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Kaesler N, Schurgers LJ, Floege J. Vitamin K and cardiovascular complications in CKD patients. Kidney Int 2021; 100:1023-1036. [PMID: 34310988 DOI: 10.1016/j.kint.2021.06.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 01/07/2023]
Abstract
Vitamin K, well known for its role in coagulation, encompasses two major subgroups: Vitamin K1 is exclusively synthesized by plants, whereas vitamin K2 mostly originates from bacterial synthesis. Vitamin K serves as a cofactor for the enzyme γ-glutamyl carboxylase, which carboxylates and thereby activates various vitamin K dependent proteins. Several vitamin K-dependent proteins are synthesized in bone but the role of vitamin K for bone health in CKD patients, in particular the prevention of osteoporosis is still not firmly established. Here we focus on another prominent action of vitamin K, in particular vitamin K2, namely the activation of matrix Gla protein (MGP), the most potent inhibitor of cardiovascular calcifications. Multiple observational studies link relative vitamin K deficiency or low intake to cardiovascular calcification progress, morbidity and mortality. Patients with advanced chronic kidney disease (CKD) are particularly vitamin K deficient, in part because of dietary restrictions but possibly also due to impaired endogenous recycling of vitamin K. At the same time this population is characterized by markedly accelerated cardiovascular calcifications and mortality. High dose dietary supplementation with vitamin K2, in particular the most potent form menaquinone-7 (MK7), can potently reduce circulating levels of dephosphorylated uncarboxylated, i.e. inactive MGP in patients with end stage kidney disease. However, despite this compelling data basis, several randomized controlled trials with high dose MK7 supplements in patients with advanced CKD have failed to confirm cardiovascular benefits. Here we discuss potential reasons and solutions for this.
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Affiliation(s)
- Nadine Kaesler
- Division of Nephrology and Rheumatology, University Hospital, Rheinisch Westfälische Technische Hochschule, Aachen, Germany
| | - Leon J Schurgers
- Department of Biochemistry and Cardiovascular Research Institute Maastricht, School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands; Institute of Experimental Medicine and Systems Biology, Rheinisch Westfälische Technische Hochschule, Aachen University, Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Rheumatology, University Hospital, Rheinisch Westfälische Technische Hochschule, Aachen, Germany.
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Roumeliotis S, Roumeliotis A, Dounousi E, Eleftheriadis T, Liakopoulos V. Vitamin K for the Treatment of Cardiovascular Disease in End-Stage Renal Disease Patients: Is there Hope? Curr Vasc Pharmacol 2021; 19:77-90. [PMID: 32196451 DOI: 10.2174/1570161118666200320111745] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 01/07/2023]
Abstract
In Chronic Kidney Disease, vascular calcification (VC) is highly prevalent even at early stages and is gradually enhanced, along with disease progression to End-Stage Renal Disease (ESRD). The calcification pattern in uremia includes all types of mineralization and contributes to the heavy cardiovascular (CV) burden that is common in these patients. Ectopic mineralization is the result of the imbalance between inhibitors and promoters of vascular calcification, with the latter overwhelming the former. The most powerful, natural inhibitor of calcification is Matrix Gla Protein (MGP), a small vitamin K dependent protein, secreted by chondrocytes and vascular smooth muscle cells. In uremia, MGP was reported as the only molecule able to reverse VC by "sweeping" calcium and hydroxyapatite crystals away from the arterial wall. To become biologically active, this protein needs to undergo carboxylation and phosphorylation, reactions highly dependent on vitamin K status. The inactive form of MGP reflects the deficiency of vitamin K and has been associated with CV events and mortality in ESRD patients. During the past decade, vitamin K status has emerged as a novel risk factor for vascular calcification and CV disease in various populations, including dialysis patients. This review presents evidence regarding the association between vitamin K and CV disease in ESRD patients, which are prone to atherosclerosis and atheromatosis.
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Affiliation(s)
- Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelia Dounousi
- Department of Nephrology, Medical School, University Hospital of Ioannina, Ioannina, Greece
| | | | - Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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3
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Vitamin K effects in human health: new insights beyond bone and cardiovascular health. J Nephrol 2019; 33:239-249. [DOI: 10.1007/s40620-019-00685-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 12/02/2019] [Indexed: 12/31/2022]
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Viegas C, Araújo N, Marreiros C, Simes D. The interplay between mineral metabolism, vascular calcification and inflammation in Chronic Kidney Disease (CKD): challenging old concepts with new facts. Aging (Albany NY) 2019; 11:4274-4299. [PMID: 31241466 PMCID: PMC6628989 DOI: 10.18632/aging.102046] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/17/2019] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease (CKD) is one of the most powerful predictors of premature cardiovascular disease (CVD), with heightened susceptibility to vascular intimal and medial calcification associated with a high cardiovascular mortality. Abnormal mineral metabolism of calcium (Ca) and phosphate (P) and underlying (dys)regulated hormonal control in CKD-mineral and bone disorder (MBD) is often accompanied by bone loss and increased vascular calcification (VC). While VC is known to be a multifactorial process and a major risk factor for CVD, the view of primary triggers and molecular mechanisms complexity has been shifting with novel scientific knowledge over the last years. In this review we highlight the importance of calcium-phosphate (CaP) mineral crystals in VC with an integrated view over the complexity of CKD, while discuss past and recent literature aiming to highlight novel horizons on this major health burden. Exacerbated VC in CKD patients might result from several interconnected mechanisms involving abnormal mineral metabolism, dysregulation of endogenous calcification inhibitors and inflammatory pathways, which function in a feedback loop driving disease progression and cardiovascular outcomes. We propose that novel approaches targeting simultaneously VC and inflammation might represent valuable new prognostic tools and targets for therapeutics and management of cardiovascular risk in the CKD population.
