1
|
Asadipooya K, Abdalbary M, Ahmad Y, Kakani E, Monier-Faugere MC, El-Husseini A. Bone Quality in Chronic Kidney Disease Patients: Current Concepts and Future Directions - Part II. KIDNEY DISEASES (BASEL, SWITZERLAND) 2021; 7:359-371. [PMID: 34604343 PMCID: PMC8443940 DOI: 10.1159/000515542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 12/16/2022]
Abstract
Background Patients with chronic kidney disease (CKD) have an increased risk of osteoporotic fractures, which is due not only to low bone volume and mass but also poor microarchitecture and tissue quality. The pharmacological and nonpharmacological interventions detailed, herein, are potential approaches to improve bone health in CKD patients. Various medications build up bone mass but also affect bone tissue quality. Antiresorptive therapies strikingly reduce bone turnover; however, they can impair bone mineralization and negatively affect the ability to repair bone microdamage and cause an increase in bone brittleness. On the other hand, some osteoporosis therapies may cause a redistribution of bone structure that may improve bone strength without noticeable effect on BMD. This may explain why some drugs can affect fracture risk disproportionately to changes in BMD. Summary An accurate detection of the underlying bone abnormalities in CKD patients, including bone quantity and quality abnormalities, helps in institution of appropriate management strategies. Here in this part II, we are focusing on advancements in bone therapeutics that are anticipated to improve bone health and decrease mortality in CKD patients. Key Messages Therapeutic interventions to improve bone health can potentially advance life span. Emphasis should be given to the impact of various therapeutic interventions on bone quality.
Collapse
Affiliation(s)
- Kamyar Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, Kentucky, USA
| | - Mohamed Abdalbary
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA.,Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Yahya Ahmad
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Elijah Kakani
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | | | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| |
Collapse
|
2
|
Moe SM. Current Issues in the Management of Secondary Hyperparathyroidism and Bone Disease. Perit Dial Int 2020. [DOI: 10.1177/089686080102103s43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sharon M. Moe
- Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| |
Collapse
|
3
|
Brunerová L, Kasalický P, Verešová J, Lažanská R, Potočková J, Rychlík I. Loss of bone mineral density and trabecular bone score in elderly hemodialysis patients: a 2-year follow-up, prospective, single-centre study. Int Urol Nephrol 2020; 52:379-385. [PMID: 32016906 DOI: 10.1007/s11255-020-02378-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Low bone mineral density (BMD) and trabecular bone score (TBS) are established risk factors for fractures even in hemodialysis population and they seem to be significantly lower in comparison with general population. The aim of our study was to describe 2-year loss of BMD and TBS and their predictors in hemodialysis patients. METHODS From 59 non-selected patients (mean age 67.6 ± 13.1 years) from one dialysis centre, treated with hemodiafiltration (HDF), clinical and laboratory characteristics were obtained and densitometry examinations (with BMD and TBS results) were performed initially and at the end of 2-year follow-up. RESULTS Two-year decrease in BMD of lumbar spine reached 4.1% (ns), of proximal femur 9.1% (p = 0.004), and of femoral neck 1.3% (ns). In the co-educated cohort, BMD decrease in all the sites correlated significantly with age and only the change of BMD of lumbar spine was negatively associated with serum calcium (r = - 0.39; p = 0.04) and dialysis vintage (r = - 0.387; p = 0.062), no other predictors of BMD loss were identified. Some predictors of BMD loss were identified with regard to gender. TBS decrease was 0.05 (3.9%; p = 0.03), and similarly, it was not predicted by any of selected parameters. No differences in BMD changes or TBS were observed between the patients with and without fractures. CONCLUSIONS In patients with HDF, significant BMD and TBS annual losses were observed, and they were associated only with age and (in BMD of lumbar spine) with serum calcium and dialysis vintage.
Collapse
Affiliation(s)
- Ludmila Brunerová
- 2nd Department of Medicine, Faculty Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic.
| | | | - Jana Verešová
- Dialysis Centre, Fresenius Medical Care, Prague-Vinohrady, Czech Republic
| | - Renata Lažanská
- Dialysis Centre, Fresenius Medical Care, Prague-Vinohrady, Czech Republic
| | - Jana Potočková
- 2nd Department of Medicine, Faculty Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ivan Rychlík
- 1st Department of Medicine, Faculty Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Šrobárova 50, 100 34, Prague 10, Czech Republic
| |
Collapse
|
4
|
Lima PS, de Campos AS, de Faria Neto O, Ferreira TCA, Amorim CEN, Stone WJ, Prestes J, Garcia AMC, Urtado CB. Effects of Combined Resistance Plus Aerobic Training on Body Composition, Muscle Strength, Aerobic Capacity, and Renal Function in Kidney Transplantation Subjects. J Strength Cond Res 2019; 35:3243-3250. [PMID: 31714457 DOI: 10.1519/jsc.0000000000003274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Lima, PS, de Campos, AS, de Faria Neto, O, Ferreira, TCA, Amorim, CEN, Stone, WJ, Prestes, J, Garcia, AMC, and Urtado, CB. Effects of combined resistance plus aerobic training on body composition, muscle strength, aerobic capacity, and renal function in kidney transplantation subjects. J Strength Cond Res XX(X): 000-000, 2019-Immunosuppression and a sedentary lifestyle may exacerbate complications such as early graft dysfunction and muscle loss, and reduce patient survival after kidney transplantation (KT). Therefore, the purpose of this study was to evaluate changes in body composition (BC), muscular strength, aerobic, and renal function in KT subjects submitted to combined resistance plus aerobic training. Twelve KT subjects were randomly assigned into groups: (G1) 12 weeks of combined training (3 males and 4 females, 54 ± 3 years); or (G2) nonexercise control (5 females, 43 ± 18 years). The subjects were evaluated for BC (dual-energy X-ray absorptiometry), estimated V[Combining Dot Above]O2peak, right-hand maximal grip strength (RHMGS) and left-hand maximal grip strength (LHMGS), and renal function. Post-training revealed that G1 reduced body fat percentage (p = 0.046), uric acid (Δ = -0.87; p = 0.023), urea (Δ = -9.43; p = 0.032), and creatinine (Δ = -0.15; p = 0.045), increased fat-free mass, estimated V[Combining Dot Above]O2peak, RHMGS, LHMGS (p < 0.05), and estimated glomerular filtration rate (eGFR) (Δ = 11.64; p = 0.017). G2 increased urea (Δ = 8.20; p = 0.017), creatinine (Δ = 0.37; p = 0.028), and decreased eGFR (Δ = -16.10; p = 0.038). After 12 weeks, urea (Δ = 24.94; p = 0.013), uric acid (Δ = 1.64; p = 0.044), and creatinine (Δ = 0.9; p = 0.011) were lower, whereas eGFR (Δ = 36.51; p = 0.009) was higher in G1. These data indicate that combined training instigates positive changes in BC, muscular strength, aerobic capacity, and renal function after KT.
Collapse
Affiliation(s)
- Paulo S Lima
- Graduate Program on Physical Education, Department of Physical Education, Federal University of Maranhao (UFMA), São Luis, Brazil
| | - Alexandre S de Campos
- Multiprofessional Program of Internship in Health, Kidney Health Care Unit, University Hospital of the Federal University of Maranhao (HU-UFMA), São Luis, Brazil
| | - Omar de Faria Neto
- Graduate Program on Physical Education, Department of Physical Education, Catholic University of Brasilia, Brasilia, Federal District, Brazil
| | - Teresa C A Ferreira
- Kidney Transplant Unit, University Hospital of the Federal University of Maranhao (HU-UFMA), São Luis, Brazil.,Department of Medicine, Federal University of Maranhão (UFMA), Pinheiro, Brazil
| | - Carlos E N Amorim
- Department of Physical Education, Federal University of Maranhao (UFMA), São Luis, Brazil
| | - Whitley J Stone
- School of Nutrition, Kinesiology, and Psychological Sciences, University of Central Missouri, Missouri
| | - Jonato Prestes
- Graduation Program on Physical Education, Department of Physical Education, Catholic University of Brasilia, Brasilia, Federal District, Brazil
| | - Alessandra M C Garcia
- Department of Physical Education, Federal University of Maranhao (UFMA), São Luis, Brazil
| | - Christiano B Urtado
- Department of Physical Education, Federal University of Maranhao (UFMA), São Luis, Brazil
| |
Collapse
|
5
|
Leonard MB, Wehrli FW, Ziolkowski SL, Billig E, Long J, Nickolas TL, Magland JF, Nihtianova S, Zemel BS, Herskovitz R, Rajapakse CS. A multi-imaging modality study of bone density, bone structure and the muscle - bone unit in end-stage renal disease. Bone 2019; 127:271-279. [PMID: 31158505 DOI: 10.1016/j.bone.2019.05.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 01/10/2023]
Abstract
End stage renal disease (ESRD) is associated with sarcopenia and skeletal fragility. The objectives of this cross-sectional study were to (1) characterize body composition, bone mineral density (BMD) and bone structure in hemodialysis patients compared with controls, (2) assess whether DXA areal BMD (aBMD) correlates with peripheral quantitative CT (pQCT) measures of volumetric BMD (vBMD), cortical dimensions and MRI measures of trabecular microarchitecture, and (3) determine the magnitude of bone deficits in ESRD after adjustment for muscle mass. Thirty ESRD participants, ages 25 to 64 years, were compared with 403 controls for DXA and pQCT outcomes and 104 controls for MRI outcomes; results were expressed as race- and sex- specific Z-scores relative to age. DXA appendicular lean mass index (ALMI kg/m2) and total hip, femoral neck, ultradistal and 1/3rd radius aBMD were significantly lower in ESRD, vs. controls (all p < 0.01). pQCT trabecular vBMD (p < 0.01), cortical vBMD (p < 0.001) and cortical thickness (due to a greater endosteal circumference, p < 0.02) and MRI measures of trabecular number, trabecular thickness, and whole bone stiffness were lower (all p < 0.01) in ESRD, vs. controls. ALMI was positively associated with total hip, femoral neck, ultradistal radius and 1/3rd radius aBMD and with tibia cortical thickness (R = 0.46 to 0.64). Adjustment for ALMI significantly attenuated bone deficits at these sites: e.g. mean femoral neck aBMD was 0.79 SD lower in ESRD, compared with controls and this was attenuated to 0.33 with adjustment for ALMI. In multivariate models within the dialysis participants, pQCT trabecular vBMD and cortical area Z-scores were significant and independently (all p < 0.02) associated with DXA femoral neck, total hip, and ultradistal radius aBMD Z-scores. Cortical vBMD (p = 0.01) and cortical area (p < 0.001) Z-scores were significantly and independently associated with 1/3rd radius areal aBMD Z-scores (R2 = 0.62). These data demonstrate that DXA aBMD captures deficits in trabecular and cortical vBMD and cortical area. The strong associations with ALMI, as an index of skeletal muscle, highlight the importance of considering the role of sarcopenia in skeletal fragility in patients with ESRD.
