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Levy RV, McMahon DJ, Agarwal S, Dempster D, Zhou H, Misof BM, Guo X, Kamanda-Kosseh M, Aponte MA, Reidy K, Kumar J, Fusaro M, Brown DD, Melamed ML, Nickolas TL. Comprehensive Associations between Acidosis and the Skeleton in Patients with Kidney Disease. J Am Soc Nephrol 2023; 34:668-681. [PMID: 36749125 PMCID: PMC10103353 DOI: 10.1681/asn.0000000000000085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/10/2023] [Indexed: 02/08/2023] Open
Abstract
SIGNIFICANCE STATEMENT Renal osteodystrophy (ROD) contributes substantially to morbidity in CKD, including increased fracture risk. Metabolic acidosis (MA) contributes to the development of ROD, but an up-to-date skeletal phenotype in CKD-associated acidosis has not been described. We comprehensively studied associations between acidosis and bone in patients with CKD using advanced methods to image the skeleton and analyze bone-tissue, along with biochemical testing. Cross-sectionally, acidosis was associated with higher markers of bone remodeling and female-specific impairments in cortical and trabecular bone quality. Prospectively, acidosis was associated with cortical expansion and trabecular microarchitectural deterioration. At the bone-tissue level, acidosis was associated with deficits in bone mineral content. Future work investigating acidosis correction on bone quality is warranted. BACKGROUND Renal osteodystrophy is a state of impaired bone quality and strength. Metabolic acidosis (MA) is associated with alterations in bone quality including remodeling, microarchitecture, and mineralization. No studies in patients with CKD have provided a comprehensive multimodal skeletal phenotype of MA. We aim to describe the structure and makeup of bone in patients with MA in the setting of CKD using biochemistry, noninvasive imaging, and histomorphometry. METHODS The retrospective cross-sectional analyses included 180 patients with CKD. MA was defined as bicarbonate ≤22 mEq/L. We evaluated circulating bone turnover markers and skeletal imaging with dual energy x-ray absorptiometry and high-resolution peripheral computed tomography. A subset of 54 participants had follow-up. We assessed associations between baseline and change in bicarbonate with change in bone outcomes. Histomorphometry, microCT, and quantitative backscatter electron microscopy assessed bone biopsy outcomes in 22 participants. RESULTS The mean age was 68±10 years, 54% of participants were male, and 55% were White. At baseline, acidotic subjects had higher markers of bone turnover, lower areal bone mineral density at the radius by dual energy x-ray absorptiometry, and lower cortical and trabecular volumetric bone mineral density and impaired trabecular microarchitecture. Over time, acidosis was associated with opposing cortical and trabecular effects: cortical expansion but trabecular deterioration. Bone-tissue analyses showed reduced tissue mineral density with increased heterogeneity of calcium distribution in acidotic participants. CONCLUSIONS MA is associated with multiple impairments in bone quality. Future work should examine whether correction of acidosis improves bone quality and strength in patients with CKD.
