| Abstract|| |
Nutrition is essential for children with end-stage renal disease, especially for those suffering from peritoneal dialysis (PD). Although the number of PD children has increased annually at the Vietnam National Hospital of Pediatrics, studies about the diet and nutritional deficiencies status of PD children is still limited. The aim of this study was to describe the actual diet and status of nutritional deficiencies of PD patients. This cross-sectional study was conducted on 31 PD children aged 2–15 years old using the 24-h dietary recall and biochemical parameters in blood (albumin, hemoglobin, calcium, sodium, potassium, and chloride). The energy intake was lowest in children over 13-year-old with only 32.9% of dietary reference intakes (DRIs). Carbohydrate intake among 10–15-year-old children was 38.1% of DRIs. Daily consumption of sodium was 65.6% and 33%–35% of DRIs for children under and over three-year-old, respectively. In comparison with DRIs, daily consumption of magnesium, iron, and calcium of over 10-year-old children was lower than that of younger children. In terms of vitamins, B-group vitamins, Vitamin C achieved the recommended levels except Vitamin A (63.0%) and Vitamin D (20.0%). The prevalence of children with serum albumin concentration lower than the normal range was 45.2% and prevalence of anemia was 51.6%. The proportion of children with decreased plasma calcium, sodium, and potassium levels was 83.8%, 77.4%, and 12.9%, respectively. PD children’s diet lacks energy, protein, lipid, carbohydrate, as well as micronutrients. The prevalence of nutritional deficiencies is remarkably high in PD children.
|How to cite this article:|
My Thuc LT, Dung NQ, Ha VN, Tam ND, Hang Nga NT. Actual diet and nutritional deficiencies status in children on peritoneal dialysis at the Vietnam National Hospital of Pediatrics. Saudi J Kidney Dis Transpl 2019;30:924-31
|How to cite this URL:|
My Thuc LT, Dung NQ, Ha VN, Tam ND, Hang Nga NT. Actual diet and nutritional deficiencies status in children on peritoneal dialysis at the Vietnam National Hospital of Pediatrics. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Nov 18];30:924-31. Available from: http://www.sjkdt.org/text.asp?2019/30/4/924/265470
| Introduction|| |
Children need a healthy diet for optimum growth. For those suffering from serious chronic diseases such as end-stage renal disease (ESRD), nutrition even plays a more important role in their health status. Due to the growth retardation caused by ESRD, the diet for children should be adjusted depending on each stage of child development as well as disease’s conditions. Furthermore, they need special nutritional care in order to catch up with the growth rate of other normal kids and slow down the progression of renal disease.
Prevalence of malnourishment among children is quite high, in which contributes to increasing morbidity and mortality rates among peritoneal dialysis (PD) patients.,,,, The common state of losing body protein mass and fuel reserves (body protein and fat mass) in PD patients is regarded as protein-energy wasting. PD patients are vulnerable to micronutrient (vitamin and mineral) deficiencies, which may aggravate other clinical conditions such as anemia, loss of appetite, and cardiovascular diseases. Micronutrient deficiencies and malnutrition in PD patients are mainly caused by poor nutrition intake, intestinal dysfunction, and abnormal metabolism., Meanwhile, the micronutrient status depends on the food intake, bioavailability, and the presence of absorption inhibitors, all of which varies by demographic factors and traditional nutrition practices. In addition, the act of taking many medications as well as changing in psychological status during hospitalization results in a higher rate of malnutrition, poorer treatment outcomes, longer hospital stay, and higher hospital costs. Therefore, the diet of PD children should be established carefully and strictly adhered by the patients and their care-givers. For this reason, nutrition at health-care facilities as well as at home is considered as an essential medicine since it has significant impact on the treatment outcomes. The Vietnam National Pediatrics Hospital often treats PD children who are transferred from many hospitals of provincial level making the number of PD children admitted to this Hospital increase annually. Therefore, we conducted this study with the purpose of describing the actual diet and nutritional deficiencies status of PD children.
| Subjects and Methods|| |
We conducted a cross-sectional study on 31 PD children aged from 2 to 15 years old and their parents at the Department of Renal Disease and Nutrition, Vietnam National Hospital of Pediatrics from October 2015 to August 2016. The study’s participant only went to the hospital twice a week to get dialysis liquid and underwent the re-examination every three weeks. Children were excluded if they suffered from heart failure, liver disease, intestinal malabsorption or immunodeficiency syndrome.
