Managing the Nutritional Requirements of the Pediatric End-Stage Kidney Disease Graduate

      The pediatric patient with end-stage kidney disease who transitions to the adult dialysis unit or nephrology center requires a unique nutritional focus. Clinicians in the adult center may be faced with complex issues that have often been part of the patient's journey since early childhood. The causes of kidney disease in children are often quite different than those which affect the adult population and may require different nutritional priorities. Abnormal growth including severe short stature, underweight, overweight or obesity, and poor musculature may affect the long-term health and psychosocial well-being of these patients. Nutritional assessment of these patients should include a focus on past growth and anthropometric data, dietary information, including appetite, quality of diet, and assessment of biochemical data through a pediatric lens. This review discusses the unique factors that must be considered when transitioning pediatric patients and notes major recommendations from a compilation of pediatric guideline statements.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Advances in Chronic Kidney Disease
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • KDOQI Work Group
        KDOQI clinical practice guideline for nutrition in children with CKD: 2008 update. Executive summary.
        Am J Kidney Dis. 2009; 53: S11-S104
        • Kramer A.
        • Stel V.S.
        • Tizard J.
        • et al.
        Characteristics and survival of young adults who started renal replacement therapy during childhood.
        Nephrol Dial Transplant. 2009; 24: 926-933
        • Harambat J.
        • van Stralen K.J.
        • Kim J.J.
        • Tizard E.J.
        Epidemiology of chronic kidney disease in children.
        Pediatr Nephrol. 2012; 27: 363-373
        • Warady B.A.
        • Chadha V.
        Chronic kidney disease in children: the global perspective.
        Pediatr Nephrol. 2007; 22: 1999-2009
        • Becherucci F.
        • Roperto R.M.
        • Materassi M.
        • Romagnani P.
        Chronic kidney disease in children.
        Clin Kidney J. 2016; 9: 583-591
        • Anderson J.E.
        Brain development in adolescents: new research--implications for physicians and parents in regard to medical decision making.
        Issues Law Med. 2015; 30 (Autumn): 193-196
        • Johnson R.J.
        • Gerson A.C.
        • Harshman L.A.
        • et al.
        A longitudinal examination of parent-reported emotional-behavioral functioning of children with mild to moderate chronic kidney disease.
        Pediatr Nephrol. 2020; 35: 1287-1295
        • Nelms C.L.
        • Johnson E.
        • Peseski S.
        Determination of renal nutrition training and education need for pediatric-focused and adult-focused clinicians: the North American Pediatric Rrenal Nutrition Education Survey (NAPRNES).
        J Ren Nutr. 2019; 29: 91-96
        • Chand D.H.
        • Swartz S.
        • Tuchman S.
        • Valentini R.P.
        • Somers M.J.
        Dialysis in children and adolescents: the pediatric nephrology perspective.
        Am J Kidney Dis. 2017; 69: 278-286
        • Nelms C.L.
        • Shaw V.
        • Greenbaum L.A.
        • et al.
        Assessment of nutritional status in children with kidney diseases-clinical practice recommendations from the pediatric renal nutrition taskforce.
        Pediatr Nephrol. 2021; 36: 995-1010
        • Rodig N.M.
        • McDermott K.C.
        • Schneider M.F.
        • et al.
        Growth in children with chronic kidney disease: a report from the chronic kidney disease in children study.
        Pediatr Nephrol. 2014; 29: 1987-1995
        • Furth S.L.
        • Hwang W.
        • Yang C.
        • Neu A.M.
        • Fivush B.A.
        • Powe N.R.
        Growth failure, risk of hospitalization and death for children with end-stage renal disease.
        Pediatr Nephrol. 2002; 17: 450-455
        • Wong C.S.
        • Gipson D.S.
        • Gillen D.L.
        • et al.
        Anthropometric measures and risk of death in children with end-stage renal disease.
        Am J Kidney Dis. 2000; 36: 811-819
        • Zimet G.D.
        • Cutler M.
        • Litvene M.
        • Dahms W.
        • Owens R.
        • Cuttler L.
        Psychological adjustment of children evaluated for short stature: a preliminary report.
        J Dev Behav Pediatr. 1995; 16: 264-270
        • Gao T.
        • Leonard M.B.
        • Zemel B.
        • Kalwarf H.J.
        • Foster B.J.
        Interpretation of body mass index in children with CKD.
        Clin J Am Soc Nephrol. 2012; 7: 558-564
        • Sgambat K.
        • Roem J.
        • Mitsnefes M.
        • et al.
        Waist-to-height ratio, body mass index, and cardiovascular risk profile in children with chronic kidney disease.
        Pediatr Nephrol. 2018; 33: 1577-1583
        • Hogan J.
        • Schneider M.F.
        • Pai R.
