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Ideal Caloric/Protein Intake in CKD
John D Mahan, MD
Professor, Department of Pediatrics
Nationwide Children’s Hospital
The Ohio State University
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Objectives
1. Define goals for ideal caloric and protein intake in children with CKD.
2. Describe appropriate methods to assess nutritional status in children with CKD.
3. Define potential interventions for children with CKD who have inadequate nutritional intake.
4. Compare/contrast the outcomes of early, aggressive nutrition versus conservative nutrition in children with CKD.
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Nutrition: Key for Growth
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Case 1: RP: Need for Good Nutrition
Now 13 yo male -Joubert Syndrome, renal HTN, growth failure, developmental delay, congenital hypothyroidism, PKD and renal transplant. Meds: FeSO4, transplant medications
GT placed at 8 yo due to poor nutrition with regular diet po
Suggested that original TF provide 50% of goal kcals/protein; remaining calories from po diet (“renal friendly” formula)
Transplant @ 12 yo –TF continued (changed to standard polymeric formula)
At 13 yo –TF decreased as pt was taking more po foods and maintaining growth/development
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Case 1: Questions
1. What is the ideal caloric/protein intake for the child with CKD?
2. At what point in a child with CKD does the child require extra attention to nutrition and growth?
3. For child with CKD, how do you make the decision that supplements and/or extraordinary intake methods (tubes) are required?
4. How do you balance calories from PO with that from tube feeds to meet caloric goals?
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1. What are the goals for ideal caloric/protein intake in children with CKD?
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2. What the best methods to assess caloric/protein intake in children with CKD?
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KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 Update
Recommendation 1. Evaluation of Growth and Nutritional Status
1.1: The nutritional status and growth of all children with CKD stages 2 to 5 and 5D should be evaluated on a periodic basis. (A)
1.2: The following parameters of nutritional status and growth should be considered in combination for evaluation in children with CKD stages 2 to 5 and 5D. (B)
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Pediatric CKD Parameters and Frequency of Nutritional Assessment
National Kidney Foundation. KDOQI Clinical
Practice Guideline for Nutrition in Children with
CKD: 2008 update. Executive summary. Am J
Kidney Dis 2009; 53:S11
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Nutrition in Childhood CKD: Challenges in Nutritional Assessment
Length or height -measure regularly –consistent measurers as well as appropriate equipment -length boards/stadiometers
Weight -measure regularly –fluid/edema issues
BMI –used BMI for age vs Wt/Ht [Wt/Ht SDS gives important insights into child’s growth]
Head Circumference –measure regularly in < 3 yo
Body composition –no reliable method for children
Dietary intake –obtain regularly (q month at least)
Dietary recall vrs diet records
Metabolic parameters – rigorous control requires real effort
Albumin = multiple reasons to be low, important to monitor
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Recommendation 4. Energy Requirements and Therapy
4.1: Energy requirements for children with CKD stages 2 to 5 and 5D should be considered to be 100% of the EER for chronological age, individually adjusted for PAL and body size (i.e., BMI). (B) Further adjustment to energy intake is suggested based upon the response in rate of weight gain or loss. (B)
4.2: Supplemental nutritional support should be considered when the usual intake of a child with CKD stages 2 to 5 or 5D fails to meet his or her energy requirements and the child is not achieving expected rates of weight gain and/or growth for age. (B)
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Recommendation 5. Protein Requirements and Therapy
5.1: It is suggested to maintain dietary protein intake (DPI) at 100% to 140% of the DRI for ideal body weight in children with CKD stage 3 and at 100% to 120% of the DRI in children with CKD stages 4 to 5. (C)
5.2: In children with CKD stage 5D, it is suggested to maintain dietary protein intake at 100% of the DRI for ideal body weight plus allowance for dialytic protein and amino acid losses. (C)
5.3: The use of protein supplements to augment inadequate oral and/or enteral protein intake should be considered when children with CKD stages 2 to 5 and 5D are unable to meet their protein requirements through food and fluids alone. (B)
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Protein Intake in CKD 3-5 & 5D
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Recommendation 6. Vitamin and Trace Element Requirements and Therapy6.1:The provision of dietary intake consisting of at least 100% of
the DRI for thiamin (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), biotin (B8), cobalamin (B12), ascorbic acid (C), retinol (A), α-tocopherol (E), vitamin K, folic acid, copper, and zinc should be considered for children with CKD stages 2 to 5 and 5D. (B)
6.2: It is suggested that supplementation of vitamins and trace elements be provided to children with CKD stages 2 to 5 if dietary intake alone does not meet 100% of the DRI or if clinical evidence of a deficiency, possibly confirmed by low blood levels of the vitamin or trace element, is present. (C)
6.3:It is suggested that children with CKD stage 5D receive a water-soluble vitamin supplement. (C)
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DRI: Vitamins/Trace Elements
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Summary: Pediatric CKD Nutritional Goals
100% of RDA for age: calories; protein, water soluble vitamins, trace elements
Children who need catch-up growth may require 120-140% of RDA calorie/protein to catch-up
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3. What are the best ways to achieve ideal caloric/protein intake in children with CKD?
