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Yamauchi M, Kamejima S, Ueda R, Nakashima A, Urabe F, Yamamoto I, Ohkido I, Yokoo T. Marked Metabolic Acidosis Due to a Transverse Stoma after Urethroplasty for Congenital Epispadias. Intern Med 2023; 62:3663-3668. [PMID: 37164676 PMCID: PMC10781559 DOI: 10.2169/internalmedicine.1523-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 03/23/2023] [Indexed: 05/12/2023] Open
Abstract
A 58-year-old woman was admitted to our hospital. At 10 years old, she had undergone bilateral uretero-sigmoid anastomosis for congenital epispadias, and at 57 years old, she had received transverse colostomy. Biochemical tests showed marked metabolic acidosis. Computed tomography showed urine stagnation in the sigmoid colon, leading to a diagnosis of metabolic acidosis associated with transverse stoma after bilateral uretero-sigmoid anastomosis. Her bone mineral density was below normal, and the bone metabolic marker levels were high, indicating high-turnover osteoporosis. Both metabolic acidosis and bone metabolism were stabilized by treatment with a transanal urinary catheter, sodium bicarbonate, and vitamin D.
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Affiliation(s)
- Mariko Yamauchi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Sahoko Kamejima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Risa Ueda
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Akio Nakashima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Fumihiko Urabe
- Department of Urology, The Jikei University School of Medicine, Japan
| | - Izumi Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
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Bacchetta J, Schmitt CP, Bakkaloglu SA, Cleghorn S, Leifheit-Nestler M, Prytula A, Ranchin B, Schön A, Stabouli S, Van de Walle J, Vidal E, Haffner D, Shroff R. Diagnosis and management of mineral and bone disorders in infants with CKD: clinical practice points from the ESPN CKD-MBD and Dialysis working groups and the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2023; 38:3163-3181. [PMID: 36786859 PMCID: PMC10432337 DOI: 10.1007/s00467-022-05825-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/19/2022] [Accepted: 11/09/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Infants with chronic kidney disease (CKD) form a vulnerable population who are highly prone to mineral and bone disorders (MBD) including biochemical abnormalities, growth retardation, bone deformities, and fractures. We present a position paper on the diagnosis and management of CKD-MBD in infants based on available evidence and the opinion of experts from the European Society for Paediatric Nephrology (ESPN) CKD-MBD and Dialysis working groups and the Pediatric Renal Nutrition Taskforce. METHODS PICO (Patient, Intervention, Comparator, Outcomes) questions were generated, and relevant literature searches performed covering a population of infants below 2 years of age with CKD stages 2-5 or on dialysis. Clinical practice points (CPPs) were developed and leveled using the American Academy of Pediatrics grading matrix. A Delphi consensus approach was followed. RESULTS We present 34 CPPs for diagnosis and management of CKD-MBD in infants, including dietary control of calcium and phosphate, and medications to prevent and treat CKD-MBD (native and active vitamin D, calcium supplementation, phosphate binders). CONCLUSION As there are few high-quality studies in this field, the strength of most statements is weak to moderate, and may need to be adapted to individual patient needs by the treating physician. Research recommendations to study key outcome measures in this unique population are suggested. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Justine Bacchetta
- Reference Center for Rare Renal Diseases, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, Pediatric Nephrology Rheumatology and Dermatology Unit, Hopital Femme Mère Enfant, Boulevard Pinel, 69677 Bron, France
- INSERM 1033 Research Unit, Lyon, France
- Lyon Est Medical School, Université Claude Bernard, Lyon 1, Lyon, France
| | - Claus Peter Schmitt
- Center for Pediatric and Adolescent Medicine, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sevcan A. Bakkaloglu
- Department of Pediatric Nephrology, School of Medicine, Gazi University, Ankara, Turkey
| | - Shelley Cleghorn
- Renal Unit, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Pediatric Research Center, Hannover, Germany
| | - Agnieszka Prytula
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Bruno Ranchin
- Reference Center for Rare Renal Diseases, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, Pediatric Nephrology Rheumatology and Dermatology Unit, Hopital Femme Mère Enfant, Boulevard Pinel, 69677 Bron, France
| | - Anne Schön
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Pediatric Research Center, Hannover, Germany
| | - Stella Stabouli
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
| | - Johan Van de Walle
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Enrico Vidal
- Pediatric Nephrology Unit, University-Hospital of Padova, Padua, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Pediatric Research Center, Hannover, Germany
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
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3
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Levy RV, McMahon DJ, Agarwal S, Dempster D, Zhou H, Misof BM, Guo X, Kamanda-Kosseh M, Aponte MA, Reidy K, Kumar J, Fusaro M, Brown DD, Melamed ML, Nickolas TL. Comprehensive Associations between Acidosis and the Skeleton in Patients with Kidney Disease. J Am Soc Nephrol 2023; 34:668-681. [PMID: 36749125 PMCID: PMC10103353 DOI: 10.1681/asn.0000000000000085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/10/2023] [Indexed: 02/08/2023] Open
Abstract
SIGNIFICANCE STATEMENT Renal osteodystrophy (ROD) contributes substantially to morbidity in CKD, including increased fracture risk. Metabolic acidosis (MA) contributes to the development of ROD, but an up-to-date skeletal phenotype in CKD-associated acidosis has not been described. We comprehensively studied associations between acidosis and bone in patients with CKD using advanced methods to image the skeleton and analyze bone-tissue, along with biochemical testing. Cross-sectionally, acidosis was associated with higher markers of bone remodeling and female-specific impairments in cortical and trabecular bone quality. Prospectively, acidosis was associated with cortical expansion and trabecular microarchitectural deterioration. At the bone-tissue level, acidosis was associated with deficits in bone mineral content. Future work investigating acidosis correction on bone quality is warranted. BACKGROUND Renal osteodystrophy is a state of impaired bone quality and strength. Metabolic acidosis (MA) is associated with alterations in bone quality including remodeling, microarchitecture, and mineralization. No studies in patients with CKD have provided a comprehensive multimodal skeletal phenotype of MA. We aim to describe the structure and makeup of bone in patients with MA in the setting of CKD using biochemistry, noninvasive imaging, and histomorphometry. METHODS The retrospective cross-sectional analyses included 180 patients with CKD. MA was defined as bicarbonate ≤22 mEq/L. We evaluated circulating bone turnover markers and skeletal imaging with dual energy x-ray absorptiometry and high-resolution peripheral computed tomography. A subset of 54 participants had follow-up. We assessed associations between baseline and change in bicarbonate with change in bone outcomes. Histomorphometry, microCT, and quantitative backscatter electron microscopy assessed bone biopsy outcomes in 22 participants. RESULTS The mean age was 68±10 years, 54% of participants were male, and 55% were White. At baseline, acidotic subjects had higher markers of bone turnover, lower areal bone mineral density at the radius by dual energy x-ray absorptiometry, and lower cortical and trabecular volumetric bone mineral density and impaired trabecular microarchitecture. Over time, acidosis was associated with opposing cortical and trabecular effects: cortical expansion but trabecular deterioration. Bone-tissue analyses showed reduced tissue mineral density with increased heterogeneity of calcium distribution in acidotic participants. CONCLUSIONS MA is associated with multiple impairments in bone quality. Future work should examine whether correction of acidosis improves bone quality and strength in patients with CKD.
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Affiliation(s)
- Rebecca V. Levy
- Nephrology, Department of Medicine, University of Rochester Medical Center Rochester, New York, USA
- Pediatric Nephrology, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | | | | | - David Dempster
- Columbia University Irving Medical Center, New York, USA
| | - Hua Zhou
- Columbia University Irving Medical Center, New York, USA
| | - Barbara M. Misof
- Ludwig Boltzmann Institute for Osteology at the Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - X.E. Guo
- Columbia University Biomedical Engineering, New York, New York, USA
| | | | | | - Kimberly Reidy
- Nephrology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Juhi Kumar
- Nephrology, Department of Pediatrics, Weill-Cornell Medical Center, New York, New York
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
- Department of Medicine, University of Padova, Padova, Padua, Italy
| | - Denver D. Brown
- Division of Nephrology, Children's National Hospital, Washington, DC
| | - Michal L. Melamed
- Nephrology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Moe OW, Maalouf NM, Sakhaee K, Lederer E. Preclinical and Clinical Evidence of Effect of Acid on Bone Health. Adv Chronic Kidney Dis 2022; 29:381-394. [PMID: 36175076 DOI: 10.1053/j.ackd.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Acid can have ill effect on bone health in the absence of frank clinical acidosis but affecting the bone mioneral matrix and bone cells via complex pathways botyh ascute;y and chronically. While the reaction of bone to an acid load is conserved in evolution and is adaptive, the capacity can be overwhelmed resulting in dire consequences. The preclinical an clincl evidence of the acdi effect on bone is very convincing and the clinical evidence in both association and interventiopn studies are also quite credible, The adverse effects of acid on bone is underappreoicated, under-investigated, and the potential benefits of alkali therapy is not generrally known.
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Affiliation(s)
- Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX; Department of Physiology, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Naim M Maalouf
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Khashayar Sakhaee
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Eleanor Lederer
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX; Medical Service, VA North Texas Health Care System, Dallas, TX
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5
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Bushinsky DA, Krieger NS. Effects of Acid on Bone. Kidney Int 2022; 101:1160-1170. [DOI: 10.1016/j.kint.2022.02.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 12/11/2022]
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Wójcik M, Stachal K, Burzec M, Gruszczyński K, Korga-Plewko A. Growth Rate and Bone Hydroxyproline Concentration in Turkeys Fed with a Silage-Composed Diet Modified with Different Diet Cation-Anion Differences (DCADs). Animals (Basel) 2021; 12:ani12010066. [PMID: 35011172 PMCID: PMC8749675 DOI: 10.3390/ani12010066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/15/2021] [Accepted: 12/24/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary In this study, we point to the possibility of using dietary cation–anion difference manipulation to improve growth rates and bone condition, especially in the last phase of poultry turkey husbandry, when birds have many bone abnormalities. Abstract Our goal was to determine the responses of body weight (BW) and bone hydroxyproline (Hyp) concentration in turkeys fed a corn silage (CS) diet with different values of dietary cation–anion differences (DCADs). The turkeys (n = 90) were divided into five groups and fed as follows: group A (control)—standard diet (SD) (60%) plus CS (40%); group B—SD (60%), CS (40%) plus 240 g of CaCl2 per 100 kg of diet; group C—SD (60%), CS (40%) plus 480 g of CaCl2 per 100 kg of diet; group D—SD (60%), CS (40%) plus 240 g of NaHCO3 per 100 kg of diet; group E—SD (60%), CS (40%) plus 480 g NaHCO3 per 100 kg of diet. The addition of a lesser amount of CaCl2 lowered the DCAD, which ranged between 52.5 ± 4.19 and 91.14 ± 3.14 mEq/kg DM. An increased content of CaCl2 led to high negative values of DCAD. NaHCO3 supplemented in both doses resulted in a significant elevation of DCAD. Compared to each experimental group, feeding birds with a diet supplemented only with CS resulted in a lower BW. Addition of CaCl2 or NaHCO3 to the diet improved BW, but only CaCl2 addition enhanced the bone Hyp amount. In conclusion, we suggest that an anionic diet with low DCAD can prevent bone abnormalities in large turkeys, especially in the final course of production.
