Obesity and metabolic syndrome (O&MS) due to the worldwide obesity epidemic affects children at all stages of chronic kidney disease (CKD) including dialysis and after kidney transplantation. The presence of O&MS in the pediatric CKD population may augment the already increased cardiovascular risk and contribute to the loss of kidney function. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. We present CPRs for the assessment and management of O&MS in children with CKD stages 2–5, on dialysis and after kidney transplantation. We address the risk factors and diagnostic criteria for O&MS and discuss their management focusing on non-pharmacological treatment management, including diet, physical activity, and behavior modification in the context of age and CKD stage. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT.
Optimizing cardiovascular (CV) health is one of the major treatment goals in patients with chronic kidney disease (CKD) since CV disease contributes to significant morbidity and mortality . Unfortunately, children with CKD have an increased prevalence of traditional CV risk factors , even in the absence of overt kidney dysfunction. The cluster of cardio-metabolic risk factors, referred to as metabolic syndrome (MS), affects children at all stages of CKD, including those on dialysis and after a kidney transplant, due to the worldwide obesity epidemic [3, 4].
The prevalence of MS in children with CKD is currently reported at 15–30% [2, 5, 6], higher than the 3.8–9.8% prevalence in European and United States (US) general adolescent populations [7, 8]. Registry data suggests that obesity may affect CKD progression, patient mortality, access to transplantation, and graft function [9,10,11]. Studies on MS in children with CKD and kidney transplantation highlight the adverse effects of cardio-metabolic risk factors, in addition to obesity, on outcomes [5, 6, 12,13,14,15]. Finally, emerging evidence that obesity can impair kidney function, even in otherwise healthy obese adolescents , highlights the importance of managing cardio-metabolic risk factors in children with pre-existing kidney diseases.
The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric nephrologists and pediatric renal dietitians, provides clinical practice recommendations (CPRs) on various aspects of the dietary management of children with CKD. In this CPR, we discuss the management of obesity and metabolic syndrome (O&MS) in children and adolescents with CKD stages 2–5 and on dialysis, as well as after kidney transplantation, focusing on non-pharmacological treatment (diet, physical activity and behavior modification). As with all CPRs produced by the PRNT, resources for the practical management of O&MS will be developed by the Taskforce during the dissemination phase of the guideline .
The composition of the PRNT and the full development process for the CPRs and their purpose, search criteria, grading of evidence, and plans for audit and revision of the CPRs is described in previous PRNT guidelines . PICO questions and literature search are described in the supplementary material. Consensus from consideration of the PICO questions led to specific recommendations.
Clinical practice recommendations
How is O&MS defined?
Children aged 2–5 years:
We define overweight as weight-for-height for age > +2SD, using the World Health Organization (WHO) child growth standard chart.
We define obesity as weight-for-height for age > +3SD, using the WHO child growth standard chart.
Children aged > 5 years:
We define overweight as body mass index (BMI) for age > +1SD, equivalent to BMI > 25 kg/m2 at 19 years, using the WHO growth reference chart or a country-specific growth chart.
We define obesity as BMI for age > +2SD, equivalent to BMI > 30 kg/m2 at 19 years, using the WHO growth reference chart or a country-specific growth chart.
Children aged 2–18 years:
We define metabolic syndrome as the presence of overweight or obesity and at least 2 of 4 additional CV risk factors:
Systolic and/or diastolic office blood pressure (BP) ≥ 90th centile for age, sex and height or ≥ 130/80 mmHg, whichever is lower, or on anti-hypertensive medication
Fasting triglycerides ≥ 100 mg/dL (1.1 mmol/L) if age < 10 years, or ≥ 130 mg/dL (1.5 mmol/L) if age ≥ 10 years
Fasting high-density lipoprotein (HDL) < 40 mg/dL (1.03 mmol/L)
Fasting serum glucose ≥ 100 mg/dL (5.6 mmol/L) or known type 2 diabetes mellitus (T2DM)
We recommend using BMI-height-age to define overweight or obesity in children who are below the 3rd centile for height and have not reached their final adult height (Level B; moderate recommendation).
Evidence and rationale
Definitions of MS in the general pediatric population
Several scientific organizations have provided consensus definitions for MS in children and adolescents [18, 19] (Table 1). Obesity, especially abdominal, is considered the main pathophysiological drive for the evolution of cardio-metabolic risk factors in healthy children and adolescents . However, not all definitions of O&MS have included overweight or obesity as a prerequisite for the definition of metabolic syndrome. Further discrepancies among definitions are due to different thresholds for other components. The use of various definitions may result in different prevalence numbers and different attributable risk levels for future adverse cardio-metabolic outcomes .
The significance of a clustering of CV risk is highlighted by the hallmark Bogalusa Heart Study showing the effect of increasing number of childhood CV risk factors on atherosclerotic lesions . Similarly, the Young Finns Study has shown that the number of CV risk factors in 12- to 18-year-olds was directly related to carotid intima media thickness (cIMT) measured in young adults at ages 33–39 years . In the Pathobiological Determinants of Atherosclerosis in Youth Study, CV risk factors were associated with atherosclerotic lesions in the left anterior descending coronary artery, right coronary artery, and abdominal aorta in persons aged 15 to 34 years who died from external causes . An AAP publication pointed out limitations of using MS definitions in pediatrics, including the instability of definitions over time and at transition from adolescence to adulthood .
Performance of previous O&MS syndrome definitions in CKD patients
O&MS is of particular concern in kidney transplant recipients (Table 2). Studies in adults have mostly used the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) definition for MS, but there is heterogeneity among the definitions used in pediatric studies (Table 1) [5, 6, 12,13,14, 20, 21, 27,28,29]. Nevertheless, most studies have found an association of O&MS with declining kidney function and CV outcome, independent of the definition used [5, 6, 12,13,14, 27]. No clear conclusion on the superiority of any single definition can be drawn as study designs have not provided head-to-head comparisons.
Definition of O&MS components by the PRNT
Children with CKD have an increased prevalence of cardio-metabolic risk factors, independent of weight status . Therefore, using overweight or obesity as a necessary criterion to define MS in children with CKD is important in order to emphasize the additive effect of adiposity on the cardio-metabolic risk profile, although it is not possible to differentiate the discrete impact of kidney disease and obesity in a given individual (Fig. 1). The definition proposed by the PRNT is consistent with the concept proposed by the International Diabetes Federation and AAP that obesity and overweight are central to the definition of MS and CV risk clustering [18, 25]. In this PRNT CPR, we use BMI for age or BMI-height-age to define overweight and obesity. Although central adiposity is well recognized for identifying MS, only a few studies in pediatric CKD patients have used waist circumference or waist-to-height ratio to define obesity with conflicting results on the clinical superiority of these measurements over BMI; these measurements need further research before being widely recommended in clinical practice [26, 30]. In addition, waist measurement in children on peritoneal dialysis (PD), or in those with an increased abdominal girth, such as patients with autosomal recessive polycystic kidney disease, nephrotic syndrome and ascites, and those on steroid treatment, may not represent true visceral adiposity, thereby limiting the routine use of waist circumference and waist-to-height ratio in all children with CKD. The PRNT Assessment of Nutritional Status CPR previously discussed the rationale of using BMI-height-age for children shorter than the 3rd height centile who had not reached their final height . Finally, data from the Pediatric Growth and Development Special Study (PGDSS) from the US Renal Data System showed increased mortality rates and decreased access to transplantation in obese children using BMI SDS values, supporting the clinical value of BMI to define obesity [10, 11].
Children with CKD are at increased risk for CV morbidity and mortality . Assuming that the proposed thresholds defining MS components would also serve as thresholds for treatment, it was the consensus among PRNT members to introduce lower thresholds for these parameters in children with CKD2-5D and after transplantation than in healthy children for several MS components.
Height BP centile thresholds for O&MS should more accurately reflect the BP thresholds for children and adolescents with CKD and compromised growth. The 2021 Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline on the management of BP in CKD introduced a BP target < 130/80 mmHg in kidney recipients or lower if tolerated in non-transplant adult CKD patients . In children, evidence is limited. The European Society of Hypertension guidelines recommend BP targets lower than the 50th and 75th centiles for age, sex, and height in proteinuric and non-proteinuric pediatric CKD patients, respectively [33, 34]. These recommendations are based on the ESCAPE study, a large, randomized trial on intensified BP control in children with CKD showing slower progression of CKD when using these BP targets . Also, in the few available studies in children with CKD that examined the effect of MS on subclinical target organ damage or disease progression, the use of 95th BP centile for age, sex, and height was consistently associated with adverse associations. Thus, lower BP limits might be considered in this population vulnerable to adverse CV outcomes. The use of the 90th centile threshold in children, when it is lower than 130/80 mmHg (the therapeutic BP target for adult CKD patients according to KDIGO), has been considered appropriate to be included in the current definition of MS in children with CKD2-5D and after transplantation.
For triglycerides and HDL cholesterol, the thresholds for healthy children are used for the definition of MS . This is despite the fact that HDL molecules are dysfunctional in CKD patients and have reduced protective or even a pro-atherogenic vascular effect . With regard to glucose metabolism, it seems prudent to maintain the diagnostic criteria for diabetes  in children with CKD and O&MS.
How is O&MS assessed?
