Skip to main content

Advertisement

SpringerLink
Log in

The malnutrition and inflammation axis in pediatric patients with chronic kidney disease

  • Original Article
  • Published:
Pediatric Nephrology Aims and scope Submit manuscript

Abstract

Malnutrition and inflammation are closely linked in adult chronic kidney disease (CKD) patients and are both related to poor outcome, but data on pediatric patients are lacking. To describe the prevalence of inflammation, evaluate nutritional status, their correlation to each other, and their possible determinants in pediatric patients with CKD in predialysis, on hemodialysis (HD), and peritoneal dialysis (PD) who were submitted to demographic, nutritional, and inflammatory evaluations. Patients’ nutritional status was evaluated according to anthropometric parameters and body composition assessed by measurements of skinfold thickness and bioelectrical impedance. Inflammation was assessed by measurement of highly sensitive C-reactive protein (CRP), ferritin, and albumin. Patients with CRP >1 mg/l were considered inflamed. Sixty-four pediatric patients (mean age 9 ± 4 years-, 40% on HD, 22% on PD, and 38% predialysis) were studied. Mean CRP concentration was 3.4 ± 6.5 mg/l (median 0.78 mg/l, range 0.78−33.4 mg/l), and 41% presented CRP levels above 1 mg/l. Mean ferritin was 148 ± 197 mg/dl and was above the normal reference values in 28% of patients. On the other hand, mean albumin was 3.9 ± 0.5 mg/dl, below reference value in only 13% of patients. A larger proportion of HD patients (52%) were inflamed compared with those on PD (31%; p < 0.05). Malnutrition prevalence varied from 5% to 65% according to the method used. While inflamed patients presented lower serum bicarbonate and were on HD for a longer time, there were no consistent associations between malnutrition and inflammation. Inflammation is highly prevalent in the pediatric CKD population and was not consistently related to malnutrition. Other risk factors linked to high mortality and morbidity (acidosis and longer time on dialysis) were associated with inflammation. Prospective studies will need to analyze the predictive value of inflammation and malnutrition markers in the pediatric CKD population.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Offner G, Latta K, Hoyer PF, Baum HJ, Ehrich JH, Pichlmayr R, Brodehl J (1999) Kidney transplanted children come of age. Kidney Int 55:1509–1517

    Article  CAS  PubMed  Google Scholar 

  2. Goodman WG, Goldin J, Kuizon BD, Yoon C, Gales B, Sider D, Wang Y, Chung J, Emerick A, Greaser L, Elashoff RM, Salusky IB (2000) Coronary-artery calcification in young adults with end-stage renal disease who are undergoing dialysis. N Engl J Med 342:1478–1483

    Article  CAS  PubMed  Google Scholar 

  3. 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 

  4. Mitsnefes MM (2005) Cardiovascular morbidity and mortality in children with chronic kidney disease in North America: lessons from the USRDS and NAPRTCS databases. Perit Dial Int 25(Suppl 3):S120–S122

    Article  PubMed  Google Scholar 

  5. Cheung AK, Sarnak MJ, Yan G, Dwyer JT, Heyka RJ, Rocco MV, Teehan BP, Levey AS (2000) Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients. Kidney Int 58:353–362

    Article  CAS  PubMed  Google Scholar 

  6. Oh J, Wunsch R, Turzer M, Bahner M, Raggi P, Querfeld U, Mehls O, Schaefer F (2002) Advanced coronary and carotid arteriopathy in young adults with childhood-onset chronic renal failure. Circulation 106:100–105

    Article  PubMed  Google Scholar 

  7. Nascimento MM, Pecoits-Filho R, Qureshi AR, Hayashi SY, Manfro RC, Pachaly MA, Renner L, Stenvinkel P, Lindholm B, Riella MC (2004) The prognostic impact of fluctuating levels of C-reactive protein in Brazilian haemodialysis patients: a prospective study. Nephrol Dial Transplant 19:2803–2809

    Article  CAS  PubMed  Google Scholar 

  8. Qureshi AR, Alvestrand A, Divino-Filho JC, Gutierrez A, Heimburger O, Lindholm B, Bergstrom J (2002) Inflammation, malnutrition, and cardiac disease as predictors of mortality in hemodialysis patients. J Am Soc Nephrol 13(Suppl 1):S28–S36

    Article  PubMed  Google Scholar 

  9. Libetta C, De Nicola L, Rampino T, De Simone W, Memoli B (1996) Inflammatory effects of peritoneal dialysis: evidence of systemic monocyte activation. Kidney Int 49:506–511

