Calcium and vitamin D supplementation in children with frequently relapsing and steroid-dependent nephrotic syndrome
Keywords:
frequent relapse nephrotic syndrome, steroid dependent, supplementation, calcium, vitamin D, bone mineral density, osteoporosis
Abstract
Background Children with frequently relapsing and steroiddependentnephrotic syndrome (FRNS/SDNS) are at risk
for osteoporosis due to impaired metabolism of calcium and
vitamin D.
Objective To determine the effect of calcium and vitamin D
supplementation on bone mineral density, serum ionized calcium
levels and serum 25-hydroxy-vitamin D levels in children with
FRNS and SDNS.
Methods A clinical trial with a before and after design was
performed. Subjects were SDNS or FRNS pediatric patients 2: 5
years of age. Subjects received 800 mg elemental calcium and 400
IU vitamin D supplementation for 8 weeks. Serum ionized calcium,
serum 25-hydroxy-vitamin D [25(0H)D], and bone mineral density
(BMD) were determined before and after the supplementation.
Results Of the 30 subjects, 28 completed the study. However,
only 20 subjects underwent BMD determination before and after
supplementation. Of the 28 subjects, 22 had hypocalcemia and 26
had low vitamin D levels. Osteopenia was found in 14/20 subjects and
osteoporosis was in 2/20 subjects. After 8 weeks of supplementation,
mean serum ionized calcium increased from low [1.15 mmol/L (SD
O.oJ)] to normal [1.18 mmol/L (SD 0.04)] (P< 0.001) levels, but
mean serum 25(0H)D only increased from vitamin D deficiency
category [20 ng/mL (SD 7 .7)] to vitamin D insufficiency category
[25.5 ng/mL (7.7)] (P=0.010). Mean z-score BMD increased from
-1.1 (SD 0.9) to -0.7 (SD 0.2) after supplementation (P<0.001).
Conclusion Calcium vitamin D supplementation effectively increased
serum ionized calcium, serum 25 (OH)D, and BMD in subjects
with FRNS and SDNS. [Paediatr lndones. 2012;52:16-21].
References
1. Alatas H, Tambunan T, Trihono PP, Pardede SO. Konsensus
tata laksana sindrom nefrotik primer pada anak. Jakarta: Unit
Kerja Koordinasi Nefrologi Ikatan Dokter Anak Indonesia;
2005. p. 1-18.
2. Vogt BA, Avner ED. Nephrotic syndrome. In: Behrman
RE, Kliegman RM, Jenson HB, editors. Nelson's textbook of
pediatrics. 17th ed. Philadelphia: Saunders; 2004. p. 1753-7.
3. Kano K, Hoshi M, Nishikura K, Yamada Y, Arisaka 0.
Skeletal effects of short-term prednisolone therapy in
children with steroid-responsive nephrotic syndrome. Clin
Exp Nephrol. 2001;5:40-3.
4. Fujita T, Satomura A, Hidaka M, Ohsawa I, Endo M, Ohi
H. Acute alteration in bone mineral density and biochemical
markers for bone metabolism in nephrotic patients receiving
high-dose glucocorticoid and one-cycle etidronate therapy.
CalcifTissue Int. 2000;66:195-9.
5. Basiratnia M, Fallahzadeh MH, DerakhshanA, Hosseini-AlHashemi
G. Bone mineral density in children with relapsing
nephrotic syndrome. Iran J Med Sci. 2006;31:82-6.
6. Olgaard K, Storm T, Van Wovem N. Glucorticoid induced
osteoporosis in lumbar spine, forearm and mandible of
nephrotic patients: a double blind study on high dose longterm
effects of prednisolone versus deflazocort. CalcifTissue
Int. 1992;50:460-7.
7. Mittal SK, Dash SC, Tiwari SC, Agarwal SK, Saxena S,
Fish bane S. Bone histology in patients with nephrotic syndrome
and normal renal function. Kidney Int. 1999;55 :1912-9.
8. Freundlich M, Bourgoignie J, Zilleruelo G, Abitbol
C, Cantebury JM, Strauss J. Calcium and vitamin D
metabolism in children with nephrotic syndrome. J Pediatr.
l 986;108:383-7.
9. Gulati S, Godbole M, Singh U, Gulati K, Srivastava A. Are
children with idiopathic nephrotic syndrome at risk for
metabolic bone disease? AmJ Kidney Dis. 2003;41:1163-9.
10. American Academy of Pediatrics. Calcium requirements
of infants, children, and adolescents. Pediatrics. 1999;104:
1152-7.