Calculate BMI or weight-for-height and plot on centile growth charts (level A; strong recommendation)
Calculate z-scores (standard deviation scores (SDS)) to complement growth chart plots (level X; strong recommendation).
Utilize trends in growth parameters to assist clinical decision-making (level D; weak recommendation).
Measure BP, fasting TG, HDL, and glucose levels in children with CKD2-5D and after transplantation if BMI > +1 SD (level A; strong recommendation).
Evaluate for MS risk factors, including focused history and physical exam, biochemical measurements for comorbidities, and assessment of cardio-metabolic risk factors (level C; weak recommendation).
Evaluate lifestyle habits, including diet, physical activity, sleep, and screen time (level C; weak recommendation).
The frequency of assessment should be individualized based on the child’s CV risk factors, disease severity and progression and the presence of comorbidities (Ungraded).
Evidence and rationale
The assessment of children with CKD and O&MS is described in Table 3. A detailed document on the assessment of nutritional status in children with CKD has been published by the PRNT . These CPRs suggest the minimum frequency of assessment given that children with CKD and O&MS are at higher risk for CV disease. Regular assessment of BP status by Ambulatory Blood Pressure Monitoring (ABPM), in addition to office BP measurement, has already been incorporated into the routine care of CKD patients [32, 33, 38].
Risk factors and comorbidities
Genetic, environmental, and perinatal factors determine the risk of O&MS in healthy children. Extensive evidence has highlighted the role of modifiable risk factors for O&MS, including poor nutritional habits, physical inactivity, excessive screen time, and short sleep duration, as well as non-modifiable risk factors, including parental obesity, maternal gestational diabetes, low birth weight, and rapid catch-up growth . Obesity and insulin resistance share common pathogenetic mechanisms for causing comorbidities including non-alcoholic fatty liver disease (NAFLD), polycystic ovary syndrome (PCOS), obstructive sleep apnea, hyperuricemia, anxiety, and depression [25, 39]. In a large cohort of obese children, high levels of uric acid were independently associated with lower glomerular filtration rate (GFR) and NAFLD . Although hard CV outcomes related to O&MS may not be seen until adulthood, subclinical organ damage may start from childhood. Left ventricular hypertrophy (LVH) is common and its prevalence increases with the number of CV clustering factors in addition to obesity .
Risk factors for the development of O&MS in children with CKD are those reported in the general pediatric population, including poor nutritional habits, lack of physical activity, and excessive screen time. Poor nutritional habits, including high energy intake and fast-food consumption, were reported in children with non-dialysis CKD in the Chronic Kidney Disease in Childhood (CKiD) cohort and are comparable to the general pediatric population [42, 43]. Moreover, children in the CKiD cohort had more sedentary behaviors compared to healthy youth from the National Health and Nutrition Examination Survey (NHANES) . Hyperuricemia is frequent in children with CKD and associated with increased BMI, hypertension, and albuminuria . Perinatal factors, including birth weight and maternal diabetes and obesity that are known risk factors for O&MS in the general pediatric population, are also associated with a higher risk of developing congenital anomalies of the kidney and urinary tract (CAKUT) . Thus, common perinatal factors increase the risk of CAKUT at birth and subsequently increase the risk of O&MS.
In children with CKD, additional risk factors for the development of O&MS include disease-specific factors, CKD-related dietary modifications, enteral tube feeding, and treatment-related effects (Fig. 1). Steroid use after kidney transplantation is a major risk factor for the development of O&MS . In a multicenter, randomized, open-label study in pediatric kidney transplant recipients, steroid withdrawal was associated with a significantly reduced incidence of MS .
Treatment with mTOR inhibitors may promote severe dyslipidemia in children after kidney transplantation . Moreover, children with specific underlying kidney diseases, including cystic kidney diseases, nephropathic cystinosis, and Bardet–Biedl and Alstrom syndromes, are at greater risk of developing new onset diabetes after transplantation as well as other cardio-metabolic risk factors and subsequently O&MS .
Despite dietary excesses, some obese children may have inadequate protein intake that may contribute to sarcopenia. Sarcopenia, a condition characterized by progressive and generalized loss of muscle mass and strength , is more commonly seen in the frail and elderly, but may also be present in young obese people with or without CKD . Several risk factors can lead to muscle loss in CKD, including the kidney disease itself, the dialysis procedure, chronic low-grade inflammation, metabolic acidosis, and vitamin D deficiency that together increase protein catabolism, decrease protein synthesis, and lead to a negative protein balance . In obese CKD patients, obesity per se may act as a pro-inflammatory factor due to adipocyte dysfunction, characterized by increased synthesis of cytokines and chemokines (adipokines) that occurs as a consequence of adipocyte hypertrophy and hypoxia . In addition, metabolic acidosis acts as a potent stimulator of protein catabolism and can promote insulin, triggering a vicious cycle of worsening sarcopenia [51,52,53]. Obesity can mask underlying muscle wasting and, although uncommon in children, must be considered in the evaluation of CKD patients. Hand grip strength has been used to assess children at risk of obese sarcopenia .
Relations of O&MS with outcomes in children with CKD
Few studies in children with CKD and O&MS, largely in children after kidney transplantation, have studied the effect on outcomes such as graft function and subclinical CV damage (Table 2). In 234 kidney transplant recipients from 6 centers in the Midwest Pediatric Nephrology Consortium, MS associated with 2.6 times higher odds for post-transplant LVH with 3 times higher odds of eccentric LVH post-transplant . The latter finding is consistent with a large single-center prospective study in adults showing association of MS with higher frequency of CV events in about 2,000 kidney recipients . In non-dialysis CKD children from the CKiD cohort, the odds of LVH were 1.5-fold higher in boys and 3.1-fold higher in girls for each 1-unit higher BMI z-score . In view of this evidence, along with data from the healthy pediatric population indicating the early effects of O&MS, we recommend that children with O&MS and CKD2-5D or after kidney transplantation should have yearly echocardiography (Table 3).
Increased cIMT has been associated with hypertension and dyslipidemia , and higher pulse wave velocity (PWV) with BMI and fat mass in pre-dialysis children , but the clinical value of these findings needs to be validated by future studies. Measurement of cIMT or PWV for assessment of vascular subclinical damage is not advised.
How is O&MS managed?
We suggest a comprehensive multicomponent intervention that includes a nutrition care plan, physical activity prescription, and behavioral modification to reduce BMI and improve components of the MS (ungraded).
We recommend an individualized energy intake, adjusted for age, CKD stage, dialysis, and comorbidities, to achieve weight loss or weight maintenance in children without compromising their nutrition (ungraded).
The nutrition care plan should aim to improve the overall diet quality, with an emphasis on an intake composed primarily of fruits and vegetables, whole grains, low- or non-fat dairy products, pulses (peas, beans, lentils), fish and lean meat, and avoidance of sugar-sweetened beverages, highly processed foods, and foods high in saturated fat (level B; weak recommendation).
In children who are enterally tube fed, the energy content of the formula must be frequently reviewed and adjusted to avoid development of underweight or overweight (level B; moderate recommendation).
We recommend that children engage in daily physical activity with intensity and duration individualized according to age, physical tolerance, CKD stage, and comorbidities (level B; moderate recommendation).
Behavioral modifications, including regular and adequate sleep, reduction of screen time, and managing psychosocial stressors, should be tailored to the individual child and their family’s needs. Counseling or psychological support may be warranted (level D; weak recommendation).
We do not recommend the use of anti-obesity medications in children with CKD2-5D or with a kidney transplant and O&MS (ungraded).
Weight loss surgery may be considered in a selected subgroup of children with CKD2-5D or with a kidney transplant and O&MS when all other interventions have failed. Patients who may be considered for weight loss surgery include:
Adolescents with extreme obesity (BMI ≥ 40 kg/m2) and other comorbidities associated with long-term risks (Level C; weak recommendation)
Adolescents with BMI ≥ 35 kg/m2 with specific obesity-related comorbidities including T2DM, severe steatohepatitis, pseudotumor cerebri, and moderate-to-severe obstructive sleep apnea (Level C; weak recommendation)
Evidence and rationale
In the general pediatric population, a meta-analysis on the health effects of adherence to a Mediterranean diet found improvements in BMI and waist circumference in most, but not all studies . One systematic review found that the Dietary Approaches to Stop Hypertension (DASH) diet in adolescents had beneficial effects on BP, overweight and obesity . A systematic review and meta-analysis on the effects of low glycemic index/low glycemic load dietary regimens provided evidence of a beneficial effect of such a diet pattern when looking for alternative regimens in the management of obese children and adolescents . Whereas very low energy diets providing less than 800 kcal/day may be effective for treating children and adolescents with obesity, conclusions with respect to their overall safety are unclear . While the quality of evidence is generally low, findings of one meta-analysis involving over 400 children and adolescents from 9 randomized controlled trials (RCTs) suggested that modulation of gut microbiota through probiotics and synbiotic supplements did not have favorable effects in the management of overweight and obese children and adolescents .
