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Jørgensen HS, Vervloet M, Cavalier E, Bacchetta J, de Borst MH, Bover J, Cozzolino M, Ferreira AC, Hansen D, Herrmann M, de Jongh R, Mazzaferro S, Wan M, Shroff R, Evenepoel P. The role of nutritional vitamin D in chronic kidney disease-mineral and bone disorder in children and adults with chronic kidney disease, on dialysis, and after kidney transplantation-a European consensus statement. Nephrol Dial Transplant 2025; 40:797-822. [PMID: 39875204 PMCID: PMC11960744 DOI: 10.1093/ndt/gfae293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Indexed: 01/30/2025] Open
Abstract
Vitamin D deficiency is common in patients with chronic kidney disease (CKD) and associates with poor outcomes. Current clinical practice guidelines recommend supplementation with nutritional vitamin D as for the general population. However, recent large-scale clinical trials in the general population failed to demonstrate a benefit of vitamin D supplementation on skeletal or non-skeletal outcomes, fueling a debate on the rationale for screening for and correcting vitamin D deficiency, both in non-CKD and CKD populations. In a collaboration between the European Renal Osteodystrophy initiative of the European Renal Association (ERA) and the European Society for Paediatric Nephrology (ESPN), an expert panel performed an extensive literature review and formulated clinical practice points on vitamin D supplementation in children and adults with CKD and after kidney transplantation. These were reviewed by a Delphi panel of members from relevant working groups of the ERA and ESPN. Key clinical practice points include recommendations to monitor for, and correct, vitamin D deficiency in children and adults with CKD and after kidney transplantation, targeting 25-hydroxyvitamin D levels >75 nmol/l (>30 ng/ml). Although vitamin D supplementation appears well-tolerated and safe, it is recommended to avoid mega-doses (≥100 000 IU) and very high levels of 25 hydroxyvitamin D (>150-200 nmol/l, or 60-80 ng/ml) to reduce the risk of toxicity. Future clinical trials should investigate the benefit of vitamin D supplementation on patient-relevant outcomes in the setting of vitamin D deficiency across different stages of CKD.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Marc Vervloet
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Etienne Cavalier
- Department of Clinical Chemistry, CIRM, University of Liege, CHU de Liège, Liège, Belgium
| | - Justine Bacchetta
- Department of Pediatric Nephrology, Reference Center for Rare Diseases of Calcium and Phosphate, INSERM1033 Research Unit, Hospices Civils de Lyon, Université Lyon 1, Lyon, France
| | - Martin H de Borst
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jordi Bover
- Department of Nephrology, University Hospital Germans Trias i Pujol, Badalona (Barcelona), Catalonià, Spain
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, Milan, Italy
| | - Ana Carina Ferreira
- Nephrology Department, Hospital Curry Cabral | ULS São José, Lisbon, Portugal and Nova Medical School, Lisbon, Portugal
| | - Ditte Hansen
- Department of Nephrology, Copenhagen University Hospital-Herlev, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Markus Herrmann
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Renate de Jongh
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sandro Mazzaferro
- Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Mandy Wan
- Institute of Pharmaceutical Science, King's College London, London, UK and Department of Evelina Pharmacy, Guys' & St Thomas' NHS Foundation Trust, London, UK
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children; University College London, London, UK
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
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Magagnoli L, Cassia M, Galassi A, Ciceri P, Massó E, Gelpi R, Bover J, Cozzolino M. Vitamin D: are all compounds equal? Clin Kidney J 2025; 18:i61-i96. [PMID: 40083955 PMCID: PMC11903094 DOI: 10.1093/ckj/sfae417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Indexed: 03/16/2025] Open
Abstract
Vitamin D is a pre-hormone essential for maintaining mineral homeostasis and also plays significant roles in bone, cardiovascular and renal health. Vitamin D deficiency is prevalent in the general population, and even more so in chronic kidney disease (CKD) patients, in which it contributes to the development and progression of mineral and bone disorder. The landscape of vitamin D treatment has evolved, with several analogues now available, each possessing distinct pharmacokinetic and pharmacodynamic properties, efficacies and safety profiles. This diversity allows for tailored, personalized approaches to treatment in CKD patients. This review aims to provide a comprehensive overview of vitamin D, including its natural sources and metabolism, and examines the main available pharmacological vitamin D products. Particular emphasis is placed on their application in CKD management, highlighting how these compounds can be strategically used to address both vitamin D deficiency and secondary hyperparathyroidism, while also acknowledging the ongoing debate about their impact on bone health and other clinical outcomes.
