1
|
Yang TY, Lin HM, Wang HY, Chuang MH, Hsieh CC, Tsai KT, Chen JY. Sodium Bicarbonate Treatment and Clinical Outcomes in Chronic Kidney Disease with Metabolic Acidosis: A Meta-Analysis. Clin J Am Soc Nephrol 2024; 19:959-969. [PMID: 38980732 DOI: 10.2215/cjn.0000000000000487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 06/11/2024] [Indexed: 07/11/2024]
Abstract
Key Points
Sodium bicarbonate for patients with CKD and metabolic acidosis leads to a significant improvement in kidney function.Treatment with sodium bicarbonate increases in mid-arm muscle circumference, indicating a positive effect on enhancing muscle mass.Sodium bicarbonate supplementation is associated with a higher risk of elevated systolic BP, marking a potential side effect.
Background
In patients with CKD, impaired kidney acid excretion leads to the onset of metabolic acidosis (MA). However, the evidence is not yet conclusive regarding the effects of sodium bicarbonate in treating CKD with MA.
Methods
Databases with PubMed, Embase, and the Cochrane Library were used to search for randomized controlled trials (RCTs) from the inception until November 11, 2023, to identify RCTs investigating the effect of sodium bicarbonate in participants with CKD and MA. The primary outcome was the change in eGFR. Secondary outcomes included hospitalization rates, change in systolic BP, all-cause mortality, and mid-arm muscle circumference. A random-effects model was applied for analysis, and subgroup, sensitivity analyses were also performed.
Results
Fourteen RCTs comprising 2037 patients demonstrated that sodium bicarbonate supplementation significantly improved eGFR (standardized mean difference [SMD], 0.33; 95% confidence interval [CI], 0.03 to 0.63; P = 0.03). The group receiving sodium bicarbonate had a lower hospitalization rate (odds ratio, 0.37; 95% CI, 0.25 to 0.55; P < 0.001). Higher mid-arm muscle circumference was observed with sodium bicarbonate treatment compared with those without (SMD, 0.23; 95% CI, 0.08 to 0.38; P = 0.003, I2<0.001). However, higher risk of elevated systolic BP was found with sodium bicarbonate treatment (SMD, 0.10; 95% CI, 0.01 to 0.20; P = 0.03). No significant difference in all-cause mortality was noted.
Conclusions
In patients with CKD and MA, sodium bicarbonate supplementation may provide potential benefits in preventing the deterioration of kidney function and increasing muscle mass. However, treatment may be associated with higher BP. Owing to the risk of bias stemming from the absence of double-blinded designs and inconsistencies in control group definitions across the studies, further research is crucial to verify these findings.
Collapse
Affiliation(s)
- Ting-Ya Yang
- Department of Family Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Hong-Min Lin
- Department of Family Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Hsien-Yi Wang
- Division of Nephrology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Sport Management, College of Leisure and Recreation Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Min-Hsiang Chuang
- Division of Nephrology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chia-Chen Hsieh
- Department of Family Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Kang-Ting Tsai
- Department of Family Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Senior Welfare and Services, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jui-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| |
Collapse
|
2
|
Cozzo D, Merkel N, Bellasi A. Serum bicarbonate levels, kidney injury progression, and overall survival: which came first, the chicken or the egg? Int Urol Nephrol 2024:10.1007/s11255-024-04120-7. [PMID: 38884684 DOI: 10.1007/s11255-024-04120-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 06/10/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Domenico Cozzo
- Service of Nephrology, Ospedale Regionale di Lugano, Ospedale Civico, Ente Ospedaliero Cantonale, Via Tesserete 46, 6903, Lugano, Switzerland
| | - Nathalie Merkel
- Service of Nephrology, Ospedale Regionale di Lugano, Ospedale Civico, Ente Ospedaliero Cantonale, Via Tesserete 46, 6903, Lugano, Switzerland
| | - Antonio Bellasi
- Service of Nephrology, Ospedale Regionale di Lugano, Ospedale Civico, Ente Ospedaliero Cantonale, Via Tesserete 46, 6903, Lugano, Switzerland.
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
| |
Collapse
|
3
|
Abe M, Yamaguchi T, Koshiba S, Takayama S, Nakai T, Nishioka K, Yamasaki S, Kawaguchi K, Umeyama M, Masaura A, Ishizawa K, Arita R, Kanno T, Akaishi T, Miyazaki M, Abe T, Tanaka T, Ishii T. Oral alkalinizing supplementation suppressed intrarenal reactive oxidative stress in mild-stage chronic kidney disease: a randomized cohort study. Clin Exp Nephrol 2024:10.1007/s10157-024-02517-3. [PMID: 38872014 DOI: 10.1007/s10157-024-02517-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 05/15/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND The beneficial effects of oral supplements with alkalinizing agents in patients with chronic kidney disease (CKD) have been limited to the severe stages. We investigated whether two types of supplements, sodium bicarbonate (SB) and potassium citrate/sodium citrate (PCSC), could maintain renal function in patients with mild-stage CKD. METHODS This was a single-center, open-labeled, randomized cohort trial. Study participants with CKD stages G2, G3a, and G3b were enrolled between March 2013 and January 2019 and randomly assigned by stratification according to age, sex, estimated glomerular filtration rate (eGFR), and diabetes. They were followed up for 6 months (short-term study) for the primary endpoints and extended to 2 years (long-term study) for the secondary endpoints. Supplementary doses were adjusted to achieve an early morning urinary pH of 6.8-7.2. We observed renal dysfunction or new-onset cerebrovascular disease and evaluated urinary surrogate markers for renal injury. RESULTS Overall, 101 participants were registered and allocated to three groups: standard (n = 32), SB (n = 34), and PCSC (n = 35). Two patients in the standard group attained the primary endpoints (renal stones and overt proteinuria) but were not statistically significant. There was one patient in the standard reduced eGFR during the long-term study (p = 0.042 by ANOVA). SB increased proteinuria (p = 0.0139, baseline vs. 6 months), whereas PCSC significantly reduced proteinuria (p = 0.0061, baseline vs. 1 year, or p = 0.0186, vs. 2 years) and urinary excretion of 8-hydroxy-2'-deoxyguanosine (p = 0.0481, baseline vs. 6 months). CONCLUSION This study is the first to report supplementation of PCSC reduced intrarenal oxidative stress in patients with mild-stage CKD.
Collapse
Affiliation(s)
- Michiaki Abe
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, 1-1 Seiryo-Machi, Sendai, Miyagi, 9808574, Japan.
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan.
- Department of Nephrology, Rheumatology and Endocrinology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
| | - Takuhiro Yamaguchi
- Clinical Research Data Center, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Seizo Koshiba
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan
| | - Shin Takayama
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, 1-1 Seiryo-Machi, Sendai, Miyagi, 9808574, Japan
| | - Toshiki Nakai
- Medical Affairs Department, Nippon Chemiphar Co., Ltd, Chiyoda-Ku, Tokyo, Japan
| | - Koichiro Nishioka
- Medical Affairs Department, Nippon Chemiphar Co., Ltd, Chiyoda-Ku, Tokyo, Japan
| | - Satomi Yamasaki
- Medical Affairs Department, Nippon Chemiphar Co., Ltd, Chiyoda-Ku, Tokyo, Japan
| | - Kazuhiko Kawaguchi
- Medical Affairs Department, Nippon Chemiphar Co., Ltd, Chiyoda-Ku, Tokyo, Japan
| | - Masanori Umeyama
- Development Planning Department, Nippon Chemiphar Co., Ltd, Chiyoda-Ku, Tokyo, Japan
| | - Atsuko Masaura
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, 1-1 Seiryo-Machi, Sendai, Miyagi, 9808574, Japan
| | - Kota Ishizawa
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, 1-1 Seiryo-Machi, Sendai, Miyagi, 9808574, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan
| | - Ryutaro Arita
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, 1-1 Seiryo-Machi, Sendai, Miyagi, 9808574, Japan
| | - Takeshi Kanno
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, 1-1 Seiryo-Machi, Sendai, Miyagi, 9808574, Japan
| | - Tetsuya Akaishi
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, 1-1 Seiryo-Machi, Sendai, Miyagi, 9808574, Japan
| | - Mariko Miyazaki
- Department of Nephrology, Rheumatology and Endocrinology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Takaaki Abe
- Department of Nephrology, Rheumatology and Endocrinology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
- Department of Clinical Biology and Hormonal Regulation, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Tetsuhiro Tanaka
- Department of Nephrology, Rheumatology and Endocrinology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Tadashi Ishii
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, 1-1 Seiryo-Machi, Sendai, Miyagi, 9808574, Japan
| |
Collapse
|
4
|
Ash SR, Batlle D, Kendrick J, Oluwatosin Y, Kooienga L, Eudicone JM, Sundin AK, Guerrieri E, Fried LF. Sodium Zirconium Cyclosilicate in CKD, Hyperkalemia, and Metabolic Acidosis: NEUTRALIZE Randomized Study. KIDNEY360 2024; 5:812-820. [PMID: 38622759 PMCID: PMC11219110 DOI: 10.34067/kid.0000000000000446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/09/2024] [Indexed: 04/17/2024]
Abstract
Key Points Sodium zirconium cyclosilicate effectively lowers serum potassium and maintains normokalemia in patients with CKD with concomitant hyperkalemia and metabolic acidosis. Despite high screen failure and small sample size, a nominally significant increase in sHCO3– was seen for sodium zirconium cyclosilicate versus placebo. Further studies on the basis of an appropriate cohort size may help validate the trend observed in sHCO3– levels, supporting these clinically relevant findings. Background Metabolic acidosis and hyperkalemia are common in CKD. A potential dual effect of sodium zirconium cyclosilicate (SZC), a selective binder of potassium in the gastrointestinal tract, on serum potassium (sK+) and serum bicarbonate (sHCO3−) was evaluated in patients with hyperkalemia and metabolic acidosis associated with CKD. Methods In the NEUTRALIZE study (NCT04727528 ), non-dialysis patients with stage 3–5 CKD, hyperkalemia (sK+>5.0 to ≤5.9 mmol/L), and metabolic acidosis (sHCO3− 16–20 mmol/L) received open-label SZC 10 g three times daily for ≤48 hours. Patients achieving normokalemia (sK+ 3.5–5.0 mmol/L) were randomized 1:1 to SZC 10 g or placebo daily for 4 weeks. The primary end point was patients (%) maintaining normokalemia at the end of treatment (EOT) without rescue. Secondary end points included mean change in sHCO3− at EOT (day 29) and patients (%) with normokalemia with a ≥3-mmol/L increase in sHCO3− without rescue. Results Of 229 patients screened, 37 were randomized (SZC, n =17; placebo, n =20). High screen failure led to early study termination. At EOT, 88.2% (SZC) versus 20.0% (placebo) of patients maintained normokalemia (odds ratio, 56.2; P = 0.001). Low enrollment rendered secondary end point P values nominal. SZC treatment provided nominally significant increases in sHCO3– versus placebo from day 15 onward. Patients with normokalemia with a ≥3-mmol/L increase in sHCO3− without rescue were 35.3% (SZC) and 5.0% (placebo; P < 0.05). No new safety concerns were reported. Conclusions SZC effectively lowered sK+ and maintained normokalemia, with nominally significant increases in sHCO3– observed for SZC versus placebo.
Collapse
Affiliation(s)
- Stephen R. Ash
- Nephrology Department, Indiana University Health Arnett, Lafayette, Indiana
| | - Daniel Batlle
- Division of Nephrology and Hypertension, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jessica Kendrick
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | | - James M. Eudicone
- BioPharmaceuticals Medical (Evidence), AstraZeneca, Wilmington, Delaware
| | | | | | - Linda F. Fried
- Renal Section, Veterans Affairs Pittsburgh Healthcare System and Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
5
|
Raphael KL. Metabolic Acidosis in CKD: Pathogenesis, Adverse Effects, and Treatment Effects. Int J Mol Sci 2024; 25:5187. [PMID: 38791238 PMCID: PMC11121226 DOI: 10.3390/ijms25105187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/28/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024] Open
Abstract
Metabolic acidosis is a frequent complication of chronic kidney disease and is associated with a number of adverse outcomes, including worsening kidney function, poor musculoskeletal health, cardiovascular events, and death. Mechanisms that prevent metabolic acidosis detrimentally promote further kidney damage, creating a cycle between acid accumulation and acid-mediated kidney injury. Disrupting this cycle through the provision of alkali, most commonly using sodium bicarbonate, is hypothesized to preserve kidney function while also mitigating adverse effects of excess acid on bone and muscle. However, results from clinical trials have been conflicting. There is also significant interest to determine whether sodium bicarbonate might improve patient outcomes for those who do not have overt metabolic acidosis. Such individuals are hypothesized to be experiencing acid-mediated organ damage despite having a normal serum bicarbonate concentration, a state often referred to as subclinical metabolic acidosis. Results from small- to medium-sized trials in individuals with subclinical metabolic acidosis have also been inconclusive. Well-powered clinical trials to determine the efficacy and safety of sodium bicarbonate are necessary to determine if this intervention improves patient outcomes.
