Role of Quadriceps Muscle Ultrasound in Nutritional Assessment of Children on Maintenance Hemodialysis: A Tertiary Center Study

Role of Quadriceps Muscle Ultrasound in Nutritional Assessment of Children on Maintenance Hemodialysis: A Tertiary Center Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Role of Quadriceps Muscle Ultrasound in Nutritional Assessment of Children on Maintenance Hemodialysis: A Tertiary Center Study Amal Elsaid Gohary, Azza Soliman Soliman, Sara Eldemerdash Kamel Eldemerdash, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8503873/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Protein-energy wasting (PEW) is highly prevalent among children receiving maintenance hemodialysis, yet accurate and objective assessment of nutritional status remains challenging. Muscle mass assessment is one of the diagnostic tools for malnutrition according to current definitions, and muscle ultrasound (US) can be used for the diagnosis and monitoring of malnutrition. Methods: A tertiary hemodialysis center case–control study enrolled 42 children on hemodialysis (age range: 1–16 years) and 42 age- and sex-matched apparently healthy children as a control group. Demographic, anthropometric, clinical, and laboratory information were gathered. A dietary evaluation using a 3-day food intake record was performed to assess protein adequacy. The thickness of the quadriceps muscle, primarily the rectus femoris, the largest skeletal muscle in the body, was assessed using B-mode muscle US in both groups. Results: Children on hemodialysis had significantly lower caloric and protein intake compared with controls (both p < 0.001) and 40.5% of patients had inadequate protein intake. Children on maintenance hemodialysis had significantly reduced peripheral muscle thickness compared with healthy controls. Correlation analysis showed that total caloric and protein intake were positively associated with muscle thickness (p < 0.001). The ROC curve showed that among muscle parameters, rectus femoris thickness ≤10.4 mm demonstrated excellent sensitivity (100%) but moderate specificity (48%), with an AUC of 0.731 (p < 0.001).While anthropometric and dietary measures identified malnutrition in 21–43% of patients, ultrasound-based muscle mass classified approximately half of cases had low muscle mass, suggesting a higher sensitivity for detecting nutritional impairment Conclusion: Quadriceps muscle ultrasonography is a simple, non-invasive bedside tool that may aid in screening and monitoring PEW in children on maintenance hemodialysis. Malnutrition Hemodialysis Muscle Ultrasound Quadriceps Muscle Protein Energy Wasting Figures Figure 1 Introduction Chronic kidney disease (CKD) is a significant global health issue. The degrees of albuminuria and glomerular filtration rate (GFR) determine the definition of CKD. Hemodialysis (HD) has become a vital treatment option for children with chronic renal illnesses, thanks to advancements in medical technology. About 50% of patients preparing for a kidney transplant require HD as a bridge [ 1 ]. The definition of nutritional status is complicated. Consuming the right kinds and quantities of food to support normal growth and a normal body composition is referred to as having an adequate nutritional status. It can be challenging to distinguish between mild to moderate malnutrition and adequate nutrition. To effectively distinguish malnourished children, the World Health Organization established a cutoff of two standard deviations below gender-specific medians for weight-for-age, height-for-age, and weight-for-height. Therefore, in addition to anthropometric measurements, clinical and biochemical data, we used caloric count and adequate protein intake for our patients' nutritional evaluation [ 2 ]. Cases with CKD are more likely to experience malnutrition and studies on this topic in CKD and hemodialysis children are minimal, malnutrition involves vitamin deficiencies and protein-energy wasting (PEW). Research has revealed a high occurrence of malnutrition in children and individuals with CKD. Malnutrition causes growth retardation and raises morbidity and mortality rates in CKD patients. The processes contributing to malnutrition include inadequate nutrient intake and appetite, hormonal imbalance, catabolic state, inflammation, and dialysis-related issues [ 3 , 4 ]. A multidisciplinary team and a personalized approach are required for the management of malnutrition in persons with CKD. It should begin with a thorough evaluation of the patient and a customized nutrition plan that includes adequate calories, protein, and micronutrients for the child's growth and development. With the assistance of the nephrologist, nurses, caregivers, and social workers on the dialysis team, the renal dietitian plays a crucial role in evaluating and monitoring the nutritional status of children [ 5 , 6 ]. PEW is seen in up to 50%–75% of individuals with CKD stages IV–V. Therefore, it is advised that children with end-stage kidney disease (ESKD), particularly those receiving regular hemodialysis (HD), undergo accurate and frequent nutritional evaluations [ 7 , 8 ]. Four diagnostic standards were established by the International Society of Renal Nutrition and Metabolism (ISRNM) expert panel for PEW: low body weight and biochemical standards, decreased caloric and protein intake, as well as decreased muscle mass [ 9 ]. The three-day food history is currently the gold standard for evaluating nutritional intake in children with CKD [ 10 ]. However, it is not very easy for respondents and caregivers, who require motivation, knowledgeable supervision, and an examination of usual intake over several days [ 11 ]. Additionally, food records are prone to errors and may alter eating patterns, lowering the accuracy of reported food intake [ 12 ]. Reduced muscle mass is one of the diagnostic criteria for malnutrition according to new definitions [ 13 , 14 ]. Muscle mass assessment can be performed using various techniques to monitor and screen for muscle loss in high-risk populations. These methods, including bioimpedance analysis (BIA), enable the measurement of muscle mass but are affected by overhydration, a frequent side effect in hemodialysis patients [ 15 – 17 ]. The "gold standard" techniques for assessing muscle mass, including computed tomography (CT), dual-energy X-ray absorptiometry (DEXA), and magnetic resonance imaging (MRI), are primarily used for research due to their high cost, potential for radiation exposure, and specialized equipment requirements [ 18 ]. Currently, muscle ultrasound (US) has become a popular bedside technique for evaluating body composition because of its portability, affordability, accessibility, convenience of use, and low training requirements [ 19 ]. Research has revealed that US data provide more sensitive screening for patients at nutritional risk, as well as follow-up and assessment of nutrition intervention outcomes. US measurements of the body's skeletal muscles, particularly the quadriceps muscle group, the largest skeletal muscle in the body, show a good correlation with muscle mass as assessed by gold-standard procedures and are as accurate as those obtained with CT or MRI [ 20 , 21 ]. According to recent research, quadriceps femoris US is a reliable and straightforward method for assessing muscle thickness in patients with kidney failure [ 22 ]. US is a useful technique for measuring muscle mass and identifying malnutrition in patients on hemodialysis, as studies have shown that rapid fluid fluctuations caused by overhydration do not affect the thickness of the quadriceps muscle [ 13 ]. Research on the application of quadriceps muscle ultrasonography for nutritional evaluation in children receiving hemodialysis is limited. The objective of our study is to analyze the utility of muscle ultrasonography as a screening method for the evaluation of malnutrition and decreased muscle mass in children on maintenance hemodialysis who are at high risk of developing PEW. Patients and methods Research design and patients A case–control study was conducted in the pediatric nephrology and hemodialysis unit of a tertiary children's hospital between October 2024 and October 2025. The study included 42 cases; all patients were included as a sequential sample for the case group, and 42 matching healthy individuals were included as a control group. Children between the ages of one and sixteen years receiving regular maintenance hemodialysis (excluding those receiving acute hemodialysis), patients who declined to take part in the study, and patients with muscle disorders were among the cases. The 42 children in the control group, who attended our outpatient general pediatric clinic, appeared to be in good health. Sample size Due to the limited number of pediatric hemodialysis patients, a convenience sample was used. The sample size was calculated as follows: the total number of dialysis cases referred to the pediatric hemodialysis unit was 42; therefore, all cases were included in the study as a consecutive sample for the case group, and 42 matched healthy individuals were included as a control group. Biochemical measurements Using the proper chemical analyzer, tests were conducted for serum creatinine, BUN, uric acid (UA), cholesterol, total protein, albumin, calcium, and phosphorus (Pi). Nutritional status assessment Mothers or patients were asked to complete a retrospective 3-day food intake recall. This involved keeping track of everything the case drank and ate, including specific amounts, with a focus on daily energy and protein consumption in the children's nourishment. The results were then compared to the suggested consumption based on the estimated energy requirements (EERs) calculations, which took into account gender, weight, age, and height (using the 50th percentile height for weight). The Acceptable Macronutrient Distribution Range (AMDR) for protein is 5–20% and 10–30% of energy intake for children aged 1–3 years and 4–18 years, respectively. Individuals who consume less protein than these suggested amounts are considered to be at risk of malnutrition [ 23 ]. US measurements A low-frequency curvilinear-array transducer (3.5 MHz) and a high-frequency linear-array transducer (7 MHz) were used with the Siemens ACUSON X300 US machine. All cases were examined after completion of the hemodialysis session to avoid the influence of fluid overload and fluid shifts. Patients were positioned in either a supine or a slight lateral decubitus posture for thigh assessments. The skin over the designated assessment sites was exposed and disinfected using alcohol swabs. Assessment Techniques Muscle thickness measurements (Vastus intermedius, Vastus medialis, Vastus lateralis, Rectus femoris): The case was positioned supine with the leg semi-extended and relaxed. Procedure: A transverse (cross-sectional) approach was used at standardized anatomical sites. The thickness of each muscle was measured as the distance between the deep and superficial fasciae of the respective, at the level of two particular landmarks, the midpoint, and the border between the upper two-thirds and the lower third between the upper pole of the patella and the superior anterior iliac spine[ 22 ] Data Recording and Analysis All US measurements were performed by a single trained radiologist operator. All measurements were taken in triplicate, and the mean value was calculated for analysis. Care was taken to maintain consistent probe pressure and angle to avoid measurement bias. The assessor was blinded to clinical data to reduce measurement bias. Statistical analysis Following data collection, Microsoft Excel 2016 for Windows, part of the Microsoft Office bundle (2016, Microsoft Corporation, United States), was used to code the information into a spreadsheet. The IBM Statistical Package for the Social Sciences software (SPSS), 27th edition, published by IBM in the United States, was then utilized for analysis. The normal distribution of continuous data was assessed utilizing the Kolmogorov–Smirnov test. The information presentation included numbers and percentages for qualitative information, as well as means, standard deviations, and ranges for quantitative information with a parametric distribution. Additionally, it included medians and interquartile ranges (IQR) for quantitative information with a non-parametric distribution. Analytic statistics To explore the relationship between two categorical variables, the chi-square test is a commonly used statistical method for analyzing this relationship. When comparing quantitative data between two groups, the unpaired Student's t-test is used if the data are normally distributed, while the Mann-Whitney test is preferred for data that do not follow a normal distribution. To assess the strength and direction of the association between two quantitative variables, correlation analysis, often using the Spearman method, is employed. The correlation coefficient, denoted as "r," indicates both the strength and direction of the association. Additionally, the receiver operating characteristic (ROC) curve is a valuable tool for evaluating the sensitivity and specificity of quantitative diagnostic measures in classifying cases into two categories.Missing data in Group 2 were replaced using single imputation with plausible values based on the observed range of each variable. This approach preserved natural variability and allowed for complete analysis, as the proportion of missing data don’t exceeded 10% for several variables [ 24 ]. Results Patients' baseline characteristics The patient group consisted of 42 children undergoing hemodialysis at the Pediatric Nephrology Unit of our tertiary care hospital, while the control group consisted of 42 healthy children who were age- and sex-matched to the patients. Table 1 summarizes the demographic and anthropometric characteristics of children undergoing maintenance hemodialysis compared with healthy controls. There was no statistically significant difference between the two groups in terms of sex distribution (p = 0.661) or age (p = 0.192). Most participants in both groups belonged to low- to moderate-socioeconomic levels. Among hemodialysis cases, the most common primary diagnoses were unexplained renal failure (23.8%), glomerulopathy (nephrotic syndrome) (19%), and neurogenic bladder (14.3%), while other causes were less frequent. The median duration of dialysis was 2 years, with an interquartile range (IQR) of 1–5 years, and KT/V values had a median of 1.1. Anthropometric assessment revealed that hemodialysis patients had significantly lower weights (p < 0.001), heights (p = 0.014), BMIs (p < 0.001), mid-arm circumferences (p < 0.001), and skin-fold thicknesses (p < 0.001) compared to controls. However, no significant difference was observed in waist circumference (p = 0.427). Table (1): Demographic and Clinical Characteristics of the Studied Groups : HD cases (N=42) Controls (N=42) Test value p- value N % N % Gender: Female 24 57.1% 22 52.4% 0.192 0.661 ‡ Male 18 42.9% 20 47.6% Age (years): Mean± SD Min.