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Growth and nutrition in CKD child

growth and nutrition in children with chronic kidney disease

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‫هستی‬ ‫خالق‬ ‫یگانه‬ ‫نام‬ ‫به‬
Growth and Nutrition in Pediatric
Chronic Kidney Disease
 Growth failure is a major complication of CKD
 Growth retardation is rarely seen in CKD stages 1–2, often noted
in CKD stages above 3, and is generally more pronounced in children on
dialysis
 This may, at least partly, be due to the negative association
between GH-insensitivity and glomerular filtration rate (GFR)
 Final height in about 50% of all children with ESRD will be below the 3rd
centile
 The risk for greatest growth impairment occurs if CKD begins in early
childhood
 After infancy, growth closely correlates with GFR and is most pronounced
once the GFR falls below 25ml/min per 1.73m2
 Adolescents with CKD often display below-normal peak height velocity and
final height is less than target height
 The impact of nutrition on growth is significant in any child with CKD, but is
most profound in infants and young children
 poor nutrition is the most important factor contributing to growth impairment
in younger children
 Studies show that optimizing caloric intake in younger children with CKD and
ESRD is the most effective strategy to enhance growth velocity.
CAUSES OF GROWTH IMPAIRMENT IN
CKD
 disturbances in growth hormone
(GH) metabolism and insulin-like
growth factor-I (IGF-I)
 electrolyte abnormalities
 nutritional deficiency
 metabolic acidosis
 uremia
 Anemia
 inflammation
 vitamin D deficiency
 hyperparathyroidism
 hypogonadism
Growth and nutrition in CKD child

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Growth and nutrition in CKD child

