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Prevalence and Disease Burden of Chronic Kidney Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1165:3-15. [PMID: 31399958 DOI: 10.1007/978-981-13-8871-2_1] [Citation(s) in RCA: 433] [Impact Index Per Article: 86.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic kidney disease (CKD) has been recognized as a leading public health problem worldwide. The global estimated prevalence of CKD is 13.4% (11.7-15.1%), and patients with end-stage kidney disease (ESKD) needing renal replacement therapy is estimated between 4.902 and 7.083 million. Through its effect on cardiovascular risk and ESKD, CKD directly affects the global burden of morbidity and mortality worldwide. The global increase in this disease is mainly driven by the increase in the prevalence of diabetes mellitus, hypertension, obesity, and aging. But in some regions, other causes such as infection, herbal and environmental toxins are still common. The large number of deaths for poor access to renal replacement therapy in developing countries, and also large increase of patients with ESKD in future, will produce substantial financial burden for even the most wealthy countries. Cost-effectiveness of preventive strategies to reduce the disease burden should be evaluated in relation to the local economic development and resource. Strategies reducing the cardiovascular risk in CKD still need further evaluation in large trials especially including patients with advanced kidney disease or end-stage kidney disease.
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102
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Mizobuchi M, Ogata H, Koiwa F. Secondary Hyperparathyroidism: Pathogenesis and Latest Treatment. Ther Apher Dial 2018; 23:309-318. [PMID: 30411503 DOI: 10.1111/1744-9987.12772] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/23/2018] [Accepted: 11/02/2018] [Indexed: 01/02/2023]
Abstract
The classic pathogenesis of secondary hyperparathyroidism (SHPT) began with the trade-off hypothesis based on parathyroid hormone hypersecretion brought about by renal failure resulting from a physiological response to correct metabolic disorder of calcium, phosphorus, and vitamin D. In dialysis patients with failed renal function, physiological mineral balance control by parathyroid hormone through the kidney fails and hyperparathyroidism progresses. In this process, many significant genetic findings have been established. Abnormalities of Ca-sensing receptor and vitamin D receptor are associated with the pathogenesis of SHPT, and fibroblast growth factor 23 has also been shown to be involved in the pathogenesis. Vitamin D receptor activators (VDRAs) are widely used for treatment of SHPT. However, VDRAs have calcemic and phosphatemic effects that limit their use to a subset of patients, and calcimimetics have been developed as alternative drugs for SHPT. Hyperphosphatemia also affects progression of SHPT, and control of hyperphosphatemia is, therefore, thought to be fundamental for control of SHPT. Currently, a combination of a VDRA and a calcimimetic is recognized as the optimal strategy for SHPT, and for other outcomes such as reduced cardiovascular disease and improved survival. The latest findings on the pathogenesis and treatment of SHPT are summarized in this review.
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Affiliation(s)
- Masahide Mizobuchi
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hiroaki Ogata
- Department of Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Fumihiko Koiwa
- Division of Nephrology, Department of Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
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Owaki A, Inaguma D, Aoyama I, Inaba S, Koide S, Ito E, Takahashi K, Hayashi H, Hasegawa M, Yuzawa Y. Serum phosphate level at initiation of dialysis is associated with all-cause mortality: a multicenter prospective cohort study. Ren Fail 2018; 40:475-482. [PMID: 30153079 PMCID: PMC6116670 DOI: 10.1080/0886022x.2018.1499530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Introduction: As glomerular filtration rate (GFR) decreases, serum phosphate level increases. Previous reports indicated that serum phosphate level was associated with mortality in patients on dialysis. However, few reports have examined the association using dialysis initiation as the baseline period. Methods: This was a multicenter prospective cohort analysis including 1492 patients. Patients were classified into four quartiles based on the serum phosphate level at dialysis initiation, with Q1 being the lowest and Q4 the highest. All-cause mortality after dialysis initiation was compared using the log-rank test. The propensity score represented the probability of being assigned to group Q1 or Q2–4. All-cause mortality was compared in propensity score-matched patients by using the log-rank test for Kaplan–Meier curves. All-cause mortality of Q1 was compared with that for Q2–4 using multivariate Cox proportional hazard regression analysis. All-cause mortality was also determined among stratified groups with or without use of phosphate binders. Results: Significant differences in cumulative survival rates were observed between the four groups (p < .001). After propensity score-matching, mortality was significantly higher in the Q1 group than the Q2-4 group (p = .046). All-cause mortality was significantly higher in the Q1 group after adjustment for history of CAD (hazard ratio [HR] = 0.76, 95% confidence interval [CI]: 0.58 − 1.00, p = .048). However, there was no significant difference between the two groups after adjustment for estimated GFR. Conclusion: The serum phosphate level at the time of dialysis initiation was associated with all-cause mortality. However, the serum phosphate level was dependent on the renal function.
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Affiliation(s)
- Akiko Owaki
- a Tosei General Hospital , Seto , Aichi , Japan.,b The Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis (AICOPP) Group
| | - Daijo Inaguma
- b The Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis (AICOPP) Group.,c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Isao Aoyama
- b The Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis (AICOPP) Group.,d Japan Community Health Care Organization Chukyo Hospital , Nagoya , Aichi , Japan
| | | | - Shigehisa Koide
- b The Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis (AICOPP) Group.,c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Eri Ito
- c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Kazuo Takahashi
- c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Hiroki Hayashi
- c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Midori Hasegawa
- c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
| | - Yukio Yuzawa
- c Fujita Health University School of Medicine , Toyoake , Aichi , Japan
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Jin JJ, Zhang SL, Xu JS, Cui LW, Zhang HR, Bai YL. Prevalence of Chronic Kidney Disease-Mineral Bone Disorder in Hemodialysis Patients in Hebei, China. Chin Med J (Engl) 2018; 131:2749-2751. [PMID: 30425204 PMCID: PMC6247600 DOI: 10.4103/0366-6999.245264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jing-Jing Jin
- Department of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Sheng-Lei Zhang
- Department of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Jin-Sheng Xu
- Department of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Li-Wen Cui
- Department of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Hui-Ran Zhang
- Department of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Ya-Ling Bai
- Department of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei 050011, China
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105
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Whittaker CF, Miklich MA, Patel RS, Fink JC. Medication Safety Principles and Practice in CKD. Clin J Am Soc Nephrol 2018; 13:1738-1746. [PMID: 29915131 PMCID: PMC6237057 DOI: 10.2215/cjn.00580118] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ensuring patient safety is a priority of medical care because iatrogenic injury has been a primary concern. Medications are an important source of medical errors, and kidney disease is a thoroughfare of factors threatening safe administration of medicines. Principal among these is reduced kidney function because almost half of all medications used are eliminated via the kidney. Additionally, kidney patients often suffer from multimorbidity, including diabetes, hypertension, and heart failure, with a range of prescribers who often do not coordinate treatments. Patients with kidney disease are also susceptible to further kidney injury and metabolic derangements from medications, which can worsen the disease. In this review, we will present the key issues and threats to safe medication use in kidney disease, with a focus on predialysis CKD, as the scope of medication safety in ESKD and transplantation are unique and deserve their own consideration. We discuss drugs that need to be avoided or dose modified, and review the complications of a range of medications routinely administered in CKD, as these also call for cautious use.
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Affiliation(s)
- Chanel F. Whittaker
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Margaret A. Miklich
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, Pennsylvania
| | - Roshni S. Patel
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Philadelphia, Pennsylvania; and
| | - Jeffrey C. Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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106
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Damasiewicz MJ, Nickolas TL. Rethinking Bone Disease in Kidney Disease. JBMR Plus 2018; 2:309-322. [PMID: 30460334 PMCID: PMC6237213 DOI: 10.1002/jbm4.10117] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/05/2018] [Accepted: 10/03/2018] [Indexed: 12/17/2022] Open
Abstract
Renal osteodystrophy (ROD) is the bone component of chronic kidney disease mineral and bone disorder (CKD-MBD). ROD affects bone quality and strength through the numerous hormonal and metabolic disturbances that occur in patients with kidney disease. Collectively these disorders in bone quality increase fracture risk in CKD patients compared with the general population. Fractures are a serious complication of kidney disease and are associated with higher morbidity and mortality compared with the general population. Furthermore, at a population level, fractures are at historically high levels in patients with end-stage kidney disease (ESKD), whereas in contrast the general population has experienced a steady decline in fracture incidence rates. Based on these findings, it is clear that a paradigm shift is needed in our approach to diagnosing and managing ROD. In clinical practice, our ability to diagnose ROD and initiate antifracture treatments is impeded by the lack of accurate noninvasive methods that identify ROD type. The past decade has seen advances in the noninvasive measurement of bone quality and strength that have been studied in kidney disease patients. Below we review the current literature pertaining to the epidemiology, pathology, diagnosis, and management of ROD. We aim to highlight the pressing need for a greater awareness of this condition and the need for the implementation of strategies that prevent fractures in kidney disease patients. Research is needed for more accurate noninvasive assessment of ROD type, clinical studies of existing osteoporosis therapies in patients across the spectrum of kidney disease, and the development of CKD-specific treatments. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
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Affiliation(s)
- Matthew J Damasiewicz
- Department of NephrologyMonash HealthClaytonAustralia
- Department of MedicineMonash UniversityClaytonAustralia
| | - Thomas L Nickolas
- Columbia University Medical CenterDepartment of MedicineDivision of NephrologyNew YorkNYUSA
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107
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CKD, arterial calcification, atherosclerosis and bone health: Inter-relationships and controversies. Atherosclerosis 2018; 278:49-59. [DOI: 10.1016/j.atherosclerosis.2018.08.046] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 07/12/2018] [Accepted: 08/29/2018] [Indexed: 01/14/2023]
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Iwashita Y, Ohya M, Kunimoto S, Iwashita Y, Mima T, Negi S, Shigematsu T. A Survey of Drug Burden in Patients Undergoing Maintenance Hemodialysis in Japan. Intern Med 2018; 57:2937-2944. [PMID: 29780106 PMCID: PMC6232020 DOI: 10.2169/internalmedicine.0108-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/15/2017] [Indexed: 11/06/2022] Open
Abstract
Objective This report presents a part of a survey pertaining to drug burden in maintenance hemodialysis patients in Japan. Methods A patient-reported questionnaire-based survey was conducted from September to November 2016 in six regions in Japan. Patients A total of 700 patients (50-79 years old) on maintenance hemodialysis for >3 years and members of the Japan Association of Kidney Disease Patients (JAKDP) were provided with the questionnaire. They were randomly selected using stratified sampling according to patient distribution observed from the Japanese Society for Dialysis Therapy Renal Data Registry (JSDT JRDR). Results A total of 524 (74.9%) patient questionnaires were evaluated [mean (standard deviation; SD) age, 66.6 (7.2) years; males, 63.4%; dialysis vintage, 16.9 (9.1) years]. Patients' age, gender, and regional distribution were similar to the JSDT JRDR. They were taking an average (SD) of 16.4 (8.34) and 16.3 (8.55) oral medications/day on dialysis and nondialysis days, respectively. A majority of the patients were taking ≥10 oral medications/day on dialysis (75.1%) and nondialysis (74.4%) days, with phosphate binders being the most taken (7.0 tablets/day). A similar proportion (74.4%, 72.9%, respectively) was taking ≥6 different types of oral medications/day. Most patients were taking oral medications 3 (31%, 33%), 4 (24%, 22%), and ≥5 times (31%, 30%) a day, respectively. The drug burden was similar on dialysis and nondialysis days and did not vary with dialysis vintage. Conclusion The number, type, and frequency of oral medications in maintenance hemodialysis patients are high in Japan. The proportion of phosphate binders was highest among the prescription medications.