–Max. 10.41± 3.29 3.3- 16 9.52± 2.83 3- 15 1.315 0.192 # Primary diagnosis Atypical HUS 4 9.5% - - - Bartter syndrome 1 2.4% Prune belly syndrome 1 2.4% Chronic interstitial nephritis 2 4.8% CKD recurrent stones 1 2.4% Congenital atrophic kidneys 1 2.4% Glomerulopathy Nephrotic syndrome 8 19% Nephrocalcinosis 1 2.4% Neurogenic bladder 6 14.3% Obstructive uropathy 3 7.1% Polycystic kidney 1 2.4% SLE 3 7.1% Unexplained renal failure 10 23.8% Dialysis duration (years): Median (IQR) Min.–Max. 2.0 (1.0–5.0) 6 months- 12 years - - - KT/V Median (IQR) Min.–Max. 1.1 (0.9–1.3) 0.7- 1.7 - - - Weight (Kg) Mean± SD 30.84± 11.6 41.57± 12.26 4.121 <0.001 # Min.–Max. 11.0–56.0 18–75.0 Height (cm) Median (IQR) 130.75 (120–142) 137 (131.0–148.0) 2.466 0.014 ╪ Min.–Max. 90–165 100.0–155.0 BMI (Kg/m 2 ) Median (IQR) 17.0 (15.6–19.0) 21.35 (19.5–24.0) 4.963 <0.001 ╪ Min.–Max. 11.0–31.8 15.0–33.0 MAC (cm) Median (IQR) 19 (18–24) 27.0 (23.0–35.0) 5.545 <0.001 ╪ Min.–Max. 10.0–31.0 15.0–35.0 SFC (mm) Mean± SD 19.38± 6.57 24.79± 5.42 4.113 0.05 is non-significant; p≤0.05 is significant. #Student T test, , ╪ Mann- Whitney U test, ‡ Chi-square test, BMI: Body Mass Index. MAC: Mid-Arm Circumference, SFC: Subcutaneous Fat Caliper, WC: Waist Circumference Daily Nutritional Intake in Hemodialysis Children and Controls Table 2 shows a comparison of daily caloric and macronutrient intake between children on maintenance hemodialysis and healthy controls. The total daily calorie intake was significantly lower in HD children compared with the controls. Similarly, daily protein intake was significantly reduced in HD children (p < 0.001). In contrast, fat intake did not differ significantly between the groups (p = 0.120). The protein energy percentage was lower in HD cases, with a median of 12.1% versus 17.2% in controls (p = 0.006). Regarding protein adequacy, 59.5% of HD cases had adequate intake compared with 95% of controls (p < 0.001). Table ( 2 ): Comparison of daily nutritional intake among the two groups : HD cases (N=42) Controls (N=42) Test value p- value N % N % Total calories Median (IQR) 1060 (859–1300) 1575 (1380–2000) 5.493 <0.001 ╪ Min.–Max. 569–2174 569–2174 Protein intake (g/kg/day) Mean± SD 1.33± 0.64 1.73± 0.29 3.793 <0.001 # Min.–Max. 0.40–2.9 1.0–2.3 Protein (%En) Median (IQR) 12.1 (8.09–19.31) 17.2 (14.24–19.63) 2.769 0.006 ╪ Min.–Max. 2.0–73.53 9.45–27.59 Fat intake Median (IQR) 1.6 (1.3–2.0) 1.8 (1.6–1.9) 1.555 0.120 ╪ Min.–Max. 0.70–3.0 1.0–2.3 Protein adequacy Adequate 25 59.5% 40 95.0% 21.31 0.05 is non-significant; p≤0.05 is significant. #Student T test, ╪ Mann- Whitney U test, ‡Chi-square test Laboratory Parameters of Children and Controls As shown in Table 3, children undergoing hemodialysis exhibited markedly higher creatinine (p < 0.001) and BUN levels (p < 0.001), indicating impaired renal function. Hemoglobin levels were significantly reduced in HD children (p = 0.001), indicating anemia, while total protein (p = 0.004) and albumin (p < 0.001) showed significant differences. Calcium and phosphorus concentrations were also significantly different, with HD children showing lower calcium levels (p = 0.002) and higher phosphorus levels (p < 0.001), indicating disturbances in mineral metabolism. UA levels were elevated in the HD group (p < 0.001). A higher total cholesterol level was observed in the HD group compared with the controls (p < 0.001). Table ( 3 ): Comparison between the two groups regarding Laboratory Parameters HD cases (N=42) Controls (N=42) Test value P- value ╪ Median IQR Min. Max. Median IQR Min. Max. Creatinine (mg/dL) 7.4 6.3 8.0 2.7 10.0 0.8 0.7 0.9 0.2 2.1 7.907 <0.001 BUN (mg/dL) 59.0 48.0 70.0 30.0 86.0 25.0 21.0 29.0 7.0 70.0 7.504 <0.001 HB (g/dL) 10.2 9.2 11.0 8.3 13.0 11.0 10.9 11.2 10.5 11.7 3.456 0.001 Total protein (g/dL) 6.6 6.0 7.0 5.3 8.0 6.9 6.7 7.0 6.0 8.3 2.845 0.004 Albumin (g/dL) 3.7 3.6 3.8 3.0 4.1 4.2 4.0 4.5 3.2 44.0 6.167 <0.001 Ca (mg/dL) 8.7 8.5 8.9 6.5 9.9 9.2 8.6 9.7 6.9 11.0 3.109 0.002 Ph. (mg/dL) 5.6 5.0 6.8 2.8 8.6 4.5 4.1 4.8 2.5 6.0 5.166 <0.001 Uric acid (mg/dL) 6.7 5.8 7.3 3.5 8.3 4.1 4.0 4.2 3.8 4.3 6.007 <0.001 Cholesterol (mg/dL) 149.0 127.0 168.0 92.0 225.0 121.0 120.0 123.0 118.0 126.0 4.515 0.05 is non-significant; p≤0.05 is significant. #Student T test, ╪ Mann- Whitney U test Ultrasonographic Assessment of Muscle Thickness among the Studied Groups Table 4 demonstrates the comparison of US measurements of muscle thickness between children undergoing maintenance hemodialysis and healthy controls. Children on maintenance hemodialysis had significantly reduced peripheral muscle thickness compared with healthy controls. Rectus femoris thickness was significantly lower in HD children (8.81 ± 3.47 mm vs. 10.14 ± 3.24 mm, p = 0.026), as were the vastus intermedius (median 7.5 mm vs. 9.5 mm, p = 0.012), vastus medialis (median 12.0 mm vs. 15.0 mm, p = 0.031), and vastus lateralis (median 14.95 mm vs. 20.0 mm, p = 0.022). Table (4): Comparison of US assessment of muscle thickness among the two groups. HD cases (N=42) Controls (N=42) Test value p- value Rectus femoris thickness (mm) Mean± SD 8.81± 3.47 10.14± 3.24 2.227 0.026 # Min.–Max. 2.6–18.3 4.5–16.0 Vastus intermedius (mm) Median (IQR) 7.5 (5.7–10.6) 9.5 (7.0–13.0) 2.498 0.012 ╪ Min.–Max. 2.1–16.0 5.0–17.0 Vastus medialis (mm) Median (IQR) 12.0 (6.4–16.8) 15.0 (13.0–16.0) 2.160 0.031 ╪ Min.–Max. 6.4–31.0 8.0–22.8 Vastus lateralis (mm) Median (IQR) 14.95 (11.8–24.4) 20.0 (18.0–22.0) 2.299 0.022 ╪ Min.–Max. 9.8–39.2 11.0–27.0 p>0.05 is non-significant; p≤0.05 is significant. #Student T test, ╪ Mann- Whitney U test, ‡Chi-square test Correlation of Muscle with Clinical, Nutritional, and Laboratory Parameters in Children on Hemodialysis As shown in Table 5, association analysis illustrated that total caloric intake was positively related to muscle thickness, including rectus femoris (r = 0.573, p < 0.001), vastus intermedius (r = 0.486, p = 0.001), vastus medialis (r = 0.422, p = 0.006), and vastus lateralis (r = 0.290, p = 0.066). In addition, protein intake showed significant positive correlations with rectus femoris (r = 0.427, p = 0.005), vastus intermedius (r = 0.444, p = 0.004), vastus medialis (r = 0.514, p = 0.001), and vastus lateralis (r = 0.354, p = 0.023). Renal function markers, particularly creatinine, were positively correlated with all muscle thickness measurements: rectus femoris (r = 0.604, p < 0.001), vastus intermedius (r = 0.480, p = 0.001), vastus medialis (r = 0.526, p < 0.001), and vastus lateralis (r = 0.467, p = 0.002). Other laboratory parameters, including total protein, albumin, calcium, phosphorus, UA, and lipid profile, showed no significant correlations with muscle thickness. Table (5): Correlation of muscle thickness with clinical, nutritional, and laboratory parameters in hemodialysis children: Rectus femoris thickness (mm) Vastus intermedius (mm) Vastus medialis (mm) Vastus lateralis (mm) r P-value r P-value r P-value r P-value Age (years) 0.048 0.767 -0.011 0.945 0.063 0.696 0.049 0.760 Dialysis duration (years) 0.106 0.510 -0.030 0.852 -0.099 0.540 -0.153 0.339 BMI 0.073 0.647 0.164 0.299 0.052 0.744 0.159 0.314 KT/V 0.098 0.536 -0.187 0.236 -0.070 0.661 -0.128 0.420 Total calories 0.573 <0.001 0.486 0.001 0.422 0.006 0.290 0.066 Protein intake 0.427 0.005 0.444 0.004 0.514 0.001 0.354 0.023 Fat intake -0.208 0.191 -0.191 0.231 -0.099 0.540 -0.187 0.242 Creatinine (mg/dL) 0.604 <0.001 0.480 0.001 0.526 <0.001 0.467 0.002 BUN (mg/dL) 0.008 0.960 0.260 0.096 0.130 0.411 0.198 0.210 HB (g/dL) 0.070 0.661 -0.145 0.360 -0.024 0.882 -0.157 0.321 Total protein (g/dL) 0.202 0.200 0.110 0.489 0.195 0.215 0.032 0.839 Albumin (g/dL) 0.226 0.149 0.212 0.178 0.134 0.399 0.231 0.141 p>0.05 is non-significant, *p≤0.05 is significant, **p≤0.01 is highly significant,r: Spearman correlation coefficient Validity of muscle thickness to detect malnutrition: Receiver operating characteristic (ROC) analysis was performed to evaluate the capability of US measurements to detect malnutrition in children undergoing maintenance hemodialysis. Among muscle parameters, rectus femoris thickness ≤10.4 mm showed excellent sensitivity (100%) but moderate specificity (48%) with an AUC of 0.731 (p < 0.001), indicating good discriminatory ability. Vastus lateralis ≤20.6 mm also demonstrated 100% sensitivity and 52% specificity (AUC = 0.736, p = 0.001). Vastus intermedius ≤8.3 mm and vastus medialis ≤14.4 mm showed lower sensitivity (88.9% and 77.8%, respectively) with moderate specificity (61.3% for both) and AUC values of 0.705 (p = 0.012) and 0.678 (p = 0.032) ( Figure 1). Comparison between different tools to assess malnutrition in cases group: As summarized in Table 6, the prevalence of malnutrition varied considerably depending on the assessment modality. While anthropometric and dietary measures identified malnutrition in 21–43% of patients, ultrasound-based muscle mass assessment classified approximately half of the cohort as having low muscle mass, suggesting a higher sensitivity for detecting nutritional impairment. Table (6):Prevalence of malnutrition according to different assessment modalities in children on maintenance hemodialysis in comparison to muscle ultrasound cut off (n = 42) and composite score for malnutrition: Parameter Definition n (%) Weight and length -for-age Weight z-score < −2 SD 18 (42.9) BMI-for-age Height z-score < −2 SD 9 (21.4) Caloric intake (chronological age) Intake < estimated energy requirement (EER) 3 (7.1) Caloric intake (corrected age for height) Intake < height-age–adjusted EER 18 (42.9) Protein intake inadequacy Intake below age-specific recommendations 17 (40.5) Low muscle mass (ultrasound-based) Below predefined quadriceps muscle thickness cut-off 21 (50.0) Data are presented as number (percentage). EER, estimated energy requirement. Muscle mass was assessed using quadriceps muscle ultrasonography Composite malnutrition score for nutritional risk in cases : To better characterize nutritional risk, a composite malnutrition score integrating anthropometric impairment, caloric inadequacy, protein inadequacy, and low muscle mass was applied. Use of this composite score resulted in reclassification of several children who would not have been identified as malnourished based solely on conventional anthropometric or dietary assessment, highlighting the additive value of muscle ultrasonography in nutritional evaluation. Table(7) a composite malnutrition score for malnutrition risk : Each patient is scored 0–4, based on the presence of the following domains: Domain Criterion Score Anthropometry ≥1 of BMI, weight, or height < −2 SD 1 Energy intake Caloric intake below EER (corrected age/height) 1 Protein intake Intake below recommended level 1 Muscle mass Low muscle mass by ultrasound cut-off 1 Total score equals 0–1: No / mild nutritional risk ,2: Moderate malnutrition risk and ≥3: Severe malnutrition risk. Discussion PEW is a major problem that increases with advanced stages of CKD, with a high occurrence in patients on maintenance dialysis, raising the possibility of morbidity, mortality, and increased healthcare costs [ 25 , 26 ]. Nutritional ultrasonography is a useful tool for evaluating both muscle mass and muscle quality [ 27 ]. The US assessment of quadriceps femoris muscle thickness is highly reliable in hemodialysis patients and can accurately assess muscle thickness that reflects nutritional status, as it is unaffected by changes in fluid balance, which are prevalent in children undergoing hemodialysis [ 28 ]. In the present study, we evaluated skeletal muscle quadriceps thickness using US and its role in nutritional assessment in children on chronic regular hemodialysis. To our knowledge, this topic has not been previously studied in the pediatric age group. We studied 42 cases on regular hemodialysis compared to 42 healthy controls. Children on hemodialysis had significantly lower weights (p < 0.001), heights (p = 0.014), BMIs (p < 0.001), mid-arm circumferences (p < 0.001), and skin-fold thicknesses (p < 0.001) than controls, according to our clinical evaluation. This finding is consistent with earlier research, which has shown that growth is significantly impaired and that the severity of growth impairment increases with the duration of hemodialysis [ 29 ]. In our study, two patients had high BMIs above 2 SD; 21% had BMIs below − 2 SD for age, and 59% of patients had short stature with lengths below − 2 SD for age. This agrees with many studies reporting growth failure in late-stage renal failure, where comorbidity treatment, improved diet, and metabolic control are all part of management. Research also revealed that kidney transplantation considerably enhances growth [ 30 ]. This is also consistent with a study on the nutritional evaluation of children with CKD, which indicated that sixty percent of children had moderate to severe malnutrition at the time of assessment, and that the incidence of growth retardation was much higher in children with advanced stages of CKD [ 31 , 32 ]. In a previous study, thirty children receiving regular hemodialysis in our nation were included. According to the data, children receiving hemodialysis who were proportionately short in stature were most affected in terms of height, whereas weight was less affected. Dietary analysis revealed that 76.7% of patients had consumed the recommended daily calorie allotment [ 12 ]. Additionally, anthropometric evaluation revealed that children with CKD had lower weights, heights, skinfold thicknesses, body mass indices, and mid-arm circumferences compared with healthy controls (p < 0.05), which is in line with our results [ 32 ]. In our study, nutritional evaluation revealed differences in daily caloric and macronutrient intake between children on maintenance hemodialysis and healthy controls. The total daily calorie intake was significantly reduced in HD children compared to the controls (p < 0.001). Similarly, daily protein intake was significantly reduced in HD children (p < 0.001), with 40.5% showing protein intake inadequacy. This agrees with a study on the nutritional evaluation of children with CKD, in which approximately 46% had considerably decreased protein consumption as their renal failure progressed [ 33 ]. In our study, laboratory parameters revealed that hemoglobin levels were significantly reduced in children with HD (p = 0.001), indicating anemia. Additionally, total protein (p = 0.004) and albumin (p < 0.001) showed significant differences. Calcium and phosphorus levels were also significantly different, with HD children showing lower calcium levels (p = 0.002) and higher phosphorus levels (p < 0.001), indicating disturbances in mineral metabolism. This is consistent with research on children receiving hemodialysis, which indicated that 34% of patients had a height z-score below the third percentile and that 70% of patients had phosphorus levels above the age-recommended range [ 34 ]. Additionally, research revealed that 37% of children receiving hemodialysis had a mean hemoglobin level of less than 11 g/dL (indicating anemia) (p < 0.05), compared with normal levels. This is attributed to erythropoietin deficiency, inadequate dialysis, decreased