All patients underwent clinical, biochemical, dialysis adequacy, and nutrition measurements at the beginning of the study. Macro- and micronutrient intakes were evaluated using a 24-h dietary questionnaire, which was processed against a computerized database of nutritional values for the main foods consumed in Vietnam. Plastic food models were used to provide more accurate estimations of the daily food portions. The 24-h dietary assessment did not take into account the calories from dialysate as the intention of the study was to measure the calories from diets only (those associated with micronutrient intake). Once the total intake was acquired from the questionnaire, the percentage of calories, protein, lipid and carbohydrate intakes were calculated and compared with the usual recommendations for individuals on PD children. In this study, micronutrient intakes were compared with the dietary reference intakes (DRIs) for the Vietnamese general population.
Biochemical parameters (including albumin, hemoglobin, calcium, sodium, potassium, and chloride) being measured at the Central Laboratory of the National Hospital of Pediatrics were compared with normal standard range, which was modified according to the machine standard, adjusted for Vietnamese children and referenced from the biochemical index.
| Statistical Analysis|| |
Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) for Windows, version 16.0 (SPSS Inc., Chicago IL, USA). Nutrition and food intake were analyzed using EXCEL Eiyo-kun software version 5.0. The results were presented as mean ± standard deviation (SD), median, or percentages, as appropriate. Nutritional status was classified by body mass index for children older than five -year-old and Weight for Height Z score for children under five-year- old, following the guideline from WHO 2007.
| Results|| |
General characteristics of PD children are presented in [Table 1]. There were 31 PD children with 15 boys (48.4%) and 16 girls (51.6%). Mean age (mean ± SD) was 8.5 ± 4.2 years old (min: 2 years and max: 15 years old). Children under five years accounted for 25.8% of the study sample, while the figures for those from five to 10 years and from 10 to 15 years were 38.7% and 35.5%, respectively. 74.2% of the children had been in PD treatment for <1 year. There were 61.3% children having normal nutritional status. Total proportion of children suffering from malnutrition was 35.5%, 12.9% of which was moderately malnourished, while the rest of them were severely malnourished. The prevalence of overweight was 3.2%.
Energy distribution from food intake is described in [Figure 1]. Energy from protein/ lipid/carbohydrate was 16.5%/27.5%/56%,respectively.
The median daily energy and nutrient intake was presented in [Table 2]. The energy intake was the lowest in girls over 13 years with only 32.9% compared to DRIs. Meanwhile, the protein intake the lowest among the age group of 13–15 years with 49.4% and 54.4% of DRIs in girls and boys, respectively. 7–9-year-old children ate an exceeding amount of lipid, as this nutrient intake was 2.5% higher than the DRIs. The children did not have enough carbohydrate according to the DRIs, especially among the age group of 10–15 years.
The median daily intakes of minerals and vitamins are shown in [Table 3]. Daily consumption of sodium in children aging from four to 15 years was only around one-third of DRIs. The daily potassium consumption was less than half of DRIs for all the age group. Children over 10 years consumed a less percentage of DRIs of magnesium, iron, and calcium daily than their younger counterpart. While the water-soluble vitamin group exceeded the recommended intake levels, the fat-soluble vitamins were much lower than the DRIs.
The concentration of several biochemical parameters in blood is illustrated in [Table 4]. The prevalence of low biochemical parameters in blood was as follow: albumin (45.2%), hemoglobin (51.6%), calcium (83.8%), sodium (77.4%), potassium (12.9%), and chloride (38.7%). We were not able to test the concentration of Vitamin A in blood, but we diagnosed two patients with Vitamin A deficiency due to the signs of ulcerative lesions in their eyes.
|Table 4: The prevalence of children who had low biochemical parameters in blood compared with the normal range (n = 31).|
Click here to view
| Discussion|| |
In this study, we showed that the total energy and amount of nutrients consumed daily by PD children was lower than the recommendation and the prevalence of children having low biochemical parameters in blood was high.
