Serum Retinol, Retinol-Binding Protein, and

Transthyretin in Children Receiving Dialysis

Nancy Fassinger, PhD, RD,*† Abubakr Imam, MD,† and David M. Klurfeld, PhD*

Objective: We investigated the relationships of retinol (ROH), retinol-binding protein (RBP), and transthyretin (TTR)
in children with end-stage renal disease (ESRD). Our hypothesis was that levels of ROH and RBP would be elevated
in children with ESRD.
Methods and Patients: We measured ROH, RBP, and TTR serum concentrations in a group of pediatric ESRD
patients biannually. Children were grouped according to age and method of dialysis, i.e., hemodialysis (HD) or
peritoneal dialysis (PD): HD1, aged ,12 years (n 5 8); PD1, aged ,12 years (n 5 19); HD2, aged $12 years
(n 519); and PD2, aged $12 years (n 5 29).
Results: No differences in ROH, RBP, TTR, or their ratios were found as a function of type of dialysis in groups PD2
and HD2. The ROH and TTR were significantly higher in PD1 than HD1 (P 5 .01 and P 5 .003, respectively). No
correlations were evident between ROH and RBP or TTR with length of time on dialysis, serum calcium, or serum
creatinine, except for group PD2, in which ROH was positively correlated with RBP (P 5 .025). There were no
significant differences among any of the ratios in terms of age or method of dialysis.
Conclusions: The data indicate that children with ESRD exhibit elevated levels of serum ROH, RBP, and TTR, in
proportions similar to those reported in the adult ESRD literature. Further study is needed to clarify the consequences
of increased ROH in uremic children.
Ó 2010 by the National Kidney Foundation, Inc. All rights reserved

I T IS ESTABLISHED that adults with end-stage

renal disease (ESRD) exhibit high levels of se-
rum retinol (ROH), retinol-binding protein
(RBP), and transthyretin (TTR),1 but these are
not routinely measured as part of standard ESRD
treatment protocols. Several studies reported that
ROH and RBP were consistently elevated in adult
ESRD patients, with serum concentrations of
ROH and RBP at 3.5 to 5 times normal but
with normal or low molar ratios of ROH to
RBP.2–5 In view of these findings, it is assumed
that increases in ROH and RBP are not harmful,
but are a result of the diseased kidney’s inability
to degrade and excrete RBP.6 Few studies
*Department of Nutrition and Food Science, Wayne State
University, Detroit, Michigan.
†Children’s Hospital of Michigan and Department of Pediatrics,
Wayne State University, Detroit, Michigan.
A.I. is presently at the Children’s Hospital Medical Center of
Akron, Akron, Ohio.
D.M.K. is presently at the Agricultural Research Service, United
States Department of Agriculture, Beltsville, Maryland.
Address reprint requests to Nancy Fassinger, PhD, RD,
Children’s Hospital of Michigan, 3901 Beaubien, Detroit,
MI 48201. E-mail: nfassing@dmc.org
Ó 2010 by the National Kidney Foundation, Inc. All rights reserved
1051-2276/10/2001-0000$36.00/0
doi:10.1053/j.jrn.2009.05.005
reported on serum concentrations of ROH,
RBP, and TTR in children with chronic kidney
disease. The limited literature for the pediatric
age group presents conflicting data.7,8
Our investigation began after a 12-year-old girl
with ESRD, who had never been on human
growth hormone, presented at our nephrology
service with pseudotumor cerebri. Her level of
ROH was 8.2 mmol/L (normal, 0.9 to 2.4
mmol/L), her level of RBP was 22.2 mg/dL
(normal, 3 to 6 mg/dL), and her level of TTR
was 52.2 mg/dL (normal, 17 to 42 mg/dL). There
is no consensus on the presumed safe levels of
ROH and RBP for the pediatric ESRD popula-
tion, nor are clinical signs of toxicity easily distin-
guishable from those of uremia before an onset of
pseudotumor cerebri. The ROH and RBP of all
dialysis patients at our center are measured and
recorded as part of routine laboratory assessment
protocols. We tested the hypothesis that ROH
and RBP would be high in children with ESRD,
and that the ratio of ROH to RBP would be
similar to that found in adults with ESRD.
Patients and Methods
To determine if serum ROH and RBP levels in
children with ESRD were similar to those of

