Original Article 16 Paediatr Indones, Vol. 52, No. 1, January 2012 Calcium and vitamin D supplementation in children with frequently relapsing and steroid-dependent nephrotic syndrome Ayi Dilla Septarini, Taralan Tambunan, Pustika Amalia Abstract Background Children with frequently relapsing and steroid- dependent nephrotic svndrome (lRNS/SDNS) are at risk for osteoporosis due to impaired metabolism of calcium and vitamin D. Objective 1o determine the effect of calcium and vitamin D supplementation on bone mineral density, serum ionized calcium levels and serum 25-hvdroxv-vitamin D levels in children with lRNS and SDNS. Methods A clinical trial with a before and after design was performed. Subjects were SDNS or lRNS pediatric patients ~ 5 vears of a,e. Subjects received oOO m, elemental calcium and 1OO lU vitamin D supplementation for o weeks. Serum ionized calcium, serum 25-hvdroxv-vitamin D |25(H)D], and bone mineral densitv (BMD) were determined before and after the supplementation. Results f the 3O subjects, 2o completed the studv. However, onlv 2O subjects underwent BMD determination before and after supplementation. Of the 28 subjects, 22 had hypocalcemia and 26 had low vitamin D levels. steopenia was found in 11/2O subjects and osteoporosis was in 2/2O subjects. After o weeks of supplementation, mean serum ionized calcium increased from low |1.15 mmol/l (SD O.O3)] to normal |1.1o mmol/l (SD O.O1)] (P<O.OO1) levels, but mean serum 25(H)D onlv increased from vitamin D deficiencv cate,orv |2O n,/ml (SD 7.7)] to vitamin D insufficiencv cate,orv |25.5 n,/ml (7.7)] (P~O.O1O). Mean z-score BMD increased from -1.1 (SD O.9) to -O.7 (SD O.2) after supplementation (P<O.OO1). Conclusion Calcium vitamin D supplementation effectivelv in- creased serum ionized calcium, serum 25(H)D, and BMD in subjects with lRNS and SDNS. [Paediatr Indones. 2012;52:16-21]. Keywords: frequent relapse nephrotic syndrome, steroid dependent, supplementation, calcium, vitamin D, bone mineral density, osteoporosis lrom the Department of Child Health, lacultv of Medicine, Universitv of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Reprint requests to: Avi Dilla Septarini, Department of Child Health, lacultv of Medicine, Universitv of lndonesia, Cipto Man,unkusumo Hospital, Jl. Dipone,oro 71, Jakarta, 1el. 62o5711362319. P atients with nephrotic syndrome (NS), a glomerular disease, usually respond to steroid treatment, but may experience relapses. Of those who achieve remission, 6O-7O' will experience relapses and 5O' of those with relapses will become frequent relapsers. 1,2 Steroid dependency will occur in 5O' of frequent relapsers. 2 Treatment of lRNS and SDNS is challen,in, because children with these conditions must receive hi,h-dose and long-term steroid therapy. Steroids are known to cause osteoporosis and affect bone mineral densitv (BMD) in NS patients. 3-6 Durin, relapse, the condition is thou,ht to worsen, due to frequent loss of vitamin D metabolites and calcium in the urine. 7,o The disease itself and the treatment medication affects skeletal mineralization. Diminished bone mineralization has been reported in children with NS tested by densitometry methods. 5,9 Calcium and vitamin D plav an important role in maintaining bone health. 