Clinical practice recommendations for treatment with active vitamin D analogues in children with chronic kidney disease Stages 2–5 and on dialysis

Abstract

In patients with chronic kidney disease (CKD), renal synthesis of active vitamin D [1,25-dihydroxyvitamin D (1,25(OH)2D)] declines and is associated with hypocalcaemia, secondary hyperparathyroidism and the spectrum of CKD-mineral and bone disorder (MBD). In advanced CKD, active vitamin D analogues, including alfacalcidol, calcitriol and paricalcitol, are routinely administered. There are few studies on the use of vitamin D analogues in children with CKD and on dialysis. It is difficult to define bone-specific outcomes that can guide treatment with active vitamin D analogues in children with CKD-MBD. A core working group (WG) of the European Society for Paediatric Nephrology (ESPN) CKD-MBD and Dialysis WGs has developed recommendations for the use of active vitamin D therapy in children with CKD and on dialysis. A second document in parallel with this one covers treatment recommendations for native vitamin D therapy. The WGs have performed an extensive literature review to include systematic reviews and randomized controlled trials in adults and children with CKD and prospective observational studies in children with CKD. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system was 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.

Clinical practice recommendations for the diagnosis and management of X-linked hypophosphataemia

“…This difference is probably because of the roughly twice higher oral bioavailability of calcitriol than alfacalcidol. A single evening dose might help prevent excessive calcium absorption after food intake and thus hypercalciuria 120 . Several other vitamin D analogues are also available 62,117,121,122 .…”

IPNA clinical practice recommendations for the diagnosis and management of children with steroid-resistant nephrotic syndrome

“…Children with SRNS have urinary losses of vitamin-D binding protein and 25-dihydroxyvitamin D and may develop vitamin D deficiency leading to hypocalcemia, hyperparathyroidism, and impaired bone mineralization [171]. Vitamin D supplementation in these patients is effective [172][173][174], and recommended as in other CKD patients [175]. CNI treatment may cause hypomagnesemia causing leg cramps.…”

“…As in any child with CKD, high blood pressure (> 95th age-sex and height specific percentile) should be treated aiming for blood pressure values < 75th percentile in children without proteinuria, and < 50th percentile in children with proteinuria [182,183]. Other CKDassociated complications should be treated according to current guidelines [133,175,184].…”

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

“…Furthermore, intestinal Ca absorption may be impaired due to dysregulation of the normal homeostatic mechanisms. Low levels of activated vitamin D may lead to reduced Ca absorption [9,40], even in the presence of Ca deficiency [89]. Extrapolation of data from adult CKD studies is not appropriate in this field, as the growing skeleton of children has significantly higher Ca requirements than a mature, possibly osteoporotic, adult skeleton.…”