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Affiliation(s)
- Marta Wójcik
- Sub-Department of Pathophysiology, Department of Preclinical Veterinary Sciences, Faculty of Veterinary Medicine, University of Life Sciences in Lublin, Akademicka 12, 20-033 Lublin, Poland; (K.S.); (M.B.); (K.G.)
- Correspondence:
| | - Klaudia Stachal
- Sub-Department of Pathophysiology, Department of Preclinical Veterinary Sciences, Faculty of Veterinary Medicine, University of Life Sciences in Lublin, Akademicka 12, 20-033 Lublin, Poland; (K.S.); (M.B.); (K.G.)
| | - Mateusz Burzec
- Sub-Department of Pathophysiology, Department of Preclinical Veterinary Sciences, Faculty of Veterinary Medicine, University of Life Sciences in Lublin, Akademicka 12, 20-033 Lublin, Poland; (K.S.); (M.B.); (K.G.)
| | - Kamil Gruszczyński
- Sub-Department of Pathophysiology, Department of Preclinical Veterinary Sciences, Faculty of Veterinary Medicine, University of Life Sciences in Lublin, Akademicka 12, 20-033 Lublin, Poland; (K.S.); (M.B.); (K.G.)
| | - Agnieszka Korga-Plewko
- Independent Medical Biology Unit, Medical University of Lublin, 8b Jaczewski Street, 20-090 Lublin, Poland;
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Abstract
Rationale & Objective Acid retention may occur in the absence of overt metabolic acidosis; thus it is important to identify populations at risk. Because obesity may alter renal acid-base handling, we sought to determine whether overweight and obesity are associated with increased risk for low serum bicarbonate levels, suggesting metabolic acidosis. Study Design Retrospective cohort study. Setting & Participants Adult patients (n = 96,147) visiting outpatient clinics in the Bronx, NY, between January 1, 2010, and December 31, 2015. Predictor Body mass index (BMI). Outcome Low serum bicarbonate level (≤23 mEq/L). Analytical Approach Longitudinal analyses were conducted using mixed-effects models to examine associations of BMI with serum bicarbonate levels over time and Cox proportional hazards models to examine associations of BMI with incident low bicarbonate levels. Results During a median follow-up of 4.4 (interquartile range, 2.3-6.3) years, patients had a median of 8 serum bicarbonate measurements and 34,539 patients developed low bicarbonate levels. Higher BMI was associated with progressively lower serum bicarbonate levels, with attenuation of the association in the highest BMI groups, suggesting a J-shaped relationship. Compared with the reference group (BMI, 18.5 to <25 kg.m2), patients with BMIs of 25 to <30, 30 to <35, 35 to <40, and ≥40 kg/m2 had HRs for incident low bicarbonate levels of 1.10 (95% CI, 1.05-1.14), 1.16 (95% CI, 1.11-1.21), 1.20 (95% CI, 1.14-1.26), and 1.15 (95% CI, 1.09-1.22). Results were similar after adjustment for serum urea nitrogen level and exclusion of patients with diabetes, hypertension, or estimated glomerular filtration rates < 60 mL/min/1.73 m2. Limitations Arterial pH measurements were unavailable. Conclusions Higher BMI is independently associated with progressively greater risk for developing low serum bicarbonate levels, indicating likely metabolic acidosis. Further research should explore the causes of low bicarbonate levels in patients with overweight and obesity.
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Affiliation(s)
- Douglas C Lambert
- Department of General Internal Medicine, Northwell Health, Great Neck.,Division of Obesity Medicine, Northwell Health, Great Neck
| | - Matthew K Abramowitz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY.,Institute for Aging Research, Albert Einstein College of Medicine, Bronx, NY.,Diabetes Research Center, Albert Einstein College of Medicine, Bronx, NY.,Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, NY
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8
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Influence of Strain and Diet on Urinary pH in Laboratory Mice. Animals (Basel) 2021; 11:ani11030702. [PMID: 33807730 PMCID: PMC8000841 DOI: 10.3390/ani11030702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 12/01/2022] Open
Abstract
Simple Summary Dietary cation anion balance (DCAB) influences urine pH in several species, e.g., cats, dogs, pigs and cattle suggesting a species-specific impact. In the present study, we aimed to explore the impact of three diets with different DACB on wildtype laboratory mice. During a two-month feeding trial urine pH and body weight were measured in C57Bl/6J and CD1 male mice. Remarkable, we observed strong impact of the genetic background and diet on urine pH levels. A plausible explanation is that differences in renal phosphorus excretion and, in turn, phosphate buffering capacity account for these differences. It is tempting to speculate that standard laboratory mouse models show DCAB dependent variations in urine pH. Abstract Acid base homeostasis and urine pH is influenced by the dietary cation anion balance (DCAB) in many species. Here, a negative DCAB acidifies the urine, while higher DCABs alkalize the urine. The dimension of the DCAB effect can be species-specific, because of differences in urine buffer systems. The aim of the present study was to describe the response of laboratory mice to diets with different DCAB. We used 8-week-old wildtype male mice of the C57Bl/6J inbred strain and CD1 outbred stock. Three groups (n = 15 animals/group) were formed and fed standard diet A for adaptation. For the 7-week feeding trial, mice were either kept on diet A (DCAB −7 mmol/kg dry matter (DM) or switched to diet B (246 mmol/kg DM) or C (−257 mmol/kg DM). Urine pH was measured weekly from a pooled sample per cage. There was a significant difference in the basal urine pH on diet A between C57Bl6/J and CD1 mice. The shift in urine pH was also significantly different between the two groups investigated.
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Han Y, An M, Yang L, Li L, Rao S, Cheng Y. Effect of Acid or Base Interventions on Bone Health: A Systematic Review, Meta-Analysis, and Meta-Regression. Adv Nutr 2021; 12:1540-1557. [PMID: 33684217 PMCID: PMC8321841 DOI: 10.1093/advances/nmab002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/04/2020] [Accepted: 01/06/2021] [Indexed: 12/29/2022] Open
Abstract
Osteoporosis is a global health issue among the aging population. The effect of the acid or base interventions on bone health remains controversial. This study performed a systematic review and meta-analysis to investigate effects of acidic diets and alkaline supplements on bone health simultaneously. We conducted a comprehensive literature search in 5 available databases and 1 registered clinical trial system to identify randomized controlled trials (RCTs) that assessed effects of the acid-base intervention on bone health. Depending on heterogeneity across studies, the pooled effects were calculated by fixed-effects or random-effects models. The present study included 13 acidic diet intervention studies and 13 alkaline supplement studies for final quantitative assessments. The meta-analysis showed that acidic diets significantly increased net acid excretion [NAE; standardized mean difference (SMD) = 2.99; P = 0.003] and urinary calcium excretion (SMD = 0.47, P < 0.00001) but had no significant effect on bone turnover markers and bone mineral density (BMD). On the other hand, alkaline supplement intervention significantly reduced NAE (SMD = -1.29, P < 0.00001), urinary calcium excretion (SMD = -0.44, P = 0.007), bone resorption marker aminoterminal cross-linking telopeptide (NTX; SMD = -0.29, P = 0.003), and bone formation marker osteocalcin (OC; SMD = -0.23, P = 0.02), but did not affect the other bone turnover markers. Furthermore, alkaline supplements significantly increased BMD in femoral neck [mean difference (MD) = 1.62, P < 0.00001, I2 = 0%], lumbar spine (MD = 1.66, P < 0.00001, I2 = 87%), and total hip (MD = 0.98, P = 0.02, I2 = 99%). Subsequently, meta-regression analyses identified 1 study that substantially contributed to the high heterogeneity of BMD in the latter 2 sites, but sensitivity analysis suggested that this study did not affect the significant pooled effects. Despite that, the results should be interpreted with caution and need to be further validated by a larger RCT. In summary, through integrating evidence from RCTs, the present meta-analysis initially suggests that alkaline supplements may be beneficial to bone metabolism and acidic diets may not be harmful to bone health. This work may be clinically useful for both clinicians and patients with osteoporosis.
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Affiliation(s)
- Yibing Han
- Department of Endocrinology, Zhujiang Hospital of Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Min An
- Department of Endocrinology, Zhujiang Hospital of Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Li Yang
- Department of Endocrinology, Zhujiang Hospital of Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Liuran Li
- Department of Endocrinology, Zhujiang Hospital of Southern Medical University, Guangzhou City, Guangdong Province, China
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Bakkaloglu SA, Bacchetta J, Lalayiannis AD, Leifheit-Nestler M, Stabouli S, Haarhaus M, Reusz G, Groothoff J, Schmitt CP, Evenepoel P, Shroff R, Haffner D. Bone evaluation in paediatric chronic kidney disease: clinical practice points from the European Society for Paediatric Nephrology CKD-MBD and Dialysis working groups and CKD-MBD working group of the ERA-EDTA. Nephrol Dial Transplant 2021; 36:413-425. [PMID: 33245331 DOI: 10.1093/ndt/gfaa210] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Indexed: 11/13/2022] Open
Abstract
Mineral and bone disorder (MBD) is widely prevalent in children with chronic kidney disease (CKD) and is associated with significant morbidity. CKD may cause disturbances in bone remodelling/modelling, which are more pronounced in the growing skeleton, manifesting as short stature, bone pain and deformities, fractures, slipped epiphyses and ectopic calcifications. Although assessment of bone health is a key element in the clinical care of children with CKD, it remains a major challenge for physicians. On the one hand, bone biopsy with histomorphometry is the gold standard for assessing bone health, but it is expensive, invasive and requires expertise in the interpretation of bone histology. On the other hand, currently available non-invasive measures, including dual-energy X-ray absorptiometry and biomarkers of bone formation/resorption, are affected by growth and pubertal status and have limited sensitivity and specificity in predicting changes in bone turnover and mineralization. In the absence of high-quality evidence, there are wide variations in clinical practice in the diagnosis and management of CKD-MBD in childhood. We present clinical practice points (CPPs) on the assessment of bone disease in children with CKD Stages 2-5 and on dialysis based on the best available evidence and consensus of experts from the CKD-MBD and Dialysis working groups of the European Society for Paediatric Nephrology and the CKD-MBD working group of the European Renal Association-European Dialysis and Transplant Association. These CPPs should be carefully considered by treating physicians and adapted to individual patients' needs as appropriate. Further areas for research are suggested.
