K D O Q I C Linical P Ractice G Uideline For N Utrition In C Hildren W .

ns and AcronymsNational Kidney FoundationNormalized protein catabolic rateNormalized protein nitrogen appearance25-Hydroxyvitamin D1,25-Dihydroxyvitamin DPhysical activity coefficientPhysical activity levelPeritoneal dialysisProtein-energy malnutritionPeritoneal equilibration testParathyroid hormoneRecommended Dietary AllowanceRecombinant human growth hormoneStandard deviationStandard deviation score(s)Subjective Global AssessmentSubjective Global Nutrition AssessmentTotal energy expenditureTriglyceridesTotal nitrogen appearanceTriceps skinfold thicknessTolerable upper intake levelUS Department of AgricultureVery low-density lipoproteinWorld Health Organization

Glossary of DefinitionsAcceptable Macronutrient Distribution Ranges(AMDR): A range of intake for each energy sourceassociated with reduced risk of chronic disease whileproviding adequate intake of essential nutrients. TheAMDR is based on evidence that consumption greateror less than these ranges may be associated withnutrient inadequacy and increased risk of developingchronic diseases, such as coronary heart disease, obesity, diabetes, and/or cancer. The AMDR is expressedas a percentage of total energy intake because itsrequirement is not independent of other energy sourcesor of the individual’s total energy requirement.Adequate Intake (AI): The recommended averagedaily nutrient intake level based on observed or experimentally determined approximations or estimates ofnutrient intake by a group (or groups) of apparentlyhealthy people who are assumed to be maintaining anadequate nutritional state. The AI is expected to meetor exceed the needs of most individuals in a specificlife-stage and gender group. When a RecommendedDietary Allowance (RDA) is not available for a nutrient, the AI can be used as the goal for usual intake byan individual. The AI is not equivalent to an RDA.Children: Infants, children, and adolescents between the ages of birth and 19 years.Dietary Reference Intakes (DRI): Set of 4 nutrientbased values that apply to the apparently healthygeneral population consisting of RDA, EstimatedAverage Requirement (EAR), AI, and TolerableUpper Intake Level (UL).Enteral Nutrition*: Nutrition provided through thegastrointestinal tract through a tube, catheter, orstoma that delivers nutrients distal to the oral cavity.Estimated Energy Requirement (EER): An EER isdefined as the average dietary energy intake that ispredicted to maintain energy balance in healthy normal-weight individuals of a defined age, sex, weight,height, and level of physical activity consistent withgood health. In children, the EER includes the needsassociated with growth at rates consistent with goodhealth. Relative body weight (ie, loss, stable, or gain)is the preferred indicator of energy adequacy.Fiber: Combination of dietary fiber, the edible nondigestible carbohydrate and lignin components existingnaturally in plant foods, and functional fiber, the isolated,extracted, or synthetic fiber that has proven health benefits. Fiber includes viscous or soluble forms that maydecrease serum cholesterol levels (eg, oat bran andlegumes/beans) and insoluble forms or bulking agentsthat prevent or alleviate constipation (eg, wheat bran,whole grains, vegetables, and fruits).Height Age: The age at which the child’s heightwould be on the 50th percentile.Ideal Body Weight: The weight at the same percentile as the child’s height percentile, for the sameage and sex.Macronutrients: Dietary fat, carbohydrate, protein, and fiber.Nutrition Care*: Interventions and counseling ofindividuals on appropriate nutrition intake throughthe integration of information from the nutritionassessment.Nutrition Care Plan*: A formal statement of thenutrition goals and interventions prescribed for anindividual using the data obtained from a nutritionassessment. The plan, formulated by an interdisciplinary process, should include: statements of nutritiongoals and monitoring parameters, the most appropriate route of administration of specialized nutritionsupport (oral, enteral, and/or parenteral), method ofnutrition access, anticipated duration of therapy, andtraining and counseling goals and methods.Nutrition Therapy*: A component of medical treatment that includes oral, enteral, and parenteral nutrition.Obesity: Body mass index (BMI) for age at 95thpercentile or greater.Oral Nutrition*: Nutrition taken by mouth.Overweight: BMI for age at 85th or greater andless than 95th percentiles.Parenteral Nutrition*: The administration of nutrients intravenously.Physical Activity Level (PAL): The ratio of totalenergy expenditure (TEE) to basal energy expenditure. PAL categories are defined as sedentary (PAL,1.0 to 1.39), low active (PAL, 1.4 to 1.59), active(PAL, 1.6 to 1.89), and very active (PAL, 1.9 to2.5). PAL should not be confused with the physicalactivity coefficient (PA values) used in the equations to estimate energy requirement.Recommended Dietary Allowance (RDA): The intake that meets the nutrient needs of almost all(97% to 98%) individuals in a group. It may beused as a goal for individual intake.Tolerable Upper Intake Level (UL): The highest average daily nutrient intake level likely to pose no risk ofadverse health effects to almost all individuals in a givenlife-stage and sex group. The UL is not a recommendedlevel of intake. As intake increases above the UL, thepotential risk of adverse effects increases.* Source: Teitelbaum et al.1American Journal of Kidney Diseases, Vol 53, No 3, Suppl 2 (March), 2009: p S5S5

