Interventions for metabolic bone disease in children with chronic kidney disease.

Systematic review of randomized and controlled pediatric trials in children and adolescents with chronic kidney disease stages 2-5D, including dialysis patients, up to age 21 years. The review assessed vitamin D preparations and phosphate binders for effects on growth, bone health, parathyroid hormone, calcium-phosphate balance, and related harms.

The review evaluated multiple pediatric CKD regimens, including calcitriol, paricalcitol, 1 alpha-hydroxyvitamin D, ergocalciferol, and doxercalciferol given orally, intravenously, or intraperitoneally, plus phosphate binders such as calcium carbonate, calcium acetate, aluminium hydroxide, and sevelamer. Doses and schedules varied widely across small trials, and comparators included another vitamin D regimen, placebo or no specific treatment, or a different phosphate binder.

Overall, vitamin D preparations improved biochemical markers of bone disease, mainly by lowering PTH, but there were no consistent advantages by route, dosing frequency, or specific formulation. Intraperitoneal calcitriol lowered PTH versus oral calcitriol (MD -501.00 pg/mL, 95% CI -721.54 to -280.46), IV vitamin D increased the chance of achieving a 30% fall in PTH on at least two occasions (RR 2.75, 95% CI 1.39 to 5.47), and ergocalciferol delayed secondary hyperparathyroidism in one trial (hazard ratio 0.30, 95% CI 0.09 to 0.93). Phosphate binders had broadly similar biochemical effects overall, but sevelamer reduced hypercalcaemia compared with calcium-containing binders. Most other comparisons were neutral, and the overall certainty was limited by small, short-term studies.

The evidence base was small, heterogeneous, and mostly short term, with many trials using different doses, routes, and outcome definitions. Patient-centered outcomes such as fractures, deformities, and growth were infrequently reported, and several analyses relied on limited or cross-over data that could not always be separated cleanly. Many interventions are older, so applicability to current pediatric CKD care is limited and estimates remain imprecise.