1O,11 Studies on the role of calcium and vitamin D supplementation in NS Ayi Dilla Septarini et al: Calcium and vitamin D supplementation in nephrotic svndrome Paediatr Indones, Vol. 52, No. 1, January 2012 17 patients are limited. However, lon,itudinal studies bv Oulati et al. 12 showed that calcium and vitamin D supplementation mav improve the BMD in NS patients. Randomized, controlled clinical trials by Bak et al. 13 concluded that calcium and vitamin D supplementation can reduce the incidence of low BMD in NS patients. Althou,h the deteriorative effect of steroid treatment on childrens bones has been well known for years, no recommendation has been suggested for the prevention or treatment of diminished BMD in children with NS. 1here have been few lndonesian studies to date evaluatin, the role of calcium and vitamin D supplementation in lNRS and SDNS patients. 1his studv was conducted to determine the role of calcium and vitamin D supplementation on BMD, serum ionized calcium levels, and serum 25(H)D levels in children with lRNS and SDNS. Methods A clinical trial with a before and after design was performed in the Nephrology Outpatient Care Unit, Department of Child Health, Cipto Man,unkusumo Hospital, Jakarta from November 2O1O until April 2O11. Subjects were SDNS or lRNS children with normal renal function ~ 5 vears of a,e. lxclusion criteria were osteo,enesis imperfecta, juvenile osteoporosis, historv of calcium and vitamin D supplementation for the preceding 6 months, and previous bisphosphonate (anti-resorptive a,ent) therapy. We consecutivelv recruited 3O subjects who fulfilled the study criteria, but only 28 completed the study. These subjects consisted of 16 FRNS patients and 12 SDNS patients. nlv 2O subjects underwent BMD determination before and after supplementation. NS was defined bv edema, massive proteinuria (> 1O m,/m 2 /hr), hypoalbuminemia (<2.5 g/dl), and hyperlipidemia. Frequent relapse was defined as ~ 2 relapses within the first 6 months after presentation or ~ 1 relapses within anv 12 month period. Steroid dependency was defined as two consecutive relapses while under steroid treatment or relapse at least 14 days after steroid withdrawal. History of illness was obtained from each subject, including disease onset, duration of illness, number of total relapses, steroid therapy duration, and cumulative steroid dose. Urea and creatinine levels were also tested. Subjects received oOO m, elemental calcium and 1OO lU vitamin D supplementation daily for 8 weeks. Serum ionized calcium, serum 25(H)D, and BMD were determined before and after supplementation. Serum ionized calcium was measured by Ciba-Corning Model 288 blood gas analyzer
, using electrochemiluminescence immunoassay (ECLIA). BMD of the lumbar spine (l 1 -L 4 ) was measured bv dual ener,v x-rav absorptiometrv (DlXA) lunar Ol Medical Svstems
, and the patients data were
expressed as z-scores (number of SDs from the mean values of healthv Asian children matched for sex and chronolo,ical a,e). A lumbar spine BMD z-score of between -1.O and -2.O was classified as osteopenia, while a z-score of less than -2.O was classified as osteoporosis. Data was analvzed usin, SPSS for windows version 17.O pro,ram, with P<O.O5 considered as si,nificant. Studv approval was obtained from the lthics Committee, lacultv of Medicinem, Universitv of Indonesia. Results We recruited 28 subjects for our study, consisting of 16 lRNS and 12 SDNS patients. 1here were 21 bovs and 7 ,irls (3:1) a,ed 5-11.7 vears. Oender, a,e, a,e at onset of illness, body weight, body height, nutritional status based on body mass index (BMI), and blood pressure between the two groups were comparable. Subjects with SDNS had ,reater cumulative steroid dose compared to that of FRNS subjects. All subjects had normal renal function (Table 1). verall, 22/2o subjects were hvpocalcemic (serum ionized calcium level <1.17 mmol/l). 1wentv- six subjects had low serum vitamin D levels, with 1O subjects classified to be in a state of insufficiencv (serum 25(H)D at 2O - 3O n,/ml) and the other 16 subjects to be in a state of deficiency (serum 25(OH) D at < 2O n,/ml). 