Table 12.1 Causes of acute renal injury in children.

Pre-renal failure Intrinsic renal failure Post-renal failure

Hypovolaemia (gastroenteritis,haemorrhage)

Diseases of the kidney or vessels (acute glomerulonephritis,acute tubular necrosis, haemolytic uraemic syndrome,vasculitis, hypoplasia)

Obstruction (posterioruretheral valves, calculi,tumours, trauma)

Peripheral vasodilation (sepsis,antihypertensive medications)

Myoglobinuria

Impaired cardiac output Intratubular obstruction (uric acid)

Bilateral renal vessel occlusion Iatrogenic factors (removal of solitary kidney)

Drugs (ciclosporin, diuretics) Tumour infiltrate

Nephrotoxic drugs (antimicrobials, heavy metals, insecticides,cytotoxic agents)

Hypoxic/ischaemic insults

Clinical Paediatric Dietetics, Fourth Edition. Edited by Vanessa Shaw.© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd.Companion Website: www.wiley.com/go/shaw/paediatricdietetics

Table 12.2 Indications for choice of renal replacementtherapy in acute kidney injury.

Indication fordialysis

Clinicalcondition

Modalityindicated

Solute removal Stable

Unstable

HD

CRRT, PD

Fluid removal Stable

Unstable

PD, isolatedultrafiltration on HD

CRRT

Solute and fluidremoval

Stable/unstable HD, PD, CRRT

Tumour lysissyndrome

Stable/unstable HD followed byCRRT

Toxin or drugremoval

Stable/unstable CRRT, IHD for somedrugs

HD, haemodialysis; CRRT, continuous renal replacementtherapy; PD, peritoneal dialysis; IHD, intermittenthaemodialysis.

Table 12.3 Reference ranges (Central ManchesterFoundation Trust).

(a) Guidelines for normal serum values

Analyte Age Range

Sodium (mmol/L) <1 month 130–145>1 month 135–145

Potassium (mmol/L) <1 month 3.5–6.0>1 month 3.5–5.0

Bicarbonate (mmol/L) All 20–26

Urea (mmol/L) 1 month 2.0–5.01 year 2.5–6.0Child 2.5–6.5Teenager 3.0–7.5

Albumin (g/L) <1 month 25–351–6 months 28–44Child 30–45

Calcium (mmol/L) <2 weeks 1.9–2.8serum total >2 weeks 2.2–2.7

Phosphate (mmol/L) <1 month 1.4–2.85 weeks to 1 year 1.2–2.21–3 years 1.1–2.04–12 years 1.0–1.815 years 0.95–1.5Adult 0.8–1.4

PTH (pg/mL) All 10–60normocalcaemic

Magnesium (mmol/L) All 0.65–1.0

Ferritin (μg/L) All 30–275

Glucose (mmol/L) <1 month 2.5–5.5fasting >1 month 3–6.0

(b) Guidelines for normal serum creatinine values

Age Serum creatinine (μmol/L)

<1 week <1001–2 weeks <802–4 weeks <551 month to 1 year <401–3 years <404–6 years <467–9 years 10–5610–12 years 30–6013–15 years 40–8016 years to adult male 40–96016 years to adult female 26–86

Ketones interfere positively. Bilirubin interferes negatively.

Table 12.4 Nutritional guidelines for the child with acute kidney injury.

Energy∗ Protein(kcal/kg body weight/day) (g/kg body weight/day)

Conservative management0–2 months 95–120 (400–500 kJ) 1.0–2.1Infants/children/adolescents EAR for chronological age 1.0

Peritoneal dialysis0–2 months 95–120 (400–500 kJ) 2.1–2.5†

Infants/children/adolescents EAR for chronological age 1.0–2.5

Haemodialysis0–2 months 95–120 (400–500 kJ) 1.0–2.1Infants/children/adolescents EAR for chronological age 1.0–1.8

CRRT0–2 months 95–120 (400–500 kJ) 2.5–3.0Infants/children/adolescents EAR for chronological age 2.5

EAR, estimated average requirement [8, 9]; CRRT, continuous renal replacement therapy.∗These guidelines are rarely achieved in the acute stage when fluid is restricted.†If dialysis is prolonged, increased protein may be required.

Table 12.5 Nutritional supplements.

