Intake (mg/d) Age Calcium (mmol/L) (mg/dL) (mg/dL)

absorption: increased consumption of calcium-

hild- High PTH and High PTH and
rich and/or calcium-fortified foods or tube feed- 0-5 mo 1.22-1.40 8.7-11.3 5.2-8.4
t, in- Bone Health with calcium-containing Normal High
Fluid
6-12 mo and1.20-1.40
Electrolyte Requirements
8.7-11.0 5.0-7.8

Nutritional
ings, supplementation Age DRI (mg/d) Phosphorus* Phosphorus†
bone pharmacological agents between meals or bolus 1-5 y 1.22-1.32 9.4-10.8 4.5-6.5
and 0-6 mo 100 �100 �80 6-12 y 1.15-1.32 9.4-10.3 3.6-5.8
tube feedings, use of calcium-containing phos-
Calcium Phosphorus Fluids Abbreviations:
7-12 mo 275 �275 �220 13-20 y and electrolyte
Fluid 1.12-1.30 8.8-10.2
requirements of individual2.3-4.5
children vary according to their primary kidney-
may ACEI Angiotensin-converting enzyme inhibitor

Management
phorus binders
Insufficient calciumfor managing
supply hyperphosphatemia,
may cause deficient mineralization of the skeleton. Evidence suggests that moderate dietary phosphate restriction is beneficial with respect to the
1-3 y 460 �460 �370 disease,
Adapted degree
with of residual
permission 121 kidney function,
; Specker.524 and method of kidney replacement therapy. Restrict fluid intake in children with CKD stages 3 to 5 and 5D who are oligoanuric to prevent AMDR Acceptable macronutrient distribution ranges
cium Calcium overload may be associated
and supplementation with D.
with vitamin severe vascular morbidity and prevention and treatment of hyperparathyroidism and safe with respect to growth, nutrition,
with soft-tissue calcifications. 4-8 y 500 �500 �400
and bone mineralization. The dietary prescription should aim at minimizing phosphate intake Conversion factor for calcium and ionized calcium: mg/dL � the complications of fluid overload (R 8.4). ARB Angiotensin-receptor blocker
If spontaneous intestinal calcium absorption is 9-18 y 1,250
while ensuring an adequate protein intake. �1,250 �1,000 0.25 � mmol/L. – Concurrent fluid and sodium restriction is needed to overcome thirst. BMI Body mass index
itriol low, as typically observed in early stages of Recommendations
Conversion factor forforphosphorus:
Children With CKD Stages
mg/dL 2 to�5 and 5D:
� 0.323 CDC Centers for Disease Control and Prevention
de- Recommendations
CKD, vitamin forDChildren shouldWith
be CKD Stages 2 to 5 and
supplemented to 5D: Multiple pitfalls, including the physicalSource: Health Canada:
and psychological http://www.hc-sc.gc.ca/fn-an/
challenge of the phosphate binder pill mmol/L. Daily fluid restriction = insensible fluid losses + urine output + amount to replace additional CHD Coronary heart disease
in D It augment
is suggested the total
plasma oral and/or
1,25(OH) D enteral calcium
synthesis and intake from nutritional sources
maxi- burden, inadvertent consumption of food containing phosphate additives, and nonadherenceRe-
alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. in Sodium losses (eg, vomiting, diarrhea, enterostomy output) - amount to be deficited CKD Chronic kidney disease
and phosphate binders be in the2range of 100%–200% of the DRI for calcium for older children and adolescents, mayproduced with the lowering
result in inefficient permission of thephosphorus
of serum Minister oflevels.
Public D Dialysis

Children
ently agemize calcium absorption.
(R 7.1.1). Works and Government Services Canada, 2008. Consider supplemental free water and sodium supplements for children with CKD and polyuria
Insensible Fluid Losses DRI Dietary reference intake
hom If plasma calcium levels and urinary calcium Conversely, overrestriction may lead to*�
signs
100%of phosphate
of the DRI.deficiency, particularly in dation 5). Most
to avoid chronicfood sourcesdepletion
intravascular exhibitand good phos- optimal growth (R 8.1).
to promote DV Daily value
To avoid the critical accumulation of calcium, oligoanuric children on dialysis young infants. Age Group Fluid Loss
d and excretion
therapy remaina further
may require low and dietary
reduction assessment
in total oral and enteral calcium intake †� 80% of the DRI. phate– Infants and children with obstructive uropathy plant
bioavailability with the exception of or renal dysplasia have polyuria, polydypsia, EER Estimated energy requirement
The
cium
suggests inadequate calcium intake,
from nutritional sources and phosphate binders.
tion of foods with high endogenous calcium
consump-
greater than the target normal range for age
seeds difficulty
(beans, conserving
phosphate
peas, cereals,
in phytic acid.
supplementation.
sodium and nuts)and
chloride thatdevelop
contain a salt-wasting state, requiring salt
Preterm infants
Neonates
Children and adolescents
40 mL/kg/d
20–30 mL/kg/d
20 mL/kg/d or 400 mL/m2
HD
IDPN
nPCR
Hemodialysis
Intradialytic parenteral nutrition
Normalized protein catabolic rate
With Chronic
Recommendations for Children With CKD Stages 2 to 5 and 5D:
Kidney Disease
dren Milk and dairy products are a major source of NSAID Nonsteroidal anti-inflammatory drugs
Recommended Calcium Intake for Children Consider reducing dietary phosphorus (Table
intake 25) andof hyperparathyroidism
to 100% the DRI for age (R 7.3.1): is already Consider sodium supplements
Cal- Table 20. Recommended Calcium Intake for Children
With CKD Stages 2 to 5 and 5D Methods to improve low oral – When the serum PTH concentration established, phosphorus
is above the target range forrestriction
CKD stage, and to approxi- dietary phosphorus. In youngforinfants all infantswithon PDCKD,therapy (R 8.2). PAL Physical activity level
PD Peritoneal dialysis
se of with CKD Stages 2 to 5 and 5D
and/or enteral calcium intake – When the serum phosphorus concentration
mately 80% is within
of thethe DRI
normalisreference range for age
recommended. phosphorus control can be achieved easily by sodium losses, even when anuric,
– Infants on PD therapy are predisposed to substantial Potassium PTH Parathyroid hormone Stages 2 to 5 and 5D
H)2D.
Upper Limit Upper Limit for CKD Stages
and absorption include: Consider reducing dietary phosphorus intake
Higher to 80% of the DRI forserum
physiological age (R 7.3.2):
concentrations of using because
formulas ultrafiltration
with a low removes significant
phosphorus amountsItof sodium chloride that cannot be
content. Limit potassium intake for children with CKD who have or are at risk of hyperkalemia (R 8.5). R Recommendation
y be replaced throughand breast milk or standard
(for healthy 2-5, 5D (Dietary �
• Increased consumption – When the serum PTH concentration is aboveand
calcium the target range forare
phosphorus CKDobserved
stage, andin healthy usually is feasible, common clinical commercial
practice, infant formulas. – The nutrition facts panel on food labels is not required to list potassium, but may provide rhGH Recombinant human growth hormone
of calcum-rich and/or cal- – When the serum phosphorus concentration exceeds the normal reference range for age SDS Standard deviation score
Age DRI children) Phosphate Binders*)
cium-fortified foods or tube infants and young children, presumably reflect- to continue oral and/or enteral
Restrict sodium intake for children with CKD who use of a low-
have hypertension (systolic and/or diastolic potassium content as actual amount (mg) and % DV:
UL Tolerable upper intake level
ctive – Foods low in potassium: <100 mg or <3% DV
feedings After initiation of dietary phosphorus restriction, monitor the serum phosphorus concentration phosphorus
blood formula
pressure and delay
percentile) orthe introduction
prehypertension (systolic and/or distolic blood pressure WHO World Health Organization
idol) 0-6 mo 210 ND �420
(R 7.3.3):
ing the increased requirements of these minerals ≥95th
• Supplementation with calcium of phosphorus-rich cow’s milk until the age of 18 – Foods high in potassium: >200 to 250 mg or >6% DV
– At least every 3 months in childrenby theCKD
rapidly
stages growing skeleton. Rickets due to percentile and <95th percentile)
7-12 mo 270 ND �540 ≥90th (R 8.3).
Oral containing pharmacological with 3 to 4
ning
1-3 y 500 2,500 �1,000
– Monthly in children with CKD stages phosphorus
5 and 5D deficiency occurs in preterm infants to 36– months.
Severe hypertension increases risk of hypertensive encephalopathy, seizures, Reference:
4-8 y 800 2,500 �1,600 agents between meals or Bone Mineral and Vitamin D Requirements and Therapy S67 Children can lower potassium intake by restricting foods such as bananas, oranges, potatoes, National Kidney Foundation. KDOQI clinical practice guideline for nutrition in children with
lysis bolus tube feedings fed insufficient
In all CKD stages, it is suggested to avoid serum phosphorus amounts of phosphorus
concentrations both aboveand and in
Dietary phosphateevents,
cerebrovascular restriction
congestive canheartbe hindered
failure, and progression of CKD. CKD: 2008 update. Am J Kidney Dis. 2009:53(suppl 2);S1-S124.
9-18 y 1,300 2,500 �2,500 potato chips, tomato products, legumes, lentils, yogurt, and chocolate, and by avoiding
• Use of calcium-containing below the normal reference range for age (R and
infants 7.3.3). by the inadvertent consumption ofhasfood contain-
Table 23. children with hypophosphatemia
Maximum Oral and/or due – Modest dietary sodium restriction ofbeen demonstrated to reduce blood pressure in
ntent Abbreviation: ND, not determined. potassum-containing salt substitutes.
Abbreviation: ND, not determined. phosphorus binders for Recommended
ingTable 25. Age-Specific
phosphate additives, Normal
which Ranges
can Blood
increase phos- Notice:
asing *Determined as 200% of the DRI, to a maximum of 2,500
*Determined as 200% of the DRI, to a maximum of managing hyperphosphatemia
to Enteral
inherited disorders of renal phosphate
Phosphorus Intake for Children With CKD trans- hypertensive children without
Ionized Calcium, Total Calcium and Phosphorus CKD. SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE
posi- mg elemental calcium. port. 426
Hence, when dietary phosphorus is re- phorus
– Inintake
dialysisup to 2-fold
patients, compared
restricting sodiumwith intake unproc-
is essential to volume and blood
2,500 mg elemental calcium. • Supplementation with Children on PD or frequent HD therapy (ie, >5 sessions/wk) rarely need dietary potassium This Clinical Practice Guideline document is based upon the best information available at the
vitamin D stricted to control hyperphosphatemia
Recommended Recommended Phosphorus
Maximum Oral and/or and sec- essed foods.
pressure
This
Ionized
control.
is a particular
Calcium problem
Phosphorus in
time of publication. It is designed to provide information and assist decision-making. It is not
Intake (mg/d) Age Calcium (mmol/L) (mg/dL) restriction and may actually develop hypokalemia.
Suppl 2 (March), 2009: pp S61-S69 S61 ondary Enteral Phosphorus Intake for Children
hyperparathyroidism With CKDwith
in children patients with CKD who rely heavily (mg/dL) on pro- intended to define a standard of care and should not be construed as one, nor should
Age-Specific Normal 427,428
CKD, subnormal serum phosphorus
High PTH and High PTH and
values should cessed
0-5 mo foods. 1.22-1.40 8.7-11.3 5.2-8.4 it be interpreted as prescribing an exclusive course of management. Variations in practice will
Ranges of Serum Phosphorus Normal High Tips to reduce
6-12Unfortunately,
mo sodium
1.20-1.40 mostintake include:
available
8.7-11.0nutrient 5.0-7.8data- inevitably and appropriately occur when clinicians take into account the needs of individual
Vitamin D be Age
avoidedDRI (Table
(mg/d)25). Phosphorus* Phosphorus† Non-dietary causes of hyperkalemia:
Age Serum Phosphorus 1-5 y – Consuming fresh foods
1.22-1.32 instead of processed
9.4-10.8 and on
4.5-6.5 canned foods patients, available resources, and limitations unique to an institution or a type of practice.
Recent clinical evidence suggests a high prevalence of vitamin D insufficiency in children The dietary prescription should aim at minimiz- bases do not consider the impact of additives – Hemolysis
with CKD. 6-12 y– Reading 1.15-1.32 9.4-10.3 3.6-5.8 Every health care professional making use of these recommendations is responsible for
(mg/dL) 0-6 mo 100 �100 �80 total phosphorus food labels to identify
content of 8.8-10.2 those foods
foods. An exception containing no more than 170–280 mg of sodium, – Metabolic acidosis
ing phosphate 275
7-12 mo
intake while ensuring an adequate 13-20 y 1.12-1.30 2.3-4.5 evaluating the appropriateness of applying them in the setting of any particular
Reasons for the high prevalence of low vitamin D levels in patients with CKD include: �275 �220 or 6%–10%
is the USDA National of the sodium DV
Nutrient Database for – Constipation
0–5 mo 5.2–8.4 protein
1-3 y intake. 460To achieve �460 this aim,�370 protein clinical situation.
– Sedentary lifestyle with reduced exposure to sunlight Adapted with permission121; Specker.524 – Medications (ie, ACEIs, ARBs, NSAIDs and potassium-sparing diuretics)
6–12 mo 5.0–7.8 sources
4-8 y with 500 low specific �500phosphorus�400 content Standard
– Reference,
Reducing salt added which
to foods; lists more substituting
in cooking,
Conversion factor for calcium and ionized calcium: mg/dL �
than 60 fresh herbs and spices to flavor foods
– Limited ingestion of foods rich in vitamin D – Tissue destruction due to catabolism, infection, surgery, or chemotherapy SECTION II: DISCLOSURE
– Reduced endogenous synthesis of vitamin D3 in the skin of patients with uremia 9-18 y 1,250
should be prescribed (see Table 13, Recommen-
�1,250 �1,000 phosphate-containing
– Minimizing
0.25 � mmol/L. intake of food
fast additives
foods (www.ars. – Inadequate dialysis
1–5 y 4.5–6.5 The National Kidney Foundation (NKF) makes every effort to avoid any actual or reasonably
– Urinary losses of 25(OH)D and vitamin D–binding protein in nephrotic patients ≤100% ofHealth
*Source: the DRI Canada:
†
≤80% ofhttp://www.hc-sc.gc.ca/fn-an/
the DRI usda.gov/Main/site_main.htm?modecode�12-
Conversion factor for phosphorus: mg/dL � 0.323 �
perceived conflicts of interest that may arise as a result of an outside relationship or a person-
6–12 y 3.6–5.8 alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. Re- mmol/L.
35-45-00; last accessed October 23, 2008).
Measure serum 25-hydroxyvitamin D levels once per year in children with CKD (R 7.2.1). Table 24. Target Range of Serum PTH by Stage al, professional, or business interest of a member of the Work Group. All members of the Work
produced with the permission
Target Range of Serum of the Minister
PTH by Stage of CKD of Public The aspects mentioned illustrate that dietary Group are required to complete, sign, and submit a disclosure and attestation form showing all
Supplementation with vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol) is 13–20 y 2.3–4.5 of CKD
Works and Government Services Canada, 2008. such relationships that might be perceived as actual conflicts of interest.
suggested if the serum level of 25-hydroxyvitamin D is less than 30 ng/mL (75 nmol/L) *� 100% of the DRI.
modification
dation 5). Mostoffood phosphorus
sources exhibit intake good is a complex
phos-
(R 7.2.2). Conversion factor for †� 80% of the DRI.
GFR Range Target Serum and
phate challenging
bioavailability task.withMultiple
the pitfalls,
exception ofincluding
plant
CKD Stage (mL/min/1.73m2) PTH (pg/mL)
In the repletion phase, it is suggested that serum levels of corrected total calcium and phosphorus: nonadherence
seeds (beans, peas, in older
cereals, children
and nuts) andthat adolescents,
contain
phosphorus be measured at 1 month following initiation or change in dose of vitamin D mg/dL x 0.323 = mmol/L 3greater than the target 30-59normal range for 35-70 may resultinin
phosphate inefficient
phytic acid. lowering of phosphorus
and at least every 3 months thereafter (R 7.2.3). age
4 15-29
(Table 25) and hyperparathyroidism is already 70-110 intake; conversely,
Milk and dairy products overrestriction
are a majormay source leadof to 30 East 33rd Street • New York, NY 10016 Based on the KDOQI Clinical Practice
800.622.9010 • 212.889.2210 • www.kidney.org
When patients are replete with vitamin D, it is suggested to supplement vitamin D 5, 5D �15 200-300 signs phosphorus.
dietary of phosphate deficiency,
In young infantsparticularly
with CKD, in Guideline for Nutrition in Children
continuously and to monitor serum levels of 25-hydroxyvitamin D yearly (R 7.2.4). established, phosphorus restriction to approxi-
Reprinted with permission. 121
mately 80% of the DRI is recommended. phosphorus
young control
infants. Hence, can be achieved
involvement ofeasily by
an experi- With CKD: 2008 Update
Higher physiological serum concentrations of using formulas with a low phosphorus content. It ©2009 National Kidney Foundation, Inc. All rights reserved. 02-10-978A_JAJ

calcium and phosphorus are observed in healthy usually is feasible, and common clinical practice,
 status and growth should be considered in be performed in a healthy child of the
combination for evaluation in children same age. (C) Infants and children with
with CKD stages 2 to 5 and 5D. (B) polyuria, evidence of growth delay, de-
Overview Evaluation of Growth and Nutritional Status i Dietary intake (3-day diet record or creasing or low BMI, comorbidities influ- Energy Requirements Protein Requirements
three 24-hour dietary recalls) encing growth or nutrient intake, or re-

