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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2016  |  Volume : 27  |  Issue : 4  |  Page : 733-739
Nutritional assessment in children with chronic kidney disease

1 Department of Pediatrics, Maulana Azad Medical College and Associated Hospitals, University of Delhi, New Delhi, India
2 Department of Dietetics and Nutrition, Maulana Azad Medical College and Associated Hospitals, University of Delhi, New Delhi, India

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Date of Web Publication5-Jul-2016


Growth failure is a major problem in pediatric patients with chronic kidney disease (CKD), and the onset of the condition in infancy is more likely to have an adverse impact on growth than its development in later childhood. This study was aimed to assess nutritional intake and anthropometry of children presenting with CKD in a developing country. In this cross-sectional observational study, children (1-18 years) with CKD visiting the outpatient services were enrolled. The age of onset, cause of CKD, and anthropometry were recorded. Dietary intakes from three 24 h dietary recall (2 mid-week and 1 weekend day) were recorded. A blood sample was taken from all subjects for biochemical parameters. A total of 45 children (forty males and five females) with CKD underwent nutritional assessment. The median age at assessment was 108 months (13-167). Twenty-seven (60%) subjects had CKD stage 1, 2, or 3 while the remaining 40% had CKD stage 4 or 5. Of the 45 children, 27 (60%) had moderate to severe malnutrition at assessment. The mean weight and height (standard deviation scores) were −2.77 ± 2.07 and −2.30 ± 1.38, respectively. The prevalence of growth retardation was much higher in late stages of CKD; the difference was statistically significant (P <0.01). The mean caloric deficit from recommended daily allowance was −40.33% for calories, +6.2% for proteins, and −10.51% for fats. The diet was highly deficient in iron (mean 48.9% deficit); deficient in calcium (mean −22.2%) and had excess phosphates (mean 18.3%). There was a progressive decrease in intake of nutrients in advanced stages of CKD. There was a high prevalence of malnutrition (60%) in children with CKD, especially in higher stages of CKD. An appropriate dietary assessment and nutritional counseling should be planned for all patients with CKD to prevent complications associated with malnutrition and anemia.

How to cite this article:
Gupta A, Mantan M, Sethi M. Nutritional assessment in children with chronic kidney disease. Saudi J Kidney Dis Transpl 2016;27:733-9

How to cite this URL:
Gupta A, Mantan M, Sethi M. Nutritional assessment in children with chronic kidney disease. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2022 Sep 25];27:733-9. Available from: https://www.sjkdt.org/text.asp?2016/27/4/733/185235

   Introduction Top

Chronic kidney disease (CKD) is associated with malnutrition and impaired growth in pediatric patients due to anemia, metabolic acidosis, renal osteodystrophy, and tissue resistance to the actions of growth hormone and insulin-like growth factors. [1] Moreover, renal replacement procedures like hemodialysis and peritoneal dialysis are associated with protein losses and malnutrition. [2],[3] Most patients with CKD in childhood have a congenital structural renal anomaly that leads to an early onset of renal failure. The slowing of linear growth leads to severe height loss in infants. The onset of the pubertal growth spurt is also delayed though it occurs at the appropriate bone age. In children with obstructive uropathy and renal dysplasia, salt wasting and recurrent dehydration are also contributory causes. The North American Pediatric Renal Transplant Cooperative (NAPRTCS) data on 5022 children with a glomerular filtration rate (GFR) of <75 mL /min/1.73 m 2 , published in 2011 found that the children were 1.6 standard deviations scores (SDS) below appropriate height level and the height SDS worsened with progression of CKD. [4]

Regular evaluation of nutritional status is a key component in the overall management of children with CKD. Various methods to assess the nutritional status of patients with CKD include dietary assessment, various biochemical parameters, and evaluation of anthropometric measures. [5],[6]

Provision of sufficient energy has been suggested to be the most important factor in preventing growth retardation and malnutrition in children with CKD. The exact prevalence of undernutrition in children with CKD is not known. However, studies have reported prevalence varying widely from 20-65%. [7],[8] Published literature on nutritional intake of children with CKD from the developing world is scant. The present study was undertaken to assess the nutritional status of children with CKD and also to determine the prevalence of malnutrition in the study group.

   Materials and Methods Top

This cross-sectional observational study was conducted in the Department of Pediatrics of a tertiary care teaching hospital during the period January 2012 to January 2013. The subjects of the study were children who visited the outpatient department or pediatric nephrology services of the hospital, fulfilled the inclusion criteria, and provided consent for the study. The study was approved by the Institute's Ethical Committee (ethics committee approval number F.no./11/IEC/MAMC/2011).

Inclusion criteria

All children (1-18 years) with CKD stages 1-5 who visited the outpatient/pediatric nephrology clinic were not on dialysis and gave consent for participation in the study were included in the study.

