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Yang CJ, Chang CM, Chang GP, Tsai HT, Yu TY, Han YY. Unveiling the heightened susceptibility: Exploring early hypophosphatemia in critically ill trauma patients. J Formos Med Assoc 2024:S0929-6646(24)00286-9. [PMID: 38880709 DOI: 10.1016/j.jfma.2024.06.010] [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: 09/27/2023] [Revised: 05/31/2024] [Accepted: 06/12/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Phosphorus is a vital mineral crucial for various physiological functions. Critically ill trauma patients frequently experience hypophosphatemia during the immediate post-traumatic phase, potentially impacting outcomes. This study aims to investigate the incidence of early hypophosphatemia in critically major trauma patients. METHODS In this prospective observational study, trauma patients admitted to the intensive care unit (ICU) within one day were enrolled. These patients were categorized into Hypo-P groups and Non-hypo groups based on the development of new-onset hypophosphatemia within 72 h after feeding. The primary outcome assessed was the incidence of new-onset hypophosphatemia. The secondary outcomes included ICU and hospital stay, ventilation duration, and mortality. RESULTS 76.1% of patients developed a new onset of hypophosphatemia within 72 h after feeding. The Hypo-P group had significantly longer ICU stays (8.1 days ± 5.5 vs. 4.4 days ± 3.1; p = 0.0251) and trends towards extended hospital stay, ventilation duration, and higher mortality. Additionally, they demonstrated significantly higher urine fractional excretion of phosphate (FEPO4) on the first ICU day (29.2% ± 14.23 vs. 19.5% ± 8.39; p = 0.0242). CONCLUSION Critically ill trauma patients exhibited a significantly higher incidence of early hypophosphatemia than typical ICU rates, indicating their heightened vulnerability. The significantly high urine FEPO4 underscores the crucial role of renal loss in disrupting phosphate metabolism in this early acute phase after trauma. A significant correlation was observed between hypophosphatemia and longer ICU stays. Monitoring and managing phosphate levels may influence outcomes, warranting further investigation.
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Affiliation(s)
- Chi-Ju Yang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Ming Chang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Environment and Occupational Health Sciences, National Taiwan University, Taipei, Taiwan
| | - Gyu-Ping Chang
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Huei-Ting Tsai
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ting-Yu Yu
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yin-Yi Han
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan; Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan.
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2
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Thillard EM, Sade P, Michot J, Bres V, Jonville-Bera AP. Drug-related hypophosphatemia: Descriptive study and case/non-case analysis of the French national pharmacovigilance database. Therapie 2024; 79:371-378. [PMID: 37634954 DOI: 10.1016/j.therap.2023.07.007] [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: 02/09/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023]
Abstract
Phosphorus is an essential element for all living organisms and is involved in various biological pathways. A severe hypophosphatemia can lead to serious complications (acute heart or respiratory failure, rhabdomyolysis, hemolysis…) and increases mortality in patients at risk. Various drugs are known to induce hypophosphatemia through various mechanisms. The aim of this study was to highlight the main drugs associated with hypophosphatemia and to deduce the underlying mechanisms based on a descriptive analysis and a case/non-case analysis using the cases of drug-induced hypophosphatemia reported to the French Pharmacovigilance Network. A total of 368 cases of hypophosphatemia were included in the study. Patients' mean age was 52±18 years. One hundred and ninety-one cases (52%) were serious including 131 (36%) hospitalizations. The median value of serum phosphorus level was 0.54mmol/L [0.40-0.66] (n=309). Those 368 cases corresponded to 185 different suspected substances among which the most frequent drugs were tenofovir disoproxil (n=175; 48%), ferric carboxymaltose (n=29; 8%), denosumab (n=16; 4%), zoledronic acid (n=14; 4%) and hydrochlorothiazide (n=10; 3%). For these five drugs, a significant disproportionality was found. Tenofovir-disoproxil related hypophosphatemia occurred more than one year after its introduction, and a renal tubulopathy (Fanconi's syndrome) was reported in 44 cases (25%). Hypophosphatemia related to iron carboxymaltose occurred within a median of 20 days after injection and was mostly severe. Mechanism included the fibroblast growth factor 23 which can be measured to confirm drug origin. Concerning anti-osteoporosis treatments, hypophosphatemia could be explained by their mechanism of action (abrupt increase of parathormone induced by hypocalcemia) but the patient history (malignancy condition) was a major bias. For hydrochlorothiazide, hyphosphatemia was often moderate, associated with other electrolytic disturbances and occurred during a long-term treatment. Awareness of healthcare professionals is essential to detect as soon as possible hypophosphatemia and its complications related to these drugs.
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Affiliation(s)
- Eve-Marie Thillard
- Department of Pharmacosurveillance, Pharmacovigilance Regional Center of Centre Val de Loire, University Hospital of Tours, 37044 Tours, France.
| | - Paula Sade
- Department of Pharmacosurveillance, Pharmacovigilance Regional Center of Centre Val de Loire, University Hospital of Tours, 37044 Tours, France
| | - Joelle Michot
- Pharmacovigilance Regional Center of Paris Saint-Antoine, University of Sorbonne, AP-HP, 75012 Paris, France
| | - Virginie Bres
- Department of Medical Pharmacology and Toxicology, Pharmacovigilance Regional Center of Montpellier, CHU de Montpellier, 34000 Montpellier, France
| | - Annie-Pierre Jonville-Bera
- Department of Pharmacosurveillance, Pharmacovigilance Regional Center of Centre Val de Loire, University Hospital of Tours, 37044 Tours, France
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3
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Walker V. The Intricacies of Renal Phosphate Reabsorption-An Overview. Int J Mol Sci 2024; 25:4684. [PMID: 38731904 PMCID: PMC11083860 DOI: 10.3390/ijms25094684] [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: 03/24/2024] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
To maintain an optimal body content of phosphorus throughout postnatal life, variable phosphate absorption from food must be finely matched with urinary excretion. This amazing feat is accomplished through synchronised phosphate transport by myriads of ciliated cells lining the renal proximal tubules. These respond in real time to changes in phosphate and composition of the renal filtrate and to hormonal instructions. How they do this has stimulated decades of research. New analytical techniques, coupled with incredible advances in computer technology, have opened new avenues for investigation at a sub-cellular level. There has been a surge of research into different aspects of the process. These have verified long-held beliefs and are also dramatically extending our vision of the intense, integrated, intracellular activity which mediates phosphate absorption. Already, some have indicated new approaches for pharmacological intervention to regulate phosphate in common conditions, including chronic renal failure and osteoporosis, as well as rare inherited biochemical disorders. It is a rapidly evolving field. The aim here is to provide an overview of our current knowledge, to show where it is leading, and where there are uncertainties. Hopefully, this will raise questions and stimulate new ideas for further research.
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Affiliation(s)
- Valerie Walker
- Department of Clinical Biochemistry, University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton S016 6YD, UK
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4
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Tao W, Zhan S, Shen Y, Zhao T, Li F, Gao M, Yang T, Yu J. Nomogram for predicting early hypophosphatemia in term infants. BMC Pediatr 2024; 24:255. [PMID: 38627752 PMCID: PMC11020330 DOI: 10.1186/s12887-024-04737-8] [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: 10/23/2023] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Physiological processes rely on phosphate, which is an essential component of adenosine triphosphate (ATP). Hypophosphatasia can affect nearly every organ system in the body. It is crucial to monitor newborns with risk factors for hypophosphatemia and provide them with the proper supplements. We aimed to evaluate the risk factors and develop a nomogram for early hypophosphatemia in term infants. METHODS We conducted a retrospective study involving 416 term infants measured serum phosphorus within three days of birth. The study included 82 term infants with hypophosphatemia (HP group) and 334 term infants without hypophosphatemia (NHP group). We collected data on the characteristics of mothers, newborn babies, and childbirth. Furthermore, univariate and multivariate logistic regression analyses were performed to identify independent risk factors for hypophosphatemia in term infants, and a nomogram was developed and validated based on the final independent risk factors. RESULTS According to our analysis, the multivariate logistic regression analysis showed that male, maternal diabetes, cesarean delivery, lower serum magnesium, and lower birth weight were independent risk factors for early hypophosphatemia in term infants. In addition, the C-index of the developed nomogram was 0.732 (95% CI = 0.668-0.796). Moreover, the calibration curve indicated good consistency between the hypophosphatemia diagnosis and the predicted probability, and a decision curve analysis (DCA) confirmed the clinical utility of the nomogram. CONCLUSIONS The analysis revealed that we successfully developed and validated a nomogram for predicting early hypophosphatemia in term infants.
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Affiliation(s)
- Wan Tao
- Neonatal Center, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, No.1 Shunkang Road, Shunyi District Beijing, Beijing, 101300, China
| | - Shina Zhan
- Neonatal Center, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, No.1 Shunkang Road, Shunyi District Beijing, Beijing, 101300, China
| | - Yingjie Shen
- Neonatal Center, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, No.1 Shunkang Road, Shunyi District Beijing, Beijing, 101300, China
| | - Tianjiao Zhao
- Neonatal Center, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, No.1 Shunkang Road, Shunyi District Beijing, Beijing, 101300, China
| | - Feitian Li
- Neonatal Center, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, No.1 Shunkang Road, Shunyi District Beijing, Beijing, 101300, China
| | - Miao Gao
- Neonatal Center, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, No.1 Shunkang Road, Shunyi District Beijing, Beijing, 101300, China
| | - Tingting Yang
- Neonatal Center, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, No.1 Shunkang Road, Shunyi District Beijing, Beijing, 101300, China
| | - Jinqian Yu
- Neonatal Center, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, No.1 Shunkang Road, Shunyi District Beijing, Beijing, 101300, China.
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5
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Parameshwar VC, Rekhi B, Duggad A, Ramadwar M. Phosphaturic mesenchymal tumor: Clinicopathological features with outcomes in 10 patients with review of literature. INDIAN J PATHOL MICR 2024; 67:306-311. [PMID: 38394416 DOI: 10.4103/ijpm.ijpm_295_23] [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: 04/15/2023] [Accepted: 05/09/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Phosphaturic mesenchymal tumors (PMTs) are rare mesenchymal tumors, associated with long-standing, non-specific but often debilitating symptoms in the affected patients. These tumors display characteristic histopathological features and in case, identified timely, can be a boon for patients, given an excision is completely curative. AIMS To evaluate the clinical and histopathological features of 10 PMTs, diagnosed at our institution, along with clinical outcomes in those patients. MATERIALS AND METHODS This was a retrospective study, wherein 10 PMTs, diagnosed from January 2013 to July 2022, were included. RESULTS The average age at the time of diagnosis was 40 years with an M:F ratio of 4:1. Clinical features included lumps, weakness, bone pain, difficulty in moving and walking, and pathologic fractures. The biochemical analysis showed normal serum calcium levels (average = 9.5 mg/dL), with low serum phosphorus (average = 2.2 mg/dL) and raised serum fibroblast growth factor 23 (FGF23) levels, in all the cases, wherever available. On histopathology, all tumors showed cells arranged in a hemangiopericytomatous pattern, including oval to short spindle forms. Multinucleate giant cells were present in nine tumors, and characteristic "grungy calcifications" was observed in eight tumors. Prominent pseudo cystic spaces were seen in eight tumors. A significant number of mitotic figures and tumor necrosis were not seen in any tumor. In five cases where follow-up was available, there was complete resolution of symptoms post-resection with no recurrence or metastasis. All those patients were free of disease until the last follow-up. CONCLUSION This constitutes the first largest comprehensive study on these rare tumors from our country. PMTs can be diagnosed based on certain histopathological features and correlation with clinicoradiological and biochemical findings. These are invariably benign neoplasms. Patients are relieved of their debilitating symptoms after adequate surgical tumor resection. Therefore, their correct and timely diagnosis is crucial.
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Affiliation(s)
| | - Bharat Rekhi
- Department of Pathology, Tata Memorial Hospital, HBNI University, Mumbai, Maharashtra, India
| | - Ashwini Duggad
- Department of Pathology, Tata Memorial Hospital, HBNI University, Mumbai, Maharashtra, India
| | - Mukta Ramadwar
- Department of Pathology, Tata Memorial Hospital, HBNI University, Mumbai, Maharashtra, India
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Oris C, Lautrette A, Dougé A, Bouraima F, Kahouadji S, Pickering ME, Garrouste C, Gagnière J, Guièze R, D'Ostrevy N, Futier E, Grobost V, Buisson A, Batisse M, Bouillon-Minois JB, Pereira B, Durif J, Sapin V, Bouvier D. Prevalence of FGF23 elevation in patients with hypophosphatemia. Clin Chim Acta 2024; 554:117782. [PMID: 38224930 DOI: 10.1016/j.cca.2024.117782] [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: 11/26/2023] [Revised: 12/28/2023] [Accepted: 01/10/2024] [Indexed: 01/17/2024]
Abstract
BACKGROUND AND AIMS To investigate the contribution of FGF23 in explaining the cases of hypophosphatemia observed in clinical practice, we aimed to determine for the first time the prevalence of FGF23 elevation in patients with hypophosphatemia and to describe the different mechanisms of FGF23-related hypophosphatemic disorders. MATERIALS AND METHODS We performed a prospective, observational, multicenter, cohort study of 260 patients with hypophosphatemia. Blood measurements (PTH, 1,25-dihydroxyvitamin D, bone alkaline phosphatase, 25-hydroxyvitamin D, and FGF23) were performed on a Liaison XL® (DiaSorin) analyzer. RESULTS Primary elevation of FGF23 (>95.4 pg/mL) was reported in 10.4% (95CI: 7.0-14.7) of patients (n = 27) with hypophosphatemia, suggesting that at least 1 in 10 cases of hypophosphatemia was erroneously attributed to an etiology other than FGF23 elevation. Patients with elevated blood FGF23 were grouped according to the etiology of the FGF23 elevation. Thus, 10 patients had a renal pathology, chronic kidney disease or post-renal transplantation condition. The remaining patients (n = 17) had the following etiologies: malignancies (n = 9), benign pancreatic tumor (n = 1), post-cardiac surgery (n = 4), cirrhosis (n = 2), and chronic obstructive pulmonary disease (n = 1). CONCLUSION In order to improve patient management, it seems essential to better integrate plasma FGF23 measurement into the routine evaluation of hypophosphatemia.