Collapse
Affiliation(s)
- Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America; Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America.
| | - Felix W Wehrli
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Susan L Ziolkowski
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Erica Billig
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jin Long
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Thomas L Nickolas
- Department of Medicine, Columbia University, New York, NY, United States of America
| | - Jeremy F Magland
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Snejana Nihtianova
- Susanne M. Glasscock School of Continuing Studies, Rice University, Houston, TX, United States of America
| | - Babette S Zemel
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Rita Herskovitz
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Chamith S Rajapakse
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America; Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States of America
| |
Collapse
|
6
|
Melamed ML, Chonchol M, Gutiérrez OM, Kalantar-Zadeh K, Kendrick J, Norris K, Scialla JJ, Thadhani R. The Role of Vitamin D in CKD Stages 3 to 4: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2018; 72:834-845. [PMID: 30297082 PMCID: PMC6615058 DOI: 10.1053/j.ajkd.2018.06.031] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/24/2018] [Indexed: 02/07/2023]
Abstract
Deficiency of 25-hydroxyvitamin D (25[OH]D) is common in patients with chronic kidney disease stages 3 and 4 and is associated with poor outcomes. However, the evaluation and management of vitamin D deficiency in nephrology remains controversial. This article reports on the proceedings from a "controversies conference" on vitamin D in chronic kidney disease that was sponsored by the National Kidney Foundation. The report outlines the deliberations of the 3 work groups that participated in the conference. Until newer measurement methods are widely used, the panel agreed that clinicians should classify 25(OH)D "adequacy" as concentrations > 20ng/mL without evidence of counter-regulatory hormone activity (ie, elevated parathyroid hormone). The panel also agreed that 25(OH)D concentrations < 15ng/mL should be treated irrespective of parathyroid hormone level. Patients with 25(OH)D concentrations between 15 and 20ng/mL may not require treatment if there is no evidence of counter-regulatory hormone activity. The panel agreed that nutritional vitamin D (cholecalciferol, ergocalciferol, or calcifediol) should be supplemented before giving activated vitamin D compounds. The compounds need further study evaluating important outcomes that observational studies have linked to low 25(OH)D levels, such as progression to end-stage kidney disease, infections, fracture rates, hospitalizations, and all-cause mortality. We urge further research funding in this field.
Collapse
Affiliation(s)
- Michal L Melamed
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.
| | | | | | | | | | - Keith Norris
- University of California-Los Angeles, Los Angeles, CA
| | | | - Ravi Thadhani
- Massachusetts General Hospital, Boston, MA; Cedars-Sinai Medical Center, Los Angeles, CA
| |
Collapse
|
7
|
Development of a novel chronic kidney disease mouse model to evaluate the progression of hyperphosphatemia and associated mineral bone disease. Sci Rep 2017; 7:2233. [PMID: 28533541 PMCID: PMC5440375 DOI: 10.1038/s41598-017-02351-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/07/2017] [Indexed: 12/02/2022] Open
Abstract
Medial arterial calcification (MAC) and renal osteodystrophy are complications of mineral bone disease (MBD) associated with chronic kidney disease (CKD). Our aim was to develop a novel mouse model to investigate the clinical course of CKD-MBD. Eight-week-old C57BL/6 J male mice were assigned to the following groups: the control group, fed a standard chow for 6 or 12 weeks; the CKD-normal phosphorus (NP) group, fed a chow containing 0.2% adenine, with normal (0.8%) phosphorus, for 6 or 12 weeks; and the CKD-high phosphorus (HP) group, fed 6 weeks with the 0.2% adenine/0.8% phosphorus diet, followed by a chow with 1.8% phosphorus for 2 weeks, 4 weeks or 6 weeks. Serum phosphorus was significantly increased in the CKD-HP group, and associated with MAC formation; the volume of calcification increased with longer exposure to the high phosphorus feed. MAC was associated with upregulated expression of runt-related transcription factor 2, alkaline phosphatase, and osteopontin, indicative of osteoblastic trans-differentiation of vascular smooth muscle cells. A significant mineral density depletion of cortical bone was observed. We describe the feasibility of developing a model of CKD-MBD and provide findings of a direct association between elevated serum phosphorus and the formation of MAC and renal osteodystrophy.
Collapse
|
8
|
Norris KC, Williams SF, Rhee CM, Nicholas SB, Kovesdy CP, Kalantar-Zadeh K, Boulware LE. Hemodialysis Disparities in African Americans: The Deeply Integrated Concept of Race in the Social Fabric of Our Society. Semin Dial 2017; 30:213-223. [PMID: 28281281 PMCID: PMC5418094 DOI: 10.1111/sdi.12589] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
End-stage renal disease (ESRD) is one of the starkest examples of racial/ethnic disparities in health. Racial/ethnic minorities are 1.5 to nearly 4 times more likely than their non-Hispanic White counterparts to require renal replacement therapy (RRT), with African Americans suffering from the highest rates of ESRD. Despite improvements over the last 25 years, substantial racial differences are persistent in dialysis quality measures such as RRT modality options, dialysis adequacy, anemia, mineral and bone disease, vascular access, and pre-ESRD care. This report will outline the current status of racial disparities in key ESRD quality measures and explore the impact of race. While the term race represents a social construct, its association with health is more complex. Multiple individual and community level social determinants of health are defined by the social positioning of race in the U.S., while biologic differences may reflect distinct epigenetic changes and linkages to ancestral geographic origins. Together, these factors conspire to influence dialysis outcomes among African Americans with ESRD.
Collapse
Affiliation(s)
- Keith C. Norris
- Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Sandra F. Williams
- Department of Integrated Medical Science, Florida Atlantic University, Florida
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
| | - Susanne B. Nicholas
- Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Csaba P. Kovesdy
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
| | | |
Collapse
|
9
|
Abstract
Sexual dysfunction is a common finding in both men and women with chronic kidney failure. Common disturbances include erectile dysfunction in men, menstrual abnormalities in women, and decreased libido and fertility in both sexes. These abnormalities are primarily organic in nature and are related to uremia as well as the other comorbid conditions that frequently occur in the chronic kidney failure patient. Fatigue and psycho social factors related to the presence of a chronic disease are also contributory factors. Disturbances in the hypothalamic-pituitary-gonadal axis can be detected prior to the need for dialysis but continue to worsen once dialytic therapy is initiated. Impaired gonadal function is prominent in uremic men while the disturbances in the hypothalamic-pituitary axis are more subtle. By contrast, central disturbances are more prominent in uremic women. Therapy is initially directed towards optimizing the delivery of dialysis, correcting anemia with recombinant erythropoietin, and controlling the degree of secondary hyperparathyroidism with vitamin D. For many practicing nephrologists sildenafil has become the first line therapy in the treatment of impotence. In the hypogonadal man whose only complaint is decreased libido, testosterone may be of benefit. Regular gynecologic follow up is required in uremic women to guard against potential complications of unopposed estrogen effect. Uremic women should be advised against pregnancy while on dialysis. Successful transplantation is the most effective means of restoring normal sexual function in both men and women with chronic kidney failure.
Collapse
Affiliation(s)
- Biff F Palmer
- Department of Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | - Deborah J Clegg
- Biomedical Research Department, Diabetes and Obesity Research Division, Cedars-Sinai Medical Center, California, LA, USA
| |
Collapse
|
10
|
Jeong S, Oh JM, Oh KH, Kim IW. Differentially expressed miR-3680-5p is associated with parathyroid hormone regulation in peritoneal dialysis patients. PLoS One 2017; 12:e0170535. [PMID: 28152049 PMCID: PMC5289431 DOI: 10.1371/journal.pone.0170535] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/05/2017] [Indexed: 01/26/2023] Open
Abstract
Mineral and bone disorder (MBD) is observed universally in patients with chronic kidney disease (CKD). Detrimental MBD-related skeletal changes include increased prevalence of fracture, cardiovascular disease, and mortality. MicroRNAs (miRNAs) have been identified as useful biomarkers in various diseases, and the aim of this study was to identify miRNAs associated with parathyroid hormone level in peritoneal dialysis (PD) patients. Fifty-two PD patients were enrolled and grouped by their intact parathyroid hormone (iPTH) level; 11 patients had low iPTH (<150 pg/mL) and 41 patients had high iPTH (≥150 pg/mL). Total RNA was extracted from whole blood samples. Total RNA from 15 patients (7 and 8 patients in the low and high iPTH groups, respectively) underwent miRNA microarray analysis, and three differentially upregulated (>2-fold change) miRNAs previously associated with human disease were selected for real-time quantitative PCR (qPCR) analysis. Interaction analyses between miRNAs and genes were performed by using TargetScan and the KEGG pathway database. Microarray results revealed 165 miRNAs were differentially expressed between patients with high iPTH levels and low iPTH levels. Of those miRNAs, 81 were upregulated and 84 were downregulated in patients with high iPTH levels. Expression levels of miR-1299, miR-3680-5p, and miR-548b-5p (previously associated with human disease) in 52 patients were analyzed by using qPCR. MiR-3680-5p was differentially expressed in low and high iPTH patients (P < 0.05). The predicted target genes of miR-3680-5p were USP6, USP32, USP46, and DLT, which are involved in the ubiquitin proteolysis pathway. This pathway has roles in PTH and parathyroid hormone related protein degradation and proteolysis. The mechanisms involved in the associations among low PTH, adynamic bone disease, miR-3680-5p, and the target genes should be explored further in order to elucidate their roles in CKD-MBD development.