        • et al.
        Grip strength in children with chronic kidney disease.
        Pediatr Nephrol. 2020; 35: 891-899
        • Sgambat K.
        • Clauss S.
        • Moudgil A.
        Comparison of BMI, waist circumference, and waist-to-height ratio for identification of subclinical cardiovascular risk in pediatric kidney transplant recipients.
        Pediatr Transplant. 2018; 22: e13300
        • Ayestaran F.W.
        • Schneider M.F.
        • Kaskel F.J.
        • et al.
        Perceived appetite and clinical outcomes in children with chronic kidney disease.
        Pediatr Nephrol. 2016; 31: 1121-1127
        • Stephens K.
        • Orlick M.
        • Beattie S.
        • et al.
        Examining mid-upper arm circumference malnutrition z-score Thresholds.
        Nutr Clin Pract. 2020; 35: 344-352
        • Secker D.
        • Cornelius V.
        • Teh J.C.
        Validation of subjective global (nutritional) assessment (SGNA) in children with CKD.
        J Ren Nutr. 2011; 21: 207
      1. Tower J, Oladitan, L, Abdel-Rahman S. Understanding the role of mid-upper arm circumference in assessing the nutrition status of children on dialysis. Poster presented at: The Annual Dialysis Conference; March 11-14, 2017; Long Beach, CA.

        • Shaw V.
        • Polderman N.
        • Renken-Terhaerdt J.
        • et al.
        Energy and protein requirements for children with CKD stages 2-5 and on dialysis-clinical practice recommendations from the pediatric renal nutrition taskforce.
        Pediatr Nephrol. 2020; 35: 519-531
        • Mak R.H.
        • Cheung W.W.
        • Zhan J.Y.
        • Shen Q.
        • Foster B.J.
        Cachexia and protein-energy wasting in children with chronic kidney disease.
        Pediatr Nephrol. 2012; 27: 173-181
        • McAlister L.
        • Pugh P.
        • Greenbaum L.
        • et al.
        The dietary management of calcium and phosphate in children with CKD stages 2-5 and on dialysis-clinical practice recommendation from the pediatric renal nutrition taskforce.
        Pediatr Nephrol. 2020; 35: 501-518
        • Desloovere A.
        • Renken-Terhaerdt J.
        • Tuokkola J.
        • et al.
        The dietary management of potassium in children with CKD stages 2-5 and on dialysis-clinical practice recommendations from the pediatric renal nutrition taskforce.
        Pediatr Nephrol. 2021; 36: 1331-1346
        • Lima A.G.T.
        • Sales C.C.D.S.
        • Serafim W.F.L.
        Burden, depression and anxiety in primary caregivers of children and adolescents in renal replacement therapy.
        J Bras Nefrol. 2019; 41: 356-363
        • Kho H.S.
        • Lee S.W.
        • Chung S.C.
        • Kim Y.K.
        Oral manifestations and salivary flow rate, pH, and buffer capacity in patients with end-stage renal disease undergoing hemodialysis.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999; 88: 316-319
        • Chen W.
        • Ducharme-Smith K.
        • Davis L.
        • et al.
        Dietary sources of energy and nutrient intake among children and adolescents with chronic kidney disease.
        Pediatr Nephrol. 2017; 32: 1233-1241
        • Hui W.F.
        • Betoko A.
        • Savant J.D.
        • et al.
        Assessment of dietary intake of children with chronic kidney disease.
        Pediatr Nephrol. 2017; 32: 485-494
        • Taylor J.M.
        • Oladitan L.
        • Degnan A.
        • Henderson S.
        • Dai H.
        • Warady B.A.
        Psychosocial factors that create Barriers to managing serum phosphorus levels in pediatric dialysis patients: a retrospective analysis.
        J Ren Nutr. 2016; 26: 270-275
        • Borzych D.
        • Rees L.
        • Ha I.S.
        • et al.
        International Pediatric PD Network (IPPN). The bone and mineral disorder of children undergoing chronic peritoneal dialysis.
        Kidney Int. 2010; 78: 1295-1304
        • Young E.W.
        • Akiba T.
        • Albert J.M.
        • et al.
        Magnitude and impact of abnormal mineral metabolism in hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS).
        Am J Kidney Dis. 2004; 44: 34-38
        • Al Aly Z.
        • González E.A.
        • Martin K.J.
        • Gellens M.E.
        Achieving K/DOQI laboratory target values for bone and mineral metabolism: an uphill battle.
        Am J Nephrol. 2004; 24: 422-426
        • Lorenzo V.
        • Martin-Malo A.
        • Perez-Garcia R.
        • et al.
        Prevalence, clinical correlates and therapy cost of mineral abnormalities among haemodialysis patients: a cross-sectional multicentre study.