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Affiliation(s)
- Charlotte Oris
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France
| | - Alexandre Lautrette
- Department of Intensive Care Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Aurore Dougé
- Department of Oncology, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Farouk Bouraima
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Samy Kahouadji
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France
| | - Marie-Eva Pickering
- Rheumatology Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Cyril Garrouste
- Department of Nephrology, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Johan Gagnière
- Department of Digestive and Hepatobiliary Surgery, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Romain Guièze
- Department of Clinical Hematology, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Nicolas D'Ostrevy
- Department of Cardiac Surgery, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, Anesthesia & Critical Care, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Vincent Grobost
- Department of Internal Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Anthony Buisson
- Department of Hepato-Gastroenterology, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Marie Batisse
- Department of Oncology, Centre Jean Perrin, 63000 Clermont-Ferrand, France
| | | | - Bruno Pereira
- Biostatistics Unit (DRCI) Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Julie Durif
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Vincent Sapin
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France
| | - Damien Bouvier
- Biochemistry and Molecular Genetics Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Clermont Auvergne University, CNRS, INSERM, iGReD, Clermont-Ferrand, France.
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Lee JP, Darlington K, Henson JB, Kothari D, Niedzwiecki D, Farooq A, Liddle RA. Hypophosphatemia as a Predictor of Clinical Outcomes in Acute Pancreatitis: A Retrospective Study. Pancreas 2024; 53:e3-e8. [PMID: 37968112 PMCID: PMC10841211 DOI: 10.1097/mpa.0000000000002265] [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] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Phosphate is crucial for cellular repair after injury and may be important in recovery following acute pancreatitis (AP). This study aimed to evaluate the association between hypophosphatemia and severity of AP. METHODS Patients admitted with AP between 2014-2018 were identified and their records were retrospectively reviewed. Pancreatitis severity was defined using the modified Atlanta Criteria. Hypophosphatemia was defined as phosphate <2 mg/dL and was assessed at three time points: within one day, within two days, at any time during admission. The proportion of patients who developed severe AP was compared between patients with and without hypophosphatemia. RESULTS Of 312 patients, 30.1% (n = 94) developed severe AP. Hypophosphatemia occurred in 25.0% overall, within one day in 19.7%, and within two days in 20.0%. A higher proportion of patients with hypophosphatemia developed severe AP (overall: 47.4% vs. 24.4%, P < 0.001; one day: 47.4% vs. 23.9%, P = 0.004; two days: 42.9% vs. 24.5%, P = 0.01). Patients with hypophosphatemia within one day were also more likely to have ICU admission ( P < 0.001) and longer length of stay ( P < 0.001). CONCLUSIONS Early hypophosphatemia during an admission for AP was associated with increased AP severity, ICU admission, and longer length of stay.
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Affiliation(s)
- Joshua P. Lee
- Department of Medicine, Division of Gastroenterology, Duke University Medical Center Durham, North Carolina
| | - Kimberly Darlington
- Division of Gastroenterology & Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jacqueline B. Henson
- Department of Medicine, Division of Gastroenterology, Duke University Medical Center Durham, North Carolina
| | - Darshan Kothari
- Department of Medicine, Division of Gastroenterology, Duke University Medical Center Durham, North Carolina
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Ahmad Farooq
- Department of Medicine, Division of Gastroenterology, Duke University Medical Center Durham, North Carolina
| | - Rodger A. Liddle
- Department of Medicine, Division of Gastroenterology, Duke University Medical Center Durham, North Carolina
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Fischman M, Elias A, Klein A, Cohen Y, Levy Y, Azzam ZS, Ghersin I. The association between phosphate level at admission and early mortality in acute pancreatitis. J Gastroenterol 2023; 58:1157-1164. [PMID: 37594581 DOI: 10.1007/s00535-023-02034-2] [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: 01/01/2023] [Accepted: 08/10/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Abnormal phosphate levels are associated with adverse outcomes in critical illness. However, there is scarce evidence on phosphate's impact on acute pancreatitis outcomes, and the few studies examining this subject are relatively small and show conflicting data. We sought to determine the association between phosphate level at admission and the clinical course and outcomes of acute pancreatitis. METHODS In this retrospective single-center observational study, we included all adult patients admitted with a primary diagnosis of acute pancreatitis between January 2008 and June 2021. Phosphate levels at admission were classified as normal (2.8-4.5 mg/dl), low (below 2.8 mg/dl), or high (above 4.5 mg/dl). RESULTS Out of 2308 cases, 1868 patients had documented phosphate levels at admission and were thus included in our final analysis. 1096 (59%) had normal phosphate levels, 686 (37%) had hypophosphatemia, and 86 (4.6%) had hyperphosphatemia on admission. 30-day mortality rates were 3.4%, 3.8%, and 19% in normal, low, and high phosphate levels, respectively. In univariate analysis, hyperphosphatemia was significantly associated with 30-day mortality, with an OR of 6.54 (95% CI 3.39-12.2, p < 0.001; AUC = 0.58). In a multivariate analysis adjusting for age, MAP, GFR, BUN, and pH, hyperphosphatemia remained a statistically significant independent predictor of early mortality (OR-2.93, 95% CI 1.28-6.51, p = 0.009). Hypophosphatemia was not significantly associated with 30-day mortality in univariate analysis, OR of 1.13 (95% CI 0.67-1.87, p = 0.6). CONCLUSION Hyperphosphatemia at admission was independently associated with increased 30-day mortality in patients with acute pancreatitis. Hypophosphatemia at admission was not significantly associated with 30-day mortality.
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Affiliation(s)
- Maya Fischman
- Department of Military Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Adi Elias
- Heart Institute, Rambam Health Care Campus, Haifa, Israel
| | - Amir Klein
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Yaron Cohen
- Department of Military Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yael Levy
- Department of Internal Medicine "B", Rambam Health Care Campus, Haifa, Israel
| | - Zaher Shafiq Azzam
- Department of Internal Medicine "B", Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Itai Ghersin
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.
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Alsabri M, Street H, Sircy A, Labib B. Misdiagnosed metabolic bone abnormality: a case report. J Med Case Rep 2023; 17:436. [PMID: 37858137 PMCID: PMC10588102 DOI: 10.1186/s13256-023-04164-w] [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: 01/31/2023] [Accepted: 09/05/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Metabolic bone disease causes significant morbidity and mortality, especially when misdiagnosed. With genetic testing, multiple disease pathologies can be analyzed. CASE PRESENTATION A 5-year and 9-month-old otherwise healthy Yemeni girl presented to her Yemen physician for evaluation of inward bending of her right knee and short stature. After extensive medical testing, she was given a diagnosis of hypophosphatemic rickets and growth hormone deficiency and started on treatment. Despite appropriate treatment, however, her condition continued to progress, prompting her family to pursue additional workup including genetic testing outside of Yemen. Genetic testing ultimately revealed a variation of unknown significance associated with amelogenesis imperfecta. CONCLUSIONS Hypophosphatemic rickets secondary to renal tubular acidosis was the working diagnosis. However, the patient's condition did not improve. Further genetic testing revealed a variation of unknown significance associated with amelogenesis imperfecta. We aim to present this case, provide an overview of the causes, and diagnostic metabolic bone health evaluation.
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Affiliation(s)
- Mohammed Alsabri
- Pediatrics, 1 Brookdale University Hospital and Medical Center, 1Brookdale Plaza, Brooklyn, NY, 11212, USA.
- Emergency Medicine Department, Al Thawra Modern General Hospital (TMGH), Sana'a City, Yemen.
- College of Osteopathic Medicine, NYIT, Glen Head, NY, USA.
| | - Hannah Street
- NYU Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA
| | - Aaron Sircy
- CMEF Aultman Hospital, 2600 6th st. SW, Canton, OH, 44710, USA
| | - Bahaaeldin Labib
- Rutgers-Robert Wood Johnson University Hospital, 200 Somerset Street, New Brunswick, NJ, 08901, USA
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10
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Kim KJ, Song JE, Kim JH, Hong N, Kim SG, Lee J, Rhee Y. Elevated morbidity and mortality in patients with chronic idiopathic hypophosphatemia: a nationwide cohort study. Front Endocrinol (Lausanne) 2023; 14:1229750. [PMID: 37635983 PMCID: PMC10448510 DOI: 10.3389/fendo.2023.1229750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Background Chronic idiopathic hypophosphatemia (CIH) induced by X-linked hypophosphatemic rickets or tumor-induced osteomalacia is a rare inherited or acquired disorder. However, due to its rarity, little is known about the epidemiology and natural course of CIH. Therefore, we aimed to identify the prevalence and long-term health outcomes of CIH patients. Methods Using the Korean Health Insurance Review and Assessment claims database, we evaluated the incidence of hypophosphatemia initially diagnosed from 2003 to 2018. After excluding secondary conditions that could change serum phosphorus levels, we identified 154 patients (76 men and 78 women) with non-secondary and non-renal hypophosphatemia. These hypophosphatemic patients were compared at a ratio of 1:10 with age-, sex-, and index-year-matched controls (n = 1,540). Results In the distribution of age at diagnosis, a large peak was observed in patients aged 1-4 years and small peaks were observed in ages from 40-70 years. The age-standardized incidence rate showed non-statistically significant trend from 0.24 per 1,000,000 persons in 2003 to 0.30 in 2018. Hypophosphatemic patients had a higher risk of any complication (adjusted hazard ratio [aHR], 2.17; 95% confidence interval [CI], 1.67-2.69) including cardiovascular outcomes, chronic kidney disease, hyperparathyroidism, osteoporotic fractures, periodontitis, and depression. Hypophosphatemic patients also had higher risks of mortality and hospitalization than the controls (aHR, 3.26; 95% CI, 1.83-5.81; and aHR, 2.49; 95% CI, 1.97-3.16, respectively). Conclusion This first nationwide study of CIH in South Korea found a bimodal age distribution and no sex differences among patients. Hypophosphatemic patients had higher risks of complications, mortality, and hospitalization compared to age- and sex-matched controls.
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Affiliation(s)
- Kyoung Jin Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji Eun Song
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sin Gon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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11
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Hamada K, Sagiyama K, Nishi R, Fukumoto T, Kato R, Fuku Y, Amitani H, Asakawa A. Unpredictable refeeding syndrome with severe hypophosphatemia in borderline personality disorder comorbidity: A case report. Medicine (Baltimore) 2023; 102:e34103. [PMID: 37352052 PMCID: PMC10289500 DOI: 10.1097/md.0000000000034103] [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: 04/13/2023] [Accepted: 06/05/2023] [Indexed: 06/25/2023] Open
Abstract
RATIONALE Refeeding syndrome (RS) is a fatal condition caused by rapid calorie intake during starvation. Self-neglected fasting in psychiatric disorders is associated with RS. However, overeating resulting from circumventing the clinician's instructions does not have a reportedly high risk of RS. PATIENT CONCERNS A 47-year-old undernourished woman with borderline personality disorder was hospitalized for nausea, vomiting, and diarrhea. CLINICAL FINDINGS She had not eaten much for 10 days and had lost weight (56.5-51.1 kg) over 3 weeks. No abnormalities were indicated on physical examination and imaging examinations. DIAGNOSES, INTERVENTIONS, AND OUTCOMES Infectious diseases and malignancies were excluded from the differential diagnosis. On the third day of admission, the patient's serum phosphorus level significantly decreased to 0.7 mg/dL, and additional sodium phosphate was administered intravenously. On the fourth day, despite our instructions, the patient was found to be eating nonhospital food from the first day of admission. In conjunction with her history, a final diagnosis of RS was made. After appropriate treatments, the patient was discharged on the 15th day of hospitalization. The patient's nausea, vomiting, and diarrhea were improved. LESSONS When undernourished patients have psychiatric disorders, including borderline personality disorder or schizophrenia, the occurrence of RS should be considered based on the patients' poor adherence to physicians' instructions.