11. Wagner CL, Greer FR. Prevention of rickets and vitamin D
deficiency in infants, children, and adolescents. Pedia tries.
2008;122: 1142-52.
12. 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.
13. Bak M, Serdaroglu E, Guclu R. Prophylactic calcium and
vitamin D treatments in steroid-treated children with
nephrotic syndrome. Pediatr Nephrol. 2006;21:350-4.
14. Freundlich M, Jofe M, Goodman W, Salusky IB. Bone
histology in steroid-treated children with non-azotemic
nephrotic syndrome. Pediatr N ephrol. 2004; 19 :400-7.
15. Canalis E. Mechanisms of glucocorticoid action in bone:
implications to glucocorticoid-induced osteoporosis.
Endocrinology. 199 6;81:3441-7.
16. Shaw N. A practical approach to hypocalcaemia in
children. In: Algrove J, Shaw NJ, editors. Calcium and
bone disorders in children and adolescents. Basel: Karger;
2009.p. 73-92.
17. Skugor M. Cleveland Clinic Center for Continuing
Education. Hypocalcemia. [Cited 2011 May 1). Available
from: http: //www.clevelandclinicmeded.com/medicalpubs/
diseasemanagement/endocrinology/hypocalcemifl/#cesec6
18. Nurmalia LD, Tambunan T, Amir I. Comparison of bone
mineral density in steroid dependent, frequent relapse, and
infrequent relaps nephrotic syndrome children. Paediatr
Indones. 2010;50:193-8.
19. Levine MA. Normal mineral homeostasis. In: Hochberg Z,
editor. Vitamin D and rickets. 2nd ed. Switzerland: Karger;
2003. pp. 14-33.
20. Holick MF. Vitamin D deficiency. N Engl J Med. 2007;
357:266-81.
21. Hartman C, Hochberg Z, Shamir R. Osteoporosis in
pediatrics. IMAJ. 2003;5:509-15.
22. Leonard MB. Glucocorticoid-induced osteoporosis in
children: impact of the underlying disease. Pediatrics.
2007;119:166-74.
23. Mishra OP, Meena SK, Singh SK, Prasad R, Mishra RN. Bone
mineral density in children with steroid-sensitive nephrotic
syndrome. Indian] Pediatr. 2009;76:1237-9.
24. Shouman MG, Nagwa Abdallah I, El Meguid A, Salama
EEE, El Ghoroury E, Abou Ismail IA, et al. Bone mineral
density markers in children with steroid sensitive idiopathic
nephrotic syndrome. IJAR. 2010;2:150-6.
25. Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D
concentrations, and safety. Am J Clin Nutr. 1999;69:842-56.
26. Straub DA. Calcium supplementation in clinical practice:
a review of forms, doses, and indications. Nutr Clin Pract.
2007;22:286-96.
27. Vieth R. Vitamin D toxicity, policy, and science. J Bone Miner
Res. 2007 ;22:64-8.
28. Vieth R, Chan PR, Macfarlane GD. Efficacy and safety of
vitamin DJ intake exceeding the lowest observed adverse
effect level. Am J Clin Nutr. 2001 ;73:288-94.
tata laksana sindrom nefrotik primer pada anak. Jakarta: Unit
Kerja Koordinasi Nefrologi Ikatan Dokter Anak Indonesia;
2005. p. 1-18.
2. Vogt BA, Avner ED. Nephrotic syndrome. In: Behrman
RE, Kliegman RM, Jenson HB, editors. Nelson's textbook of
pediatrics. 17th ed. Philadelphia: Saunders; 2004. p. 1753-7.
3. Kano K, Hoshi M, Nishikura K, Yamada Y, Arisaka 0.
Skeletal effects of short-term prednisolone therapy in
children with steroid-responsive nephrotic syndrome. Clin
Exp Nephrol. 2001;5:40-3.
4. Fujita T, Satomura A, Hidaka M, Ohsawa I, Endo M, Ohi
H. Acute alteration in bone mineral density and biochemical
markers for bone metabolism in nephrotic patients receiving
high-dose glucocorticoid and one-cycle etidronate therapy.
CalcifTissue Int. 2000;66:195-9.
5. Basiratnia M, Fallahzadeh MH, DerakhshanA, Hosseini-AlHashemi
G. Bone mineral density in children with relapsing
nephrotic syndrome. Iran J Med Sci. 2006;31:82-6.
6. Olgaard K, Storm T, Van Wovem N. Glucorticoid induced
osteoporosis in lumbar spine, forearm and mandible of
nephrotic patients: a double blind study on high dose longterm
effects of prednisolone versus deflazocort. CalcifTissue
Int. 1992;50:460-7.
