Guidelines for the diagnosis and management of osteoporosis in Poland. Update 2022.

Guidelines to provide an update of the previously published Polish recommendations for the management of women and men with osteoporosis have been developed in line with advances in medical knowledge, evidence-based data, and new concepts in diagnostic and therapeutic strategies. A Working Group of experts from the Multidisciplinary Osteoporosis Forum and from the National Institute of Geriatrics, Rheumatology, and Rehabilitation in Warsaw performed a thorough comprehensive review of current relevant publications in the field (including all age groups of people and management of secondary osteoporosis), and they evaluated epidemiological data on osteoporosis in Poland and the existing standards of care and costs. A voting panel of all co-authors assessed and discussed the quality of evidence to formulate 29 specific recommendations and voted independently the strength of each recommendation. This updated practice guidance highlights a new algorithm of the diagnostic and therapeutic procedures for individuals at high and very high fracture risk and presents a spectrum of general management and the use of medication including anabolic therapy. Furthermore, the paper discusses the strategy of primary and secondary fracture prevention, detection of fragility fractures in the population, and points to vital elements for improving management of osteoporosis in Poland.

Evidence of a significant vitamin D deficiency among 9-13-year-old Polish children: results of a multicentre study.

PURPOSE: To evaluate the extent to which the population of Polish preadolescents is vitamin D deficient and to assess seasonal variations in vitamin D status. PARTICIPANTS AND METHODS: A total of 720 healthy children aged 9-13 years (409 girls, 311 boys) residing in 6 representative geographical locations in Poland were studied. A parental-assisted questionnaire provided data on nutritional habits, vitamin D supplements and sun exposure. Serum concentration of 25-hydroxyvitamin was determined twice, after the winter in March and after the summer in October. RESULTS: In March, vitamin D deficiency (25-50 nmol/L) was found in 64%, and severe deficiency (< 25 nmol/L) in 20.2% of children. In October, the deficiency and severe deficiency were still noticed in 25.9 and 0.1% of children, respectively. The mean serum concentration of 25-OHD was 52% higher in October (55.4 ± 14.0 nmol/L) than in March (36.4 ± 13.5 nmol/L), (p < 0.01). In children with 25-OHD < 50 nmol/L in March, their 25-OHD concentration increased by 64% through March to October (32.5 ± 8.2 vs. 53.2 ± 7.9 nmol/L, p < 0.01). An association was found between 25-OHD concentration and regular consumption of vitamin D supplements, cod-liver oil and fish. CONCLUSIONS: The majority of preadolescent Polish boys and girls show vitamin D deficiency after the winter period, although a distinct amelioration over summertime is found in this age group. There is a need to implement effective prevention and intervention strategies in the management of vitamin D deficiency among schoolchildren in Poland, with the supplementation throughout the entire year.

Guidelines for the diagnosis and management of osteoporosis in Poland : Update 2017.

In the rapidly ageing society in Poland, osteoporosis is a growing epidemiological problem, and osteoporosis-related fractures are a cause of chronic disability and considerable increase of death risk. It turns out that 80 to 90% of patients suffering from osteoporosis, including osteoporosis accompanied by fractures, do not receive adequate pharmacotherapy. In this paper, a Guideline Working Group of experts from the Multidisciplinary Osteoporosis Forum update the existing Polish guidelines concerning the diagnosis and management of osteoporosis (last revised in 2013), taking account of the latest literature, availability and reimbursement of drugs, and current health care organisation. In the revised guidelines, we still postulate that tasks are divided between primary care doctors (stage I) and specialists in osteoporosis management (stage II). We emphasise the necessity of early initiation of pharmacotherapy and rehabilitation in all patients with low-energy fractures. We recommend that the 10-year fracture risk should be estimated in all patients (including those without fractures) who are over 50 years of age, and that the Polish threshold for therapeutic intervention should be adopted: ≥ 10% for FRAX PL calculator. We add strategies of drug choice and therapy monitoring with imaging, and densitometric and biochemical diagnostics. We define basic guidelines concerning prevention of falls, rehabilitation, and dietary procedures, and elimination of environmental and other fracture risk factors. We point to two vital elements for improving osteoporosis management: 1) strategy of supervision over fractures management - Fracture Liaison Service (FLS), and, optimally, 2) strategies of short-term monitoring of the therapeutic efficacy with the use of biochemical markers.

Requirement for vitamin D supplementation in patients using photoprotection: variations in vitamin D levels and bone formation markers.

