What is the management for Chronic Kidney Disease (CKD) related growth retardation?

Management of Growth Retardation in Chronic Kidney Disease

The management of CKD-related growth retardation requires addressing underlying metabolic factors first, followed by growth hormone therapy in children with persistent growth failure despite optimal metabolic control. 1

Initial Assessment and Evaluation

Before initiating treatment, a comprehensive evaluation should include:

• Growth parameters assessment (height, weight, growth velocity)
• Left wrist radiography to assess bone age and growth potential
• Laboratory tests:
  • Serum creatinine and eGFR
  • Electrolytes (sodium, potassium, calcium, phosphorus)
  • Bicarbonate levels
  • Parathyroid hormone (PTH)
  • 25-OH vitamin D
  • Albumin
  • Fasting glucose and HbA1c
  • Thyroid function (TSH and free T3)
  • Insulin-like growth factor 1 (IGF-1)
  • Fundoscopic examination
  • Pubertal status assessment (Tanner staging) 1

Step 1: Address CKD-Associated Growth-Limiting Factors

Nutritional Management

• Optimize caloric and protein intake appropriate for age and CKD stage
• Consider nasogastric or gastrostomy tube feeding in infants and young children with severe nutritional deficiencies
• Nutritional optimization alone may result in catch-up growth in infants with severe CKD 1

Metabolic Acidosis Correction

• Maintain serum bicarbonate levels ≥22 mEq/L
• Administer sodium bicarbonate supplements
• For dialysis patients, use bicarbonate-based or lactate-based dialysis solutions 1, 2

Electrolyte Management

• Correct hyponatremia and prevent dehydration
• Provide free water and sodium supplementation for children with salt-wasting nephropathies 1

CKD-Mineral Bone Disorder Management

• Control secondary hyperparathyroidism
• Maintain PTH within CKD-stage-dependent target ranges
• Ensure 25-OH vitamin D levels >30 ng/mL
• Manage hyperphosphatemia 1, 3

Dialysis Optimization

• Use biocompatible peritoneal dialysate
• Ensure adequate protein intake and urea clearance for children on hemodialysis
• Optimize dialysis regimens to improve growth potential 1

Hormonal Disturbances

• Evaluate and treat hypothyroidism if present
• Refer children with delayed puberty to pediatric endocrinology:
  • Boys: testicular volume <4 mL at age 14 years
  • Girls: breast stage <B2 at age 13.5 years 1

Step 2: Growth Hormone Therapy

After addressing all modifiable factors above, consider growth hormone (GH) therapy:

Indications for GH Therapy

• Persistent growth failure despite optimization of nutritional and metabolic parameters
• Open epiphyses on wrist radiography (indicating growth potential)
• No active malignancy or uncontrolled diabetes mellitus 1

Contraindications to GH Therapy

• Pre-existing papilledema
• Active malignancy
• Uncontrolled diabetes mellitus
• Known hypersensitivity to GH or its components 1

Monitoring During GH Therapy

• Regular assessment of growth velocity
• Monitor for potential adverse effects:
  • Glucose intolerance
  • Intracranial hypertension
  • Slipped capital femoral epiphysis
  • Progression of scoliosis 1

Special Considerations

Comorbidities

• Children with systemic diseases or genetic syndromes associated with CKD (e.g., Schimke immune-osseous dysplasia, Bardet-Biedl syndrome) may have different responses to standard growth interventions 1

Post-Transplant Patients

• Consider graft function and glucocorticoid therapy when evaluating growth potential
• Minimize steroid exposure when possible 1

Common Pitfalls to Avoid

1. Failing to address modifiable metabolic factors before initiating GH therapy
2. Not maintaining adequate nutritional support, especially in infants and young children
3. Inadequate correction of metabolic acidosis (target bicarbonate ≥22 mEq/L)
4. Overlooking mineral metabolism disorders (hyperparathyroidism, vitamin D deficiency)
5. Delaying referral to pediatric endocrinology for children with delayed puberty
6. Using adult height prediction methods for children with CKD (not recommended) 1

By systematically addressing these factors, the negative impact of CKD on growth can be minimized, potentially improving not only height outcomes but also overall morbidity and mortality in children with CKD 4.