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Affiliation(s)
| | - Matthias Cassia
- Nephrology Unit, Spedali Civili di Brescia Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Andrea Galassi
- Renal and Dialysis Unit, ASST Rhodense, Garbagnate, Milan, Italy
| | - Paola Ciceri
- Laboratory of Experimental Nephrology, Department of Health Sciences, University of Milan, Milan, Italy
| | - Elisabet Massó
- Nephrology Department, University Hospital Germans Trias I Pujol, REMAR-IGTP Group, RICORS 2040 Network, Barcelona, Spain
| | - Rosana Gelpi
- Nephrology Department, University Hospital Germans Trias I Pujol, REMAR-IGTP Group, RICORS 2040 Network, Barcelona, Spain
| | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias I Pujol, REMAR-IGTP Group, RICORS 2040 Network, Barcelona, Spain
| | - Mario Cozzolino
- Department of Health Sciences, University of Milan, Milan, Italy
- Renal Division, ASST Santi Paolo e Carlo, Milan, Italy
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Bover J, Gunnarsson J, Csomor P, Kaiser E, Cianciolo G, Lauppe R. Impact of nutritional vitamin D supplementation on parathyroid hormone and 25-hydroxyvitamin D levels in non-dialysis chronic kidney disease: a meta-analysis. Clin Kidney J 2021; 14:2177-2186. [PMID: 34603696 PMCID: PMC8483691 DOI: 10.1093/ckj/sfab035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/11/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Secondary hyperparathyroidism (SHPT) is a common and major complication in chronic kidney disease (CKD), reflecting the increase of parathyroid hormone (PTH) in response to reduced vitamin D signalling and hypocalcaemia. This meta-analysis evaluated the impact of nutritional vitamin D (NVD) (cholecalciferol or ergocalciferol) on SHPT-related biomarkers. METHODS A systematic literature search was performed in PubMed to identify relevant randomized control trials to be included in the meta-analysis. Fixed- and random-effects models were used to pool study-level results. Effects were studied within NVD study arms and relative to control groups (placebo/no treatment); the former in order to identify the effect of actively altering biomarkers levels. RESULTS Reductions in PTH from supplementation with NVD were small when observed within the NVD study arms (pooled reduction: 10.5 pg/mL) and larger when compared with placebo/no treatment (pooled reduction: 49.7 pg/mL). NVD supplementation increased levels of 25-hydroxyvitamin D [25(OH)D] in both analyses (increase within NVD study arm: 20.6 ng/mL, increase versus placebo/no treatment: 26.9 ng/mL). While small and statistically non-significant changes in phosphate and fibroblast growth factor 23 were observed, NVD supplementation caused calcium levels to increase when compared with placebo/no treatment (increase: 0.23 mg/dL). CONCLUSIONS Our results suggest that supplementation with NVD can be used to increase 25(OH)D to a certain extent, while the potential of NVD to actively reduce PTH in non-dialysis-CKD patients with SHPT is limited.
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Affiliation(s)
- Jordi Bover
- Fundació Puigvert, Servicio de Nefrología, IIB Sant Pau, REDinREN, Barcelona, Spain
| | | | | | | | - Giuseppe Cianciolo
- Nephrology Dialysis and Kidney Transplantation Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Malpighi Hospital, Bologna, Italy
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Galassi A, Ciceri P, Porata G, Iatrino R, Boni Brivio G, Fasulo E, Magagnoli L, Stucchi A, Frittoli M, Cara A, Cozzolino M. Current treatment options for secondary hyperparathyroidism in patients with stage 3 to 4 chronic kidney disease and vitamin D deficiency. Expert Opin Drug Saf 2021; 20:1333-1349. [PMID: 33993809 DOI: 10.1080/14740338.2021.1931117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Secondary hyperparathyroidism (SHPT) represents a complication of chronic kidney disease (CKD). Vitamin D system is altered since early CKD, and vitamin D deficiency is an established trigger of SHPT. Although untreated SHPT may degenerate into tertiary hyperparathyroidism with detrimental consequences in advanced CKD, best treatments for counteracting SHPT from stage 3 CKD are still debated. Enthusiasm on prescription of vitamin D receptor activators (VDRA) in non-dialysis renal patients, has been mitigated by the risk of low bone turnover and positive calcium-phosphate balance. Nutritional vitamin D is now suggested as first-line therapy to treat SHPT with low 25(OH)D insufficiency. However, no high-grade evidence supports the best choice between ergocalciferol, cholecalciferol, and calcifediol (in its immediate or extended-release formulation).Areas covered: The review discusses available data on safety and efficacy of nutritional vitamin D, VDRA and nutritional therapy in replenishing 25(OH)D deficiency and counteracting SHPT in non-dialysis CKD patients.Expert opinion: Best treatment for low 25(OH)D and SHPT remains unknown, due to incomplete understanding of the best homeostatic, as mutable, adaptation of mineral metabolism to CKD progression. Nutritional vitamin D and nutritional therapy appear safest interventions, whenever contextualized with single-patient characteristics. VDRA should be restricted to uncontrolled SHPT by first-line therapy.