BACKGROUND: Avoiding sun exposure is obligatory in photodermatoses; however, the need for oral supplementation with vitamin D appears unrecognized. The aim of the study was to investigate the seasonal variation of vitamin D level and bone formation markers in healthy individuals and to compare it with vitamin D status in patients using photoprotection. METHODS: Thirty-four healthy inhabitants of the Lodz region, Poland, a country in central Europe (51° and 52° north latitudes), were examined at the baseline visit within 2 weeks of peak sun exposure during recreational activity on vacation, after 8, and after 16 weeks. The group of patients using photoprotection comprised 104 patients with systemic lupus erythematosus. Serum 25(OH) vitamin D, procollagen type I N-terminal propeptide (PINP), and osteocalcin levels were measured. RESULTS: The serum 25-hydroxyvitamin D concentration was lower and vitamin D deficiency more common in patients using photoprotection than in healthy individuals during the warm and the cold season (P < 0.05). In healthy individuals, vitamin D deficiency was more prevalent after 8 and 16 weeks than at baseline assessment (P < 0.001). PINP level was 39.56 (30.51-53.22) ng/ml, and elevated in 50% of individuals, whereas osteocalcin was 18.88 (13.52-21.33) ng/ml, and within reference range. CONCLUSIONS: Diagnoses of vitamin D deficiency and oral supplementation in patients using photoprotection need to be included in practice. Peak 25-hydroxyvitamin D levels are probably achieved from vitamin D skin synthesis during the summertime and fall over time, starting from August. Elevated levels of PINP appear in line with the process of bone remodeling related to age.

Viabilidade da mensuração de marcadores de remodelação óssea em mulheres com lúpus eritematoso sistêmico / Feasibility of measurement of bone turnover markers in female patients with systemic lupus erythematosus

Objetivo: Investigar a viabilidade dos marcadores de remodelação óssea (MRO) na avaliação do metabolismo ósseo em pacientes com lúpus eritematoso sistêmico (LES), de acordo com as diretrizes da International Osteoporosis Foundation e da International Federation of Clinical Chemistry and Laboratory Medicine. Métodos: O estudo incluiu 43 pacientes do sexo feminino com LES. Foram medidos os níveis séricos de propeptídeo N-terminal do procolágeno tipo I (PINP), telopeptídeo C-terminal do colágeno tipo I (CTX), osteocalcina, HPT, 25(OH)D, anticorpos anticardiolipina, antidsDNA e antinucleossomo. Resultados: Os níveis de PINP e CTX estavam elevados em pacientes com LES com idade > 45, em comparação com aqueles com idade < 45 anos, embora com significância estatística limítrofe (p = 0,05). Foram encontradas correlações entre os MRO: a mais forte foi entre o PINP e a osteocalcina (τ = 0,69, p < 0,05). Encontrou-se que o PINP e a osteocalcina estão correlacionados com o HPT (τ = 0,3, τ = 0,29, respectivamente, p < 0,05). A idade estava correlacionada com o PINP (τ = 0,23, p < 0,05). Valores elevados de PINP foram encontrados em maior frequência do que valores elevados de osteocalcina ou CTX, tanto em pacientes com idade < 45 (p = 0,001) quanto > 45 (p < 0,001). Não houve diferença estatisticamente significativa nos níveis de PINP, osteocalcina ou CTX com relação à estação do ano, nem em todo o grupo de pacientes com LES, nem naqueles com mais ou menos de 45 anos. O uso prévio de glucocorticoides não esteve associado a diferenças nos MRO. Conclusões: O aumento nos MRO no LES parece refletir predominantemente o padrão de remodelação óssea relacionado com a idade. Pode-se esperar que o PINP aumentado seja o desfecho mais comumente encontrado entre os MRO. É necessário incluir melhores diagnósticos de distúrbios ósseos com MRO, feitos de acordo com as normas internacionais de referência, na abordagem de ...

