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Evenepoel P, Jørgensen HS. Skeletal parathyroid hormone hyporesponsiveness: a neglected, but clinically relevant reality in chronic kidney disease. Curr Opin Nephrol Hypertens 2024; 33:383-390. [PMID: 38651491 DOI: 10.1097/mnh.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
PURPOSE OF REVIEW Defining the optimal parathyroid hormone (PTH) target in chronic kidney disease (CKD) is challenging, especially for bone outcomes, due to the substantial variability in the skeleton's response to PTH. Although PTH hyporesponsiveness is as integral a component of CKD-mineral bone disorder as elevated PTH levels, clinical awareness of this condition is limited. In this review, we will discuss factors and mechanisms contributing to PTH hyporesponsiveness in CKD. This knowledge may provide clues towards a personalized approach to treating secondary hyperparathyroidism in CKD. RECENT FINDINGS Indicates a link between disturbed phosphate metabolism and impaired skeletal calcium sensing receptor signaling as an important mediator of PTH hyporesponsiveness in CKD. Further, cohort studies with diverse populations point towards differences in mineral metabolism control, rather than genetic or environmental factors, as drivers of the variability of PTH responsiveness. IN SUMMARY Skeletal PTH hyporesponsiveness in CKD has a multifactorial origin, shows important interindividual variability, and is challenging to estimate in clinical practice. The variability in skeletal responsiveness compromises PTH as a biomarker of bone turnover, especially when considering populations that are heterogeneous in ethnicity, demography, kidney function, primary kidney disease and mineral metabolism control, and in patients treated with bone targeting drugs.
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Affiliation(s)
- Pieter Evenepoel
- Department of Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium
- Department of Medicine, Division of Nephrology, Leuven University Hospitals, Leuven, Belgium
| | - Hanne Skou Jørgensen
- Institute of Clinical Medicine, Aarhus University, Aarhus
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
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2
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Cavalier E. Determination of parathyroid hormone: from radioimmunoassay to LCMS/MS. Clin Chem Lab Med 2023; 61:946-953. [PMID: 36640443 DOI: 10.1515/cclm-2022-0942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
Parathyroid hormone (PTH) determination is of paramount importance for the exploration of diseases related with calcium metabolism and for the follow-up of patients suffering from bone and mineral disorders associated with chronic kidney diseases (CKD-MBD). Unfortunately, the biologically active form of PTH, i.e. 1-84 PTH, circulates in the blood stream with many fragments and post-translationally modified forms, which decreases the specificity of immunoassays. The assays used to measure PTH, either from 2nd or 3rd generation, are not standardised, which may lead to interpretation errors and clinical consequences. Reference ranges for PTH have neither been always correctly established and the stability of the peptide is also a matter of concern. Fortunately, these last years, newer techniques using mass spectrometry (either high resolution or triple quadripole) coupled with liquid chromatography have been developed, which will help to standardise the different assays. Indeed, PTH assays standardisation is one of the task of the IFCC Committee for Bone Metabolism. Such standardisation will allow a better consistency in the interpretation of the results and will promote studies aiming at the establishment of correct reference ranges.
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Affiliation(s)
- Etienne Cavalier
- Department of Clinical Chemistry, CHU de Liège, CIRM, University of Liege, Liège, Belgium
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Bone Disease in Chronic Kidney Disease and Kidney Transplant. Nutrients 2022; 15:nu15010167. [PMID: 36615824 PMCID: PMC9824497 DOI: 10.3390/nu15010167] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022] Open
Abstract
Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) comprises alterations in calcium, phosphorus, parathyroid hormone (PTH), Vitamin D, and fibroblast growth factor-23 (FGF-23) metabolism, abnormalities in bone turnover, mineralization, volume, linear growth or strength, and vascular calcification leading to an increase in bone fractures and vascular disease, which ultimately result in high morbidity and mortality. The bone component of CKD-MBD, referred to as renal osteodystrophy, starts early during the course of CKD as a result of the effects of progressive reduction in kidney function which modify the tight interaction between mineral, hormonal, and other biochemical mediators of cell function that ultimately lead to bone disease. In addition, other factors, such as osteoporosis not apparently dependent on the typical pathophysiologic abnormalities resulting from altered kidney function, may accompany the different varieties of renal osteodystrophy leading to an increment in the risk of bone fracture. After kidney transplantation, these bone alterations and others directly associated or not with changes in kidney function may persist, progress or transform into a different entity due to new pathogenetic mechanisms. With time, these alterations may improve or worsen depending to a large extent on the restoration of kidney function and correction of the metabolic abnormalities developed during the course of CKD. In this paper, we review the bone lesions that occur during both CKD progression and after kidney transplant and analyze the factors involved in their pathogenesis as a means to raise awareness of their complexity and interrelationship.
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Schini M, Vilaca T, Gossiel F, Salam S, Eastell R. Bone Turnover Markers: Basic Biology to Clinical Applications. Endocr Rev 2022; 44:417-473. [PMID: 36510335 PMCID: PMC10166271 DOI: 10.1210/endrev/bnac031] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 11/26/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
Bone turnover markers (BTMs) are used widely, in both research and clinical practice. In the last 20 years, much experience has been gained in measurement and interpretation of these markers, which include commonly used bone formation markers bone alkaline phosphatase, osteocalcin, and procollagen I N-propeptide; and commonly used resorption markers serum C-telopeptides of type I collagen, urinary N-telopeptides of type I collagen and tartrate resistant acid phosphatase type 5b. BTMs are usually measured by enzyme-linked immunosorbent assay or automated immunoassay. Sources contributing to BTM variability include uncontrollable components (e.g., age, gender, ethnicity) and controllable components, particularly relating to collection conditions (e.g., fasting/feeding state, and timing relative to circadian rhythms, menstrual cycling, and exercise). Pregnancy, season, drugs, and recent fracture(s) can also affect BTMs. BTMs correlate with other methods of assessing bone turnover, such as bone biopsies and radiotracer kinetics; and can usefully contribute to diagnosis and management of several diseases such as osteoporosis, osteomalacia, Paget's disease, fibrous dysplasia, hypophosphatasia, primary hyperparathyroidism, and chronic kidney disease-mineral bone disorder.
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Affiliation(s)
- Marian Schini
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Tatiane Vilaca
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Fatma Gossiel
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Syazrah Salam
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Richard Eastell
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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Yajima A, Tsuchiya K, Kuro-O M, Urena P, Tominaga Y, Okada M, Ichimori T, Tomosugi T, Hiramitsu T, Murata T, Nakamura M, Sasaki M, Ito A, Nitta K. Renal hyperparathyroidism. VITAMINS AND HORMONES 2022; 120:305-343. [PMID: 35953115 DOI: 10.1016/bs.vh.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The number of the patients with chronic kidney disease is now increasing in the world. The pathophysiology of renal hyperparathyroidism is closely associated with Klotho-FGF-endocrine axes, which must be solved definitively as early as possible. It was revealed that the expression of fgf23 is activated by calciprotein particles, which induces vascular ossification. And it is well known that phosphorus overload directly increases parathyroid hormone and hyperparathyroid bone disease develops in those subjects. On the other hand, low turnover bone disease is often recently. Both the patients with chronic kidney disease suffering from hyperparathyroid bone disease or low turnover bone disease are associated with increased fracture risk. Micropetrosis may be one of the causes of increased fracture risk in the subjects with low turnover bone disease. In this chapter, we now describe the diagnosis, pathophysiology and treatments of renal hyperparathyroidism.
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Affiliation(s)
- Aiji Yajima
- Department of Anatomy, Cell Biology and Physiology, Indiana University, School of Medicine, Indianapolis, IN, United States; Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan; Department Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan.
| | - Ken Tsuchiya
- Department Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Makoto Kuro-O
- Division of Anti-aging Medicine, Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Pablo Urena
- Division of Nephrology, Clinique du Landy, Saint Ouen, France
| | - Yoshihiro Tominaga
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Manabu Okada
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Toshihiro Ichimori
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Toshihide Tomosugi
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Taro Murata
- Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan
| | - Masaki Nakamura
- Department of Nephrology and Urology, NTT East Kanto Hospital, Tokyo, Japan
| | - Masahiko Sasaki
- Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan
| | - Akemi Ito
- Ito Bone Histomorphometry Institute, Niigata, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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Galassi A, Fasulo EM, Ciceri P, Casazza R, Bonelli F, Zierold C, Calleri M, Blocki FA, Palmieri MA, Mastronardo C, Cozzolino MG. 1,25-dihydroxyvitamin D as Predictor of Renal Worsening Function in Chronic Kidney Disease. Results From the PASCaL-1,25D Study. Front Med (Lausanne) 2022; 9:840801. [PMID: 35308556 PMCID: PMC8924653 DOI: 10.3389/fmed.2022.840801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/07/2022] [Indexed: 01/01/2023] Open
Abstract
Background Heterogeneous progression of chronic kidney disease (CKD) toward dialysis advocates improving in renal care management. Diagnosis and staging of CKD relies on estimated glomerular filtration rate (eGFR) and albuminuria. Tubular biomarkers emerged as new predictors of worsening renal function (WRF), due to partial inaccuracy of eGFR and existing WRF in non-proteinuric patients. Active vitamin D is synthesized in renal tubules and participates to mineral adaptation in CKD. Circulating 1,25-dihydroxyvitamin D [1,25(OH)2D] was poorly investigated as a biomarker of endocrine tubular function and predictor of WRF. Objective Investigate capability of 1,25(OH)2D to predict parathormone (PTH) increase and WRF in CKD stage 3-4. Methods PASCaL-1,25D was an observational, prospective, monocentric study. Primary outcomes were absolute and 20% increase in PTH, and WRF defined as 20% reduction in eGFR or dialysis initiation at 6 months. Results Seventy-one patients completed follow up. Absolute increase in PTH (1-84) was independently predicted by lower 1,25(OH)2D levels (p = 0.0134). No association was detected between 1,25(OH)2D and iPTH increase. Higher 1,25(OH)2D was associated with reduced risk of WRF at univariate analysis [OR 0.89 (95% CI 0.86-0.93), p = 0.006]. The 1,25(OH)2D/PTH (1-84) ratio was associated with non-significant 84% risk reduction for WRF [OR 0.16 (95% CI 0.06-0.41), p = 0.05]. Low 1,25(OH)2D reached 100% sensitivity in predicting WRF in CKD stage 3 (AUC 9.909, p < 0.0001) and non-elderly patients (AUC 0.883, p < 0.0001). Machine learning models retained 1,25(OH)2D/PTH (1-84) as relevant predictor of WRF together with eGFR and albuminuria. Age influenced interaction between renal and mineral biomarkers. Conclusion 1,25(OH)2D deserves attention as biomarker of tubular health, and sensible predictor of WRF on the short run among non-elderly patients affected by stage 3 CKD. The 1,25(OH)2D/PTH (1-84) ratio may represent a composite biomarker of tubular reserve/endocrine response to the transition from adaptive to maladaptive equilibrium in CKD-MBD.
