1. Consensus procedure for the management of children with ESRD

2. 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?

3. 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?

4. Indicators -Hemoglobin -Blood pressure -Phosphate -PTH (target) -Calcium -CaXP -Dyslipidemia Benchmark

5. Hemoglobin Lower treshold: 2 yr: 11 g/dl or 6.8 mmol/l Upper threshold: normal value for age Target: 70%

6. Hb Hb too high Anemia 15% 46% 40% 8% 12% 41% 47% 50% 38% 12% 44% 52% 4%

7. Best practice i 52% 35% 13% M0 N=31 M12 N=14 7% 71% 22% M24 N= 6 83% Hb too high Anemia

8. Blood Pressure ( diastolic and systolic) < p95 for age, gender and height According to the Task Force Report 2004 Target: 75%

9. Blood pressure > p95 38% 33% 24% 17% 38% 62% 38% 65% 35% 25% 19% 22% 75% 81% 78%

10. Best Practice Systolic Diastolic 29% 71% 38% 62% 100% 17% 83% 100% M0M12M24 N=24 N=8 N=6 M0M12M24 N=24 N=8 N=6 BP> p95

11. 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%

12. Phosphate 40% 36% 25% 30% Too high Too low Age corrected Too high Too low according to ESPN 39% 53% 8% 38% 55% 7% 48% 39% 13%

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

14. Indicators -PTH Target -CalciumBenchmarks -Dyslipidemia

15. Proposal iPTH ? pg/mL Based on:Evidence: 1.KDOQI >145 pg/ml (>16 pmol/l) <300 pg/mL (<33 pmol/l) Adults: C Children: C

16. iPTH 24% 52% 33% 42% 43% Too high Too low According to KDOQI 24% 25% 14%

17. Best Practice (iPTH) Too high Too low 37% 56% 7% 43% 14% 25% 50% 25% M0 M12 M24 N=30 N= 14 N=4

18. Target???

19. Proposal Calcium ? mg/dL Based 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

20. Calcium (ESPN) 12% 11% Too high Too low According to ESPN 10% 14% 19% 1% 4% 76% 80% 77%

21. Best practice 30% 70% 100% N=10 N=4 Too high Too low According to ESPN

22. Proposal CaXP ? mg/dL Based on:Evidence: 1.KDOQI <12yr:CaXP<65 mg 2 /dL 2 (5.2 mmol 2 /l 2 ) >12yr:CaXP<55 mg 2 /dL 2 (4.4 mmol 2 /l 2 ) Adults: C Children: D 2. ESPN CaXP < 60 mg 2 /dL 2 (4.8mmol 2 /l 2 ) Children: D 3. NfN CaXP<55 mg 2 /dL 2 ( 4.4 mmol 2 /l 2 )

23. Proposal all lipids Based on:Evidence: 1.KDOQI Normal 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

24. Total cholesterol 24% 13% 17% ) Too high According to ESPN

25. LDL cholesterol 22% 16% 19% Too high> 110 mg/dl

26. HDL cholesterol 24% 35% 39% Too low< 35 mg/dl

27. Triglycerides (not after fasting!) 60% 75% 61% ESPN handbook 2002, after 12 h fasting! Age and gender corrected

28. Questions/remarks?

29. Proposal CRP< ? Mg/L Based on:Evidence: 1.KDOQIAdults: D Children: D