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Dietary fiber is considered an essential constituent of a healthy child's diet. Diets of healthy children with adequate dietary fiber intake are characterized by a higher diet quality, a higher nutrient density, and a higher intake of vitamins and minerals in comparison to the diets of children with poor dietary fiber intake. Nevertheless, a substantial proportion of children do not meet the recommended dietary fiber intake. This is especially true in those children with kidney diseases, as traditional dietary recommendations in kidney diseases have predominantly focused on the quantities of energy and protein, and often restricting potassium and phosphate, while overlooking the quality and diversity of the diet. Emerging evidence suggests that dietary fiber and, by extension, a plant-based diet with its typically higher dietary fiber content are just as important for children with kidney diseases as for healthy children. Dietary fiber confers several health benefits such as prevention of constipation and fewer gastrointestinal symptoms, reduced inflammatory state, and decreased production of gut-derived uremic toxins. Recent studies have challenged the notion that a high dietary fiber intake confers an increased risk of hyperkalemia or nutritional deficits in children with kidney diseases. There is an urgent need of new studies and revised guidelines that address the dietary fiber intake in children with kidney diseases., Author(s): Evelien Snauwaert [sup.1] , Fabio Paglialonga [sup.2] , Johan Vande Walle [sup.1] , Mandy Wan [sup.3] , An Desloovere [sup.1] , Nonnie Polderman [sup.4] , José Renken-Terhaerdt [sup.5] , [...]

Obesity and metabolic syndrome (O&MS) due to the worldwide obesity epidemic affects children at all stages of chronic kidney disease (CKD) including dialysis and after kidney transplantation. The presence of O&MS in the pediatric CKD population may augment the already increased cardiovascular risk and contribute to the loss of kidney function. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. We present CPRs for the assessment and management of O&MS in children with CKD stages 2-5, on dialysis and after kidney transplantation. We address the risk factors and diagnostic criteria for O&MS and discuss their management focusing on non-pharmacological treatment management, including diet, physical activity, and behavior modification in the context of age and CKD stage. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT., Author(s): Stella Stabouli [sup.1] , Nonnie Polderman [sup.2] , Christina L. Nelms [sup.3] , Fabio Paglialonga [sup.4] , Michiel J. S. Oosterveld [sup.5] , Larry A. Greenbaum [sup.6] [sup.7] , [...]

Background Our multidisciplinary clinical pathway for treatment of childhood nephrotic syndrome (NS) was established with the goal of standardizing local clinical practice. This descriptive study aimed to assess nutrient intakes of children with newly diagnosed NS compared with nutrition goals defined by our pathway. Methods Our pathway includes evidence-based recommendations that target daily intakes during corticosteroid induction therapy: energy (Estimated Energy Requirements (EER) x Sedentary Physical Activity (PA)), sodium (1 mg/kcal), calcium (Dietary Reference Intake (DRI) + 500 mg elemental calcium), and vitamin D (DRI +800-1000 IU). After dietitian-led education at initial diagnosis, 3-day food records were completed at 4 weeks post-diagnosis. Daily nutrient intakes were compared to pathway targets and DRIs. Results Thirty-six children (median age 4.8 years, 44% female) with newly diagnosed NS submitted food records. Mean energy and sodium intakes were 103±22% and 99±53% of pathway targets, respectively. Fourteen (39%) children exceeded pathway sodium recommendations, with four (11%) exceeding them by greater than 50%. Seven (19%) children met DRI for calcium, while six (17 %) met pathway targets for calcium. No children met DRI for vitamin D from diet alone; and only one met the target with supplementation. Conclusions This is the first study to describe dietary intakes of children with newly diagnosed NS. Our clinical pathway targets for energy and sodium were achievable; however, calcium and vitamin D intakes fell short of pathway guidelines and DRIs. Prescription of supplemental calcium and vitamin D may be needed to achieve target intakes of calcium and vitamin D. Graphical abstract, Author(s): Nonnie Polderman [sup.1] [sup.2] , Meredith Cushing [sup.1] , Kirsten McFadyen [sup.1] , Marisa Catapang [sup.1] , Robert Humphreys [sup.1] , Cherry Mammen [sup.1] , Douglas G. Matsell [sup.1] [...]

