In my practice with children with reduced renal function, I see common problems such as
metabolic acidosis, renal osteodystrophy, anemia and hypertension.
Typically, with children who develop chronic kidney disease (CKD),
at a young age, I may see growth retardation,
at times severe, with a growth velocity significantly below normal for their age.
The etiology of this growth failure is multi-factorial.
Occasionally, growth failure is the presenting symptom leading to a diagnosis of an
underlying renal disorder. Identifying and addressing growth failure early on is vital to
managing the child with CKD. Presently, although most patients with CKD receive
treatment for their anemia, acidosis and renal osteodystrophy, which can improve their
growth, data suggests that most pediatric CKD patients in the United States are not
treated with growth hormone for their growth failure. It is important that each of us on
the renal team recognize growth failure, make assessments, and intervene early on with
appropriate medical interventions so our young patients can achieve their optimal height
potential.
In addition to its physical impact, growth failure may affect the quality of life of children
with CKD (chronic kidney disease).
Studies have shown that children with End Stage Renal Disease,
who have short stature, are less likely to attend school full time than their counterparts
with ESRD who have normal height. Additionally, it has been shown that growth failure
in children with CKD or ESRD results in a more complicated medical course and results
in an increased risk of death.
Variables that can contribute to growth failure in patients with CKD include:
age at onset, primary renal disease, caloric deficiency, abnormal protein metabolism,
metabolic acidosis, renal osteodystrophy, anemia, as well as other co-morbidities.
Additionally, in these patients, they may not respond normally to their naturally produced
growth hormone.
Managing all of these problems in patients with CKD and promoting optimal growth is
complex.
Monitoring appropriate laboratory data, as well as routine growth assessments should be
a component of nephrology care.
Pediatric patients with kidney disease should have their height and weight measured and
plotted regularly as growth patterns seen in children with CKD are generally altered from
the normal pattern.
The initial evaluation of the child with growth failure associated with CKD should
include obtaining appropriate laboratory and radiographic studies.
A detailed nutritional evaluation, as well as assessment of the child’s growth pattern
including: calculation of growth velocity, assessment of height potential by calculating
mid-parental height, and tanner staging are an important and necessary part of the workup.
Once common medical concerns which occur in patients with CKD such as anemia,
acidosis, and hyperparathyroidism are addressed, growth may improve.
If growth failure continues without significant improvement in growth velocity,
further laboratory work-up is indicated.
Unusual causes for poor growth in the CKD population, such as hypothyroidism should
be screened for.
If this work-up is negative, growth hormone therapy should be strongly considered in
patients who have: a standardized height less than 2 SDS below the mean,
a downward crossing of growth percentiles on their growth curve, or an annualized
growth rate which is falling.
At this time it is imperative to initiate discussions concerning Growth Hormone use with
the family.
Beginning growth hormone treatment, as early as possible, especially if the child is
expected to require kidney transplant, will give your patient the best chance of reaching a
height that is normal or close to normal.
The baseline assessment for Growth Hormone therapy includes a recalculation of the
height SDS, height velocity SDS and height velocity of the patient.
An assessment of pubertal stage, and bone age is required.
The patient will need to have hip and knee x-rays done, a funduscopic exam, blood
chemistries, PTH level, and thyroid studies.
If indicated, growth hormone therapy should be initiated.
Currently, there is an FDA approved product for the treatment of growth failure in
children with CKD.
Due to the complexity of their illness, children with CKD require higher doses of Growth
Hormone.
GH is administered as a daily subcutaneous injection.
Once treatment is initiated, the patient should be monitored closely and regularly,
to determine if growth is adequate, and if dose adjustments in treatment are needed.
Monitoring of height, weight, and pubertal stage, as well as a nutritional evaluation,
funduscopic exam, assessment of blood chemistries and PTH levels should occur every
3-4 months.
Patients under the age of 3 should have their head circumference monitored routinely.
On a yearly basis, bone films should be obtained to evaluate for renal osteodystrophy and
bone age should be determined.
Growth Hormone is administered by injection and your patient may experience injection
site discomfort.
Patients that are old enough to administer their own injection must be taught proper
technique for Growth Hormone administration and they and their families should be
encouraged to adhere to the treatment plan.
As with any drug intervention, your patients and their families need to be advised of
possible side effects.
If you are considering recommending a patient for growth hormone therapy,
please see the attached list for information on warnings, precautions,
and contraindications for use of GH at www.nutropin.com/index.jsp - click on
‘Information For Healthcare Professionals’, then ‘Important Safety Information’.
Hopefully, your patient will have a dramatic response to the Growth Hormone, and there
will be significant improvement in growth.
If your patient achieves his or her height goal based on the mid-parental height or 50%
percentile height for age, the Growth Hormone should be discontinued.
The coordination of care of the child with growth failure is a multidisciplinary team
effort: the child’s physician, nurse, nutritionist and social worker.
The patient and family members should be encouraged to actively participate in the
treatment plan, to discuss expectations and any concerns.
If you would like more information about CKD related growth failure or available
treatments, contact the Kidney & Urology Foundation of America: 800.633.6628 or email
info@kidneyurology.org.