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Affiliation(s)
- Yuko Iwashita
- Department of Nephrology, Wakayama Medical University, Japan
| | - Masaki Ohya
- Department of Nephrology, Wakayama Medical University, Japan
| | - Satoko Kunimoto
- Department of Nephrology, Wakayama Medical University, Japan
| | - Yu Iwashita
- Department of Nephrology, Wakayama Medical University, Japan
| | - Toru Mima
- Department of Nephrology, Wakayama Medical University, Japan
| | - Shigeo Negi
- Department of Nephrology, Wakayama Medical University, Japan
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109
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Burton JO, Goldsmith DJ, Ruddock N, Shroff R, Wan M. Renal association commentary on the KDIGO (2017) clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of CKD-MBD. BMC Nephrol 2018; 19:240. [PMID: 30236082 PMCID: PMC6149202 DOI: 10.1186/s12882-018-1037-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/04/2018] [Indexed: 11/24/2022] Open
Abstract
This report comments on the relevance and utility of the recently published (2017) KDIGO Clinical Practice Guideline Update for the diagnosis, evaluation, prevention and treatment of mineral bone disease in patients with chronic kidney disease (CKD-MBD) with respect to UK clinical practice. This document replaces all previously published Renal Association guidelines on the topic.
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Affiliation(s)
- James O. Burton
- College of Life Sciences, University of Leicester, Leicester, UK
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Nicki Ruddock
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rukshana Shroff
- Great Ormond Street Hospital for Children and University College London, London, UK
| | - Mandy Wan
- Institute of Pharmaceutical Science, King’s College, London, UK
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110
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The interplay between bone and vessels in pediatric CKD: lessons from a single-center study. Pediatr Nephrol 2018; 33:1565-1575. [PMID: 29872964 DOI: 10.1007/s00467-018-3978-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/12/2018] [Accepted: 05/01/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Mineral and bone disorders associated to chronic kidney disease (CKD-MBD) are a daily challenge for pediatric nephrologists, with a significant risk of long-term bone and vascular comorbidities. METHODS This single-center study is a prospective transversal evaluation of pediatric CKD patients of our center, part of the European 4C study. In addition to clinical and biochemical data, vascular and bone evaluation was performed: 24-h blood pressure assessment, carotid intima-media thickness (cIMT), pulse wave velocity (PWV), and high-resolution peripheral quantitative computed tomography (HR-pQCT) at the ultra-distal tibia. Results are presented as median (range). RESULTS At a median age of 12.9 years (10.2-17.9), SDS height of - 1.0 (- 3.3-1.2) and estimated glomerular filtration rate (eGFR) of 33 mL/min/1.73m2 (11-72), 32 patients (8 girls) were evaluated. Median calcium, phosphate, parathyroid hormone (PTH), and 25 OHD3 levels were 2.44 mmol/L (2.24-2.78), 1.43 mmol/L (1.0-2.7), 80 pg/mL (9-359), and 70 nmol/L (32-116), respectively. Bivariate Spearman and backward multivariable analyses showed that calcium and bone trabecular thickness (Tb.Th), were positively associated with diastolic and mean arterial blood pressure (both for the 24 h, day and night assessment), whereas PTH and vitamin D did not predict blood pressure. CONCLUSIONS We show that the greater the serum levels of calcium, the greater the (diastolic and mean) blood pressure; moreover, the greater the Tb. Th, the greater the (diastolic and mean) blood pressure. The role of calcium supplements to explain such findings in early pediatric CKD can be discussed.
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111
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Edmonston D, Morris JD, Middleton JP. Working Toward an Improved Understanding of Chronic Cardiorenal Syndrome Type 4. Adv Chronic Kidney Dis 2018; 25:454-467. [PMID: 30309463 DOI: 10.1053/j.ackd.2018.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/09/2018] [Accepted: 08/15/2018] [Indexed: 12/17/2022]
Abstract
Chronic diseases of the heart and of the kidneys commonly coexist in individuals. Certainly combined and persistent heart and kidney failure can arise from a common pathologic insult, for example, as a consequence of poorly controlled hypertension or of severe diffuse arterial disease. However, strong evidence is emerging to suggest that cross talk exists between the heart and the kidney. Independent processes are set in motion when kidney function is chronically diminished, and these processes can have distinct adverse effects on the heart. The complex chronic heart condition that results from chronic kidney disease (CKD) has been termed cardiorenal syndrome type 4. This review will include an updated description of the cardiac morphology in patients who have CKD, an overview of the most likely CKD-sourced culprits for these cardiac changes, and the potential therapeutic strategies to limit cardiac complications in patients who have CKD.
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112
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Ruospo M, Palmer SC, Natale P, Craig JC, Vecchio M, Elder GJ, Strippoli GFM. Phosphate binders for preventing and treating chronic kidney disease-mineral and bone disorder (CKD-MBD). Cochrane Database Syst Rev 2018; 8:CD006023. [PMID: 30132304 PMCID: PMC6513594 DOI: 10.1002/14651858.cd006023.pub3] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Phosphate binders are used to reduce positive phosphate balance and to lower serum phosphate levels for people with chronic kidney disease (CKD) with the aim to prevent progression of chronic kidney disease-mineral and bone disorder (CKD-MBD). This is an update of a review first published in 2011. OBJECTIVES The aim of this review was to assess the benefits and harms of phosphate binders for people with CKD with particular reference to relevant biochemical end-points, musculoskeletal and cardiovascular morbidity, hospitalisation, and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs of adults with CKD of any GFR category comparing a phosphate binder to another phosphate binder, placebo or usual care to lower serum phosphate. Outcomes included all-cause and cardiovascular death, myocardial infarction, stroke, adverse events, vascular calcification and bone fracture, and surrogates for such outcomes including serum phosphate, parathyroid hormone (PTH), and FGF23. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess evidence certainty. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised MD (SMD) for continuous outcomes. MAIN RESULTS We included 104 studies involving 13,744 adults. Sixty-nine new studies were added to this 2018 update.Most placebo or usual care controlled studies were among participants with CKD G2 to G5 not requiring dialysis (15/25 studies involving 1467 participants) while most head to head studies involved participants with CKD G5D treated with dialysis (74/81 studies involving 10,364 participants). Overall, seven studies compared sevelamer with placebo or usual care (667 participants), seven compared lanthanum to placebo or usual care (515 participants), three compared iron to placebo or usual care (422 participants), and four compared calcium to placebo or usual care (278 participants). Thirty studies compared sevelamer to calcium (5424 participants), and fourteen studies compared lanthanum to calcium (1690 participants). No study compared iron-based binders to calcium. The remaining studies evaluated comparisons between sevelamer (hydrochloride or carbonate), sevelamer plus calcium, lanthanum, iron (ferric citrate, sucroferric oxyhydroxide, stabilised polynuclear iron(III)-oxyhydroxide), calcium (acetate, ketoglutarate, carbonate), bixalomer, colestilan, magnesium (carbonate), magnesium plus calcium, aluminium hydroxide, sucralfate, the inhibitor of phosphate absorption nicotinamide, placebo, or usual care without binder. In 82 studies, treatment was evaluated among adults with CKD G5D treated with haemodialysis or peritoneal dialysis, while in 22 studies, treatment was evaluated among participants with CKD G2 to G5. The duration of study follow-up ranged from 8 weeks to 36 months (median 3.7 months). The sample size ranged from 8 to 2103 participants (median 69). The mean age ranged between 42.6 and 68.9 years.Random sequence generation and allocation concealment were low risk in 25 and 15 studies, respectively. Twenty-seven studies reported low risk methods for blinding of participants, investigators, and outcome assessors. Thirty-one studies were at low risk of attrition bias and 69 studies were at low risk of selective reporting bias.In CKD G2 to G5, compared with placebo or usual care, sevelamer, lanthanum, iron and calcium-based phosphate binders had uncertain or inestimable effects on death (all causes), cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. Sevelamer may lead to constipation (RR 6.92, CI 2.24 to 21.4; low certainty) and lanthanum (RR 2.98, CI 1.21 to 7.30, moderate certainty) and iron-based binders (RR 2.66, CI 1.15 to 6.12, moderate certainty) probably increased constipation compared with placebo or usual care. Lanthanum may result in vomiting (RR 3.72, CI 1.36 to 10.18, low certainty). Iron-based binders probably result in diarrhoea (RR 2.81, CI 1.18 to 6.68, high certainty), while the risks of other adverse events for all binders were uncertain.In CKD G5D sevelamer may lead to lower death (all causes) (RR 0.53, CI 0.30 to 0.91, low certainty) and induce less hypercalcaemia (RR 0.30, CI 0.20 to 0.43, low certainty) when compared with calcium-based binders, and has uncertain or inestimable effects on cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. The finding of lower death with sevelamer compared with calcium was present when the analysis was restricted to studies at low risk of bias (RR 0.50, CI 0.32 to 0.77). In absolute terms, sevelamer may lower risk of death (all causes) from 210 per 1000 to 105 per 1000 over a follow-up of up to 36 months, compared to calcium-based binders. Compared with calcium-based binders, lanthanum had uncertain effects with respect to all-cause or cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification and probably had reduced risks of treatment-related hypercalcaemia (RR 0.16, CI 0.06 to 0.43, low certainty). There were no head-to-head studies of iron-based binders compared with calcium. The paucity of placebo-controlled studies in CKD G5D has led to uncertainty about the effects of phosphate binders on patient-important outcomes compared with placebo.It is uncertain whether the effects of binders on clinically-relevant outcomes were different for patients who were and were not treated with dialysis in subgroup analyses. AUTHORS' CONCLUSIONS In studies of adults with CKD G5D treated with dialysis, sevelamer may lower death (all causes) compared to calcium-based binders and incur less treatment-related hypercalcaemia, while we found no clinically important benefits of any phosphate binder on cardiovascular death, myocardial infarction, stroke, fracture or coronary artery calcification. The effects of binders on patient-important outcomes compared to placebo are uncertain. In patients with CKD G2 to G5, the effects of sevelamer, lanthanum, and iron-based phosphate binders on cardiovascular, vascular calcification, and bone outcomes compared to placebo or usual care, are also uncertain and they may incur constipation, while iron-based binders may lead to diarrhoea.
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Affiliation(s)
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Patrizia Natale
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | | | - Grahame J Elder
- Westmead HospitalDepartment of Renal MedicineWestmeadNSWAustralia2145
- Garvan Institute of Medical ResearchOsteoporosis and Bone Biology DivisionDarlinghurstNSWAustralia2010
| | - Giovanni FM Strippoli
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Diaverum AcademyBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
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Zhang W, Xu J, Li P, Gao X, Zhang W, Wang H, Tang B. Treatment of hyperphosphatemia based on specific interactions between phosphorus and Zr(iv) active centers of nano-MOFs. Chem Sci 2018; 9:7483-7487. [PMID: 30319748 PMCID: PMC6176778 DOI: 10.1039/c8sc02638f] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 07/20/2018] [Indexed: 12/24/2022] Open
Abstract
We describe a kind of Zr(iv)-based nano-MOF that is well suited for specific adsorption and selective fluorescence sensing of phosphate based on specific interactions between Zr(iv) and phosphate which provides a new approach for treatment of hyperphosphatemia.