No single dietary modification is effective in the management of O&MS in all children with CKD. Data from the CKiD cohort suggests that several aspects of the usual dietary intake of these children put them at risk for O&MS. On average, they were found to have intakes in excess of age-appropriate amounts for energy, sodium, and phosphorus [42, 64]. Fast foods contributed a large percentage of this intake. Food sources with the highest amounts of dietary fats, primarily saturated fat, were processed foods. Consumption of excess “empty calories” foods was also prevalent . There is no evidence supporting the use of a specific diet pattern in children with CKD2-5D or with a kidney transplant and O&MS. In a single-center study, yearly tailored dietary assessment and counselling had a poor effect on preventing post-transplantation weight gain in children, suggesting the need for more comprehensive interventions to reduce post-transplant obesity . Healthy dietary patterns, including Mediterranean and DASH diets, have been associated with reduced chronic disease incidence and improved CV and kidney outcomes in the general adult population [66, 67]. In a recent meta-analysis, higher adherence to a healthy dietary pattern was associated with a 28% lower risk of kidney disease in an analysis of 8 prospective adult cohort studies .
Cardio-protective mechanisms of the Mediterranean and DASH diets are largely driven by improved lipid, glycemic, and BP control. In adults, the DASH, Nordic, and Mediterranean diets have been shown to significantly lower systolic BP and diastolic BP . A Cochrane review on dietary interventions in adults with CKD, including a carbohydrate-restricted, low-iron, polyphenol-enriched diet; increased fruit and vegetable intake; Mediterranean diet; and high-protein, low-carbohydrate diet, showed no impact on BMI, but beneficial effects on BP and lipid levels. Of note, all the studies included in the Cochrane review were designed to assess CV and total mortality but failed to show any effect of dietary modification on primary outcome .
Although not specific to pediatrics, the European Renal Nutrition (ERN) Working Group of the European Renal Association-European Dialysis Transplant Association (ERA-EDTA) promotes the Mediterranean diet as the preferred diet for adults with CKD . Adjustments through choice of low-potassium fruits and vegetables and potassium-lowering medications may be necessary. The intake of a more favorable fat profile, low glycemic index, high fruit, vegetable and fiber intake, low-sodium intake, reduced acid load, and the promotion of non-processed foods are all features consistent with standard recommendations for obesity prevention and improved kidney health.
In healthy children with O&MS, attainment of BMI below overweight threshold is usually targeted . A BMI reduction of −0.25 SDS has been reported to result in significantly improved BP, triglycerides, and HDL levels . Still, individualized energy intake according to age, CKD stage, dialysis, and comorbidities in order to achieve normal growth should be provided according to PRNT recommendations for energy requirements in children with CKD2-5D . In children on PD, the energy intake from dialysate must be considered, with a report of 9.08 ± 4.13 kcal/kg/day contributing to total energy intake , with variation depending on peritoneal glucose exposure and peritoneal membrane transporter status. Dietary modifications for CKD and enteral tube feeding to protect from underweight may also increase the risk of developing obesity if not carefully managed [4, 74]; these issues have been discussed in the PRNT’s recommendations on enteral feeding .
In the general pediatric population, a meta-analysis of studies including 2239 overweight and obese children and adolescents showed that thrice weekly 50-min sessions of aerobic and combined aerobic and strength training exercise were associated with a reduction in BMI z-score . There is a consistent favorable impact of exercise on both anthropometric and cardio-metabolic parameters, with variable improvements in body weight, body fat percentage, waist circumference, and cardio-metabolic parameters . A systematic review found that structured physical activity interventions decreased energy intake in obese but otherwise healthy adolescents . Expert recommendations for physical activity for healthy children and adolescents from numerous professional organizations suggest 60 min of physical activity daily, ideally with a combination of aerobic, stretching, flexibility, and balance, with muscle and bone strengthening activities included [19, 78].
Compared to the 2012 NHANES survey, adolescents in the CKiD study self-reported engaging in significantly less physical activity and greater screen time compared to healthy adolescents in the NHANES population . Only 13% of the children with CKD met current physical activity recommendations and 98% exceeded recommended daily screen time. Screen time is associated with obesity and lower GFR. Similar results have been reported in a single-center study that included non-dialysis and dialysis patients and kidney transplant recipients using objective measurements of physical activity and performance by 7-day pedometer assessment and 6-min walk distance . Cardiorespiratory fitness by treadmill exercise testing (VO2max) is lower in children with non-dialysis CKD3-4, on dialysis and after kidney transplantation, and is associated with the presence of obesity and cardio-metabolic risk factors [80, 81]. The exercise capacity does not seem to improve after kidney transplantation and negatively associates with increase in fat weight [82, 83].
Kidney function is a key determinant of exercise capacity in CKD patients. Low physical activity in children with CKD may be explained by poor exercise tolerance and early fatigue due to anemia, inflammation, and the effects of uremia and metabolic acidosis on skeletal muscles and the heart [84, 85]. Advanced CKD is associated with deficits in lean leg mass and muscle wasting . There is evidence that exercise may result in a transient worsening of pre-existing metabolic acidosis which may, in turn, reverse the normal anabolic effects of exercise .
Understanding an individual’s physical capability is paramount when advising an exercise prescription which, ideally, should involve the child and the family and be customized to their individual capacity and comorbidities. Aerobic physical activity may be advised daily. Also, muscle strengthening activities 2–3 times per week, or as tolerated, should be considered to improve muscle mass and enhance individual tolerance . Small studies in children with CKD have shown mixed results with regards to feasibility of exercise programs and long-term adherence [88, 89]. Although evidence is limited, intradialytic exercise may be considered as an option for children on maintenance hemodialysis. Ongoing and consistent attention to adequate physical activity must be addressed and re-enforced during clinic visits.
Studies in the general pediatric population suggest that longer sleep duration is associated with lower adiposity scores and better quality of life . An overview of 39 systematic reviews reported a strong association between sleep duration and reduced adiposity and improved emotional outcomes, but the effect on cardio-metabolic outcomes was variable . In addition to sleep duration, there are reports of sleep quality and its association with obesity . Sleep disturbances are common in children with CKD , but there are no studies on the effect of poor sleep duration or sleep quality on the incidence of O&MS in this patient group.
Systematic reviews in the general pediatric population indicate an association between increased screen time and poorer diet , with increased energy intake and increased adiposity , but only limited evidence showing a direct relationship with cardio-metabolic outcomes [95, 96]. In line with this and as noted previously, data from the CKiD cohort showed that increased screen time is associated with increased rates of obesity .
Psychosocial stressors may lead to emotional or comfort eating, lack of sleep, impulsive and selective food behaviors, as well as higher levels of cortisol and catecholamine secretion, contributing to the development of central O&MS . Although there are no studies of the impact of psychological stress and emotional response on O&MS in children with CKD, there are several such studies involving adult CKD patients. While there is awareness of weight problems and the benefit of weight loss, adult dialysis patients report barriers to successfully addressing weight related issues such as lack of motivation, time, money, resources, and knowledge regarding strategies to achieve weight loss goals .
Currently, five anti-obesity drugs have been approved by the US Food and Drug Administration (FDA) for long-term use in adults without kidney disorders. Randomized trials in adults suggest that the weight lowering potential of these five anti-obesity drugs appears to be in the following descending order: phentermine/topiramate, liraglutide, naltrexone/bupropion, lorcaserin, and orlistat . Lorcaserin and orlistat allow easier dosing and better tolerability compared to other approved anti-obesity drugs.
There are no RCTs of anti-obesity medications in children or adults with kidney disorders. In obese adolescents without kidney disorders, RCTs have shown conflicting results. Although orlistat did not significantly reduce BMI in comparison with placebo at 6 months , a longer-term RCT found that in combination with diet, exercise, and behavioral modification, orlistat did significantly improve weight management compared with placebo at 1-year follow-up . Importantly, orlistat has been implicated in causing acute kidney injury in patients with CKD with calcium oxalate crystal deposition in the lumen of the kidney tubules. Given these safety issues and the absence of studies in this cohort, we do not recommend the use of orlistat or other anti-obesity medications in children with kidney disorders.
There is emerging evidence that bariatric surgery (BS) in obese adolescents with and without diabetes may prevent or even reverse kidney abnormalities. The results from the Teen Longitudinal Assessment of BS (Teen-LABS) study, a multicenter study of 242 adolescents who underwent bariatric surgery, showed improvement in albuminuria and eGFR. In another study, 5-year kidney outcomes were compared in adolescents with severe obesity and T2DM enrolled in the Teen-LABS and the Treatment Options for T2DM in Adolescents and Youth (TODAY) studies . At baseline, elevated albuminuria was present in 21% and it increased to 43% at 5 years in TODAY participants. In contrast, albuminuria decreased from 27% of Teen-LABS participants prior to surgery to 5% at 5 years’ follow-up. At 5 years, there were 27-fold higher odds of diabetic kidney disease (DKD) in TODAY participants compared to Teen-LABS participants in adjusted analyses. A recent comparison of BS in adults (LABS study) and adolescents (Teen-LABS study) showed that adolescents experienced earlier remission of elevated albuminuria than adults . These data indicate that BS improves kidney outcomes in youths with severe obesity, including those with T2DM.
The benefits of BS have also been assessed in adults with CKD, but there is no data in children. Available data from retrospective studies in adults with CKD conclude that CKD or chronic dialysis should not be a contraindication for BS [104, 105] and that BS may improve transplant candidacy .
How are MS components managed?
We suggest avoiding excessive sodium intake in all children with CKD2-5D or with a kidney transplant and O&MS to prevent hypertension and to further reduce dietary sodium intake in those with hypertension (level B; moderate recommendation).
