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Yamamoto S, Jørgensen HS, Zhao J, Karaboyas A, Komaba H, Vervloet M, Mazzaferro S, Cavalier E, Bieber B, Robinson B, Evenepoel P, Fukagawa M. Alkaline Phosphatase and Parathyroid Hormone Levels: International Variation and Associations With Clinical Outcomes in the DOPPS. Kidney Int Rep 2024; 9:863-876. [PMID: 38765600 PMCID: PMC11101738 DOI: 10.1016/j.ekir.2024.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/26/2023] [Accepted: 01/02/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Secondary hyperparathyroidism (SHPT) increases the risk of fractures and cardiovascular (CV) disease in patients on hemodialysis (HD). The relationship between parathyroid hormone (PTH) and outcomes has been inconsistent, possibly due to variable bone responsiveness to PTH. The KDIGO guideline suggests monitoring total alkaline phosphatase (ALP), but the role of ALP versus PTH in the management of mineral and bone disorder (MBD) is not clear. Methods The analysis included 28,888 patients on HD in 9 countries in Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 3 to 7 (2005-2021). The primary exposures of interest were normalized ALP and PTH, which are raw values divided by facility upper normal limit, measured at study enrollment. Cox models were used to estimate hazard ratios of all-cause or CV mortality and any or hip fracture adjusted for potential confounders. Linear mixed models, adjusted for potential confounders, were employed to investigate the relationship between normalized ALP levels and patient characteristics. Results Normalized PTH showed a J-shaped association with all-cause or CV mortality, and a weak linear association with fracture. In contrast, normalized ALP showed a strong association with all outcomes. Factors associated with higher ALP levels after controlling for PTH included Black race, longer dialysis vintage, diabetes mellitus, hypocalcemia, hypophosphatemia, elevated C-reactive protein (CRP), and the use of cinacalcet. Conclusion Total ALP is a more robust exposure of adverse outcomes than PTH in patients on HD. PTH responsiveness is affected by race, primary renal disease, comorbidities, and mineral metabolism and therapy. Our results indicate that it may be useful to evaluate target organ response, rather than PTH alone when considering the consequences of (SHPT).
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Affiliation(s)
- Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Angelo Karaboyas
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Marc Vervloet
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Sandro Mazzaferro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU de Liège, Sart Tilman, Liège, Belgium
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Bruce Robinson
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
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Elkhouli E, Nagy E, Santos CGS, Barreto FC, Chaer J, Jorgetti V, El-Husseini A. Mixed uremic osteodystrophy: an ill-described common bone pathology in patients with chronic kidney disease. Osteoporos Int 2023; 34:2003-2012. [PMID: 37658999 DOI: 10.1007/s00198-023-06886-5] [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: 06/17/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023]
Abstract
Renal osteodystrophy (ROD) starts early and progresses with further loss of kidney function in patients with chronic kidney disease (CKD). There are four distinct types of ROD based on undecalcified bone biopsy results. Adynamic bone disease and osteomalacia are the predominant forms of low bone turnover, while hyperparathyroid bone disease and mixed uremic osteodystrophy (MUO) are typically associated with high bone turnover. MUO is a prevalent but poorly described pathology that demonstrates evidence of osteomalacia on top of the high bone formation/resorption. The prevalence of MUO ranges from 5 to 63% among different studies. The pathogenesis of MUO is multi-factorial. Altered phosphate homeostasis, hypocalcemia, vitamin D deficiency, increased FGF-23, interleukins 1 and 6, TNF-α, amyloid, and heavy metal accumulation are the main inducers of MUO. The clinical findings of MUO are usually non-specific. The use of non-invasive testing such as bone turnover markers and imaging techniques might help to suspect MUO. However, it is usually impossible to precisely diagnose this condition without performing bone biopsy. The principal management of MUO is to control the maladaptive hyperparathyroidism along with correcting any nutritional mineral deficiencies that may induce mineralization defect. MUO is a common but still poorly understood bone pathology category; it demonstrates the complexity and difficulty in understanding ROD. A large prospective bone biopsy-based studies are needed for better identification as proper diagnosis and management would improve the outcome of patients with MUO.