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Affiliation(s)
- Sevcan A Bakkaloglu
- Department of Paediatric Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Justine Bacchetta
- Department of Paediatric Nephrology, Rheumatology and Dermatology, University Children's Hospital, Lyon, France
| | - Alexander D Lalayiannis
- Renal Unit, UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK
| | - Maren Leifheit-Nestler
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | - Stella Stabouli
- First Department of Paediatrics, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Mathias Haarhaus
- Division of Renal Medicine and Baxter Novum, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Diaverum AB, Stockholm, Sweden
| | - George Reusz
- First Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Jaap Groothoff
- Department of Paediatric Nephrology, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Claus Peter Schmitt
- Division of Paediatric Nephrology, Center for Paediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Pieter Evenepoel
- Department of Microbiology and Immunology, Laboratory of Nephrology, KU Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK
| | - Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
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11
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Effects of acidosis on the structure, composition, and function of adult murine femurs. Acta Biomater 2021; 121:484-496. [PMID: 33242638 DOI: 10.1016/j.actbio.2020.11.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 12/14/2022]
Abstract
Physiologic pH is maintained in a narrow range through multiple systemic buffering systems. Metabolic Acidosis (MA) is an acid-base disorder clinically characterized by a decrease in systemic pH and bicarbonate (HCO3-) levels. Acidosis affects millions annually, resulting in decreased bone mineral density and bone volume and an increased rate of fracture. We developed an adult murine model of diet-induced metabolic acidosis via graded NH4Cl administration that successfully decreased systemic pH over a 14 day period to elucidate the effects of acidosis on the skeletal system. Blood gas analyses measured an increase in blood calcium and sodium levels indicating a skeletal response to 14 days of acidosis. MA also significantly decreased femur ultimate strength, likely due to modifications in bone morphology as determined from decreased microcomputed tomography values of centroid distance and area moment of inertia. These structural changes may be caused by aberrant remodeling based on histological data evidencing altered OCL activity in acidosis. Additionally, we found that acidosis significantly decreased bone CO3 content in a site-specific manner similar to the bone phenotype observed in human MA. We determined that MA decreased bone strength thus increasing fracture risk, which is likely caused by alterations in bone shape and compounded by changes in bone composition. Additionally, we suggest the temporal regulation of cell-mediated remodeling in MA is more complex than current literature suggests. We conclude that our model reliably induces MA and has deleterious effects on skeletal form and function, presenting similarly to the MA bone phenotype in humans.
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Kuczera P, Ciaston-Mogilska D, Oslizlo B, Hycki A, Wiecek A, Adamczak M. The Prevalence of Metabolic Acidosis in Patients with Different Stages of Chronic Kidney Disease: Single-Centre Study. Kidney Blood Press Res 2020; 45:863-872. [PMID: 33070125 DOI: 10.1159/000508980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/26/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Metabolic acidosis (MA) is one of the most common consequences of CKD. MA is also a risk factor of CKD progression and increased mortality in these patients. AIM The aim of this retrospective, cross-sectional study was to assess the prevalence of MA in different stages of CKD and renal replacement therapy (RRT) modalities - haemodialysis (HD) and peritoneal dialysis (PD). Additionally, the relationship between the prevalence of MA and aetiology of kidney disease was analysed. METHODS One thousand five patients in different stages of CKD, or modalities of RRT were enrolled into this single-centre cross-sectional study. Forty-one patients were ruled out because of oral bicarbonate supplementation. In the remaining 964 patients (698 CKD stages 1-5, 226 HD, 40 PD), venous blood HCO3- concentration, as well as serum Cr and urea concentrations were assessed. MA was diagnosed when blood HCO3- concentration was below 22 mmol/L. RESULTS The prevalence of MA increased among all stages of CKD. Patients on HD had lower prevalence of MA in comparison with CKD 5 patients with no RRT (38.5 vs. 56.0%; p = 0.02) In PD patients, the prevalence of MA was significantly lower than in HD patients (2.5 vs. 38.5%; p < 0.001). In the whole study group, there were no significant differences in the prevalence of MA between different aetiologies of CKD (glomerulonephritis 24%, hypertension 23%, diabetes 25%, and tubule-interstitial diseases 24%). Also, when only patients in stages CKD 3-5 were compared, no significant differences in the prevalence of acidosis were found (glomerulonephritis 28%, hypertension 22%, diabetes 24%, and tubule-interstitial 21%). CONCLUSIONS (1) MA is more frequent in patients with more advanced stages of CKD. (2) RRT reduces the prevalence of MA. (3) In PD patients, MA is rare. (4) Aetiology of CKD seems not to have a significant impact on MA prevalence.
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Affiliation(s)
- Piotr Kuczera
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Dorota Ciaston-Mogilska
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Barbara Oslizlo
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Anna Hycki
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland,
| | - Marcin Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
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Copur S, Sag AA, Afsar B, Rossignol P, Covic A, Kanbay M. Complications of metabolic acidosis and alkalinizing therapy in chronic kidney disease patients: a clinician-directed organ-specific primer. Int Urol Nephrol 2020; 52:2311-2320. [PMID: 32661618 DOI: 10.1007/s11255-020-02563-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/29/2020] [Indexed: 01/09/2023]
Abstract
Chronic kidney disease is prevalent, affecting more than one in ten adults. In this population, metabolic acidosis is considered a key underlying pathophysiological feature, tying together bone mineral disorders, sarcopenia, insulin resistance, vascular calcification, pro-inflammatory and pro-thrombotic states. This review aims to address the paucity of literature on alkalinizing agents, a promising treatment option that has known adverse effects.
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Affiliation(s)
- Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Alan A Sag
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, USA
| | - Baris Afsar
- Division of Nephrology, Department of Internal Medicine, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Patrick Rossignol
- Université de Lorraine, INSERM CIC-P 1433, CHRU de Nancy, INSERM U1116, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Adrian Covic
- Department of Nephrology, Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, 34010, Istanbul, Turkey.
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Melamed ML, Horwitz EJ, Dobre MA, Abramowitz MK, Zhang L, Lo Y, Mitch WE, Hostetter TH. Effects of Sodium Bicarbonate in CKD Stages 3 and 4: A Randomized, Placebo-Controlled, Multicenter Clinical Trial. Am J Kidney Dis 2019; 75:225-234. [PMID: 31699517 DOI: 10.1053/j.ajkd.2019.07.016] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 07/16/2019] [Indexed: 01/18/2023]
Abstract
RATIONALE & OBJECTIVE Metabolic acidosis associated with chronic kidney disease (CKD) may contribute to muscle dysfunction and bone disease. We aimed to test whether treatment with sodium bicarbonate improves muscle and bone outcomes. STUDY DESIGN Multicenter, randomized, placebo-controlled, clinical trial. SETTING & PARTICIPANTS 149 patients with CKD stages 3 and 4 between July 2011 and April 2016 at 3 centers in Cleveland, OH, and the Bronx, NY. INTERVENTION Sodium bicarbonate (0.4 mEq per kg of ideal body weight per day) (n=74) or identical-appearing placebo (n=75). OUTCOMES Dual primary outcomes were muscle function assessed using sit-to-stand test and bone mineral density. Muscle biopsies were performed at baseline and 2 months. Participants were seen at baseline and 2, 6, 12, and 24 months. RESULTS Mean baseline serum bicarbonate level was 24.0±2.2 (SD) mEq/L and mean baseline estimated glomerular filtration rate was 36.3±11.2mL/min/1.73m2. Baseline characteristics did not differ between groups. Mean serum bicarbonate levels in the intervention arm during follow-up were 26.4±2.2, 25.5±2.3, 25.6±2.6, and 24.4±2.8 mEq/L (at 2, 6, 12, and 24 months). These were significantly higher than in the placebo group (P<0.001). Compared to the placebo group, participants randomly assigned to sodium bicarbonate treatment had no significant differences in sit-to-stand time (5 repetitions: P=0.1; and 10 repetitions P=0.07) or bone mineral density (P=0.3). Sodium bicarbonate treatment caused a decrease in serum potassium levels that was of borderline statistical significance (P=0.05). There were no significant differences in estimated glomerular filtration rates, blood pressure, weight, serious adverse events, or levels of muscle gene expression between the randomly assigned groups. LIMITATIONS Initial mean serum bicarbonate level was in the normal range. CONCLUSIONS Sodium bicarbonate therapy in patients with CKD stages 3 and 4 significantly increases serum bicarbonate and decreases potassium levels. No differences were found in muscle function or bone mineral density between the randomly assigned groups. Larger trials are required to evaluate effects on kidney function. FUNDING National Institutes of Health grant. TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT01452412.
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Affiliation(s)
- Michal L Melamed
- Department of Medicine (Nephrology), Albert Einstein College of Medicine/ Montefiore Medical Center, Bronx, NY; Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY.
| | - Edward J Horwitz
- Department of Medicine (Nephrology), MetroHealth Medical Center, Cleveland, OH
| | - Mirela A Dobre
- Department of Medicine (Nephrology), Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Matthew K Abramowitz
- Department of Medicine (Nephrology), Albert Einstein College of Medicine/ Montefiore Medical Center, Bronx, NY
| | - Liping Zhang
- Department of Medicine (Nephrology), Baylor College of Medicine, Houston, TX
| | - Yungtai Lo
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - William E Mitch
- Department of Medicine (Nephrology), Baylor College of Medicine, Houston, TX
| | - Thomas H Hostetter
- Department of Medicine (Nephrology), Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH
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Effect of Sodium Bicarbonate in Kidney Transplant Recipients With Chronic Metabolic Acidosis. Transplant Direct 2019; 5:e464. [PMID: 31334338 PMCID: PMC6616137 DOI: 10.1097/txd.0000000000000910] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/22/2019] [Accepted: 05/24/2019] [Indexed: 11/25/2022] Open
Abstract
Background Metabolic acidosis (MA) is a common complication after kidney transplantation and regarded to increase mortality, graft failure, and bone fractures. Here, we conducted a retrospective cohort study to analyze the effect of sodium bicarbonate on those events. Methods All kidney transplant recipients of the German health insurance Allgemeine Ortskrankenkasse (AOK) were selected, who received their transplantation between 2007 and 2015. Three groups were formed: (1) control group (no acidosis, n = 3602), (2) acidosis group (encoded acidosis, n = 370), and (3) treatment group (encoded therapy, n = 769). The study endpoints were mortality, death-censored graft failure, and bone fractures. Results The prevalence of MA in the first year after transplantation was 46.2%. The 5-year patient and graft survival were 89.8% and 89.3% in the control group, 90% and 90.8% in the acidosis group, and 87.5% and 81.6% in the treatment group, respectively. The rate of bone fractures did not differ between the groups. Neither log-rank tests nor multivariable Cox regression analyses could detect a negative impact of MA on mortality (hazard ratio [HR] 0.94; confidence interval [CI] 0.67-1.30), graft failure (HR1.18; CI 0.82-1.72), or the incidence of bone fractures (HR1.19; CI 0.92-1.55). Treatment with sodium bicarbonate was associated with an increased risk of graft failure (HR1.52; CI 1.03-2.25), whereas mortality (HR0.86; CI 0.59-1.26) and the incidence of bone fractures (HR1.16; CI 0.86-1.56) were not altered. Conclusions MA is common after kidney transplantation but not associated with an increased frequency of death, graft failure, or bone fractures. Conversely, sodium bicarbonate therapy increased the incidence of graft failure.