Collapse
Affiliation(s)
- Sohyun Jeong
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Jung Mi Oh
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- * E-mail: (IK); (KO)
| | - In-Wha Kim
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
- * E-mail: (IK); (KO)
| |
Collapse
|
11
|
Marinho SM, Moraes C, Barbosa JEDSM, Carraro Eduardo JC, Fouque D, Pelletier S, Mafra D. Exercise Training Alters the Bone Mineral Density of Hemodialysis Patients. J Strength Cond Res 2016; 30:2918-23. [PMID: 26863587 DOI: 10.1519/jsc.0000000000001374] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Marinho, SM, Moraes, C, Barbosa, JEdSM, Eduardo, JCC, Fouqe, D, Pelletier, S, and Mafra, D. Exercise training alters the bone mineral density of hemodialysis patients. J Strength Cond Res 30(10): 2918-2923, 2016-Patients with chronic kidney disease undergoing hemodialysis (HD) frequently present low bone mineral density (BMD), and exercise may be useful for treating bone loss. This study aimed to assess the effects of an intradialytic resistance exercise training program (RETP) on BMD in HD patients. Twenty-one patients were enrolled into 2 groups; 10 patients performed exercise (80.0% men; 46.9 ± 12.1 years; 27.0 ± 3.4 kg·m) and 11 patients were in the control group (54.5% men; 50.5 ± 11.5 years; 24.1 ± 8.7 kg·m). Dual-energy x-ray absorptiometry was used to measure the BMD, lean mass, and body fat before and after the supervised RETP (performed with elastic bands and ankle cuffs in both lower limbs 3 times a week for 24 weeks-72 sessions). In the exercise group, 30.0% of patients presented with osteopenia and 20.0% osteoporosis and in the control group, 45.5% osteopenia and 36.4% osteoporosis. Only in the exercise group, the osteoporosis percentage was reduced to 10.0% and the femoral neck BMD and T-score improved from 0.89 ± 0.1 to 0.93 ± 0.1 g·cm and from -1.3 ± 0.8 to -1.0 ± 0.8 g·cm (p ≤ 0.05), respectively, after the intervention. In contrast, these parameters were reduced in the control group. The results suggest that resistance exercise may be useful for improving the BMD in HD patients. In summary, 24 weeks of the supervised RETP played a role in improving the BMD of HD patients.
Collapse
Affiliation(s)
- Sandra M Marinho
- 1Graduate Program in Medical Sciences, Fluminense Federal University (UFF), Niterói-RJ, Brazil; 2Graduate Program in Cardiovascular Sciences, Fluminense Federal University (UFF), Niterói-RJ, Brazil; 3Fluminense Federal University (UFF), Medicine Faculty, Niterói-RJ, Brazil; and 4Department of Nephrology, Lyon Sud Hospital Center, CARMEN, CENS, University of Lyon, France
| | | | | | | | | | | | | |
Collapse
|
12
|
Chapter 4.1: Treatment of CKD-MBD targeted at lowering high serum phosphorus and maintaining serum calcium. Kidney Int 2016; 76113:S50-99. [PMID: 26746397 DOI: 10.1038/ki.2009.192] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
13
|
Kuipers AL, Egwuogu H, Evans RW, Patrick AL, Youk A, Bunker CH, Zmuda JM. Renal Function and Bone Loss in a Cohort of Afro-Caribbean Men. J Bone Miner Res 2015; 30:2215-20. [PMID: 26011289 PMCID: PMC4775470 DOI: 10.1002/jbmr.2562] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 05/08/2015] [Accepted: 05/15/2015] [Indexed: 11/11/2022]
Abstract
Poor renal function is associated with increased rates of bone loss and osteoporotic fractures in Caucasian men. The importance of kidney function for skeletal health in African ancestry men, who are a population segment with a high prevalence of chronic kidney disease as well as high peak bone mass, is not well known. We examined the relationship between estimated glomerular filtration rate (eGFR) and rates of bone loss in a large population cohort of otherwise healthy Afro-Caribbean men aged 40 years and older. Dual X-ray absorptiometry of the proximal femur and quantitative computed tomography of the proximal radius and tibia were obtained approximately 6 years apart. We calculated eGFR from serum creatinine that was measured in fasting samples in 1451 men. Impaired kidney function (IKF, eGFR<60 ml/min/1.7 m(2)) was observed in 8.6% of the cohort. The relationship between IKF and baseline BMD and annualized rate of change in BMD was analyzed controlling for potentially important confounders. IKF was not associated with baseline BMD. In contrast, men with IKF experienced a rate of decline in areal BMD at the total hip, femoral neck and trochanter and cortical volumetric BMD compared to those with normal kidney function (p<0.05 for all). Impaired kidney function was not associated with changes in trabecular volumetric BMD. In conclusion, poorer kidney function is associated with accelerated bone loss among otherwise healthy Afro-Caribbean men even after controlling for age and other important medical and lifestyle related variables.
Collapse
Affiliation(s)
- Allison L Kuipers
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Heartley Egwuogu
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rhobert W Evans
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alan L Patrick
- The Tobago Health Studies Office, Scarborough, Tobago, Trinidad & Tobago
| | - Ada Youk
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clareann H Bunker
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph M Zmuda
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
14
|
Ethnic differences in bone and mineral metabolism in healthy people and patients with CKD. Kidney Int 2013; 85:1283-9. [PMID: 24352156 DOI: 10.1038/ki.2013.443] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 08/07/2013] [Accepted: 08/15/2013] [Indexed: 12/24/2022]
Abstract
Several studies have shown racial differences in the regulation of mineral metabolism, in the acquisition of bone mass and structure of individuals. In this review, we examine ethnic differences in bone and mineral metabolism in normal individuals and in patients with chronic kidney disease. Black individuals have lower urinary excretion and increased intestinal calcium absorption, reduced levels of 25(OH)D, and high levels of 1.25(OH)2D and parathyroid hormone (PTH). Body phosphorus concentration is higher and the levels of FGF-23 are lower than in whites. Mineral density and bone architecture are better in black individuals. These differences translate into advantages for blacks who have stronger bones, less risk of fractures, and less cardiovascular calcification. In the United States of America, the prevalence of kidney disease is similar in different ethnic groups. However, black individuals progress more quickly to advanced stages of kidney disease than whites. This faster progression does not translate into increased mortality, higher in whites, especially in the first year of dialysis. Some ethnicity-related variations in mineral metabolism persist when individuals develop CKD. Therefore, black patients have lower serum calcium concentrations, less hyperphosphatemia, low levels of 25(OH)D, higher levels of PTH, and low levels of FGF-23 compared with white patients. Bone biopsy studies show that blacks have greater bone volume. The rate of fractures and cardiovascular diseases are also less frequent. Further studies are required to better understand the cellular and molecular bases of these racial differences in bone mineral metabolism and thus better treat patients.
Collapse
|
15
|
Özkan O, Öztürk S, Karadağ S, Gürsu M, Şumnu A, Cebeci E, Sevim Y, Uzun S, Aydın Z, Kazancıoğlu R. The Factors Effective on Bone Mineral Density in
Peritoneal Dialysis Patients. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2013. [DOI: 10.29333/ejgm/82214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
16
|
Aggarwal HK, Jain D, Yadav S, Kaverappa V. Bone mineral density in patients with predialysis chronic kidney disease. Ren Fail 2013; 35:1105-11. [DOI: 10.3109/0886022x.2013.815102] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
17
|
Abstract
Cohort studies, mainly US, show that vitamin D deficiency is more common in African-American population. Social and environmental factors play a role but the difference in skin color is essential. Despite low 25-hydroxyvitamin D concentrations, a lower risk of fragility or fracture exists in these populations. Vitamin D deficiency is a contributing factor in many chronic diseases. There is a relationship between vitamin D deficiencies, progression of chronic kidney disease and increased relative risk of mortality. If the ethnicity of patients is now taken into account to estimate renal function, probably specific recommendations for vitamin D deficiency are needed.