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Affiliation(s)
- Ekbal Elkhouli
- Mansoura pathology department, Mansoura University, Mansoura, Egypt
| | - Eman Nagy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Cassia Gomes S Santos
- Division of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Fellype Carvalho Barreto
- Division of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Juliana Chaer
- University of São Paulo, Department of Internal Medicine, São Paulo, Brazil
| | - Vanda Jorgetti
- University of São Paulo, Department of Internal Medicine, São Paulo, Brazil
| | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, USA.
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Cejka D, Wakolbinger-Habel R, Zitt E, Fahrleitner-Pammer A, Amrein K, Dimai HP, Muschitz C. [Diagnosis and treatment of osteoporosis in patients with chronic kidney disease : Joint guidelines of the Austrian Society for Bone and Mineral Research (ÖGKM), the Austrian Society of Physical and Rehabilitation Medicine (ÖGPMR) and the Austrian Society of Nephrology (ÖGN)]. Wien Med Wochenschr 2023; 173:299-318. [PMID: 36542221 PMCID: PMC10516794 DOI: 10.1007/s10354-022-00989-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
DEFINITION AND EPIDEMIOLOGY Chronic kidney disease (CKD): abnormalities of kidney structure or function, present for over 3 months. Staging of CKD is based on GFR and albuminuria (not graded). Osteoporosis: compromised bone strength (low bone mass, disturbance of microarchitecture) predisposing to fracture. By definition, osteoporosis is diagnosed if the bone mineral density T‑score is ≤ -2.5. Furthermore, osteoporosis is diagnosed if a low-trauma (inadequate trauma) fracture occurs, irrespective of the measured T‑score (not graded). The prevalence of osteoporosis, osteoporotic fractures and CKD is increasing worldwide (not graded). PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENT OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER (CKD-MBD): Definition of CKD-MBD: a systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following: abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; renal osteodystrophy; vascular calcification (not graded). Increased, normal or decreased bone turnover can be found in renal osteodystrophy (not graded). Depending on CKD stage, routine monitoring of calcium, phosphorus, alkaline phosphatase, PTH and 25-OH-vitamin D is recommended (2C). Recommendations for treatment of CKD-MBD: Avoid hypercalcemia (1C). In cases of hyperphosphatemia, lower phosphorus towards normal range (2C). Keep PTH within or slightly above normal range (2D). Vitamin D deficiency should be avoided and treated when diagnosed (1C). DIAGNOSIS AND RISK STRATIFICATION OF OSTEOPOROSIS IN CKD Densitometry (using dual X‑ray absorptiometry, DXA): low T‑score correlates with increased fracture risk across all stages of CKD (not graded). A decrease of the T‑score by 1 unit approximately doubles the risk for osteoporotic fracture (not graded). A T-score ≥ -2.5 does not exclude osteoporosis (not graded). Bone mineral density of the lumbar spine measured by DXA can be increased and therefore should not be used for the diagnosis or monitoring of osteoporosis in the presence of aortic calcification, osteophytes or vertebral fracture (not graded). FRAX can be used to aid fracture risk estimation in all stages of CKD (1C). Bone turnover markers can be measured in individual cases to monitor treatment (2D). Bone biopsy may be considered in individual cases, especially in patients with CKD G5 (eGFR < 15 ml/min/1.73 m2) or CKD 5D (dialysis). SPECIFIC TREATMENT OF OSTEOPOROSIS IN PATIENTS WITH CKD Hypocalcemia should be treated and serum calcium normalized before initiating osteoporosis therapy (1C). CKD G1-G2 (eGFR ≥ 60 ml/min/1.73 m2): treat osteoporosis as recommended for the general population (1A). CKD G3-G5D (eGFR < 60 ml/min/1.73 m2 to dialysis): treat CKD-MBD first before initiating osteoporosis treatment (2C). CKD G3 (eGFR 30-59 ml/min/1.73 m2) with PTH within normal limits and osteoporotic fracture and/or high fracture risk according to FRAX: treat osteoporosis as recommended for the general population (2B). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) with osteoporotic fracture (secondary prevention): Individualized treatment of osteoporosis is recommended (2C). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) and high fracture risk (e.g. FRAX score > 20% for a major osteoporotic fracture or > 5% for hip fracture) but without prevalent osteoporotic fracture (primary prevention): treatment of osteoporosis may be considered and initiated individually (2D). CKD G4-5D (eGFR < 30 ml/min/1.73 m2 to dialysis): Calcium should be measured 1-2 weeks after initiation of antiresorptive therapy (1C). PHYSICAL MEDICINE AND REHABILITATION Resistance training prioritizing major muscle groups thrice weekly (1B). Aerobic exercise training for 40 min four times per week (1B). Coordination and balance exercises thrice weekly (1B). Flexibility exercise 3-7 times per week (1B).
