Otto
Mehls,2
Eberhard
Ritz,3
Giulio
ABSTRACT been
Acceleration
demonstrated
Clinical
by
improvement
rats
(subtotal
animals
animals
growth
rate
animals. vitamin
were
D. Since
D-treated actions
with greater
uremic to the of
growth.
vitamin Am.
and
vitamin in
intake
with
Both
animals,
the effects Nuir.
Journal
ofClinical
Nutrition
and
with
may
D.
be associated
31: 1927-1931,
3 1: OCTOBER
and
on food
D
growth
were
vitamin
controls zone
than
intake
rate
under
study
with
or causally
perhaps
study
lesions. associated
in which
uremic
were
compared
supplementation.
In
signficantly in the
rats
uremic
This
D has
of skeletal
related
D
than cannot
imporant to the
in and
uremic
markedly
animals
vitamin
than gain
corresponding
were
demonstrates
weight
with uremic
greater
D supplements,
of uremic
D-treated
in growth
of vitamin
of vitamin
to healing
vitamin
and without
in vitamin
administration
D supplementation
pair-fed
increase
after attributed
in an experimental
without gain
B. Krempien4
an effect
vitamin
in the growth
In children with chronic renal insufficiency, retardation of growth is commonly observed. Several factors have been implicated in its pathogenesis, such as, protein and calorie malnutrition, acidosis, renal osteodystrophy, and endocrine abnormalitie i.e., somatomedin deficiency, hyperdrenocorticism, and insulin resistance (1). Betts and Magrath (2) proposed that in children with chronic renal insufficiency “growth progresses steadily throughout childhood, but at a lower centile, until they develop renal rickets”. This is in agreement with the observation of West and Smith (3) that renal osteodystrophy is associated with cessation of growth. It has been shown that so called “renal rickets” is the consequence of an acquired resistance to vitamin D resulting from a disturbance in the metabolism of vitamin D (4). It is possible that the alterations in vitamin D metabolism affect growth long before changes in skeletal x-rays become noticeable. This notion is supported by an observation of Dent et al. (5). This author noted a resumption of growth with evidence of accelerated growth in children with renal osteodystrophy who were treated with vitamin D. Improvement in growth was associated with healing The American
without
sham-operated
skeletal J. Clin.
D has also be confirmed
was greater
D which
been
has
D, weight
diet.
abnormalities food
children
This
could rats
on the control
Histological
exclusively
with
and
of uremic
vitamin
control
supplemented
uremic
that This
nephrectomy) pair-fed
Wangdak,3
authors.
of vitality.
sham-operated
Tashi
of growth
various
suggest
observations
with
Gilli,2
in
reduced
by
in nonvitamin be attributed extraskeletal
improvement
of
1978.
of the bony lesions. But in one child studied (case 13) vitamin D was given although radiological evidence of rickets was not present, and in this child growth velocity also increased. An increase in growth subsequent to the administration ofvitamin D has also been noted by Royer et al. (6), Potter et al. (7) and ourselves (unpublished observations). These authors showed that linear growth was promoted in parallel with the healing of rickets. However, as correctly pointed out by Tiddens (8), it is impossible to accept a direct relationship between vitamin D treatment and the marked increase in the growth rate without data on calorie intake. This factor is difficult to control in clinical studies. Therefore, the present investigation was designed to study the effect of vitamin D on food intake, weight gain, longitudinal growth, and bone histology in nonvitamin D-depleted uremic rats. tThis work was supported schungsgemienschaft. 2 Universit#{228}ts-Kinderklinik,
by
the
Deutsche
Im
Neuenheimer
ForFeld
150, D-6900 Heidelberg, Federal Republic of Germany. 3 Medizinische Universit#{228}tsklinik, Bergheimerstr. 58, D-6900 Heidelberg, Federal Republic of Germany. 4 Pathologisches Institut der Universit#{228}t, Im Neuenheimer Feld 120, D-6900 Heidelberg, Federal Republic of Germany.
1978, pp.
1927-193
1 . Printed
in U.S.A.
1927
Downloaded from https://academic.oup.com/ajcn/article-abstract/31/10/1927/4656062 by University of Rhode Island user on 08 December 2018
Effect of vitamin D on growth 1 experimental uremia
MEHLS
I 928
Materials
and
Ivanovas, KisAfter arrival
to the diet and metabolic
cages
for I week. The animals received Altromin R (1000) (Fa. Altromin, Lage/Lippe) (Ca 0.95%; ; P 0.8%; vitamin D 1600 lU/kg; 3.3 kcal/g; protein 17.5%). The group with vitamin D therapy received the same diet to which vitamin D3 (Vigantol R/ Fa. Merck Darmstadt) had been added to a final concentration of 9600 lU/kg. The animals were exposed to a 12-hr on- 12-hr off-lighting cycle at constant temperature (24 C) and humidity (60%). After the adaptation period, the animals were subjected to two-stage subtotal (8/10) nephrectomy (subtotal resection and irradiation (400 rad) ofthe left kidney
length 39 without with
----
vlt.D vO.D
37
35
33 fed 31 rats
39
27
I
t
FIG.