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Affiliation(s)
- Kazumasa Hamada
- Department of Psychosomatic Internal Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Sakuragaoka, Kagoshima, Japan
| | - Kenichiro Sagiyama
- Department of Psychosomatic Internal Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Sakuragaoka, Kagoshima, Japan
| | - Ryusei Nishi
- Department of Psychosomatic Internal Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Sakuragaoka, Kagoshima, Japan
| | - Takamasa Fukumoto
- Department of Psychosomatic Internal Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Sakuragaoka, Kagoshima, Japan
| | - Ryuichi Kato
- Department of Psychosomatic Internal Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Sakuragaoka, Kagoshima, Japan
| | - Yuuki Fuku
- Department of Psychosomatic Internal Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Sakuragaoka, Kagoshima, Japan
| | - Haruka Amitani
- Department of Psychosomatic Internal Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Sakuragaoka, Kagoshima, Japan
| | - Akihiro Asakawa
- Department of Psychosomatic Internal Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Sakuragaoka, Kagoshima, Japan
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12
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Struppe A, Schanda JE, Baierl A, Watzl P, Muschitz C. Impact of Intravenous Iron Substitution on Serum Phosphate Levels and Bone Turnover Markers-An Open-Label Pilot Study. Nutrients 2023; 15:2693. [PMID: 37375595 DOI: 10.3390/nu15122693] [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: 05/12/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
The association between intravenous iron substitution therapy and hypophosphatemia was previously reported in patients with iron deficiency anemia. However, the extent of hypophosphatemia is thought to depend on the type of iron supplementation. We hypothesized that the intravenous application of ferric carboxymaltose and iron sucrose leads to a different longitudinal adaptation in serum phosphate levels. In this open-label pilot study, a total of 20 patients with inflammatory bowel diseases or iron deficiency anemia were randomly assigned to one of two study groups (group 1: ferric carboxymaltose, n = 10; group 2: iron sucrose, n = 10). Serum values were controlled before iron substitution therapy, as well as 2, 4, and 12 weeks after the last drug administration. The primary objective of the study was the longitudinal evaluation of serum phosphate levels after iron substitution therapy with ferric carboxymaltose and iron sucrose. The secondary objective was the longitudinal investigation of calcium, 25-hydroxyvitamin D (25(OH)D), intact parathyroid hormone, procollagen type 1 amino-terminal propeptide (P1NP), beta-CrossLaps (CTX), hemoglobin (Hb), iron, ferritin, and transferrin saturation levels. Two weeks after drug administration, phosphate levels were significantly lower (p < 0.001) in group 1 and ferritin levels were significantly higher (p < 0.001) in group 1. Phosphate levels (0.8-1.45 mmol/L) were below the therapeutic threshold and ferritin levels (10-200 ng/mL for women and 30-300 ng/mL for men) were above the therapeutic threshold in group 1. P1NP (15-59 µg/L) and CTX (<0.57 ng/mL) levels were above the therapeutic threshold in group 2. Four weeks after drug administration, significant differences were still observed between both study groups for phosphate (p = 0.043) and ferritin (p = 0.0009). All serum values except for Hb were within the therapeutic thresholds. Twelve weeks after drug administration, no differences were observed in all serum values between both study groups. Hb values were within the therapeutic threshold in both study groups. Serum 25(OH)D levels did not differ between both study groups throughout the whole study period and remained within the therapeutic threshold.
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Affiliation(s)
- Alexandra Struppe
- St. Vincent Hospital Vienna, II Medical Department-Gastroenterology, Hepatology, Metabolic, and Inflammation Medicine, Academic Teaching Hospital of the Medical University of Vienna, 1060 Vienna, Austria
| | - Jakob E Schanda
- AUVA Trauma Center Vienna-Meidling, Department for Trauma Surgery, 1120 Vienna, Austria
- Ludwig Boltzmann Institute for Traumatology, 1200 Vienna, Austria
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria
| | - Andreas Baierl
- Insitute for Statistics and Operations Research, University of Vienna, 1090 Vienna, Austria
| | - Paul Watzl
- St. Vincent Hospital Vienna, II Medical Department-Gastroenterology, Hepatology, Metabolic, and Inflammation Medicine, Academic Teaching Hospital of the Medical University of Vienna, 1060 Vienna, Austria
| | - Christian Muschitz
- St. Vincent Hospital Vienna, II Medical Department-Gastroenterology, Hepatology, Metabolic, and Inflammation Medicine, Academic Teaching Hospital of the Medical University of Vienna, 1060 Vienna, Austria
- HealthPi Medical Center, 1010 Vienna, Austria
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13
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Rosano GMC, Kalantar‐Zadeh K, Jankowska EA. Hypophosphataemia risk associated with ferric carboxymaltose in heart failure: A pooled analysis of clinical trials. ESC Heart Fail 2023; 10:1294-1304. [PMID: 36722321 PMCID: PMC10053364 DOI: 10.1002/ehf2.14286] [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: 08/30/2022] [Revised: 11/30/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023] Open
Abstract
AIMS Iron deficiency is a common finding among patients with heart failure (HF) and is associated with adverse outcomes, including decreased quality of life, increased risk of hospitalization, and decreased survival. Intravenous ferric carboxymaltose (FCM) has been shown to improve outcomes among patients with HF and concomitant iron deficiency, but FCM is associated with an increased risk of hypophosphataemia. We aimed to better characterize this risk among HF populations. METHODS AND RESULTS This pooled analysis examined data from 41 studies of adults with iron deficiency across disease states and therapeutic areas. Among the 7931 patients treated with FCM available for analysis, 14% made up the HF subgroup. Additional subgroups included women's health (36%), non-dialysis-dependent chronic kidney disease (NDD-CKD; 27%), haemodialysis-dependent chronic kidney disease (HD-CKD; 1%), gastrointestinal (10%), neurology (3%), and other (10%). The incidence of post-baseline moderate or severe hypophosphataemia (i.e. serum phosphate [PO4 3- ] level <2.0 mg/dL) varied across the therapeutic areas, with the lowest incidences observed in the HD-CKD (0%), HF (8.1%), and NDD-CKD (12.8%) subgroups. The prevalence of moderate or severe hypophosphataemia among the women's health, other, gastrointestinal, and neurology subgroups was 30.1%, 40.6%, 51.0%, and 55.6%, respectively. In the HF subgroup, one patient (<0.1%) had a serum PO4 3- of <1.0 mg/dL recorded, compared with 4.8% and 4.0% of the subjects in the neurology and gastrointestinal groups, respectively. With the exception of the HD-CKD subgroup, mean serum PO4 3- levels decreased through weeks 2 to 4, and then returned toward baseline and plateaued by week 8. The strongest predictor of hypophosphataemia was preserved kidney function (estimated glomerular filtration rate: >60 mL/min/1.73 m2 vs. <30 mL/min/1.73 m2 ; odds ratio: 12.2). Among patients in the HF subgroup, the incidence of treatment-emergent adverse events potentially related to hypophosphataemia (e.g. cardiac failure, ventricular tachyarrhythmias, fatigue, muscle weakness, bone pain, neurological symptoms, and muscle pain) was lower among FCM-treated patients than among those receiving placebo, and lower among patients with a post-baseline PO4 3- <2 mg/dL vs. those not meeting such criteria. CONCLUSIONS The risk of laboratory-assessed hypophosphataemia in HF patients treated with FCM was lower than that seen in patients in other therapeutic areas treated with FCM, and clinical events associated with hypophosphataemia are uncommon with FCM therapy in this population. Appropriate monitoring, particularly soon after administration in the unlikely event of repeated dosing in HF patients, will allow for further refinement of management strategies. [Correction added on 24 February 2023, after first online publication: In the preceding sentence, "…administration, will allow…" has been corrected to "…administration in the unlikely event of repeated dosing in HF patients, will allow…" in this version.].
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Affiliation(s)
| | - Kamyar Kalantar‐Zadeh
- Division of Nephrology and Hypertension and Kidney TransplantationUniversity of CaliforniaIrvineCaliforniaUSA
| | - Ewa A. Jankowska
- Institute of Heart DiseasesWrocław Medical UniversityWrocławPoland
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14
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Bsar AESMES, El-Wakiel SAR, El-Harrisi MAH, Elshafei ASH. Frequency and Risk Factors of Hypophosphatemia in Patients admitted to Emergency Intensive Care Unit in Zagazig University Hospitals. Indian J Crit Care Med 2023. [DOI: 10.5005/jp-journals-10071-24431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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15
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Jennings ML. Role of transporters in regulating mammalian intracellular inorganic phosphate. Front Pharmacol 2023; 14:1163442. [PMID: 37063296 PMCID: PMC10097972 DOI: 10.3389/fphar.2023.1163442] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/17/2023] [Indexed: 03/31/2023] Open
Abstract
This review summarizes the current understanding of the role of plasma membrane transporters in regulating intracellular inorganic phosphate ([Pi]In) in mammals. Pi influx is mediated by SLC34 and SLC20 Na+-Pi cotransporters. In non-epithelial cells other than erythrocytes, Pi influx via SLC20 transporters PiT1 and/or PiT2 is balanced by efflux through XPR1 (xenotropic and polytropic retrovirus receptor 1). Two new pathways for mammalian Pi transport regulation have been described recently: 1) in the presence of adequate Pi, cells continuously internalize and degrade PiT1. Pi starvation causes recycling of PiT1 from early endosomes to the plasma membrane and thereby increases the capacity for Pi influx; and 2) binding of inositol pyrophosphate InsP8 to the SPX domain of XPR1 increases Pi efflux. InsP8 is degraded by a phosphatase that is strongly inhibited by Pi. Therefore, an increase in [Pi]In decreases InsP8 degradation, increases InsP8 binding to SPX, and increases Pi efflux, completing a feedback loop for [Pi]In homeostasis. Published data on [Pi]In by magnetic resonance spectroscopy indicate that the steady state [Pi]In of skeletal muscle, heart, and brain is normally in the range of 1–5 mM, but it is not yet known whether PiT1 recycling or XPR1 activation by InsP8 contributes to Pi homeostasis in these organs. Data on [Pi]In in cultured cells are variable and suggest that some cells can regulate [Pi] better than others, following a change in [Pi]Ex. More measurements of [Pi]In, influx, and efflux are needed to determine how closely, and how rapidly, mammalian [Pi]In is regulated during either hyper- or hypophosphatemia.
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16
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Portales-Castillo I, Rieg T, Khalid SB, Nigwekar SU, Neyra JA. Physiopathology of Phosphate Disorders. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:177-188. [PMID: 36868732 PMCID: PMC10565570 DOI: 10.1053/j.akdh.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/24/2022] [Accepted: 12/29/2022] [Indexed: 03/05/2023]
Abstract
Intracellular phosphate is critical for cellular processes such as signaling, nucleic acid synthesis, and membrane function. Extracellular phosphate (Pi) is an important component of the skeleton. Normal levels of serum phosphate are maintained by the coordinated actions of 1,25-dihydroxyvitamin D3, parathyroid hormone and fibroblast growth factor-23, which intersect in the proximal tubule to control the reabsorption of phosphate via the sodium-phosphate cotransporters Npt2a and Npt2c. Furthermore, 1,25-dihydroxyvitamin D3 participates in the regulation of dietary phosphate absorption in the small intestine. Clinical manifestations associated with abnormal serum phosphate levels are common and occur as a result of genetic or acquired conditions affecting phosphate homeostasis. For example, chronic hypophosphatemia leads to osteomalacia in adults and rickets in children. Acute severe hypophosphatemia can affect multiple organs leading to rhabdomyolysis, respiratory dysfunction, and hemolysis. Patients with impaired kidney function, such as those with advanced CKD, have high prevalence of hyperphosphatemia, with approximately two-thirds of patients on chronic hemodialysis in the United States having serum phosphate levels above the recommended goal of 5.5 mg/dL, a cutoff associated with excess risk of cardiovascular complications. Furthermore, patients with advanced kidney disease and hyperphosphatemia (>6.5 mg/dL) have almost one-third excess risk of death than those with phosphate levels between 2.4 and 6.5 mg/dL. Given the complex mechanisms that regulate phosphate levels, the interventions to treat the various diseases associated with hypophosphatemia or hyperphosphatemia rely on the understanding of the underlying pathobiological mechanisms governing each patient condition.
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Affiliation(s)
- Ignacio Portales-Castillo
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA; Endocrine Unit, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Timo Rieg
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, FL; James A. Haley Veterans' Hospital, Tampa, FL; Center for Hypertension and Kidney Research, University of South Florida, Tampa, FL
| | - Sheikh B Khalid
- Department of Internal Medicine, The Indus Hospital, Lahore Pakistan
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL.
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17
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Postoperative Hypophosphatemia as a Prognostic Factor for Postoperative Pancreatic Fistula: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020274. [PMID: 36837475 PMCID: PMC9960534 DOI: 10.3390/medicina59020274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/24/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
Background and Objectives: Postoperative pancreatic fistula (POPF) is one of the most challenging complications after pancreatic resections, associated with prolonged hospital stay and high mortality. Early identification of pancreatic fistula is necessary for the treatment to be effective. Several prognostic factors have been identified, although it is unclear which one is the most crucial. Some studies show that post-pancreatectomy hypophosphatemia may be associated with the development of POPF. The aim of this systematic review was to determine whether postoperative hypophosphatemia can be used as a prognostic factor for postoperative pancreatic fistula. Materials and Methods: The systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations (PRISMA) and was registered in the International Prospective Register of Systematic Reviews (PROSPERO). The PubMed, ScienceDirect, and Web of Science databases were systematically searched up to the 31st of January 2022 for studies analyzing postoperative hypophosphatemia as a prognostic factor for POPF. Data including study characteristics, patient characteristics, operation type, definitions of postoperative hypophosphatemia and postoperative pancreatic fistula were extracted. Results: Initially, 149 articles were retrieved. After screening and final assessment, 3 retrospective studies with 2893 patients were included in this review. An association between postoperative hypophosphatemia and POPF was found in all included studies. Patients undergoing distal pancreatectomy were more likely to develop severe hypophosphatemia compared to patients undergoing proximal pancreatectomy. Serum phosphate levels on postoperative day 4 (POD 4) and postoperative day 5 (POD 5) remained significantly lower in patients who developed leak-related complications showing a slower recovery of hypophosphatemia from postoperative day 3 (POD 3) through postoperative day 7 (POD 7). Moreover, body mass index (BMI) higher than 30 kg/m2, soft pancreatic tissue, abnormal white blood cell count on postoperative day 3 (POD 3), and shorter surgery time were associated with leak-related complications (LRC) and lower phosphate levels. Conclusions: Early postoperative hypophosphatemia might be used as a prognostic biomarker for early identification of postoperative pancreatic fistula. However, more studies are needed to better identify significant cut-off levels of postoperative hypophosphatemia and development of hypophosphatemia in the postoperative period.
