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de Baaij JHF, Hoenderop JGJ, Bindels RJM. Magnesium in man: implications for health and disease. Physiol Rev 2015; 95:1-46. [PMID: 25540137 DOI: 10.1152/physrev.00012.2014] [Citation(s) in RCA: 886] [Impact Index Per Article: 98.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Magnesium (Mg(2+)) is an essential ion to the human body, playing an instrumental role in supporting and sustaining health and life. As the second most abundant intracellular cation after potassium, it is involved in over 600 enzymatic reactions including energy metabolism and protein synthesis. Although Mg(2+) availability has been proven to be disturbed during several clinical situations, serum Mg(2+) values are not generally determined in patients. This review aims to provide an overview of the function of Mg(2+) in human health and disease. In short, Mg(2+) plays an important physiological role particularly in the brain, heart, and skeletal muscles. Moreover, Mg(2+) supplementation has been shown to be beneficial in treatment of, among others, preeclampsia, migraine, depression, coronary artery disease, and asthma. Over the last decade, several hereditary forms of hypomagnesemia have been deciphered, including mutations in transient receptor potential melastatin type 6 (TRPM6), claudin 16, and cyclin M2 (CNNM2). Recently, mutations in Mg(2+) transporter 1 (MagT1) were linked to T-cell deficiency underlining the important role of Mg(2+) in cell viability. Moreover, hypomagnesemia can be the consequence of the use of certain types of drugs, such as diuretics, epidermal growth factor receptor inhibitors, calcineurin inhibitors, and proton pump inhibitors. This review provides an extensive and comprehensive overview of Mg(2+) research over the last few decades, focusing on the regulation of Mg(2+) homeostasis in the intestine, kidney, and bone and disturbances which may result in hypomagnesemia.
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Affiliation(s)
- Jeroen H F de Baaij
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost G J Hoenderop
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - René J M Bindels
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Abstract
PURPOSE OF REVIEW The review focuses on the rationale and evidence behind management strategies for hyperphosphatemia in patients with chronic kidney disease (CKD). RECENT FINDINGS Optimal management of phosphate in CKD remains an area of uncertainty, but multiple studies now point to a clinical benefit from the use of phosphate binders. Evidence of improved survival is particularly strong with sevelamer, though it remains unclear whether the absence of calcium or other properties of sevelamer are responsible for this relationship. Newer agents, such as iron-based binders or niacin compounds to inhibit phosphorus absorption, may have additional benefits which will be better defined with additional experience. A reduced pill count may be a particularly beneficial characteristic of newer agents, and has been associated with improved response to therapy. Increased use of frequent, nocturnal hemodialysis is an additional tool to help ameliorate phosphate control. Data on the reduction of fibroblast growth factor 23 through use of phosphate binders remain weak. SUMMARY An improved understanding of phosphate regulation and the development of new therapeutic agents have reinvigorated a once stagnant field, but significant changes to practice cannot yet be justified. There is increasing support for using sevelamer in place of calcium-based binders, though economic practicability remains challenging.
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Galassi A, Cupisti A, Santoro A, Cozzolino M. Phosphate balance in ESRD: diet, dialysis and binders against the low evident masked pool. J Nephrol 2014; 28:415-29. [PMID: 25245472 DOI: 10.1007/s40620-014-0142-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 09/11/2014] [Indexed: 12/11/2022]
Abstract
Phosphate metabolism is crucial in the pathophysiology of secondary hyperparathyroidism and vascular calcification. High phosphate levels have been consistently associated with unfavorable outcomes in dialysis patients, but several limitations are still hampering a resolutive definition of the optimal targets of phosphate serum levels to be achieved in this cohort. Nonetheless, hyperphosphatemia is a late marker of phosphate overload in humans. Clinical nephrologists routinely counteract the positive phosphate balance in dialysis patients through nutritional counseling, stronger phosphate removal by dialysis and prescription of phosphate binders. However, the superiority against placebo of phosphate control by diet, dialysis or binders in terms of survival has never been tested in dedicated randomized controlled trials. The present review discusses this conundrum with particular emphasis on the rationale supporting the value of a simultaneous intervention against phosphate overload in dialysis patients via the improvement of dietary intakes, dialysis efficiency and an individualized choice of phosphate binders.
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Affiliation(s)
- A Galassi
- Department of Medicine, Renal and Dialysis Unit, Desio Hospital, Desio, Italy,
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A magnesium based phosphate binder reduces vascular calcification without affecting bone in chronic renal failure rats. PLoS One 2014; 9:e107067. [PMID: 25229549 PMCID: PMC4167554 DOI: 10.1371/journal.pone.0107067] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 08/07/2014] [Indexed: 11/19/2022] Open
Abstract
The alternative phosphate binder calcium acetate/magnesium carbonate (CaMg) effectively reduces hyperphosphatemia, the most important inducer of vascular calcification, in chronic renal failure (CRF). In this study, the effect of low dose CaMg on vascular calcification and possible effects of CaMg on bone turnover, a persistent clinical controversy, were evaluated in chronic renal failure rats. Adenine-induced CRF rats were treated daily with 185 mg/kg CaMg or vehicle for 5 weeks. The aortic calcium content and area% calcification were measured to evaluate the effect of CaMg. To study the effect of CaMg on bone remodeling, rats underwent 5/6th nephrectomy combined with either a normal phosphorus diet or a high phosphorus diet to differentiate between possible bone effects resulting from either CaMg-induced phosphate deficiency or a direct effect of Mg. Vehicle or CaMg was administered at doses of 185 and 375 mg/kg/day for 8 weeks. Bone histomorphometry was performed. Aortic calcium content was significantly reduced by 185 mg/kg/day CaMg. CaMg ameliorated features of hyperparathyroid bone disease. In CRF rats on a normal phosphorus diet, the highest CaMg dose caused an increase in osteoid area due to phosphate depletion. The high phosphorus diet combined with the highest CaMg dose prevented the phosphate depletion and thus the rise in osteoid area. CaMg had no effect on osteoblast/osteoclast or dynamic bone parameters, and did not alter bone Mg levels. CaMg at doses that reduce vascular calcification did not show any harmful effect on bone turnover.
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Ruggeri M, Cipriani F, Bellasi A, Russo D, Di Iorio B. Sevelamer is cost-saving vs. calcium carbonate in non-dialysis-dependent CKD patients in italy: a patient-level cost-effectiveness analysis of the INDEPENDENT study. Blood Purif 2014; 37:316-24. [PMID: 25171148 DOI: 10.1159/000365746] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 07/06/2014] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To conduct a cost-effectiveness analysis of sevelamer versus calcium carbonate in patients with non-dialysis-dependent CKD (NDD-CKD) from the Italian NHS perspective using patient-level data from the INDEPENDENT-CKD study. METHODS Patient-level data on all-cause mortality, dialysis inception and phosphate binder dose were obtained for all 107 sevelamer and 105 calcium carbonate patients from the INDEPENDENT-CKD study. Hospitalization and frequency of dialysis data were collected post hoc for all patients via a retrospective chart review. Phosphate binder, hospitalization, and dialysis costs were expressed in 2012 euros using hospital pharmacy, Italian diagnosis-related group and ambulatory tariffs, respectively. Total life years (LYs) and costs per treatment group were calculated for the 3-year period of the study. Bootstrapping was used to estimate confidence intervals around outcomes, costs, and cost-effectiveness and to calculate the cost-effectiveness acceptability curve. A subgroup analysis of patients who did not initiate dialysis during the INDEPENDENT-CKD study was also conducted. RESULTS Sevelamer was associated with 0.06 additional LYs (95% CI -0.04 to 0.16) and cost savings of EUR -5,615 (95% CI -10,066 to -1,164) per patient compared with calcium carbonate. On the basis of the bootstrap analysis, sevelamer was dominant compared to calcium carbonate in 87.1% of 10,000 bootstrap replicates. Similar results were observed in the subgroup analysis. RESULTS were driven by a significant reduction in all-cause mortality and significantly fewer hospitalizations in the sevelamer group, which offset the higher acquisition cost for sevelamer. CONCLUSIONS Sevelamer provides more LYs and is less costly than calcium carbonate in patients with NDD-CKD in Italy.
