Nutritional Challenges In Children With Chronic Kidney Disease

Chronic kidney disease (CKD) is a devastating condition in children and can upend their lives. It alters their 'normal', and transforms everyday activities – from play to mealtimes – into medical concerns that demand constant vigilance.

Nutrition is the cornerstone of effective CKD management. Poor appetite, significantly elevated energy requirements, and stringent dietary restrictions produce a compounded risk environment. Without adequate intervention this can lead to growth failure, developmental delays, and compromised long-term outcomes.

However, achieving optimal nutrition in paediatric CKD patients remains one of the most complex challenges in clinical practice.

The NNIA webinar on Kidney Disease Nutrition: Nutritional Challenges In Children With Kidney Disease, presented by leading Paediatric Nephrologist Dr Rukshana Shroff, examines the critical intersection of nutrition and paediatric CKD management.

Dr Shroff provides an evidence-based exploration of the nutritional complexities inherent in treating young CKD patients, the clinical consequences of suboptimal nutrition, and actionable strategies that healthcare professionals can implement to optimise nutritional outcomes and improve the lives of these vulnerable children.

Top Causes of Kidney Disease in South African Children

Globally, with data primarily drawn from high-income countries, causes are dominated by issues with which a child is born: Congenital Anomalies of the Kidney and Urinary Tract (CAKUT), hereditary diseases, and Glomerulonephritis (inflammation of the kidney filters).

In South Africa, causes of kidney disease include aggressive genetic predispositions and acquired inflammatory conditions.

• Glomerulonephritis: Aggressive glomerulonephritis, particularly FSGS common in children of African ancestry, is the most frequent cause of end-stage renal disease (ESRD).
• CAKUT: Though initiating kidney damage, CAKUT's progression to ESRD is often compounded by delays and complications, ranking it secondary to aggressive glomerulonephritis.
• Hypertension: Severe, often undiagnosed, high blood pressure is a significant and aggressive cause of kidney failure.
• HIV-Associated Nephropathy (HIVAN): This involves direct HIV infection of kidney cells, leading to inflammation and scarring within the glomeruli.
• Hereditary Nephropathies: Conditions like Polycystic Kidney Disease (PKD) and Alport Syndrome (affecting kidneys, hearing, and vision) also contribute to the renal disease burden.

Key Nutritional Challenges: Kidney Disease and Diet

During a child’s growth and development, their nutritional needs differ markedly from adults, particularly when dealing with chronic kidney disease. Additional challenges to nutritional intake include taste changes, relentless thirst due to fluid restrictions in late-stage renal failure, and the physical demands imposed by kidney disease treatment.

The Growth Paradox

The growing process demands a constant supply of calories (energy), protein, and micronutrients, and CKD “attacks” this process by suppressing appetite and creating a highly catabolic state in the body (where the body breaks down tissue) – all of this while the growing child’s energy needs are at their most critical.

The Protein Paradox

Protein is crucial for growth, yet its metabolic waste product, urea, accumulates when damaged kidneys can no longer filter it efficiently. This urea buildup leads to a toxic condition called uremia, causing appetite loss, nausea, severe fatigue, and a metallic taste in the mouth. Healthcare professionals must delicately balance restricting protein to reduce this toxic burden, whilst simultaneously providing enough for a child's essential growth.

Consequences of Poor Nutrition

In a child with a chronic kidney disease diagnosis, poor nutrition has destructive effects on physical and psychological levels:

• Severe growth failure: Inadequate nutrition forces the body into “survival mode,” prioritising essential functions over building bones and muscle, leading to irreversible stunting.
• Protein-Energy Wasting (PEW): This severe metabolic malnutrition breaks down muscle and fat for energy, leaving children highly susceptible to infections and unable to tolerate dialysis stress.
• Impaired immune function: Lacking essential protein, zinc, selenium, and other micronutrients, the immune system fails, increasing kidney infection risk.
• Worsening cardiovascular disease: Poor nutrition fuels chronic inflammation, damaging blood vessels and increasing the risk of hypertension, stroke, and heart attacks.
• Impaired Cognitive Development: Fatigue, low energy, and deficiencies in brain-building nutrients impair concentration, learning, and memory, affecting overall development.

Strategies for Nutritional Management

The paediatric nephrology fraternity is shifting the CKD management focus from merely managing failure towards a multidisciplinary approach that’s aimed at preserving kidney function and ensuring overall quality of life. Some nutritional strategies include:

• Regular Anthropometric Assessment: The meticulous and detailed tracking of weight, height and body mass index (BMI) at every healthcare appointment helps to detect growth faltering early.
• Dietary counselling: Consulting a dietitian with a special interest in paediatric renal disease is critical in the management of nutrition and kidney health. These professionals offer personalised advice to families on how to maximise calorie intake and optimise protein intake within the dietary restrictions.
• Managing anorexia: Lack of appetite is a big player in the progression of CKD, so medical treatments need to be optimised to reduce uremic toxins. Acidosis should also be treated, as this can suppress appetite.
• Enteral tube feeding (gastrostomy): Often the most effective intervention, gastrostomy can include overnight feeds that provide concentrated calories and protein without the daily battle of low appetite.
• Intradialytic Parenteral Nutrition (IDPN): This allows nutrition to be delivered straight into a child’s bloodstream, especially if he or she is on haemodialysis, and can be done during dialysis treatment.
• Supplements: These are not recommended as a primary strategy, but renal-specific formulations may help with certain vitamins and minerals intake.

The biggest challenge we are faced with in South African CKD management is the massive gap between the number of children needing specialised care, and the resources available to provide it. So, slowing disease progression through meticulous nutritional and medical management is the most critical intervention strategy for any HCP supporting a child with CKD.