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Meet Nutritional Goals for Children with CKDOral, balanced intake – if possibleSupplementation if necessary
GT/
Formula
Nasal Tube/Formula
Appetite stimulants
Oral supplements, modulars where appropriate
Per KDOQI guidelines:3 day food records
TPN
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Prevent/Mitigate Malnutrition-Inflammation Cachexia Syndrome: Now Termed ‘Protein-Energy Wasting in KD’
‘Cachexia in Slow Motion’ – Protein-energy malnutrition + inflammation
Malnutrition Protein Energy Wasting
Inadequate intake of nutrients Inadequate intake of nutrients only partially responsible
Body fat is lost Normal or even increase fat mass
Lean body mass initially preserved,later loss of muscle mass and protein stores
Loss of lean body mass
Low resting energy expenditure High resting energy expenditure
Can be reversed by dietary supplements
Inadequate response to dietary supplements
Fouque D. KI 2011
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Protein Energy Wasting in CKD
Carrero JJ. J Ren Nutr 2013
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Protein Energy Wasting Syndrome
Fouque D. KI 2011
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Major Nutritional Considerations in CKD –From Pediatric Nephrologist + Renal Dietician Perspective
Routine monitoring of growth parameters, intake (24-72 hr diet records/recall), chemistries –prevention/early detection is key
Poor appetite expected: uremic anorexia/decreased appetite
Energy issues/malnutrition: all too common (fatigue, taste alterations, meds, restricted diets, delayed gastric emptying)
Challenge to achieve positive nitrogen balance – albumin as indirect marker of nutritional status (+ protein losses in nephrosis)
Metabolic acidosis –increases protein catabolism/decreases protein synthesis negative nitrogen balance and loss of LBM
Chronic anemia adversely affects appetite, anabolism, organ system function, growth
Growth issues: calories, modifiable factors, protein-energy wasting
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4. What are the typical outcomes of early, aggressive nutrition versus conservative nutrition in children with CKD?
Beaumont Hospital
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Case 2: NS –The Case for Aggressive Nutrition4 yo male; PMH: hydronephrosis, arrhythmia, VUR right grade IV, feeding
problems/aversion/FTT, renal dysplasia, ESRD
Surgeries: lap GT (1.5 yo); PD catheter, Partial omentectomy (1.75 yo)
Medications: sodium citrate, B-complex/VitC/folic acid, ergocalciferol, somatotropin (2.5 yo), EPO, ferrous sulfate, TMP-SFX
• Nutrition: PO SimPM 60/40 (20 kcal/oz) + some breast feeds at birth
• SimAdv powder added to human milk –24->27kcal/oz (for 11 months) PO
• Multiple formula changes -EBM, whey + soy formula; milk allergy?
• Feeding Clinic for presumed feeding aversion (1.5 yo)
• GT placed (1.6 yo) –night feeds ½ str Suplena, regular diet PO thru day
• GH initiated (2.4 yo)
• Night time TF discontinued (3.75 yo) as PO intake had improved
LD Transplant(3.9 yo) –need for continued TF? – to be determined
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Case For Aggressive Nutrition in Childhood CKD
Best Outcomes
Take advantage of age for maximum growth in infancy/ early childhood
Avoid ‘losing ground’ and then striving to catch up
Not just somatic growth! –intellectual, social development
Best long-term height outcomes (adult height)
Potential to avoid PEW and possible long-term CV and systemic effects (vascular/myocardial, CNS, endocrine, etc)
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Case For Aggressive Nutrition in Childhood CKD
Best Outcomes
Take advantage of age for maximum growth in infancy/ early childhood
Avoid ‘losing ground’ and then striving to catch up
Not just somatic growth! –intellectual, social development
Best long-term height outcomes (adult height)
Potential to avoid PEW and possible long-term CV and systemic effects (vascular/myocardial, CNS, endocrine, etc)
Barriers Optimism that things will get better with a little more time Parental resistance to ‘medicalizing’ feedings Extra procedures –hassles, stress, complications Additional burden for the care-givers Sense that once started, can not stop the extra measures Complexity of medical regime can be overwhelming for health
care team
Aggressive Nutrition in CKD: Principles
Never too soon to start additional efforts – do not wait for significant growth failure!
Hard to overcome anorexia, dysgeusia, fatigue
NG Tube with Tube Feeds –for short term use
G-Tube with Tube Feeds –most reliable way to meet goals
Appetite stimulants have variable usefulness
In infant – aggressive nutrition as pathway to Transplant
In child/teen – aggressive nutrition as pathway to better Transplant procedure (less complications with good nutrition)
Anchor–Best way to achieve normal adult height and good quality of life/satisfaction
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Aggressive Nutrition in CKD: Evidence for Outcomes
Prevention of growth disturbances as major goal nutrition Rx
Initiation of enteral feedings (NG/GT) before important height deficits provides with superior height outcomes [Parekh]
Infants show significant increases in growth velocity after provision of adequate calories NG/GT [Parekh, Kari, Ledermann]
Childhood CKD data not as rich – growth benefits not clear –often BMI gains but not Ht gains – however improved albumin may be important [Rees]
GT associated with better growth than NG [Rees] – may have less oral aversion with GT; neither associated with more obesity
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Conclusions
1. Growth, anthropometric parameters and nutrition intake must be regularly monitored in all children with CKD.
2. Goals for nutrition intake are the same as normal children.
3. Malnutrition Inflammation Cachexia Syndrome (now known as Protein Wasting Syndrome) has severe consequences -must prevent and/or treat.
4. Aggressive nutritional therapy = aggressive in delivery, not excessive in amounts - should be the rule rather than exception to meet nutritional and growth goals in children with CKD.