Journal of Renal Nutrition, Vol 20, No 1 (January), 2010: pp 17–22 17

18 FASSINGER ET AL
adults with ESRD, a retrospective chart review of
ROH, RBP, and TTR levels was conducted. This
study was reviewed and approved by the Human
Investigation Committee of Wayne State
University.
Seventy-five sets of laboratory data from pediat-
ric dialysis patients were reviewed. Transthyretin
was already part of the nutrition assessment proto-
col, as were other standard monthly measurements
such as blood urea nitrogen, serum creatinine,
serum electrolytes, calcium, phosphorus, alkaline
phosphatase, and triglycerides.
Patients were divided into two groups accord-
ing to age, and then again by method of dialysis.
No patient was receiving a vitamin supplement
with vitamin A. However, vitamin A intake was
not quantified. Separation by method of dialysis
was performed to identify differences, if any, in
vitamin A status between those on hemodialysis
(HD) and those on peritoneal dialysis (PD). Age
separation was necessary because normal ROH
levels for children aged ,12 years are quite
different from those for children aged $12 years
(0.7 to 1.7 mmol/L vs. 1.0 to 3.2 mmol/L, respec-
tively).9 Groups of children included those on HD,
aged ,12 years (HD1, n 5 8); those on PD, aged
,12 years (PD1, n 5 19); those on hemodialysis,
aged 12 to 18 years (HD2, n 5 19); and those on
peritoneal dialysis, aged 12 to 18 years (PD2,
n 5 29). Because children with renal disease
exhibit abnormal growth and often fall below
the 5th percentile for age on the National Center
for Health Statistics growth charts, and because
available comparison data for ROH are based on
body surface area before the onset of puberty, three
children with a body surface area ,5th percentile
for 12-year-olds, who were assessed at Tanner
stage 1,10 were grouped with the youngest
patients, although they were above age 12 years.
In the PD1 group, one child received growth
hormone, two received prednisone, and 14 of
the 19 received nighttime tube-feeding to provide
approximately 75% of their individual nutrient
requirements. No subjects in the HD1 group
received growth hormone, four received predni-
sone, two received anticonvulsants, and 3 of 8
received nighttime tube-feeding for approxi-
mately 75% of their estimated nutrient require-
ments. Of the PD2 subjects, none received
growth hormone, two received prednisone, nine
received anticonvulsants, four received 50%
of their estimated nutrient requirements via
nighttime tube-feeding, and two received occa-
sional oral supplements. No HD2 subjects
received growth hormone, one received predni-
sone, two required anticonvulsants, one received
50% of his estimated nutrients via gastrostomy
tube (GT), and two received occasional oral sup-
plements. The HD patients fasted. Peritoneal
dialysis patients had indwelling peritoneal fluid
containing glucose, and were not considered to
be fasting. Blood was drawn, protected from light,
and immediately transported to an outside labora-
tory for analysis of retinol by high-pressure liquid
chromatography (HPLC) with ultraviolet (UV)
detection. The RBP was measured by nephelom-
etry at the same laboratory. The TTR was
analyzed by the Detroit Medical Center’s labora-
tory, using turbidimetry. Both laboratories are
certified by the Office of the Inspector General
for the Center for Medicaid and Medicare
Services, and perform these assays on a routine
basis. Data were analyzed with Student’s t-test,
analysis of variance, and regression analysis, as
applicable, using Statistix 4.1 (Analytical Software,
Tallahassee, FL).
Results
Comparisons of groups based on method of
dialysis showed no significant differences in
ROH, RBP, and TTR between the groups PD2
and HD2 (Table 1). However, serum ROH
concentrations in group PD1 were significantly
higher than those in HD1 (P 5 .01). There was
no difference between groups for RBP. The
TTR was significantly higher in the PD1 group
than in the HD1 group (P 5 .01).
Because triglycerides (TGs) affect the serum
concentrations of some fat-soluble vitamins, we
compared the TGs of HD and PD in the respective
age groups. There was a significant difference in
TG levels between PD1 and HD1, and TG levels
in the PD1 group were higher than in the HD1
group (P 5 .01). There was no significant differ-
ence in TGs between PD2 and HD2, and no cor-
relation between ROH and TGs within any
groups (data not shown).
We found no statistically significant correlations
between ROH, RBP, or TTR with length of time
on dialysis, serum calcium, or serum creatinine,
except for group PD2, in which ROH and RBP
were positively correlated (r 5 0.75, P 5 .025).
The ratios of ROH to the two binding proteins
 ROH, RBT, AND TTR IN CHILDREN ON DIALYSIS 19