Supplement Suggested use

EnergyGlucose polymersPowder, e.g. Polycal, Super Soluble Maxijul, Vitajoule Add to infant formula, baby juice, cow’s milk, squash,

fizzy drinks, tea, milk shake, ice cubes and lollies

Liquid, e.g. Polycal Dilute with water, cordial or fizzy drinks of choice(unless fluid restricted), add to jelly

Fat emulsione.g. Calogen, Liquigen Add to infant formula, cow’s milk, nutritionally

complete supplementsCombined fat and carbohydratee.g. Super Soluble Duocal Powder, QuickCal Add to infant formula, cow’s milk, nutritionally

complete supplementsProteinProtein powderse.g. Protifar, Vitapro, Renapro Add to infant formula, Liquid Duocal, modular feed

components

Renal specific infant formulasKindergenPowder per 100 g: 7.5 g protein, 503 kcal (2104 kJ), 93 mg phosphorus,3 mmol potassium, 10 mmol sodium

For infants with CKD or conservatively managed AKI

20% solution (20 g powder made up to 100 mL with water): 1.5 g protein,101 kcal (421 kJ), 18.6 mg phosphorus, 0.6 mmol potassium, 2 mmolsodium

RenastartPowder per 100 g: 7.5 g protein, 494 kcal (2066 kJ), 92 mg phosphorus,3 mmol potassium, 10.5 mmol sodium

20% solution (20 g powder made up to 100 mL with water): 1.5 g protein,99 kcal (413 kJ), 18 mg phosphorus, 0.6 mmol potassium, 2.1 mmolsodium

Nutritionally complete feedsNutrini per 100 mL: 2.8 g protein, 100 kcal (420 kJ), 50 mg phosphorus,2.8 mmol potassium, 2.6 mmol sodium

For oral or supplementary tube feeding in children >1year and weight >8 kg

Paediasure per 100 mL: 2.8 g protein, 101 kcal (422 kJ), 53 mg phosphorus,2.8 mmol potassium, 2.6 mmol sodium

Can be combined with energy supplements

Nutrini Energy per 100 mL: 4.1 g protein, 150 kcal (630 kJ), 75 mgphosphorus, 4.2 mmol potassium, 3.9 mmol sodiumPaediasure Plus per 100 mL: 4.2 g protein, 151 kcal (632 kJ), 80 mgphosphorus, 3.5 mmol potassium, 2.6 mmol sodiumNepro HP per 100 mL: 8.1 g protein, 180 kcal (722 kJ), 72 mg phosphorus,2.7 mmol potassium, 3.0 mmol sodium

Consider micronutrient contribution in youngerchildren

Low electrolyte supplements (not nutritionally complete)Fortijuce per 100 mL: 4 g protein, 150 kcal (640 kJ), 12 mg phosphorus,0.2 mmol potassium, 0.4 mmol sodium

Can be diluted with water or fizzy drinks

Ensure Plus Juce per 100 mL: 4.8 g protein, 150 kcal (638 kJ), 11 mgphosphorus, 0.4 mmol potassium, 0.5 mmol sodiumRenilon 7.5 per 100 mL: 7.5 g protein, 200 kcal (835 kJ), 3 mg phosphorus,0.6 mmol potassium, 2.6 mmol sodiumVita-Bite per 25 g bar: 0.06 g protein, 137 kcal (571 kJ), <12.5 mgphosphorus, 0.63 mmol potassium, <0.1 mmol sodium

Low protein milk substituteSno-Pro per 100 mL: 0.16 g protein, 89 kcal (371 kJ), <30 mg phosphorus,<1.3 mmol potassium, <3.3 mmol sodium, <20 mg calcium

Use as a substitute for cow’s milk to reduce protein andphosphate intakes

Renamil per 100 g: 4.6 g protein, 477 kcal (2003 kJ), 25 mg phosphorus,0.2 mmol potassium, 2.6 mmol sodium

CKD, chronic kidney disease; AKI, acute kidney injury.

Table 12.6 Potassium rich foods and suggested alternatives.