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Affiliation(s)
- Rebecca V. Levy
- Nephrology, Department of Medicine, University of Rochester Medical Center Rochester, New York, USA
- Pediatric Nephrology, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | | | | | - David Dempster
- Columbia University Irving Medical Center, New York, USA
| | - Hua Zhou
- Columbia University Irving Medical Center, New York, USA
| | - Barbara M. Misof
- Ludwig Boltzmann Institute for Osteology at the Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - X.E. Guo
- Columbia University Biomedical Engineering, New York, New York, USA
| | | | | | - Kimberly Reidy
- Nephrology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Juhi Kumar
- Nephrology, Department of Pediatrics, Weill-Cornell Medical Center, New York, New York
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
- Department of Medicine, University of Padova, Padova, Padua, Italy
| | - Denver D. Brown
- Division of Nephrology, Children's National Hospital, Washington, DC
| | - Michal L. Melamed
- Nephrology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Osho AA, Hirji SA, Castleberry AW, Mulvihill MS, Ganapathi AM, Speicher PJ, Yerokun B, Snyder LD, Davis RD, Hartwig MG. Long-term survival following kidney transplantation in previous lung transplant recipients-An analysis of the unos registry. Clin Transplant 2017; 31. [PMID: 28295652 DOI: 10.1111/ctr.12953] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Kidney transplantation has been advocated as a therapeutic option in lung recipients who develop end-stage renal disease (ESRD). This analysis outlines patterns of allograft survival following kidney transplantation in previous lung recipients (KAL). METHODS Data from the UNOS lung and kidney transplantation registries (1987-2013) were cross-linked to identify lung recipients who were subsequently listed for and/or underwent kidney transplantation. Time-dependent Cox models compared the survival rates in KAL patients with those waitlisted for renal transplantation who never received kidneys. Survival analyses compared outcomes between KAL patients and risk-matched recipients of primary, kidney-only transplantation with no history of lung transplantation (KTx). RESULTS A total of 270 lung recipients subsequently underwent kidney transplantation (KAL). Regression models demonstrated a lower risk of post-listing mortality for KAL patients compared with 346 lung recipients on the kidney waitlist who never received kidneys (P<.05). Comparisons between matched KAL and KTx patients demonstrated significantly increased risk of death and graft loss (P<.05), but not death-censored graft loss, for KAL patients (P = .86). CONCLUSIONS KAL patients enjoy a significant survival benefit compared with waitlisted lung recipients who do not receive kidneys. However, KAL patients do poorly compared with KTx patients. Decisions about KAL transplantation must be made on a case-by-case basis considering patient and donor factors.
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Affiliation(s)
- Asishana A Osho
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sameer A Hirji
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Asvin M Ganapathi
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Paul J Speicher
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Babatunde Yerokun
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Laurie D Snyder
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Robert D Davis
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mathew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Banga A, Mohanka M, Mullins J, Bollineni S, Kaza V, Torres F, Tanriover B. Association of pretransplant kidney function with outcomes after lung transplantation. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12932] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Amit Banga
- Lung Transplant Program; Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Manish Mohanka
- Lung Transplant Program; Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Jessica Mullins
- Lung Transplant Program; Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Srinivas Bollineni
- Lung Transplant Program; Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Vaidehi Kaza
- Lung Transplant Program; Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Fernando Torres
- Lung Transplant Program; Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Bekir Tanriover
- Division of Nephrology; University of Texas Southwestern Medical Center; Dallas TX USA
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Osho AA, Castleberry AW, Snyder LD, Ganapathi AM, Speicher PJ, Hirji SA, Stafford-Smith M, Daneshmand MA, Duane Davis R, Hartwig MG. Determining eligibility for lung transplantation: A nationwide assessment of the cutoff glomerular filtration rate. J Heart Lung Transplant 2015; 34:571-9. [DOI: 10.1016/j.healun.2014.09.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 09/23/2014] [Accepted: 09/24/2014] [Indexed: 11/27/2022] Open
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Osho AA, Castleberry AW, Snyder LD, Palmer SM, Stafford-Smith M, Lin SS, Duane Davis R, Hartwig MG. The Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) equation best characterizes kidney function in patients being considered for lung transplantation. J Heart Lung Transplant 2014; 33:1248-54. [PMID: 25107351 DOI: 10.1016/j.healun.2014.06.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 06/12/2014] [Accepted: 06/18/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Methods for direct measurement of glomerular filtration rate (GFR) are expensive and inconsistently applied across transplant centers. The Modified Diet in Renal Disease (MDRD) equation is commonly used for GFR estimation, but is inaccurate for GFRs >60 ml/min per 1.73 m(2). The Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) and Wright equations have shown improved predictive capabilities in some patient populations. We compared these equations to determine which one correlates best with direct GFR measurement in lung transplant candidates. METHODS We conducted a retrospective cohort analysis of 274 lung transplant recipients. Pre-operative GFR was measured directly using a radionuclide GFR assay. Results from the MDRD, CKDEPI, Wright, and Cockroft-Gault equations were compared with direct measurement. Findings were validated using logistic regression models and receiver operating characteristic (ROC) analyses in looking at GFR as a predictor of mortality and renal function outcomes post-transplant. RESULTS Assessed against the radionuclide GFR measurement, CKDEPI provided the most consistent results, with low values for bias (0.78), relative standard error (0.03) and mean absolute percentage error (15.02). Greater deviation from radionuclide GFR was observed for all other equations. Pearson's correlation between radionuclide and calculated GFR was significant for all equations. Regression and ROC analyses revealed equivalent utility of the radionuclide assay and GFR equations for predicting post-transplant acute kidney injury and chronic kidney disease (p < 0.05). CONCLUSIONS In patients being evaluated for lung transplantation, CKDEPI correlates closely with direct radionuclide GFR measurement and equivalently predicts post-operative renal outcomes. Transplant centers could consider replacing or supplementing direct GFR measurement with less expensive, more convenient estimation by using the CKDEPI equation.