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Affiliation(s)
- Andrea Galassi
- Renal Division, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Department of Health Science, University of Milan, Milan, Italy
| | - Eliana Maria Fasulo
- Renal Division, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Department of Health Science, University of Milan, Milan, Italy
| | - Paola Ciceri
- Renal Division, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Department of Health Science, University of Milan, Milan, Italy
| | - Roberta Casazza
- Renal Division, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Department of Health Science, University of Milan, Milan, Italy
| | | | | | | | | | | | | | - Mario G Cozzolino
- Renal Division, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Department of Health Science, University of Milan, Milan, Italy
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Bover J, Arana C, Ureña P, Torres A, Martín-Malo A, Fayos L, Coll V, Lloret MJ, Ochoa J, Almadén Y, Guirado L, Rodríguez M. Hyporesponsiveness or resistance to the action of parathyroid hormone in chronic kidney disease. Nefrologia 2021; 41:514-528. [PMID: 36165134 DOI: 10.1016/j.nefroe.2021.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/20/2020] [Indexed: 06/16/2023] Open
Abstract
Secondary hyperparathyroidism (SHPT) is an integral component of the chronic kidney disease-mineral and bone disorder (CKD-MBD). Many factors have been associated with the development and progression of SHPT but the presence of skeletal or calcemic resistance to the action of PTH in CKD has often gone unnoticed. The term hyporesponsiveness to PTH is currently preferred and, in this chapter, we will not only review the scientific timeline but also some of the molecular mechanisms behind. Moreover, the presence of resistance to the biological action of PTH is not unique in CKD since resistance to other hormones has also been described ("uremia as a receptor disease"). This hyporesponsiveness carries out important clinical implications since it explains, at least partially, not only the progressive nature of the pathogenesis of CKD-related PTH hypersecretion and parathyroid hyperplasia but also the increasing prevalence of adynamic bone disease in the CKD population. Therefore, we underline the importance of PTH control in all CKD stages, but not aiming to completely normalize PTH levels since a certain degree of SHPT may represent an adaptive clinical response. Future studies at the molecular level, i.e. on uremia or the recent description of the calcium-sensing receptor as a phosphate sensor, may become of great value beyond their significance to explain just the hyporesponsiveness to PTH in CKD.
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Affiliation(s)
- Jordi Bover
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, Spain.
| | - Carolt Arana
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, Spain
| | - Pablo Ureña
- AURA Nord Saint Ouen y Departamento de Fisiología Renal, Hospital Necker, Universidad de París Descartes, Paris, France
| | - Armando Torres
- Servicio de Nefrología, Hospital Universitario de Canarias, REDinREN, Universidad de La Laguna, Tenerife, Spain
| | - Alejandro Martín-Malo
- Unidad de Gestión Clinica Nefrología, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, Spain; Red Nacional de Investigación en Nefrología (REDinREN), Instituto de Salud Carlos III, Madrid, Spain
| | - Leonor Fayos
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, Spain
| | - Verónica Coll
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, Spain
| | - María Jesús Lloret
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, Spain
| | - Jackson Ochoa
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, Spain
| | - Yolanda Almadén
- Unidad de Gestión Clínica Medicina Interna, Lipid and Atherosclerosis Unit, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, Spain; CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Lluis Guirado
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, Spain
| | - Mariano Rodríguez
- Unidad de Gestión Clinica Nefrología, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, Spain; Red Nacional de Investigación en Nefrología (REDinREN), Instituto de Salud Carlos III, Madrid, Spain
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Tominaga N, Yonaha T, Yamanouchi M, Sumi H, Taki Y, Shibagaki Y, Shiizaki K, Yano S. Bone responsiveness to parathyroid hormone is negatively associated with parathyroid hormone-lowering drug use in patients undergoing hemodialysis: a cross-sectional study. BMC Nephrol 2021; 22:275. [PMID: 34372813 PMCID: PMC8353797 DOI: 10.1186/s12882-021-02482-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/23/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Parathyroid hormone (PTH) acts on bone to indirectly increase the number and activity of osteoclasts. Thus, PTH has a stimulatory effect on bone resorption and upregulates bone turnover. However, the responsiveness of bone to PTH varies widely among patients receiving dialysis. In fact, relative to the serum PTH level, the level of serum tartrate-resistant acid phosphatase-5b (TRACP-5b), a bone resorption marker derived from osteoclasts, varies as well. This study aimed to examine factors related to bone responsiveness to PTH in patients undergoing chronic hemodialysis (HD). METHODS This study included patients receiving chronic HD in Kawasaki Municipal Tama Hospital (Kanagawa, Japan) and Yonaha Medical Clinic (Okinawa, Japan) and excluded patients who received HD for less than 6 months, those who received a combination of HD and peritoneal dialysis, and those who had cancer bone metastases or myeloma. The TRACP-5b/intact PTH (iPTH) ratio was created as an index of bone responsiveness to PTH, categorized into tertiles (low, medium, and high), and a cross-sectional study was conducted. P < 0.05 indicated statistically significant differences. RESULTS One hundred and six patients were analyzed. Age (P = 0.010), body mass index (BMI) (P = 0.003), use of calcium-sensing receptor (CaSR) agonists (P = 0.008), use of vitamin D receptor activators (VDRAs) (P = 0.012), plasma iPTH level (P < 0.001), serum 1,25(OH)2D level (P = 0.003), and serum TRACP-5b level (P < 0.001) were significantly different among the three categories. In the single linear regression analysis, age (P = 0.016), corrected serum calcium level (P = 0.007), and ln [1,25(OH)2D] (P = 0.044) showed a significant positive correlation with ln [TRACP-5b/iPTH], whereas BMI (P = 0.026), use of CaSR agonists (P = 0.001), use of VDRAs (P = 0.009), and serum phosphorus level (P = 0.018) showed a significant negative correlation. Upon conducting multiple linear regression analysis incorporating significant variables in the single linear regression analysis, a significant negative correlation was observed between the TRACP-5b/iPTH ratio and intravenous administration of a CaSR agonist (etelcalcetide) and/or a VDRA (calcitriol or maxacalcitol) in all the adjusted models. CONCLUSIONS Bone responsiveness to PTH is negatively correlated with the intravenous administration of a CaSR agonist and/or a VDRA in patients undergoing chronic HD.
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Affiliation(s)
- Naoto Tominaga
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan. .,Division of Nephrology and Hypertension, Kawasaki Municipal Tama Hospital, Kawasaki, Kanagawa, Japan.
| | - Tomoki Yonaha
- Nephrology and Dialysis Center, Yohana Medical Clinic, Ishigaki, Okinawa, Japan
| | | | - Hirofumi Sumi
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.,Division of Nephrology and Hypertension, Kawasaki Municipal Tama Hospital, Kawasaki, Kanagawa, Japan
| | - Yasuhiro Taki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.,Division of Nephrology and Hypertension, Kawasaki Municipal Tama Hospital, Kawasaki, Kanagawa, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | | | - Shozo Yano
- Department of Laboratory Medicine, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
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Chen H, Ren W, Gao Z, Zeng M, Tang S, Xu F, Huang Y, Zhang L, Cui Y, Yang G, Qian H, Zhou W, Ouyang C, Gao X, Zhang J, Xiao Y, Zhao B, Wang J, Bian A, Li F, Wan H, Gao W, Wang X, Xing C, Zha X, Wang N. Effects of parathyroidectomy on plasma PTH fragments and heart rate variability in stage 5 chronic kidney disease patients. Ren Fail 2021; 43:890-899. [PMID: 34044733 PMCID: PMC8168729 DOI: 10.1080/0886022x.2021.1931318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Circulating intact parathyroid hormone (iPTH) levels include full-length (1-84) PTH and long C-PTH fragments, but primarily (7-84) PTH, which have been reported to have antagonistic effects on the bones and kidneys. However, their effects on the cardiovascular system remain unclear. In this study, the relationships between the plasma PTH fragments levels and heart rate variability (HRV) in stage 5 chronic kidney disease (CKD5) patients are explored. Furthermore, the effects of parathyroidectomy (PTX) on the above indices are investigated. METHODS In this cross-sectional study, 164 healthy controls and 354 CKD5 patients, including 208 secondary hyperparathyroidism (SHPT) subgroup with PTX, were enrolled. Circulating (7-84) PTH levels were calculated by subtracting plasma (1-84) PTH levels from iPTH levels. The HRV parameters were measured using a 24-hour Holter. RESULTS The baseline levels of plasma iPTH, (1-84) PTH, and (7-84) PTH in the CKD5 patients were 930.40 (160.65, 1792.50) pg/mL, 448.60 (99.62, 850.45) pg/mL, and 468.20 (54.22, 922.55) pg/mL, respectively. In the CKD5 patients, plasma (1-84) PTH levels were independently correlated with the standard deviation of the normal-to-normal R-R intervals (SDNN) and the standard deviation of the five-minute average of the normal R-R intervals (SDANN). With a median follow up time of 6.50 months after PTX in the SHPT patients (n = 30), improved SDNN and SDANN markers were related with decreased (1-84) PTH levels. Furthermore, an improved SDNN was related with decreased (7-84) PTH levels. CONCLUSIONS The CKD5 patients' baseline (1-84) PTH levels were correlated with the SDNN and SDANN. After PTX, an improved SDNN was related with decreased (1-84) PTH and (7-84) PTH levels, while improved SDANN was related with decreased (1-84) PTH levels. No antagonistic effects of (1-84) PTH and (7-84) PTH on HRV were found in the CKD5 patients.
