KDOQI (Kidney Disease Outcomes Quality Initiative)
NKF KDOQI GUIDELINES

KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease


III. CLINICAL PRACTICE RECOMMENDATIONS FOR ANEMIA IN CHRONIC KIDNEY DISEASE IN CHILDREN

CPR FOR PEDIATRICS 3.3: USING PHARMACOLOGICAL AND NONPHARMACOLOGICAL ADJUVANTS TO ESA TREATMENT IN HD-CKD

Several pharmacological agents and nonpharmacological manipulations of the HD prescription have been examined for potential efficacy as adjuvants to ESA treatment. Studies are not available to address the use of pharmacological or nonpharmacological adjuvants to ESA treatment in patients with ND-CKD and PD-CKD.

3.3.1 L-carnitine: (FULLY APPLICABLE TO CHILDREN)
In the opinion of the Work Group, there is insufficient evidence to recommend the use of L-carnitine in the management of anemia in patients with CKD.

3.3.2 Vitamin C: (FULLY APPLICABLE TO CHILDREN)
In the opinion of the Work Group, there is insufficient evidence to recommend the use of vitamin C (ascorbate) in the management of anemia in patients with CKD.

3.3.3 Androgens: (FULLY APPLICABLE TO CHILDREN)
Androgens should not be used as an adjuvant to ESA treatment in anemic patients with CKD. (STRONG RECOMMENDATION)

RATIONALE

L-carnitine
This guideline is considered applicable to children because there are no special data in the pediatric population and there is no reason for a different recommendation.

There are only a few small studies published addressing the topic of L-carnitine in children. Pediatric patients on HD therapy may have low plasma carnitine levels366-368; this is less clear in pediatric PD patients, for whom the data are more conflicting.369-370 However, any justification for use of L-carnitine in children is much sparser than in the adult literature.

One extremely small trial in which 2 children on HD therapy were administered IV L-carnitine showed an increase in their Hct by 34% with no change in erythropoietin dose delivered.371

A relatively small study of 16 pediatric dialysis patients, 11 on HD therapy, administered oral carnitine divided twice daily at a dose of 20 mg/kg/d for 26 weeks and did not show a benefit with respect to increased Hb or Hct values or decreased dose requirement for erythropoietin.372 There also is indirect evidence that because the study was not designed to look at Hb or Hct levels, achieving much higher serum L-carnitine levels using a 5 times greater oral dose in children on continuous ambulatory PD therapy would not change the Hb levels.370

Finally, a word of caution is warranted: there also has been concern expressed over the use of oral carnitine because it may produce toxic metabolites.202

Vitamin C
This guideline is considered applicable to children because there are no special data in the pediatric population and there is no reason for a different recommendation.

Androgens
This guideline is considered applicable to children because there are no special data in the pediatric population and there is no reason for a different recommendation.