1here were no differences in Ayi Dilla Septarini et al: Calcium and vitamin D supplementation in nephrotic svndrome 18 Paediatr Indones, Vol. 52, No. 1, January 2012 calcium status or vitamin D status between the two groups (Table 2). f the 2O subjects who underwent bone densitometrv, 11/2O had osteopenia (z-score BMD between -1.O and -2.O) and 2/2O had osteoporosis (z-score BMD < -2.O) (Table 3). Table 4 shows the mean serum ionized calcium levels, mean serum 25(H)D levels and BMD before and after o weeks of supplementation. Mean serum ionized calcium increased from low |1.15 mmol/l (SD O.O3)] to normal |1.1o mmol/l (SD O.O1)] (P <O.OO1). However, mean serum 25(H)D onlv increased from the cate,orv of vitamin D deficiencv |2O n,/ ml (SD 7.7)] to insufficiencv |25.5 n,/ml (SD 7.7)] (P~O.O1), possiblv indicatin, a suboptimal duration of supplementation. Mean z-score BMD increased from the cate,orv of osteopenia |-1.1 (SD O.9)] to normal |-O.7 (SD O.2)] after supplementation (P<O.OO1). Discussion Disorders of mineral metabolism mav occur in NS patients with normal kidney function, including hvpocalcemia and hvpovitaminosis D. 14 Hypocalcemia in NS patients may be due to loss of calcium in the urine, decreased calcium absorption in the intestine, and steroidal side effects. 8,15 As a consequence, BMD may decrease, leading to the risk of fracture. 14 Table 1. Subjects characteristics Characteristic FRNS (n = 16) SDNS (n = 12) Gender Male, n Female, n Median age, years (range) Median onset, years (range) Median duration of illness months (range) Mean total no. of relapses (SD) Median steroid therapy duration, months (range) Mean cumulative steroid dose, mg (SD) Mean body weight, kg (SD) Mean body height, cm ( SD) Median BMI, kg/m2 (range) Nutritional status (based on BMI) Undernourished, n Well-nourished, n Overweight, n Obese, n Blood pressure Mean systolic, mmHg (SD) Mean diastolic, mmHg (SD) Median urea, mg/dL (range) Mean creatinine, mg/dL (SD) 11 5 8.3 (5.1-14.5) 3 (1.8-8.6) 64 (30-131) 12.2 (6) 34.5 (18-89) 14,943 (7,137) 30 (8.8) 125 (13.6) 19.8 (13.8-23.5) 0 9 1 6 104 (11) 72 (10) 17 (12-34) 0.43 (0.12) 10 2 6.8 (5-13.7) 2.6 (1-7.8) 35.5 (11-138) 11 (4.5) 25 (9-62) 20,780 (27,937) 23.8 (10.4) 115 (15.3) 17.1 (13.1-21.5) 1 8 2 1 107 (12) 72 (7) 16.5 (9-26) 0.37 (0.1) SD: standard deviation Table 2. Calcium and vitamin D status before supplemen- tation Criteria FRNS (n = 16) SDNS (n = 12) P Calcium status Hypocalcemia Normal Vitamin D status Normal nsufciency Deciency 13 3 2 5 9 9 3 0 5 7 0.159 ) 0.719 < ) Chi-square test < Kolmogorov-Smirnov test Table 3. Bone mineral density in FRNS and SDNS patients before supplementation Criteria FRNS (n = 10) SDNS (n = 10) P Bone mineral density Normal Osteopenia Osteoporosis 2 7 1 2 7 1 0.975 < < Kolmogorov-Smirnov test Ayi Dilla Septarini et al: Calcium and vitamin D supplementation in nephrotic svndrome Paediatr Indones, Vol. 52, No. 1, January 2012 19 Clinical manifestations of hvpocalcemia varv from asvmptomatic to convulsions, dependin, on the duration, severitv, and rapiditv of the hvpocalcemia. Dia,nosis should not depend on the ionized calcium level at one random examination. 