Skip to main content
SpringerLink
Log in

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

  • Brief Report
  • Published:
Pediatric Nephrology Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

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

References

  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 105:1242–1249

    Article  CAS  PubMed  Google Scholar 

  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 18:913–918

    Article  PubMed  Google Scholar 

  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 24:1326–1334

    Article  PubMed  Google Scholar 

  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 41:1163–1169

    Article  PubMed  Google Scholar 

  5. Bak M, Serdaroglu E, Guclu R (2006) Prophylactic calcium and vitamin D treatments in steroid-treated children with nephrotic syndrome. Pediatr Nephrol 21:350–354

    Article  PubMed  Google Scholar 

  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 351:868–875

    Article  CAS  PubMed  Google Scholar 

  7. Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8:1137–1148

    Article  CAS  PubMed  Google Scholar 

  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 15:887–896

    Article  CAS  PubMed  Google Scholar 

  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 109:45–60

    Article  PubMed  Google Scholar 

  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 341–347

    Article  PubMed  Google Scholar 

  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 26:103–109

    Article  CAS  PubMed  Google Scholar 

  12. Dempster DW (1989) Bone histomorphometry in glucocorticoid-induced osteoporosis. J Bone Miner Res 4:137–141

    Article  CAS  PubMed  Google Scholar 

  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 24:503–513

    Article  CAS  PubMed  Google Scholar 

  14. Acott PD, Wong JA, Lang BA, Crocker JF (2005) Pamidronate treatment of pediatric fracture patients on chronic steroid therapy. Pediatr Nephrol 20:368–373

    Article  PubMed  Google Scholar 

  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 25:37–47

    Article  PubMed  Google Scholar 

  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 54:801–806

    Article  CAS  PubMed  Google Scholar 

Download references

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

Author information

Authors and Affiliations

  1. Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada

    Anne Marie Sbrocchi, Janusz Feber & Leanne M. Ward

  2. Genetics Unit, Shriners Hospital for Children, Montreal, QC, Canada

    Frank Rauch

  3. Department of Diagnostic Imaging, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada

    MaryAnn Matzinger

  4. Pediatric Bone Health Clinical and Research Programs, Children’s Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Rd, K1H 8L1, Ottawa, ON, Canada

    Leanne M. Ward

Authors
  1. Anne Marie Sbrocchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Frank Rauch
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. MaryAnn Matzinger
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Janusz Feber
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Leanne M. Ward
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Leanne M. Ward.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sbrocchi, A., Rauch, F., Matzinger, M. et al. Vertebral fractures despite normal spine bone mineral density in a boy with nephrotic syndrome. Pediatr Nephrol 26, 139–142 (2011). https://doi.org/10.1007/s00467-010-1652-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00467-010-1652-5

Keywords

Search

Navigation