The bone and mineral disorder of children undergoing chronic peritoneal dialysis

Abstract

The mineral and bone disorder of chronic kidney disease remains a challenging complication in pediatric end-stage renal disease. Here, we assessed symptoms, risk factors and management of this disorder in 890 children and adolescents from 24 countries reported to the International Pediatric Peritoneal Dialysis Network Registry. Signs of this disease were most common in North American patients. The prevalence of hyperphosphatemia increased with age from 6% in young infants to 81% in adolescents. Serum parathyroid hormone (PTH) was outside the guideline targets in the majority of patients and associated with low calcium, high phosphorus, acidosis, dialysis vintage and female gender. Serum calcium was associated with dialytic calcium exposure, serum phosphorus with low residual renal function and pubertal status. PTH levels were highest in Latin America and lowest in Europe. Vitamin D and its active analogs were most frequently administered in Europe; calcium-free phosphate binders and cinacalcet in North America. Clinical and radiological symptoms markedly increased when PTH exceeded 300 pg/ml, the risk of hypercalcemia increased with levels below 100 pg/ml, and time-averaged PTH concentrations above 500 pg/ml were associated with impaired longitudinal growth. Hence, the symptoms and management of the mineral and bone disorder of chronic kidney disease in children on peritoneal dialysis showed substantial regional variation. Our findings support a PTH target range of 100-300 pg/ml in the pediatric age group.

Mineral Metabolism in European Children Living with a Renal Transplant

“…The prevalence of hyperparathyroidism was lower after a longer time since transplantation. When applying the same guidelines, the prevalence of hyperparathyroidism in our study is lower compared with North America (5) and Iran (28) (both 57%), and might reflect regional differences in PTH control, in keeping with data from pediatric patients on peritoneal dialysis (4).…”

Hemodialysis in Children

“…PTH itself is thought to be an independent risk factor for myocardial fibrosis, arteriolar thickening, and hypertension [58]. There are detailed guidelines from the USA (KDOQI) [59] and Europe [60,61] on PTH management and all aspects of calcium, phosphate, and vitamin D control in order to achieve these aims. European recommendations for children on dialysis are that the plasma PTH should be kept at up to 3 times the upper limit of normal and KDOQI sets higher levels of 3-5 times the upper limit of normal.…”

Peritoneal Dialysis in Children

“…In infants fed with low-phosphorus formulas and otherwise adequate PD treatment, hypophosphatemia is common [228,30], additional oral supplementation may be indicated. In contrast, older children frequently need to restrict phosphate dietary intake (still ensuring an adequate protein intake) and require phosphate binders in order to avoid hyperphosphatemia and its adverse effect on cardiovascular, bone, and endocrine function.…”