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Growth of children with end-stage renal disease undergoing daily hemodialysis
Abstract and Figures
The aim of this report is to describe the effect of daily hemodialysis on the growth of children with end-stage renal disease (ESRD).
We performed a prospective, observational study on 24 children with ESRD undergoing daily hemodialysis (DHD). The control group comprised 26 children on concurrent conventional hemodialysis (CHD), and the follow-up for both groups was 9.3 ± 3.0 months. No patient received growth hormone (GH) therapy.
At the onset of the study, the height-for-age Z-score was -2.12 ± 1.54 in the CHD group and -2.84 ± 2.27 in the DHD group (p = 0.313). Assuming an increase of 0.5 standard deviation scores (SDS) of the height-for-age parameter as an improvement of growth, there were 33 % of patients in the DHD group and 8 % in the CHD group (p = 0.035). The cumulative probability of gain in height for age at 12 months was 40 % in the DHD group versus 15 % in the CHD group (p = 0.047). Also, 98 % of patients in the DHD group had an adequate total caloric intake, whereas 38 % in the CHD group reached this goal (p < 0.001). No patient left the study due to intensification of the dialysis modality.
Our data show that the DHD favored a 0.5 SDS height gain in a third of patients without GH treatment. Dialysis intensification was not a cause for treatment dropouts, and DHD should be considered as a treatment for selected cases, especially small children.
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... The NAPRTCS registry finds that children on dialysis tend to have greater stunting, the average height moving from -1.64 SD to -1.84 at two years of dialysis [6]. However, pediatric studies have shown contrary results, with growth recovery in both hemodialysis and PD, when optimized dialysis and/or adequate nutritional measures were applied [16][17][18][19][20]. Children on PD very often have nutritional difficulties with insufficient caloric intake [4,6,21] contributing to stunting. ...
... The adequacy of dialysis is not, however, reduced to the dialysis dose, and the optimized PD improves all the parameters involved in the genesis of PEM and growth disorders [69]. Like the evidence-based results shown in HD on growth through intensive diets, it seems logical to propose optimized PD regimens in children to promote adequate nutritional status and growth [16,17]. ...
Stunting and malnutrition are common in children with chronic kidney disease and increase with the degree of impairment to be maximal in children at the dialysis stage, leading to a risk of excess mortality. Despite many advances in the field of pediatric dialysis, small size in adulthood remains very common in this population. The origin of malnutrition and stunting is complex and multifactorial. In infants on peritoneal dialysis, insufficient nutritional intake is recognized as a major barrier to adequate growth. The diagnostic approach to undernutrition and stunting in peritoneal dialysis requires the use of several elements: an interrogation, a clinical examination, and various complementary examinations. Due to the multifactorial aspect of the nutritional and statural status of the child, several therapeutic axes are to be taken into account, namely a nutritional treatment adapted to the needs of the child, a treatment by growth hormone, and an optimization of dialysis to allow optimal metabolic control.
... After 6 months, the only prepubertal child included showed a significant catch-up growth, resulting in a height SDS gain of 1.5 over 24 months. De Camargo et al. performed an observational study on 24 children with CKD 5 undergoing daily HD [33]. The authors found that the intensified prescription favored a 0.5 SDS height gain in one-third of patients without rhGH treatment as compared with 8% in a control group of 26 children on a concurrent conventional HD regimen. ...
Growth retardation is a major complication in children with chronic kidney disease (CKD) and on kidney replacement therapy (KRT). Conversely, better growth in childhood CKD is associated with an improvement in several hard morbidity–mortality endpoints. Data from pediatric international registries has demonstrated that improvements in the overall conservative management of CKD, the search for optimal dialysis, and advances in immunosuppression and kidney transplant techniques have led to a significant improvement of final height over time. Infancy still remains a critical period for adequate linear growth, and the loss of stature during the first years of life influences final height. Preliminary new original data from the European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry confirm an association between the final height and the height attained at 2 years in children on KRT.
... Also in 2005, a program for in-center NIHD was established in Berlin, Germany [140], reporting further improvement of dialysis efficacy with HDF compared to HD in a crossover study of NIHD patients; this dialysis modality may be especially attractive for adolescents [141]. Improved growth was also reported in patients undergoing NHHD in Sao Paolo, Brazil, during 2008-2010 [142]. In short, patients with all forms of intensified HD were free of fluid or dietary restrictions; medications (including phosphate binders, erythropoietin, and antihypertensive agents) could be reduced; and control of blood pressure, phosphate levels, and anemia was improved. ...