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Affiliation(s)
- Daniel Cejka
- Abteilung für Innere Medizin III, Nieren- und Hochdruckerkrankungen, Transplantationsmedizin, Rheumatologie, Akutgeriatrie, Ordensklinikum Linz – Krankenhaus der Elisabethinen, Fadingerstr. 1, 4020 Linz, Österreich
| | - Robert Wakolbinger-Habel
- Department of Physical and Rehabilitation Medicine (PRM), Vienna Healthcare Group – Clinic Donaustadt, Langobardenstr. 122, 1220 Wien, Österreich
| | - Emanuel Zitt
- Department of Internal Medicine 3 (Nephrology and Dialysis), Feldkirch Academic Teaching Hospital, Feldkirch, Österreich
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Österreich
- Agency for Preventive and Social Medicine (aks), Bregenz, Österreich
| | - Astrid Fahrleitner-Pammer
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Hans Peter Dimai
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Christian Muschitz
- Medical Department II – VINFORCE, St. Vincent Hospital Vienna (Barmherzige Schwestern Krankenhaus Wien), Stumpergasse 13, 1060 Wien, Österreich
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Sabanis N, Paschou E, Drylli A, Papanikolaou P, Zagkotsis G. Uremic Leontiasis Ossea: Theoretical Concepts and Practical Considerations. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:702-715. [PMID: 37955462 DOI: 10.4103/1319-2442.389430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
Leontiasis ossea (LO) in chronic kidney disease patients, also known as Sagliker syndrome, is an exceptionally uncommon uremic complication of long-lasting and severe secondary hyperparathyroidism. The prominent features of uremic LO (ULO) encompass the characteristic clinical trial of massive thickening of maxillary and mandibular bones, widening of interdental spaces, and flattening of nasal bridges and nares. Moreover, during the transformation of craniofacial architecture, significant structural and functional consequences may appear, including upper airway patency, visual and hearing acuity, oral phase of swallowing as well as various neurological and psychiatric disorders. Only few cases of ULO have been reported in the literature until now, making challenging not only the traditional diagnostic procedures but also the optimal therapeutic approach. In this narrative review, we aim to explore the underlying pathophysiological mechanisms, summarize the evidence for adverse outcomes, and highlight the current therapeutic strategies for ULO prevention and treatment, given that precise genetic determinants remain elusive.
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Affiliation(s)
- Nikolaos Sabanis
- Department of Nephrology, General Hospital of Livadia, Livadia, Greece
| | - Eleni Paschou
- Department of General Practice and Family Medicine, Medical Unit of St George, Livadia, Greece
| | - Aikaterini Drylli
- Department of Otorhinolaryngology, National and Kapodistrian University of Athens, Athens, Greece
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Yajima A, Tsuchiya K, Kuro-O M, Urena P, Tominaga Y, Okada M, Ichimori T, Tomosugi T, Hiramitsu T, Murata T, Nakamura M, Sasaki M, Ito A, Nitta K. Renal hyperparathyroidism. VITAMINS AND HORMONES 2022; 120:305-343. [PMID: 35953115 DOI: 10.1016/bs.vh.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The number of the patients with chronic kidney disease is now increasing in the world. The pathophysiology of renal hyperparathyroidism is closely associated with Klotho-FGF-endocrine axes, which must be solved definitively as early as possible. It was revealed that the expression of fgf23 is activated by calciprotein particles, which induces vascular ossification. And it is well known that phosphorus overload directly increases parathyroid hormone and hyperparathyroid bone disease develops in those subjects. On the other hand, low turnover bone disease is often recently. Both the patients with chronic kidney disease suffering from hyperparathyroid bone disease or low turnover bone disease are associated with increased fracture risk. Micropetrosis may be one of the causes of increased fracture risk in the subjects with low turnover bone disease. In this chapter, we now describe the diagnosis, pathophysiology and treatments of renal hyperparathyroidism.