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Affiliation(s)
- Matteo Ruggeri
- Faculty of Economics, Università Cattolica del Sacro Cuore, Rome, Italy
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McCarty MF, DiNicolantonio JJ. Bioavailable dietary phosphate, a mediator of cardiovascular disease, may be decreased with plant-based diets, phosphate binders, niacin, and avoidance of phosphate additives. Nutrition 2014; 30:739-47. [DOI: 10.1016/j.nut.2013.12.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 12/02/2013] [Accepted: 12/03/2013] [Indexed: 12/17/2022]
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The Authors Reply:. Kidney Int 2014; 86:212-3. [DOI: 10.1038/ki.2014.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pakfetrat M, Sharifpour S, Malekmakan L, Ezzatzadegan Jahromi S, Roozbeh J, Aslani A. The Effect of Magnesium Oxide on Hyperphosphatemia in Female Hemodialysis Patients. WOMEN’S HEALTH BULLETIN 2014. [DOI: 10.17795/whb-20048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Locatelli F, Dimkovic N, Spasovski G. Efficacy of colestilan in the treatment of hyperphosphataemia in renal disease patients. Expert Opin Pharmacother 2014; 15:1475-88. [DOI: 10.1517/14656566.2014.928285] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Vo TM, Disthabanchong S. Are there ways to attenuate arterial calcification and improve cardiovascular outcomes in chronic kidney disease? World J Cardiol 2014; 6:216-226. [PMID: 24944752 PMCID: PMC4062121 DOI: 10.4330/wjc.v6.i5.216] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 04/18/2014] [Accepted: 04/19/2014] [Indexed: 02/06/2023] Open
Abstract
The risk of cardiovascular mortality among patients with end-stage renal disease is several times higher than general population. Arterial calcification, a marker of atherosclerosis and a predictor of cardiovascular mortality, is common in chronic kidney disease (CKD). The presence of traditional cardiovascular risk factors such as diabetes, hypertension, hyperlipidemia, and advanced age cannot fully explain the high prevalence of atherosclerosis and arterial calcification. Other factors specific to CKD such as hyperphosphatemia, excess of calcium, high dose active vitamin D and prolonged dialysis vintage play important roles in the development of arterial calcification. Due to the significant health risk, it is prudent to attempt to lower arterial calcification burden in CKD. Treatment of hyperlipidemia with statin has failed to lower atherosclerotic and arterial calcification burden. Data on diabetes and blood pressure controls as well as smoking cessation on cardiovascular outcomes in CKD population are limited. Currently available treatment options include non-calcium containing phosphate binders, low dose active vitamin D, calcimimetic agent and perhaps bisphosphonates, vitamin K and sodium thiosulfate. Preliminary data on bisphosphonates, vitamin K and sodium thiosulfate are encouraging but larger studies on efficacy and outcomes are needed.
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Nastou D, Fernández-Fernández B, Elewa U, González-Espinoza L, González-Parra E, Sanchez-Niño MD, Ortiz A. Next-Generation Phosphate Binders: Focus on Iron-Based Binders. Drugs 2014; 74:863-77. [DOI: 10.1007/s40265-014-0224-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Locatelli F, Del Vecchio L, Violo L, Pontoriero G. Phosphate binders for the treatment of hyperphosphatemia in chronic kidney disease patients on dialysis: a comparison of safety profiles. Expert Opin Drug Saf 2014; 13:551-61. [PMID: 24702470 DOI: 10.1517/14740338.2014.907791] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Hyperphosphatemia is common in the late stages of chronic kidney disease (CKD) and is associated with elevated parathormone levels, abnormal bone mineralization, extraosseous calcification and increased risk of cardiovascular events and death. Several classes of oral phosphate binders are available to help control phosphorus levels. Although effective at lowering serum phosphorus, they all have safety issues that need to be considered when selecting which one to use. AREAS COVERED This paper reviews the use of phosphate binders in patients with CKD on dialysis, with a focus on safety and tolerability. In addition to the more established agents, a new resin-based phosphate binder, colestilan, is discussed. EXPERT OPINION Optimal phosphate control is still an unmet need in CKD. Nonetheless, we now have an extending range of phosphate binders available. Aluminium has potentially serious toxic risks. Calcium-based binders are still very useful but can lead to hypercalcemia and/or positive calcium balance and cardiovascular calcification. No long-term data are available for the new calcium acetate/magnesium combination product. Lanthanum is an effective phosphate binder, but there is insufficient evidence about possible long-term effects of tissue deposition. The resin-based binders, colestilan and sevelamer, appear to have profiles that would lead to less vascular calcification, and the main adverse events seen with these agents are gastrointestinal effects.
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Affiliation(s)
- Francesco Locatelli
- Alessandro Manzoni Hospital, Department of Nephrology Dialysis , Via dell'Eremo 9, 23900 Lecco , Italy +39 0341 489850 ; +39 0341 489860 ;
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Evsanaa B, Liu I, Aliazardeh B, Mahdavi S, Bajwa G, Gula J, Tam M, Sze E, Roscoe JM, Tam PY, Sikaneta T. MgCaCO3 versus CaCO3 in peritoneal dialysis patients--a cross-over pilot trial. Perit Dial Int 2014; 35:31-4. [PMID: 24584605 DOI: 10.3747/pdi.2013.00129] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite adverse effects such as constipation, vascular calcification, and hypercalcemia, calcium-based salts are relatively affordable and effective phosphate binders that remain in widespread use in the dialysis population. We conducted a pilot study examining whether the use of a combined magnesium/calcium-based binder was as effective as calcium carbonate at lowering serum phosphate levels in peritoneal dialysis (PD) patients. METHODS This was a cross-over, investigator-masked pilot study in which prevalent PD patients received calcium carbonate alone (200 mg calcium per tablet) or calcium magnesium carbonate (100 mg calcium, 85 mg magnesium per tablet). Primary outcome was serum phosphate level at 3 months. Analysis was as per protocol. RESULTS Twenty patients were recruited, 17 completed the study. Mean starting dose was 11.35 ± 7.04 pills per day of MgCaCO3 and 9.00 ± 4.97 pills per day of CaCO3. Mean phosphate levels fell from 2.13 mmol/L to 2.01 mmol/L (95% confidence interval (CI): 1.76 - 2.30, p = 0.361) in the MgCaCO3 group, and 1.81 mmol/L (95% CI: 1.56 - 2.0, p = 0.026) in the CaCO3 alone group. Six (35%) patients taking MgCaCO3 and 9 (54%) taking CaCO3 alone achieved Kidney Disease Outcomes Quality Initiative (KDOQI) serum phosphate targets at 3 months. Diarrhea developed in 9 patients taking MgCaCO3 and 3 taking CaCO3. Serum magnesium exceeded 1.4 mmol/L in 5 patients taking MgCaCO3 while serum calcium exceeded 2.65 mmol/L in 3 patients receiving CaCO3. When compared to the initial dose, the prescribed dose at 3 months was reduced by 44% (to 6.41 tablets/day) in the MgCaCO3 group and by 8% (to 8.24 pills per day) in the CaCO3 alone group. CONCLUSION Compared with CaCO3 alone, the preparation and dose of MgCaCO3 used in this pilot study was no better at lowering serum phosphate levels in PD patients, and was associated with more dose-limiting side effects.