Objective: To investigate the feasibility of bone turnover markers (BTMs) for the assessment of bone metabolism in patients with systemic lupus erythematosus (SLE), according to the guidelines of the International Osteoporosis Foundation and the International Federation of Clinical Chemistry and Laboratory Medicine. Methods: The study included 43 female SLE patients. Serum pro-collagen type I N propeptide (PINP), C-terminal telopeptide of type I collagen (CTX), osteocalcin, PTH, 25(OH)D, anti-cardiolipin, anti-dsDNA, and anti-nucleosome levels were measured. Results: PINP and CTX levels were elevated in SLE patients aged > 45 in comparison to those aged < 45, although with borderline significance (p = 0.05, respectively). Correlations were found between BTMs: the strongest being between PINP and osteocalcin (τ= 0.69, p < 0.05). PINP and osteocalcin were found to be associated with PTH (τ = 0.3, τ = 0.29, respectively, p < 0.05). Age correlated with PINP (τ= 0.23, p < 0.05). Elevated PINP was found more frequently than elevated osteocalcin or CTX, both in patients aged < 45 (p = 0.001) and > 45 (p < 0.001). No significant difference in PINP, osteocalcin or CTX levels was found with respect to season, neither in the entire SLE group, nor in the under-45 or over-45 groups. Previous glucocorticoid treatment was not associated with difference in BTMs. Conclusions: Increased BTMs in SLE appear to predominantly reflect the pattern of bone remodeling related to age. Increased PINP is expected to be the most frequent outcome among BTMs. Better diagnoses of bone disturbances with BTMs performed in accordance with international reference standards need to be included in the approach to SLE patients, in addition to bone mineral density assessment. .

Feasibility of measurement of bone turnover markers in female patients with systemic lupus erythematosus.

OBJECTIVE: To investigate the feasibility of bone turnover markers (BTMs) for the assessment of bone metabolism in patients with systemic lupus erythematosus (SLE), according to the guidelines of the International Osteoporosis Foundation and the International Federation of Clinical Chemistry and Laboratory Medicine. METHODS: The study included 43 female SLE patients. Serum procollagen type I N propeptide (PINP), C-terminal telopeptide of type I collagen (CTX), osteocalcin, PTH, 25(OH)D, anti-cardiolipin, anti-dsDNA, and anti-nucleosome levels were measured. RESULTS: PINP and CTX levels were elevated in SLE patients aged > 45 in comparison to those aged < 45, although with borderline significance (p = 0.05, respectively). Correlations were found between BTMs: the strongest being between PINP and osteocalcin (τ = 0.69, p < 0.05). PINP and osteocalcin were found to be associated with PTH (τ = 0.3, τ = 0.29, respectively, p < 0.05). Age correlated with PINP (τ = 0.23, p < 0.05). Elevated PINP was found more frequently than elevated osteocalcin or CTX, both in patients aged < 45 (p = 0.001) and > 45 (p < 0.001). No significant difference in PINP, osteocalcin or CTX levels was found with respect to season, neither in the entire SLE group, nor in the under-45 or over-45 groups. Previous glucocorticoid treatment was not associated with difference in BTMs. CONCLUSIONS: Increased BTMs in SLE appear to predominantly reflect the pattern of bone remodeling related to age. Increased PINP is expected to be the most frequent outcome among BTMs. Better diagnoses of bone disturbances with BTMs performed in accordance with international reference standards need to be included in the approach to SLE patients, in addition to bone mineral density assessment.

Impact of vitamin D supplementation during lactation on vitamin D status and body composition of mother-infant pairs: a MAVID randomized controlled trial.

OBJECTIVE: The optimal vitamin D intake for nursing women is controversial. Deterioration, at least in bone mass, is reported during lactation. This study evaluated whether vitamin D supplementation during lactation enhances the maternal and infant's vitamin D status, bone mass and body composition. DESIGN AND METHODS: After term delivery, 174 healthy mothers were randomized to receive 1200 IU/d (800 IU/d+400 IU/d from multivitamins) or 400 IU/d (placebo+400 IU/d from multivitamins) of cholecalciferol for 6 months while breastfeeding. All infants received 400 IU/d of cholecalciferol. Serum 25-hydroxyvitamin D [25(OH)D], iPTH, calcium, urinary calcium, and densitometry were performed in mother-offspring pairs after delivery, and at 3 and 6 months later. RESULTS: A total of 137 (79%) (n = 70; 1200 IU/d, n = 67; 400 IU/d) completed the study. 25(OH)D was similar in both groups at baseline (13.7 ng/ml vs. 16.1 ng/ml; P = 0.09) and at 3 months (25.7 ng/ml vs. 24.5 ng/ml; P = 0.09), but appeared higher in the 1200 IU/d group at 6 months of supplementation (25.6 ng/ml vs. 23.1 ng/ml; P = 0.009). The prevalence of 25(OH)D <20 ng/ml was comparable between groups at baseline (71% vs. 64%, P = 0.36) but lower in the 1200 IU/d group after 3 months (9% vs. 25%, P = 0.009) and 6 months (14% vs. 30%, P = 0.03). Maternal and infants' iPTH, calciuria, bone mass and body composition as well as infants' 25(OH)D levels were not significantly different between groups during the study. Significant negative correlations were noted between maternal 25(OH)D and fat mass (R =  -0.49, P = 0.00001), android fat mass (R = -0.53, P = 0.00001), and gynoid fat mass (R = -0.43, P = 0.00001) after 6 months of supplementation. CONCLUSIONS: Vitamin D supplementation at a dose of 400 IU/d was not sufficient to maintain 25(OH)D >20 ng/ml in nursing women, while 1200 IU/d appeared more effective, but had no effect on breastfed offspring vitamin D status, or changes in the bone mass and the body composition observed in both during breastfeeding. TRIAL REGISTRATION: ClinicalTrials.gov NCT01506557.

