The dietary management of calcium and phosphate in children with CKD stages 2-5 and on dialysis—clinical practice recommendation from the Pediatric Renal Nutrition Taskforce

Abstract

In children with chronic kidney disease (CKD), optimal control of bone and mineral homeostasis is essential, not only for the prevention of debilitating skeletal complications and achieving adequate growth but also for preventing vascular calcification and cardiovascular disease. Complications of mineral bone disease (MBD) are common and contribute to the high morbidity and mortality seen in children with CKD. Although several studies describe the prevalence of abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels as well as associated clinical and radiological complications and their medical management, little is known about the dietary requirements and management of calcium (Ca) and phosphate (P) in children with CKD. 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 various aspects of renal disease management in children. We present CPRs for the dietary intake of Ca and P in children with CKD stages 2-5 and on dialysis (CKD2-5D), describing the common Ca-and P-containing foods, the assessment of dietary Ca and P intake, requirements for Ca and P in healthy children and necessary modifications for children with CKD2-5D, and dietary management of hypo-and hypercalcemia and hyperphosphatemia. The statements have been graded, and 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.

Protein energy wasting; what is it and what can we do to prevent it?

“…Given the well-recognised incidence of low vitamin D levels in CKD, and the association of low levels with inflammation, it is logical to ensure that patients are vitamin D-replete [33].…”

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

“…The full development process for the CPRs and their purpose has been published (4). PICO (Patient, Intervention, Comparator, and Outcome) questions have been developed in order to develop recommendations that provide specific actionable advice, including choosing between alternative approaches in particular clinical situations.…”

“…After a critical review of the literature for each PICO question, CPRs were derived and graded using the American Academy of Pediatrics grading matrix (5) (Supplementary Table 3). The Delphi method was used as previously described (4) to seek consensus from experts in the field.…”

“…The Pediatric Renal Nutrition Taskforce (PRNT) provides clinical practice recommendations (CPRs), updated wherever there is new evidence subsequent to the publication by KDOQI, on various aspects of the dietary management of children with kidney diseases; this document focuses on energy and protein requirements. The composition of the PRNT, limitations, and grading of evidence, and plans for audit and revision of the CPRs have been previously described (4).…”

“…Additional information about nutritional management in CKD not covered here, including potassium, sodium, and micronutrients, is discussed by KDOQI (3) and will be addressed by the PRNT in future CPRs. As with all documents produced by the PRNT, the practical day-to-day management of the nutritional prescription will be developed by the Taskforce during the dissemination phase of the guideline (4).…”