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Affiliation(s)
- Baigalmaa Evsanaa
- Health Sciences University of Mongolia, Ulaanbaatar, Mongolia; and The Scarborough General Hospital, Scarborough, Ontario, Canada
| | - Irene Liu
- Health Sciences University of Mongolia, Ulaanbaatar, Mongolia; and The Scarborough General Hospital, Scarborough, Ontario, Canada
| | - Babak Aliazardeh
- Health Sciences University of Mongolia, Ulaanbaatar, Mongolia; and The Scarborough General Hospital, Scarborough, Ontario, Canada
| | - Sara Mahdavi
- Health Sciences University of Mongolia, Ulaanbaatar, Mongolia; and The Scarborough General Hospital, Scarborough, Ontario, Canada
| | - Gursarn Bajwa
- Health Sciences University of Mongolia, Ulaanbaatar, Mongolia; and The Scarborough General Hospital, Scarborough, Ontario, Canada
| | - Jerry Gula
- Health Sciences University of Mongolia, Ulaanbaatar, Mongolia; and The Scarborough General Hospital, Scarborough, Ontario, Canada
| | - Michelle Tam
- Health Sciences University of Mongolia, Ulaanbaatar, Mongolia; and The Scarborough General Hospital, Scarborough, Ontario, Canada
| | - Elena Sze
- Health Sciences University of Mongolia, Ulaanbaatar, Mongolia; and The Scarborough General Hospital, Scarborough, Ontario, Canada
| | - Janet M Roscoe
- Health Sciences University of Mongolia, Ulaanbaatar, Mongolia; and The Scarborough General Hospital, Scarborough, Ontario, Canada
| | - Paul Y Tam
- Health Sciences University of Mongolia, Ulaanbaatar, Mongolia; and The Scarborough General Hospital, Scarborough, Ontario, Canada
| | - Tabo Sikaneta
- Health Sciences University of Mongolia, Ulaanbaatar, Mongolia; and The Scarborough General Hospital, Scarborough, Ontario, Canada
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Galassi A, Cozzolino M. Magnesium: a renewed player of vascular ageing in diabetic CKD patients? Clin Kidney J 2014; 7:93-6. [PMID: 25852855 PMCID: PMC4377787 DOI: 10.1093/ckj/sfu011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 02/05/2014] [Indexed: 12/24/2022] Open
Affiliation(s)
- Andrea Galassi
- Renal and Dialysis Unit, Department of Medicine , Desio Hospital , Desio , Italy
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division , San Paolo Hospital, University of Milan , Milan , Italy
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Montes de Oca A, Guerrero F, Martinez-Moreno JM, Madueño JA, Herencia C, Peralta A, Almaden Y, Lopez I, Aguilera-Tejero E, Gundlach K, Büchel J, Peter ME, Passlick-Deetjen J, Rodriguez M, Muñoz-Castañeda JR. Magnesium inhibits Wnt/β-catenin activity and reverses the osteogenic transformation of vascular smooth muscle cells. PLoS One 2014; 9:e89525. [PMID: 24586847 PMCID: PMC3934896 DOI: 10.1371/journal.pone.0089525] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 01/21/2014] [Indexed: 11/18/2022] Open
Abstract
Magnesium reduces vascular smooth muscle cell (VSMC) calcification in vitro but the mechanism has not been revealed so far. This work used only slightly increased magnesium levels and aimed at determining: a) whether inhibition of magnesium transport into the cell influences VSMC calcification, b) whether Wnt/β-catenin signaling, a key mediator of osteogenic differentiation, is modified by magnesium and c) whether magnesium can influence already established vascular calcification. Human VSMC incubated with high phosphate (3.3 mM) and moderately elevated magnesium (1.4 mM) significantly reduced VSMC calcification and expression of the osteogenic transcription factors Cbfa-1 and osterix, and up-regulated expression of the natural calcification inhibitors matrix Gla protein (MGP) and osteoprotegerin (OPG). The protective effects of magnesium on calcification and expression of osteogenic markers were no longer observed in VSMC cultured with an inhibitor of cellular magnesium transport (2-aminoethoxy-diphenylborate [2-APB]). High phosphate induced activation of Wnt/β-catenin pathway as demonstrated by the translocation of β-catenin into the nucleus, increased expression of the frizzled-3 gene, and downregulation of Dkk-1 gene, a specific antagonist of the Wnt/β-catenin signaling pathway. The addition of magnesium however inhibited phosphate-induced activation of Wnt/β-catenin signaling pathway. Furthermore, TRPM7 silencing using siRNA resulted in activation of Wnt/β-catenin signaling pathway. Additional experiments were performed to test the ability of magnesium to halt the progression of already established VSMC calcification in vitro. The delayed addition of magnesium decreased calcium content, down-regulated Cbfa-1 and osterix and up-regulated MGP and OPG, when compared with a control group. This effect was not observed when 2-APB was added. In conclusion, magnesium transport through the cell membrane is important to inhibit VSMC calcification in vitro. Inhibition of Wnt/β-catenin by magnesium is one potential intracellular mechanism by which this anti-calcifying effect is achieved.
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Affiliation(s)
- Addy Montes de Oca
- IMIBIC, Hospital Univ Reina Sofia, REDInRen, Cordoba, Spain
- Depto. Medicina y Cirugía Animal, University of Cordoba, Cordoba, Spain
| | - Fatima Guerrero
- IMIBIC, Hospital Univ Reina Sofia, REDInRen, Cordoba, Spain
- Depto. Medicina y Cirugía Animal, University of Cordoba, Cordoba, Spain
| | | | | | | | - Alan Peralta
- Depto. Medicina y Cirugía Animal, University of Cordoba, Cordoba, Spain
| | - Yolanda Almaden
- IMIBIC, Hospital Univ Reina Sofia, REDInRen, Cordoba, Spain
- Lipid and Atherosclerosis Unit, IMIBIC/Reina Sofia University Hospital/University of Cordoba, and CIBER Fisiopatologia Obesidad y Nutricion (CIBEROBN), Instituto de Salud Carlos III, Cordoba, Spain
| | - Ignacio Lopez
- Depto. Medicina y Cirugía Animal, University of Cordoba, Cordoba, Spain
| | | | | | - Janine Büchel
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Mirjam E. Peter
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | - Mariano Rodriguez
- IMIBIC, Hospital Univ Reina Sofia, REDInRen, Cordoba, Spain
- Servicio de Nefrologia, Hospital Univ Reina Sofia, REDInRen, Cordoba, Spain
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Alhosaini M, Walter JS, Singh S, Dieter RS, Hsieh A, Leehey DJ. Hypomagnesemia in hemodialysis patients: role of proton pump inhibitors. Am J Nephrol 2014; 39:204-9. [PMID: 24577494 DOI: 10.1159/000360011] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 01/24/2014] [Indexed: 01/03/2023]
Abstract
BACKGROUND Recent observations have associated hypomagnesemia with increased risk of cardiovascular morbidity and mortality in hemodialysis patients. METHODS We did a 3-month chart review of 62 chronic hemodialysis patients at a single US hospital. All were dialyzed using a dialysate [Mg] of 0.75-1.0 mEq/l. Patients were divided into two groups: hypomagnesemic (mean predialysis plasma [Mg] <1.5 mEq/l) and non-hypomagnesemic (mean predialysis plasma [Mg] ≥1.5 mEq/l). RESULTS All patients were male; mean age was 64.3 ± 8.7 years and the majority (73%) diabetic. 24 patients (39%) had hypomagnesemia and 38 (61%) were not hypomagnesemic. There were no significant differences between the two groups in age, diabetes status, blood pressure, duration of dialysis, plasma calcium, phosphorus, albumin, intact parathyroid hormone (PTH), dialysis adequacy (Kt/V), or dietary protein intake (as estimated by normalized protein catabolic rate, nPCR). However, use of proton pump inhibitors (PPIs) was significantly associated with hypomagnesemia (plasma [Mg] 1.48 ± 0.16 mEq/l in the PPI group vs. 1.65 ± 0.26 mEq/l in the non-PPI group, p = 0.007). Adjustment for age, diabetes status, duration of dialysis, plasma albumin, Kt/V, nPCR, and diuretic use did not affect the association between PPI use and hypomagnesemia. CONCLUSIONS Use of PPIs in patients dialyzed using a dialysate [Mg] of 0.75-1.0 mEq/l is associated with hypomagnesemia. We suggest monitoring plasma [Mg] in patients taking PPIs, with discontinuation of the medication if possible and/or adjustment of dialysate [Mg] to normalize plasma [Mg].