Collapse
Affiliation(s)
- Kalani L. Raphael
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT 84112, USA;
- Medicine Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT 84148, USA
| |
Collapse
|
6
|
Bodker K, Freidin N, Arora N. A basic solution for a complex problem: does treatment of metabolic acidosis slow CKD progression? Curr Opin Nephrol Hypertens 2024; 33:304-310. [PMID: 38420899 DOI: 10.1097/mnh.0000000000000978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
PURPOSE OF THIS REVIEW Metabolic acidosis is frequently encountered in patients with chronic kidney disease (CKD), with increasing prevalence as kidney function worsens. Treating electrolyte disturbances is the sine qua non of Nephrologists, and alkali therapy to normalize serum bicarbonate levels and slow progression of kidney disease has been embedded in clinical practice guidelines for decades on the basis of animal models and controversial clinical trials. This review will critically appraise the literature base for this recommendation and determine whether the available evidence supports this common practice, which is a timely endeavor considering the impending demotion of metabolic acidosis treatment from recommendation to practice point in forthcoming KDIGO guidelines. RECENT FINDINGS Earlier, open-label, studies supporting the utility of sodium bicarbonate therapy to slow progression of chronic kidney disease have been challenged by more recent, blinded, studies failing to show benefit on CKD progression. This was further demonstrated in the absence of concomitant sodium administration with the hydrochloric acid binder veverimer, which failed to demonstrate benefit on renal death, end stage kidney disease or 40% reduction in estimated glomerular filtration rate in a large multicenter trial. SUMMARY The current body of literature does not support the routine treatment of metabolic acidosis in patients with CKD and the authors agree with the forthcoming KDIGO guidelines to de-emphasize this common practice.
Collapse
Affiliation(s)
| | | | - Nayan Arora
- University of Washington, Seattle, Washington, USA
| |
Collapse
|
7
|
Raju S, Manoharan K, Ramachandran N, Sahoo J, Vairappan B, Subramaniyam V, Parameswaran S, Priyamvada P. Randomized Trial on the Efficacy and Safety of Standard Versus Higher Bicarbonate Supplementation in CKD of Unknown Etiology. Kidney Int Rep 2024; 9:1504-1507. [PMID: 38707819 PMCID: PMC11068943 DOI: 10.1016/j.ekir.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/24/2024] [Accepted: 02/05/2024] [Indexed: 05/07/2024] Open
Affiliation(s)
- Swathy Raju
- Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Karthikeyan Manoharan
- Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Natarajan Ramachandran
- Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Jayaprakash Sahoo
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Balasubramanian Vairappan
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Velkumary Subramaniyam
- Department of Physiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sreejith Parameswaran
- Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - P.S. Priyamvada
- Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| |
Collapse
|
8
|
Kuhn C, Mohebbi N, Ritter A. Metabolic acidosis in chronic kidney disease: mere consequence or also culprit? Pflugers Arch 2024; 476:579-592. [PMID: 38279993 PMCID: PMC11006741 DOI: 10.1007/s00424-024-02912-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/29/2024]
Abstract
Metabolic acidosis is a frequent complication in non-transplant chronic kidney disease (CKD) and after kidney transplantation. It occurs when net endogenous acid production exceeds net acid excretion. While nephron loss with reduced ammoniagenesis is the main cause of acid retention in non-transplant CKD patients, additional pathophysiological mechanisms are likely inflicted in kidney transplant recipients. Functional tubular damage by calcineurin inhibitors seems to play a key role causing renal tubular acidosis. Notably, experimental and clinical studies over the past decades have provided evidence that metabolic acidosis may not only be a consequence of CKD but also a driver of disease. In metabolic acidosis, activation of hormonal systems and the complement system resulting in fibrosis have been described. Further studies of changes in renal metabolism will likely contribute to a deeper understanding of the pathophysiology of metabolic acidosis in CKD. While alkali supplementation in case of reduced serum bicarbonate < 22 mmol/l has been endorsed by CKD guidelines for many years to slow renal functional decline, among other considerations, beneficial effects and thresholds for treatment have lately been under intense debate. This review article discusses this topic in light of the most recent results of trials assessing the efficacy of dietary and pharmacological interventions in CKD and kidney transplant patients.
Collapse
Affiliation(s)
- Christian Kuhn
- Clinic for Nephrology and Transplantation Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | | | - Alexander Ritter
- Clinic for Nephrology and Transplantation Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
- Clinic for Nephrology, University Hospital Zurich, Zurich, Switzerland.
| |
Collapse
|
9
|
Garofalo C, Borrelli S, Liberti ME, Chiodini P, Peccarino L, Pennino L, Polese L, De Gregorio I, Scognamiglio M, Ruotolo C, Provenzano M, Conte G, Minutolo R, De Nicola L. Secular Trend in GFR Decline in Non-Dialysis CKD Based on Observational Data From Standard of Care Arms of Trials. Am J Kidney Dis 2024; 83:435-444.e1. [PMID: 37956953 DOI: 10.1053/j.ajkd.2023.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 08/24/2023] [Accepted: 09/07/2023] [Indexed: 11/21/2023]
Abstract
RATIONALE & OBJECTIVE The standard of care (SoC) group of randomized controlled trials (RCTs) is a useful setting to explore the secular trends in kidney disease progression because implementation of best clinical practices is pursued for all patients enrolled in trials. This meta-analysis evaluated the secular trend in the change of glomerular filtration rate (GFR) decline in the SoC arm of RCTs in chronic kidney disease (CKD) published in the last 30 years. STUDY DESIGN Systematic review and meta-analysis of the SoC arms of RCTs analyzed as an observational study. SETTING & STUDY POPULATIONS Adult patients with CKD enrolled in the SoC arm of RCTs. SELECTION CRITERIA FOR STUDIES Phase 3 RCTs evaluating GFR decline as an outcome in SoC arms. DATA EXTRACTION Two independent reviewers evaluated RCTs for eligibility and extracted relevant data. ANALYTICAL APPROACH The mean of GFR declines extracted in the SoC arm of selected RCTs were pooled by using a random effects model. Meta-regression analyses were performed to identify factors that may explain heterogeneity. RESULTS The SoC arms from 92 RCTs were included in the meta-analysis with a total of 32,202 patients. The overall mean GFR decline was-4.00 (95% CI, -4.55 to-3.44) mL/min/1.73m2 per year in the SoC arms with a high level of heterogeneity (I2, 98.4% [95% CI, 98.2-98.5], P<0.001). Meta-regression analysis showed an association between publication year (β estimate, 0.09 [95% CI, 0.032-0.148], P=0.003) and reduction in GFR over time. When evaluating publication decade categorically, GFR decline was-5.44 (95% CI, -7.15 to-3.73), -3.92 (95% CI, -4.82 to-3.02), and -3.20 (95% CI, -3.75 to -2.64) mL/min/1.73m2 per year during 1991-2000, 2001-2010, and 2011-2023, respectively. Using meta-regression, the heterogeneity of GFR decline was mainly explained by age and proteinuria. LIMITATIONS Different methods assessing GFR in selected trials and observational design of the study. CONCLUSIONS In the last 3 decades, GFR decline has decreased over time in patients enrolled in RCTs who received the standard of care. TRIAL REGISTRATION Registered at PROSPERO with record number CRD42022357704. PLAIN-LANGUAGE SUMMARY This study evaluated the secular trend in the change in glomerular filtration rate (GFR) decline in the placebo arms of randomized controlled trials (RCTs) that were studying approaches to protect the kidneys in the setting of chronic kidney disease. The placebo groups of RCTs are useful for examining whether the rate of progression of kidney disease has changed over time. We found an improvement in the slope of change in GFR over time. These findings suggest that adherence to standards of kidney care as implemented in clinical trials may be associated with improved clinical outcomes, and these data may inform the design of future RCTs in nephrology.
Collapse
Affiliation(s)
- Carlo Garofalo
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy.
| | - Silvio Borrelli
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Maria Elena Liberti
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Paolo Chiodini
- Medical Statistics Unit, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Laura Peccarino
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Luigi Pennino
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Lucio Polese
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Ilaria De Gregorio
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | | | - Chiara Ruotolo
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Michele Provenzano
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giuseppe Conte
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Roberto Minutolo
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Luca De Nicola
- Division of Nephrology, University of Campania "Luigi Vanvitelli," Naples, Italy
| |
Collapse
|
10
|
Sorohan BM, Obrișcă B, Jurubiță R, Lupușoru G, Achim C, Andronesi A, Frățilă G, Berechet A, Micu G, Ismail G. Sodium citrate versus sodium bicarbonate for metabolic acidosis in patients with chronic kidney disease: A randomized controlled trial. Medicine (Baltimore) 2024; 103:e37475. [PMID: 38457574 PMCID: PMC10919529 DOI: 10.1097/md.0000000000037475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/29/2024] [Accepted: 02/12/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Metabolic acidosis (MA) is frequently associated with chronic kidney disease (CKD) progression. Our aim was to compare the effect of oral sodium citrate (SC) with that of oral sodium bicarbonate (SB) on renal function and serum bicarbonate correction, as well as to evaluate their safety profile in patients with MA of CKD. METHODS We conducted a prospective, single-center, randomized 1:1, parallel, controlled, unblinded clinical trial of 124 patients with MA and CKD stages 3b and 4. The primary outcome was the mean change in estimated glomerular filtration rate (eGFR). The secondary outcomes were mean change in serum bicarbonate level, eGFR decrease by 30%, eGFR decrease by 50%, dialysis, death or prolonged hospitalization, and a combined endpoint. RESULTS No significant difference was found between the groups in terms of mean eGFR change [adjusted mean difference = -0.99 mL/min/1.73 m2 (95% CI: -2.51 to 0.93, P = .20)]. We observed a mean serum bicarbonate change of 6.15 mmol/L [(95% CI: 5.55-6.74), P < .001] in the SC group and of 6.19 mmol/L [(95% CI: 5.54-6.83), P < .001] in the SB group, but no significant difference between the 2 groups [adjusted mean difference = 0.31 mmol/L (-0.22 to 0.85), P = .25]. Cox proportional hazard analysis showed similar risks regarding eGFR decrease by 30% (P = .77), eGFR decrease by 50% (P = .50), dialysis (P = .85), death or prolonged hospitalization (P = .29), and combined endpoint (P = .57). Study drug discontinuation due to adverse events was significantly more common in the SB group (17.7% vs 4.8%, P = .02). CONCLUSIONS SC and SB have a similar effect on kidney function decline, both improve serum bicarbonate level, but SB is associated with higher rates of medication discontinuation due to adverse events.
Collapse
Affiliation(s)
- Bogdan Marian Sorohan
- “Carol Davila” University of Medicine and Pharmacy, Department of Nephrology, Bucharest, Romania
- Fundeni Clinical Institute, Department of Kidney Transplantation, Bucharest, Romania
| | - Bogdan Obrișcă
- “Carol Davila” University of Medicine and Pharmacy, Department of Nephrology, Bucharest, Romania
- Fundeni Clinical Institute, Department of Nephrology, Bucharest, Romania
| | - Roxana Jurubiță
- “Carol Davila” University of Medicine and Pharmacy, Department of Nephrology, Bucharest, Romania
- Fundeni Clinical Institute, Department of Nephrology, Bucharest, Romania
| | - Gabriela Lupușoru
- “Carol Davila” University of Medicine and Pharmacy, Department of Nephrology, Bucharest, Romania
- Fundeni Clinical Institute, Department of Nephrology, Bucharest, Romania
| | - Camelia Achim
- “Carol Davila” University of Medicine and Pharmacy, Department of Nephrology, Bucharest, Romania
- Fundeni Clinical Institute, Department of Nephrology, Bucharest, Romania
| | - Andreea Andronesi
- “Carol Davila” University of Medicine and Pharmacy, Department of Nephrology, Bucharest, Romania
- Fundeni Clinical Institute, Department of Nephrology, Bucharest, Romania
| | - Georgiana Frățilă
- “Carol Davila” University of Medicine and Pharmacy, Department of Nephrology, Bucharest, Romania
| | - Andreea Berechet
- Fundeni Clinical Institute, Department of Nephrology, Bucharest, Romania
| | - Georgia Micu
- Fundeni Clinical Institute, Department of Nephrology, Bucharest, Romania
| | - Gener Ismail
- “Carol Davila” University of Medicine and Pharmacy, Department of Nephrology, Bucharest, Romania
- Fundeni Clinical Institute, Department of Nephrology, Bucharest, Romania
| |
Collapse
|
11
|
Chan JYM, Islahudin F, Mohd Tahir NA, Makmor-Bakry M, Tan CHH. Prevalence, Risk Factors, and Management of Metabolic Acidosis in Chronic Kidney Disease Patients: A Multicenter Retrospective Study in Malaysia. Cureus 2024; 16:e56314. [PMID: 38628987 PMCID: PMC11020729 DOI: 10.7759/cureus.56314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 04/19/2024] Open
Abstract
Background Metabolic acidosis in chronic kidney disease (CKD) patients has lately gained attention due to the growing evidence of its treatment benefits. This study aims to provide baseline data on the prevalence, risk factors, and current management of metabolic acidosis among the pre-dialysis adult Malaysian CKD population. Methodology This multicenter cross-sectional retrospective study involved pre-dialysis CKD patients above 18 years old on regular nephrology clinic follow-up at three Malaysian government hospitals with nephrology subspecialty. Demographic data, clinical information, laboratory data, and a list of concomitant medications were collected. Factors associated with the occurrence of metabolic acidosis were identified via multiple logistic regression. Results Six hundred and fifty-seven CKD patients were screened for this study, in which only 39.4% (n=259) had available bicarbonate levels. From this, a total of 86.1% (n=223) had metabolic acidosis. Higher estimated glomerular filtration rate (odds ratio (OR) 0.96, 95% confidence interval (CI) 0.93-1.00, p=0.043) and those with cardiovascular disease (OR 0.33, 95% CI 0.15-0.73; p=0.007) were significantly associated with lower odds of metabolic acidosis. There were 43.0% (n=96) on alkali therapy with sodium bicarbonate solution being the most common (n=91, 94.8%). Among those receiving alkali therapy, only 19.8% (n=19) achieved bicarbonate levels of ≥ 22 mEq/L. Conclusion Our study showed that metabolic acidosis was highly prevalent, although few achieved target levels despite supplementation, supporting the need for focused management of metabolic acidosis in the CKD population.