We suggest dietary interventions and lifestyle modifications to treat dyslipidemia in children with CKD2-5D or with a kidney transplant and O&MS (level D; weak recommendation).
We do not suggest the routine use of statins and other lipid lowering agents (level D; weak recommendation).
We suggest that all children with CKD2-5D or with a kidney transplant and O&MS receive comprehensive education to manage abnormal glucose metabolism (level D; weak recommendation).
Medications that are known to cause abnormal glucose must be reviewed and the dose adjusted, if appropriate (ungraded).
Evidence and rationale
Trials investigating the role of dietary sodium intake in children with kidney diseases and O&MS are lacking. However, a single interventional trial  and several cross-sectional studies  in children without kidney disease showed that BP in obese children is characterized by a higher sodium sensitivity than in non-obese children. In the general pediatric population, a significant association between sodium intake and BP has been reported by multiple observational and intervention studies . Based on the available evidence and in accordance with KDIGO and Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, we suggest not to exceed age-based recommended daily sodium intake for healthy children  in all patients with O&MS to prevent hypertension and to further reduce dietary sodium intake in case of high BP. An RCT on the use of the DASH diet in adolescents with newly diagnosed hypertension supports a beneficial long-term effect on systolic BP over nutrition counseling according to the National High BP Education Program . The pharmacological approach to hypertension in children with O&MS and kidney diseases is beyond the scope of this CPR.
Nutrition and exercise are the first-line treatments for the management of dyslipidemia in children with CKD and O&MS, as in healthy children. There are no RCTs evaluating the use of statins in children with O&MS with or without kidney disease. Two small RCTs have compared statins to placebo in children with various kidney disorders (mainly nephrotic syndrome), with conflicting results in terms of lipid profile improvement [112, 113]. No long-term studies looking at hard outcomes are available. Various systematic reviews have assessed statin therapy in adult patients with CKD or following kidney transplantation. Only in patients with CKD not on dialysis and without CV disease at baseline was statin therapy found to reduce death, major CV events, and myocardial infarction . In our view, it is hard to extrapolate these adult studies to pediatric patients.
There is a lack of consensus among current guidelines. The 2011 Expert Panel on integrated guidelines for CV health risk reduction in children and adolescents of the National Heart, Lung, and Blood Institute recommended the initiation of statins in patients between 10 and 21 years of age with persistently elevated low-density lipoprotein (LDL) cholesterol after 6 months of dietary management . The 2013 KDIGO clinical practice guideline for lipid management in CKD did not suggest the initiation of statins or a statin/ezetimibe combination in CKD patients under 18 years due to the lack of long-term safety data and the low level of evidence for benefit . Another debated issue is the pharmacological treatment of hypertriglyceridemia in children with CKD, in particular with fibric acid derivatives, niacin, and fish oil . Once again, the evidence regarding the use of these agents is extremely scarce and not specific for children with O&MS and CKD.
Weight management through lifestyle modification, including nutrition and exercise, is the cornerstone of treatment for O&MS and improvement of glucose metabolism in children with CKD. Children with risk factors for new onset diabetes after transplantation (NODAT) and post-transplant glucose intolerance, including African-American race, obesity, family history of diabetes, and those on immunosuppressant regimens with steroids, calcineurin inhibitors, and sirolimus, would especially benefit from early implementation of lifestyle modification . All CKD patients with abnormal glucose metabolism should receive comprehensive self-management education. Examples of an education program might include, but not be limited to, information about T2DM and how to prevent it: healthy eating habits, portion sizes, and reading food labels. The program should be individualized according to the child and the family’s abilities and preferences. Health care providers should assess potential barriers including food insecurity, home stability, and financial difficulties. Psychological assessment for symptoms of depression and eating disorders should be performed. Patients with pre-diabetes who fail lifestyle modification, or those diagnosed with diabetes, should be referred to an endocrinologist for potential pharmacological treatment of abnormal glucose metabolism. Decreasing the dose, stopping, or changing medications associated with abnormal glucose metabolism (e.g., steroids, calcineurin inhibitors) should be considered, if possible .
How can O&MS be prevented?
We recommend a healthy diet, regular physical activity, and other behavioral modifications to prevent O&MS (level D; weak recommendation).
Evidence and rationale
Prevention of pediatric obesity through promotion of a healthy diet, activity, and healthy lifestyle is paramount (Fig. 1). The principles outlined in the management of O&MS are equally applicable to prevention. This is of particular importance in children with nephrotic syndrome or after kidney transplantation on steroid regimens. Dietary principles should follow the recommendations in statement 3.2. No single diet plan works best for all patients, but concepts such as avoiding excess energy intake by limiting sugar and total fat intake (favoring unsaturated fats and, in particular, higher omega-3 fats over saturated fats), promoting fiber, fruits, vegetables, pulses, and whole grains, while considering the individual’s age and CKD-appropriate requirements, seem appropriate for prevention of O&MS in children with CKD. Physical activity may help prevent O&MS and is important for overall health. Recommendations, previously discussed in statement 3.3 related to physical activity, should be followed adjusting as needed for age, CKD stage, and comorbidities. Limiting screen time and other positive psychosocial influences, such as family meals, mindfulness when eating, stress, and emotional management, are prudent to prevent the onset of O&MS. Awareness and early recognition of evolving MS components may reinforce implementation of lifestyle modifications and guide clinical decision-making.
Results of the Delphi survey
There were 50 responses to the electronic Delphi survey with joint responses submitted by some dietitians and physicians from the same facility. All professionals who completed the survey are listed in “Participants in the Delphi survey.”
The 22 clinical practice recommendation statements received an overall 87% consensus with a “strongly agree” or “agree” response and 11% with a “neutral” response; these largely reflected the wide variations in practice in the absence of robust evidence. Two statements did not reach the stipulated 70% level of consensus. The Taskforce members reviewed the comments and agreed that the statements did not require changing as the GRADE clearly reflects the low level of evidence, indicating that these statements are based on expert opinion.
The highest “disagree and strongly disagree” rate was in response to statement 3.6.1 on bariatric surgery. On careful review of the literature and discussion within the Taskforce team, it was agreed that despite country policy, legal stipulations and few centers with the relevant experience, bariatric surgery may be considered in a selected subgroup of children with CKD2-5D or with a kidney transplant and O&MS when all other interventions have failed. Based on suggestions from Delphi respondents, minor rewording of statements and further clarification to the text were done.
Summary of recommendations
A summary of recommendations is provided in Table 4.
We recommend the following areas of study to provide future evidence-based recommendations for O&MS in children with CKD2-5D and after transplantation:
To investigate the role of waist-to-height ratio to assess central adiposity, both its practical application and its ability to provide additional guidance regarding management and outcomes compared to BMI.
To investigate the utility of different measurements of adiposity, BMI, and weight-for-length (WFL), in the assessment of overweight and obesity in infants with CKD and their associations with clinical outcomes.
To investigate the use of handgrip strength to assess muscle deficits and obese sarcopenia and the effectiveness of interventions to correct these muscle disorders.
To examine the possible role of adipokines including ghrelin and leptin in the pathogenesis of protein energy wasting and pathophysiology of obese sarcopenia in children with CKD.
To increase evidence on the impact of O&MS on target organ damage other than LVH, including cIMT and PWV, as well as the effect of treatment of O&MS on short- and long-term CV outcomes.
To investigate the role of management of uric acid levels in the treatment of O&MS.
To conduct controlled trials on the effect of specific diet plans, notably Mediterranean and DASH diets, in large pediatric CKD populations.
To assess the role of the microbiome on the prevalence of O&MS in children with CKD and potential of modification by different diet patterns.
To study the effectiveness of behavioral modification interventions on O&MS prevention and treatment in pediatric CKD patients and after kidney transplantation.