TABLE
1 . Growth
rates
1
1l
in uremic
and
control
animals
Serum P
mEq/iizer
Without vitamin D supplement (I) Control ad libitum n = 12 Control pair-fed n = 13 Uremia n = 13
26days
containing
All values differences).
or lacking
vitamin
D.
40.2
± 0.26
± 2.7
4.39
6.8
54.3
814
±0.04 4.09
± 0.12
±6.46 348.3
± 45 137
14.96 ± 085b
±0.06
±
SEM.
between
47.5 ±3.2 30.2 ±4.3
1125b
29l.l’
1.02
±46.7
719 ±38 131b
± 17
Difference between uremia and I and II P < 0.05 (Wilcoxon test for b
Initial
27b
760b
6.97 ±0.19 7.34 ±0.12 ±
.
weight
Final
control random
Cumulative . food intake
weight
g
gal/min/I6WJg
7.7
4.71 ±0.11’ are given as ‘ Difference
Crcatinine clearance
4.18 ± 0.07a
4.59 ±0.llc 4.64
11
Urea mg/100m1
± 0.13
With vitamin D supplement (II) Control ad hibitum n= 12 Control pair-fed n= 11
a
diets
1
Ca
Uremia n=
20
fed
93.8 ± 2.4
198.1 ± 5.1
295
91.9
117.2
159.9
± 2.9 90.8 2.4
± 5.6
± 7.2
±
8.3
104.5
159.9
± 5.5
± 7.2
94.4 ±2.5 92.8 ±2.5 908?)
204.6
302 ±8.7 200.3 ± 8.8’
±2.44
±7.1’
P < 0.02 samples).
±4.6 158.6 ±5.2’ 1317b
(Wilcoxon
200.3 ± 8.8’
test
for paired
Downloaded from https://academic.oup.com/ajcn/article-abstract/31/10/1927/4656062 by University of Rhode Island user on 08 December 2018
were adapted
rats, 50 g, (Fa. for the experiments.
AL.
followed after 1 week by resection of the contralateral right kidney) or sham operation, irradiation, and decapsulation of the kidney. Animals were matched on the basis of body weight. The uremic animals were given 20 g food at 7 PM; after 12 hr the remaining food was removed and weighed. On the following day, the corresponding control animals were given exactly the amount of food consumed by the uremic animals. Snout-tail length was measured in deep relaxation (ether anesthesia). The animals were killed after 24 days. Serum and urine chemistries were measured with a SMA-l2 Technicon autoanalyzer (9). Bone histology was studied on undecalcified sections of the tibia after embedding in methyhnetacrylate. The sections were stained after Masson-Goldner or after Krutsay and evaluated as described previously (9).
methods
Male Sprague-Dawley legg/Allg#{228}u) were used
the animals
ET
VITAMIN
D
IN
EXPERIMENTAL rd------
-
/
.
f
w:
:8
fI
. ‘
-
‘
..,
S.
,‘.
...,
...
s
I
, rFIG. 2. Uremic animal, nonfortified diet (proximal x37). Zone ofgrowth cartilage (top), marked increase slender irregular trabecules with persisting chondrocyte
8
‘
tibia, undecalcified in the width ofprimary “capsules”. Cortical
Results The degree of uremia in uremic animals with and without vitamin D supplementation was comparable as indicated by endogenous creatinine clearances. Under vitamin D, there was a moderate increase in serum Ca and no noticeable change in serum P levels. Animals treated with vitamin D grew faster (Fig. 1) and achieved higher final length and weight (Table 1). But cumulative intake of
-
--
i
section, v. Kossa stain, microphotograph spongiosa which consists of numerous bone exhibiting erosive defects.
food was also significantly higher in vitamin D treated as compared to nonvitamin Dtreated uremic rats. Pair-fed control animals grew better than the corresponding nonvitamin D or vitamin D-treated uremic animats, pointing to the higher energy cost of growth in uremia (10). In the growth zone of the upper tibia of uremic animals without vitamin D therapy (Fig. 2), irregularities of the growth cartilage, particularly in the zone of degenerative cartilage, were noted. There
Downloaded from https://academic.oup.com/ajcn/article-abstract/31/10/1927/4656062 by University of Rhode Island user on 08 December 2018
ZI,”
_,.,
1929
UREMIA
193()
animals under vitamin D therapy. Vitamin D improved the histological abnormalities (rickets) in the growth zone and in metaphyseal bone. However, food intake was markedly higher in uremic animals with vitamin D. Consequently, it does not necessarily follow that the increase in longitudinal growth is exclusively due to a skeletal action of vitamin D. The increase in growth is the more remarkable since uremic animals given vitamin D were considerably more active than uremic
increase in the width of the zone of spongiosa which consisted of dense, irregularly formed spicules. The cxof osteoid seams on the trabecular was markedly increased. These abwere markedly reduced in uremic with vitamin D therapy (Fig. 3).
Discussion The growth
above results document velocity and weight
an increase of gain in uremic
‘i&__ ;
.
...,
,,.#
I’
.