appetite, and poor nutrition [ 35 ]. Research has also shown that CKD5 is linked to higher total cholesterol levels (183 mg/dL vs. 162 mg/dL), which is consistent with our findings [ 35 ]. US methods offer the advantage of easy bedside application for assessing skeletal muscle, with the quadriceps being the largest group of muscles and ideal for evaluating muscle mass. In our study, children on maintenance hemodialysis had significantly reduced peripheral muscle thickness compared with healthy controls. Rectus femoris thickness was significantly lower in HD children (p = 0.026), as were the vastus intermedius (p = 0.012), vastus medialis (p = 0.031), and vastus lateralis (p = 0.022). In related studies, muscle thickness was compared in 35 healthy individuals, 30 hospitalized cases, and 121 patients with ESRD receiving hemodialysis. ESRD patients receiving HD exhibited lower QVIT and QRFT than both control groups (p < 0.001). It was determined that skeletal muscle US is a simple, bedside method that can be utilized in hemodialysis facilities and is a helpful tool for assessing muscle mass [ 13 ]. Additionally, a related study assessing the use of muscle ultrasonography in the nutritional evaluation of critically ill children found that it is a helpful, non-invasive method for identifying changes in muscle size. The quadriceps are the muscle group most frequently measured [ 36 ]. In our study, children on hemodialysis were compared with controls using US measurements of quadriceps muscle thickness. We found that rectus femoris thickness ≤ 10.4 mm showed excellent sensitivity (100%) but moderate specificity (48%) with an AUC of 0.731 (p < 0.001), indicating good discriminatory ability. In the hemodialysis cohort, 21% of patients had a BMI below − 2 SD, while 42% had both weight and height below − 2 SD. Caloric inadequacy was identified in 7% when assessed for chronological age and in 42% when adjusted for corrected age for height, and 40% of patients had inadequate protein intake. In contrast, assessment using ultrasound-derived muscle mass cut-off values identified low muscle mass in approximately 50% of patients. These findings suggest that muscle ultrasonography may detect a higher proportion of children at risk of malnutrition compared with conventional anthropometric and dietary assessment methods. To our knowledge, comparable pediatric hemodialysis studies directly contrasting these assessment modalities are lacking. A comparable study used ultrasonography (US) to evaluate muscle and PEW in hemodialysis (HD) patients. Rectus femoris (RF) and vastus intermedius (VI) quadriceps muscle thickness measured by ultrasonography (all p < 0.001) correctly distinguished patients with PEW from those without, which is consistent with our findings [ 37 ]. In another study, adults on HD underwent US and CT scans on the same day following a dialysis session to examine the effects of US and CT on muscle thickness. Quadriceps muscle thickness (QMT) of the vastus intermedius (VI) and rectus femoris (RF) muscles showed that US imaging provides a reliable, bedside, and rapid method for evaluating muscle atrophy in HD patients [ 38 ]. In our study, total caloric intake was positively related to muscle thickness, including rectus femoris (p < 0.001), vastus intermedius (p = 0.001), vastus medialis (p = 0.006), and vastus lateralis (p = 0.066). In addition, protein intake showed significant positive correlations with rectus femoris (p = 0.005), vastus intermedius (p = 0.004), vastus medialis (p = 0.001), and vastus lateralis (p = 0.023) serum creatinine positively corrolated with muscle mass in our study and that is expected in hemodialysis patients in those patients creatinine reflect muscle mass not renal status. This finding is consistent with a study on adults undergoing maintenance hemodialysis. The cases were divided into two groups: the usual care group and the early nutrition intervention group. The early nutrition intervention group showed notable improvements in muscle mass. Patients receiving dietary intervention showed improvements in their intake of calories, protein, vitamins, and iron [ 39 ]. Additionally, research revealed a predictive role for muscle US as a straightforward technique for nutritional assessment in maintenance HD patients. Indexed distal vastus intermedius (VIT) was linked to mortality [ 40 ]. A meta-analysis of 15 studies, including 1,584 cases of hemodialysis, found that QRFT and QVIT were significantly lower in hemodialysis patients compared to healthy individuals, although there was no significant difference before or after dialysis. The authors concluded that ultrasonography is a dependable and readily available method for evaluating quadriceps muscle thickness in hemodialysis patients, following the discovery of QRFT variations in thickness during US examination. These results underscore the importance of routine US follow-up of muscle thickness in hemodialysis patients and highlight the need for increased use in the pediatric population [ 41 ]. We suggest a composite malnutrition score integrating anthropometric impairment, caloric inadequacy, protein inadequacy, and low muscle mass to be applied to avoid missed malnourished patients assessed by conventional anthropometric or dietary assessment, highlighting the additive value of muscle ultrasonography in nutritional evaluation.Thus, screening of muscle mass and early detection of PEW using muscle US is highly valuable and may provide prognostic insight for better nutritional evaluation of children with CKD stage 5 on hemodialysis. Conclusion In children on maintenance hemodialysis, muscle US is a non-invasive, simple, and precise tool for screening muscle mass in patients with PEW. Its clinical application for screening and follow-up of PEW should be taken into consideration. Further multicenter longitudinal studies are required to validate its clinical utility and prognostic significance. Strengths,Limitations and recommendations: The study had multiple strength points beginning with evaluation of malnutrition risks and early detection of malnutrition in hemodialysis children with limited other comparative studies in those patients and also evaluating the role of bed side tool available in every hemodialysis unit as ultrasound that can help in screening of muscle mass and early detection of malnutrition Limitations include being single-center study,small sample size,cross-sectional design (no prognostic inference),lack of gold-standard muscle mass comparison and due to financial constraints, unnecessary radiation exposure, a single study site, a small sample size, and a lack of longitudinal monitoring, it was not possible to compare CT scans and muscle US. We recommend further research on the predictive significance of muscle ultrasonography in children receiving hemodialysis, particularly because two of our patients passed away during the study due to hemodialysis-related complications. Declarations Author contribution All authors participated in the planning and conceptualization of the study. AG, MS, AS, SD, and MM carried out material preparation, data collection, and statistical analysis. AG drafted the manuscript, and all authors provided feedback on earlier drafts. All authors reviewed and approved the final manuscript. Funding No funding was received. Data availability The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. Ethics approval Following institutional review board approval (ZU-IRB#751/20), the Pediatrics Department of Zagazig University Hospitals approved this study. Legal guardians provided informed consent. The study was conducted in accordance with the World Medical Association's Declaration of Helsinki, which outlines ethical principles for research involving human subjects. Conflicts of interest The authors declare no competing interests. References Cirillo, L., et al., Chronic kidney disease in children: an update. Clinical kidney journal, 2023. 16 (10): p. 1600–1611https://doi.org/10.1093/ckj/sfad097 Fraser, S.D., et al., Prevalence and associations of limited health literacy in chronic kidney disease: a systematic review. Nephrology Dialysis Transplantation, 2013. 28 (1): p. 129–137https://doi.org/10.1093/ndt/gfs371. Iorember, F.M., Malnutrition in chronic kidney disease. Frontiers in pediatrics, 2018. 6 : p. 161https://doi.org/10.3389/fped.2018.00161 Mahan, J.D., Chronic Kidney Disease , in Clinician's Manual Of Pediatric Nephrology . 2011, World Scientific. p. 487–503. Suárez-González, M., et al., Nutritional assessment and support in children with chronic kidney disease: the benefits of working with a registered dietitian. Nutrients, 2023. 15 (3): p. 528https://doi.org/10.3390/nu15030528. Marsenić, O., A. Peco-Antić, and O. Jovanović, Effect of dialysis dose on nutritional status of children on chronic hemodialysis. Nephron, 2001. 88 (3): p. 273–275https://doi.org/10.1159/000046002 Sabatino, A., et al., Protein-energy wasting and nutritional supplementation in patients with end-stage renal disease on hemodialysis. Clinical nutrition, 2017. 36 (3): p. 663–671https://doi.org/10.1016/j.clnu.2016.06.007. Wong, C.S., et al., Anthropometric measures and risk of death in children with end-stage renal disease. American Journal of Kidney Diseases, 2000. 36 (4): p. 811–819https://doi.org/10.1053/ajkd.2000.17674. Furth, S.L., et al., Adverse clinical outcomes associated with short stature at dialysis initiation: a report of the North American Pediatric Renal Transplant Cooperative Study. Pediatrics, 2002. 109 (5): p. 909–913https://doi.org/10.1542/peds.109.5.909. Ashuntantang, G., et al., Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic review. The Lancet Global Health, 2017. 5 (4): p. e408–e417https://doi.org/10.1016/S2214-109X(17)30057-8. Foster, B.J. and M.B. Leonard, Measuring nutritional status in children with chronic kidney disease. The American journal of clinical nutrition, 2004. 80 (4): p. 801–814https://doi.org/10.1093/ajcn/80.4.801. Zaki, M.E., et al., Nutritional status in children with chronic renal failure on hemodialysis. 2012http://dx.doi.org/10.3889/MJMS.1857-5773.2012.0234. Sabatino, A., et al., Noninvasive evaluation of muscle mass by ultrasonography of quadriceps femoris muscle in End-Stage Renal Disease patients on hemodialysis. Clinical nutrition, 2019. 38 (3): p. 1232–1239https://doi.org/10.1016/j.clnu.2018.05.004 Mastrangelo, A., F. Paglialonga, and A. Edefonti, Assessment of nutritional status in children with chronic kidney disease and on dialysis. Pediatric Nephrology, 2014. 29 (8): p. 1349–1358https://doi.org/10.1007/s00467-013-2612-7. Bakr, A.M.A.E.B., B.M. Hasaneen, and D.A.H. Bassiouni, Assessment of nutritional status in children with chronic kidney disease using hand grip strength tool. Journal of Renal Nutrition, 2018. 28 (4): p. 265–269https://doi.org/10.1053/j.jrn.2017.12.007 Seewer, E., The Validity and Reliability of Ultrasound as a Tool for Assessing Skeletal Muscle Characteristics in the Pediatric Population . 2024, The University of Tennessee Health Science Center. Iyengar, A., Nutrition Assessment Tools in Children with Chronic Kidney Disease. Asian Journal of Pediatric Nephrology, 2022. 5 (1): p. 7–13DOI: 10.4103/ajpn.ajpn_8_22. Gollie, J.M., et al., Chronic kidney disease: considerations for monitoring skeletal muscle health and prescribing resistance exercise. Clinical kidney journal, 2018. 11 (6): p. 822–831https://doi.org/10.1093/ckj/sfy054. Shaw, V., et al., Energy and protein requirements for children with CKD stages 2-5 and on dialysis–clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatric nephrology, 2020. 35 (3): p. 519–531https://doi.org/10.1007/s00467-019-04426-0 Bataille, S., et al., The diagnosis of sarcopenia is mainly driven by muscle mass in hemodialysis patients. Clinical Nutrition, 2017. 36 (6): p. 1654–1660https://doi.org/10.1016/j.clnu.2016.10.016. Arbeille, P., et al., Quantification of muscle volume by echography: comparison with MRI data on subjects in long-term bed rest. Ultrasound in medicine & biology, 2009. 35 (7): p. 1092–1097https://doi.org/10.1016/j.ultrasmedbio.2009.01.004 Sabatino, A., et al., Reliability of bedside ultrasound for measurement of quadriceps muscle thickness in critically ill patients with acute kidney injury. Clinical Nutrition, 2017. 36 (6): p. 1710–1715https://doi.org/10.1016/j.clnu.2016.09.029. Chang, S.O., Dietary reference intakes for protein: protein requirement and estimation method, AMDR (Amount of Macronutrient Distribution Range), for protein. Korean Journal of Nutrition, 2011. 44 (4): p. 338–343 Little, R.J. and D.B. Rubin, Statistical analysis with missing data . 2019: John Wiley & Sons. Azzouz, J.Z., et al., Nutritional assessment and management in paediatric chronic kidney disease. Journal of Nutrition and Metabolism, 2021. 2021 (1): p. 8283471https://doi.org/10.1155/2021/8283471. Canpolat, N., et al., Malnutrition and its association with inflammation and vascular disease in children on maintenance dialysis. Pediatric Nephrology, 2013. 28 (11): p. 2149–2156https://doi.org/10.1007/s00467-013-2527-3. Fischer, A., et al., Validation of bedside ultrasound to predict lumbar muscle area in the computed tomography in 200 non-critically ill patients: The USVALID prospective study. Clinical Nutrition, 2022. 41 (4): p. 829–837https://doi.org/10.1016/j.clnu.2022.01.034 Özdemir, U., et al., The role of maximum compressed thickness of the quadriceps femoris muscle measured by ultrasonography in assessing nutritional risk in critically-ill patients with different volume statuses. Revista da Associação Médica Brasileira, 2019. 65 (7): p. 952–958https://doi.org/10.1590/1806-9282.65.7.952. Lotfy, H.M., et al., The effect of regular hemodialysis on the nutritional status of children with end-stage renal disease. Saudi Journal of Kidney Diseases and Transplantation, 2015. 26 (2): p. 263–270DOI: 10.4103/1319-2442.152416. Todisco, T., et al., Chronic kidney disease and growth failure in children. Children, 2024. 11 (7): p. 808https://doi.org/10.3390/children11070808 Gupta, A., M. Mantan, and M. Sethi, Nutritional assessment in children with chronic kidney disease. Saudi Journal of Kidney Diseases and Transplantation, 2016. 27 (4): p. 733–739 Pontón-Vázquez, C., et al., Dietary intake, nutritional status, and body composition in children with end-stage kidney disease on hemodialysis or peritoneal dialysis. Journal of Renal Nutrition, 2017. 27 (3): p. 207–215https://doi.org/10.1093/tropej/fmv094 Sahpazova, E., et al., Nutritional status, protein intake and progression of renal failure in children. Pediatric Nephrology, 2006. 21 (12): p. 1879–1883https://doi.org/10.1007/s00467-006-0241-0 Hussein, R., et al., A cross-sectional study of growth and metabolic bone disease in a pediatric global cohort undergoing chronic hemodialysis. The Journal of Pediatrics, 2018. 202 : p. 171–178. e3https://doi.org/10.1016/j.jpeds.2018.07.033 Zitnik, E., E. Streja, and M. Laster, The Impact of Glomerular Disease on Dyslipidemia in Pediatric Patients Treated with Dialysis. Nutrients, 2025. 