Dyskalemias are often seen in children with chronic kidney disease (CKD). While hyperkalemia is common, with an increasing prevalence as glomerular filtration rate declines, hypokalemia may also occur, particularly in children with renal tubular disorders and those on intensive dialysis regimens. Dietary assessment and adjustment of potassium intake is critically important in children with CKD as hyperkalemia can be life-threatening. Manipulation of dietary potassium can be challenging as it may affect the intake of other nutrients and reduce palatability. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPRs) for the dietary management of potassium in children with CKD stages 2-5 and on dialysis (CKD2-5D). We describe the assessment of dietary potassium intake, requirements for potassium in healthy children, and the dietary management of hypo- and hyperkalemia in children with CKD2-5D. Common potassium containing foods are described and approaches to adjusting potassium intake that can be incorporated into everyday practice discussed. Given the poor quality of evidence available, a Delphi survey was conducted to seek consensus from international experts. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs, based on the clinical judgment of the treating physician and dietitian. These CPRs will be regularly audited and updated by the PRNT., Author(s): An Desloovere [sup.1] , José Renken-Terhaerdt [sup.2] , Jetta Tuokkola [sup.3] , Vanessa Shaw [sup.4] [sup.5] , Larry A. Greenbaum [sup.6] [sup.7] , Dieter Haffner [sup.8] , Caroline Anderson [...]

In children with kidney diseases, an assessment of the child's growth and nutritional status is important to guide the dietary prescription. No single metric can comprehensively describe the nutrition status; therefore, a series of indices and tools are required for evaluation. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. Herein, we present CPRs for nutritional assessment, including measurement of anthropometric and biochemical parameters and evaluation of dietary intake. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Audit and research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT., Author(s): Christina L. Nelms [sup.1] , Vanessa Shaw [sup.2] [sup.3] , Larry A. Greenbaum [sup.4] [sup.5] , Caroline Anderson [sup.6] , An Desloovere [sup.7] , Dieter Haffner [sup.8] , Michiel [...]

In children with chronic kidney disease (CKD), optimal control of bone and mineral homeostasis is essential, not only for the prevention of debilitating skeletal complications and achieving adequate growth but also for preventing vascular calcification and cardiovascular disease. Complications of mineral bone disease (MBD) are common and contribute to the high morbidity and mortality seen in children with CKD. Although several studies describe the prevalence of abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels as well as associated clinical and radiological complications and their medical management, little is known about the dietary requirements and management of calcium (Ca) and phosphate (P) in children with CKD. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists, who develop clinical practice recommendations (CPRs) for the nutritional management of various aspects of renal disease management in children. We present CPRs for the dietary intake of Ca and P in children with CKD stages 2-5 and on dialysis (CKD2-5D), describing the common Ca- and P-containing foods, the assessment of dietary Ca and P intake, requirements for Ca and P in healthy children and necessary modifications for children with CKD2-5D, and dietary management of hypo- and hypercalcemia and hyperphosphatemia. The statements have been graded, and statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. These CPRs will be regularly audited and updated by the PRNT., Author(s): Louise McAlister [sup.1] , Pearl Pugh [sup.2] , Laurence Greenbaum [sup.3] , Dieter Haffner [sup.4] , Lesley Rees [sup.1] , Caroline Anderson [sup.5] , An Desloovere [sup.6] , Christina [...]

Dietary management in pediatric chronic kidney disease (CKD) is an area fraught with uncertainties and wide variations in practice. Even in tertiary pediatric nephrology centers, expert dietetic input is often lacking. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, was established to develop clinical practice recommendations (CPRs) to address these challenges and to serve as a resource for nutritional care. We present CPRs for energy and protein requirements for children with CKD stages 2-5 and those on dialysis (CKD2-5D). We address energy requirements in the context of poor growth, obesity, and different levels of physical activity, together with the additional protein needs to compensate for dialysate losses. We describe how to achieve the dietary prescription for energy and protein using breastmilk, formulas, food, and dietary supplements, which can be incorporated into everyday practice. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgment. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT., Author(s): Vanessa Shaw [sup.1] [sup.2] , Nonnie Polderman [sup.3] , José Renken-Terhaerdt [sup.4] , Fabio Paglialonga [sup.5] , Michiel Oosterveld [sup.6] , Jetta Tuokkola [sup.7] , Caroline Anderson [sup.8] , [...]