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Laboux T, Azar R. [Dietary control of metabolic acidosis in chronic kidney disease]. Nephrol Ther 2019; 15:491-497. [PMID: 31056406 DOI: 10.1016/j.nephro.2018.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/24/2018] [Indexed: 02/06/2023]
Abstract
Metabolic acidosis is a frequent complication of chronic kidney disease. Although it is known to appear at advanced stages, many studies suggest a state of "global protonic retention" starting at early stages of the disease, responsible of tissue damage, particularly musculoskeletal, alteration of protidic metabolism and endocrine disorders, promoting malnutrition and chronic inflammation, and finally increasing mortality. The majority of international recommandations suggest of supplementation by alkali, most of the time by sodium bicarbonate, to struggle against this complication. An interesting alternative to correct acidosis would consist on the modulation of the endogenous production of acid by playing with the alimentary incomes. In fact, it has been demonstrated that some different types of food produce or consume protons during their metabolism. Low protein diet and rich fresh fruits and vegetables diet would manage to correct at least as well as the supplementation by sodium bicarbonate the metabolic acidosis, and to struggle against its complications, noteworthy by slowing the decline of glomerular filtration rate by limiting the toxic adaptative fibrotic mechanisms, demonstrated by the decrease of urinary tubulo-interstitial suffering markers. Of the condition of being well led, those diets do not seem to expose patients to an over-risk of malnutrition or hyperkaliemia. They therefore appear to be an attractive alternative, efficiency and safe, to fight against chronic kidney disease metabolic acidosis and its complications.
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Affiliation(s)
- Timothée Laboux
- Service de néphrologie-transplantation, hôpital Claude-Huriez, centre hospitalier régional universitaire de Lille, 2, avenue Oscar-Lambret, 59000 Lille, France.
| | - Raymond Azar
- Service de néphrologie-hémodialyse, centre hospitalier de Dunkerque, 130, avenue Louis-Herbeaux, 59240 Dunkerque, France
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17
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Kraut JA, Madias NE. Adverse Effects of the Metabolic Acidosis of Chronic Kidney Disease. Adv Chronic Kidney Dis 2017; 24:289-297. [PMID: 29031355 DOI: 10.1053/j.ackd.2017.06.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/27/2017] [Indexed: 01/01/2023]
Abstract
The kidney has the principal role in the maintenance of acid-base balance, and therefore, a fall in renal net acid excretion and positive H+ balance often leading to reduced serum [HCO3-] are observed in the course of CKD. This metabolic acidosis can be associated with muscle wasting, development or exacerbation of bone disease, hypoalbuminemia, increased inflammation, progression of CKD, protein malnutrition, alterations in insulin, leptin, and growth hormone, and increased mortality. Importantly, some of the adverse effects can be observed even in the absence of overt hypobicarbonatemia. Administration of base decreases muscle wasting, improves bone disease, restores responsiveness to insulin, slows progression of CKD, and possibly reduces mortality. Base is recommended when serum [HCO3-] is <22 mEq/L, but the target serum [HCO3-] remains unclear. Evidence that increments of serum [HCO3-] >26 mEq/L might be associated with worsening of cardiovascular disease adds complexity to treatment decisions. Further study of the mechanisms through which positive H+ balance in CKD contributes to its various adverse effects and the pathways involved in mediating the benefits and complications of base therapy is warranted.
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18
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Harambat J, Kunzmann K, Azukaitis K, Bayazit AK, Canpolat N, Doyon A, Duzova A, Niemirska A, Sözeri B, Thurn-Valsassina D, Anarat A, Bessenay L, Candan C, Peco-Antic A, Yilmaz A, Tschumi S, Testa S, Jankauskiene A, Erdogan H, Rosales A, Alpay H, Lugani F, Arbeiter K, Mencarelli F, Kiyak A, Dönmez O, Drozdz D, Melk A, Querfeld U, Schaefer F. Metabolic acidosis is common and associates with disease progression in children with chronic kidney disease. Kidney Int 2017; 92:1507-1514. [PMID: 28729033 DOI: 10.1016/j.kint.2017.05.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/27/2017] [Accepted: 05/04/2017] [Indexed: 10/19/2022]
Abstract
Recent studies in adult chronic kidney disease (CKD) suggest that metabolic acidosis is associated with faster decline in estimated glomerular filtration rate (eGFR). Alkali therapies improve the course of kidney disease. Here we investigated the prevalence and determinants of abnormal serum bicarbonate values and whether metabolic acidosis may be deleterious to children with CKD. Associations between follow-up serum bicarbonate levels categorized as under 18, 18 to under 22, and 22 or more mmol/l and CKD outcomes in 704 children in the Cardiovascular Comorbidity in Children with CKD Study, a prospective cohort of pediatric patients with CKD stages 3-5, were studied. The eGFR and serum bicarbonate were measured every six months. At baseline, the median eGFR was 27 ml/min/1.73m2 and median serum bicarbonate level 21 mmol/l. During a median follow-up of 3.3 years, the prevalence of metabolic acidosis (serum bicarbonate under 22 mmol/l) was 43%, 60%, and 45% in CKD stages 3, 4, and 5, respectively. In multivariable analysis, the presence of metabolic acidosis as a time-varying covariate was significantly associated with log serum parathyroid hormone through the entire follow-up, but no association with longitudinal growth was found. A total of 211 patients reached the composite endpoint (ESRD or 50% decline in eGFR). In a multivariable Cox model, children with time-varying serum bicarbonate under 18 mmol/l had a significantly higher risk of CKD progression compared to those with a serum bicarbonate of 22 or more mmol/l (adjusted hazard ratio 2.44; 95% confidence interval 1.43-4.15). Thus, metabolic acidosis is a common complication in pediatric patients with CKD and may be a risk factor for secondary hyperparathyroidism and kidney disease progression.
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Affiliation(s)
- Jérôme Harambat
- Pediatric Nephrology Unit, Department of Pediatrics, Bordeaux University Hospital, and Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team LEHA, UMR 1219, Bordeaux, France
| | - Kevin Kunzmann
- Institute for Medical Biometry and Informatics, Heidelberg University Hospital, Heidelberg, Germany
| | - Karolis Azukaitis
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany; Pediatric Center, Vilnius University, Vilnius, Lithuania
| | - Aysun K Bayazit
- Division of Pediatric Nephrology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Nur Canpolat
- Department of Pediatric Nephrology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Anke Doyon
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Duzova
- Division of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Anna Niemirska
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Betul Sözeri
- Division of Pediatric Nephrology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Daniela Thurn-Valsassina
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany; Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ali Anarat
- Division of Pediatric Nephrology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Lucie Bessenay
- Department of Pediatrics, University Hospital Estaing, Clermont Ferrand, France
| | - Cengiz Candan
- Division of Pediatric Nephrology, Istanbul Medeniyet University, Göztepe Hospital, Istanbul, Turkey
| | - Amira Peco-Antic
- Department of Nephrology, University Children's Hospital, Faculty of Medicine, Belgrade, Serbia
| | - Alev Yilmaz
- Department of Pediatric Nephrology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | | | - Sara Testa
- Department of Pediatric Nephrology, Fondazione IRCCS Ca' Granda Osp Maggiore Policlinico, Milano, Italy
| | | | - Hakan Erdogan
- Bursa Yuksek Ihtisas Teaching and Researching Hospital, Bursa, Turkey
| | - Alejandra Rosales
- University Children's Hospital, Innsbruck Medical University, Innsbruck, Austria
| | - Harika Alpay
- Department of Pediatric Nephrology, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Francesca Lugani
- Division of Nephrology, Dialysis, Transplantation, University of Genoa, G. Gaslini Institute, Genoa, Italy
| | - Klaus Arbeiter
- Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Francesca Mencarelli
- Pediatric Nephrology Unit, Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Aysel Kiyak
- Division of Pediatric Nephrology, Department of Pediatrics, Bakirkoy Children's Hospital, Istanbul, Turkey
| | - Osman Dönmez
- Division of Pediatric Nephrology, Uludağ University Faculty of Medicine, Bursa, Turkey
| | - Dorota Drozdz
- Department of Pediatric Nephrology, Jagiellonian University Medical College, Krakow, Poland
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Uwe Querfeld
- Department of Pediatric Nephrology, Charité University, Berlin, Germany
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany.
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Abstract
Although phosphorus is an essential nutrient required for multiple physiological functions, recent research raises concerns that high phosphorus intake could have detrimental effects on health. Phosphorus is abundant in the food supply of developed countries, occurring naturally in protein-rich foods and as an additive in processed foods. High phosphorus intake can cause vascular and renal calcification, renal tubular injury, and premature death in multiple animal models. Small studies in human suggest that high phosphorus intake may result in positive phosphorus balance and correlate with renal calcification and albuminuria. Although serum phosphorus is strongly associated with cardiovascular disease, progression of kidney disease, and death, limited data exist linking high phosphorus intake directly to adverse clinical outcomes. Further prospective studies are needed to determine whether phosphorus intake is a modifiable risk factor for kidney disease.
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Affiliation(s)
- Alex R Chang
- Kidney Health Research Institute, Geisinger Health System, Danville, Pennsylvania 17822; .,Department of Epidemiology and Health Services Research, Geisinger Health System, Geisinger Health System, Danville, Pennsylvania 17822
| | - Cheryl Anderson
- Division of Preventive Medicine, School of Medicine, University of California, San Diego, La Jolla, California 92093
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20
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Heer F, Dobenecker B, Kienzle E. Effect of cation-anion balance in feed on urine pH in rabbits in comparison with other species. J Anim Physiol Anim Nutr (Berl) 2017; 101:1324-1330. [PMID: 28299839 DOI: 10.1111/jpn.12653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 11/08/2016] [Indexed: 10/20/2022]
Abstract
In the present investigation, the impact of diet composition on urine pH in rabbits was compared with previous studies on rabbits, cats, dogs, pigs and horses. A total of 13 dwarf rabbits were fed six different diets with a cation-anion balance (CAB) between -39 and +320 mmol/kg dry matter (DM) using ammonium chloride (NH4 Cl) as an acidifier. CAB was calculated as follows: CAB (mmol/kg DM) = 49.9*Ca + 82.3*Mg +43.5*Na + 25.6*K - 59*P - 62.4*S - 28.2*Cl; minerals in g/kg DM. Urine, faeces and blood were collected. Urine pH ranged from 5.26 ± 0.22 at a CAB of -39 mmol/kg DM to 8.56 ± 0.24 at a CAB of +320 mmol/kg DM. A low CAB in the feed reduced blood pH and blood base excess significantly. Renal excretion of Ca, P, Na and Mg and water was significantly higher in rabbits eating acidifying diets. In comparison with other species, rabbits reacted to acidifying diets in a similar way as cats, dogs and pigs. Rabbits on a mildly alkalizing diet, however, had a trend to higher urine pH than other monogastric species on such diets (cats, dogs, pigs, horses).