17 (3): p. 459https://doi.org/10.3390/nu17030459 Ong, C., et al., Skeletal muscle ultrasonography in nutrition and functional outcome assessment of critically ill children: Experience and insights from pediatric disease and adult critical care studies. Journal of Parenteral and Enteral Nutrition, 2017. 41 (7): p. 1091–1099https://doi.org/10.1177/0148607116683143. Sahathevan, S., et al., Association of ultrasound-derived metrics of the quadriceps muscle with protein energy wasting in hemodialysis patients: a multicenter cross-sectional study. Nutrients, 2020. 12 (11): p. 3597https://doi.org/10.3390/nu12113597 Sahathevan, S., et al., Validity of ultrasound imaging in measuring quadriceps muscle thickness and cross‐sectional area in patients receiving maintenance hemodialysis. Journal of Parenteral and Enteral Nutrition, 2021. 45 (2): p. 422–426 https://doi.org/10.1002/jpen.1867. Sun, W. and L. Liu, Nutritional counseling's impact on muscle mass and quality of life in stage 4 chronic kidney disease malnourished patients. Technology and Health Care, 2025. 33 (2): p. 951–958https://doi.org/10.1177/09287329241291370 Sabatino, A., et al., Quadriceps muscle thickness assessed by ultrasound is independently associated with mortality in hemodialysis patients. European Journal of Clinical Nutrition, 2022. 76 (12): p. 1719–1726https://doi.org/10.1038/s41430-022-01166-7 Elgenidy, A., et al., Utility of ultrasound in measuring quadriceps muscle thickness in patients receiving maintenance hemodialysis: comprehensive systematic review and meta-analysis. Clinical and Experimental Nephrology, 2025. 29 (2): p. 192–211https://doi.org/10.1007/s10157-024-02557-9. 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1","display":"","copyAsset":false,"role":"figure","size":64150,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eROC curve of muscle thickness in detection of malnutrition\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8503873/v1/0a2b0e18bea814a37a8ffef3.png"},{"id":101202563,"identity":"ed08de51-1a6f-4bf1-b677-ec18bc1e56e8","added_by":"auto","created_at":"2026-01-27 09:36:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1718416,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8503873/v1/88a695d5-f26e-4ad7-8353-15fa9084306d.pdf"},{"id":99814687,"identity":"e2f42988-5763-47ce-b83b-8f35be9de719","added_by":"auto","created_at":"2026-01-08 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The degrees of albuminuria and glomerular filtration rate (GFR) determine the definition of CKD. Hemodialysis (HD) has become a vital treatment option for children with chronic renal illnesses, thanks to advancements in medical technology. About 50% of patients preparing for a kidney transplant require HD as a bridge [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe definition of nutritional status is complicated. Consuming the right kinds and quantities of food to support normal growth and a normal body composition is referred to as having an adequate nutritional status. It can be challenging to distinguish between mild to moderate malnutrition and adequate nutrition. To effectively distinguish malnourished children, the World Health Organization established a cutoff of two standard deviations below gender-specific medians for weight-for-age, height-for-age, and weight-for-height. Therefore, in addition to anthropometric measurements, clinical and biochemical data, we used caloric count and adequate protein intake for our patients' nutritional evaluation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCases with CKD are more likely to experience malnutrition and studies on this topic in CKD and hemodialysis children are minimal, malnutrition involves vitamin deficiencies and protein-energy wasting (PEW). Research has revealed a high occurrence of malnutrition in children and individuals with CKD. Malnutrition causes growth retardation and raises morbidity and mortality rates in CKD patients. The processes contributing to malnutrition include inadequate nutrient intake and appetite, hormonal imbalance, catabolic state, inflammation, and dialysis-related issues [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA multidisciplinary team and a personalized approach are required for the management of malnutrition in persons with CKD. It should begin with a thorough evaluation of the patient and a customized nutrition plan that includes adequate calories, protein, and micronutrients for the child's growth and development. With the assistance of the nephrologist, nurses, caregivers, and social workers on the dialysis team, the renal dietitian plays a crucial role in evaluating and monitoring the nutritional status of children [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. PEW is seen in up to 50%\u0026ndash;75% of individuals with CKD stages IV\u0026ndash;V. Therefore, it is advised that children with end-stage kidney disease (ESKD), particularly those receiving regular hemodialysis (HD), undergo accurate and frequent nutritional evaluations [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFour diagnostic standards were established by the International Society of Renal Nutrition and Metabolism (ISRNM) expert panel for PEW: low body weight and biochemical standards, decreased caloric and protein intake, as well as decreased muscle mass [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The three-day food history is currently the gold standard for evaluating nutritional intake in children with CKD [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, it is not very easy for respondents and caregivers, who require motivation, knowledgeable supervision, and an examination of usual intake over several days [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, food records are prone to errors and may alter eating patterns, lowering the accuracy of reported food intake [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eReduced muscle mass is one of the diagnostic criteria for malnutrition according to new definitions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Muscle mass assessment can be performed using various techniques to monitor and screen for muscle loss in high-risk populations. These methods, including bioimpedance analysis (BIA), enable the measurement of muscle mass but are affected by overhydration, a frequent side effect in hemodialysis patients [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The \"gold standard\" techniques for assessing muscle mass, including computed tomography (CT), dual-energy X-ray absorptiometry (DEXA), and magnetic resonance imaging (MRI), are primarily used for research due to their high cost, potential for radiation exposure, and specialized equipment requirements [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, muscle ultrasound (US) has become a popular bedside technique for evaluating body composition because of its portability, affordability, accessibility, convenience of use, and low training requirements [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Research has revealed that US data provide more sensitive screening for patients at nutritional risk, as well as follow-up and assessment of nutrition intervention outcomes. US measurements of the body's skeletal muscles, particularly the quadriceps muscle group, the largest skeletal muscle in the body, show a good correlation with muscle mass as assessed by gold-standard procedures and are as accurate as those obtained with CT or MRI [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to recent research, quadriceps femoris US is a reliable and straightforward method for assessing muscle thickness in patients with kidney failure [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. US is a useful technique for measuring muscle mass and identifying malnutrition in patients on hemodialysis, as studies have shown that rapid fluid fluctuations caused by overhydration do not affect the thickness of the quadriceps muscle [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch on the application of quadriceps muscle ultrasonography for nutritional evaluation in children receiving hemodialysis is limited. The objective of our study is to analyze the utility of muscle ultrasonography as a screening method for the evaluation of malnutrition and decreased muscle mass in children on maintenance hemodialysis who are at high risk of developing PEW.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch design and patients\u003c/h2\u003e \u003cp\u003eA case\u0026ndash;control study was conducted in the pediatric nephrology and hemodialysis unit of a tertiary children's hospital between October 2024 and October 2025. The study included 42 cases; all patients were included as a sequential sample for the case group, and 42 matching healthy individuals were included as a control group. Children between the ages of one and sixteen years receiving regular maintenance hemodialysis (excluding those receiving acute hemodialysis), patients who declined to take part in the study, and patients with muscle disorders were among the cases. The 42 children in the control group, who attended our outpatient general pediatric clinic, appeared to be in good health.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample size\u003c/h3\u003e\n\u003cp\u003eDue to the limited number of pediatric hemodialysis patients, a convenience sample was used. The sample size was calculated as follows: the total number of dialysis cases referred to the pediatric hemodialysis unit was 42; therefore, all cases were included in the study as a consecutive sample for the case group, and 42 matched healthy individuals were included as a control group.\u003c/p\u003e\n\u003ch3\u003eBiochemical measurements\u003c/h3\u003e\n\u003cp\u003eUsing the proper chemical analyzer, tests were conducted for serum creatinine, BUN, uric acid (UA), cholesterol, total protein, albumin, calcium, and phosphorus (Pi).\u003c/p\u003e\n\u003ch3\u003eNutritional status assessment\u003c/h3\u003e\n\u003cp\u003eMothers or patients were asked to complete a retrospective 3-day food intake recall. This involved keeping track of everything the case drank and ate, including specific amounts, with a focus on daily energy and protein consumption in the children's nourishment. The results were then compared to the suggested consumption based on the estimated energy requirements (EERs) calculations, which took into account gender, weight, age, and height (using the 50th percentile height for weight). The Acceptable Macronutrient Distribution Range (AMDR) for protein is 5\u0026ndash;20% and 10\u0026ndash;30% of energy intake for children aged 1\u0026ndash;3 years and 4\u0026ndash;18 years, respectively. Individuals who consume less protein than these suggested amounts are considered to be at risk of malnutrition [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eUS measurements\u003c/h3\u003e\n\u003cp\u003eA low-frequency curvilinear-array transducer (3.5 MHz) and a high-frequency linear-array transducer (7 MHz) were used with the Siemens ACUSON X300 US machine.\u003c/p\u003e \u003cp\u003eAll cases were examined after completion of the hemodialysis session to avoid the influence of fluid overload and fluid shifts. Patients were positioned in either a supine or a slight lateral decubitus posture for thigh assessments. The skin over the designated assessment sites was exposed and disinfected using alcohol swabs.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAssessment Techniques\u003c/h2\u003e \u003cp\u003eMuscle thickness measurements (Vastus intermedius, Vastus medialis, Vastus lateralis, Rectus femoris):\u003c/p\u003e \u003cp\u003eThe case was positioned supine with the leg semi-extended and relaxed.\u003c/p\u003e \u003cp\u003eProcedure: A transverse (cross-sectional) approach was used at standardized anatomical sites. The thickness of each muscle was measured as the distance between the deep and superficial fasciae of the respective, at the level of\u003c/p\u003e \u003cp\u003etwo particular landmarks, the midpoint, and the border between the upper two-thirds and the lower third between the upper pole of the patella and the superior anterior iliac spine[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Recording and Analysis\u003c/h3\u003e\n\u003cp\u003eAll US measurements were performed by a single trained radiologist operator. All measurements were taken in triplicate, and the mean value was calculated for analysis. Care was taken to maintain consistent probe pressure and angle to avoid measurement bias. The assessor was blinded to clinical data to reduce measurement bias.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eFollowing data collection, Microsoft Excel 2016 for Windows, part of the Microsoft Office bundle (2016, Microsoft Corporation, United States), was used to code the information into a spreadsheet. The IBM Statistical Package for the Social Sciences software (SPSS), 27th edition, published by IBM in the United States, was then utilized for analysis. The normal distribution of continuous data was assessed utilizing the Kolmogorov\u0026ndash;Smirnov test. The information presentation included numbers and percentages for qualitative information, as well as means, standard deviations, and ranges for quantitative information with a parametric distribution. Additionally, it included medians and interquartile ranges (IQR) for quantitative information with a non-parametric distribution.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAnalytic statistics\u003c/h2\u003e \u003cp\u003eTo explore the relationship between two categorical variables, the chi-square test is a commonly used statistical method for analyzing this relationship. When comparing quantitative data between two groups, the unpaired Student's t-test is used if the data are normally distributed, while the Mann-Whitney test is preferred for data that do not follow a normal distribution. To assess the strength and direction of the association between two quantitative variables, correlation analysis, often using the Spearman method, is employed. The correlation coefficient, denoted as \"r,\" indicates both the strength and direction of the association. Additionally, the receiver operating characteristic (ROC) curve is a valuable tool for evaluating the sensitivity and specificity of quantitative diagnostic measures in classifying cases into two categories.Missing data in Group 2 were replaced using single imputation with plausible values based on the observed range of each variable. This approach preserved natural variability and allowed for complete analysis, as the proportion of missing data don\u0026rsquo;t exceeded 10% for several variables [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatients\u0026apos; baseline characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient group consisted of 42 children undergoing hemodialysis at the Pediatric Nephrology Unit of our tertiary care hospital, while the control group consisted of 42 healthy children who were age- and sex-matched to the patients. Table 1 summarizes the demographic and anthropometric characteristics of children undergoing maintenance hemodialysis compared with healthy controls. There was no statistically significant difference between the two groups in terms of sex distribution (p = 0.661) or age (p = 0.192). Most participants in both groups belonged to low- to moderate-socioeconomic levels. Among hemodialysis cases, the most common primary diagnoses were unexplained renal failure (23.8%), glomerulopathy (nephrotic syndrome) (19%), and neurogenic bladder (14.3%), while other causes were less frequent. The median duration of dialysis was 2 years, with an interquartile range (IQR) of 1\u0026ndash;5 years, and KT/V values had a median of 1.1.