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Affiliation(s)
- Mohamad Alhosaini
- Department of Medicine, Edward Hines Jr. Veterans Affairs Hospital, Hines, Ill., USA
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Sonikian M, Papachristou E, Goumenos DS. Optimal use of phosphate binders in chronic kidney disease. Expert Opin Pharmacother 2013; 14:2521-32. [PMID: 24215605 DOI: 10.1517/14656566.2013.852183] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Hyperphosphatemia is one of the major factors associated with the development of vascular calcification in patients with chronic kidney disease (CKD). Since phosphate is retained in such patients, pharmacological treatment and other measures are necessary to control hyperphosphatemia. Several phosphate binders (calcium salts, magnesium salts, non-calcium-based binders and aluminium) are available for the treatment of hyperphosphatemia. Nevertheless, none of the above mentioned agents has shown an overall superiority over others, while potency and side effects are quite variable among them creating difficulties in choosing the optimal drug for each patient. AREAS COVERED The authors discuss the disturbed phosphate metabolism, the available phosphate binders, as well as the general therapeutic principles of treating hyperphosphatemia in CKD patients. The literature used for this review had been retrieved from PubMed and covers a large number of original and retrospective studies as well as prospective cohort studies, meta-analyses and international clinical guidelines. EXPERT OPINION Lowering serum phosphate levels in CKD patients may potentially have a positive impact on cardiovascular morbidity and mortality. Factors that should be taken into consideration when selecting a specific drug include CKD stage, cardiovascular disease, severity of secondary hyperparathyroidism, concomitant medications, life expectancy and patient compliance. Therefore, when selecting a specific phosphate binder, individualisation is mandatory.
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Affiliation(s)
- Makrouhi Sonikian
- Sismanoglion - A. Fleming General Hospital, Department of Nephrology , 15232 Athens , Greece +0030 210 6859562 ; +0030 2610 994424 ;
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Lloret M, Ruiz-García C, DaSilva I, Furlano M, Barreiro Y, Ballarín J, Bover J. Lanthanum carbonate for the control of hyperphosphatemia in chronic renal failure patients: a new oral powder formulation - safety, efficacy, and patient adherence. Patient Prefer Adherence 2013; 7:1147-56. [PMID: 24235818 PMCID: PMC3826937 DOI: 10.2147/ppa.s31694] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Chronic kidney disease (CKD) is associated with very high mortality rates, mainly of cardiovascular origin. The retention of phosphate (P) and increased fibroblast growth factor-23 levels are common, even at early stages of CKD, due to disturbances in normal P homeostasis. Later, hyperphosphatemia appears, which has also been strongly associated with high mortality rates linked to P-mediated cardiovascular and procalcifying effects. Treatment guidelines for these patients continue to be poorly implemented, at least partially due to the lack of adherence to a P-restricted diet and P-binder therapy. Calcium-free P binders, such as lanthanum carbonate, have been associated with a decreased progression of vascular calcification, rendering them an important therapeutic alternative for these high cardiovascular risk CKD patients. Lanthanum carbonate has typically been available as chewable tablets, and the new presentation as an oral powder may provide a useful alternative in the therapeutic armamentarium. This powder is a tasteless, odorless, and colorless semisolid compound miscible with food. In a recent study in healthy individuals, the safety and efficacy of this novel form were evaluated, and it was concluded that it is well tolerated and pharmacodynamically equivalent to the chewable form. In the long run, individualization of preferences and treatments seems an achievable goal prior to final demonstration of improvements in hard outcomes in wide clinical trials in CKD patients.
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Affiliation(s)
- MªJesús Lloret
- Nephrology Department, Fundació Puigvert, IIB Sant Pau, Barcelona, Spain; REDinREN, Instituto de Investigación Carlos III, Madrid, Spain
| | - César Ruiz-García
- Nephrology Department, Fundació Puigvert, IIB Sant Pau, Barcelona, Spain; REDinREN, Instituto de Investigación Carlos III, Madrid, Spain
| | - Iara DaSilva
- Nephrology Department, Fundació Puigvert, IIB Sant Pau, Barcelona, Spain; REDinREN, Instituto de Investigación Carlos III, Madrid, Spain
| | - Mónica Furlano
- Nephrology Department, Fundació Puigvert, IIB Sant Pau, Barcelona, Spain; REDinREN, Instituto de Investigación Carlos III, Madrid, Spain
| | - Yaima Barreiro
- Nephrology Department, Fundació Puigvert, IIB Sant Pau, Barcelona, Spain; REDinREN, Instituto de Investigación Carlos III, Madrid, Spain
| | - José Ballarín
- Nephrology Department, Fundació Puigvert, IIB Sant Pau, Barcelona, Spain; REDinREN, Instituto de Investigación Carlos III, Madrid, Spain
| | - Jordi Bover
- Nephrology Department, Fundació Puigvert, IIB Sant Pau, Barcelona, Spain; REDinREN, Instituto de Investigación Carlos III, Madrid, Spain
- Correspondence: Jordi Bover, Nephrology Department, Fundació Puigvert, C Cartagena 340-350, 08025 Barcelona, Spain, Tel +34 93 416 97 00, Fax +34 93 416 97 30, Email
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Individualize phosphate binder therapy in patients with chronic hyperphosphataemia and renal failure. DRUGS & THERAPY PERSPECTIVES 2013. [DOI: 10.1007/s40267-013-0072-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Rodríguez-Ortiz ME, Canalejo A, Herencia C, Martínez-Moreno JM, Peralta-Ramírez A, Perez-Martinez P, Navarro-González JF, Rodríguez M, Peter M, Gundlach K, Steppan S, Passlick-Deetjen J, Muñoz-Castañeda JR, Almaden Y. Magnesium modulates parathyroid hormone secretion and upregulates parathyroid receptor expression at moderately low calcium concentration. Nephrol Dial Transplant 2013; 29:282-9. [PMID: 24103811 PMCID: PMC3910342 DOI: 10.1093/ndt/gft400] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The interest on magnesium (Mg) has grown since clinical studies have shown the efficacy of Mg-containing phosphate binders. However, some concern has arisen for the potential effect of increased serum Mg on parathyroid hormone (PTH) secretion. Our objective was to evaluate the direct effect of Mg in the regulation of the parathyroid function; specifically, PTH secretion and the expression of parathyroid cell receptors: CaR, the vitamin D receptor (VDR) and FGFR1/Klotho. METHODS The work was performed in vitro by incubating intact rat parathyroid glands in different calcium (Ca) and Mg concentrations. RESULTS Increasing Mg concentrations from 0.5 to 2 mM produced a left shift of PTH-Ca curves. With Mg 5 mM, the secretory response was practically abolished. Mg was able to reduce PTH only if parathyroid glands were exposed to moderately low Ca concentrations; with normal-high Ca concentrations, the effect of Mg on PTH inhibition was minor or absent. After 6-h incubation at a Ca concentration of 1.0 mM, the expression of parathyroid CaR, VDR, FGFR1 and Klotho (at mRNA and protein levels) was increased with a Mg concentration of 2.0 when compared with 0.5 mM. CONCLUSIONS Mg reduces PTH secretion mainly when a moderate low calcium concentration is present; Mg also modulates parathyroid glands function through upregulation of the key cellular receptors CaR, VDR and FGF23/Klotho system.