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Affiliation(s)
- F Heer
- Department of Veterinary Science, Ludwig-Maximilians-University, Munich, Germany
| | - B Dobenecker
- Department of Veterinary Science, Ludwig-Maximilians-University, Munich, Germany
| | - E Kienzle
- Department of Veterinary Science, Ludwig-Maximilians-University, Munich, Germany
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21
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Van der Veen G, Fosgate GT, Botha FK, Meissner HH, Jacobs L, Prozesky L. Response of cattle with clinical osteochondrosis to mineral supplementation. Onderstepoort J Vet Res 2017; 84:e1-e6. [PMID: 28281772 PMCID: PMC6238688 DOI: 10.4102/ojvr.v84i1.1365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/21/2016] [Accepted: 11/25/2016] [Indexed: 11/01/2022] Open
Abstract
Since 1982, farmers in the North West province and other parts of South Africa have noticed an increase in the incidence of lameness in cattle. Macro- and microscopical lesions of joints resembled osteochondrosis. Pre-trial data indicated that cattle with osteochondrotic lesions recovered almost completely when fed a supplement containing bio-available micro- and macrominerals of high quality. In the present trial, 43 clinically affected cattle of varying ages (1-5 years) and sexes were randomly divided into three groups. Each group was fed the same commercial supplement base with differing micro- and macromineral concentrations to determine the effect of mineral concentrations on the recovery from osteochondrosis. Both supplements 1 and 2 contained 25% of the recommended National Research Council (NRC) mineral values. Additional phosphate was added to supplement 2. Supplement 3, containing 80% of the NRC mineral values, was used as the control. Results from all three groups indicated no recovery from osteochondrosis. Urine pH of a small sample of the test cattle showed aciduria (pH < 6). Supplement analysis revealed addition of ammonium sulphate that contributed sulphate and nitrogen to the supplement. Supplementary dietary cation anion difference (DCAD) values were negative at -411 mEq/kg, -466 mEq/kg and -467 mEq/kg for supplements 1, 2 and 3, respectively, whereas the pre-trial supplement was calculated at +19.87 mEq/kg. It was hypothesised that feeding a low (negative) DCAD diet will predispose growing cattle to the development of osteochondrosis or exacerbate subclinical or clinical osteochondrosis in cattle.
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22
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Prozesky L, Neser J, Meissner H, Botha K, Jacobs L, Shepstone C, Viljoen H, Köster H, De Brouwer C, Van Zyl J, Van der Veen G. Preliminary report on osteochondrosis in cattle in the north-western parts of South Africa. ACTA ACUST UNITED AC 2016; 83:e1-7. [PMID: 27543146 PMCID: PMC6238666 DOI: 10.4102/ojvr.v83i1.1083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 12/09/2015] [Indexed: 11/22/2022]
Abstract
The north-western part of South Africa, in particular, is well known for mineral imbalances. Aphosphorosis, resulting in rickets and osteomalacia, received a lot of attention at the turn of the nineteenth century (1882–1912). This was followed in 1997 by research on Vryburg hepatosis, another area-specific mineral imbalance–related disease in young calves reared on manganese-rich soil derived from the weathering of dolomitic (carbonate) rock formations. In 1982, a totally new syndrome (osteochondrosis) manifested in, amongst others, areas in South Africa where aphosphorosis was rife. Osteochondrosis was also identified in the south-western parts of Namibia as well as southern Botswana and other areas in South Africa. Osteochondrosis has a multifactorial aetiology and this study focused on the role of minerals, particularly phosphorus, in the development of the disease. A significant improvement in the clinical signs in experimental animals and a reduction of osteochondrosis occurred on farms where animals received bioavailable trace minerals and phosphorus as part of a balanced lick. An increase in the occurrence of the disease on farms during severe drought conditions in 2012–2013 prompted researchers to investigate the possible role of chronic metabolic acidosis in the pathogenesis of the disease.
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Affiliation(s)
- Leon Prozesky
- Department of Paraclinical Sciences, University of Pretoria.
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Chen W, Melamed ML, Abramowitz MK. Serum bicarbonate and bone mineral density in US adults. Am J Kidney Dis 2015; 65:240-8. [PMID: 25168294 PMCID: PMC4305466 DOI: 10.1053/j.ajkd.2014.07.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 07/02/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Chronic metabolic acidosis leads to bone mineral loss and results in lower bone mineral density (BMD), which is a risk factor for osteoporosis-related fractures. The effect of low-level metabolic acidosis on bone density in the general population is unknown. STUDY DESIGN Cross-sectional study. SETTING & PARTICIPANTS 9,724 nationally representative adults 20 years or older in NHANES (National Health and Nutrition Examination Survey) 1999-2004. FACTOR Serum bicarbonate level. OUTCOMES Lumbar and total BMD, as well as low lumbar and total bone mass, defined as 1.0 SD below the sex-specific mean value of young adults. MEASUREMENTS BMD was measured by dual-energy x-ray absorptiometry and serum bicarbonate was measured in all participants. RESULTS Both men and women with lower serum bicarbonate levels were more likely to be current smokers and had higher body mass index and estimated net endogenous acid production. There was a significant linear trend across quartiles of serum bicarbonate with lumbar BMD in the total population, as well as in sex-specific models (P=0.02 for all 3 models, P=0.1 for interaction). For total BMD, a significant association was seen with serum bicarbonate level for women but not men (P=0.02 and P=0.1, respectively; P=0.8 for interaction), and a significant association was seen for postmenopausal women but not premenopausal women (P=0.02 and P=0.2, respectively; P=0.5 for interaction). Compared with women with serum bicarbonate levels <24mEq/L, those with serum bicarbonate levels ≥27mEq/L had 0.018-g/cm(2) higher total BMD (95% CI, 0.004-0.032; P=0.01) and 31% lower odds of having low total bone mass (OR, 0.68; 95% CI, 0.46-0.99; P=0.049). LIMITATIONS Cross-sectional study using a single measurement of serum bicarbonate. Subgroup differences are not definitive. CONCLUSIONS Lower serum bicarbonate levels are associated with lower BMD in US adults. Further studies should examine whether serum bicarbonate levels should be incorporated into the diagnostic assessment and management of osteoporosis.
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Affiliation(s)
- Wei Chen
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY.
| | - Michal L Melamed
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY; Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Matthew K Abramowitz
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY; Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
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Rastegar M, Levine BS, Felsenfeld AJ. Metabolic acidosis-induced hypercalcemia in an azotemic patient with primary hyperparathyroidism. Clin Kidney J 2014; 7:299-302. [PMID: 25852894 PMCID: PMC4377759 DOI: 10.1093/ckj/sfu041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 04/18/2014] [Indexed: 11/29/2022] Open
Abstract
A 58-year-old man with Stage 3b chronic kidney disease and primary hyperparathyroidism treated with cinacalcet was admitted for acute cholecystitis. A cholecystostomy tube was placed, estimated glomerular filtration rate decreased, metabolic acidosis developed and ionized calcium increased from 1.33 to 1.76 mM despite cinacalcet administration. A sodium bicarbonate infusion corrected the metabolic acidosis restoring ionized calcium to normal despite no improvement in renal function. The correlation between the increase in serum bicarbonate and decrease in ionized calcium was r = −0.93, P < 0.001. In summary, severe hypercalcemia was attributable to metabolic acidosis increasing calcium efflux from bone while renal failure decreased the capacity to excrete calcium.
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Affiliation(s)
- Mandana Rastegar
- Department of Medicine , Greater Los Angeles VA Healthcare System and the David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
| | - Barton S Levine
- Department of Medicine , Greater Los Angeles VA Healthcare System and the David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
| | - Arnold J Felsenfeld
- Department of Medicine , Greater Los Angeles VA Healthcare System and the David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
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Chen W, Abramowitz MK. Metabolic acidosis and the progression of chronic kidney disease. BMC Nephrol 2014; 15:55. [PMID: 24708763 PMCID: PMC4233646 DOI: 10.1186/1471-2369-15-55] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 03/31/2014] [Indexed: 11/10/2022] Open
Abstract
Metabolic acidosis is a common complication of chronic kidney disease. Accumulating evidence identifies acidosis not only as a consequence of, but as a contributor to, kidney disease progression. Several mechanistic pathways have been identified in this regard. The dietary acid load, even in the absence of overt acidosis, may have deleterious effects. Several small trials now suggest that the treatment of acidosis with oral alkali can slow the progression of kidney disease.
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Affiliation(s)
| | - Matthew K Abramowitz
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
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26
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Silva BC, Freitas GR, Silva VB, Abensur H, Luders C, Pereira BJ, de Oliveira RB, Castro MC, Moysés RM, Elias RM. Hemodynamic Behavior During Hemodialysis: Effects of Dialysate Concentrations of Bicarbonate and Potassium. ACTA ACUST UNITED AC 2014; 39:490-6. [DOI: 10.1159/000368459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2014] [Indexed: 11/19/2022]
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Gasser JA, Hulter HN, Imboden P, Krapf R. Effect of chronic metabolic acidosis on bone density and bone architecture in vivo in rats. Am J Physiol Renal Physiol 2013; 306:F517-24. [PMID: 24352505 DOI: 10.1152/ajprenal.00494.2013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Chronic metabolic acidosis (CMA) might result in a decrease in vivo in bone mass based on its reported in vitro inhibition of bone mineralization, bone formation, or stimulation of bone resorption, but such data, in the absence of other disorders, have not been reported. CMA also results in negative nitrogen balance, which might decrease skeletal muscle mass. This study analyzed the net in vivo effects of CMA's cellular and physicochemical processes on bone turnover, trabecular and cortical bone density, and bone microarchitecture using both peripheral quantitative computed tomography and μCT. CMA induced by NH4Cl administration (15 mEq/kg body wt/day) in intact and ovariectomized (OVX) rats resulted in stable CMA (mean Δ[HCO3(-)]p = 10 mmol/l). CMA decreased plasma osteocalcin and increased TRAP5b in intact and OVX animals. CMA decreased total volumetric bone mineral density (vBMD) after 6 and 10 wk (week 10: intact normal +2.1 ± 0.9% vs. intact acidosis -3.6 ± 1.2%, P < 0.001), an effect attributable to a decrease in cortical thickness and, thus, cortical bone mass (no significant effect on cancellous vBMD, week 10) attributed to an increase in endosteal bone resorption (nominally increased endosteal circumference). Trabecular bone volume (BV/TV) decreased significantly in both CMA groups at 6 and 10 wk, associated with a decrease in trabecular number. CMA significantly decreased muscle cross-sectional area in the proximal hindlimb at 6 and 10 wk. In conclusion, chronic metabolic acidosis induces a large decrease in cortical bone mass (a prime determinant of bone fragility) in intact and OVX rats and impairs bone microarchitecture characterized by a decrease in trabecular number.
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Affiliation(s)
- Jürg A Gasser
- Hirslanden Klinik St. Anna, CH-6006 Lucerne, Switzerland.
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28
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Rahman N, Buck J, Levin LR. pH sensing via bicarbonate-regulated "soluble" adenylyl cyclase (sAC). Front Physiol 2013; 4:343. [PMID: 24324443 PMCID: PMC3838963 DOI: 10.3389/fphys.2013.00343] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 11/06/2013] [Indexed: 01/03/2023] Open
Abstract
Soluble adenylyl cyclase (sAC) is a source of the second messenger cyclic adenosine 3′, 5′ monophosphate (cAMP). sAC is directly regulated by bicarbonate (HCO−3) ions. In living cells, HCO−3 ions are in nearly instantaneous equilibrium with carbon dioxide (CO2) and pH due to the ubiquitous presence of carbonic anhydrases. Numerous biological processes are regulated by CO2, HCO−3, and/or pH, and in a number of these, sAC has been shown to function as a physiological CO2/HCO3/pH sensor. In this review, we detail the known pH sensing functions of sAC, and we discuss two highly-studied, pH-dependent pathways in which sAC might play a role.