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Affiliation(s)
- Huimin Chen
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Department of Nephrology, Taizhou People's Hospital, Taizhou, China
| | - Wenkai Ren
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Zhanhui Gao
- Department of Nephrology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Shaowen Tang
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Fangyan Xu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yaoyu Huang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Lina Zhang
- Department of Nephrology, Henan Provincial Key Laboratory of Kidney Disease and Immunology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Cui
- Department of Nephrology, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Hanyang Qian
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Wenbin Zhou
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Chun Ouyang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Department of Nephrology, Liyang Branch, Jiangsu Province Hospital, Liyang People's Hospital, Liyang, China
| | - Xueyan Gao
- Department of General Medicine, Geriatric Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Yujie Xiao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Baiqiao Zhao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Jing Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Anning Bian
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Fan Li
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Huiting Wan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Wei Gao
- National Health Commission Key Laboratory of Antibody Techniques, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, China
| | - Xiaoyun Wang
- Department of Nephrology, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Xiaoming Zha
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
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10
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Bover J, Arana C, Ureña P, Torres A, Martín-Malo A, Fayos L, Coll V, Lloret MJ, Ochoa J, Almadén Y, Guirado L, Rodríguez M. Hyporesponsiveness or resistance to the action of parathyroid hormone in chronic kidney disease. Nefrologia 2021. [PMID: 33985858 DOI: 10.1016/j.nefro.2020.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Secondary hyperparathyroidism (SHPT) is an integral component of the chronic kidney disease-mineral and bone disorder (CKD-MBD). Many factors have been associated with the development and progression of SHPT but the presence of skeletal or calcemic resistance to the action of PTH in CKD has often gone unnoticed. The term hyporesponsiveness to PTH is currently preferred and, in this chapter, we will not only review the scientific timeline but also some of the molecular mechanisms behind. Moreover, the presence of resistance to the biological action of PTH is not unique in CKD since resistance to other hormones has also been described ("uremia as a receptor disease"). This hyporesponsiveness carries out important clinical implications since it explains, at least partially, not only the progressive nature of the pathogenesis of CKD-related PTH hypersecretion and parathyroid hyperplasia but also the increasing prevalence of adynamic bone disease in the CKD population. Therefore, we underline the importance of PTH control in all CKD stages, but not aiming to completely normalize PTH levels since a certain degree of SHPT may represent an adaptive clinical response. Future studies at the molecular level, i.e. on uremia, or the recent description of the calcium-sensing receptor as a phosphate sensor, may become of great value beyond their significance to explain just the hyporesponsiveness to PTH in CKD.
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Affiliation(s)
- Jordi Bover
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, España.
| | - Carolt Arana
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, España
| | - Pablo Ureña
- AURA Nord Saint Ouen y Departamento de Fisiología Renal, Hospital Necker, Universidad de París Descartes, París, Francia
| | - Armando Torres
- Servicio de Nefrología, Hospital Universitario de Canarias, REDinREN, Universidad de La Laguna, Tenerife, España
| | - Alejandro Martín-Malo
- Unidad de Gestión Clínica Nefrología, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, España; Red Nacional de Investigación en Nefrología (REDinREN), Instituto de Salud Carlos III, Madrid, España
| | - Leonor Fayos
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, España
| | - Verónica Coll
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, España
| | - María Jesús Lloret
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, España
| | - Jackson Ochoa
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, España
| | - Yolanda Almadén
- Unidad de Gestión Clínica Medicina Interna, Lipid and Atherosclerosis Unit, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, España; CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, España
| | - Lluis Guirado
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, España
| | - Mariano Rodríguez
- Unidad de Gestión Clínica Nefrología, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, España; Red Nacional de Investigación en Nefrología (REDinREN), Instituto de Salud Carlos III, Madrid, España
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11
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Berner C, Marculescu R, Frommlet F, Kurnikowski A, Schairer B, Aigner C, Bieglmayer C, Hecking M. Parathyroid Hormone Concentrations in Maintenance Hemodialysis: Longitudinal Evaluation of Intact and Biointact Assays. Kidney Med 2021; 3:343-352.e1. [PMID: 34136780 PMCID: PMC8178455 DOI: 10.1016/j.xkme.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
RATIONALE & OBJECTIVE Management of chronic kidney disease mineral and bone disorder requires parathyroid hormone (PTH) concentrations. "Biointact" PTH immunoassays detect "whole" PTH (wPTH), whereas "intact" immunoassays measure PTH plus PTH fragments (iPTH). We aimed to determine whether longitudinal changes in PTH concentrations can be evaluated using biointact and intact immunoassays alike. STUDY DESIGN Open noninterventional longitudinal cohort study. SETTING & PARTICIPANTS PTH concentrations were measured quarterly up to 5 times in 102 hemodialysis patients. PREDICTORS & TESTS COMPARED Age, sex, phosphate levels, and others as clinical predictors for PTH trend. Tests compared were iPTH immunoassays from Siemens and Roche and wPTH immunoassays from Roche and DiaSorin. OUTCOMES PTH concentration trend; regression equations; test bias. ANALYTICAL APPROACH Predictive regression-to-the-mean model for PTH slope; Bland-Altman plots, Passing-Bablok regression, and reference change values for test comparisons. RESULTS wPTH concentrations were similar with both immunoassays (wPTH-Roche = 11.7 + 0.97 × wPTH-DiaSorin, r = 0.99; mean ± 1.96 SD bias, 8.2 ± 43.3 pg/mL [17.5% ± 40.9%], by Bland-Altman plots). iPTH-Siemens concentrations were higher than iPTH-Roche concentrations (iPTH-Siemens = -5.4 + 1.33 × iPTH-Roche, r = 0.99; mean ± 1.96 SD bias, 84.0 ± 180.2 pg/mL [21.1% ± 29.8%], by Bland-Altman plots). iPTH-Roche and iPTH-Siemens concentrations were 2- and 2.5-fold higher than wPTH concentrations, respectively. Full agreement among all 4 immunoassays in detecting both significant and insignificant changes in PTH concentrations, upward or downward from one quarter to the next, was reached in 87% of consecutive measurements. In a predictive model, baseline PTH concentrations > 199 pg/mL (wPTH-Roche), 204 pg/mL (wPTH-DiaSorin), 386 pg/mL (iPTH-Roche), and 417 pg/mL (iPTH-Siemens) correctly predicted declining PTH concentration trend in 62% to 68% of patients, but age, sex, hemodialysis vintage, and calcium and phosphate levels were no significant predictors. LIMITATIONS Limited number of immunoassays, only 59 patients attended all quarterly samplings. CONCLUSIONS wPTH-Roche and wPTH-DiaSorin concentrations were similar, while iPTH was higher than wPTH concentrations. The iPTH-Siemens immunoassay is either higher calibrated or detects more fragments than iPTH-Roche. However, longitudinal PTH concentration changes largely coincided with all tested immunoassays.
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Affiliation(s)
- Carolin Berner
- Division of Nephrology & Dialysis, Department of Medicine III, Medical University of Vienna
- Nephrology & Dialysis, 1st Medical Department, Kaiser Franz Josef Hospital Vienna, Medical University of Vienna, Vienna, Austria
| | - Rodrig Marculescu
- Clinical Institute for Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - Florian Frommlet
- Center for Medical Statistics, Informatics and Intelligent Systems, Section for Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Amelie Kurnikowski
- Division of Nephrology & Dialysis, Department of Medicine III, Medical University of Vienna
| | - Benjamin Schairer
- Division of Nephrology & Dialysis, Department of Medicine III, Medical University of Vienna
| | - Christof Aigner
- Division of Nephrology & Dialysis, Department of Medicine III, Medical University of Vienna
| | - Christian Bieglmayer
- Clinical Institute for Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria
| | - Manfred Hecking
- Division of Nephrology & Dialysis, Department of Medicine III, Medical University of Vienna
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12
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Kritmetapak K, Losbanos LA, Hines JM, O'Grady KL, Ulmer CZ, Vesper HW, Enders FT, Singh RJ, Kumar R. Chemical Characterization and Quantification of Circulating Intact PTH and PTH Fragments by High-Resolution Mass Spectrometry in Chronic Renal Failure. Clin Chem 2021; 67:843-853. [PMID: 33693557 PMCID: PMC8167341 DOI: 10.1093/clinchem/hvab013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 01/12/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND The precise concentrations of full-length parathyroid hormone (PTH1-84) and the identity and concentrations of PTH fragments in patients with various stages of chronic renal failure are unknown. METHODS We developed a liquid chromatography-high resolution mass spectrometry (LC-HRMS) method to characterize and quantify PTH1-84 and PTH fragments in serum of 221 patients with progressive renal dysfunction. Following capture by matrix-bound amino-terminal or carboxyl-terminal region-specific antibodies and elution from matrix, PTH1-84 and PTH fragments were identified and quantitated using LC-HRMS. PTH was simultaneously measured using an intact PTH (iPTH) immunoassay. RESULTS Full-length PTH1-84 and 8 PTH fragments (PTH28-84, 34-77, 34-84, 37-77, 37-84, 38-77, 38-84, and 45-84) were unequivocally identified and were shown to increase significantly when an eGFR declined to ≤17-23 mL/min/1.73m2. Serum concentrations of PTH1-84 were similar when measured by LC-HRMS following capture by amino-terminal or carboxyl-terminal immunocapture methods. In patients with an eGFR of <30 mL/min/1.73 m2, serum PTH concentrations measured using LC-HRMS were significantly lower than PTH measured using an iPTH immunoassay. PTH7-84 and oxidized forms of PTH1-84 were below the limit of detection (30 and 50 pg/mL, respectively). CONCLUSIONS LC-HRMS identifies circulating PTH1-84, carboxyl-terminal PTH fragments, and mid-region PTH fragments, in patients with progressive renal failure. Serum PTH1-84 and its fragments markedly rise when an eGFR decreases to ≤17-23 mL/min/1.73 m2. PTH concentrations measured using LC-HRMS tend to be lower than those measured using an iPTH immunoassay, particularly in severe chronic renal failure. Our data do not support the existence of circulating PTH7-84 and oxidized PTH1-84.