Vitamin d status in central europe.

Little published information is available regarding epidemiological data on vitamin D status in the large geographical region of Central Europe (CE). We searched the journal literature with regard to 25(OH)D concentrations among community-dwelling or healthy people living in CE. 25(OH)D concentrations varied by age, season, study sample size, and methodological approach [i.e., 25(OH)D assay used]. Concentrations of 25(OH)D in CE appeared lower than 30 ng/mL, and the magnitude of hypovitaminosis D was similar to that reported in Western Europe. While most of the studies reviewed were cross-sectional studies, a longitudinal study was also included to obtain information on seasonal variability. The longitudinal study reported wintertime 25(OH)D values close to 21-23 ng/mL for all studied age groups, with a significant increase of 25(OH)D in August reaching 42 ng/mL for those aged 0-9 years, but only 21 ng/mL for the elderly aged 80-89 years. The decrease in 25(OH)D with respect to age was attributed to decreased time spent in the sun and decreased vitamin D production efficiency. Based on the literature review on vitamin D status in the CE populations, it can be concluded that 25(OH)vitamin D levels are on average below the 30 ng/mL level.

Polish guidelines for the diagnosis and management of osteoporosis: a review of 2013 update.

To decrease the risk of osteoporotic fractures in Poland, the Multidisciplinary Osteoporotic Forum has set up a joint Working Group including the representatives of the Polish Associations of Orthopedics and Traumatology, Rehabilitation, Gerontology, Rheumatology, Family Medicine, Diabetology, Laboratory Diagnostics, Andropause and Menopause, Endocrinology, Radiology, and the STENKO group as well as experts in the fields of rheumatology, obstetrics, and geriatrics to update the Polish guidelines for the diagnosis and management of osteoporosis in men and postmenopausal women in Poland. The assessment of fracture risk and intervention thresholds was made using the FRAX® calculation tool for Poland. The strength of recommendations was evaluated according to the principles of the Scottish Intercollegiate Guidelines Network and the results have been approved by national consultants. Finally, the Working Group has formulated the updated guidelines and recommended two -step diagnostic and therapeutic procedures. The first stage applies to family physicians or general practitioners and involves the assessment of fracture risk using the FRAX®-BMI to identify patients at high risk of fractures. An osteoporotic fracture remains an absolute indication both for the general practitioner and specialist to implement treatment. At the second stage, the specialist (in an osteoporosis or other specialty clinic) should review the primary or secondary causes of fracture risk, confirm the diagnosis, and introduce an appropriate treatment and monitoring. In patients (men aged >50 years and postmenopausal women) without low-energy fractures, the absolute risk of fractures exceeding 10% should be considered an indication for treatment. The Polish guidelines were compared with other international guidelines in terms of diagnostic measures, pharmacotherapy, as well as calcium and vitamin D supplementation.

Vitamin D status, body composition and hypertensive target organ damage in primary hypertension.