    Article  CAS  PubMed  Google Scholar 

  10. Pecoits-Filho R, Barany P, Lindholm B, Heimburger O, Stenvinkel P (2002) Interleukin-6 is an independent predictor of mortality in patients starting dialysis treatment. Nephrol Dial Transplant 17:1684–1688

    Article  CAS  PubMed  Google Scholar 

  11. Lowrie EG, Lew NL (1990) Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 15:458–482

    Article  CAS  PubMed  Google Scholar 

  12. Besbas N, Ozdemir S, Saatci U, Coskun T, Ozen S, Topaloglu R, Bakkaloglu A, El Nahas AM (1998) Nutritional assessment of children on haemodialysis: value of IGF-I, TNF-alpha and IL-1beta. Nephrol Dial Transplant 13:1484–1488

    Article  CAS  PubMed  Google Scholar 

  13. 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 

  14. Foster BJ, Leonard MB (2004) Measuring nutritional status in children with chronic kidney disease. Am J Clin Nutr 80:801–814

    Article  CAS  PubMed  Google Scholar 

  15. Stenvinkel P, Heimburger O, Paultre F, Diczfalusy U, Wang T, Berglund L, Jogestrand T (1999) Strong association between malnutrition, inflammation, and atherosclerosis in chronic renal failure. Kidney Int 55:1899–1911

    Article  CAS  PubMed  Google Scholar 

  16. 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

    Article  CAS  PubMed  Google Scholar 

  17. Cockcroft DW, Gault MH (1976) Prediction of creatinine clearance from serum creatinine. Nephron 16:31–41

    Article  CAS  PubMed  Google Scholar 

  18. Pearson TA, Mensah GA, Alexander RW, Anderson JL, Cannon RO 3rd, Criqui M, Fadl YY, Fortmann SP, Hong Y, Myers GL, Rifai N, Smith SC Jr, Taubert K, Tracy RP, Vinicor F (2003) Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professionals from the centers for disease control and prevention and the American Heart Association. Circulation 107:499–511

    Article  PubMed  Google Scholar 

  19. K/DOQI, National Kidney Foundation (2000) Clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis 35:S1–S140

    Google Scholar 

  20. Schaefer F, Wuhl E, Feneberg R, Mehls O, Scharer K (2000) Assessment of body composition in children with chronic renal failure. Pediatr Nephrol 14:673–678

    Article  CAS  PubMed  Google Scholar 

  21. Frisancho A (1990) Anthropometric standards for the assessment of growth and nutritional status. University of Michigan Press, Ann Arbor

  22. CDC (2000) CDC Growth Charts. In https://doi.org/www.cdc.gov/growthcharts/

  23. Pecoits-Filho R, Lindholm B, Stenvinkel P (2002) The malnutrition, inflammation, and atherosclerosis (MIA) syndrome—the heart of the matter. Nephrol Dial Transplant 17(Suppl 11):28–31

    Article  CAS  PubMed  Google Scholar 

  24. Goldstein SL, Currier H, Watters L, Hempe JM, Sheth RD, Silverstein D (2003) Acute and chronic inflammation in pediatric patients receiving hemodialysis. J Pediatr 143:653–657

    Article  CAS  PubMed  Google Scholar 

  25. Watson AR (1996) Chronic renal failure in childhood. Br J Hosp Med 55:329–331

    CAS  PubMed  Google Scholar 

  26. Warady BA, Ho M (2003) Morbidity and mortality in children with anemia at initiation of dialysis. Pediatr Nephrol 18:1055–1062

    Article  PubMed  Google Scholar 

  27. Foley RN, Parfrey PS, Sarnak MJ (1998) Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 32:S112–S119

    Article  CAS  PubMed  Google Scholar 

  28. Gruppen MP, Groothoff JW, Prins M, van der Wouw P, Offringa M, Bos WJ, Davin JC, Heymans HS (2003) Cardiac disease in young adult patients with end-stage renal disease since childhood: a Dutch cohort study. Kidney Int 63:1058–1065

    Article  PubMed  Google Scholar 

  29. Mitsnefes MM (2002) Pediatric end-stage renal disease: heart as a target. J Pediatr 141:162–164

    Article  PubMed  Google Scholar 

  30. Querfeld U, Salusky IB, Nelson P, Foley J, Fine RN (1988) Hyperlipidemia in pediatric patients undergoing peritoneal dialysis. Pediatr Nephrol 2:447–452