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Affiliation(s)
- Kittrawee Kritmetapak
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Nephrology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Louis A Losbanos
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jolaine M Hines
- Immunochemical Core Laboratory, Mayo Clinic, Rochester, MN, USA
| | | | - Candice Z Ulmer
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Hubert W Vesper
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Felicity T Enders
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Ravinder J Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Rajiv Kumar
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
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13
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Okada M, Hiramitsu T, Ichimori T, Goto N, Narumi S, Watarai Y, Sato T, Tominaga Y. Comparison of Pre- and Post-transplant Parathyroidectomy in Renal Transplant Recipients and the Impact of Parathyroidectomy Timing on Calcium Metabolism and Renal Allograft Function: A Retrospective Single-Center Analysis. World J Surg 2020; 44:498-507. [PMID: 31399797 DOI: 10.1007/s00268-019-05124-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The effect of parathyroidectomy (PTx) timing on serum calcium (Ca) levels and renal functions in renal transplant recipients with severe hyperparathyroidism (HPT) remains unclear. We retrospectively aimed to investigate and compare the clinical data of patients who underwent pre- and post-transplant PTx and elucidated the impact of PTx timing on serum Ca levels and renal graft outcomes after renal transplantation (RTx). METHODS During January 2000-December 2016, 53 and 55 patients underwent post-transplant PTx (Post-RTx group) and pretransplant PTx (Pre-RTx group), respectively. The serum Ca levels and estimated glomerular filtration rate (eGFR) were assessed in both groups. RESULTS At the end of the follow-up, the serum Ca levels were significantly higher and the incidence of hypocalcemia was significantly lower in the Pre-RTx group than in the Post-RTx group [9.5 vs. 8.9 mg/dL, P < 0.001; 14.5% vs. 34.0%, P = 0.024]. The decrease in the eGFR 12-36 months after RTx was more significant in the Post-RTx group than in the Pre-RTx group (-13.8% vs. -0.9%; P = 0.001). A logistic regression involving age, sex, dialysis period, and serum parathormone level revealed that post-transplant PTx is an independent risk factor for persistent hypocalcemia at the end of the follow-up (P = 0.034) and for a >20% decrease in the eGFR 12-36 months after RTx (P = 0.029). CONCLUSIONS In renal transplant candidates with severe HPT, pretransplant PTx should be considered to prevent persistent hypocalcemia and deterioration of the renal graft function.
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Affiliation(s)
- Manabu Okada
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan.
| | - Takahisa Hiramitsu
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
| | - Toshihiro Ichimori
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
| | - Norihiko Goto
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
| | - Shunji Narumi
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
| | - Yoshihiko Watarai
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
| | - Tetsuhiko Sato
- Department of General Internal Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yoshihiro Tominaga
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
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14
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Abstract
The term “renal osteodystrophy” encompasses all forms of metabolic bone disease found in dialysis patients. The primary approach to the treatment of renal osteodystrophy in peritoneal dialysis (PD) patients is similar to that in hemodialysis patients. However, the increased prevalence of adynamic bone histology, together with the difficulty in judging calcium balance, the inability to practicably give intravenous vitamin D, and the clearance of vitamin D and parathyroid hormone via dialysate require a different therapeutic approach in PD compared to hemodialysis patients. Clearly, more comparative studies of new agents are needed to find the optimal approach to achieving the K/DOQI guidelines in PD patients. The unique aspects of the approach to renal osteodystrophy in PD patients are the focus of this review.
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Affiliation(s)
- Sharon M. Moe
- Medicine/Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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15
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Moe SM. Current Issues in the Management of Secondary Hyperparathyroidism and Bone Disease. Perit Dial Int 2020. [DOI: 10.1177/089686080102103s43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sharon M. Moe
- Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
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16
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Affiliation(s)
- Cheryl P. Sanchez
- Pediatrics University of Wisconsin Medical School Madison, Wisconsin, USA
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17
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Okamoto K, Fujii H, Goto S, Kono K, Watanabe K, Nishi S. Changes in the whole/intact parathyroid hormone ratio and their clinical implications in patients with chronic kidney disease. J Nephrol 2020; 33:795-802. [PMID: 31919783 DOI: 10.1007/s40620-019-00690-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/21/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although a previous study has reported the relationship between intact parathyroid hormone (iPTH) and whole parathyroid hormone (wPTH) levels in patients undergoing dialysis, the w/i PTH ratio (whole/intact PTH ratio) among predialysis chronic kidney disease (CKD) patients remains unclear. The present study therefore aimed to examine the relationship between w/i PTH ratio and kidney function and determine other factors affecting the w/i PTH ratio. METHODS An observational study including 773 predialysis CKD patients was conducted. The correlation between w/i PTH ratio and kidney function, as well as clinical factors at different CKD stages, were assessed using univariate and multivariate analyses. In addition, the relationship between w/i PTH ratio and composite renal outcome [kidney transplantation, dialysis, and 30% decline in estimated glomerular filtration rate (eGFR)] was examined. RESULTS The w/i PTH ratio decreased as the CKD stage progressed. Patients in each CKD stage (1/2, 3, 4, and 5) had a w/i PTH ratio of 0.85, 0.81, 0.78, and 0.59, respectively. The inflection point in the correlation lines between eGFR and w/i PTH ratio was 24.1 mL/min/1.73 m2. In multivariate analysis, the w/i PTH ratio was significantly correlated with serum calcium levels only in the CKD5 group and with eGFR in the CKD3, CKD4 and CKD5 group. Furthermore, w/i PTH ratio, eGFR, serum phosphate levels, and urinary protein/creatinine ratio were determined to be significant independent predictors for composite renal outcome. CONCLUSIONS Our study demonstrated that changes in the w/i PTH ratio were associated with kidney function, abnormal mineral metabolism, and renal outcome.
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Affiliation(s)
- Kohei Okamoto
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hideki Fujii
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Shunsuke Goto
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Keiji Kono
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kentaro Watanabe
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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18
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Abstract
Parathyroid hormone (PTH), PTH-related peptide (PTHrP), PTHR, and their cognate G protein-coupled receptor play defining roles in the regulation of extracellular calcium and phosphate metabolism and in controlling skeletal growth and repair. Acting through complex signaling mechanisms that in many instances proceed in a tissue-specific manner, precise control of these processes is achieved. A variety of direct and indirect disease processes, along with genetic anomalies, can cause these schemes to become dysfunctional. Here, we review the basic components of this regulatory network and present both the well-established elements and emerging findings and concepts with the overall objective to provide a framework for understanding the elementary aspects of how PTH and PTHrP behave and as a call to encourage further investigation that will yield more comprehensive understanding of the physiological and pathological steps at play, with a goal toward novel therapeutic interventions.
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19
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Bone biomarkers in de novo renal transplant recipients. Clin Chim Acta 2019; 501:179-185. [PMID: 31734147 DOI: 10.1016/j.cca.2019.10.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/24/2019] [Indexed: 12/30/2022]
Abstract
Successful kidney transplantation (partly) corrects the physiologic and metabolic abnormalities driving chronic kidney disease - mineral and bone disorders. At the same time, renal transplant recipients are exposed to immunosuppressive agents that may affect bone metabolism. Bone biomarkers have been suggested as surrogates of or adjuncts to bone biopsy and imaging techniques to assess bone health and to classify risk of bone loss and fractures. Bone biomarkers may be classified as circulating factors that affect bone metabolism (commonly referred to as bone metabolism markers) or that reflect bone cell number and/or activity (commonly referred to as bone turnover markers). A growing body of evidence shows that successful renal transplantation has a major impact on both bone metabolism and bone turnover. Analytical issues, including the cross-reactivity with fragments, complicate the interpretation of bone biomarkers, especially in the setting of a rapid changing kidney function, as is the case after successful renal transplantation. Overall, bone turnover seems to decline following renal transplantation, but inter-individual variability is substantial. Preliminary evidence indicates that bone biomarkers may be useful in guiding mineral and bone therapy in renal transplant recipients.
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20
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Kritmetapak K, Pongchaiyakul C. Parathyroid Hormone Measurement in Chronic Kidney Disease: From Basics to Clinical Implications. Int J Nephrol 2019; 2019:5496710. [PMID: 31637056 PMCID: PMC6766083 DOI: 10.1155/2019/5496710] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/04/2019] [Indexed: 11/18/2022] Open
Abstract
Accurate measurement of parathyroid hormone (PTH) is crucial for therapeutic decision-making in patients with chronic kidney disease-mineral and bone disorder (CKD-MBD). The second-generation PTH assays, often referred to as "intact PTH" assays, are the current standard and most available assays in clinical practice. However, intact PTH assays measure both full-length biologically active PTH and heterogeneous PTH fragments in the circulation, providing the equivocal value of PTH measurement in patients with CKD-MBD. Due to the variability of PTH assays, preanalytical sample errors, and the phenomenon of end-organ PTH hyporesponsiveness, current CKD-MBD guidelines recommend a wide range for serum PTH targets (2-9 the upper normal limit of the intact PTH assay) in dialysis patients to diminish the risk of developing adynamic bone disease. Nevertheless, a sizeable proportion of CKD patients still experience renal osteodystrophy despite having serum PTH levels within the recommended range. The primary cause of this inconsistency is the analytical interference of various PTH fragments and oxidized PTH forms that considerably accumulate in CKD patients. Therefore, a new mass spectrometry-based assay, which is capable of specifically measuring the whole spectra of PTH fragments, can potentially improve diagnostic accuracy for renal osteodystrophy. However, the effects of different PTH fragments on bone metabolism, vascular calcification, and mortality in CKD patients warrant further research.