Suggested Dietary Protein Intake for Children With CKD Stages 3 to 5 and 5D (R 5.1):
Poor energy intake is common in children with CKD due to reduced appetite and vomiting. CVD is the leading cause of morbidity and mortality in the pediatric CKD population,
Recommendations for Children With CKD Stages 2 to 5 and 5D: Recommended Parameters and Frequency of Nutritional Assessment for accounting for ~25% of total deaths (a rate 1000 times higher than the national pediatric • CKD stage 3: 100%–140% of the DRI for ideal body weight
Table 1. Recommended Parameters and Frequency of Nutritional Assessment for Children Children with excessive energy intake are at risk for short- and long-term complications • CKD stages 4 to 5: 100%–120% of the DRI for ideal body weight
Children
withWith CKD Stages
CKD Stages 2 to
2 to 5 and 5D5 and 5D CVD death rate).
The number of children with Evaluate nutritional status and growth on a periodic basis (R 1.1). associated with being overweight or obese. • CKD stage 5D: 100% of the DRI for ideal body weight, plus an allowance
CKD continues to increase.
Minimum Interval (mo)
National registry data for pediatric dialysis or transplant patients showed a significantly for dialytic protein and amino acid losses (R 5.2).
Consider the following parameters of nutritional status and growth in combination for Consider a trial of IDPN to augment inadequate nutritional intake for malnourished children These requirements refer to a stable child and assume that energy intake meets 100%
Age 0 to �1 y Age 1-3 y Age �3 y higher mortality rate at the upper and lower extremes of BMI-for-age.
(BMI-for-height-age <5th percentile) receiving maintenance HD who are unable to meet their of estimated requirements.
evaluation (R 1.2): Measure CKD 2-3 CKD 4-5 CKD 5D CKD 2-3 CKD 4-5 CKD 5D CKD 2 CKD 3 CKD 4-5 CKD 5D
Recommendations for Children With CKD Stages 2 to 5 and 5D: nutritional requirements through oral and tube feeding (R 4.4).
Modified protein requirements may be needed in children with proteinuria, those who are
– Dietary intake (3-day diet record or three 24-hour dietary recalls) Dietary intake 0.5-3 0.5-3 0.5-2 1-3 1-3 1-3 6-12 6 3-4 3-4
– IDPN should not be promoted as a sole nutrition source; it should be used to augment obese or stunted, on dialysis, during and after peritonitis episodes, and during recovery
Nutritional status can affect Malnutrition, growth delay, and
Height or length-for-age Consider energy requirements for children with CKD to be 100% of the EER for chronological
– Length- or height-for-age percentile or SDS. Use the following: percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1 3-6 3-6 1-3 1-3
age, individually adjusted for PAL and body size (ie, BMI) (R 4.1). other sources. from intercurrent illness.
overall health and well-being. nutrition-related metabolic abnormalities Height or length Protein Requirements and Therapy S49
• WHO Growth Standards from birth to 2 years velocity-for-age – Further adjustment to energy intake is suggested based upon the response in rate of weight Balance calories from carbohydrate and unsaturated fats within the physiological ranges
are common and are associated with a percentile or SDS 0.5-2 0.5-2 0.5-1 1-6 1-3 1-2 6 6 6 6 recommended as the AMDR of the DRI when prescribing oral, enteral, or parenteral energy
• CDC growth reference charts after age 2 gain or loss (R 4.1). Table 12. Recommended Dietary Protein Intake in Children with CKD Stages 3 to 5 and 5D
Recommended Dietary Protein Intake in Children with CKD Stages 3 to 5 and 5D
greater risk of morbidity and mortality. Estimated dry weight
supplementation (R 4.5).
– Length or height velocity-for-age percentile or SDS
and weight-for-age Consider supplemental nutritional support when (R 4.2): DRI
percentile or SDS 0.5-1.5 0.5-1.5 0.25-1 1-3 1-2 0.5-1 3-6 3-6 1-3 1-3 – Uneven distribution of calories from each macronutrient may be associated with increased Recommended for Recommended for
BMI-for-height-age – The usual intake of a child fails to meet his or her energy requirements, and CKD Stage 3 CKD Stages 4-5
– Estimated dry weight and weight-for-age percentile or SDS percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1 3-6 3-6 1-3 1-3 risk of CHD, obesity, and diabetes. DRI (g/kg/d) (g/kg/d) Recommended for HD Recommended for PD
– The child is not achieving expected rates of weight gain and/or growth for age.
– BMI-for-height-age percentile or SDS Head circumference-for- – Atherogenic dyslipidemia occurs in CKD stage 3 and increases in prevalence as kidney Age (g/kg/d) (100%-140% DRI) (100%-120% DRI) (g/kg/d)* (g/kg/d)†
age percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1-2 N/A N/A N/A N/A
Consider oral intake of an energy-dense diet and commercial nutritional supplements as the function deteriorates. 0-6 mo 1.5 1.5-2.1 1.5-1.8 1.6 1.8
( years old only)
– Head circumference-for-age percentile or SDS (≤3 nPCR N/A N/A N/A N/A N/A N/A N/A N/A N/A 1*
preferred route for supplemental nutritional support (R 4.3). 7-12 mo 1.2 1.2-1.7 1.2-1.5 1.3 1.5
Nutritional care for children with CKD should be centered on the following goals: Abbreviation: N/A, not applicable. 1-3 y 1.05 1.05-1.5 1.05-1.25 1.15 1.3
– nPCR in adolescents receiving hemodialysis – Consider tube feeding when energy requirements cannot be met with oral supplementation. Encourage dietary and lifestyle changes to achieve weight control in overweight or obese
• Maintenance of an optimal nutritional status *Only applies to adolescents receiving HD. 4-13 y 0.95 0.95-1.35 0.95-1.15 1.05 1.1
children with CKD (R 4.6). 14-18 y 0.85 0.85-1.2 0.85-1.05 0.95 1.0
• Avoidance of uremic toxicity, metabolic abnormalities, and malnutrtion – Energy-dense foods may be needed in children with CKD stage 5 with oligoanuria.
Base the frequency of monitoring nutritional and growth parameters on the child’s age and S16 American Journal of Kidney Diseases, Vol 53, No 3, Suppl 2 (March), 2009: pp S16-S26 *DRI � 0.1 g/kg/d to compensate for dialytic losses.
• Reduction of the risk of chronic morbidities and mortality in adulthood Possible factors affecting poor appetite include: †DRI � 0.15-0.3 g/kg/d depending on patient age to compensate for peritoneal losses.
Acceptable Macronutrient Distribution Ranges
stage of CKD (R 1.3): • Thirst for water rather than food in those with polyuric CKD
– Perform assessments at least twice as frequently as they would be performed in a healthy GROWTH FAILURE • Administration of multiple unpleasant medications Macronutrient Children 1–4 y Children 4–18 y These protein recommendations refer to a indications of inadequate protein intake (see Rec-
• Preference for salty rather than energy-dense sweetened foods Consider
stable child using proteinthat
and assume supplements
energy intake to augment
is inadequate5.3).
ommendation oral and/or enteral protein
Recommendations to Manage Growth Failure in Children With CKD Stages 2 to 5 and 5D: intake (ie, when children
child of the same age. • Accumulation of appetite-regulating cytokines and hormones Carbohydrate 45%–65% 45%–65% adequate it meets 100%with CKD stages
of estimated require- 2 to 5 and5.2: 5D are unable to
In children meet
with CKD their protein
stage 5D, it is
Identify and treat existing nutritional deficiencies and metabolic abnormalities in children • Gastroesophageal reflux requirements
ments). Inadequate through
caloricfood intake and fluidsinalone
results the (R suggested
5.3). to maintain dietary protein intake at
– More frequent evaluation may be warranted in infants and children with: Fat 30%–40% 25%–35% inefficient use of dietary protein as a calorie
with CKD, short stature*, and potential for linear growth (R 2.1). Factors contributing to • Disordered gastric motility Possible Signs of Inadequate Protein Intake: 100% of the DRI for ideal body weight plus an
• Polyuria source, with increased generation of urea. Ensur-
– Abnormally low serum urea nitrogen levels allowance for dialytic protein and amino acid
Consider nutrition counsel- Frequent reevaluation and Nutritional management • Delayed gastric emptying Protein 5%–20% 10%–30%
poor growth include: ing caloric needs are met is an important step in
– Undesirable downward trend losses. (C)
in nPCR for adolescents on HD therapy, and/or
ing based on an individual- modification of the nutrition should be collaborative, • Evidence of growth delay assessing protein requirements and modifying Our recommendations for DPI in dialyzed
– Inadequate protein and calorie intake – Documentation
protein intake. of low protein intake using food records, food questionnaires, or diet recall
ized assessment and plan plan of care are suggested. involving the child, care- • Decreasing or low BMI children differ from previous adult and pediatric
of care for children and More frequent review is giver, dietitian, and other
– Polyuric and salt-wasting conditions Vitamins and Trace Elements Protein requirements
Strategies to Supplement may beProtein
increased in pa-
Intake: guidelines based on several lines of reasoning.
• Comorbidities influencing growth or nutrient intake – Metabolic acidosis S54 Recommendation 6
tients with proteinuria and during recovery from
– Add powdered protein modules to expressed breast First, the milk,Food and formula,
infant Nutritionbeverages,
Board of the
their caregivers (R 3.1). indicated for children members of the pediatric intercurrent illness. Modification of protein rec- Institute of Medicine of the National Academy of
• Recent acute changes in medical status or dietary intake – Renal osteodystrophy Dietary Reference Intake: Recommended Dietary Allowance and Adequate Intake pureed foods, or other
ommendations also may be necessary in obese ormoist foods.
with (R 3.3): nephrology team (R 3.4). – Add mincedObese or chopped meat, Sciences in 2002 replaced
milk the RDA of to 1989 with
havechicken,
a greater fish,DRI egg, tofu, or skim powder soups,
Table 14. Dietary Reference Intake: Recommended Dietary Allowance and Adequate Intake
– Resistance to hormones mediating growth Patients with CKD and those on dialysis therapy are at risk of vitamin and mineral stunted children. individuals values for the intake of nutrients by Ameri-
Individualize nutritional • Advanced stages of CKD deficiencies as a result of abnormal renal metabolism, inadequate intake/poor gastrointestinal pasta, or casseroles.
percentage of body fat, which is much less meta-
Infants Infants Children Children Males Males Females Females cans and Canadians. For protein, the DRI values
intervention, according • Relevant comorbidities Coordinate nutritional absorption, and dialysis-related losses. 0-6 mo 7-12 mo 1-3 y 4-8 y 9-13 y 14-18 y 9-13 y 14-18 y –Protein
Oral active
bolically or enteral
than liquid
lean mass.
Requirements and Therapy
protein-rich
Therefore,renal it is supplements
are lower than the RDA across all age S51 groups.175
to (R 3.2): influencing growth or management with a Correct serum bicarbonate level to at least the lower limit of normal (22 mmol/L) (R 2.2). believed that basing protein (and energy) require-
Average Ratio of Phosphorus Second, previous recommendations for dia-
Vitamin A (�g/d) 400 500 300 400 600 900 600 700 ments of
Table obese individuals
13. Average on theirtoactual
Ratio of Phosphorus
Proteinweight
to Protein Peritoneal permeability for protein shows large that in
• Results of the nutritional nutrient intake, and dietitian, ideally one who Consider rhGH therapy in children with (R 2.3): Vitamin C (mg/d) 40 50 15 25 45 75 45 65 Content
may overestimate in Various Protein-Rich
requirements. Foods
Conversely,
lyzed patients were based
us- interindividual variation, but appears to be rela-
on the concept
Recommendations for Children With CKD Stages 2 to 5 and 5D Vitamin E (mg/d) 4 5 6 7 11 15 11 15
Content in Various Protein-Rich Foods
addition
Although there to replacements
is no evidence forfordialytic amino acid
a nephroprotective
assessment evidence of inadequate has expertise in children – Short stature*, and Vitamin K (�g/d) 2.0 2.5 30 55 60 75 60 75
ing ideal body weightRatio forof mg
an obese person does tively
and constant within subjects. Transperitoneal
effectprotein
of dietary losses,
proteinatrestriction,
least 0.3thetogrowing
0.4 g/kg of
Consider the provision of a dietary intake consisting of at least 100% of the DRI for thiamin (B1), not take into account Phosphorusthe increase in body
Ratio Adjusted
protein protein transport correlated with small-molecule
• Age intake or malnutrition, or with CKD (R 3.4). – Potential for linear growth if growth failure† persists beyond 3 months despite treatment of Thiamin (mg/d) 0.2 0.3 0.5 0.6 0.9 1.2 0.9 1.0
for Digestion/
evidenceprotein
dietary for a major impactbeof added
should phosphorusthe
transportertostatus
overload
intake
riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), biotin (B8), cobalamin (B12), Riboflavin (mg/d) 0.3 0.4 0.5 0.6 0.9 1.3 0.9 1.0
needed for structural tosupport
Food Category g Protein of extra Absorption
fat tissue. transport rates; the peritoneal
on cardiovascularfor morbidity in children and
62 adults with
• Development • Acute illness or adverse nutritional deficiencies and metabolic abnormalities ascorbic acid (C), retinol (A), α-tocopherol (E), vitamin K, folic acid, copper, and zinc (R 6.1). Niacin (mg/d; NE) 2* 4 6 8 12 16 12 14 Therefore,
Egg white a common 1.4 practice is to estimate 1
as recommended
assessed
CKD provides
by using
a rationale
healthy
the PET
to avoid
subjects.
provides
excessive
some The evi-
protein
dence
indication base
of thefor this
level of notion
peritonealis protein
weak and primarily
losses.
• Food preferences events that may Vitamin B6 (mg/d) 0.1 0.3 0.5 0.6 1.0 1.3 1.0 1.2 protein
Meat requirements of 9obese individuals6based intake in this population.
*Short stature: Height SDS <−1.88 or height-for-age <3rd percentile It is suggested to provide supplementation of vitamins and trace elements to children with CKD on Tofu
an “adjusted” weight 12
(ie, adjusted weight 7
� High based on adulttransporters
peritoneal literature. tend to have low
• Cultural beliefs negatively impact †Growth failure: Height velocity-for-age SDS <−1.88 or height velocity-for-age <3rd percentile
stages 2 to 5 if dietary intake alone does not meet 100% of the DRI or if clinical evidence of a
Folate (�g/d) 65 80 150 200 300 400 300 400 Egg
ideal weight for
14
height � 25% �
10
[actual serum
At albumin
The
a widespread
given levels;
level of these
notion patients
quantitative that
proteinmay be atinduces
dialysis
intake, the
Vitamin B12 (�g/d) 0.4 0.5 0.9 1.2 1.8 2.4 1.8 2.4 Legumes 17 10
• Psychosocial status nutritional status deficiency, possibly confirmed by low blood levels of the vitamin or trace element, Pantothenic Acid (mg/d) 1.7 1.8 2 3 4 5 4 5
need for increased
generalized
phosphorus
weight � ideal weight], where 25% represents cause dialytic protein concentrations can be mea-
Lentils 20 12 protein
content dietary
and protein supply.
catabolism through
bioavailability of Be-
the general-
protein
is present (R 6.2). Biotin (�g/d) 5 6 8 12 20 25 20 25 theNuts
percentage of body fat 25 15
tissue that is metaboli- sources,
ized the quality
protein of protein,
degradation and thefrom
resulting metabolic
cytokine
Milk 29 21 sured easily, consideration
environment are important should be factors
additional given toto
Copper (�g/d) 200 220 340 440 700 890 700 890 cally active) rather than their actual body release
regular
induced
monitoring
by exposure
of peritoneal
to bioincompatible
protein excre-
It is suggested that children with CKD stage 5D receive a water-soluble vitamin supplement, with 20 30 40 55 40 55
Seeds 50 29
consider
membranes in the (indietary
HD) protein
or prescription.
dialysis
Selenium (�g/d) 15 20 of fluids (in PD) has
259
weight.
Note: Note: This estimations
Mathematical formula is based
based onprotein
physiologi-
on protein tion and individual adaptation the dietary
the exception of children with healthy appetites for a variety of nutritious foods and children Zinc (mg/d) 2 3 3 5 8 11 8 9
Mathematical
cal ibility-corrected
theory rather
estimations
aminothan
digestibility-corrected amino
based
scientific
acid scores
acid scores
on
evidence.
(PDCAA)
(PDCAA)
digest-
and data onIn
and data protein prescription according to actual by
not been universally confirmed metabolic
perito-
receiving most or all of their energy requirements from adult renal formulas (R 6.3). Note: RDAs are in bold type; Als are in ordinary type. *As preformed niacin, not niacin equivalents (NE) for this age group. on estimated
young phosphorus
children
estimated (ie,bioavailability.
phosphorus age �3 years) or stunted neal
bioavailability. studies.
losses. Net protein “catabolism” seems to be
©1998, Vegetarian Diets in Renal Disease article in Amino
Source: Health Canada: http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. Reprinted children
Nutrition(ie, length-
Update, or height-for-age
Vegetarian � �1.88
Nutrition DPG Newsletter;
limitedacid to and the protein
dialyticlosses duringof
removal HDamino
vary acids
with the permission of the Minister of Public Works and Government Services, Canada, 2008. SDS),
DPG,protein requirements
a dietetic practice initiallyDietetic
group of American shouldAsso-be
according
and/or to dialyzer
protein and membrane
a slightly characteristics
reduced protein
*As preformed niacin, not niacin equivalents (NE) for this age group. chronological age, but may andsynthesis reuse. Losses duringhave HDnot been quantified
sessions. Whole-body in pro-
291
estimated by with
ciation. Used using
permission.
children. In adults, an average of 8 to
26010 g of
 status and growth should be considered in be performed in a healthy child of the
combination for evaluation in children same age. (C) Infants and children with
with CKD stages 2 to 5 and 5D. (B) polyuria, evidence of growth delay, de-
Overview Evaluation of Growth and Nutritional Status i Dietary intake (3-day diet record or creasing or low BMI, comorbidities influ- Energy Requirements Protein Requirements
three 24-hour dietary recalls) encing growth or nutrient intake, or re-