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Affiliation(s)
- Asishana A Osho
- School of Medicine, Duke University Medical Center, Durham, North Carolina.
| | | | - Laurie D Snyder
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Scott M Palmer
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Shu S Lin
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - R Duane Davis
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Paradela de la Morena M, Bravos MDLT, Prado RF, Roel MD, Salcedo JG, Costa EF, Rivas DG, Maté JB. Chronic Kidney Disease After Lung Transplantation: Incidence, Risk Factors, and Treatment. Transplant Proc 2010; 42:3217-9. [DOI: 10.1016/j.transproceed.2010.05.064] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Cardinal H, Poirier C, Fugère J, Ferraro P, Girardin C. The Evolution of Kidney Function After Lung Transplantation: A Retrospective Cohort Study. Transplant Proc 2009; 41:3342-4. [DOI: 10.1016/j.transproceed.2009.08.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Al-Naamani N, Maarouf OH, Wilt JS, Bacchetta M, D'Ovidio F, Sonett JR, Arcasoy SM, Lederer DJ, Nickolas TL, Kawut SM. The modification of diet in renal disease (MDRD) and the prediction of kidney outcomes after lung transplantation. J Heart Lung Transplant 2008; 27:1191-7. [PMID: 18971090 DOI: 10.1016/j.healun.2008.07.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Revised: 06/20/2008] [Accepted: 07/29/2008] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is prevalent after lung transplantation. This study evaluated the ability of the 24-hour urine creatinine clearance (CrCl) and the Modification of Diet in Renal Disease (MDRD) equation at the time of listing to predict CKD after lung transplantation and to determine risk factors for CKD. METHODS This was a retrospective cohort study of 122 patients who underwent lung transplantation at Columbia Presbyterian Medical Center between May 2002 and August 2006. The primary end point was CKD Stage 3 or higher, defined as glomerular filtration rate (GFR) </= 59 ml/min/1.73 m(2) or renal replacement therapy, for at least 3 months. RESULTS Patients were a mean age of 51 +/- 14 years, 55% women, and 83% non-Hispanic white. CKD developed in 62% by 1 year after lung transplantation. Older age, female gender, a diagnosis of sarcoidosis, and diabetes mellitus independently increased the risk of CKD (all p < 0.05). The MDRD equation was significantly better than CrCl at predicting CKD Stage 3 or higher at 1 year after transplantation, with an area under the receiver operating characteristic curve of 0.71 for MDRD (95% confidence interval [CI], 0.61-0.81) and 0.51 for CrCl (95% CI, 0.40-0.61) (P < 0.001). CONCLUSIONS Older age, female gender, and diabetes mellitus increased the risk of developing CKD after lung transplant. The MDRD estimate of GFR at listing was a better predictor of CKD than CrCl. MDRD estimates should be used during lung transplant evaluation for risk stratification for CKD.
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Affiliation(s)
- Nadine Al-Naamani
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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