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Affiliation(s)
- Kittrawee Kritmetapak
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Chatlert Pongchaiyakul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
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21
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Jean G, Chazot C. Complications et prises en charge thérapeutiques des anomalies du métabolisme phosphocalcique de l’insuffisance rénale chronique. Nephrol Ther 2019; 15:242-258. [DOI: 10.1016/j.nephro.2019.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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22
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Nyssen L, Fillet M, Cavalier E, Servais A. Highly sensitive and selective separation of intact parathyroid hormone and variants by sheathless CE‐ESI‐MS/MS. Electrophoresis 2019; 40:1550-1557. [DOI: 10.1002/elps.201800507] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/28/2019] [Accepted: 02/22/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Laurent Nyssen
- Department of Clinical ChemistryCenter for Interdisciplinary Research on Medicines (CIRM)University of Liège Liège Belgium
- Laboratory for the Analysis of Medicines (LAM)Center for Interdisciplinary Research on Medicines (CIRM)University of Liège Liège Belgium
| | - Marianne Fillet
- Laboratory for the Analysis of Medicines (LAM)Center for Interdisciplinary Research on Medicines (CIRM)University of Liège Liège Belgium
| | - Etienne Cavalier
- Department of Clinical ChemistryCenter for Interdisciplinary Research on Medicines (CIRM)University of Liège Liège Belgium
| | - Anne‐Catherine Servais
- Laboratory for the Analysis of Medicines (LAM)Center for Interdisciplinary Research on Medicines (CIRM)University of Liège Liège Belgium
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23
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Chen H, Han X, Cui Y, Ye Y, Purrunsing Y, Wang N. Parathyroid Hormone Fragments: New Targets for the Diagnosis and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9619253. [PMID: 30627584 PMCID: PMC6304519 DOI: 10.1155/2018/9619253] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 10/22/2018] [Accepted: 10/28/2018] [Indexed: 12/28/2022]
Abstract
As a common disorder, chronic kidney disease (CKD) poses a great threat to human health. Chronic kidney disease-mineral and bone disorder (CKD-MBD) is a complication of CKD characterized by disturbances in the levels of calcium, phosphorus, parathyroid hormone (PTH), and vitamin D; abnormal bone formation affecting the mineralization and linear growth of bone; and vascular and soft tissue calcification. PTH reflects the function of the parathyroid gland and also takes part in the metabolism of minerals. The accurate measurement of PTH plays a vital role in the clinical diagnosis, treatment, and prognosis of patients with secondary hyperparathyroidism (SHPT). Previous studies have shown that there are different fragments of PTH in the body's circulation, causing antagonistic effects on bone and the kidney. Here we review the metabolism of PTH fragments; the progress being made in PTH measurement assays; the effects of PTH fragments on bone, kidney, and the cardiovascular system in CKD; and the predictive value of PTH measurement in assessing the effectiveness of parathyroidectomy (PTX). We hope that this review will help to clarify the value of accurate PTH measurements in CKD-MBD and promote the further development of multidisciplinary diagnosis and treatment.
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Affiliation(s)
- Huimin Chen
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu Province 210029, China
| | - Xiaxia Han
- Nanjing Medical University, Nanjing, Jiangsu Province 211166, China
| | - Ying Cui
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu Province 210029, China
| | - Yangfan Ye
- Nanjing Medical University, Nanjing, Jiangsu Province 211166, China
| | - Yogendranath Purrunsing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu Province 210029, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, Jiangsu Province 210029, China
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Sánchez-González C, Gonzalez-Casaus ML, Sellares VL, Albalate M, Torregrosa JV, Mas S, Ortiz A, Rodriguez M, Gonzalez-Parra E. Higher Proportion of Non-1-84 PTH Fragments in Peritoneal Dialysis Patients Compared to Hemodialysis Patients Using Solutions Containing 1.75 mmol/l Calcium. Front Physiol 2018; 9:1643. [PMID: 30524306 PMCID: PMC6262178 DOI: 10.3389/fphys.2018.01643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/30/2018] [Indexed: 11/13/2022] Open
Abstract
Background: The prevalence of low- turnover bone disease (LTBD) in peritoneal dialysis (PD) patients is higher than in hemodialysis (HD) patients. LTBD patients may be at risk for vascular calcification, and cardiovascular disease. Current therapy for chronic kidney disease metabolic bone disorders (CKD-MBD) is guided by biochemical parameters, as bone biopsy is not used in routine clinical care. Methods: We assessed intact PTH (iPTH: 1-84PTH plus non-1-84PTH), 1-84PTH, and the 1-84PTH/non-1-84PTH ratio in 129 hemodialysis and 73 PD prevalent patients dialyzed with solutions containing 1.75 mmol/L calcium. Results: Hemodialysis and PD patients presented similar iPTH and tCa values and prevalence of putative LTBD as defined according to KDOQI iPTH cut-off levels or 1-84 PTH levels. However, iCa accounted for a higher percentage of tCa in PD (53%) than in hemodialysis (39%) p < 0.001, and the 1-84PTH/non-1-84PTH ratio was lower in PD than in hemodialysis patients (0.44 ± 0.12) vs. (0.60 ± 0.10), p < 0.001. The prevalence of putative LTBD when using the coexistence of 1-84PTH/non-1-84PTH ratio < 1.0 and iPTH < 420 pg/m, was higher in PD than in hemodialysis patients (73 vs. 16% respectively, p < 0.001). In a multivariate logistic regression analysis, dialysis modality was the main determinant of the 1-84PTH/non-1-84PTH ratio. Conclusion: Solutions containing 1.75 mmol/L calciums are associated to a higher proportion of non-1-84PTH fragments in PD than in HD patients. Different analytical criteria result in widely different estimates of LTBD prevalence, thus impairing the ability of clinicians to optimize therapy for CKD-MBD.
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Affiliation(s)
| | | | | | | | | | - Sebastian Mas
- Unidad de Diálsis IIS Fundación Jiménez Díaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Alberto Ortiz
- REDINREN, Madrid, Spain
- Unidad de Diálsis IIS Fundación Jiménez Díaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mariano Rodriguez
- REDINREN, Madrid, Spain
- Nefrología y Unidad de Investigación, Hospital Universitario Reina Sofia, Córdoba, Spain
| | - Emilio Gonzalez-Parra
- REDINREN, Madrid, Spain
- Unidad de Diálsis IIS Fundación Jiménez Díaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
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Liu WC, Wu CC, Lim PS, Chien SW, Hou YC, Zheng CM, Shyu JF, Lin YF, Lu KC. Effect of uremic toxin-indoxyl sulfate on the skeletal system. Clin Chim Acta 2018; 484:197-206. [PMID: 29864403 DOI: 10.1016/j.cca.2018.05.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/26/2018] [Accepted: 05/29/2018] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease-mineral bone disorders (CKD-MBD) exhibit abnormalities in the circulating mineral levels, vitamin D metabolism, and parathyroid function that contribute to the formation of a bone lesion. The uremic toxin, indoxyl sulfate (IS), accumulates in the blood in cases of renal failure and leads to bone loss. The bone and renal responses to the action of the parathyroid hormone (PTH) are progressively decreased in CKD in spite of increasing PTH levels, a condition commonly called PTH resistance. There is a high prevalence of low bone turnover or adynamic bone disease in the early stages of CKD. This could be due to the inhibition of bone turnover, such as in PTH resistance, reduced active vitamin D levels, diabetes, aluminum, and, increased IS. With an increase in IS, there is a decrease in the osteoblast Wnt/b-catenin signaling and increase in the expression of Wnt signaling inhibitors, such as sclerostin and Dickkopf-1 (DKK1). Thus, a majority of early CKD patients exhibit deterioration of bone quality owing to the action of IS, this scenario could be termed uremic osteoporosis. However, this mechanism is complicated and not fully understood. With progressive deterioration in the renal function, IS accumulates along with persistent PTH secretion, potentially leading to high-turnover bone disease because high serum PTH levels have the ability of overriding peripheral PTH resistance and other inhibitory factors of bone formation. Finally, it leads to deterioration in bone quantity with prominent bone resorption in end stage renal disease. Uremic toxins adsorbents may decelerate oxidative stress and improve bone health in CKD patients. This review article focuses on IS and bone loss in CKD patients.
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Affiliation(s)
- Wen-Chih Liu
- Division of Nephrology, Department of Internal Medicine, Tungs' Taichung Metro Harbor Hospital, Taichung City, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chia-Chao Wu
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Paik-Seong Lim
- Division of Nephrology, Department of Internal Medicine, Tungs' Taichung Metro Harbor Hospital, Taichung City, Taiwan
| | - Shiaw-Wen Chien
- Division of Nephrology, Department of Internal Medicine, Tungs' Taichung Metro Harbor Hospital, Taichung City, Taiwan
| | - Yi-Chou Hou
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Nephrology, Department of Medicine, Cardinal Tien Hospital, School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Cai-Mei Zheng
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, New Taipei City, Taiwan
| | - Jia-Fwu Shyu
- Department of Biology and Anatomy, National Defense Medical Center, Taipei, Taiwan
| | - Yuh-Feng Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, New Taipei City, Taiwan
| | - Kuo-Cheng Lu
- Division of Nephrology, Department of Medicine, Fu-Jen Catholic University Hospital & Cardinal-Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan.
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Fernández-Galán E, Bedini JL, Filella X. Analytical verification and method comparison of the ADVIA Centaur® Intact Parathyroid Hormone assay. Clin Biochem 2017; 50:1222-1227. [PMID: 28912096 DOI: 10.1016/j.clinbiochem.2017.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 09/06/2017] [Accepted: 09/10/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study is the first verification of the novel iPTH Siemens ADVIA Centaur® Intact Parathyroid Hormone (iPTHm) chemiluminescence immunoassay based on monoclonal antibodies. We also compared the iPTH results obtained using this assay with the previous ADVIA Centaur® Parathyroid Hormone assay (iPTHp) based on polyclonal antibodies. DESIGN AND METHODS The analytical performance study of iPTHm assay included LoD, LoQ, intra- and inter-assay reproducibility, and linearity. A comparison study was performed on 369 routine plasma samples. The results were analyzed independently for patients with normal and abnormal GFR, as well as patients on hemodialysis. In addition, clinical concordance between assays was assessed. Finally, we studied PTH stability of plasma samples at 4°C. RESULTS For the iPTHm assay LoD and LoQ were 0.03pmol/L and 0.10pmol/L, respectively. Intra- and inter-assay CV were between 2.3% and 6.2%. Linearity was correct in the range from 3.82 to 203.08pmol/L. Correlation studies showed a good correlation (r=0.99) between iPTHm and iPTHp, with bias of -2.55% (IC -3.48% to -1.62%) in the range from 0.32 to 117.07pmol/L. Clinical concordance, assessed by Kappa Index, was 0.874. The stability study showed that differences compared to basal iPTH concentration did not exceed 20% in any of the samples analyzed. CONCLUSIONS The iPTHm assay demonstrated acceptable performance and a very good clinical concordance with iPTHp assay, currently used in our laboratory. Thus, the novel iPTHm assay can replace the previous iPTHp assay, since results provided by both assays are very similar. In our study, the stability of iPTH is not affected by storage up to 14days.