        Nephrol Dial Transplant. 2006; 21: 459-465
        • Larson N.I.
        • Perry C.L.
        • Story M.
        • Neumark-Sztainer D.
        Food preparation by young adults is associated with better diet quality.
        J Am Diet Assoc. 2006; 106: 2001-2007
        • Morris A.
        • Love H.
        • van Aar Z.
        • Liles C.
        • Roskell C.
        The problematic world of following a renal diet outside the home.
        J Ren Care. 2015; 41: 253-259
        • Baxter-Jones A.D.
        • Faulkner R.A.
        • Forwood M.R.
        • Mirwald R.L.
        • Bailey D.A.
        Bone mineral accrual from 8 to 30 years of age: an estimation of peak bone mass.
        J Bone Miner Res. 2011; 26: 1729-1739
        • Wesseling-Perry K.
        • Pereira R.C.
        • Tseng C.H.
        • et al.
        Early skeletal and biochemical alterations in pediatric chronic kidney disease.
        Clin J Am Soc Nephrol. 2012; 7: 146-152
        • Denburg M.R.
        • Tsampalieros A.K.
        • de Boer I.H.
        • et al.
        Mineral metabolism and cortical volumetric bone mineral density in childhood chronic kidney disease.
        J Clin Endocrinol Metab. 2013; 98: 1930-1938
        • Shroff R.
        • Long D.A.
        • Shanahan C.
        Mechanistic insights into vascular calcification in CKD.
        J Am Soc Nephrol. 2013; 24: 179-189
        • McAlister L.
        • Silva S.
        • Shaw V.
        • Shroff R.
        Dietary calcium intake does not meet the nutritional requirements of children with chronic kidney disease and on dialysis.
        Pediatr Nephrol. 2020; 35: 1915-1923
        • Wassner S.J.
        • Kulin H.E.
        Diminished linear growth associated with chronic salt depletion.
        Clin Pediatr (Phila). 1990; 29: 719-721
        • US Department of Health and Human Services, US Department of Agriculture
        Dietary Guidelines for Americans.
        US Government Printing Office, WA, DC2005: 70
        • Rees L.
        • Shaw V.
        • Qizalbash L.
        • et al.
        Pediatric renal nutrition taskforce. Delivery of a nutritional prescription by enteral tube feeding in children with chronic kidney disease stages 2-5 and on dialysis-clinical practice recommendations from the pediatric renal nutrition taskforce.
        Pediatr Nephrol. 2021; 36: 187-204
        • Schaefer F.
        • Benner L.
        • Borzych-Dużałka D.
        • et al.
        International Pediatric Peritoneal Dialysis Network (IPPN) Registry. Global variation of nutritional status in children undergoing chronic peritoneal dialysis: a longitudinal study of the international pediatric peritoneal dialysis network.
        Sci Rep. 2019; 9: 4886
        • Salusky I.
        • Fine R.
        • Nelson P.
        • Blumenkrantz M.
        • Kopple J.
        Nutritional status of children undergoing continuous ambulatory peritoneal dialysis.
        Am J Clin Nutr. 1983; 38: 599-611
        • Samaan S.
        • Secker D.
        Oral feeding challenges in infants with chronic kidney disease.
        Infant Child Adolesc Nutr. 2014; 6: 164-171
        • Lerret S.M.
        • Erato G.
        • Goday P.S.
        • Silverman A.H.
        A clinical description of children with solid organ transplants who present with feeding disorder.
        Pediatr Transplant. 2019; 23: e13389
        • Sgambat K.
        • Cheng Y.I.
        • Charnaya O.
        • Moudgil A.
        The prevalence and outcome of children with failure to thrive after pediatric kidney transplantation.
        Pediatr Transplant. 2019; 23: e13321
        • Nelms C.L.
        Optimizing enteral nutrition for growth in pediatric Chronic Kidney Disease (CKD).
        Front Pediatr. 2018; 6: 214
        • Watson A.R.
        • Coleman J.E.
        • Warady B.A.
        When and how to use nasogastric and gastrostomy feeding for nutritional support in infants and children on CAPD/CCPD.
        in: Fine R.N. Alexander S.R. Warady B.A. CAPD/CCPD in Children. Springer US, Boston, MA1998: 281-300
        • Warady B.A.
        • Bakkaloglu S.
        • Newland J.
        • et al.
        Consensus guidelines for the prevention and treatment of catheter-related infections and peritonitis in pediatric patients receiving peritoneal dialysis: 2012 update.
        Perit Dial Int. 2012; 32 Suppl 2: S32-S86
        • Marlais M.
        • Stojanovic J.
        • Jones H.
        • Cleghorn S.
        • Rees L.
        Catch-up growth in children with chronic kidney disease started on enteral feeding after 2 years of age.