We surveyed 31 PD children from two to 15 years, with mean age (mean ± SD) of 8.5 ± 4.2 years [Table 1], which was comparable with other studies with mean age of eight-year- old., The prevalence of malnutrition among PD children was 35.5% [Table 1], which may be caused by the lack of nutrients in their diet and prolonged illness. According to Vietnam DRIs for PD children, 55%–60% of the total energy intake should come carbohydrate, while protein and lipid account for 12%–15% and 20%-30% of the amount of energy, respectively. Our findings showed that the energy distribution of our participants’ energy intakes was in line with the recommendation [Figure 1]. In this study, we did not mention the energy from the glucose in the dialysis fluid. In our results, there were 3.2% of children overweight, so dietarians and nutritionists should restrict this source of energy for those children. PD children need a balanced diet with enough protein, lipid, and carbohydrate. Even though our results showed a quite balanced energy distribution, the total energy was lower than the recommendation [Table 2] due to the low amount of macronutrients in the food. Therefore, the prevalence of malnutrition was still high among PD children [Table 1]. Furthermore, most of children over 10 years, especially those who were over 13 years of age had an energy intake ranging from 32.9% to 48.0% of the recommended level and their energy levels were also low compared to other age groups (similar patterns were witnessed regarding the protein, lipid, and carbohydrate levels). This was explained by the fact that as the children got older, they had to suffer from the longer duration and treatment of PD. The prolonged duration and treatment of PD might affect the quality of child care of parents and caregivers, which resulted in more attention to PD treatment and dialysis rather than the diet. In fact, it was essential to pay attention to the children’s diets, especially those who were under five years of age regardless of their disease statuses. In Vietnam, even though the National Institute of Nutrition had annually reported the nutritional status of children under five years of age, there was limited data on the nutritional status of children older than five years. In addition, the guidelines for diet of PD patients in Vietnam had not taken into account the children’s appetite, resulting in high prevalence of malnutrition in children and longer PD treatment duration. Due to the loss of substances and nutrients throughout the dialysis process, the energy and nutrients for PD children were generally recommended to be higher than those for normal children (such as protein should be added, but not added more than 0.2 g/kg/day). Protein was an important substance for all tissues and organs in the sense of tissue damage reinforcement and immune system fortification. However, in patients with ESRD and continuous hemo-dialysis (HD), protein in the diet should be properly controlled. Most patients’ parents were aware of that, so they strictly limited protein in PD children’s diet that led to the issue of protein deficiency. Our result showed that the older the children got, the severer PD condition they were prone to, which caused the restriction of protein in their diet, especially over 10-year-old patients [Table 2]. This might explain the 35.5% prevalence of malnutrition in our study [Table 1]. Lotfy et al did a survey on 50 ESRD patients with an average age of 10 years having regular HD and concluded that the prevalence of stunting and underweight was 78% and 34%, respectively. Apart from energy and protein, the bioactivity of food is also important. Lotfy et al found that if the patients consumed a higher energy and protein level than recommendation, but the bioavailability protein and other nutrients of the meals were poor, the situation of malnutrition would remain unchanged. The same thing went for other macronutrients, including potassium, sodium, calcium, iron, and magnesium, which were also low in the diet [Table 3]. Pereira et al studied PD children of the same age group and came up with the same results of the prevalence of malnutrition and low nutrients intake in the diet, while Fouque et al had the similar conclusion about nutrition status and food consumption in PD children.
Regarding the vitamins, most children consumed enough B-group vitamins but not Vitamin D and A in the diet [Table 3]. Most water-soluble vitamins were lost through dialysis, so PD children in our study were supplied with additional water-soluble vitamins, which made the intakes of those vitamins reach the recommendation level [Table 3]. Meanwhile, as fat-soluble vitamins (such as A, D, E, and K) could not be lost by dialysis process, they were not supplied in the diet of PD children. In addition, some researches showed serum retinol concentration was three times higher in PD children than in normal children,, which resulted in retinol poisoning for PD patients. As the result, it was not recommended to supply Vitamin A in PD children’s diet. The main source of Vitamin A in Vietnamese food came from dark green vegetables or red and orange-yellow fruits. Unfortunately, those foods were also rich sources of potassium that must be limited in PD patients’ diet. Our study reported two cases of patients having problems of Vitamin A deficiency with the symptom of damaged eye. The relationship between the levels of retinol in plasma with inflammation risk in dialysis patients showed that low level of retinol consumption led to the risk of mortality, morbidity, and cardiovascular complications in those patients. Only in these cases, it was considered necessary to take Vitamin A supplements in the diet.
Due to the low urinary sodium excretion in children with ESRD, it was advisable to reduce the amount of sodium in their diets. According to K/DOQI, ESRD children should take at least 1000–1500 mg/day. As the children in our studies consumed little amount of sodium [Table 3], there were 77.4% children having low plasma sodium concentration [Table 4]. Therefore, not all patients with ESRD must be restricted to sodium in their diet (unless those with hypertension, anuria, or oliguria). Sodium-free diet could be of potential harms as too low sodium level could lead to mortality and heart diseases in ESRD patients.
High potassium concentration in plasma is very dangerous due to arrhythmias – sudden cardiac arrest. According to K/DOQI, the amount of potassium intake varied in each patient and kidney failure. [Table 4] showed that 12.9% of patients had low potassium concentration in plasma, while the amount of potassium in their diet was still quite low [Table 3]. Therefore, PD children should not be restricted the potassium in their food consumption.