Collapse
|
18
|
Ruas G, Fatureto MC, Santana JH, Di Lorenzo VAP, Jamami M. Avaliação da prevalência de osteoporose e fraturas vertebrais em pacientes portadores de doença pulmonar obstrutiva crônica. FISIOTERAPIA EM MOVIMENTO 2012. [DOI: 10.1590/s0103-51502012000200015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUÇÃO: A osteoporose é uma doença progressiva que contribui para o surgimento de fraturas vertebrais. OBJETIVOS: Avaliar a prevalência da osteoporose, fraturas vertebrais e intensidade da dor nas regiões da coluna vertebral em pacientes com DPOC moderada e grave, além de verificar se há relação entre tais variáveis e a gravidade da obstrução pulmonar. MATERIAIS E MÉTODOS: Foram avaliados 34 indivíduos portadores de DPOC (GDPOC) e 33 indivíduos saudáveis (GC), por meio da densitometria óssea e radiografias da coluna torácica e lombar. RESULTADOS: Não houve diferenças significativas intergrupos nos dados antropométricos. O GDPOC apresentou valores menores nas variáveis espirométricas, na densidade mineral óssea (DMO) e no escore-T, quando comparado com o GC (p < 0,05; Teste t Student); além disso, não se observou correlação entre VEF1 e DMO e escore-T (Correlação de Pearson, p > 0,05). Verificou-se uma alta prevalência de osteoporose, sendo que 20 indivíduos (59%) com obstrução moderada apresentaram na coluna lombar, l (3%) no colo do fêmur e l (3%) no trocânter; 4 (12%) com obstrução pulmonar grave na coluna lombar, l (3%) no colo do fêmur e l (3%) no trocânter. Vinte indivíduos (59%) do GDPOC com osteoporose apresentaram fraturas de graus I e II, 4 (12%) grau III (k = 0,90; IC: 95%) e 3 indivíduos do GDPOC relataram presença de dor com intensidade "leve" na região toracolombar, enquanto 21 apresentaram fraturas vertebrais osteoporóticas assintomáticas. CONCLUSÃO Concluímos que os indivíduos com DPOC de moderada a grave apresentaram, além do comprometimento pulmonar, diminuição da DMO e fraturas vertebrais osteoporóticas, o que indica a necessidade de se adotar medidas de prevenção da osteoporose nesses pacientes.
Collapse
|
19
|
Kiattisunthorn K, Moe SM. Chronic kidney disease-mineral bone disorder (CKD-MBD). ACTA ACUST UNITED AC 2010. [DOI: 10.1138/20100479] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
20
|
Hruska KA, Choi ET, Memon I, Davis TK, Mathew S. Cardiovascular risk in chronic kidney disease (CKD): the CKD-mineral bone disorder (CKD-MBD). Pediatr Nephrol 2010; 25:769-78. [PMID: 19898875 PMCID: PMC3719392 DOI: 10.1007/s00467-009-1337-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 09/14/2009] [Accepted: 09/17/2009] [Indexed: 01/01/2023]
Abstract
Recent advances in our understanding of the excess mortality of chronic kidney disease (CKD) due to cardiovascular complications, obtained through observational studies, demonstrate that vascular calcification and hyperphosphatemia are major cardiovascular risk factors. Mechanistic studies demonstrate that these two risk factors are related and that hyperphosphatemia directly stimulates vascular calcification. The role of hyperphosphatemia in stimulating vascular calcification in CKD is associated with a block to the skeletal reservoir function in phosphate balance due to excess bone resorption. This has led to the realization that renal osteodystrophy is linked to vascular calcification by disordered mineral homeostasis (phosphate) and that a multiorgan system fails in CKD, leading to cardiovascular mortality. In children with renal disease, the multiorgan system fails, just as in adults, but the outcomes have been less well studied, and perceptions of differences from adults are possibly incorrect. Vascular calcification and cardiovascular mortality are less prevalent among pediatric patients, but they are present. However, CKD-induced vascular disease causes stiffness of the arterial tree causing, in turn, systolic hypertension and left ventricular hypertrophy as early manifestations of the same pathology in the adult. Because of the role of the skeleton in these outcomes, renal osteodystrophy has been renamed as the CKD mineral bone disorder (CKD-MBD). This review, which focuses on the pediatric patient population, describes our current state of knowledge with regards to the pathophysiology of the CKD-MBD, including the new discoveries related to early stages of CKD. As a new necessity, cardiovascular function issues are incorporated into the CKD-MBD, and new advances in our knowledge of this critical component of the disorder will lead to improved outcomes in CKD.
Collapse
Affiliation(s)
- Keith A Hruska
- Division of Pediatric Nephrology, Washington University, St. Louis, MO, USA.
| | | | | | | | | |
Collapse
|
21
|
Kovesdy CP, Ureche V, Lu JL, Kalantar-Zadeh K. Outcome predictability of serum alkaline phosphatase in men with pre-dialysis CKD. Nephrol Dial Transplant 2010; 25:3003-11. [PMID: 20299338 DOI: 10.1093/ndt/gfq144] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Serum alkaline phosphatase (ALP) increases in patients with chronic kidney disease (CKD) and high-turnover bone disease. ALP may represent an adjunct marker of high bone turnover devoid of drawbacks of serum parathyroid hormone (PTH), and it may also be associated with cardiovascular calcification in CKD. Higher ALP has been recently associated with increased mortality and coronary calcification in dialysis patients. In pre-dialysis CKD patients, this association is not clear. METHODS We examined the association of baseline, time-varying and time-averaged ALP with all-cause mortality and the composite of pre-dialysis mortality or end-stage renal disease in a historical prospective cohort of 1158 male veterans with pre-dialysis CKD from a single institution by using multivariable-adjusted Cox models. RESULTS Higher ALP was associated with increased mortality irrespective of the statistical model. Time-averaged ALP displayed a consistent linear association with mortality: a 50-U/L higher serum ALP was associated with a multivariable-adjusted death hazard ratio (95% confidence interval) of 1.17 (1.08-1.28), P < 0.001. Baseline and time-varying ALP showed non-linear associations with mortality, with serum levels above 70 U/L in all models and with lower levels in time-varying models. Associations between ALP levels and the composite outcomes were similar. However, compared to serum PTH, mortality predictability of ALP appeared more incremental. CONCLUSIONS Elevated ALP is associated with increased mortality in patients with pre-dialysis CKD. Low ALP appears to be associated with short-term mortality.
Collapse
Affiliation(s)
- Csaba P Kovesdy
- Division of Nephrology, Salem Veterans Affairs Medical Center, Salem, VA, USA.
| | | | | | | |
Collapse
|
22
|
Ambrus C, Marton A, Nemeth ZK, Mucsi I. Bone mineral density in patients on maintenance dialysis. Int Urol Nephrol 2009; 42:723-39. [DOI: 10.1007/s11255-009-9666-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Accepted: 10/13/2009] [Indexed: 01/09/2023]
|
23
|
|
24
|
|
25
|
Abstract
BACKGROUND Although it is known that the incidence of fracture events is increased in renal transplantation recipients, the timing and the factors associated with risk of fractures are less well understood. The objective of this study was to estimate the time to fracture in renal transplantation recipients and to determine whether risk was associated with patient and transplantation characteristics. METHODS Using the U. S. Renal Data System, we retrospectively studied 68,814 patients, who underwent renal transplantation between 1988 and 1998. Fractures were identified from International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes in billing data. Time to first fracture was modeled during the first 5 years posttransplant using the Kaplan-Meier method and Cox proportional hazards models. RESULTS Of the patients who underwent transplantation, 22.5% developed a fracture within 5 years. Woman (hazard ratio [HR] 1.36, P<0.0001), patients older than 45 years of age (HR 1.14, P<0.0001) especially older than 65 years (HR 1.69, P<0.0001), and whites (HR 1.28, P<0.0001) were at increased risk of a fracture. Additionally, receipt of a deceased donor kidney (HR 1.30, P<0.0001), increased human leukocyte antigen mismatches (HR 1.09, P<0.014), diabetes (HR 1.88, P<0.0001), pretransplant dialysis (HR 1.08, P<0.0001), and an aggressive induction immunosuppression regimen (HR 1.14, P<0.0001) all significantly increased risk of fracture events during the first 5 years. CONCLUSIONS In addition to patient demographic features, donor factors, including suboptimal organ quality and the need for more intense immunosuppression, were associated with an increased risk of fractures during the first 5 years after a renal transplant.
Collapse
|
26
|
da Costa JAC, de Castro JAS, Foss MC. The Evaluation of Renal Osteodystrophy with Cortical Quantitative Ultrasound at Various Bone Sites. Ren Fail 2009; 26:237-41. [PMID: 15354971 DOI: 10.1081/jdi-120039521] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In this study we evaluated bone abnormalities of patients with chronic renal failure (CRF) by cortical quantitative bone ultrasound (QUS) measurements at different bone sites because these abnormalities may be of variable etiology and may start before symptoms or radiological changes are manifested. METHODS Of fifteen patients with chronic renal failure, seven had moderate-severe disease and eight had been on chronic hemodialysis from 5 to 17 years, with renal osteodystrophy (ROD) confirmed by bone biopsies. Twelve normal subjects of similar age and gender volunteered for the control group. RESULTS Patients and controls differed in creatinine clearance, in serum phosphate levels and in serum total alkaline phosphatase. Mean intact-PTH levels differed significantly amongst the three groups of subjects. All patients with ROD had intact-PTH higher than 200 pg/mL. The cortical ultrasound parameter, speed of sound (SOS), was slower in patients with more severe renal failure at all bone sites measured. The group with ROD had significantly lower cortical ultrasound values than the other patients and the control group at all sites. SOS values at the proximal phalanx, distal radius and midtibial sites were positively and significantly correlated. Cortical ultrasound measurements at the radial site correlated with midtibial and phalangeal sites but the correlation between midtibial and phalangeal sites did not reach significance. IPTH levels correlated negatively and significantly with cortical QUS values at all sites being the correlations higher at phalangeal and radial sites than at the midtibial region. CONCLUSIONS The differences in cortical ultrasound observed indicate the potential clinical application of this methodology to evaluate bone abnormalities in chronic renal failure, especially in patients on chronic hemodialysis.