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Affiliation(s)
- Maria E Rodríguez-Ortiz
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Reina Sofia University Hospital/University of Cordoba, Spain
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Cupisti A, Gallieni M, Rizzo MA, Caria S, Meola M, Bolasco P. Phosphate control in dialysis. Int J Nephrol Renovasc Dis 2013; 6:193-205. [PMID: 24133374 PMCID: PMC3797240 DOI: 10.2147/ijnrd.s35632] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Prevention and correction of hyperphosphatemia is a major goal of chronic kidney disease–mineral and bone disorder (CKD–MBD) management, achievable through avoidance of a positive phosphate balance. To this aim, optimal dialysis removal, careful use of phosphate binders, and dietary phosphate control are needed to optimize the control of phosphate balance in well-nourished patients on a standard three-times-a-week hemodialysis schedule. Using a mixed diffusive–convective hemodialysis tecniques, and increasing the number and/or the duration of dialysis tecniques are all measures able to enhance phosphorus (P) mass removal through dialysis. However, dialytic removal does not equal the high P intake linked to the high dietary protein requirement of dialysis patients; hence, the use of intestinal P binders is mandatory to reduce P net intestinal absorption. Unfortunately, even a large dose of P binders is able to bind approximately 200–300 mg of P on a daily basis, so it is evident that their efficacy is limited in the case of an uncontrolled dietary P load. Hence, limitation of dietary P intake is needed to reach the goal of neutral phosphate balance in dialysis, coupled to an adequate protein intake. To this aim, patients should be informed and educated to avoid foods that are naturally rich in phosphate and also processed food with P-containing preservatives. In addition, patients should preferentially choose food with a low P-to-protein ratio. For example, patients could choose egg white or protein from a vegetable source. Finally, boiling should be the preferred cooking procedure, because it induces food demineralization, including phosphate loss. The integrated approach outlined in this article should be actively adapted as a therapeutic alliance by clinicians, dieticians, and patients for an effective control of phosphate balance in dialysis patients.
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Affiliation(s)
- Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Nistor I, Palmer SC, Covic A, Craig JC, Strippoli GFM. Magnesium-based interventions for people with chronic kidney disease. Hippokratia 2013. [DOI: 10.1002/14651858.cd010733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ionut Nistor
- "Gr. T. Popa" University of Medicine and Pharmacy; Nephrology Department; Bdul Carol I, No 50 Iasi Iasi Romania 700503
- Ghent University Hospital; European Renal Best Practice Methods Support Team; Ghent Belgium
| | - Suetonia C Palmer
- University of Otago Christchurch; Department of Medicine; 2 Riccarton Ave PO Box 4345 Christchurch New Zealand 8140
| | - Adrian Covic
- "Gr. T. Popa" University of Medicine and Pharmacy; Nephrology Department; Bdul Carol I, No 50 Iasi Iasi Romania 700503
| | - Jonathan C Craig
- The University of Sydney; Sydney School of Public Health; Edward Ford Building A27 Sydney NSW Australia 2006
- The Children's Hospital at Westmead; Cochrane Renal Group, Centre for Kidney Research; Westmead NSW Australia 2145
| | - Giovanni FM Strippoli
- The University of Sydney; Sydney School of Public Health; Edward Ford Building A27 Sydney NSW Australia 2006
- The Children's Hospital at Westmead; Cochrane Renal Group, Centre for Kidney Research; Westmead NSW Australia 2145
- Mario Negri Sud Consortium; Department of Clinical Pharmacology and Epidemiology; Santa Maria Imbaro Italy
- Diaverum; Medical-Scientific Office; Lund Sweden
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Dasgupta I, Shroff R, Bennett-Jones D, McVeigh G. Management of hyperphosphataemia in chronic kidney disease: summary of National Institute for Health and Clinical Excellence (NICE) guideline. Nephron Clin Pract 2013; 124:1-9. [PMID: 24022619 DOI: 10.1159/000354711] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Bone disease and ectopic calcification are the two main consequences of hyperphosphataemia of chronic kidney disease (CKD). Observational studies have demonstrated that hyperphosphataemia in CKD is associated with increased mortality. Furthermore, the use of phosphate binders in dialysis patients is associated with significantly lower mortality. The UK Renal Registry data show significant underachievement of phosphate targets in dialysis patients. It is believed to be due to wide variation in how management interventions are used. The National Institute for Health and Clinical Excellence (NICE) has developed a guideline on the management of hyperphosphataemia in CKD. This is based on the evidence currently available using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. This review outlines the recommendations including research recommendations and discusses methodology, rationale and challenges faced in developing this guideline and the health economic model used to assess the cost-effectiveness of different phosphate binders.
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Disthabanchong S. Lowering vascular calcification burden in chronic kidney disease: Is it possible? World J Nephrol 2013; 2:49-55. [PMID: 24255887 PMCID: PMC3832912 DOI: 10.5527/wjn.v2.i3.49] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 05/21/2013] [Accepted: 07/18/2013] [Indexed: 02/06/2023] Open
Abstract
High prevalence of atherosclerosis and arterial calcification in chronic kidney disease is far beyond the explanation by common cardiovascular risk factors such as aging diabetes, hypertension and dyslipidemia. The magnitude of coronary artery calcification is independently and inversely associated with renal function. In addition to cardiovascular risk factors, other chronic kidney disease-related risks such as phosphate retention, excess of calcium and prolonged dialysis vintage also contribute to the development of vascular calcification. Strategies to lower vascular calcification burden in chronic kidney disease population should include minimizing chronic kidney disease and atherosclerotic risk factors. Current therapies available are non-calcium containing phosphate binders, low dose active vitamin D and calcimimetic agent. The role of bisphosphonates in vascular calcification in chronic kidney disease population remains unclear. Preliminary data on sodium thiosulfate are promising, however, larger studies on efficacy and patient outcomes are necessary. Several large randomized controlled trials have confirmed the lack of benefit of statin in attenuating the progression of vascular calcification.
