Clinical practice recommendations for native vitamin D therapy in children with chronic kidney disease Stages 2–5 and on dialysis

Abstract

Vitamin D deficiency is widely prevalent and often severe in children and adults with chronic kidney disease (CKD). Although native vitamin D {25-hydroxyvitamin D [25(OH)D]} is thought to have pleiotropic effects on many organ systems, its skeletal effects have been most widely studied. The 25(OH)D deficiency is causally linked with rickets and fractures in healthy children and those with CKD, contributing to the CKD-mineral and bone disorder (MBD) complex. There are few studies to provide evidence for vitamin D therapy or guidelines for its use in CKD. A core working group (WG) of the European Society for Paediatric Nephrology (ESPN) CKD-MBD and Dialysis WGs have developed recommendations for the evaluation, treatment and prevention of vitamin D deficiency in children with CKD. We present clinical practice recommendations for the use of ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3) in children with CKD Stages 2-5 and on dialysis. A parallel document addresses treatment recommendations for active vitamin D analogue therapy. The WG has performed an extensive literature review to include meta-analyses and randomized controlled trials in healthy children as well as children and adults with CKD, and prospective observational studies in children with CKD. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system has been used to develop and grade the recommendations. In the absence of applicable study data, the opinion of experts from the ESPN CKD-MBD and Dialysis WGs is provided, but clearly GRADE-ed as such and must be carefully considered by the treating physician, and adapted to individual patient needs as appropriate.

The dietary management of calcium and phosphate in children with CKD stages 2-5 and on dialysis—clinical practice recommendation from the Pediatric Renal Nutrition Taskforce

“…The management of hyperphosphatemia in childhood CKD is covered in the Kidney Disease Improving Global Outcomes (KDIGO) 2017 CKD-MBD update [6] and the UK based National Institute for Health and Care Excellence (NICE) guideline on hyperphosphatemia management (published in 2013 and updated in July 2017) [7,8]. We have not discussed dietary sources of vitamin D as natural (non-fortified) foods provide only a negligible amount of vitamin D [9] and do not significantly alter the serum levels of 25OHD or Ca [10].…”

“…The efficiency of absorption is influenced by the oxalate and phytic acid content of the food, the amount consumed [32], vitamin D status [39], and the child's age. In patients with v i t a m i n D d ef i c i en c y, de f i n ed as a se r u m 2 5hydroxyvitamin D level less than 75 nmol/L [10], only 10-15% of dietary Ca and approximately 60% of dietary P is absorbed, while the efficacy of intestinal Ca and P absorption in vitamin D replete subjects increases to 30-40% and 80%, respectively [9,40]. The amount of Ca absorbed from P-binders is not fully understood [41].…”

“…The Ca intake from the diet may not provide sufficient Ca, particularly as most Ca-rich foods also contain large amounts of P, and are likely to be restricted in CKD patients, as discussed in "Introduction." Furthermore, as reviewed in "Introduction," the bioavailability of Ca and P from different foods varies and also depends on the vitamin D status of the individual [9,10,40].…”

Management of bone disease in cystinosis: Statement from an international conference

“…High doses of active vitamin D may increase hypercalciuria and nephrocalcinosis, and can promote extraskeletal (vascular) calcifications as reported in other patients with advanced CKD . Supplementation of native vitamin D (eg, cholecalciferol) should be titrated to achieve normal values . For most patients, calcium requirements can be met by adequate nutrition and vitamin D administration, but calcium supplementation can serve as “insurance” against imperceptible daily losses of calcium that eventually lower bone density.…”

“…56 Supplementation of native vitamin D (eg, cholecalciferol) should be titrated to achieve normal values. 57 For most patients, calcium requirements can be met by adequate nutrition and vitamin D administration, but calcium supplementation can serve as "insurance" against imperceptible daily losses of calcium that eventually lower bone density. However, calcium supplements may contribute to the development of ectopic (vascular) calcifications in patients with advanced CKD and cumulative calcium intake should be within the recommended daily allowance as recommended for other patients with CKD.…”