Use of a Phosphorus Points Education Program to Maintain Normal Serum Phosphorus in Pediatric Chronic Kidney Disease: A Case Report.

A 14-year-old male, with chronic kidney disease stage 4 (glomerular filtration rate 20 mL/min/1.73 m2) secondary to reflux nephropathy required dietary modification with evidence of renal osteodystrophy, presented with elevated serum phosphorus and parathyroid hormone. He was educated using a novel phosphorus point system where 1 point is equivalent to ∼50 mg of phosphorus. Dietary counseling was provided by a pediatric renal dietitian on phosphorus content of foods the patient typically consumed and converted to point system for daily tracking. The family reported limiting daily phosphorus points to less than 20 points daily for 15 months. The family completed a 3-day food record and provided points assigned to each food item. A Spearman's correlation of 0.7 (P < .001) was found between the family's and the dietitian's assignment of phosphorus points. The patient's recorded phosphorus intake remained below 1000 mg each day and met estimated calorie and protein needs. The patient also continued with age-appropriate weight gain and linear growth. Laboratory values showed phosphorus and intact parathyroid hormone remained within desired range. A phosphorus point system tool can be used to maintain normal serum phosphorus levels and subsequently prevent secondary hyperparathyroidism in patients with pediatric chronic kidney disease.

Examining Mid-Upper Arm Circumference Malnutrition z-Score Thresholds.

BACKGROUND: Anthropometric z-scores used commonly for diagnosis and determining degree of malnutrition, specifically body mass index (BMIz), weight-for-length (WLz), and mid-upper arm circumference (MUACz), are not wholly concordant, yet the proposed thresholds for classification are identical. This study was designed to critically examine MUACz thresholds and their ability to correctly classify nutrition status. METHODS: This was a 2-year, prospective single-center study of children ≤18 years seen by registered dietitians within a large pediatric institution. The sensitivity, specificity, and predictive performance of the malnutrition classification thresholds were estimated against clinician-based classification. RESULTS: Sixty-one dietitians enrolled 10,401 patients with distributions of z-scores for weight (-0.5 ± 1.9), length (-0.8 ± 1.6), BMI or WL (-0.1 ± 1.8), and MUAC (-0.4 ± 1.5), suggesting participants were smaller and shorter than the reference U.S. POPULATION: Distributions of MUACz were broad and overlapped between nutrition classification groups, an observation that extended to BMIz and WLz as well. Consequently, existing thresholds do not accurately classify 100% of children. Misclassification rates increase, with increasing severity ranging from 8% in children with no malnutrition to 71% in children with severe malnutrition. Algorithm- and manually-based refinement of thresholds result in mixed improvements and can be explored by the reader with the associated supplement. CONCLUSION: The sensitivity of proposed MUACz thresholds systematically decreases with increasing severity of malnutrition and will require optimization if we aim to limit the number of children at risk of misclassification. Indicators for overnutrition remain to be addressed but are explored herein.

Psychosocial Factors That Create Barriers to Managing Serum Phosphorus Levels in Pediatric Dialysis Patients: A Retrospective Analysis.

OBJECTIVE: Abnormal phosphorus homeostasis is among the medley of metabolic disturbances commonly associated with chronic kidney disease. We sought to determine the psychosocial factors that create barriers to controlling serum phosphorus levels in children on dialysis and to evaluate the perceptions of children and caregivers on the ease or difficulty of following a dietary phosphorus restriction and taking phosphorus binder medications. DESIGN: Single center cross-sectional study. SETTING: Pediatric dialysis unit at a children's hospital. SUBJECTS: Forty-eight patients on chronic hemodialysis or peritoneal dialysis (mean age: 11.03 ± 6.88 years; 69% male). MAIN OUTCOME MEASURE: Serum phosphorus levels were recorded from electronic health records and converted to a mean phosphorus standard deviation score (SDS) for each individual. Mean phosphorus SDS values were compared to each independent categorical variable using an analysis of variance test, continuous variables were analyzed using linear regression, and logistic regression was used to determine odds ratios. RESULTS: There was a significant relationship between age and phosphorus SDS (P < .001), with patients over 13 years of age having the highest prevalence of hyperphosphatemia (88%). Patients and caregivers who identified phosphorus levels as "controlled" had lower phosphorus SDS values compared to the other subjects (P = .003). However, of the patients and caregivers who reported that serum phosphorus levels were "controlled," 46% were hyperphosphatemic. Furthermore, 73% and 87% of patients and caregivers reported that following a phosphorus-restricted diet and taking phosphorus binders were "easy"; yet, 40% and 49% of these patients were hyperphosphatemic, respectively. CONCLUSION: In the present study, elevated serum phosphorus levels were most common in adolescent dialysis patients. There also appears to be a disconnect between the perceived ease of following a phosphorus-restricted diet and taking phosphorus binders and the achievement of normal serum phosphorus levels. These data further emphasize the importance of ongoing education regarding dietary and medical management requirements.

