The publication of the Kidney Disease Outcomes Quality Initiative (KDOQI™) Clinical Practice Guideline for Nutrition in Children with Chronic Kidney Disease: Update 2008 represents the first update of the K/DOQI Nutrition and Chronic Renal Failure guidelines that were published in 2000.
The number of pediatric patients with chronic kidney disease (CKD) continues to grow. Patients with CKD are at significant risk of protein-energy malnutrition (PEM). Nutritional status in these children is especially important because it has a significant impact on linear growth, neurocognitive development, and sexual development. The effect of nutrition is especially important in infants because deficits in either linear growth or development that are acquired during infancy may not be fully correctable.
This guideline was developed to assist practitioners in Pediatric Nephrology in assessing the nutritional status of children with CKD, including patients on dialysis therapy or who have a kidney transplant; providing adequate macronutrient and micronutrient intake; and monitoring and treating complications of CKD, including bone mineral, vitamin D, fluid, and electrolyte derangements. This guideline will be of great importance to a broad audience of pediatric caregivers who endeavor to mitigate the effects of CKD on nutritional status and thus on the growth and development of these children.
This guideline has been developed by involving multiple disciplines from both US and international sources. These perspectives have been invaluable in ensuring a robust document with broad perspective. Each statement is graded based on the strength of recommendations (see the Reference Key on page S6 and Appendix 6). As for all KDOQI guidelines, these suggested interventions have been thoroughly discussed by all members of the Work Group to ensure they reflect state-of-the-art opinion on diagnosis, and management of these nutritional disorders. This final version of the document has undergone revision in response to comments during the public review process, an important and integral part of the KDOQI guideline process. Nonetheless, as with all guideline documents, there will be a need in the future for revision in the light of new evidence and, more importantly, a concerted effort to translate the guidelines into practice.
The recommendations are intended to serve as starting points for clinical decision making, and it is emphasized that the clinical judgment of the health care provider must always be included in the decision-making process and in the application of these recommendations. They are not to be considered as rules or standards of clinical practice, in keeping with the objectives of KDOQI. It is hoped that the information in this guideline document and the research recommendations provided will help improve the quality of care provided to children who have CKD and will stimulate additional research that will augment and refine this guideline in the future.
KDOQI is moving into an exciting new phase of activities. With the publication of the Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease in February 2007, KDOQI achieved its primary goal of producing evidence-based guidelines for the 12 aspects of CKD care most likely to improve patient outcomes. We now seek to apply the knowledge acquired in the development and refinement of the KDOQI processes to improve clinical practice through a broader range of activities that include directed research, public policy, guideline updates, commentaries on Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, publication forums, and new guidelines, if not being addressed by KDIGO or other guideline developers. We are looking forward to working with various members of the kidney health care community regarding these new and continuing KDOQI activities.
In a voluntary and multidisciplinary undertaking of this magnitude, many individuals make contributions to the final guideline document. It is impossible to acknowledge each of these individuals here, but to each and every one of them, I extend my sincerest appreciation. This limitation notwithstanding, the members of the Nutrition in Children with CKD Work Group and the Methods Consultants are to be commended for all their time and effort in reviewing the literature on pediatric nutrition since the release of the first nutrition guidelines in 2000 and for providing this update. Special thanks are given to the Co-Chairs, Dr Bradley Warady and Dr Donna Secker, for coordinating the activities of the Work Group. It is their commitment and dedication to the KDOQI process that has made this document possible.
Michael Rocco, MD, MSCE
KDOQI Vice-Chair