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Part V
Management of Secondary Complications
of Chronic Dialysis


Nutritional Assessment
and Prescription for Children
Receiving Maintenance Dialysis

26

Christina L. Nelms, Nonnie Polderman,
and Rosanne J. Woloschuk

Introduction and Overview
Among the many priorities for the child receiving
maintenance dialysis, attaining an optimal nutritional status is paramount and forms the foundation
for a number of positive patient outcomes ranging
from clinical status and biochemical control to
quality of life and psychological well-being.
Adequate nutritional intake, especially in the
early years of life, optimizes long-term growth
[1]. Neurocognitive development and final adult
height outcomes, which are established in the
early years of life, are negatively impacted by
poor nutritional intake in a child nearing or reaching end-stage kidney disease (ESKD) [2].
Historically, the focus of nutrition intervention
has been to improve upon inadequate nutrition;
however, the rising incidence of obesity is refocusing nutrition goals toward providing adequate,

but not excessive, nutrition in order to reduce
long-term obesity-related health concerns [3, 4].

C. L. Nelms (*)
PedsFeeds, University of Nebraska, Kearney, NE,
USA
e-mail:
N. Polderman
Division of Nephrology, British Columbia Children’s
Hospital, Vancouver, BC, Canada
e-mail:
R. J. Woloschuk
Jim Pattison Children’s Hospital, Royal University
Hospital, Saskatoon, SK, Canada

Nutritional management, in concert with other
medical management such as pharmacology, fluid
balance, and dialysis prescription plays a key role
in the achievement of electrolyte and biochemical
control [5]. Each child on dialysis is unique, and
each nutrition care plan must be individualized
accordingly. Management of unique formula prescriptions and determination of best delivery route
increase management complexity [6]. The multidisciplinary team caring for infants, children, and
adolescents on dialysis must include a skilled
clinical nutrition expert, such as a pediatric renal
dietitian, who specializes in both pediatric and
dialysis-specific nutrition management [7].

Nutrition Overview
for Hemodialysis

A classic “sodium-, potassium-, and phosphorus-­
controlled diet” is the usual nutrition prescription
for the pediatric hemodialysis (HD) patient. The
typical thrice-weekly HD regimen does not provide adequate reduction of solutes to allow for
complete diet liberalization. Post-dialysis treatment side effects impair appetite. While children
with greater urine output enjoy more liberal fluid
allowances, most children require some degree of
fluid restriction. The use of HD in infants is rare,
but in these patients, strict fluid management is
imperative given the small size of the young child
and concern for blood volume shifts during treatment [5, 8, 9].

© Springer Nature Switzerland AG 2021
B. A. Warady et al. (eds.), Pediatric Dialysis, />
463


C. L. Nelms et al.

464

Less than 2% of all North American dialysis
patients receive home hemodialysis [10] with the
numbers of pediatric recipients unknown. One
advantage of home HD is flexibility in providing
intensified dialysis regimens in the form of
shorter sessions of daily dialysis or nocturnal
dialysis [11]. Patients undergoing nocturnal dialysis typically achieve excellent solute removal;
supplementation of phosphorus, calcium, and
vitamin D may be required. Although fluid and

diet restrictions may be discontinued, electrolytes must be closely monitored to avoid suboptimal levels [12–14]. Patients receiving frequent
daily dialysis do not enjoy the same dietary freedoms as those on nocturnal hemodialysis, but do
report improved mental affect and quality of life,
liberalized fluid allowances, and improved appetites [11, 15].

 utrition Overview for Peritoneal
N
Dialysis
Peritoneal dialysis (PD) is the most common
modality of dialysis in pediatric patients worldwide [7]. The use of PD therapy requires in-depth
assessment of factors related to PD to individualize the nutrition prescription. The National
Kidney Foundation (NKF) Kidney Disease
Outcomes Quality Initiative (KDOQI) pediatric
nutrition care guidelines [5] identify higher protein needs for PD patients compared to HD
patients because of protein losses associated with
PD (Tables 26.1 and 26.2). Ad lib eaters including children on PD typically consume adequate
protein, but children receiving formula may
require additional protein [16, 17].
The transport capacity of the peritoneum
also impacts dietary needs (Table  26.1). High
transporters have higher protein needs and
greater peritoneal losses of other nutrients and
will occasionally need potassium supplementation [18, 19]. Children who are low transporters have fewer nutrient losses, but
potentially suffer from greater uremic affects
resulting from relatively low solute removal,
which can have a negative impact on appetite
and gastrointestinal symptoms. Glucose

absorption from the dextrose-­containing dialysate is greater in high transporters and may
alter the recommended nutrition prescription

and biochemical status [5, 7]. For the young
child with an underlying renal tubular disorder
who is managed on PD, increased sodium supplementation and tighter potassium control
may be required to offset an increased loss of
sodium in the dialysis effluent and urine and
associated potassium retention [5].

Growth
Suboptimal growth is a complication of CKD
unique to children. Growth failure or “short stature” occurs at all stages of reduced kidney function, worsening with the progressive decline in
kidney function [20, 21]. For each standard deviation score (SDS) decline in growth velocity,
there is a reported 12–14% increase in mortality.
Short stature is also associated with increased
hospitalizations and infections, suggesting that
linear growth is not just a cosmetic issue [21, 22].
Patients who receive a kidney transplant and who
have very short stature have, on average, reduced
allograft survival [20]. Lastly, final adult height
impacts the education level and employment outcomes and thus overall quality of life [22, 23].
Early reports on growth from the North
American Pediatric Renal Trials and
Collaborative Studies (NAPTRCS) found that in
the years leading up to 2004, 37% of pre-dialysis
children fell below a height standard deviation
score (HtSDS) of −1.88. While improvements to
linear growth are being realized, recent reports
from the Chronic Kidney Disease in Children
(CKiD) study (2014) suggest that growth retardation remains prevalent with 12% of children
with moderate CKD exhibiting a HtSDS of ≤
−1.88. Data suggests that for each drop in estimated glomerular filtration rate (eGFR) of

10  ml/min/1.73  m2, height is expected to drop
by 0.14 SDS [24]. A child at or below the
3rd%ile, which is equivalent to a HtSDS of
−1.88, or with a height velocity of −2 SDS, warrants further evaluation of factors which may be
contributing to the poor growth and may ulti-