NKF KDOQI GUIDELINES

KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 Update

I. EXECUTIVE SUMMARY

INTRODUCTION

Regular evaluation of nutritional status and provision of adequate nutrition are key components in the overall management of children with CKD. The traditional and predominant focus of nutritional management for children with impaired kidney function is to prevent the development of PEM and meet the patient's vitamin and mineral needs. More recently, overnutrition characterized by obesity and the long-term implications of unbalanced dietary and lifestyle practices are of increasing concern to the pediatric CKD population, and attention to this issue must be incorporated into the nutrition management scheme. Thus, the focus of nutritional care for children across the spectrum of CKD must always be centered on the achievement of the following goals:

Maintenance of an optimal nutritional status (ie, achievement of a normal pattern of growth and body composition by intake of appropriate amounts and types of nutrients).
Avoidance of uremic toxicity, metabolic abnormalities, and malnutrition.
Reduction of the risk of chronic morbidities and mortality in adulthood.

This publication represents the first revision of the K/DOQI Pediatric Clinical Practice Guidelines for Nutrition in Chronic Renal Failure and is a completely revised and expanded document. The revision of the document published in 2000 was considered necessary for the following reasons:

To modify prior guideline statements based upon the availability of information published subsequent to the development of the 2000 guidelines.
To expand the target population with recommendations to address patients with CKD stages 2 to 5 and kidney transplant recipients, in addition to the dialysis population addressed in the prior publication.
To address a variety of topics not covered in the original guidelines, such as the dietary modification of sodium, potassium, fluid, calcium, and phosphorus, all of which can have a profound impact on patient outcomes.
To incorporate references to dietary recommendations, anthropometric reference values, and growth charts for the healthy population that replaced those on which the 2000 guidelines were based.
To reconcile discrepancies in recommendations for nutrient modification that exist between the pediatric nutrition guidelines and recent KDOQI guidelines on Hypertension and Dialysis Adequacy.

One of the challenges for the Work Group in revising the 2000 K/DOQI Pediatric Nutrition Guidelines was the remarkable lack of published data available for the topic of nutrition in children with all stages of CKD. In addition, the quality of evidence in pediatric nephrology studies related to the issues addressed in these guidelines was frequently low due to small sample size, the lack of randomized controlled trials, and the lack of information for both short- and long-term clinical outcomes. Thus, the Work Group has generated a set of guideline recommendations to provide guidance to practitioners on the clinical aspects of nutrition management while at the same time recognizing the limited evidence that exists.These recommendations are based on available evidence, such as it exists; they also rely heavily on the opinion of the Work Group members and are graded accordingly. All submitted suggestions from physicians, nurses, and dietitians who participated in the public review of the draft recommendations were carefully reviewed and considered for incorporation into the recommendations by the Work Group Chairs and individual Work Group members. Most importantly, the absence of randomized controlled trials to support the recommendations made precludes the subsequent development of clinical performance measurements by oversight bodies on most, if not all, of the issues addressed by the guidelines.

The process of revising the guidelines has also provided a unique opportunity to detect and highlight deficiencies in the scientific literature and to identify much needed areas of research for clinicians and scientists to undertake in the future. Areas of uncertainty arose for several reasons. For some issues, research in the pediatric CKD population has never been undertaken. For others, studies have provided indeterminate results, either because of small sample size or because infants, children, and adolescents were considered together, precluding the ability to relate outcomes to specific age groups. Studies that are rigorously designed to consider these issues and more and that address such topics as the role of inflammation on the nutritional status of children, the contribution of nutrition management to modification of cardiovascular risk, and the impact of frequent hemodialysis (HD) on energy, protein, and vitamin needs are required to ensure that future recommendations are truly evidence based.

The charge to the Work Group was to develop comprehensive guideline recommendations that could provide valuable assistance to all clinicians (eg, dietitians, physicians, and nurses) involved in the nutritional management of children with CKD.

We believe we have accomplished that goal. Of course, the primary use of these recommendations is to complement—but not replace—clinical judgment and to recognize that this is a “living document” that requires regular modification as new information becomes available. When used in this manner, we are confident that the information contained in this document will contribute to improved clinical management and outcomes of children with CKD.

Finally, the Work Group expresses its appreciation to Michael Cheung, Dekeya Slaughter-Larkem, and Donna Fingerhut of the NKF-KDOQI Management Team and to Katrin Uhlig and Ethan Balk at the Tufts Center for Kidney Disease Guideline Development and Implementation for their guidance and assistance in the development of this guideline.