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Affiliation(s)
- Andrea Galassi
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and Fondazione D'Amico per La Ricerca Sulle Malattie Renali, Milan, Italy
| | - Giulia Porata
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy
| | | | - Giulia Boni Brivio
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy.,Department of Health and Science, University of Milan, Milan, Italy
| | - Eliana Fasulo
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy
| | - Lorenza Magagnoli
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy.,Department of Health and Science, University of Milan, Milan, Italy
| | - Andrea Stucchi
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy
| | - Michela Frittoli
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy.,Department of Health and Science, University of Milan, Milan, Italy
| | - Anila Cara
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy.,Department of Health and Science, University of Milan, Milan, Italy
| | - Mario Cozzolino
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy.,Department of Health and Science, University of Milan, Milan, Italy
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Rastogi A, Bhatt N, Rossetti S, Beto J. Management of Hyperphosphatemia in End-Stage Renal Disease: A New Paradigm. J Ren Nutr 2020; 31:21-34. [PMID: 32386937 DOI: 10.1053/j.jrn.2020.02.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/27/2020] [Accepted: 02/08/2020] [Indexed: 12/12/2022] Open
Abstract
Bone and mineral metabolism becomes dysregulated with progression of chronic kidney disease (CKD), and increasing levels of parathyroid hormone serve as an adaptive response to maintain normal phosphorus and calcium levels. In end-stage renal disease, this response becomes maladaptive and high levels of phosphorus may occur. We summarize strategies to control hyperphosphatemia based on a systematic literature review of clinical trial and real-world observational data on phosphorus control in hemodialysis patients with CKD-mineral bone disorder (CKD-MBD). These studies suggest that current management options (diet and lifestyle changes; regular dialysis treatment; and use of phosphate binders, vitamin D, calcimimetics) have their own benefits and limitations with variable clinical outcomes. A more integrated approach to phosphorus control in dialysis patients may be necessary, incorporating measurement of multiple biomarkers of CKD-MBD pathophysiology (calcium, phosphorus, and parathyroid hormone) and correlation between diet adjustments and CKD-MBD drugs, which may facilitate improved patient management.
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Affiliation(s)
- Anjay Rastogi
- David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - Nisha Bhatt
- Division of Nephrology, Department of Medical Affairs, Amgen Inc., Thousand Oaks, California
| | - Sandro Rossetti
- Division of Nephrology, Department of Medical Affairs, Amgen Inc., Thousand Oaks, California
| | - Judith Beto
- Division of Nephrology and Hypertension, Loyola University Chicago, Maywood, Illinois
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Capelli I, Cianciolo G, Gasperoni L, Galassi A, Ciceri P, Cozzolino M. Nutritional vitamin D in CKD: Should we measure? Should we treat? Clin Chim Acta 2019; 501:186-197. [PMID: 31770508 DOI: 10.1016/j.cca.2019.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 02/08/2023]
Abstract
Vitamin Ddeficiency is frequently present in patients affected by chronic kidney disease (CKD). Experimental studies demonstrated that Vitamin D may play a role in the pathophysiology of diseases beyond mineral bone disorders in CKD (CKD-MBD). Unfortunately, the lack of large and interventional studies focused on the so called "non-classic" effects of 25(OH) Vitamin D supplementation in CKD patients, doesn't permit to conclude definitely about the beneficial effects of this supplementation in clinical practice. In conclusion, treatment of nutritional vitamin D deficiency in CKD may play a central role in both bone homeostasis and cardiovascular outcomes, but there is not clear evidence to support one formulation of nutritional vitamin D over another in CKD.
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Affiliation(s)
- Irene Capelli
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Cianciolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Lorenzo Gasperoni
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy.
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Galassi A, Bellasi A, Ciceri P, Pivari F, Conte F, Cozzolino M. Calcifediol to treat secondary hyperparathyroidism in patients with chronic kidney disease. Expert Rev Clin Pharmacol 2017; 10:1073-1084. [DOI: 10.1080/17512433.2017.1371011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Andrea Galassi
- Department of Health Sciences, Renal Division, University of Milan, Milan, Italy
| | - Antonio Bellasi
- Department of Health Sciences, Renal Division, University of Milan, Milan, Italy
- Renal & Dialysis Unit ASST Lariana, S. Anna Hospital, Como, Italy
| | - Paola Ciceri
- Department of Health Sciences, Renal Division, University of Milan, Milan, Italy
| | - Francesca Pivari
- Department of Health Sciences, Renal Division, University of Milan, Milan, Italy
| | - Ferruccio Conte
- Department of Health Sciences, Renal Division, University of Milan, Milan, Italy
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, Milan, Italy
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