        Pediatr Nephrol. 2020; 35: 113-118
        • Coleman J.
        • Watson A.
        • Rance C.
        • Moore E.
        Gastrostomy buttons for nutritional support on chronic dialysis.
        Nephrol Dial Transplant. 1998; 13: 2041-2046
        • Kiffel J.
        • Rahimzada Y.
        • Trachtman H.
        Focal segmental glomerulosclerosis and chronic kidney disease in pediatric patients.
        Adv Chronic Kidney Dis. 2011; 18: 332-338
        • Rodig N.M.
        • Roem J.
        • Schneider M.F.
        • et al.
        Longitudinal outcomes of body mass index in overweight and obese children with chronic kidney disease.
        Pediatr Nephrol. 2021; 36: 1851-1860
        • Roberts M.J.
        • Mitsnefes M.M.
        • McCulloch C.E.
        • et al.
        Association between BMI changes and mortality risk in children with end-stage renal disease.
        Pediatr Nephrol. 2019; 34: 1557-1563
        • Foster B.J.
        • Kalkwarf H.J.
        • Shults J.
        • et al.
        Association of chronic kidney disease with muscle deficits in children.
        J Am Soc Nephrol. 2011; 22: 377-386
        • Rashid R.
        • Neill E.
        • Smith W.
        • et al.
        Body composition and nutritional intake in children with chronic kidney disease.
        Pediatr Nephrol. 2006; 21: 1730-1738
        • Clark S.L.
        • Denburg M.R.
        • Furth S.L.
        Physical activity and screen time in adolescents in the chronic kidney disease in children (CKiD) cohort.
        Pediatr Nephrol. 2016; 31: 801-808
        • Abraham A.G.
        • Mak R.H.
        • Mitsnefes M.
        • et al.
        Protein energy wasting in children with chronic kidney disease.
        Pediatr Nephrol. 2014; 29: 1231-1238
        • Stabouli S.
        • Polderman N.
        • Nelms C.L.
        • et al.
        Assessment and management of obesity and metabolic syndrome in children with CKD stages 2-5 on dialysis and after kidney transplantation-clinical practice recommendations from the pediatric renal nutrition taskforce.
        Pediatr Nephrol. 2022; 37: 1-20
        • Nourbakhsh N.
        • Rhee C.M.
        • Kalantar-Zadeh K.
        Protein-energy wasting and uremic failure to thrive in children with chronic kidney disease: they are not small adults.
        Pediatr Nephrol. 2014; 29: 2249-2252
        • Fouque D.
        • Kalantar-Zadeh K.
        • Kopple J.
        • et al.
        A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease.
        Kidney Int. 2008; 73: 391-399
        • Iyengar A.
        • Raj J.M.
        • Vasudevan A.
        Protein energy wasting in children with chronic kidney disease and end-stage kidney disease: an observational study.
        J Ren Nutr. 2021; 31: 270-277
        • Secker D.J.
        • Jeejeebhoy K.N.
        How to perform subjective global nutritional assessment in children. J.
        Acad Nutr Diet. 2012; 112: 424-431.e6
        • Mak R.H.
        Cachexia in children with chronic kidney disease: challenges in diagnosis and treatment.
        Curr Opin Support Palliat Care. 2016; 10: 293-297
      2. National Institutes of health: causes of chronic kidney disease.
        • de Ferris M.E.D.-G.
        • Villar-Vilchis M.D.
        • Guerrero R.
        • et al.
        Self-management and health care transition among adolescents and young adults with chronic kidney disease: medical and psychosocial considerations.
        Adv Chron Kidney Dis. 2017; 24: 405-409
        • Raina R.
        • Wang J.
        • Krishnappa V.
        • Ferris M.
        Pediatric renal transplantation: focus on current transition care and proposal of the “RISE to transition” protocol.
        Ann Transplant. 2018; 23: 45-60
        • Bell L.E.
        • Ferris M.E.
        • Fenton N.
        • Hooper S.R.
        Health care transition for adolescents with CKD—the journey from pediatric to adult care.
        Adv Chron Kidney Dis. 2011; 18: 384-390
        • Ketteler M.
        • Block G.A.
        • Evenepoel P.
        • et al.
        Diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder: Synopsis of the kidney disease: improving global outcomes 2017 clinical practice guideline update.
        Ann Intern Med. 2018; 168: 422-430
        • Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group
        KDIGO clinical practice guideline for the care of kidney transplant recipients.
        Am J Transplant. 2009; 9: S1-S155
        • Wanner C.
        • Tonelli M.
        Kidney disease: improving global outcomes lipid guideline development work group members. KDIGO clinical practice guideline for lipid management in CKD: summary of recommendation statements and clinical approach to the patient.
        Kidney Int. 2014; 85: 1303-1309