Potassium rich foods∗ Suggested alternatives

Banana, apricots, kiwi fruit, grapes, avocado, citrus fruits, e.g.orange, grapefruit; dried fruit, e.g. raisins; tinned fruit in fruitjuice; melon, plums, rhubarb, blackcurrants

Apple, pear, satsuma, blueberries, tinned fruit in syrup

Hi juice squash, fruit juices including orange, apple, tomatoInstant coffee and coffee essenceMalted drinksCocoa, drinking chocolate

Squash, cordials, Lucozade, lemonade and fizzy drinks,tea

Potato crisps and potato containing snacks, nuts, peanut butter,salt substitutes, meat extract, yeast extract

Corn or rice snacks (without added potassium chlorideand take account of sodium content), sweetenedpopcorn, jam, honey, marmalade, syrup

Jacket potatoes, chips (oven and frozen), roast potatoes Rice (boiled or fried), spaghetti, pasta, noodles, bread,chapatti, naan, crackers

Mushrooms, spinach, tomatoes, spaghetti in tomato sauce,baked beans, pulses and hummus, tinned and packet soups

Carrots, cauliflower, swede, broccoli, cabbage

Chocolate and all foods containing it, toffee, fudge, marzipan,liquorice

Boiled sweets, jellies, mints, marshmallows

Chocolate biscuits Biscuits: plain, sandwich, jam filled, wafer

Chocolate cake, fruit cake Cake: plain sponge filled with cream and/or jamJam tarts, apple pie, doughnuts, plain scones

Milk, yoghurt, evaporated and condensed milk Low protein milk substitutes, e.g. Sno-Pro, Renamil

∗Allowance will depend on individual assessment.

Table 12.7 Phosphate rich foods and suggested alternatives.

Phosphate rich foods∗ Suggested alternatives

Cow’s milk (full cream, semi-skimmed, skimmed)Dried milk powder and other milk products

InfantsWhey based infant formulas, e.g., Cow & Gate 1, SMA1, Aptamil 1 for at least 1–2 yearsChildrenReduced intake, consider low protein milk substitute(Table 12.5)

Large portions of meat, poultry and fishProcessed meats containing phosphate additives

Reduced portion sizes

Yoghurt, fromage frais, mousse, ice cream, milk puddingsincluding custard

Reduce intakeCustard made with milk substitute

Evaporated milk, condensed milk, single cream Double cream†

Cheese, e.g. Cheddar, Edam, processed cheese and cheese spread Limit intake and/or encourage use of cottage cheese orfull fat cream cheese

Egg yolk Meringues

Cocoa, chocolate and chocolate containing foods, toffee, fudge Boiled sweets, mints, dolly mixtures

Sardines, pilchards, tuna White fish

Baked beans, pulses Vegetables

Nuts, peanut butter, marzipan Jam, honey, marmalade, syrup

Cola drinks and any others containing phosphoric acid Squash, cordials, lemonade, Lucozade

Convenience and processed foods with phosphorus additivesincluding dicalcium phosphate, disodium phosphate,monosodium phosphate, sodium tripolyphosphate, tetrasodiumpyrophosphate

Foods with no phosphorus containing food additives

∗Allowance will depend on individual assessment.†Caution: vitamin A content (p. 266).

Table 12.8 Sodium rich foods and suggested alternatives.

Sodium rich foods Suggested alternatives

Salted crisps, nuts and savoury snacks Unsalted crisps, unsalted nuts, rice cakes, unsalted popcornTinned and packet soups Homemade soupsPot savouries Sweet snacks instead of savouryTinned foods with added salt ∗ Reduced salt products, e.g. reduced salt baked beansBacon, sausages and other processed meats and fish Fresh meats and fishCheese and cheese products Cottage cheese, ricotta and cream cheeseStock cubes, meat and vegetable extracts Halve the amounts used or use reduced salt varieties;

add herbs and spices in their placePickles, sauces and chutneysReady-made meals and take-away meals Homemade meals using fresh ingredients

∗Many processed/manufactured foods contain high amounts of salt and even lower salt varieties can have a high salt content.

Table 12.9 Stages of renal failure [16].

Stage DescriptionGFR

(mL/min/1.73 m2)

1 Kidney damage with normal orincreased GFR

>90

2 Kidney damage with milddecrease in GFR

60–89

3 Moderate decrease in GFR 30–594 Severe decrease in GFR 15–295 Kidney failure <15 or dialysis

GFR, glomerular filtration rate.

Table 12.10 Causes of chronic kidney disease in childhoodin the UK [18].

