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Protein energy wasting in children with chronic kidney disease

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Abstract

Background

In adults with chronic kidney disease (CKD), protein-energy wasting (PEW) is a risk factor for hospitalization and death. However, PEW in children with CKD is not well characterized or defined.

Methods

Using data from the Chronic Kidney Disease in Children study, we assessed three alternate definitions of PEW using biochemical parameters, body and muscle mass measurements, and reported appetite as described in adults: (1) a minimal PEW definition (≥2 of the four criteria); (2) a standard PEW definition (≥3 of the four criteria); (3) a modified PEW definition (≥3 of the four criteria plus a pediatric-focused criterion of short stature or poor growth).

Results

Of the 528 children analyzed in this study (median age 12 years, median glomerular filtration rate 45 mL/min/1.73 m2, 39 % female, 18 % African American), 7–20 % met the spectrum of definitions for PEW. The unadjusted incidence rates for incident hospitalizations were 1.9-, 2.1-, and 2.2-fold higher for those children diagnosed with PEW using the minimal, standard, and modified definitions, respectively (P = 0.08, 0.09 and 0.03). Following adjustment, only the modified PEW definition, which added short stature or poor growth as a criterion, showed modest significance (P = 0.06).

Conclusions

The inclusion of a criterion based on growth may augment the definition of PEW and improve risk discrimination in children with CKD.

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References

  1. Fouque D, Kalantar-Zadeh K, Kopple J, Cano N, Chauveau P, Cuppari L, Franch H, Guarnieri G, Ikizler TA, Kaysen G, Lindholm B, Massy Z, Mitch W, Pineda E, Stenvinkel P, Trevino-Becerra A, Wanner C (2008) A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int 73:391–398

    Article  CAS  PubMed  Google Scholar 

  2. Kovesdy CP, Kalantar-Zadeh K (2009) Why is protein-energy wasting associated with mortality in chronic kidney disease? Semin Nephrol 29:3–14

    Article  CAS  PubMed  Google Scholar 

  3. Wong CS, Hingorani S, Gillen DL, Sherrard DJ, Watkins SL, Brandt JR, Ball A, Stehman-Breen CO (2002) Hypoalbuminemia and risk of death in pediatric patients with end-stage renal disease. Kidney Int 61:630–637

    Article  PubMed  Google Scholar 

  4. Menon V, Greene T, Wang X, Pereira AA, Marcovina SM, Beck GJ, Kusek JW, Collins AJ, Levey AS, Sarnak MJ (2005) C-reactive protein and albumin as predictors of all-cause and cardiovascular mortality in chronic kidney disease. Kidney Int 68:766–772

    Article  CAS  PubMed  Google Scholar 

  5. Muntner P, He J, Astor BC, Folsom AR, Coresh J (2005) Traditional and nontraditional risk factors predict coronary heart disease in chronic kidney disease: results from the atherosclerosis risk in communities study. J Am Soc Nephrol 16:529–538

    Article  PubMed  Google Scholar 

  6. Weiner DE, Tighiouart H, Elsayed EF, Griffith JL, Salem DN, Levey AS, Sarnak MJ (2008) The relationship between nontraditional risk factors and outcomes in individuals with stage 3 to 4 CKD. Am J Kidney Dis 51:212–223

    Article  CAS  PubMed  Google Scholar 

  7. Wong CS, Gipson DS, Gillen DL, Emerson S, Koepsell T, Sherrard DJ, Watkins SL, Stehman-Breen C (2000) Anthropometric measures and risk of death in children with end-stage renal disease. Am J Kidney Dis 36:811–819

    Article  CAS  PubMed  Google Scholar 

  8. Evans M, Fryzek JP, Elinder CG, Cohen SS, McLaughlin JK, Nyren O, Fored CM (2005) The natural history of chronic renal failure: results from an unselected, population-based, inception cohort in Sweden. Am J Kidney Dis 46:863–870

    Article  PubMed  Google Scholar 

  9. Kovesdy CP, Anderson JE, Kalantar-Zadeh K (2007) Paradoxical association between body mass index and mortality in men with CKD not yet on dialysis. Am J Kidney Dis 49:581–591