Hyperphosphatemia is closely associated with the occurrence of multiple organ dysfunctions in patients with end-stage renal disease (ESRD). The application of phosphorus binders as an effective clinical approach for such diseases still suffers from serious side effects. Therefore, development of new phosphorus binders for the treatment of hyperphosphatemia remains a great challenge. Herein, we describe a kind of zirconium (Zr(iv))-based nano-MOF that is well suited for specific adsorption and selective fluorescence sensing of phosphate, and is based on the particular interactions between Zr(iv) and phosphate. The reduced levels of phosphate were quantitatively monitored using the MOF-based fluorescence nanosensor. Notably, the MOFs exhibit a greater reduction in phosphorus levels than commercially available phosphorus binders, and comparable therapeutic effects in the treatment of hyperphosphatemia of a mice model. Hence, the MOF acts as a promising medication for hyperphosphatemia by directly adsorbing phosphorus in the blood, which offers new perspectives in future applications of MOFs.
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Affiliation(s)
- Wei Zhang
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Jiheng Xu
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Ping Li
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Xiaonan Gao
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Wen Zhang
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Hui Wang
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Bo Tang
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
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Comparison of the Inhibitory Mechanisms of Diethyl Citrate, Sodium Citrate, and Phosphonoformic Acid on Calcification Induced by High Inorganic Phosphate Contents in Mouse Aortic Smooth Muscle Cells. J Cardiovasc Pharmacol 2018; 70:411-419. [PMID: 28902664 DOI: 10.1097/fjc.0000000000000537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This study aimed to investigate the differences and inhibitory effects of diethyl citrate (Et2Cit), sodium citrate (Na3Cit), and phosphonoformic acid (PFA) on calcification induced by high inorganic phosphate (Pi) contents in mouse aortic smooth muscle cells (MOVAS) and to develop drugs that can induce anticoagulation and inhibit vascular calcification (VC). METHODS Alive and fixed MOVAS were assessed for 14 days in the presence of high Pi with increasing Et2Cit, Na3Cit, and PFA concentrations. Calcification on MOVAS was measured through Alizarin red staining and the deposited calcium amount; apoptosis was detected by annexin V staining; and cell transdifferentiation was examined by measuring smooth muscle lineage gene (α-SMA) expression and alkaline phosphatase activity. RESULTS Coincubation of MOVAS with Et2Cit, Na3Cit, and PFA significantly decreased Pi-induced VC in live MOVAS, and the apoptotic rate was reduced by low inhibitor concentrations. The 3 inhibitors could prevent the alkaline phosphatase activity induced by high Pi contents and increased the expression of α-smooth muscle actin genes. Thus, the transdifferentiation of MOVAS into osteoblast-like cells was blocked. Their inhibitory effects exhibited concentration dependence. The inhibitory effect of each inhibitor at the same concentration showed the following trend: PFA > Na3Cit > Et2Cit. CONCLUSIONS Et2Cit, Na3Cit, and PFA prevented the calcification of MOVAS and inhibited the osteochondrocytic conversion of vascular smooth muscle cells. Thus, Et2Cit and Na3Cit as anticoagulants may alleviate VC in clinical applications.
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Sprague SM, Floege J. Sucroferric oxyhydroxide for the treatment of hyperphosphatemia. Expert Opin Pharmacother 2018; 19:1137-1148. [PMID: 29985725 DOI: 10.1080/14656566.2018.1491548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Sucroferric oxyhydroxide is a non-calcium, iron-based phosphate binder indicated for the treatment of hyperphosphatemia in patients with chronic kidney disease undergoing dialysis. Areas covered: Herein, the preclinical development and clinical data for sucroferric oxyhydroxide are reviewed, including the key data from the Phase III registration study and the latest evidence from the real-world clinical setting. Expert opinion: Sucroferric oxyhydroxide displays potent phosphate-binding capacity and clinical studies demonstrate its effectiveness for the long-term reduction of serum phosphorus levels in dialysis patients. Observational study data also show that sucroferric oxyhydroxide provides effective serum phosphorus control for hyperphosphatemic patients in the real-world clinical setting. The serum phosphorus reductions with sucroferric oxyhydroxide can be achieved with a relatively low pill burden in comparison with other phosphate binders, which may translate into better treatment adherence in clinical practice. The Phase III data also indicate that sucroferric oxyhydroxide has a favorable impact on other chronic kidney disease-related mineral bone disease parameters, including a fibroblast growth factor-23-lowering effect. Sucroferric oxyhydroxide is well tolerated and associated with low systemic iron absorption, minimizing the potential for iron accumulation or overload. These attributes render sucroferric oxyhydroxide an attractive non-calcium-containing phosphate binder for the treatment of hyperphosphatemia.
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Affiliation(s)
- Stuart M Sprague
- a Division of Nephrology and Hypertension , NorthShore University Health System, University of Chicago Pritzker School of Medicine , Evanston , IL , USA
| | - Jürgen Floege
- b Department of Nephrology and Clinical Immunology, Division of Nephrology , RWTH University Hospital Aachen , Aachen , Germany
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Scialla JJ. Evidence basis for integrated management of mineral metabolism in patients with end-stage renal disease. Curr Opin Nephrol Hypertens 2018; 27:258-267. [PMID: 29677006 PMCID: PMC6413862 DOI: 10.1097/mnh.0000000000000417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Treatment of mineral metabolism is a mainstay of dialysis care including some of its most widely used and costly pharmaceuticals. Although many mineral metabolites are associated with increased risk of mortality, cardiovascular disease, and other morbidities, few clinical trials are available to guide therapy and most focus on single drug approaches. In practice, providers manage many aspects of mineral metabolism simultaneously in integrated treatment approaches that incorporate multiple agents and changes in the dialysis prescription. The present review discusses the rationale and existing evidence for evaluating integrated, as opposed to single drug, approaches in mineral metabolism. RECENT FINDINGS Drugs used to treat mineral metabolism have numerous, and sometimes, opposing effects on biochemical risk factors, such as fibroblast growth factor 23 (FGF23), calcium, and phosphorus. Although vitamin D sterols raise these risk markers when lowering parathyroid hormone (PTH), calcimimetics lower them. Trials demonstrate that combined approaches best 'normalize' the mineral metabolism axis in end-stage renal disease (ESRD). Observations embedded within major trials of calcimimetics reveal that adjustment of calcium-based binders and dialysate calcium is a common approach to adverse effects of these drugs with some initial, but inconclusive, evidence that these co-interventions may impact outcomes. SUMMARY The multiple, and often opposing, biochemical effects of many mineral metabolism drugs provides a strong rationale for studying integrated management strategies that consider combinations of drugs and co-interventions as a whole. This remains a current gap in the field with opportunities for clinical trials.
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Affiliation(s)
- Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Cheungpasitporn W, Thongprayoon C, Mao MA, Kittanamongkolchai W, Sakhuja A, Erickson SB. Admission serum phosphate levels predict hospital mortality. Hosp Pract (1995) 2018; 46:121-127. [PMID: 29848117 DOI: 10.1080/21548331.2018.1483172] [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] [Indexed: 10/14/2022]
Abstract
BACKGROUND The aim of this study was to assess the relationship between admission serum phosphate levels and in-hospital mortality in all hospitalized patients. METHODS All adult hospitalized patients who had admission serum phosphate available between years 2009 and 2013 were enrolled. Admission serum phosphate was categorized based on its distribution into six groups (<2.5, 2.5-3.0, 3.1-3.6, 3.7-4.2, 4.3-4.8 and ≥4.9 mg/dL). The odds ratio (OR) of in-hospital mortality by admission serum phosphate, using the phosphate category of 3.1-3.6 mg/dL as the reference group, was obtained by logistic regression analysis. RESULTS 42,336 patients were studied. The lowest incidence of in-hospital mortality was associated with a serum phosphate within 3.1-4.2 mg/dL. A U-shaped curve emerged demonstrating higher in-hospital mortality associated with both serum phosphate <3.1 and >4.2 mg/dL. After adjusting for potential confounders, both serum phosphate <2.5 and >4.2 mg/dL were associated with in-hospital mortality with ORs of 1.60 (95%CI 1.25-2.05), 1.60 (95%CI 1.29-1.97), and 3.89 (95%CI 3.20-4.74) when serum phosphate were <2.5, 4.3-4.8 and ≥4.9 mg/dL, respectively. Among subgroups of patients with chronic kidney disease (CKD) and cardiovascular disease (CVD), the highest mortality was associated with a serum phosphate ≥4.9 mg/dL with ORs of 4.11 (95%CI 3.16-5.39) in CKD patients and 5.11 (95%CI 3.33-7.95) in CVD patients. CONCLUSION Hospitalized patients with admission serum phosphate <2.5 and >4.2 mg/dL are associated with an increased risk of in-hospital mortality. The highest mortality risk is associated with CKD and CVD patients with admission hyperphosphatemia.
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Affiliation(s)
- Wisit Cheungpasitporn
- a Division of Nephrology and Hypertension, Department of Medicine , Mayo Clinic , Rochester , MN , USA.,b Division of Nephrology, Department of Medicine , University of Mississippi Medical Center , Jackson , MS , USA
| | - Charat Thongprayoon
- a Division of Nephrology and Hypertension, Department of Medicine , Mayo Clinic , Rochester , MN , USA.,c Department of Internal Medicine , Bassett Medical Center , Cooperstown , NY , USA
| | - Michael A Mao
- a Division of Nephrology and Hypertension, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | | | - Ankit Sakhuja
- d Division of Pulmonary and Critical Care Medicine, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Stephen B Erickson
- a Division of Nephrology and Hypertension, Department of Medicine , Mayo Clinic , Rochester , MN , USA
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Hernando N, Wagner CA. Mechanisms and Regulation of Intestinal Phosphate Absorption. Compr Physiol 2018; 8:1065-1090. [PMID: 29978897 DOI: 10.1002/cphy.c170024] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
States of hypo- and hyperphosphatemia have deleterious consequences including rickets/osteomalacia and renal/cardiovascular disease, respectively. Therefore, the maintenance of appropriate plasma levels of phosphate is an essential requirement for health. This control is executed by the collaborative action of intestine and kidney whose capacities to (re)absorb phosphate are regulated by a number of hormonal and metabolic factors, among them parathyroid hormone, fibroblast growth factor 23, 1,25(OH)2 vitamin D3 , and dietary phosphate. The molecular mechanisms responsible for the transepithelial transport of phosphate across enterocytes are only partially understood. Indeed, whereas renal reabsorption entirely relies on well-characterized active transport mechanisms of phosphate across the renal proximal epithelia, intestinal absorption proceeds via active and passive mechanisms, with the molecular identity of the passive component still unknown. The active absorption of phosphate depends mostly on the activity and expression of the sodium-dependent phosphate cotransporter NaPi-IIb (SLC34A2), which is highly regulated by many of the factors, mentioned earlier. Physiologically, the contribution of NaPi-IIb to the maintenance of phosphate balance appears to be mostly relevant during periods of low phosphate availability. Therefore, its role in individuals living in industrialized societies with high phosphate intake is probably less relevant. Importantly, small increases in plasma phosphate, even within normal range, associate with higher risk of cardiovascular disease. Therefore, therapeutic approaches to treat hyperphosphatemia, including dietary phosphate restriction and phosphate binders, aim at reducing intestinal absorption. Here we review the current state of research in the field. © 2017 American Physiological Society. Compr Physiol 8:1065-1090, 2018.
