Global Variation of Nutritional Status in Children Undergoing Chronic Peritoneal Dialysis: A Longitudinal Study of the International Pediatric Peritoneal Dialysis Network

www.nature.com/scientificreports OPEN Received: 27 June 2018 Accepted: 26 November 2018 Published: xx xx xxxx Global Variation of Nutritional Status in Children Undergoing Chronic Peritoneal Dialysis: A Longitudinal Study of the International Pediatric Peritoneal Dialysis Network Franz Schaefer1, Laura Benner2, Dagmara Borzych-Dużałka3, Joshua Zaritsky4, Hong Xu5, Lesley Rees6, Zenaida L. Antonio7, Erkin Serdaroglu8, Nakysa Hooman 9, Hiren Patel10, Lale Sever11, Karel Vondrak12, Joseph Flynn13, Anabella Rébori14, William Wong15, Tuula Hölttä16, Zeynep Yuruk Yildirim17, Bruno Ranchin18, Ryszard Grenda19, Sara Testa20, Dorota Drożdz21, Attila J. Szabo22, Loai Eid23, Biswanath Basu24, Renata Vitkevic25, Cynthia Wong26, Stephen J. Pottoore27, Dominik Müller28, Ruhan Dusunsel29, Claudia Gonzalez Celedon30, Marc Fila 31, Lisa Sartz32, Anja Sander2, Bradley A. Warady33 & International Pediatric Peritoneal Dialysis Network (IPPN) Registry* While children approaching end-stage kidney disease (ESKD) are considered at risk of uremic anorexia and underweight they are also exposed to the global obesity epidemic. We sought to investigate the variation of nutritional status in children undergoing chronic peritoneal dialysis (CPD) around the globe. The distribution and course of body mass index (BMI) standard deviation score over time was examined prospectively in 1001 children and adolescents from 35 countries starting CPD who were followed in the International Pediatric PD Network (IPPN) Registry. The overall prevalence of underweight, and 1 Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany. 2Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany. 3Medical University of Gdansk, Department of Pediatrics, Nephrology and Hypertension, Gdańsk, Poland. 4Nemours/A.I. duPont Hospital for Children, Wilmington, DE, USA. 5Children’s Hospital of Fundan University, Shanghai, China. 6Great Ormond Street Hospital, London, United Kingdom. 7Department of Pediatric Nephrology, National Kidney and Transplant Institute, Quezon City, Philippines. 8Dr. Behcet Uz Children Research and Educational Hospital, Izmir, Turkey. 9Iran University of Medical Sciences, Tehran, Iran. 10Nationwide Children’s Hospital, Columbus, OH, USA. 11Carrahpasa School of Medicine, Istanbul, Turkey. 12University Hospital Motol, Prague, Czech Republic. 13Seattle Children’s Hospital, Seattle, WA, USA. 14S.E.N.N.I.A.D, Montevideo, Uruguay. 15Department of Nephrology, Starship Children’s Hospital, Auckland, New Zealand. 16HUCH Hospital for Children and Adolescents, Helsinki, Finland. 17Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey. 18Service de Néphrologie Pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France. 19Children’s Memorial Health Institute, Warsaw, Poland. 20Pediatric nephrology, Dialysis and Transplantation Unit Fondazione IRCCS Ca’ Granda Osp. Maggiore Policlinico, Milan, Italy. 21Jagellonian University Medical College, Kraków, Poland. 22Semmelweis University, Budapest, Hungary. 23Dubai Hospital, Dubai, United Arab Emirates. 24NRS Medical College & Hospital, Kolkata, India. 25Children Hospital, affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania. 26Lucile Packard Children’s Hospital at Stanford, Palo Alto, USA. 27 Children’s Medical Center Dallas, Dallas, Tx, USA. 28Department of Pediatric Gastroenterology, Nephrology and Metabolism, Charité, Berlin, Germany. 29Erciyes University, Kayseri, Turkey. 30Hospital Sotero del Rio, Santiago, Chile. 31CHU Arnaud de Villeneuve, Université de Montpellier, Montpellier, France. 32Barnkliniken, Lund, Sweden. 33 Children’s Mercy Hospital, Kansas City, MO, USA. *A comprehensive list of consortium members appears at the end of the paper. Correspondence and requests for materials should be addressed to F.S. (email: franz.schaefer@ med.uni-heidelberg.de) Scientific Reports | (2019) 9:4886 | https://doi.org/10.1038/s41598-018-36975-z 1 www.nature.com/scientificreports/ www.nature.com/scientificreports overweight/obesity at start of CPD was 8.9% and 19.7%, respectively. Underweight was most prevalent in South and Southeast Asia (20%), Central Europe (16.7%) and Turkey (15.2%), whereas overweight and obesity were most common in the Middle East (40%) and the US (33%). BMI SDS at PD initiation was associated positively with current eGFR and gastrostomy feeding prior to PD start. Over the course of PD BMI SDS tended to increase on CPD in underweight and normal weight children, whereas it decreased in initially overweight patients. In infancy, mortality risk was amplified by obesity, whereas in older children mortality was markedly increased in association with underweight. Both underweight and overweight are prevalent in pediatric ESKD, with the prevalence varying across the globe. Late dialysis start is associated with underweight, while enteral feeding can lead to obesity. Nutritional abnormalities tend to attenuate with time on dialysis. Mortality risk appears increased with obesity in infants and with underweight in older children. The nutritional status is a principal concern when caring for children undergoing chronic peritoneal dialysis (CPD). While early studies revealed providing sufficient nutrition was essential for adequate growth in this population, advances in enteral feeding practices have enabled the elimination of underweight but have not improved linear growth as much as expected1–3. Recent concerns have emerged on the potential for adverse effects of excessive caloric intake in patients who receive supplemental feeding1–3. The majority of published studies assessing the nutritional status of dialyzed children were performed at highly specialized pediatric dialysis units in North America and Western Europe. In contrast, on a global scale the risk of nutritional abnormalities in individual regions and countries is likely to be affected by a range of medical and non-medical factors including the patient case-mix regarding age, underlying disease and co-morbidities, national economic strength and healthcare expenditure, cultural acceptability of dietary and feeding prescriptions, availability of special formula diets and enteral feeding equipment, and differences in local, national or regional nutritional recommendations4. The International Pediatric Peritoneal Dialysis Network (IPPN) has been collecting comprehensive clinical and laboratory data in a standardized manner from children undergoing CPD worldwide since 2007. Since these data include detailed anthropometric measures, feeding prescriptions and outcome measures, it provides an opportunity to address the global demographics of nutritional abnormalities in children receiving CPD. The objective of this study was to examine and follow prospectively the nutritional status of 1,001 children commencing CPD around the globe, analyze factors associated with the nutritional status at the start an (...truncated)