    Article  PubMed  Google Scholar 

  10. Kwan BC, Murtaugh MA, Beddhu S (2007) Associations of body size with metabolic syndrome and mortality in moderate chronic kidney disease. Clin J Am Soc Nephrol 2:992–998

    Article  PubMed  Google Scholar 

  11. Foster BJ, Kalkwarf HJ, Shults J, Zemel BS, Wetzsteon RJ, Thayu M, Foerster DL, Leonard MB (2011) Association of chronic kidney disease with muscle deficits in children. J Am Soc Nephrol 22:377–386

    Article  PubMed Central  PubMed  Google Scholar 

  12. Furth SL, Cole SR, Moxey-Mims M, Kaskel F, Mak R, Schwartz G, Wong C, Muñoz A, Warady BA (2006) Design and methods of the Chronic Kidney Disease in Children (CKiD) prospective cohort study. Clin J Am Soc Nephrol 1:1006–1015

    Article  PubMed Central  PubMed  Google Scholar 

  13. Schwartz GJ, Haycock GB, Edelmann CM Jr, Spitzer A (1976) A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. Pediatrics 58:259–263

    CAS  PubMed  Google Scholar 

  14. Schwartz GJ, Gauthier B (1985) A simple estimate of glomerular filtration rate in adolescent boys. J Pediatr 106:522–526

    Article  CAS  PubMed  Google Scholar 

  15. Schwartz GJ, Brion LP, Spitzer A (1987) The use of plasma creatinine concentration for estimating glomerular filtration rate in infants, children, and adolescents. Pediatr Clin N Am 34:571–590

    CAS  Google Scholar 

  16. Schwartz GJ, Furth S, Cole SR, Warady B, Munoz A (2006) Glomerular filtration rate via plasma iohexol disappearance: pilot study for chronic kidney disease in children. Kidney Int 69:2070–2077

    Article  CAS  PubMed  Google Scholar 

  17. Schwartz GJ, Munoz A, Schneider MF, Mak RH, Kaskel F, Warady BA, Furth SL (2009) New equations to estimate GFR in children with CKD. J Am Soc Nephrol 20:629–637

    Article  PubMed Central  PubMed  Google Scholar 

  18. Schwartz GJ, Schneider MF, Maier PS, Moxey-Mims M, Dharnidharka VR, Warady BA, Furth SL, Munoz A (2012) Improved equations estimating GFR in children with chronic kidney disease using an immunonephelometric determination of cystatin C. Kidney Int 82:445–453

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  19. Ogden CL, Kuczmarski RJ, Flegal KM, Mei Z, Guo S, Wei R, Grummer-Strawn LM, Curtin LR, Roche AF, Johnson CL (2002) Centers for Disease Control and Prevention 2000 growth charts for the United States: improvements to the 1977 National Center for Health Statistics version. Pediatrics 109:45–60

    Article  PubMed  Google Scholar 

  20. KDOQI Work Group (2009) KDOQI clinical practice guideline for nutrition in children with CKD: 2008 update. Executive summary (2009). Am J Kidney Dis 53:S11–S104

    Google Scholar 

  21. Centers for Disease Control and Prevention (CDC)/ National Center for Health Statistics (NCHS) (2008) National health and nutrition examination survey data. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Hyattsville. Available at: http://www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm

  22. Tanner JM (1962) Growth at adolescence. Blackwell Scientific Publication, Oxford

    Google Scholar 

  23. Haycock GB, Schwartz GJ, Wisotsky DH (1978) Geometric method for measuring body surface area: a height–weight formula validated in infants, children, and adults. J Pediatr 93:62–66

    Article  CAS  PubMed  Google Scholar 

  24. Mak RH, Cheung WW, Zhan JY, Shen Q, Foster BJ (2012) Cachexia and protein-energy wasting in children with chronic kidney disease. Pediatr Nephrol 27:173–181

    Article  PubMed Central  PubMed  Google Scholar 

  25. Kalantar-Zadeh K, Kleiner M, Dunne E, Ahern K, Nelson M, Koslowe R, Luft FC (1998) Total iron-binding capacity-estimated transferrin correlates with the nutritional subjective global assessment in hemodialysis patients. Am J Kidney Dis 31:263–272