Shroff R, Weaver DJ Jr, Mitsnefes MM (2011) Cardiovascular complications in children with chronic kidney disease. Nat Rev Nephrol 7:642–649. https://doi.org/10.1038/nrneph.2011.116
Wilson AC, Schneider MF, Cox C, Greenbaum LA, Saland J, White CT, Furth S, Warady BA, Mitsnefes MM (2011) Prevalence and correlates of multiple cardiovascular risk factors in children with chronic kidney disease. Clin J Am Soc Nephrol 6:2759–2765. https://doi.org/10.2215/cjn.03010311
Bonthuis M, van Stralen KJ, Verrina E, Groothoff JW, Alonso Melgar A, Edefonti A, Fischbach M, Mendes P, Molchanova EA, Paripovic D, Peco-Antic A, Printza N, Rees L, Rubik J, Stefanidis CJ, Sinha MD, Zagozdzon I, Jager KJ, Schaefer F (2013) Underweight, overweight and obesity in paediatric dialysis and renal transplant patients. Nephrol Dial Transplant 28(Suppl 4):iv195–iv204. https://doi.org/10.1093/ndt/gft259
Schaefer F, Benner L, Borzych-Duzalka D, Zaritsky J, Xu H, Rees L, Antonio ZL, Serdaroglu E, Hooman N, Patel H, Sever L, Vondrak K, Flynn J, Rebori A, Wong W, Holtta T, Yildirim ZY, Ranchin B, Grenda R, Testa S, Drozdz D, Szabo AJ, Eid L, Basu B, Vitkevic R, Wong C, Pottoore SJ, Muller D, Dusunsel R, Celedon CG, Fila M, Sartz L, Sander A, Warady BA (2019) Global variation of nutritional status in children undergoing chronic peritoneal dialysis: a longitudinal study of the International Pediatric Peritoneal Dialysis Network. Sci Rep 9:4886. https://doi.org/10.1038/s41598-018-36975-z
Lalan S, Jiang S, Ng DK, Kupferman F, Warady BA, Furth S, Mitsnefes MM (2018) Cardiometabolic risk factors, metabolic syndrome, and chronic kidney disease progression in children. J Pediatr 202:163–170. https://doi.org/10.1016/j.jpeds.2018.06.007
Sgambat K, Clauss S, Moudgil A (2018) Cardiovascular effects of metabolic syndrome after transplantation: convergence of obesity and transplant-related factors. Clin Kidney J 11:136–146. https://doi.org/10.1093/ckj/sfx056
Vanlancker T, Schaubroeck E, Vyncke K, Cadenas-Sanchez C, Breidenassel C, Gonzalez-Gross M, Gottrand F, Moreno LA, Beghin L, Molnar D, Manios Y, Gunter MJ, Widhalm K, Leclercq C, Dallongeville J, Ascension M, Kafatos A, Castillo MJ, De Henauw S, Ortega FB, Huybrechts I (2017) Comparison of definitions for the metabolic syndrome in adolescents. The HELENA study. Eur J Pediatr 176:241–252. https://doi.org/10.1007/s00431-016-2831-6
DeBoer MD, Filipp SL, Gurka MJ (2019) Geographical variation in the prevalence of obesity and metabolic syndrome among US adolescents. Pediatr Obes 14:e12483. https://doi.org/10.1111/ijpo.12483
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. https://doi.org/10.1053/ajkd.2000.17674
Ku E, Glidden DV, Hsu CY, Portale AA, Grimes B, Johansen KL (2016) Association of Body Mass Index with Patient-Centered Outcomes in Children with ESRD. J Am Soc Nephrol 27:551–558. https://doi.org/10.1681/asn.2015010008
Roberts MJ, Mitsnefes MM, McCulloch CE, Greenbaum LA, Grimes BA, Ku E (2019) Association between BMI changes and mortality risk in children with end-stage renal disease. Pediatr Nephrol 34:1557–1563. https://doi.org/10.1007/s00467-019-04249-z
Tainio J, Qvist E, Holtta T, Pakarinen M, Jahnukainen T, Jalanko H (2014) Metabolic risk factors and long-term graft function after paediatric renal transplantation. Transpl Int 27:583–592. https://doi.org/10.1111/tri.12300
Wilson AC, Greenbaum LA, Barletta GM, Chand D, Lin JJ, Patel HP, Mitsnefes M (2010) High prevalence of the metabolic syndrome and associated left ventricular hypertrophy in pediatric renal transplant recipients. Pediatr Transplant 14:52–60. https://doi.org/10.1111/j.1399-3046.2009.01141.x
Maduram A, John E, Hidalgo G, Bottke R, Fornell L, Oberholzer J, Benedetti E (2010) Metabolic syndrome in pediatric renal transplant recipients: comparing early discontinuation of steroids vs. steroid group. Pediatr Transplant 14:351–357. https://doi.org/10.1111/j.1399-3046.2009.01243.x
Hanevold CD, Ho PL, Talley L, Mitsnefes MM (2005) Obesity and renal transplant outcome: a report of the North American Pediatric Renal Transplant Cooperative Study. Pediatrics 115:352–356. https://doi.org/10.1542/peds.2004-0289
Vivante A, Golan E, Tzur D, Leiba A, Tirosh A, Skorecki K, Calderon-Margalit R (2012) Body mass index in 1.2 million adolescents and risk for end-stage renal disease. Arch Intern Med 172:1644–1650. https://doi.org/10.1001/2013.jamainternmed.85
Shaw V, Polderman N, Renken-Terhaerdt J, Paglialonga F, Oosterveld M, Tuokkola J, Anderson C, Desloovere A, Greenbaum L, Haffner D, Nelms C, Qizalbash L, Vande Walle J, Warady B, Shroff R, Rees L (2020) 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 35:519–531. https://doi.org/10.1542/peds.2004-1260
Zimmet P, Alberti KG, Kaufman F, Tajima N, Silink M, Arslanian S, Wong G, Bennett P, Shaw J, Caprio S (2007) The metabolic syndrome in children and adolescents - an IDF consensus report. Pediatr Diabetes 8:299–306. https://doi.org/10.1111/j.1399-5448.2007.00271.x
Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report (2011). Pediatrics 128 Suppl 5:S213-256. https://doi.org/10.1542/peds.2009-2107C
Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, Yeckel CW, Allen K, Lopes M, Savoye M, Morrison J, Sherwin RS, Caprio S (2004) Obesity and the metabolic syndrome in children and adolescents. N Engl J Med 350:2362–2374. https://doi.org/10.1056/NEJMoa031049
Cruz ML, Weigensberg MJ, Huang TT, Ball G, Shaibi GQ, Goran MI (2004) The metabolic syndrome in overweight Hispanic youth and the role of insulin sensitivity. J Clin Endocrinol Metab 89:108–113. https://doi.org/10.1210/jc.2003-031188
Berenson GS, Srinivasan SR, Bao W, Newman WP 3rd, Tracy RE, Wattigney WA (1998) Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med 338:1650–1656. https://doi.org/10.1056/nejm199806043382302
Raitakari OT, Juonala M, Kähönen M, Taittonen L, Laitinen T, Mäki-Torkko N, Järvisalo MJ, Uhari M, Jokinen E, Rönnemaa T, Akerblom HK, Viikari JS (2003) Cardiovascular risk factors in childhood and carotid artery intima-media thickness in adulthood: the Cardiovascular Risk in Young Finns Study. JAMA 290:2277–2283. https://doi.org/10.1001/jama.290.17.2277
McMahan CA, Gidding SS, Malcom GT, Tracy RE, Strong JP, McGill HC Jr, Pathobiological Determinants of Atherosclerosis in Youth Research Group (2006) Pathobiological determinants of atherosclerosis in youth risk scores are associated with early and advanced atherosclerosis. Pediatrics 118:1447–1455. https://doi.org/10.1542/peds.2006-0970
Magge SN, Goodman E, Armstrong SC (2017) The metabolic syndrome in children and adolescents: shifting the focus to cardiometabolic risk factor clustering. Pediatrics 140. https://doi.org/10.1542/peds.2017-1603
Sgambat K, Roem J, Mitsnefes M, Portale AA, Furth S, Warady B, Moudgil A (2018) Waist-to-height ratio, body mass index, and cardiovascular risk profile in children with chronic kidney disease. Pediatr Nephrol. https://doi.org/10.1007/s00467-018-3987-2
Sgambat K, Clauss S, Lei KY, Song J, Rahaman SO, Lasota M, Moudgil A (2018) Increased carotid intima-media thickness in African American pediatric kidney transplant recipients. Pediatr Transplant 22:e13163. https://doi.org/10.1111/petr.13163
Ramirez-Cortes G, Fuentes-Velasco Y, Garcia-Roca P, Guadarrama O, Lopez M, Valverde-Rosas S, Velasquez-Jones L, Romero B, Toussaint G, Medeiros M (2009) Prevalence of metabolic syndrome and obesity in renal transplanted Mexican children. Pediatr Transplant 13:579–584. https://doi.org/10.1111/j.1399-3046.2008.01032.x
Hocker B, Weber LT, Feneberg R, Drube J, John U, Fehrenbach H, Pohl M, Zimmering M, Frund S, Klaus G, Wuhl E, Tonshoff B (2009) Prospective, randomized trial on late steroid withdrawal in pediatric renal transplant recipients under cyclosporine microemulsion and mycophenolate mofetil. Transplantation 87:934–941. https://doi.org/10.1097/TP.0b013e31819b6d4a
Patel HP, Saland JM, Ng DK, Jiang S, Warady BA, Furth SL, Flynn JT (2017) Waist circumference and body mass index in children with chronic kidney disease and metabolic, cardiovascular, and renal outcomes. J Pediatr 191:133–139. https://doi.org/10.1016/j.jpeds.2017.08.047