Cardiovascular disease (CVD) is a life-limiting comorbidity in patients with chronic kidney disease (CKD). In childhood, imaging studies have demonstrated early phenotypic characteristics including increases in left ventricular mass, carotid artery intima-media thickness, and pulse wave velocity, which occur even in young children with early stages of CKD. Vascular calcifications are the signature of an advanced phenotype and are mainly found in adolescents and young adults treated with dialysis. Association studies have provided valuable information regarding the significance of a multitude of risk factors in promoting CVD in children with CKD by using intermediate endpoints of measurements of surrogate parameters of CVD. Dialysis aggravates pre-existing risk factors and accelerates the progression of CVD with additional dialysis-related risk factors. Coronary artery calcifications in children and young adults with CKD accumulate in a time-dependent manner on dialysis. Identification of risk factors has led to improved understanding of principal mechanisms of CKD-induced damage to the cardiovascular system. Treatment strategies include assessment and monitoring of individual risk factor load, optimization of treatment of modifiable risk factors, and intensified hemodialysis if early transplantation is not possible.
... C HILDREN WITH END-STAGE kidney disease (ESKD) reach a frequency of protein-energy malnutrition ranging from 20% to 80%. [1][2][3][4] This pathological entity that affects children with ESKD causes loss of lean mass, depletion of fat mass, and deceleration of growth with affectation in height. These alterations are a consequence of multiple factors, including hormonal imbalance, low nutrient intake, decreased residual renal function, use of renal replacement programs (hemodialysis [HD] and peritoneal dialysis [PD]), chronic inflammation, and metabolic acidosis. ...
Objective:
The objective of the study was to demonstrate that there are differences in the factors associated with anthropometric indicators of nutritional status, with particular emphasis on arm indicators, in children with end-stage kidney disease undergoing peritoneal dialysis (PD), hemodialysis (HD), and after kidney transplant (KT).
Methods:
An analytical cross-sectional study of consecutive cases included 130 children and adolescents with end-stage kidney disease undergoing substitutive treatment: 49 patients who underwent KT, 33 undergoing PD, and 47 undergoing HD. Socioeconomic data were obtained from all the 3 groups; anthropometric indicators of nutritional status were calculated. Student's t-test and analysis of variance were used for parametric variables. Chi-square test, Mann-Whitney U test, Kruskal-Wallis test, and odds ratio (OR) were used for nonparametric variables.
Results:
The number of parents living as couples was higher for patients who underwent KT (OR = 3.5 [95% confidence interval {CI} 1.34-9.0]) and undergoing PD (OR = 3.0 [95% CI 1.06-8.8]) than those undergoing HD. The number of mothers who worked outside the home was higher for patients who underwent KT and undergoing PD than the mothers of patients undergoing HD (OR = 13.7 [95% CI: 4.56-41.05]; OR = 15.4 [CI 95% 4.8-49], respectively). Family income was higher for patients who underwent KT and undergoing PD (P = .019, P = .093, respectively). More than 40% of patients in all the 3 groups had growth impairment. Body mass index, mid-upper arm circumference, tricipital and subscapular skinfolds, total arm area, and arm fat area were affected in HD and PD groups (9 to 40%), while of the patients who underwent KT, 36.7% were overweight or obese. More than 50% of patients who underwent KT and undergoing HD and PD had involvement in the arm muscular area.
Conclusions:
Socioeconomic conditions are more influential for children in the HD program. The nutritional status of children after KT improves; however, not all anthropometric indicators are fully recovered. Children after KT are up to 9 times more likely to be overweight or obese.
... When considering dialysis treatment alone, recent data indicate that daily hemodialysis promotes better outcomes for children when compared with conventional dialysis. 17 Consequently, the interest in daily hemodialysis has increased but, to date, the costs of this therapy have not been evaluated. ...
Objective: End‐stage renal disease is a health problem that consumes public and private resources. This study aimed to identify the cost of hemodialysis (either daily or conventional hemodialysis) and transplantation in children and adolescents.
Methods: This was a retrospective cohort of pediatric patients with End‐stage renal disease who underwent hemodialysis followed by kidney transplant. All costs incurred in the treatment were collected and the monthly total cost was calculated per patient and for each renal therapy. Subsequently, a dynamic panel data model was estimated.