Renal formulas pretreated with medications alters the nutrient profile.

BACKGROUND: Pretreating renal formulas with medications to lower the potassium and phosphorus content is common in clinical practice; however, the effect of this treatment on other nutrients is relatively unstudied. We examine whether nutrient composition is affected by pretreating renal formulas with sodium polystyrene sulfonate (SPS) suspension and sevelamer carbonate. METHODS: Fixed medication doses and treatment times were utilized to determine changes in the nutrient composition of Suplena® and Similac® PM 60/40. The effect of simultaneously adding both medications (co-administration) to the formula on the nutrient composition of Suplena® was also evaluated. RESULTS: Pretreatment of Suplena® with SPS reduced the concentrations of calcium (11-38 %), copper (3-11 %), manganese (3-16 %), phosphorus (0-7 %), potassium (6-34 %), and zinc (5-20 %) and increased those of iron (9-34 %), sodium (89-260 %), and sulfur (19-45 %) and the pH (0.20-0.50 units). Pretreatment of Similac® PM 60/40 with SPS reduced the concentrations of calcium (8-29 %), copper (5-19 %), magnesium (3-26 %), and potassium (33-63 %) and increased those of iron (13-87 %) and sodium (86-247 %) and the pH (0.40-0.81 units). Pretreatment of both formulas with the SPS suspension led to significant increases in the aluminum concentration in both formulas (507-3957 %). No differences in potassium concentration were observed between treatment times. Unexpectedly, the levels of neither phosphorus nor potassium were effectively reduced in Suplena® pretreated with sevelamer carbonate alone or when co-administered with SPS. CONCLUSIONS: Pretreating formula with medications alters nutrients other than the intended target(s). Future studies should be aimed at predicting the loss of these nutrients or identifying alternative methods for managing serum potassium and phosphorus levels in formula-fed infants. The safety of pretreating formula with SPS suspension should also be examined.

Development and validation of a questionnaire to measure research involvement among registered dietitians.

Research involvement among registered dietitians (RDs) is important in advancing dietetics practice and ensuring high-quality and cost-effective health care. There are no standardized approaches to measuring levels of research involvement. The aim of the study was to develop a standardized measure of research involvement and test its validity and reliability among RDs. The Research Involvement Questionnaire (RIQ) was developed and underwent content validation, resulting in a content validity index of 0.92. A postal questionnaire survey of RDs was undertaken at two time points. RDs were purposively selected and, based on their number of publications and grants, were assigned by the authors to one of four levels of research involvement: evidence-based practice, collaborating on research, leading research, and leadership in research. Of 192 questionnaires mailed, 111 RDs (58%) returned the first RIQ, of whom 82 (74%) also returned the second RIQ. Total scores and scores for each level were higher for RDs with higher levels of research involvement (P<0.001). RDs assigned by the RIQ to higher levels of research involvement had higher qualifications; were qualified for longer; and had greater evidence of research output, including journal publications and grants (P<0.001). There was excellent internal consistency as measured using Cronbach's coefficient (α=.98). The level of research involvement assigned by the RIQ and by the purposive selection process agreed on 76% of occasions, indicating substantial agreement beyond chance (κ=0.67; P<0.001). The level of research involvement assigned by the RIQ at two time points agreed on 86% of occasions, indicating almost perfect agreement beyond chance (κ=0.81; P<0.001). A valid and reliable questionnaire has been developed to measure research involvement among RDs, providing a useful tool for evaluating and supporting members of the profession to become more involved in research.