Table 1. Comparisons of ROH, RBP, and TTR According to Method of Dialysis

ROH (mmol/L) RBP (mmol/L) TTR (mmol/L) TG (mg/dL)

PD1 (n 5 19) 4.6 6 1.8 9.3 6 2.2 6.6 6 1.7 268 6 117
HD1 (n 5 8) 3.4 6 0.6 6.6 6 1.1 5.1 6 0.6 171 6 39
P value .01 .20 .003 .004
PD2 (n 5 29) 4.4 6 1.6 8.0 6 2.4 7.1 6 3.6 225 6 140
HD2 (n 5 21) 3.6 6 1.4 7.3 6 1.8 6.1 6 1.4 166 6 128
P value .09 .36 .48 .21
Values are mean 6 SD.
ROH, serum retinol; RBP, retinol-binding protein; TTR, transthyretin; TG, triglycerides; PD1, children aged 0 to 11 years on
peritoneal dialysis; HD1, children aged 0 to 11 years on hemodialysis; PD2, children aged 12 to 18 years on peritoneal
dialysis; HD2, children aged 12 to 18 years on hemodialysis.

and the ratio of the binding proteins to each other
were calculated. There were no significant differ-
ences between any of these ratios in terms of age or
method of dialysis (Table 2).
Discussion
This study established that measured levels of
ROH, RBP, and TTR in children with ESRD
are similar to those reported earlier for adult
patients with ESRD (Table 3). These values for se-
rum ROH concentrations are also in accordance
with those in the study of Kriley and Warady7 in
a group of children receiving PD. Conversely,
a study conducted in Poland with children receiv-
ing HD reported lower-than-normal values for se-
rum ROH when compared with control subjects,
although both patients and subjects in that study
had serum ROH values within normal limits (0.7
to 2.6 mmol/L).8 Levels of RBP and TTR were
not reported in either study.7,8 Typically, the
ROH:RBP ratios reported in ESRD adult studies
range from 0.40 to 0.73. (Table 4).11,12 The ratio of
ROH:RBP in our study group was 0.74.
Method of dialysis did not appear to influence
any of the values measured. When ROH, RBP,
and TTR were compared in terms of the two
methods of dialysis, the only differences were in
the younger age group, in which both ROH and
TTR were significantly lower in children treated
with HD. Because only the two younger groups
had significantly different serum concentrations of
ROH, TG, and TTR when method of dialysis
was compared, we reviewed other clinical-
management issues that may have influenced
ROH, TR, and TTR. Triglycerides may be higher
in children on PD because samples are drawn in the
postabsorptive state, and glucose in dialysate is lipo-
genic. A possible explanation for the differences in
ROH, TTR, and TTR between groups PD1 and
HD1 could be related to the fact that a larger pro-
portion of children in the PD1 group were fed via
GT. The PD1 group had a higher proportion of
patients fed .75% of their total daily calories
with commercially prepared formulas: 14 of 19
(78%) of the PD1 patients versus 3 of 8 (38%) of
the HD1 patients were fed via GT. The formula
used for GT feeding in all patients had been man-
ufactured for adult ESRD patients, and was diluted
to a caloric density well-tolerated by the children.
Each GT feeding regimen provided adequate calo-
ries for the individual patient. Caloric intake for