Results: The study included 30 children who underwent hemodialysis (16 conventional/14 daily hemodialysis) followed by renal transplantation. The mean monthly outlay for hemodialysis was USD 3500 and USD 1900 for transplant. Hemodialysis costs added up to over USD 87,000 in 40 months for conventional dialysis patients and USD 131,000 in 50 months for daily dialysis patients. In turn, transplant costs in 50 months reached USD 48,000 and USD 70,000, for conventional and daily dialysis patients, respectively. For conventional dialysis patients, transplant is less costly when therapy exceeds 16 months, whereas for daily dialysis patients, the threshold is around 13 months.
Conclusion: Transplantation is less expensive than dialysis in children, and the estimated thresholds indicate that renal transplant should be the preferred treatment for pediatric patients.
Poor growth is an important complication of chronic kidney disease (CKD). Normal growth can be divided into four important phases: prenatal, infantile, childhood, and pubertal. Maintenance of normal growth is extremely difficult in the young child with CKD: poor feeding and vomiting are common and urological complications, the commonest cause of CKD in infancy, may result in sepsis, further aggravating the feeding problems or necessitating investigation and treatments with associated periods of fasting. One of the best described causes of poor growth is inadequate intake of calories and protein. This is particularly the case during the infantile phase, when growth is more rapid than at any other time and so demands relative to body size exceed any other age. Malnutrition and poor growth are associated with increased morbidity and mortality. Short stature is common in children of all ages with renal disease and has an important influence on outcome.
Background: Chronic kidney disease is a worldwide major public health problem. Most of the data related to the epidemiology of this condition during childhood focuses on the severe and late stages of renal impairment which is associated with malnutrition. It is an influential problem among those children and is essential to be recognised as early as possible.Objectives: To assess the nutritional status of children with chronic kidney disease on haemodialysis using anthropometric measurements.Patients and Method: A cross-sectional study was conducted in three randomly selected dialysis centres in Baghdad, the capital of Iraq, on a sample of patients with chronic kidney disease who attended these dialysis centres. Direct interviews were used to collect data during the period of the study which extended from the 15th of January to the 15th of July 2019. Results: This study enrolled 140 children. The mean age of the respondents was 9.9 ± 3.6 years and 42.9% of them had an age range of 10-14 years. 57.1% of the study sample was diagnosed with the disease since 5-9 years, and 42.1% were on HD for 12-23 months. 37.1% of the sample were thin for age according to their gender, and 72.2% of them were stunted and severely stunted. Conclusions:A considerable proportion (75%) of children with chronic kidney disease were undernourished, with a significant percentage of the study sample detected with chronic malnutrition (stunted and severely stunted).
Background
The effectiveness of rhGH on growth and final height (FH) was determined in children with CKD and kidney failure using data linkage from two national databases.Methods
Data on Australian children with CKD and kidney failure treated with rhGH were obtained by linking ANZDATA and OzGrow registries. The CKD cohort included children treated with rhGH prior to kidney replacement therapy (KRT). The KRT cohort consisted of children with kidney failure, some received rhGH, and some were untreated. Height standard deviation scores (Ht-SDS) were calculated with final height defined as last height recorded in girls > 16 years of age and boys > 17 years of age.ResultsIn the CKD group, there were 214 children treated with rhGH prior to KRT. In the KRT group, there were 1,032 children, 202 (19%) treated with rhGH and 830 (81%) untreated. Growth significantly improved in the rhGH-treated CKD group (ΔHt-SDS = +0.80 [+0.68 to +0.92]; p < 0.001) and the rhGH-treated KRT group (ΔHt-SDS = +0.38 [+0.27 to +0.50]; p < 0.001). Within the KRT cohort, final height was available for 423 patients (41%), of which 137 (32%) had been treated with rhGH. The rhGH-treated group demonstrated marginally better catch-up growth (ΔHt-SDS = +0.05 [−0.18 to 0.29]) compared to the non-rhGH-treated group (ΔHt-SDS = −0.03 [−0.16 to 0.10]; p = 0.49).Conclusions
This large linkage study confirms rhGH is effective in improving height in children with CKD pre-KRT. However, rhGH appears to have a variable impact on growth once children have commenced KRT resulting in a marginal impact on final height.Graphical abstract
Since the inception of pediatric dialysis programs more than 50 years ago, there have been vast improvements in both the technology and expertise in the care of children with chronic kidney disease (CKD). Nevertheless, children on dialysis continue to have an unacceptably high mortality, and cardiovascular disease (CVD) is a life-limiting comorbidity in patients with CKD. Although cardiac and vascular damage likely begins early in the course of CKD, dialysis aggravates preexisting risk factors and accelerates the progression of CVD with additional dialysis-related risk factors. Coronary artery calcifications in children and young adults with CKD accumulate in a time-dependent manner on dialysis. Risk factors for CVD, which include hypertension and dysregulated mineral metabolism leading to ectopic vascular calcification, have been consistently implicated in clinical, epidemiological, and cell biology studies as key, but importantly modifiable, risk factors in the development of CVD. Identifying potentially modifiable damage-inducing agents in the uremic milieu and understanding their role in the pathophysiology of CVD may allow us to inhibit progression or even induce regression of existing cardiac and vascular injury in CKD patients.
