Comparisons of bone mineral density in steroid dependent, frequent relapse, and infrequent relapse nephrotic syndrome children

Lies Dewi Nurmala; Taralan Tambunan; Idham Amir

doi:10.14238/pi50.4.2010.193-8

Lies Dewi Nurmala Department of Child Health, University of Indonesia Medical School/Dr. Cipto Mangunkusumo Hospital, Jakarta
Taralan Tambunan Department of Child Health, University of Indonesia Medical School/Dr. Cipto Mangunkusumo Hospital, Jakarta
Idham Amir Department of Child Health, University of Indonesia Medical School/Dr. Cipto Mangunkusumo Hospital, Jakarta

DOI: https://doi.org/10.14238/pi50.4.2010.193-8

Keywords: bone mineral density, steroid dependent nephrotic syndrome, frequent relapse, infrequent relapse

Abstract

Background Children with nephrotic syndrome, especially those with steroid dependent and frequent relapse are at greater risk of reduced bone mineral density (BMD).

Objective To determine bone mineral density (BMD) in steroid dependent and frequent relapse compared to infrequent relapse nephrotic syndrome.

Methods We conducted a cross-sectional study at the Child Health Department, Cipto Mangunkusumo Hospital, from August until November 2009. Subjects were 5 to 18 year-old children with steroid dependent nephrotic syndrome (SDNS), frequent relapse

nephrotic syndrome (FRNS), or infrequent relapse nephrotic syndrome (IRNS). Ionized calcium level, vitamin 25(OH)D3 level, and BMD were measured us ng dual energy x-ray absorptiometry (DEXA).

Results 11 SDNS and 11 FRNS cbildren (group I) were compared with 22 IRNS children (Group II). Children of SDNS and FRNS had significantly longer duration of illness, more relapses, longer steroid therapy duration, and greater cumulative steroid dose compared to group 11 (IRNS). There were no differences betweenÂ the two groups with regard to mean ionized calcium level and vitamin 25(OH)D3 level. Children in group I had lower z-scores compared to group lI, but the difference was not statistically significant r mean (SD) -1.182 (1.21) vs. -0.795 (1.25), P=0.305]. Subgroup analysis showed that SDNS children had lower z-scores than FRNS [-1.791 (1.17) vs. -0.57 (0.94), P=0.019] and IRNS [-1.791 (1.17) vs. -0.795 (1.25), P=O.026].

Conclusion Children with SDNS have significantly lower BMD z-scores compared to those with FRNS and IRNS.

References

1. Alatas H, Tambunan T, Trihono P p, Parde de so. Konsensus tata laksana sindrom nefrotik primer pada anak. 2nd ed. Jakarta: Unit Kerja Koordinasi Nefrologi lkatan Dokter Anak Indonesia; 2008. p.1-15..
2. Trihono PP, Alatas H. Tata laksana sindrom ne[rotik idiopatik pada anak. In: Trihono PP, Syarif DR, Amir I, Kurniati N, editors. Pendidikan kedokteran berkelanjutan Ilmu Kesehatan Anak XLVI: Current management of pediatrics problems. 5-6 September 2004. Jakarta: Departemen Ilmu Kesehatan Anak FKUI-RSCM; 2004. p.1- 9.
3. Iriani Y, Tambunan T, Sastroasmoro S. Cyclophosphamide in frequent relapsing or steroid-dependent nephrotic syndrome: review of 38 patients. Paediatr Indones. 2005;45:18-23.
4. Fakhouri F, Bocquet N, Taupin P, Presne C, Gagnadoux MF, Landais P, et aL Steroid-sensitive nephrotic syndrome: from childhood to adulthood. Am J Kidney Die. 2003;41:550-7.
5. Hartman C, Hochberg Z, Shamir R. Osteoporosis in pediatrice. IMAJ. 2003;5:509-15.
6. Canalis E. Mechanism of glucocorticoid action in bone: implication to glucocorticoid-induced osteoporosis. J Clin Endouinol Metab. 1996;81:441-47.
7. Freundlich M, Bourgoignie JJ, Zilleruelo G, Jacob AI, Canterbury JM, Srauss J. Bone modulating factors in nephrotic children with normal glomerular filtration rate. Pediatrics. 1985;76:280-5.
8. Freundlich M, Bourgoignie JJ, Zilleruelo G, Abitbol C , Canterbury JM, Strauss J. Calcium and vitamin D metabolism in children with nephrotic syndrome. J Pediatr. 1986;108:383-7.
9. Abitbol C, Zilleruelo G, Frelllldlich M, Strauss J. Quantitation of proteinuria with urinary protein/creatinine ratios and random testing with dipsticks in nephrotic children. J Pediatr. 1990;116:243-7.
10. Felsenfeld AJ, Rodriguez M. P hosphorus, regulation of plasma calcium, and secondary hyperparathyroidism: a hypothesis to integrate a historical and modern perspective. J Am Soc Nephml.I999;10:878-90.
11. Skugor M, Cleveland Clinic Center for Continuing Education. Hypocalcemia [homepage on the internet]. c2004 [cited 2009 December 7]. Available from http://www.
clevelandclinicmeded.com/medicalpubs.
12. Lanham SA. Importance of calcium, vitamin D, and vitamin K for osteoporosis prevention and treatment. Proceeding of The Summer Meeting of the Nutrition Society; 2007 July 16-19; Surrey, UK.
13. American Academy of Pediatrics: Committee on Nutrition. Calcium requirements of infants, children, and adolescents.Pediatrics. 1999;104:1152-7.
14. Holick ME Vitamin D deficiency. N Engl J Med. 2007;266- 81.
15. Chesney RW. Metabolic bone disease. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson's textbook of pediatrics. 17th ed. Pennsylvania: Saunders; 2004. p.2341-3.
16. Gulati S, Godbole M, Singh U, Gulati K, Srivastava A. Are children with idiopathic nephrotic syndrome at risk for metabolic bone disease. Am J Kidney Dis. 2003;41:1163-9.
17. Leonard MB. Glucocorticoid-induced osteoporosis in children: impact of the underlying disease. Pediatrics. 2007;119:166-74.
18. Cohran VC, Griffiths M, Heubi JE. Bone mineral density in children exposed to chronic glucocorticoid therapy. Clin Pediatr. 2008;47,469-7S.
19. KanoK, Hoshi M, Nishikura K, Yamada Y, ArisakaO. Skeletal effects of short-term prednisolone therapy in children with steroid-responsive nephrotic syndrome. Clin Exp NephroL 2001;S,40-3.
20. Gulati S, Sharma RK, Gulati K, Singh U, Srivastava A. Longitudinal follow-up of bone mineral density in children with nephrotic syndrome and the role of calcium and vitamin D supplements. Nephrol Dial Transplant. 2005;20:1598-1603.