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Affiliation(s)
- Carla Viegas
- Centre of Marine Sciences (CCMAR), University of Algarve, Faro 8005-139, Portugal
- GenoGla Diagnostics, Centre of Marine Sciences (CCMAR), University of Algarve, Faro 8005-139, Portugal
| | - Nuna Araújo
- Centre of Marine Sciences (CCMAR), University of Algarve, Faro 8005-139, Portugal
| | - Catarina Marreiros
- Centre of Marine Sciences (CCMAR), University of Algarve, Faro 8005-139, Portugal
| | - Dina Simes
- Centre of Marine Sciences (CCMAR), University of Algarve, Faro 8005-139, Portugal
- GenoGla Diagnostics, Centre of Marine Sciences (CCMAR), University of Algarve, Faro 8005-139, Portugal
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Turner ME, Adams MA, Holden RM. The Vitamin K Metabolome in Chronic Kidney Disease. Nutrients 2018; 10:E1076. [PMID: 30103541 PMCID: PMC6115832 DOI: 10.3390/nu10081076] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/08/2018] [Accepted: 08/10/2018] [Indexed: 12/25/2022] Open
Abstract
The purpose of this review is to summarize the research to date on the impact of chronic kidney disease (CKD) on the vitamin K metabolome. Vitamin K-dependent proteins contribute to cardiovascular disease (CVD) prevention via the prevention of ectopic mineralization. Sub-clinical vitamin K deficiency is common in CKD patients, and evidence suggests that it may contribute to the CVD burden in this population. Research from animal models suggests that CKD alters tissue measures of the two predominant forms of vitamin K: KI and MK-4. The expression and/or activity of enzymes that regulate the recycling of vitamin K and the carboxylation of vitamin K-dependent proteins also appear to be altered in CKD. Evidence suggests that statins, a common pharmaceutical prescribed to CKD patients to prevent cardiovascular events, may impact the metabolism of vitamin K and therefore contribute to its relative inefficiency at preventing CVD in this population as kidney disease progresses. Human research on the tissue vitamin K metabolome in CKD patients is lacking.
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Affiliation(s)
- Mandy E Turner
- Department of Biomedical and Molecular Science, Queen's University, Kingston, ON K7L 3V6, Canada.
| | - Michael A Adams
- Department of Biomedical and Molecular Science, Queen's University, Kingston, ON K7L 3V6, Canada.
| | - Rachel M Holden
- Department of Biomedical and Molecular Science, Queen's University, Kingston, ON K7L 3V6, Canada.
- Department of Medicine, Queen's University, Kingston, ON K7L 3V6, Canada.
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Ruderman I, Holt SG, Hewitson TD, Smith ER, Toussaint ND. Current and potential therapeutic strategies for the management of vascular calcification in patients with chronic kidney disease including those on dialysis. Semin Dial 2018; 31:487-499. [PMID: 29733462 DOI: 10.1111/sdi.12710] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with CKD have accelerated vascular stiffening contributing significantly to excess cardiovascular morbidity and mortality. Much of the arterial stiffening is thought to involve vascular calcification (VC), but the pathogenesis of this phenomenon is complex, resulting from a disruption of the balance between promoters and inhibitors of calcification in a uremic milieu, along with derangements in calcium and phosphate metabolic pathways. Management of traditional cardiovascular risk factors to reduce VC may be influential but has not been shown to significantly improve mortality. Control of mineral metabolism may potentially reduce the burden of VC, although using conventional approaches of restricting dietary phosphate, administering phosphate binders, and use of active vitamin D and calcimimetics, remains controversial because recommended biochemical targets are hard to achieve and clinical relevance hard to define. Increasing time on dialysis is perhaps another therapy with potential effectiveness in this area. Despite current treatments, cardiovascular morbidity and mortality remain high in this group. Novel therapies for addressing VC include magnesium and vitamin K supplementation, which are currently being investigated in large randomized control trials. Other therapeutic targets include crystallization inhibitors, ligand trap for activin receptors and BMP-7. This review summarizes current treatment strategies and therapeutic targets for the future management of VC in patients with CKD.