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Affiliation(s)
- Esther Fernández-Galán
- Department of Biochemistry and Molecular Genetics & Core Lab (CDB), Hospital Clínic, IDIBAPS, Barcelona, Catalonia, Spain
| | - Josep Lluís Bedini
- Department of Biochemistry and Molecular Genetics & Core Lab (CDB), Hospital Clínic, IDIBAPS, Barcelona, Catalonia, Spain
| | - Xavier Filella
- Department of Biochemistry and Molecular Genetics & Core Lab (CDB), Hospital Clínic, IDIBAPS, Barcelona, Catalonia, Spain.
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Shroff R, Wan M, Nagler EV, Bakkaloğlu S, Cozzolino M, Bacchetta J, Edefonti A, Stefanidis CJ, Vande Walle J, Ariceta G, Klaus G, Haffner D, Schmitt CP. Clinical practice recommendations for treatment with active vitamin D analogues in children with chronic kidney disease Stages 2-5 and on dialysis. Nephrol Dial Transplant 2017; 32:1114-1127. [PMID: 28873971 PMCID: PMC5837664 DOI: 10.1093/ndt/gfx080] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 04/01/2017] [Indexed: 01/11/2023] Open
Abstract
In patients with chronic kidney disease (CKD), renal synthesis of active vitamin D [1,25-dihydroxyvitamin D (1,25(OH)2D)] declines and is associated with hypocalcaemia, secondary hyperparathyroidism and the spectrum of CKD-mineral and bone disorder (MBD). In advanced CKD, active vitamin D analogues, including alfacalcidol, calcitriol and paricalcitol, are routinely administered. There are few studies on the use of vitamin D analogues in children with CKD and on dialysis. It is difficult to define bone-specific outcomes that can guide treatment with active vitamin D analogues in children with CKD-MBD. A core working group (WG) of the European Society for Paediatric Nephrology (ESPN) CKD-MBD and Dialysis WGs has developed recommendations for the use of active vitamin D therapy in children with CKD and on dialysis. A second document in parallel with this one covers treatment recommendations for native vitamin D therapy. The WGs have performed an extensive literature review to include systematic reviews and randomized controlled trials in adults and children with CKD and prospective observational studies in children with CKD. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to develop and grade the recommendations. In the absence of applicable study data, the opinion of experts from the ESPN CKD-MBD and Dialysis WGs is provided, but clearly GRADE-ed as such and must be carefully considered by the treating physician and adapted to individual patient needs as appropriate.
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Affiliation(s)
- Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mandy Wan
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Mario Cozzolino
- Ospedale San Paolo, Department of Health Sciences, University of Milan, Milan, Italy
| | | | - Alberto Edefonti
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - Gema Ariceta
- Servicio de Nefrología Pediátrica, Hospital Universitari Vall d'Hebron, Barcelona, España
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Okada M, Futamura K, Hiramitsu T, Tsujita M, Goto N, Narumi S, Watarai Y, Ichimori T, Tominaga Y. Hypercalcemia resistant to cinacalcet caused by a mediastinal hyperplastic parathyroid gland in a renal transplant patient. Eur Surg 2017. [DOI: 10.1007/s10353-017-0484-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Saab G, Whaley-Connell AT, Khanna R, Sowers JR. Review: Therapy for the altered mineral metabolism of chronic kidney disease: implications for vascular calcification. Ther Adv Cardiovasc Dis 2016; 1:107-12. [DOI: 10.1177/1753944707085444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The development of chronic kidney disease (CKD) is associated with poor outcomes largely due an increased likelihood of adverse cardiovascular events. Many factors are playing a role in cardiovascular disease in CKD including the development of vascular calcification (VC). Studies have indeed shown that the presence of VC is associated with decreased survival among patients with CKD. The pathogenesis of VC is itself multi-factorial. LikeLy playing a significant role is the altered mineral metabolism of CKD. Management of the altered mineral metabolism in CKD is quite difficult and may also play a role in the pathogenesis of VC. In this manuscript, we will review the pathogenesis of the altered mineral metabolism of CKD, its management, and how both may play a role in the development of VC.
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Affiliation(s)
- Georges Saab
- University of Missouri-Columbia School of Medicine, Department on Internal Medicine, Division of Nephrology, MA436 Health Sciences Center, One Hospital Drive, Columbia, MO 65212,
| | - Adam T. Whaley-Connell
- University of Missouri-Columbia School of Medicine, Department on Internal Medicine, Division of Nephrology
| | - Ramesh Khanna
- University of Missouri-Columbia School of Medicine, Department on Internal Medicine, Division of Nephrology
| | - James R. Sowers
- University of Missouri-Columbia School of Medicine, Department on Internal Medicine, Division of Endocrinology
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Felsenfeld AJ, Levine BS, Rodriguez M. Pathophysiology of Calcium, Phosphorus, and Magnesium Dysregulation in Chronic Kidney Disease. Semin Dial 2015; 28:564-77. [DOI: 10.1111/sdi.12411] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Arnold J. Felsenfeld
- Department of Medicine; VA Greater Los Angeles Healthcare System and the David Geffen School of Medicine at UCLA; Los Angeles California
| | - Barton S. Levine
- Department of Medicine; VA Greater Los Angeles Healthcare System and the David Geffen School of Medicine at UCLA; Los Angeles California
| | - Mariano Rodriguez
- Nephrology Service; IMIBIC; Hospital Universitario Reina Sofia; University of Cordoba; Cordoba Spain
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Bover J, Ureña P, Brandenburg V, Goldsmith D, Ruiz C, DaSilva I, Bosch RJ. Adynamic bone disease: from bone to vessels in chronic kidney disease. Semin Nephrol 2015; 34:626-40. [PMID: 25498381 DOI: 10.1016/j.semnephrol.2014.09.008] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Adynamic bone disease (ABD) is a well-recognized clinical entity in the complex chronic kidney disease (CKD)-mineral and bone disorder. Although the combination of low intact parathyroid hormone (PTH) and low bone alkaline phosphatase levels may be suggestive of ABD, the gold standard for precise diagnosis is histomorphometric analysis of tetracycline double-labeled bone biopsies. ABD essentially is characterized by low bone turnover, low bone volume, normal mineralization, and markedly decreased cellularity with minimal or no fibrosis. ABD is increasing in prevalence relative to other forms of renal osteodystrophy, and is becoming the most frequent type of bone lesion in some series. ABD develops in situations with reduced osteoanabolic stimulation caused by oversuppression of PTH, multifactorial skeletal resistance to PTH actions in uremia, and/or dysregulation of Wnt signaling. All may contribute not only to bone disease but also to the early vascular calcification processes observed in CKD. Various risk factors have been linked to ABD, including calcium loading, ageing, diabetes, hypogonadism, parathyroidectomy, peritoneal dialysis, and antiresorptive therapies, among others. The relationship between low PTH level, ABD, increased risk fracture, and vascular calcifications may at least partially explain the association of ABD with increased mortality rates. To achieve optimal bone and cardiovascular health, attention should be focused not only on classic control of secondary hyperparathyroidism but also on prevention of ABD, especially in the steadily growing proportions of diabetic, white, and elderly patients. Overcoming the insufficient osteoanabolic stimulation in ABD is the ultimate treatment goal.
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Affiliation(s)
- Jordi Bover
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain.
| | - Pablo Ureña
- Department of Nephrology and Dialysis, Clinique du Landy, Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Vincent Brandenburg
- Department of Cardiology and Intensive Care Medicine, Rheinisch-Westfälische Technische Hochschule (RWTH) University Hospital, Aachen, Germany
| | - David Goldsmith
- King's Health Partners Academic Health Sciences Centre (AHSC), London, United Kingdom
| | - César Ruiz
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Iara DaSilva
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Ricardo J Bosch
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
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Nordholm A, Mace ML, Gravesen E, Olgaard K, Lewin E. A potential kidney-bone axis involved in the rapid minute-to-minute regulation of plasma Ca2+. BMC Nephrol 2015; 16:29. [PMID: 25885328 PMCID: PMC4377030 DOI: 10.1186/s12882-015-0019-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 02/19/2015] [Indexed: 12/22/2022] Open
Abstract
Background Understanding the regulation of mineral homeostasis and function of the skeleton as buffer for Calcium and Phosphate has regained new interest with introduction of the syndrome “Chronic Kidney Disease-Mineral and Bone Disorder”(CKD-MBD). The very rapid minute-to-minute regulation of plasma-Ca2+ (p-Ca2+) takes place via an exchange mechanism of Ca2+ between plasma and bone. A labile Ca storage pool exists on bone surfaces storing excess or supplying Ca when blood Ca is lowered. Aim was to examine minute-to-minute regulation of p-Ca2+ in the very early phase of acute uremia, as induced by total bilateral nephrectomy and to study the effect of absence of kidneys on the rapid recovery of p-Ca2+ from a brief induction of acute hypocalcemia. Methods The rapid regulation of p-Ca2+ was examined in sham-operated rats, acute nephrectomized rats(NX), acute thyroparathyrectomized(TPTX) rats and NX-TPTX rats. Results The results clearly showed that p-Ca2+ falls rapidly and significantly very early after acute NX, from 1.23 ± 0.02 to 1.06 ± 0.04 mM (p < 0.001). Further hypocalcemia was induced by a 30 min iv infusion of EGTA. Control groups had saline. After discontinuing EGTA a rapid increase in p-Ca2+ took place, but with a lower level in NX rats (p < 0.05). NX-TPTX model excluded potential effect of accumulation of Calcitonin and C-terminal PTH, both having potential hypocalcemic actions. Acute TPTX resulted in hypercalcemia, 1.44 ± 0.02 mM and less in NX-TPTX rats,1.41 ± 0.02 mM (p < 0.05). Recovery of p-Ca2+ from hypocalcemia resulted in lower levels in NX-TPTX than in TPTX rats, 1.20 ± 0.02 vs.1.30 ± 0.02 (p < 0.05) demonstrating that absence of kidneys significantly affected the rapid regulation of p-Ca2+ independent of PTH, C-PTH and CT. Conclusions P-Ca2+ on a minute-to-minute basis is influenced by presence of kidneys. Hypocalcemia developed rapidly in acute uremia. Levels of p-Ca2+, obtained during recovery from hypocalcemia resulted in lower levels in acutely nephrectomized rats. This indicates that kidneys are of significant importance for the ‘set-point’ of p-Ca2+ on bone surface, independently of PTH and calcitonin. Our results point toward existence of an as yet unknown factor/mechanism, which mediates the axis between kidney and bone, and which is involved in the very rapid regulation of p-Ca2+.