Sample size

The sample size was calculated by estimating the proportion of protein-energy malnourished in individuals with CKD, i.e., likely population prevalence of malnourished patients being 50% with confidence level 95%, and with 15% precision, the sample size was calculated to be 44. Hence, 45 children with CKD were enrolled in the study.

Data collection

A predesigned performa consisting of clinical details, history regarding the age of onset, and causes of CKD was filled. The information was obtained from previous records available with the patient.

For assessment of dietary intake, data from three 24 h dietary recalls were taken. The data were assessed under the guidance of a skilled pediatric dietitian. Two assessments were made on weekdays and a third on a post week-end day over a span of one month. The parents, mostly mothers, were interviewed for assessment of dietary intake. Standard-sized cups, glasses, spoons, and small bowls were shown to the mothers to calculate the average portion in the diet. For intake of chapattis (Indian homemade bread), cutouts from cardboards were used for various sizes. Each dietary assessment lasted for around 30-45 min.

An average of all the three days' dietary assessment was taken. A software program DietSoft version 1.2.0 (Invincible IDeAs 2008-2009) based on the National Institute of Nutrition (a national body on nutrition in India) standards was used for calculation of individual dietary intake components. These values were compared to standard tables for recommended daily allowances (RDA) based on Indian Council of Medical Research (ICMR) standards and percentage intake of macronutrients (calories, proteins, and fat) and micronutrients (sodium, potassium, calcium, phosphorous, and iron) was calculated. [9] An energy/ nutrient deficit or excess was calculated based on these.

Anthropometric assessment of all the patients was made. This included measurement of weight, height/length, weight for height calculation of body mass index (BMI) for patients older than five years. These were measured using standard techniques according to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines. [10] These values were compared for chronological age to CDC-2000 growth charts. The data were represented as standard deviation scores (SDS). Standard definitions of malnutrition were used. [10] After an informed consent from parents, 4 mL of venous blood sample was collected from each patient under all aseptic precautions for biochemistry (hemoglobin, serum creatinine, sodium, potassium, serum protein, serum albumin, calcium, phosphate, alkaline phosphatase, and venous blood gas). The GFR was calculated using the standard Schwartz equation. [11]

   Results Top

A total of 45 children with CKD due to various causes were included in the study. Nutritional assessment, anthropometry, and biochemical parameters were assessed in all these patients. Of the 45 children enrolled in the study, forty (88.8%) were males. The mean age of the study population was 9.19 (3.8) years and eight (17.7%) were between one and five years, 22 (48.8%) between five and 12 years, and 15 (33.3%) were between 12 and 18 years of age. Twenty-seven (60%) subjects had CKD stage 1, 2, or 3 (15, 12, and 7 patients, respectively) while the remaining 40% had CKD stage 4 or 5 (5 and 13 patients, respectively). An underlying structural abnormality of the urinary tract was a cause of CKD in 37 children (82.2%). The various causes of CKD in these patients are listed in [Table 1].
Table 1: Underlying renal abnormality of 45 children with CKD.

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Anthropometric evaluation

The mean weight and height (SDS) of the subjects were −2.77±2.07 and −2.30±1.38, respectively. The mean BMI SDS for children above five years was −2.09±1.58. The height and weight SDS parameters in different stages of CKD are shown in [Table 2]. Both the parameters deteriorated with increasing severity of CKD. Of the 45 children, 27 (60%) had moderate to severe malnutrition on assessment.
Table 2: Anthropometry in different stages of CKD.

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Nutrient intake

The mean intakes of energy, protein, fat, and micronutrients are given in [Table 3]. Analysis of the three-day dietary recall records showed a generalized reduction in intake of all constituents with the progression of CKD. The calorie deficit in CKD stage 1 was 23.9% and progressed to a deficit of 61.6% in CKD stage 5. Children in stage 1-3 were taking more protein (+6.2%) than that recommended for their age, whereas in children with stage 4 and 5, there was a deficit of protein intake of −21% and −29.6%, respectively. A comparison between early stages (1-3) and late stages (4-5) of CKD showed that there was a significant decrease in the intake of energy in the later stage of CKD, that was statistically significant [Table 4]. The protein and fat intake were more than the recommended RDA in stage 1-3 CKD with a mean of +28.4% and +10.8% and decreased to −27.2% and −42.5%, respectively, in stages 4-5. This difference was also statistically significant (P = 0.002 and P = 0.003, respectively).
Table 3: Average daily dietary intake of CKD patients.

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Table 4: A comparison of macronutrient and micronutrient intake between early (stage 1–3) and late stages of CKD (stage 4–5).