Chronic kidney disease and end‐stage renal disease (ESRD) in children are major health concerns worldwide with increasing incidence and prevalence. Renal replacement therapies and kidney transplants have remarkably improved the management of patients with ESRD in both adult and pediatric populations. Kidney transplant has the best patient outcomes, but many a time it has a considerable waiting period. In the meantime, the majority of patients with pediatric ESRD are dependent on dialysis. The conventionally utilized hemodialysis regimen is the three times weekly, in‐center hemodialysis. Many studies have demonstrated the unfavorable long‐term morbidity associated with the conventional regimen. Intensified dialysis programs, which include extended nocturnal hemodialysis or short daily hemodialysis, are being increasingly advocated over the past two decades. In addition to having much better clinical outcomes as compared with the conventional regimen, the flexibility to provide dialysis at home serves as a great incentive. PubMed/Medline, Embase and Cochrane databases for literature on nocturnal home hemodialysis in children with ESRD were extensively searched. Contrary to the noticeable literature available on adult home hemodialysis, a small number of studies exist in the pediatric population. In this review, the benefits, implementation and associated barriers of nocturnal home hemodialysis in children were addressed.
In observational studies, investigators have no control over the treatment assignment. The treated and non-treated (that is, control) groups may have large differences on their observed covariates, and these differences can lead to biased estimates of treatment effects. Even traditional covariance analysis adjustments may be inadequate to eliminate this bias. The propensity score, defined as the conditional probability of being treated given the covariates, can be used to balance the covariates in the two groups, and therefore reduce this bias. In order to estimate the propensity score, one must model the distribution of the treatment indicator variable given the observed covariates. Once estimated the propensity score can be used to reduce bias through matching, stratification (subclassification), regression adjustment, or some combination of all three. In this tutorial we discuss the uses of propensity score methods for bias reduction, give references to the literature and illustrate the uses through applied examples. © 1998 John Wiley & Sons, Ltd.
In observational studies, investigators have no control over the treatment assignment. The treated and non-treated (that is, control) groups may have large differences on their observed covariates, and these differences can lead to biased estimates of treatment effects. Even traditional covariance analysis adjustments may be inadequate to eliminate this bias. The propensity score, defined as the conditional probability of being treated given the covariates, can be used to balance the covariates in the two groups, and therefore reduce this bias. In order to estimate the propensity score, one must model the distribution of the treatment indicator variable given the observed covariates. Once estimated the propensity score can be used to reduce bias through matching, stratification (subclassification), regression adjustment, or some combination of all three. In this tutorial we discuss the uses of propensity score methods for bias reduction, give references to the literature and illustrate the uses through applied examples.