\u003c/p\u003e\n\u003cp\u003eAnthropometric assessment revealed that hemodialysis patients had significantly lower weights (p \u0026lt; 0.001), heights (p = 0.014), BMIs (p \u0026lt; 0.001), mid-arm circumferences (p \u0026lt; 0.001), and skin-fold thicknesses (p \u0026lt; 0.001) compared to controls. However, no significant difference was observed in waist circumference (p = 0.427).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (1): Demographic and Clinical Characteristics of the Studied Groups\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" rowspan=\"2\" valign=\"top\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHD cases\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=42)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControls\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=42)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep- value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eGender:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e57.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e52.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e0.192\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.661\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e42.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e47.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eAge (years):\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eMean\u0026plusmn; SD\u003c/p\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e10.41\u0026plusmn; 3.29\u003c/p\u003e\n \u003cp\u003e3.3- 16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e9.52\u0026plusmn; 2.83\u003c/p\u003e\n \u003cp\u003e3- 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e1.315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.192\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"13\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003ePrimary diagnosis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eAtypical HUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e9.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"13\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"13\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"13\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBartter syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ePrune belly syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eChronic interstitial nephritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCKD recurrent stones\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCongenital atrophic kidneys\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eGlomerulopathy Nephrotic syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e19%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eNephrocalcinosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eNeurogenic bladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e14.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eObstructive uropathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ePolycystic kidney\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eSLE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eUnexplained renal failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e23.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eDialysis duration (years):\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2.0 (1.0\u0026ndash;5.0)\u003c/p\u003e\n \u003cp\u003e6 months- 12 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eKT/V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1.1 (0.9\u0026ndash;1.3)\u003c/p\u003e\n \u003cp\u003e0.7- 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eWeight (Kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMean\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30.84\u0026plusmn; 11.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e41.57\u0026plusmn; 12.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e4.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e11.0\u0026ndash;56.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e18\u0026ndash;75.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e130.75 (120\u0026ndash;142)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e137 (131.0\u0026ndash;148.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e2.466\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.014\u003csup\u003e╪\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e90\u0026ndash;165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e100.0\u0026ndash;155.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eBMI (Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e17.0 (15.6\u0026ndash;19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e21.35 (19.5\u0026ndash;24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e4.963\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e╪\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e11.0\u0026ndash;31.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e15.0\u0026ndash;33.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eMAC (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e19 (18\u0026ndash;24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e27.0 (23.0\u0026ndash;35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e5.545\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e╪\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e10.0\u0026ndash;31.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e15.0\u0026ndash;35.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eSFC (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMean\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e19.38\u0026plusmn; 6.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e24.79\u0026plusmn; 5.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e4.113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e9.0\u0026ndash;30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e13.0\u0026ndash;35.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eWC (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e62.0 (57.0\u0026ndash;69.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e62.0 (55.0\u0026ndash;66.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e7.193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.427\u003csup\u003e╪\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e20.0\u0026ndash;95.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e48.0\u0026ndash;71.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 138px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 48px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ep\u0026gt;0.05 is non-significant; p\u0026le;0.05 is significant. #Student T test, , \u003csup\u003e╪\u003c/sup\u003e Mann- Whitney U test, \u003csup\u003e\u0026Dagger;\u003c/sup\u003eChi-square test, BMI: Body Mass Index.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;MAC: Mid-Arm Circumference, SFC: Subcutaneous Fat Caliper, WC: Waist Circumference\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDaily Nutritional Intake in Hemodialysis Children and Controls\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 shows a comparison of daily caloric and macronutrient intake between children on maintenance hemodialysis and healthy controls. The total daily calorie intake was significantly lower in HD children compared with the controls. Similarly, daily protein intake was significantly reduced in HD children (p \u0026lt; 0.001). In contrast, fat intake did not differ significantly between the groups (p = 0.120). The protein energy percentage was lower in HD cases, with a median of 12.1% versus 17.2% in controls (p = 0.006). Regarding protein adequacy, 59.5% of HD cases had adequate intake compared with 95% of controls (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e): Comparison of daily nutritional intake among the two groups\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"625\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHD cases\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=42)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControls\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=42)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep- value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eTotal calories\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e1060 (859\u0026ndash;1300)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e1575 (1380\u0026ndash;2000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e5.493\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e╪\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e569\u0026ndash;2174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e569\u0026ndash;2174\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eProtein intake (g/kg/day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMean\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e1.33\u0026plusmn; 0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e1.73\u0026plusmn; 0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3.793\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0.40\u0026ndash;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e1.0\u0026ndash;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eProtein (%En)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e12.1 (8.09\u0026ndash;19.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e17.2 (14.24\u0026ndash;19.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.006\u003csup\u003e╪\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e2.0\u0026ndash;73.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e9.45\u0026ndash;27.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eFat intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e1.6 (1.3\u0026ndash;2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e1.8 (1.6\u0026ndash;1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1.555\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.120\u003csup\u003e╪\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e0.70\u0026ndash;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e1.0\u0026ndash;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eProtein adequacy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eAdequate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e59.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e95.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e21.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eInadequate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e40.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e5.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eCaloric inadequacy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e(16.7%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e(0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e7.636\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.012\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ep\u0026gt;0.05 is non-significant; p\u0026le;0.05 is significant. #Student T test, ╪ Mann- Whitney U test, \u0026Dagger;Chi-square test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLaboratory Parameters of Children and Controls\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 3, children undergoing hemodialysis exhibited markedly higher creatinine (p \u0026lt; 0.001) and BUN levels (p \u0026lt; 0.001), indicating impaired renal function. Hemoglobin levels were significantly reduced in HD children (p = 0.001), indicating anemia, while total protein (p = 0.004) and albumin (p \u0026lt; 0.001) showed significant differences.\u003c/p\u003e\n\u003cp\u003eCalcium and phosphorus concentrations were also significantly different, with HD children showing lower calcium levels (p = 0.002) and higher phosphorus levels (p \u0026lt; 0.001), indicating disturbances in mineral metabolism. UA levels were elevated in the HD group (p \u0026lt; 0.001). A higher total cholesterol level was observed in the HD group compared with the controls (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (\u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e): Comparison between the two groups regarding Laboratory Parameters\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"669\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHD cases\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=42)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControls\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=42)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003csup\u003e╪\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMax.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMax.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eCreatinine (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e7.907\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eBUN (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e59.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e48.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e70.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e86.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e29.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e70.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e7.504\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eHB (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e13.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e3.456\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eTotal protein (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e2.845\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAlbumin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e44.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e6.167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eCa (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e3.109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003ePh. \u0026nbsp;(mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e5.166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003eUric acid (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e6.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003eCholesterol (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e149.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e127.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e168.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e92.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e225.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e121.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e120.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e123.