Collapse
Affiliation(s)
- José Abrão Cardeal da Costa
- Nephrology Division, Department of Internal Medicine, Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil.
| | | | | |
Collapse
|
27
|
OTT SUSANM. Review article: Bone density in patients with chronic kidney disease stages 4-5. Nephrology (Carlton) 2009; 14:395-403. [DOI: 10.1111/j.1440-1797.2009.01159.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
28
|
Ishani A, Paudel M, Taylor BC, Barrett-Connor E, Jamal S, Canales M, Steffes M, Fink HA, Orwoll E, Cummings SR, Ensrud KE. Renal function and rate of hip bone loss in older men: the Osteoporotic Fractures in Men Study. Osteoporos Int 2008; 19:1549-56. [PMID: 18392664 DOI: 10.1007/s00198-008-0608-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Accepted: 01/15/2008] [Indexed: 10/22/2022]
Abstract
UNLABELLED Older men with reduced renal function are at increased risk of hip bone loss. Given the robustness of this association across different measures and a growing body of literature, our findings indicate that clinicians should take into account renal function when evaluating older men for osteoporosis risk and bone loss. Future randomized controlled trials should test whether interventions in this high risk population are effective in preventing bone loss and decreasing fracture incidence. INTRODUCTION Studies examining whether kidney impairment, not requiring dialysis, is associated with osteoporosis have reported conflicting results. METHODS We tested the hypothesis that reduced renal function in older men as manifested by higher concentrations of cystatin C or lower levels of estimated glomerular filtration rate (eGFR) is associated with higher rates of bone loss. We measured serum cystatin C, serum creatinine and total hip bone mineral density (BMD) at baseline in a cohort of 404 older men enrolled in the Osteoporotic Fractures in Men (MrOS) Study and followed them prospectively for an average of 4.4 years for changes in BMD. Associations between renal function and change in hip BMD were examined using linear regression. RESULTS In multivariable analysis, the mean rate of decline in total hip BMD showed an increase in magnitude with higher cystatin C concentration (mean annualized percent change -0.29, -0.34, -0.37 and -0.65% for quartiles 1 to 4; p for trend=0.004). Similarly, adjusted rates of hip bone loss were higher among men with lower eGFR as defined by the modification of diet in renal disease formula (mean annualized percent change -0.58, -0.39, -0.37, and -0.31 for quartiles 1 to 4; p for trend=0.02), but not among men with lower eGFR as defined by the Cockcroft-Gault formula (mean annualized percent change -0.47, -0.44, -0.31 and -0.43 for quartiles 1 to 4; p for trend=0.48). CONCLUSIONS Older men with reduced renal function are at increased risk of hip bone loss. Our findings suggest that health care providers should consider renal function when evaluating older men for risk factors for bone loss and osteoporosis.
Collapse
Affiliation(s)
- A Ishani
- Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Goodman WG, Quarles LD. Development and progression of secondary hyperparathyroidism in chronic kidney disease: lessons from molecular genetics. Kidney Int 2008; 74:276-88. [PMID: 17568787 DOI: 10.1038/sj.ki.5002287] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The identification of the calcium-sensing receptor (CaSR) and the clarification of its role as the major regulator of parathyroid gland function have important implications for understanding the pathogenesis and evolution of secondary hyperthyroidism in chronic kidney disease (CKD). Signaling through the CaSR has direct effects on three discrete components of parathyroid gland function, which include parathyroid hormone (PTH) secretion, PTH synthesis, and parathyroid gland hyperplasia. Disturbances in calcium and vitamin D metabolism that arise owing to CKD diminish the level of activation of the CaSR, leading to increases in PTH secretion, PTH synthesis, and parathyroid gland hyperplasia. Each represents a physiological adaptive response by the parathyroid glands to maintain plasma calcium homeostasis. Studies of genetically modified mice indicate that signal transduction via the CaSR is a key determinant of parathyroid cell proliferation and parathyroid gland hyperplasia. Because enlargement of the parathyroid glands has important implications for disease progression and disease severity, it is possible that clinical management strategies that maintain adequate calcium-dependent signaling through the CaSR will ultimately prove useful in diminishing parathyroid gland hyperplasia and in modifying disease progression.
Collapse
Affiliation(s)
- William G Goodman
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
| | | |
Collapse
|
30
|
Abstract
Observational studies have determined hyperphosphatemia to be a cardiovascular risk factor in chronic kidney disease. Mechanistic studies have elucidated that hyperphosphatemia is a direct stimulus to vascular calcification, which is one cause of morbid cardiovascular events contributing to the excess mortality of chronic kidney disease. This review describes the pathobiology of hyperphosphatemia that develops as a consequence of positive phosphate balance in chronic kidney disease and the mechanisms by which hyperphosphatemia acts on neointimal vascular cells that are stimulated to mineralize in chronic kidney disease. The characterization of hyperphosphatemia of chronic kidney disease as a distinct syndrome in clinical medicine with unique disordered skeletal remodeling, heterotopic mineralization and cardiovascular morbidity is presented.
Collapse
Affiliation(s)
- Keith A Hruska
- Department of Pediatrics, Renal Division, Washington University, St Louis, Missouri 63110, USA.
| | | | | | | | | |
Collapse
|
31
|
Araujo AB, Travison TG, Leder BZ, McKinlay JB. Correlations between serum testosterone, estradiol, and sex hormone-binding globulin and bone mineral density in a diverse sample of men. J Clin Endocrinol Metab 2008; 93:2135-41. [PMID: 18364385 PMCID: PMC2435644 DOI: 10.1210/jc.2007-1469] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 03/13/2008] [Indexed: 11/19/2022]
Abstract
CONTEXT The relationship between hormones and bone mineral density (BMD) in men has received considerable attention. However, most studies have been conducted in homogenous populations, and it is not known whether differences in hormones impact racial and ethnic differences in BMD. OBJECTIVE Our objective was to examine associations of testosterone, estradiol, and sex hormone-binding globulin (SHBG) with BMD in a racially and ethnically diverse population. DESIGN This was a population-based, observational survey. PARTICIPANTS A total of 976 Black, Hispanic, and white randomly selected men ages 30-79 yr from the Boston Area Community Health/Bone Survey were included. OUTCOME BMD at the hip, wrist, and spine were calculated. RESULTS The mean age of the sample was 46.7 +/- 12.4 yr. BMD levels were highest in black men, followed by Hispanic and then white men. Associations between hormones and BMD were consistent across racial and ethnic groups. Total and free testosterone was not correlated with BMD in age- or multivariate-adjusted models. SHBG was inversely correlated with total hip and ultradistal radius BMD after age adjustment, but not with multivariate adjustment for age, lean mass, fat mass, physical activity, self-rated health, and smoking. Total and free estradiol levels were positively and significantly correlated with femoral neck and total hip BMD, even with multivariate adjustment (partial correlations ranged between 0.11 and 0.16). However, estradiol levels failed to account for racial and ethnic differences in hip BMD. CONCLUSIONS In our diverse population, neither serum total nor free testosterone levels were associated with BMD. Correlations between BMD and estradiol were significant but did not appear to account for any of the observed racial and ethnic differences in BMD. These findings suggest that differences in hormone levels are not a major contributor to the observed differences in BMD between Black, Hispanic, and white men.
Collapse
Affiliation(s)
- Andre B Araujo
- New England Research Institutes, 9 Galen Street, Watertown, MA 02472, USA.
| | | | | | | |
Collapse
|
32
|
Kovesdy CP, Ahmadzadeh S, Anderson JE, Kalantar-Zadeh K. Obesity is associated with secondary hyperparathyroidism in men with moderate and severe chronic kidney disease. Clin J Am Soc Nephrol 2007; 2:1024-9. [PMID: 17702720 DOI: 10.2215/cjn.01970507] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Obesity is associated with secondary hyperparathyroidism in the general population. The objective of this study is to explore whether the same association is present in patients with chronic kidney disease. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS Linear regression models were used to examine the association between intact parathyroid hormone level and body mass index in 496 male US veterans (age 69.4 +/- 10.2 yr, 22.8% black) who had chronic kidney disease stages 2 to 5 and were not yet on dialysis (estimated GFR 31.8 +/- 11.2 ml/min per 1.73 m2). RESULTS Higher intact parathyroid hormone was associated with higher body mass index after adjustment for age, race, diabetes, and serum calcium and phosphorus levels. This association was independent of age, race, diabetes status, and serum calcium and phosphorus but was limited to patient groups with lower albumin (P = 0.005 for the interaction term) or higher white blood cell count (P = 0.026 for the interaction term). CONCLUSIONS Higher body mass index is associated with secondary hyperparathyroidism in patients who have chronic kidney disease and are not yet on dialysis, especially in patients with evidence of malnutrition and inflammation. Confirmation of these findings in other patient groups with chronic kidney disease and better characterization of the underlying mechanisms of action will be necessary before advocating weight loss as a means to treat secondary hyperparathyroidism in chronic kidney disease.
Collapse
Affiliation(s)
- Csaba P Kovesdy
- Division of Nephrology, Salem VA Medical Center, 1970 Roanoke Boulevard, Salem, VA 24153, USA.
| | | | | | | |
Collapse
|
33
|
Araujo AB, Travison TG, Harris SS, Holick MF, Turner AK, McKinlay JB. Race/ethnic differences in bone mineral density in men. Osteoporos Int 2007; 18:943-53. [PMID: 17340219 DOI: 10.1007/s00198-006-0321-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Accepted: 12/27/2006] [Indexed: 01/30/2023]
Abstract
UNLABELLED The epidemiology of osteoporosis in male and minority populations is understudied. We compared BMD in 1,209 Black, Hispanic, and White men. Black men exhibited higher BMD than Hispanic or White men. Age-related BMD decreases were greatest among Hispanic men. Results may help explain variation in hip fracture rates by race/ethnicity. INTRODUCTION The epidemiology of osteoporosis in male and minority populations is understudied. To address this concern, we conducted a study of skeletal health in a diverse population of adult males. METHODS A total of 367 Black, 401 Hispanic, and 451 White men aged 30-79 years were randomly sampled from Boston, MA. Bone densitometry (bone area (BA), bone mineral content (BMC), and bone mineral density (BMD)) at the whole body, hip, lumbar spine, and forearm was performed. Multiple regression analyses on 1,209 men with available data were used to describe race/ethnic group-specific means (height- and age-adjusted) and age trends (height-adjusted) in BMC, BA, and BMD. Results were weighted to represent the Boston male population aged 30-79 years. RESULTS Black men had greater BMC and BMD than Hispanic or White men. Femoral neck BMD was 5.6% and 13.3% higher in Black men than in Hispanic and White men, respectively. Differences between Hispanic and White subjects were restricted to the hip. Age-related declines in BMC and BMD were significantly steeper among Hispanic than Black or White men. CONCLUSIONS Differences in BMC and BMD could explain variation in fracture rates among Black, Hispanic, and White men. The steeper age-related BMD decline in Hispanic men is of particular concern.