Suggested Dietary Protein Intake for Children With CKD Stages 3 to 5 and 5D (R 5.1):
Poor energy intake is common in children with CKD due to reduced appetite and vomiting. CVD is the leading cause of morbidity and mortality in the pediatric CKD population,
Recommendations for Children With CKD Stages 2 to 5 and 5D: Recommended Parameters and Frequency of Nutritional Assessment for accounting for ~25% of total deaths (a rate 1000 times higher than the national pediatric • CKD stage 3: 100%–140% of the DRI for ideal body weight
Table 1. Recommended Parameters and Frequency of Nutritional Assessment for Children Children with excessive energy intake are at risk for short- and long-term complications • CKD stages 4 to 5: 100%–120% of the DRI for ideal body weight
Children
withWith CKD Stages
CKD Stages 2 to
2 to 5 and 5D5 and 5D CVD death rate).
The number of children with Evaluate nutritional status and growth on a periodic basis (R 1.1). associated with being overweight or obese. • CKD stage 5D: 100% of the DRI for ideal body weight, plus an allowance
CKD continues to increase.
Minimum Interval (mo)
National registry data for pediatric dialysis or transplant patients showed a significantly for dialytic protein and amino acid losses (R 5.2).
Consider the following parameters of nutritional status and growth in combination for Consider a trial of IDPN to augment inadequate nutritional intake for malnourished children These requirements refer to a stable child and assume that energy intake meets 100%
Age 0 to �1 y Age 1-3 y Age �3 y higher mortality rate at the upper and lower extremes of BMI-for-age.
(BMI-for-height-age <5th percentile) receiving maintenance HD who are unable to meet their of estimated requirements.
evaluation (R 1.2): Measure CKD 2-3 CKD 4-5 CKD 5D CKD 2-3 CKD 4-5 CKD 5D CKD 2 CKD 3 CKD 4-5 CKD 5D
Recommendations for Children With CKD Stages 2 to 5 and 5D: nutritional requirements through oral and tube feeding (R 4.4).
Modified protein requirements may be needed in children with proteinuria, those who are
– Dietary intake (3-day diet record or three 24-hour dietary recalls) Dietary intake 0.5-3 0.5-3 0.5-2 1-3 1-3 1-3 6-12 6 3-4 3-4
– IDPN should not be promoted as a sole nutrition source; it should be used to augment obese or stunted, on dialysis, during and after peritonitis episodes, and during recovery
Nutritional status can affect Malnutrition, growth delay, and
Height or length-for-age Consider energy requirements for children with CKD to be 100% of the EER for chronological
– Length- or height-for-age percentile or SDS. Use the following: percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1 3-6 3-6 1-3 1-3
age, individually adjusted for PAL and body size (ie, BMI) (R 4.1). other sources. from intercurrent illness.
overall health and well-being. nutrition-related metabolic abnormalities Height or length Protein Requirements and Therapy S49
• WHO Growth Standards from birth to 2 years velocity-for-age – Further adjustment to energy intake is suggested based upon the response in rate of weight Balance calories from carbohydrate and unsaturated fats within the physiological ranges
are common and are associated with a percentile or SDS 0.5-2 0.5-2 0.5-1 1-6 1-3 1-2 6 6 6 6 recommended as the AMDR of the DRI when prescribing oral, enteral, or parenteral energy
• CDC growth reference charts after age 2 gain or loss (R 4.1). Table 12. Recommended Dietary Protein Intake in Children with CKD Stages 3 to 5 and 5D
Recommended Dietary Protein Intake in Children with CKD Stages 3 to 5 and 5D
greater risk of morbidity and mortality. Estimated dry weight
supplementation (R 4.5).
– Length or height velocity-for-age percentile or SDS
and weight-for-age Consider supplemental nutritional support when (R 4.2): DRI
percentile or SDS 0.5-1.5 0.5-1.5 0.25-1 1-3 1-2 0.5-1 3-6 3-6 1-3 1-3 – Uneven distribution of calories from each macronutrient may be associated with increased Recommended for Recommended for
BMI-for-height-age – The usual intake of a child fails to meet his or her energy requirements, and CKD Stage 3 CKD Stages 4-5
– Estimated dry weight and weight-for-age percentile or SDS percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1 3-6 3-6 1-3 1-3 risk of CHD, obesity, and diabetes. DRI (g/kg/d) (g/kg/d) Recommended for HD Recommended for PD
– The child is not achieving expected rates of weight gain and/or growth for age.
– BMI-for-height-age percentile or SDS Head circumference-for- – Atherogenic dyslipidemia occurs in CKD stage 3 and increases in prevalence as kidney Age (g/kg/d) (100%-140% DRI) (100%-120% DRI) (g/kg/d)* (g/kg/d)†
age percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1-2 N/A N/A N/A N/A
Consider oral intake of an energy-dense diet and commercial nutritional supplements as the function deteriorates. 0-6 mo 1.5 1.5-2.1 1.5-1.8 1.6 1.8
( years old only)
– Head circumference-for-age percentile or SDS (≤3 nPCR N/A N/A N/A N/A N/A N/A N/A N/A N/A 1*
preferred route for supplemental nutritional support (R 4.3). 7-12 mo 1.2 1.2-1.7 1.2-1.5 1.3 1.5
Nutritional care for children with CKD should be centered on the following goals: Abbreviation: N/A, not applicable. 1-3 y 1.05 1.05-1.5 1.05-1.25 1.15 1.3
– nPCR in adolescents receiving hemodialysis – Consider tube feeding when energy requirements cannot be met with oral supplementation. Encourage dietary and lifestyle changes to achieve weight control in overweight or obese
• Maintenance of an optimal nutritional status *Only applies to adolescents receiving HD. 4-13 y 0.95 0.95-1.35 0.95-1.15 1.05 1.1
children with CKD (R 4.6). 14-18 y 0.85 0.85-1.2 0.85-1.05 0.95 1.0
• Avoidance of uremic toxicity, metabolic abnormalities, and malnutrtion – Energy-dense foods may be needed in children with CKD stage 5 with oligoanuria.
Base the frequency of monitoring nutritional and growth parameters on the child’s age and S16 American Journal of Kidney Diseases, Vol 53, No 3, Suppl 2 (March), 2009: pp S16-S26 *DRI � 0.1 g/kg/d to compensate for dialytic losses.
• Reduction of the risk of chronic morbidities and mortality in adulthood Possible factors affecting poor appetite include: †DRI � 0.15-0.3 g/kg/d depending on patient age to compensate for peritoneal losses.
Acceptable Macronutrient Distribution Ranges
stage of CKD (R 1.3): • Thirst for water rather than food in those with polyuric CKD
– Perform assessments at least twice as frequently as they would be performed in a healthy GROWTH FAILURE • Administration of multiple unpleasant medications Macronutrient Children 1–4 y Children 4–18 y These protein recommendations refer to a indications of inadequate protein intake (see Rec-
• Preference for salty rather than energy-dense sweetened foods Consider
stable child using proteinthat
and assume supplements
energy intake to augment
is inadequate5.3).
ommendation oral and/or enteral protein
Recommendations to Manage Growth Failure in Children With CKD Stages 2 to 5 and 5D: intake (ie, when children
child of the same age. • Accumulation of appetite-regulating cytokines and hormones Carbohydrate 45%–65% 45%–65% adequate it meets 100%with CKD stages
of estimated require- 2 to 5 and5.2: 5D are unable to
In children meet
with CKD their protein
stage 5D, it is
Identify and treat existing nutritional deficiencies and metabolic abnormalities in children • Gastroesophageal reflux requirements
ments). Inadequate through
caloricfood intake and fluidsinalone
results the (R suggested
5.3). to maintain dietary protein intake at
– More frequent evaluation may be warranted in infants and children with: Fat 30%–40% 25%–35% inefficient use of dietary protein as a calorie
with CKD, short stature*, and potential for linear growth (R 2.1). Factors contributing to • Disordered gastric motility Possible Signs of Inadequate Protein Intake: 100% of the DRI for ideal body weight plus an
• Polyuria source, with increased generation of urea. Ensur-
– Abnormally low serum urea nitrogen levels allowance for dialytic protein and amino acid
Consider nutrition counsel- Frequent reevaluation and Nutritional management • Delayed gastric emptying Protein 5%–20% 10%–30%
poor growth include: ing caloric needs are met is an important step in
– Undesirable downward trend losses. (C)
in nPCR for adolescents on HD therapy, and/or
ing based on an individual- modification of the nutrition should be collaborative, • Evidence of growth delay assessing protein requirements and modifying Our recommendations for DPI in dialyzed
– Inadequate protein and calorie intake – Documentation
protein intake. of low protein intake using food records, food questionnaires, or diet recall
ized assessment and plan plan of care are suggested. involving the child, care- • Decreasing or low BMI children differ from previous adult and pediatric
of care for children and More frequent review is giver, dietitian, and other
– Polyuric and salt-wasting conditions Vitamins and Trace Elements Protein requirements
Strategies to Supplement may beProtein
increased in pa-
Intake: guidelines based on several lines of reasoning.
• Comorbidities influencing growth or nutrient intake – Metabolic acidosis S54 Recommendation 6
tients with proteinuria and during recovery from
– Add powdered protein modules to expressed breast First, the milk,Food and formula,
infant Nutritionbeverages,
Board of the
their caregivers (R 3.1). indicated for children members of the pediatric intercurrent illness. Modification of protein rec- Institute of Medicine of the National Academy of
• Recent acute changes in medical status or dietary intake – Renal osteodystrophy Dietary Reference Intake: Recommended Dietary Allowance and Adequate Intake pureed foods, or other
ommendations also may be necessary in obese ormoist foods.
with (R 3.3): nephrology team (R 3.4). – Add mincedObese or chopped meat, Sciences in 2002 replaced
milk the RDA of to 1989 with
havechicken,
a greater fish,DRI egg, tofu, or skim powder soups,
Table 14. Dietary Reference Intake: Recommended Dietary Allowance and Adequate Intake
– Resistance to hormones mediating growth Patients with CKD and those on dialysis therapy are at risk of vitamin and mineral stunted children. individuals values for the intake of nutrients by Ameri-
Individualize nutritional • Advanced stages of CKD deficiencies as a result of abnormal renal metabolism, inadequate intake/poor gastrointestinal pasta, or casseroles.
percentage of body fat, which is much less meta-
Infants Infants Children Children Males Males Females Females cans and Canadians. For protein, the DRI values
intervention, according • Relevant comorbidities Coordinate nutritional absorption, and dialysis-related losses. 0-6 mo 7-12 mo 1-3 y 4-8 y 9-13 y 14-18 y 9-13 y 14-18 y –Protein
Oral active
bolically or enteral
than liquid
lean mass.
Requirements and Therapy
protein-rich
Therefore,renal it is supplements
are lower than the RDA across all age S51 groups.175
to (R 3.2): influencing growth or management with a Correct serum bicarbonate level to at least the lower limit of normal (22 mmol/L) (R 2.2). believed that basing protein (and energy) require-
Average Ratio of Phosphorus Second, previous recommendations for dia-
Vitamin A (�g/d) 400 500 300 400 600 900 600 700 ments of
Table obese individuals
13. Average on theirtoactual
Ratio of Phosphorus
Proteinweight
to Protein Peritoneal permeability for protein shows large that in
• Results of the nutritional nutrient intake, and dietitian, ideally one who Consider rhGH therapy in children with (R 2.3): Vitamin C (mg/d) 40 50 15 25 45 75 45 65 Content
may overestimate in Various Protein-Rich
requirements. Foods
Conversely,
lyzed patients were based
us- interindividual variation, but appears to be rela-
on the concept
Recommendations for Children With CKD Stages 2 to 5 and 5D Vitamin E (mg/d) 4 5 6 7 11 15 11 15
Content in Various Protein-Rich Foods
addition
Although there to replacements
is no evidence forfordialytic amino acid
a nephroprotective
assessment evidence of inadequate has expertise in children – Short stature*, and Vitamin K (�g/d) 2.0 2.5 30 55 60 75 60 75
ing ideal body weightRatio forof mg
an obese person does tively
and constant within subjects. Transperitoneal
effectprotein
of dietary losses,
proteinatrestriction,
least 0.3thetogrowing
0.4 g/kg of
Consider the provision of a dietary intake consisting of at least 100% of the DRI for thiamin (B1), not take into account Phosphorusthe increase in body
Ratio Adjusted
protein protein transport correlated with small-molecule
• Age intake or malnutrition, or with CKD (R 3.4). – Potential for linear growth if growth failure† persists beyond 3 months despite treatment of Thiamin (mg/d) 0.2 0.3 0.5 0.6 0.9 1.2 0.9 1.0
for Digestion/
evidenceprotein
dietary for a major impactbeof added
should phosphorusthe
transportertostatus
overload
intake
riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), biotin (B8), cobalamin (B12), Riboflavin (mg/d) 0.3 0.4 0.5 0.6 0.9 1.3 0.9 1.0
needed for structural tosupport
Food Category g Protein of extra Absorption
fat tissue. transport rates; the peritoneal
on cardiovascularfor morbidity in children and
62 adults with
• Development • Acute illness or adverse nutritional deficiencies and metabolic abnormalities ascorbic acid (C), retinol (A), α-tocopherol (E), vitamin K, folic acid, copper, and zinc (R 6.1). Niacin (mg/d; NE) 2* 4 6 8 12 16 12 14 Therefore,
Egg white a common 1.4 practice is to estimate 1
as recommended
assessed
CKD provides
by using
a rationale
healthy
the PET
to avoid
subjects.
provides
excessive
some The evi-
protein
dence
indication base
of thefor this
level of notion
peritonealis protein
weak and primarily
losses.
• Food preferences events that may Vitamin B6 (mg/d) 0.1 0.3 0.5 0.6 1.0 1.3 1.0 1.2 protein
Meat requirements of 9obese individuals6based intake in this population.
*Short stature: Height SDS <−1.88 or height-for-age <3rd percentile It is suggested to provide supplementation of vitamins and trace elements to children with CKD on Tofu
an “adjusted” weight 12
(ie, adjusted weight 7
� High based on adulttransporters
peritoneal literature. tend to have low
• Cultural beliefs negatively impact †Growth failure: Height velocity-for-age SDS <−1.88 or height velocity-for-age <3rd percentile
stages 2 to 5 if dietary intake alone does not meet 100% of the DRI or if clinical evidence of a
Folate (�g/d) 65 80 150 200 300 400 300 400 Egg
ideal weight for
14
height � 25% �
10
[actual serum
At albumin
The
a widespread
given levels;
level of these
notion patients
quantitative that
proteinmay be atinduces
dialysis
intake, the
Vitamin B12 (�g/d) 0.4 0.5 0.9 1.2 1.8 2.4 1.8 2.4 Legumes 17 10
• Psychosocial status nutritional status deficiency, possibly confirmed by low blood levels of the vitamin or trace element, Pantothenic Acid (mg/d) 1.7 1.8 2 3 4 5 4 5
need for increased
generalized
phosphorus
weight � ideal weight], where 25% represents cause dialytic protein concentrations can be mea-
Lentils 20 12 protein
content dietary
and protein supply.
catabolism through
bioavailability of Be-
the general-
protein
is present (R 6.2). Biotin (�g/d) 5 6 8 12 20 25 20 25 theNuts
percentage of body fat 25 15
tissue that is metaboli- sources,
ized the quality
protein of protein,
degradation and thefrom
resulting metabolic
cytokine
Milk 29 21 sured easily, consideration
environment are important should be factors
additional given toto
Copper (�g/d) 200 220 340 440 700 890 700 890 cally active) rather than their actual body release
regular
induced
monitoring
by exposure
of peritoneal
to bioincompatible
protein excre-
It is suggested that children with CKD stage 5D receive a water-soluble vitamin supplement, with 20 30 40 55 40 55
Seeds 50 29
consider
membranes in the (indietary
HD) protein
or prescription.
dialysis
Selenium (�g/d) 15 20 of fluids (in PD) has
259
weight.
Note: Note: This estimations
Mathematical formula is based
based onprotein
physiologi-
on protein tion and individual adaptation the dietary
the exception of children with healthy appetites for a variety of nutritious foods and children Zinc (mg/d) 2 3 3 5 8 11 8 9
Mathematical
cal ibility-corrected
theory rather
estimations
aminothan
digestibility-corrected amino
based
scientific
acid scores
acid scores
on
evidence.
(PDCAA)
(PDCAA)
digest-
and data onIn
and data protein prescription according to actual by
not been universally confirmed metabolic
perito-
receiving most or all of their energy requirements from adult renal formulas (R 6.3). Note: RDAs are in bold type; Als are in ordinary type. *As preformed niacin, not niacin equivalents (NE) for this age group. on estimated
young phosphorus
children
estimated (ie,bioavailability.
phosphorus age �3 years) or stunted neal
bioavailability. studies.
losses. Net protein “catabolism” seems to be
©1998, Vegetarian Diets in Renal Disease article in Amino
Source: Health Canada: http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. Reprinted children
Nutrition(ie, length-
Update, or height-for-age
Vegetarian � �1.88
Nutrition DPG Newsletter;
limitedacid to and the protein
dialyticlosses duringof
removal HDamino
vary acids
with the permission of the Minister of Public Works and Government Services, Canada, 2008. SDS),
DPG,protein requirements
a dietetic practice initiallyDietetic
group of American shouldAsso-be
according
and/or to dialyzer
protein and membrane
a slightly characteristics
reduced protein
*As preformed niacin, not niacin equivalents (NE) for this age group. chronological age, but may andsynthesis reuse. Losses duringhave HDnot been quantified
sessions. Whole-body in pro-
291
estimated by with
ciation. Used using
permission.
children. In adults, an average of 8 to
26010 g of
 status and growth should be considered in be performed in a healthy child of the
combination for evaluation in children same age. (C) Infants and children with
with CKD stages 2 to 5 and 5D. (B) polyuria, evidence of growth delay, de-
Overview Evaluation of Growth and Nutritional Status i Dietary intake (3-day diet record or creasing or low BMI, comorbidities influ- Energy Requirements Protein Requirements
three 24-hour dietary recalls) encing growth or nutrient intake, or re-

