Consensus procedure for the management of

children with ESRD

Questions/aims

Aim

Defining consensus-based benchmarks

1. Do we agree with the current guidelines for the management of ESRD in children?

2. Are there any gaps?

3. What needs to be improved?

Questions:

• Do we/you know the guideline?• Do we/you agree with it? • What are the limitations?• Do we/you use it?• If so, is this visible in the results?• What needs to be improved?

Indicators

- Hemoglobin- Blood pressure - Phosphate

- PTH (target) - Calcium- CaXP- Dyslipidemia

• Benchmark

Hemoglobin

Lower treshold: < 2 yr: 10 g/dl or 6.2 mmol/l > 2 yr: 11 g/dl or 6.8 mmol/l

Upper threshold: normal value for age

Target: 70%

Hb

Hb too high

Anemia

15%

46%

40%

8%

12%

41%

47% 50%

38%

12%

44%52%4%

Best practice

i

52%

35%

13%

M0

N=31

M12

N=14

7%

71%

22%

M24

N= 6

83%

Hb too high

Anemia

Blood Pressure(diastolic and systolic)

< p95 for age, gender and height According to the Task Force Report 2004

Target: 75%

Blood pressure

> p95

38%

33%

24%

17%

38%

62%

62%

38%

65%35%

25%

19%

22%

75%

81%78%

Best PracticeSystolic Diastolic

29%

71%

38%

62% 100%

17%

83%

100%100%

M0 M12 M24

N=24 N=8 N=6

M0 M12 M24

N=24 N=8 N=6

BP> p95

Phosphate normal values for age (ESPN)

Based on: ESPN

0-1 yr:1.55 - 2.20 mmol/l (4.8 - 6.8 mg/dl)

1-4 yr:1.29 - 2.20 mmol/l (4.0 - 6.8 mg/dl)

5-11yr:1.19 - 2.10 mmol/l (3.7 - 6.5 mg/dl)11yr:1.10 - 1.90 mmol/l (3.4 - 5.9 mg/dl)

Target: 60%

Phosphate

40%

36%

25%

30%

Too highToo low Age corrected

Too high

Too low

according to ESPN

39%

53%

8%

38%

55%

7%

48%39%13%

Best Practice phosphate

32%

58%

10%

43%

57% 83%

17%

M0

N=31

M12

N=14

M24

N=6

Too high

Too low

according to ESPN

Indicators

- PTH Target

- Calcium Benchmarks

- Dyslipidemia

Proposal iPTH ? pg/mLBased on: Evidence:

1. KDOQI

>145 pg/ml (>16 pmol/l)

<300 pg/mL (<33 pmol/l)

Adults: C

Children: C

iPTH

24%

52% 33%

42%43%

43%

Too highToo low According to KDOQI24%

25%

14%

Best Practice (iPTH)

Too highToo low

37%

56%

7%

43%

43%

14%

25%50%25%

M0 M12 M24 N=30 N= 14 N=4

• Target???

Proposal Calcium ? mg/dLBased on: Evidence:

1. KDOQI

mg/dl (mmol/l) 0-5 mo 8,7 -11,3 (2,18-2,83)

6-12mo 8,7- 11,0 (2,18-2,75)

1-5 y 9,4 -10,8 (2,35-2,70)

6-12 y 9,4- 10,3 (2,35-2,58)

13-20y 8,8 –10,2 (2,20-2,55)

Adults: D

Children: D

2. ESPN

mg/dl (mmol/l) “child”: 8.8-10.8 (2.20 - 2.70) “thereafter”: 8.7-10.3 (2.20 - 2.58)

Children: D

Calcium (ESPN)

12%

11%

Too highToo low

According to ESPN

10%

14%

19%

19%

1% 4%

76%

80%

77%

Best practice

30%

70%

100%

N=10 N=4

Too highToo low

According to ESPN

Proposal CaXP ? mg/dL

Based on: Evidence:

1. KDOQI<12yr:CaXP<65 mg2/dL2 (5.2 mmol2/l2)

>12yr:CaXP<55 mg2/dL2 (4.4 mmol2/l2) Adults: C

Children: D

2. ESPN

CaXP < 60 mg2/dL2 (4.8mmol2/l2) Children: D

3. NfN CaXP<55 mg2/dL2 (4.4 mmol2/l2)

Proposal all lipids

Based on: Evidence:

1. KDOQINormal values (for age and

gender)

Adults: D

Children: D

2. ESPN Only normal values for total

cholesterol and triglycerides

(for age and gender)

None

- Cholesterol ( Total, LDL, HDL) - Triglycerides

Total cholesterol

24%

13%

17%

)

Too highAccording to ESPN

LDL cholesterol

22%

16%

19%

Too high> 110 mg/dl

HDL cholesterol

24%35%

39%

Too low< 35 mg/dl

Triglycerides (not after fasting!)

60%

75%

61%

ESPN handbook 2002, after 12 h fasting! Age and gender corrected

Questions/remarks?

Proposal CRP< ? Mg/L

Based on: Evidence:

1. KDOQI Adults: D

Children: D