    Article  CAS  PubMed  Google Scholar 

  31. Silverstein DM, Palmer J, Polinsky MS, Braas C, Conley SB, Baluarte HJ (2000) Risk factors for hyperlipidemia in long-term pediatric renal transplant recipients. Pediatr Nephrol 14:105–110

    Article  CAS  PubMed  Google Scholar 

  32. Cook DG, Mendall MA, Whincup PH, Carey IM, Ballam L, Morris JE, Miller GJ, Strachan DP (2000) C-reactive protein concentration in children: relationship to adiposity and other cardiovascular risk factors. Atherosclerosis 149:139–150

    Article  CAS  PubMed  Google Scholar 

  33. Lambert M, Delvin EE, Paradis G, O’Loughlin J, Hanley JA, Levy E (2004) C-reactive protein and features of the metabolic syndrome in a population-based sample of children and adolescents. Clin Chem 50:1762–1768

    Article  CAS  PubMed  Google Scholar 

  34. Haubitz M, Schulze M, Koch KM (1990) Increase of C-reactive protein serum values following haemodialysis. Nephrol Dial Transplant 5:500–503

    Article  CAS  PubMed  Google Scholar 

  35. Schindler R, Boenisch O, Fischer C, Frei U (2000) Effect of the hemodialysis membrane on the inflammatory reaction in vivo. Clin Nephrol 53:452–459

    CAS  PubMed  Google Scholar 

  36. Tielemans C, Husson C, Schurmans T, Gastaldello K, Madhoun P, Delville JP, Marchant A, Goldman M, Vanherweghem JL (1996) Effects of ultrapure and non-sterile dialysate on the inflammatory response during in vitro hemodialysis. Kidney Int 49:236–243

    Article  CAS  PubMed  Google Scholar 

  37. Mitch WE (2002) Malnutrition: a frequent misdiagnosis for hemodialysis patients. J Clin Invest 110:437–439

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Boirie Y, Broyer M, Gagnadoux MF, Niaudet P, Bresson JL (2000) Alterations of protein metabolism by metabolic acidosis in children with chronic renal failure. Kidney Int 58:236–241

    Article  CAS  PubMed  Google Scholar 

  39. Ekim M, Ikinciogullari A, Ulukol B, Bakkaloglu SA, Ozkaya N, Kendirli T, Adiyaman P, Babacan E, Ocal G (2003) Evaluation of nutritional status and factors related to malnutrition in children on CAPD. Perit Dial Int 23:557–562

    Article  CAS  PubMed  Google Scholar 

  40. Karupaiah T, Chooi CH, Lim YN, Morad Z (2002) Anthropometric and growth assessment of children receiving renal replacement therapy in Malaysia. J Ren Nutr 12:113–121

    Article  PubMed  Google Scholar 

  41. Koretz RL (1999) Does nutritional intervention in protein-energy malnutrition improve morbidity or mortality? J Ren Nutr 9:119–121

    Article  CAS  PubMed  Google Scholar 

  42. Kaysen GA, Dubin JA, Muller HG, Rosales LM, Levin NW (2000) The acute-phase response varies with time and predicts serum albumin levels in hemodialysis patients. The HEMO Study Group. Kidney Int 58:346–352

    Article  Google Scholar 

  43. Stenvinkel P, Heimburger O, Lindholm B, Kaysen GA, Bergstrom J (2000) Are there two types of malnutrition in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIA syndrome). Nephrol Dial Transplant 15:953–960

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

This study was supported by CNPq (Brazilian Council for Research Support).

Author information

Authors and Affiliations

  1. Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição, 1155, Curitiba, PR, 80215-901, Brazil

    Lucimary C. Sylvestre, Andréa E. M. Stinghen & Roberto Pecoits-Filho

  2. Hospital Infantil Pequeno Príncipe, Curitiba, Brazil

    Lucimary C. Sylvestre, Karla P. D. Fonseca & Rejane P. Meneses

  3. CAAA-Departamento de Pediatria e Hospital do Rime Hipertensão-UNIFESP/EPM, São Paulo, Brazil

    Aline Maria Pereira

Authors
  1. Lucimary C. Sylvestre
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Karla P. D. Fonseca
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andréa E. M. Stinghen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Aline Maria Pereira
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Rejane P. Meneses
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Roberto Pecoits-Filho
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Roberto Pecoits-Filho.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sylvestre, L.C., Fonseca, K.P.D., Stinghen, A.E.M. et al. The malnutrition and inflammation axis in pediatric patients with chronic kidney disease. Pediatr Nephrol 22, 864–873 (2007). https://doi.org/10.1007/s00467-007-0429-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00467-007-0429-y

Keywords

Search

Navigation