Cause Percentage

Renal dysplasia and related conditions 28Obstructive uropathy 20Glomerular disease 17Reflux nephropathy 9Primary tubular and interstitial disorders 7Congenital nephrotic syndrome 7Renal vascular disorders 5Metabolic disease 3Polycystic disease 2Malignant and related disorders 2

Table 12.11 Nutritional guidelines for the child with chronic kidney disease.

Energy (per kg body weight per day)Protein (per kg body weight per day)

Age (kcal) (kJ) (g)

Conservative managementInfantsPreterm 110–135 460–560 2.5–3.00–2 months 96–120 400–500 2.13–12 months 72–96 300–400 1.5–1.61–3 years 78–82 325–340 1.1

Children/adolescents4 years to puberty Minimum of EAR for chronological age

(use height age if <2nd percentile forheight)

1.0–1.1Pubertal 0.9–1.0Post-pubertal 0.8–0.9

Peritoneal dialysis (APD/CAPD)InfantsPreterm 110–135 460–560 3.0–4.00–2 months 96–120 400–500 2.43–12 months 72–96 300–400 1.91–3 years 78–82 325–340 1.4

Children/adolescents4 years to puberty Minimum of EAR for chronological age

(use height age if <2nd percentile forheight)

1.3Pubertal 1.2Post-pubertal 1.0–1.2

HaemodialysisInfantsPreterm 110–135 460–560 3.00–2 months 96–120 400–500 2.23–12 months 72–96 300–400 1.71–3 years 78–82 325–340 1.2

Children/adolescents4 years to puberty Minimum of EAR for chronological age

(use height age if <2nd percentile forheight)

1.1Pubertal 1.1Post-pubertal 1.1

These guidelines are for the initiation of management and require adjustments based on individual nutritional assessment.Protein intakes reflect the reference nutrient intake (RNI) in the UK [9] plus an increment to achieve positive nitrogen balanceincluding any transperitoneal losses [16].EAR, estimated average requirement [8]; APD, automated peritoneal dialysis; CAPD, continuous ambulatory peritoneal dialysis.

Table 12.12 Guide to the phosphorus content of foodsrelated to their protein content.

Type of foodPhosphorus

(mg/g protein)

Poultry, meat and white fish 7–9Pulses 12–18Tofu 12Shell fish, oily fish, offal 15–20Egg 16Hard cheese 20Milk, yoghurt 28Peanuts 15Almonds 26Walnuts 48

Table 12.13 Phosphate binders.

Elemental calcium,mg (mmol)per tablet

Dose Flavour Estimate ofpotential bindingpower

Calcium carbonate bindersSetler’s Tums tablets (500 mg) 200 (5.0) 1–3 tds Spearmint,

peppermint, variousfruit flavours

Approximately 39 mgphosphorus bound per 1 gcalcium carbonate

Calcium carbonate (20% solution) 400 (10.0) per5 mL

5–15 mL tds –

Rennie tablets 272 (6.8) 1 tds Peppermint/spearmintDigestif/Spearmint (680 mg)

Remegel tablets (800 mg) 320 (8.0) 1–3 tds MintCalcichew tablets (1250 mg) 500 (12.6) 1 tds OrangeAdcal (1500 mg) 600 (15.0) 1 tds Fruit flavour

Calcium acetate bindersPhosex tablets (1000 mg) 250 (6.25) 1–3 tds (swallow whole) Approximately 45 mg

phosphorus bound per 1 gcalcium acetate

Phosex tablets (500 mg) namedpatient basis

125 (3.1) 2–4 tds (swallow whole)

Sevelamer bindersSevelamer hydrochlorideRenagel tablet (800 mg) None 1–3 tds (swallow whole) Approximately 80 mg

phosphorus bound per 1 gsevelamer

Sevelamer carbonateRenvela tablet (800 mg) or powder(2.4 g)

None 1–3 tds or 1sachet of powder

Powder in natural orcitrus flavour

tds, three times a day.Total intake of elemental calcium (including diet) should not be >1500 mg of calcium per day [42].

Table 12.14 Recommendations on salt consumption inchildren.