Collapse
Affiliation(s)
- Jaime Yoke May Chan
- Center for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, MYS
| | - Farida Islahudin
- Center for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, MYS
| | - Nurul Ain Mohd Tahir
- Center for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, MYS
| | - Mohd Makmor-Bakry
- Center for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, MYS
- Faculty of Pharmacy, Universitas Airlangga, Surabaya, IDN
| | | |
Collapse
|
12
|
Tangri N, Mathur VS, Bushinsky DA, Klaerner G, Li E, Parsell D, Stasiv Y, Walker M, Wesson DE, Wheeler DC, Perkovic V, Inker LA. VALOR-CKD: A Multicenter, Randomized, Double-Blind Placebo-Controlled Trial Evaluating Veverimer in Slowing Progression of CKD in Patients with Metabolic Acidosis. J Am Soc Nephrol 2024; 35:311-320. [PMID: 38261535 PMCID: PMC10914188 DOI: 10.1681/asn.0000000000000292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/03/2023] [Indexed: 01/25/2024] Open
Abstract
SIGNIFICANCE STATEMENT Metabolic acidosis is a common complication of CKD and is associated with more rapid decline of kidney function, but well-powered controlled randomized trials testing the effect of treating metabolic acidosis on slowing CKD progression have not been conducted. The VALOR-CKD study randomized 1480 individuals with CKD and metabolic acidosis, across 320 sites to placebo or veverimer (a novel hydrochloric acid binder). The findings did not demonstrate the efficacy of veverimer in slowing CKD progression, but the difference in serum bicarbonate between placebo and drug arms was only approximately 1 mEq/L. Veverimer was safe and well tolerated. BACKGROUND Metabolic acidosis is common in CKD, but whether its treatment slows CKD progression is unknown. Veverimer, a novel hydrochloric acid binder that removes acid from the gastrointestinal tract, leads to an increase in serum bicarbonate. METHODS In a phase 3, double-blind, placebo-controlled trial, patients with CKD (eGFR of 20-40 ml/min per 1.73 m 2 ) and metabolic acidosis (serum bicarbonate of 12-20 mEq/L) from 35 countries were randomized to veverimer or placebo. The primary outcome was the composite end point of CKD progression, defined as the development of ESKD (kidney transplantation or maintenance dialysis), a sustained decline in eGFR of ≥40% from baseline, or death due to kidney failure. RESULTS The mean (±SD) baseline eGFR was 29.2±6.3 ml/min per 1.73 m 2 , and serum bicarbonate was 17.5±1.4 mEq/L; this increased to 23.4±2.0 mEq/L after the active treatment run-in. After randomized withdrawal, the mean serum bicarbonate was 22.0±3.0 mEq/L and 20.9±3.3 mEq/L in the veverimer and placebo groups at month 3, and this approximately 1 mEq/L difference remained stable for the first 24 months. A primary end point event occurred in 149/741 and 148/739 patients in the veverimer and placebo groups, respectively (hazard ratio, 0.99; 95% confidence interval, 0.8 to 1.2; P = 0.90). Serious and overall adverse event incidence did not differ between the groups. CONCLUSIONS Among patients with CKD and metabolic acidosis, treatment with veverimer did not slow CKD progression. The lower than expected bicarbonate separation may have hindered the ability to test the hypothesis. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER VALOR-CKD, NCT03710291 .
Collapse
Affiliation(s)
- Navdeep Tangri
- Department of Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | | | | | | | - Yuri Stasiv
- Tricida, Inc., South San Francisco, California
| | | | - Donald E. Wesson
- Dell Medical School, The University of Texas at Austin, Austin, Texas
- Donald E. Wesson Consulting, LLC, Dallas, Texas
| | - David C. Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Vlado Perkovic
- University of New South Wales, Sydney, New South Wales, Australia
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
13
|
Mannon EC, Muller PR, Sun J, Bush WB, Coleman A, Ocasio H, Polichnowski AJ, Brands MW, O'Connor PM. NaHCO3 loading causes increased arterial pressure and kidney damage in rats with chronic kidney disease. Clin Sci (Lond) 2024; 138:189-203. [PMID: 38300615 DOI: 10.1042/cs20231709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/26/2024] [Accepted: 02/01/2024] [Indexed: 02/02/2024]
Abstract
Sodium bicarbonate (NaHCO3) is commonly utilized as a therapeutic to treat metabolic acidosis in people with chronic kidney disease (CKD). While increased dietary sodium chloride (NaCl) is known to promote volume retention and increase blood pressure, the effects of NaHCO3 loading on blood pressure and volume retention in CKD remain unclear. In the present study, we compared the effects of NaCl and NaHCO3 loading on volume retention, blood pressure, and kidney injury in both 2/3 and 5/6 nephrectomy remnant kidney rats, a well-established rodent model of CKD. We tested the hypothesis that NaCl loading promotes greater volume retention and increases in blood pressure than equimolar NaHCO3. Blood pressure was measured 24 h daily using radio telemetry. NaCl and NaHCO3 were administered in drinking water ad libitum or infused via indwelling catheters. Rats were housed in metabolic cages to determine volume retention. Our data indicate that both NaHCO3 and NaCl promote hypertension and volume retention in remnant kidney rats, with salt-sensitivity increasing with greater renal mass reduction. Importantly, while NaHCO3 intake was less pro-hypertensive than equimolar NaCl intake, NaHCO3 was not benign. NaHCO3 loading significantly elevated blood pressure and promoted volume retention in rats with CKD when compared with control rats receiving tap water. Our findings provide important insight into the effects of sodium loading with NaHCO3 in CKD and indicate that NaHCO3 loading in patients with CKD is unlikely to be benign.
Collapse
Affiliation(s)
- Elinor C Mannon
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - P Robinson Muller
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Jingping Sun
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Weston B Bush
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Alex Coleman
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Hiram Ocasio
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Aaron J Polichnowski
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee, U.S.A
| | - Michael W Brands
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Paul M O'Connor
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| |
Collapse
|
14
|
Goraya N, Wesson DE. Pathophysiology of Diet-Induced Acid Stress. Int J Mol Sci 2024; 25:2336. [PMID: 38397012 PMCID: PMC10888592 DOI: 10.3390/ijms25042336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Diets can influence the body's acid-base status because specific food components yield acids, bases, or neither when metabolized. Animal-sourced foods yield acids and plant-sourced food, particularly fruits and vegetables, generally yield bases when metabolized. Modern diets proportionately contain more animal-sourced than plant-sourced foods, are, thereby, generally net acid-producing, and so constitute an ongoing acid challenge. Acid accumulation severe enough to reduce serum bicarbonate concentration, i.e., manifesting as chronic metabolic acidosis, the most extreme end of the continuum of "acid stress", harms bones and muscles and appears to enhance the progression of chronic kidney disease (CKD). Progressive acid accumulation that does not achieve the threshold amount necessary to cause chronic metabolic acidosis also appears to have deleterious effects. Specifically, identifiable acid retention without reduced serum bicarbonate concentration, which, in this review, we will call "covert acidosis", appears to cause kidney injury and exacerbate CKD progression. Furthermore, the chronic engagement of mechanisms to mitigate the ongoing acid challenge of modern diets also appears to threaten health, including kidney health. This review describes the full continuum of "acid stress" to which modern diets contribute and the mechanisms by which acid stress challenges health. Ongoing research will develop clinically useful tools to identify stages of acid stress earlier than metabolic acidosis and determine if dietary acid reduction lowers or eliminates the threats to health that these diets appear to cause.
Collapse
Affiliation(s)
- Nimrit Goraya
- Department of Internal Medicine, Baylor Scott & White Health, Temple, TX 76508, USA;
- Department of Internal Medicine, Texas A&M Health Science Center College of Medicine, Temple, TX 76508, USA
| | - Donald E. Wesson
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Dallas, TX 78712, USA
| |
Collapse
|
15
|
Machado AD, Marchioni DM, Lotufo PA, Benseñor IM, Titan SM. Dietary acid load and the risk of events of mortality and kidney replacement therapy in people with chronic kidney disease: the Progredir Cohort Study. Eur J Clin Nutr 2024; 78:128-134. [PMID: 37891227 DOI: 10.1038/s41430-023-01361-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND/OBJECTIVES The association between dietary acid load (DAL) and chronic kidney disease (CKD) progression remains controversial. Also, there is a gap in the literature on the association between DAL and mortality. In this study, we evaluated the association between NEAP (net endogenous acid production) and PRAL (potential renal acid load) and the risk of events of all-cause mortality and kidney replacement therapy (KRT) in people with CKD. SUBJECTS/METHODS We included 442 patients (250 diabetics) from the Progredir Cohort Study, based in São Paulo, Brazil. We estimated NEAP and PRAL from dietary intake. Events of death before KRT and KRT were ascertained after a median follow-up of 5.8 and 5.1 years, respectively. Cox proportional hazards regression, Weibull regression, and competing risk models were performed. RESULTS Median NEAP and PRAL were 49.5 and 4.8 mEq/d. There were 200 deaths and 75 KRT events. Neither NEAP nor PRAL were associated with mortality or KRT when all participants were analyzed. After stratification for diabetes, both estimates were positively related to the risk of KRT even after adjustment for age, sex, weight status, glomerular filtration rate, serum bicarbonate, and intakes of protein, phosphorus, and energy (HR 1.31; 95% CI 1.07, 1.60 for NEAP, and HR 1.27; 95% CI 1.04, 1.57 for every 10 mEq/d increments). Competing risk analyses confirmed these findings. CONCLUSIONS DAL estimates were associated with the risk of KRT in people with CKD and diabetes but not in non-diabetics. There was no association between all-cause mortality and DAL.
Collapse
Affiliation(s)
- Alisson Diego Machado
- Division of Nephrology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil.
| | - Dirce Maria Marchioni
- Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, SP, Brazil
| | - Paulo Andrade Lotufo
- Epidemiological and Clinical Research Center, University Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Isabela Martins Benseñor
- Epidemiological and Clinical Research Center, University Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Silvia Maria Titan
- Division of Nephrology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
- Division of Nephrology & Hypertension, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
16
|
Kilduff S, Hayde N, Viswanathan S, Reidy K, Abramowitz MK. Metabolic acidosis in pediatric kidney transplant recipients. Pediatr Nephrol 2023; 38:4165-4173. [PMID: 37422606 DOI: 10.1007/s00467-023-06072-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Metabolic acidosis is a risk factor for faster kidney function decline in chronic kidney disease (CKD) and in adult kidney transplant recipients (KTRs). We hypothesized that metabolic acidosis would be highly prevalent and associated with worse allograft function in pediatric KTRs. METHODS Pediatric KTRs at Montefiore Medical Center from 2010 to 2018 were included. Metabolic acidosis was defined as serum bicarbonate < 22 mEq/L or receiving alkali therapy. Regression models were adjusted for demographic factors and donor/recipient characteristics. RESULTS Sixty-three patients were identified with a median age at transplant of 10.5 (interquartile range (IQR) 4.4-15.2) years and post-transplant follow-up of 3 (IQR 1-5) years. Baseline serum bicarbonate was 21.7 ± 2.4 mEq/L, serum bicarbonate < 22 mEq/L was present in 28 (44%), and 44% of all patients were receiving alkali therapy. The prevalence of acidosis ranged from 58 to 70% during the first year of follow-up. At baseline, each 1-year higher age at transplant and every 10 ml/min/1.73 m2 higher eGFR were associated with 0.16 mEq/L (95% CI: 0.03-0.3) and 0.24 mEq/L (95% CI: 0.01-0.5) higher serum bicarbonate, respectively. Older age at transplant was associated with lower odds of acidosis (OR: 0.84; 95% CI: 0.72-0.97). During follow-up, metabolic acidosis was independently associated with 8.2 ml/min/1.73 m2 (95% CI 4.4-12) lower eGFR compared to not having acidosis; furthermore, eGFR was significantly lower among KTRs with unresolved acidosis compared with resolved acidosis. CONCLUSIONS Among pediatric KTRs, metabolic acidosis was highly prevalent in the first year post-transplantation and was associated with lower eGFR during follow-up. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Stella Kilduff
- The Children's Hospital at Montefiore/Einstein, Bronx, NY, USA.
- Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Nicole Hayde
- The Children's Hospital at Montefiore/Einstein, Bronx, NY, USA
| | | | - Kimberly Reidy
- The Children's Hospital at Montefiore/Einstein, Bronx, NY, USA
| | - Matthew K Abramowitz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Institute for Aging Research, Albert Einstein College of Medicine, Bronx, NY, USA
- Diabetes Research Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
17
|
Visser WJ, van de Braak EE, de Mik ‐ van Egmond AM, van der Burgh AC, de Roos NM, Jans I, van der Hoef I, Olieman JF, Hoorn EJ, Severs D. Effects of correcting metabolic acidosis on muscle mass and functionality in chronic kidney disease: a systematic review and meta-analysis. J Cachexia Sarcopenia Muscle 2023; 14:2498-2508. [PMID: 37728018 PMCID: PMC10751416 DOI: 10.1002/jcsm.13330] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/07/2023] [Accepted: 08/21/2023] [Indexed: 09/21/2023] Open
Abstract
Metabolic acidosis unfavourably influences the nutritional status of patients with non-dialysis dependent chronic kidney disease (CKD) including the loss of muscle mass and functionality, but the benefits of correction are uncertain. We investigated the effects of correcting metabolic acidosis on nutritional status in patients with CKD in a systematic review and meta-analysis. A search was conducted in MEDLINE and the Cochrane Library from inception to June 2023. Study selection, bias assessment, and data extraction were independently performed by two reviewers. The Cochrane risk of bias tool was used to assess the quality of individual studies. We applied random effects meta-analysis to obtain pooled standardized mean difference (SMD) and 95% confidence intervals (CIs). We retrieved data from 12 intervention studies including 1995 patients, with a mean age of 63.7 ± 11.7 years, a mean estimated glomerular filtration rate of 29.8 ± 8.8 mL/min per 1.73 m2 , and 58% were male. Eleven studies performed an intervention with oral sodium bicarbonate compared with either placebo or with standard care and one study compared veverimer, an oral HCl-binding polymer, with placebo. The mean change in serum bicarbonate was +3.6 mEq/L in the intervention group and +0.4 mEq/L in the control group. Correcting metabolic acidosis significantly improved muscle mass assessed by mid-arm muscle circumference (SMD 0.35 [95% CI 0.16 to 0.54], P < 0.001) and functionality assessed with the sit-to-stand test (SMD -0.31 [95% CI -0.52 to 0.11], P = 0.003). We found no statistically significant effects on dietary protein intake, handgrip strength, serum albumin and prealbumin concentrations, and blood urea nitrogen. Correcting metabolic acidosis in patients with CKD improves muscle mass and physical function. Correction of metabolic acidosis should be considered as part of the nutritional care for patients with CKD.
Collapse
Affiliation(s)
- Wesley J. Visser
- Department of Internal Medicine, Division of Dietetics, Erasmus MCUniversity Medical CenterRotterdamThe Netherlands
| | - Elma E.M. van de Braak
- Division of Human NutritionWageningen Centre for Food Sciences, Wageningen UniversityWageningenThe Netherlands
| | | | - Anna C. van der Burgh
- Department of Epidemiology, Erasmus MCUniversity Medical CenterRotterdamThe Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MCUniversity Medical CenterRotterdamThe Netherlands
| | - Nicole M. de Roos
- Division of Human NutritionWageningen Centre for Food Sciences, Wageningen UniversityWageningenThe Netherlands
| | - Inez Jans
- Department of DieteticsHospital Gelderse ValleiEdeThe Netherlands
| | - Iris van der Hoef
- Department of DieteticsHospital St. AntoniusNieuwegeinThe Netherlands
| | - Joanne F. Olieman
- Department of Internal Medicine, Division of Dietetics, Erasmus MCUniversity Medical CenterRotterdamThe Netherlands
| | - Ewout J. Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MCUniversity Medical CenterRotterdamThe Netherlands
| | - David Severs
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MCUniversity Medical CenterRotterdamThe Netherlands
| |
Collapse
|
18
|
Zhang X, Jia R, Zheng Z, Jiang L, Xu Y, Raj A, Sun D. Effect of roxadustat on iron metabolism in patients with peritoneal dialysis: a real-world 24-week study. Eur J Med Res 2023; 28:489. [PMID: 37936193 PMCID: PMC10629011 DOI: 10.1186/s40001-023-01465-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/21/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Roxadustat is an oral hypoxia inducing factor-prolyl hydroxylase inhibitor (HIF-PHI) that regulates iron metabolism in patients with chronic kidney disease (CKD) primarily by reducing hepcidin levels and mobilizing internal iron stores. More data are needed to demonstrate the efficacy of roxadustat in regulating iron metabolism in patients with peritoneal dialysis (PD) compared with erythropoiesis stimulating agents (ESAs). METHODS This prospective cohort study enrolled PD patients with a mean hemoglobin level of 60-100 g/L. All subjects were randomized into two groups at a ratio of 2:1 the roxadustat group (106 cases), and the ESA group (53 cases). The primary endpoint was the change in the iron biomarker levels and the proportion of patients with absolute iron deficiency and functional iron deficiency. RESULTS Compared with ESAs, roxadustat significantly decreased hepcidin level (difference, - 20.09 ng/mL; 95% CI, - 30.26 to - 9.92), attenuated the increase in serum soluble transferrin receptor (sTFR) level (difference, - 7.87 nmol/L; 95% CI, - 12.11 to - 3.64), and reduced the proportion of patients with functional iron deficiency (roxadustat, 11.43%; ESA, 33.33%). There was no significant difference in safety of the two groups over the duration of the study. CONCLUSIONS Compared with ESA group, roxadustat group showed significant differences in all iron biomarker levels except serum ferritin (sFt) and transferrin saturation (TSAT). These results suggest that roxadustat was superior to ESAs as a therapy for iron metabolism in PD patients. TRIAL REGISTRATION This study completed Chinese Clinical Trial Registration on March 4, 2022 (registration number: ChiCTR2200057231).
Collapse
Affiliation(s)
- Xuejie Zhang
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, 99 West Huai-Hai Road, Xuzhou, 221002, Jiangsu, China
- Department of Nephrology, Jintan Hospital,Affiliated Hospital of Jiangsu University, Changzhou, China
| | - Ruoyu Jia
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhifang Zheng
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, 99 West Huai-Hai Road, Xuzhou, 221002, Jiangsu, China
| | - Luhua Jiang
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, 99 West Huai-Hai Road, Xuzhou, 221002, Jiangsu, China
| | - Yizhou Xu
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, 99 West Huai-Hai Road, Xuzhou, 221002, Jiangsu, China
| | - Ashok Raj
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, 99 West Huai-Hai Road, Xuzhou, 221002, Jiangsu, China
- Department of Urology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Dong Sun
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, 99 West Huai-Hai Road, Xuzhou, 221002, Jiangsu, China.
- Department of Internal Medicine and Diagnostics, Xuzhou Medical University, Xuzhou, China.
| |
Collapse
|
19
|
Ortiz A, Galán CDA, Carlos Fernández-García J, Cerezo JG, Ochoa RI, Núñez J, Gutiérrez FP, Navarro-González JF. Consensus document on the management of hyperkalemia. Nefrologia 2023; 43:765-782. [PMID: 38169239 DOI: 10.1016/j.nefroe.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 01/05/2024] Open
Abstract
Hyperkalaemia is a common electrolyte imbalance with potentially serious short-, medium- and long-term consequences on morbidity and mortality rates and the use of national health service resources. The fact that different medical specialities can manage hyperkalaemia makes it important to have a unified approach, and the recent availability of new specific drug treatments means that the approach needs to be updated. This consensus document from the scientific societies most directly involved in the management of hyperkalaemia (Sociedad Española de Cardiología [Spanish Society of Cardiology], Sociedad Española de Endocrinología y Nutrición [Spanish Society of Endocrinology and Nutrition], Sociedad Española de Medicina Interna [Spanish Society of Internal Medicine], Sociedad Española de Medicina de Urgencias y Emergencias [Spanish Society of Accident and Emergency Medicine] and Sociedad Española de Nefrología [Spanish Society of Nephrology]) first of all reviews basic aspects of potassium balance and blood potassium. Then it goes on to focus on the concept, epidemiology, pathophysiology and diagnostic and therapeutic approaches to hyperkalaemia. The available evidence and the main published studies have been reviewed with the aim of providing a useful tool in the multidisciplinary approach to patients with hyperkalaemia.
Collapse
Affiliation(s)
| | | | | | | | - Rosa Ibán Ochoa
- Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), Spain
| | - Julio Núñez
- Sociedad Española de Cardiología (SEC), Spain
| | | | | |
Collapse
|
20
|
Mohebbi N, Ritter A. Bicarbonate ineffectiveness for kidney transplant - Authors' reply. Lancet 2023; 402:1528. [PMID: 37898532 DOI: 10.1016/s0140-6736(23)01624-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/02/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Nilufar Mohebbi
- Division of Nephrology, University Hospital, Zurich 8091, Switzerland.
| | - Alexander Ritter
- Division of Nephrology, University Hospital, Zurich 8091, Switzerland
| |
Collapse
|
21
|
Wang YC, Ling XC, Tsai WH, Liu JS, Kuo KL. Risks of Topical Carbonic Anhydrase Inhibitors in Glaucoma Patients With Chronic Kidney Disease: A Nationwide Population-Based Study. Am J Ophthalmol 2023; 253:49-55. [PMID: 37149244 DOI: 10.1016/j.ajo.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 04/27/2023] [Accepted: 05/01/2023] [Indexed: 05/08/2023]
Abstract
PURPOSE To investigate the risks of metabolic acidosis and renal outcomes after topical carbonic anhydrase inhibitor (CAI) use in patients with both primary open-angle glaucoma (POAG) and advanced chronic kidney disease (CKD). DESIGN Nationwide, population-based cohort study. METHODS This study was conducted with population data from Taiwan's National Health Insurance (NHI) Research Database between January 2000 and June 2009. Patients with advanced CKD who were diagnosed with glaucoma (International Classification of Diseases, Ninth Revision [ICD-9] code 365) and had been receiving eye drops for glaucoma (including carbonic anhydrase inhibitors selected by NHI drug code) were enrolled. Using Kaplan-Meier methods, we compared the cumulative incidence of mortality, long-term dialysis, and cumulative incidence of metabolic acidosis over time between CAI users and CAI non-users. Primary outcomes comprised mortality, renal outcome (progression to hemodialysis), and metabolic acidosis. RESULTS In this cohort, topical CAI users had a higher incidence of long-term dialysis than non-users (incidence = 1,216.85 vs 764.17 events per 100 patient-years; adjusted hazard ratio = 1.17, 95% CI = 1.01-1.37). Hospital admissions due to metabolic acidosis were higher in CAI users compared with non-users (incidence = 21.54 vs 11.87 events per 100 patient-years; adjusted hazard ratio = 1.89, 95% CI = 1.07-3.36). CONCLUSIONS Topical CAIs may be associated with higher risks of long-term dialysis and metabolic acidosis in patients with POAG and pre-dialysis advanced CKD. Therefore, topical CAIs should be used with caution in advanced CKD patients.
Collapse
Affiliation(s)
- Yi-Chun Wang
- From the Division of Nephrology (Y.-C.W., K.-L.K.), Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan; School of Medicine (Y.-C.W., W.-H.T., K.-L.K.), Buddhist Tzu Chi University, Hualien, Taiwan
| | - Xiao Chun Ling
- Department of Ophthalmology (X.C.L.), Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Wen-Hsin Tsai
- School of Medicine (Y.-C.W., W.-H.T., K.-L.K.), Buddhist Tzu Chi University, Hualien, Taiwan; Department of Pediatrics (W.-H.T.), Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Jia-Sin Liu
- Department of Public Health (J.-S.L.), Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ko-Lin Kuo
- From the Division of Nephrology (Y.-C.W., K.-L.K.), Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan; School of Medicine (Y.-C.W., W.-H.T., K.-L.K.), Buddhist Tzu Chi University, Hualien, Taiwan; School of Post-Baccalaureate Chinese Medicine (K.-L.K.), Tzu Chi University, Hualien, Taiwan.
| |
Collapse
|
22
|
Stompór T, Adamczak M, Kurnatowska I, Naumnik B, Nowicki M, Tylicki L, Winiarska A, Krajewska M. Pharmacological Nephroprotection in Non-Diabetic Chronic Kidney Disease-Clinical Practice Position Statement of the Polish Society of Nephrology. J Clin Med 2023; 12:5184. [PMID: 37629226 PMCID: PMC10455736 DOI: 10.3390/jcm12165184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/03/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Chronic kidney disease (CKD) is a modern epidemic worldwide. Introducing renin-angiotensin system (RAS) inhibitors (i.e., ACEi or ARB) not only as blood-pressure-lowering agents, but also as nephroprotective drugs with antiproteinuric potential was a milestone in the therapy of CKD. For decades, this treatment remained the only proven strategy to slow down CKD progression. This situation changed some years ago primarily due to the introduction of drugs designed to treat diabetes that turned into nephroprotective strategies not only in diabetic kidney disease, but also in CKD unrelated to diabetes. In addition, several drugs emerged that precisely target the pathogenetic mechanisms of particular kidney diseases. Finally, the role of metabolic acidosis in CKD progression (and not only the sequelae of CKD) came to light. In this review, we aim to comprehensively discuss all relevant therapies that slow down the progression of non-diabetic kidney disease, including the lowering of blood pressure, through the nephroprotective effects of ACEi/ARB and spironolactone independent from BP lowering, as well as the role of sodium-glucose co-transporter type 2 inhibitors, acidosis correction and disease-specific treatment strategies. We also briefly address the therapies that attempt to slow down the progression of CKD, which did not confirm this effect. We are convinced that our in-depth review with practical statements on multiple aspects of treatment offered to non-diabetic CKD fills the existing gap in the available literature. We believe that it may help clinicians who take care of CKD patients in their practice. Finally, we propose the strategy that should be implemented in most non-diabetic CKD patients to prevent disease progression.
