Changes in bone matrix mineralization after growth hormone treatment in children and adolescents with chronic kidney failure treated by dialysis: a paired biopsy study.

Background: Patients with chronic kidney disease (CKD) develop renal osteodystrophy with alterations in bone turnover, mineralization, and volume (TMV). A specific skeletal complication in children is growth impairment, which currently is treated by recombinant human growth hormone (rhGH). The effects on bone material properties are poorly understood. This study assesses the effects of rhGH treatment on bone matrix mineralization. Study Design: Observational study. Setting & Participants: 18 short children and adolescents (aged 3.6-16 years) with CKD on dialysis therapy. Predictor: rhGH treatment for 1 year. Outcomes: Tetracycline-labeled bone biopsy classified according to the TMV system. Measurements: Bone mineralization density distribution (BMDD) was evaluated by quantitative backscattered electron imaging in trabecular and cortical compartments. Additional data for patients' height and biochemical bone serum parameters were obtained. Results: Prior to rhGH treatment, our cohort showed low bone turnover and high mineralization densities versus reference data: Ca-mean (weighted mean calcium content) in cancellous bone, +3.3% (P = 0.04); Ca-mean in cortical bone, +6.7% (P < 0.001); Ca-peak (mode of the BMDD) in cancellous bone, +5.0% (P < 0.001); Ca-peak in cortical bone, +8.2% (P < 0.001); Ca-width (heterogeneity in mineralization), no significant difference for cancellous (P = 0.2) and cortical (P = 0.1) bone; Ca-high (portion of fully mineralized bone) in cancellous bone, 5-fold greater (P < 0.001); Ca-high in cortical bone, 14-fold greater (P < 0.001); Ca-low (portion of low mineralized bone) in cancellous bone, +23.9% (P = 0.02); Ca-low in cortical bone, -22.2% (P = 0.05). After rhGH treatment, height increased by 9.1 cm (P < 0.001) and bone turnover indices to normal values or beyond. Matrix mineralization was lesser and more heterogeneous compared to baseline: Ca-width for cancellous bone, +15.3% (P < 0.001); Ca-width for cortical bone, +34.1% (P < 0.001). Ca-mean, Ca-peak, and Ca-high for cancellous bone and Ca-mean and Ca-peak for cortical bone were no longer significantly different from reference data. Ca-high for cortical bone dramatically decreased after treatment but was still substantially greater than reference data. Limitations: Low case number per TMV subgroup, no measurements of fibroblast growth factor 23. Conclusions: Children and adolescents with CKD and growth deficiency are at risk of having low bone turnover. rhGH treatment improves height and concomitantly bone modeling/remodeling, which appears beneficial for bone matrix mineralization. Am J Kidney Dis. 61(5): 767-777. (C) 2013 by the National Kidney Foundation, Inc.