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Affiliation(s)
- Aiji Yajima
- Department of Anatomy, Cell Biology and Physiology, Indiana University, School of Medicine, Indianapolis, IN, United States; Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan; Department Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan.
| | - Ken Tsuchiya
- Department Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Makoto Kuro-O
- Division of Anti-aging Medicine, Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Pablo Urena
- Division of Nephrology, Clinique du Landy, Saint Ouen, France
| | - Yoshihiro Tominaga
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Manabu Okada
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Toshihiro Ichimori
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Toshihide Tomosugi
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Taro Murata
- Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan
| | - Masaki Nakamura
- Department of Nephrology and Urology, NTT East Kanto Hospital, Tokyo, Japan
| | - Masahiko Sasaki
- Department of Urology, Tokyo, Teishin Hospital, Tokyo, Japan
| | - Akemi Ito
- Ito Bone Histomorphometry Institute, Niigata, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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Hannarici Z, Uçler R, Yıldız S, Usul Soyoral Y, Alay M. Evaluation of Clinical and Laboratory Factors Affecting Bone Mineral Density Measurements in Patients with Kidney Transplant. J Clin Densitom 2022; 25:343-348. [PMID: 35168896 DOI: 10.1016/j.jocd.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 12/30/2021] [Accepted: 01/04/2022] [Indexed: 11/22/2022]
Abstract
Histological evidence of osteodystrophy and osteopenia is encountered in most patients who have undergone successful renal transplantation. Renal transplantation may be beneficial for correcting uremia-related problems in end-stage renal disease patients; however, its benefit is limited in bone metabolism disorders. The present study aims to evaluate bone mass measurements and investigate the influencing factors in patients with renal transplant. One hundred and eighteen patients (83 males and 35 females) with a mean age of 40.2 ± 11.8 yr (range 20-67) were included in the present study. The laboratory and the clinical data of the patients were retrospectively analyzed. The association between bone mineral density (BMD) measurements and the demographic characteristics of the patients, serum creatinine, parathormone, calcium, phosphorous, alkaline phosphatase, 25-hydroxyvitamin D and the glomerular filtration rate were evaluated. Of the patients, 23.7% (n =28) had normal, 48.3% (n = 57) had osteopenic and 28% (n = 33) had osteoporotic BMD values. A significant positive correlation was determined between the body mass index (BMI) and the BMD measurement results (p = 0.001; r = 0.385). A negative correlation was determined between the BMD values and the serum parathormone (p = 0.012; r = -0.237). BMD values were significantly lower in the group that had not received mammalian target of rapamycin (mTOR) inhibitor (p = 0.026). Conclusion: BMI values, mTOR inhibitor treatment and serum parathormone levels had an effect on the BMD measurement values.
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Affiliation(s)
- Zekeriya Hannarici
- Department of Internal Medicine, Yuzuncu Yıl University, Faculty of Medicine, Van, Turkey.