16 Signs and symptoms of hypocalcemia usually occur if the ionized calcium level is < 1.1 mmol/l and rapid intravenous correction is indicated if the level is < O.o mmol/l. 17 In our study, 22/28 subjects were hypocalcemic (serum ionized calcium < 1.17 mmol/l), but no subjects had < 1.1 mmol/L serum ionized calcium. Furthermore, all subjects with hypocalcemia were asymptomatic. Similar to our results, Nurmalia et al. 18 reported the proportion of hypocalcemia in FRNS and SDNS subjects to be 16/22. We observed that the pre-supplementation mean serum ionized calcium was 1.15 mmol/l (SD O.O3), similar to the results of Nurmalia et al. 18 |1.11 n,/ml (SD O.O1)]. Serum 25(H)Dtends to decrease in NS patients due to the loss of vitamin D-bindin, protein in urine. Vitamin D plavs an important role for maintenance of calcium and phosphorus metabolism, involved in controlling interactions between the intestine, bone, and kidnev. 1he active form of vitamin D (1,25(OH) 2 D) has several functions: stimulatin, the absorption of calcium and phosphorus in the intestine, calcium mobilization from bone, and stimulating calcium reabsorption at the distal renal tubules (parathormone-dependent). 19 Without vitamin D, onlv 1O to 15' of dietarv calcium is absorbed. 2O We found that 26/2o subjects had low levels of vitamin D, with 1O subjects in a vitamin D insufficiency state and 16 subjects in a deficiency state. Nurmalia et al. 18 reported the proportion of vitamin D insufficiencv to be 1O/22 and vitamin D deficiencv to be 9/22. ur subjects had mean serum 25(H)D level of 2O n,/ml (SD 7.7), while Nurmalia et al. 18 reported a similar mean serum 25(H)D of 21.32 n,/ ml (SD 6.65). Two subjects had osteoporosis but none experien- ced fractures. Children with NS, especially those who are frequent relapsers or steroid-dependent, are exposed to the risk of reduced BMD, and thus have a greater risk of fracture or inadequate peak bone mass attainment. 16 These conditions may occur due to biochemical and metabolic disturbances caused by loss of protein and minerals in urine during the nephrotic stage. 7,o ln addition to calcium and vitamin D levels, side effects of steroid therapy are another important factor affecting bone health. Steroids are the mainstay of therapy for NS patients. It is uncertain when the most rapid bone loss occurs, but it is thought that the highest decrease occurs in the first 6-12 months of steroid therapv. Several studies showed that the extent of the decrease of bone mass correlated with the dose and duration of therapy. The greater dose and the longer duration of steroid therapy, the greater the bone loss. Therefore, patients with NS, particularlv lRNS and SDNS, have a hi,her risk of Table 4. Serum ionized calcium, serum 25(OH)D and BMD before and after supplementation in FRNS and SDNS groups Parameter by group Before supplementation After supplementation P FRNS (n=16) Mean ionized calcium, mmol/L (SD) Mean 25(OH)D, ng/mL (SD) SDNS (n=12) Mean ionized calcium, mmol/L (SD) Mean 25(OH)D, ng/mL (SD) FRNS and SDNS (n=28) Mean ionized calcium, mmol/L (SD) Mean 25(OH)D, ng/mL (SD) FRNS (n=10) Mean z-score BMD L1-4 (SD) SDNS (n=10) Mean z-score BMD L1-4 (SD) FRNS and SDNS (n=20) Mean z-score BMD L1-4 (SD) 1.15 (0.02) 20.8 (8.5) 1.15 (0.03) 18.9 (6.7) 1.15 (0.03) 20 (7.7) -1.2 (1) -1 (0.7) -1.1 (0.9) 1.19 (0.04) 27.4 (6.8) 1.18 (0.04) 22.8 (8.4) 1.18 (0.04) 25.5 (7.7) -0.7 (1.3) -0.8 (0.9) -0.7 (0.2) 0.042* 0.021* <0.001^ 0.217* <0.001* 0.010* 0.325* 0.018^ 0.003^ * Paired t-test; ^Wilcoxon test Ayi Dilla Septarini et al: Calcium and vitamin D supplementation in nephrotic svndrome 20 Paediatr Indones, Vol. 52, No. 1, January 2012 impaired BMD. 15,21 Risk factors for reduced BMD are cumulative steroid dose >5OO m,, steroid exposure >12 months, prednisone dose >7.5 m,/dav, and ~1 courses of high-dose prednisone. 