Agerange

Target daily intake of salt(g) and sodium (mmol)

0–6 months <1 g <17 mmol7–12 months 1 g 17 mmol1–3 years 2 g 34 mmol4–6 years 3 g 50 mmol7–10 years 5 g 84 mmol11–14 years 6 g 100 mmol

Target salt intakes for infants and children have beenestimated as an increase in the reference nutrient intake (RNI)by a factor of 1.5 [37].

Table 12.15 Glucose absorption from peritoneal dialysate(PD).

Grams of anhydrousglucose per

PD solutionconcentration 1 L 1.5 L 2 L Osmotic effect

1.36% 13.6 20.5 27.2 Weak hypotonicsolution

2.27% 22.7 34.1 45.4 Intermediate3.86% 38.6 57.9 77.2 Strong hypertonic

solution

To calculate the energy obtained from glucose absorbed fromPD fluid: total the grams of glucose from all the exchanges,multiply by 4 kcal (17 kJ) per gram and then multiply by60%–80%.

Table 12.16 Sample feed to meet the requirements of an infant on automated peritoneal dialysis (APD).

Feed recipe Energy Protein CHO Fat Na+ K+ PO4(kcal (kJ)) (g) (g) (g) (mmol) (mmol) (mg)

An 8-month-old boy on APD: weight 8 kg; fluid allowance 800 mL; energy requirement 72 kcal (300 kJ)/kg; proteinrequirement 1.9 g/kg

110 g Cow & Gate 1 534 (2232) 10.7 59.5 28.1 6.0 13.1 2235 g Duocal 25 (104) 0.0 29.1 8.9 0.4 0.0 26 g Vitapro 22 (90) 4.5 0.5 0.4 0.8 1.1 193.4 mL 30% NaCl 0 0.0 0.0 0.0 17.0 0.0 0+ water to 800 mLTotal per 100 mL 73 (303) 1.9 11.1 4.7 3.0 1.8 31Total per 800 mL 580 (2413) 15.2 89.1 37.4 24.2 14.2 244

Total per kg 73 (303) 1.9 11.1 4.7 3.0 1.8 31

The feed needs to be modified following drainage and clearance issues with the dialysis and a period off APD. His serumbiochemistry shows increased levels of urea (12.3 mmol/L), K+ (6.5 mmol/L), PO4 (2.4 mmol/L). Fluid needs to be restricted to500 mL per 24 hours

112 g Renastart 553 (2300) 9.4 78.1 29.8 13.1 3.8 1155 g Vitapro 18 (75) 3.8 0.5 0.3 0.7 0.9 16+ water to 500 mLTotal per 100 ml 114 (474) 2.4 14.1 5.4 2.5 0.9 24Total per 500 mL 571 (2375) 12.2 70.5 27.0 12.5 4.3 119

Total per kg 72 (300) 1.5 8.8 3.4 1.6 0.5 15

The feed parameters need to be continually revised with ongoing biochemistry results. The calcium content of the feed is lessthan half the reference nutrient intake and needs to be addressed if the feed is used over a prolonged period of time.

Table 12.17 Sample feed to meet the requirements of a child on haemodialysis.

Energy Protein CHO Fat Na+ K+ PO4Feed recipe (kcal (kJ)) (g) (g) (g) (mmol) (mmol) (mg)

A 6-year-old girl established on haemodialysis becomes acutely unwell and requires an enteral feed. Weight 17 kg; fluidallowance 800 mL with 700 mL reserved for the feed; energy requirement 1480 kcal (6.2 MJ); protein requirement 1.1 gprotein/kg. The feed should be built up gradually to ensure tolerance

200 mL Nepro HP∗ 360 (1498) 16.2 41.2 19.5 6.1 5.4 144100 ml Paediasure∗ 101 (420) 2.8 11.2 4.5 2.6 2.8 53170 g Polycal powder 652 (2712) 0.0 163.2 0.0 0.4 0.2 080 mL Calogen 360 (1498) 0.0 0.0 40.0 0.3 0.0 03g Paediatric Renal Seravit 9 (37) 0.0 2.25 0.0 0.0 0.0 51+ water to 700 mLTotal per 100 ml 212 (882) 2.7 31.1 9.2 1.34 1.21 36Total per 700 mL 1483 (6170) 19.0 217.9 64.5 9.4 8.5 249

Total per kg 87 (362) 1.1 12.8 3.8 0.6 0.5 15

∗Adult renal specific feeds may be useful to achieve energy and protein requirements in a restricted fluid volume, but care needsto be taken with their micronutrient profile especially if used in large quantities.Feed provides 78% of RNI for calcium and needsreviewing if feed used in the longer term.