! -
.‘
r’. ..-
_,#{149},
-
I ilS’-,.
FIG. 3. microphotograph longitudinally:
Uremic
animal, diet fortified with vitamin x40). Zone of primary spongiosa plump trajectorially oriented, secondary
D (proximal narrow; primary trabecules.
tibia, undecalcified section, v. trabecules regularly formed
Kossa stain, and aligned
Downloaded from https://academic.oup.com/ajcn/article-abstract/31/10/1927/4656062 by University of Rhode Island user on 08 December 2018
was an primary slender, tension surface normalities animals
ET AL.
MEHLS
VITAMIN
D
IN
EXPERIMENTAL
References 1.
2.
3.
4.
5.
6.
7.
mats.
This
difference was not demonstrable in a study when older animals with lower growth rates and diets with lower calorie content were used (9). This observation suggests that the energy cost of growth is increased in uremia as previously proposed by Cantler et at. (10). The difference in growth rate (i.e., the difference in efficiency of utilization of food) was not abolished by vitamin D, i.e., uremic animals weighed less at the end of the experiment than pair-fed sham-operated controls that had received an identical amount of food. This indicates that the effect of vitamin D on growth does not result from increased efficiency of utilization of food. previous
8.
9.
10.
1 1.
12.
13. The authors thank Dr. H. Udes des Theoretikums, Im Neuenheimer for help and assistance.
(Versuchstiezentrale Feld, Heidelberg)
1931
14.
C., AND M. A. HOLLIDAY. Growth in children with renal disease with particular reference to the effects of calorie malnutrition: a review. Chin. Nephrol. 1: 238, 1973. BETTS, P. R., AND G. MAGRATH. Growth pattern and dietary intake of children with chronic renal insufficiency. Brit. Med. J. 2: 189, 1974. WEST, C. D., AND W. C. SMITH. An attempt to elucidate the cause of growth retardation in renal disease. Am. J. Disease Children 91: 460, 1965. DE LUCA, H. F. Recent advances in our understanding of the vitamin D endocrine system. J. Lab. Clin. Med 87: 7, 1976. DENT, C. E., C. HARPER AND 0. R. PHILPOT. The treatment of renal-glomerular osteodystrophy. Quart. J. Med. 30: 1, 1961. ROYER, P., H. MATHIEU AND S. GERBEAUX. Explorations biologiques du m#{233}tabolisme calcique chez l’enfant. In: Rein et Foie. Maladies de Ia Nutrition. Vittel: Symposium International sur la Lithiase Calcique, 1962. POTTER, D., D. LARSEN, E. LEUMANN, D. PERIN, J. SIMMONS, C. F. PIEL AND M. A. HOLLIDAY. Treatment of chronic uremia in childhood. II. Hemodialysis. Pediatrics 46: 678, 1970. TIDDENS, H. A. W. M. Growth limiting factors in renal disease. In: Somatic Growth of the Child, edited by J. J. van der Werfften Bosch and A. Haak. Leiden: 1966, p. 215. MEHLS, 0., E. RITZ, G. GILLI, H. SCHMIDT-GAYK, B. KREMPIEN, B. K0uRIST, H. WESCH AND P. GER. Skeletal changes and growth in experimental uremia. Nephron 18: 288, 1977. CHANTLER, C., E. LIEBERMAN AND M. A. HOLLIDAY. A rat model for the study ofgrowth failure in uremia. Pediat. Res. 8: 109, 1974. MATFHEWS, C., K. W. HEIMBERG, E. RITZ, B. AGOSTINI, J. FRITSCHE AND W. HASSELBACH. Effect of l,25-dihydroxycholecalciferol on impaired calcium transport by the sarcoplasmic reticulum in experimental uremia. Kidney Internat. 1 1 : 227, 1977. ARIEFF, A. I., AND S. G. MASSRY. Calcium metabolism of brain in acute renal failure. Effects of uremia, hemodialysis and parathyroid hormone. J. Chin. Invest. 53: 387, 1974. BETrS, P. R., AND R. H. R. WHITE. Growth potential and skeletal maturity in children with chronic renal insufficiency. Nephron 16: 325, 1976. HOLLIDAY, M. A. Calorie intake and growth in uremia. Kidney Internat. 2: 73, 1975. CHANTLER,
Downloaded from https://academic.oup.com/ajcn/article-abstract/31/10/1927/4656062 by University of Rhode Island user on 08 December 2018
animals not given vitamin D. It is unlikely that addition of vitamin D altered the palatability of the food, since nonuremic ad libitum fed animals failed to consume more vitamin D-supplemcntcd food. Vitamin D might increase longitudinal growth primarily by stimulating food intake. Such an increase in food intake could result from changes in serum calcium, muscle tone (1 1), or brain calcium (1 2) and from improvement in well being. Alternatively, the increase in food intake could merely result from the resumption of growth. Recent clinical observations (13) suggest that a change in energy intake of children with chronic renal insufficiency is a factor related to, but not a cause for, changes in growth velocity. The above measurements show that at a given intake offood (Le., calories and protein) uremic animals grow less than control ani-
UREMIA