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  • Review Article
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Mineral and bone disorders in children with chronic kidney disease

Nature Reviews Nephrology volume 7, pages 624–634 (2011)Cite this article

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Abstract

As children with chronic kidney disease (CKD) have a long lifespan, optimal control of bone and mineral homeostasis is essential not only for the prevention of debilitating skeletal complications and for achieving adequate growth but also for preserving long-term cardiovascular health. As the growing skeleton is highly dynamic and at particular risk of deterioration, close control of bone and mineral homeostasis is required in children with CKD. However, assessment of bone disease is hampered by the limited validity of biochemical parameters—major controversy exists on key issues such as parathyroid hormone target ranges and the lack of useful imaging techniques. The role of newly discovered factors in bone and mineral homeostasis, such as fibroblast growth factor 23, is not yet established. Even though scientific evidence is limited in children with CKD, ergocalciferol or cholecalciferol supplementation and the use of calcium-free phosphate binders is recommended. The new drug cinacalcet is highly promising; however, pediatric experience is still limited to observational data and the effect of cinacalcet on longitudinal growth and pubertal development is unknown. Randomized, controlled trials are underway, including studies of cinacalcet pharmacokinetics and pharmacodynamics in infants.

Key Points

  • Chronic kidney disease (CKD) mineral and bone disorder (MBD) is highly dynamic in growing children and requires close monitoring of age-dependent target values and repeated therapeutic adaptations

  • The validity of biochemical and imaging tools in children with CKD is uncertain

  • Ergocalciferol or cholecalciferol supplementation is advised in children who have CKD and a 25-hydroxyvitamin D level of <75 nmol/l

  • In children, sevelamer carbonate and paricalcitol or doxercalciferol should improve control of CKD-MBD; however, this effect has not been conclusively demonstrated

  • Cinacalcet could help control bone and mineral homeostasis in children with CKD; however, caution is advised until the results of current pediatric clinical research trials are available

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Figure 1: The age-dependent calcium and phosphate percentiles in the plasma of healthy children.
Figure 2: The relative distribution of 890 pediatric patients on peritoneal dialysis with regard to mean serum levels of calcium, phosphate and iPTH above (blue), within (yellow) and below (green) target values as recommended by KDOQI.
Figure 3: Clinical and/or radiological symptoms and/or raised levels of calcium × phosphate product according to serum levels of iPTH in 890 children on peritoneal dialysis.
Figure 4: Cinacalcet affects various levels of parathyroid gland function, which explains the powerful action on PTH secretion even in advanced states of parathyroid gland autonomy.
Figure 5: Serum levels of PTH and calcium × phosphate product in 17 children following parathyroidectomy (left, those on dialysis with a functioning graft, right, those who subsequently received a transplant).

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Authors and Affiliations

  1. Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, INF 430, University of Heidelberg, 69120, Heidelberg, Germany

    Claus Peter Schmitt & Otto Mehls

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  2. Otto Mehls
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Both authors contributed equally to all aspects of this Review.

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Correspondence to Claus Peter Schmitt.

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Competing interests

C. P. Schmitt has been a consultant and speaker for Amgen and is a patent holder/applicant with Amgen. C. P. Schmitt has received grant/research support from Amgen and Fresenius. O. Mehls declares no competing interests.

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Schmitt, C., Mehls, O. Mineral and bone disorders in children with chronic kidney disease. Nat Rev Nephrol 7, 624–634 (2011). https://doi.org/10.1038/nrneph.2011.139

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