Table 12.18 Sample feed to meet the requirements of a 4-week-old girl with congenital nephrotic syndrome.

Feed recipeEnergy

(kcal (kJ))Protein

(g)CHO

(g)Fat(g)

Na+

(mmol)Calcium

(mg)

A 4-week-old girl with congenital nephrotic syndrome whose mother is expressing breast milk. Weight 3.3 kg; fluid restriction120 mL/kg = 400 mL; energy requirement = 130 kcal (545 kJ)/kg = 429 kcal (1795 kJ); protein requirement 3 g/kg

390 mL EBM 269 (1125) 5.1 28.1 16.0 2.5 13325 g Polycal powder 96 (402) 0 24.0 0 0.1 1.010 mL Calogen 45 (188) 0 0 5.0 0 07 g Vitapro 25 (105) 5.3 0.6 0.4 0.9 28Total per 100 mL 109 (456) 2.6 13.2 5.4 0.9 40Total per 400 mL 435 (1820) 10.4 52.7 21.4 3.5 162Total per kg 132 (552) 3.2 16.0 6.5 1.1 49

The mother can no longer supply expressed breast milk (EBM). The baby is fed on a modified energy dense infant formula

400 mL Infatrini 404 (1690) 10.4 41.2 21.6 4.4 32010 g Polycal powder 38 (159) 0 9.6 0 0 0.4Total per 100 mL 111 (464) 2.6 12.72 5.4 1.1 80Total per 400 mL 442 (1849) 10.4 50.8 21.6 4.4 320Total per kg 134 (560) 3.2 15.4 6.5 1.3 97

Table 12.19 Sample feed for an infant with nephrogenic diabetes insipidus.

A 6-month-old boy with nephrogenic diabetes insipidus. Weight 6.8 kg. He is taking700 mL feed with an additional 700 mL water, offered after each feed. He hasstarted some weaning foods. Feed volume 100 mL/kg. Water volume 100 mL/kg.Total fluid volume 200 mL/kg

Energy (kcal (kJ)) Protein (g) Na+ (mmol) K+ (mmol)

100g Cow & Gate 1 485 (2029) 9.7 5.4 12.245g Maxijul 171 (715) 0 0.4 0.1+ water to 700 mLTotal 656 (2745) 9.7 5.8 12.3Per kg 96 (402) 1.4 0.9 1.8Req/kg 96 (402) 1.6

+ 1 g protein from weaning foods

Renal solute load of feed =Na+K+ (2× [Na+K])+ (4×protein)=5.8+12.3+ (2× [5.8+12.3])+ 4×9.7)=93.1 mOsm/kg H2O=13.7 mOsm/kg H2O/kg body weight

Table 12.20 Dietary sources of oxalate [121].

High oxalate content Moderate oxalate content Low oxalate content

Rhubarb, strawberries Apples, apricots, oranges,peaches, pears, pineapples, plums

Banana, grapefruit, green grapes, melon

Blackberries, blueberries, raspberries andtheir juices

Orange juice Apple juice

Chocolate, cocoa, tea Coffee, cola Lemonade, jelly

Nuts Beef, lamb, poultry, pork, seafoodCheese, eggs, milk, yoghurt

Beetroot, beans in tomato sauce, celery,leeks, parsley, spinach, sweet potatoes

Asparagus, broccoli, carrots,tomatoes

Cabbage, cauliflower, onions, peas

Noodles, pasta, rice and oil

Table 12.21 Dietary sources of purines [122].

High purine content Moderate purine content Low purine content

Organ meats: kidney, liverGame meats: duck, gooseMackerel, sardines, mussels, scallops

Meat, poultryDried peas, beans, lentilsOther fish and shellfish

EggsNuts, peanut butter

All milk and milk productsAsparagus, cauliflower, green beans,mushrooms, spinach

Most fruit and vegetables

Wholegrain bread and cerealsWheat germ and bran, oatmeal

Low fibre bread and cerealsRice, pasta

Meat extracts, yeast supplements Meat soups, bouillon Vegetable soups and stocksCakes, biscuitsCoffee, tea