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Covic A, Passlick-Deetjen J, Kroczak M, Büschges-Seraphin B, Ghenu A, Ponce P, Marzell B, de Francisco ALM. A comparison of calcium acetate/magnesium carbonate and sevelamer-hydrochloride effects on fibroblast growth factor-23 and bone markers: post hoc evaluation from a controlled, randomized study. Nephrol Dial Transplant 2013; 28:2383-92. [PMID: 23787550 PMCID: PMC3769980 DOI: 10.1093/ndt/gft203] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Different phosphate binders exert differing effects on bone mineral metabolism and levels of regulating hormones. The objective of this post hoc evaluation of the CALcium acetate MAGnesium carbonate (CALMAG) study was to compare the effects of calcium acetate/magnesium carbonate (CaMg) and a calcium-free phosphate binder, sevelamer-hydrochloride (HCl), on serum levels of fibroblast growth factor-23 (FGF-23) and markers of bone turnover. METHODS This secondary analysis of the controlled, randomized CALMAG study, comparing the effect of CaMg and sevelamer-HCl on serum phosphorus (P), aimed to investigate the parameters described above. The analysis included 204 patients who completed the initial study per protocol (CaMg, n = 105; sevelamer-HCl, n = 99). RESULTS The study showed that serum levels of FGF-23 were significantly reduced with CaMg and sevelamer-HCl, with no difference between groups at Week 25 [analysis of covariance (ANCOVA); log-intact FGF-23 (iFGF-23), P = 0.1573]. FGF-23 levels strongly correlated with serum P levels at all time points in both groups. The bone turnover parameters alkaline phosphatase (AP), bone AP (BAP), procollagen type 1 amino-terminal propeptide 1 (P1NP), osteoprotegerin (OPG), beta-crosslaps (β-CTX) and tartrate-resistant acid phosphatase 5b (TRAP 5b) increased significantly in the sevelamer-HCl group; they remained almost unchanged in the CaMg group, after the initial phase of P lowering (ANCOVA, P < 0.0001 for all except OPG, P = 0.1718). CONCLUSIONS CaMg and sevelamer-HCl comparably lower serum levels of iFGF-23. Changes in bone parameters were dependent on characteristics of the phosphate binder; in contrast with sevelamer-HCl, CaMg had no influence on bone turnover markers.
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Affiliation(s)
- Adrian Covic
- Clinic of Nephrology, C. I. Parhon University Hospital, Gr T. Popa; University of Medicine and Pharmacy, IASI, Romania
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De Schutter TM, Behets GJ, Geryl H, Peter ME, Steppan S, Gundlach K, Passlick-Deetjen J, D'Haese PC, Neven E. Effect of a magnesium-based phosphate binder on medial calcification in a rat model of uremia. Kidney Int 2013; 83:1109-17. [PMID: 23486515 PMCID: PMC3674404 DOI: 10.1038/ki.2013.34] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 11/21/2012] [Accepted: 11/30/2012] [Indexed: 12/13/2022]
Abstract
Calcium-based phosphate binders are used to control hyperphosphatemia; however, they promote hypercalcemia and may accelerate aortic calcification. Here we compared the effect of a phosphate binder containing calcium acetate and magnesium carbonate (CaMg) to that of sevelamer carbonate on the development of medial calcification in rats with chronic renal failure induced by an adenine diet for 4 weeks. After 1 week, rats with chronic renal failure were treated with vehicle, 375 or 750 mg/kg CaMg, or 750 mg/kg sevelamer by daily gavage for 5 weeks. Renal function was significantly impaired in all groups. Vehicle-treated rats with chronic renal failure developed severe hyperphosphatemia, but this was controlled in treated groups, particularly by CaMg. Neither CaMg nor sevelamer increased serum calcium ion levels. Induction of chronic renal failure significantly increased serum PTH, dose-dependently prevented by CaMg but not sevelamer. The aortic calcium content was significantly reduced by CaMg but not by sevelamer. The percent calcified area of the aorta was significantly lower than vehicle-treated animals for all three groups. The presence of aortic calcification was associated with increased sox9, bmp-2, and matrix gla protein expression, but this did not differ in the treatment groups. Calcium content in the carotid artery was lower with sevelamer than with CaMg but that in the femoral artery did not differ between groups. Thus, treatment with either CaMg or sevelamer effectively controlled serum phosphate levels in CRF rats and reduced aortic calcification.
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Affiliation(s)
- Tineke M De Schutter
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Geert J Behets
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Hilde Geryl
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Mirjam E Peter
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Sonja Steppan
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | | | - Patrick C D'Haese
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Ellen Neven
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
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Fukagawa M, Komaba H, Kakuta T. Hyperparathyroidism in chronic kidney disease patients: an update on current pharmacotherapy. Expert Opin Pharmacother 2013; 14:863-71. [PMID: 23521343 DOI: 10.1517/14656566.2013.783017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Secondary hyperparathyroidism is the most common abnormalities of mineral metabolism in chronic kidney disease (CKD), which causes bone disease and vascular calcification, leading to increased risk of mortality. AREAS COVERED The aim of this review is to provide an overview of pharmacological therapies for secondary hyperparathyroidism, based on current understanding of the disease. EXPERT OPINION The initial event in the pathogenesis of secondary hyperparathyroidism is the phosphorus overload per nephron that lead to the secretion of a new phosphaturic hormone, fibroblast growth factor 23 from the bone. Such an abnormality develops very early in CKD, even without hyperphosphatemia. When hyperphosphatemia develops, phosphate binders are prescribed in many CKD patients. Non-calcium containing binders are gaining popularity because of less risk of excess calcium load; however, no specific superiority in patient-level outcomes has been fully established yet. For the direct control of parathyroid hormone secretion, cinacalcet hydrochloride has become widespread in addition to vitamin D receptor activators. As adverse events related to these therapeutic agents occur occasionally, however, and better adherence is one of the most important determinants of the benefits of the drugs, fewer adverse events as well as more potent therapeutic effects should be aimed in the development of new agents in future.
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Affiliation(s)
- Masafumi Fukagawa
- Tokai University School of Medicine, Division of Nephrology, Endocrinology, and Metabolism, 143 Shimo-Kasuya, Isehara, Kanagawa, 259-1193, Japan.
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Ketteler M, Wüthrich RP, Floege J. Management of hyperphosphataemia in chronic kidney disease-challenges and solutions. Clin Kidney J 2013; 6:128-36. [PMID: 26019840 PMCID: PMC4432434 DOI: 10.1093/ckj/sfs173] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 11/13/2012] [Indexed: 12/11/2022] Open
Abstract
Hyperphosphataemia is a clinical consequence of the advanced stages of chronic kidney disease (CKD). Considerable evidence points to a role of hyperphosphataemia in the pathogenesis of CKD-associated cardiovascular (CV) complications, including vascular calcification, and with increased all-cause and CV mortality. These observations place management of hyperphosphataemia at the centre of CKD treatment. Although our increased understanding of the physiological role of FGF-23 may provide a long-term alternative biomarker of phosphate load and underlying disease progression, regular determination of serum phosphate is currently the most frequently used parameter to evaluate phosphate load in clinical practice. This review considers the challenges physicians and patients face in trying to control hyperphosphataemia. Amongst these are the limitations of dietary phosphate restriction, giving rise to the need for phosphate binder therapy to maintain serum phosphate control. Once the decision to use phosphate binders has been made, considerations include the relative efficacy, different potential side effects and pill burden associated with various phosphate binders. Although a number of phosphate binders are available, adherence poses a major obstacle to effective treatment. This emphasizes that further improvements to phosphate binder therapy can be made. Evaluation of novel agents and their potential role in the clinic should continue.