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Affiliation(s)
- Nawreen Rahman
- Department of Pharmacology, Weill Cornell Medical College New York, NY, USA
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29
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Chen W, Abramowitz MK. Treatment of metabolic acidosis in patients with CKD. Am J Kidney Dis 2013; 63:311-7. [PMID: 23932089 DOI: 10.1053/j.ajkd.2013.06.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/19/2013] [Indexed: 01/02/2023]
Abstract
Metabolic acidosis is a common complication of chronic kidney disease and is believed to contribute to a number of sequelae, including bone disease, altered protein metabolism, skeletal muscle wasting, and progressive glomerular filtration rate loss. Small trials in animal models and humans suggest a role for alkali therapy to lessen these complications. Recent studies support this notion, although more definitive evidence is needed on the long-term benefits of alkali therapy and the optimal serum bicarbonate level. The role of dietary modification also should be given greater consideration. In addition, potential adverse effects of alkali treatment must be taken into consideration, including sodium retention and the theoretical concern of promoting vascular calcification. This teaching case summarizes the rationale for and benefits and complications of base therapy in patients with chronic kidney disease.
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Affiliation(s)
- Wei Chen
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Matthew K Abramowitz
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY; Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY.
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30
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Kuragano T, Furuta M, Yahiro M, Kida A, Otaki Y, Hasuike Y, Matsumoto A, Nakanishi T. Acetate free citrate-containing dialysate increase intact-PTH and BAP levels in the patients with low intact-PTH. BMC Nephrol 2013; 14:18. [PMID: 23327614 PMCID: PMC3583681 DOI: 10.1186/1471-2369-14-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 01/11/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recently, acetate-free citrate containing dialysate (A(-)D) was developed. We have already reported about the significant effect of A(-)D on metabolic acidosis, anemia, and malnutrition in maintenance hemodialysis (MHD) patients. In this study, we compared the effect of A(-)D and acetate containing dialysate (A(+)D) on serum calcium and intact-parathyroid hormone (int-PTH) levels. METHOD Single session study: Seventeen patients were treated with A(+)D in one session and also treated with A(-)D in another session. Serum levels of pH, HCO3-, total (t)-calcium, ionized (i)-calcium, and int-PTH were evaluated at the beginning and the end of each session. Cross over study: A total of 29 patients with MHD were treated with A(+)D for 4 months, switched to A(-)D for next 4 months, and returned to A(+)D for the final 4 months. RESULTS In single session study, serum i-calcium and t-calcium levels significantly increased, and int-PTH levels decreased after HD with A(+)D, whereas HD with A(-)D did not affect iCa and int-PTH. In cross over study, if all patients were analyzed, there was no significant difference in serum int-PTH or bone alkaline phosphatase (BAP) levels during each study period. In contrast, in the patients with low int-PTH (<60 pg/mL), serum levels of int-PTH and BAP were significantly increased during the A(-)D, without significant changes in serum t-calcium or i-calcium levels. CONCLUSION A(-)D containing citrate could affect calcium and PTH levels, and, in 4 month period of crossover study, increased int-PTH levels pararelled with increasing BAP levels, exclusively in MHD patients with low int-PTH levels.
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Affiliation(s)
- Takahiro Kuragano
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
- Takahiro Kuragano, 1-1, Mukogawa cho, 663-8501, Nishinomiya, Japan
| | | | - Mana Yahiro
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
| | - Aritoshi Kida
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshinaga Otaki
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yukiko Hasuike
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Takeshi Nakanishi
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
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31
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Starke A, Corsenca A, Kohler T, Knubben J, Kraenzlin M, Uebelhart D, Wüthrich RP, von Rechenberg B, Müller R, Ambühl PM. Correction of metabolic acidosis with potassium citrate in renal transplant patients and its effect on bone quality. Clin J Am Soc Nephrol 2012; 7:1461-72. [PMID: 22773591 DOI: 10.2215/cjn.01100112] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acidosis and transplantation are associated with increased risk of bone disturbances. This study aimed to assess bone morphology and metabolism in acidotic patients with a renal graft, and to ameliorate bone characteristics by restoration of acid/base homeostasis with potassium citrate. METHODS This was a 12-month controlled, randomized, interventional trial that included 30 renal transplant patients with metabolic acidosis (S-[HCO(3)(-)] <24 mmol/L) undergoing treatment with either potassium citrate to maintain S-[HCO(3)(-)] >24 mmol/L, or potassium chloride (control group). Iliac crest bone biopsies and dual-energy X-ray absorptiometry were performed at baseline and after 12 months of treatment. Bone biopsies were analyzed by in vitro micro-computed tomography and histomorphometry, including tetracycline double labeling. Serum biomarkers of bone turnover were measured at baseline and study end. Twenty-three healthy participants with normal kidney function comprised the reference group. RESULTS Administration of potassium citrate resulted in persisting normalization of S-[HCO(3)(-)] versus potassium chloride. At 12 months, bone surface, connectivity density, cortical thickness, and cortical porosity were better preserved with potassium citrate than with potassium chloride, respectively. Serological biomarkers and bone tetracycline labeling indicate higher bone turnover with potassium citrate versus potassium chloride. In contrast, no relevant changes in bone mineral density were detected by dual-energy X-ray absorptiometry. CONCLUSIONS Treatment with potassium citrate in renal transplant patients is efficient and well tolerated for correction of metabolic acidosis and may be associated with improvement in bone quality. This study is limited by the heterogeneity of the investigated population with regard to age, sex, and transplant vintage.
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Affiliation(s)
- Astrid Starke
- Renal Division, Stadtspital Waid Zurich, Zurich, Switzerland
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Kraut JA, Madias NE. Consequences and therapy of the metabolic acidosis of chronic kidney disease. Pediatr Nephrol 2011; 26:19-28. [PMID: 20526632 PMCID: PMC2991191 DOI: 10.1007/s00467-010-1564-4] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 04/22/2010] [Accepted: 05/04/2010] [Indexed: 01/18/2023]
Abstract
Metabolic acidosis is common in patients with chronic kidney disease (CKD), particularly once the glomerular filtration rate (GFR) falls below 25 ml/min/1.73 m(2). It is usually mild to moderate in magnitude with the serum bicarbonate concentration ([HCO(3)(-)]) ranging from 12 to 23 mEq/l. Even so, it can have substantial adverse effects, including development or exacerbation of bone disease, growth retardation in children, increased muscle degradation with muscle wasting, reduced albumin synthesis with a predisposition to hypoalbuminemia, resistance to the effects of insulin with impaired glucose tolerance, acceleration of the progression of CKD, stimulation of inflammation, and augmentation of β(2)-microglobulin production. Also, its presence is associated with increased mortality. The administration of base to patients prior to or after initiation of dialysis leads to improvement in many of these adverse effects. The present recommendation by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) is to raise serum [HCO(3)(-)] to ≥ 22 mEq/l, whereas Caring for Australians with Renal Impairment (CARI) recommends raising serum [HCO(3)(-)] to >22 mEq/l. Base administration can potentially contribute to volume overload and exacerbation of hypertension as well as to metastatic calcium precipitation in tissues. However, sodium retention is less when given as sodium bicarbonate and sodium chloride intake is concomitantly restricted. Results from various studies suggest that enhanced metastatic calcification is unlikely with the pH values achieved during conservative base administration, but the clinician should be careful not to raise serum [HCO(3)(-)] to values outside the normal range.
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Affiliation(s)
- Jeffrey A. Kraut
- Medical and Research Services, VHAGLA Healthcare System, UCLA Membrane Biology Laboratory, Los Angeles, CA USA ,Division of Nephrology, VHAGLA Healthcare System, Los Angeles, USA ,David Geffen School of Medicine, Los Angeles, CA USA
| | - Nicolaos E. Madias
- Division of Nephrology, Department of Medicine, St. Elizabeth’s Medical Center, 736 Cambridge St., Boston, MA 02135 USA ,Department of Medicine, Tufts University School of Medicine, Boston, MA USA
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Bühler K, Liesegang A, Bucher B, Wenk C, Broz J. Influence of benzoic acid and phytase in low-phosphorus diets on bone characteristics in growing-finishing pigs. J Anim Sci 2010; 88:3363-71. [PMID: 20562353 DOI: 10.2527/jas.2009-1940] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In 2 simultaneous experiments (Exp. 1 and Exp. 2), the effects of benzoic acid (BA) and phytase (Phy) in low-P diets on bone metabolism, bone composition, and bone stability in growing and growing-finishing pigs were examined. Experiment 1 was conducted with 16 crossbred gilts in the BW range of 25 to 66 kg of BW, whereas in Exp. 2, 32 crossbred gilts (25 to 108 kg of BW) were used. All pigs were individually housed in pens and restrictively fed 1 of 4 diets throughout the experiment. Total P content of the wheat-soybean diets was 4 g/kg (all values on an as-fed basis). The experimental diets were 1) unsupplemented control diet; 2) control diet with 0.5% BA; 3) Phy diet with 750 Phy units (FTU) of Phy/kg and no BA; and 4) PhyBA, control diet with 750 FTU of Phy/kg and 0.5% BA. Blood samples were taken at the beginning of the experiment, wk 3 (only for pigs in Exp. 1), wk 6, and before slaughter to determine P and Ca in serum and concentrations of total alkaline phosphatase, serum crosslaps (marker for bone resorption), and osteocalcin (marker for bone formation). Ash, P, and Ca contents of bones and bone stability were examined using the left metatarsal bones and tibia of the pigs after slaughter. Benzoic acid did not influence any of the blood variables (P > 0.09). The addition of Phy increased (P < or =0.03) P concentration in serum from 2.71 +/- 0.08 to 3.03 +/- 0.07 mmol/L at wk 3 and content of serum crosslaps from 0.39 +/- 0.02 to 0.45 +/- 0.02 ng/mL at wk 6 and decreased (P < 0.05) osteocalcin at wk 6 by 160 ng/mL. No long-term effect of diets on serum mineral concentrations, alkaline phosphatase, and bone markers in serum could be detected. Benzoic acid negatively affected (P < or = 0.03) Ca content in bones and distal bone mineral density, especially in the younger pigs. In the control diet with 0.5% BA and the control diet with 750 FTU of Phy/kg and 0.5% BA, the CA content in bones and distal bone mineral density were reduced by 6 and 11%, respectively. Throughout the whole growing and finishing period, Phy increased (P < or =0.02) ash, P, and Ca contents in bones by 29.4, 4.8, and 11.6 g/kg of DM, respectively. Bone mineral density and bone mineral content were greater in diets with Phy (P < or = 0.03), as well as breaking strength of tibia (+22%) and metatarsal bones (+27%; P < 0.01). The results of this study indicate that for a healthy skeleton, BA should not be used in low-P diets without the addition of Phy.
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Affiliation(s)
- K Bühler
- Institute of Animal Sciences, ETH Zurich, Zurich, Switzerland.
