This may be explained by the fact that although both Cys C and Cr are filtered by the glomerulus, a portion of Cr is also secreted by the tubules and excreted in urine [21]. When glomerular filtration is compromised, tubular secretion of Cr is increased in order to maintain normal plasma Cr concentration [22]. The results therefore suggest that RFU children had a less efficient glomerular filtration

rate and a compensatory Metformin cell line increase in tubular secretion of Cr. An alternative possibility is that the RFU children had a lower lean body mass/weight ratio than LC children resulting in a lower daily release of Cr into the circulation which may have obscured the lower GFR. Cys C is regarded as a more sensitive marker for the calculation of eGFR in children because of problems of interpreting those based on Cr [23]. The data therefore suggest that RFU children had a less efficient GFR but not sufficient to cause clinical problems. Both the original and follow-up studies measured FGF23 concentrations using the learn more Immutopics C-terminal FGF23 assay which detects both the intact FGF23 hormone and its C-terminal fragments. In the case of RFU

it is likely that the elevated FGF23 was reflecting both an increased production of intact and biologically active FGF23 hormone and possibly a greater proportion of presumed inactive C-terminal fragments. Another intriguing finding was the inverse correlation between Hb and FGF23 in RFU children. As iron deficiency anaemia is endemic in The Gambia [24] a lower Hb in these children is likely to imply a lower iron status. A finding of a relationship between Hb and FGF23 therefore supports previous suggestions of the involvement of iron in FGF23 metabolic pathways [25] and [26]. Researchers have hypothesised that iron is required for the clearance of FGF23 fragments by the kidney and also that iron may inhibit the cleavage of intact FGF23 [25]. It is possible that the combination of low iron status and lower eGFR may have resulted in greater amounts of

circulating FGF23 fragments in RFU children, due to less efficient clearance by the Vitamin B12 kidney and/or an increased production of C-terminal fragments. None of the RFU children had radiological signs of active rickets but only half of the children had recovered from their lower-limb deformities. Those with persisting deformities were of similar age but had higher 1,25(OH)2D and lower Cys C-eGFR when compared with those who had recovered. A study carried out in Nigeria suggested incomplete distal renal tubular acidosis (idRTA) as a possible cause of differing rates of recovery from rickets-like-deformities [27]. However, it is an unlikely explanation in this Gambian study as idRTA is characteristically accompanied by high uCa which was not seen in the RFU children.