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Affiliation(s)
- Nati Hernando
- National Center for Competence in Research NCCR Kidney.CH, Institute of Physiology, University Zurich-Irchel, Zurich, Switzerland
| | - Carsten A Wagner
- National Center for Competence in Research NCCR Kidney.CH, Institute of Physiology, University Zurich-Irchel, Zurich, Switzerland
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Severe secondary hyperparathyroidism in patients on haemodialysis is associated with a high initial serum parathyroid hormone and beta-CrossLaps level: Results from an incident cohort. PLoS One 2018; 13:e0199140. [PMID: 29912988 PMCID: PMC6005469 DOI: 10.1371/journal.pone.0199140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 06/01/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Secondary hyperparathyroidism (SHPT) is a frequent complication of renal disease and most commonly occurs in patients on haemodialysis (HD) with metabolic, vascular, endocrine, and bone complications. The aim of this study was to analyze the evolution of mineral metabolism parameters during the first 36 months of HD treatment and identify the initial factors associated with severe SHPT. METHODS Serum parathyroid hormone (PTH), calcium and phosphate levels were measured monthly; bone-specific alkaline phosphatase (b-ALP) and beta-CrossLaps (CTX) were measured biannually. Severe SHPT was defined as the need for cinacalcet treatment. Patients with less than 24 months of follow-up were excluded. RESULTS One hundred thirty-three incident HD patients were included. Baseline mean PTH was 275 ± 210 pg/mL. After an initial drop at the third month (172 ± 133 pg/mL), the serum PTH level progressively increased to the maximum at 36 months (367 ± 254 pg/mL). This initial drop was associated with the initial correction of both hypocalcaemia and hyperphosphataemia. Serum CTX and b-ALP revealed no significant changes over time. Severe SHPT was observed in 18% of patients and was associated with higher mean calcaemia and phosphataemia. In logistic regression, the initial factors associated with the risk of severe SHPT were: female sex, higher baseline PTH and CTX values. A receiver operation characteristic curve analysis identified a cut-off value of >374 pg/mL for baseline PTH and >1.2 μg/L for CTX for increased risk of developing severe SHPT. The relative risk of developing severe SHPT was 3.7 (1.8-7.5, p = 0.002) for high baseline CTX, 4.9 (2.4-9.7, p = 0.001) for high baseline PTH, and 7.7 (3.6-16, p< 0.0001) when both criteria were present. CONCLUSION After an initial drop, a progressive increase in the serum PTH level during the first 3 years of HD treatment was observed despite aggressive therapy. High baseline levels of PTH and CTX increased the risk of developing severe SHPT.
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Vanholder R, Van Laecke S, Glorieux G, Verbeke F, Castillo-Rodriguez E, Ortiz A. Deleting Death and Dialysis: Conservative Care of Cardio-Vascular Risk and Kidney Function Loss in Chronic Kidney Disease (CKD). Toxins (Basel) 2018; 10:E237. [PMID: 29895722 PMCID: PMC6024824 DOI: 10.3390/toxins10060237] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/11/2018] [Indexed: 02/07/2023] Open
Abstract
The uremic syndrome, which is the clinical expression of chronic kidney disease (CKD), is a complex amalgam of accelerated aging and organ dysfunctions, whereby cardio-vascular disease plays a capital role. In this narrative review, we offer a summary of the current conservative (medical) treatment options for cardio-vascular and overall morbidity and mortality risk in CKD. Since the progression of CKD is also associated with a higher cardio-vascular risk, we summarize the interventions that may prevent the progression of CKD as well. We pay attention to established therapies, as well as to novel promising options. Approaches that have been considered are not limited to pharmacological approaches but take into account lifestyle measures and diet as well. We took as many randomized controlled hard endpoint outcome trials as possible into account, although observational studies and post hoc analyses were included where appropriate. We also considered health economic aspects. Based on this information, we constructed comprehensive tables summarizing the available therapeutic options and the number and kind of studies (controlled or not, contradictory outcomes or not) with regard to each approach. Our review underscores the scarcity of well-designed large controlled trials in CKD. Nevertheless, based on the controlled and observational data, a therapeutic algorithm can be developed for this complex and multifactorial condition. It is likely that interventions should be aimed at targeting several modifiable factors simultaneously.
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Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Steven Van Laecke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Francis Verbeke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | | | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain.
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Obi Y, Park C, Soohoo M, Sumida K, Hamano T, Rhee CM, Kovesdy CP, Kalantar-Zadeh K, Streja E. Association of Pre-ESRD Serum Calcium With Post-ESRD Mortality Among Incident ESRD Patients: A Cohort Study. J Bone Miner Res 2018; 33:1027-1036. [PMID: 29342320 DOI: 10.1002/jbmr.3391] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 12/12/2017] [Accepted: 01/05/2018] [Indexed: 12/12/2022]
Abstract
Albumin-corrected serum calcium (cSCa) decline at late stages of chronic kidney disease and rise after dialysis initiation. Although hypercalcemia is associated with higher mortality in end-stage renal disease (ESRD), there are scarce data on the impact of pre-ESRD cSCa on post-ESRD mortality. Therefore, we used a large national cohort of 21,826 US veterans who transitioned to dialysis in all US Department of Veterans Affairs health care facilities over 2009 to 2014 to examine the associations with all-cause and cause-specific post-ESRD mortality of (1) cSCa concentrations averaged over the last 6 months and (2) its rate of decline during the last 12 months before dialysis initiation. Mean concentrations and median rate of decline of cSCa were 9.3 ± 0.7 mg/dL and -0.15 (interquartile range -0.39 to 0.07) mg/dL/year, respectively. A total of 9596 patients died during the follow-up period (mean 1.9 years; total 41,541 patient-years) with an incidence rate of 23.1 per 100 patient-years. There was an independent linear association between higher cSCa with higher mortality (ptrend < 0.001). The mortality risk associated with cSCa ≥9.0 mg/dL was attenuated among active vitamin D users (pinteraction < 0.001). Patients with faster decline in cSCa showed lower mortality irrespective of baseline cSCa concentrations. These cSCa-mortality associations were stronger for noncardiovascular versus cardiovascular death. In conclusion, lower pre-ESRD cSCa and faster decline in cSCa were consistently and linearly associated with better post-ESRD survival among US veterans, especially for noncardiovascular death. Further studies are needed to determine if correcting hypocalcemia is beneficial or harmful and which intervention is preferred when indicated among patients transitioning to ESRD. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Takayuki Hamano
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA.,Fielding School of Public Health at UCLA, Los Angeles, CA, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
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Jansz TT, Verhaar MC, London GM, van Jaarsveld BC. Is progression of coronary artery calcification influenced by modality of renal replacement therapy? A systematic review. Clin Kidney J 2018; 11:353-361. [PMID: 29942499 PMCID: PMC6007793 DOI: 10.1093/ckj/sfx124] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 09/12/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Progression of coronary artery calcification is an important marker for cardiovascular morbidity in end-stage renal disease patients. Therefore, we reviewed the evidence on coronary artery calcification progression in different renal replacement therapies. METHODS MEDLINE (PubMed), Embase and TRIP databases were searched from 1999 - 2016. Additionally, bibliographies were searched by hand and citation tracking of key publications was performed. Prospective studies were included that examined coronary artery calcification with two or more multislice computed tomography scans ≥6 months apart in patients 18-75 years old receiving any renal replacement therapy, including kidney transplantation. Reporting of separate scores for different modalities was required. Two researchers extracted data independently with pilot-tested forms and assessed the risk of bias using a validated tool. RESULTS We identified 29 eligible studies that assessed coronary artery calcification progression in end-stage renal disease patients, of which 19 studies evaluated haemodialysis and 8 kidney transplantation. Evidence on progression in peritoneal dialysis (three studies) and nocturnal haemodialysis (one study) was limited. Meta-analysis was not possible due to diverse reporting methods of coronary artery calcification scores and definitions of progression. Median coronary artery calcification scores were considerably higher in haemodialysis cohorts at baseline, presumably due to a generally higher age and dialysis vintage. Median coronary artery calcification progressed universally. Visual inspection suggested the least progression in kidney transplant recipients. CONCLUSIONS There is insufficient evidence to compare the influence of renal replacement therapies on coronary artery calcification progression. We advocate the adoption of a standardized reporting method of coronary artery calcification progression.
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Affiliation(s)
- Thijs T Jansz
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Gérard M London
- INSERM U970, Hôpital Européen Georges Pompidou, Paris, France
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Carfagna F, Del Vecchio L, Pontoriero G, Locatelli F. Current and potential treatment options for hyperphosphatemia. Expert Opin Drug Saf 2018; 17:597-607. [PMID: 29783873 DOI: 10.1080/14740338.2018.1476487] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Hyperphosphatemia is common in late stages of chronic kidney disease and is often associated with elevated parathormone levels, abnormal bone mineralization, extra-osseous calcification, and increased risk of cardiovascular events and death. Several classes of oral phosphate binders are available to help control plasma phosphorus levels. Although effective at lowering serum phosphorus, they all have safety, tolerability, and compliance issues that need to be considered when selecting which one to use. AREAS COVERED This paper reviews the most established treatment options for hyperphosphatemia, in patients with chronic kidney disease, focusing on the new inhibitors of active phosphate absorption. EXPERT OPINION The prevention and the treatment of hyperphosphatemia is today far to be satisfactory. Nonetheless, an extending range of phosphate binders are now available. Aluminum has potentially serious toxic risks. Calcium-based binders are very effective but can lead to hypercalcemia and/or positive calcium balance and progression of cardiovascular calcification. No long-term data are available for the new calcium acetate/magnesium combination product. Lanthanum is an effective phosphate binder, and long-term effects of tissue deposition seem clinically irrelevant. Sevelamer, appear to have profiles that would lead to pleiotropic effects and reduced progression of vascular calcification, and the main adverse events seen with these agents are gastrointestinal. Iron has a powerful capability of binding phosphate, thus numerous preparations are available, both with and without significant systemic absorption of the iron component. The inhibitors of active intestinal phosphate transport, with their very selective mechanism of action and low pill burden seem the most interesting approach; however, do not seem at present to be effective alone, in reducing serum phosphorus levels.
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Affiliation(s)
- Fabio Carfagna
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
| | - Lucia Del Vecchio
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
| | - Giuseppe Pontoriero
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
| | - Francesco Locatelli
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
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Ruderman I, Holt SG, Hewitson TD, Smith ER, Toussaint ND. Current and potential therapeutic strategies for the management of vascular calcification in patients with chronic kidney disease including those on dialysis. Semin Dial 2018; 31:487-499. [PMID: 29733462 DOI: 10.1111/sdi.12710] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with CKD have accelerated vascular stiffening contributing significantly to excess cardiovascular morbidity and mortality. Much of the arterial stiffening is thought to involve vascular calcification (VC), but the pathogenesis of this phenomenon is complex, resulting from a disruption of the balance between promoters and inhibitors of calcification in a uremic milieu, along with derangements in calcium and phosphate metabolic pathways. Management of traditional cardiovascular risk factors to reduce VC may be influential but has not been shown to significantly improve mortality. Control of mineral metabolism may potentially reduce the burden of VC, although using conventional approaches of restricting dietary phosphate, administering phosphate binders, and use of active vitamin D and calcimimetics, remains controversial because recommended biochemical targets are hard to achieve and clinical relevance hard to define. Increasing time on dialysis is perhaps another therapy with potential effectiveness in this area. Despite current treatments, cardiovascular morbidity and mortality remain high in this group. Novel therapies for addressing VC include magnesium and vitamin K supplementation, which are currently being investigated in large randomized control trials. Other therapeutic targets include crystallization inhibitors, ligand trap for activin receptors and BMP-7. This review summarizes current treatment strategies and therapeutic targets for the future management of VC in patients with CKD.