Nelms CL, Shaw V, Greenbaum LA, Anderson C, Desloovere A, Haffner D, Oosterveld MJS, Paglialonga F, Polderman N, Qizalbash L, Rees L, Renken-Terhaerdt J, Tuokkola J, Vande Walle J, Shroff R, Warady BA (2021) Assessment of nutritional status in children with kidney diseases-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 36:995–1010. https://doi.org/10.1007/s00467-020-04852-5
Cheung AK, Chang TI, Cushman WC, Furth SL, Hou FF, Ix JH, Knoll GA, Muntner P, Pecoits-Filho R, Sarnak MJ, Tobe SW, Tomson CRV, Lytvyn L, Craig JC, Tunnicliffe DJ, Howell M, Tonelli M, Cheung M, Earley A, Mann JFE (2021) Executive summary of the KDIGO 2021 clinical practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int 99:559–569. https://doi.org/10.1016/j.kint.2020.10.026
Lurbe E, Agabiti-Rosei E, Cruickshank JK, Dominiczak A, Erdine S, Hirth A, Invitti C, Litwin M, Mancia G, Pall D, Rascher W, Redon J, Schaefer F, Seeman T, Sinha M, Stabouli S, Webb NJ, Wuhl E, Zanchetti A (2016) 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens 34:1887–1920. https://doi.org/10.1097/hjh.0000000000001039
Gimpel C, Bergmann C, Bockenhauer D, Breysem L, Cadnapaphornchai MA, Cetiner M, Dudley J, Emma F, Konrad M, Harris T, Harris PC, König J, Liebau MC, Marlais M, Mekahli D, Metcalfe AM, Oh J, Perrone RD, Sinha MD, Titieni A, Torra R, Weber S, Winyard PJD, Schaefer F (2019) International consensus statement on the diagnosis and management of autosomal dominant polycystic kidney disease in children and young people. Nat Rev Nephrol 15:713–726. https://doi.org/10.1038/s41581-019-0155-2
Wühl E, Trivelli A, Picca S, Litwin M, Peco-Antic A, Zurowska A, Testa S, Jankauskiene A, Emre S, Caldas-Afonso A, Anarat A, Niaudet P, Mir S, Bakkaloglu A, Enke B, Montini G, Wingen AM, Sallay P, Jeck N, Berg U, Caliskan S, Wygoda S, Hohbach-Hohenfellner K, Dusek J, Urasinski T, Arbeiter K, Neuhaus T, Gellermann J, Drozdz D, Fischbach M, Möller K, Wigger M, Peruzzi L, Mehls O, Schaefer F (2009) Strict blood-pressure control and progression of renal failure in children. N Engl J Med 361:1639–1650. https://doi.org/10.1056/NEJMoa0902066
Shroff R, Speer T, Colin S, Charakida M, Zewinger S, Staels B, Chinetti-Gbaguidi G, Hettrich I, Rohrer L, O'Neill F, McLoughlin E, Long D, Shanahan CM, Landmesser U, Fliser D, Deanfield JE (2014) HDL in children with CKD promotes endothelial dysfunction and an abnormal vascular phenotype. J Am Soc Nephrol 25:2658–2668. https://doi.org/10.1681/asn.2013111212
American Diabetes Association (2020) 13. Children and adolescents: standards of medical care in diabetes-2020. Diabetes Care 43:S163–s182. https://doi.org/10.2337/dc20-S013
Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM (2017) Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 140:e20171904. https://doi.org/10.1542/peds.2017-1904
Steinberger J, Daniels SR, Eckel RH, Hayman L, Lustig RH, McCrindle B, Mietus-Snyder ML, American Heart Association Atherosclerosis, Hypertension, and Obesity in the Young Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular Nursing; and Council on Nutrition, Physical Activity, and Metabolism (2009) Progress and challenges in metabolic syndrome in children and adolescents: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in the Young Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular Nursing; and Council on Nutrition, Physical Activity, and Metabolism. Circulation 119:628–647. https://doi.org/10.1161/circulationaha.108.191394
Di Bonito P, Valerio G, Licenziati MR, Miraglia Del Giudice E, Baroni MG, Morandi A, Maffeis C, Campana G, Spreghini MR, Di Sessa A, Morino G, Crinò A, Chiesa C, Pacifico L, Manco M (2020) High uric acid, reduced glomerular filtration rate and non-alcoholic fatty liver in young people with obesity. J Endocrinol Investig 43:461–468. https://doi.org/10.1007/s40618-019-01130-6
Litwin M, Sladowska J, Antoniewicz J, Niemirska A, Wierzbicka A, Daszkowska J, Wawer ZT, Janas R, Grenda R (2007) Metabolic abnormalities, insulin resistance, and metabolic syndrome in children with primary hypertension. Am J Hypertens 20:875–882. https://doi.org/10.1016/j.amjhyper.2007.03.005
Chen W, Ducharme-Smith K, Davis L, Hui WF, Warady BA, Furth SL, Abraham AG, Betoko A (2017) Dietary sources of energy and nutrient intake among children and adolescents with chronic kidney disease. Pediatr Nephrol 32:1233–1241. https://doi.org/10.1007/s00467-017-3580-0
Hui WF, Betoko A, Savant JD, Abraham AG, Greenbaum LA, Warady B, Moxey-Mims MM, Furth SL (2017) Assessment of dietary intake of children with chronic kidney disease. Pediatr Nephrol 32:485–494. https://doi.org/10.1007/s00467-016-3491-5
Clark SL, Denburg MR, Furth SL (2016) Physical activity and screen time in adolescents in the chronic kidney disease in children (CKiD) cohort. Pediatr Nephrol 31:801–808. https://doi.org/10.1007/s00467-015-3287-z
Noone DG, Marks SD (2013) Hyperuricemia is associated with hypertension, obesity, and albuminuria in children with chronic kidney disease. J Pediatr 162:128–132. https://doi.org/10.1016/j.jpeds.2012.06.008
Hsu CW, Yamamoto KT, Henry RK, De Roos AJ, Flynn JT (2014) Prenatal risk factors for childhood CKD. J Am Soc Nephrol 25:2105–2111. https://doi.org/10.1681/asn.2013060582
Garro R, Warshaw B, Felner E (2015) New-onset diabetes after kidney transplant in children. Pediatr Nephrol 30:405–416. https://doi.org/10.1007/s00467-014-2830-7
Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, Martin FC, Michel JP, Rolland Y, Schneider SM, Topinková E, Vandewoude M, Zamboni M, European Working Group on Sarcopenia in Older People (2010) Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People. Age Ageing 39:412–423. https://doi.org/10.1093/ageing/afq034
Ooi PH, Thompson-Hodgetts S, Pritchard-Wiart L, Gilmour SM, Mager DR (2020) Pediatric sarcopenia: a paradigm in the overall definition of malnutrition in children? J Parenter Enter Nutr 44:407–418. https://doi.org/10.1002/jpen.1681
Raj DS, Sun Y, Tzamaloukas AH (2008) Hypercatabolism in dialysis patients. Curr Opin Nephrol Hypertens 17:589–594. https://doi.org/10.1097/MNH.0b013e32830d5bfa
Stenvinkel P, Zoccali C, Ikizler TA (2013) Obesity in CKD--what should nephrologists know? J Am Soc Nephrol 24:1727–1736. https://doi.org/10.1681/asn.2013040330
Honda H, Qureshi AR, Axelsson J, Heimburger O, Suliman ME, Barany P, Stenvinkel P, Lindholm B (2007) Obese sarcopenia in patients with end-stage renal disease is associated with inflammation and increased mortality. Am J Clin Nutr 86:633–638. https://doi.org/10.1093/ajcn/86.3.633
Sharma D, Hawkins M, Abramowitz MK (2014) Association of sarcopenia with eGFR and misclassification of obesity in adults with CKD in the United States. Clin J Am Soc Nephrol 9:2079–2088. https://doi.org/10.2215/cjn.02140214
Steffl M, Chrudimsky J, Tufano JJ (2017) Using relative handgrip strength to identify children at risk of sarcopenic obesity. PLoS One 12:e0177006. https://doi.org/10.1371/journal.pone.0177006
Prasad GV, Huang M, Silver SA, Al-Lawati AI, Rapi L, Nash MM, Zaltzman JS (2015) Metabolic syndrome definitions and components in predicting major adverse cardiovascular events after kidney transplantation. Transpl Int 28:79–88. https://doi.org/10.1111/tri.12450
Brady TM, Roem J, Cox C, Schneider MF, Wilson AC, Furth SL, Warady BA, Mitsnefes M (2020) Adiposity, sex, and cardiovascular disease risk in children with CKD: a longitudinal study of youth enrolled in the Chronic Kidney Disease in Children (CKiD) study. Am J Kidney Dis 76:166–173. https://doi.org/10.1053/j.ajkd.2020.01.011
Brady TM, Schneider MF, Flynn JT, Cox C, Samuels J, Saland J, White CT, Furth S, Warady BA, Mitsnefes M (2012) Carotid intima-media thickness in children with CKD: results from the CKiD study. Clin J Am Soc Nephrol 7:1930–1937. https://doi.org/10.2215/cjn.03130312
Karava V, Printza N, Dotis J, Demertzi D, Antza C, Kotsis V, Papachristou F, Stabouli S (2019) Body composition and arterial stiffness in pediatric patients with chronic kidney disease. Pediatr Nephrol 34:1253–1260. https://doi.org/10.1007/s00467-019-04224-8
Iaccarino Idelson P, Scalfi L, Valerio G (2017) Adherence to the Mediterranean Diet in children and adolescents: a systematic review. Nutr Metab Cardiovasc Dis 27:283–299. https://doi.org/10.1016/j.numecd.2017.01.002
