Assessment of Dietary Acid Load in Children with Chronic Kidney Disease: An Observational Study.

Introduction: Dietary acid load (DAL), which reflects the balance between acid- and alkaline-forming foods, is a modifiable risk factor for metabolic acidosis in CKD. Owing to the paucity of data in the Indian context, we undertook this cross-sectional study to estimate DAL and assess acid and alkaline food consumption in children with CKD2-5D (Chronic kidney disease stage 2 to 5 and 5D-those on hemodialysis). Methods: Clinical profile, dietary assessment of energy, protein intake/deficits, and macronutrients were noted and computed using software created by the division of nutrition, St John's research institute based on Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines in clinically stable children with CKD2-5D. DAL was estimated using potential renal acid load (PRAL in mEq/day) = (0.49 × protein intake in g/day) + (0.037 × phosphorus-intake in mg/day) - (0.02 × potassium intake in mg/day) - (0.013 × calcium intake in mg/day) - (0.027 × magnesium intake in mg/day). A positive dietary PRAL (>0) favors acidic content and negative (<0) favors alkaline content. PRAL was stratified into quartiles for analysis. The association of various clinical and dietary parameters were analysed across these quartiles. Results: Eighty-one children [of mean age 122 ± 47 months; 56 (69%) boys, 29 (36%) on dialysis, 62 (77%) non-vegetarians] were studied. Twenty-eight (34%) were on bicarbonate supplements. A positive PRAL (9.97 ± 7.7 mEq/day) was observed in 74/81 (91%) children with comparable proportions in those with CKD2-5 and 5D [47/52 (90%) vs. 27/29 (93%) respectively, P > 0.05]. Protein intake was significantly higher in the highest quartile compared to the lowest quartile of PRAL in CKD2-5 (55 ± 16 g/day vs. 40 ± 14 g/day, P < 0.001) and 5D groups (47 ± 15 g/day vs. 25 ± 11 g/day, P = 0.002). A majority of the participants 60/81 (74%) consumed highly acidic and minimal alkali foods. Conclusion: In children with CKD2-5D, PRAL estimation revealed high DAL in the majority with a high consumption of acidic foods. These findings provide implications for appropriate dietary counseling in children with CKD.

Nutrition-Focused Physical Examination for Detecting Protein Energy Wasting in Children with Chronic Kidney Disease.

Introduction: There is a need to explore less laborious point-of-care assessment tools to diagnose protein energy wasting (PEW) in children with chronic kidney disease (CKD). This cross-sectional study was undertaken to assess the profile of specific nutrition-focused physical examination (NFPE) and mid-arm muscle area (MAMA) in children with CKD and determine their role in the diagnosis of PEW. Methods: PEW criterion was applied to all eligible children and MAMA was derived from mid-arm circumference and triceps skin fold thickness. NFPE signs examined were muscle wasting (MW) and subcutaneous fat loss (FL). Results: One hundred and twenty-six children with CKD (86 in CKD stages 2-4 and 40 on dialysis) were studied. PEW was prevalent in 41.8% children with CKD2-4 and in 72.5% on dialysis. In children with CKD 2-4, low MAMA, MW, and FL were significantly associated with PEW with an odd's ratio of 5.3 (1.55,18.30), 10.6 (3.8,29.8), and 10.5 (3.7,29.2) respectively (P = <0.001). Similarly, in children on dialysis, low MAMA, MW, and FL were more likely to be associated with PEW with an odd's ratio of 17 (2.2,127.7); P = 0.017, 16.6 (3,90.8); P = 0.001 and 19 (2.1,170.3); and P = 0.009, respectively. MW demonstrated high sensitivity and specificity [80.6 and 72%, respectively, with a positive predictive value (PPV) of 67.4%] to diagnose PEW in the CKD 2-4 group and in those on dialysis [86.2 and 72.1%, respectively, with PPV of 89.3%]. Conclusion: Clinical signs based on NFPE are useful in detecting PEW in children with CKD2-4 and in those on dialysis.