Collapse
Affiliation(s)
- Tomasz Stompór
- Department of Nephrology, Hypertension and Internal Medicine, University of Warmia and Mazury in Olsztyn, 10-516 Olsztyn, Poland
| | - Marcin Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, 40-027 Katowice, Poland
| | - Ilona Kurnatowska
- Department of Internal Diseases and Transplant Nephrology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Beata Naumnik
- Ist Department of Nephrology and Transplantation with Dialysis Unit, Medical University of Bialystok, Zurawia 14 St., 15-540 Bialystok, Poland
| | - Michał Nowicki
- Department of Nephrology, Hypertension and Kidney Transplantation, Central University Hospital, Medical University of Lodz, 92-213 Lodz, Poland
| | - Leszek Tylicki
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdansk, 80-952 Gdansk, Poland
| | - Agata Winiarska
- Department of Nephrology, Hypertension and Internal Medicine, University of Warmia and Mazury in Olsztyn, 10-516 Olsztyn, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland;
| |
Collapse
|
23
|
Mirioglu S, Frangou E. Sodium bicarbonate in kidney transplant recipients: do some apples a day keep the doctor away? Clin Kidney J 2023; 16:1211-1212. [PMID: 37529649 PMCID: PMC10387388 DOI: 10.1093/ckj/sfad117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Indexed: 08/03/2023] Open
Affiliation(s)
- Safak Mirioglu
- Correspondence to: Safak Mirioglu; E-mail: ; Twitter handle: @smirioglu
| | - Eleni Frangou
- Department of Nephrology, Limassol General Hospital, State Health Services Organization, Limassol, Cyprus
- University of Nicosia Medical School, Nicosia, Cyprus
| |
Collapse
|
24
|
Pao AC, Shahzad SR, Song S, Ganesan C, Conti S, Leppert J, Cheung AK, Ix JH, Isakova T, Wolf M, Raj DS, Sprague SM, Fried LF, Gassman J, Fong P, Koike S, Raphael KL. Response to Alkali Administration in Women and Men With and Without CKD. Kidney Med 2023; 5:100670. [PMID: 37492113 PMCID: PMC10363557 DOI: 10.1016/j.xkme.2023.100670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Affiliation(s)
- Alan C. Pao
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
- Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Sheikh R. Shahzad
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Shen Song
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Simon Conti
- Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - John Leppert
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
- Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Alfred K. Cheung
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Joachim H. Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego School of Medicine, San Diego, California
| | - Tamara Isakova
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Dominic S. Raj
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
| | - Stuart M. Sprague
- Department of Medicine, Northshore University Health System, University of Chicago, Evanston, Illinois
| | - Linda F. Fried
- Department of Medicine, University of Pittsburgh and Renal Section, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| | - Jennifer Gassman
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Peter Fong
- Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University School of Medicine, Portland, Oregon
| | - Seiji Koike
- Biostatistics and Design Program, Oregon Health and Science University, Portland, Oregon
| | - Kalani L. Raphael
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| |
Collapse
|
25
|
Richards E, Ye SH, Ash SR, Li L. A Perfluorocarbon-Coated ZrP Cation Exchanger with Excellent Ammonium Selectivity and Chemical Stability: An Oral Sorbent for End-Stage Kidney Disease (ESKD). LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2023. [PMID: 37227933 DOI: 10.1021/acs.langmuir.3c00753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
An oral sorbent to remove NH4+ within the small intestine of end-stage kidney disease (ESKD) patients could reduce blood urea levels and diminish their dialysis treatment burden. But current sorbent materials like amorphous zirconium phosphate particles Zr(HPO4)2·H2O (ZrP) lack the selectivity to remove NH4+ in water solution with other competing ions. Our previous work found that a gas-permeable, hydrophobic polydimethylsiloxane (PDMS) coating on ZrP improved the material's selectivity for NH4+. However, a competing ion Ca2+ was still removed by PDMS-coated ZrP sorbent, and the permeability of the PDMS coating to Ca2+ was increased after low-pH stomach-like condition exposure. An alternative hydrophobic and gas permeable coating has been investigated─perfluorooctyltriethoxysilane (FOTS). The coating was attached in place of PDMS to a tetraethyl orthosilicate-coated ZrP surface. Surface atomic composition analysis and scanning electron microscopy observation verified the successful application of the FOTS coating. Water contact angle analysis validated the FOTS coating was hydrophobic (145.0 ± 3.2°). In vitro competing ion studies indicated the FOTS coating attached to ZrP increased NH4+ removal by 53% versus uncoated ZrP. FOTS offers complete selectivity for NH4+ over Ca2+ with similar NH4+ capacity as the previous PDMS coating. Moreover, FOTS-coated ZrP maintained NH4+ removal capacity and selectivity after the acid exposure study, indicating excellent acid resistance while NH4+ selectivity of ZrP-PDMS decreased by 72%. The results suggested that FOTS-coated ZrP is promising as an oral sorbent for ESKD patients.
Collapse
Affiliation(s)
- Evan Richards
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - Sang-Ho Ye
- McGowan Institute for Regenerative Medicine, Pittsburgh, Pennsylvania 15219, United States
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - Stephen R Ash
- CEO, HemoCleanse Technologies, LLC, Lafayette, Indiana 47904, United States
| | - Lei Li
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| |
Collapse
|
26
|
Cheng YL, Huang SC, Ho MY, Li YR, Yen CL, Chen KH, Sun WC, Fan PY, Chen JS, Lin C, Hsiao CC. Effect of sodium bicarbonate on cardiovascular outcome and mortality in patients with advanced chronic kidney disease. Front Pharmacol 2023; 14:1146668. [PMID: 37251318 PMCID: PMC10213883 DOI: 10.3389/fphar.2023.1146668] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/20/2023] [Indexed: 05/31/2023] Open
Abstract
Background: Metabolic acidosis is a common complication in patients with chronic kidney disease (CKD). Oral sodium bicarbonate is often used to treat metabolic acidosis and prevent CKD progression. However, there is limited information about the effect of sodium bicarbonate on major adverse cardiovascular events (MACE) and mortality in patients with pre-dialysis advanced CKD. Method: 25599 patients with CKD stage V between January 1, 2001 and December 31, 2019 were identified from the Chang Gung Research Database (CGRD), a multi-institutional electronic medical record database in Taiwan. The exposure was defined as receiving sodium bicarbonate or not. Baseline characteristics were balanced using propensity score weighting between two groups. Primary outcomes were dialysis initiation, all-cause mortality, and major adverse cardiovascular events (MACE) (myocardial infarction, heart failure, stroke). The risks of dialysis, MACE, and mortality were compared between two groups using Cox proportional hazards models. In addition, we performed analyzes using Fine and Gray sub-distribution hazard models that considered death as a competing risk. Result: Among 25599 patients with CKD stage V, 5084 patients (19.9%) were sodium bicarbonate users while 20515 (80.1%) were sodium bicarbonate non-users. The groups had similar risk of dialysis initiation (hazard ratio (HR): 0.98, 95% confidence interval (CI): 0.95-1.02, p < 0.379). However, taking sodium bicarbonate was associated with a significantly lower risks of MACE (HR: 0.95, 95% CI 0.92-0.98, p < 0.001) and hospitalizations for acute pulmonary edema (HR: 0.92, 95% CI 0.88-0.96, p < 0.001) compared with non-users. The mortality risks were significantly lower in sodium bicarbonate users compared with sodium bicarbonate non-users (HR: 0.75, 95% CI 0.74-0.77, p < 0.001). Conclusion: This cohort study revealed that in real world practice, use of sodium bicarbonate was associated with similar risk of dialysis compared with non-users among patients with advanced CKD stage V. Nonetheless, use of sodium bicarbonate was associated with significantly lower rate of MACE and mortality. Findings reinforce the benefits of sodium bicarbonate therapy in the expanding CKD population. Further prospective studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Ya-Lien Cheng
- Kidney Research Center and Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shu-Chun Huang
- Department of Physical Medicine and Rehabilitation, New Taipei Municipal Tucheng Hospital, Chang Gung Memorial Hospital, New Taipei, Taiwan
| | - Ming-Yun Ho
- Division of Cardiology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yan-Rong Li
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chieh-Li Yen
- Kidney Research Center and Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuan-Hsing Chen
- Kidney Research Center and Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Chiao Sun
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Nephrology, New Taipei Municipal Tucheng Hospital, New Taipei, Taiwan
| | - Pei-Yi Fan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Nephrology, New Taipei Municipal Tucheng Hospital, New Taipei, Taiwan
| | - Jung-Sheng Chen
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Chihung Lin
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Ching-Chung Hsiao
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Nephrology, New Taipei Municipal Tucheng Hospital, New Taipei, Taiwan
| |
Collapse
|
27
|
Beynon-Cobb B, Louca P, Hoorn EJ, Menni C, Padmanabhan S. Effect of Sodium Bicarbonate on Systolic Blood Pressure in CKD: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol 2023; 18:435-445. [PMID: 36758154 PMCID: PMC10103210 DOI: 10.2215/cjn.0000000000000119] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Individuals with CKD are at a higher risk of cardiovascular morbidity and mortality. Acidosis is positively correlated with CKD progression and elevated systolic BP. Sodium bicarbonate is an efficacious treatment of acidosis, although this may also increase systolic BP. In this systematic review and meta-analysis, we summarize the evidence evaluating systolic BP and antihypertensive medication change (which may indicate systolic BP change) in response to sodium bicarbonate therapy in individuals with CKD. METHODS Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Cochrane Central Register of Controlled Trials, and World Health Organization (WHO) trials registry databases were searched for randomized control trials where sodium bicarbonate was compared with placebo/usual care in CKD stage G1-5 non-dialysis-dependent populations. Random effects meta-analyses were used to evaluate changes in systolic BP and BP-modifying drugs after sodium bicarbonate intervention. RESULTS Fourteen randomized control trials (2110 individuals, median follow-up 27 [interquartile range 97] weeks, mean age 60 [SD 10] years, mean systolic BP 136 [SD 17] mm Hg, mean eGFR 38 [SD 10] ml/min, mean serum bicarbonate 22 [SD 4] mmol/L) were eligible for inclusion. Meta-analysis suggested that sodium bicarbonate did not influence systolic BP in individuals with CKD stage G1-5. Results were consistent when stratifying by dose of sodium bicarbonate or duration of intervention. Similarly, there was no significant increase in the use of antihypertensive medication or diuretics in individuals taking sodium bicarbonate, whereas there was a greater decrease in antihypertensive medication use in individuals taking sodium bicarbonate compared with controls. CONCLUSIONS Our results suggest, with moderate certainty, that sodium bicarbonate supplementation does not adversely affect systolic BP in CKD or negatively influence antihypertensive medication requirements.
Collapse
Affiliation(s)
- Beverley Beynon-Cobb
- Department of Nutrition & Dietetics, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
- Department of Twin Research and Genetic Epidemiology, King's College London, London, United Kingdom
| | - Panayiotis Louca
- Department of Twin Research and Genetic Epidemiology, King's College London, London, United Kingdom
| | - Ewout J. Hoorn
- Department of Internal Medicine, Divisions of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Cristina Menni
- Department of Twin Research and Genetic Epidemiology, King's College London, London, United Kingdom
| | - Sandosh Padmanabhan
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| |
Collapse
|
28
|
Humphries TLR, Vesey DA, Galloway GJ, Gobe GC, Francis RS. Identifying disease progression in chronic kidney disease using proton magnetic resonance spectroscopy. PROGRESS IN NUCLEAR MAGNETIC RESONANCE SPECTROSCOPY 2023; 134-135:52-64. [PMID: 37321758 DOI: 10.1016/j.pnmrs.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/16/2023] [Accepted: 04/01/2023] [Indexed: 06/17/2023]
Abstract
Chronic kidney disease (CKD) affects approximately 10% of the world population, higher still in some developing countries, and can cause irreversible kidney damage eventually leading to kidney failure requiring dialysis or kidney transplantation. However, not all patients with CKD will progress to this stage, and it is difficult to distinguish between progressors and non-progressors at the time of diagnosis. Current clinical practice involves monitoring estimated glomerular filtration rate and proteinuria to assess CKD trajectory over time; however, there remains a need for novel, validated methods that differentiate CKD progressors and non-progressors. Nuclear magnetic resonance techniques, including magnetic resonance spectroscopy and magnetic resonance imaging, have the potential to improve our understanding of CKD progression. Herein, we review the application of magnetic resonance spectroscopy both in preclinical and clinical settings to improve the diagnosis and surveillance of patients with CKD.
Collapse
Affiliation(s)
- Tyrone L R Humphries
- Kidney Disease Research Collaborative, University of Queensland and Translational Research Institute, Brisbane, Queensland 4102, Australia; Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland 4102, Australia.
| | - David A Vesey
- Kidney Disease Research Collaborative, University of Queensland and Translational Research Institute, Brisbane, Queensland 4102, Australia; Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland 4102, Australia
| | - Graham J Galloway
- Kidney Disease Research Collaborative, University of Queensland and Translational Research Institute, Brisbane, Queensland 4102, Australia
| | - Glenda C Gobe
- Kidney Disease Research Collaborative, University of Queensland and Translational Research Institute, Brisbane, Queensland 4102, Australia
| | - Ross S Francis
- Kidney Disease Research Collaborative, University of Queensland and Translational Research Institute, Brisbane, Queensland 4102, Australia; Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland 4102, Australia
| |
Collapse
|
29
|
Melamed ML, Raphael KL. Safety of Alkalinization in CKD. Clin J Am Soc Nephrol 2023; 18:433-434. [PMID: 37026750 PMCID: PMC10103364 DOI: 10.2215/cjn.0000000000000130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Affiliation(s)
- Michal L. Melamed
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Kalani L. Raphael
- Department of Internal Medicine, University of Utah Health and VA Salt Lake City Health Care System, Salt Lake City, Utah
| |
Collapse
|
30
|
Bardhi O, Clegg DJ, Palmer BF. The Role of Dietary Potassium in the Cardiovascular Protective Effects of Plant-Based Diets. Semin Nephrol 2023; 43:151406. [PMID: 37544060 DOI: 10.1016/j.semnephrol.2023.151406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Dietary intervention is an essential factor in managing a multitude of chronic health conditions such as cardiovascular and chronic kidney disease. In recent decades, there has been a host of research suggesting the potential benefit of plant-based diets in mitigating the health outcomes of these conditions. Plant-based diets are rich in vegetables and fruits, while limiting processed food and animal protein sources. The underlying physiological mechanism involves the interaction of several macronutrients and micronutrients such as plant protein, carbohydrates, and dietary potassium. Specifically, plant-based foods rich in potassium provide cardiorenal protective effects to include urinary alkalization and increased sodium excretion. These diets induce adaptive physiologic responses that improve kidney and cardiovascular hemodynamics and improve overall metabolic health. A shift toward consuming plant-based diets even in subjects with cardiorenal decrements may reduce their morbidity and mortality. Nonetheless, randomized controlled trials are needed to confirm the clinical benefits of plant-based diets.