Suggested Dietary Protein Intake for Children With CKD Stages 3 to 5 and 5D (R 5.1):
Poor energy intake is common in children with CKD due to reduced appetite and vomiting. CVD is the leading cause of morbidity and mortality in the pediatric CKD population,
Recommendations for Children With CKD Stages 2 to 5 and 5D: Recommended Parameters and Frequency of Nutritional Assessment for accounting for ~25% of total deaths (a rate 1000 times higher than the national pediatric • CKD stage 3: 100%–140% of the DRI for ideal body weight
Table 1. Recommended Parameters and Frequency of Nutritional Assessment for Children Children with excessive energy intake are at risk for short- and long-term complications • CKD stages 4 to 5: 100%–120% of the DRI for ideal body weight
Children
withWith CKD Stages
CKD Stages 2 to
2 to 5 and 5D5 and 5D CVD death rate).
The number of children with Evaluate nutritional status and growth on a periodic basis (R 1.1). associated with being overweight or obese. • CKD stage 5D: 100% of the DRI for ideal body weight, plus an allowance
CKD continues to increase.
Minimum Interval (mo)
National registry data for pediatric dialysis or transplant patients showed a significantly for dialytic protein and amino acid losses (R 5.2).
Consider the following parameters of nutritional status and growth in combination for Consider a trial of IDPN to augment inadequate nutritional intake for malnourished children These requirements refer to a stable child and assume that energy intake meets 100%
Age 0 to �1 y Age 1-3 y Age �3 y higher mortality rate at the upper and lower extremes of BMI-for-age.
(BMI-for-height-age <5th percentile) receiving maintenance HD who are unable to meet their of estimated requirements.
evaluation (R 1.2): Measure CKD 2-3 CKD 4-5 CKD 5D CKD 2-3 CKD 4-5 CKD 5D CKD 2 CKD 3 CKD 4-5 CKD 5D
Recommendations for Children With CKD Stages 2 to 5 and 5D: nutritional requirements through oral and tube feeding (R 4.4).
Modified protein requirements may be needed in children with proteinuria, those who are
– Dietary intake (3-day diet record or three 24-hour dietary recalls) Dietary intake 0.5-3 0.5-3 0.5-2 1-3 1-3 1-3 6-12 6 3-4 3-4
– IDPN should not be promoted as a sole nutrition source; it should be used to augment obese or stunted, on dialysis, during and after peritonitis episodes, and during recovery
Nutritional status can affect Malnutrition, growth delay, and
Height or length-for-age Consider energy requirements for children with CKD to be 100% of the EER for chronological
– Length- or height-for-age percentile or SDS. Use the following: percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1 3-6 3-6 1-3 1-3
age, individually adjusted for PAL and body size (ie, BMI) (R 4.1). other sources. from intercurrent illness.
overall health and well-being. nutrition-related metabolic abnormalities Height or length Protein Requirements and Therapy S49
• WHO Growth Standards from birth to 2 years velocity-for-age – Further adjustment to energy intake is suggested based upon the response in rate of weight Balance calories from carbohydrate and unsaturated fats within the physiological ranges
are common and are associated with a percentile or SDS 0.5-2 0.5-2 0.5-1 1-6 1-3 1-2 6 6 6 6 recommended as the AMDR of the DRI when prescribing oral, enteral, or parenteral energy
• CDC growth reference charts after age 2 gain or loss (R 4.1). Table 12. Recommended Dietary Protein Intake in Children with CKD Stages 3 to 5 and 5D
Recommended Dietary Protein Intake in Children with CKD Stages 3 to 5 and 5D
greater risk of morbidity and mortality. Estimated dry weight
supplementation (R 4.5).
– Length or height velocity-for-age percentile or SDS
and weight-for-age Consider supplemental nutritional support when (R 4.2): DRI
percentile or SDS 0.5-1.5 0.5-1.5 0.25-1 1-3 1-2 0.5-1 3-6 3-6 1-3 1-3 – Uneven distribution of calories from each macronutrient may be associated with increased Recommended for Recommended for
BMI-for-height-age – The usual intake of a child fails to meet his or her energy requirements, and CKD Stage 3 CKD Stages 4-5
– Estimated dry weight and weight-for-age percentile or SDS percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1 3-6 3-6 1-3 1-3 risk of CHD, obesity, and diabetes. DRI (g/kg/d) (g/kg/d) Recommended for HD Recommended for PD
– The child is not achieving expected rates of weight gain and/or growth for age.
– BMI-for-height-age percentile or SDS Head circumference-for- – Atherogenic dyslipidemia occurs in CKD stage 3 and increases in prevalence as kidney Age (g/kg/d) (100%-140% DRI) (100%-120% DRI) (g/kg/d)* (g/kg/d)†
age percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1-2 N/A N/A N/A N/A
Consider oral intake of an energy-dense diet and commercial nutritional supplements as the function deteriorates. 0-6 mo 1.5 1.5-2.1 1.5-1.8 1.6 1.8
( years old only)
– Head circumference-for-age percentile or SDS (≤3 nPCR N/A N/A N/A N/A N/A N/A N/A N/A N/A 1*
preferred route for supplemental nutritional support (R 4.3). 7-12 mo 1.2 1.2-1.7 1.2-1.5 1.3 1.5
Nutritional care for children with CKD should be centered on the following goals: Abbreviation: N/A, not applicable. 1-3 y 1.05 1.05-1.5 1.05-1.25 1.15 1.3
– nPCR in adolescents receiving hemodialysis – Consider tube feeding when energy requirements cannot be met with oral supplementation. Encourage dietary and lifestyle changes to achieve weight control in overweight or obese
• Maintenance of an optimal nutritional status *Only applies to adolescents receiving HD. 4-13 y 0.95 0.95-1.35 0.95-1.15 1.05 1.1
children with CKD (R 4.6). 14-18 y 0.85 0.85-1.2 0.85-1.05 0.95 1.0
• Avoidance of uremic toxicity, metabolic abnormalities, and malnutrtion – Energy-dense foods may be needed in children with CKD stage 5 with oligoanuria.
Base the frequency of monitoring nutritional and growth parameters on the child’s age and S16 American Journal of Kidney Diseases, Vol 53, No 3, Suppl 2 (March), 2009: pp S16-S26 *DRI � 0.1 g/kg/d to compensate for dialytic losses.
• Reduction of the risk of chronic morbidities and mortality in adulthood Possible factors affecting poor appetite include: †DRI � 0.15-0.3 g/kg/d depending on patient age to compensate for peritoneal losses.
Acceptable Macronutrient Distribution Ranges
stage of CKD (R 1.3): • Thirst for water rather than food in those with polyuric CKD
– Perform assessments at least twice as frequently as they would be performed in a healthy GROWTH FAILURE • Administration of multiple unpleasant medications Macronutrient Children 1–4 y Children 4–18 y These protein recommendations refer to a indications of inadequate protein intake (see Rec-
• Preference for salty rather than energy-dense sweetened foods Consider
stable child using proteinthat
and assume supplements
energy intake to augment
is inadequate5.3).
ommendation oral and/or enteral protein
Recommendations to Manage Growth Failure in Children With CKD Stages 2 to 5 and 5D: intake (ie, when children
child of the same age. • Accumulation of appetite-regulating cytokines and hormones Carbohydrate 45%–65% 45%–65% adequate it meets 100%with CKD stages
of estimated require- 2 to 5 and5.2: 5D are unable to
In children meet
with CKD their protein
stage 5D, it is
Identify and treat existing nutritional deficiencies and metabolic abnormalities in children • Gastroesophageal reflux requirements
ments). Inadequate through
caloricfood intake and fluidsinalone
results the (R suggested
5.3). to maintain dietary protein intake at
– More frequent evaluation may be warranted in infants and children with: Fat 30%–40% 25%–35% inefficient use of dietary protein as a calorie
with CKD, short stature*, and potential for linear growth (R 2.1). Factors contributing to • Disordered gastric motility Possible Signs of Inadequate Protein Intake: 100% of the DRI for ideal body weight plus an
• Polyuria source, with increased generation of urea. Ensur-
– Abnormally low serum urea nitrogen levels allowance for dialytic protein and amino acid
Consider nutrition counsel- Frequent reevaluation and Nutritional management • Delayed gastric emptying Protein 5%–20% 10%–30%
poor growth include: ing caloric needs are met is an important step in
– Undesirable downward trend losses. (C)
in nPCR for adolescents on HD therapy, and/or
ing based on an individual- modification of the nutrition should be collaborative, • Evidence of growth delay assessing protein requirements and modifying Our recommendations for DPI in dialyzed
– Inadequate protein and calorie intake – Documentation
protein intake. of low protein intake using food records, food questionnaires, or diet recall
ized assessment and plan plan of care are suggested. involving the child, care- • Decreasing or low BMI children differ from previous adult and pediatric
of care for children and More frequent review is giver, dietitian, and other
– Polyuric and salt-wasting conditions Vitamins and Trace Elements Protein requirements
Strategies to Supplement may beProtein
increased in pa-
Intake: guidelines based on several lines of reasoning.
• Comorbidities influencing growth or nutrient intake – Metabolic acidosis S54 Recommendation 6
tients with proteinuria and during recovery from
– Add powdered protein modules to expressed breast First, the milk,Food and formula,
infant Nutritionbeverages,
Board of the
their caregivers (R 3.1). indicated for children members of the pediatric intercurrent illness. Modification of protein rec- Institute of Medicine of the National Academy of
• Recent acute changes in medical status or dietary intake – Renal osteodystrophy Dietary Reference Intake: Recommended Dietary Allowance and Adequate Intake pureed foods, or other
ommendations also may be necessary in obese ormoist foods.
with (R 3.3): nephrology team (R 3.4). – Add mincedObese or chopped meat, Sciences in 2002 replaced
milk the RDA of to 1989 with
havechicken,
a greater fish,DRI egg, tofu, or skim powder soups,
Table 14. Dietary Reference Intake: Recommended Dietary Allowance and Adequate Intake
– Resistance to hormones mediating growth Patients with CKD and those on dialysis therapy are at risk of vitamin and mineral stunted children. individuals values for the intake of nutrients by Ameri-
Individualize nutritional • Advanced stages of CKD deficiencies as a result of abnormal renal metabolism, inadequate intake/poor gastrointestinal pasta, or casseroles.
percentage of body fat, which is much less meta-
Infants Infants Children Children Males Males Females Females cans and Canadians. For protein, the DRI values
intervention, according • Relevant comorbidities Coordinate nutritional absorption, and dialysis-related losses. 0-6 mo 7-12 mo 1-3 y 4-8 y 9-13 y 14-18 y 9-13 y 14-18 y –Protein
Oral active
bolically or enteral
than liquid
lean mass.
Requirements and Therapy
protein-rich
Therefore,renal it is supplements
are lower than the RDA across all age S51 groups.175
to (R 3.2): influencing growth or management with a Correct serum bicarbonate level to at least the lower limit of normal (22 mmol/L) (R 2.2). believed that basing protein (and energy) require-
Average Ratio of Phosphorus Second, previous recommendations for dia-
Vitamin A (�g/d) 400 500 300 400 600 900 600 700 ments of
Table obese individuals
13. Average on theirtoactual
Ratio of Phosphorus
Proteinweight
to Protein Peritoneal permeability for protein shows large that in
• Results of the nutritional nutrient intake, and dietitian, ideally one who Consider rhGH therapy in children with (R 2.3): Vitamin C (mg/d) 40 50 15 25 45 75 45 65 Content
may overestimate in Various Protein-Rich
requirements. Foods
Conversely,
lyzed patients were based
us- interindividual variation, but appears to be rela-
on the concept
Recommendations for Children With CKD Stages 2 to 5 and 5D Vitamin E (mg/d) 4 5 6 7 11 15 11 15
Content in Various Protein-Rich Foods
addition
Although there to replacements
is no evidence forfordialytic amino acid
a nephroprotective
assessment evidence of inadequate has expertise in children – Short stature*, and Vitamin K (�g/d) 2.0 2.5 30 55 60 75 60 75
ing ideal body weightRatio forof mg
an obese person does tively
and constant within subjects. Transperitoneal
effectprotein
of dietary losses,
proteinatrestriction,
least 0.3thetogrowing
0.4 g/kg of
Consider the provision of a dietary intake consisting of at least 100% of the DRI for thiamin (B1), not take into account Phosphorusthe increase in body
Ratio Adjusted
protein protein transport correlated with small-molecule
• Age intake or malnutrition, or with CKD (R 3.4). – Potential for linear growth if growth failure† persists beyond 3 months despite treatment of Thiamin (mg/d) 0.2 0.3 0.5 0.6 0.9 1.2 0.9 1.0
for Digestion/
evidenceprotein
dietary for a major impactbeof added
should phosphorusthe
transportertostatus
overload
intake
riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), biotin (B8), cobalamin (B12), Riboflavin (mg/d) 0.3 0.4 0.5 0.6 0.9 1.3 0.9 1.0
needed for structural tosupport
Food Category g Protein of extra Absorption
fat tissue. transport rates; the peritoneal
on cardiovascularfor morbidity in children and
62 adults with
• Development • Acute illness or adverse nutritional deficiencies and metabolic abnormalities ascorbic acid (C), retinol (A), α-tocopherol (E), vitamin K, folic acid, copper, and zinc (R 6.1). Niacin (mg/d; NE) 2* 4 6 8 12 16 12 14 Therefore,
Egg white a common 1.4 practice is to estimate 1
as recommended
assessed
CKD provides
by using
a rationale
healthy
the PET
to avoid
subjects.
provides
excessive
some The evi-
protein
dence
indication base
of thefor this
level of notion
peritonealis protein
weak and primarily
losses.
• Food preferences events that may Vitamin B6 (mg/d) 0.1 0.3 0.5 0.6 1.0 1.3 1.0 1.2 protein
Meat requirements of 9obese individuals6based intake in this population.
*Short stature: Height SDS <−1.88 or height-for-age <3rd percentile It is suggested to provide supplementation of vitamins and trace elements to children with CKD on Tofu
an “adjusted” weight 12
(ie, adjusted weight 7
� High based on adulttransporters
peritoneal literature. tend to have low
• Cultural beliefs negatively impact †Growth failure: Height velocity-for-age SDS <−1.88 or height velocity-for-age <3rd percentile
stages 2 to 5 if dietary intake alone does not meet 100% of the DRI or if clinical evidence of a
Folate (�g/d) 65 80 150 200 300 400 300 400 Egg
ideal weight for
14
height � 25% �
10
[actual serum
At albumin
The
a widespread
given levels;
level of these
notion patients
quantitative that
proteinmay be atinduces
dialysis
intake, the
Vitamin B12 (�g/d) 0.4 0.5 0.9 1.2 1.8 2.4 1.8 2.4 Legumes 17 10
• Psychosocial status nutritional status deficiency, possibly confirmed by low blood levels of the vitamin or trace element, Pantothenic Acid (mg/d) 1.7 1.8 2 3 4 5 4 5
need for increased
generalized
phosphorus
weight � ideal weight], where 25% represents cause dialytic protein concentrations can be mea-
Lentils 20 12 protein
content dietary
and protein supply.
catabolism through
bioavailability of Be-
the general-
protein
is present (R 6.2). Biotin (�g/d) 5 6 8 12 20 25 20 25 theNuts
percentage of body fat 25 15
tissue that is metaboli- sources,
ized the quality
protein of protein,
degradation and thefrom
resulting metabolic
cytokine
Milk 29 21 sured easily, consideration
environment are important should be factors
additional given toto
Copper (�g/d) 200 220 340 440 700 890 700 890 cally active) rather than their actual body release
regular
induced
monitoring
by exposure
of peritoneal
to bioincompatible
protein excre-
It is suggested that children with CKD stage 5D receive a water-soluble vitamin supplement, with 20 30 40 55 40 55
Seeds 50 29
consider
membranes in the (indietary
HD) protein
or prescription.
dialysis
Selenium (�g/d) 15 20 of fluids (in PD) has
259
weight.
Note: Note: This estimations
Mathematical formula is based
based onprotein
physiologi-
on protein tion and individual adaptation the dietary
the exception of children with healthy appetites for a variety of nutritious foods and children Zinc (mg/d) 2 3 3 5 8 11 8 9
Mathematical
cal ibility-corrected
theory rather
estimations
aminothan
digestibility-corrected amino
based
scientific
acid scores
acid scores
on
evidence.
(PDCAA)
(PDCAA)
digest-
and data onIn
and data protein prescription according to actual by
not been universally confirmed metabolic
perito-
receiving most or all of their energy requirements from adult renal formulas (R 6.3). Note: RDAs are in bold type; Als are in ordinary type. *As preformed niacin, not niacin equivalents (NE) for this age group. on estimated
young phosphorus
children
estimated (ie,bioavailability.
phosphorus age �3 years) or stunted neal
bioavailability. studies.
losses. Net protein “catabolism” seems to be
©1998, Vegetarian Diets in Renal Disease article in Amino
Source: Health Canada: http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. Reprinted children
Nutrition(ie, length-
Update, or height-for-age
Vegetarian � �1.88
Nutrition DPG Newsletter;
limitedacid to and the protein
dialyticlosses duringof
removal HDamino
vary acids
with the permission of the Minister of Public Works and Government Services, Canada, 2008. SDS),
DPG,protein requirements
a dietetic practice initiallyDietetic
group of American shouldAsso-be
according
and/or to dialyzer
protein and membrane
a slightly characteristics
reduced protein
*As preformed niacin, not niacin equivalents (NE) for this age group. chronological age, but may andsynthesis reuse. Losses duringhave HDnot been quantified
sessions. Whole-body in pro-
291
estimated by with
ciation. Used using
permission.
children. In adults, an average of 8 to
26010 g of
 status and growth should be considered in be performed in a healthy child of the
combination for evaluation in children same age. (C) Infants and children with
with CKD stages 2 to 5 and 5D. (B) polyuria, evidence of growth delay, de-
Overview Evaluation of Growth and Nutritional Status i Dietary intake (3-day diet record or creasing or low BMI, comorbidities influ- Energy Requirements Protein Requirements
three 24-hour dietary recalls) encing growth or nutrient intake, or re-

