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Arpana Iyengar Professor Department of Pediatric Nephrology

Arpana Iyengar Professor Department of Pediatric Nephrology St John’s Medical College Hospital Bangalore. IFKF Meet 2018, Chennai. 1. Nutrition-A neglected player 2. Nutritional- Links in children 3. Nutrition-Exciting tools. Growth is the third kidney!.

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Arpana Iyengar Professor Department of Pediatric Nephrology

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  1. ArpanaIyengar Professor Department of Pediatric Nephrology St John’s Medical College Hospital Bangalore IFKF Meet 2018, Chennai

  2. 1. Nutrition-A neglected player • 2. Nutritional- Links in children • 3. Nutrition-Exciting tools

  3. Growth is the third kidney!

  4. Do we need more evidence to diagnose undernutrition? 5 year old 11kgs 7 years 10 kgs 10 years 14 kgs 15 year old 15 kgs

  5. Children with CKD/ ESRD – where is our focus? Nutrition? Quality of life? Life sustaining therapy Battling costs Life threatening comorbidities

  6. Adults with ESRD Children with ESRD Kamyar Kalantar-Zadeh et al AJKD 2018 North American Pediatric Renal Transplant Cooperative Study. 2005

  7. Challenges of nutritional assessment in CKD Height influences eGFR Dynamic phase of growth Biochemical markers unreliable Etiology and comorbidities of CKD influences growth Non nutritional links

  8. Protein Energy Wasting Pediatr Nephrol (2012) 27:173–181

  9. Kidney International (2008) Pediatr Nephrol. 2014

  10. Burden of Protein Energy Wasting IN STABLE DIALYSIS ADULT PATIENTS 28% 46.8% 60.2% 64.7%

  11. How are our children different? A Iyengar Ind J Nephrol 2017 A Abraham Ped Nephrol 2014

  12. Burden of PEW in Indian Children with CKD 2-4 and ESRD

  13. In our study on 50 children (CKD 2-4 :22) and ( ESRD: 28): • Parameters that fulfil the criteria of diagnosing PEW: BMI for height age (p<0.001) Mid upper arm circumference ( p<0.001) No significant role for serum cholesterol, CRP, transferrin and appetite. • Factors associated with PEW: PEW was observed with longer duration of CKD (p 0.006) No difference in aetiology of CKD, presence of comorbidities, energy and protein intake in children with and without PEW. PEW assessment in children with CKD/ESRD needs better markers to reflect the underlying nutritional imbalance and reduced muscle mass. The utility of the pediatric PEW criteria over conventional clinical nutritional parameters is questionable.

  14. Subjective Global Nutritional Assessment (SGNA) Moderate malnutrition Normal malnutrition • Nutrition focused medical history: 1.Linear growth 2.Changes in body weight 3.Dietary Intake 4.GI symptoms 5.Functional impairment 6.Metabolic stress • Nutrition focused physical examination: • Loss of subcutaneous fat • Muscle wasting • Edema Severe malnutrition *Validated in children undergoing surgery and post operative care Abstract from CKiD group : 68 CKD children, a valid nutritional tool to diagnose malnutrition that correlated well with anthropometry and not biochemical parameters

  15. Dietary intake • Serum Albumin • Height • Weight • MUAC • SFT -Underestimation ( Underreporting) -Under estimation ( Fluid overload dilutes albumin) -Over estimation ( non nutritional causes) -Over estimation ( edema) -Over estimation ( edema) -Over estimation ( edema)

  16. Body composition and anthropometry Cellular tissue mass Body Mass Index Body Cell Mass Intracellular water TBW Fat free mass Body weight Mid arm muscle circumference Extracellular water Extracellular mass Bone and non active components Fat Skin fold thickness

  17. Tools for Body composition Cellular tissue mass TBK BIA Body Cell Mass Intracellular water BIA Fat free mass TBW Body weight Extracellular water Extracellular mass BIA DEXA Bod pod Dilution techniques Bone and non active components Fat

  18. Bio impedance analysis Multi frequency segmental body compositional analyser Nutrition parameters: Phase angle Nutrition index Fat mass index

  19. Capacity building Nutritionist Renal Nurse HD Technician PD Nurse

  20. Targeting the dry weight Reference ellipse of 22 controls Reference ellipse 35.3kgs 35.8kgs 37.3kgs Pre and Post dialysis

  21. Body Cell Mass BCM is the metabolically active component of the FFM Contains the energy-metabolising and work-performing tissue. BCM is an ideal indicator of nutritional status, as it is the part of the body which is vital for function, with malnutrition being defined as a loss of functional cell mass. BCM estimation by total body K (TBK) counting can be used in health and disease, because the K concentrations in the BCM are extremely constant and kept within strict limits by homeostatic mechanisms J Parenter Enteral 1972

  22. The Whole body Potassium Counter- body cell mass Body cell K Isotopes K40 Na Iodide detector Gamma spectrum Counts per sec CPS ( Counts per sec) ⇢ TBK grams ⇢ TBK mmol Body cell mass= TBK mmol x 0.0092

  23. 1. Nutrition needs special focus in our children with CKD 2. Malnutrition- Inflammation link needs further study in children 3. Estimating body cell mass could be meaningful in CKD Thank you!

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