Biochemical bone markers in children with steroid sensitive nephrotic syndrome in remission

Authors

  • Neha Sinha Department of Pediatrics, T.N.M.C and B.Y.L Nair Hospital, Mumbai, Maharashtra, India
  • Poonam Wade Department of Pediatrics, T.N.M.C and B.Y.L Nair Hospital, Mumbai, Maharashtra, India
  • Radha Gulati Ghildiyal Department of Pediatrics, T.N.M.C and B.Y.L Nair Hospital, Mumbai, Maharashtra, India
  • Hemil Maniar Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA

DOI:

https://doi.org/10.18203/2349-3291.ijcp20182570

Keywords:

Glucocorticoids, Steroid sensitive nephrotic syndrome (SSNS), Vitamin D

Abstract

Background: Glucocorticoids, the recommended first line treatment of steroid sensitive nephrotic syndrome (SSNS), are notorious for causing osteoporosis. There are very few studies from tropical countries looking at the lasting effects of a short course of glucocorticoids in SSNS. The objective is to study the effect of glucocorticoids and its dose on Vitamin D levels and biochemical markers of calcium metabolism in children with SSNS and to formulate a criterion to administer prophylactic calcium and vitamin D supplementation to such patients.

Methods: A cross-sectional case-control study was conducted on 30 children with SSNS in remission and 30 healthy controls. Serum levels of 25 hydroxycholecalciferol [25(OH)D], calcium, phosphorous, albumin, alkaline phosphatase (ALP) and intact parathyroid (PTH) were measured. Total glucocorticoid exposure during the illness was summarized.

Results: Children with SSNS had significantly lower height [median-100.00 (interquartile range {IQR}- 14.5) vs. controls [115.50 (17.5)] cm; P= 0.0003. Serum ALP levels was significantly higher in the cases [median 264 (IQR-80.7)] IU/L vs. controls [median 234 (IQR- 132)] IU/L; P= 0.028.  Though hypovitaminosis D was universal in the study cohort; children with SSNS had worse Vitamin D status (76.7%) than healthy controls (50%). Levels of serum calcium, phosphorous, vitamin D and PTH were not significantly different between the two groups, nor were they related to total cumulative dose of steroid. Vitamin D levels showed no significant co-relation with number of relapses, age, calcium, phosphate, ALP, or PTH levels.

Conclusions: Children with SSNS may benefit from routine measurement of 25 (OH) D and prophylactic supplementation with calcium and Vitamin D.

References

Niaudet P. Long-term outcome of children with steroid-sensitive idiopathic nephrotic syndrome. Clin J Am Soc Nephrol. 2009Oct;4(10):1547-8.

Bak M, Serdaroglu E, Guclu R. Prophylactic calcium and vitamin D treatments in steroid-treated children with nephrotic syndrome. Pediatr Nephrol. 2006 Mar;21(3):350-4.

Goldstein DA, Haldimann B, Sherman D, Norman AW, Massry SG. Vitamin D metabolites and calcium metabolism in patients with nephrotic syndrome and normal renal function. J Clin Endocrinol Metab. 1981 Jan;52(1):116-21.

Biyikli NK, Emre S, Sirin A, Bilge I. Biochemical bone markers in nephrotic children. Pediatr Nephrol. 2004 Aug;19(8):869-73.

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 Mar;108(3):383-7.

Huang JP, Bai KM, Wang BL. Vitamin D and calcium metabolism in children with nephrotic syndrome of normal renal function. Chin Med J (Engl). 1992 Oct;105(10):828-32.

Greenbaum LA, Benndorf R, Smoyer WE. Childhood nephrotic syndrome--current and future therapies. Nat Rev Nephrol. 2012 Jun 12;8(8):445-58.

Sinha A, Bagga A. Nephrotic syndrome. Indian J Pediatr. 2012 Aug;79(8):1045-55.

Weng FL, Shults J, Herskovitz RM, Zemel BS, Leonard MB. Vitamin D insufficiency in steroid-sensitive nephrotic syndrome in remission. Pediatr Nephrol. 2005 Jan;20(1):56-63.