Suggested Dietary Protein Intake for Children With CKD Stages 3 to 5 and 5D (R 5.1):
Poor energy intake is common in children with CKD due to reduced appetite and vomiting. CVD is the leading cause of morbidity and mortality in the pediatric CKD population,
Recommendations for Children With CKD Stages 2 to 5 and 5D: Recommended Parameters and Frequency of Nutritional Assessment for accounting for ~25% of total deaths (a rate 1000 times higher than the national pediatric • CKD stage 3: 100%–140% of the DRI for ideal body weight
Table 1. Recommended Parameters and Frequency of Nutritional Assessment for Children Children with excessive energy intake are at risk for short- and long-term complications • CKD stages 4 to 5: 100%–120% of the DRI for ideal body weight
Children
withWith CKD Stages
CKD Stages 2 to
2 to 5 and 5D5 and 5D CVD death rate).
The number of children with Evaluate nutritional status and growth on a periodic basis (R 1.1). associated with being overweight or obese. • CKD stage 5D: 100% of the DRI for ideal body weight, plus an allowance
CKD continues to increase.
Minimum Interval (mo)
National registry data for pediatric dialysis or transplant patients showed a significantly for dialytic protein and amino acid losses (R 5.2).
Consider the following parameters of nutritional status and growth in combination for Consider a trial of IDPN to augment inadequate nutritional intake for malnourished children These requirements refer to a stable child and assume that energy intake meets 100%
Age 0 to �1 y Age 1-3 y Age �3 y higher mortality rate at the upper and lower extremes of BMI-for-age.
(BMI-for-height-age <5th percentile) receiving maintenance HD who are unable to meet their of estimated requirements.
evaluation (R 1.2): Measure CKD 2-3 CKD 4-5 CKD 5D CKD 2-3 CKD 4-5 CKD 5D CKD 2 CKD 3 CKD 4-5 CKD 5D
Recommendations for Children With CKD Stages 2 to 5 and 5D: nutritional requirements through oral and tube feeding (R 4.4).
Modified protein requirements may be needed in children with proteinuria, those who are
– Dietary intake (3-day diet record or three 24-hour dietary recalls) Dietary intake 0.5-3 0.5-3 0.5-2 1-3 1-3 1-3 6-12 6 3-4 3-4
– IDPN should not be promoted as a sole nutrition source; it should be used to augment obese or stunted, on dialysis, during and after peritonitis episodes, and during recovery
Nutritional status can affect Malnutrition, growth delay, and
Height or length-for-age Consider energy requirements for children with CKD to be 100% of the EER for chronological
– Length- or height-for-age percentile or SDS. Use the following: percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1 3-6 3-6 1-3 1-3
age, individually adjusted for PAL and body size (ie, BMI) (R 4.1). other sources. from intercurrent illness.
overall health and well-being. nutrition-related metabolic abnormalities Height or length Protein Requirements and Therapy S49
• WHO Growth Standards from birth to 2 years velocity-for-age – Further adjustment to energy intake is suggested based upon the response in rate of weight Balance calories from carbohydrate and unsaturated fats within the physiological ranges
are common and are associated with a percentile or SDS 0.5-2 0.5-2 0.5-1 1-6 1-3 1-2 6 6 6 6 recommended as the AMDR of the DRI when prescribing oral, enteral, or parenteral energy
• CDC growth reference charts after age 2 gain or loss (R 4.1). Table 12. Recommended Dietary Protein Intake in Children with CKD Stages 3 to 5 and 5D
Recommended Dietary Protein Intake in Children with CKD Stages 3 to 5 and 5D
greater risk of morbidity and mortality. Estimated dry weight
supplementation (R 4.5).
– Length or height velocity-for-age percentile or SDS
and weight-for-age Consider supplemental nutritional support when (R 4.2): DRI
percentile or SDS 0.5-1.5 0.5-1.5 0.25-1 1-3 1-2 0.5-1 3-6 3-6 1-3 1-3 – Uneven distribution of calories from each macronutrient may be associated with increased Recommended for Recommended for
BMI-for-height-age – The usual intake of a child fails to meet his or her energy requirements, and CKD Stage 3 CKD Stages 4-5
– Estimated dry weight and weight-for-age percentile or SDS percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1 3-6 3-6 1-3 1-3 risk of CHD, obesity, and diabetes. DRI (g/kg/d) (g/kg/d) Recommended for HD Recommended for PD
– The child is not achieving expected rates of weight gain and/or growth for age.
– BMI-for-height-age percentile or SDS Head circumference-for- – Atherogenic dyslipidemia occurs in CKD stage 3 and increases in prevalence as kidney Age (g/kg/d) (100%-140% DRI) (100%-120% DRI) (g/kg/d)* (g/kg/d)†
age percentile or SDS 0.5-1.5 0.5-1.5 0.5-1 1-3 1-2 1-2 N/A N/A N/A N/A
Consider oral intake of an energy-dense diet and commercial nutritional supplements as the function deteriorates. 0-6 mo 1.5 1.5-2.1 1.5-1.8 1.6 1.8
( years old only)
– Head circumference-for-age percentile or SDS (≤3 nPCR N/A N/A N/A N/A N/A N/A N/A N/A N/A 1*
preferred route for supplemental nutritional support (R 4.3). 7-12 mo 1.2 1.2-1.7 1.2-1.5 1.3 1.5
Nutritional care for children with CKD should be centered on the following goals: Abbreviation: N/A, not applicable. 1-3 y 1.05 1.05-1.5 1.05-1.25 1.15 1.3
– nPCR in adolescents receiving hemodialysis – Consider tube feeding when energy requirements cannot be met with oral supplementation. Encourage dietary and lifestyle changes to achieve weight control in overweight or obese
• Maintenance of an optimal nutritional status *Only applies to adolescents receiving HD. 4-13 y 0.95 0.95-1.35 0.95-1.15 1.05 1.1
children with CKD (R 4.6). 14-18 y 0.85 0.85-1.2 0.85-1.05 0.95 1.0
• Avoidance of uremic toxicity, metabolic abnormalities, and malnutrtion – Energy-dense foods may be needed in children with CKD stage 5 with oligoanuria.
Base the frequency of monitoring nutritional and growth parameters on the child’s age and S16 American Journal of Kidney Diseases, Vol 53, No 3, Suppl 2 (March), 2009: pp S16-S26 *DRI � 0.1 g/kg/d to compensate for dialytic losses.
• Reduction of the risk of chronic morbidities and mortality in adulthood Possible factors affecting poor appetite include: †DRI � 0.15-0.3 g/kg/d depending on patient age to compensate for peritoneal losses.
Acceptable Macronutrient Distribution Ranges
stage of CKD (R 1.3): • Thirst for water rather than food in those with polyuric CKD
– Perform assessments at least twice as frequently as they would be performed in a healthy GROWTH FAILURE • Administration of multiple unpleasant medications Macronutrient Children 1–4 y Children 4–18 y These protein recommendations refer to a indications of inadequate protein intake (see Rec-
• Preference for salty rather than energy-dense sweetened foods Consider
stable child using proteinthat
and assume supplements
energy intake to augment
is inadequate5.3).
ommendation oral and/or enteral protein
Recommendations to Manage Growth Failure in Children With CKD Stages 2 to 5 and 5D: intake (ie, when children
child of the same age. • Accumulation of appetite-regulating cytokines and hormones Carbohydrate 45%–65% 45%–65% adequate it meets 100%with CKD stages
of estimated require- 2 to 5 and5.2: 5D are unable to
In children meet
with CKD their protein
stage 5D, it is
Identify and treat existing nutritional deficiencies and metabolic abnormalities in children • Gastroesophageal reflux requirements
ments). Inadequate through
caloricfood intake and fluidsinalone
results the (R suggested
5.3). to maintain dietary protein intake at
– More frequent evaluation may be warranted in infants and children with: Fat 30%–40% 25%–35% inefficient use of dietary protein as a calorie
with CKD, short stature*, and potential for linear growth (R 2.1). Factors contributing to • Disordered gastric motility Possible Signs of Inadequate Protein Intake: 100% of the DRI for ideal body weight plus an
• Polyuria source, with increased generation of urea. Ensur-
– Abnormally low serum urea nitrogen levels allowance for dialytic protein and amino acid
Consider nutrition counsel- Frequent reevaluation and Nutritional management • Delayed gastric emptying Protein 5%–20% 10%–30%
poor growth include: ing caloric needs are met is an important step in
– Undesirable downward trend losses. (C)
in nPCR for adolescents on HD therapy, and/or
ing based on an individual- modification of the nutrition should be collaborative, • Evidence of growth delay assessing protein requirements and modifying Our recommendations for DPI in dialyzed
– Inadequate protein and calorie intake – Documentation
protein intake. of low protein intake using food records, food questionnaires, or diet recall
ized assessment and plan plan of care are suggested. involving the child, care- • Decreasing or low BMI children differ from previous adult and pediatric
of care for children and More frequent review is giver, dietitian, and other
– Polyuric and salt-wasting conditions Vitamins and Trace Elements Protein requirements
Strategies to Supplement may beProtein
increased in pa-
Intake: guidelines based on several lines of reasoning.
• Comorbidities influencing growth or nutrient intake – Metabolic acidosis S54 Recommendation 6
tients with proteinuria and during recovery from
– Add powdered protein modules to expressed breast First, the milk,Food and formula,
infant Nutritionbeverages,
Board of the
their caregivers (R 3.1). indicated for children members of the pediatric intercurrent illness. Modification of protein rec- Institute of Medicine of the National Academy of
• Recent acute changes in medical status or dietary intake – Renal osteodystrophy Dietary Reference Intake: Recommended Dietary Allowance and Adequate Intake pureed foods, or other
ommendations also may be necessary in obese ormoist foods.
with (R 3.3): nephrology team (R 3.4). – Add mincedObese or chopped meat, Sciences in 2002 replaced
milk the RDA of to 1989 with
havechicken,
a greater fish,DRI egg, tofu, or skim powder soups,
Table 14. Dietary Reference Intake: Recommended Dietary Allowance and Adequate Intake
– Resistance to hormones mediating growth Patients with CKD and those on dialysis therapy are at risk of vitamin and mineral stunted children. individuals values for the intake of nutrients by Ameri-
Individualize nutritional • Advanced stages of CKD deficiencies as a result of abnormal renal metabolism, inadequate intake/poor gastrointestinal pasta, or casseroles.
percentage of body fat, which is much less meta-
Infants Infants Children Children Males Males Females Females cans and Canadians. For protein, the DRI values
intervention, according • Relevant comorbidities Coordinate nutritional absorption, and dialysis-related losses. 0-6 mo 7-12 mo 1-3 y 4-8 y 9-13 y 14-18 y 9-13 y 14-18 y –Protein
Oral active
bolically or enteral
than liquid
lean mass.
Requirements and Therapy
protein-rich
Therefore,renal it is supplements
are lower than the RDA across all age S51 groups.175
to (R 3.2): influencing growth or management with a Correct serum bicarbonate level to at least the lower limit of normal (22 mmol/L) (R 2.2). believed that basing protein (and energy) require-
Average Ratio of Phosphorus Second, previous recommendations for dia-
Vitamin A (�g/d) 400 500 300 400 600 900 600 700 ments of
Table obese individuals
13. Average on theirtoactual
Ratio of Phosphorus
Proteinweight
to Protein Peritoneal permeability for protein shows large that in
• Results of the nutritional nutrient intake, and dietitian, ideally one who Consider rhGH therapy in children with (R 2.3): Vitamin C (mg/d) 40 50 15 25 45 75 45 65 Content
may overestimate in Various Protein-Rich
requirements. Foods
Conversely,
lyzed patients were based
us- interindividual variation, but appears to be rela-
on the concept
Recommendations for Children With CKD Stages 2 to 5 and 5D Vitamin E (mg/d) 4 5 6 7 11 15 11 15
Content in Various Protein-Rich Foods
addition
Although there to replacements
is no evidence forfordialytic amino acid
a nephroprotective
assessment evidence of inadequate has expertise in children – Short stature*, and Vitamin K (�g/d) 2.0 2.5 30 55 60 75 60 75
ing ideal body weightRatio forof mg
an obese person does tively
and constant within subjects. Transperitoneal
effectprotein
of dietary losses,
proteinatrestriction,
least 0.3thetogrowing
0.4 g/kg of
Consider the provision of a dietary intake consisting of at least 100% of the DRI for thiamin (B1), not take into account Phosphorusthe increase in body
Ratio Adjusted
protein protein transport correlated with small-molecule
• Age intake or malnutrition, or with CKD (R 3.4). – Potential for linear growth if growth failure† persists beyond 3 months despite treatment of Thiamin (mg/d) 0.2 0.3 0.5 0.6 0.9 1.2 0.9 1.0
for Digestion/
evidenceprotein
dietary for a major impactbeof added
should phosphorusthe
transportertostatus
overload
intake
riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), biotin (B8), cobalamin (B12), Riboflavin (mg/d) 0.3 0.4 0.5 0.6 0.9 1.3 0.9 1.0
needed for structural tosupport
Food Category g Protein of extra Absorption
fat tissue. transport rates; the peritoneal
on cardiovascularfor morbidity in children and
62 adults with
• Development • Acute illness or adverse nutritional deficiencies and metabolic abnormalities ascorbic acid (C), retinol (A), α-tocopherol (E), vitamin K, folic acid, copper, and zinc (R 6.1). Niacin (mg/d; NE) 2* 4 6 8 12 16 12 14 Therefore,
Egg white a common 1.4 practice is to estimate 1
as recommended
assessed
CKD provides
by using
a rationale
healthy
the PET
to avoid
subjects.
provides
excessive
some The evi-
protein
dence
indication base
of thefor this
level of notion
peritonealis protein
weak and primarily
losses.
• Food preferences events that may Vitamin B6 (mg/d) 0.1 0.3 0.5 0.6 1.0 1.3 1.0 1.2 protein
Meat requirements of 9obese individuals6based intake in this population.
*Short stature: Height SDS <−1.88 or height-for-age <3rd percentile It is suggested to provide supplementation of vitamins and trace elements to children with CKD on Tofu
an “adjusted” weight 12
(ie, adjusted weight 7
� High based on adulttransporters
peritoneal literature. tend to have low
• Cultural beliefs negatively impact †Growth failure: Height velocity-for-age SDS <−1.88 or height velocity-for-age <3rd percentile
stages 2 to 5 if dietary intake alone does not meet 100% of the DRI or if clinical evidence of a
Folate (�g/d) 65 80 150 200 300 400 300 400 Egg
ideal weight for
14
height � 25% �
10
[actual serum
At albumin
The
a widespread
given levels;
level of these
notion patients
quantitative that
proteinmay be atinduces
dialysis
intake, the
Vitamin B12 (�g/d) 0.4 0.5 0.9 1.2 1.8 2.4 1.8 2.4 Legumes 17 10
• Psychosocial status nutritional status deficiency, possibly confirmed by low blood levels of the vitamin or trace element, Pantothenic Acid (mg/d) 1.7 1.8 2 3 4 5 4 5
need for increased
generalized
phosphorus
weight � ideal weight], where 25% represents cause dialytic protein concentrations can be mea-
Lentils 20 12 protein
content dietary
and protein supply.
catabolism through
bioavailability of Be-
the general-
protein
is present (R 6.2). Biotin (�g/d) 5 6 8 12 20 25 20 25 theNuts
percentage of body fat 25 15
tissue that is metaboli- sources,
ized the quality
protein of protein,
degradation and thefrom
resulting metabolic
cytokine
Milk 29 21 sured easily, consideration
environment are important should be factors
additional given toto
Copper (�g/d) 200 220 340 440 700 890 700 890 cally active) rather than their actual body release
regular
induced
monitoring
by exposure
of peritoneal
to bioincompatible
protein excre-
It is suggested that children with CKD stage 5D receive a water-soluble vitamin supplement, with 20 30 40 55 40 55
Seeds 50 29
consider
membranes in the (indietary
HD) protein
or prescription.
dialysis
Selenium (�g/d) 15 20 of fluids (in PD) has
259
weight.
Note: Note: This estimations
Mathematical formula is based
based onprotein
physiologi-
on protein tion and individual adaptation the dietary
the exception of children with healthy appetites for a variety of nutritious foods and children Zinc (mg/d) 2 3 3 5 8 11 8 9
Mathematical
cal ibility-corrected
theory rather
estimations
aminothan
digestibility-corrected amino
based
scientific
acid scores
acid scores
on
evidence.
(PDCAA)
(PDCAA)
digest-
and data onIn
and data protein prescription according to actual by
not been universally confirmed metabolic
perito-
receiving most or all of their energy requirements from adult renal formulas (R 6.3). Note: RDAs are in bold type; Als are in ordinary type. *As preformed niacin, not niacin equivalents (NE) for this age group. on estimated
young phosphorus
children
estimated (ie,bioavailability.
phosphorus age �3 years) or stunted neal
bioavailability. studies.
losses. Net protein “catabolism” seems to be
©1998, Vegetarian Diets in Renal Disease article in Amino
Source: Health Canada: http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. Reprinted children
Nutrition(ie, length-
Update, or height-for-age
Vegetarian � �1.88
Nutrition DPG Newsletter;
limitedacid to and the protein
dialyticlosses duringof
removal HDamino
vary acids
with the permission of the Minister of Public Works and Government Services, Canada, 2008. SDS),
DPG,protein requirements
a dietetic practice initiallyDietetic
group of American shouldAsso-be
according
and/or to dialyzer
protein and membrane
a slightly characteristics
reduced protein
*As preformed niacin, not niacin equivalents (NE) for this age group. chronological age, but may andsynthesis reuse. Losses duringhave HDnot been quantified
sessions. Whole-body in pro-
291
estimated by with
ciation. Used using
permission.
children. In adults, an average of 8 to
26010 g of
 Intake (mg/d) Age Calcium (mmol/L) (mg/dL) (mg/dL)
absorption: increased consumption of calcium-
hild- High PTH and High PTH and
rich and/or calcium-fortified foods or tube feed- 0-5 mo 1.22-1.40 8.7-11.3 5.2-8.4
t, in- Bone
ings, Health with calcium-containing
supplementation
Normal High
Fluid
6-12 mo and1.20-1.40
Electrolyte Requirements
8.7-11.0 5.0-7.8