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A comparison of intake of micronutrients, i.e., calcium, phosphorous, and iron in the diet with stages of CKD revealed that there was a progressive decrease in the intake of these nutrients with the progression of stages of CKD. The intake of phosphorous was in excess of recommended in stages 1-3 while in stages 4-5, there was a deficit of −33.3% and −23.8%, respectively. However, iron intake was less in all the children with the deficit increasing to more than half in stages 4-5. None of our patients were receiving any extra supplemental diets at the time of evaluation. All our patients belonged to lower socioeconomic strata of the population.

Biochemical parameters

A comparison of biochemical parameters in different stages of CKD is given in [Table 5]. The mean value of hemoglobin was 10.9 g/dL in early stages of CKD and 7.3 g/dL in late stages of CKD (P <0.01). The serum sodium values were not significantly different in early and late stages of CKD. As expected, there was a significant increase (P = 0.045) in serum potassium in higher stages of CKD. The mean serum phosphates were higher in later stages (5.8 mg/dL vs. 4.75 mg/dL; P = 0.010). Similarly, there was a significant decline in serum calcium levels in higher stages of CKD (P = 0.00).
Table 5: A comparison of biochemical parameters between early stages of CKD (stage 1–3) and late stages of CKD (stage 4–5).

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The mean serum albumin of the study population was 3.60 ± 0.38 g/dL. Using serum albumin criteria of less than 3.5 g/dL for hypoalbuminemia, 35.5% (16/45) of the subjects had hypoalbuminemia. The mean bicarbonate levels of the entire study group were 16.6 ± 4.96 mEq/L; the mean values in CKD stage 1-3 and in stage 4-5 were 19.3 and 11.8 mEq/L, respectively; the difference being statistically significant.

   Discussion Top

The present study was conducted in a tertiary care hospital to evaluate the nutritional status of patients in various stages of CKD. Nutritional surveys have shown that undernutrition is highly prevalent among adults with CKD, with 20-75% of adults undergoing maintenance dialysis showing some evidence of wasting. [2] Most descriptions of growth patterns in children with CKD are in the dialysis and transplant populations, primarily because the majority of the large registries collect data from these groups. The reported prevalence of malnutrition among pediatric patients with chronic renal insufficiency is around 35%. [3],[4],[7] The literature from developing countries, especially India, is scant where the proportion of expected malnutrition is much higher than the Western counterparts.

Sixty percent of the children enrolled in the present study were in early stages (CKD 1-3) at the time of registration. The causes of CKD in our patients included obstructive uropathy in 40% of the patients, while 17.7% had neuroenic bladder and renal hypoplasia/dysplasia/aplasia were seen in 17.3% of the subjects. In the NAPRTCS registry also, obstructive uropathy was the most common cause (20.7%), renal aplasia/hypoplasia/dysplasia was seen in 17.3% of patients and reflux in 8.4% of CKD patients. [4] In the ESRD population reported by the European Society of Pediatric Nephrology-EDTA registry, it was found that congenital anomalies contributed to 36% patients as the cause of CKD. [12] In the Indian Pediatric CKD Registry, about 52% patients had congenital anomalies as the underlying cause. [13]

Almost 60% of the subjects had moderate to severe malnutrition in the present study. None of the subjects were overweight or obese. This is in contrast to the data published by the CKD in children (CKiD) study group that reported a prevalence of severe short stature in only 12% of the 799 American children with CKD. In fact, 46% of children with glomerular CKD were overweight or obese. The primary reason for this difference is the contrasting socioeconomic conditions and lack of adequate nutritional interventions in children with CKD in developing countries. [7]

The mean height SDS and weight SDS were −2.30 and −2.77, respectively. The height deficit worsened in higher stages of CKD. The median height and weight SDS in the CKiD study group were −0.55 and −0.03, respectively, again contrasting the nutritional disparity of developed and developing worlds. [7] Similarly, the recent NAPRTCS data report from patients on renal replacement therapies showed a mean height and weight SDS of −1.6 and −1.13 at start of dialysis. [4] In a recent study from South Korea on 19 children with CKD, the mean height and weight SDS observed were −0.2 and −0.2. [14] Besides poor socioeconomic conditions, inadequate dietary interventions due to limited availability of skilled manpower contribute to growth failure in resource-poor settings like ours.