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Affiliation(s)
- Irene Ruderman
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Tim D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
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Harvey NC, D'Angelo S, Paccou J, Curtis EM, Edwards M, Raisi‐Estabragh Z, Walker‐Bone K, Petersen SE, Cooper C. Calcium and Vitamin D Supplementation Are Not Associated With Risk of Incident Ischemic Cardiac Events or Death: Findings From the UK Biobank Cohort. J Bone Miner Res 2018; 33:803-811. [PMID: 29314248 PMCID: PMC5915292 DOI: 10.1002/jbmr.3375] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/20/2017] [Accepted: 12/23/2017] [Indexed: 12/20/2022]
Abstract
We investigated associations between calcium/vitamin D supplementation and incident cardiovascular events/deaths in a UK population-based cohort. UK Biobank is a large prospective cohort comprising 502,637 men and women aged 40 to 69 years at recruitment. Supplementation with calcium/vitamin D was self-reported, and information on incident hospital admission (ICD-10) for ischemic heart disease (IHD), myocardial infarction (MI), and subsequent death was obtained from linkage to national registers. Cox proportional hazards models were used to investigate longitudinal relationships between calcium/vitamin D supplementation and hospital admission for men/women, controlling for covariates. A total of 475,255 participants (median age 58 years, 55.8% women) had complete data on calcium/vitamin D supplementation. Of that number, 33,437 participants reported taking calcium supplements; 19,089 vitamin D; and 10,007 both. In crude and adjusted analyses, there were no associations between use of calcium supplements and risk of incident hospital admission with either IHD, or subsequent death. Thus, for example, in unadjusted models, the hazard ratio (HR) for admission with myocardial infarction was 0.97 (95% confidence interval [CI] 0.79-1.20, p = 0.79) among women taking calcium supplementation. Corresponding HR for men is 1.16 (95% CI 0.92-1.46, p = 0.22). After full adjustment, HR (95% CI) were 0.82 (0.62-1.07), p = 0.14 among women and 1.12 (0.85-1.48), p = 0.41 among men. Adjusted HR (95% CI) for admission with IHD were 1.05 (0.92-1.19), p = 0.50 among women and 0.97 (0.82-1.15), p = 0.77 among men. Results were similar for vitamin D and combination supplementation. There were no associations with death, and in women, further adjustment for hormone-replacement therapy use did not alter the associations. In this very large prospective cohort, there was no evidence that use of calcium/vitamin D supplementation was associated with increased risk of hospital admission or death after ischemic cardiovascular events. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Nicholas C Harvey
- MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
- NIHR Southampton Biomedical Research CentreUniversity of Southampton and University Hospital Southampton NHS Foundation TrustSouthamptonUK
| | - Stefania D'Angelo
- MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
| | - Julien Paccou
- MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
- Université Lille Nord‐de‐FranceLilleFrance
| | | | - Mark Edwards
- MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
- Portsmouth Hospitals NHS TrustPortsmouthUK
| | - Zahra Raisi‐Estabragh
- NIHR Barts Biomedical Research CentreWilliam Harvey Research InstituteQueen Mary University of LondonLondonUK
| | - Karen Walker‐Bone
- MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
| | - Steffen E Petersen
- NIHR Barts Biomedical Research CentreWilliam Harvey Research InstituteQueen Mary University of LondonLondonUK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
- NIHR Southampton Biomedical Research CentreUniversity of Southampton and University Hospital Southampton NHS Foundation TrustSouthamptonUK
- NIHR Oxford Biomedical Research CentreUniversity of OxfordOxfordUK
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126
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Cheungpasitporn W, Thongprayoon C, Mao MA, Kittanamongkolchai W, Sakhuja A, Erickson SB. Impact of admission serum calcium levels on mortality in hospitalized patients. Endocr Res 2018; 43:116-123. [PMID: 29381079 DOI: 10.1080/07435800.2018.1433200] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To assess the relationship between admission serum calcium levels and in-hospital mortality in all hospitalized patients. METHODS All adult hospitalized patients who had admission serum calcium levels available between years 2009 and 2013 were enrolled. Admission serum calcium was categorized based on its distribution into six groups (<7.9, 7.9 to <8.4, 8.4 to <9.0, 9.0 to <9.6, 9.6 to <10.1, and ≥10.1 mg/dL). The odds ratio (OR) of in-hospital mortality by admission serum calcium, using the calcium category of 9.6-10.1 mg/dL as the reference group, was obtained by logistic regression analysis. RESULTS 18,437 patients were studied. The lowest incidence of in-hospital mortality was associated with admission serum calcium within 9.6 to <10.1 mg/dL. A higher in-hospital mortality rate was observed in patients with serum calcium <9.6 and ≥10.1 mg/dL. Also, 38% and 33% of patients with admission serum calcium <7.9 and ≥10.1 mg/dL were on calcium supplements before admission, respectively. After adjusting for potential confounders, both serum calcium <8.4 and ≥10.1 mg/dL were associated with an increased risk of in-hospital mortality with ORs of 2.86 [95% confidence interval (CI) 1.98-4.17], 1.74 (95% CI 1.21-2.53), and 1.69 (95% CI 1.10-2.59) when serum calcium were within <7.9, 7.9 to <8.4, and ≥10.1 mg/dL, respectively. CONCLUSION Hypocalcemia and hypercalcemia on admission were associated with in-hospital mortality. Highest mortality risk is observed in patients with admission hypocalcemia (<7.9 mg/dL). One-third of patients with hypercalcemia on admission were on calcium supplements.
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Affiliation(s)
- Wisit Cheungpasitporn
- a Division of Nephrology and Hypertension, Department of Medicine , Mayo Clinic , Rochester , MN , USA
- b Division of Nephrology, Department of Internal Medicine , University of Mississippi Medical Center , Jackson , Mississippi , USA
| | - Charat Thongprayoon
- c Department of Internal Medicine , Bassett Medical Center , Cooperstown , NY , USA
| | - Michael A Mao
- a Division of Nephrology and Hypertension, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | | | - Ankit Sakhuja
- d Division of Pulmonary and Critical Care Medicine, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Stephen B Erickson
- d Division of Pulmonary and Critical Care Medicine, Department of Medicine , Mayo Clinic , Rochester , MN , USA
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127
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Dhillon-Jhattu S, Sprague SM. Should phosphate management be limited to the KDIGO/ KDOQI guidelines? Semin Dial 2018; 31:377-381. [PMID: 29671909 DOI: 10.1111/sdi.12702] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Hyperphosphatemia is a common complication of CKD. Prior to development of overt hyperphosphatemia, there are several adaptive mechanisms that occur to maintain normal phosphorus equilibrium in patients with CKD. These include an early and progressive rise in fibroblast growth factor 23 (FGF 23), followed by an increase in parathyroid hormone (PTH) with a decrease in 1,25-dihydroxyvitamin D (1,25 Vit D). Over the last 20 years, a large number of studies have shown that hyperphosphatemia is a strong predictor of adverse clinical outcomes including increased incidence of vascular calcification, cardiovascular disease, and all-cause mortality in both individuals with CKD as well as those with normal kidney function. In addition, elevations of both FGF 23 and PTH are independently associated with increased morbidity and mortality. Therefore, phosphorus lowering therapies are a vital part of the treatment strategy for patients with CKD and include dietary phosphorus restriction, treatment with phosphate binders and removal with dialysis. However, there has been a lack of high quality evidence demonstrating beneficial effects of phosphate lowering therapy on clinical outcomes. Furthermore, we do not have definitive data as to whether effective phosphate control with phosphate binders will prevent elevations in FGF 23, and whether lowering FGF 23 levels will lead to improved patient outcomes. As a result of the presently available data (or lack thereof) clinical guidelines recommend treatment only after hyperphosphatemia develops and in dialysis patients; KDOQI recommends a treatment target of less than 5.5 mg/dL, whereas KDIGO recommends treating "towards normal." We are left with a clinical dilemma, being whether these recommendations are adequate, or should we be more aggressive in phosphate management. In this article, our goal is to discuss some of the studies concerning the adverse consequences of phosphate excess and as well as elevated FGF 23 levels, and present our opinion on what we believe the goal of treatment should be.
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Affiliation(s)
- Sangeet Dhillon-Jhattu
- NorthShore University HealthSystem and University of Chicago-Pritzker School of Medicine, Chicago, IL, USA
| | - Stuart M Sprague
- NorthShore University HealthSystem and University of Chicago-Pritzker School of Medicine, Chicago, IL, USA
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128
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Wang F, Lu X, Zhang J, Xiong R, Li H, Wang S. Effect of Lanthanum Carbonate on All-Cause Mortality in Patients Receiving Maintenance Hemodialysis: a Meta-Analysis of Randomized Controlled Trials. Kidney Blood Press Res 2018; 43:536-544. [PMID: 29627829 DOI: 10.1159/000488700] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/23/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Hyperphosphatemia is common in patients on hemodialysis. The efficacy of lanthanum carbonate (LC) in the treatment of hyperphosphatemia in these patients remains controversial. The objective of this meta-analysis was to evaluate the effect of LC on all-cause mortality in patients on maintenance hemodialysis. METHODS We electronically searched the PubMed, EMBASE, and Cochrane Library databases for all randomized controlled trials (RCTs) comparing LC with other phosphate binders used in adult hemodialysis patients, including calcium carbonate, calcium acetate, and sevelamer. RESULTS Nine RCTs involving 2813 patients were suitable for inclusion. Our results showed that all-cause mortality was significantly lower in patients who received LC than in those who received standard therapy (odds ratio [OR]: 0.45, 95% confidence interval [CI]: 0.32-0.63, P<0.00001). Compared with the controls, patients who received LC had significantly lower serum calcium and higher serum intact parathyroid hormone levels. However, there was no significant difference between the groups in the cardiovascular event rate (OR: 0.58, 95% CI: 0.31-1.06, P=0.07) or in serum phosphorus levels. CONCLUSION Compared with standard therapy, LC reduced all-cause mortality in patients on hemodialysis but did not decrease the risk of cardiovascular events. The decrease in serum phosphorus level was similar between LC and the other phosphate binders, but the risk of hypercalcemia was lower in patients who received LC.
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Affiliation(s)
- Fang Wang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiangxue Lu
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jingli Zhang
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ruifang Xiong
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Han Li
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shixiang Wang
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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129
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Jones CB, Bargman JM. Should we look beyond Kt/V urea in assessing dialysis adequacy? Semin Dial 2018; 31:420-429. [PMID: 29573025 DOI: 10.1111/sdi.12684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Since the advent of maintenance dialysis therapy, our interpretation of what adequate dialysis really is has broadened and become more controversial. This is not only due to our changing and aging dialysis population but also to our evolving knowledge base. As nephrologists, we strive to achieve both quality and (often) quantity of life for our patients and we feel reassured when we have a quantifiable marker to show for our efforts. However, we suggest that adequate dialysis reaches far beyond the realms of attaining a particular biochemical result. Dialysis adequacy should encompass a more comprehensive assessment of patient well-being. This metric could comprise quality of life and patient-specified goals, sufficient small solute and middle molecule clearance, optimal blood pressure control, and effective bone-mineral balance, all in the context of minimizing mortality and morbidity, and a livable dialysis regimen for the patient.