Background Historically, children with nephrotic syndrome (NS) across British Columbia (BC), Canada have been cared for without formal standardization of induction prednisone dosing. We hypothesized that local historical practice variation in induction dosing was wide and that children treated with lower doses had worse relapsing outcomes. Methods This retrospective cohort study included 92 NS patients from BC Children's Hospital (1990-2010). We excluded secondary causes of NS, age 3000 mg/m.sup.2 doses. Conclusions Results strongly justify our development of a standardized, province-wide NS clinical pathway to reduce practice variation and minimize under-treatment. The lowest induction prednisone dosing threshold to minimize future relapsing risks is likely between 2000 and 2500 mg/m.sup.2. Further prospective studies are warranted., Author(s): Matthew Sibley [sup.1] , Abishek Roshan [sup.1] , Alanoud Alshami [sup.1] , Marisa Catapang [sup.1] , Jasper J. Jöbsis [sup.1] , Trevor Kwok [sup.1] , Nonnie Polderman [sup.1] , [...]

Background Most cases of childhood nephrotic syndrome (NS) are due to minimal change disease (MCD), while a minority of children have focal segmental glomerulosclerosis (FSGS) and an unfavorable clinical course, requiring a kidney biopsy to confirm diagnosis. We hypothesized that clinical characteristics at diagnosis and initial response to corticosteroid treatment accurately predict FSGS and can be used to guide consistent practice in the indications for kidney biopsy. Methods This was a case control study (1990-2012). Inclusion criteria included age 1-17 years, meeting the diagnostic criteria for NS, and having biopsy-proven FSGS or MCD. Clinical characteristics at diagnosis included age, kidney function [estimated glomerular filtration rate (eGFR)], hypertension, hematuria, nephritis (reduced eGFR, hematuria, hypertension), and response to steroids. Results From a total of 169 children who underwent kidney biopsy for NS we included 65 children with MCD and 22 with FSGS for analysis. There were no significant between-group differences in age, sex, or eGFR at the time of diagnosis. The FSGS group had a higher proportion of hypertension (40 vs. 15%; p = 0.02), hematuria (80 vs. 47%; p = 0.01), and nephritis (22 vs. 2%; p = 0.004) and was more likely to be steroid resistant after 6 weeks of treatment than the MCD group (67 vs. 19%; p < 0.001). As predictors of FSGS, hematuria had a high sensitivity of 0.80 [95% confidence interval (CI) 0.56-0.93] and low specificity of 0.53 (95% CI 0.39-0.66), nephritis had a low sensitivity of 0.22 (95% CI 0.07-0.48) and high specificity of 0.98 (95% CI 0.88-0.99), and steroid resistance had a low sensitivity of 0.67 (95% CI 0.43-0.85) and high specificity of 0.81 (95% CI 0.68-0.90). The combination of steroid resistance after 6 weeks of therapy and/or nephritis at diagnosis yielded the optimal sensitivity and specificity at 0.80 (95% CI 0.56-0.93) and 0.75 (95% CI 0.60-0.86), respectively, confirmed by the highest receiver operator characteristic area under the curve of 0.77. Conclusion Steroid resistance after 6 weeks of therapy and/or nephritis at initial presentation is an accurate predictor of FSGS in children with NS and will be used as the indication for kidney biopsy in our newly developed clinical pathway. This approach will maximize the yield of diagnostic FSGS biopsies while minimizing the number of unnecessary MCD biopsies., Author(s): Alanoud Alshami [sup.1] , Abishek Roshan [sup.1] , Marisa Catapang [sup.1] , Jasper J. Jöbsis [sup.1] , Trevor Kwok [sup.1] , Nonnie Polderman [sup.1] , Jennifer Sibley [sup.1] , [...]

The nutritional prescription (whether in the form of food or liquid formulas) may be taken orally when a child has the capacity for spontaneous intake by mouth, but may need to be administered partially or completely by nasogastric tube or gastrostomy device ("enteral tube feeding"). The relative use of each of these methods varies both within and between countries. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPRs) based on evidence where available, or on the expert opinion of the Taskforce members, using a Delphi process to seek consensus from the wider community of experts in the field. We present CPRs for delivery of the nutritional prescription via enteral tube feeding to children with chronic kidney disease stages 2–5 and on dialysis. We address the types of enteral feeding tubes, when they should be used, placement techniques, recommendations and contraindications for their use, and evidence for their effects on growth parameters. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgement. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT. [ABSTRACT FROM AUTHOR]