Pediatric Nephrology

, Volume 28, Issue 2, pp 265–275 | Cite as

Nutritional vitamin D use in chronic kidney disease: a survey of pediatric nephrologists

  • Lindsay M. Griffin
  • Michelle R. Denburg
  • Justine Shults
  • Susan L. Furth
  • Isidro B. Salusky
  • Wenke Hwang
  • Mary B. Leonard
Original Article



Vitamin D deficiency may contribute to risk of cardiovascular disease, diabetes, and infections, in addition to known effects on mineral metabolism. Controversy remains regarding the use of nutritional vitamin D supplementation in chronic kidney disease (CKD), and the supplementation practices of pediatric nephrologists are unknown.


An electronic survey containing eight vignettes was sent to physician members of the International Pediatric Nephrology Association in 2011 to identify physician and patient characteristics that influence nephrologists to supplement CKD patients with nutritional vitamin D. Vignettes contained patient characteristics including light vs dark skin, CKD stage, cause of renal disease, parathyroid hormone (PTH), and 25(OH) vitamin D levels. Multivariate logistic generalized estimating equation regression was used to identify predictors of supplementation.


Of 1,084 eligible physicians, 504 (46%) completed the survey. Supplementation was recommended in 73% of cases overall (ranging from 91% of those with vitamin D levels <10 ng/mL to 35% with levels >30). Greater CKD severity was associated with greater recommendation of supplementation, especially for patients with higher vitamin D levels (test for interaction p < 0.0001). PTH level above target for CKD stage was associated with greater recommendation to supplement in pre-dialysis CKD, but did not have an impact on recommendations in dialysis patients (test for interaction p < 0.0001). Skin color, cause of CKD, and albumin levels were not associated with supplementation recommendation.


Recommending nutritional vitamin D is common worldwide, driven by CKD stage and vitamin D and PTH levels. Future studies are needed to establish the risks and benefits of supplementation.


Vitamin D Nutrition Case vignettes Survey Chronic kidney disease Pediatrics 


Funding sources

Lindsay Griffin is supported by the Doris Duke Clinical Research Foundation and Dr. Leonard by K24-DK076808.