22 We found osteopenia in 11/2O subjects and osteoporosis in 2/2O subjects. Nurmalia et al. 18 reported osteopenia in 4/22 subjects and osteoporosis in 5/22 subjects. ln a studv on 1OO subjects with lRNS, SDNS, infrequent NS (llNS), and steroid-resistant NS (SRNS), Oulati et al. 12 found that 61' had osteopenia and 22' had osteoporosis. ln contrast leonard et al. 22 , Mishra et al. 23 , and Shouman et al., 24 found that children with NS had BMDs not si,nificantlv different from healthv children. ur subjects had mean BMD z-score of -1.1 (SD O.9), which was included in the osteopenia category, similar to results of Nurmalia et al. 18 Compliance in our study was good in both groups (o2.2 ' and oO.1'). 1wo previous studies examined the role of calcium and vitamin D supplementation in NS patients. ln a studv bv Oulati et al., 12 oo subjects with lRNS, SDNS, llNS, and SRNS received fixed doses (5OO m, calcium carbonate equivalent to 2OO m, elemental calcium and 2OO lU vitamin D) per dav for 6-12 months. 1hev reported that the mean spinal BMD values were si,nificantlv better on follow-up (O.6O7O.O13 ,/ cm2) as compared to baseline values (O.561O.O1O ,/ cm2) (P<O.OOO1). 12 Bak et al. 13 examined the role of calcium and vitamin D supplementation in llNS and new NS patients. 1hev were ,iven 1OOO m, elemental calcium and 1OO lU vitamin D for o weeks. BMD was significantly decreased in both the treatment and non- treatment ,roups, but the percenta,e of BMD decrease was found to be significantly lower in the treatment ,roup than in the non-treatment ,roup (1.62.1' vs. 13.O1.O', respectivelv, P<O.OO1). Side effects due to the use of calcium and vitamin D supplementation have been rarelv reported. 1he maximum safe dose of vitamin D is 2OOO lU/dav, 25 while that of elemental calcium is 25OO m,/dav. 26 Vitamin D intoxication is defined as the occurrence of hvpercalcemia (>2.65 mmol/l) and increased level of 25(H)D (>15O n,/ml). 27 Hypercalcemia causes svmptoms such as anorexia, nausea, vomitin,, polyuria, weakness, constipation, abdominal pain, headache, arrhythmia, and bradycardia. 28 No side effects were reported by our subjects after 8 weeks of calcium and vitamin D supplementation. A limitation of this study was the design used (before and after treatment) because we had no control subjects who did not receive supplementation. Another limitation was the lack of analvsis of dietarv intake of calcium and vitamin D. Compliance rate was also obtained bv historv- taking only and thus may result in inaccurate information. ln conclusion, we observed that supplementation with oOO m, elemental calcium and 1OO lU vitamin D dailv for o weeks, effectivelv increased serum ionized calcium levels, serum 25(H)D levels, and BMD in NS patients. Since 25(H)D levels were not adequately increased, further randomized, controlled trials with longer treatment duration and more subjects are needed. No side effects were associated with the supplementation. References 1. Alatas H, 1ambunan 1, 1rihono PP, Pardede S. Konsensus tata laksana sindrom nefrotik primer pada anak. Jakarta: Unit Kerja Koordinasi Nefrolo,i lkatan Dokter Anak lndonesia, 2OO5. p. 1-1o. 2. Vo,t BA, Avner lD. Nephrotic svndrome. ln: Behrman RE, Kliegman RM, Jenson HB, editors. Nelsons textbook of pediatrics. 17th ed. Philadelphia: Saunders, 2OO1. p. 1753-7. 3. Kano K, Hoshi M, Nishikura K, Yamada Y, Arisaka . Skeletal effects of short-term prednisolone therapy in children with steroid-responsive nephrotic svndrome. Clin lxp Nephrol. 2OO1,5:1O-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 receivin, high-dose glucocorticoid and one-cycle etidronate therapy. Calcif 1issue lnt. 2OOO,66:195-9. 5. Basiratnia M, lallahzadeh MH, Derakhshan A, Hosseini-Al- Hashemi O. Bone mineral densitv in children with relapsin, nephrotic svndrome. lran J Med Sci. 2OO6,31:o2-6. 