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18
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Muacevic A, Adler JR, Anderson C, Sheraton M. Seizures, Vitamin D Deficiency, and Severe Hypophosphatemia: The Unique Presentation of a SARS-CoV-2 Case. Cureus 2023; 15:e33303. [PMID: 36606109 PMCID: PMC9809502 DOI: 10.7759/cureus.33303] [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: 01/02/2023] [Indexed: 01/04/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a virus that belongs to the species severe acute respiratory syndrome-related coronavirus (SARSr-CoV), which is related to the SARS-CoV-1 virus that caused the 2002-2004 SARS outbreak. SARS-CoV-2 causes coronavirus disease 2019 (COVID-19). It has been associated with electrolyte abnormalities. In this report, we discuss the case of a SARS-CoV-2-infected person presenting with recurrent seizure episodes resulting from hypophosphatemia. A 52-year-old male patient with questionable prior seizure history presented to the emergency department (ED) twice within eight days with recurring seizure episodes. While the physical examination at the first presentation was significant for a head laceration with post-ictal confusion, that at the second presentation was only significant for post-ictal confusion. Laboratory examination at the first visit revealed SARS-CoV-2 positivity, hypokalemia, hypophosphatemia, and low vitamin D levels. On the second visit, the patient was again found to have hypophosphatemia. CT of the head and the cervical spine, as well as radiographs of the chest done on the first visit, were all normal. On his first visit, the patient's electrolyte abnormalities were corrected, and he was discharged with antiepileptic medications after 24 hours of observation and consultation with neurology. However, his vitamin D levels, the results of which came back only after his first discharge, were corrected only during his second visit. This time, he was discharged from the ED and had an effective resolution of symptoms. SARS-CoV-2 infections can result in vitamin D deficiency and hypophosphatemia, resulting in seizures, and hence should be treated with both replacement therapies and antiepileptic medications. This case also highlights the importance of obtaining phosphorus and vitamin D levels in SARS-CoV-2-infected patients with seizures.
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19
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Di Mario F, Regolisti G, Maggiore U, Pacchiarini MC, Menegazzo B, Greco P, Maccari C, Zambrano C, Cantarelli C, Pistolesi V, Morabito S, Fiaccadori E. Hypophosphatemia in critically ill patients undergoing Sustained Low-Efficiency Dialysis with standard dialysis solutions. Nephrol Dial Transplant 2022; 37:2505-2513. [PMID: 35481705 DOI: 10.1093/ndt/gfac159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In patients admitted to the Intensive Care Unit (ICU), Kidney Replacement Therapy (KRT) is an important risk factor for hypophosphataemia. However, studies addressing the development of hypophosphatemia during prolonged intermittent KRT modalities are lacking. Thus, we evaluated the incidence of hypophosphatemia during Sustained Low-Efficiency Dialysis (SLED) in ICU patients; we also examined the determinants of post-SLED serum phosphate level (s-P) and the relation between s-P and phosphate supplementation and ICU mortality. METHODS We conducted a retrospective analysis on a cohort of critically ill patients with severe renal failure and KRT need, who underwent at least three consecutive SLED sessions at 24-72 h time intervals with daily monitoring of s-P concentration. SLED with Regional Citrate Anticoagulation (RCA) was performed with either conventional dialysis machines or continuous-KRT monitors and standard dialysis solutions. When deemed necessary by the attending physician, intravenous phosphate supplementation was provided by sodium glycerophosphate pentahydrate. We used mixed-effect models to examine the determinants of s-P and Cox proportional hazards regression models with time-varying covariates to examine the adjusted relation between s-P, intravenous phosphate supplementation and ICU mortality. RESULTS We included 65 patients [mean age 68 years (SD 10.0); mean Acute Physiology and Chronic Health Evaluation II score 25 (range 9-40)] who underwent 195 SLED sessions. The mean s-P before the start of the first SLED session (baseline s-P) was 5.6 ± 2.1 mg/dL (range 1.5-12.3). Serum phosphate levels at the end of each SLED decreased with increasing age, SLED duration and number of SLED sessions (P < .05 for all). The frequency of hypophosphatemia increased after the first through the third SLED session (P = .012). Intravenous phosphate supplementation was scheduled after 12/45 (26.7%) SLED sessions complicated by hypophosphataemia. The overall ICU mortality was 23.1% (15/65). In Cox regression models, after adjusting for potential confounders and for current s-P, intravenous phosphate supplementation was associated with a decrease in ICU mortality [adjusted hazard ratio: 0.24 (95% confidence interval: 0.06 to 0.89; P = 0.033)]. CONCLUSIONS Hypophosphatemia is a frequent complication in critically ill patients undergoing SLED with standard dialysis solutions, that worsens with increasing SLED treatment intensity. In patients undergoing daily SLED, phosphate supplementation is strongly associated with reduced ICU mortality.
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Affiliation(s)
- Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Giuseppe Regolisti
- Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy.,UO Clinica e Immunologia Medica, Azienda Ospedaliero-Universitaria, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Umberto Maggiore
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Maria Chiara Pacchiarini
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Brenda Menegazzo
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Paolo Greco
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Caterina Maccari
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Cristina Zambrano
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Chiara Cantarelli
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
| | - Valentina Pistolesi
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Rome, Italy
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Rome, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
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20
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Jia J, Guo J, Liu X, Li G, Liu Y, Zhao X. Impact of serum phosphate on severity and functional outcomes after ischemic stroke in young adults. Nutr Metab Cardiovasc Dis 2022; 32:2553-2560. [PMID: 36163211 DOI: 10.1016/j.numecd.2022.08.008] [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: 04/13/2022] [Revised: 07/29/2022] [Accepted: 08/04/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIMS Serum phosphate is an essential nutrient that plays multiple physiological roles in cardiovascular function. The aim of this study was to investigate the association between serum phosphate and stroke severity and prognosis in ischemic stroke and transient ischemic attack (TIA) among young adults. METHODS AND RESULTS We retrospectively recruited patients with acute ischemic stroke and TIA aged 18-45 years. The primary outcome was 90-day poor functional outcome (modified Rankin Scale score of 2-6). The secondary outcomes included stroke severity (NIHSS ≥5 was defined as moderate to severe stroke) and poor functional outcome at hospital discharge. A total of 687 patients with a mean age of 36.8 years were enrolled. Lower serum phosphate levels were significantly associated with more severe stoke (P for trend = 0.017). Compared with the fourth quartile, the odds ratio (95% CI) of the first quartile was 1.85 (1.19-3.22) for moderate to severe stroke. After adjusting for confounders other than stroke severity, the odds ratio (95% CI) of the first quartile was 1.74 (1.06-2.86) for poor functional outcome at hospital discharge and 1.90 (1.09-3.31) at 90-day follow-up compared with the fourth quartile. However, the significant association between serum phosphate and poor functional outcomes disappeared after stroke severity was further adjusted. CONCLUSIONS Serum phosphate is more likely a marker of stroke severity than a contributor to poor functional outcomes after ischemic stroke and TIA in young adults. Lower serum phosphate levels were associated with more severe stroke.
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Affiliation(s)
- Jiaokun Jia
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiahuan Guo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinmin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Guangshuo Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Yanfang Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China.
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
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21
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Veldscholte K, Veen MAN, Eveleens RD, de Jonge RCJ, Vanhorebeek I, Gunst J, Casaer MP, Wouters PJ, Guerra GG, Van den Berghe G, Joosten KFM, Verbruggen SCAT. Early hypophosphatemia in critically ill children and the effect of parenteral nutrition: A secondary analysis of the PEPaNIC RCT. Clin Nutr 2022; 41:2500-2508. [PMID: 36219978 DOI: 10.1016/j.clnu.2022.09.001] [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: 07/12/2022] [Revised: 08/25/2022] [Accepted: 09/06/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS Hypophosphatemia during critical illness has been associated with adverse outcome. The reintroduction of enteral or parenteral nutrition, leading to refeeding hypophosphatemia (RFH), has been presented as potential risk factor. We investigated the occurrence of early RFH, its association with clinical outcome, and the impact of early parenteral nutrition (PN) on the development of early RFH in pediatric critical illness. METHODS This is a secondary analysis of the PEPaNIC randomized controlled trial (N = 1440), which showed that withholding supplemental parenteral nutrition (PN) for 1 week (late-PN) in the pediatric intensive care unit (PICU) accelerated recovery and reduced new infections compared to early-PN (<24 h). Patients with renal replacement therapy or unavailable phosphate concentrations were excluded from this analysis. Early RFH was defined as serum/plasma phosphate <0.65 mmol/L and a drop of >0.16 mmol/L within 3 days of admission to the PICU. The association between baseline characteristics and early RFH, and the association of early RFH with clinical outcome were investigated using logistic and linear regression models, both uncorrected and corrected for possible confounders. To examine the impact of nutritional intake on phosphate concentrations, structural nested mean models with propensity score and censoring models were used. RESULTS A total of 1247 patients were eligible (618 early-PN, 629 late-PN). Early RFH occurred in 40 patients (3%) in total, significantly more in the early-PN group (n = 31, within-group occurrence 5%) than in the late-PN-group (n = 9, within-group occurrence 1%, p < 0.001). Patients who were older (OR 1.14 (95% CI 1.08; 1.21) per year added, p < 0.001) and who had a higher Pediatric Risk of Mortality (PIM3) score had a higher risk of developing early RFH (OR 1.36 (95% CI 1.15; 1.59) per unit added, p < 0.001), whereas patients in the late-PN group had a lower risk of early RFH (OR 0.24 (95% CI 0.10; 0.49), p < 0.001). Early RFH was significantly associated with a 56% longer PICU stay (p = 0.003) and 42% longer hospital stay (p = 0.007), but not with new infections (OR 2.01 (95% CI 0.90; 4.30), p = 0.08) or length of mechanical ventilatory support (OR 1.05 (95% CI -3.92; 6.03), p = 0.68), when adjusted for possible confounders. Increase of parenteral nutrition intake (in % kcal of predicted resting energy expenditure) decreased phosphate concentrations (c = -0.002 (95% CI -0.002; -0.001). CONCLUSIONS Early RFH occurred in 3% of critically ill children. Patients randomized to late-PN had a lower chance of developing early RFH, which may be explained by the more gradual build-up of nutrition. As early RFH might impact recovery, it is important to closely monitor phosphate concentrations in patients, especially of those at risk for early RFH.
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Affiliation(s)
- K Veldscholte
- Pediatric Intensive Care Unit, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - M A N Veen
- Pediatric Intensive Care Unit, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - R D Eveleens
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - R C J de Jonge
- Pediatric Intensive Care Unit, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - I Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - J Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - M P Casaer
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - P J Wouters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Gonzalo Garcia Guerra
- Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada
| | - G Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - K F M Joosten
- Pediatric Intensive Care Unit, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - S C A T Verbruggen
- Pediatric Intensive Care Unit, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.
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22
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Hypophosphatemia in Coronavirus Disease 2019 (COVID-19), Complications, and Considerations: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2022; 2022:1468786. [PMID: 36312855 PMCID: PMC9616661 DOI: 10.1155/2022/1468786] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 08/07/2022] [Accepted: 09/16/2022] [Indexed: 01/10/2023]
Abstract
Coronavirus disease 2019 (COVID-19) has various manifestations on different body organs, including the lungs, heart, kidneys, and central nervous system. However, the frequency of electrolyte abnormalities, especially hypophosphatemia, is still debated in this pandemic. Our main aim in this review is to evaluate the frequency and complications of hypophosphatemia in COVID-19-infected individuals. A systematic literature review was performed in Web of Science, Scopus, PubMed, EMBASE, and Cochrane electronic databases with the combination of different keywords till October 2021. We recruited all relevant published records (including cross-sectional and case-control studies as well as editorials and brief reports) assessing hypophosphatemia among patients with COVID-19 infection. After assessing all 928 recruited records and discarding duplicates, 4 records met the inclusion criteria. Three articles were further included during a manual search of the literature. Overall, the included studies reported 1757 subjects (males: 51.3%), with the mean age ranging from 37.2 ± 13.6 years to 65.9 ± 13.9 years. Hypophosphatemia prevalence has been reported from 7.6% to 19.5%. Patients with the severe status of COVID-19 had a higher prevalence of low serum phosphate levels than those with moderate infection. This review indicates that hypophosphatemia might be categorized as a complication in clinical settings during the COVID-19 pandemic, requiring a high clinical suspicion to implement appropriate diagnostic and therapeutic interventions to prevent life-threatening outcomes. However, it needs to be more elucidated by further studies whether hypophosphatemia in severe COVID-19 is directly related to COVID-19 or is just a complication of severe illness.
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23
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Boots JMM, Quax RAM. High-Dose Intravenous Iron with Either Ferric Carboxymaltose or Ferric Derisomaltose: A Benefit-Risk Assessment. Drug Saf 2022; 45:1019-1036. [PMID: 36068430 PMCID: PMC9492608 DOI: 10.1007/s40264-022-01216-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/22/2022]
Abstract
The intravenous iron formulations ferric carboxymaltose (FCM) and ferric derisomaltose (FDI) offer the possibility of administering a large amount of iron in one infusion. This results in faster correction of anemia and the formulations being better tolerated than oral iron formulations. This triad of logistic advantages, improved patient convenience, and fast correction of anemia explains the fact that intravenous iron formulations nowadays are frequently prescribed worldwide in the treatment of iron deficiency anemia. However, these formulations may result in hypophosphatemia by inducing a strong increase in active fibroblast growth factor-23 (FGF-23), a hormone that stimulates renal phosphate excretion. This effect is much more pronounced with FCM than with FDI, and therefore the risk of developing hypophosphatemia is remarkably higher with FCM than with FDI. Repeated use of FCM may result in severe osteomalacia, which is characterized by bone pain, Looser zones (pseudofractures), and low-trauma fractures. Intravenous iron preparations are also associated with other adverse effects, of which hypersensitivity reactions are the most important and are usually the result of a non-allergic complement activation on nanoparticles of free labile iron-Complement Activation-Related Pseudo-Allergy (CARPA). The risk on these hypersensitivity reactions can be reduced by choosing a slow infusion rate. Severe hypersensitivity reactions were reported in < 1% of prospective trials and the incidence seems comparable between the two formulations. A practical guideline has been developed based on baseline serum phosphate concentrations and predisposing risk factors, derived from published cases and risk factor analyses from trials, in order to establish the safe use of these formulations.