Collapse
Affiliation(s)
- Olgert Bardhi
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Deborah J Clegg
- Department of Internal Medicine, Texas Tech Health Sciences Center, El Paso, TX
| | - Biff F Palmer
- Department of Internal Medicine, Texas Tech Health Sciences Center, El Paso, TX; Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
| |
Collapse
|
31
|
The mechanisms of alkali therapy in targeting renal diseases. Biochem Soc Trans 2023; 51:223-232. [PMID: 36744634 DOI: 10.1042/bst20220690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/28/2022] [Accepted: 01/19/2023] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease (CKD) is characterized by progressive reduction in kidney function and treatments aiming at stabilizing or slowing its progression may avoid or delay the necessity of kidney replacement therapy and the increased mortality associated with reduced kidney function. Metabolic acidosis, and less severe stages of the acid stress continuum, are common consequences of CKD and some interventional studies support that its correction slows the progression to end-stage kidney disease. This correction can be achieved with mineral alkali in the form of bicarbonate or citrate salts, ingestion of diets with fewer acid-producing food components or more base-producing food components, or a pharmacological approach. In this mini-review article, we summarize the potential mechanisms involved in the beneficial effects of alkali therapy. We also discuss the perspectives in the field and challenges that must be overcome to advance our understanding of such mechanisms.
Collapse
|
32
|
Zhang S, Yang Y, Liu W, Yuan B, Tao C, Dou G. Effects of Nursing Care Using a Fast-Track Surgery Approach in 49 Patients with Early-Stage Hepatocellular Carcinoma Undergoing First-Line Treatment with Radiofrequency Ablation: A Retrospective Study. Med Sci Monit 2023; 29:e939044. [PMID: 36823968 PMCID: PMC9972691 DOI: 10.12659/msm.939044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Fast-track surgery (FTS), also known as enhanced recovery after surgery (ERAS), includes a coordinated perioperative approach to patient care that aims to facilitate postoperative recovery. The role of nursing care is central to the concept of FTS. This retrospective study aimed to evaluate the effects of nursing care using an FTS approach in 49 patients with early-stage hepatocellular carcinoma (HCC) undergoing first-line treatment with radiofrequency ablation (RFA). MATERIAL AND METHODS A retrospective analysis was made of 49 patients with early-stage hepatocellular carcinoma who underwent first-line treatment with radiofrequency ablation in the Department of Hepatobiliary Surgery in our hospital from January 2020 to December 2021. The nurses have been nursing the patients in accordance with the requirements of FTS from 2021. Compared with the data of patients receiving traditional nursing, the detailed differences in postoperative recovery, pain score, complication rate, liver and kidney function, and nursing satisfaction were analyzed. RESULTS After applying the FTS nursing model, the patients had significantly shorter time to first flatus, infusion, postoperative hospital stay, and lower total hospitalization expenses (P<0.05). Moreover, the Numerical Pain Rating Scale score was lower than that in the control group, the postoperative complications in the 2021 group were lower than those in the 2020 group, and the nursing satisfaction was also better than that of the 2020 group (P<0.05). CONCLUSIONS Nursing care using a fast-track surgery approach with early-stage hepatocellular carcinoma patients undergoing first-line treatment with radiofrequency ablation is better than conventional nursing, and improves recovery of patients.
Collapse
Affiliation(s)
- Shuqi Zhang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Jiaxing University, Jiaxin, Zhejiang, China (mainland)
| | - Yanting Yang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Jiaxing University, Jiaxin, Zhejiang, China (mainland)
| | - Wen Liu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Jiaxing University, Jiaxin, Zhejiang, China (mainland)
| | - Bijin Yuan
- Department of Gastrointestinal Surgery, Affiliated Hospital of Jiaxing University, Jiaxin, Zhejiang, China (mainland)
| | - Chunyan Tao
- Department of Gastrointestinal Surgery, Affiliated Hospital of Jiaxing University, Jiaxin, Zhejiang, China (mainland)
| | - Guangjian Dou
- Department of Gastrointestinal Surgery, Affiliated Hospital of Jiaxing University, Jiaxin, Zhejiang, China (mainland)
| |
Collapse
|
33
|
Budde K, Halleck F. Six pills less: no benefit for bicarbonate supplementation in renal allograft recipients. Lancet 2023; 401:526-527. [PMID: 36708731 DOI: 10.1016/s0140-6736(22)02630-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 12/15/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany.
| | - Fabian Halleck
- Department of Nephrology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| |
Collapse
|
34
|
Mohebbi N, Ritter A, Wiegand A, Graf N, Dahdal S, Sidler D, Arampatzis S, Hadaya K, Mueller TF, Wagner CA, Wüthrich RP. Sodium bicarbonate for kidney transplant recipients with metabolic acidosis in Switzerland: a multicentre, randomised, single-blind, placebo-controlled, phase 3 trial. Lancet 2023; 401:557-567. [PMID: 36708734 DOI: 10.1016/s0140-6736(22)02606-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/17/2022] [Accepted: 12/13/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Metabolic acidosis is common in kidney transplant recipients and is associated with declining graft function. Sodium bicarbonate treatment effectively corrects metabolic acidosis, but no prospective studies have examined its effect on graft function. Therefore, we aimed to test whether sodium bicarbonate treatment would preserve graft function and slow the progression of estimated glomerular filtration rate (GFR) decline in kidney transplant recipients. METHODS The Preserve-Transplant Study was a multicentre, randomised, single-blind, placebo-controlled, phase 3 trial at three University Hospitals in Switzerland (Zurich, Bern, and Geneva), which recruited adult (aged ≥18 years) male and female long-term kidney transplant recipients if they had undergone transplantation more than 1 year ago. Key inclusion criteria were an estimated GFR between 15 mL/min per 1·73 m2 and 89 mL/min per 1·73 m2, stable allograft function in the last 6 months before study inclusion (<15% change in serum creatinine), and a serum bicarbonate of 22 mmol/L or less. We randomly assigned patients (1:1) to either oral sodium bicarbonate 1·5-4·5 g per day or matching placebo using web-based data management software. Randomisation was stratified by study centre and gender using a permuted block design to guarantee balanced allocation. We did multi-block randomisation with variable block sizes of two and four. Treatment duration was 2 years. Acid-resistant soft gelatine capsules of 500 mg sodium bicarbonate or matching 500 mg placebo capsules were given at an initial dose of 500 mg (if bodyweight was <70 kg) or 1000 mg (if bodyweight was ≥70 kg) three times daily. The primary endpoint was the estimated GFR slope over the 24-month treatment phase. The primary efficacy analyses were applied to a modified intention-to-treat population that comprised all randomly assigned participants who had a baseline visit. The safety population comprised all participants who received at least one dose of study drug. The trial is registered with ClinicalTrials.gov, NCT03102996. FINDINGS Between June 12, 2017, and July 10, 2019, 1114 kidney transplant recipients with metabolic acidosis were assessed for trial eligibility. 872 patients were excluded and 242 were randomly assigned to the study groups (122 [50%] to the placebo group and 120 [50%] to the sodium bicarbonate group). After secondary exclusion of two patients, 240 patients were included in the intention-to-treat analysis. The calculated yearly estimated GFR slopes over the 2-year treatment period were a median -0·722 mL/min per 1·73 m2 (IQR -4·081 to 1·440) and mean -1·862 mL/min per 1·73 m2 (SD 6·344) per year in the placebo group versus median -1·413 mL/min per 1·73 m2 (IQR -4·503 to 1·139) and mean -1·830 mL/min per 1·73 m2 (SD 6·233) per year in the sodium bicarbonate group (Wilcoxon rank sum test p=0·51; Welch t-test p=0·97). The mean difference was 0·032 mL/min per 1·73 m2 per year (95% CI -1·644 to 1·707). There were no significant differences in estimated GFR slopes in a subgroup analysis and a sensitivity analysis confirmed the primary analysis. Although the estimated GFR slope did not show a significant difference between the treatment groups, treatment with sodium bicarbonate effectively corrected metabolic acidosis by increasing serum bicarbonate from 21·3 mmol/L (SD 2·6) to 23·0 mmol/L (2·7) and blood pH from 7·37 (SD 0·06) to 7·39 (0·04) over the 2-year treatment period. Adverse events and serious adverse events were similar in both groups. Three study participants died. In the placebo group, one (1%) patient died from acute respiratory distress syndrome due to SARS-CoV-2 and one (1%) from cardiac arrest after severe dehydration following diarrhoea with hypotension, acute kidney injury, and metabolic acidosis. In the sodium bicarbonate group, one (1%) patient had sudden cardiac death. INTERPRETATION In adult kidney transplant recipients, correction of metabolic acidosis by treatment with sodium bicarbonate over 2 years did not affect the decline in estimated GFR. Thus, treatment with sodium bicarbonate should not be generally recommended to preserve estimated GFR (a surrogate marker for graft function) in kidney transplant recipients with chronic kidney disease who have metabolic acidosis. FUNDING Swiss National Science Foundation.
Collapse
Affiliation(s)
- Nilufar Mohebbi
- Division of Nephrology, University Hospital, Zurich, Switzerland.
| | - Alexander Ritter
- Division of Nephrology, University Hospital, Zurich, Switzerland
| | - Anna Wiegand
- Division of Nephrology, University Hospital, Zurich, Switzerland
| | | | - Suzan Dahdal
- Division of Nephrology and Hypertension, Inselspital, Bern, Switzerland
| | - Daniel Sidler
- Division of Nephrology and Hypertension, Inselspital, Bern, Switzerland
| | | | - Karine Hadaya
- Division of Nephrology and Hypertension, University Hospital, Geneva, Switzerland
| | - Thomas F Mueller
- Division of Nephrology, University Hospital, Zurich, Switzerland
| | - Carsten A Wagner
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | | |
Collapse
|
35
|
Alvarez MR, Alarcon JM, Roman CA, Lazaro D, Bobrowski-Khoury N, Baena-Caldas GP, Esber GR. Can a basic solution activate the inflammatory reflex? A review of potential mechanisms, opportunities, and challenges. Pharmacol Res 2023; 187:106525. [PMID: 36441036 DOI: 10.1016/j.phrs.2022.106525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/09/2022] [Accepted: 10/25/2022] [Indexed: 11/24/2022]
Abstract
Stimulation of the inflammatory reflex (IR) is a promising strategy to treat systemic inflammatory disorders. However, this strategy is hindered by the cost and side effects of traditional IR activators. Recently, oral intake of sodium bicarbonate (NaHCO3) has been suggested to activate the IR, providing a safe and inexpensive alternative. Critically, the mechanisms whereby NaHCO3 might achieve this effect and more broadly the pathways underlying the IR remain poorly understood. Here, we argue that the recognition of NaHCO3 as a potential IR activator presents exciting clinical and research opportunities. To aid this quest, we provide an integrative review of our current knowledge of the neural and cellular pathways mediating the IR and discuss the status of physiological models of IR activation. From this vantage point, we derive testable hypotheses on potential mechanisms whereby NaHCO3 might stimulate the IR and compare NaHCO3 with classic IR activators. Elucidation of these mechanisms will help determine the therapeutic value of NaHCO3 as an IR activator and provide new insights into the IR circuitry.
Collapse
Affiliation(s)
- Milena Rodriguez Alvarez
- Department of Internal Medicine, Division of Rheumatology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA.
| | - Juan Marcos Alarcon
- Department of Pathology, The Robert F. Furchgott Center for Neural and Behavioral Science, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Christopher A Roman
- Department of Cell Biology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Deana Lazaro
- Division of Rheumatology, Department of Internal Medicine, Veterans Affairs New York Harbor Healthcare System, Brooklyn, NY, USA
| | | | | | | |
Collapse
|
36
|
Serum Bicarbonate and Graft and Patient Outcomes Among Kidney Transplant Recipients: A Retrospective Cohort Study Evaluating Changes in Serum Bicarbonate Over Time. Kidney Med 2022; 5:100573. [PMID: 36683962 PMCID: PMC9850186 DOI: 10.1016/j.xkme.2022.100573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Rationale & Objective Identification of treatable risk factors for kidney allograft failure is necessary to improve graft longevity. Metabolic acidosis with either low serum bicarbonate or normal serum bicarbonate (eubicarbonatemic metabolic acidosis) is implicated in native kidney disease progression but its effects in kidney transplant recipients are unclear. Study Design Retrospective cohort study. Setting & Participants An Integrated Claims-Clinical dataset of US patients with chronic kidney disease (estimated glomerular filtration rates <60 mL/min/1.73 m2) and serum bicarbonate data were used to generate a cohort of kidney transplant recipients with data from ≥1 year before and after transplantation. Primary Predictor The primary independent variable was a change in serum bicarbonate from baseline. Outcomes The primary outcomes were graft failure and all-cause mortality. The secondary outcomes were major adverse cardiac events and all-cause hospitalization. Analytical Approach We used adjusted time-dependent Cox proportional hazards models to assess the risk of graft failure, all-cause mortality, major adverse cardiac events, and time to first hospitalization. Results In this US community-based cohort of 1,915 kidney transplant recipients with a median follow-up of ∼2.5 years, each 1-mEq/L increase in serum bicarbonate was associated with significantly lower hazard of graft loss, death, major adverse cardiac events, and hospitalization by 10%, 8%, 4%, and 8%, respectively. Limitations Possible residual confounding. Conclusions In a US community-based population of kidney transplant recipients, even small incremental increases in serum bicarbonate (1 mEq/L) were significantly associated with reduced hazard of graft loss, all-cause mortality, cardiovascular events, and hospitalization. Interventional trials evaluating the potential benefits of treating metabolic acidosis in kidney transplant recipients are warranted.