Banerjee S, Basu S, Sengupta J. Vitamin D in nephrotic syndrome remission: a case-control study. Pediatr Nephrol. 2013 Oct;28(10):1983-9.

Schwartz GJ, Brion LP, Spitzer A. The use of plasma creatinine concentration for estimating glomerular filtration rate in infants, children, and adolescents. Pediatr Clin North Am. 1987 Jun;34(3):571-90.

Ross AC, Manson JAE, Abrams SA, Aloia JF, Brannon PM, Clinton SK, et al. The 2011 Report on Dietary Reference Intakes for Calcium and Vitamin D from the Institute of Medicine: What Clinicians Need to Know. J Clin Endocrinol Metab. 2011 Jan;96(1):53-8.

Munns C, Zacharin MR, Rodda CP, Batch JA, Morley R, Cranswick NE et al. Prevention and treatment of infant and childhood vitamin D deficiency in Australia and New Zealand: a consensus statement. Med J Aust. 2006 Sep 4;185(5):268-72.

Indian Pediatric Nephrology Group, Indian Academy of Pediatrics, Bagga A, Ali U, Banerjee S, Kanitkar M, Phadke KD, et al. Management of steroid sensitive nephrotic syndrome: revised guidelines. Indian Pediatr. 2008 Mar;45(3):203-14.

WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards: Length/ height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and development. Geneva: World Health Organization, 2006.

Wootton AM. Improving the measurement of 25-hydroxyvitamin D. Clin Biochem Rev. 2005 Feb;26(1):33-6.

Leonard MB, Feldman HI, Shults J, Zemel BS, Foster BJ, Stallings VA. Long-term, high-dose glucocorticoids and bone mineral content in childhood glucocorticoid-sensitive nephrotic syndrome. N Engl J Med. 2004 Aug 26;351(9):868-75.

Feber J, Gaboury I, Ni A, Alos N, Arora S, Bell L, et al. Skeletal findings in children recently initiating glucocorticoids for the treatment of nephrotic syndrome. Osteoporos Int. 2012 Feb;23(2):751-60.

Kosan C, Ayar G, Orbak Z. Effects of steroid treatment on bone mineral metabolism in children with glucocorticoid-sensitive nephrotic syndrome. West Indian Med J. 2012 Sep;61(6):627-30.

Rathi N, Rathi A. Vitamin D and child health in the 21st century. Indian Pediatr. 2011 Aug;48(8):619-25.

Freundlich M, Jofe M, Goodman WG, Salusky IB. Bone histology in steroid-treated children with non-azotemic nephrotic syndrome. Pediatr Nephrol. 2004 Apr;19(4):400-7.

Eddy AA, Symons JM. Nephrotic syndrome in childhood. Lancet. 2003 Aug 23;362(9384):629-39.

Short versus standard prednisone therapy for initial treatment of idiopathic nephrotic syndrome in children. Arbeitsgemeinschaft fur Padiatrische Nephrologie. Lancet. 1988 Feb;1(8582):380-3.

The primary nephrotic syndrome in children. Identification of patients with minimal change nephrotic syndrome from initial response to prednisone. A report of the International Study of Kidney Disease in Children. J Pediatr. 1981 Apr;98(4):561-4.

Gordon CM, DePeter KC, Feldman HA, Grace E, Emans SJ. Prevalence of vitamin D deficiency among healthy adolescents. Arch Pediatr Adolesc Med. 2004 Jun;158(6):531-7.

Gessner BD, Plotnik J, Muth PT. 25-hydroxyvitamin D levels among healthy children in Alaska. J Pediatr. 2003 Oct;143(4):434-7.

Guillemant J, Cabrol S, Allemandou A, Peres G, Guillemant S. Vitamin D-dependent seasonal variation of PTH in growing male adolescents. Bone. 1995 Dec;17(6):513-6.

National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis. 2003 Oct;42(4 Suppl 3):S1-201.

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Published

2018-06-22

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