Nutritional
Age DRI (mg/d) Phosphorus* Phosphorus†
bone pharmacological agents between meals or bolus 1-5 y 1.22-1.32 9.4-10.8 4.5-6.5
and 0-6 mo 100 6-12 y 1.15-1.32 9.4-10.3 3.6-5.8
tube feedings, use of calcium-containing phos-
Calcium Phosphorus
�100 �80
Fluids Abbreviations:
7-12 mo 275 13-20 y and electrolyte
Fluid 1.12-1.30 8.8-10.2
requirements of individual2.3-4.5
children vary according to their primary kidney-
may phorus binders
calciumfor managing hyperphosphatemia, �275 �220
ACEI Angiotensin-converting enzyme inhibitor

Management
Insufficient supply may cause deficient mineralization of the skeleton. Evidence suggests that moderate dietary phosphate restriction is beneficial with respect to the
cium 1-3 y 460 �460 �370 disease,
Adapted degree
with of residual
permission 121 kidney function,
; Specker.524 and method of kidney replacement therapy. Restrict fluid intake in children with CKD stages 3 to 5 and 5D who are oligoanuric to prevent AMDR Acceptable macronutrient distribution ranges
and supplementation
Calcium with vitamin
overload may be associated with D.
severe vascular morbidity and prevention and treatment of hyperparathyroidism and safe with respect to growth, nutrition,
with soft-tissue calcifications. 4-8 y 500 �500 �400
and bone mineralization. The dietary prescription should aim at minimizing phosphate intake Conversion factor for calcium and ionized calcium: mg/dL � the complications of fluid overload (R 8.4). ARB Angiotensin-receptor blocker
If spontaneous intestinal calcium absorption is 9-18 y 1,250
while ensuring an adequate protein intake. �1,250 �1,000 0.25 � mmol/L. – Concurrent fluid and sodium restriction is needed to overcome thirst. BMI Body mass index
itriol low, as typically observed in early stages of Recommendations
Conversion factor forforphosphorus:
Children With CKD Stages
mg/dL 2 to�5 and 5D:
� 0.323 CDC Centers for Disease Control and Prevention
de- Recommendations
CKD, vitamin forDChildren shouldWith
be CKD Stages 2 to 5 and
supplemented to 5D: Multiple pitfalls, including the physicalSource: Health Canada:
and psychological http://www.hc-sc.gc.ca/fn-an/
challenge of the phosphate binder pill mmol/L. Daily fluid restriction = insensible fluid losses + urine output + amount to replace additional CHD Coronary heart disease
in D It augment
is suggested the total
plasma oral and/or
1,25(OH) D enteral calcium
synthesis and intake from nutritional sources
maxi- burden, inadvertent consumption of food containing phosphate additives, and nonadherenceRe-
alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. in Sodium losses (eg, vomiting, diarrhea, enterostomy output) - amount to be deficited CKD Chronic kidney disease
and phosphate binders be in the2range of 100%–200% of the DRI for calcium for older children and adolescents, mayproduced with the lowering
result in inefficient permission of thephosphorus
of serum Minister oflevels.
Public D Dialysis
ently mize calcium absorption.
Children
age (R 7.1.1). Works and Government Services Canada, 2008. Consider supplemental free water and sodium supplements for children with CKD and polyuria
Insensible Fluid Losses DRI Dietary reference intake
hom If plasma calcium levels and urinary calcium Conversely, overrestriction may lead to*�
signs
100%of phosphate
of the DRI.deficiency, particularly in dation 5). Most
to avoid chronicfood sourcesdepletion
intravascular exhibitand good phos- optimal growth (R 8.1).
to promote DV Daily value
d and To avoid the critical accumulation of calcium, oligoanuric children on dialysis young infants. Age Group Fluid Loss
excretion
therapy remaina further
may require low and dietary
reduction assessment
in total oral and enteral calcium intake †� 80% of the DRI. phate– Infants and children with obstructive uropathy plant
bioavailability with the exception of or renal dysplasia have polyuria, polydypsia, EER Estimated energy requirement
The
cium
suggests inadequate calcium intake,
from nutritional sources and phosphate binders.
tion of foods with high endogenous calcium
consump-
greater than the target normal range for age
seeds difficulty
(beans, conserving
phosphate
peas, cereals,
in phytic acid.
supplementation.
sodium and nuts)and
chloride thatdevelop
contain a salt-wasting state, requiring salt
Preterm infants
Neonates
Children and adolescents
40 mL/kg/d
20–30 mL/kg/d
20 mL/kg/d or 400 mL/m2
HD
IDPN
nPCR
Hemodialysis
Intradialytic parenteral nutrition
Normalized protein catabolic rate
With Chronic
dren Recommendations for Children With CKD Stages 2 to 5 and 5D:
Kidney Disease
Consider reducing dietary phosphorus (Table
intake 25) andof hyperparathyroidism
to 100% the DRI for age (R 7.3.1): is already
Milk and dairy products are a major source of NSAID Nonsteroidal anti-inflammatory drugs
Cal- Recommended Calcium Intake for Children Consider sodium supplements
Table 20. Recommended Calcium Intake for Children
With CKD Stages 2 to 5 and 5D Methods to improve low oral – When the serum PTH concentration established, phosphorus
is above the target range forrestriction
CKD stage, and to approxi- dietary phosphorus. In youngforinfants all infantswithon PDCKD,therapy (R 8.2). PAL Physical activity level
se of PD Peritoneal dialysis
with CKD Stages 2 to 5 and 5D
and/or enteral calcium intake – When the serum phosphorus concentration
mately 80% is within
of thethe DRI
normalisreference range for age
recommended. phosphorus control can be achieved easily by sodium losses, even when anuric,
– Infants on PD therapy are predisposed to substantial Potassium PTH Parathyroid hormone Stages 2 to 5 and 5D
H)2D. and absorption include: using because
formulas ultrafiltration
with a low removes significant
phosphorus amountsItof sodium chloride that cannot be
content.
Upper Limit Upper Limit for CKD Stages Consider reducing dietary phosphorus intake
Higher to 80% of the DRI forserum
physiological age (R 7.3.2):
concentrations of Limit potassium intake for children with CKD who have or are at risk of hyperkalemia (R 8.5). R Recommendation
y be replaced throughand breast milk or standard
(for healthy 2-5, 5D (Dietary �
• Increased consumption – When the serum PTH concentration is aboveand
calcium the target range forare
phosphorus CKDobserved
stage, andin healthy usually is feasible, common clinical commercial
practice, infant formulas. – The nutrition facts panel on food labels is not required to list potassium, but may provide rhGH Recombinant human growth hormone
Age DRI children) Phosphate Binders*) of calcum-rich and/or cal- – When the serum phosphorus concentration exceeds the normal reference range for age SDS Standard deviation score
cium-fortified foods or tube infants and young children, presumably reflect- to continue oral and/or enteral
Restrict sodium intake for children with CKD who use of a low-
have hypertension (systolic and/or diastolic potassium content as actual amount (mg) and % DV:
UL Tolerable upper intake level
ctive – Foods low in potassium: <100 mg or <3% DV
feedings After initiation of dietary phosphorus restriction, monitor the serum phosphorus concentration phosphorus
blood formula
pressure and delay
percentile) orthe introduction
prehypertension (systolic and/or distolic blood pressure WHO World Health Organization
idol) 0-6 mo 210 ND �420
(R 7.3.3):
ing the increased requirements of these minerals ≥95th
7-12 mo 270 ND • Supplementation with calcium of phosphorus-rich cow’s milk until the age of 18 – Foods high in potassium: >200 to 250 mg or >6% DV
– At least every 3 months in childrenby theCKD
rapidly
stages growing skeleton. Rickets due to percentile and <95th percentile)
�540 (R 8.3).
Oral containing pharmacological with 3 to 4 ≥90th
1-3 y 500 2,500 to 36– months.
�1,000
ning 4-8 y 800 2,500 agents between meals or – Monthly in children with CKD stages phosphorus
5 and 5D deficiency occurs in preterm infants Severe hypertension increases risk of hypertensive encephalopathy, seizures,
Children can lower potassium intake by restricting foods such as bananas, oranges, potatoes,
Reference:
�1,600 Bone Mineral and Vitamin D Requirements and Therapy Dietary phosphateevents, restriction canheart S67
be hindered National Kidney Foundation. KDOQI clinical practice guideline for nutrition in children with
lysis 9-18 y 1,300 2,500 �2,500 bolus tube feedings fed insufficient
In all CKD stages, it is suggested to avoid serum phosphorus amounts of phosphorus
concentrations both aboveand and in cerebrovascular congestive failure, and progression of CKD. potato chips, tomato products, legumes, lentils, yogurt, and chocolate, and by avoiding CKD: 2008 update. Am J Kidney Dis. 2009:53(suppl 2);S1-S124.
ntent • Use of calcium-containing below the normal reference range for age (R and
infants 7.3.3). by the inadvertent consumption ofhasfood contain-
Abbreviation: ND, not determined. phosphorus binders for Table 23. children
Recommended with hypophosphatemia
Maximum Oral and/or due – Modest
Table dietary sodium
25. Age-Specific Normalrestriction
Ranges ofbeen
Blood demonstrated to reduce blood pressure in potassum-containing salt substitutes.
Notice:
asing Abbreviation: ND, not determined.
*Determined as 200% of the DRI, to a maximum of 2,500 to Enteral
inherited disorders of renal phosphate
Phosphorus Intake for Children With CKD trans- ing phosphate
hypertensiveadditives,
children which
without
Ionized Calcium, Total Calcium and Phosphorus
can
CKD. increase phos-
*Determined as 200% of the DRI, to a maximum of managing hyperphosphatemia SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE
posi- mg elemental calcium. port. 426
Hence, when dietary phosphorus is re- phorus
– Inintake
dialysisup to 2-fold
patients, compared
restricting sodiumwith intake unproc-
is essential to volume and blood
2,500 mg elemental calcium. • Supplementation with Children on PD or frequent HD therapy (ie, >5 sessions/wk) rarely need dietary potassium This Clinical Practice Guideline document is based upon the best information available at the
vitamin D stricted to control hyperphosphatemia
Recommended Recommended Phosphorus
Maximum Oral and/or and sec- essed foods.
pressure
This
Ionized
control.
is a particular
Calcium problem
Phosphorus in
time of publication. It is designed to provide information and assist decision-making. It is not
Intake (mg/d) Age Calcium (mmol/L) (mg/dL) restriction and may actually develop hypokalemia.
Suppl 2 (March), 2009: pp S61-S69 S61 ondary Enteral Phosphorus Intake for Children
hyperparathyroidism With CKDwith
in children patients with CKD who rely heavily (mg/dL) on pro- intended to define a standard of care and should not be construed as one, nor should
Age-Specific Normal 427,428
CKD, subnormal serum phosphorus
High PTH and High PTH and
values should cessed
0-5 mo foods. 1.22-1.40 8.7-11.3 5.2-8.4 it be interpreted as prescribing an exclusive course of management. Variations in practice will
Ranges of Serum Phosphorus Normal High Tips to reduce
6-12Unfortunately,
mo sodium
1.20-1.40 mostintake include:
available
8.7-11.0nutrient 5.0-7.8data- inevitably and appropriately occur when clinicians take into account the needs of individual
Vitamin D be Age
avoidedDRI (Table
(mg/d)25). Phosphorus* Phosphorus† Non-dietary causes of hyperkalemia:
Age Serum Phosphorus 1-5 y – Consuming fresh foods
1.22-1.32 instead of processed
9.4-10.8 and on
4.5-6.5 canned foods patients, available resources, and limitations unique to an institution or a type of practice.
Recent clinical evidence suggests a high prevalence of vitamin D insufficiency in children The dietary prescription should aim at minimiz- bases do not consider the impact of additives – Hemolysis
with CKD. 6-12 y– Reading 1.15-1.32 9.4-10.3 3.6-5.8 Every health care professional making use of these recommendations is responsible for
(mg/dL) 0-6 mo 100 �100 �80 total phosphorus food labels to identify
content of 8.8-10.2 those foods
foods. An exception containing no more than 170–280 mg of sodium, – Metabolic acidosis
ing phosphate 275
7-12 mo
intake while ensuring an adequate 13-20 y 1.12-1.30 2.3-4.5 evaluating the appropriateness of applying them in the setting of any particular
Reasons for the high prevalence of low vitamin D levels in patients with CKD include: �275 �220 or 6%–10%
is the USDA National of the sodium DV
Nutrient Database for – Constipation
0–5 mo 5.2–8.4 protein
1-3 y intake. 460To achieve �460 this aim,�370 protein clinical situation.
– Sedentary lifestyle with reduced exposure to sunlight Adapted with permission121; Specker.524 – Medications (ie, ACEIs, ARBs, NSAIDs and potassium-sparing diuretics)
6–12 mo 5.0–7.8 sources
4-8 y with 500 low specific �500phosphorus�400 content Standard
– Reference,
Reducing salt added which
to foods; lists more substituting
in cooking,
Conversion factor for calcium and ionized calcium: mg/dL �
than 60 fresh herbs and spices to flavor foods
– Limited ingestion of foods rich in vitamin D – Tissue destruction due to catabolism, infection, surgery, or chemotherapy SECTION II: DISCLOSURE
– Reduced endogenous synthesis of vitamin D3 in the skin of patients with uremia 9-18 y 1,250
should be prescribed (see Table 13, Recommen-
�1,250 �1,000 phosphate-containing
– Minimizing
0.25 � mmol/L. intake of food
fast additives
foods (www.ars. – Inadequate dialysis
1–5 y 4.5–6.5 The National Kidney Foundation (NKF) makes every effort to avoid any actual or reasonably
– Urinary losses of 25(OH)D and vitamin D–binding protein in nephrotic patients ≤100% ofHealth
*Source: the DRI Canada:
†
≤80% ofhttp://www.hc-sc.gc.ca/fn-an/
the DRI usda.gov/Main/site_main.htm?modecode�12-
Conversion factor for phosphorus: mg/dL � 0.323 �
perceived conflicts of interest that may arise as a result of an outside relationship or a person-
6–12 y 3.6–5.8 alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. Re- mmol/L.
35-45-00; last accessed October 23, 2008).
Measure serum 25-hydroxyvitamin D levels once per year in children with CKD (R 7.2.1). Table 24. Target Range of Serum PTH by Stage al, professional, or business interest of a member of the Work Group. All members of the Work
produced with the permission
Target Range of Serum of the Minister
PTH by Stage of CKD of Public The aspects mentioned illustrate that dietary Group are required to complete, sign, and submit a disclosure and attestation form showing all
Supplementation with vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol) is 13–20 y 2.3–4.5 of CKD
Works and Government Services Canada, 2008. such relationships that might be perceived as actual conflicts of interest.
suggested if the serum level of 25-hydroxyvitamin D is less than 30 ng/mL (75 nmol/L) *� 100% of the DRI.
modification
dation 5). Mostoffood phosphorus
sources exhibit intake good is a complex
phos-
(R 7.2.2). Conversion factor for †� 80% of the DRI.
GFR Range Target Serum and
phate challenging
bioavailability task.withMultiple
the pitfalls,
exception ofincluding
plant
CKD Stage (mL/min/1.73m2) PTH (pg/mL)
In the repletion phase, it is suggested that serum levels of corrected total calcium and phosphorus: nonadherence
seeds (beans, peas, in older
cereals, children
and nuts) andthat adolescents,
contain
phosphorus be measured at 1 month following initiation or change in dose of vitamin D mg/dL x 0.323 = mmol/L 3greater than the target 30-59normal range for 35-70 may resultinin
phosphate inefficient
phytic acid. lowering of phosphorus
and at least every 3 months thereafter (R 7.2.3). age
4 15-29
(Table 25) and hyperparathyroidism is already 70-110 intake; conversely,
Milk and dairy products overrestriction
are a majormay source leadof to 30 East 33rd Street • New York, NY 10016 Based on the KDOQI Clinical Practice
800.622.9010 • 212.889.2210 • www.kidney.org
When patients are replete with vitamin D, it is suggested to supplement vitamin D 5, 5D �15 200-300 signs phosphorus.
dietary of phosphate deficiency,
In young infantsparticularly
with CKD, in Guideline for Nutrition in Children
continuously and to monitor serum levels of 25-hydroxyvitamin D yearly (R 7.2.4). established, phosphorus restriction to approxi-
Reprinted with permission. 121
phosphorus
young control
infants. Hence, can be achieved
involvement ofeasily by
an experi- With CKD: 2008 Update
mately 80% of the DRI is recommended.
Higher physiological serum concentrations of using formulas with a low phosphorus content. It ©2009 National Kidney Foundation, Inc. All rights reserved. 02-10-978A_JAJ

calcium and phosphorus are observed in healthy usually is feasible, and common clinical practice,
 Intake (mg/d) Age Calcium (mmol/L) (mg/dL) (mg/dL)
absorption: increased consumption of calcium-
hild- High PTH and High PTH and
rich and/or calcium-fortified foods or tube feed- 0-5 mo 1.22-1.40 8.7-11.3 5.2-8.4
t, in- Bone
ings, Health with calcium-containing
supplementation
Normal High
Fluid
6-12 mo and1.20-1.40
Electrolyte Requirements
8.7-11.0 5.0-7.8