Collapse
|
37
|
Wanner C, Fioretto P, Kovesdy CP, Malyszko J, Pecoits‐Filho R, Schnell O, Rossignol P. Potassium management with finerenone: Practical aspects. Endocrinol Diabetes Metab 2022; 5:e360. [PMID: 36574588 PMCID: PMC9659654 DOI: 10.1002/edm2.360] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/10/2022] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist, has favourable effects on cardiorenal outcomes in patients with mild-to-severe chronic kidney disease with increased albuminuria and type 2 diabetes. METHODS Two large, randomized trials have evaluated the effects of finerenone on clinical outcomes. The first trial (FIDELIO-DKD) investigated renal outcomes, and the second (FIGARO-DKD) cardiovascular outcomes. RESULTS Patients in the two studies had a high intrinsic risk of hyperkalemia due to type 2 diabetes, treatment with optimized doses of an inhibitor of the renin-angiotensin system, and, in some patients, their advanced chronic kidney disease. This was reflected in the incidence of hyperkalemia in the placebo group during the trials. Patients on finerenone had a significantly higher incidence of hyperkalemia compared with patients on placebo, but treatment discontinuation due to hyperkalemia was low, and no patients experienced death attributable to hyperkalemia. Structured routine potassium monitoring with temporary treatment interruption and dose reduction, as used in the two trials, should ensure the safe use of finerenone to protect the kidneys and cardiovascular system of patients with albuminuric chronic kidney disease and type 2 diabetes. CONCLUSIONS The aim of this document is to highlight the routine potassium management required when using finerenone and to provide practical recommendations.
Collapse
Affiliation(s)
| | | | - Csaba P. Kovesdy
- Department of MedicineUniversity of Tennessee Health Science CenterMemphisTennesseeUSA
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal MedicineMedical University of WarsawWarsawPoland
| | - Roberto Pecoits‐Filho
- School of MedicinePontifical Catholic University of ParanáCuritibaBrazil
- DOPPS Program Area, Arbor Research Collaborative for HealthAnn ArborMichiganUSA
| | - Oliver Schnell
- Sciarc GmbHBaierbrunnGermany
- Forschergruppe Diabetes e. V.Neuherberg (Munich)Germany
| | - Patrick Rossignol
- Université de LorraineINSERM CIC‐P 1433, CHRU de Nancy, INSERM U1116, F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists)NancyFrance
- Department of Medical specialties and Nephrology‐HemodialysisPrincess Grace Hospital, Monaco, and Centre d'Hémodialyse Privé de MonacoMonaco
| |
Collapse
|
38
|
New mechanisms for the kidney-protective effect of alkali in chronic kidney disease. Clin Sci (Lond) 2022; 136:1433-1437. [DOI: 10.1042/cs20220395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 11/17/2022]
Abstract
Abstract
Worldwide, more than one in ten adults are estimated to have chronic kidney disease (CKD). As CKD progresses, both the cost of treatment and associated risk of morbidity and mortality increase exponentially. As such, there is a great need for therapies that effectively slow CKD progression. Evidence from several small clinical trials indicates that alkali therapy may slow the rate of CKD progression. The biological mechanisms underlying this protective effect, however, remain unknown. In their recently published manuscript, Pastor Arroyo et al. (Clin Sci (Lond) (2022) 136(8): https://doi.org/10.1042/CS20220095) demonstrate that the alkali sodium bicarbonate protects against loss of renal function in a crystal nephropathy model in mice. Using unbiased approaches in both mice and human tissue, the authors go on to identify two novel mechanisms that may underly this protection. The first pathway is through promoting pathways of cell metabolism, which they speculate helps the remaining functional nephrons adapt to the greater metabolic needs required to maintain kidney filtration. The second pathway is by restoration of α-Klotho levels, which may limit the expression of adhesion molecules in the injured kidney. This, the authors speculate, may prevent inflammation from driving the functional decline of the kidney. Identifying these novel pathways represents an important step forward harnessing the potential benefits of alkali therapy in CKD.
Collapse
|
39
|
Bicarbonate Effects on Antibacterial Immunity and Mucus Glycobiology in the Cystic Fibrosis Lung: A Review With Selected Experimental Observations. INFECTIOUS MICROBES & DISEASES 2022; 4:103-110. [PMID: 36793929 PMCID: PMC9928163 DOI: 10.1097/im9.0000000000000101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The primary defect in cystic fibrosis (CF) is abnormal chloride and bicarbonate transport in the cystic fibrosis transmembrane conductance regulator (CFTR) epithelial ion channel. The apical surface of the respiratory tract is lined by an airway surface liquid layer (ASL) composed of mucin comprising mainly MUC5A and MUC5B glycoproteins. ASL homeostasis depends on sodium bicarbonate secretion into the airways and secretion deficits alter mucus properties leading to airway obstruction, inflammation, and infections. Downstream effects of abnormal ion transport in the lungs include altered intrinsic immune defenses. We observed that neutrophils killed Pseudomonas aeruginosa more efficiently when it had been exposed to sodium bicarbonate, and formation of neutrophil extracellular traps (NETs) by neutrophils was augmented in the presence of increasing bicarbonate concentrations. Physiological levels of bicarbonate sensitized P. aeruginosa to the antimicrobial peptide cathelicidin LL-37, which is present in both lung ASL and in NETs. Sodium bicarbonate has various uses in clinical medicine and in the care of CF patients, and could be further explored as a therapeutic adjunct against Pseudomonas infections.
Collapse
|
40
|
Goraya N, Narayanan M, Wesson DE. Management of Metabolic Acidosis in Chronic Kidney Disease: Past, Present, and Future Direction. Adv Chronic Kidney Dis 2022; 29:416-423. [PMID: 36175079 DOI: 10.1053/j.ackd.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/20/2022] [Accepted: 02/28/2022] [Indexed: 01/25/2023]
Abstract
Chronic kidney disease (CKD) is a major global epidemic associated with increased morbidity and mortality. Despite the effectiveness of kidney protection strategies of hypertension, diabetes, and lipid control and use of newer hypoglycemic agents and anti-angiotensin II drugs, the nephropathy in CKD continues unabated toward irreversible kidney failure. Thus, interventions targeting modifiable risk factors in CKD such as metabolic acidosis (MA) are needed. Acid reduction with sodium-based alkali has been shown to be an effective kidney-protection strategy for patients with CKD and reduced glomerular filtration rate (GFR). Small-scale studies reveal diets emphasizing ingestion of plant-sourced over animal-sourced protein reduce dietary acid, improve MA, and slow further nephropathy progression in patients with CKD and reduced GFR. Additionally, veverimer, an investigational, nonabsorbed polymer that binds and removes gastrointestinal hydrochloric acid, is being developed as a novel treatment for MA. As further studies define how to best use these interventions for kidney protection, clinicians must become aware of their potential utility in the management of patients with CKD. The aim of the present review is to explore the various intervention strategies that increase or normalize serum [HCO3-] in patients with CKD-associated MA or low normal serum [HCO3-] that may further slow progression of CKD.
Collapse
Affiliation(s)
- Nimrit Goraya
- Scott & White Medical Center-Temple, Division of Nephrology and Hypertension, Department of Medicine, Temple, TX.
| | - Mohanram Narayanan
- Scott & White Medical Center-Temple, Division of Nephrology and Hypertension, Department of Medicine, Temple, TX
| | - Donald E Wesson
- Dell Medical School, The University of Texas at Austin, Austin, TX
| |
Collapse
|
41
|
Ravikumar NPG, Pao AC, Raphael KL. Acid-Mediated Kidney Injury Across the Spectrum of Metabolic Acidosis. Adv Chronic Kidney Dis 2022; 29:406-415. [PMID: 36175078 DOI: 10.1053/j.ackd.2022.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/15/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023]
Abstract
Metabolic acidosis affects about 15% of patients with chronic kidney disease. As kidney function declines, the kidneys progressively fail to eliminate acid, primarily reflected by a decrease in ammonium and titratable acid excretion. Several studies have shown that the net acid load remains unchanged in patients with reduced kidney function; the ensuing acid accumulation can precede overt metabolic acidosis, and thus, indicators of urinary acid or potential base excretion, such as ammonium and citrate, may serve as early signals of impending metabolic acidosis. Acid retention, with or without overt metabolic acidosis, initiates compensatory responses that can promote tubulointerstitial fibrosis via intrarenal complement activation and upregulation of endothelin-1, angiotensin II, and aldosterone pathways. The net effect is a cycle between acid accumulation and kidney injury. Results from small- to medium-sized interventional trials suggest that interrupting this cycle through base administration can prevent further kidney injury. While these findings inform current clinical practice guidelines, large-scale clinical trials are still necessary to prove that base therapy can limit chronic kidney disease progression or associated adverse events.
Collapse
Affiliation(s)
- Naveen P G Ravikumar
- Division of Nephrology & Hypertension, Department of Medicine, Oregon Health & Science University, Portland, OR; Veterans Affairs Portland Health Care System, Portland, OR
| | - Alan C Pao
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Kalani L Raphael
- Division of Nephrology & Hypertension, Department of Medicine, Oregon Health & Science University, Portland, OR; Veterans Affairs Portland Health Care System, Portland, OR.
| |
Collapse
|
42
|
Vincent-Johnson A, Scialla JJ. Importance of Metabolic Acidosis as a Health Risk in Chronic Kidney Disease. Adv Chronic Kidney Dis 2022; 29:329-336. [PMID: 36175070 DOI: 10.1053/j.ackd.2022.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/09/2022] [Accepted: 05/25/2022] [Indexed: 01/25/2023]
Abstract
Human kidneys are well adapted to excrete the daily acid load from diet and metabolism in order to maintain homeostasis. In approximately 30% of patients with more advanced stages of CKD, these homeostatic processes are no longer adequate, resulting in metabolic acidosis. Potential deleterious effects of chronic metabolic acidosis in CKD, including muscle wasting, bone demineralization, hyperkalemia, and more rapid progression of CKD, have been well cataloged. Based primarily upon concerns related to nutrition and bone disease, early Kidney Disease Outcomes Quality Initiative guidelines recommended treating metabolic acidosis with alkali therapy targeting a serum bicarbonate ≥22 mEq/L. More recent guidelines have suggested similar targets based upon potential slowing of CKD progression. However, appropriately powered, long-term, randomized controlled trials to study efficacy and safety of alkali therapy for these outcomes are largely lacking. As a result, practice among physicians varies, underscoring the complexity of treatment of chronic metabolic acidosis in real-world CKD practice. Novel treatment approaches and rigorous phase 3 trials may resolve some of this controversy in the coming years. Metabolic acidosis is an important complication of CKD, and where it "falls" in the priority schema of CKD care will depend upon the generation of strong clinical evidence.
Collapse
Affiliation(s)
- Anita Vincent-Johnson
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Julia J Scialla
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA; Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA.
| |
Collapse
|
43
|
Dobre M. Acidosis in renal disease: should we be concerned? Nephrol Dial Transplant 2022; 37:1043-1045. [DOI: 10.1093/ndt/gfaa309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/21/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mirela Dobre
- Medicine – Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University , Cleveland, OH, USA
| |
Collapse
|
44
|
Cao X, An T, Fu W, Zhang J, Zhao H, Li D, Jin X, Liu B. Genome-Wide Identification of Cellular Pathways and Key Genes That Respond to Sodium Bicarbonate Stress in Saccharomyces cerevisiae. Front Microbiol 2022; 13:831973. [PMID: 35495664 PMCID: PMC9042421 DOI: 10.3389/fmicb.2022.831973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/23/2022] [Indexed: 12/04/2022] Open
Abstract
Sodium bicarbonate (NaHCO3) is an important inorganic salt. It is not only widely used in industrial production and daily life, but is also the main stress in alkaline saline soil. NaHCO3 has a strong ability to inhibit the growth of fungi in both natural environment and daily application. However, the mechanism by which fungi respond to NaHCO3 stress is not fully understood. To further clarify the toxic mechanisms of NaHCO3 stress and identify the specific cellular genes and pathways involved in NaHCO3 resistance, we performed genome-wide screening with NaHCO3 using a Saccharomyces cerevisiae deletion mutant library. A total of 33 deletion mutants with NaHCO3 sensitivity were identified. Compared with wild-type strains, these mutants had significant growth defects in the medium containing NaHCO3. Bioinformatics analysis found that the corresponding genes of these mutants are mainly enriched in the cell cycle, mitophagy, cell wall integrity, and signaling pathways. Further study using transcriptomic analysis showed that 309 upregulated and 233 downregulated genes were only responded to NaHCO3 stress, when compared with yeast transcriptomic data under alkaline and saline stress. Upregulated genes were mainly concentrated in amino acid metabolism, steroid biosynthesis, and cell wall, while downregulated genes were enriched in various cellular metabolisms. In summary, we have identified the cellular pathways and key genes that respond to NaHCO3 stress in the whole genome, providing resource and direction for understanding NaHCO3 toxicity and cellular resistance mechanisms.