  1. 1.
    Kidney Disease: Improving Global Outcomes (2009) KDIGO guidelines: chapter 3.1: diagnosis of CKD-MBD: biochemical abnormalities. Kidney Int 76 [Suppl 113]:S22–S24Google Scholar
  2. 2.
    Kidney Disease Outcomes Quality Initiative (2003) KDOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease: guideline 7. Prevention and treatment of vitamin D insufficiency and vitamin D deficiency in CKD patients. Am J Kidney Dis 42 [Suppl 3]:4Google Scholar
  3. 3.
    Kidney Disease Outcomes Quality Initiative (2005) KDOQI clinical practice guidelines for bone metabolism and disease in children with chronic kidney disease: guideline 8. Prevention and treatment of vitamin D insufficiency and vitamin D deficiency in CKD patients. Am J Kidney Dis 46 [Suppl 1]:4Google Scholar
  4. 4.
    Kidney Disease Outcomes Quality Initiative (2009) KDOQI clinical practice guideline for nutrition in children with CKD: 2008 update: recommendation 7: bone mineral and vitamin D requirements and therapy. Am J Kidney Dis 53 [Suppl 2]:3Google Scholar
  5. 5.
    Mehrotra R, Kermah DA, Salusky IB, Wolf MS, Thadhani RI, Chiu YW, Martins D, Adler SG, Norris KC (2009) Chronic kidney disease, hypovitaminosis D, and mortality in the United States. Kidney Int 76:977–983PubMedCrossRefGoogle Scholar
  6. 6.
    Chonchol M, Scragg R (2007) 25-Hydroxyvitamin D, insulin resistance, and kidney function in the Third National Health and Nutrition Examination Survey. Kidney Int 71:134–139PubMedCrossRefGoogle Scholar
  7. 7.
    Stefíková K, Spustová V, Krivošíková Z, Okša A, Gazdíková K, Fedelešová V, Dzúrik R (2011) Insulin resistance and vitamin D deficiency in patients with chronic kidney disease stage 2–3. Physiol Res 60:149–155PubMedGoogle Scholar
  8. 8.
    Lac PT, Choi K, Liu IA, Meguerditchian S, Rasgon SA, Sim JJ (2010) The effects of changing vitamin D levels on anemia in chronic kidney disease patients: a retrospective cohort review. Clin Nephrol 74:25–32PubMedGoogle Scholar
  9. 9.
    Patel NM, Gutierrez OM, Andress DL, Coyne DW, Levin A, Wolf M (2010) Vitamin D deficiency and anemia in early chronic kidney disease. Kidney Int 77:715–720PubMedCrossRefGoogle Scholar
  10. 10.
    Isakova T, Gutierrez OM, Patel NM, Andress DL, Wolf M, Levin A (2011) Vitamin D deficiency, inflammation, and albuminuria in chronic kidney disease: complex interactions. J Ren Nutr 21:295–302PubMedCrossRefGoogle Scholar
  11. 11.
    Stubbs JR, Idiculla A, Slusser J, Menard R, Quarles LD (2010) Cholecalciferol supplementation alters calcitriol-responsive monocyte proteins and decreases inflammatory cytokines in ESRD. J Am Soc Nephrol 21:353–361PubMedCrossRefGoogle Scholar
  12. 12.
    Barreto DV, Barreto FC, Liabeuf S, Temmar M, Boitte F, Choukroun G, Fournier A, Massy ZA (2009) Vitamin D affects survival independently of vascular calcification in chronic kidney disease. Clin J Am Soc Nephrol 4:1128–1135PubMedCrossRefGoogle Scholar
  13. 13.
    Jean G, Lataillade D, Genet L, Legrand E, Kuentz F, Moreau-Gaudry X, Fouque D, ARNOS Study Investigators (2011) Impact of hypovitaminosis D and alfacalcidol therapy on survival of hemodialysis patients: results from the French ARNOS Study. Nephron Clin Pract 118:c204–c210PubMedCrossRefGoogle Scholar
  14. 14.
    Ravani P, Malberti F, Tripepi G, Pecchini P, Cutrupi S, Pizzini P, Mallamaci F, Zoccali C (2009) Vitamin D levels and patient outcome in chronic kidney disease. Kidney Int 75:88–95PubMedCrossRefGoogle Scholar
  15. 15.
    Shroff R, Wan M, Gullett A, Ledermann S, Shute R, Knott C, Wells D, Aitkenhead H, Manickavasagar B, Van’t Hoff W, Rees L (2012) Ergocalciferol supplementation in children with CKD delays the onset of secondary hyperparathyroidism: a randomized trial. Clin J Am Soc Nephrol 7:216–223PubMedCrossRefGoogle Scholar
  16. 16.
    IOM (Institute of Medicine) (2011) Dietary reference intakes for calcium and vitamin D. The National Academies Press, Washington, DCGoogle Scholar
  17. 17.
    Shroff R, Knott C, Rees L (2010) The virtues of vitamin D—but how much is too much? Pediatr Nephrol 25:1607–1620PubMedCrossRefGoogle Scholar
  18. 18.
    Furth SL, Hwang W, Yang C, Neu AM, Fivush BA, Powe NR (2001) Relation between pediatric experience and treatment recommendations for children and adolescents with kidney failure. JAMA 285:1027–1033PubMedCrossRefGoogle Scholar
  19. 19.
    Swanson DB, Barrow HS, Friedman CP (1982) Issues in assessment of clinical competence. Prof Educ Res 4:2Google Scholar
  20. 20.
    Jones TV, Gerrity MS, Earp J (1990) Written case simulations: do they predict physicians’ behavior? J Clin Epidemiol 43:805–815PubMedCrossRefGoogle Scholar
  21. 21.
    Sandvik H (1995) Criterion validity of responses to patient vignettes: an analysis based on management of female urinary incontinence. Fam Med 27:388–392PubMedGoogle Scholar
  22. 22.
    Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M (2000) Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA 283:1715–1722PubMedCrossRefGoogle Scholar
  23. 23.
    Shah R, Edgar DF, Evans BJ (2010) A comparison of standardised patients, record abstraction and clinical vignettes for the purpose of measuring clinical practice. Ophthalmic Physiol Opt 30:209–224PubMedCrossRefGoogle Scholar
  24. 24.