| | - Rıfkı Uçler
- Department of Endocrinology and Metabolism, Yuzuncu Yıl University, Faculty of Medicine, Van, Turkey
| | - Saliha Yıldız
- Department of Endocrinology and Metabolism, Yuzuncu Yıl University, Faculty of Medicine, Van, Turkey
| | - Yasemin Usul Soyoral
- Department of Nephrology, Yuzuncu Yıl University, Faculty of Medicine, Van, Turkey
| | - Murat Alay
- Department of Endocrinology and Metabolism, Yuzuncu Yıl University, Faculty of Medicine, Van, Turkey
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Jørgensen HS, Behets G, Bammens B, Claes K, Meijers B, Naesens M, Sprangers B, Kuypers DR, Cavalier E, D’Haese P, Evenepoel P. Natural History of Bone Disease following Kidney Transplantation. J Am Soc Nephrol 2022; 33:638-652. [PMID: 35046132 PMCID: PMC8975071 DOI: 10.1681/asn.2021081081] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/09/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Knowledge of the effect of kidney transplantation on bone is limited and fragmentary. The aim of this study was to characterize the evolution of bone disease in the first post-transplant year. METHODS We performed a prospective, observational cohort study in patients referred for kidney transplantation under a steroid-sparing immunosuppressive protocol. Bone phenotyping was done before, or at the time of, kidney transplantation, and repeated at 12 months post-transplant. The phenotyping included bone histomorphometry, bone densitometry by dual-energy x-ray absorptiometry, and biochemical parameters of bone and mineral metabolism. RESULTS Paired data were obtained for 97 patients (median age 55 years; 72% male; 21% of patients had diabetes). Bone turnover remained normal or improved in the majority of patients (65%). Bone histomorphometry revealed decreases in bone resorption (eroded perimeter, mean 4.6% pre- to 2.3% post-transplant; P<0.001) and disordered bone formation (fibrosis, 27% pre- versus 2% post-transplant; P<0.001). Whereas bone mineralization was normal in all but one patient pretransplant, delayed mineralization was seen in 15% of patients at 1 year post-transplant. Hypophosphatemia was associated with deterioration in histomorphometric parameters of bone mineralization. Changes in bone mineral density were highly variable, ranging from -18% to +17% per year. Cumulative steroid dose was related to bone loss at the hip, whereas resolution of hyperparathyroidism was related to bone gain at both spine and hip. CONCLUSIONS Changes in bone turnover, mineralization, and volume post-transplant are related both to steroid exposure and ongoing disturbances of mineral metabolism. Optimal control of mineral metabolism may be key to improving bone quality in kidney transplant recipients. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Evolution of Bone Histomorphometry and Vascular Calcification Before and After Renal Transplantation, NCT01886950.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Geert Behets
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Bert Bammens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Bjorn Meijers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Dirk R.J. Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, Liège, Belgium
| | - Patrick D’Haese
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium .,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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Yajima A, Tsuchiya K, Burr DB, Murata T, Nakamura M, Inaba M, Tominaga Y, Tanizawa T, Nakayama T, Ito A, Nitta K. Micropetrosis in hemodialysis patients. Bone Rep 2021; 15:101150. [PMID: 34926729 PMCID: PMC8649646 DOI: 10.1016/j.bonr.2021.101150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/06/2021] [Accepted: 11/15/2021] [Indexed: 01/03/2023] Open
Abstract
Micropetrosis develops as a result of stagnation of calcium, phosphorus and bone fluid, which appears as highly mineralized bone area in the osteocytic perilacunar/canalicular system regardless of bone turnover of the patients. And microcracks are predisposed to increase in these areas, which leads to increased bone fragility. However, micropetrosis of hemodialysis (HD) patients has not been discussed at all. Micropetrosis area per bone area (Mp.Ar/B·Ar) and osteocyte number per micropetrosis area (Ot.N/Mp.Ar) were measured in nine HD patients with renal hyperparathyroidism (Group I), twelve patients with hypoparathyroidism within 1 year after the treatment of renal hyperparathyroidism (Group II) and seven patients suffering from hypoparathyroidism for over two years (Group III). And bone mineral density (BMD) and tissue mineral density (TMD) were calculated using μCT to evaluate bone mineral content of iliac bone of the patients. These parameters were compared among the three groups. Only Mp.Ar/B·Ar was statistically greater in Group II and III compared to Group I in the parameters of bone mineral content and micropetrosis. However, the other parameters were not statistically different among the three groups. In long-term HD patients, BMD and TMD may be modified by the causes of renal insufficiency and the treatment of renal bone disease. We concluded that Mp.Ar/B·Ar was greater in patients with long-term hypoparathyroidism than both those with short-term hypoparathyroidism and with renal hyperparathyroidism. Special attention should be paid to avoid long-term hypoparathyroidism of the patients from the view point of increased fracture risk caused by increased micropetrosis area.
