Acquired Vitamin D resistant rickets in patients with human immunodeficiency virus due to tenofovir antiretroviral treatment.

1. ACQUIRED VITAMIN D RESISTANT RICKETS
IN PATIENTS WITH HUMAN
IMMUNODEFFICEINCY VIRUS DUE TO
TENOFOVIR ANTIRETROVIRAL TREATMENT
Sonia Iyobosa Omoregie, Olivia Ohikhuare
Scientific Leader: Olesia Singh
KYIV MEDICAL UNIVERSITY

2. Introduction
 Rickets is known as reduced bone mass with calcification
disorders causing large amounts of unmineralized bone tissue
before closure of the epiphysis in adolescence.
 Rickets can either be caused by Vitamin D deficiency or
mineralization defects.
 Vitamin D deficiency can be caused by deficiency in vitamin D
reuptake or absorption, defective 25-hyroxylation, loss of
vitamin binding protein, defective 1--25 hydroxylation, (Kim
2017).

3. Case report
 Our case of study is Patient A, 12 years old female brought into the hospital with severe X-
deformation of the legs called Genu Valgum.
 The X-deformation developed during last 6 months
 Patient A, born with Human Immunodeficiency virus (HIV), was on a different antiretroviral
drug prior and was previously absent of any complications, and later changed to Tenofovir
which she has been on for the past two and a half years.
Patient A on Tenofovir treatment Patient A before Tenofovir treatment

4. Lab Result of Patient A
Biochemical Test Urine Analysis

5. Densitometry of patient A.
A Z-score of below -2 indicates low bone density
Z-score L1-L4 = - 3.5 SD
Z-score left femur =-4.1 SD
Z-score right femur = - 4.4 SD

6. AIM OF STUDY:
To find if there is a connection between Tenofovir and development
of vitamin D, calcium and phosphate disorders leading to severe
osteomalacia.
MATERIALS AND METHODS OF STUDY:
◦ Analysis was done with scientific research papers between 2009 and 2019 for
literature connecting osteomalacia (vitamin D resistant rickets) to use of
Tenofovir.
◦ Our key words were Vitamin D, Vitamin D deficiency, Osteomalacia, calcium,
phosphate, Antiretroviral therapy/drugs, Tenofovir, HIV.
◦ Using our key words we narrowed our search down to 19 scientific research
papers.
◦ These include various studies done about effects of Tenofovir on all age groups.

7. Ashley D. Holec, Subhra Mandal, Pavan Kumar Prathipati, Christopher J. Destache, Nucleotide Reverse
Transcriptase Inhibitors: A Thorough Review, Present Status and Future Perspective as HIV Therapeutics,
Current HIV Research, Volume 13, Issue 6, 2017

8. Evidence of Osteopathies in Research
 In research done by T. Brown in 2006, 884 HIV patients were surveyed. 67% had reduced BMD
as well as 15% of those patients having osteoporosis.
 There have been 81 various research papers written about the status of vitamin D in
patients with HIV and 49% of them include information about decrease in bone health. 23%
note the use of Tenofovir increased risk of developing proximal renal tubulopathy ( as
manifested with patient A) perhaps ultimately causing development of osteomalacia.
95% 5%
Normal Patient without fanconi syndrome
Fanconi syndrome
75%
25%
In patients with
Fanconi syndrome
Normal Fanconi manifesation
hypophosphatemia, decrease in spine and
total body z score
Pediatric study showing Fanconi Developed in
Pediatric Patient taking Tenofovir

9. What is Fanconi Syndrome?
 Fanconi Syndrome is also known as Proximal Renal Tubulopathy. It may be congenital or
acquired. Congenitally, it develops at birth. Some acquired causes: chemotherapy,
antiretroviral treatment or vitamin D deficiency.
 Main symptoms are proteinuria, glucosuria, acidic pH, deformation of legs ( knocked knee or
bow legs),and hypophosphatemia, syndrome of osteomalacia.
Yuka Kinoshita, Seiji Fukumoto, X-Linked Hypophosphatemia and FGF23-Related Hypophosphatemic Diseases: Prospect for New Treatment, Endocrine Reviews, Volume 39, Issue 3, June 2018,
Mechanism of development of osteomalacia in patients who take
Tenofovir

10. Conclusion
 In children who take Tenofovir, 5% may develop Fanconi’s
Syndrome.
 Before Tenofovir treatment, 25-hydroxy vitamin D, calcium and
phosphate in blood and urine analysis should be checked.
 The child must reach optimal vitamin D level before beginning
treatment and then take vitamin D 2000 IU/daily.
 Every 3 months biochemical (calcium, phosphate, and alkaline
phosphatase) and urinalysis should be checked.
 In cases of Fanconi’s syndrome development, vitamin D
(4000IU/Daily or calcitriol) should be taken with treatment.