Feast or Famine: Survival and Chronic Kidney Disease

Kerin Worley and Deb GipsonUNC Chapel Hill

April, 2004

1. Select the patient for whom a UNC standard renal diet is appropriate

Answer yes or no to each option:A. 6 month old with posterior urethral valves and

chronic renal insufficiency (eGFR 35)B. 15 year old with nephrotic syndrome (Urinary protein

excretion 5 gm/day) and normal serum creatinine (0.7)

C. 8 year old dependent on peritoneal dialysisD. 5 year old dependent on hemodialysisE. 11 year old with a functioning kidney transplant

1. Select the patient for whom a UNC standard renal diet is appropriate

Answer yes or no to each option:A. 6 month old with posterior urethral valves and chronic

renal insufficiency (eGFR 35) NoB. 15 year old with nephrotic syndrome (Urinary protein

excretion 5 gm/day) and normal serum creatinine (0.7) No

C. 8 year old dependent on peritoneal dialysis NoD. 5 year old dependent on hemodialysis NoE. 11 year old with a functioning kidney transplant No

2. What are the restricted ingredients of a standard UNC Hospitals renal diet?

Answer yes or no to each option:

A. waterB. sodiumC. potassiumD. phosphorusE. flavor

2. What are the restricted ingredients of a standard UNC Hospitals renal diet?

Answer yes or no to each option:

A. water NoB. sodium YesC. potassium YesD. phosphorus NoE. flavor :)

3. What is the proper diet for a child with dialysis dependence?

Write the order please:Diet: ____________________________

4. What is the most appropriate diet for an infant with posterior urethral valves and chronic renal insufficiency (eGFR 30)?

Write the order please:Diet: ____________________________

Somatic Growth in Children with CKD

Impairment related to – Diminished caloric intake– Increased risk of calorie loss: GERD– Acidosis– Polyuria w/ early satiety– IGF/Growth Hormone Axis disturbance– Age of onset of CKD– Severity of renal failure– co-morbidities/syndromes

How do our children grow? NAPRTCS 2003 ADR: CRI Registry

-3

-2.5

-2

-1.5

-1

-0.5

0

0-12-56-12>12H

t SD

S

Time (months) Entry 12 24 36

Weight and CRI NAPRTCS 2003 ADR: CRI Registry

-3

-2.5

-2

-1.5

-1

-0.5

0

0-12-56-12>12

entry 12m 24 m 36 m

Wei

ght S

DS

Growth and Dialysis in Children NAPRTCS 2003 ADR: Dialysis Registry

Entry Month 12 Month 24Weight SDSAge 0-1 -2.36 -1.83 -1.30

2-5 -1.28 -1.32 -1.216-12 -1.26 -1.24 -1.42>12 -1.00 -1.02 -1.28

Height SDSAge 0-1 -2.52 -2.31 -2.12

2-5 -1.99 -2.24 -2.036-12 -1.75 -1.89 -2.17>12 -1.33 -1.45 -1.59

Nutritional Focus: 1985 and beyondUSRDS, 2001 ADR

Death rates on dialysis for children age 0-19Hemodialysis

Year 1: 29/1000 patient years Year 2: 32/ 1000 patient years

Peritoneal DialysisYear 1: 60 / 1000 patient yearsYear 2: 34 / 1000 patient years

Hypoalbuminemia and Survival in ESRDC. Wong, Kidney Int. 61, 2002

• Incident dialysis patients 1995 - 1998• N=1723• Age 0-18 years• Outcome: mortality • 93 deaths over 2953 patient-years observed

Mortality rate of 31.5 / 1000 pt years

Hypoalbuminemia and Survival in ESRDC. Wong, Kidney Int. 61, 2002

Insert fig 1 c. wong 2002 ki

Mortality Risk Albumin < 3.5 g/dL RR 1.90 (1.16, 3.10)

Adjusted for gender, age, race, modality, etiology of esrd, height sds and wt sds

Prevalence of Protein MalnutritionA. Brem, P. Nephrol, 2002

• Given hypoalbuminemia is a surrogate for mortality risk

• Question the prevalence of serum albumin<2.9 in– children PD– children HD– adults PD

• Assess nutritional protein intake

Prevalence of Protein MalnutritionA. Brem, P. Nephrol, 2002

Dietary protein intake isassessed as Protein Catabolic Rate (PCR).

National dialysis guidelines recommend PCR of 1g/kg/day (KDOQI)

Correlates of Protein Malnutrition in Children

A. Brem, P. Nephrol, 2002S Alb at dialysis initiation correlateswith future hypoalbuminemia risk

Relationship between Inflammation and S Alb

CKD Severity and NutritionL Norman, P Nephrol. 15, 2000

GFR N Age RD consult Cal Intake(% Goal)> 75 35 8.2 3% 10350-75 23 8.2 13% 9925-49 19 8.5 37% 92<25 61 10.2 61% 85

Insert figure 1Comparison of anthros and CKD severity

CKD and BMI: The big UC. Wong, AJKD 36, 2000

0.80.9

11.11.21.31.41.51.61.71.8

-3 -2 -1 0 1 2 3

BMI Standard Deviation Score

aRR

for

De a

th

P=0.001

N=1949Prevalent ESRD All Modes‘89-’91

Dietary protein and progressive CKD• Adults (Klahr, NEJM, 1994)

– Modification of Diet in Renal Disease Study (MDRD)– RCT of protein restriction– Inclusion GFR 25 - 55ml/min– Usual diet (P 1.3 g/d) vs Low diet (P 0.58 g/d) – 2-3 years follow up– GFR decline ~ 5 ml/min/yr in both

• Pediatrics– Dietary protein intake to RDA / optimize nutritional status– No association between protein restriction and CKD progression in small

studies

Kerin Worley, RD

Distribution of height SDS of 1949 patients compared with children in US general population

Wong CS et al. Am J Kidney Dis 2000; 36(4):811-819