Advertisement

Pediatric Nephrology

, Volume 26, Issue 1, pp 139–142 | Cite as

Vertebral fractures despite normal spine bone mineral density in a boy with nephrotic syndrome

  • Anne Marie Sbrocchi
  • Frank Rauch
  • MaryAnn Matzinger
  • Janusz Feber
  • Leanne M. WardEmail author
Brief Report

Abstract

Glucocorticoids (GCs) are associated with fragility fractures in children with various chronic illnesses. The impact of GCs on bone health in children with nephrotic syndrome (NS) is less well understood. Here we report skeletal findings in a 10-year-old boy with steroid-sensitive NS who presented with back pain due to vertebral fractures 5 years after NS diagnosis. Spine radiographs showed a Genant grade 2 fracture at T7 and a grade 1 fracture at T8. Dual-energy X-ray absorptiometry (DXA) revealed a lumbar spine areal bone mineral density (BMD) Z-score of −0.5 and a total body areal BMD Z-score of −0.4. Quantitative transiliac bone histomorphometry revealed low trabecular bone volume and cortical width but no osteomalacia. Our findings show the potential for significant bone morbidity due to osteoporosis in steroid-sensitive NS treated with intermittent GC therapy and emphasize that vertebral fractures may be an underrecognized complication. Furthermore, our report highlights that vertebral fractures can be associated with normal spine areal BMD in this context, suggesting that DXA-based, anteroposterior areal BMD should not be relied upon exclusively for assessing bone health and disease in children with steroid-sensitive NS.

Keywords

Clinical/pediatrics Corticosteroid osteoporosis Bone histomorphometry Bone densitometry Vertebral fractures 

Abbreviations

AP

anteroposterior

BMD

bone mineral density

BMC

bone mineral content

Cr

creatinine

DXA

dual-energy X-ray absorptiometry

GC

glucocorticoid

NS

nephrotic syndrome

SS

steroid-sensitive

N

normal

Notes

Grants or Fellowships supporting the paper

Dr. Sbrocchi is supported by a NovoNordisk Canadian Pediatric Endocrine Group Clinical Research Fellowship. Dr. Ward is supported by a Canadian Institutes for Health Research New Investigator Award and a Canadian Child Health Clinician Scientist Career Enhancement Award. This study was also supported by the Shriners of North America.

