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      Energy and protein requirements for children with CKD stages 2-5 and on dialysis–clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

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          Dietary management in pediatric chronic kidney disease (CKD) is an area fraught with uncertainties and wide variations in practice. Even in tertiary pediatric nephrology centers, expert dietetic input is often lacking. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, was established to develop clinical practice recommendations (CPRs) to address these challenges and to serve as a resource for nutritional care. We present CPRs for energy and protein requirements for children with CKD stages 2–5 and those on dialysis (CKD2–5D). We address energy requirements in the context of poor growth, obesity, and different levels of physical activity, together with the additional protein needs to compensate for dialysate losses. We describe how to achieve the dietary prescription for energy and protein using breastmilk, formulas, food, and dietary supplements, which can be incorporated into everyday practice. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgment. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT.

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          The online version of this article (10.1007/s00467-019-04426-0) contains supplementary material, which is available to authorized users.

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          Most cited references 88

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          Body composition of reference children from birth to age 10 years.

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            Classifying recommendations for clinical practice guidelines.

            Clinical practice guidelines are intended to improve the quality of clinical care by reducing inappropriate variations, producing optimal outcomes for patients, minimizing harm, and promoting cost-effective practices. This statement proposes an explicit classification of recommendations for clinical practice guidelines of the American Academy of Pediatrics (AAP) to promote communication among guideline developers, implementers, and other users of guideline knowledge, to improve consistency, and to facilitate user understanding. The statement describes 3 sequential activities in developing evidence-based clinical practice guidelines and related policies: 1) determination of the aggregate evidence quality in support of a proposed recommendation; 2) evaluation of the anticipated balance between benefits and harms when the recommendation is carried out; and 3) designation of recommendation strength. An individual policy can be reported as a "strong recommendation," "recommendation," "option," or "no recommendation." Use of this classification is intended to improve consistency and increase the transparency of the guideline-development process, facilitate understanding of AAP clinical practice guidelines, and enhance both the utility and credibility of AAP clinical practice guidelines.
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              Amino acid and albumin losses during hemodialysis.

              Protein and calorie malnutrition are prevalent in chronic hemodialysis (HD) patients and has been linked to increased mortality and morbidity in this patient population. Concern has been raised that the open pore structure of high flux membranes may induce the loss of more amino acids (AA) compared to low flux membranes. To address this issue, we prospectively analyzed pre- and post-HD plasma AA profiles with three different membranes in nine patients. Simultaneously, we measured dialysate AA losses during HD. The membranes studied were: cellulosic (cuprophane-CU), low flux polymethylmethacrylate (LF-PMMA), and high flux polysulfone (HF-PS) during their first use. Our results show that pre-HD plasma AA profiles were abnormal compared to controls and decreased significantly during HD with all dialyzers. The use of HF-PS membranes resulted in significantly more AA losses into the dialysate when compared to LF-PMMA membranes (mean +/- SD; 8.0 +/- 2.8 g/dialysis for HF-PS, 6.1 +/- 1.5 g/dialysis for LF-PMMA, p < 0.05, and 7.2 +/- 2.6 g/dialysis for CU membranes, P = NS). When adjusted for surface area and blood flow, AA losses were not different between any of the dialyzers. We also measured dialysate AA losses during the sixth reuse of the HF-PS membrane. Losses of total AA increased by 50% during the sixth reuse of HF-PS membrane compared to its first use. In addition, albumin was detected in the dialysate during the sixth reuse of HF-PS membrane. We therefore measured albumin losses in all patients dialyzed with HF-PS membranes as a function of reuse.(ABSTRACT TRUNCATED AT 250 WORDS)

                Author and article information

                Pediatr Nephrol
                Pediatr. Nephrol
                Pediatric Nephrology (Berlin, Germany)
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                16 December 2019
                16 December 2019
                : 35
                : 3
                : 519-531
                [1 ]GRID grid.11201.33, ISNI 0000 0001 2219 0747, University of Plymouth, ; Plymouth, PL6 8BH UK
                [2 ]GRID grid.83440.3b, ISNI 0000000121901201, University College London Institute of Child Health, ; London, UK
                [3 ]GRID grid.414137.4, ISNI 0000 0001 0684 7788, British Columbia Children’s Hospital, ; Vancouver, Canada
                [4 ]GRID grid.7692.a, ISNI 0000000090126352, Wilhelmina Children’s Hospital, , University Medical Center Utrecht, ; Utrecht, The Netherlands
                [5 ]GRID grid.414818.0, ISNI 0000 0004 1757 8749, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, ; Milan, Italy
                [6 ]GRID grid.414503.7, ISNI 0000 0004 0529 2508, Emma Children’s Hospital, , Amsterdam University Medical Center, ; Amsterdam, The Netherlands
                [7 ]GRID grid.7737.4, ISNI 0000 0004 0410 2071, Children’s Hospital and Clinical Nutrition Unit, Internal Medicine and Rehabilitation, , University of Helsinki and Helsinki University Hospital, ; Helsinki, Finland
                [8 ]GRID grid.430506.4, Southampton Children’s Hospital, , University Hospital Southampton NHS Foundation Trust, ; Southampton, UK
                [9 ]GRID grid.410566.0, ISNI 0000 0004 0626 3303, University Hospital Ghent, ; Ghent, Belgium
                [10 ]GRID grid.428158.2, ISNI 0000 0004 0371 6071, Emory University and Children’s Healthcare of Atlanta, ; Atlanta, USA
                [11 ]GRID grid.10423.34, ISNI 0000 0000 9529 9877, Children’s Hospital, , Hannover Medical School, ; Hannover, Germany
                [12 ]GRID grid.24434.35, ISNI 0000 0004 1937 0060, PedsFeeds LLC, , University of Nebraska, ; Lincoln, USA
                [13 ]Great Northern Children’s Hospital, Newcastle Upon Tyne, UK
                [14 ]GRID grid.239559.1, ISNI 0000 0004 0415 5050, Children’s Mercy, ; Kansas City, USA
                [15 ]GRID grid.424537.3, ISNI 0000 0004 5902 9895, Great Ormond Street Hospital for Children NHS Foundation Trust, ; London, UK
                [16 ]GRID grid.83440.3b, ISNI 0000000121901201, The Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health, , University College London, ; London, UK
                © The Author(s) 2019

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

                Funded by: University College London (UCL)
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