Overall, the subjects were consuming 40.3% less of calories when compared to age-specific RDA, 6.2% excess proteins while the fat intake was 10.5% less than the RDA. In CKD stage 1, the children were consuming 23.9% fewer calories than the RDA which progressed to 61.6% deficit in stage 5. Thus, the intake correlated with GFR negatively. While the protein intake was +28.4% of RDA in CKD stages 1-3, it decreased to −27% in later stages. In a previous study on Italian children with CKD, the energy intake was 76-88% of RDA in patients with chronic renal failure and protein intake was 33% lower than age-specific healthy controls. [15] In a recent study on 19 Korean children with CKD the average intake of calories was 70% of RDA but the protein intakes were 100% of RDA. [14] Our patients were consuming fewer calories and proteins, especially in the later stages of CKD, which resulted in greater height and weight deficit in them. Adequate dietary calcium intake during childhood is necessary for growth and skeletal development. In this study, the overall intake of calcium was low (−22.2% deficit) and was −52.03% in higher stages of CKD. The intake of phosphates in our children with stages 4-5 CKD was 26.4% less than RDA, indicating no role of dietary phosphate reduction in malnourished populations. The serum phosphate levels were normal in all stages of CKD again implying a little role of dietary restrictions. None of our subjects had dysnatremia or hyperkalemia. Similar observations have been reported from previous studies. [7],[14],[15]

The prevalence of anemia in this study increased from 45.7% in early stages of CKD to 80% and 100% in stages 4 and 5, respectively. In a previous study on CKD, patients using <12 g/dL as a cutoff, the prevalence of anemia in children ranged from 31.2% in stage 1 CKD to 93.3% in stages 4 and 5 CKD. [16] While a major reason for anemia in later stages was lack of use of erythropoietin due to financial constraints, iron deficiency, malnutrition, and worm infestations could have been contributory causes. The iron intake was especially low (−48.8%) in all children.

Sixteen of the total 45 subjects enrolled (35.5%) had albumin levels below 3.5 g/dL and none below 3 g/dL. In the CKiD cohort, 3% subjects had serum albumin levels below 3.0 g/d. [7] However, the mean levels of albumin were lower in this study as compared to previous ones possibly due to higher degree of malnutrition among our patients. [7],[14]

The proportion of patients with acidosis (bicarbonate e<22 mEqL) was 64.4% which could be an important cause for growth failure. In the CKiD cohort, 74% patients had bicarbonate values above 22 mEq/L. The same study had also concluded that bicarbonate values below 18 mEq/L were associated with poor height SDS scores. [7]

We conclude that there was a high prevalence of malnutrition (60%) in our CKD patients. The average dietary intake of calories was less in all stages of CKD and proteins, in later stages. The diet was highly deficient in iron and calcium with a high prevalence of anemia and acidosis in all stages. The study implies the need to assess the nutritional status of CKD patients periodically. Dietary interventions and supplementation as early as possible might prevent or at least retard growth failure.

Conflict of interest: None declared.

   References Top

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Kopple JD. McCollum Award Lecture, 1996: Protein-energy malnutrition in maintenance dialysis patients. Am J Clin Nutr 1997;65: 1544-57.  Back to cited text no. 3
North American Pediatric Renal Transplant Cooperative (NAPRTCS) 2011 Annual Report. Available from: http://www.web.emmes.com. [Last accessed on 1-3-2013].   Back to cited text no. 4
Foster BJ, Leonard MB. Measuring nutritional status in children with chronic kidney disease. Am J Clin Nutr 2004;80:801-14.   Back to cited text no. 5
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Rodig NM, McDermott KC, Schneider MF, et al. Growth in children with chronic kidney disease: A report from the Chronic Kidney Disease in Children Study. Pediatr Nephrol 2014;29:1987-95.  Back to cited text no. 7
Sylvestre LC, Fonseca KP, Stinghen AE, Pereira AM, Meneses RP, Pecoits-Filho R. The malnutrition and inflammation axis in pediatric patients with chronic kidney disease. Pediatr Nephrol 2007;22:864-73.   Back to cited text no. 8
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Schwartz GJ, Haycock GB, Edelmann CM Jr., Spitzer A. A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. Pediatrics 1976;58:259-63.  Back to cited text no. 11
ESPN/ERA-EDTA Registry Annual Report; 2008. Available from: http://www.espn-reg.org. [Last accessed on 1-3-2013].  Back to cited text no. 12
CKD Annual Report; November, 2011. Available from: http://www.ckdri.org. [Last accessed on 1-3-2013].   Back to cited text no. 13
Kim H, Lim H, Choue R. Compromised diet quality is associated with decreased renal function in children with chronic kidney disease. Clin Nutr Res 2014;3:142-9.   Back to cited text no. 14
Rätsch IM, Catassi C, Verrina E, et al. Energy and nutrient intake of patients with mild-tomoderate chronic renal failure compared with healthy children: An Italian multicentre study. Eur J Pediatr 1992;151:701-5.  Back to cited text no. 15
Atkinson MA, Martz K, Warady BA, Neu AM. Risk for anemia in pediatric chronic kidney disease patients: A report of NAPRTCS. Pediatr Nephrol 2010;25:1699-706.  Back to cited text no. 16

Correspondence Address:
Mukta Mantan
Department of Pediatrics, Maulana Azad Medical College, University of Delhi, New Delhi - 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.185235

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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