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Adirekkiat S, Sumethkul V, Ingsathit A, Domrongkitchaiporn S, Phakdeekitcharoen B, Kantachuvesiri S, Kitiyakara C, Klyprayong P, Disthabanchong S. Sodium thiosulfate delays the progression of coronary artery calcification in haemodialysis patients. Nephrol Dial Transplant 2010; 25:1923-9. [PMID: 20083471 DOI: 10.1093/ndt/gfp755] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Coronary artery calcification (CAC) is prevalent among haemodialysis patients and predicts cardiovascular mortality. In addition to modifying traditional cardiovascular risk factors, therapy aimed at lowering serum phosphate and calcium-phosphate product has been advocated. Sodium thiosulfate, through its chelating property, removes calcium from precipitated minerals decreasing calcification burden in calcific uraemic arteriolopathy and soft tissue calcification. The effect of sodium thiosulfate on CAC in haemodialysis patients has never been studied. METHODS Eighty-seven stable chronic haemodialysis patients underwent multi-row spiral computed tomography and bone mineral density (BMD) measurement. Patients with a CAC score >or=300 were included to receive intravenous sodium thiosulfate infusion twice weekly post-haemodialysis for 4 months. CAC and BMD were re-evaluated at the end of the treatment course. RESULTS Progression of CAC occurred in 25% and 63% of the patients in the treatment and control group, respectively (P = 0.03). CAC score was unchanged in the treatment group but increased significantly in the control group. BMD of the total hip declined significantly in the treatment group. In multivariate analysis adjusted for factors that influenced CAC progression, therapy with sodium thiosulfate was an independent protective factor (odds ratio = 0.05, P = 0.04). Major side effects were persistent anorexia and metabolic acidosis. CONCLUSIONS The effect of sodium thiosulfate in delaying the progression of CAC is encouraging and will require a larger study. Determination of the safe therapeutic window is necessary in order to avoid bone demineralization.
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Affiliation(s)
- Surawat Adirekkiat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Riihonen R, Nielsen S, Väänänen HK, Laitala-Leinonen T, Kwon TH. Degradation of hydroxyapatite in vivo and in vitro requires osteoclastic sodium-bicarbonate co-transporter NBCn1. Matrix Biol 2010; 29:287-94. [PMID: 20079835 DOI: 10.1016/j.matbio.2010.01.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Revised: 12/01/2009] [Accepted: 01/06/2010] [Indexed: 01/19/2023]
Abstract
Dissolution of the inorganic bone matrix releases not only calcium and phosphate ions, but also bicarbonate. Electroneutral sodium-bicarbonate co-transporter (NBCn1) is expressed in inactive osteoclasts, but its physiological role in bone resorption has remained unknown. We show here that NBCn1, encoded by the SLC4A7 gene, is directly involved in bone resorption. NBCn1 protein was specifically found at the bone-facing ruffled border areas, and metabolic acidosis increased NBCn1 expression in rats in vivo. In human hematopoietic stem cell cultures, NBCn1 mRNA expression was observed only after formation of resorbing osteoclasts. To further confirm the critical role of NBCn1 during bone resorption, human hematopoietic stem cells were transduced with SLC4A7 shRNA lentiviral particles. Downregulation of NBCn1 both on mRNA and protein level by lentiviral shRNAs significantly inhibited bone resorption and increased intracellular acidification in osteoclasts. The lentiviral particles did not impair osteoclast survival, or differentiation of the hematopoietic or mesenchymal precursor cells into osteoclasts or osteoblasts in vitro. Inhibition of NBCn1 activity may thus provide a new way to regulate osteoclast activity during pathological bone resorption.
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Affiliation(s)
- Riikka Riihonen
- Bone Biology Research Consortium, Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku, FIN-20520 Turku, Finland
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Bushinsky DA. Contribution of Intestine, Bone, Kidney, and Dialysis to Extracellular Fluid Calcium Content. Clin J Am Soc Nephrol 2010; 5 Suppl 1:S12-22. [PMID: 20089498 DOI: 10.2215/cjn.05970809] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- David A Bushinsky
- Departments of Medicine and of Pharmacology and Physiology, University of Rochester School of Medicine, Rochester, New York, USA.
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Sevelamer carbonate increases serum bicarbonate in pediatric dialysis patients. Pediatr Nephrol 2010; 25:373-5. [PMID: 19876653 PMCID: PMC7811522 DOI: 10.1007/s00467-009-1328-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 09/03/2009] [Accepted: 09/04/2009] [Indexed: 11/27/2022]
Abstract
Sevelamer hydrochloride (HCl), a calcium-free phosphate binder, is increasingly used due to concerns related to calcium exposure and the development of vascular calcifications. However, a common side effect of sevelamer HCl, metabolic acidosis, is particularly concerning in children, as it can contribute to poor growth. Sevelamer carbonate is now available and has been shown to increase serum bicarbonate in adult patients. We conducted a prospective single-center study of pediatric dialysis patients comparing serum bicarbonate before and 3 months after a switch from sevelamer HCl to sevelamer carbonate. Inclusion criteria were a minimum of 3 months of dialysis therapy and either a serum bicarbonate <20 mmol/L or the need for sodium bicarbonate supplementation. Ten hemodialysis and 14 peritoneal dialysis patients, aged 16 +/- 3 years, were enrolled. Whereas serum calcium and phosphorus remained unchanged, serum bicarbonate increased from 20 (17.2-22.0) to 24.5 (20.75-26) mmol/L (p < 0.001) after 3 months of sevelamer carbonate therapy. Sodium bicarbonate supplementation was stopped in all patients (n = 10), reducing the mean daily sodium intake by an average of 2.3 g per patient. These results demonstrate that sevelamer carbonate is an effective phosphate binder that improves acid-base status in pediatric dialysis patients.
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Wongdee K, Riengrojpitak S, Krishnamra N, Charoenphandhu N. Claudin expression in the bone-lining cells of female rats exposed to long-standing acidemia. Exp Mol Pathol 2009; 88:305-10. [PMID: 20035748 DOI: 10.1016/j.yexmp.2009.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 12/09/2009] [Accepted: 12/09/2009] [Indexed: 10/20/2022]
Abstract
Besides enhancing osteoclast-mediated bone resorption, chronic metabolic acidosis (CMA) induces mineral efflux across the epithelial-like bone membrane formed by bone-lining cells (inactive osteoblasts), possibly via the paracellular pathway. However, there was a compensatory mechanism that restricted bone loss in the late phase of CMA, and changes in the expression of claudins, which are tight junction proteins known to regulate epithelial barrier function, were therefore anticipated in bone-lining cells. Herein, primary rat osteoblasts were found to express several transcripts of claudins, i.e., claudin-5, -11, -14, -15 and -16. Their protein expressions in bone-lining cells were demonstrated by immunohistochemistry in decalcified tibial sections. After exposure to CMA induced by oral administration of 1.5% NH(4)Cl for 21 days, expression of claudin-14, which normally seals the paracellular space and restricts ion movement, was increased, whereas that of claudin-15 and -16 which form pores for ion transport were decreased. Expressions of claudin-5 and -11 were not changed by CMA. In conclusion, the bone-lining cells of rats exposed to CMA for 21 days upregulated an ion-restrictive claudin (i.e., claudin-14), while downregulating ion-permeable claudins (i.e., claudin-15 and -16). These cellular responses might be parts of a compensatory mechanism accounting for deceleration of bone loss in late CMA.
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Affiliation(s)
- Kannikar Wongdee
- Consortium for Calcium and Bone Research, Faculty of Science, Mahidol University, Bangkok, Thailand
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Assapun J, Charoenphandhu N, Krishnamra N. Early acceleration phase and late stationary phase of remodeling imbalance in long bones of male rats exposed to long-standing acidemia: a 10-month longitudinal study using bone histomorphometry. Calcif Tissue Int 2009; 85:1-9. [PMID: 19458886 DOI: 10.1007/s00223-009-9254-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Accepted: 04/16/2009] [Indexed: 11/28/2022]
Abstract
Chronic metabolic acidosis (CMA) is known to have a detrimental effect on bone metabolism as a result of accelerated bone resorption and impaired bone formation. Typically, a number of compensatory adaptations must have occurred which may help palliate negative calcium balance and acidemia, e.g., increased intestinal calcium and phosphorus absorption. The final outcome with respect to bone remodeling after exposure to CMA for several months was, therefore, elusive. Herein, we investigated bone changes in male rats fed 1.5% NH(4)Cl in drinking water for up to 10 months to induce CMA with plasma pH of 7.2-7.3. Significant decreases in bone mineral density and content were detected by dual-energy X-ray absorptiometry after 6 months of CMA, whereas histomorphometric analysis revealed a significant decrease in bone volume already at week 2 after CMA induction. Exposure to CMA longer than 2 weeks also decreased trabecular number, trabecular thickness, osteoblast surface, mineral apposition rate, and bone formation rate, while increasing trabecular separation, osteoclast surface, and eroded surface. Bone resorption was rapid during weeks 2-16 (acceleration phase) and thereafter persisted at a slower rate (stationary phase) until week 40. Furthermore, CMA markedly reduced the total calcium content in bone and enhanced urinary calcium excretion as measured by atomic absorption spectrophotometry. It could be concluded that, after exposure to a long-standing acidemia, the enhanced bone resorption and suppressed bone formation led to osteopenia throughout the 10-month period, with accelerated bone loss seen only during the first 6 months. Thereafter, the compensatory adaptations appeared to help stabilize bone mass at a subnormal level.
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Affiliation(s)
- Jenjira Assapun
- Department of Physiology, Faculty of Science, Mahidol University, Rama VI Road, Bangkok 10400, Thailand
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Geng W, Hill K, Zerwekh JE, Kohler T, Müller R, Moe OW. Inhibition of osteoclast formation and function by bicarbonate: role of soluble adenylyl cyclase. J Cell Physiol 2009; 220:332-40. [PMID: 19360717 DOI: 10.1002/jcp.21767] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
High [HCO(3)(-)] inhibits and low [HCO(3)(-)] stimulates bone resorption, which mediates part of the effect of chronic acidosis or acid feeding on bone. Soluble adenylyl cyclase (sAC) is a bicarbonate sensor that can potentially mediate the effect of bicarbonate on osteoclasts. Osteoclasts were incubated in 0, 12, and 24 mM HCO(3)(-) at pH 7.4 for 7-8 days and assayed for tartrate-resistant acid phosphatase (TRAP) and vacuolar-ATPase expression, and H+ accumulation. Total number and area of TRAP (+) multinucleated osteoclasts was decreased by HCO(3)(-) in a dose-dependent manner. V-ATPase expression and H+ accumulation normalized to cell cross-sectional area or protein were not significantly changed. The HCO(3)(-) -induced inhibition of osteoclast growth and differentiation was blocked by either 2-hydroxyestradiol, an inhibitor of sAC or sAC knockdown by sAC specific siRNA. The model of HCO(3)(-) inhibiting osteoclast via sAC was further supported by the fact that the HCO(3)(-) dose-response on osteoclasts is flat when cells were saturated with 8-bromo-cAMP, a permeant cAMP analog downstream from sAC thus simulating sAC activation. To confirm our in vitro findings in intact bone, we developed a 1-week mouse calvaria culture system where osteoclasts were shown to be viable. Bone volume density (BV/TV) determined by micro-computed tomography (microCT), was higher in 24 mM HCO(3)(-) compared to 12 mM HCO(3)(-) treated calvaria. This HCO(3)(-) effect on BV/TV was blocked by 2-hydroxyestradiol. In summary, sAC mediates the inhibition of osteoclast function by HCO(3)(-), by acting as a HCO(3)(-) sensor.