Table 2. Ratios of ROH to Binding Proteins According to Method of Dialysis

ROH:RBP ROH:TTR RBP:TTR

PD1 (n 5 19) 0.61 6 0.26 2.14 6 0.38 1.94 6 0.33

HD1 (n 5 8) 0.54 6 0.17 2.0 6 0.19 1.95 6 0.22
P value .70 .64 .71
PD2 (n 5 29) 0.54 6 0.14 1.77 6 0.26 1.98 6 0.98
HD2 (n 5 21) 0.52 6 0.20 1.80 6 0.27 1.85 6 0.29
P value .62 .72 .62
Values are mean 6 SD.
ROH, serum retinol; RBP, retinol-binding protein; TTR, transthyretin; PD1, children aged 0 to 11 years on peritoneal
dialysis; HD1, children aged 0 to 11 years on hemodialysis; PD2, children aged 12 to 18 years on peritoneal dialysis;
HD2, children aged 12 to 18 years on hemodialysis.
20 FASSINGER ET AL

Table 3. Comparisons of Published Studies Describing Vitamin A and Its Binding Proteins in Adults With
End-Stage Renal Disease
Vitamin A (mmol/L) RBP (mmol/L) TTR (mmol/L)
Study MVI No MVI C MVI No MVI C No MVI C Dialysis Method Analysis Method

[1] 3.57 1.43 H F

[3] 7.2 6.4 12.9 13.1 P LC/UV
[4] 5.2 3.9 1.8 H F
[5] 6.6 5.36 1.7 12.5 11.8 2.7 H F
[6] 4.8 1.8 7.9 2.1 5.0 4.8 H F/LC
[10] 5.5 13.6 H F
[19] 7.48H 3.6 10.3H 3.0 7.69H 7.2 H/T F
5.71T 5.4T 5.36T
[20] 4.62H 2.5 13.62H 3.19 5.2H 5.55 H/T F
4.41H 2.14T 7.2T
[21] 3.8 3.7 P F
[22] 6.4ND 9.9ND P
4.5D 7.3D
[23] 7.0 2.16 11.77 2.76 H LC
RBP, retinol-binding protein; TTR, transthyretin; MVI, multivitamin; C, control; H, hemodialysis; P, peritoneal dialysis;
T, transplant; F, fluorometric method; LC, HPLC separation; UV, ultraviolet absorbance detection method; D, diabetic;
ND, nondiabetic.

children in this age group ranged from 70 to 120
kcal/kg/day. The retinyl palmitate and proportion-
ately higher fat content of commercially prepared
feedings may have altered ROH, TTR, and TG
in the PD1 group. The formula used was designed
to be lower in vitamin A per calorie than in stan-
dard enteral feeding formulas. However, it did con-
tain preformed vitamin A in the form of retinyl
palmitate (348 mg/L, or 0.175 mg/kcal). The fat
content of the formula was 43% of total calories,
from a mixture of high oleic safflower and soy
oils. Most children who were fed via GT received
between 1000 and 1500 kcal/day or 175 to 263
mg of retinyl palmitate, and 48 to 72 g/day of poly-
unsaturated fat. Fewer children in the HD1 group
(38%, vs. 78% in the PD1 group) were fed via
Table 4. Ratios of ROH to Binding Proteins According to Published Studies
ROH:RBP ROH:TTR
Study MVI No MVI C MVI No MVI
GT. This may account for the higher ROH con-
centrations in the PD1 group. Formula-fed
patients’ diets may also contain significantly more
vitamin A than the diets of those who do not
receive GT feeding or other supplements, because
diets for renal patients typically tend to be relatively
low in vitamin A due to restrictions on foods high
in phosphorus (dairy) and potassium (deep yellow
and green leafy vegetables). The only patient who
exhibited overt signs of vitamin A toxicity did
not receive tube-feeding, but did receive a daily
multivitamin with 5000 IU of retinyl palmitate.
None of the patients fed via GT exhibited overt
signs of vitamin A toxicity. Although we report
on elevated serum concentrations of ROH and its
binding proteins in children with ESRD, we have
RBP:TTR
C No MVI C Dialysis Method Analysis Method