Background. Kidneys from child donors are very efficient at adapting to the recipient organism. This research aims to verify the size of kidney grafts from pediatric donors after transplant and to identify factors responsible for the size attained by these kidneys. Moreover, it aims to seek relationships between size and function of the transplanted pediatric kidney. Methods. Seventy-seven renal transplants performed at least 6 months earlier, with cadaver donor 15 years old or younger, had ultrasound measurements of the graft and renal function assessment. Potential factors for graft volume were analyzed using bivariate analysis, followed by multiple linear regression. Results. After a follow up of 4.2 +/- 3.3 years posttransplant, the grafts presented the following range of measures: length 10.61 +/- 1.13 cm, width 4.67 +/- 0.84 cm, and depth 4.76 +/- 0.99 cm. Graft volumes were 126.62 +/- 47.76 cm(3). Bivariate analysis showed that (1) age of both donor and recipient at transplantation; (2) sex of recipient; (3) occurrence of acute rejection episodes were statistically significant. After multivariate analysis, age and sex of recipients were the only significant factors influencing graft volume; child kidneys reached greater volumes when transplanted into adult and male individuals. Larger volume kidneys presented significantly more proteinuria. No difference was evident with regard to creatinine clearance values or urinary retinol binding protein among kidneys of differing sizes. Conclusions. The size of the recipient (age and sex) is the main factor responsible for volumes achieved by kidneys from pediatric donors. The volume attained by these kidneys demonstrated no relationship with glomerular or tubular function of the organ.
La croissance des enfants allaités s’écarte notablement des courbes de croissance nationales ou internationales, basées sur l’observation d’enfants pour la plupart non allaités, alors que l’Organisation mondiale de la santé (OMS) recommande un allaitement maternel exclusif pendant 6 mois. Une étude de l’OMS, ayant pour objectif de décrire la croissance des enfants allaités, indemnes de maladie et élevés dans de bonnes conditions d’hygiène, s’est déroulée de 1997 à 2003 dans 6 pays : Brésil, États-Unis d’Amérique, Ghana, Inde, Norvège et Oman. De la naissance à 2 ans, ces standards de croissance ont été déterminés grâce au suivi longitudinal de 882 enfants dont les mères acceptaient de suivre les recommandations de l’OMS en matière d’alimentation (allaitement exclusif ou prédominant pendant au moins 4 mois, diversification alimentaire à 6 mois, poursuite de l’allaitement jusqu’au moins 12 mois). De 2 à 5 ans, ces standards ont été déterminés par l’étude transversale de 6669 enfants ayant bénéficié d’un allaitement, exclusif ou non, d’une durée minimale de 3 mois. Les percentiles et les Z-scores des indices poids/âge, taille/âge, poids/taille et masse corporelle/âge ont été calculés pour les garçons et les filles âgés de 0 à 60 mois. Ces standards (www.who.int/childgrowth/en) constituent un outil adapté à la mesure de la croissance rapide de la petite enfance. Ils montrent que les enfants qui sont dans un environnement favorable et sont nourris suivant les recommandations de l’OMS ont, jusqu’à l’âge de 5 ans, une croissance en poids et en taille étonnamment identique à travers le monde, malgré la diversité ethnique des populations.
The shortage of cadaveric donors for kidney transplantation has prompted many centers to use cadaver kidneys from pediatric donors. Use of kidneys from pediatric donors has been shown to have a lower graft survival.
Recipients receiving cadaver kidneys from pediatric and adult donors between 1988 and 1995 were analyzed. The data were obtained from United Network of Organ Sharing database. The actuarial kidney transplant graft survival was estimated by the Kaplan-Meier method. A logistic regression analysis was used to identify various risk factors for 1-year graft failure. Odds ratios (OR) were estimated for various risk factors.
Kidney transplant survival rates for donor age <18 years (n=12,838) at 1, 2, 3, 4, and 5 years were 81.5%, 76.3%, 71.3%, 66.4%, and 61.7%, respectively. The corresponding results for adult donors from age 18 to 50 years (n=35, 442) were 83.5%, 78.4%, 73.1%, 67.9%, and 62.4%, respectively, Log-rank test P<0.01. Pediatric donors were further divided into three groups according to donor age: group I (0-5 years), group II (6-11 years), and group III (12-17 years). The actuarial survival rates for 1, 3, and 5 years for group I (n=2198) were 73.6%, 63.3%, and 55.6%, respectively. The corresponding values for group II (n=2873) were 78.0%, 67.5%, and 57.8% and for group III (n=7767) were 85%, 75.0%, and 64.8%, respectively, P<0.01. Although the recipients of group I had lower graft survival, en bloc grafts (n=751) had much better 1-, 3-, and 5-year graft survival rates (76.3%, 67.7%, and 60.7%, respectively) compared with single grafts (n=1447; 72.2%, 61.1%, and 53.2%, P=0.02) from donors 0 to 5 years. Graft thrombosis as a cause of graft failure was seen in 10% of group I compared with 6% in group II and 5% in group III. In group I, lower OR were seen when an en bloc transplant was performed (0.688, P<0.01) and when donor body weight was>15 kg (0.547, P<0.01). However, OR were elevated in recipients of previous transplants (1.556, P<0.01), with prolonged cold ischemic time (1.097, P=0.03), for black recipients (1.288, P=0.03), and for recipients with body mass index> or =25 (1.286, P=0.02). Progressive increase in the donor age was associated with lower OR in group II (0.894, P<0.01).