7. Mittal SK, Dash SC, Tiwari SC, Agarwal SK, Saxena S,
Fish bane S. Bone histology in patients with nephrotic syndrome
and normal renal function. Kidney Int. 1999;55 :1912-9.
8. Freundlich M, Bourgoignie J, Zilleruelo G, Abitbol
C, Cantebury JM, Strauss J. Calcium and vitamin D
metabolism in children with nephrotic syndrome. J Pediatr.
l 986;108:383-7.
9. Gulati S, Godbole M, Singh U, Gulati K, Srivastava A. Are
children with idiopathic nephrotic syndrome at risk for
metabolic bone disease? AmJ Kidney Dis. 2003;41:1163-9.
10. American Academy of Pediatrics. Calcium requirements
of infants, children, and adolescents. Pediatrics. 1999;104:
1152-7.
11. Wagner CL, Greer FR. Prevention of rickets and vitamin D
deficiency in infants, children, and adolescents. Pedia tries.
2008;122: 1142-52.
12. 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.
13. Bak M, Serdaroglu E, Guclu R. Prophylactic calcium and
vitamin D treatments in steroid-treated children with
nephrotic syndrome. Pediatr Nephrol. 2006;21:350-4.
14. Freundlich M, Jofe M, Goodman W, Salusky IB. Bone
histology in steroid-treated children with non-azotemic
nephrotic syndrome. Pediatr N ephrol. 2004; 19 :400-7.
15. Canalis E. Mechanisms of glucocorticoid action in bone:
implications to glucocorticoid-induced osteoporosis.
Endocrinology. 199 6;81:3441-7.
16. Shaw N. A practical approach to hypocalcaemia in
children. In: Algrove J, Shaw NJ, editors. Calcium and
bone disorders in children and adolescents. Basel: Karger;
2009.p. 73-92.
17. Skugor M. Cleveland Clinic Center for Continuing
Education. Hypocalcemia. [Cited 2011 May 1). Available
from: http: //www.clevelandclinicmeded.com/medicalpubs/
diseasemanagement/endocrinology/hypocalcemifl/#cesec6
18. Nurmalia LD, Tambunan T, Amir I. Comparison of bone
mineral density in steroid dependent, frequent relapse, and
infrequent relaps nephrotic syndrome children. Paediatr
Indones. 2010;50:193-8.
19. Levine MA. Normal mineral homeostasis. In: Hochberg Z,
editor. Vitamin D and rickets. 2nd ed. Switzerland: Karger;
2003. pp. 14-33.
20. Holick MF. Vitamin D deficiency. N Engl J Med. 2007;
357:266-81.
21. Hartman C, Hochberg Z, Shamir R. Osteoporosis in
pediatrics. IMAJ. 2003;5:509-15.
22. Leonard MB. Glucocorticoid-induced osteoporosis in
children: impact of the underlying disease. Pediatrics.
2007;119:166-74.
23. Mishra OP, Meena SK, Singh SK, Prasad R, Mishra RN. Bone
mineral density in children with steroid-sensitive nephrotic
syndrome. Indian] Pediatr. 2009;76:1237-9.
24. Shouman MG, Nagwa Abdallah I, El Meguid A, Salama
EEE, El Ghoroury E, Abou Ismail IA, et al. Bone mineral
density markers in children with steroid sensitive idiopathic
nephrotic syndrome. IJAR. 2010;2:150-6.
25. Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D
concentrations, and safety. Am J Clin Nutr. 1999;69:842-56.
26. Straub DA. Calcium supplementation in clinical practice:
a review of forms, doses, and indications. Nutr Clin Pract.
2007;22:286-96.
27. Vieth R. Vitamin D toxicity, policy, and science. J Bone Miner
Res. 2007 ;22:64-8.
28. Vieth R, Chan PR, Macfarlane GD. Efficacy and safety of
vitamin DJ intake exceeding the lowest observed adverse
effect level. Am J Clin Nutr. 2001 ;73:288-94.
Published
2012-03-30
How to Cite
1.
Septarini A, Tambunan T, Amalia P. Calcium and vitamin D supplementation in children with frequently relapsing and steroid-dependent nephrotic syndrome. PI [Internet]. 30Mar.2012 [cited 27Apr.2024];52(1):16-1. Available from: https://paediatricaindonesiana.org/index.php/paediatrica-indonesiana/article/view/293
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Received 2016-08-21
Accepted 2016-08-21
Published 2012-03-30
Accepted 2016-08-21
Published 2012-03-30