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Affiliation(s)
- Johannes M M Boots
- Department of Internal Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands.
| | - Rogier A M Quax
- Department of Internal Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ, Rotterdam, The Netherlands
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24
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An adolescent with abdominal pain and tremors: Answers. Pediatr Nephrol 2022; 38:1467-1469. [PMID: 36094671 DOI: 10.1007/s00467-022-05727-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 10/14/2022]
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Abstract
Inorganic phosphate (Pi) in the mammalian body is balanced by its influx and efflux through the intestines, kidneys, bones, and soft tissues, at which several sodium/Pi co-transporters mediate its active transport. Pi homeostasis is achieved through the complex counter-regulatory feedback balance between fibroblast growth factor 23 (FGF23), 1,25-dihydroxyvitamin D (1,25(OH)2D), and parathyroid hormone. FGF23, which is mainly produced by osteocytes in bone, plays a central role in Pi homeostasis and exerts its effects by binding to the FGF receptor (FGFR) and αKlotho in distant target organs. In the kidneys, the main target, FGF23 promotes the excretion of Pi and suppresses the production of 1,25(OH)2D. Deficient and excess FGF23 result in hyperphosphatemia and hypophosphatemia, respectively. FGF23-related hypophosphatemic rickets/osteomalacia include tumor-induced osteomalacia and various genetic diseases, such as X-linked hypophosphatemic rickets. Coverage by the national health insurance system in Japan for the measurement of FGF23 and the approval of burosumab, an FGF23-neutralizing antibody, have had a significant impact on the diagnosis and treatment of FGF23-related hypophosphatemic rickets/osteomalacia. Some of the molecules responsible for genetic hypophosphatemic rickets/osteomalacia are highly expressed in osteocytes and function as local regulators of FGF23 production. A number of systemic factors also regulate FGF23 levels. Although the mechanisms responsible for Pi sensing in mammals have not yet been elucidated in detail, recent studies have suggested the involvement of FGFR1. The further clarification of the mechanisms by which osteocytes detect Pi levels and regulate FGF23 production will lead to the development of better strategies to treat hyperphosphatemic and hypophosphatemic conditions.
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Affiliation(s)
- Toshimi Michigami
- Department of Bone and Mineral Research, Research Institute, Osaka Women's and Children's Hospital, Osaka 594-1101, Japan
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26
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Liu Z, Li T, Du Y, Li C, Chong W. Both hypophosphatemia and hyperphosphatemia are associated with increased mortality in septic patients. FRONTIERS IN NEPHROLOGY 2022; 2:935288. [PMID: 37745280 PMCID: PMC10513022 DOI: 10.3389/fneph.2022.935288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/15/2022] [Indexed: 09/26/2023]
Abstract
Objective This study was intended to explore the relationship between level of serum phosphate and prognosis in septic patients. Methods Data were obtained from the public database, which were divided into 2 subgroups according to whether they were complicated with chronic kidney disease. Initial values of serum phosphate were extracted from patients on admission to hospital. Propensity score-matched analysis was performed. The relationship between hypophosphatemia, hyperphosphatemia and the severity of the disease in septic patients was explored separately. The lowess smoothing technique and the Kaplan-Meier method were utilized for a preliminary analysis of serum phosphate levels in relation to in-hospital mortality and 28-day survival. The initial values of serum phosphate were graded as level 1 (<1.5 mg/dL), level 2 (1.5-2.7 mg/dL), level 3 (2.7-4.5 mg/dL), level 4 (4.5-5.5 mg/dL), level 5 (5.5-6.5 mg/dL), level 6 (6.5-7.5 mg/dL) and level 7 (> 7.5 mg/dL). Multivariate logistic regression and cox regression was used to analyse the relationship between serum phosphate levels and mortality. Results There were 4059 cases (17.4%) combined with chronic kidney disease, including 419 cases (10.3%) with hypophosphatemia and 1091 cases (26.8%) with hyperphosphatemia. There were 19224 cases (82.6%) not combined with chronic kidney disease, including 3769 cases (19.6%) hypophosphatemia and 2158 cases (11.2%) hyperphosphatemia. After propensity score-matched, in-hospital mortality, 28-day mortality, risk of septic shock was significantly higher in the 2 subgroups of hypophosphatemia patients than in normophosphatemia patients. In-hospital mortality, 28-day mortality, risk of septic shock, occurrence of renal replacement therapy, occurrence of acute renal failure, and maximum clinical score were all significantly higher in the 2 subgroups of patients with hyperphosphatemia than in patients with normophosphatemia. Multivariate logistic regression was consistent with cox regression results. In septic patients without chronic kidney disease, hypophosphatemia was an independent risk factor for death. When serum phosphate was lower, the risk of death was higher. In all septic patients, hyperphosphatemia was an independent risk factor for death. When serum phosphate was higher, the risk of death was greater. Conclusions Both hypophosphatemia and hyperphosphatemia are associated with increased mortality in septic patients and are independent risk factors for death.
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Affiliation(s)
| | | | | | | | - Wei Chong
- The First Affiliated Hospital of China Medical University, Shenyang, China
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27
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Zheng WH, Yao Y, Zhou H, Xu Y, Huang HB. Hyperphosphatemia and Outcomes in Critically Ill Patients: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:870637. [PMID: 35665344 PMCID: PMC9156794 DOI: 10.3389/fmed.2022.870637] [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] [Received: 02/07/2022] [Accepted: 04/05/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Serum phosphate level is often deranged during critical illness. Hyperphosphatemia, as a marker of disease severity, attracts more and more attention. This study aimed to evaluate the impact of hyperphosphatemia on clinical outcomes in critically ill patients. Methods We searched for relevant studies in PubMed, EMBASE, and the Cochrane database up to Jan 10, 2022. Two authors independently screened studies, extracted data, and assessed the study quality. Meta-analyses were performed to determine hyperphosphatemia prevalence and evaluate its relationship with prognosis and important clinical outcomes. We also conducted subgroup analysis and sensitivity analyses to explore the sources of heterogeneity. Results Ten studies with 60,358 patients met the inclusion criteria. These studies were moderate to high quality. The median prevalence of hyperphosphatemia was 30% (range from 5.6 to 45%). Patients with hyperphosphatemia had a significantly higher risk of all-cause mortality than those without (OR 2.85; 95% CI, 2.35 to 3.38, P < 0.0001). Subgroup analyses, sensitivity analyses, and regression analyses further confirmed these results. In addition, patients with hyperphosphatemia required more CRRT (OR 4.96; 95% CI, 2.43 to 10.2, P < 0.0001) but not significantly increased duration of mechanical ventilation (mean difference, MD 0.13, 95% CI −0.04 to 0.30; P = 0.138), length of stay in intensive care unit (ICU) (SMD 0.164 day, 95% CI −0.007 to 0.335; P = 0.06), and length of stay in hospital (SMD 0.005 day, 95% CI −0.74 to 0.75; P = 0.99). Conclusions Our results indicated that hyperphosphatemia was associated with all-cause mortality in critically ill patients. However, due to the retrospective design of the included studies, more prospective, well-designed research is required in the future. Systematic Review Registration [https://doi.org/10.37766/inplasy2021.12.0130], identifier [INPLASY2021120130].
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Affiliation(s)
- Wen-He Zheng
- Department of Critical Care Medicine, The Second People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Yan Yao
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hua Zhou
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yuan Xu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hui-Bin Huang
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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28
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Pathogenesis of FGF23-Related Hypophosphatemic Diseases Including X-linked Hypophosphatemia. ENDOCRINES 2022. [DOI: 10.3390/endocrines3020025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Since phosphate is indispensable for skeletal mineralization, chronic hypophosphatemia causes rickets and osteomalacia. Fibroblast growth factor 23 (FGF23), which is mainly produced by osteocytes in bone, functions as the central regulator of phosphate metabolism by increasing the renal excretion of phosphate and suppressing the production of 1,25-dihydroxyvitamin D. The excessive action of FGF23 results in hypophosphatemic diseases, which include a number of genetic disorders such as X-linked hypophosphatemic rickets (XLH) and tumor-induced osteomalacia (TIO). Phosphate-regulating gene homologous to endopeptidase on the X chromosome (PHEX), dentin matrix protein 1 (DMP1), ectonucleotide pyrophosphatase phosphodiesterase-1, and family with sequence similarity 20c, the inactivating variants of which are responsible for FGF23-related hereditary rickets/osteomalacia, are highly expressed in osteocytes, similar to FGF23, suggesting that they are local negative regulators of FGF23. Autosomal dominant hypophosphatemic rickets (ADHR) is caused by cleavage-resistant variants of FGF23, and iron deficiency increases serum levels of FGF23 and the manifestation of symptoms in ADHR. Enhanced FGF receptor (FGFR) signaling in osteocytes is suggested to be involved in the overproduction of FGF23 in XLH and autosomal recessive hypophosphatemic rickets type 1, which are caused by the inactivation of PHEX and DMP1, respectively. TIO is caused by the overproduction of FGF23 by phosphaturic tumors, which are often positive for FGFR. FGF23-related hypophosphatemia may also be associated with McCune-Albright syndrome, linear sebaceous nevus syndrome, and the intravenous administration of iron. This review summarizes current knowledge on the pathogenesis of FGF23-related hypophosphatemic diseases.
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Rashed R, Hyassat D, Batieha A, Aldabbas M, Aldarabah F, EL-Khateeb M, Ajlouni K. Prevalence and Correlates of Hypophosphatemia Among Type 2 diabetic patients attending the National Center for Diabetes, Endocrinology and genetics (NCDEG). Ann Med Surg (Lond) 2022; 78:103770. [PMID: 35592823 PMCID: PMC9110974 DOI: 10.1016/j.amsu.2022.103770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/08/2022] [Accepted: 05/08/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives To estimate the prevalence of hypophosphatemia and its associated factors among type 2 diabetic patients attending (NCDEG) in Amman-Jordan, and compare the prevalence of hypophosphatemia between diabetics, nondiabetic subjects. Patients and methods A case-control study was carried out at (NCDEG). A total of 1580 diabetic patients (59.7% females, 40.3% males), mean age (SD) of 55.15 ± 15.3 attended this center from January 1st, 2020 till March 31st, 2020 were included. Our study included 2155 non-diabetic from the national population-based multipurpose study in Jordan in 2017, to compare serum inorganic phosphate between diabetic, nondiabetic. Pregnant, those aged <18 or >80 years, GFR below 30 ml/min or those on hemodialysis were excluded. The data included patient's age, gender, smoking and medication, HbA1c. Statistical analysis were performed using the Package for Social Sciences (SPSS) version 21. Results The overall prevalence of hypophosphatemia in the diabetic patients was significantly higher (10.5% vs. 3.2%, P-value 0.001). Multivariate logistic regression analysis showed that in diabetic: males, current smokers, diabetic patients with HbA1c between 7 and 9% and >9%, those who on thiazide diuretics were 2, 1.9, 1.8, 1.7, and 1.9 times, more likely to have hypophosphatemia than their counterparts (P-values 0.001, 0.001, 0.006, 0.018 and 0.003), respectively, and it was found those on statin were less likely to have hypophosphatemia. Conclusion The prevalence of hypophosphatemia among type 2 diabetic patients is high. Factors independently related to hypophosphatemia in diabetic patients: male gender, smoking, poor glycemic control, taking thiazides and not being on statin. The objectives is to estimate the prevalence of hypophosphatemia and its associated factors among type 2 diabetic patients. Also, to compare the prevalence of hypophosphatemia between diabetics, nondiabetic subjects. The overall prevalence of hypophosphatemia in the diabetic patients was significantly 10.5%. The overall prevalence of hypophosphatemia in the non- diabetic patients was 3.2%. Factors independently related to hypophosphatemia in diabetic patients included: male gender, smoking, poor glycemic control.
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Affiliation(s)
- Rula Rashed
- The National Center for Diabetes, Endocrinology and Genetics, The University of Jordan, Amman, Jordan
| | - Dana Hyassat
- The National Center for Diabetes, Endocrinology and Genetics, The University of Jordan, Amman, Jordan
| | - Anwar Batieha
- Jordan University of Science and Technology (JUST), Jordan
| | - Mohammad Aldabbas
- The National Center for Diabetes, Endocrinology and Genetics, The University of Jordan, Amman, Jordan
| | - Faiq Aldarabah
- The National Center for Diabetes, Endocrinology and Genetics, The University of Jordan, Amman, Jordan
| | - Mohammed EL-Khateeb
- The National Center for Diabetes, Endocrinology and Genetics, The University of Jordan, Amman, Jordan
| | - Kamel Ajlouni
- The National Center for Diabetes, Endocrinology and Genetics, The University of Jordan, Amman, Jordan
- Corresponding author. The National Center for Diabetes, Endocrinology and Genetics, P.O. Box 13165, Amman, 11942, Jordan.