Collapse
Affiliation(s)
- A B Araujo
- New England Research Institutes, Watertown, MA 02472, USA.
| | | | | | | | | | | |
Collapse
|
34
|
Ersoy FF. Osteoporosis in the elderly with chronic kidney disease. Int Urol Nephrol 2006; 39:321-31. [PMID: 17103030 DOI: 10.1007/s11255-006-9109-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2006] [Accepted: 08/17/2006] [Indexed: 11/28/2022]
Abstract
Considering the aging dialysis population of today, increasing our knowledge about the nature, diagnosis and the treatment of bone mineral density (BMD) problems in end-stage renal disease (ESRD) patients deserves more attention. Osteoporosis is basicly defined as a decrease in bone mass. Large epidemiological studies in general population have identified several risk factors for osteoporosis including advancing age, female gender, white race, decreased calcium intake, gastric acid suppression therapy, sedentary lifestyle, premature loss of gonadal function, decreased estrogen secretion, thin body habitus, decreased physical activity, cigarette smoking, alcohol abuse, excess glucocorticoid exposure, and possibly some genetic factors. Osteoporosis in ESRD patients is only a part of a wider spectrum of metabolic bone problems, namely uremic osteodystrophy. Therefore, its diagnosis, management and follow-up may differ from the general population and an individualization of diagnosis and definition for dialysis population may be necessary. However, standard diagnostic tools such as dual energy X-ray absorptiometry (DEXA) have been widely used for the assessment of bone mineral deficiency status in ESRD patients. Regardless of the methods, most of the studies are in concordance with a reduced BMD in HD and PD patients. Dialysis patients are known to be at increased risk for low-trauma fractures. Thinning of cortical bone, which is responsible for the largest contribution toward reduced bone mineral content in chronic renal failure results in increased fracture risk. In either normal population and dialysis patients, fracture risk is increased with age. But in dialysis patients, besides age, several other factors may also affect the degree of bone mineral deficiency, and age-BMD relationship may be blunted. Female sex, in hemodialysis patients is negatively associated with total hip BMD. While several studies have been unable to demonstrate any association between BMD and PTH levels, larger body size has been shown to have a significant positive effect on BMD in both hemodialysis and peritoneal dialysis patients. Although they have been used in small groups of chronic kidney disease (CKD) and ESRD patients, because of their potential nephrotoxicity and hypocalcemic effects, use of biphosphonates in renal patients is questionable. Currently, bone biopsy, in order to exclude adynamic bone disease is recommended before beginning treatment with bisphosphonates in chronic kidney disease and dialysis patients.
Collapse
Affiliation(s)
- F Fevzi Ersoy
- Division of Nephrology, Department of Medicine, Akdeniz University Medical School, Duluphar Bulvari, Kampus, 07070 Antalya, Turkey.
| |
Collapse
|
35
|
Barreto FC, Barreto DV, Moyses RMA, Neves CL, Jorgetti V, Draibe SA, Canziani ME, Carvalho AB. Osteoporosis in hemodialysis patients revisited by bone histomorphometry: a new insight into an old problem. Kidney Int 2006; 69:1852-7. [PMID: 16612334 DOI: 10.1038/sj.ki.5000311] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Osteoporosis in hemodialysis patients is associated with high morbidity and mortality and, although extensively studied by noninvasive methods, has never been assessed through bone biopsy. The aim of this study was to use histomorphometry to evaluate osteoporosis and identify factors related to its development in hemodialysis patients. We conducted a cross-sectional study involving 98 patients (35 women and 63 men; mean age: 48.4 +/- 13 years) on hemodialysis for 36.9 +/- 24.7 months. Patients were submitted to transiliac bone biopsy with double tetracycline labeling. The bone metabolism factors ionized calcium, phosphorus, bone alkaline phosphatase, deoxypyridinoline, intact parathyroid hormone, and 25(OH) vitamin D were evaluated, as were the bone remodeling cytokines osteoprotegerin (OPG), soluble receptor-activator of NF-kappabeta ligand (sRANKL) and tumor necrosis factor-alpha (TNF)alpha. Osteoporosis was defined as trabecular bone volume (BV/TV) greater than 1 s.d. below normal (men <17.4%; women <14.7%). Forty-five patients (46%) presented osteoporosis, which was correlated with white race. We found BV/TV to correlate with age, OPG/sRANKL ratio, TNFalpha levels, and length of amenorrhea. In multiple regression analysis adjusted for sex and age, length of amenorrhea, white race, and OPG/sRANKL ratio were independent determinants of BV/TV. Histomorphometric analysis demonstrated that osteoporotic patients presented normal eroded surface and low bone formation rate (BFR/BS). Osteoporosis is prevalent in hemodialysis patients. Low BFR/BS could be involved in its development, even when bone resorption is normal. Cytokines may also play a role as may traditional risk factors such as advanced age, hypogonadism, and white race.
Collapse
Affiliation(s)
- F C Barreto
- Department of Internal Medicine, Division of Nephrology, Federal University of São Paulo, Brazil.
| | | | | | | | | | | | | | | |
Collapse
|
36
|
Fan SLS, Chan A, Raftery MJ, Yaqoob MM. Race and sex: predictors of the severity of hyperparathyroidism in peritoneal dialysis patients. Nephrology (Carlton) 2006; 11:15-20. [PMID: 16509926 DOI: 10.1111/j.1440-1797.2006.00531.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Uraemic hyperparathyroidism remains a common clinical problem. Conversely, oversuppression of parathyroid hormone (PTH), particularly in diabetic patients on peritoneal dialysis, has been implicated in low bone turnover disease. Race may also be an important factor determining susceptibility to hyperparathyroidism and the different forms of renal osteodystrophy. These compounding factors that might influence the severity of hyperparathyroidism have been studied in US dialysis and predialysis populations. Dialysis-dependant Africans and Afro-Caribbeans (AC) are known to have higher circulating PTH concentrations than comparable Caucasians (C) but Indo-Asians (IA) living in temperate climates have not been studied. METHODS We performed a cross-sectional study of all patients undergoing peritoneal dialysis at St Bartholomew's and The Royal London Hospital on 1 May 2000. The highest historical recorded PTH was recorded with concurrent biochemical and demographic details. Regression models were used for the analysis of covariance and separate manova was performed incorporating the factors that were shown on univariate analysis to be significant. RESULTS The current study confirmed that in 50 AC patients on peritoneal dialysis, the mean (+/- SEM) peak PTH concentration (93.9 +/- 9.3 pmol/L) was higher than in 148 C (56.7 +/- 4.3 pmol/L) and 67 IA (60.2 +/- 5.7 pmol/L), P < 0.0001 and P < 0.002, respectively. This is despite there being no significant difference in serum calcium concentrations and AC having a lower serum phosphate concentration at the time of peak hyperparathyroidism. There was no significant difference in mean peak PTH concentration between C and IA. Females were also found to have higher peak PTH concentrations, but the presence of diabetes did not influence the peak PTH concentration in this study. CONCLUSION Although we have demonstrated that patients of African (but not Asian) descent undergoing peritoneal dialysis have more severe hyperparathyroidism than Caucasians, other studies suggest that Afro-Americans develop low bone turnover at higher PTH. This would suggest that PTH values should be interpreted with care and that bone biopsies to determine histology remain important. It may emerge that there are different optimal PTH concentrations according to race.
Collapse
Affiliation(s)
- Stanley L-S Fan
- Department of Renal Medicine and Transplantation, St Bartholomew's and The London NHS Trust, London, UK.
| | | | | | | |
Collapse
|
37
|
Leinau L, Perazella MA. Hip fractures in end-stage renal disease patients: incidence, risk factors, and prevention. Semin Dial 2006; 19:75-9. [PMID: 16423185 DOI: 10.1111/j.1525-139x.2006.00122a.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hip fractures are an important problem for end-stage renal disease (ESRD) patients treated with dialysis. The incidence of hip fractures in the dialysis population is approximately four times that of the general population. Even more concerning is the associated 1 year mortality, which is twice that of other dialysis patients. Management of this problem is complicated by the heterogeneous nature of renal osteodystrophy and the inadequate methods of diagnosis currently available. Fall prevention has been shown to reduce the incidence of hip fracture and associated decline in functional ability in the general population. Because falls occur frequently in the dialysis population, simple fall prevention may be one important way of protecting dialysis patients from the morbidity and mortality of hip fracture.