Overweight/obesity and high blood pressure during growth period are important risk factors of cardiovascular disease later in life. Cardiovascular system, fat and muscles are among target tissues for vitamin D and low 25(OH)D levels are likely to attenuate potential benefits of its action. The study was aimed to evaluate vitamin D status and body composition in children and adolescents with primary hypertension (PH). The study population comprised 78 patients aged 15.4±2.3yrs (9-18yrs; 15 girls) with diagnosed PH. Total 25(OH)D and parathyroid hormone (PTH) were assayed by Cobas e411 machine (Roche Diagnostics). DXA (Prodigy, GE Lunar) was used to assess total body bone mineral content (TBBMC; g), total body bone mineral density (TBBMD; g/cm(2)), lean body mass (LBM; g), % lean body mass (%LBM), fat mass (FM; g), % fat mass (% FM), Android %Fat, Gynoid %Fat and Trunk fat mass (Trunk FM; g). Hypertensive cases (BMI=25.6±4.2kg/m(2)), compared to reference, had slightly increased TBBMD and TBBMC Z-scores (+0.40±0.91 and +0.59±0.96; both p<0.001), and had markedly increased FM and FM/body weight ratio Z-scores of ±1.83±1.63 (p<0.0001) and +1.43±1.05 (p<0.0001). LBM Z-scores were slightly increased as well (+0.34±1.08, p<0.001). In contrast, markedly reduced LBM/body weight ratio Z-scores of -1.47±0.90 (p<0.0001) and disturbed relationship between FM and LBM as assessed by FM/LBM ratio Z-score of +1.53±1.29 (p<0.0001) were noted. The average serum levels of 25(OH)D of 17.8±6.9ng/mL and PTH of 34.8±16.8pg/mL were noted in PH group. 91% PH cases showed 25(OH)D levels lower than 30ng/mL. 71% of PH subjects revealed vitamin D deficiency (25(OH)D<20ng/ml). 10% of PH cases showed 25(OH)D levels lower than 10ng/mL. 25(OH)D levels negatively correlated with PTH showing r=-0.24 (p=0.03). Absolute LBM/body weight ratio values positively correlated with 25(OH)D levels (r=0.31; p=0.01). In contrast, absolute FM/body weight ratio values correlated negatively with 25(OH)D levels (r=-0.32; p<0.01). Moreover, 25(OH)D levels negatively correlated with absolute Trunk FM (r=-0.29; p<0.05), Android %Fat (r=-0.32; p<0.01) and with Gynoid %Fat (r=-0.28; p<0.05). PTH and 25(OH)D concentrations did not differ when severity of hypertension, left ventricular mass and carotid intima-media thickness were controlled for. Concluding, higher muscle mass stores in body weight coincided with higher 25(OH)D levels. Higher fat mass stores coincided with lower 25(OH)D levels in PH group. Whether vitamin D insufficiency/deficiency in PH group should be considered as a cause of disease or epiphenomenon remains unknown. This article is part of a Special Issue entitled '16th Vitamin D Workshop'.

Effect of vitamin D status on pharmacological treatment efficiency: Impact on cost-effective management in medicine.

At least 80% of the whole Polish population, including prepubertal children and adolescents, adults and seniors, are vitamin D deficient, defined as 25(OH)D < 50 nmol/L. 83% of Polish newborns start their lives at the state of vitamin D deficiency because 78% of their mothers are also deficient. It was observed that treating patient vitamin D deficiency to vitamin D status serum 25(OH)D) 75-100 nmol/L increased effectiveness of therapies in infectious diseases (chronic hepatitis C, tuberculosis), osteoporosis, multiple sclerosis, epilepsy, Chronic Kidney Diseases and atopic dermatitis. . For these reasons doctors should take special attention to vitamin D status in patients suffering for these diseases properly implementing recent vitamin D recommendation.

Practical guidelines for the supplementation of vitamin D and the treatment of deficits in Central Europe - recommended vitamin D intakes in the general population and groups at risk of vitamin D deficiency.

INTRODUCTION: Adequate Vitamin D intake and its concentration in serum are important for bone health and calcium-phosphate metabolism as well as for optimal function of many organs and tissues. Documented trends in lifestyle, nutritional habits and physical activity appear to be associated with moderate or severe Vitamin D deficits resulting in health problems. Most epidemiological studies suggest that Vitamin D deficiency is prevalent among Central European populations. Concern about this problem led to the organising of a conference focused on overcoming Vitamin D deficiency. METHODS: After reviewing the epidemiological evidence and relevant literature, a Polish multidisciplinary group formulated theses on recommendations for Vitamin D screening and supplementation in the general population. These theses were subsequently sent to Scientific Committee members of the 'Vitamin D - minimum, maximum, optimum' conference for evaluation based on a ten-point scale.With 550 international attendees, the meeting 'Vitamin D - minimum, maximum, optimum' was held on October 19-20, 2012 in Warsaw(Poland). Most recent scientific evidence of both skeletal and non-skeletal effects of Vitamin D as well as the results of panellists' voting were reviewed and discussed during eight plenary sessions and two workshops. RESULTS: Based on many polemical discussions, including post-conference networking, the key opinion leaders established ranges of serum 25-hydroxyVitamin D concentration indicating Vitamin D deficiency [< 20 ng/mL (< 50 nmol/L)], suboptimal status [20-30 ng/mL(50-75 nmol/L)], and target concentration for optimal Vitamin D effects [30-50 ng/mL (75-125 nmol/L)]. General practical guidelines regarding supplementation and updated recommendations for prophylactic Vitamin D intakes in Central European neonates, infants, children and adolescents as well as in adults (including recommendations for pregnant and breastfeeding women and the elderly) were developed. CONCLUSIONS: Improving the Vitamin D status of children, adolescents, adults and the elderly must be included in the priorities of physicians,healthcare professionals and healthcare regulating bodies. The present paper offers elaborated consensus on supplementation guidance and population strategies for Vitamin D in Central Europe.