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Correlations between First 72 h Hypophosphatemia, Energy Deficit, Length of Ventilation, and Mortality-A Retrospective Cohort Study. Nutrients 2022; 14:nu14071332. [PMID: 35405945 PMCID: PMC9002762 DOI: 10.3390/nu14071332] [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] [Received: 01/25/2022] [Revised: 03/15/2022] [Accepted: 03/21/2022] [Indexed: 12/10/2022] Open
Abstract
INTRODUCTION Hypophosphatemia may prolong ventilation and induce weaning failure. Some studies have associated hypophosphatemia with increased mortality. Starting or restarting nutrition in a critically ill patient may be associated with refeeding syndrome and hypophosphatemia. The correlation between nutrition, mechanical ventilation, and hypophosphatemia has not yet been fully elucidated. METHODS A retrospective cohort study of 825 admissions during two consecutive years was conducted. Using the electronic medical chart, demographic and clinical data were obtained. Hypophosphatemia was defined as a phosphate level below 2.5 mg/dL (0.81 mmol/L) in the first 72 h of ICU admission. Comparisons between baseline characteristics and outcomes and multivariate analysis were performed. RESULTS A total of 324 (39.27%) patients had hypophosphatemia during the first 72 h of ICU admission. Patients with hypophosphatemia tended to be younger, with lower APACHE-II, SOFA24, and ΔSOFA scores. They had a longer length of stay and length of ventilation, more prevalent prolonged ventilation, and decreased mortality. Their energy deficit was lower. There was no effect of hypophosphatemia severity on these results. In multivariate analysis, hypophosphatemia was not found to be statistically significant either with respect to mortality or survivor's length of ventilation, but lower average daily energy deficit and SOFA24 were found to be statistically significant with respect to survivor's length of ventilation. CONCLUSION Hypophosphatemia had no effect on mortality or length of ventilation. Lower average daily energy deficit is associated with a longer survivor's length of ventilation.
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Lu A, Pu M, Mo S, Su J, Hu J, Li C, Wang W, Yang T. (Pro)renin Receptor Regulates Phosphate Homeostasis in Rats via Releasing Fibroblast Growth Factor-23. Front Physiol 2022; 13:784521. [PMID: 35222071 PMCID: PMC8874195 DOI: 10.3389/fphys.2022.784521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/14/2022] [Indexed: 11/13/2022] Open
Abstract
Phosphate (Pi) is one of the basic necessities required for sustenance of life and its metabolism largely relies on excretory function of the kidney, a process chiefly under the endocrine control of bone-derived fibroblast growth factor 23 (FGF23). However, knowledge gap exists in understanding the regulatory loop responsible for eliciting phophaturic response to Pi treatment. Here, we reported a novel role of (pro)renin receptor (PRR) in mediating phosphaturic response to Pi treatment via upregulation of FGF23 production. Male Sprague-Dawley rats were pretreated for 5 days via osmotic pump-driven infusion of a PRR antagonist PRO20 or vehicle, and then treated with high Pi (HP) solution as drinking fluid for the last 24 h. PRO20 reduced HP-induced Pi excretion by 42%, accompanied by blunted upregulation of circulating FGF23 and parathyroid hormone (PTH) and downregulation of renal Na/Pi-IIa expression. In cultured osteoblast cells, exposure to HP induced a 1.56-fold increase in FGF23 expression, which was blunted by PRO20 or siRNA against PRR. Together, these results suggest that activation of PRR promotes phosphaturic response through stimulation of FGF23 production and subsequent downregulation of renal Na/Pi-IIa expression.
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Affiliation(s)
- Aihua Lu
- Institute of Hypertension, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Min Pu
- Institute of Hypertension, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Shiqi Mo
- Institute of Hypertension, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Jiahui Su
- Institute of Hypertension, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Jiajia Hu
- Institute of Hypertension, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Chunling Li
- Institute of Hypertension, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Weidong Wang
- Institute of Hypertension, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Tianxin Yang
- Department of Internal Medicine, University of Utah and Veterans Affairs Medical Center, Salt Lake City, UT, United States
- *Correspondence: Tianxin Yang,
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Razzaque MS. Salivary phosphate as a biomarker for human diseases. FASEB Bioadv 2022; 4:102-108. [PMID: 35141474 PMCID: PMC8814558 DOI: 10.1096/fba.2021-00104] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Mohammed S. Razzaque
- Department of Pathology Lake Erie College of Osteopathic Medicine Erie Pennsylvania USA
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Vitamin D and Phosphate Interactions in Health and Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1362:37-46. [DOI: 10.1007/978-3-030-91623-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Morimoto Y, Ishiguro T, Uozumi R, Takano K, Kobayashi Y, Kobayashi Y, Shimizu Y, Takayanagi N. Significance of Hypophosphatemia in Patients with Pneumonia. Intern Med 2022; 61:979-988. [PMID: 35370255 PMCID: PMC9038449 DOI: 10.2169/internalmedicine.6949-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective Phosphate is a fundamental element involved in a number of physiological pathways. A previous study showed abnormal laboratory findings and a higher mortality in hypophosphatemic patients than in normophosphatemic patients with pneumonia. Sporadic cases of pneumonia due to Legionella spp., Streptococcus pneumoniae, and viruses have been reported; however, the significance of hypophosphatemia in patients with pneumonia has not been adequately studied. We determined whether or not hypophosphatemia in patients with community-acquired pneumonia (CAP) was associated with specific pathogens, patient factors, disease severity, and mortality. Method We retrospectively analyzed 600 patients with CAP who were admitted to our hospital between January 1, 2010, and December 31, 2019. Results Hypophosphatemia was found in 72 (12.0%) of the 600 patients. The most frequent causative microbial agents of CAP in patients with hypophosphatemia were S. pneumoniae, Legionella spp., and influenza virus, whereas in severely ill patients with hypophosphatemia, influenza virus was the most common. Legionella spp., diabetes mellitus, and severe pneumonia were the independent factors for hypophosphatemia in the multivariable analysis. An impaired performance status, severe status on admission, interstitial pneumonia, bacteremia, and guideline-discordant therapy were the independent factors associated with mortality in the multivariable analysis. Hypophosphatemia was not significantly associated with mortality but showed a trend towards higher mortality in the multivariable analysis. Conclusion Hypophosphatemia was not associated with the prognosis in patients with CAP. However, the significance of hypophosphatemia for clinicians lies in the laboratory findings that predict abnormal glucose metabolism, Legionella infection, and severe disease.
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Affiliation(s)
- Yasuhiro Morimoto
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan
- Department of Respiratory Medicine, The Jikei University Hospital, Japan
| | - Takashi Ishiguro
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan
| | - Ryuji Uozumi
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Japan
| | - Kenji Takano
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan
| | - Yoichi Kobayashi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan
| | - Yasuhito Kobayashi
- Department of Pathology, Saitama Cardiovascular and Respiratory Center, Japan
| | - Yoshihiko Shimizu
- Department of Pathology, Saitama Cardiovascular and Respiratory Center, Japan
| | - Noboru Takayanagi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Japan
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Leifheit-Nestler M, Vogt I, Haffner D, Richter B. Phosphate Is a Cardiovascular Toxin. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1362:107-134. [DOI: 10.1007/978-3-030-91623-7_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Adhikari S, Mamlouk O, Rondon-Berrios H, Workeneh BT. Hypophosphatemia in cancer patients. Clin Kidney J 2021; 14:2304-2315. [PMID: 34754427 PMCID: PMC8572986 DOI: 10.1093/ckj/sfab078] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Indexed: 12/19/2022] Open
Abstract
Dysregulation of phosphorus homeostasis resulting in hypophosphatemia is common in cancer patients and can result in serious complications and impact outcomes. Several factors, including critical illness, nutritional status, cancer type and therapy, influence the development of hypophosphatemia. Hypophosphatemia can develop as a result of phosphaturic mesenchymal tumors or as a paraneoplastic phenomenon. The clinical presentation for hypophosphatemia varies depending on the duration and severity of the hypophosphatemia and affects several organ systems. Among other serious effects, hypophosphatemia can impair tissue oxygenation and can cause hemolysis, leukocyte and platelet dysfunction, encephalopathy, seizures, arrhythmias, cardiomyopathy, rhabdomyolysis and coma. Multiple studies have demonstrated that hypophosphatemia is an adverse prognostic marker in inpatients with increased in-hospital stay, mortality and postoperative complications. The phosphate level is homeostatically regulated and maintained in a narrow range by three main hormones: parathyroid hormone, fibroblast growth factor 23 and 1,25-dihydroxyvitaminD3. Together, these hormones regulate how the intestine, kidneys and bones traffic phosphorus. Several hematological malignancies and cancer therapies are associated with proximal tubular dysfunction (Fanconi syndrome), resulting in phosphaturia. Caution should be taken with parenteral administration of phosphate salts, because secondary complications can develop, principally due to hypocalcemia. The general approach to hypophosphatemia should target the underlying cause. Early recognition and prevention are essential and the approach to hypophosphatemia in the cancer patient, because of the nuances and complexity, should be multidisciplinary.
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Affiliation(s)
- Shreedhar Adhikari
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Omar Mamlouk
- Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Helbert Rondon-Berrios
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Biruh T Workeneh
- Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Bosman A, Campos-Obando N, Medina-Gomez C, Voortman T, Uitterlinden AG, Zillikens MC. Serum Phosphate, BMI, and Body Composition of Middle-Aged and Older Adults: A Cross-Sectional Association Analysis and Bidirectional Mendelian Randomization Study. J Nutr 2021; 152:276-285. [PMID: 34601595 PMCID: PMC8754515 DOI: 10.1093/jn/nxab351] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/20/2021] [Accepted: 09/24/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Observational studies have reported associations between serum phosphate and BMI in specific clinical settings, but the nature of this relation in the general population is unclear. OBJECTIVES The aim of this study was twofold: to investigate the association between serum phosphate and BMI and body composition, as well as to explore evidence of causality through a bidirectional one-sample Mendelian randomization (MR) in the population-based Rotterdam Study (RS). METHODS Observational associations between phosphate (mg/dL) and BMI, lean mass, and fat percentage (fat%), estimated by DXA, were analyzed using multivariable regression models in 9202 participants aged 45-100 y from 3 RS cohorts. The role of serum leptin was examined in a subgroup of 1089 participants. For MR analyses, allele scores with 6 single-nucleotide polymorphisms (SNPs) for phosphate and 905 SNPs for BMI were constructed in 7983 participants. RESULTS Phosphate was inversely associated with BMI in the total population (β: -0.89; 95% CI: -1.17, -0.62), and stronger in women (β: -1.92; 95% CI: -2.20, -1.65) than in men (β: -0.37; 95% CI: -0.68, -0.06) (P-interaction < 0.05). Adjustment for leptin did not change results in men. In women, adjustment for leptin attenuated the association, but it was not abolished (β: -0.94; 95% CI: -1.45, -0.42). Phosphate was inversely associated with fat%, but not with lean mass, in both sexes. MR analyses suggested a causal effect of BMI on serum phosphate (β: -0.01; 95% CI: -0.02, 0.00) but not vice versa. CONCLUSIONS Serum phosphate was inversely associated with BMI and fat% in a population-based study of middle-aged and older adults, with a stronger effect in women than in men. Adjusting for leptin attenuated this relation in women only. MR results suggest a causal effect of BMI on phosphate but not vice versa. An underlying sex dimorphism in phosphate homeostasis should be further explored.
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Affiliation(s)
| | | | - Carolina Medina-Gomez
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Trudy Voortman
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - André G Uitterlinden
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Erritzøe‐Jervild M, Wesierski J, Romano S, Frikke‐Schmidt R, Orre M, Eskesen V, Olsen MH, Møller K. Hypophosphataemia is common in patients with aneurysmal subarachnoid haemorrhage. Acta Anaesthesiol Scand 2021; 65:1431-1438. [PMID: 34383290 DOI: 10.1111/aas.13973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/29/2021] [Accepted: 08/07/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Hypophosphataemia is common in critically ill patients, but neither its prevalence nor its association with outcome have been investigated specifically in patients with aneurysmal subarachnoid haemorrhage (aSAH). METHODS Patients with aSAH and at least one phosphate measurement were included from two independent cohorts; an American cohort extracted from two open-access databases (Medical Information Mart for Intensive Care-III and eICU Collaborative Research Database v. 2.0) and a Danish cohort consisting of patients with aSAH admitted to Rigshospitalet, Denmark over a 4-year period. In each cohort, we calculated the prevalence of mild (0.32-0.80 mmol/L) and severe (<0.32 mmol/L) hypophosphataemia and their association with in-hospital mortality before and after propensity-score matching. RESULTS Hypophosphataemia occurred in 72.4% (95% CI: 68.1-76.3) of patients in the American cohort (n = 471) and 54.9% (50.0-59.7) in the Danish cohort (n = 419). However, it was not associated with mortality in neither full (American: Mild, Odds ratio (OR) 0.99 (0.91-1.07), Severe OR 1.20 (0.95-1.51); Danish: Mild, OR 1.01 (0.95-1.08), Severe OR 1.20 (0.95-1.51)) nor propensity-score matched cohorts (American (n = 168): Mild, OR 1.06 (0.88-1.28), Severe OR 1.46 (0.96-2.12); Danish (n = 44): Mild, OR 1.16 (0.82-1.65), Severe OR 0.45 (0.13-1.55)). CONCLUSION In this retrospective study of patients with aSAH, hypophosphataemia was common.
