Feast or Famine: Survival and Chronic Kidney Disease Kerin Worley and Deb Gipson UNC 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 dialysis D. 5 year old dependent on hemodialysis E. 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) No B. 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 No D. 5 year old dependent on hemodialysis No E. 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. water B. sodium C. potassium D. phosphorus E. flavor

2. What are the restricted ingredients of a standard UNC Hospitals renal diet? Answer yes or no to each option: A. water No B. sodium Yes C. potassium Yes D. phosphorus No E. 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 Ht SDS Time (months) Entry

Weight and CRI NAPRTCS 2003 ADR: CRI Registry entry 12m 24 m36 m Weight SDS

Growth and Dialysis in Children NAPRTCS 2003 ADR: Dialysis Registry EntryMonth 12Month 24 Weight SDS Age > Height SDS Age >

Nutritional Focus: 1985 and beyond USRDS, 2001 ADR Death rates on dialysis for children age 0-19 Hemodialysis Year 1: 29/1000 patient years Year 2: 32/ 1000 patient years Peritoneal Dialysis Year 1: 60 / 1000 patient years Year 2: 34 / 1000 patient years

Hypoalbuminemia and Survival in ESRD C. Wong, Kidney Int. 61, 2002 Incident dialysis patients 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 ESRD C. 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 Malnutrition A. 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 Malnutrition A. Brem, P. Nephrol, 2002 Dietary protein intake is assessed 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, 2002 S Alb at dialysis initiation correlates with future hypoalbuminemia risk Relationship between Inflammation and S Alb

CKD Severity and Nutrition L Norman, P Nephrol. 15, 2000 GFR NAgeRD consult Cal Intake(% Goal) > % % % 92 < % 85 Insert figure 1 Comparison of anthros and CKD severity

CKD and BMI: The big U C. Wong, AJKD 36, 2000 BMI Standard Deviation Score aRR for Death P=0.001 N=1949 Prevalent 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 ml/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):