Nutritional
Age DRI (mg/d) Phosphorus* Phosphorus†
bone pharmacological agents between meals or bolus 1-5 y 1.22-1.32 9.4-10.8 4.5-6.5
and 0-6 mo 100 6-12 y 1.15-1.32 9.4-10.3 3.6-5.8
tube feedings, use of calcium-containing phos-
Calcium Phosphorus
�100 �80
Fluids Abbreviations:
7-12 mo 275 13-20 y and electrolyte
Fluid 1.12-1.30 8.8-10.2
requirements of individual2.3-4.5
children vary according to their primary kidney-
may phorus binders
calciumfor managing hyperphosphatemia, �275 �220
ACEI Angiotensin-converting enzyme inhibitor

Management
Insufficient supply may cause deficient mineralization of the skeleton. Evidence suggests that moderate dietary phosphate restriction is beneficial with respect to the
cium 1-3 y 460 �460 �370 disease,
Adapted degree
with of residual
permission 121 kidney function,
; Specker.524 and method of kidney replacement therapy. Restrict fluid intake in children with CKD stages 3 to 5 and 5D who are oligoanuric to prevent AMDR Acceptable macronutrient distribution ranges
and supplementation
Calcium with vitamin
overload may be associated with D.
severe vascular morbidity and prevention and treatment of hyperparathyroidism and safe with respect to growth, nutrition,
with soft-tissue calcifications. 4-8 y 500 �500 �400
and bone mineralization. The dietary prescription should aim at minimizing phosphate intake Conversion factor for calcium and ionized calcium: mg/dL � the complications of fluid overload (R 8.4). ARB Angiotensin-receptor blocker
If spontaneous intestinal calcium absorption is 9-18 y 1,250
while ensuring an adequate protein intake. �1,250 �1,000 0.25 � mmol/L. – Concurrent fluid and sodium restriction is needed to overcome thirst. BMI Body mass index
itriol low, as typically observed in early stages of Recommendations
Conversion factor forforphosphorus:
Children With CKD Stages
mg/dL 2 to�5 and 5D:
� 0.323 CDC Centers for Disease Control and Prevention
de- Recommendations
CKD, vitamin forDChildren shouldWith
be CKD Stages 2 to 5 and
supplemented to 5D: Multiple pitfalls, including the physicalSource: Health Canada:
and psychological http://www.hc-sc.gc.ca/fn-an/
challenge of the phosphate binder pill mmol/L. Daily fluid restriction = insensible fluid losses + urine output + amount to replace additional CHD Coronary heart disease
in D It augment
is suggested the total
plasma oral and/or
1,25(OH) D enteral calcium
synthesis and intake from nutritional sources
maxi- burden, inadvertent consumption of food containing phosphate additives, and nonadherenceRe-
alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. in Sodium losses (eg, vomiting, diarrhea, enterostomy output) - amount to be deficited CKD Chronic kidney disease
and phosphate binders be in the2range of 100%–200% of the DRI for calcium for older children and adolescents, mayproduced with the lowering
result in inefficient permission of thephosphorus
of serum Minister oflevels.
Public D Dialysis
ently mize calcium absorption.
Children
age (R 7.1.1). Works and Government Services Canada, 2008. Consider supplemental free water and sodium supplements for children with CKD and polyuria
Insensible Fluid Losses DRI Dietary reference intake
hom If plasma calcium levels and urinary calcium Conversely, overrestriction may lead to*�
signs
100%of phosphate
of the DRI.deficiency, particularly in dation 5). Most
to avoid chronicfood sourcesdepletion
intravascular exhibitand good phos- optimal growth (R 8.1).
to promote DV Daily value
d and To avoid the critical accumulation of calcium, oligoanuric children on dialysis young infants. Age Group Fluid Loss
excretion
therapy remaina further
may require low and dietary
reduction assessment
in total oral and enteral calcium intake †� 80% of the DRI. phate– Infants and children with obstructive uropathy plant
bioavailability with the exception of or renal dysplasia have polyuria, polydypsia, EER Estimated energy requirement
The
cium
suggests inadequate calcium intake,
from nutritional sources and phosphate binders.
tion of foods with high endogenous calcium
consump-
greater than the target normal range for age
seeds difficulty
(beans, conserving
phosphate
peas, cereals,
in phytic acid.
supplementation.
sodium and nuts)and
chloride thatdevelop
contain a salt-wasting state, requiring salt
Preterm infants
Neonates
Children and adolescents
40 mL/kg/d
20–30 mL/kg/d
20 mL/kg/d or 400 mL/m2
HD
IDPN
nPCR
Hemodialysis
Intradialytic parenteral nutrition
Normalized protein catabolic rate
With Chronic
dren Recommendations for Children With CKD Stages 2 to 5 and 5D:
Kidney Disease
Consider reducing dietary phosphorus (Table
intake 25) andof hyperparathyroidism
to 100% the DRI for age (R 7.3.1): is already
Milk and dairy products are a major source of NSAID Nonsteroidal anti-inflammatory drugs
Cal- Recommended Calcium Intake for Children Consider sodium supplements
Table 20. Recommended Calcium Intake for Children
With CKD Stages 2 to 5 and 5D Methods to improve low oral – When the serum PTH concentration established, phosphorus
is above the target range forrestriction
CKD stage, and to approxi- dietary phosphorus. In youngforinfants all infantswithon PDCKD,therapy (R 8.2). PAL Physical activity level
se of PD Peritoneal dialysis
with CKD Stages 2 to 5 and 5D
and/or enteral calcium intake – When the serum phosphorus concentration
mately 80% is within
of thethe DRI
normalisreference range for age
recommended. phosphorus control can be achieved easily by sodium losses, even when anuric,
– Infants on PD therapy are predisposed to substantial Potassium PTH Parathyroid hormone Stages 2 to 5 and 5D
H)2D. and absorption include: using because
formulas ultrafiltration
with a low removes significant
phosphorus amountsItof sodium chloride that cannot be
content.
Upper Limit Upper Limit for CKD Stages Consider reducing dietary phosphorus intake
Higher to 80% of the DRI forserum
physiological age (R 7.3.2):
concentrations of Limit potassium intake for children with CKD who have or are at risk of hyperkalemia (R 8.5). R Recommendation
y be replaced throughand breast milk or standard
(for healthy 2-5, 5D (Dietary �
• Increased consumption – When the serum PTH concentration is aboveand
calcium the target range forare
phosphorus CKDobserved
stage, andin healthy usually is feasible, common clinical commercial
practice, infant formulas. – The nutrition facts panel on food labels is not required to list potassium, but may provide rhGH Recombinant human growth hormone
Age DRI children) Phosphate Binders*) of calcum-rich and/or cal- – When the serum phosphorus concentration exceeds the normal reference range for age SDS Standard deviation score
cium-fortified foods or tube infants and young children, presumably reflect- to continue oral and/or enteral
Restrict sodium intake for children with CKD who use of a low-
have hypertension (systolic and/or diastolic potassium content as actual amount (mg) and % DV:
UL Tolerable upper intake level
ctive – Foods low in potassium: <100 mg or <3% DV
feedings After initiation of dietary phosphorus restriction, monitor the serum phosphorus concentration phosphorus
blood formula
pressure and delay
percentile) orthe introduction
prehypertension (systolic and/or distolic blood pressure WHO World Health Organization
idol) 0-6 mo 210 ND �420
(R 7.3.3):
ing the increased requirements of these minerals ≥95th
7-12 mo 270 ND • Supplementation with calcium of phosphorus-rich cow’s milk until the age of 18 – Foods high in potassium: >200 to 250 mg or >6% DV
– At least every 3 months in childrenby theCKD
rapidly
stages growing skeleton. Rickets due to percentile and <95th percentile)
�540 (R 8.3).
Oral containing pharmacological with 3 to 4 ≥90th
1-3 y 500 2,500 to 36– months.
�1,000
ning 4-8 y 800 2,500 agents between meals or – Monthly in children with CKD stages phosphorus
5 and 5D deficiency occurs in preterm infants Severe hypertension increases risk of hypertensive encephalopathy, seizures,
Children can lower potassium intake by restricting foods such as bananas, oranges, potatoes,
Reference:
�1,600 Bone Mineral and Vitamin D Requirements and Therapy Dietary phosphateevents, restriction canheart S67
be hindered National Kidney Foundation. KDOQI clinical practice guideline for nutrition in children with
lysis 9-18 y 1,300 2,500 �2,500 bolus tube feedings fed insufficient
In all CKD stages, it is suggested to avoid serum phosphorus amounts of phosphorus
concentrations both aboveand and in cerebrovascular congestive failure, and progression of CKD. potato chips, tomato products, legumes, lentils, yogurt, and chocolate, and by avoiding CKD: 2008 update. Am J Kidney Dis. 2009:53(suppl 2);S1-S124.
ntent • Use of calcium-containing below the normal reference range for age (R and
infants 7.3.3). by the inadvertent consumption ofhasfood contain-
Abbreviation: ND, not determined. phosphorus binders for Table 23. children
Recommended with hypophosphatemia
Maximum Oral and/or due – Modest
Table dietary sodium
25. Age-Specific Normalrestriction
Ranges ofbeen
Blood demonstrated to reduce blood pressure in potassum-containing salt substitutes.
Notice:
asing Abbreviation: ND, not determined.
*Determined as 200% of the DRI, to a maximum of 2,500 to Enteral
inherited disorders of renal phosphate
Phosphorus Intake for Children With CKD trans- ing phosphate
hypertensiveadditives,
children which
without
Ionized Calcium, Total Calcium and Phosphorus
can
CKD. increase phos-
*Determined as 200% of the DRI, to a maximum of managing hyperphosphatemia SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE
posi- mg elemental calcium. port. 426
Hence, when dietary phosphorus is re- phorus
– Inintake
dialysisup to 2-fold
patients, compared
restricting sodiumwith intake unproc-
is essential to volume and blood
2,500 mg elemental calcium. • Supplementation with Children on PD or frequent HD therapy (ie, >5 sessions/wk) rarely need dietary potassium This Clinical Practice Guideline document is based upon the best information available at the
vitamin D stricted to control hyperphosphatemia
Recommended Recommended Phosphorus
Maximum Oral and/or and sec- essed foods.
pressure
This
Ionized
control.
is a particular
Calcium problem
Phosphorus in
time of publication. It is designed to provide information and assist decision-making. It is not
Intake (mg/d) Age Calcium (mmol/L) (mg/dL) restriction and may actually develop hypokalemia.
Suppl 2 (March), 2009: pp S61-S69 S61 ondary Enteral Phosphorus Intake for Children
hyperparathyroidism With CKDwith
in children patients with CKD who rely heavily (mg/dL) on pro- intended to define a standard of care and should not be construed as one, nor should
Age-Specific Normal 427,428
CKD, subnormal serum phosphorus
High PTH and High PTH and
values should cessed
0-5 mo foods. 1.22-1.40 8.7-11.3 5.2-8.4 it be interpreted as prescribing an exclusive course of management. Variations in practice will
Ranges of Serum Phosphorus Normal High Tips to reduce
6-12Unfortunately,
mo sodium
1.20-1.40 mostintake include:
available
8.7-11.0nutrient 5.0-7.8data- inevitably and appropriately occur when clinicians take into account the needs of individual
Vitamin D be Age
avoidedDRI (Table
(mg/d)25). Phosphorus* Phosphorus† Non-dietary causes of hyperkalemia:
Age Serum Phosphorus 1-5 y – Consuming fresh foods
1.22-1.32 instead of processed
9.4-10.8 and on
4.5-6.5 canned foods patients, available resources, and limitations unique to an institution or a type of practice.
Recent clinical evidence suggests a high prevalence of vitamin D insufficiency in children The dietary prescription should aim at minimiz- bases do not consider the impact of additives – Hemolysis
with CKD. 6-12 y– Reading 1.15-1.32 9.4-10.3 3.6-5.8 Every health care professional making use of these recommendations is responsible for
(mg/dL) 0-6 mo 100 �100 �80 total phosphorus food labels to identify
content of 8.8-10.2 those foods
foods. An exception containing no more than 170–280 mg of sodium, – Metabolic acidosis
ing phosphate 275
7-12 mo
intake while ensuring an adequate 13-20 y 1.12-1.30 2.3-4.5 evaluating the appropriateness of applying them in the setting of any particular
Reasons for the high prevalence of low vitamin D levels in patients with CKD include: �275 �220 or 6%–10%
is the USDA National of the sodium DV
Nutrient Database for – Constipation
0–5 mo 5.2–8.4 protein
1-3 y intake. 460To achieve �460 this aim,�370 protein clinical situation.
– Sedentary lifestyle with reduced exposure to sunlight Adapted with permission121; Specker.524 – Medications (ie, ACEIs, ARBs, NSAIDs and potassium-sparing diuretics)
6–12 mo 5.0–7.8 sources
4-8 y with 500 low specific �500phosphorus�400 content Standard
– Reference,
Reducing salt added which
to foods; lists more substituting
in cooking,
Conversion factor for calcium and ionized calcium: mg/dL �
than 60 fresh herbs and spices to flavor foods
– Limited ingestion of foods rich in vitamin D – Tissue destruction due to catabolism, infection, surgery, or chemotherapy SECTION II: DISCLOSURE
– Reduced endogenous synthesis of vitamin D3 in the skin of patients with uremia 9-18 y 1,250
should be prescribed (see Table 13, Recommen-
�1,250 �1,000 phosphate-containing
– Minimizing
0.25 � mmol/L. intake of food
fast additives
foods (www.ars. – Inadequate dialysis
1–5 y 4.5–6.5 The National Kidney Foundation (NKF) makes every effort to avoid any actual or reasonably
– Urinary losses of 25(OH)D and vitamin D–binding protein in nephrotic patients ≤100% ofHealth
*Source: the DRI Canada:
†
≤80% ofhttp://www.hc-sc.gc.ca/fn-an/
the DRI usda.gov/Main/site_main.htm?modecode�12-
Conversion factor for phosphorus: mg/dL � 0.323 �
perceived conflicts of interest that may arise as a result of an outside relationship or a person-
6–12 y 3.6–5.8 alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. Re- mmol/L.
35-45-00; last accessed October 23, 2008).
Measure serum 25-hydroxyvitamin D levels once per year in children with CKD (R 7.2.1). Table 24. Target Range of Serum PTH by Stage al, professional, or business interest of a member of the Work Group. All members of the Work
produced with the permission
Target Range of Serum of the Minister
PTH by Stage of CKD of Public The aspects mentioned illustrate that dietary Group are required to complete, sign, and submit a disclosure and attestation form showing all
Supplementation with vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol) is 13–20 y 2.3–4.5 of CKD
Works and Government Services Canada, 2008. such relationships that might be perceived as actual conflicts of interest.
suggested if the serum level of 25-hydroxyvitamin D is less than 30 ng/mL (75 nmol/L) *� 100% of the DRI.
modification
dation 5). Mostoffood phosphorus
sources exhibit intake good is a complex
phos-
(R 7.2.2). Conversion factor for †� 80% of the DRI.
GFR Range Target Serum and
phate challenging
bioavailability task.withMultiple
the pitfalls,
exception ofincluding
plant
CKD Stage (mL/min/1.73m2) PTH (pg/mL)
In the repletion phase, it is suggested that serum levels of corrected total calcium and phosphorus: nonadherence
seeds (beans, peas, in older
cereals, children
and nuts) andthat adolescents,
contain
phosphorus be measured at 1 month following initiation or change in dose of vitamin D mg/dL x 0.323 = mmol/L 3greater than the target 30-59normal range for 35-70 may resultinin
phosphate inefficient
phytic acid. lowering of phosphorus
and at least every 3 months thereafter (R 7.2.3). age
4 15-29
(Table 25) and hyperparathyroidism is already 70-110 intake; conversely,
Milk and dairy products overrestriction
are a majormay source leadof to 30 East 33rd Street • New York, NY 10016 Based on the KDOQI Clinical Practice
800.622.9010 • 212.889.2210 • www.kidney.org
When patients are replete with vitamin D, it is suggested to supplement vitamin D 5, 5D �15 200-300 signs phosphorus.
dietary of phosphate deficiency,
In young infantsparticularly
with CKD, in Guideline for Nutrition in Children
continuously and to monitor serum levels of 25-hydroxyvitamin D yearly (R 7.2.4). established, phosphorus restriction to approxi-
Reprinted with permission. 121
phosphorus
young control
infants. Hence, can be achieved
involvement ofeasily by
an experi- With CKD: 2008 Update
mately 80% of the DRI is recommended.
Higher physiological serum concentrations of using formulas with a low phosphorus content. It ©2009 National Kidney Foundation, Inc. All rights reserved. 02-10-978A_JAJ

calcium and phosphorus are observed in healthy usually is feasible, and common clinical practice,
 Intake (mg/d) Age Calcium (mmol/L) (mg/dL) (mg/dL)
absorption: increased consumption of calcium-
hild- High PTH and High PTH and
rich and/or calcium-fortified foods or tube feed- 0-5 mo 1.22-1.40 8.7-11.3 5.2-8.4
t, in- Bone
ings, Health with calcium-containing
supplementation
Normal High
Fluid
6-12 mo and1.20-1.40
Electrolyte Requirements
8.7-11.0 5.0-7.8