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e118.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e126.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e4.515\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ep\u0026gt;0.05 is non-significant; p\u0026le;0.05 is significant. #Student T test, ╪ Mann- Whitney U test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUltrasonographic Assessment of Muscle Thickness among the Studied Groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 demonstrates the comparison of US measurements of muscle thickness between children undergoing maintenance hemodialysis and healthy controls. Children on maintenance hemodialysis had significantly reduced peripheral muscle thickness compared with healthy controls. Rectus femoris thickness was significantly lower in HD children (8.81 \u0026plusmn; 3.47 mm vs. 10.14 \u0026plusmn; 3.24 mm, p = 0.026), as were the vastus intermedius (median 7.5 mm vs. 9.5 mm, p = 0.012), vastus medialis (median 12.0 mm vs. 15.0 mm, p = 0.031), and vastus lateralis (median 14.95 mm vs. 20.0 mm, p = 0.022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (4): Comparison of US assessment of muscle thickness among the two groups.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHD cases\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=42)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControls\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=42)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep- value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eRectus femoris thickness (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMean\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e8.81\u0026plusmn; 3.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e10.14\u0026plusmn; 3.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e2.227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.026\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2.6\u0026ndash;18.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e4.5\u0026ndash;16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eVastus intermedius (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7.5 (5.7\u0026ndash;10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e9.5 (7.0\u0026ndash;13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e2.498\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.012\u003csup\u003e╪\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2.1\u0026ndash;16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e5.0\u0026ndash;17.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eVastus medialis (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e12.0 (6.4\u0026ndash;16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e15.0 (13.0\u0026ndash;16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e2.160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.031\u003csup\u003e╪\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e6.4\u0026ndash;31.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e8.0\u0026ndash;22.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eVastus lateralis (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e14.95 (11.8\u0026ndash;24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e20.0 (18.0\u0026ndash;22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e2.299\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.022\u003csup\u003e╪\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e9.8\u0026ndash;39.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e11.0\u0026ndash;27.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ep\u0026gt;0.05 is non-significant; p\u0026le;0.05 is significant. #Student T test, \u003csup\u003e╪\u003c/sup\u003e Mann- Whitney U test, \u0026Dagger;Chi-square test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation of Muscle with Clinical, Nutritional, and Laboratory Parameters in Children on Hemodialysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 5, association analysis illustrated that total caloric intake was positively related to muscle thickness, including rectus femoris (r = 0.573, p \u0026lt; 0.001), vastus intermedius (r = 0.486, p = 0.001), vastus medialis (r = 0.422, p = 0.006), and vastus lateralis (r = 0.290, p = 0.066). In addition, protein intake showed significant positive correlations with rectus femoris (r = 0.427, p = 0.005), vastus intermedius (r = 0.444, p = 0.004), vastus medialis (r = 0.514, p = 0.001), and vastus lateralis (r = 0.354, p = 0.023).\u003c/p\u003e\n\u003cp\u003eRenal function markers, particularly creatinine, were positively correlated with all muscle thickness measurements: rectus femoris (r = 0.604, p \u0026lt; 0.001), vastus intermedius (r = 0.480, p = 0.001), vastus medialis (r = 0.526, p \u0026lt; 0.001), and vastus lateralis (r = 0.467, p = 0.002). Other laboratory parameters, including total protein, albumin, calcium, phosphorus, UA, and lipid profile, showed no significant correlations with muscle thickness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (5): Correlation of muscle thickness with clinical, nutritional, and laboratory parameters in hemodialysis children:\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"684\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRectus femoris thickness (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVastus intermedius (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVastus medialis (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVastus lateralis (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003er\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003er\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003er\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003er\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u0026nbsp;Age (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.767\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.945\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.696\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.760\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eDialysis duration (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.510\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.852\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e-0.099\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e-0.153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.339\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.647\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.299\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.744\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eKT/V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.536\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-0.187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e-0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.661\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e-0.128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.420\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eTotal calories\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.573\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.486\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.290\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eProtein intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.427\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.444\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.514\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eFat intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e-0.208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-0.191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e-0.099\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e-0.187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.242\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eCreatinine (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.604\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.526\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.467\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eBUN (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.960\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.260\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.411\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.210\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eHB (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.661\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-0.145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.360\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e-0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.882\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e-0.157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.321\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eTotal protein (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.489\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.215\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.839\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eAlbumin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.399\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.141\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 174px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ep\u0026gt;0.05 is non-significant, *p\u0026le;0.05 is significant, **p\u0026le;0.01 is highly significant,r: Spearman correlation coefficient\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eValidity of muscle thickness to detect malnutrition:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReceiver operating characteristic (ROC) analysis was performed to evaluate the capability of US measurements to detect malnutrition in children undergoing maintenance hemodialysis. Among muscle parameters, rectus femoris thickness \u0026le;10.4 mm showed excellent sensitivity (100%) but moderate specificity (48%) with an AUC of 0.731 (p \u0026lt; 0.001), indicating good discriminatory ability. Vastus lateralis \u0026le;20.6 mm also demonstrated 100% sensitivity and 52% specificity (AUC = 0.736, p = 0.001). Vastus intermedius \u0026le;8.3 mm and vastus medialis \u0026le;14.4 mm showed lower sensitivity (88.9% and 77.8%, respectively) with moderate specificity (61.3% for both) and AUC values of 0.705 (p = 0.012) and 0.678 (p = 0.032) ( Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison between different tools to assess malnutrition in cases group:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs summarized in Table 6, the prevalence of malnutrition varied considerably depending on the assessment modality. While anthropometric and dietary measures identified malnutrition in 21\u0026ndash;43% of patients, ultrasound-based muscle mass assessment classified approximately half of the cohort as having low muscle mass, suggesting a higher sensitivity for detecting nutritional impairment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (6):Prevalence of malnutrition according to different assessment modalities in children on maintenance hemodialysis in comparison to muscle ultrasound cut off \u0026nbsp;(n = 42) and composite score for malnutrition:\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 310px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eWeight and length -for-age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 310px;\"\u003e\n \u003cp\u003eWeight z-score \u0026lt; \u0026minus;2 SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e18 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eBMI-for-age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 310px;\"\u003e\n \u003cp\u003eHeight z-score \u0026lt; \u0026minus;2 SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e9 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eCaloric intake (chronological age)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 310px;\"\u003e\n \u003cp\u003eIntake \u0026lt; estimated energy requirement (EER)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e3 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eCaloric intake (corrected age for height)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 310px;\"\u003e\n \u003cp\u003eIntake \u0026lt; height-age\u0026ndash;adjusted EER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e18 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eProtein intake inadequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 310px;\"\u003e\n \u003cp\u003eIntake below age-specific recommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e17 (40.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eLow muscle mass (ultrasound-based)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 310px;\"\u003e\n \u003cp\u003eBelow predefined quadriceps muscle thickness cut-off\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e21 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003cp\u003eData are presented as number (percentage). EER, estimated energy requirement. Muscle mass was assessed using quadriceps muscle ultrasonography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComposite malnutrition score for nutritional risk in cases :\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo better characterize nutritional risk, a composite malnutrition score integrating anthropometric impairment, caloric inadequacy, protein inadequacy, and low muscle mass was applied. Use of this composite score resulted in reclassification of several children who would not have been identified as malnourished based solely on conventional anthropometric or dietary assessment, highlighting the additive value of muscle ultrasonography in nutritional evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable(7) a composite malnutrition score for malnutrition risk :\u003c/strong\u003eEach patient is scored 0\u0026ndash;4, based on the presence of the following domains:\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 268px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCriterion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eAnthropometry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 268px;\"\u003e\n \u003cp\u003e\u0026ge;1 of BMI, weight, or height \u0026lt; \u0026minus;2 SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eEnergy intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 268px;\"\u003e\n \u003cp\u003eCaloric intake below EER (corrected age/height)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eProtein intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 268px;\"\u003e\n \u003cp\u003eIntake below recommended level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eMuscle mass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 268px;\"\u003e\n \u003cp\u003eLow muscle mass by ultrasound cut-off\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTotal score equals 0\u0026ndash;1: No / mild nutritional risk ,2: Moderate malnutrition risk and \u0026ge;3: Severe malnutrition risk.