Paula Bricarello L, Poltronieri F, Fernandes R, Retondario A, de Moraes Trindade EBS, de Vasconcelos FAG (2018) Effects of the Dietary Approach to Stop Hypertension (DASH) diet on blood pressure, overweight and obesity in adolescents: A systematic review. Clin Nutr ESPEN 28:1–11. https://doi.org/10.1016/j.clnesp.2018.09.003
Schwingshackl L, Hobl LP, Hoffmann G (2015) Effects of low glycaemic index/low glycaemic load vs. high glycaemic index/high glycaemic load diets on overweight/obesity and associated risk factors in children and adolescents: a systematic review and meta-analysis. Nutr J 14:87. https://doi.org/10.1186/s12937-015-0077-1
Andela S, Burrows TL, Baur LA, Coyle DH, Collins CE, Gow ML (2019) Efficacy of very low-energy diet programs for weight loss: a systematic review with meta-analysis of intervention studies in children and adolescents with obesity. Obes Rev 20:871–882. https://doi.org/10.1111/obr.12830
Mohammadi H, Ghavami A, Hadi A, Askari G, Symonds M, Miraghajani M (2019) Effects of pro-/synbiotic supplementation on anthropometric and metabolic indices in overweight or obese children and adolescents: a systematic review and meta-analysis. Complement Ther Med 44:269–276. https://doi.org/10.1016/j.ctim.2019.05.008
Hu EA, Steffen LM, Grams ME, Crews DC, Coresh J, Appel LJ, Rebholz CM (2019) Dietary patterns and risk of incident chronic kidney disease: the Atherosclerosis Risk in Communities study. Am J Clin Nutr 110:713–721. https://doi.org/10.1093/ajcn/nqz146
Cameron C, Krmar RT (2016) Single-center assessment of nutritional counseling in preventing excessive weight gain in pediatric renal transplants recipients. Pediatr Transplant 20:388–394. https://doi.org/10.1111/petr.12668
Siervo M, Lara J, Chowdhury S, Ashor A, Oggioni C, Mathers JC (2015) Effects of the Dietary Approach to Stop Hypertension (DASH) diet on cardiovascular risk factors: a systematic review and meta-analysis. Br J Nutr 113:1–15. https://doi.org/10.1017/s0007114514003341
Bach KE, Kelly JT, Palmer SC, Khalesi S, Strippoli GFM, Campbell KL (2019) Healthy dietary patterns and incidence of CKD: a meta-analysis of cohort studies. Clin J Am Soc Nephrol 14:1441–1449. https://doi.org/10.2215/cjn.00530119
Soltani S, Jayedi A (2020) Adherence to healthy dietary pattern and risk of kidney disease: a systematic review and meta-analysis of observational studies. Int J Vitam Nutr Res 0:1-13. https://doi.org/10.1024/0300-9831/a000647
Ndanuko RN, Tapsell LC, Charlton KE, Neale EP, Batterham MJ (2016) Dietary patterns and blood pressure in adults: a systematic review and meta-analysis of randomized controlled trials. Adv Nutr 7:76–89. https://doi.org/10.3945/an.115.009753
Palmer SC, Maggo JK, Campbell KL, Craig JC, Johnson DW, Sutanto B, Ruospo M, Tong A, Strippoli GF (2017) Dietary interventions for adults with chronic kidney disease. Cochrane Database Syst Rev 4:CD011998. https://doi.org/10.1002/14651858.CD011998
Chauveau P, Aparicio M, Bellizzi V, Campbell K, Hong X, Johansson L, Kolko A, Molina P, Sezer S, Wanner C, Ter Wee PM, Teta D, Fouque D, Carrero JJ (2018) Mediterranean diet as the diet of choice for patients with chronic kidney disease. Nephrol Dial Transplant 33:725–735. https://doi.org/10.1093/ndt/gfx085
Reinehr T, Lass N, Toschke C, Rothermel J, Lanzinger S, Holl RW (2016) Which amount of BMI-SDS reduction is necessary to improve cardiovascular risk factors in overweight children? J Clin Endocrinol Metab 101:3171–3179. https://doi.org/10.1210/jc.2016-1885
Edefonti A, Picca M, Damiani B, Loi S, Ghio L, Giani M, Consalvo G, Grassi MR (1999) Dietary prescription based on estimated nitrogen balance during peritoneal dialysis. Pediatr Nephrol 13:253–258. https://doi.org/10.1007/s004670050604
Rees L, Shaw V, Qizalbash L, Anderson C, Desloovere A, Greenbaum L, Haffner D, Nelms C, Oosterveld M, Paglialonga F, Polderman N, Renken-Terhaerdt J, Tuokkola J, Warady B, Walle JV, Shroff R (2021) 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 36:187–204. https://doi.org/10.1007/s00467-020-04623-2
Kelley GA, Kelley KS, Pate RR (2017) Exercise and BMI z-score in overweight and obese children and adolescents: a systematic review and network meta-analysis of randomized trials. J Evid Based Med 10:108–128. https://doi.org/10.1111/jebm.12228
Stoner L, Beets MW, Brazendale K, Moore JB, Weaver RG (2019) Exercise dose and weight loss in adolescents with overweight-obesity: a meta-regression. Sports Med 49:83–94. https://doi.org/10.1007/s40279-018-01040-2
Schwartz C, King NA, Perreira B, Blundell JE, Thivel D (2017) A systematic review and meta-analysis of energy and macronutrient intake responses to physical activity interventions in children and adolescents with obesity. Pediatr Obes 12:179–194. https://doi.org/10.1111/ijpo.12124
Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, George SM, Olson RD (2018) The physical activity guidelines for Americans. JAMA 320:2020–2028. https://doi.org/10.1001/jama.2018.14854
Akber A, Portale AA, Johansen KL (2012) Pedometer-assessed physical activity in children and young adults with CKD. Clin J Am Soc Nephrol 7:720–726. https://doi.org/10.2215/cjn.06330611
Tangeraas T, Midtvedt K, Fredriksen PM, Cvancarova M, Morkrid L, Bjerre A (2010) Cardiorespiratory fitness is a marker of cardiovascular health in renal transplanted children. Pediatr Nephrol 25:2343–2350. https://doi.org/10.1007/s00467-010-1596-9
Weaver DJ Jr, Kimball TR, Knilans T, Mays W, Knecht SK, Gerdes YM, Witt S, Glascock BJ, Kartal J, Khoury P, Mitsnefes MM (2008) Decreased maximal aerobic capacity in pediatric chronic kidney disease. J Am Soc Nephrol 19:624–630. https://doi.org/10.1681/asn.2007070773
Painter P, Krasnoff J, Mathias R (2007) Exercise capacity and physical fitness in pediatric dialysis and kidney transplant patients. Pediatr Nephrol 22:1030–1039. https://doi.org/10.1007/s00467-007-0458-6
Tangeraas T, Midtvedt K, Cvancarova M, Hirth A, Fredriksen PM, Tonstad S, Isaksen GA, Bjerre A (2011) Cardiorespiratory fitness in young adults with a history of renal transplantation in childhood. Pediatr Nephrol 26:2041–2049. https://doi.org/10.1007/s00467-011-1898-6
Patel DR, Raj VM, Torres A (2009) Chronic kidney disease, exercise, and sports in children, adolescents, and adults. Phys Sportsmed 37:11–19. https://doi.org/10.3810/psm.2009.10.1724
Clapp EL, Bevington A (2011) Exercise-induced biochemical modifications in muscle in chronic kidney disease: occult acidosis as a potential factor limiting the anabolic effect of exercise. J Ren Nutr 21:57–60. https://doi.org/10.1053/j.jrn.2010.10.023
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. https://doi.org/10.1681/asn.2010060603
Fatima Y, Doi SA, Mamun AA (2016) Sleep quality and obesity in young subjects: a meta-analysis. Obes Rev 17:1154–1166. https://doi.org/10.1111/obr.12444
Paglialonga F, Lopopolo A, Scarfia RV, Consolo S, Galli MA, Salera S, Grassi MR, Brivio A, Edefonti A (2014) Intradialytic cycling in children and young adults on chronic hemodialysis. Pediatr Nephrol 29:431–438. https://doi.org/10.1007/s00467-013-2675-5
van Bergen M, Takken T, Engelbert R, Groothoff J, Nauta J, van Hoeck K, Helders P, Lilien M (2009) Exercise training in pediatric patients with end-stage renal disease. Pediatr Nephrol 24:619–622. https://doi.org/10.1007/s00467-008-1015-7
Chaput JP, Gray CE, Poitras VJ, Carson V, Gruber R, Olds T, Weiss SK, Connor Gorber S, Kho ME, Sampson M, Belanger K, Eryuzlu S, Callender L, Tremblay MS (2016) Systematic review of the relationships between sleep duration and health indicators in school-aged children and youth. Appl Physiol Nutr Metab 41:S266–S282. https://doi.org/10.1139/apnm-2015-0627
Matricciani L, Paquet C, Galland B, Short M, Olds T (2019) Children’s sleep and health: a meta-review. Sleep Med Rev 46:136–150. https://doi.org/10.1016/j.smrv.2019.04.011
Stabouli S, Papadimitriou E, Printza N, Dotis J, Papachristou F (2016) Sleep disorders in pediatric chronic kidney disease patients. Pediatr Nephrol 31:1221–1229. https://doi.org/10.1007/s00467-015-3237-9
Marsh S, Ni Mhurchu C, Maddison R (2013) The non-advertising effects of screen-based sedentary activities on acute eating behaviours in children, adolescents, and young adults. A systematic review. Appetite 71:259–273. https://doi.org/10.1016/j.appet.2013.08.017
