The dietary management of potassium in children with CKD stages 2–5 and on dialysis—clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

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.

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

“…The PRNT has published a full account of the nutritional management of calcium and phosphate [ 54 ] and potassium [ 55 ]. While dietary intakes may need to be adjusted to maintain serum levels within the age-appropriate normal range, restrictions should be limited as much as possible so as not to worsen any pre-existing reluctance to eat.…”

“…There are no data to suggest potassium requirements for children with CKD. Extrapolating from adult data, KDOQI recommends an initial target potassium intake of 1–3 mmol/kg/day for infants to maintain a normal serum concentration [ 25 ]; however, the PRNT recommends that dietary potassium intake is only adjusted if the serum potassium level is outside the normal range: 3.5–5.0 mmol/L in infants, and 3.5–5.5 mmol/L in neonates, based on serial measurements [ 55 ].…”

Accuracy of equations for predicting 24-h urinary potassium excretion from spot urine samples in Chinese children

“…Elevated blood pressure in childhood is an important risk factor for hypertension and cardiovascular metabolic diseases in adulthood (28,29) . Considering the recent well-documented association between abnormal potassium intake and cardiovascular disorders, such as blood pressure (27,30) and stroke (31) , as well as the evidence that potassium intake is critically important for children with chronic kidney disease as hyperkalemia can be life-threatening (32) , many international authorities, including US National Academy of Medicine (33) and the European Food Safety Authority (34) , have recommended proper potassium intake to prevent hypertension and cardiovascular diseases.…”

Nutritional Assessment and Management in Paediatric Chronic Kidney Disease

“…Patients with mild-to-moderate hypokalemia tend to be asymptomatic compared with those with severe hypokalemia who can experience weakness, cramps, and even paralysis. In contrast, decreased GFR, urinary obstruction, and treatments with potassium-sparing agents would be risk factors for hyperkalemia, which has more undesirable cardiac effects including arrhythmias and cardiac arrest [16,65,66]. e KDOQI recommends restricting potassium in infants and young children to 40-120 mg/kg/ day and to 30-40 mg/kg/day in older children.…”