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePEW is a major problem that increases with advanced stages of CKD, with a high occurrence in patients on maintenance dialysis, raising the possibility of morbidity, mortality, and increased healthcare costs [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNutritional ultrasonography is a useful tool for evaluating both muscle mass and muscle quality [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The US assessment of quadriceps femoris muscle thickness is highly reliable in hemodialysis patients and can accurately assess muscle thickness that reflects nutritional status, as it is unaffected by changes in fluid balance, which are prevalent in children undergoing hemodialysis [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study, we evaluated skeletal muscle quadriceps thickness using US and its role in nutritional assessment in children on chronic regular hemodialysis. To our knowledge, this topic has not been previously studied in the pediatric age group. We studied 42 cases on regular hemodialysis compared to 42 healthy controls.\u003c/p\u003e \u003cp\u003eChildren on hemodialysis had significantly lower weights (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), heights (p\u0026thinsp;=\u0026thinsp;0.014), BMIs (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), mid-arm circumferences (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and skin-fold thicknesses (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than controls, according to our clinical evaluation. This finding is consistent with earlier research, which has shown that growth is significantly impaired and that the severity of growth impairment increases with the duration of hemodialysis [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, two patients had high BMIs above 2 SD; 21% had BMIs below \u0026minus;\u0026thinsp;2 SD for age, and 59% of patients had short stature with lengths below \u0026minus;\u0026thinsp;2 SD for age. This agrees with many studies reporting growth failure in late-stage renal failure, where comorbidity treatment, improved diet, and metabolic control are all part of management. Research also revealed that kidney transplantation considerably enhances growth [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This is also consistent with a study on the nutritional evaluation of children with CKD, which indicated that sixty percent of children had moderate to severe malnutrition at the time of assessment, and that the incidence of growth retardation was much higher in children with advanced stages of CKD [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a previous study, thirty children receiving regular hemodialysis in our nation were included. According to the data, children receiving hemodialysis who were proportionately short in stature were most affected in terms of height, whereas weight was less affected. Dietary analysis revealed that 76.7% of patients had consumed the recommended daily calorie allotment [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Additionally, anthropometric evaluation revealed that children with CKD had lower weights, heights, skinfold thicknesses, body mass indices, and mid-arm circumferences compared with healthy controls (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), which is in line with our results [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, nutritional evaluation revealed differences in daily caloric and macronutrient intake between children on maintenance hemodialysis and healthy controls. The total daily calorie intake was significantly reduced in HD children compared to the controls (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, daily protein intake was significantly reduced in HD children (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with 40.5% showing protein intake inadequacy. This agrees with a study on the nutritional evaluation of children with CKD, in which approximately 46% had considerably decreased protein consumption as their renal failure progressed [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, laboratory parameters revealed that hemoglobin levels were significantly reduced in children with HD (p\u0026thinsp;=\u0026thinsp;0.001), indicating anemia. Additionally, total protein (p\u0026thinsp;=\u0026thinsp;0.004) and albumin (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) showed significant differences. Calcium and phosphorus levels were also significantly different, with HD children showing lower calcium levels (p\u0026thinsp;=\u0026thinsp;0.002) and higher phosphorus levels (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating disturbances in mineral metabolism. This is consistent with research on children receiving hemodialysis, which indicated that 34% of patients had a height z-score below the third percentile and that 70% of patients had phosphorus levels above the age-recommended range [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, research revealed that 37% of children receiving hemodialysis had a mean hemoglobin level of less than 11 g/dL (indicating anemia) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), compared with normal levels. This is attributed to erythropoietin deficiency, inadequate dialysis, decreased appetite, and poor nutrition [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Research has also shown that CKD5 is linked to higher total cholesterol levels (183 mg/dL vs. 162 mg/dL), which is consistent with our findings [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUS methods offer the advantage of easy bedside application for assessing skeletal muscle, with the quadriceps being the largest group of muscles and ideal for evaluating muscle mass. In our study, children on maintenance hemodialysis had significantly reduced peripheral muscle thickness compared with healthy controls. Rectus femoris thickness was significantly lower in HD children (p\u0026thinsp;=\u0026thinsp;0.026), as were the vastus intermedius (p\u0026thinsp;=\u0026thinsp;0.012), vastus medialis (p\u0026thinsp;=\u0026thinsp;0.031), and vastus lateralis (p\u0026thinsp;=\u0026thinsp;0.022).\u003c/p\u003e \u003cp\u003eIn related studies, muscle thickness was compared in 35 healthy individuals, 30 hospitalized cases, and 121 patients with ESRD receiving hemodialysis. ESRD patients receiving HD exhibited lower QVIT and QRFT than both control groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). It was determined that skeletal muscle US is a simple, bedside method that can be utilized in hemodialysis facilities and is a helpful tool for assessing muscle mass [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Additionally, a related study assessing the use of muscle ultrasonography in the nutritional evaluation of critically ill children found that it is a helpful, non-invasive method for identifying changes in muscle size. The quadriceps are the muscle group most frequently measured [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, children on hemodialysis were compared with controls using US measurements of quadriceps muscle thickness. We found that rectus femoris thickness\u0026thinsp;\u0026le;\u0026thinsp;10.4 mm showed excellent sensitivity (100%) but moderate specificity (48%) with an AUC of 0.731 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating good discriminatory ability.\u003c/p\u003e \u003cp\u003eIn the hemodialysis cohort, 21% of patients had a BMI below \u0026minus;\u0026thinsp;2 SD, while 42% had both weight and height below \u0026minus;\u0026thinsp;2 SD. Caloric inadequacy was identified in 7% when assessed for chronological age and in 42% when adjusted for corrected age for height, and 40% of patients had inadequate protein intake. In contrast, assessment using ultrasound-derived muscle mass cut-off values identified low muscle mass in approximately 50% of patients. These findings suggest that muscle ultrasonography may detect a higher proportion of children at risk of malnutrition compared with conventional anthropometric and dietary assessment methods. To our knowledge, comparable pediatric hemodialysis studies directly contrasting these assessment modalities are lacking.\u003c/p\u003e \u003cp\u003eA comparable study used ultrasonography (US) to evaluate muscle and PEW in hemodialysis (HD) patients. Rectus femoris (RF) and vastus intermedius (VI) quadriceps muscle thickness measured by ultrasonography (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) correctly distinguished patients with PEW from those without, which is consistent with our findings [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn another study, adults on HD underwent US and CT scans on the same day following a dialysis session to examine the effects of US and CT on muscle thickness. Quadriceps muscle thickness (QMT) of the vastus intermedius (VI) and rectus femoris (RF) muscles showed that US imaging provides a reliable, bedside, and rapid method for evaluating muscle atrophy in HD patients [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, total caloric intake was positively related to muscle thickness, including rectus femoris (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), vastus intermedius (p\u0026thinsp;=\u0026thinsp;0.001), vastus medialis (p\u0026thinsp;=\u0026thinsp;0.006), and vastus lateralis (p\u0026thinsp;=\u0026thinsp;0.066). In addition, protein intake showed significant positive correlations with rectus femoris (p\u0026thinsp;=\u0026thinsp;0.005), vastus intermedius (p\u0026thinsp;=\u0026thinsp;0.004), vastus medialis (p\u0026thinsp;=\u0026thinsp;0.001), and vastus lateralis (p\u0026thinsp;=\u0026thinsp;0.023) serum creatinine positively corrolated with muscle mass in our study and that is expected in hemodialysis patients in those patients creatinine reflect muscle mass not renal status. This finding is consistent with a study on adults undergoing maintenance hemodialysis. The cases were divided into two groups: the usual care group and the early nutrition intervention group. The early nutrition intervention group showed notable improvements in muscle mass. Patients receiving dietary intervention showed improvements in their intake of calories, protein, vitamins, and iron [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Additionally, research revealed a predictive role for muscle US as a straightforward technique for nutritional assessment in maintenance HD patients. Indexed distal vastus intermedius (VIT) was linked to mortality [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA meta-analysis of 15 studies, including 1,584 cases of hemodialysis, found that QRFT and QVIT were significantly lower in hemodialysis patients compared to healthy individuals, although there was no significant difference before or after dialysis. The authors concluded that ultrasonography is a dependable and readily available method for evaluating quadriceps muscle thickness in hemodialysis patients, following the discovery of QRFT variations in thickness during US examination. These results underscore the importance of routine US follow-up of muscle thickness in hemodialysis patients and highlight the need for increased use in the pediatric population [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe suggest a composite malnutrition score integrating anthropometric impairment, caloric inadequacy, protein inadequacy, and low muscle mass to be applied to avoid missed malnourished patients assessed by conventional anthropometric or dietary assessment, highlighting the additive value of muscle ultrasonography in nutritional evaluation.Thus, screening of muscle mass and early detection of PEW using muscle US is highly valuable and may provide prognostic insight for better nutritional evaluation of children with CKD stage 5 on hemodialysis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn children on maintenance hemodialysis, muscle US is a non-invasive, simple, and precise tool for screening muscle mass in patients with PEW. Its clinical application for screening and follow-up of PEW should be taken into consideration.\u003c/p\u003e \u003cp\u003eFurther multicenter longitudinal studies are required to validate its clinical utility and prognostic significance.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eStrengths,Limitations and recommendations:\u003c/h2\u003e \u003cp\u003eThe study had multiple strength points beginning with evaluation of malnutrition risks and early detection of malnutrition in hemodialysis children with limited other comparative studies in those patients and also evaluating the role of bed side tool available in every hemodialysis unit as ultrasound that can help in screening of muscle mass and early detection of malnutrition\u003c/p\u003e \u003cp\u003eLimitations include being single-center study,small sample size,cross-sectional design (no prognostic inference),lack of gold-standard muscle mass comparison and due to financial constraints, unnecessary radiation exposure, a single study site, a small sample size, and a lack of longitudinal monitoring, it was not possible to compare CT scans and muscle US.\u003c/p\u003e \u003cp\u003eWe recommend further research on the predictive significance of muscle ultrasonography in children receiving hemodialysis, particularly because two of our patients passed away during the study due to hemodialysis-related complications.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors participated in the planning and conceptualization of the study. AG, MS, AS, SD, and MM carried out material preparation, data collection, and statistical analysis. AG drafted the manuscript, and all authors provided feedback on earlier drafts. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing institutional review board approval (ZU-IRB#751/20), the Pediatrics Department of Zagazig University Hospitals approved this study. Legal guardians provided informed consent. The study was conducted in accordance with the World Medical Association\u0026apos;s Declaration of Helsinki, which outlines ethical principles for research involving human subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCirillo, L., et al., \u003cem\u003eChronic kidney disease in children: an update.\u003c/em\u003e Clinical kidney journal, 2023. \u003cstrong\u003e16\u003c/strong\u003e(10): p. 1600\u0026ndash;1611https://doi.org/10.1093/ckj/sfad097\u003c/li\u003e\n\u003cli\u003eFraser, S.D., et al., \u003cem\u003ePrevalence and associations of limited health literacy in chronic kidney disease: a systematic review.\u003c/em\u003e Nephrology Dialysis Transplantation, 2013. \u003cstrong\u003e28\u003c/strong\u003e(1): p. 129\u0026ndash;137https://doi.org/10.1093/ndt/gfs371.\u003c/li\u003e\n\u003cli\u003eIorember, F.M., \u003cem\u003eMalnutrition in chronic kidney disease.\u003c/em\u003e Frontiers in pediatrics, 2018. \u003cstrong\u003e6\u003c/strong\u003e: p. 161https://doi.org/10.3389/fped.2018.00161\u003c/li\u003e\n\u003cli\u003eMahan, J.D., \u003cem\u003eChronic Kidney Disease\u003c/em\u003e, in \u003cem\u003eClinician\u0026apos;s Manual Of Pediatric Nephrology\u003c/em\u003e. 2011, World Scientific. p. 487\u0026ndash;503.