Effect of vitamin D status on pharmacological treatment efficiency: Impact on cost-effective management in medicine.

At least 80% of the whole Polish population, including prepubertal children and adolescents, adults and seniors, are vitamin D deficient, defined as 25(OH)D < 50 nmol/L. 83% of Polish newborns start their lives at the state of vitamin D deficiency because 78% of their mothers are also deficient. It was observed that treating patient vitamin D deficiency to vitamin D status serum 25(OH)D) 75-100 nmol/L increased effectiveness of therapies in infectious diseases (chronic hepatitis C, tuberculosis), osteoporosis, multiple sclerosis, epilepsy, Chronic Kidney Diseases and atopic dermatitis. . For these reasons doctors should take special attension to vitamin D status in patients suffering for these diseases properly implementing recent vitamin D recommendation.

Impact of vitamin D supplementation on markers of bone mineral metabolism in term infants.

UNLABELLED: 25-Hydroxyvitamin D (25OHD) may influence bone turnover. We compared the dynamics of bone markers in 30 infants on vitamin D supplementation (≅550 IU/day) with different degrees of hypovitaminosis D (25OHD <11 ng/ml - deficiency vs. ≥ 11 <20 ng/ml - insufficiency). Baseline and follow-up (after 10 weeks), 25OHD, 1,25-dihydroxyvitamin D (1,25(OH)(2)D), alkaline phosphatase (ALP), PTH, osteocalcin (OC), N-terminal propeptide of type I procollagen (PINP), C-terminal telopeptide of type I collagen (CTX), and amino-terminal propeptide of C-type natriuretic peptide (NT-proCNP) were measured. None of the newborns had craniotabes, hypocalcemia or hyperparathyroidism. The median (Q1;Q3) 25OHD increased from a baseline of 8.45 (7;11.9) ng/ml to 54.6 (34.7;67.3) ng/ml (p<0.001). The baseline 25OHD negatively correlated with total increment of 25OHD (r=-0.54; p=0.002). There were changes in ALP (241 vs. 331 IU; p<0.001), 1,25(OH)(2)D (48 vs. 95.5 pg/ml, p<0.001), OC (88.8 vs. 159.1 ng/ml, p<0.001), PINP (3886 vs. 2409 ng/ml; p<0.001), CTX (1.6 vs. 1.1 ng/ml; p<0.001), and NT-proCNP (75.1 vs. 35.1 pmol/l; p<0.001). Vitamin D deficient infants at baseline, compared to the insufficient group, revealed significantly higher percentage changes for 25OHD (745% vs. 167%, p<0.0001), OC (113% vs. 40%, p<0.05) and 1,25(OH)(2)D (95% vs. 58%, p<0.05). CONCLUSIONS: Vitamin D supplements had little to no impact on markers of bone turnover in term infants in the first few months of life, with the exception of osteocalcin. Ten weeks of cholecalciferol supplementation at a dose of 550 IU/day led to a marked increase of 25OHD concentration. The magnitude of 25OHD increment was inversely related to vitamin D status at baseline. Irrespective of the severity of vitamin D deficiency, a secondary hyperparathyroidism with elevated iPTH, ALP, phosphaturia or hypophosphatemia was not observed in the studied neonates.

[Pathologies of calcium-phosphate homeostasis]. / Patologie zwiazane z gospodarka wapniowo-fosforanowa.

The colossal progress in understanding of vitamin D and phosphate metabolism introduces new perspectives in chronic kidney disease (CKD) therapy. Increasing demand for phosphate excretion per nephron triggers the vicious cycle that leads to increase in FGF-23 and PTH and decrease in vitamin D and Klotho. Restriction of dietary phosphate intake (low phosphate diet) and administration of phosphate binder can be regarded as the most important interventions in this case. Because the vicious cycle is likely activated long before hyperphosphatemia occurs during CKD progression, phosphate restriction would have been more effective if started before serum phosphate levels increased, perhaps as soon as serum FGF-23 levels rose. Phosphate restriction alleviates phosphate overload per nephron and can disrupt the vicious cycle: phosphate restriction can reduce serum FGF-23 levels and increase vitamin D, which in turn increase Klotho expression in kidney and parathyroid glands. Inhibitors of rennin-angiotensin system (rosiglitazone, angiotensin-converting enzyme inhibitors) and proper vitamin D supplementation may also up-regulate Klotho expression. Increased Klotho in the kidney may improve FGF-23 sensitivity, which further reduce the amount of FGF-23 required for excreting a given amount of phosphate. Increased Klotho in parathyroid may improve the ability of FGF-23 to suppress PTH. Proper supplementation with vitamin D increase the concentration of substrate for local 1,25(OH)2D synthesis 25(OH)D, which directly suppress PTH, increase Klotho, and decrease FGF-23 by proanabolic action on bone. Improving vitamin D status by inhibition of CYP24A is also under evaluation, as well as antibodies against FGF-23, as modern therapies in CKD.