(1) Overall, poorer graft survival was seen in pediatric donor transplants, (2) transplant kidney survival with en bloc kidneys was better than a single kidney from donors 0-5 years, (3) progressive increase in donor age was associated with improved graft survival when the donors were 6-11 years, whereas progressive increase in donor weight was associated with improved graft survival when the donors were 0-5 years.
The purpose of this study was to examine the utility of the random urine protein to creatinine ratio (P/C) in evaluation and longitudinal management of proteinuria in adult renal transplant recipients with or without overt nephropathy in an outpatient clinic.
A total of 289 adult renal transplant recipients provided 24-hr urine collections for total protein and creatinine, followed by a random urine for protein and creatinine. For longitudinal analysis, 192 of these patients provided two 24-hr urine collections with concomitant random urine specimens separated on average by 6.8 months. As well, 134 patients provided a total of 851 multiple-paired spot and 24-hr urine samples (range 2 to 12) over a 2-year period.
The log random urine P/C ratio correlated significantly to the log 24 UP (r=0.749, P<0.0001) with or without nephrotic range proteinuria. High sensitivity (74.4-90%) and specificity values (93-98%) were found for estimating proteinuria from 0.5 to 2 g/day. However, the precision of estimation decreased as the level of urinary protein excretion increased to >3 g/day. The positive predictive value decreased as proteinuria became >3 g/day, perhaps because of the low prevalence of patients with high level proteinuria in our sample. The direction of change in P/C ratio longitudinally was accompanied by a similar direction of change in 24 UP, which was highly significant (r=0.7555, P<0.0001).
We conclude that the urine P/C ratio is a useful and convenient screening and longitudinal test for proteinuria.
Renal transplant patients with stable graft function and proximal tubular dysfunction (PTD) have an increased risk for chronic allograft nephropathy (CAN). In this study, we investigated the histologic pattern associated with PTD and its correlation with graft outcome. Forty-nine transplant patients with stable graft function were submitted to a biopsy. Simultaneously, urinary retinol-binding protein (uRBP) was measured and creatinine clearance was also determined. Banff’s score and semi-quantitative histologic analyses were performed to assess tubulointerstitial alterations. Patients were followed for 24.0 ± 7.8 months. At biopsy time, mean serum creatinine was 1.43 ± 0.33 mg/dl. Twelve patients (24.5%) had uRBP ≥1 mg/l, indicating PTD and 67% of biopsies had some degree of tubulointerstitial injury. At the end of the study period, 18 (36.7%) patients had lost renal function. uRBP levels were not associated with morphologic findings of interstitial fibrosis and tubular atrophy (IF/TA), interstitial fibrosis measured by Sirius red or tubulointerstitial damage. However, in multivariate analysis, the only variable associated with the loss of renal function was uRBP level ≥1 mg/l, determining a risk of 5.290 of loss of renal function (P = 0.003). Renal transplant patients who present PTD have functional alteration, which is not associated with morphologic alteration. This functional alteration is associated to progressive decrease in renal function.
Poor growth in chronic kidney disease (CKD) is a marker of disease severity and of quality of care. Causes are multifactorial, and include malnutrition, cachexia, hematological factors, endocrine problems and metabolic abnormalities. In this Review, we focus on the impact of inadequate nutrition on growth disturbances in children with CKD, and discuss all aspects of the epidemiology, causes and potential treatments. Regional variations in resources may be a factor that contributes to the observed differences. Successful nutritional management requires a multidisciplinary team that includes not only doctors but also skilled nurses and dieticians. Extremes of body mass index, representing undernutrition and overnutrition, are associated with poor outcomes and should be avoided when designing therapeutic strategies for optimizing nutrition and growth in children with CKD. Improved understanding of the pathophysiology of cachexia and wasting in patients with CKD could lead to the development of novel therapeutic strategies.