    Article  CAS  PubMed  Google Scholar 

  26. Furth SL, Abraham AG, Jerry-Fluker J, Schwartz GJ, Benfield M, Kaskel F, Wong C, Mak RH, Moxey-Mims M, Warady BA (2011) Metabolic abnormalities, cardiovascular disease risk factors, and GFR decline in children with chronic kidney disease. Clin J Am Soc Nephrol 6:2132–2140

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  27. Little RJA, Rubin DB (2002) Statistical analysis with missing data, 2nd edn. Wiley, New York

    Google Scholar 

  28. Schafer JL (1997) Analysis of incomplete multivariate data. Chapman and Hill, New York

    Book  Google Scholar 

  29. Liang KY, Zeger SL (1986) Longitudinal data analysis using generalized linear models. Biometrika 73:13–22

    Article  Google Scholar 

  30. Mak RH, Ikizler AT, Kovesdy CP, Raj DS, Stenvinkel P, Kalantar-Zadeh K (2011) Wasting in chronic kidney disease. J Cachex Sarcopenia Muscle 2:9–25

    Article  Google Scholar 

  31. Cheung WW, Mak RH (2012) Melanocortin antagonism ameliorates muscle wasting and inflammation in chronic kidney disease. Am J Physiol Ren Physiol 303:F1315–F1324

    Article  CAS  Google Scholar 

  32. Rashid R, Neill E, Smith W, King D, Beattie TJ, Murphy A, Ramage IJ, Maxwell H, Ahmed SF (2006) Body composition and nutritional intake in children with chronic kidney disease. Pediatr Nephrol 21:1730–1738

    Article  PubMed  Google Scholar 

  33. Evans WJ, Morley JE, Argiles J, Bales C, Baracos V, Guttridge D, Jatoi A, Kalantar-Zadeh K, Lochs H, Mantovani G, Marks D, Mitch WE, Muscaritoli M, Najand A, Ponikowski P, Rossi FF, Schambelan M, Schols A, Schuster M, Thomas D, Wolfe R, Anker SD (2008) Cachexia: a new definition. Clin Nutr 27:793–799

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

The authors would like to acknowledge the efforts of Derek Ng and Rachel Zack in the analysis of the data presented in this manuscript. Data in this manuscript were collected by the Chronic Kidney Disease in children prospective cohort study (CKiD) with clinical coordinating centers (Principal Investigators) at Children’s Mercy Hospital and the University of Missouri–Kansas City (Bradley Warady, MD) and Children’s Hospital of Philadelphia (Susan Furth, MD, Ph.D.), data coordinating center at the Johns Hopkins Bloomberg School of Public Health (Alvaro Muñoz, PhD), and the Central Biochemistry Laboratory at the University of Rochester (George J. Schwartz, MD). The CKiD is funded by the National Institute of Diabetes and Digestive and Kidney Diseases, with additional funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Heart, Lung, and Blood Institute (U01 DK82194, U01-DK-66143, U01-DK-66174, and U01-DK-66116). The CKID website is located at http://www.statepi.jhsph.edu/ckid.

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Author information

Authors and Affiliations

  1. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA

    Alison G. Abraham

  2. Department of Pediatrics, UC San Diego School of Medicine, San Diego, CA, USA

    Robert H. Mak

  3. Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH, USA

    Mark Mitsnefes

  4. Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada

    Colin White

  5. Division of Kidney, Urology and Hematology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA

    Marva Moxey-Mims

  6. Department of Pediatrics, Children’s Mercy Hospitals and Clinics, Kansas City, MO, USA

    Bradley Warady

  7. Department of Pediatrics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

    Susan L. Furth

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  1. Alison G. Abraham
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  2. Robert H. Mak
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  3. Mark Mitsnefes
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  7. Susan L. Furth
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Correspondence to Alison G. Abraham.

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Abraham, A.G., Mak, R.H., Mitsnefes, M. et al. Protein energy wasting in children with chronic kidney disease. Pediatr Nephrol 29, 1231–1238 (2014). https://doi.org/10.1007/s00467-014-2768-9

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  • DOI: https://doi.org/10.1007/s00467-014-2768-9

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