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Affiliation(s)
- Clare B Jones
- Division of Nephrology, University Health Network, Toronto, Canada
| | - Joanne M Bargman
- Division of Nephrology, University Health Network, Toronto, Canada
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130
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Vervloet MG, van Ballegooijen AJ. Prevention and treatment of hyperphosphatemia in chronic kidney disease. Kidney Int 2018; 93:1060-1072. [PMID: 29580635 DOI: 10.1016/j.kint.2017.11.036] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/21/2017] [Accepted: 11/27/2017] [Indexed: 12/20/2022]
Abstract
Hyperphosphatemia has consistently been shown to be associated with dismal outcome in a wide variety of populations, particularly in chronic kidney disease (CKD). Compelling evidence from basic and animal studies elucidated a range of mechanisms by which phosphate may exert its pathological effects and motivated interventions to treat hyperphosphatemia. These interventions consisted of dietary modifications and phosphate binders. However, the beneficial effects of these treatment methods on hard clinical outcomes have not been convincingly demonstrated in prospective clinical trials. In addition, exposure to high amounts of dietary phosphate may exert untoward actions even in the absence of overt hyperphosphatemia. Based on this concept, it has been proposed that the same interventions used in CKD patients with normal phosphate concentrations be used in the presence of hyperphosphatemia to prevent rise of phosphate concentration and as an early intervention for cardiovascular risk. This review describes conceptual models of phosphate toxicity, summarizes the evidence base for treatment and prevention of hyperphosphatemia, and identifies important knowledge gaps in the field.
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Affiliation(s)
- Marc G Vervloet
- Department of Nephrology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands.
| | - Adriana J van Ballegooijen
- Department of Nephrology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics, Amsterdam Public Health Institute, VU University Medical Center, Amsterdam, the Netherlands
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131
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Fujii H, Kono K, Nakai K, Goto S, Nishii T, Kono A, Nishi S. Effects of Lanthanum Carbonate on Coronary Artery Calcification and Cardiac Abnormalities After Initiating Hemodialysis. Calcif Tissue Int 2018; 102:310-320. [PMID: 29058057 DOI: 10.1007/s00223-017-0347-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 10/13/2017] [Indexed: 12/14/2022]
Abstract
It is known that calcium-containing phosphate binders are more closely associated with the progression of vascular calcification than non-calcium-containing phosphate binders. In this study, we investigated the effect of the non-calcium-containing phosphate binder, lanthanum carbonate on the progression of coronary artery calcification and cardiovascular abnormalities compared to that of calcium-containing phosphate binder in chronic kidney disease patients during the early period after initiating hemodialysis. This was a randomized open-label study in which patients were divided into the calcium carbonate or lanthanum carbonate group. We evaluated blood samples, coronary artery calcification using high-resolution computed tomography, and cardiac abnormalities using echocardiography prior to and after initiating hemodialysis. Cardiac dimension and systolic function were significantly improved in the lanthanum carbonate group compared to those in the calcium carbonate group. Although statistically significant differences were not observed in all the patients, only among patients with moderate coronary artery calcification, the changes in coronary artery calcification score at 18 months were significantly smaller in the lanthanum carbonate group than those in the calcium carbonate group. The percent change in coronary artery calcification at 18 months was significantly correlated with the serum fibroblast growth factor 23 levels at 18 months (r = 0.245, P < 0.05). This significant correlation was particularly strong in patients with moderate coronary artery calcification (r = 0.593, P < 0.001). Our study suggests that lanthanum carbonate ameliorates cardiac abnormalities, and may slow coronary artery calcification development in patients with moderate coronary artery calcification, during the early period following hemodialysis initiation.
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Affiliation(s)
- 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.
| | - 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 Nakai
- 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
| | - Tatsuya Nishii
- Division of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsushi Kono
- Division of Radiology, Kobe University Graduate School of Medicine, Kobe, 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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132
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Wang Z, Jiang A, Wei F, Chen H. Cardiac valve calcification and risk of cardiovascular or all-cause mortality in dialysis patients: a meta-analysis. BMC Cardiovasc Disord 2018; 18:12. [PMID: 29370754 PMCID: PMC5785897 DOI: 10.1186/s12872-018-0747-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 01/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vascular calcification is a risk factor for the pathogenesis of cardiovascular disease and mortality in dialysis patients. Nevertheless, the association between cardiac valve calcification (CVC) and the outcome of dialysis is still illusive. The purpose of this meta-analysis is to evaluate the association between theCVC and cardiovascular or all-cause mortality in dialysis patients. METHODS Literatures involving the baseline CVC and cardiovascular or all-cause mortality in dialysis patients were searchedfrom the PubMed, Embase, as well as two Chinese databases (i.e. Wanfang and CNKI databases). Articles published before November 2016were eligible to the study. RESULTS Ten studies involving 2686 participants were included. CVC was correlated with increased risk of cardiovascular mortality (hazard risk [HR]: 2.81; 95% confidence intervals [CI]: 1.92-4.10) and all-cause mortality (HR: 1.73; 95% CI: 1.42-2.11). Subgroup analysis showed an excess risk of all-cause mortality (HR: 1.35; 95% CI: 1.02-1.79) among patients with one CVC, and increased risk of all-cause mortality in patients with two CVCs (HR 2.15; 95% CI 1.57-2.94). CONCLUSIONS CVC is correlated with higher cardiovascular and all-cause mortality risk in dialysis patients. Regular follow-up monitoring of CVC may be helpful for risk stratification of patients underwent dialysis.
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Affiliation(s)
- Zhe Wang
- Department of Blood Purification, The Second Hospital of Tianjin Medical University, Hexi District, 23 Pingjiang Road, Tianjin, 300211, China
| | - Aili Jiang
- Department of Blood Purification, The Second Hospital of Tianjin Medical University, Hexi District, 23 Pingjiang Road, Tianjin, 300211, China.
| | - Fang Wei
- Department of Blood Purification, The Second Hospital of Tianjin Medical University, Hexi District, 23 Pingjiang Road, Tianjin, 300211, China
| | - Haiyan Chen
- Department of Blood Purification, The Second Hospital of Tianjin Medical University, Hexi District, 23 Pingjiang Road, Tianjin, 300211, China
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Cho JH, Jang HM, Jung HY, Choi JY, Park SH, Kim CD, Yang CW, Jin DC, Kim YL. A Real-world Cost-effectiveness Analysis of Sevelamer Versus Calcium Acetate in Korean Dialysis Patients. Clin Ther 2018; 40:123-134. [DOI: 10.1016/j.clinthera.2017.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 02/09/2017] [Accepted: 02/11/2017] [Indexed: 11/28/2022]
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134
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Dzingarski D, Mladenovska K. Pharmacotherapy in chronic kidney disease hyperphosphatemia – effects on vascular calcification and bone health. MAKEDONSKO FARMACEVTSKI BILTEN 2017. [DOI: 10.33320/maced.pharm.bull.2017.63.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Hyperphosphatemia (HP) in patients with chronic kidney disease (CKD) leads to complications such as renal osteodistrophy, cardiovascular calcification and hemodynamic abnormalities, all of them having a serious impact on the survival rate and quality of life. Also, HP is a key pathogenic factor in the development of secondary hyperparathyroidism (SHPT) in CKD. Having in regard the significance of controlling serum phosphorus levels (Pi), in this paper, the needs and obstacles to successful pharmacological management of HP in CKD are presented, with an overview of major classes of phosphate binders (PBs) and other drugs affecting Pi level, such as active vitamin D sterols and calcimimetics (CMs). In addition, their effects on progression of cardiovascular calcification and bone health are elaborated. In this regard, a PubMed search was carried out to capture all abstracts and articles relevant to the topic of CKD, HP and mineral metabolism, bone disorders and vascular/valvular calcification (VC), published from January 2007 to August 2017. The search was limited to English language, with the search terms including drug name AND hyperphosphatemia or cardiovascular calcification or bone disorder. Comparative studies, clinical studies/trials and meta-analyses related to different classes/representatives of PBs, vitamin D analogues and CMs were reviewed and research data related to their efficacy and safety compared.
Keywords: chronic kidney disease, hyperphosphatemia, phosphate binders, active vitamin D sterols, calcimimetics, bone disorders, cardiovascular calcification
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Affiliation(s)
- Dimce Dzingarski
- Faculty of Pharmacy, University “Ss Cyril and Methodius”, Mother Theresa St. 47, 1000 Skopje, Republic of Macedonia
| | - Kristina Mladenovska
- Faculty of Pharmacy, University “Ss Cyril and Methodius”, Mother Theresa St. 47, 1000 Skopje, Republic of Macedonia
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135
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Yang X, Bai Q, Li Y, Liu H, Guo H, Zhang X. Comparative Efficacy and Safety of Phosphate Binders in Hyperphosphatemia Patients With Chronic Kidney Disease. JPEN J Parenter Enteral Nutr 2017; 42:766-777. [PMID: 28777915 DOI: 10.1177/0148607117715440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/23/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND In this study, we coordinated a network meta-analysis to establish the efficacy and safety of different agents used in the treatment of hyperphosphatemia patients with chronic kidney disease. METHODS PubMed, CNKI, and Embase were systematically searched to retrieve relevant studies. Outcomes were presented by mean differences, odds ratios, and corresponding 95% credible intervals for continuous outcomes and binary outcomes, respectively. Each therapy was ranked according to the value of surface under the cumulative ranking curve. Consistencies between direct and indirect comparisons were assessed with a node-splitting plot. RESULTS In terms of efficacy end points (including levels of serum phosphate, serum calcium, serum intact parathyroid hormone, and serum calcium × phosphorus product), all 7 kinds of agents outperformed or performed at least equally to placebo, with iron-based phosphate-binding agents being potentially the most effective. As for safety end points (including mortality, adverse events, and all-cause discontinuation), almost all agents were equivalent in term of mortality and all-cause discontinuation except in the comparison between iron-based phosphate-binding agents and placebo. Meanwhile, iron-based phosphate-binding agents colestilan and nicotinic acid performed poorly compared with placebo in terms of adverse events. Furthermore, iron-based phosphate-binding agents were potentially the safest agents followed sequentially by calcium-based phosphate-binding agents and placebo. CONCLUSION Iron-based phosphate-binding agents were the preferable agents when considering efficacy and safety simultaneously.
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Affiliation(s)
- Xiuqin Yang
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Qingning Bai
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Yanguo Li
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Haijun Liu
- Linyi Medical College, Linyi, Shandong, China
| | - Haiying Guo
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Xiaolei Zhang
- Department of Geriatrics, Linyi People's Hospital, Linyi, Shandong, China
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136
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Clinical Practices and Therapeutic Management of Mineral and Bone Disorders in Chronic Kidney Disease 4, 5 and 5D: The OCEANOS Study in Iran. Nephrourol Mon 2017. [DOI: 10.5812/numonthly.61632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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137
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Sakaguchi Y, Hamano T, Wada A, Hoshino J, Masakane I. Magnesium and Risk of Hip Fracture among Patients Undergoing Hemodialysis. J Am Soc Nephrol 2017; 29:991-999. [PMID: 29191960 DOI: 10.1681/asn.2017080849] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 10/31/2017] [Indexed: 01/06/2023] Open
Abstract
Magnesium is an essential mineral for bone metabolism. However, little is known about the relationship between magnesium and the risk of fractures. In this cohort study, we elucidated the association between serum magnesium level and the risk of incident hip fracture among patients undergoing hemodialysis. We identified 113,683 patients undergoing hemodialysis with no history of hip fracture from a nation-wide database of patients undergoing dialysis in Japan. During a 2-year follow-up, a total of 2305 (2%) new hip fractures occurred. The crude incidence rate was significantly higher among patients in the lower quartiles of serum magnesium levels (2.63%, 2.08%, 1.76%, and 1.49% in Q1-Q4, respectively; P<0.001 for trend). The range of serum magnesium levels (in milligrams per deciliter) in each quartile was as follows: Q1, <2.3; Q2, 2.4-2.6; Q3, 2.7-2.8, and Q4, >2.9. After adjustment for demographic and clinical factors, patients in Q1 had a 1.23-fold higher risk for hip fracture than those in Q4 (95% confidence interval, 1.06 to 1.44; P<0.01). Similarly, an inverse probability weighting analysis showed an increased risk of hip fracture among patients in the lower magnesium quartiles. We did not observe significant effect modifications in subgroup analyses. The population-attributable fraction of serum magnesium level for incident hip fractures was 13.7% (95% confidence interval, 3.7% to 22.7%), which was much higher than that of serum calcium, serum phosphate, and parathyroid hormone levels. Thus, mild hypermagnesemia is associated with a lower risk of hip fracture among patients undergoing hemodialysis.