  • 2. Growth and Nutrition in Pediatric Chronic Kidney Disease
  • 3.  Growth failure is a major complication of CKD  Growth retardation is rarely seen in CKD stages 1–2, often noted in CKD stages above 3, and is generally more pronounced in children on dialysis  This may, at least partly, be due to the negative association between GH-insensitivity and glomerular filtration rate (GFR)  Final height in about 50% of all children with ESRD will be below the 3rd centile  The risk for greatest growth impairment occurs if CKD begins in early childhood
  • 4.  After infancy, growth closely correlates with GFR and is most pronounced once the GFR falls below 25ml/min per 1.73m2  Adolescents with CKD often display below-normal peak height velocity and final height is less than target height  The impact of nutrition on growth is significant in any child with CKD, but is most profound in infants and young children  poor nutrition is the most important factor contributing to growth impairment in younger children  Studies show that optimizing caloric intake in younger children with CKD and ESRD is the most effective strategy to enhance growth velocity.
  • 5. CAUSES OF GROWTH IMPAIRMENT IN CKD  disturbances in growth hormone (GH) metabolism and insulin-like growth factor-I (IGF-I)  electrolyte abnormalities  nutritional deficiency  metabolic acidosis  uremia  Anemia  inflammation  vitamin D deficiency  hyperparathyroidism  hypogonadism
  • 7. Nutritional Deficiency  The causes of reduced intake include recurrent vomiting, anorexia and feeding problems  Gastroesophageal reflux  Reduced gastric and esophageal motility and delayed gastric emptying  Abnormal secretion and destruction of gut peptides that cause dysregulated motility, hunger, and satiety
  • 8. Metabolic Acidosis  Metabolic acidosis is associated with poor growth in children with CKD  Metabolic acidosis induces degradation of proteins, endogenous production of corticosteroids, and end-organ resistance to growth hormone (GH)  children with the lowest quartile of serum bicarbonate level (<18 mmol/l) demonstrate the greatest risk of CKD progression and worsening secondary hyperparathyroidism.
  • 9. Inflammation  Accumulating evidence strongly supports the deleterious role of inflammation in the secondary complications of CKD. called the malnutrition— inflammation complex  Pro-inflammatory cytokines such as interleukin-6 play major roles in the inflammatory process  direct effect of pro-inflammatory cytokines on muscle catabolism , as demonstrated in animal studies
  • 10. Pubertal Dysfunction  Children with CKD also exhibit delayed puberty, featured by hypergonadotrophic hypogonadism with elevated gonadotrophins with concomitant low-normal or reduced gonadal hormone levels.  About 50% exhibit delayed pubertal onset, with those requiring renal replacement therapy before age 13 being the most affected.  Impaired sensitivity to gonadotrophins and luteinizing hormone pulsatility and bioactivity
  • 11. Drug Toxicity  Medications can have a deleterious effect on linear growth in patients with CKD.  The most common drugs include corticosteroids and calcineurin inhibitors.  Corticosteroids are effective drugs for some glomerular diseases, but, may adversely affect linear growth by a variety of mechanisms, including reduced pulsatile secretion of GH, impaired sensitivity of the GH receptor to IGF-1, and decreased production of IGF-1.  In addition, steroid therapy may result in reduced bone density and disordered calcium-phosphorous metabolism
  • 12. Strategies for Optimizing Growth in Children With Chronic Kidney Disease
  • 13. Preservation of Renal Function and Dialysis  There is a negative association between GH-insensitivity and glomerular filtration rate (GFR)  The logical consequence of these findings is to keep up GFR rates and provide adequate dialysis in children requiring maintenance dialysis  Preservation of renal function requires treatment of elevated blood pressure, with the goal of blood pressure values below the 50th and 75th percentile in proteinuric and non-proteinuric children, respectively  Nephrotoxic medication should be avoided
  • 14.  urinary tract infections in children with congenital abnormalities of the kidneys and urinary tract (CAKUT) should be treated  There is increasing evidence that intensified dialysis, achieved either through extended thrice weekly, nocturnal or short daily sessions, are effective measures to improve growth in short children presenting with persistent growth failure while on conventional dialysis  recent non-randomized study demonstrated superior growth in children treated with hemodiafiltration compared to those with conventional hemodialysis  “Therefore, initiation of intensified dialysis or hemodiafiltration should be considered in children on maintenance dialysis presenting with persistent growth failure”
  • 16. Nutrition  The assurance of adequate caloric intake is of major importance to prevent CKD-associated growth failure, especially in infants and young children  In some patients, oral feeding may be sub-optimal, and, in such cases, feeding by nasogastric (NG) or gastrostomy tube (G-tube) may be necessary.  There is clear evidence that G-tube feeds are generally more effective.  Physicians should be proactive in instituting tube feeding in any infant or young child not achieving adequate energy intake, as this may result in suboptimal growth outcome
  • 17. Correction of Acid-Base/Electrolyte Abnormalities  Metabolic acidosis should be corrected aiming for serum bicarbonate levels equal to or above 22 mEq/L.  This can be assured by treatment with sodium bicarbonate and/or the use of HCO3-based or lactate-based dialysis solutions in patients on dialysis  Supplementation of water and/or electrolytes is often required in polyuric patients and those with salt-losing nephropathies.  It is important to note, that young children on peritoneal dialysis often require supplementation with large amounts of sodium chloride, since considerable losses (i.e., 2–5 mmol/kg body weight) via peritoneal ultrafiltration may occur
  • 18. Physical Activity  Physical activity is often reduced in children with CKD and is associated with abnormalities in serum markers of bone formation and remodeling .  Although endurance exercise improves bone formation in subtotal nephrectomized young rats , studies demonstrating better growth after increased physical activity in children with CKD are lacking
  • 19. Growth Hormone Treatment  Treatment with recombinant human growth hormone (rhGH) is a measure proven to improve adult height in short children with CKD  Infancy and early childhood are the most sensitive phases for the growth- suppressing effects of CKD which is at least partly related to GH insensitivity  RhGH induced catch-up growth is positively associated with estimated glomerular filtration,mid-parental height, initial target height deficit and duration of rhGH therapy, and negatively correlated with patient age  “Therefore, rhGH should be initiated as soon as growth retardation becomes evident
  • 20.  The presence of open epiphysis on the X-ray of the left wrist indicates growth potential, which is a prerequisite for the indication of rhGH treatment in children presenting with persistent short stature  “Children above 6 months of age with stages 3–5 CKD or on dialysis should be candidates for rhGH therapy if they have persistent growth failure—defined as a height below the 3rd percentile for age and sex, and a height velocity below the 25th percentile—once other potentially treatable risk factors for growth failure have been adequately addressed and provided the child has growth potential”  “RhGH therapy should also be considered for children with stages 3–5 CKD or on dialysis aged above 6 months who present with a height between the 3rd and 10th percentile, but with persistent low height velocity (< 25th percentile), once other potentially treatable risk factors for growth failure have been adequately addressed”
  • 21.  “Such early, preventive therapy is probably more cost-effective than starting at a more advanced age, when growth retardation has become more evident and higher absolute rhGH doses are required”  RhGH is substantially less effective in children requiring maintenance dialysis compared to children prior to dialysis.  However, there is evidence that rhGH-induced catch-up growth can be markedly improved by intensified dialysis, e.g., by daily hemodialfiltration, which enhances dialytic clearance and thereby, probably, GH sensitivity  Children suffering from nephropathic cystinosis often show severe growth retardation despite somewhat mild reductions in GFR, which is thought to be related to the deleterious effects of Fanconi syndrome, resulting in hypophosphatemic rickets and malnutrition and/or an underlying obsteoblast/osteoclast defect
  • 22.  “Therefore, rhGH treatment is recommended in short children with nephropathic cystinosis in all stages of CKD”  “Daily dosing is more effective than three doses per week and the optimal dose is 0.045–0.05 mg/kg body weight per day by subcutaneous injection in the evening”  “In rhGH treated patients with residual kidney function, rhGH should be continued after the initiation of dialysis, but stopped at the time of kidney transplantation”  “Growth should be monitored for at least 1 year post-transplantation before rhGH therapy is considered, in order to allow for spontaneous catch-up growth without the use of rhGH therapy”
  • 23. ‫و‬ ‫شما‬ ‫توجه‬ ‫از‬ ‫تشکر‬ ‫با‬ ‫این‬ ‫برگزارکنندگان‬ ‫زحمات‬ ‫کنگره‬