Maniccia DM, Davison KK, Marshall SJ, Manganello JA, Dennison BA (2011) A meta-analysis of interventions that target children’s screen time for reduction. Pediatrics 128:e193–e210. https://doi.org/10.1542/peds.2010-2353
van Ekris E, Altenburg TM, Singh AS, Proper KI, Heymans MW, Chinapaw MJ (2016) An evidence-update on the prospective relationship between childhood sedentary behaviour and biomedical health indicators: a systematic review and meta-analysis. Obes Rev 17:833–849. https://doi.org/10.1111/obr.12426
Carson V, Hunter S, Kuzik N, Gray CE, Poitras VJ, Chaput JP, Saunders TJ, Katzmarzyk PT, Okely AD, Connor Gorber S, Kho ME, Sampson M, Lee H, Tremblay MS (2016) Systematic review of sedentary behaviour and health indicators in school-aged children and youth: an update. Appl Physiol Nutr Metab 41:S240–S265. https://doi.org/10.1139/apnm-2015-0630
Pervanidou P, Chrousos GP (2011) Stress and obesity/metabolic syndrome in childhood and adolescence. Int J Pediatr Obes 6(Suppl 1):21–28. https://doi.org/10.3109/17477166.2011.615996
Saeed Z, Janda KM, Tucker BM, Dudley L, Cutter P, Friedman AN (2017) Personal attitudes toward weight in overweight and obese US hemodialysis patients. J Ren Nutr 27:340–345. https://doi.org/10.1053/j.jrn.2017.03.004
Singh AK, Singh R (2020) Pharmacotherapy in obesity: a systematic review and meta-analysis of randomized controlled trials of anti-obesity drugs. Expert Rev Clin Pharmacol 13:53–64. https://doi.org/10.1080/17512433.2020.1698291
Maahs D, de Serna DG, Kolotkin RL, Ralston S, Sandate J, Qualls C, Schade DS (2006) Randomized, double-blind, placebo-controlled trial of orlistat for weight loss in adolescents. Endocr Pract 12:18–28. https://doi.org/10.4158/ep.12.1.18
Chanoine JP, Hampl S, Jensen C, Boldrin M, Hauptman J (2005) Effect of orlistat on weight and body composition in obese adolescents: a randomized controlled trial. JAMA 293:2873–2883. https://doi.org/10.1001/jama.293.23.2873
Bjornstad P, Hughan K, Kelsey MM, Shah AS, Lynch J, Nehus E, Mitsnefes M, Jenkins T, Xu P, Xie C, Inge T, Nadeau K (2020) Effect of surgical versus medical therapy on diabetic kidney disease over 5 years in severely obese adolescents with type 2 diabetes. Diabetes Care 43:187–195. https://doi.org/10.2337/dc19-0708
Bjornstad P, Nehus E, Jenkins T, Mitsnefes M, Moxey-Mims M, Dixon JB, Inge TH (2020) Five-year kidney outcomes of bariatric surgery differ in severely obese adolescents and adults with and without type 2 diabetes. Kidney Int 97:995–1005
Imam TH, Fischer H, Jing B, Burchette R, Henry S, DeRose SF, Coleman KJ (2017) Estimated GFR before and after bariatric surgery in CKD. Am J Kidney Dis 69:380–388. https://doi.org/10.1016/j.kint.2020.01.016
Cohen JB, Lim MA, Tewksbury CM, Torres-Landa S, Trofe-Clark J, Abt PL, Williams NN, Dumon KR, Goral S (2019) Bariatric surgery before and after kidney transplantation: long-term weight loss and allograft outcomes. Surg Obes Relat Dis 15:935–941. https://doi.org/10.1016/j.soard.2019.04.002
Kassam AF, Mirza A, Kim Y, Hanseman D, Woodle ES, Quillin RC 3rd, Johnson BL, Govil A, Cardi M, Schauer DP, Smith EP, Diwan TS (2020) Long-term outcomes in patients with obesity and renal disease after sleeve gastrectomy. Am J Transplant 20:422–429. https://doi.org/10.1111/ajt.15650
Rocchini AP, Key J, Bondie D, Chico R, Moorehead C, Katch V, Martin M (1989) The effect of weight loss on the sensitivity of blood pressure to sodium in obese adolescents. N Engl J Med 321:580–585. https://doi.org/10.1056/nejm198908313210905
Yang Q, Zhang Z, Kuklina EV, Fang J, Ayala C, Hong Y, Loustalot F, Dai S, Gunn JP, Tian N, Cogswell ME, Merritt R (2012) Sodium intake and blood pressure among US children and adolescents. Pediatrics 130:611–619. https://doi.org/10.1542/peds.2011-3870
Leyvraz M, Chatelan A, da Costa BR, Taffé P, Paradis G, Bovet P, Bochud M, Chiolero A (2018) Sodium intake and blood pressure in children and adolescents: a systematic review and meta-analysis of experimental and observational studies. Int J Epidemiol 47:1796–1810. https://doi.org/10.1093/ije/dyy121
World Health Organization (2012) Guideline: sodium intake for adults and children. World Health Organization, Geneva http://www.who.int/nutrition/publications/guidelines/sodium_intake/en/. Accessed 28 October 2020
Couch SC, Saelens BE, Khoury PR, Dart KB, Hinn K, Mitsnefes MM, Daniels SR, Urbina EM (2021) Dietary approaches to stop hypertension dietary intervention improves blood pressure and vascular health in youth with elevated blood pressure. Hypertension 77:241–251. https://doi.org/10.1161/hypertensionaha.120.16156
García-de-la-Puente S, Arredondo-García JL, Gutiérrez-Castrellón P, Bojorquez-Ochoa A, Maya ER, Pérez-Martínez Mdel P (2009) Efficacy of simvastatin in children with hyperlipidemia secondary to kidney disorders. Pediatr Nephrol 24:1205–1210. https://doi.org/10.1007/s00467-009-1128-7
Hari P, Khandelwal P, Satpathy A, Hari S, Thergaonkar R, Lakshmy R, Sinha A, Bagga A (2018) Effect of atorvastatin on dyslipidemia and carotid intima-media thickness in children with refractory nephrotic syndrome: a randomized controlled trial. Pediatr Nephrol 33:2299–2309. https://doi.org/10.1007/s00467-018-4036-x
Hwang SD, Kim K, Kim YJ, Lee SW, Lee JH, Song JH (2020) Effect of statins on cardiovascular complications in chronic kidney disease patients: a network meta-analysis. Medicine (Baltimore) 99:e20061. https://doi.org/10.1097/md.0000000000020061
Wanner C, Tonelli M (2014) KDIGO Clinical Practice Guideline for Lipid Management in CKD: summary of recommendation statements and clinical approach to the patient. Kidney Int 85:1303–1309. https://doi.org/10.1038/ki.2014.31
Vitaflo International Ltd is a nutrition company which produces specialized clinical nutrition products for metabolic disorders, nutrition support and specific conditions such as kidney disease. Vitaflo International Ltd has funded the meetings held by the Pediatric Renal Nutrition Taskforce. RS is funded by a National Institute for Health Research (NIHR), CDF-2016-09-038; Career Development Fellowship). This publication presents independent research funded by the NIHR.
No funding obtained.
Conflict of interest
The authors declare no competing interests.
The Pediatric Renal Nutrition Taskforce wishes to confirm that Vitaflo has not influenced the development or content of these Clinical Practice Recommendations. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.
Participants in the Delphi survey
Baglam N, Ankara, Turkey; Bartleman J, Birmingham, UK; Cader S, Cape Town, South Africa; Collins S, Sydney, Australia; Ezzat M, Riyadh, Saudi Arabia; Ferreira-Ring L, Hamburg, Germany; Friedlander S, Auckland, New Zealand; Gille J, Marburg, Germany; Grassi MR, Milan, Italy; Huesman S, Cincinnati, USA; Hörmann P, Marburg, Germany; Jing L, Beijing, China; Juarez-Calderon M, Houston, USA; Laureti F, Rome, Italy; Marino D, Rome, Italy; Mattilda A, Bangalore, India; Nowogorska I, Gdansk, Poland; Pedarsani P, Los Angeles, USA; Parnarauskienė J, Vilnius, Lithuania; Rowe C, Sydney, Australia; Sgambat K, Washington DC, USA; Sharma S, New Delhi, India; Venrooij L, Rotterdam, Netherlands; Winderlich J, Melbourne, Australia; Yeung C, Hong Kong; Zwolsman M, Groningen, Netherlands.
Bakkaloglu S, Ankara, Turkey; Claes, D, Cincinnati, USA; Besouw M, Groningen, Netherlands; Dong J, Beijing, China; Edefonti A, Milan, Italy; Erickson R, Auckland, New Zealand; Geßner M, Tuebingen, Germany; Hahn D, Sydney, Australia; Iyengar A, Bangalore, India; Jankauskiene A, Vilnius, Lithuania; Klaus G, Marburg, Germany; Lalayiannis A, Birmingham, UK; Ma A, Hong Kong; Moudgil A, Washington DC, USA; McCulloch M, Cape Town, South Africa; Nourse P, Cape Town, South Africa; Oh J, Hamburg, Germany; Pizzo H, Los Angeles, USA; Prytula A, Ghent, Belgium; Reusz G, Budapest, Hungary; Sinha A, New Delhi, India; Srivaths P, Houston, USA; Topaloglu R, Ankara, Turkey; Zagozdzon I, Gdansk, Poland.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
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 37, 1–20 (2022). https://doi.org/10.1007/s00467-021-05148-y