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Affiliation(s)
- Yusuke Sakaguchi
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takayuki Hamano
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan; .,Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Suita, Japan
| | - Atsushi Wada
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan.,Department of Nephrology, Kitasaito Hospital, Asahikawa, Japan
| | - Junichi Hoshino
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan.,Nephrology Center, Toranomon Hospital, Kawasaki, Japan; and
| | - Ikuto Masakane
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan.,Yabuki Hospital, Yamagata, Japan
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138
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Airy M, Winkelmayer WC, Navaneethan SD. Phosphate Binders: The Evidence Gap Persists. Am J Kidney Dis 2017; 68:667-670. [PMID: 27772629 DOI: 10.1053/j.ajkd.2016.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 08/11/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Medha Airy
- Baylor College of Medicine, Houston, Texas
| | | | - Sankar D Navaneethan
- Baylor College of Medicine, Houston, Texas; Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
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139
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Treat secondary hyperparathyroidism in chronic kidney disease according to disease severity and trends in laboratory markers. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-017-0441-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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140
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Abstract
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). The rate of death in incident dialysis patients remains high. This has led to interest in the study of the evolution of CVD during the critical transition period from CKD to ESRD. Understanding the natural history and risk factors of clinical and subclinical CVD during this transition may help guide the timing of appropriate CVD therapies to improve outcomes in patients with kidney disease. This review provides an overview of the epidemiology of subclinical and clinical CVD during the transition from CKD to ESRD and discusses clinical trials of CVD therapies to mitigate risk of CVD in CKD and ESRD patients.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA.
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141
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Wu MY, Chen YC, Lin CH, Wu YC, Tu YK, Tarng DC. Safety and efficacy of ferric citrate in phosphate reduction and iron supplementation in patients with chronic kidney disease. Oncotarget 2017; 8:107283-107294. [PMID: 29291028 PMCID: PMC5739813 DOI: 10.18632/oncotarget.21990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 09/20/2017] [Indexed: 01/13/2023] Open
Abstract
Ferric citrate has been reported to have the potential to reduce phosphate and increase iron availability in patients with chronic kidney disease. In the present study, we evaluated its safety and efficacy in phosphate reduction and iron supplementation in chronic kidney disease stage 3-5 requiring dialysis patients. We systematically searched for clinical trials published in PubMed, Medline, and Cochrane databases. Only randomized controlled trials on the effects of ferric citrate in chronic kidney disease stage 3–5 requiring dialysis patients were selected. The primary outcomes were changes in serum phosphate, calcium, and anemia-related parameters. The secondary outcomes were the adverse effects of ferric citrate. Nine studies providing data on 1755 patients were included in the meta-analysis. Ferric citrate significantly reduced serum phosphate compared with placebo (mean difference, –1.39; 95% confidence interval, –2.12 to –0.66) and had a non-inferior effect compared with active treatment. Furthermore, ferric citrate significantly improved hemoglobin, transferrin saturation and ferritin. Adverse effects of constipation did not differ significantly between ferric citrate and placebo or active treatment. This review provides evidence that ferric citrate effectively alleviates hyperphosphatemia and iron deficiency in patients with chronic kidney disease stage 3–5 requiring dialysis patients. However, the included studies did not have cardiovascular complications or mortality information and could not assess whether ferric citrate affected the risk of all-cause death or cardiovascular complications in patients with chronic kidney disease. Further studies are required to assess whether the long-term use of ferric citrate can reduce the risk of cardiovascular events and all-cause mortality.
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Affiliation(s)
- Mei-Yi Wu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Ying-Chun Chen
- Department of Pharmacy, Taipei Medical University, Shuang Ho Hospital, Taipei, Taiwan
| | - Chun-Hung Lin
- Department of Education, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yun-Chun Wu
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yu-Kang Tu
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Der-Cherng Tarng
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department and Institute of Physiology, National Yang-Ming University, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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142
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Habbous S, Przech S, Acedillo R, Sarma S, Garg AX, Martin J. The efficacy and safety of sevelamer and lanthanum versus calcium-containing and iron-based binders in treating hyperphosphatemia in patients with chronic kidney disease: a systematic review and meta-analysis. Nephrol Dial Transplant 2017; 32:111-125. [PMID: 27651467 DOI: 10.1093/ndt/gfw312] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 07/13/2016] [Indexed: 12/17/2022] Open
Abstract
Background It remains unclear which phosphate binders should be preferred for hyperphosphatemia management in chronic kidney disease (CKD). Methods We performed a systematic review and meta-analysis of randomized trials comparing sevelamer or lanthanum with other phosphate binders in CKD. Results Fifty-one trials (8829 patients) were reviewed. Compared with calcium-based binders, all-cause mortality was nonsignificantly lower with sevelamer {risk ratio [RR] 0.62 [95% confidence interval (CI) 0.35-1.08]} and lanthanum [RR 0.73 (95% CI 0.18-3.00)], but risk of bias was concerning. Compared with calcium-based binders, sevelamer reduced the risk of hypercalcemia [RR 0.27 (95% CI 0.17-0.42)], as did lanthanum [RR 0.12 (95% CI 0.05-0.32)]. Sevelamer reduced hospitalizations [RR 0.50 (95% CI 0.31-0.81)], but not lanthanum [RR 0.80 (95% CI 0.34-1.93)]. The presence/absence of other clinically relevant outcomes was infrequently reported. Compared with calcium-based binders, sevelamer reduced serum calcium, low-density lipoprotein and coronary artery calcification, but increased intact parathyroid hormone. The clinical relevance of these changes is unknown since corresponding clinical outcomes were not reported. Lanthanum had less favorable impact on biochemical parameters. Sevelamer hydrochloride and sevelamer carbonate were similar in three studies. Sevelamer was similar to lanthanum (three studies) and iron-based binders (three studies). Conclusion Sevelamer was associated with a nonsignificant reduction in mortality and significantly lower hospitalization rates and hypercalcemia compared with calcium-based binders. However, differences in important outcomes, such as cardiac events, fractures, calciphylaxis, hyperchloremic acidosis and health-related quality of life remain understudied. Lanthanum and iron-based binders did not show superiority for any clinically relevant outcomes. Future studies that fail to measure clinically important outcomes (the reason why phosphate binders are prescribed in the first place) will be wasteful.
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Affiliation(s)
- Steven Habbous
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Sebastian Przech
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Rey Acedillo
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.,London Health Sciences Centre, Division of Nephrology, Western University, London, ON, Canada
| | - Sisira Sarma
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Amit X Garg
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.,London Health Sciences Centre, Division of Nephrology, Western University, London, ON, Canada
| | - Janet Martin
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.,Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Department of Anesthesia & Perioperative Medicine, Western University, London, ON, Canada
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143
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Nagai K, Matsuura M, Tsuchida K, Kanayama HO, Doi T, Minakuchi J. Prognostic factors for mortality in middle-aged and older hemodialysis patients: a 5-year observational study. J Artif Organs 2017; 21:94-101. [PMID: 28918555 DOI: 10.1007/s10047-017-0993-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 09/11/2017] [Indexed: 02/05/2023]
Abstract
Clinical guidelines for hemodialysis therapy have been described in an evidence-based manner with most evidence from randomized control trials or retrospective studies in which all generations of the hemodialysis patients were enrolled. Therefore, the question still remains whether these guidelines can be applied to increasing older patients. This study is an observational study, including 735 patients who received maintenance hemodialysis in April 2006. At baseline, the participants' age was 62.1 ± 12.8 years (mean ± SD). Hemodialysis duration was 103.7 ± 89.3 months. In a 5-year observation period (actual follow-up period: 1551 ± 499 days), 175 patients died. Prognostic factors were investigated by multivariate analysis with Cox proportional hazard model. Next, we stratified the patients according to their age. 363 patients were included in the middle-aged patient's category between 40 and 64 years, and 314 were involved in the older patient's category between 65 and 84 years old. As a subanalysis, significant predictors of 5-year survival were examined in the age-stratified cohort. Then, Kt/V, serum β2-microglobulin and calcium concentration were significant predictors in our entire cohort, as well as body mass index, neutrophil count, and serum sodium concentration even after adjustment for age, gender, diabetic status and hemodialysis duration. However, Kt/V, serum β2-microglobulin and calcium concentration controlled by hemodialysis prescriptions were independent risk factors especially in older patients, not in middle-aged patients. In conclusion, hemodialysis prescriptions for lowering uremic toxins and managing mineral-bone disorder are important to decrease the risk of death even in older hemodialysis patients.
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Affiliation(s)
- Kojiro Nagai
- Department of Nephrology, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan.
| | - Motokazu Matsuura
- Department of Nephrology, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Kenji Tsuchida
- Department of Kidney Disease (Dialysis and Transplantation), Kawashima Hospital, 1-39, Kitasakoichiban-cho, Tokushima, 770-0011, Japan.
| | - Hiro-Omi Kanayama
- Department of Urology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Toshio Doi
- Department of Nephrology, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Jun Minakuchi
- Department of Kidney Disease (Dialysis and Transplantation), Kawashima Hospital, 1-39, Kitasakoichiban-cho, Tokushima, 770-0011, Japan
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144
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Komaba H, Wang M, Taniguchi M, Yamamoto S, Nomura T, Schaubel DE, Smith AR, Zee J, Karaboyas A, Bieber B, Fukagawa M, Tentori F. Initiation of Sevelamer and Mortality among Hemodialysis Patients Treated with Calcium-Based Phosphate Binders. Clin J Am Soc Nephrol 2017; 12:1489-1497. [PMID: 28724618 PMCID: PMC5586586 DOI: 10.2215/cjn.13091216] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/30/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Prior studies have shown that sevelamer attenuates progression of arterial calcification and may reduce the risk of death compared with calcium-based phosphate binders. In clinical practice, however, sevelamer is used not only as an alternative but also as an add-on therapy in patients already being treated with calcium-based phosphate binders. We analyzed the Dialysis Outcomes and Practice Patterns Study (DOPPS) data to test the hypothesis that the initiation of sevelamer is associated with improved survival in patients on hemodialysis treated with calcium-based phosphate binders. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We included 12,564 patients from DOPPS phase 3 and phase 4 (2005-2011) who were prescribed calcium-based phosphate binders at baseline or before sevelamer treatment. Mortality risk was assessed using a sequential stratification method to identify as-yet-untreated patients who were appropriately matched to the newly treated patients on the basis of their risk of death. RESULTS Of 12,564 patients, 2606 were subsequently treated with sevelamer hydrochloride or sevelamer carbonate. After beginning sevelamer therapy, mean serum phosphorus levels decreased by 0.3 mg/dl in the first 4 months and gradually decreased thereafter. We matched 2501 treated patients with at least one as-yet-untreated patient. Patients treated with sevelamer had a 14% lower risk for mortality compared with as-yet-untreated patients (hazard ratio, 0.86; 95% confidence interval, 0.76 to 0.97). Similar results were observed in the sensitivity analyses when changing the matching calipers or the treated and as-yet-untreated ratios, and by using propensity score matching. CONCLUSIONS The use of sevelamer as an add-on or alternative therapy to calcium-based phosphate binders is associated with improved survival in patients on maintenance hemodialysis.
