Prevention and treatment of renal osteodystrophy in children on chronic renal failure: European guidelines

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Abstract

Childhood renal osteodystrophy (ROD) is the consequence of disturbances of the calcium-regulating hormones vitamin D and parathyroid hormone (PTH) as well as of the somatotroph hormone axis associated with local modulation of bone and growth cartilage function. The resulting growth retardation and the potentially rapid onset of ROD in children are different from ROD in adults. The biochemical changes of ROD as well as its prevention and treatment affect calcium and phosphorus homeostasis and are directly associated with the development of cardiovascular disease in pediatric renal patients. The aims of the clinical and biochemical surveillance of pediatric patients with CRF or on dialysis are prevention of hyperphosphatemia, avoidance of hypercalcemia and keeping the calcium phosphorus product below 5 mmol ²/l ². The PTH levels should be within the normal range in chronic renal failure (CRF) and up to 2–3 times the upper limit of normal levels in dialysed children. Prevention of ROD is expected to result in improved growth and less vascular calcification.

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Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis.

Geoffrey A Block, Kevin J Martin, Angel de Francisco … (2004)

Treatment of secondary hyperparathyroidism with vitamin D and calcium in patients receiving dialysis is often complicated by hypercalcemia and hyperphosphatemia, which may contribute to cardiovascular disease and adverse clinical outcomes. Calcimimetics target the calcium-sensing receptor and lower parathyroid hormone levels without increasing calcium and phosphorus levels. We report the results of two identical randomized, double-blind, placebo-controlled trials evaluating the safety and effectiveness of the calcimimetic agent cinacalcet hydrochloride. Patients who were receiving hemodialysis and who had inadequately controlled secondary hyperparathyroidism despite standard treatment were randomly assigned to receive cinacalcet (371 patients) or placebo (370 patients) for 26 weeks. Once-daily doses were increased from 30 mg to 180 mg to achieve intact parathyroid hormone levels of 250 pg per milliliter or less. The primary end point was the percentage of patients with values in this range during a 14-week efficacy-assessment phase. Forty-three percent of the cinacalcet group reached the primary end point, as compared with 5 percent of the placebo group (P<0.001). Overall, mean parathyroid hormone values decreased 43 percent in those receiving cinacalcet but increased 9 percent in the placebo group (P<0.001). The serum calcium-phosphorus product declined by 15 percent in the cinacalcet group and remained unchanged in the placebo group (P<0.001). Cinacalcet effectively reduced parathyroid hormone levels independently of disease severity or changes in vitamin D sterol dose. Cinacalcet lowers parathyroid hormone levels and improves calcium-phosphorus homeostasis in patients receiving hemodialysis who have uncontrolled secondary hyperparathyroidism. Copyright 2004 Massachusetts Medical Society

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Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities.

Edmund G Lowrie, Nancy Lew (1990)

Logistic regression analysis was applied to a sample of more than 12,000 hemodialysis patients to evaluate the association of various patient descriptors, treatment time (hours/treatment), and various laboratory tests with the probability of death. Advancing age, white race, and diabetes were all associated with a significantly increased risk of death. Short dialysis times were also associated with high death risk before adjustment for the value of laboratory tests. Of the laboratory variables, low serum albumin less than 40 g/L (less than 4.0 g/dL) was most highly associated with death probability. About two thirds of patients had low albumin. These findings suggest that inadequate nutrition may be an important contributing factor to the mortality suffered by hemodialysis patients. The relative risk profiles for other laboratory tests are presented. Among these, low serum creatinine, not high, was associated with high death risk. Both serum albumin concentration and creatinine were directly correlated with treatment time so that high values for both substances were associated with long treatment times. The data suggest that physicians may select patients with high creatinine for more intense dialysis exposure and patients with low creatinine for less intense treatment. In a separate analysis, observed death rates were compared with rates expected on the basis of case mix for these 237 facilities. The data suggest substantial volatility of observed/expected ratios when facility size is small. Nonetheless, a minority of facilities (less than or equal to 2%) may have higher rates than expected when compared with the pool of all patients in this sample. The effect of various laboratory variables on mortality is substantial, while relatively few facilities have observed death rates that exceed their expected values. Therefore, we suggest that strategies designed to improve the overall mortality statistic for dialysis patients in the United States would be better directed toward improving the quality of care for all patients, particularly high-risk patients, within their usual treatment settings rather than trying to identify facilities with high death rate for possible regulatory intervention.