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Affiliation(s)
- Weidong Geng
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas, Southwestern Medical Center at Dallas, Dallas, TX 75390-8885, USA
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Gabutti L, Bianchi G, Soldini D, Marone C, Burnier M. Haemodynamic consequences of changing bicarbonate and calcium concentrations in haemodialysis fluids. Nephrol Dial Transplant 2008; 24:973-81. [PMID: 18842671 PMCID: PMC2644633 DOI: 10.1093/ndt/gfn541] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background. In a previous study we demonstrated that mild metabolic alkalosis resulting from standard bicarbonate haemodialysis induces hypotension. In this study, we have further investigated the changes in systemic haemodynamics induced by bicarbonate and calcium, using non-invasive procedures. Methods. In a randomized controlled trial with a single-blind, crossover design, we sequentially changed the dialysate bicarbonate and calcium concentrations (between 26 and 35 mmol/l for bicarbonate and either 1.25 or 1.50 mmol/l for calcium). Twenty-one patients were enrolled for a total of 756 dialysis sessions. Systemic haemodynamics was evaluated using pulse wave analysers. Bioimpedance and BNP were used to compare the fluid status pattern. Results. The haemodynamic parameters and the pre-dialysis BNP using either a high calcium or bicarbonate concentration were as follows: systolic blood pressure (+5.6 and −4.7 mmHg; P < 0.05 for both), stroke volume (+12.3 and +5.2 ml; P < 0.05 and ns), peripheral resistances (−190 and −171 dyne s cm−5; P < 0.05 for both), central augmentation index (+1.1% and −2.9%; ns and P < 0.05) and BNP (−5 and −170 ng/l; ns and P < 0.05). The need of staff intervention was similar in all modalities. Conclusions. Both high bicarbonate and calcium concentrations in the dialysate improve the haemodynamic pattern during dialysis. Bicarbonate reduces arterial stiffness and ameliorates the heart tolerance for volume overload in the interdialytic phase, whereas calcium directly increases stroke volume. The slight hypotensive effect of alkalaemia should motivate a probative reduction of bicarbonate concentration in dialysis fluid for haemodynamic reasons, only in the event of failure of classical tools to prevent intradialytic hypotension.
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Affiliation(s)
- Luca Gabutti
- Division of Nephrology, Ospedale la Carità, Locarno, Switzerland.
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Cyclooxygenase-2 expression and prostaglandin E2 production in response to acidic pH through OGR1 in a human osteoblastic cell line. J Bone Miner Res 2008; 23:1129-39. [PMID: 18302504 DOI: 10.1359/jbmr.080236] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Acidosis has been shown to induce depletion of bone calcium from the body. This calcium release process is thought to be partially cell mediated. In an organ culture of bone, acidic pH has been shown to induce cyclooxygenase-2 (COX-2) induction and prostaglandin E(2) (PGE(2)) production, resulting in stimulation of bone calcium release. However, the molecular mechanisms whereby osteoblasts sense acidic circumstances and thereby induce COX-2 induction and PGE(2) production remain unknown. In this study, we used a human osteoblastic cell line (NHOst) to characterize cellular activities, including inositol phosphate production, intracellular Ca(2+) concentration ([Ca(2+)](i)), PGE(2) production, and COX-2 mRNA and protein expression, in response to extracellular acidification. Small interfering RNA (siRNA) specific to the OGR1 receptor and specific inhibitors for intracellular signaling pathways were used to characterize acidification-induced cellular activities. We found that extracellular acidic pH induced a transient increase in [Ca(2+)](i) and inositol phosphate production in the cells. Acidification also induced COX-2 induction, resulting in PGE(2) production. These proton-induced actions were markedly inhibited by siRNA targeted for the OGR1 receptor and the inhibitors for G(q/11) protein, phospholipase C, and protein kinase C. We conclude that the OGR1/G(q/11)/phospholipase C/protein kinase C pathway regulates osteoblastic COX-2 induction and subsequent PGE(2) production in response to acidic circumstances.
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Posttransplant Acidosis and Associated Disorders of Mineral Metabolism in Patients With a Renal Graft. Transplantation 2007; 84:1151-7. [DOI: 10.1097/01.tp.0000287430.19960.0e] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ambühl PM. Posttransplant metabolic acidosis: a neglected factor in renal transplantation? Curr Opin Nephrol Hypertens 2007; 16:379-87. [PMID: 17565282 DOI: 10.1097/mnh.0b013e3281bd8860] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW The occurrence and pathogenesis of metabolic acidosis after renal transplantation is reviewed. Posttransplant acidosis is shown to be a key mechanism for major metabolic complications in mineral and muscle metabolism, and for anemia, discussed in the context of both acidosis and renal transplantation. RECENT FINDINGS Continuous improvement in kidney transplant survival has shifted attention to long-term outcomes, specifically to disorders linked to cardiovascular disease, physical capacity and quality of life. Metabolic acidosis is gaining growing acceptance as a clinical entity and has occasionally come into focus in the context of renal transplantation. The possible link to metabolic disturbances resulting in impairment of musculoskeletal disorders and physical limitations, however, has not been considered specifically. SUMMARY Available evidence suggests a high prevalence of (compensated) metabolic acidosis after renal transplantation, presenting as low serum bicarbonate and impaired renal acid excretion. This condition is associated with relevant disorders in mineral metabolism and muscle function. Current knowledge about the effects of acidosis on renal electrolyte handling, mineral metabolism and protein synthesis suggests that acid/base derangements contribute to the muscle and bone pathology, as well as anemia, encountered after kidney transplantation. Consequently, posttransplant acidosis may be a relevant factor in the causal pathway of impaired physical capacity observed in this patient group.
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Affiliation(s)
- Patrice M Ambühl
- Department of Nephrology, University Hospital, Zurich, Switzerland.
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Kim HJ, Han SW. Metabolic acidosis in maintenance hemodialysis patients: clinical impact and intervention. Electrolyte Blood Press 2007; 5:42-6. [PMID: 24459499 PMCID: PMC3894505 DOI: 10.5049/ebp.2007.5.1.42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 05/07/2007] [Indexed: 11/25/2022] Open
Abstract
Metabolic acidosis has been considered as one of the reverse epidemiologic factors for the morbidity and mortality in maintenance hemodialysis patients (MHP). Expectedly, in the recent large scale epidemiologic study (The Dialysis Outcome Practice Pattern Study, DOPPS), a mild to moderate degree of predialysis metabolic acidosis has shown better nutritional status and lower relative risk for mortality and hospitalization in MHP. Similarly, another recent study of the largest sample size of MHP of more than 55,000 revealed the lowest unadjusted mortality with mild to moderate degree of predialysis HCO3 levels (17 to 23 mEq/L). However, it was reversed after case-mix and multivariate adjustment, including the malnutrition-inflammation complex syndrome, so that predialysis HCO3 levels of more than 22 mEq/L had a lower death risk. On view of this up-to-date on-going controversy about the optimal acid-base status for MHP, this paper will review the historical and break-through data about the pros and cons of metabolic acidosis published in the clinical human studies of MHP, a special subgroup of chronic kidney disease patients. Based on these results, if possible, we would like to suggest the best practice guideline, particularly, for the optimal predialysis HCO3 level, dialysate HCO3 concentration, and dietary protein intake.
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Affiliation(s)
- Ho-Jung Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Sang-Woong Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
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Abstract
Dietary protein has several opposing effects on Ca balance and its net effect on bone is not well established. It has long been recognized that increasing protein intake increases urinary Ca excretion. More recently, it has been observed that increasing dietary protein raises the circulating level of insulin-like growth factor-1, a growth factor that promotes osteoblast formation and bone growth. Other effects of protein on the Ca economy have been suggested in some studies, but they are less well established. Several studies have examined associations between protein intake and bone loss and fracture rates. In the original Framingham cohort subjects with lower total and animal protein intakes had greater rates of bone loss from the femoral neck and spine than subjects consuming more protein. In another study higher total (and animal) protein intakes were associated with a reduced incidence of hip fractures in post-menopausal women. In contrast, a high animahplant protein intake has been associated with greater bone loss from the femoral neck and a greater risk of hip fracture in older women. Higher total and higher animal protein intakes have also been associated with increased risk of forearm fracture in younger post-menopausal women. In a recent study it was found that increasing dietary protein was associated with a favourable (positive) change in bone mineral density of the femoral neck and total body in subjects taking supplemental calcium citrate malate with vitamin D, but not in those taking placebo. The possibility that Ca intake may influence the impact of dietary protein on the skeleton warrants further investigation.
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Affiliation(s)
- Bess Dawson-Hughes
- Calcium and Bone Metabolism Laboratory, The Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, 711 Washington St, Boston, MA 02111, USA.
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Mathur RP, Dash SC, Gupta N, Prakash S, Saxena S, Bhowmik D. Effects of correction of metabolic acidosis on blood urea and bone metabolism in patients with mild to moderate chronic kidney disease: a prospective randomized single blind controlled trial. Ren Fail 2006; 28:1-5. [PMID: 16526312 DOI: 10.1080/08860220500461187] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND There are no controlled trials on the efficacy of oral bicarbonate therapy in patients with mild to moderate chronic kidney disease (CKD). This prospective randomized controlled study was done to evaluate the effects of correction of metabolic acidosis on renal functions and bone metabolism in this group of patients. PATIENTS AND METHODS Forty patients were randomized to treatment with oral bicarbonate or placebo for a period of 3 months. Investigations at baseline included venous pH, bicarbonate, renal functions, serum iPTH, and bone radiology. The treatment group (Group B) received daily oral sodium bicarbonate therapy at a dose of 1.2 mEq/kg of body weight. Their venous blood pH and bicarbonate levels were estimated weekly to keep blood pH near 7.36 and bicarbonate at 22-26 mEq/L by adjusting the dose of sodium bicarbonate. At the end of 3 months, all the tests were repeated in both groups. RESULTS After oral bicarbonate therapy (OBT), there was a significant decline in the rise of blood urea level in Group B associated with a sense of well-being in 50% patients. The rise in parathormone (PTH) was six times the baseline value in Group A and only 1.5 times baseline value in Group B, although not statistically significant. There was no significant change in total calcium, phosphorus, alkaline phosphatase, creatinine, total protein, or albumin levels. CONCLUSION Correction of metabolic acidosis in patients with moderate CKD attenuates the rise in blood urea and PTH, which might prevent the deleterious long-term consequences of secondary hyperparathyroidism.
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Affiliation(s)
- Rajendra P Mathur
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
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Affiliation(s)
- William G Goodman
- Division of Nephrology and the Department of Medicine, David Geffen School of Medicine at UCLA, 7-155 Factor Bldg., UCLA Medical Center, 10833 Le Conte Ave., Los Angeles, CA, 90095, USA.
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