Bone metabolism in cholestatic children before and after living-related liver transplantation--a long-term prospective study.

Bone disorders are common in children with end-stage liver diseases, especially those associated with cholestasis. Abnormal hepatocyte function, disordered vitamin D metabolism and calcium-phosphorous homeostasis, malnutrition, and immunosuppressive treatment are potential risk factors of bone tissue pathology before and after transplantation. The aim of the study was to analyze the long-term effect of successful living-related liver transplantation (LRLTx) on skeletal status and bone metabolism in cholestatic children. Eighteen cholestatic children (1.4±0.5yr old; 12 females [F]/6 males [M]) qualified for LRLTx were analyzed; 16 (5F/11M) of them participated in long-term observation (V4). Serum levels of osteocalcin (OC), procollagen type 1 N-terminal propeptide (P1NP), cross-linked telopeptide of type 1 collagen (CTx), insulin-like growth factor I (IGF-I), IGF-I binding protein 3 (IGFBP-3), parathyroid hormone (PTH), 25-hydroxyvitamin D (25(OH)D), and 1,25-dihydroxyvitamin D (1,25(OH)(2)D) were assayed before (V0) and 6mo (V1), 12mo (V2), 18mo (V3), and 4.4yr (V4) after LRLTx. Total body bone mineral content (TBBMC) and total body bone mineral density (TBBMD) were measured by dual-energy X-ray absorptiometry (DXA) at the same pattern. Before LRLTx, the OC, P1NP, CTx, IGF-I, and IGFBP-3 levels as well as TBBMC and TBBMD were decreased compared with age-matched control group. The mean serum levels of 25(OH)D and 1,25(OH)(2)D were within reference ranges from V0 to V4. After LRLTx, the OC, P1NP, CTx, IGF-I, and IGFBP-3 as well as TBBMC and TBBMD reached the age-matched reference values. At V4, the level of P1NP decreased below and the PTH increased above the reference range that coincided with reduced Z-scores of both TBBMC (-1.11±1.24) and TBBMD (-1.00±1.19). P1NP and CTx, both measured at V3, correlated with IGF-I at V2 (R=0.86, p=0.014 and R=0.78, p=0.021, respectively) and PTH at V3 for P1NP and V1 for CTx (R=0.64, p=0.048 and R=0.54, p=0.038, respectively). The TBBMC changes between V0 and V4 correlated with IGF-I (R=0.68, p=0.015) and 1,25(OH)(2)D (R=0.54, p=0.025), both assayed at V1. The change of TBBMC Z-scores between V0 and V4 correlated with P1NP at V1 (R=0.69, p=0.002). The TBBMD changes between V0 and V4 correlated with CTx at V1 (R=0.54, p=0.027) and P1NP change between V0 and V1 (R=0.51, p=0.038). In short-term observation, successful LRLTx led to bone metabolism normalization triggered by probable anabolic action of IGF-I and PTH and manifested by TBBMC and TBBMD increases. In long-term horizon, moderately impaired DXA assessed bone status coincided with disturbances in bone metabolism. Bone metabolism markers, especially P1NP and CTx, appeared to be good predictors of changes in bone status evaluated by DXA.

Vitamin D supplementation and status in infants: a prospective cohort observational study.