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Serum vitamin D concentrations among elderly people in Europe.

C Errando Smet, Allen R. Buskirk, O Moreiras … (1995)

Vitamin D status decreases with age, mainly as a result of restricted sunlight exposure, reduced capacity of the skin to produce vitamin D, and reduced dietary vitamin D intake. We measured wintertime serum 25-hydroxyvitamin D [25(OH)D] concentrations in 824 elderly people from 11 European countries. 36% of men and 47% of women had 25(OH)D concentrations below 30 nmol/L. Users of vitamin D supplements and/or sunlamps had higher 25(OH)D (median 54 nmol/L) than non users (median 31 nmol/L). Surprisingly, lowest mean 25(OH)D concentrations were seen in southern European countries. Low 25(OH)D concentrations could largely be explained by attitudes towards sunlight exposure and factors of physical health status, after exclusion of users of vitamin D supplements or sunlamps. Problems with daily living activities and wearing clothes with long sleeves during periods of sunshine were strong predictors of low wintertime serum 25(OH)D concentrations. These findings show that free-living elderly Europeans, regardless of geographical location, are at substantial risk of inadequate vitamin D status during winter and that dietary enrichment or supplementation with vitamin D should be seriously considered during this season.

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Author and article information

Contributors

: +49-6421-2862670 , +49-6421-2865427 , klaus@med.uni-marburg.de

Journal

Journal ID (nlm-ta): Pediatr Nephrol

Title: Pediatric Nephrology (Berlin, Germany)

Publisher: Springer-Verlag (Berlin/Heidelberg )

ISSN (Print): 0931-041X

ISSN (Electronic): 1432-198X

Publication date (Electronic): 25 October 2005

Publication date (Print): February 2006

Volume: 21

Issue: 2

Pages: 151-159

Affiliations

[1 ]Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy

[2 ]Hospital de Hautepierre, Strasbourg, France

[3 ]University of Helsinki, Helsinki, Finland

[4 ]University of Heidelberg, Heidelberg, Germany

[5 ]University Hospital Motol, Prague, Czech Republic

[6 ]A&P Kyriakou Children’s Hospital, Athens, Greece

[7 ]University Hospital for Children, Riga, Latvia

[8 ]University of Ghent, Ghent, Belgium

[9 ]Nottingham City Hospital, Nottingham, UK

[10 ]Wilhelmina Kinderziekenhuis, University of Utrecht, Utrecht, The Netherlands

[11 ]University of Gdansk, Gdansk, Poland

[12 ]University of Ankara, Ankara, Turkey

[13 ]Department of Pediatrics, University of Marburg, Deutschhausstrasse 12, 35033 Marburg, Germany

Article

Publisher ID: 2082

DOI: 10.1007/s00467-005-2082-7

PMC ID: 1766475

PubMed ID: 16247644

SO-VID: ab460da4-bdc8-49e5-bf9b-aaf5d73d331f

History

Date received : 23 November 2004

Date revision received : 28 June 2005

Date accepted : 29 June 2005

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ScienceOpen disciplines: Nephrology

Keywords: chronic renal failure,parathyroidectomy,calcium-phosphate product,vitamin d,secondary hyperparathyroidism

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ScienceOpen disciplines: Nephrology

Keywords: chronic renal failure, parathyroidectomy, calcium-phosphate product, vitamin d, secondary hyperparathyroidism

Prevention and treatment of renal osteodystrophy in children on chronic renal failure: European guidelines

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Karger: Nephrology

Most cited references 77

Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis.

Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities.

Serum vitamin D concentrations among elderly people in Europe.

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