Reference KeyStages of Chronic Kidney DiseaseStageDescriptionGFR (mL/min/1.73 m2)12345Kidney damage with normal or 1 GFRKidney damage with mild 2 GFRModerate 2 GFRSevere 2 GFRKidney failure!9060–8930–5915–29!15 (or dialysis)Treatment1-5T if kidney transplant recipient5D if dialysis (HD or PD)Abbreviations: CKD, chronic kidney disease; HD, hemodialysis; GFR, glomerular filtration rate; PD, peritonealdialysis; 1, increased; 2, decreased.Nomenclature and Description for Rating Guideline RecommendationsStrength of theRecommendationS6Wording of AAn intervention“should bedone”The quality of the evidence is“high” or additionalconsiderations support a“strong” recommendationMost well-informedindividuals willmake the samechoiceThe expectation is that therecommendation will befollowed unless thereare compelling reasonsto deviate from it in anindividual. A strongrecommendation mayform the basis for aclinical performancemeasureBAn intervention“should beconsidered”The quality of the evidence is“high” or “moderate” oradditional considerationssupport a “moderate”recommendationA majority ofwell-informedindividuals willmake thischoice, but asubstantialminority may notThe expectation is that therecommendation will befollowed in the majorityof casesCAn intervention is“suggested”The quality of the evidence is“moderate,” “low,” or “verylow” or additionalconsiderations support aweak recommendationbased predominantly onexpert judgmentA majority ofwell-informedindividuals willconsider thischoiceThe expectation is thatconsideration will begiven to following therecommendationAmerican Journal of Kidney Diseases, Vol 53, No 3, Suppl 2 (March), 2009: p S6

KDOQI Clinical Practice Guideline forNutrition in Children with CKDWork Group MembershipWork Group Co-ChairsBradley A. Warady, MDChildren’s Mercy Hospitals and ClinicsKansas City, MODonna Secker, PhD, RDThe Hospital for Sick ChildrenToronto, CanadaWork GroupBethany Foster, MDMontreal Children’s HospitalMontreal, CanadaSarah E. Ledermann, MBGreat Ormond Street Hospital for ChildrenLondon, UKStuart L. Goldstein, MDBaylor College of MedicineHouston, TXFranz S. Schaefer, MDHeidelberg University HospitalHeidelberg, GermanyFrederick Kaskel, MD, PhDChildren’s Hospital at MontefioreBronx, NYNancy S. Spinozzi, RD, LDNChildren’s HospitalBoston, MAMethods ConsultantsTufts Center for Kidney Disease Guideline Development and Implementationat Tufts Medical Center, Boston, MAKatrin Uhlig, MD, MS, Program Director, NephrologyEthan Balk, MD, MPH, Program Director, Evidence Based Medicine

KDOQI Advisory Board MembersMichael Rocco, MD, MSCEKDQOI ChairAdeera Levin, MDKDOQI Immediate Past ChairGarabed Eknoyan, MDKDOQI Co-Chair EmeritusBryan Becker, MDAllan J. Collins, MDPeter Crooks, MDWilliam E. Haley, MDBertrand L. Jaber, MD, MSCynda Ann Johnson, MD, MBAKarren King, MSW, ACSW, LCSWMichael J. Klag, MD, MPHCraig B. Langman, MDDerrick Latos, MDLinda McCann, RD, LD, CSRRavindra L. Mehta, MDMaureen Michael, BSN, MBAWilliam E. Mitch, MDNathan Levin, MDKDOQI Co-Chair EmeritusGregorio Obrador, MD, MPHRulan S. Parekh, MD, MSBrian Pereira, MD, DMNeil R. Powe, MDClaudio Ronco, MDRaymond Vanholder, MD, PhDNanette K. Wenger, MDDavid Wheeler, MD, MRCPWinfred W. Williams Jr, MDShuin-Lin Yang, MDEx-OfficioJosephine P. Briggs, MDNKF-KDOQI Guideline Development StaffKerry Willis, PhD, Senior Vice-President for Scientific ActivitiesDonna Fingerhut, Managing Director of Scientific ActivitiesMichael Cheung, Guideline Development DirectorDekeya Slaughter-Larkem, Guideline Development Project ManagerSean Slifer, Scientific Activities Manager