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Affiliation(s)
- Anders Nordholm
- Nephrological Department B, Herlev Hospital, DK 2730, Copenhagen, Denmark.
| | - Maria L Mace
- Nephrological Department B, Herlev Hospital, DK 2730, Copenhagen, Denmark.
| | - Eva Gravesen
- Nephrological Department P, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Klaus Olgaard
- Nephrological Department P, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Ewa Lewin
- Nephrological Department B, Herlev Hospital, DK 2730, Copenhagen, Denmark. .,Nephrological Department P, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Abstract
The increased awareness of the potential role played by mineral and bone disorder in the appearance of cardiovascular disease in renal patients has produced research efforts aimed at discovering possible pathogenic links. Accordingly, the diagnostic significance of the classic bone markers of mineral disorders and of the new markers in the setting of chronic kidney disease-mineral and bone disorders (CKD-MBD) needs to be re-evaluated along with increasing information. In this article we include classic markers of bone metabolism and some of the noncollagenous bone proteins that are gaining experimental and clinical significance in CKD-MBD. Among classic markers of secondary hyperparathyroidism and of renal osteodystrophy, we analyzed parathyroid hormone, alkaline phosphatase, tartrate-resistant acid phosphatase, and bone collagen-derived peptides. We underlined, for each, the relevance of parent proteins (peptides or isoforms) that affect assay methods and, eventually, the diagnostic or prognostic significance. Also, we considered their relationship with cardiovascular mortality. Among the numerous noncollagenous bone proteins, we examined matrix Gla protein (MGP), osteocalcin (OC), osteoprotegerin, and the small integrin-binding ligand N-linked glycoprotein family. For MGP and OC we report the relevant involvement with the process of calcification (MGP) and with glucose and energy metabolism (OC). Both of these proteins require vitamin K to become active and this is a specific problem in renal patients who frequently are deficient of this vitamin. Finally, recent acquisitions on the fascinating family of the small integrin-binding ligand N-linked glycoprotein proteins are recapitulated briefly to underline their potential clinical interest and their complex involvement with all aspects of CKD-MBD. Their diagnostic role in clinical practice awaits further studies.
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Affiliation(s)
- Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy.
| | - Lida Tartaglione
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Silverio Rotondi
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Jordi Bover
- Department of Nephrology, Fundaciò Puigvert, IIB Sant Pau, REDinREN, Barcelona, Spain
| | - David Goldsmith
- King's Health Partners, Academic Health Science Centre, London, United Kingdom
| | - Marzia Pasquali
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
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Saab G, Navaneethan SD, Slatopolsky E. Targeting parathyroid hormone levels in dialysis patients. Semin Dial 2014; 27:562-5. [PMID: 25040125 DOI: 10.1111/sdi.12275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Georges Saab
- MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
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Abstract
Chronic kidney disease-mineral and bone disorder (CKD-MBD) is characterized by bone abnormalities, vascular calcification, and an array of laboratory abnormalities. The latter classically include disturbances in the parathyroid hormone/vitamin D axis. More recently, fibroblast growth factor 23 (FGF23) and klotho also have been identified as important regulators of mineral metabolism. Klotho deficiency and high circulating FGF23 levels precede secondary hyperparathyroidism in CKD patients. Levels of FGF23 and parathyroid hormone increase along the progression of CKD to maintain mineral homeostasis and to overcome end-organ resistance. It is hard to define when the increase of both hormones becomes maladaptive. CKD-MBD is associated with adverse outcomes including cardiovascular disease and mortality. This review summarizes the complex pathophysiology of CKD-MBD and outlines which laboratory abnormalities represent biomarkers of disease severity, which laboratory abnormalities are predictors of cardiovascular disease, and which laboratory abnormalities should be considered (direct) uremic toxins exerting organ damage. This information may help to streamline current and future therapeutic efforts.
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Wada K, Wada Y. Evaluation of Aortic Calcification With Lanthanum Carbonate vs. Calcium-Based Phosphate Binders in Maintenance Hemodialysis Patients With Type 2 Diabetes Mellitus: An Open-Label Randomized Controlled Trial. Ther Apher Dial 2014; 18:353-60. [DOI: 10.1111/1744-9987.12153] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kentaro Wada
- Division of Nephrology and Dialysis; Nippon Kokan Fukuyama Hospital; Hiroshima Japan
- Department of Internal Medicine; Central Hospital; Hiroshima Japan
| | - Yuko Wada
- Division of Nephrology and Dialysis; Nippon Kokan Fukuyama Hospital; Hiroshima Japan
- Department of Internal Medicine; Central Hospital; Hiroshima Japan
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38
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Abstract
There is growing interest in the role of fibroblast growth factor 23 (FGF23) in various diseases of disordered mineral metabolism. In chronic kidney disease (CKD), where biochemical evidence of mineral disturbances is especially common, FGF23 measurement has been advocated as an early and sensitive marker for CKD-related bone disease. In this setting, FGF23 analysis may also improve the discrimination of risk of adverse renal and cardiovascular outcomes and aid targeting of those patients that are likely to benefit from interventions. Nonetheless, while the physiological relevance of FGF23 in the control of mineral metabolism is now firmly established, relatively little attention has been paid to important preanalytical and analytical aspects of FGF23 measurement that may impact on its clinical utility. Here we review these issues and discuss the suitability of FGF23 testing strategies for routine clinical practice. The current ‘state-of-the-art’ enzyme-linked immunosorbent assay methods for FGF23 measurement show poor agreement due to differences in FGF23 fragment detection, antibody specificity and calibration. Such analytical variability does not permit direct comparison of FGF23 measurements made with different assays and is likely to at least in part account for some of the inconsistencies noted between observational studies. From a clinical perspective, the lack of concordance has implications for the development of standardized reference intervals and clinical decision limits. Finally, the inherent assay-dependent biological variability of plasma FGF23 concentration can further complicate the interpretation of results and the design of FGF23-based testing protocols. Currently, it would be premature to consider incorporating FGF23 measurements into standard testing repertoires.
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Affiliation(s)
- Edward R Smith
- Department of Renal Medicine, Eastern Health Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia
| | - Lawrence P McMahon
- Department of Renal Medicine, Eastern Health Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia
| | - Stephen G Holt
- Department of Renal Medicine, Eastern Health Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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Amerling R. Guideline bone disease. Blood Purif 2013; 36:132-5. [PMID: 24217217 DOI: 10.1159/000353422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In the current issue of Blood Purification, Palomares et al. [Blood Purif 2013;36:122-131] bemoan the poor level of compliance in dialysis units in achieving compliance with KDOQI and KDIGO bone and mineral guideline targets. These targets are based almost completely on observational data and rely on an obsolete assay for PTH. The so-called intact PTH assay measures both 1-84 PTH and 7-84 PTH; the latter has been demonstrated to possess biological activity that is antagonistic to that of 1-84 PTH. The assay cannot reliably distinguish high from low bone turnover in the target ranges suggested by the guideline panels. Targeting these ranges leads to an increased incidence of adynamic bone disease, higher calcium and phosphorus, and likely poor patient outcomes.
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Affiliation(s)
- Richard Amerling
- Division of Nephrology and Hypertension, Beth Israel Medical Center, New York, N.Y., USA
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41
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Eddington H, Hudson JE, Oliver RL, Fraser WD, Hutchison AJ, Kalra PA. Variability in parathyroid hormone assays confounds clinical practice in chronic kidney disease patients. Ann Clin Biochem 2013; 51:228-36. [PMID: 24000371 DOI: 10.1177/0004563213491236] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intact parathyroid hormone (iPTH) measurements are used to guide therapy in renal patients, but variability in results can occur depending on the assay used. This study has investigated iPTH assay variation in North West England and paired data with regional audit data to determine clinical relevance of assay variability. METHODS Thirty-seven haemodialysis patients had blood taken (EDTA plasma, and serum), and samples were processed at 17 laboratories that analyse iPTH for North West dialysis patients. Correction factors were calculated and applied to the iPTH assay results to enable direct comparisons. These correction factors were also applied to Regional Audit data to determine if iPTH assay variability explains the variation in unit performance in achieving PTH targets. RESULTS The iPTH results from the 37 patients were significantly different when either analysed by different assays and/or different laboratories (P < 0.001). The Abbott Architect method consistently produced the highest iPTH results. Of the 37 patients, between 49% and 65% would achieve the Kidney Disease: Improving Global Outcomes (KDIGO) iPTH target depending on the assay used. When results were adjusted using correction factors, 21% of the patients would require a change of management according to guidelines. Data from all haemodialysis units submitted for the regional audit were adjusted to the Roche assay and this led to a small change in achievement of KDIGO iPTH targets in individual units when compared to each other. CONCLUSIONS A combination of iPTH assay variability and diversity in clinical management leads to variation in achieving iPTH targets. Both need to be improved and/or standardized to improve patient care.
