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Beta2-microglobulin Semin Dial 2009;22(4):378–80 169 Flythe JE, Hilliard T, Castillo G, Ikeler K, Orazi J, Abdel-Rahman E, et al Symptom prioritization among adults receiving in-center hemodialysis: a mixed methods study Clin J Am Soc Nephrol 2018;13(5):735–45 Part V Management of Secondary Complications of Chronic Dialysis Nutritional Assessment and Prescription for Children Receiving Maintenance Dialysis 26 Christina L. Nelms, Nonnie Polderman, and Rosanne J. Woloschuk Introduction and Overview Among the many priorities for the child receiving maintenance dialysis, attaining an optimal nutritional status is paramount and forms the foundation for a number of positive patient outcomes ranging from clinical status and biochemical control to quality of life and psychological well-being Adequate nutritional intake, especially in the early years of life, optimizes long-term growth [1] Neurocognitive development and final adult height outcomes, which are established in the early years of life, are negatively impacted by poor nutritional intake in a child nearing or reaching end-stage kidney disease (ESKD) [2] Historically, the focus of nutrition intervention has been to improve upon inadequate nutrition; however, the rising incidence of obesity is refocusing nutrition goals toward providing adequate, but not excessive, nutrition in order to reduce long-term obesity-related health concerns [3, 4] C L Nelms (*) PedsFeeds, University of Nebraska, Kearney, NE, USA e-mail: nelmscl@unk.edu N Polderman Division of Nephrology, British Columbia Children’s Hospital, Vancouver, BC, Canada e-mail: npolderman@cw.bc.ca R J Woloschuk Jim Pattison Children’s Hospital, Royal University Hospital, Saskatoon, SK, Canada Nutritional management, in concert with other medical management such as pharmacology, fluid balance, and dialysis prescription plays a key role in the achievement of electrolyte and biochemical control [5] Each child on dialysis is unique, and each nutrition care plan must be individualized accordingly Management of unique formula prescriptions and determination of best delivery route increase management complexity [6] The multidisciplinary team caring for infants, children, and adolescents on dialysis must include a skilled clinical nutrition expert, such as a pediatric renal dietitian, who specializes in both pediatric and dialysis-specific nutrition management [7] Nutrition Overview for Hemodialysis A classic “sodium-, potassium-, and phosphorus- controlled diet” is the usual nutrition prescription for the pediatric hemodialysis (HD) patient The typical thrice-weekly HD regimen does not provide adequate reduction of solutes to allow for complete diet liberalization Post-dialysis treatment side effects impair appetite While children with greater urine output enjoy more liberal fluid allowances, most children require some degree of fluid restriction The use of HD in infants is rare, but in these patients, strict fluid management is imperative given the small size of the young child and concern for blood volume shifts during treatment [5, 8, 9] © Springer Nature Switzerland AG 2021 B A Warady et al (eds.), Pediatric Dialysis, https://doi.org/10.1007/978-3-030-66861-7_26 463 C L Nelms et al 464 Less than 2% of all North American dialysis patients receive home hemodialysis [10] with the numbers of pediatric recipients unknown One advantage of home HD is flexibility in providing intensified dialysis regimens in the form of shorter sessions of daily dialysis or nocturnal dialysis [11] Patients undergoing nocturnal dialysis typically achieve excellent solute removal; supplementation of phosphorus, calcium, and vitamin D may be required Although fluid and diet restrictions may be discontinued, electrolytes must be closely monitored to avoid suboptimal levels [12–14] Patients receiving frequent daily dialysis not enjoy the same dietary freedoms as those on nocturnal hemodialysis, but report improved mental affect and quality of life, liberalized fluid allowances, and improved appetites [11, 15] utrition Overview for Peritoneal N Dialysis Peritoneal dialysis (PD) is the most common modality of dialysis in pediatric patients worldwide [7] The use of PD therapy requires in-depth assessment of factors related to PD to individualize the nutrition prescription The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) pediatric nutrition care guidelines [5] identify higher protein needs for PD patients compared to HD patients because of protein losses associated with PD (Tables 26.1 and 26.2) Ad lib eaters including children on PD typically consume adequate protein, but children receiving formula may require additional protein [16, 17] The transport capacity of the peritoneum also impacts dietary needs (Table 26.1) High transporters have higher protein needs and greater peritoneal losses of other nutrients and will occasionally need potassium supplementation [18, 19] Children who are low transporters have fewer nutrient losses, but potentially suffer from greater uremic affects resulting from relatively low solute removal, which can have a negative impact on appetite and gastrointestinal symptoms Glucose absorption from the dextrose-containing dialysate is greater in high transporters and may alter the recommended nutrition prescription and biochemical status [5, 7] For the young child with an underlying renal tubular disorder who is managed on PD, increased sodium supplementation and tighter potassium control may be required to offset an increased loss of sodium in the dialysis effluent and urine and associated potassium retention [5] Growth Suboptimal growth is a complication of CKD unique to children Growth failure or “short stature” occurs at all stages of reduced kidney function, worsening with the progressive decline in kidney function [20, 21] For each standard deviation score (SDS) decline in growth velocity, there is a reported 12–14% increase in mortality Short stature is also associated with increased hospitalizations and infections, suggesting that linear growth is not just a cosmetic issue [21, 22] Patients who receive a kidney transplant and who have very short stature have, on average, reduced allograft survival [20] Lastly, final adult height impacts the education level and employment outcomes and thus overall quality of life [22, 23] Early reports on growth from the North American Pediatric Renal Trials and Collaborative Studies (NAPTRCS) found that in the years leading up to 2004, 37% of pre-dialysis children fell below a height standard deviation score (HtSDS) of −1.88 While improvements to linear growth are being realized, recent reports from the Chronic Kidney Disease in Children (CKiD) study (2014) suggest that growth retardation remains prevalent with 12% of children with moderate CKD exhibiting a HtSDS of ≤ −1.88 Data suggests that for each drop in estimated glomerular filtration rate (eGFR) of 10 ml/min/1.73 m2, height is expected to drop by 0.14 SDS [24] A child at or below the 3rd%ile, which is equivalent to a HtSDS of −1.88, or with a height velocity of −2 SDS, warrants further evaluation of factors which may be contributing to the poor growth and may ulti- ... sleep-disordered breathing in a dialysis-dependent child post-renal transplantation Pediatr Nephrol 2010;25(1):173–7 153 Sharma N, Harvey E, Amin R. Sleep-disordered breathing in pediatric patients... 2013;24(4):714–8 144 Amin R, Sharma N, Al-Mokali K, Sayal P, Al-Saleh S, Narang I, et al Sleep-disordered breathing in children with chronic kidney disease Pediatr Nephrol 2015;30(12):2135–43 145 Gomes C, Oliveira