VOL 53, NO 3, SUPPL 2, MARCH 2009ForewordThe publication of the Kidney Disease Outcomes Quality Initiative (KDOQI ) Clinical Practice Guideline for Nutrition in Childrenwith Chronic Kidney Disease: Update 2008 represents the first update of the K/DOQI Nutritionand Chronic Renal Failure guidelines that werepublished in 2000.The number of pediatric patients with chronickidney disease (CKD) continues to grow. Patients with CKD are at significant risk of proteinenergy malnutrition (PEM). Nutritional status inthese children is especially important because ithas a significant impact on linear growth, neurocognitive development, and sexual development.The effect of nutrition is especially important ininfants because deficits in either linear growth ordevelopment that are acquired during infancymay not be fully correctable.This guideline was developed to assist practitioners in Pediatric Nephrology in assessing thenutritional status of children with CKD, including patients on dialysis therapy or who have akidney transplant; providing adequate macronutrient and micronutrient intake; and monitoringand treating complications of CKD, includingbone mineral, vitamin D, fluid, and electrolytederangements. This guideline will be of greatimportance to a broad audience of pediatric caregivers who endeavor to mitigate the effects ofCKD on nutritional status and thus on the growthand development of these children.This guideline has been developed by involving multiple disciplines from both US and international sources. These perspectives have beeninvaluable in ensuring a robust document withbroad perspective. Each statement is graded basedon the strength of recommendations (see theReference Key on page S6 and Appendix 6). Asfor all KDOQI guidelines, these suggested inter-ventions have been thoroughly discussed by allmembers of the Work Group to ensure theyreflect state-of-the-art opinion on diagnosis, andmanagement of these nutritional disorders. Thisfinal version of the document has undergonerevision in response to comments during thepublic review process, an important and integralpart of the KDOQI guideline process. Nonetheless, as with all guideline documents, there willbe a need in the future for revision in the light ofnew evidence and, more importantly, a concertedeffort to translate the guidelines into practice.The recommendations are intended to serve asstarting points for clinical decision making, andit is emphasized that the clinical judgment of thehealth care provider must always be included inthe decision-making process and in the application of these recommendations. They are not tobe considered as rules or standards of clinicalpractice, in keeping with the objectives ofKDOQI. It is hoped that the information in thisguideline document and the research recommendations provided will help improve the quality ofcare provided to children who have CKD andwill stimulate additional research that will augment and refine this guideline in the future.KDOQI is moving into an exciting new phaseof activities. With the publication of the ClinicalPractice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic KidneyDisease in February 2007, KDOQI achieved itsprimary goal of producing evidence-based guidelines for the 12 aspects of CKD care most likely 2009 by the National Kidney Foundation, Inc.0272-6386/09/5303-0101 36.00/0doi:10.1053/j.ajkd.2008.12.011American Journal of Kidney Diseases, Vol 53, No 3, Suppl 2 (March), 2009: pp S9-S10S9

S10to improve patient outcomes. We now seek toapply the knowledge acquired in the development and refinement of the KDOQI processes toimprove clinical practice through a broader rangeof activities that include directed research, publicpolicy, guideline updates, commentaries on Kidney Disease: Improving Global Outcomes(KDIGO) guidelines, publication forums, andnew guidelines, if not being addressed by KDIGOor other guideline developers. We are lookingforward to working with various members of thekidney health care community regarding thesenew and continuing KDOQI activities.In a voluntary and multidisciplinary undertaking of this magnitude, many individuals makecontributions to the final guideline document. Itis impossible to acknowledge each of these indi-Forewordviduals here, but to each and every one of them, Iextend my sincerest appreciation. This limitationnotwithstanding, the members of the Nutrition inChildren with CKD Work Group and the Methods Consultants are to be commended for alltheir time and effort in reviewing the literatureon pediatric nutrition since the release of the firstnutrition guidelines in 2000 and for providingthis update. Special thanks are given to theCo-Chairs, Dr Bradley Warady and Dr DonnaSecker, for coordinating the activities of theWork Group. It is their commitment and dedication to the KDOQI process that has made thisdocument possible.Michael Rocco, MD, MSCEKDOQI Chair

EXECUTIVE SUMMARYINTRODUCTIONRegular evaluation of nutritional status andprovision of adequate nutrition are key components in the overall management of children withCKD. The traditional and predominant focus ofnutritional management for children with impaired kidney function is to prevent the development of PEM and meet the patient’s vitamin andmineral needs. More recently, overnutrition characterized by obesity and the long-term implications of unbalanced dietary and lifestyle practices are of increasing concern to the pediatricCKD population, and attention to this issue mustbe incorporated into the nutrition managementscheme. Thus, the focus of nutritional care forchildren across the spectrum of CKD must always be centered on the achievement of thefollowing goals: Maintenance of an optimal nutritional status(ie, achievement of a normal pattern of growthand 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 morbiditiesand mortality in adulthood.This publication represents the first revision ofthe K/DOQI Pediatric Clinical Practice Guidelines for Nutrition in Chronic Renal Failure andis a completely revised and expanded document.The revision of the document published in 2000was considered necessary for the following reasons: To modify prior guideline statements basedupon the availability

Abstract T he 2008 update of the Kidney Disease Outcomes Quality Initiative (KDOQI) pediatric nutrition clinical practice guideline is intended to assist the practitioner caring for infants, children, and adolescents with chronic kidney disease (CKD) stages 2 to 5, on long-term dialysis therapy , or with a