==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 10.5144/0256-4947.2013.201basm-2-201bCommentsReply Kari Jameela Abdulaziz Correspondence: King Abdulaziz University, Pediatrics, P.O Box 13042, Jeddah 21943. Saudi Arabia, T: 966-505-556-77904, F: 966-02-640-8353, jkari@doctors.org.ukMar-Apr 2013 33 2 201 202 Copyright © 2013, Annals of Saudi Medicine2013This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. ==== Body It is common practice to put patients with chronic kidney disease (CKD) on an activated form of vitamin D such as alphacalcidol without measuring or correcting the vitamin D3 level. However, in recent studies from different parts of the world, 25 (OH) D3 deficiencies were reported in both adults1 and children2 with CKD. The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the management of CKD-MBD recommended that 25 (OH) D3 levels should be monitored and if low, ergo- or cholecalciferol supplements should be prescribed. 3 We have conducted a study investigating the effect of daily oral vitamin D3 on the levels of 25(OH) D3 and iPTH in vitamin D insufficient/ deficient children with CKD.4 Maintenance therapy with oral vitamin D3 (2000 IU/day for 6 months) did not result in improved iPTH levels, and only 11% of the children achieved normal 25 (OH) D3 levels (≥30 ng/mL). All the children had received alphacalcidol, the active form of vitamin D, which is recommended for use in children with CKD and high iPTH, with the aim of normalizing iPTH levels in these children. We believe that nonadherence to treatment may explain the poor response to vitamin D supplementation in our study, as there is evidence that the administration of oral vitamin D3 resulted in improved vitamin D3 levels and a reduction in iPTH.2 The observed poor response could also be attributed to the low dose of oral vitamin D that we administered to the children since the current recommendation is to use doses of 1000 IU/day for infants <1 month old, 1000 to 5000 IU/day for infants 1 to 12 months old, and >5000 IU/day for children >12 months old.5 The Cochrane reviewers found 15 randomized controlled trials comparing different interventions used to prevent or treat bone disease in children with CKD stages 2–5. They concluded that bone disease, assessed by changes in PTH levels, is improved by all vitamin D preparation.6 Shroff et al used oral vitamin D3 in vitamin D deficient or severely deficient children with CKD who had normal iPTH levels.7 They used intensive replacement treatment with ergocalciferol as per the Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines for nutrition in CKD,8 and they found that after three months of therapy, there was a significant improvement in 25(OH)D levels in the treated group as compared with the placebo group. There was also an improvement in the levels of 1,25(OH)2D in the treated group compared with the placebo group.7 They concluded that ergocalciferol was effective in delaying the development of secondary hyperparathyroidism in children with CKD 2–3 who had normal iPTH. In a recent study we tested the hypothesis that in children with high iPTH who had received alphacalcidol, CKD-MBD can be improved by normalizing vitamin D3 levels. by administration of single high dose intramuscular Vitamin D3. We found that single-dose intramuscular vitamin D3 (300 000 IU) resulted in significant improvement of vitamin D3 and iPTH levels in children with CKD which was not sustained. We concluded that high-dose intramuscular vitamin D3 is effective and safe in children with CKD, and it improves hyperparathyroidism.9 Vitamin D3 levels should be measured regularly even in children who had received 1,25(OH)2 vitamin D3. ==== Refs REFERENCES 1 Holden RM Morton AR Garland JS Pavlov A Day AG Booth SL Vitamins K and D status in stages 3–5 chronic kidney disease Clin J Am Soc Nephrol 2010 4 5 4 590 7 20167683 2 Menon S Valentini RP Hidalgo G Peschansky L Mattoo TK Vitamin D insufficiency and hyperparathyroidism in children with chronic kidney disease Pediatr Nephrol 2008 10 23 10 1831 6 18575896 3 KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Kidney Int Suppl 2009 8 113 S1 130 4 Kari JA Eldesoky SM Bagdadi OT Vitamin D insufficiency and treatment with oral vitamin D3 in children with chronic kidney disease Saudi Med J 2012 7 33 7 740 4 22821307 5 Munns C Zacharin MR Rodda CP Batch JA Morley R Cranswick NE Craig ME Cutfield WS Hofman PL Taylor BJ Prevention and treatment of infant and childhood vitamin D deficiency in Australia and New Zealand: a consensus statement Med J Aust 2006 9 4 185 5 268 72 16948623 6 Geary DF Hodson EM Craig JC Interventions for bone disease in children with chronic kidney disease Cochrane Database Syst Rev 2010 1 CD008327 20091666 7 Shroff R Wan M Gullett A Ledermann S Shute R Knott C Wells D Aitkenhead H Manickavasagar B van’t HW Ergocalciferol supplementation in children with CKD delays the onset of secondary hyperparathyroidism: a randomized trial Clin J Am Soc Nephrol 2012 2 7 2 216 23 22266572 8 KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 update. Executive summary Am J Kidney Dis 2009 3 53 3 Suppl 2 S11 104 9 Kari JA Baghdadi O El-Desoky Is high dose cholecalciferol justified in children with Chronic Kidney Disease who failed low-dose maintenance therapy? Pediatric Nephrology (in press)