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Affiliation(s)
- Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
- The Institute of Medical Sciences, Tokai University, Isehara, Japan
| | - Mia Wang
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Masatomo Taniguchi
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | | | - Douglas E. Schaubel
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan; and
| | | | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Francesca Tentori
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
- Vanderbilt University Medical Center, Nashville, Tennessee
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145
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Ishii T, Nakajima Y, Oyama K. Comparative analysis of the phosphate-binding effects of sucroferric oxyhydroxide, ferric citrate, and lanthanum carbonate. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0119-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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146
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Reid IR, Birstow SM, Bolland MJ. Calcium and Cardiovascular Disease. Endocrinol Metab (Seoul) 2017; 32:339-349. [PMID: 28956363 PMCID: PMC5620030 DOI: 10.3803/enm.2017.32.3.339] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/03/2017] [Accepted: 08/16/2017] [Indexed: 11/11/2022] Open
Abstract
Circulating calcium is a risk factor for vascular disease, a conclusion arising from prospective studies involving hundreds of thousands of participants and extending over periods of up to 30 years. These associations may be partially mediated by other cardiovascular risk factors such as circulating lipid levels, blood pressure, and body mass index, but there appears to be a residual independent effect of serum calcium. Polymorphisms of the calcium-sensing receptor associated with small elevations of serum calcium are also associated with cardiovascular disease, suggesting that calcium plays a causative role. Trials of calcium supplements in patients on dialysis and those with less severe renal failure demonstrate increased mortality and/or acceleration of vascular disease, and meta-analyses of trials in those without overt renal disease suggest a similar adverse effect. Interpretation of the latter trials is complicated by a significant interaction between baseline use of calcium supplements and the effect of randomisation to calcium in the largest trial. Restriction of analysis to those who are calcium-naive demonstrates a consistent adverse effect. Observational studies of dietary calcium do not demonstrate a consistent adverse effect on cardiovascular health, though very high or very low intakes may be deleterious. Thus, obtaining calcium from the diet rather than supplements is to be encouraged.
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Affiliation(s)
- Ian R Reid
- Department of Medicine, University of Auckland, Auckland, New Zealand
- Department of Endocrinology, Auckland District Health Board, Auckland, New Zealand.
| | - Sarah M Birstow
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Mark J Bolland
- Department of Medicine, University of Auckland, Auckland, New Zealand
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147
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Zoccali C. Moderator's view: Meta-analysis: the best knowledge but not always shining gold. Nephrol Dial Transplant 2017; 31:886-9. [PMID: 27217396 DOI: 10.1093/ndt/gfw093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 03/28/2016] [Indexed: 11/13/2022] Open
Abstract
Meta-analysis has gained top status in medicine. Correctly so, well-performed meta-analysis is perceived as an unbeatable method for distilling first class medical knowledge. However, such a high status should in no way be considered as a guarantee that all information derived from meta-analyses is pure gold. Systematic reviews and meta-analyses not performed with due methodological attention abound and nephrology is not at all a protected territory. Herein I give concrete examples of meta-analyses published in major journals whose findings are not pure gold.
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Affiliation(s)
- Carmine Zoccali
- CNR-IFC Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Cal Unit, Reggio Calabria, Italy
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148
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Andrulli S, Chiavenna C, Bigi MC, Crepaldi M, Dell'Oro C, Tentori F, Manzoni C, Bacchini G, Corti MM, Pontoriero G. Predictors of first ischemic lower limb ulcer in dialysis patients: an observational cohort study. J Nephrol 2017; 31:435-443. [PMID: 28831705 DOI: 10.1007/s40620-017-0429-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 08/01/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Lower limb ischemia affects the quality of life, physical activity and life expectancy of dialysis patients. The aim of this study was to investigate the risk factors associated with ischemic foot ulcers considering clinical, laboratory and therapeutic domains. METHODS This observational cohort study was based on data from the Nephrology and Dialysis Department database of Alessandro Manzoni Hospital, Lecco (Italy). All of the incident patients who started dialysis between 1 January 1999 and 29 February 2012 were enrolled, excluding temporary guests, patients with acute renal failure and patients with previous limb ischemia or amputation. Multivariate Cox regression analysis identified the predictors in each domain, which were matched in the final model. A time-dependent approach was used to take into account the evolution of some of the prognostic covariates. RESULTS Of the 526 incident dialysis patients, 120 developed a lower limb ischemic lesion after a median of 13 months. The incidence of new ulcers was constant during the study period (6 per 100 person-years), but higher in the diabetics with a relative rate of 4.5. The variables significantly related to an increased risk of lower limb ulcers were age, male gender, diabetes, ischemic heart disease, treatment with proton pump inhibitors, iron, anticoagulants and calcium-based binders, and blood levels of phosphorus, triglycerides and C-reactive protein. CONCLUSION The incidence of lower limb ulcers was highest during the early dialysis follow-up and was associated with, in addition to diabetes, modifiable laboratory and therapeutic predictors such as anticoagulants, proton pump inhibitors, calcium-containing binders, calcimimetics and iron.
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Affiliation(s)
- Simeone Andrulli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Via dell'Eremo 9, 23900, Lecco, Italy.
| | - Chiara Chiavenna
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Via dell'Eremo 9, 23900, Lecco, Italy
| | - Maria Carla Bigi
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Via dell'Eremo 9, 23900, Lecco, Italy
| | - Monica Crepaldi
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Via dell'Eremo 9, 23900, Lecco, Italy
| | - Cesare Dell'Oro
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Via dell'Eremo 9, 23900, Lecco, Italy
| | - Flavia Tentori
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Via dell'Eremo 9, 23900, Lecco, Italy
| | - Celestina Manzoni
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Via dell'Eremo 9, 23900, Lecco, Italy
| | - Giuseppe Bacchini
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Via dell'Eremo 9, 23900, Lecco, Italy
| | - Mauro Maria Corti
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Via dell'Eremo 9, 23900, Lecco, Italy
| | - Giuseppe Pontoriero
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Via dell'Eremo 9, 23900, Lecco, Italy
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149
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Lin CJ, Pan CF, Chuang CK, Liu HL, Huang SF, Chen HH, Wu CJ. Effects of Sevelamer Hydrochloride on Uremic Toxins Serum Indoxyl Sulfate and P-Cresyl Sulfate in Hemodialysis Patients. J Clin Med Res 2017; 9:765-770. [PMID: 28811853 PMCID: PMC5544481 DOI: 10.14740/jocmr1803e] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 03/13/2014] [Indexed: 12/19/2022] Open
Abstract
Background Beside the phosphate binding effect, non-calcium non-aluminum phosphate binder, namely sevelamer hydrochloride (SH), has many other effects in dialysis patients. It can absorb many other compounds, decrease low-density lipoprotein cholesterol (LDL-C) level, and attenuate the progression of vascular calcification; it has been reported to have anti-inflammatory effect. However, it is not clear whether it has any effect on uremic toxins, i.e. serum indoxyl sulfate (IS) and p-cresyl sulfate, (PCS) in hemodialysis (HD) patients. This study was carried out to appraise the effect of sevelamer on serum IS and PCS in HD patients. Methods Five adult HD patients from a single medical center were enrolled in this study; these patients were treated with 800 mg of sevelamer thrice per day for 3 months; a series of biochemical parameters, serum IS and PCS were monitored concurrently. Results There was a significant reduction in the mean level of phosphate from 7.20 ± 0.70 mg/dL (mean ± SD) before treatment to 5.40 ± 0.50 mg/dL (mean ± SD) after treatment, total cholesterol from 151.00 ± 37.40 mg/dL (mean ± SD) before treatment to 119.20 ± 29.40 mg/dL (mean ± SD) after treatment, and PCS from 31.30 ± 10.60 mg/L (mean ± SD) before treatment to 19.70 ± 10.50 mg/L (mean ± SD) after treatment. On the contrary, this treatment had no effect on IS. Conclusion A statistically significant reduction of serum phosphate and PCS in HD patients treated with SH suggests that beside the action of lowering serum phosphate, sevelamer may have an important role in the treatment of uremic syndrome by decreasing the uremic toxin.
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Affiliation(s)
- Cheng-Jui Lin
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan, Republic of China.,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan, Republic of China.,Institute of Biotechnology, National Taipei University of Technology, Taipei, Taiwan, Republic of China
| | - Chi-Feng Pan
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan, Republic of China.,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan, Republic of China
| | - Chih-Kuang Chuang
- Institute of Biotechnology, National Taipei University of Technology, Taipei, Taiwan, Republic of China.,Division of Genetics and Metabolism, Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan, Republic of China.,College of Medicine, Fu-Jen Catholic University, Taipei County, Taiwan, Republic of China
| | - Hsuan-Liang Liu
- Institute of Biotechnology, National Taipei University of Technology, Taipei, Taiwan, Republic of China
| | - Sung-Fa Huang
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei, Taiwan, Republic of China
| | - Han-Hsiang Chen
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan, Republic of China.,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan, Republic of China
| | - Chih-Jen Wu
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan, Republic of China.,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan, Republic of China.,Graduate Institute of Medical Science, Taipei Medical University, Taipei, Taiwan, Republic of China
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150
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Locatelli F, Del Vecchio L. Iron-based phosphate binders: a paradigm shift in the treatment of hyperphosphatemic anemic CKD patients? J Nephrol 2017; 30:755-765. [PMID: 28717990 DOI: 10.1007/s40620-017-0421-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 06/24/2017] [Indexed: 02/07/2023]
Abstract
The partial correction of anemia and the normalization of phosphate and blood pressure are the mainstay of treatment of patients with chronic kidney disease (CKD). Available anti-hypertensive drugs, erythropoiesis stimulating agents (ESAs) and iron supplements have resolved quite satisfactorily the goal of controlling hypertension and partially correcting anemia. Unfortunately, the treatment of hyperphosphatemia is still far from resolved. Phosphate binders have poor tolerability and/or limited efficacy, leading to the prescription of many tablets that achieve only a mild-to-moderate effect. Moreover, increased consumption of tablets is associated with increased low tolerability, thus jeopardizing patient compliance and, in turn, the efficacy of phosphate binding. Compared to calcium-free binders, the cheaper calcium salts increase the risk of hypercalcemia, calciphylaxis and vascular calcification and possibly all-cause mortality. Calcium-free phosphate binders decrease serum phosphate levels without increasing the serum calcium concentration. The higher phosphate-binding efficacy of lanthanum carbonate compared to sevelamer should be balanced against its lack of pleiotropic effects on lipid metabolism and inflammation and the accumulation in bones. New iron-based phosphate binders are available. In addition to their phosphate binding capacity, they could also be useful to treat anemia. Iron citrate is seeking for such an indication because its iron absorption is significant. This could be of clinical importance, particularly in CKD patients not on dialysis, obviating the need for extra oral iron administration and possibly favoring compliance. In conclusion, the use of iron-based phosphate binders with significant iron absorption properties could represent a novel paradigm for correcting anemia and hyperphosphatemia in CKD patients.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, ASST Lecco, Via dell'Eremo 9/11, 23900, Lecco, Italy.
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