Nutrition aspects in children receiving maintenance hemodialysis: impact on outcome

Abstract

Children with end-stage renal disease (ESRD) have rates of mortality estimated to be 30-times higher than expected for age compared with those of healthy children. Physical manifestations of under-nutrition, such as body mass index (BMI) and low height standard deviation score (SDS), have been associated with increased risk of mortality. Traditional measures, such as height, weight and serum albumin concentration, may not be accurate indicators to assess the nutritional status of children receiving maintenance hemodialysis. Normalized protein catabolic rate (nPCR) has emerged as a better marker of nutritional status of such children. Meeting the special nutritional needs of these children often requires nutritional supplementation, by either the enteral or the parenteral route. Recently, in children receiving maintenance hemodialysis who are malnourished, intradialytic parenteral nutrition (IDPN) has been utilized as a means to provide additional protein and calories. This article is a state-of-the-art review of malnutrition in children receiving maintenance hemodialysis, with special focus on outcome, nPCR and IDPN.

Fig. 1

The relative risk of death and confidence intervals for BMI standard deviation scores among children with ESRD. The minimum relative risk of death is observed at a BMI = −0.50 SDS. The U-shaped association was statistically significant; P = 0.001. Note that the lines for all age strata and those of the 6 to 14 year age groups overlap. (Used with permission from C. Wong)

Fig. 2

Odds ratio of death among 12,965 adult patients grouped by weight-for-height percentiles. Three representations are given in a cluster of three bars. Black bars represent unadjusted odds ratio, white bars represent odds ratio adjusted for clinical variables (age, gender, race and diabetes mellitus), gray bars, adjusted for clinical and laboratory variables (pre-dialysis serum albumin, creatinine and cholesterol values). NS not significant. Reprinted with permission from Macmillan Publishers Ltd., Kidney Int 56:1136–1148 [15]. The P values symbols over a bar indicate the significant difference between the values for that bar and for the reference group. ^*P<0.001, ^**P=0.11, ^†P=0.21, ^#P=0.038