Collapse
Affiliation(s)
- Lisa Leinau
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8029, USA
| | | |
Collapse
|
38
|
Abstract
Cardiovascular disease and stroke account for 60-70% of all deaths in patients with end-stage renal disease (ESRD), at a risk that is 10-20-fold the age- and sex-matched general population. There is also increased coronary artery calcification and increased cardiovascular mortality in chronic kidney disease (CKD) and dialysis patients compared with the general population. Bone is similarly abnormal in CKD. There is an increased incidence of low bone mass and fractures in dialysis patients compared with the general population. Furthermore, a hip fracture in a dialysis patient is associated with a doubling of the mortality observed in nondialysis patients with a hip fracture. These two problems may be linked, as cross-sectional studies have demonstrated an inverse relationship between osteoporosis and coronary artery calcification in the general population and in ESRD patients. In vitro and ex vivo, there is clear evidence that vascular calcification is an active cell-mediated process, made worse by disorders of mineral metabolism. Many factors known to be associated with cardiovascular disease in CKD patients can directly increase calcification in vitro. In addition, in CKD, there are many mechanisms by which bone may adversely affect vascular calcification including disorders of bone remodelling, altered secretion of parathyroid hormone (PTH), hyperphosphatemia, hypercalcaemia, use of calcium based binders, and excessive vitamin D therapy. The coexistence of vascular risk factors and abnormal bone represent a double threat to the well being of patients with CKD.
Collapse
Affiliation(s)
- S M Moe
- Indiana University School of Medicine and Roudebush Veterans Affairs Medical Center, Indianapolis, IN 46202, USA.
| |
Collapse
|
39
|
Ersoy FF, Passadakis SP, Tam P, Memmos ED, Katopodis PK, Ozener C, Akçiçek F, Camsari T, Ateş K, Ataman R, Vlachojannis JG, Dombros AN, Utaş C, Akpolat T, Bozfakioğlu S, Wu G, Karayaylali I, Arinsoy T, Stathakis PC, Yavuz M, Tsakiris JD, Dimitriades CA, Yilmaz ME, Gültekin M, Karayalçin B, Yardimsever M, Oreopoulos DG. Bone mineral density and its correlation with clinical and laboratory factors in chronic peritoneal dialysis patients. J Bone Miner Metab 2006; 24:79-86. [PMID: 16369903 DOI: 10.1007/s00774-005-0650-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2004] [Accepted: 07/15/2005] [Indexed: 10/25/2022]
Abstract
The aim of this study was to assess the clinical and laboratory correlations of bone mineral density (BMD) measurements among a large population of patients on chronic peritoneal dialysis (PD). This cross-sectional, multicenter study was carried out in 292 PD patients with a mean age of 56 +/- 16 years and mean duration of PD 3.1 +/- 2.1 years. Altogether, 129 female and 163 male patients from 24 centers in Canada, Greece, and Turkey were included in the study. BMD findings, obtained by dual-energy X-ray absorptiometry (DEXA) and some other major clinical and laboratory indices of bone mineral deposition as well as uremic osteodystrophy were investigated. In the 292 patients included in the study, the mean lumbar spine T-score was -1.04 +/- 1.68, the lumbar spine Z-score was -0.31 +/- 1.68, the femoral neck T-score was -1.38 +/- 1.39, and the femoral neck Z score was -0.66 +/- 1.23. According to the WHO criteria based on lumbar spine T-scores, 19.2% of 292 patients were osteoporotic, 36.3% had osteopenia, and 44.4% had lumbar spine T-scores within the normal range. In the femoral neck area, the prevalence of osteoporosis was slightly higher (26%). The prevalence of osteoporosis was 23.3% in female patients and 16.6% in male patients with no statistically significant difference between the sexes. Agreements of lumbar spine and femoral neck T-scores for the diagnosis of osteoporosis were 66.7% and 27.3% and 83.3% for osteopenia and normal BMD values, respectively. Among the clinical and laboratory parameters we investigated in this study, the body mass index (BMI) (P < 0.001), daily urine output, and urea clearance time x dialysis time/volume (Kt/V) (P < 0.05) were statistically significantly positive and Ca x PO(4) had a negative correlation (P < 0.05) with the lumbar spine T scores. Femoral neck T scores were also positively correlated with BMI, daily urine output, and KT/V; and they were negatively correlated with age. Intact parathyroid hormone levels did not correlate with any of the BMD parameters. Femoral neck Z scores were correlated with BMI (P < 0.001), and ionized calcium (P < 0.05) positively and negatively with age, total alkaline phosphatase (P < 0.05), and Ca x P (P < 0.01). The overall prevalence of fractures since the initiation of PD was 10%. Our results indicated that, considering their DEXA-based BMD values, 55% of chronic PD patients have subnormal bone mass-19% within the osteoporotic range and 36% within the osteopenic range. Our findings also indicate that low body weight is the most important risk factor for osteoporosis in chronic PD patients. An insufficient dialysis dose (expressed as KT/V) and older age may also be important risk factors for osteoporosis of PD patients.
Collapse
Affiliation(s)
- Fettah Fevzi Ersoy
- Division of Nephrology, Department of Medicine, Akdeniz University Medical School, 07070 Dumlupinar Bulvari, Kampus, Antalya, Turkey.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
Chronic kidney disease is commonly accompanied by disturbances in the hypothalamic-pituitary-gonadal axis. Such disturbances in men give rise to hypogonadism and low circulating testosterone levels. The deficiency in testosterone can contribute to clinical outcomes such as sexual dysfunction, decreased bone mineralization, malnutrition and decreased muscle mass, and anemia. The administration of androgens to nonuremic hypogonadal men is usually effective in treating such outcomes. By contrast, the response to therapy in uremic men tends to be much less predictable. This variability in response is not surprising, because these same clinical outcomes can be the result of other aspects of the uremic state or the comorbid conditions that are frequently present in men with chronic kidney disease. Although further studies are needed, testosterone therapy may prove most useful as an adjunct to other more general therapies designed to address the uremic state.
Collapse
|
41
|
Abstract
Bone disease is heterogenous and highly prevalent among those with chronic kidney disease, stage V (CKD-V) patients. Although we know much regarding the risk factors and outcomes associated with renal osteodystrophy, less is known about osteoporosis in CKD-V. Factors that predict bone loss in the CKD-V population are similar to those in the general population and include female gender, Caucasian race, older age, chronic disease, and immobility. In addition, some studies suggest that chronic acidosis and renal osteodystrophy may also increase the risk for bone loss. Little is known about associated adverse outcomes or the impact of therapeutic interventions for osteoporosis. Although we know that the risk for hip fracture is high among CKD-V patients and that fracture is associated with an increased risk for death, the role that bone loss plays is largely unknown. Current recommendations suggest that risk-factor modification is the most appropriate course of treatment for CKD-V-associated osteoporosis.
Collapse
Affiliation(s)
- Catherine Stehman-Breen
- University of Washington and Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA.
| |
Collapse
|
42
|
Owda A, Elhwairis H, Narra S, Towery H, Osama S. Secondary hyperparathyroidism in chronic hemodialysis patients: prevalence and race. Ren Fail 2003; 25:595-602. [PMID: 12911164 DOI: 10.1081/jdi-120022551] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Secondary hyperparathyroidism is a common complication of renal failure. The exact prevalence in chronic hemodialysis patients in not known. We evaluated 122 patients who were receiving maintenance hemodialysis for at least 12 months in 2 dialysis centers in mid Michigan. Seventy-eight percent of the patients had iPTH above 200 pg/mL (mean 481 pg/mL), 19% had iPTH within the accepted normal range (mean 155 pg/mL), while 3% had level below 100 (mean 53 pg/mL). Phosphate, calcium, calcium phosphate product, age and time on dialysis are the important factors correlating with elevated iPTH. There was no significant difference in iPTH between diabetic and nondiabetic patients with mean iPTH of 403 pg/mL and 407 pg/mL respectively. Black patients had a statistically significant elevated iPTH compared with white patients with a mean iPTH of 438 pg/mL and 283 pg/mL respectively (p < or = 0.004). Factors that predict the response to vitamin D therapy need to be evaluated to help reduce the high prevalence of secondary hyperparathyroidism. The patterns of bone disease in black patients need to be evaluated to further define the accepted normal iPTH range for this population.
Collapse
Affiliation(s)
- Ali Owda
- Hurley Medical Center and Michigan State University, Flint Campus, Flint, Michigan, USA.
| | | | | | | | | |
Collapse
|
43
|
Araújo SMHA, Ambrosoni P, Lobão RRS, Caorsi H, Moysés RMA, Barreto FC, Olaizola I, Cruz EAS, Petraglia A, Dos Reis LM, Duarte ME, Jorgetti V, Carvalho AB. The renal osteodystrophy pattern in Brazil and Uruguay: an overview. KIDNEY INTERNATIONAL. SUPPLEMENT 2003:S54-6. [PMID: 12753266 DOI: 10.1046/j.1523-1755.63.s85.13.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The prevalence of the types of renal osteodystrophy (ROD) has changed in the last two decades. This study evaluates the prevalence and determining factors of the types of ROD in two countries in South America. METHODS Symptomatic patients who underwent bone biopsies for diagnostic purposes (1985 through 2001) were included in the study. In Brazil, a total of 2340 patients were reviewed, 93.1% on hemodialysis (HD), and 6.9% on continuous ambulatory peritoneal dialysis (CAPD). In Uruguay, 167 patients on hemodialysis were included. Uncalcified bone samples were analyzed in order to diagnose the different types of ROD. RESULTS Comparing the 1980s to the 1990s, the prevalence of Brazilian patients with hyperparathyroid bone disease (HP) increased from 32.3% to 44.0%, while Al overload decreased from 61.3% to 42.4%. A logistic regression analysis showed that the main factors associated with HP included female gender, age of less than 40 years, black patients, longer time on dialysis, and absence of Al overload. In Uruguay, HP also increased over time from 31.8% to 70.5% (P < 0.05), while Al overload decreased from 42% to 27% (P < 0.05). CONCLUSION A better control of Al overload may lead to a change in histologic pattern, as evidenced by the increasing prevalence of HP.
