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Friday, October 20, 2017
Preamble

Growth retardation is a significant major concern in children with CKD. The etiology of growth retardation in children with CKD is likely multifactorial and factors such as acidosis, malnutrition, renal osteodystrophy and end organ resistance to rhGH despite normal or high levels are thought to play a major role. Growth hormone has been shown in multiple randomized clinical trials to not only improve growth in children with CKD but also ultimately to improve final height. The aim of these guidelines, based on the available literature and expert opinion, is to assist physicians caring for children with CKD when prescribing rhGH. The guidelines should not be seen as rigid and exclude the use of rhGH in certain specific patients e.g. it is inappropriate to exclude transplant patients with CKD from treatment.

Criteria for Eligibility
  • CKD stages 2 to 5
  • Bone age: epiphyses not fused
  • Height and height velocity:
Minimum period of observation prior to rhGH:
every 3 months for up to  2 years old;
every 6 months for over 2 years old.
Height SDS <–1.88 (3rd percentile) or
Δ Height SDS < 0 when height < 10th percentile or

Height >2 SD below the midparental height.

Optimization of nutrition and medical therapy: 
Monitoring: at the paediatric nephrology centre or to a delegated paediatrician.
  • Age ≤ 2 years Q 3 months or Q monthly when CKD Stage 4 or 5 and throughout period of therapy
  • Age > 2 years Q 6 months or Q 3 months when CKD Stage 4 or 5 and throughout period of therapy.
  • More frequent assessment should be done if there is evidence of malnutrition (opinion).

Nutrition: The dietary intake for children with Stage 2 to 5 CKD should be based on the Dietary Reference Intake (DRI) and the Estimated Energy Requirement (EER) for chronological age.

Acidosis: Maintenance of bicarbonate ≥ 22 mmol/L

Exclusion criteria:
  • Pseudotumour cerebri
  • Malignancy
  • Uncorrected slipped capital femoral epiphyses
  • Transient insulin dependent diabetes
  • Recent (< 6 months) acute rejection
  • Recent (< 12 months) kidney transplant
  • Use of corticosteroids: Prednisone dose ≤  0.35 mg/kg/day or ≤  1 mg/kg/alt days

Monitoring:
Q3 months at the paediatric nephrology centre or by a delegated paediatrician.

Examination:
  • Weight & stadiometer height (+ HC in children < 3 years): at baseline & Q 3 months
  • General examination including fundoscopy and Tanner staging: at baseline & Q 3 months
  • Formal ophthalmologic assessment at baseline or prn if symptoms or signs of pseudotumour cerebri
  • Additional fundoscopic examination after 1 month of rhGH treatment
  • Anthropometric measurements: at baseline & Q3-6 months (triceps skin-fold thickness, mid-arm circumference & mid-arm muscle circumference)
Blood Tests:
  • At baseline & Q 3 months: CBC, renal "biochemistry", fasting glucose, PTH
  • At baseline & Q 12 months: thyroid function tests
GFR:
  • As per centre protocol
Radiology:
  • Bone age (hand & wrist) at baseline & Q12 months
  • Radiological evaluation of hips at baseline & Q12 months
Cessation of Therapy:
  • End of growth spurt: closure of epiphyses
  • Achievement of final predicted height
  • Unresponsiveness: no increase in Height SDS after 12 months of therapy, or growth velocity < 2 cm/yr while on therapy despite dosage increases outlined below.
  • Avascular necrosis of the femoral head; slipped femoral epiphysis
  • Malignancy
  • New kidney transplant
  • Pseudotumor cerebri
  • Patient or parent non adherence
  • Patient or parent request
Growth Hormone Re-initiation
  • Restart if Height SDS decreases by more than 0.25 in 6 months, provided there is still time for potential growth
Other Issues:
  • Consultation with a paediatric endocrinologist should be considered for patients who are Tanner stage 2 or in whom other interventions should be considered to maximize growth potential (e.g. sex hormone replacement therapy for delayed puberty or conversely leuprolide acetate to prolong puberty & delay epiphyseal closure)
Suggested dose for CKD patients:
  • 0.05 mg/kg/day. Dosage increase may be considered in patients with sub-optimal response:
Height SDS < –2 & Δ Height SDS ≤ 0 (no increase in Height SDS during preceding 6 months)
  • Increase initial dose by 25% (to 0.062 mg/kg/day)
  • Increase dose again by 25% (to 0.075 mg/kg/day) after 6 months if response still sub-optimal
  • Maximum dose 0.1 mg/kg/day
  • Maximum absolute dose: 20 mg/wk

 Reviewed May 26, 2007

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