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Affiliation(s)
| | - Jesper Wesierski
- Department of Neurointensive care and Neuroanaesthesiology RigshospitaletUniversity of Copenhagen Kobenhavn Denmark
| | - Stefano Romano
- Department of Electronic, Information and Biomedical Engineering Politecnico di Milano Milan Italy
| | - Ruth Frikke‐Schmidt
- Department of Clinical Biochemistry RigshospitaletUniversity of Copenhagen Kobenhavn Denmark
| | - Matias Orre
- Department of Neurointensive care and Neuroanaesthesiology RigshospitaletUniversity of Copenhagen Kobenhavn Denmark
| | - Vagn Eskesen
- Department of Neurosurgery Rigshospitalet Kobenhavn Denmark
| | - Markus H. Olsen
- Department of Neurointensive care and Neuroanaesthesiology RigshospitaletUniversity of Copenhagen Kobenhavn Denmark
| | - Kirsten Møller
- Department of Neurointensive care and Neuroanaesthesiology RigshospitaletUniversity of Copenhagen Kobenhavn Denmark
- Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Kobenhavn Denmark
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Thongprayoon C, Dumancas CY, Nissaisorakarn V, Keddis MT, Kattah AG, Pattharanitima P, Petnak T, Vallabhajosyula S, Garovic VD, Mao MA, Dillon JJ, Erickson SB, Cheungpasitporn W. Machine Learning Consensus Clustering Approach for Hospitalized Patients with Phosphate Derangements. J Clin Med 2021; 10:4441. [PMID: 34640457 PMCID: PMC8509302 DOI: 10.3390/jcm10194441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/18/2021] [Accepted: 09/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The goal of this study was to categorize patients with abnormal serum phosphate upon hospital admission into distinct clusters utilizing an unsupervised machine learning approach, and to assess the mortality risk associated with these clusters. METHODS We utilized the consensus clustering approach on demographic information, comorbidities, principal diagnoses, and laboratory data of hypophosphatemia (serum phosphate ≤ 2.4 mg/dL) and hyperphosphatemia cohorts (serum phosphate ≥ 4.6 mg/dL). The standardized mean difference was applied to determine each cluster's key features. We assessed the association of the clusters with mortality. RESULTS In the hypophosphatemia cohort (n = 3113), the consensus cluster analysis identified two clusters. The key features of patients in Cluster 2, compared with Cluster 1, included: older age; a higher comorbidity burden, particularly hypertension; diabetes mellitus; coronary artery disease; lower eGFR; and more acute kidney injury (AKI) at admission. Cluster 2 had a comparable hospital mortality (3.7% vs. 2.9%; p = 0.17), but a higher one-year mortality (26.8% vs. 14.0%; p < 0.001), and five-year mortality (20.2% vs. 44.3%; p < 0.001), compared to Cluster 1. In the hyperphosphatemia cohort (n = 7252), the analysis identified two clusters. The key features of patients in Cluster 2, compared with Cluster 1, included: older age; more primary admission for kidney disease; more history of hypertension; more end-stage kidney disease; more AKI at admission; and higher admission potassium, magnesium, and phosphate. Cluster 2 had a higher hospital (8.9% vs. 2.4%; p < 0.001) one-year mortality (32.9% vs. 14.8%; p < 0.001), and five-year mortality (24.5% vs. 51.1%; p < 0.001), compared with Cluster 1. CONCLUSION Our cluster analysis classified clinically distinct phenotypes with different mortality risks among hospitalized patients with serum phosphate derangements. Age, comorbidities, and kidney function were the key features that differentiated the phenotypes.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Carissa Y. Dumancas
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Voravech Nissaisorakarn
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA;
| | - Mira T. Keddis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Andrea G. Kattah
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Pattharawin Pattharanitima
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Tananchai Petnak
- Division of Pulmonary and Pulmonary Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27101, USA;
| | - Vesna D. Garovic
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Michael A. Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - John J. Dillon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Stephen B. Erickson
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 59005, USA; (C.Y.D.); (A.G.K.); (V.D.G.); (J.J.D.); (S.B.E.)
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Chen Z, Gao C, Yu H, Lu L, Liu J, Chen W, Xiang X, Hussain HMJ, Lee BJ, Li C, Wei W, Huang Y, Li X, Fang Z, Yu S, Weng Q, Ouyang Y, Hu X, Tong J, Liu J, Lin L, Liu M, Xu X, Liu D, Song Y, Lv X, Zha Y, Ye Z, Jiang T, Jia J, Chen X, Bi Y, Xue J, Chen N, Hu W, He CJ, Wang H, Liu J, Xie J. Hypophosphatemia is an independent risk factor for AKI among hospitalized patients with COVID-19 infection. Ren Fail 2021; 43:1329-1337. [PMID: 34541999 PMCID: PMC8462927 DOI: 10.1080/0886022x.2021.1979039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND This study sought to investigate incidence and risk factors for acute kidney injury (AKI) in hospitalized COVID-19. METHODS In this retrospective study, we enrolled 823 COVID-19 patients with at least two evaluations of renal function during hospitalization from four hospitals in Wuhan, China between February 2020 and April 2020. Clinical and laboratory parameters at the time of admission and follow-up data were recorded. Systemic renal tubular dysfunction was evaluated via 24-h urine collections in a subgroup of 55 patients. RESULTS In total, 823 patients were enrolled (50.5% male) with a mean age of 60.9 ± 14.9 years. AKI occurred in 38 (40.9%) ICU cases but only 6 (0.8%) non-ICU cases. Using forward stepwise Cox regression analysis, we found eight independent risk factors for AKI including decreased platelet level, lower albumin level, lower phosphorus level, higher level of lactate dehydrogenase (LDH), procalcitonin, C-reactive protein (CRP), urea, and prothrombin time (PT) on admission. For every 0.1 mmol/L decreases in serum phosphorus level, patients had a 1.34-fold (95% CI 1.14-1.58) increased risk of AKI. Patients with hypophosphatemia were likely to be older and with lower lymphocyte count, lower serum albumin level, lower uric acid, higher LDH, and higher CRP. Furthermore, serum phosphorus level was positively correlated with phosphate tubular maximum per volume of filtrate (TmP/GFR) (Pearson r = 0.66, p < .001) in subgroup analysis, indicating renal phosphate loss via proximal renal tubular dysfunction. CONCLUSION The AKI incidence was very low in non-ICU patients as compared to ICU patients. Hypophosphatemia is an independent risk factor for AKI in patients hospitalized for COVID-19 infection.
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Affiliation(s)
- Zijin Chen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Chenni Gao
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Haijin Yu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Lin Lu
- Department of Nephrology, North Huashan Hospital, Fudan University, Shanghai, China
| | - Jialin Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University, School of medicine, Shanghai, China
| | - Wei Chen
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xiaogang Xiang
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Hafiz Muhammad Jafar Hussain
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Benjamin J Lee
- Houston Kidney Consultants, Houston, TX, USA.,Houston Methodist Institute for Academic Medicine, Houston, TX, USA
| | - Chuanlei Li
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wenjie Wei
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yuhan Huang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xiang Li
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Zhengying Fang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Shuwen Yu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Qinjie Weng
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yan Ouyang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xiaofan Hu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jun Tong
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jian Liu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Li Lin
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | | | - Xiaoman Xu
- Renal Department, Wuhan Ninth Hospital, Wuhan, Hubei, China
| | - Dan Liu
- Radiology Department of Renmin Hospital, Wuhan University, Wuhan, Hubei, China
| | - Yuan Song
- Renal Department of Renmin Hospital, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xifeng Lv
- Renal Department of Renmin Hospital, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yixin Zha
- Clinical Research Center, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiyin Ye
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Tingting Jiang
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jieshuang Jia
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaonong Chen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yufang Bi
- Department of Endocrinology and Metabolism disease, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jun Xue
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Nan Chen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Weiguo Hu
- Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cijiang John He
- Division of Nephrology, Mount Sinai School of Medicine, New York, NY, USA
| | - Huiming Wang
- Renal Department of Renmin Hospital, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jun Liu
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyuan Xie
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
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Farooq A, Richman CM, Swain SM, Shahid RA, Vigna SR, Liddle RA. The Role of Phosphate in Alcohol-Induced Experimental Pancreatitis. Gastroenterology 2021; 161:982-995.e2. [PMID: 34051238 PMCID: PMC8380702 DOI: 10.1053/j.gastro.2021.05.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/05/2021] [Accepted: 05/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Heavy alcohol consumption is a common cause of acute pancreatitis; however, alcohol abuse does not always result in clinical pancreatitis. As a consequence, the factors responsible for alcohol-induced pancreatitis are not well understood. In experimental animals, it has been difficult to produce pancreatitis with alcohol. Clinically, alcohol use predisposes to hypophosphatemia, and hypophosphatemia has been observed in some patients with acute pancreatitis. Because of abundant protein synthesis, the pancreas has high metabolic demands, and reduced mitochondrial function leads to organelle dysfunction and pancreatitis. We proposed, therefore, that phosphate deficiency might limit adenosine triphosphate synthesis and thereby contribute to alcohol-induced pancreatitis. METHODS Mice were fed a low-phosphate diet (LPD) before orogastric administration of ethanol. Direct effects of phosphate and ethanol were evaluated in vitro in isolated mouse pancreatic acini. RESULTS LPD reduced serum phosphate levels. Intragastric administration of ethanol to animals maintained on an LPD caused severe pancreatitis that was ameliorated by phosphate repletion. In pancreatic acinar cells, low-phosphate conditions increased susceptibility to ethanol-induced cellular dysfunction through decreased bioenergetic stores, specifically affecting total cellular adenosine triphosphate and mitochondrial function. Phosphate supplementation prevented ethanol-associated cellular injury. CONCLUSIONS Phosphate status plays a critical role in predisposition to and protection from alcohol-induced acinar cell dysfunction and the development of acute alcohol-induced pancreatitis. This finding may explain why pancreatitis develops in only some individuals with heavy alcohol use and suggests a potential novel therapeutic approach to pancreatitis. Finally, an LPD plus ethanol provides a new model for studying alcohol-associated pancreatic injury.
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Affiliation(s)
- Ahmad Farooq
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Courtney M Richman
- School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Sandip M Swain
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Rafiq A Shahid
- Department of Pathology, Brown University, Providence, Rhode Island
| | - Steven R Vigna
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Rodger A Liddle
- Department of Medicine, Duke University Medical Center, Durham, North Carolina; Department of Veterans Affairs Health Care System, Durham, North Carolina.
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Stockman J, Villaverde C. Concerns related to dietary phosphorus intake in cats. J Am Vet Med Assoc 2021; 258:1325-1331. [PMID: 34061616 DOI: 10.2460/javma.258.12.1325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sin JCK, Laupland KB, Ramanan M, Tabah A. Phosphate abnormalities and outcomes among admissions to the intensive care unit: A retrospective multicentre cohort study. J Crit Care 2021; 64:154-159. [PMID: 33906104 DOI: 10.1016/j.jcrc.2021.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/01/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE We investigated the effect of serum phosphate abnormalities at intensive care unit (ICU) admission on risk of death and length of stay in critically ill patients. MATERIALS AND METHODS A retrospective cohort of patients admitted to three adult ICUs in Queensland, Australia from April 2014 to 2019 was studied. Hypophosphataemia, normophosphataemia and hyperphosphataemia were defined as serum phosphate level of <0.8, 0.8-1.5 and >1.5 mmol/L respectively. Univariable and logistic regression analyses were performed to investigate the association between the phosphate groups and the risk of death. MEASUREMENTS AND MAIN RESULTS We included 13,155 patients in the analysis, of which 1424 (10.8%) patients had hypophosphataemia and 2544 (19.3%) hyperphosphataemia. The mean admission phosphate level was 1.25 (SD, ±0.43) mmol/L. Both hypophosphatemia (OR 1.29; 95% CI, 1.02-1.64; p = 0.034) and hyperphosphataemia (OR 1.39; 95% CI, 1.15-1.68; p = 0.001) at admission were independently associated with increased risk of death after adjusting for covariables using logistic regression analysis. CONCLUSION Hypophosphatemia and hyperphosphatemia were both independently associated with an increased case fatality rate and ICU length of stay in a large multicentre ICU cohort.
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Affiliation(s)
- Jeremy Cheuk Kin Sin
- Department of Anaesthesia, Redcliffe Hospital, Redcliffe, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Caboolture and the Prince Charles Hospitals, Brisbane, Queensland, Australia; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia.
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Shi M, Shepard S, Zhou Z, Maique J, Seli O, Moe OW, Hu MC. High Dietary Phosphate Exacerbates and Acts Independently of Low Autophagy Activity in Pathological Cardiac Remodeling and Dysfunction. Cells 2021; 10:777. [PMID: 33915953 PMCID: PMC8065663 DOI: 10.3390/cells10040777] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 11/21/2022] Open
Abstract
High phosphate contributes to uremic cardiomyopathy. Abnormal autophagy is associated with the development and progression of heart disease. What is unknown is the effects of phosphate on autophagy and whether the ill effects of phosphate on cardiomyocytes are mediated by low autophagy. High (2.0% w/w)-phosphate diet reduced LC3 puncta in cardiomyocytes and ratio of LC3 II/I and increased p62 protein, indicating that autophagy activity was suppressed. Mice with cardiomyocyte-specific deletion of autophagy-related protein 5 (H-atg5-/-) had reduced autophagy only in the heart, developed cardiac dysfunction with hypertrophy and fibrosis, and had a short lifespan. When H-atg5-/- mice were fed a high-phosphate diet, they developed more apoptosis in cardiomyocytes, more severe cardiac remodeling, and shorter lifespan than normal phosphate-fed H-atg5-/- mice, indicating that cardiac phosphotoxicity is imparted independently of atg5. In conclusion, although high phosphate suppresses autophagy, high phosphate and low autophagy independently trigger and additionally amplify cardiac remodeling and dysfunction.
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Affiliation(s)
- Mingjun Shi
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (M.S.); (S.S.); (Z.Z.); (J.M.); (O.S.)
| | - Sierra Shepard
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (M.S.); (S.S.); (Z.Z.); (J.M.); (O.S.)
| | - Zhiyong Zhou
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (M.S.); (S.S.); (Z.Z.); (J.M.); (O.S.)
| | - Jenny Maique
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (M.S.); (S.S.); (Z.Z.); (J.M.); (O.S.)
| | - Olivia Seli
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (M.S.); (S.S.); (Z.Z.); (J.M.); (O.S.)
| | - Orson W. Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (M.S.); (S.S.); (Z.Z.); (J.M.); (O.S.)