Conflicts of interest

None

References

  1. 1.
    Hogg RJ, Portman RJ, Milliner D, Lemley KV, Eddy A, Ingelfinger J (2000) Evaluation and management of proteinuria and nephrotic syndrome in children: recommendations from a pediatric nephrology panel established at the National Kidney Foundation conference on proteinuria, albuminuria, risk, assessment, detection, and elimination (PARADE). Pediatrics 105:1242–1249CrossRefPubMedGoogle Scholar
  2. 2.
    van Staa TP, Cooper C, Leufkens HG, Bishop N (2003) Children and the risk of fractures caused by oral corticosteroids. J Bone Miner Res 18:913–918CrossRefPubMedGoogle Scholar
  3. 3.
    Halton J, Gaboury I, Grant R, Alos N, Cummings EA, Matzinger M, Shenouda N, Lentle B, Abish S, Atkinson S, Cairney E, Dix D, Israels S, Stephure D, Wilson B, Hay J, Moher D, Rauch F, Siminoski K, Ward LM, Canadian STOPP Consortium (2009) Advanced vertebral fracture among newly diagnosed children with acute lymphoblastic leukemia: results of the Canadian Steroid-Associated Osteoporosis in the Pediatric Population (STOPP) research program. J Bone Miner Res 24:1326–1334CrossRefPubMedGoogle Scholar
  4. 4.
    Gulati S, Godbole M, Singh U, Gulati K, Srivastava A (2003) Are children with idiopathic nephrotic syndrome at risk for metabolic bone disease? Am J Kidney Dis 41:1163–1169CrossRefPubMedGoogle Scholar
  5. 5.
    Bak M, Serdaroglu E, Guclu R (2006) Prophylactic calcium and vitamin D treatments in steroid-treated children with nephrotic syndrome. Pediatr Nephrol 21:350–354CrossRefPubMedGoogle Scholar
  6. 6.
    Leonard MB, Feldman HI, Shults J, Zemel BS, Foster BJ, Stallings VA (2004) Long-term, high-dose glucocorticoids and bone mineral content in childhood glucocorticoid-sensitive nephrotic syndrome. N Engl J Med 351:868–875CrossRefPubMedGoogle Scholar
  7. 7.
    Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8:1137–1148CrossRefPubMedGoogle Scholar
  8. 8.
    Jiang G, Eastell R, Barrington NA, Ferrar L (2004) Comparison of methods for the visual identification of prevalent vertebral fracture in osteoporosis. Osteoporos Int 15:887–896CrossRefPubMedGoogle Scholar
  9. 9.
    Ogden CL, Kuczmarski RJ, Flegal KM, Mei Z, Guo S, Wei R, Grummer-Strawn LM, Curtin LR, Roche AF, Johnson CL (2002) Centers for Disease Control and Prevention 2000 growth charts for the United States: improvements to the 1977 National Center for Health Statistics version. Pediatrics 109:45–60CrossRefPubMedGoogle Scholar
  10. 10.
    van der Sluis IM, de Ridder MA, Boot AM, Krenning EP, de Muinck Keizer-Schrama SM (2002) Reference data for bone density and body composition measured with dual energy x ray absorptiometry in white children and young adults. Arch Dis Child 87:341–347, discussion 341–347CrossRefPubMedGoogle Scholar
  11. 11.
    Glorieux FH, Travers R, Taylor A, Bowen JR, Rauch F, Norman M, Parfitt AM (2000) Normative data for iliac bone histomorphometry in growing children. Bone 26:103–109CrossRefPubMedGoogle Scholar
  12. 12.
    Dempster DW (1989) Bone histomorphometry in glucocorticoid-induced osteoporosis. J Bone Miner Res 4:137–141CrossRefPubMedGoogle Scholar
  13. 13.
    Wetzsteon RJ, Shults J, Zemel BS, Gupta PU, Burnham JM, Herskovitz RM, Howard KM, Leonard MB (2009) Divergent effects of glucocorticoids on cortical and trabecular compartment BMD in childhood nephrotic syndrome. J Bone Miner Res 24:503–513CrossRefPubMedGoogle Scholar
  14. 14.
    Acott PD, Wong JA, Lang BA, Crocker JF (2005) Pamidronate treatment of pediatric fracture patients on chronic steroid therapy. Pediatr Nephrol 20:368–373CrossRefPubMedGoogle Scholar
  15. 15.
    Bianchi ML, Baim S, Bishop N, Gordon CM, Hans DB, Langman CB, Leonard MB, Kalkwarf HJ (2010) Official positions of the International Society for Clinical Densitometry (ISCD) on DXA evaluation in children and adolescents. Pediatr Nephrol 25:37–47CrossRefPubMedGoogle Scholar
  16. 16.
    Peel NF, Moore DJ, Barrington NA, Bax DE, Eastell R (1995) Risk of vertebral fracture and relationship to bone mineral density in steroid treated rheumatoid arthritis. Ann Rheum Dis 54:801–806CrossRefPubMedGoogle Scholar

Copyright information

© IPNA 2010

Authors and Affiliations

  • Anne Marie Sbrocchi
    • 1
  • Frank Rauch
    • 2
  • MaryAnn Matzinger
    • 3
  • Janusz Feber
    • 1
  • Leanne M. Ward
    • 1
    • 4
    Email author
  1. 1.Department of PediatricsChildren’s Hospital of Eastern OntarioOttawaCanada
  2. 2.Genetics UnitShriners Hospital for ChildrenMontrealCanada
  3. 3.Department of Diagnostic ImagingChildren’s Hospital of Eastern OntarioOttawaCanada
  4. 4.Pediatric Bone Health Clinical and Research ProgramsChildren’s Hospital of Eastern Ontario, University of OttawaOttawaCanada

Personalised recommendations