Collapse
Affiliation(s)
- Xiuling Cao
- State Key Laboratory of Subtropical Silviculture, College of Forestry and Biotechnology, Zhejiang A&F University, Hangzhou, China
| | - Tingting An
- State Key Laboratory of Subtropical Silviculture, College of Forestry and Biotechnology, Zhejiang A&F University, Hangzhou, China
| | - Wenhao Fu
- State Key Laboratory of Subtropical Silviculture, College of Forestry and Biotechnology, Zhejiang A&F University, Hangzhou, China
| | - Jie Zhang
- State Key Laboratory of Subtropical Silviculture, College of Forestry and Biotechnology, Zhejiang A&F University, Hangzhou, China
| | - Huihui Zhao
- State Key Laboratory of Subtropical Silviculture, College of Forestry and Biotechnology, Zhejiang A&F University, Hangzhou, China
| | - Danqi Li
- State Key Laboratory of Subtropical Silviculture, College of Forestry and Biotechnology, Zhejiang A&F University, Hangzhou, China
| | - Xuejiao Jin
- State Key Laboratory of Subtropical Silviculture, College of Forestry and Biotechnology, Zhejiang A&F University, Hangzhou, China
| | - Beidong Liu
- State Key Laboratory of Subtropical Silviculture, College of Forestry and Biotechnology, Zhejiang A&F University, Hangzhou, China.,Department of Chemistry and Molecular Biology, University of Gothenburg, Gothenburg, Sweden.,Center for Large-Scale Cell-Based Screening, Faculty of Science, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
45
|
García-Maset R, Bover J, Segura de la Morena J, Goicoechea Diezhandino M, Cebollada Del Hoyo J, Escalada San Martin J, Fácila Rubio L, Gamarra Ortiz J, García-Donaire JA, García-Matarín L, Gràcia Garcia S, Isabel Gutiérrez Pérez M, Hernández Moreno J, Mazón Ramos P, Montañés Bermudez R, Muñoz Torres M, de Pablos-Velasco P, Pérez-Maraver M, Suárez Fernández C, Tranche Iparraguirre S, Luis Górriz J. Information and consensus document for the detection and management of chronic kidney disease. Nefrologia 2022; 42:233-264. [PMID: 36210616 DOI: 10.1016/j.nefroe.2022.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 06/16/2023] Open
Abstract
Chronic kidney disease (CKD) is a major public health problem worldwide that affects more than 10% of the Spanish population. CKD is associated with high comorbidity rates, poor prognosis and major consumption of health system resources. Since the publication of the last consensus document on CKD seven years ago, little evidence has emerged and few clinical trials on new diagnostic and treatment strategies in CKD have been conducted, apart from new trials in diabetic kidney disease. Therefore, CKD international guidelines have not been recently updated. The rigidity and conservative attitude of the guidelines should not prevent the publication of updates in knowledge about certain matters that may be key in detecting CKD and managing patients with this disease. This document, also prepared by 10 scientific associations, provides an update on concepts, clarifications, diagnostic criteria, remission strategies and new treatment options. The evidence and the main studies published on these aspects of CKD have been reviewed. This should be considered more as an information document on CKD. It includes an update on CKD detection, risk factors and screening; a definition of renal progression; an update of remission criteria with new suggestions in the older population; CKD monitoring and prevention strategies; management of associated comorbidities, particularly in diabetes mellitus; roles of the Primary Care physician in CKD management; and what not to do in Nephrology. The aim of the document is to serve as an aid in the multidisciplinary management of the patient with CKD based on current recommendations and knowledge.
Collapse
Affiliation(s)
| | | | - Julián Segura de la Morena
- Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA)
| | | | | | | | | | | | - Jose A García-Donaire
- Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA)
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Documento de información y consenso para la detección y manejo de la enfermedad renal crónica. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
|
47
|
Effects of Oral Bicarbonate Supplementation on the Cardiovascular Risk Factors and Serum Nutritional Markers in Non-Dialysed Chronic Kidney Disease Patients. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58040518. [PMID: 35454357 PMCID: PMC9027759 DOI: 10.3390/medicina58040518] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/26/2022] [Accepted: 03/28/2022] [Indexed: 12/03/2022]
Abstract
Background and Objectives: Kidneys play a key role in maintaining the acid−base balance. The aim of this study was to evaluate the effect of a 3-month oral sodium bicarbonate administration on arterial wall stiffness, arterial pressure and serum nutritional markers in non-dialysed patients with chronic kidney disease (CKD) stages 3−5 and metabolic acidosis. Methods: Eighteen CKD patients with eGFR < 45 mL/min/1.73 m2 and capillary blood bicarbonate (HCO3) < 22 mmol/L were enrolled in this single-centre, prospective study. Anthropometric parameters, pulse wave velocity, 24-h ambulatory blood pressure measurements, blood and urine parameters were assessed at the beginning and at the end of the study. The patients received supplementation with 2 g of sodium bicarbonate daily for three months. Results: A significant increase of pH: 7.32 ± 0.06 to 7.36 ± 0.06; p = 0.025, HCO3 from 18.7 mmol/L (17.7−21.3) to 22.2 mmol/L (20.2−23.9); p < 0.001 and a decrease in base excess from −6.0 ± 2.4 to −1.9 ± 3.1 mmol/L; p < 0.001 were found. An increase in serum total protein from 62.7 ± 6.9 to 65.8 ± 6.2; p < 0.013 and albumin from 37.3 ± 5.4 to 39.4 ± 4.8; p < 0.037 but, also, NT-pro-BNP (N-Terminal Pro-B-Type Natriuretic Peptide) from 794.7 (291.2−1819.0) to 1247.10 (384.7−4545.0); p < 0.006, CRP(C Reactive Protein) from 1.3 (0.7−2.9) to 2.8 (1.1−3.1); p < 0.025 and PTH (parathyroid hormone) from 21.5 ± 13.7 to 27.01 ± 16.3; p < 0.006 were observed, as well as an increase in erythrocyte count from 3.4 ± 0.6 to 3.6 ± 0.6; p < 0.004, haemoglobin from 10.2 ± 2.0 to 11.00 ± 1.7; p < 0.006 and haematocrit from 31.6 ± 6.00 to 33.6 ± 4.8; p < 0.009. The mean eGFR during sodium bicarbonate administration did not change significantly: There were no significant differences in pulse wave velocity or in the systolic and diastolic BP values. Conclusion: The administration of sodium bicarbonate in non-dialysed CKD patients in stages 3−5 improves the parameters of metabolic acidosis and serum nutritional markers; however, it does not affect the blood pressure and vascular stiffness.
Collapse
|
48
|
Shi H, Su X, Yan B, Li C, Wang L. Effects of oral alkali drug therapy on clinical outcomes in pre-dialysis chronic kidney disease patients: a systematic review and meta-analysis. Ren Fail 2022; 44:106-115. [PMID: 35176947 PMCID: PMC8865123 DOI: 10.1080/0886022x.2021.2023023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Metabolic acidosis accelerates the progression of chronic kidney disease (CKD) and increases the mortality rate. Whether oral alkali drug therapy benefits pre-dialysis CKD patients is controversial. We performed a meta-analysis of the effects of oral alkali drug therapy on major clinical outcomes in pre-dialysis CKD patients. METHODS We systematically searched MEDLINE using the Ovid, EMBASE, and Cochrane Library databases without language restriction. We included all eligible clinical studies that involved pre-dialysis CKD adults and compared those who received oral alkali drug therapy with controls. RESULTS A total of 18 eligible studies, including 14 randomized controlled trials and 4 cohort studies reported in 19 publications with 3695 participants, were included. Oral alkali drug therapy led to a 55% reduction in renal failure events (relative risk [RR]: 0.45; 95% confidence interval [CI]: 0.25-0.82), a rate of decline in the estimated glomerular filtration rate (eGFR) of 2.59 mL/min/1.73 m2 per year (95% CI, 0.88-4.31). There was no significant effect on decline in eGFR events (RR: 0.34; 95% CI: 0.09-1.23), proteinuria (standardized mean difference: -0.32; 95% CI: -1.08 to 0.43), all-cause mortality events (RR: 0.90; 95% CI: 0.40-2.02) and cardiovascular (CV) events (RR: 1.03; 95% CI: 0.32-3.37) compared with the control groups. CONCLUSION Based on the available and low-to-moderate certainty evidence, oral alkali drug therapy might potentially reduce the risk of kidney failure events, but no benefit in reducing all-cause mortality events, CV events, decline in eGFR and porteninuria.
Collapse
Affiliation(s)
- Honghong Shi
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaole Su
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Bingjuan Yan
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Chunfang Li
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China.,Division of Nephrology, Shanxi Cardiovascular Hospital, Taiyuan, China
| | - Lihua Wang
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| |
Collapse
|
49
|
Kaimori JY, Sakaguchi Y, Kajimoto S, Asahina Y, Oka T, Hattori K, Doi Y, Isaka Y. Diagnosing metabolic acidosis in chronic kidney disease: importance of blood pH and serum anion gap. Kidney Res Clin Pract 2022; 41:288-297. [PMID: 35172536 PMCID: PMC9184836 DOI: 10.23876/j.krcp.21.200] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/18/2021] [Indexed: 12/05/2022] Open
Abstract
Metabolic acidosis is one of the most common complications of chronic kidney disease (CKD). It is associated with the progression of CKD, and many other functional impairments. Until recently, only serum bicarbonate levels have been used to evaluate acid-base changes in patients with reduced kidney function. However, recent emerging evidence suggests that nephrologists should reevaluate the clinical approach for diagnosing metabolic acidosis in patients with CKD based on two perspectives; pH and anion gap. Biochemistry and physiology textbooks clearly indicate that blood pH is the most important acid-base parameter for cellular function. Therefore, it is important to determine if the prognostic impact of hypobicarbonatemia varies according to pH level. A recent cohort study of CKD patients showed that venous pH modified the association between a low bicarbonate level and the progression of CKD. Furthermore, acidosis with a high anion gap has recently been recognized as an important prognostic factor, because veverimer, a nonabsorbable hydrochloride-binding polymer, has been shown to improve kidney function and decrease the anion gap. Acidosis with high anion gap frequently develops in later stages of CKD. Therefore, the anion gap is a time-varying factor and renal function (estimated glomerular filtration rate) is a time-dependent confounder for the anion gap and renal outcomes. Recent analyses using marginal structural models showed that acidosis with a high anion gap was associated with a high risk of CKD. Based on these observations, reconsideration of the clinical approach to diagnosing and treating metabolic acidosis in CKD may be warranted.
Collapse
Affiliation(s)
- Jun-Ya Kaimori
- Department of Inter-Organ Communication Research in Kidney Diseases, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
- Correspondence: Jun-Ya Kaimori Department of Inter-Organ Communication Research in Kidney Diseases and Department of Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan. E-mail:
| | - Yusuke Sakaguchi
- Department of Inter-Organ Communication Research in Kidney Diseases, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Sachio Kajimoto
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuta Asahina
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tatsufumi Oka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koki Hattori
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yohei Doi
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| |
Collapse
|
50
|
Chronic Kidney Disease and SGLT2 Inhibitors: A Review of the Evolving Treatment Landscape. Adv Ther 2022; 39:148-164. [PMID: 34846711 PMCID: PMC8799531 DOI: 10.1007/s12325-021-01994-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/10/2021] [Indexed: 12/31/2022]
Abstract
There is currently an unmet need for effective treatment of chronic kidney disease (CKD) that slows disease progression, prevents development of end-stage kidney disease and cardiovascular disease, and prolongs survival of patients with CKD. In the last 20 years, the only agents to show a reduction in the risk of CKD progression in patients with and without type 2 diabetes (T2D) were angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, but neither drug class has provided a decreased risk of all-cause mortality in patients with CKD and evidence for their use in patients with CKD without T2D is relatively limited. This review discusses the mechanisms underlying the progression of CKD, its associated risk factors, and summarizes the potential therapeutic approaches for managing CKD. There is increasing evidence to support the role of sodium–glucose cotransporter 2 (SGLT2) inhibitor therapy in patients with CKD, including data from the designated kidney outcome trials in patients with T2D (CREDENCE) and in patients with or without T2D (DAPA-CKD). These studies showed a significant reduction in the risk of CKD progression with canagliflozin (in patients with T2D) or dapagliflozin (in patients with or without T2D), respectively, with DAPA-CKD being the first trial to show a reduced risk of all-cause mortality. On the basis of these data, individualized treatment with SGLT2 inhibitors represents a promising therapeutic option for patients with diabetic and nondiabetic CKD to slow disease progression. Chronic kidney disease is a common condition in which the ability of the kidneys to work correctly gradually decreases over time. It is a major risk factor for a number of other serious conditions, including cardiovascular disease and end-stage kidney disease, and for early death. Several treatments have been shown to reduce the risk of chronic kidney disease progressing (particularly in patients with type 2 diabetes), but there have been no treatments that slow chronic kidney disease progression, prevent the development of end-stage kidney disease and cardiovascular disease, and prolong survival. However, evidence is now accumulating to suggest that some drugs initially developed to treat other diseases may be potential treatments for chronic kidney disease. The sodium–glucose cotransporter 2 inhibitors, which are commonly used to lower blood sugar levels in people with type 2 diabetes, are examples of such drugs. Data from two studies of sodium–glucose cotransporter 2 inhibitors—the CREDENCE study of canagliflozin in patients with chronic kidney disease and type 2 diabetes and the DAPA-CKD study of dapagliflozin in patients with chronic kidney disease with or without type 2 diabetes—have shown that these drugs reduce the risk of chronic kidney disease progression in these patients. More importantly, the DAPA-CKD study showed that patients with chronic kidney disease who were taking dapagliflozin had a reduced risk of death compared with placebo. These results show that sodium–glucose cotransporter 2 inhibitors are slowing the progression of chronic kidney disease and improve overall outcomes for properly selected patients.
Collapse
|