6. l,aard K, Storm 1, Van Wovern N. Olucorticoid induced osteoporosis in lumbar spine, forearm and mandible of nephrotic patients: a double blind study on high dose long- term effects of prednisolone versus deflazocort. Calcif 1issue lnt. 1992,5O:16O-7. 7. Mittal SK, Dash SC, 1iwari SC, A,arwal SK, Saxena S, Fishbane S. Bone histology in patients with nephrotic syndrome and normal renal function. Kidnev lnt. 1999,55:1912-9. Ayi Dilla Septarini et al: Calcium and vitamin D supplementation in nephrotic svndrome Paediatr Indones, Vol. 52, No. 1, January 2012 21 o. lreundlich M, Bour,oi,nie J, zilleruelo O, Abitbol C, Canteburv JM, Strauss J. Calcium and vitamin D metabolism in children with nephrotic svndrome. J Pediatr. 19o6,1Oo:3o3-7. 9. Oulati S, Oodbole M, Sin,h U, Oulati K, Srivastava A. Are children with idiopathic nephrotic syndrome at risk for metabolic bone disease' Am J Kidnev Dis. 2OO3,11:1163-9. 1O. American Academv of Pediatrics. Calcium requirements of infants, children, and adolescents. Pediatrics. 1999,1O1: 1152-7. 11. Wa,ner Cl, Oreer lR. Prevention of rickets and vitamin D deficiencv in infants, children, and adolescents. Pediatrics. 2OOo,122:1112-52. 12. Oulati S, Sharma RK, Oulati K, Sin,h U, Srivastava A. Longitudinal follow-up of bone mineral density in children with nephrotic svndrome and the role of calcium and vitamin D supplements. Nephrol Dial 1ransplant. 2OO5,2O:159o- 16O3. 13. Bak M, Serdaro,lu l, Ouclu R. Prophvlactic calcium and vitamin D treatments in steroid-treated children with nephrotic svndrome. Pediatr Nephrol. 2OO6,21:35O-1. 11. lreundlich M, Jofe M, Ooodman W, Saluskv lB. Bone histology in steroid-treated children with non-azotemic nephrotic svndrome. Pediatr Nephrol. 2OO1,19:1OO-7. 15. Canalis E. Mechanisms of glucocorticoid action in bone: implications to glucocorticoid-induced osteoporosis. lndocrinolo,v. 1996,o1:3111-7. 16. Shaw N. A practical approach to hypocalcaemia in children. ln: Al,rove J, Shaw NJ, editors. Calcium and bone disorders in children and adolescents. Basel: Karger; 2OO9. p. 73-92. 17. Sku,or M. Cleveland Clinic Center for Continuin, lducation. Hvpocalcemia. |Cited 2O11 Mav 1]. Available from: http://www.clevelandclinicmeded.com/medicalpubs/ diseasemanagement/endocrinology/hypocalcemia/#cesec6 1o. Nurmalia lD, 1ambunan 1, Amir l. Comparison of bone mineral density in steroid dependent, frequent relapse, and infrequent relaps nephrotic svndrome children. Paediatr lndones. 2O1O,5O:193-o. 19. levine MA. Normal mineral homeostasis. ln: Hochber, z, editor. Vitamin D and rickets. 2 nd ed. Switzerland: Karger; 2OO3. pp. 11-33. 2O. Holick Ml. Vitamin D deficiencv. N ln,l J Med. 2OO7, 357:266-o1. 21. Hartman C, Hochber, z, Shamir R. steoporosis in pediatrics. lMAJ. 2OO3,5:5O9-15. 22. leonard MB. Olucocorticoid-induced osteoporosis in children: impact of the underlvin, disease. Pediatrics. 2OO7,119:166-71. 23. Mishra P, Meena SK, Sin,h SK, Prasad R, Mishra RN. Bone mineral densitv in children with steroid-sensitive nephrotic svndrome. lndian J Pediatr. 2OO9,76:1237-9. 21. Shouman MO, Na,wa Abdallah l, ll Me,uid A, Salama lll, ll Ohorourv l, Abou lsmail lA, et al. Bone mineral densitv markers in children with steroid sensitive idiopathic nephrotic svndrome. lJAR. 2O1O,2:15O-6. 25. Vieth R. Vitamin D supplementation, 25-hvdroxvvitamin D concentrations, and safetv. Am J Clin Nutr. 1999,69:o12-56. 26. Straub DA. Calcium supplementation in clinical practice: a review of forms, doses, and indications. Nutr Clin Pract. 2OO7,22:2o6-96. 27. Vieth R. Vitamin D toxicitv, policv, and science. J Bone Miner Res. 2OO7,22:61-o. 2o. Vieth R, Chan PR, Maclarlane OD. lfficacv and safetv of vitamin D3 intake exceedin, the lowest observed adverse effect level. Am J Clin Nutr. 2OO1,73:2oo-91.