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
- Department of Physiology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Ming Chang Hu
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (M.S.); (S.S.); (Z.Z.); (J.M.); (O.S.)
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Dhawan S, Devnani H, Babu J, Singh H, Haider MA, Khan TS, Ingole PP, Haridas V. Supersensitive Detection of Anions in Pure Organic and Aqueous Media by Amino Acid Conjugated Ellman's Reagent. ACS APPLIED BIO MATERIALS 2021; 4:2453-2464. [PMID: 35014364 DOI: 10.1021/acsabm.0c01431] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The last few decades witnessed a remarkable advancement in the field of molecular anion receptors. A variety of anion binding motifs have been discovered, and large number of designer molecular anion receptors with high selectivity are being reported. However, anion detection in an aqueous medium is still a formidable challenge as evident from only a miniscule of synthetic systems available in the literature. We, herein, report 5,5'-dithio-bis(2-nitrobenzoic acid) (Ellman's reagent) appended with amino acids as supersensitive anion sensors that can detect F- and H2PO4- ions in both aqueous as well as organic media. Interestingly, the sensors showed a dual response to anions, viz., chromogenic response in organic medium and electrochemical response in aqueous solutions. Various spectroscopic techniques such as UV-vis and 1H NMR are used to investigate the binding studies in acetonitrile, whereas electrochemical methods such as cyclic voltammetry (CV) and differential pulse voltammetry (DPV) are employed to explore the anion binding in water. The host-guest complex stoichiometry and binding constants are calculated using the BindFit software. The geometry of host-guest complex has been optimized by the density functional theory (DFT) method. These molecules are versatile sensors since these function in both water and acetonitrile with extremely low limit of detection (LOD) up to 0.07 fM and limit of quantification (LOQ) up to 0.23 fM. To our knowledge, the present system is the first example of a sensor that can detect the lowest concentration of anions in water quantitatively. The minimalistic design strategy presented here opens up the innumerable possibilities for designing dual anion sensors in a one fell swoop.
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Affiliation(s)
- Sameer Dhawan
- Department of Chemistry, Indian Institute of Technology Delhi, New Delhi, 110016, India
| | - Harsha Devnani
- Department of Chemistry, Indian Institute of Technology Delhi, New Delhi, 110016, India
| | - Jisha Babu
- Department of Chemistry, Indian Institute of Technology Delhi, New Delhi, 110016, India
| | - Hanuman Singh
- Department of Chemistry, Indian Institute of Technology Delhi, New Delhi, 110016, India
| | - M Ali Haider
- Renewable Energy and Chemicals Laboratory, Department of Chemical Engineering, Indian Institute of Technology Delhi, New Delhi, 110016, India
| | - Tuhin S Khan
- Light Stock Processing Division, CSIR-Indian Institute of Petroleum, Dehradun, 248005, India
| | - Pravin P Ingole
- Department of Chemistry, Indian Institute of Technology Delhi, New Delhi, 110016, India
| | - V Haridas
- Department of Chemistry, Indian Institute of Technology Delhi, New Delhi, 110016, India
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Chu V, Goggs R, Bichoupan A, Radhakrishnan S, Menard J. Hypophosphatemia in Dogs With Presumptive Sepsis: A Retrospective Study (2008-2018). Front Vet Sci 2021; 8:636732. [PMID: 33763464 PMCID: PMC7982394 DOI: 10.3389/fvets.2021.636732] [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] [Received: 12/01/2020] [Accepted: 02/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: In humans with sepsis, hypophosphatemia is a marker of illness severity and a negative prognostic indicator. Hypophosphatemia has not been previously investigated in dogs with sepsis, however. This study aimed to estimate the prevalence of hypophosphatemia in dogs, the prevalence of presumptive sepsis in dogs with hypophosphatemia, the prevalence of hypophosphatemia in dogs with presumptive sepsis and the association between outcome and hypophosphatemia in dogs with presumptive sepsis. Methods: Electronic medical records of the Cornell University Hospital for Animals from 2008-2018 were queried to identify all dogs with hypophosphatemia and all dogs with presumptive sepsis. Hypophosphatemia was defined as a serum phosphate concentration <2.7 mg/dL. Sepsis was presumed where ≥2 of 4 systemic inflammatory response syndrome (SIRS) criteria were satisfied associated with a documented or highly suspected infection. Variables were assessed for normality using the D'Agostino-Pearson test. Continuous variables were compared between groups using the Mann-Whitney U test. Differences in frequency between categorical variables were analyzed using contingency tables, calculation of Fisher's exact test or Chi2 and estimation of odds ratios. Results: In the study period, 47,992 phosphate concentration measurements from 23,752 unique dogs were identified. After eliminating repeat analyses, the period prevalence of hypophosphatemia on a per dog basis over the 11-year study period was 10.6% (2,515/23,752). The prevalence of presumptive sepsis within dogs with hypophosphatemia was 10.7% (268/2,515). During the 11-year study period, 4,406 dogs with an infection were identified, of which 1,233 were diagnosed with presumptive sepsis and had a contemporaneous phosphate concentration. Hypophosphatemia was more prevalent in dogs with presumptive sepsis than in dogs without 21.7 vs. 10.2%; OR 2.44 [95% CI 2.12-2.81]; P < 0.0001. The mortality rate was greater in dogs with hypophosphatemia and presumptive sepsis than in dogs with hypophosphatemia without presumptive sepsis (15.3 vs. 3.1%; OR 5.70 [95% CI 3.76-8.52]; P < 0.0001), however hypophosphatemia was not associated with outcome in dogs with presumptive sepsis OR 0.87 [95% CI 0.60-1.26]; P = 0.518. Conclusions: In dogs with hypophosphatemia, a presumed diagnosis of sepsis was associated with increased mortality compared to other associated disease processes. In dogs with presumptive sepsis, hypophosphatemia was not associated with outcome.
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Affiliation(s)
- Victoria Chu
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Robert Goggs
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Allison Bichoupan
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Shalini Radhakrishnan
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Julie Menard
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
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Wang H, Zhang L, Liao W, Huang J, Xu J, Yang J, Chen C, He Z. Hyperphosphatemia rather than hypophosphatemia indicates a poor prognosis in patients with sepsis. Clin Biochem 2021; 91:9-15. [PMID: 33600802 DOI: 10.1016/j.clinbiochem.2021.01.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/14/2021] [Accepted: 01/29/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Sepsis is the leading cause of hospitalization and death in the intensive care unit. It is vital to identify high-risk patients with poor prognosis in the early stages of sepsis. We aimed to investigate the prognostic value of serum phosphorus levels for sepsis. METHODS The data of 4767 patients with sepsis were collected from the Multiparameter Intelligent Monitoring in Intensive Care III database. The Locally Weighted Scatterplot Smoothing technique and Kaplan-Meier analysis were used to test the crude relationship between serum phosphorus levels and mortality or overall survival. The multivariable logistic regression was used to further analyze the relationship between serum phosphorus levels and in-hospital mortality. The subgroup analysis was performed according to renal failure, use of vasopressin and the Sequential Organ Failure Assessment (SOFA) score. RESULTS Only hyperphosphatemia significantly correlated with in-hospital mortality [odds ratio (OR) 1.48; 95% confidence interval (CI) 1.19-1.85], while the correlation between hypophosphatemia and in-hospital mortality was not significant (OR 0.91; 95% CI 0.70-1.19). The interactions between serum phosphorus and renal failure, use of vasopressin or the SOFA score were not significant. CONCLUSIONS Hyperphosphatemia rather than hypophosphatemia indicates a poor prognosis in patients with sepsis.
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Affiliation(s)
- Huabin Wang
- Division of Hematology/Oncology, Department of Pediatrics, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China; Department of Pediatric Intensive Care Unit, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China
| | - Lidan Zhang
- Division of Hematology/Oncology, Department of Pediatrics, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China; Department of Pediatric Intensive Care Unit, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China
| | - Wenhua Liao
- Department of Intensive Care Unit, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou 510000, China
| | - Junbin Huang
- Division of Hematology/Oncology, Department of Pediatrics, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China; Department of Pediatric Intensive Care Unit, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China
| | - Jiannan Xu
- Center of Digestive Disease, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China
| | - Jing Yang
- Division of Hematology/Oncology, Department of Pediatrics, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China; Department of Pediatric Intensive Care Unit, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China
| | - Chun Chen
- Division of Hematology/Oncology, Department of Pediatrics, the Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen 518107, China.
| | - Zhijie He
- Department of Intensive Care Unit, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou 510000, China.
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Ali S, Ijaz M, Farooqi SH, Durrani AZ, Rashid MI, Ghaffar A, Ali A, Rehman A, Aslam S, Khan I, Masud A, Mehmood K. Molecular characterisation of
Theileria equi
and risk factors associated with the occurrence of theileriosis in horses of Punjab (Pakistan). EQUINE VET EDUC 2021. [DOI: 10.1111/eve.13161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- S. Ali
- Department of Clinical Medicine and Surgery University of Veterinary and Animal Sciences LahorePakistan
- University College of Veterinary and Animal Sciences The Islamia University of Bahawalpur Bahawalpur Pakistan
| | - M. Ijaz
- Department of Clinical Medicine and Surgery University of Veterinary and Animal Sciences LahorePakistan
| | - S. H. Farooqi
- Department of Clinical Medicine and Surgery University of Veterinary and Animal Sciences LahorePakistan
| | - A. Z. Durrani
- Department of Clinical Medicine and Surgery University of Veterinary and Animal Sciences LahorePakistan
| | - M. I. Rashid
- Department of Parasitology University of Veterinary and Animal Sciences LahorePakistan
| | - A. Ghaffar
- Department of Clinical Medicine and Surgery University of Veterinary and Animal Sciences LahorePakistan
| | - A. Ali
- Department of Clinical Medicine and Surgery University of Veterinary and Animal Sciences LahorePakistan
| | - A. Rehman
- Department of Epidemiology and Public Health University of Veterinary and Animal Sciences LahorePakistan
| | - S. Aslam
- Department of Clinical Medicine and Surgery University of Veterinary and Animal Sciences LahorePakistan
| | - I. Khan
- College of Veterinary and Animal Sciences Jhang Pakistan
| | - A. Masud
- District Diagnostic Laboratory Livestock and Dairy Development Department Mianwali Pakistan
| | - K. Mehmood
- University College of Veterinary and Animal Sciences The Islamia University of Bahawalpur Bahawalpur Pakistan
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A case of severe hypophosphatemia. J Nephrol 2021; 34:2117-2121. [PMID: 33502727 DOI: 10.1007/s40620-020-00963-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
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50
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Berger MM, Appelberg O, Reintam-Blaser A, Ichai C, Joannes-Boyau O, Casaer M, Schaller SJ, Gunst J, Starkopf J. Prevalence of hypophosphatemia in the ICU - Results of an international one-day point prevalence survey. Clin Nutr 2021; 40:3615-3621. [PMID: 33454128 DOI: 10.1016/j.clnu.2020.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/16/2020] [Accepted: 12/16/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND & AIMS Hypophosphatemia (HypoP) is associated with organ dysfunction and mortality. Despite its potential severe consequences, HypoP remains poorly characterized in terms of real prevalence and timing of onset. The primary objective was to determine the prevalence of HypoP defined as blood phosphate <0.8 and < 0.65 mmol/l on one particular day at international level. METHODS One-day point prevalence survey conducted by the Section of Metabolism, Endocrinology and Nutrition (MEN) of the European Society of Intensive Care Medicine (ESICM) during week 11-2020. RESULTS In total, 56 adult and 4 paediatric ICUs, from 22 countries participated: 41 ICUs were mixed medico surgical, the 19 others being cardiac, medical or surgical. Phosphate measurements were performed daily in 21 ICUs, and 1-3 times per week in 39 ICUs. On D-Day 909 patients (883 adults) were present and 668/883 (75.7%) had serum/plasma phosphate determined, revealing a HypoP in 103 (15.4%) patients aged 62 [18 to 85] years. Of those, 49 patients presented phosphate <0.65 mmol/l: cases of hypophosphatemia were detected at any time of patient's ICU stay. No HypoP was observed in children. A treatment protocol existed only in 41.1% of adult ICUs, independently of ICU type, or size. Only 41/98 of the HypoP patients (29/41 of patients with phosphate <0.65 mmol/l) were receiving phosphate. CONCLUSION HypoP is present at least in 15.4% of ICU patients, and may occur at any time during the ICU stay. The absence of phosphate repletion protocols in 60% of participating ICUs is an unexpected finding, and confirms the necessity for the development of ICU phosphate protocols and guidelines. CLINICALTRIALS IDENTIFIER NCT04201899.
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Affiliation(s)
- M M Berger
- Lausanne University Hospital, Lausanne, Switzerland.
| | - O Appelberg
- University of Tartu, Tartu University Hospital, Tartu, Estonia.
| | - A Reintam-Blaser
- Lucerne Cantonal Hospital, Dpt of Intensive Care Medicine, Lucerne, Switzerland.
| | - C Ichai
- Université Côte d'Azur, Mixed Intensive Care Unit, Nice, France.
| | - O Joannes-Boyau
- Centre hospitalier universitaire de Bordeaux, Bordeaux, France.
| | - M Casaer
- Department of Intensive Care Medicine, University Hospital Leuven, Leuven, Belgium.
| | - S J Schaller
- Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, And Berlin Institute of Health, Dpt of Anesthesiology and Operative Intensive Care Medicine, Berlin, Germany.
| | - J Gunst
- KU Leuven, Dpt of Cellular and Molecular Medicine, Clinical, Dpt and Laboratory of Intensive Care Medicine, Belgium, Leuven.
| | - J Starkopf
- University of Tartu, Tartu University Hospital, Estonia.
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