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Affiliation(s)
- Irene Ruderman
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Tim D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
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Wyskida K, Żak-Gołąb A, Wajda J, Klein D, Witkowicz J, Ficek R, Rotkegel S, Spiechowicz U, Kocemba Dyczek J, Ciepał J, Olszanecka-Glinianowicz M, Więcek A, Chudek J. Functional deficiency of vitamin K in hemodialysis patients in Upper Silesia in Poland. Int Urol Nephrol 2016; 48:765-71. [PMID: 27000106 PMCID: PMC4839038 DOI: 10.1007/s11255-016-1255-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/24/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE Functional vitamin K deficiency (both K1 and K2) is postulated to be one of the most relevant links between chronic kidney disease and vascular calcification in hemodialysis (HD) patients. Recommended dietary restrictions in HD patients superimposed on diversity of eating habits across the countries may affect the prevalence of functional vitamin K deficiency. The aim of this study was to determine the level of functional vitamin K deficiency and its relation to vitamin K1 intake in HD patients in Upper Silesia in Poland. METHODS Protein-induced vitamin K absence or antagonist-II (PIVKA-II) and undercarboxylated matrix Gla protein (ucMGP) were assessed by ELISA in 153 stable, prevalent HD patients and 20 apparently healthy adults (to establish normal ranges for PIVKA-II and ucMGP). Daily phylloquinone intake was assessed using a food frequency questionnaire. RESULTS PIVKA-II and ucMGP levels were increased in 27.5 and 77.1 % of HD patients in comparison with the reference ranges in apparently healthy controls, respectively. In 45 % of cases, the increased PIVKA-II level was explained by insufficient phylloquinone intake for Polish population (recommended intake: >55 μg for women and >65 µg for men). Applying ROC analysis, we showed that vitamin K1 intake below 40.2 µg/day was associated with increased PIVKA-II levels. There was no correlation between vitamin K1 intake and plasma concentration of ucMGP, or between PIVKA-II and ucMGP. CONCLUSIONS (1) Functional vitamin K1 deficiency is explained by low vitamin K1 intake in less than half of HD patients. (2) Undercarboxylated matrix Gla protein level is a poor surrogate for functional vitamin K1 deficiency.
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Affiliation(s)
- Katarzyna Wyskida
- Health Promotion and Obesity Management Unit, Department of Pathophysiology, Medical Faculty in Katowice, Medical University of Silesia, Medyków 18, 40-752, Katowice, Poland
| | - Agnieszka Żak-Gołąb
- Department of Pathophysiology, Medical Faculty in Katowice, Medical University of Silesia, Medyków 18 Street, 40-752, Katowice, Poland
- Department of Internal, Autoimmune and Metabolic Diseases, Medical Faculty in Katowice, Medical University of Silesia, Medyków 14, 40-752, Katowice, Poland
| | - Jarosław Wajda
- Dialysis Center in Rybnik, Regional Specialist Hospital No. 3, Energetyków 46, 44-200, Rybnik, Poland
| | - Dariusz Klein
- Dialysis Center in Tychy, Centrum Dializa Sosnowiec, Narcyzów 24, 43-100, Tychy, Poland
- Dialysis Center in Pszczyna, Centrum Dializa Sosnowiec, Antesa 11, 43-200, Pszczyna, Poland
| | - Joanna Witkowicz
- Dialysis Center in Siemianowice Śląskie, Nefrolux, Szpitalna 6, 41-100, Siemianowice Śląskie, Poland
| | - Rafał Ficek
- Department of Nephrology, Transplantation and Internal Medicine, Medical Faculty in Katowice, Medical University of Silesia, Francuska 20-24, 40-027, Katowice, Poland
| | - Sylwia Rotkegel
- Dialysis Center in Katowice, Centrum Dializa Sosnowiec, Medyków 17, 40-752, Katowice, Poland
| | - Urszula Spiechowicz
- Dialysis Center in Chorzów, Centrum Dializa Sosnowiec, Strzelców Bytomskich 11, 41-500, Chorzów, Poland
| | - Joanna Kocemba Dyczek
- Dialysis Center in Żory, Centrum Dializa Sosnowiec, Dąbrowskiego 20, 44-241, Żory, Poland
- Dialysis Center in Wodzisław Śląski, Centrum Dializa Sosnowiec, Leszka 10, 44-313, Wodzisław Śląski, Poland
| | - Jarosław Ciepał
- Dialysis Center in Sosnowiec, Centrum Dializa Sosnowiec, Jabłoniowa 27, 41-200, Sosnowiec, Poland
| | - Magdalena Olszanecka-Glinianowicz
- Health Promotion and Obesity Management Unit, Department of Pathophysiology, Medical Faculty in Katowice, Medical University of Silesia, Medyków 18, 40-752, Katowice, Poland
| | - Andrzej Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical Faculty in Katowice, Medical University of Silesia, Francuska 20-24, 40-027, Katowice, Poland
| | - Jerzy Chudek
- Department of Pathophysiology, Medical Faculty in Katowice, Medical University of Silesia, Medyków 18 Street, 40-752, Katowice, Poland.
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