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Affiliation(s)
- Markus Ketteler
- Division of Nephrology , Coburg Clinic and KfH-Dialysis Center , Coburg , Germany
| | | | - Jürgen Floege
- Division of Nephrology and Clinical Immunology , RWTH University Hospital Aachen , Aachen , Germany
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Louvet L, Büchel J, Steppan S, Passlick-Deetjen J, Massy ZA. Magnesium prevents phosphate-induced calcification in human aortic vascular smooth muscle cells. Nephrol Dial Transplant 2012; 28:869-78. [PMID: 23229924 PMCID: PMC3611891 DOI: 10.1093/ndt/gfs520] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Vascular calcification (VC) is prevalent in patients suffering from chronic kidney disease. Factors promoting calcification include abnormalities in mineral metabolism, particularly high phosphate levels. Inorganic phosphate (Pi) is a classical inducer of in vitro VC. Recently, an inverse relationship between serum magnesium concentrations and VC has been reported. The present study aimed to investigate the effects of magnesium on Pi-induced VC at the cellular level using primary HAVSMC. Methods Alive and fixed HAVSMC were assessed during 14 days in the presence of Pi with increasing concentrations of magnesium (Mg2+) chloride. Mineralization was measured using quantification of calcium, von Kossa and alizarin red stainings. Cell viability and secretion of classical VC markers were also assessed using adequate tests. Involvement of transient receptor potential melastatin (TRPM) 7 was assessed using 2-aminoethoxy-diphenylborate (2-APB) inhibitor. Results Co-incubation with Mg2+ significantly decreased Pi-induced VC in live HAVSMC, no effect was found in fixed cells. At potent concentrations in Pi-induced HAVSMC, Mg2+ significantly improved cell viability and restored to basal level increased secretions of osteocalcin and matrix gla protein, whereas a decrease in osteopontin secretion was partially restored. The block of TRPM7 with 2-APB at 10−4 M led to the inefficiency of Mg2+ to prevent VC. Conclusions Increasing Mg2+ concentrations significantly reduced VC, improved cell viability and modulated secretion of VC markers during cell-mediated matrix mineralization clearly pointing to a cellular role for Mg2+ and 2-APB further involved TRPM7 and a potential Mg2+ entry to exert its effects. Further investigations are needed to shed light on additional cellular mechanism(s) by which Mg2+ is able to prevent VC.
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McCarty MF. Calcium supplementation, renin, and vascular risk. Osteoporos Int 2012; 23:2733-4. [PMID: 22286803 DOI: 10.1007/s00198-012-1910-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 11/23/2011] [Indexed: 11/26/2022]
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Medical and Surgical Management (Including Diet). Clin Rev Bone Miner Metab 2012. [DOI: 10.1007/s12018-011-9116-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Kanbay M, Yilmaz MI, Apetrii M, Saglam M, Yaman H, Unal HU, Gok M, Caglar K, Oguz Y, Yenicesu M, Cetinkaya H, Eyileten T, Acikel C, Vural A, Covic A. Relationship between serum magnesium levels and cardiovascular events in chronic kidney disease patients. Am J Nephrol 2012; 36:228-37. [PMID: 22948239 DOI: 10.1159/000341868] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Accepted: 07/11/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Magnesium is an essential ion for all living cells because over 300 enzymes require the presence of magnesium for their catalytic action. To date, no group has evaluated magnesium as a cardiovascular risk factor in chronic kidney disease (CKD) subjects, in which closely interrelated factors and potential confounders such as endothelial dysfunction, insulin resistance (the homeostasis model assessment (HOMA) index) and inflammation (expressed as serum C-reactive protein (CRP) levels) were also considered. METHODS Between March 2006 and December 2010, 283 CKD patients were followed up for time-to-event analysis until the occurrence of fatal or nonfatal cardiovascular events. Endothelium-dependent vasodilatation (flow-mediated dilatation; FMD) and endothelium-independent vasodilatation (nitroglycerin-mediated dilatation) of the brachial artery were assessed noninvasively using high-resolution ultrasound. RESULTS From the univariate analysis of FMD, it appears that a higher magnesium level is associated with less endothelial dysfunction. When a multivariate analysis was performed, magnesium and estimated glomerular filtration rates (eGFR) maintained a strong positive correlation with FMD, supporting the hypothesis that higher levels of magnesium may protect against endothelial damage. In univariate Cox proportional hazards models, FMD, magnesium, high sensitivity CRP, the HOMA index, eGFR, comorbid diabetes, hypertension, smoking status, systolic blood pressure, serum phosphate and intact parathormone emerged as significant predictors for cardiovascular outcomes. Kaplan-Meier curves showed significantly higher cardiovascular mortality rates in CKD patients whose serum magnesium levels were below 2.05 mg/dl. CONCLUSIONS This observational cohort study showed that magnesium may be an independent predictor of future cardiovascular outcomes and is the first study demonstrating such a role in etiologically diagnosed CKD patients, across different stages.
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Affiliation(s)
- Mehmet Kanbay
- Department of Nephrology, Gülhane School of Medicine, Ankara, Turkey
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Van Laecke S, Van Biesen W, Vanholder R. Hypomagnesaemia, the kidney and the vessels. Nephrol Dial Transplant 2012; 27:4003-10. [PMID: 22610987 DOI: 10.1093/ndt/gfs126] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Frazão JM, Adragão T. Non-calcium-containing phosphate binders: comparing efficacy, safety, and other clinical effects. Nephron Clin Pract 2012; 120:c108-19. [PMID: 22555359 DOI: 10.1159/000337087] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Phosphate-binder therapy for hyperphosphataemia is key to the treatment of patients with chronic kidney disease (CKD)-mineral and bone disorder (MBD). Calcium-free phosphate binders are increasingly favoured since calcium-based agents potentially cause harmful calcium overload and vascular calcification that confound the benefits of reducing serum phosphorus. Several calcium-free phosphate binders are available, including the non-absorbed agent sevelamer and the absorbed agents, e.g. lanthanum and magnesium salts. Randomised controlled studies consistently show that sevelamer and lanthanum carbonate offer equivalent lowering of serum phosphorus and often effectively achieve phosphorus targets versus calcium salts, with sevelamer having a positive effect on bone disease, vascular calcification, and patient-level outcomes in dialysis patients in several trials. There is also evidence that lanthanum carbonate can improve bone health, but data are limited to its effects to vascular calcification or patient-level outcomes. Magnesium salts have also been shown to reduce serum phosphorus levels, but clear evidence is lacking on bone, vascular, or clinical outcomes. It also remains to be established whether long-term systemic accumulation of lanthanum and magnesium, in tissues including bone, has clinically relevant toxic effects. This review summarises the evidence of efficacy and safety for newer calcium-free phosphate binders in CKD-MBD management.
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Affiliation(s)
- João M Frazão
- Nephrology Department, Hospital de S. João, School of Medicine, University of Porto and Nephrology Research and Development Unit, University of Porto, Porto, Portugal.