Calcium and Vitamin D are nutrients essential for the skeleton system. In [Table 4], there were 83.8% of PD children having low calcium level in plasma, which might be caused by low intake of calcium and Vitamin D [Table 3]. In addition, the Vietnamese did not have the habit of drinking milk daily, so concentration of calcium in plasma was extremely low. While it was important to increase the amount of calcium intake, Vitamin D was also essential to stimulate the calcium absorption in the intestine. Anemia is common in chronic kidney disease even in the early stage because of iron deficiency and insufficient erythropoietin production. The iron status of PD children should be evaluated at least every three months to ensure optimal iron supplementation, avoid iron depletion, and increase erythropoietin efficiency. However, nutrients contributing to the blood-forming process in PD patients’ diets such as protein and iron. were under the recommended level [Table 2] and [Table 3]. Hence, the prevalence of anemia and iron deficiency was high [Table 4].
| Conclusion|| |
This research is the first to report the diets of PD children’s in Vietnam. It studied 31 PD patients at Vietnam National Hospital of Pediatrics and showed that the total energy and amount of nutrients consumed daily by PD children was lower than the recommendation and the prevalence of children having low biochemical parameters in blood was high. Preserving the residual kidney function, while balancing the nutrition, was very important to ensure the optimal development of PD children.
Conflict of interest: None declared.
| References|| |
Chung SH, Lindholm B, Lee HB. Influence of initial nutritional status on continuous ambulatory peritoneal dialysis patient survival. Perit Dial Int 2000;20:19-26.
Kalantar-Zadeh K, Kopple JD. Trace elements and vitamins in maintenance dialysis patients. Adv Ren Replace Ther 2003;10:170-82.
Apostolou A, Printza N, Karagiozoglou- Lampoudi T, Dotis J, Papachristou F. Nutrition assessment of children with advanced stages of chronic kidney disease – A single center study. Hippokratia 2014;18:212-6.
Magdalena J, Boleslaw R, Alicja D. Adequacy of dialysis and nutrition in continuous peritoneal dialysis: Association with clinical outcomes. J Am Soc Nephrol 1996;7:198-7.
Paglialonga F, Felice C, Groppali E, Edefonti A. Assessment of nutritional status in children with chronic kidney disease. Minerva Pediatr 2010;62:295-6.
Edefonti A, Mastrangelo A, Paglialonga F. Assessment and monitoring of nutrition status in pediatric peritoneal dialysis patients. Perit Dial Int 2009;29 Suppl 2:S176-9.
Martín-del-Campo F, Batis-Ruvalcaba C, González-Espinoza L, et al. Dietary micro-nutrient intake in peritoneal dialysis patients: Relationship with nutrition and inflammation status. Perit Dial Int 2012;32:183-91.
Tuyen LD, Mai LB. Recommended Nutrition Requirement for Vietnamese. Vietnam: Medical Publishing House; 2016.
Ministry of Health. Guideline: Diet for Hospital. Vietnam: Medical Publishing House; 2007.
National Institution Nutrition. Guideline Nutrition Assessment Based on WHO Child Growth Standard: Methods and Development. National Institution Nutrition; 2007. p. 98-13.
Brody T. Nutritional Biochemistry. 2nd
ed. San Diego: Academic Press; 1998.
Lotfy HM, Sabry SM, Ghobrial EE, Abed SA. The effect of regular hemodialysis on the nutritional status of children with end-stage renal disease. Saudi J Kidney Dis Transpl 2015;26:263-70.
] [Full text]
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis 2002;39:S1-266.
Pereira AM, Hamani N, Nogueira PC, Carvalhaes JT. Oral vitamin intake in children receiving long-term dialysis. J Ren Nutr 2000; 10:24-9.
Fouque D, Vennegoor M, ter Wee P, et al. EBPG guideline on nutrition. Nephrol Dial Transplant 2007;22 Suppl 2:ii45-87.
Jankowska M, Lichodziejewska-Niemierko M, Rutkowski B, Dębska-Ślizień A, Malgorzewicz S. Water soluble vitamins and peritoneal dialysis – State of the art. Clin Nutr 2017; 36:1483-9.
Farrington K, Miller P, Varghese Z, Baillod RA, Moorhead JF. Vitamin A toxicity and hypercalcaemia in chronic renal failure. Br Med J (Clin Res Ed) 1981;282:1999-2002.
Manickavasagar B, McArdle AJ, Yadav P, et al. Hypervitaminosis A is prevalent in children with CKD and contributes to hypercalcemia. Pediatr Nephrol 2015;30:317-25.
Luu Thi My Thuc
Department of Nutrition, National Hospital of Pediatrics, Dong Da District, Hanoi
[Table 1], [Table 2], [Table 3], [Table 4]