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Affiliation(s)
- Helen Eddington
- Renal Department, Manchester Academic Health Science Centre, Salford Royal Hospital, The University of Manchester, Salford, UK
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O'Flaherty D, Sankaralingam A, Scully P, Manghat P, Goldsmith D, Hampson G. The relationship between intact PTH and biointact PTH (1-84) with bone and mineral metabolism in pre-dialysis chronic kidney disease (CKD). Clin Biochem 2013; 46:1405-9. [PMID: 23830844 DOI: 10.1016/j.clinbiochem.2013.06.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 06/12/2013] [Accepted: 06/23/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Abnormalities in PTH are implicated in the pathogenesis of bone abnormalities in chronic kidney disease (CKD)-mineral bone disorder (CKD-MBD). PTH concentrations are important in clinical decision and management. This emphasises the importance of providing an assay which measures biologically active PTH. We compared concentrations of intact PTH with biointact PTH (1-84) in CKD and end stage renal disease (ESRD) and investigated the relationship between the 2 PTH assays with bone and mineral laboratory parameters and bone mineral density (BMD) in CKD. DESIGN AND METHODS We assessed 140 patients (61 in ESRD and 79 with CKD stages 1-4) in this cross-sectional study. We measured biointact PTH (1-84) as well as routine biochemical parameters on all subjects. In the CKD cohort, bone turnover markers; bone alkaline phosphatase (BAP) and tartrate resistant acid phosphatase (TRACP)-5b and bone mineral density (BMD) were also determined. RESULTS In ESRD, intact PTH concentration was significantly higher compared to biointact PTH (1-84) (422 [443] v/s 266 [251] pg/mL, (p<0.001) with an average bias of 60%. In CKD, intact PTH concentration was also higher compared to biointact PTH (1-84) (79[55] v/s 68[49] pg/mL p<0.001) with an average bias of 18%. Only the biointact PTH (1-84) assay showed any significant correlation with serum calcium concentrations (r=-0.26, p<0.05) and phosphate (r=0.25, p<0.05) in CKD. Following multilinear regression analysis and adjustment for all significant co-variables, only eGFR, BAP and 25 (OH)vitamin remained significantly associated with intact PTH and biointact PTH (1-84). The strength of association was stronger between BAP and biointact PTH (1-84) (biointact PTH (1-84): p=0.007, intact PTH: p=0.01). In adjusted analyses, only biointact PTH (1-84) was significantly associated with BMD at the fore-arm (FARM) (p=0.049). CONCLUSIONS The study confirms the differences between intact PTH and biointact PTH (1-84) in ESRD. Whilst there may be similarities in the diagnostic ability of both intact and biointact PTH (1-84), our data suggest that biointact PTH (1-84) assay may better reflect bone metabolism and BMD in CKD. Further longitudinal studies are needed.
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Affiliation(s)
- D O'Flaherty
- Department of Clinical Chemistry, GSTS Pathology, St Thomas' Hospital, London SE1 7EH, UK.
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Fukagawa M, Yokoyama K, Koiwa F, Taniguchi M, Shoji T, Kazama JJ, Komaba H, Ando R, Kakuta T, Fujii H, Nakayama M, Shibagaki Y, Fukumoto S, Fujii N, Hattori M, Ashida A, Iseki K, Shigematsu T, Tsukamoto Y, Tsubakihara Y, Tomo T, Hirakata H, Akizawa T. Clinical Practice Guideline for the Management of Chronic Kidney Disease-Mineral and Bone Disorder. Ther Apher Dial 2013; 17:247-88. [DOI: 10.1111/1744-9987.12058] [Citation(s) in RCA: 251] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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44
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Quels marqueurs osseux chez les patients hémodialysés : phosphatases alcalines osseuses ou ß-CrossLaps ? Nephrol Ther 2013; 9:154-9. [DOI: 10.1016/j.nephro.2013.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 02/13/2013] [Accepted: 02/26/2013] [Indexed: 11/21/2022]
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Abstract
The incidence of renal osteodystrophy (ROD) increases with deteriorating kidney function, affecting virtually every patient on chronic dialysis treatment. ROD can persist after kidney transplantation and may be aggravated by immunosuppressants, mainly glucocorticoids. Fracture risk, including hip fractures, is markedly elevated in patients with renal disease compared to the general population. Depending on the type of ROD, high or low bone turnover can be found. Because of poor positive and negative predictive values of serological markers of bone turnover and limited technical capabilities of various bone imaging modalities, the only reliable method to correctly classify ROD is the transiliac bone biopsy. Elevated bone turnover can be successfully treated with active vitamin D, cinacalcet, or parathyreoidectomy, but all of these therapies may lead to oversuppression of bone metabolism. Currently, no specific therapy is available for low turnover bone disease. Bisphosphonates can be a therapeutic option for selected patients after renal transplantation.
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Haffner D, Schaefer F. Searching the optimal PTH target range in children undergoing peritoneal dialysis: new insights from international cohort studies. Pediatr Nephrol 2013; 28:537-45. [PMID: 22893310 DOI: 10.1007/s00467-012-2270-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 06/26/2012] [Accepted: 07/02/2012] [Indexed: 01/27/2023]
Abstract
The treatment of the mineral and bone disorder associated with chronic kidney disease (CKD-MBD) remains a major challenge in pediatric patients. The principal aims of therapeutic measures are not only to prevent the debilitating skeletal complications and to achieve normal growth but also to preserve long-term cardiovascular health. Serum parathyroid hormone (PTH) levels are used as a surrogate parameter of bone turnover. Whereas it is generally accepted that serum calcium and phosphate levels should be kept within the range for age, current pediatric consensus guidelines differ markedly with respect to the optimal PTH target range and operate on a limited evidence base. Recently, the International Pediatric Dialysis Network (IPPN) established a global registry collecting detailed clinical and biochemical information, including data relevant to CKD-MBD in children on chronic peritoneal dialysis (PD). This review highlights the current evidence basis regarding the optimal PTH target range in pediatric CKD patients, and re-assesses the current guidelines in view of the outcome data collected by the IPPN registry. Based on a comprehensive evaluation of CKD-MBD outcome measures in this global patient cohort, a PTH target range of 1.7-3 times the upper limit of normal (i.e. 100-200 pg/ml) appears reasonable in children undergoing chronic PD.
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MESH Headings
- Adolescent
- Animals
- Biomarkers/blood
- Bone Remodeling
- Cardiovascular Diseases/blood
- Cardiovascular Diseases/diagnosis
- Cardiovascular Diseases/etiology
- Cardiovascular Diseases/physiopathology
- Cardiovascular Diseases/prevention & control
- Child
- Child, Preschool
- Chronic Kidney Disease-Mineral and Bone Disorder/blood
- Chronic Kidney Disease-Mineral and Bone Disorder/diagnosis
- Chronic Kidney Disease-Mineral and Bone Disorder/etiology
- Chronic Kidney Disease-Mineral and Bone Disorder/physiopathology
- Chronic Kidney Disease-Mineral and Bone Disorder/prevention & control
- Guideline Adherence
- Humans
- Hyperparathyroidism, Secondary/blood
- Hyperparathyroidism, Secondary/diagnosis
- Hyperparathyroidism, Secondary/etiology
- Hyperparathyroidism, Secondary/physiopathology
- Hyperparathyroidism, Secondary/prevention & control
- Infant
- Parathyroid Hormone/blood
- Peritoneal Dialysis/adverse effects
- Peritoneal Dialysis/standards
- Practice Guidelines as Topic
- Registries
- Renal Insufficiency, Chronic/blood
- Renal Insufficiency, Chronic/complications
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/physiopathology
- Renal Insufficiency, Chronic/therapy
- Treatment Outcome
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Affiliation(s)
- Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany.
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Wesseling-Perry K. Bone disease in pediatric chronic kidney disease. Pediatr Nephrol 2013; 28:569-76. [PMID: 23064662 PMCID: PMC3594120 DOI: 10.1007/s00467-012-2324-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 08/13/2012] [Accepted: 08/26/2012] [Indexed: 01/07/2023]
Abstract
Children with long-standing chronic kidney disease (CKD) display clinical symptoms of bone disease, including bony deformities and fractures, which contribute to long-standing disability. Abnormalities in skeletal mineralization occur in a substantial proportion of this population and may contribute to chronic morbidity. Underscoring the potential contribution of parameters other than bone turnover to bone disease in CKD, a new definition for renal osteodystrophy (ROD), emphasizing the assessment of three key histologic descriptors, i.e., bone turnover (T), mineralization (M), and volume (V) (TMV), has been recommended in the assessment of all patients with CKD. Although bone biopsy is the only available method for assessing all three recommended areas of bone histology, this invasive procedure is not routinely used in any clinical setting; thus, a true understanding of the prevalence of abnormal turnover, defective mineralization, and altered bone volume throughout the course of CKD is limited. Recent data, however, have shed light on the progression of renal ROD throughout the course of CKD, including its early stages, as well as on the alterations in cell biology that accompany ROD.
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Affiliation(s)
- Katherine Wesseling-Perry
- Department of Pediatrics, David Geffen School of Medicine at UCLA, A2-383 MDCC, 650 Charles Young Drive, Los Angeles, CA, 90095, USA.
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Hecking M, Kainz A, Bielesz B, Plischke M, Beilhack G, Hörl WH, Sunder-Plassmann G, Bieglmayer C. Clinical evaluation of two novel biointact PTH(1–84) assays in hemodialysis patients. Clin Biochem 2012; 45:1645-51. [DOI: 10.1016/j.clinbiochem.2012.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 08/03/2012] [Accepted: 08/03/2012] [Indexed: 02/03/2023]
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Souberbielle JC, Cheriet S, Cavalier E. Distinctive aspects of laboratory testing to evaluate mineral and bone metabolism in patients with chronic kidney disease. Joint Bone Spine 2012; 79 Suppl 2:S99-103. [PMID: 23098848 DOI: 10.1016/s1297-319x(12)70016-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Jean-Claude Souberbielle
- Laboratoire d'Explorations Fonctionnelles, et INSERM U845, Hôpital Necker-Enfants Malades, 149 rue de Sèvres, 75015 Paris, France.
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Jean G, Lafage-Proust MH, Souberbielle JC, Granjon S, Lorriaux C, Hurot JM, Mayor B, Deleaval P, Chazot C. Que faire de ces valeurs d’hormones parathyroïdiennes réputées trop basses chez les patients dialysés ? Nephrol Ther 2012; 8:462-7. [DOI: 10.1016/j.nephro.2012.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 04/10/2012] [Accepted: 04/10/2012] [Indexed: 10/27/2022]
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