Collapse
|
44
|
Mikuls TR, Julian BA, Bartolucci A, Saag KG. Bone mineral density changes within six months of renal transplantation. Transplantation 2003; 75:49-54. [PMID: 12544870 DOI: 10.1097/00007890-200301150-00009] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The effective use of new steroid-sparing immunosuppressive regimens may lower cumulative glucocorticoid use among renal transplant recipients. However, it is unknown what effect this therapeutic trend has had on bone disease. METHODS Unselected newly transplanted inpatients (n=45) were identified and comprehensively evaluated for metabolic bone disease at a median of 16 days (range 9-33) posttransplant. A follow-up evaluation was conducted a median of 5.7 months (range 4.8-9.3) later. Follow-up values for bone mineral density (BMD) and select laboratories were compared with baseline values using nonparametric statistics. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to describe the associations of baseline characteristics, select laboratory values, and cumulative prednisone and cyclosporine use with spinal BMD loss and were calculated using logistic regression. RESULTS A significant decrease in intact parathyroid hormone (P<0.001) and a significant increase in calcitriol (P=0.02) were noted postengraftment. At follow-up, subjects had lost a mean of 2.4% BMD at the lumbar spine (P=0.003) but did not experience significant declines at the femoral neck. The highest tertiles of cumulative prednisone (OR=28.4; 95% CI 2.5-329 and OR=15.8; 95% CI 1.4-179, respectively) and past alcohol use (OR=9.3; 95% CI 1.46-58.5) were significantly associated with spinal BMD loss. CONCLUSIONS Significant loss in lumbar BMD occurred within 6 months of transplantation in more than one third of a prospective cohort of renal transplant recipients. Lumbar bone loss seemed to be mediated primarily by glucocorticoid dose and a history of alcohol use.
Collapse
Affiliation(s)
- Ted R Mikuls
- Section of Rheumatology and Immunology, Department of Medicine, University of Nebraska Medical Center, USA
| | | | | | | |
Collapse
|
45
|
Abstract
Bone disease is observed in 75-100% of patients with chronic renal failure as the glomerular filtration rate (GFR) falls below 60 ml/minute. Hyperparathyroid (high turnover) bone disease is found most frequently followed by mixed osteodystrophy, low-turnover bone disease, and osteomalacia. With advancing renal impairment, "skeletal resistance" to parathyroid hormone (PTH) occurs. To maintain bone turnover, intact PTH (iPTH) targets from two to four times the upper normal range have been suggested, but whole PTH(1-84) assays indicate that amino-terminally truncated fragments, which accumulate in end-stage renal disease (ESRD), account for up to one-half of the measured iPTH. PTH levels and bone-specific alkaline phosphatase (BSAP) provide some information on bone involvement but bone biopsy and histomorphometry remains the gold standard. Calcitriol and calcium salts can be used to suppress PTH and improve osteomalacia but there is growing concern that these agents predispose to the development of vascular calcification, cardiovascular morbidity, low-turnover bone disease and fracture. Newer therapeutic options include less calcemic vitamin D analogues, calcimimetics and bisphosphonates for hyperparathyroidism, and sevelamer for phosphate control. Calcitriol and hormone-replacement therapy (HRT) have been shown to maintain bone mineral density (BMD) in certain patients with end-stage renal disease (ESRD). After renal transplantation, renal osteodystrophy generally improves but BMD often worsens. Bisphosphonate therapy may be appropriate for some patients at risk of fracture. When renal bone disease is assessed using a combination of biochemical markers, histology and bone densitometry, early intervention and the careful use of an increasing number of effective therapies can reduce the morbidity associated with this common problem.
Collapse
Affiliation(s)
- Grahame Elder
- Garvan Institute of Medical Research, Sydney, NSW, Australia
| |
Collapse
|
46
|
De Boer IH, Gorodetskaya I, Young B, Hsu CY, Chertow GM. The severity of secondary hyperparathyroidism in chronic renal insufficiency is GFR-dependent, race-dependent, and associated with cardiovascular disease. J Am Soc Nephrol 2002; 13:2762-9. [PMID: 12397047 DOI: 10.1097/01.asn.0000034202.91413.eb] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Secondary hyperparathyroidism (SHPT) is an important complication of end-stage renal disease. However, SHPT begins during earlier stages of chronic renal insufficiency (CRI), and little is known about risk factors for SHPT in this population. This study evaluated 218 patients in an ethnically diverse ambulatory nephrology practice at the University of California San Francisco during calendar years 1999 and 2000. Demographic data, comorbid diseases, medications, and laboratory parameters were collected, and independent correlates of intact parathyroid hormone (PTH) were identified by using multiple linear regression. The mean estimated GFR was 34 ml/min per 1.73 m(2) (10%-90% range, 13 to 61 ml/min per 1.73 m(2)); PTH was inversely related to GFR (P < 0.0001). The adjusted mean PTH was higher among African Americans and lower among Asian/Pacific Islanders compared with white patients (233 versus 95 versus 139 pg/ml; P < 0.0001). Moreover, among the 196 patients with GFR <60 ml/min per 1.73 m(2), the slope of GFR versus PTH was significantly steeper among African Americans than among white patients (10.6 versus 3.9 pg/ml per ml per min per 1.73 m(2); P = 0.01). After adjusting for age and diabetes, PTH was associated with a history of myocardial infarction (OR, 1.6; 95% CI, 1.1 to 2.3 per unit natural log PTH) and congestive heart failure (OR, 2.0; 95% CI, 1.3 to 2.9 per unit natural log PTH) and not associated with other co-morbid conditions. These factors should be considered when screening and managing SHPT in CRI.
Collapse
Affiliation(s)
- Ian H De Boer
- Division of Nephrology, Department of Medicine, University of California San Francisco, 94118, USA
| | | | | | | | | |
Collapse
|
47
|
Kant KS, Cook EF, Duncan H, Freyberg R. Parathyroid hormone suppression by intravenous calcitriol: role of phosphate, calcium, race and diabetes. Am J Med Sci 2002; 323:210-5. [PMID: 12003377 DOI: 10.1097/00000441-200204000-00008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Parathyroid hormone (PTH) suppression in patients with end-stage renal disease (ESRD) undergoing maintenance hemodialysis is achieved largely by the use of intravenous calcitriol. Aspects of the utility and efficacy of this therapy remain controversial. It is debated whether oral versus intravenous therapy is more effective. Most existing studies examine the effect of calcitriol in isolation, without adjusting for other factors that might influence PTH levels. Thus, the simultaneous role of factors such as dosing, control of serum calcium and phosphorus, and demographic variables such as age, sex, race, and duration of ESRD is not well understood. METHODS We examined the relationship between the administration of calcitriol and PTH suppression in a cohort of hemodialysis patients at a large urban dialysis facility over a period of 30 months. Hemodialysis patients (n = 155) who received at least 3 months of treatment in this facility were included. RESULTS Using a time sensitive multiple linear regression modeling technique, we found that second and subsequent PTH levels were positively correlated with black race (P < 0.0001) and serum phosphate (P < 0.03) and strongly negatively correlated with serum calcium (P< 0.0001) and diabetes (P< 0.0039). Drug dose (in micrograms per kilogram per month) was weakly negatively correlated (P < 0.04). Unlike previous studies, we adjusted for the simultaneous confounding influence of demographic and laboratory variables, as well as for drug dose normalized for body weight. CONCLUSIONS This analysis suggests that calcitriol therapy in hemodialysis patients is adversely affected by higher phosphate levels and needs to account for such patient characteristics as race and diabetes and such laboratory variables as calcium and phosphate control. Finally, as has been recently suggested by others, the patient's race may require us to aim for different PTH target levels with therapy.
Collapse
Affiliation(s)
- K Shashi Kant
- Department of Internal Medicine, University of Cincinnati College of Medicine, Ohio 45267-0585, USA.
| | | | | | | |
Collapse
|
48
|
|
49
|
Stehman-Breen CO, Sherrard DJ, Alem AM, Gillen DL, Heckbert SR, Wong CS, Ball A, Weiss NS. Risk factors for hip fracture among patients with end-stage renal disease. Kidney Int 2000; 58:2200-5. [PMID: 11044242 DOI: 10.1111/j.1523-1755.2000.00394.x] [Citation(s) in RCA: 204] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although bone disease is well described among end-stage renal disease (ESRD) patients, little attention has been paid to the occurrence of fracture. We sought to identify factors that are associated with hip fracture among ESRD patients. METHODS Data from patients who participated in the United States Renal Data System Dialysis Morbidity and Mortality Study Wave 1 were used for this study. Hip fractures occurring among these patients between 1993 and 1996 were identified from Medicare claims data available from the United States Renal Data System. Cox proportional hazards models were used to estimate the risk of hip fracture associated with demographic and medical variables. RESULTS Of the 4952 patients included in this analysis, 103 sustained a hip fracture. In the multivariate analysis, age (per increasing decade, RR = 1.40, 95% CI 1.20, 1.64), female gender (RR = 2.26, 95% CI 1.48, 3.44), race (blacks compared with whites, RR = 0.58, 95% CI 0.37, 0.91), body mass index (per 1 unit increase, RR 0.89, 95% CI 0.86, 0.93), and the presence of peripheral vascular disease (RR 1.94, 95% CI 1.29, 2.92) were independently associated with hip fracture. Serum intact parathyroid hormone (iPTH), aluminum, diabetes, and bicarbonate levels did not appreciably influence the risk of hip fracture. CONCLUSIONS Demographic and other characteristics that predict risk of hip fracture in the population at large also do so in ESRD patients. However, we could identify no characteristics of ESRD or its treatment that were independently related to hip fracture incidence.
Collapse
Affiliation(s)
- C O Stehman-Breen
- Division of Nephrology, Puget Sound Health Care System, Seattle, Washington 98108, USA.
| | | | | | | | | | | | | | | |
Collapse
|