[5] 0.52 0.45 0.63 H F

[22] 0.61 0.86 0.96 0.38 1.5 0.44 H F/LC
[10] 0.40 H F
[3] 0.56 0.49 P LC/UV
[24] 0.73H 1.2 0.97H 0.5 1.34H 0.42 H/T F
1.0T 1.1T 1.01T
[22] 0.65ND P
0.62D
[23] 0.59 0.79 H LC
ROH, serum retinol; RBP, retinol-binding protein; TTR, transthyretin; MVI, multivitamin; C, control; H, hemodialysis; P,
peritoneal dialysis; T, transplant; F, fluorometric method; LC, HPLC separation; UV, ultraviolet absorbance detection
method; D, diabetic; ND, nondiabetic.
 ROH, RBT, AND TTR IN CHILDREN ON DIALYSIS
not described intracellular concentrations of ROH
or retinoic acids. This is an important issue that
needs to be resolved, because with the exception
of the visual cycle, it is the nuclear action of retinoic
acids that is responsible for the actions of vitamin A.
Given that ROH carrier proteins are also elevated
in ESRD, an examination of the mechanism of
transport of retinol across the cell membrane is im-
portant. At present, this mechanism is not com-
pletely understood. Studies indicate the
membrane transport of retinol by membrane-
bound RBP receptors, endocytosis, diffusion based
on intracellular free ROH concentration gradients,
and a form of ROH shuttling between extracellular
and intracellular carrier proteins.13–16 Recent
reports found increasing evidence for the existence
of a cell-membrane receptor that binds RBP.14 The
method of membrane transport for retinol is partic-
ularly important in the discussion of its metabolism
in renal disease, because serum concentrations of
both ROH and RBP are abnormal, and may influ-
ence intracellular concentrations of ROH and
retinoic acid. Furthermore, current therapy for
renal osteodystrophy may include high doses of
1,25-dihydroxyvitamin D3 that could disrupt the
balance of ligands necessary for the respective
nuclear proteins to regulate gene transcription, par-
ticularly those genes whose products are necessary
for calcium homeostasis.
Increased attention to nutrition, 1,25-dihy-
droxyvitamin D3 therapy, and the daily admin-
istration of growth hormone has improved the
outcomes of many children in the past 15 to
20 years. However, despite these interventions,
many children still experience growth failure, de-
creased muscle mass, pruritus, hypercalcemia,
hyperlipidemia, and abnormal bone growth.17 It
is assumed that RBP not catabolized and excreted
by the damaged kidney acquires more retinol and
returns to the plasma, increasing the total vitamin
A levels of patients with ESRD.11 However, this
assumption is not consistent with what is known
about normal apo-RBP recycling. Animal studies
suggest that when serum ROH is at normal or
high levels, RBP is sequestered in the liver, and
additional ROH is not added to the circulation.14
In the patient with ESRD, intracellular transport
may be abnormal because serum concentrations
of carrier proteins are also very high. If, in fact,
transmembrane movement is dependent on
concentration gradients of ROH or its carrier pro-
teins, the equilibrium constants could be distorted,
21
causing either increased or decreased intracellular
concentrations of ROH.
Further complicating the picture is the inability
to determine clinically the impact of elevated
serum ROH in the patient with ESRD, because
the symptoms of uremia, vitamin A toxicity, and
vitamin A deficiency are similar. Current recom-
mendations discourage the use of multivitamins
containing fat-soluble vitamins in all patients
with ESRD, including children.18 In addition,
vitamin A intake may be indirectly limited by
dietary restrictions imposed to maintain acceptable
serum potassium and phosphorus levels in the face
of decreased renal clearance of these minerals.
Given the rapid cellular turnover and growth of
children, the maintenance of intracellular retinoic
acid levels is very important. However, in light of
high total vitamin A levels, and without an under-
standing of the intracellular availability of ROH
and retinoic acid, supplementation with vitamin
A is risky. Because the action of vitamin A is hor-
mone-like and its actions are closely tied to other
growth-related hormones, it is important to iden-
tify abnormalities in its metabolism in the uremic
state, especially those abnormalities in children
with renal failure.
Conclusions
The data reported here indicate that children
with ESRD have elevated levels of serum ROH,
RBP, and TTR, in proportion to those levels
reported in the early adult ESRD literature. This
anomaly deserves further investigation, given the
plethora of new knowledge concerning the action
of vitamin A and its metabolites that has been
elucidated since the reported findings of increased
ROH and RBP in adult ESRD patients. Most
importantly, the intracellular actions of retinoic
acids in the uremic state should be investigated.
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