OBJECTIVE: Vitamin D status in infants depends on supplementation. We examined the vitamin D status in relation to supplementation dose and scheme in infants. PATIENTS AND METHODS: One hundred thirty-four infants age 6 months and 98 infants age 12 months (drop out 27%) were investigated. Vitamin D intake (diet, supplements), anthropometry, and 25-hydroxyvitamin D (25-OHD) serum concentration at the 6th and 12th months were assessed. RESULTS: Vitamin D intake of 1062 ± 694 IU at the 6th month was not different from that at the 12th month (937 ± 618 IU). Vitamin D intake expressed in international units per kilogram of body weight decreased from 141 ± 80 IU/kg at the 6th month to 93 ± 62 IU/kg at the 12th month (P < 0.0001), which was associated with a reduction in 25-OHD from 43 ± 20 ng/mL to 29 ± 12 ng/mL, respectively (P < 0.0001). In the subgroup of everyday supplemented infants (n = 43), vitamin D intake decreased from 143 ± 88 IU/kg at the 6th month to 118 ± 60 IU/kg at the 12th month (P < 0.05), which coincided with a reduction of 25-OHD from 40 ± 19 ng/mL to 32 ± 13 ng/mL (P < 0.01). In the subgroup with variable supplementation habits (n = 32), vitamin D intake decreased from 146 ± 79 IU/kg to 77 ± 56 IU/kg (P < 0.001), which was associated with a reduction of 25-OHD from 42 ± 21 ng/mL to 25 ± 8 ng/mL (P < 0.0001). 25-OHD concentration change between the 6th and the 12th months negatively correlated with the 25-OHD level assessed at the 6th month (r = -0.82; P < 0.0001). CONCLUSIONS: Vitamin D supplementation of infants should consider their rapid body weight increment. We postulate vitamin D daily dose close to 100 IU/kg body weight as favorable for infants up to age 12 months.

Bone mineral disease in children after renal transplantation in steroid-free and steroid-treated patients--a prospective study.

UNLABELLED: Bone disease may persist after transplantation. Different approaches aiming to ameliorate this problem have been investigated. The aim of the study was to compare the long-term effect of three medical interventions: (i) two prophylactic oral doses of 50 mg ibandronate; (ii) daily oral dose of 0.25 µg of 1α-OHD3 (both of these regimens in patients receiving steroids), and (iii) steroid minimization immunosuppressive protocol in patients with no other specific prophylaxis. PATIENTS: A total of 37 children, at a mean age of 13.33±3.49 yr, dialyzed for 15.93±16.7 months before transplantation, were divided into three groups, depending on medical intervention. Bone mineral content and density (BMC, BMD, DXA), serum markers of bone resorption and formation (CTX, P1NP), calcium, phosphate, 25OHD3/1.25 (OH)2D3 and PTH concentration were evaluated during two yr of follow-up. The mean values of BMD in the whole population and among the three subgroups remained within the age- and gender-matched normal range during follow-up. PATIENTS from groups II (alphacalcidiol) and III (steroid minimization) showed a significant decrease in BMD Z-scores over time, and this effect was determined with increasing age using multivariate analysis. PATIENTS receiving two doses of ibandronate maintained unchanged Z-scores for BMD and BMC over time.

[Recommendations of prophylaxis of vitamin D deficiency in Poland (2009)]. / Zalecenia dotyczace profilaktyki niedoborów witaminy D w polsce (2009).

Adequate vitamin D intake and its status as well outdoor physical activity are important not only for normal bone development and Ca-P metabolism, but for optimal function of many organs and tissues throughout the body. Due to documented changes in dietary habits and physical activity level, both observed in growing children and adults, the prevalence of vitamin D insufficiency is continuously increasing. National Consultants and experts in this field established the Polish recommendations for prophylactic vitamin D supplementation in infants, toddlers, children and adolescents as well as in adults, including pregnant and lactating women based on current literature review. Taking into consideration pleyotropic vitamin D action and safety aspects serum 25-hydroxyvitamin D (25-OHD) level of 20-60 ng/ml (50-750 nmol/l) in children and 30-80 ng/ml (75-200 nmol/I) in adults is considered as optimal. Sunlight exposure inducing vitamin D production in the skin is main endogen source of vitamin D in the body but sunscreens may reduce skin synthesis by 90%. In Poland, skin synthesis is effective only from April to September so other sources of vitamin D such as diet and supplements play an important role. All newborns should be supplemented with 400 IU/d of vitamin D beginning from the first few days of life and continue during infancy. In formula fed infants vitamin D intake from the diet should be taken into account. In preterm infants higher total vitamin D intake (400-800 IU/day) is recommended till 40 weeks post conception. Total vitamin D intake in children and adolescents required from all sources (diet and/or supplements) should be 400 IU/d between October and March and throughout the whole year in case of inadequate vitamin D skin synthesis during the summer months. In overweight/obese children supplementation with higher dosage of vitamin D up to 800-1000 IU/d should be considered. Adults require 800-1000 IU/d of vitamin D. In pregnant and lactating women such supplementation is recommended in case of inadequate intake from diet and/or skin synthesis supplementation. Monitoring of serum 25-OHD level to define optimal dosage should be considered.