The burden of protein-energy wasting in children with CKD3-5D: an observational study

Protein-energy wasting (PEW) is a critical complication in children with advanced chronic kidney disease (CKD), yet its burden remains poorly characterized in pediatric populations. This observational study aimed to determine the prevalence and clinical correlates of PEW in children with CKD stages 3-5D.

A retrospective analysis was conducted on 170 children (aged 0-18 years) treated at Beijing Children's Hospital from January 2015 to December 2024. PEW was diagnosed using modified pediatric-specific criteria, which is fully aligned with the core nutritional assessment and management principles of the 2020 KDOQI Clinical Practice Guidelines for Nutrition in CKD, requiring growth retardation (height SDS < -1.88 or growth velocity <10th percentile) plus two additional parameters (hypoalbuminemia, reduced intake, weight loss, or muscle wasting). Data on anthropometry, biochemical markers, three consecutive 24-h dietary recalls (standardized), and nutritional interventions (oral nutritional supplements, dietary counseling, specialist referral) were analyzed. A multivariate linear regression analysis was performed to assess PEW as an independent predictor of height velocity after adjusting for metabolic acidosis, GH/IGF-1 axis resistance and CKD-MBD; Spearman correlation and logistic regression analyses were conducted to explore the association between inflammatory markers (hs-CRP) and PEW.

The prevalence of PEW was 30.6%, increasing with CKD severity: 0% (stage 3), 25.9% (stage 4), 39.7% (stage 5 non-dialysis), and 20.0% (stage 5D). Hypoalbuminemia (73.1%) and reduced intake (73.1%) were predominant features. Short stature (height SDS < -1.88) affected 45.3% of the cohort. Dialysis patients exhibited lower PEW rates than non-dialysis stage 5 counterparts (P = 0.002), a disparity associated with standardized nutritional interventions (oral nutritional supplements, regular dietary counseling) in 5D patients (86.7% coverage) vs. low intervention rates in stage 5 non-dialysis patients (12.8% coverage). Over 46% of stage 5 patients were not on dialysis, primarily due to delayed referral or parental preference, which further contributed to inadequate nutritional management in this subgroup. PEW was an independent predictor of impaired height velocity after adjusting for confounders (β = -0.32, P < 0.001); hs-CRP levels were positively correlated with PEW scores (r = 0.41, P < 0.001), and elevated hs-CRP (>3 mg/L) was an independent risk factor for PEW (OR = 2.86, 95% CI: 1.52-5.38, P = 0.001).

PEW is highly prevalent in advanced pediatric CKD, driven by inflammation and nutritional deficits, and acts as an independent predictor of growth retardation. Early screening and stage-specific, evidence-based dietary and pharmacological interventions in accordance with the 2020 KDOQI guidelines are imperative to mitigate morbidity, particularly for stage 5 non-dialysis patients with low access to standardized nutritional care.