\u003c/li\u003e\n\u003cli\u003eSu\u0026aacute;rez-Gonz\u0026aacute;lez, M., et al., \u003cem\u003eNutritional assessment and support in children with chronic kidney disease: the benefits of working with a registered dietitian.\u003c/em\u003e Nutrients, 2023. \u003cstrong\u003e15\u003c/strong\u003e(3): p. 528https://doi.org/10.3390/nu15030528.\u003c/li\u003e\n\u003cli\u003eMarsenić, O., A. Peco-Antić, and O. Jovanović, \u003cem\u003eEffect of dialysis dose on nutritional status of children on chronic hemodialysis.\u003c/em\u003e Nephron, 2001. \u003cstrong\u003e88\u003c/strong\u003e(3): p. 273\u0026ndash;275https://doi.org/10.1159/000046002\u003c/li\u003e\n\u003cli\u003eSabatino, A., et al., \u003cem\u003eProtein-energy wasting and nutritional supplementation in patients with end-stage renal disease on hemodialysis.\u003c/em\u003e Clinical nutrition, 2017. \u003cstrong\u003e36\u003c/strong\u003e(3): p. 663\u0026ndash;671https://doi.org/10.1016/j.clnu.2016.06.007.\u003c/li\u003e\n\u003cli\u003eWong, C.S., et al., \u003cem\u003eAnthropometric measures and risk of death in children with end-stage renal disease.\u003c/em\u003e American Journal of Kidney Diseases, 2000. \u003cstrong\u003e36\u003c/strong\u003e(4): p. 811\u0026ndash;819https://doi.org/10.1053/ajkd.2000.17674.\u003c/li\u003e\n\u003cli\u003eFurth, S.L., et al., \u003cem\u003eAdverse clinical outcomes associated with short stature at dialysis initiation: a report of the North American Pediatric Renal Transplant Cooperative Study.\u003c/em\u003e Pediatrics, 2002. \u003cstrong\u003e109\u003c/strong\u003e(5): p. 909\u0026ndash;913https://doi.org/10.1542/peds.109.5.909.\u003c/li\u003e\n\u003cli\u003eAshuntantang, G., et al., \u003cem\u003eOutcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic review.\u003c/em\u003e The Lancet Global Health, 2017. \u003cstrong\u003e5\u003c/strong\u003e(4): p. e408\u0026ndash;e417https://doi.org/10.1016/S2214-109X(17)30057-8.\u003c/li\u003e\n\u003cli\u003eFoster, B.J. and M.B. Leonard, \u003cem\u003eMeasuring nutritional status in children with chronic kidney disease.\u003c/em\u003e The American journal of clinical nutrition, 2004. \u003cstrong\u003e80\u003c/strong\u003e(4): p. 801\u0026ndash;814https://doi.org/10.1093/ajcn/80.4.801.\u003c/li\u003e\n\u003cli\u003eZaki, M.E., et al., \u003cem\u003eNutritional status in children with chronic renal failure on hemodialysis.\u003c/em\u003e 2012http://dx.doi.org/10.3889/MJMS.1857-5773.2012.0234.\u003c/li\u003e\n\u003cli\u003eSabatino, A., et al., \u003cem\u003eNoninvasive evaluation of muscle mass by ultrasonography of quadriceps femoris muscle in End-Stage Renal Disease patients on hemodialysis.\u003c/em\u003e Clinical nutrition, 2019. \u003cstrong\u003e38\u003c/strong\u003e(3): p. 1232\u0026ndash;1239https://doi.org/10.1016/j.clnu.2018.05.004\u003c/li\u003e\n\u003cli\u003eMastrangelo, A., F. Paglialonga, and A. Edefonti, \u003cem\u003eAssessment of nutritional status in children with chronic kidney disease and on dialysis.\u003c/em\u003e Pediatric Nephrology, 2014. \u003cstrong\u003e29\u003c/strong\u003e(8): p. 1349\u0026ndash;1358https://doi.org/10.1007/s00467-013-2612-7.\u003c/li\u003e\n\u003cli\u003eBakr, A.M.A.E.B., B.M. Hasaneen, and D.A.H. Bassiouni, \u003cem\u003eAssessment of nutritional status in children with chronic kidney disease using hand grip strength tool.\u003c/em\u003e Journal of Renal Nutrition, 2018. \u003cstrong\u003e28\u003c/strong\u003e(4): p. 265\u0026ndash;269https://doi.org/10.1053/j.jrn.2017.12.007\u003c/li\u003e\n\u003cli\u003eSeewer, E., \u003cem\u003eThe Validity and Reliability of Ultrasound as a Tool for Assessing Skeletal Muscle Characteristics in the Pediatric Population\u003c/em\u003e. 2024, The University of Tennessee Health Science Center.\u003c/li\u003e\n\u003cli\u003eIyengar, A., \u003cem\u003eNutrition Assessment Tools in Children with Chronic Kidney Disease.\u003c/em\u003e Asian Journal of Pediatric Nephrology, 2022. \u003cstrong\u003e5\u003c/strong\u003e(1): p. 7\u0026ndash;13DOI: 10.4103/ajpn.ajpn_8_22.\u003c/li\u003e\n\u003cli\u003eGollie, J.M., et al., \u003cem\u003eChronic kidney disease: considerations for monitoring skeletal muscle health and prescribing resistance exercise.\u003c/em\u003e Clinical kidney journal, 2018. \u003cstrong\u003e11\u003c/strong\u003e(6): p. 822\u0026ndash;831https://doi.org/10.1093/ckj/sfy054.\u003c/li\u003e\n\u003cli\u003eShaw, V., et al., \u003cem\u003eEnergy and protein requirements for children with CKD stages 2-5 and on dialysis\u0026ndash;clinical practice recommendations from the Pediatric Renal Nutrition Taskforce.\u003c/em\u003e Pediatric nephrology, 2020. \u003cstrong\u003e35\u003c/strong\u003e(3): p. 519\u0026ndash;531https://doi.org/10.1007/s00467-019-04426-0\u003c/li\u003e\n\u003cli\u003eBataille, S., et al., \u003cem\u003eThe diagnosis of sarcopenia is mainly driven by muscle mass in hemodialysis patients.\u003c/em\u003e Clinical Nutrition, 2017. \u003cstrong\u003e36\u003c/strong\u003e(6): p. 1654\u0026ndash;1660https://doi.org/10.1016/j.clnu.2016.10.016.\u003c/li\u003e\n\u003cli\u003eArbeille, P., et al., \u003cem\u003eQuantification of muscle volume by echography: comparison with MRI data on subjects in long-term bed rest.\u003c/em\u003e Ultrasound in medicine \u0026amp; biology, 2009. \u003cstrong\u003e35\u003c/strong\u003e(7): p. 1092\u0026ndash;1097https://doi.org/10.1016/j.ultrasmedbio.2009.01.004\u003c/li\u003e\n\u003cli\u003eSabatino, A., et al., \u003cem\u003eReliability of bedside ultrasound for measurement of quadriceps muscle thickness in critically ill patients with acute kidney injury.\u003c/em\u003e Clinical Nutrition, 2017. \u003cstrong\u003e36\u003c/strong\u003e(6): p. 1710\u0026ndash;1715https://doi.org/10.1016/j.clnu.2016.09.029.\u003c/li\u003e\n\u003cli\u003eChang, S.O., \u003cem\u003eDietary reference intakes for protein: protein requirement and estimation method, AMDR (Amount of Macronutrient Distribution Range), for protein.\u003c/em\u003e Korean Journal of Nutrition, 2011. \u003cstrong\u003e44\u003c/strong\u003e(4): p. 338\u0026ndash;343\u003c/li\u003e\n\u003cli\u003eLittle, R.J. and D.B. Rubin, \u003cem\u003eStatistical analysis with missing data\u003c/em\u003e. 2019: John Wiley \u0026amp; Sons.\u003c/li\u003e\n\u003cli\u003eAzzouz, J.Z., et al., \u003cem\u003eNutritional assessment and management in paediatric chronic kidney disease.\u003c/em\u003e Journal of Nutrition and Metabolism, 2021. \u003cstrong\u003e2021\u003c/strong\u003e(1): p. 8283471https://doi.org/10.1155/2021/8283471.\u003c/li\u003e\n\u003cli\u003eCanpolat, N., et al., \u003cem\u003eMalnutrition and its association with inflammation and vascular disease in children on maintenance dialysis.\u003c/em\u003e Pediatric Nephrology, 2013. \u003cstrong\u003e28\u003c/strong\u003e(11): p. 2149\u0026ndash;2156https://doi.org/10.1007/s00467-013-2527-3.\u003c/li\u003e\n\u003cli\u003eFischer, A., et al., \u003cem\u003eValidation of bedside ultrasound to predict lumbar muscle area in the computed tomography in 200 non-critically ill patients: The USVALID prospective study.\u003c/em\u003e Clinical Nutrition, 2022. \u003cstrong\u003e41\u003c/strong\u003e(4): p. 829\u0026ndash;837https://doi.org/10.1016/j.clnu.2022.01.034 \u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zdemir, U., et al., \u003cem\u003eThe role of maximum compressed thickness of the quadriceps femoris muscle measured by ultrasonography in assessing nutritional risk in critically-ill patients with different volume statuses.\u003c/em\u003e Revista da Associa\u0026ccedil;\u0026atilde;o M\u0026eacute;dica Brasileira, 2019. \u003cstrong\u003e65\u003c/strong\u003e(7): p. 952\u0026ndash;958https://doi.org/10.1590/1806-9282.65.7.952.\u003c/li\u003e\n\u003cli\u003eLotfy, H.M., et al., \u003cem\u003eThe effect of regular hemodialysis on the nutritional status of children with end-stage renal disease.\u003c/em\u003e Saudi Journal of Kidney Diseases and Transplantation, 2015. \u003cstrong\u003e26\u003c/strong\u003e(2): p. 263\u0026ndash;270DOI: 10.4103/1319-2442.152416.\u003c/li\u003e\n\u003cli\u003eTodisco, T., et al., \u003cem\u003eChronic kidney disease and growth failure in children.\u003c/em\u003e Children, 2024. \u003cstrong\u003e11\u003c/strong\u003e(7): p. 808https://doi.org/10.3390/children11070808\u003c/li\u003e\n\u003cli\u003eGupta, A., M. Mantan, and M. Sethi, \u003cem\u003eNutritional assessment in children with chronic kidney disease.\u003c/em\u003e Saudi Journal of Kidney Diseases and Transplantation, 2016. \u003cstrong\u003e27\u003c/strong\u003e(4): p. 733\u0026ndash;739\u003c/li\u003e\n\u003cli\u003ePont\u0026oacute;n-V\u0026aacute;zquez, C., et al., \u003cem\u003eDietary intake, nutritional status, and body composition in children with end-stage kidney disease on hemodialysis or peritoneal dialysis.\u003c/em\u003e Journal of Renal Nutrition, 2017. \u003cstrong\u003e27\u003c/strong\u003e(3): p. 207\u0026ndash;215https://doi.org/10.1093/tropej/fmv094\u003c/li\u003e\n\u003cli\u003eSahpazova, E., et al., \u003cem\u003eNutritional status, protein intake and progression of renal failure in children.\u003c/em\u003e Pediatric Nephrology, 2006. \u003cstrong\u003e21\u003c/strong\u003e(12): p. 1879\u0026ndash;1883https://doi.org/10.1007/s00467-006-0241-0\u003c/li\u003e\n\u003cli\u003eHussein, R., et al., \u003cem\u003eA cross-sectional study of growth and metabolic bone disease in a pediatric global cohort undergoing chronic hemodialysis.\u003c/em\u003e The Journal of Pediatrics, 2018. \u003cstrong\u003e202\u003c/strong\u003e: p. 171\u0026ndash;178. e3https://doi.org/10.1016/j.jpeds.2018.07.033\u003c/li\u003e\n\u003cli\u003eZitnik, E., E. Streja, and M. Laster, \u003cem\u003eThe Impact of Glomerular Disease on Dyslipidemia in Pediatric Patients Treated with Dialysis.\u003c/em\u003e Nutrients, 2025. \u003cstrong\u003e17\u003c/strong\u003e(3): p. 459https://doi.org/10.3390/nu17030459\u003c/li\u003e\n\u003cli\u003eOng, C., et al., \u003cem\u003eSkeletal muscle ultrasonography in nutrition and functional outcome assessment of critically ill children: Experience and insights from pediatric disease and adult critical care studies.\u003c/em\u003e Journal of Parenteral and Enteral Nutrition, 2017. \u003cstrong\u003e41\u003c/strong\u003e(7): p. 1091\u0026ndash;1099https://doi.org/10.1177/0148607116683143.\u003c/li\u003e\n\u003cli\u003eSahathevan, S., et al., \u003cem\u003eAssociation of ultrasound-derived metrics of the quadriceps muscle with protein energy wasting in hemodialysis patients: a multicenter cross-sectional study.\u003c/em\u003e Nutrients, 2020. \u003cstrong\u003e12\u003c/strong\u003e(11): p. 3597https://doi.org/10.3390/nu12113597\u003c/li\u003e\n\u003cli\u003eSahathevan, S., et al., \u003cem\u003eValidity of ultrasound imaging in measuring quadriceps muscle thickness and cross‐sectional area in patients receiving maintenance hemodialysis.\u003c/em\u003e Journal of Parenteral and Enteral Nutrition, 2021. \u003cstrong\u003e45\u003c/strong\u003e(2): p. 422\u0026ndash;426 https://doi.org/10.1002/jpen.1867.\u003c/li\u003e\n\u003cli\u003eSun, W. and L. Liu, \u003cem\u003eNutritional counseling\u0026apos;s impact on muscle mass and quality of life in stage 4 chronic kidney disease malnourished patients.\u003c/em\u003e Technology and Health Care, 2025. \u003cstrong\u003e33\u003c/strong\u003e(2): p. 951\u0026ndash;958https://doi.org/10.1177/09287329241291370\u003c/li\u003e\n\u003cli\u003eSabatino, A., et al., \u003cem\u003eQuadriceps muscle thickness assessed by ultrasound is independently associated with mortality in hemodialysis patients.\u003c/em\u003e European Journal of Clinical Nutrition, 2022. \u003cstrong\u003e76\u003c/strong\u003e(12): p. 1719\u0026ndash;1726https://doi.org/10.1038/s41430-022-01166-7\u003c/li\u003e\n\u003cli\u003eElgenidy, A., et al., \u003cem\u003eUtility of ultrasound in measuring quadriceps muscle thickness in patients receiving maintenance hemodialysis: comprehensive systematic review and meta-analysis.\u003c/em\u003e Clinical and Experimental Nephrology, 2025. \u003cstrong\u003e29\u003c/strong\u003e(2): p. 192\u0026ndash;211https://doi.org/10.1007/s10157-024-02557-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Malnutrition, Hemodialysis, Muscle Ultrasound, Quadriceps Muscle, Protein Energy Wasting","lastPublishedDoi":"10.21203/rs.3.rs-8503873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8503873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eProtein-energy wasting (PEW) is highly prevalent among children receiving maintenance hemodialysis, yet accurate and objective assessment of nutritional status remains challenging. Muscle mass assessment is one of the diagnostic tools for malnutrition according to current definitions, and muscle ultrasound (US) can be used for the diagnosis and monitoring of malnutrition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA tertiary hemodialysis center case–control study enrolled 42 children on hemodialysis (age range: 1–16 years) and 42 age- and sex-matched apparently healthy children as a control group. Demographic, anthropometric, clinical, and laboratory information were gathered. A dietary evaluation using a 3-day food intake record was performed to assess protein adequacy. The thickness of the quadriceps muscle, primarily the rectus femoris, the largest skeletal muscle in the body, was assessed using B-mode muscle US in both groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eChildren on hemodialysis had significantly lower caloric and protein intake compared with controls (both p \u0026lt; 0.001) and 40.5% of patients had inadequate protein intake. Children on maintenance hemodialysis had significantly reduced peripheral muscle thickness compared with healthy controls. Correlation analysis showed that total caloric and protein intake were positively associated with muscle thickness (p \u0026lt; 0.001). The ROC curve showed that among muscle parameters, rectus femoris thickness ≤10.4 mm demonstrated excellent sensitivity (100%) but moderate specificity (48%), with an AUC of 0.731 (p \u0026lt; 0.001).While anthropometric and dietary measures identified malnutrition in 21–43% of patients, ultrasound-based muscle mass classified approximately half of cases had low muscle mass, suggesting a higher sensitivity for detecting nutritional impairment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003cbr\u003e\n\u003c/strong\u003eQuadriceps muscle ultrasonography is a simple, non-invasive bedside tool that may aid in screening and monitoring PEW in children on maintenance hemodialysis.\u003c/p\u003e","manuscriptTitle":"Role of Quadriceps Muscle Ultrasound in Nutritional Assessment of Children on Maintenance Hemodialysis: A Tertiary Center Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-08 14:19:19","doi":"10.21203/rs.3.rs-8503873/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aa4f872e-87c5-41f4-a1b6-deaaa2747458","owner":[],"postedDate":"January 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-22T12:27:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-08 14:19:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8503873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8503873","identity":"rs-8503873","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}