    Schwartz GJ, Munoz A, Schneider MF, Mak RH, Kaskel F, Warady BA, Furth SL (2009) New equations to estimate GFR in children with CKD. J Am Soc Nephrol 20:629–637PubMedCrossRefGoogle Scholar
  25. 25.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42:377–381PubMedCrossRefGoogle Scholar
  26. 26.
    Edwards PJ, Roberts I, Clarke MJ, DiGuiseppi C, Wentz R, Kwan I, Cooper R, Felix LM, Pratap S (2009) Methods to increase response to postal and electronic questionnaires. Cochrane Database Syst Rev (3):MR000008Google Scholar
  27. 27.
    Moorthi RN, Kandula P, Moe SM (2011) Optimal vitamin D, calcitriol, and vitamin D analog replacement in chronic kidney disease: to D or not to D: that is the question. Curr Opin Nephrol Hypertens 20:354–359PubMedCrossRefGoogle Scholar
  28. 28.
    Wolf M, Shah A, Gutierrez O, Ankers E, Monroy M, Tamez H, Steele D, Chang Y, Camargo CA Jr, Tonelli M, Thadhani R (2007) Vitamin D levels and early mortality among incident hemodialysis patients. Kidney Int 72:1004–1013PubMedCrossRefGoogle Scholar
  29. 29.
    Garcia-Canton C, Bosch E, Ramirez A, Gonzalez Y, Auyanet I, Guerra R, Perez MA, Fernandez E, Toledo A, Lago M, Checa MD (2011) Vascular calcification and 25-hydroxyvitamin D levels in non-dialysis patients with chronic kidney disease stages 4 and 5. Nephrol Dial Transplant 26:2250–2256PubMedCrossRefGoogle Scholar
  30. 30.
    Petchey WG, Howden EJ, Johnson DW, Hawley CM, Marwick T, Isbel NM (2011) Cardiorespiratory fitness is independently associated with 25-hydroxyvitamin D in chronic kidney disease. Clin J Am Soc Nephrol 6:512–518PubMedCrossRefGoogle Scholar
  31. 31.
    Palmer SC, McGregor DO, Craig JC (2009) Vitamin D compounds for people with chronic kidney disease not requiring dialysis. Cochrane Database Syst Rev (4):CD008175Google Scholar
  32. 32.
    Kandula P, Dobre M, Schold JD, Schreiber MY Jr, Mehrotra R, Navaneethan SD (2011) Vitamin D supplementation in chronic kidney disease: a systematic review and meta-analysis of observational studies and randomized controlled trials. Clin J Am Soc Nephrol 6:50–62PubMedCrossRefGoogle Scholar
  33. 33.
    Chandra P, Binongo JN, Ziegler TR, Schlanger LE, Wang W, Someren JT, Tanqpricha V (2008) Cholecalciferol (vitamin D3) therapy and vitamin D insufficiency in patients with chronic kidney disease: a randomized controlled pilot study. Endocr Pract 14:10–17PubMedGoogle Scholar
  34. 34.
    Moe SM, Saifullah A, LaClair RE, Usman SA, Yu Z (2010) A randomized trial of cholecalciferol versus doxercalciferol for lowering parathyroid hormone in chronic kidney disease. Clin J Am Soc Nephrol 5:299–306PubMedCrossRefGoogle Scholar
  35. 35.
    Heaney RP, Holick MF (2011) Why the IOM recommendations for vitamin D are deficient. J Bone Miner Res 26:455–457PubMedCrossRefGoogle Scholar
  36. 36.
    Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM, The Endocrine Society (2011) Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 96:1911–1930PubMedCrossRefGoogle Scholar
  37. 37.
    Jones G (2010) Why dialysis patients need combination therapy with both cholecalciferol and a calcitriol analog? Semin Dial 23:239–243PubMedCrossRefGoogle Scholar
  38. 38.
    Qazi RA, Martin KJ (2010) Vitamin D in Kidney Disease: Pathophysiology and the Utility of Treatment. Endocrinol Metab Clin N Am 39:355–363CrossRefGoogle Scholar
  39. 39.
    Sato KA, Gray RW, Lemann J (1982) Urinary excretion of 25-hydroxyvitamin D in health and the nephrotic syndrome. J Lab Clin Med 99:325–330PubMedGoogle Scholar
  40. 40.
    Levin A, Bakris GL, Molitch M, Smulders M, Tian J, Williams LA, Andress DL (2007) Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease. Kidney Int 71:31–38PubMedCrossRefGoogle Scholar
  41. 41.
    Kellerman SE, Herold J (2001) Physician response to surveys: a review of the literature. Am J Prev Med 20:61–67PubMedCrossRefGoogle Scholar
  42. 42.
    Asch DA, Jedrziewski MK, Christakis NA (1997) Response Rates to Mail Surveys Published in Medical Journals. J Clin Epidemiol 50:1129–1136PubMedCrossRefGoogle Scholar
  43. 43.
    Braithwaite D, Emery J, de Lusignan S, Sutton S (2003) Using the Internet to conduct surveys of health professionals: a valid alternative? Fam Pract 20:545–551PubMedCrossRefGoogle Scholar
  44. 44.
    American Board of Medical Specialties. 2010 ABMS certificate statistics. Accessed January 2012
  45. 45.
    American Board of Pediatrics. The American Board of Pediatrics 2010–2011 workforce data. Accessed January 2012
  46. 46.
    Roethlisberger FJ, Dickson WJ (1939) Management and the worker. Harvard University Press, Cambridge, MAGoogle Scholar

Copyright information

© IPNA 2012

Authors and Affiliations

  • Lindsay M. Griffin
    • 1
  • Michelle R. Denburg
    • 1
  • Justine Shults
    • 2
  • Susan L. Furth
    • 1
  • Isidro B. Salusky
    • 3
  • Wenke Hwang
    • 4
  • Mary B. Leonard
    • 1
    • 2
  1. 1.Department of PediatricsChildren’s Hospital of PhiladelphiaPhiladelphiaUSA
  2. 2.Department of Biostatistics and EpidemiologyPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaUSA
  3. 3.Department of PediatricsDavid Geffen School of Medicine at University of California–Los AngelesLos AngelesUSA
  4. 4.Department of Public Health Sciences, Division of Health Services ResearchPenn State College of MedicineHersheyUSA

Personalised recommendations