resin has been widely used in the clinic for >60 years and has shown good effectiveness to decrease potassium intake in adult patients with CKD.…”