Nutritional
Age DRI (mg/d) Phosphorus* Phosphorus†
bone pharmacological agents between meals or bolus 1-5 y 1.22-1.32 9.4-10.8 4.5-6.5
and 0-6 mo 100 6-12 y 1.15-1.32 9.4-10.3 3.6-5.8
tube feedings, use of calcium-containing phos-
Calcium Phosphorus
�100 �80
Fluids Abbreviations:
7-12 mo 275 13-20 y and electrolyte
Fluid 1.12-1.30 8.8-10.2
requirements of individual2.3-4.5
children vary according to their primary kidney-
may phorus binders
calciumfor managing hyperphosphatemia, �275 �220
ACEI Angiotensin-converting enzyme inhibitor

Management
Insufficient supply may cause deficient mineralization of the skeleton. Evidence suggests that moderate dietary phosphate restriction is beneficial with respect to the
cium 1-3 y 460 �460 �370 disease,
Adapted degree
with of residual
permission 121 kidney function,
; Specker.524 and method of kidney replacement therapy. Restrict fluid intake in children with CKD stages 3 to 5 and 5D who are oligoanuric to prevent AMDR Acceptable macronutrient distribution ranges
and supplementation
Calcium with vitamin
overload may be associated with D.
severe vascular morbidity and prevention and treatment of hyperparathyroidism and safe with respect to growth, nutrition,
with soft-tissue calcifications. 4-8 y 500 �500 �400
and bone mineralization. The dietary prescription should aim at minimizing phosphate intake Conversion factor for calcium and ionized calcium: mg/dL � the complications of fluid overload (R 8.4). ARB Angiotensin-receptor blocker
If spontaneous intestinal calcium absorption is 9-18 y 1,250
while ensuring an adequate protein intake. �1,250 �1,000 0.25 � mmol/L. – Concurrent fluid and sodium restriction is needed to overcome thirst. BMI Body mass index
itriol low, as typically observed in early stages of Recommendations
Conversion factor forforphosphorus:
Children With CKD Stages
mg/dL 2 to�5 and 5D:
� 0.323 CDC Centers for Disease Control and Prevention
de- Recommendations
CKD, vitamin forDChildren shouldWith
be CKD Stages 2 to 5 and
supplemented to 5D: Multiple pitfalls, including the physicalSource: Health Canada:
and psychological http://www.hc-sc.gc.ca/fn-an/
challenge of the phosphate binder pill mmol/L. Daily fluid restriction = insensible fluid losses + urine output + amount to replace additional CHD Coronary heart disease
in D It augment
is suggested the total
plasma oral and/or
1,25(OH) D enteral calcium
synthesis and intake from nutritional sources
maxi- burden, inadvertent consumption of food containing phosphate additives, and nonadherenceRe-
alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. in Sodium losses (eg, vomiting, diarrhea, enterostomy output) - amount to be deficited CKD Chronic kidney disease
and phosphate binders be in the2range of 100%–200% of the DRI for calcium for older children and adolescents, mayproduced with the lowering
result in inefficient permission of thephosphorus
of serum Minister oflevels.
Public D Dialysis
ently mize calcium absorption.
Children
age (R 7.1.1). Works and Government Services Canada, 2008. Consider supplemental free water and sodium supplements for children with CKD and polyuria
Insensible Fluid Losses DRI Dietary reference intake
hom If plasma calcium levels and urinary calcium Conversely, overrestriction may lead to*�
signs
100%of phosphate
of the DRI.deficiency, particularly in dation 5). Most
to avoid chronicfood sourcesdepletion
intravascular exhibitand good phos- optimal growth (R 8.1).
to promote DV Daily value
d and To avoid the critical accumulation of calcium, oligoanuric children on dialysis young infants. Age Group Fluid Loss
excretion
therapy remaina further
may require low and dietary
reduction assessment
in total oral and enteral calcium intake †� 80% of the DRI. phate– Infants and children with obstructive uropathy plant
bioavailability with the exception of or renal dysplasia have polyuria, polydypsia, EER Estimated energy requirement
The
cium
suggests inadequate calcium intake,
from nutritional sources and phosphate binders.
tion of foods with high endogenous calcium
consump-
greater than the target normal range for age
seeds difficulty
(beans, conserving
phosphate
peas, cereals,
in phytic acid.
supplementation.
sodium and nuts)and
chloride thatdevelop
contain a salt-wasting state, requiring salt
Preterm infants
Neonates
Children and adolescents
40 mL/kg/d
20–30 mL/kg/d
20 mL/kg/d or 400 mL/m2
HD
IDPN
nPCR
Hemodialysis
Intradialytic parenteral nutrition
Normalized protein catabolic rate
With Chronic
dren Recommendations for Children With CKD Stages 2 to 5 and 5D:
Kidney Disease
Consider reducing dietary phosphorus (Table
intake 25) andof hyperparathyroidism
to 100% the DRI for age (R 7.3.1): is already
Milk and dairy products are a major source of NSAID Nonsteroidal anti-inflammatory drugs
Cal- Recommended Calcium Intake for Children Consider sodium supplements
Table 20. Recommended Calcium Intake for Children
With CKD Stages 2 to 5 and 5D Methods to improve low oral – When the serum PTH concentration established, phosphorus
is above the target range forrestriction
CKD stage, and to approxi- dietary phosphorus. In youngforinfants all infantswithon PDCKD,therapy (R 8.2). PAL Physical activity level
se of PD Peritoneal dialysis
with CKD Stages 2 to 5 and 5D
and/or enteral calcium intake – When the serum phosphorus concentration
mately 80% is within
of thethe DRI
normalisreference range for age
recommended. phosphorus control can be achieved easily by sodium losses, even when anuric,
– Infants on PD therapy are predisposed to substantial Potassium PTH Parathyroid hormone Stages 2 to 5 and 5D
H)2D. and absorption include: using because
formulas ultrafiltration
with a low removes significant
phosphorus amountsItof sodium chloride that cannot be
content.
Upper Limit Upper Limit for CKD Stages Consider reducing dietary phosphorus intake
Higher to 80% of the DRI forserum
physiological age (R 7.3.2):
concentrations of Limit potassium intake for children with CKD who have or are at risk of hyperkalemia (R 8.5). R Recommendation
y be replaced throughand breast milk or standard
(for healthy 2-5, 5D (Dietary �
• Increased consumption – When the serum PTH concentration is aboveand
calcium the target range forare
phosphorus CKDobserved
stage, andin healthy usually is feasible, common clinical commercial
practice, infant formulas. – The nutrition facts panel on food labels is not required to list potassium, but may provide rhGH Recombinant human growth hormone
Age DRI children) Phosphate Binders*) of calcum-rich and/or cal- – When the serum phosphorus concentration exceeds the normal reference range for age SDS Standard deviation score
cium-fortified foods or tube infants and young children, presumably reflect- to continue oral and/or enteral
Restrict sodium intake for children with CKD who use of a low-
have hypertension (systolic and/or diastolic potassium content as actual amount (mg) and % DV:
UL Tolerable upper intake level
ctive – Foods low in potassium: <100 mg or <3% DV
feedings After initiation of dietary phosphorus restriction, monitor the serum phosphorus concentration phosphorus
blood formula
pressure and delay
percentile) orthe introduction
prehypertension (systolic and/or distolic blood pressure WHO World Health Organization
idol) 0-6 mo 210 ND �420
(R 7.3.3):
ing the increased requirements of these minerals ≥95th
7-12 mo 270 ND • Supplementation with calcium of phosphorus-rich cow’s milk until the age of 18 – Foods high in potassium: >200 to 250 mg or >6% DV
– At least every 3 months in childrenby theCKD
rapidly
stages growing skeleton. Rickets due to percentile and <95th percentile)
�540 (R 8.3).
Oral containing pharmacological with 3 to 4 ≥90th
1-3 y 500 2,500 to 36– months.
�1,000
ning 4-8 y 800 2,500 agents between meals or – Monthly in children with CKD stages phosphorus
5 and 5D deficiency occurs in preterm infants Severe hypertension increases risk of hypertensive encephalopathy, seizures,
Children can lower potassium intake by restricting foods such as bananas, oranges, potatoes,
Reference:
�1,600 Bone Mineral and Vitamin D Requirements and Therapy Dietary phosphateevents, restriction canheart S67
be hindered National Kidney Foundation. KDOQI clinical practice guideline for nutrition in children with
lysis 9-18 y 1,300 2,500 �2,500 bolus tube feedings fed insufficient
In all CKD stages, it is suggested to avoid serum phosphorus amounts of phosphorus
concentrations both aboveand and in cerebrovascular congestive failure, and progression of CKD. potato chips, tomato products, legumes, lentils, yogurt, and chocolate, and by avoiding CKD: 2008 update. Am J Kidney Dis. 2009:53(suppl 2);S1-S124.
ntent • Use of calcium-containing below the normal reference range for age (R and
infants 7.3.3). by the inadvertent consumption ofhasfood contain-
Abbreviation: ND, not determined. phosphorus binders for Table 23. children
Recommended with hypophosphatemia
Maximum Oral and/or due – Modest
Table dietary sodium
25. Age-Specific Normalrestriction
Ranges ofbeen
Blood demonstrated to reduce blood pressure in potassum-containing salt substitutes.
Notice:
asing Abbreviation: ND, not determined.
*Determined as 200% of the DRI, to a maximum of 2,500 to Enteral
inherited disorders of renal phosphate
Phosphorus Intake for Children With CKD trans- ing phosphate
hypertensiveadditives,
children which
without
Ionized Calcium, Total Calcium and Phosphorus
can
CKD. increase phos-
*Determined as 200% of the DRI, to a maximum of managing hyperphosphatemia SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE
posi- mg elemental calcium. port. 426
Hence, when dietary phosphorus is re- phorus
– Inintake
dialysisup to 2-fold
patients, compared
restricting sodiumwith intake unproc-
is essential to volume and blood
2,500 mg elemental calcium. • Supplementation with Children on PD or frequent HD therapy (ie, >5 sessions/wk) rarely need dietary potassium This Clinical Practice Guideline document is based upon the best information available at the
vitamin D stricted to control hyperphosphatemia
Recommended Recommended Phosphorus
Maximum Oral and/or and sec- essed foods.
pressure
This
Ionized
control.
is a particular
Calcium problem
Phosphorus in
time of publication. It is designed to provide information and assist decision-making. It is not
Intake (mg/d) Age Calcium (mmol/L) (mg/dL) restriction and may actually develop hypokalemia.
Suppl 2 (March), 2009: pp S61-S69 S61 ondary Enteral Phosphorus Intake for Children
hyperparathyroidism With CKDwith
in children patients with CKD who rely heavily (mg/dL) on pro- intended to define a standard of care and should not be construed as one, nor should
Age-Specific Normal 427,428
CKD, subnormal serum phosphorus
High PTH and High PTH and
values should cessed
0-5 mo foods. 1.22-1.40 8.7-11.3 5.2-8.4 it be interpreted as prescribing an exclusive course of management. Variations in practice will
Ranges of Serum Phosphorus Normal High Tips to reduce
6-12Unfortunately,
mo sodium
1.20-1.40 mostintake include:
available
8.7-11.0nutrient 5.0-7.8data- inevitably and appropriately occur when clinicians take into account the needs of individual
Vitamin D be Age
avoidedDRI (Table
(mg/d)25). Phosphorus* Phosphorus† Non-dietary causes of hyperkalemia:
Age Serum Phosphorus 1-5 y – Consuming fresh foods
1.22-1.32 instead of processed
9.4-10.8 and on
4.5-6.5 canned foods patients, available resources, and limitations unique to an institution or a type of practice.
Recent clinical evidence suggests a high prevalence of vitamin D insufficiency in children The dietary prescription should aim at minimiz- bases do not consider the impact of additives – Hemolysis
with CKD. 6-12 y– Reading 1.15-1.32 9.4-10.3 3.6-5.8 Every health care professional making use of these recommendations is responsible for
(mg/dL) 0-6 mo 100 �100 �80 total phosphorus food labels to identify
content of 8.8-10.2 those foods
foods. An exception containing no more than 170–280 mg of sodium, – Metabolic acidosis
ing phosphate 275
7-12 mo
intake while ensuring an adequate 13-20 y 1.12-1.30 2.3-4.5 evaluating the appropriateness of applying them in the setting of any particular
Reasons for the high prevalence of low vitamin D levels in patients with CKD include: �275 �220 or 6%–10%
is the USDA National of the sodium DV
Nutrient Database for – Constipation
0–5 mo 5.2–8.4 protein
1-3 y intake. 460To achieve �460 this aim,�370 protein clinical situation.
– Sedentary lifestyle with reduced exposure to sunlight Adapted with permission121; Specker.524 – Medications (ie, ACEIs, ARBs, NSAIDs and potassium-sparing diuretics)
6–12 mo 5.0–7.8 sources
4-8 y with 500 low specific �500phosphorus�400 content Standard
– Reference,
Reducing salt added which
to foods; lists more substituting
in cooking,
Conversion factor for calcium and ionized calcium: mg/dL �
than 60 fresh herbs and spices to flavor foods
– Limited ingestion of foods rich in vitamin D – Tissue destruction due to catabolism, infection, surgery, or chemotherapy SECTION II: DISCLOSURE
– Reduced endogenous synthesis of vitamin D3 in the skin of patients with uremia 9-18 y 1,250
should be prescribed (see Table 13, Recommen-
�1,250 �1,000 phosphate-containing
– Minimizing
0.25 � mmol/L. intake of food
fast additives
foods (www.ars. – Inadequate dialysis
1–5 y 4.5–6.5 The National Kidney Foundation (NKF) makes every effort to avoid any actual or reasonably
– Urinary losses of 25(OH)D and vitamin D–binding protein in nephrotic patients ≤100% ofHealth
*Source: the DRI Canada:
†
≤80% ofhttp://www.hc-sc.gc.ca/fn-an/
the DRI usda.gov/Main/site_main.htm?modecode�12-
Conversion factor for phosphorus: mg/dL � 0.323 �
perceived conflicts of interest that may arise as a result of an outside relationship or a person-
6–12 y 3.6–5.8 alt_formats/hpfb-dgpsa/pdf/nutrition/dri_tables-eng.pdf. Re- mmol/L.
35-45-00; last accessed October 23, 2008).
Measure serum 25-hydroxyvitamin D levels once per year in children with CKD (R 7.2.1). Table 24. Target Range of Serum PTH by Stage al, professional, or business interest of a member of the Work Group. All members of the Work
produced with the permission
Target Range of Serum of the Minister
PTH by Stage of CKD of Public The aspects mentioned illustrate that dietary Group are required to complete, sign, and submit a disclosure and attestation form showing all
Supplementation with vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol) is 13–20 y 2.3–4.5 of CKD
Works and Government Services Canada, 2008. such relationships that might be perceived as actual conflicts of interest.
suggested if the serum level of 25-hydroxyvitamin D is less than 30 ng/mL (75 nmol/L) *� 100% of the DRI.
modification
dation 5). Mostoffood phosphorus
sources exhibit intake good is a complex
phos-
(R 7.2.2). Conversion factor for †� 80% of the DRI.
GFR Range Target Serum and
phate challenging
bioavailability task.withMultiple
the pitfalls,
exception ofincluding
plant
CKD Stage (mL/min/1.73m2) PTH (pg/mL)
In the repletion phase, it is suggested that serum levels of corrected total calcium and phosphorus: nonadherence
seeds (beans, peas, in older
cereals, children
and nuts) andthat adolescents,
contain
phosphorus be measured at 1 month following initiation or change in dose of vitamin D mg/dL x 0.323 = mmol/L 3greater than the target 30-59normal range for 35-70 may resultinin
phosphate inefficient
phytic acid. lowering of phosphorus
and at least every 3 months thereafter (R 7.2.3). age
4 15-29
(Table 25) and hyperparathyroidism is already 70-110 intake; conversely,
Milk and dairy products overrestriction
are a majormay source leadof to 30 East 33rd Street • New York, NY 10016 Based on the KDOQI Clinical Practice
800.622.9010 • 212.889.2210 • www.kidney.org
When patients are replete with vitamin D, it is suggested to supplement vitamin D 5, 5D �15 200-300 signs phosphorus.
dietary of phosphate deficiency,
In young infantsparticularly
with CKD, in Guideline for Nutrition in Children
continuously and to monitor serum levels of 25-hydroxyvitamin D yearly (R 7.2.4). established, phosphorus restriction to approxi-
Reprinted with permission. 121
phosphorus
young control
infants. Hence, can be achieved
involvement ofeasily by
an experi- With CKD: 2008 Update
mately 80% of the DRI is recommended.
Higher physiological serum concentrations of using formulas with a low phosphorus content. It ©2009 National Kidney Foundation, Inc. All rights reserved. 02-10-978A_JAJ

calcium and phosphorus are observed in healthy usually is feasible, and common clinical practice,