Nutrition and growth
Compared with normal healthy children, pediatric patients receiving PD have significantly lower energy intake, as well as height, weight, tricep fold thickness, and mid-arm circumference. KDOQI suggests the need to provide as energy intake of at least 100% of the recommended daily allowance (RDA). High calorie formulas are often utilized to meet these requirements especially in infants who may also require gastrostomy feeds. The nutritional status of each child should be evaluated prior to commencing chronic PD and at regular intervals thereafter. Anthropometric measurements, particularly weight, length (or height) and head circumference should be measured and plotted so that growth velocity can be calculated47,48,49. Clinical assessment of children should be combined with regular dietary evaluations. Dietary recall or 3-day dietary diaries are methods of assessment often employed by the experienced dietitian. Recombinant growth hormone may be considered in pediatric PD patients with growth potential, after nutritional parameters have been corrected along with acidosis, hyperphosphatemia and secondary hyperparathyroidism48. On going studies are providing cumulative evidence that intensive nutritional support and adequate clearances in prepubertal patients promote normal and enhanced growth without growth hormone50.
Growth failure secondary to chronic renal disease has been recognized as a major challenge in children51,52. In children with renal disease, it is associated with disturbances in growth hormone-insulin like growth factor axis, malnutrition, acidosis, and renal osteodystrophy. It is also important to note that the earlier the onset of renal disease, the more severe the height deficiency. A child’s growth can be enhanced by treating the underlying etiologies of metabolic acidosis, potential sodium wasting, renal osteodystrophy, malnutrition, and short stature. Advances in dialysis and transplantation offer the potential for the child with ESRD to live into adulthood. This magnifies the problem of growth failure, as they are unlikely to reach normal adult stature. The need for adequate, sustained growth is the single most important element that sets children apart from adults with renal disease. Children with more severe renal failure and those with congenital disease and early onset of renal failure tend to have more growth delay51.
Anemia
The European Pediatric Peritoneal Dialysis Working Group (EPPWG)53 has produced guidelines for anemia management of the pediatric patient. After a thorough diagnostic work-up, the EPPWG suggests treatment goals set to achieve a target hemoglobin concentration of at least 11 grams per Liter54. This can be accomplished by the administration of erythropoietin and iron preparations. Side effects of erythropoietin therapy are rare; however, they include55: increased clotting tendency, hypertension, and seizures. These conditions are considered the consequence of the therapeutic effect rather than an adverse effect of the preparation. Nevertheless, blood pressure should be carefully monitored during therapy. Erythropoietin resistance56 can occur and may be due to a number of causes; infection, hyperparathyroidism, malnutrition, hemolytic disorders, folate or vitamin B12 deficiency, underdialysis, vitamin C deficiency, ACE inhibitors, and Anti-erythropoietin antibodies.
Renal osteodystrophy
Renal osteodystrophy is a multifactorial disease that affects children with chronic renal failure57,58,59. It leads to bone deformities, fractures, bone pain, and growth failure. Renal osteodystrophy presents with nonspecific signs and symptoms and often progresses unnoticed. Clinically, patients refrain from physical activity, making early diagnosis difficult, and radiographic changes may not reflect the severity of bone disease. By the time symptoms appear, biochemical abnormalities, hypocalcemia, hyperphosphatemia, high levels of parathormone, and low levels of 1,25-dihydroxyvitamin D3 are well established58,60,61. Thus, routine monitoring of serum calcium, phosphorous, and alkaline phosphatase is imperative. Based on current KDOQI guidelines, monitoring PTH quarterly with the goal to maintain the level 3 to 4 times the upper limit of normal is suggested. Complete annual radiographic assessment for bone age and evidence of bone disease may be considered. The overall goals of therapy are to normalize growth, prevent boney deformities and extraskeletal calcifications, and to control secondary hyperparathyroidism57,58,60.
Summary:
Pediatric end-stage renal disease patients pose unique challenges to providers and to the healthcare system, which must address not only the disease itself , but the many extra-renal manifestations that affect their lives and their families5. Success of the overall ESRD therapeutic goals for the pediatric patient can be measured by the degree of the patient’s ability to maintain normal activities of daily living, achievement of growth and developmental milestones, and maintenance of general health in preparation for expeditious transplant. Successful management of a pediatric ESRD patient relies upon the dedication and knowledge of the entire multidisciplinary healthcare team.
References:
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