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Hutchison AJ, Smith CP, Brenchley PEC. Pharmacology, efficacy and safety of oral phosphate binders. Nat Rev Nephrol 2011; 7:578-89. [DOI: 10.1038/nrneph.2011.112] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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89
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Plagemann T, Prenzler A, Mittendorf T. Considerations about the effectiveness and cost effectiveness of therapies in the treatment of hyperphosphataemia. HEALTH ECONOMICS REVIEW 2011; 1:1. [PMID: 22828213 PMCID: PMC3395041 DOI: 10.1186/2191-1991-1-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 07/20/2011] [Indexed: 05/10/2023]
Abstract
Because of an elevated serum phosphate level, patients who suffer from chronic kidney failure frequently tend to have cardiovascular calcification and are therefore exposed to a higher probability of a fatal event. Phosphate binders are able to reduce these negative effects. Currently, there are primarily two groups of phosphate binders (calcium-containing and calcium-free phosphate binders) which are considered to be almost equally effective in terms of binding of free phosphate. There are, however, a few disadvantages of the two groups. While the calcium-containing binders are associated with an increased risk of hypercalcemia, which is dose dependent, calcium-free binders have been criticized as being too expensive. As the expenditure for patients suffering from chronic kidney failure increases from year to year, as a result of increasing prevalence, there is a growing need for an alternative to existing phosphate binders. The study presented here therefore summarizes available information for the novel combination preparation OsvaRen® (calcium acetate/magnesium carbonate) as an alternative therapy to the calcium-free phosphate binder Renagel® (sevelamer-hydrochloride) and to calcium-containing preparations.The results of this systematic review showed that OsvaRen® is at least equally effective in the regulation of serum phosphate level as Renagel®. In particular, OsvaRen® shows no clinically relevant difference in terms of the control of the serum calcium levels compared to Renagel® and thereby does not increase the risk of a hypercalcaemia, in contrast to pure calcium-based phosphate binders. On the other hand, Renagel® therapy is much more frequently associated with gastrointestinal side-effects, a tendency to result in higher tablet burden for patients and high medication costs. The CALMAG study showed that OsvaRen® was at least as effective and safe in terms of controlling serum phosphate and serum calcium levels as Renagel® while, at the same time, resulting in about 80% lower costs. In addition, OsvaRen® offers a lower risk of hypercalcaemia and associated subsequent costs and is thereby also superior to pure calcium-containing phosphate binders.Because of the effectiveness and tolerability of calcium acetate/magnesium carbonate, OsvaRen® offers a clinically suitable and, at the same time, cost-effective therapeutic option in the therapy of hyperphosphataemia.
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Affiliation(s)
- Thomas Plagemann
- herescon gmbh - health economic research & consulting, Hannover, Germany
| | - Anne Prenzler
- Leibniz University Hanover, Center for Health Economics, Hannover, Germany
| | - Thomas Mittendorf
- herescon gmbh - health economic research & consulting, Hannover, Germany
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90
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Ketteler M, Rothe H, Krüger T, Biggar PH, Schlieper G. Mechanisms and treatment of extraosseous calcification in chronic kidney disease. Nat Rev Nephrol 2011; 7:509-16. [DOI: 10.1038/nrneph.2011.91] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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91
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Abstract
Phosphate binders include calcium acetate or carbonate, sevelamer hydrochloride or carbonate, magnesium and lanthanum carbonate, and aluminum carbonate or hydroxide. Their relative phosphate-binding capacity has been assessed in human, in vivo studies that have measured phosphate recovery from stool and/or changes in urinary phosphate excretion or that have compared pairs of different binders where dose of binder in each group was titrated to a target level of serum phosphate. The relative phosphate-binding coefficient (RPBC) based on weight of each binder can be estimated relative to calcium carbonate, the latter being set to 1.0. A systematic review of these studies gave the following estimated RPBC: for elemental lanthanum, 2.0, for sevelamer hydrochloride or carbonate 0.75, for calcium acetate 1.0, for anhydrous magnesium carbonate 1.7, and for "heavy" or hydrated, magnesium carbonate 1.3. Estimated RPBC for aluminum-containing binders were 1.5 for aluminum hydroxide and 1.9 for aluminum carbonate. The phosphate-binding equivalent dose was then defined as the dose of each binder in g × its RPBC, which would be the binding ability of an equivalent weight of calcium carbonate. The phosphate-binding equivalent dose may be useful in comparing changes in phosphate binder prescription over time when multiple binders are being prescribed, when estimating an initial binder prescription, and also in phosphate kinetic modeling.
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Affiliation(s)
- John T Daugirdas
- University of Illinois at Chicago, Chicago, Illinois 60612, USA.
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92
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Wyskida K, Witkowicz J, Chudek J, Więcek A. Daily magnesium intake and hypermagnesemia in hemodialysis patients with chronic kidney disease. J Ren Nutr 2011; 22:19-26. [PMID: 21620724 DOI: 10.1053/j.jrn.2011.03.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Revised: 03/01/2011] [Accepted: 03/03/2011] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate daily magnesium intake and the relation to its serum concentration in hemodialysis (HD) patients with chronic kidney disease (CKD). DESIGN This is a prospective, open-label, cross-sectional clinical study analyzing daily magnesium intake based on nutritional questionnaire. PARTICIPANTS A total of 101 HD patients with CKD were screened for hypermagnesemia. All patients with serum magnesium >1.5 mmol/L were asked to fill in the standard 3-day nutritional questionnaire. The control group consisted of twice as many randomly selected HD patients with serum magnesium concentration <1.5 mmol/L and 20 subjects with normal kidney function on usual diet. RESULTS Mean (±standard deviation) serum magnesium concentration in HD patients was 1.32 ± 0.18 mmol/L. Hypermagnesemia >1.5 mmol/L was found in 17 (16.8%) patients. There was no one case of severe hypermagnesemia (>2.0 mmol/L). The daily intake of magnesium was higher by 31.7% in the group with serum magnesium >1.5 mmol/L. Hypermagnesemia was observed in patients ingesting >281 mg of magnesium daily. In univariate analysis, there was a strong positive correlation between magnesium intake and serum concentration in the whole group (r = 0.870, P < .001). No correlation between Kt/V or residual diuresis and serum magnesium concentration was found. CONCLUSIONS Magnesium consumption is the most important determinant of serum magnesium concentration in HD patients with CKD. Magnesium-containing phosphate binders can be considered in the therapy of hyperphosphatemia in HD patients without hypermagnesemia.
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Affiliation(s)
- Katarzyna Wyskida
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland
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93
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Abstract
The kidneys are famously responsible for maintaining external balance of prevalent minerals, such as sodium, chloride, and potassium. The kidney's role in handling trace minerals is more obscure to most nephrologists. Similarly, the impact of kidney failure on trace mineral metabolism is difficult to anticipate. The associated dietary modifications and dialysis create the potential for trace mineral deficiencies and intoxications. Indeed, there are numerous reports of dialysis-associated mishaps causing mineral intoxication, notable for the challenge of assigning causation. Equally challenging has been the recognition of mineral deficiency syndromes, amid what is often a cacophony of multiple comorbidities that vie for the attention of clinicians who care for patients with chronic kidney disease. In this paper, I review a variety of minerals, some of which are required for maintenance of normal human physiology (the U.S. Food and Drug Administration's list of essential minerals), and some that have attracted attention in the care of dialysis patients. For each mineral, I will discuss its role in normal physiology and will review reported deficiency and toxicity states. I will point out the interesting inter-relationships between several of the elements. Finally, I will address the special concerns of aluminum and magnesium as they pertain to the dialysis population.
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Affiliation(s)
- Richard K Kasama
- Division of Nephrology, UMDNJ-Robert Wood Johnson Medical School, Cooper University Hospital, Camden, New Jersey 08103 , USA.
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94
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de Francisco ALM. Reply. Nephrol Dial Transplant 2011. [DOI: 10.1093/ndt/gfr018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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95
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Spasovski G, Vanholder R. Is combined calcium/magnesium phosphate binder really noninferior to sevelamer hydrochloride? Nephrol Dial Transplant 2011; 26:1442-3; author reply 1443-4. [DOI: 10.1093/ndt/gfq778] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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