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Affiliation(s)
- Aiji Yajima
- Department of Anatomy, Cell Biology and Physiology, Indiana University, School of Medicine, Indianapolis, IN, USA.,Department of Urology, Tokyo Teishin Hospital, Tokyo, Japan.,Department of Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Ken Tsuchiya
- Department of Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - David B Burr
- Department of Anatomy, Cell Biology and Physiology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Taro Murata
- Department of Urology, Tokyo Teishin Hospital, Tokyo, Japan
| | - Masaki Nakamura
- Department of Nephrology and Urology, NTT East Kanto Hospital, Tokyo, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshihiro Tominaga
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | | | | | - Akemi Ito
- Ito Bone Histomorphometry Institute, Niigata, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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Xiang T, Zhou L, Fu P, Yan XP, Zeng XQ. Value of quantitative ultrasound and bioelectrical impedance analysis in detecting low bone mineral density in hemodialysis. Ren Fail 2021; 43:1198-1204. [PMID: 34369272 PMCID: PMC8354166 DOI: 10.1080/0886022x.2021.1959347] [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] [Indexed: 02/08/2023] Open
Abstract
Introduction Patients on maintenance hemodialysis (MHD) are highly predisposed to low bone mineral density (BMD). This study aims to assess the value of quantitative ultrasound (QUS), bioelectrical impedance analysis (BIA), and their combination in detecting high-risk patients for low BMD in MHD. Methods Patients’ BMD of the total hip, femoral neck, and lumbar spine were measured using dual-energy X-ray absorptiometry (DXA). Bone mineral content (BMC) was assessed using BIA. Calcaneal BMD was measured using QUS. Patients with a T-score of ≤-2.5 were recorded as ‘low BMD.’ Results Overall, 93 subjects (62.37% female; mean age, 60.8 ± 16.2 years) were included in this cross-sectional study; approximately 36.56% met the ‘low BMD’ criteria. QUS-T score predicted low BMD with an area under the curve (AUC) value of 0.738, sensitivity of 70.59%, and specificity of 76.27%. The AUC for low BMD diagnosis using the BMC index (BMCI) measured through BIA was 0.679 (sensitivity, 91.18%; specificity, 38.98%). On the other hand, the combination of QUS-T score and BMCI yielded a higher AUC value of 0.762 with an improved specificity of 88.14%. Compared with the QUS and BIA alone, the net reclassification improvement (NRI) of the combination model increased by 47.16% (p = 0.022) and 78.36% (p < 0.0001), respectively. Integrated discrimination improvement (IDI) increased by 5.25% (p = 0.043) and 9.99% (p = 0.003), respectively. QUS-T score and BMCI were related to BMD independently assessed by DXA. Conclusion The combination of QUS and BIA is effective in screening for low BMD among MHD patients.
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Affiliation(s)
- Ting Xiang
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Li Zhou
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ping Fu
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xue-Ping Yan
- Division of Nephrology, Kidney Research Institute, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiao-Qing Zeng
- Nutrition Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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10
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Asadipooya K, Abdalbary M, Ahmad Y, Kakani E, Monier-Faugere MC, El-Husseini A. Bone Quality in CKD Patients: Current Concepts and Future Directions - Part I. KIDNEY DISEASES (BASEL, SWITZERLAND) 2021; 7:268-277. [PMID: 34395542 PMCID: PMC8314761 DOI: 10.1159/000515534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND There is ample evidence that patients with CKD have an increased risk of osteoporotic fractures. Bone fragility is not only influenced by low bone volume and mass but also by poor microarchitecture and tissue quality. More emphasis has been given to the quantitative rather than qualitative assessment of bone health, both in general population and CKD patients. Although bone mineral density (BMD) is a very useful clinical tool in assessing bone strength, it may underestimate the fracture risk in CKD patients. Serum and urinary bone biomarkers have been found to be reflective of bone activities and predictive of fractures independently of BMD in CKD patients. Bone quality and fracture risk in CKD patients can be better assessed by utilizing new technologies such as trabecular bone score and high-resolution imaging studies. Additionally, invasive assessments such as bone histology and micro-indentation are useful counterparts in the evaluation of bone quality. SUMMARY A precise diagnosis of the underlying skeletal abnormalities in CKD patients is crucial to prevent further bone loss and fractures. We must consider bone quantity and quality abnormalities for management of CKD patients. Here in this part I, we are focusing on advances in bone quality diagnostics that are expected to help in proper understanding of the bone health in CKD patients. KEY MESSAGES Assessment of bone quality and quantity in CKD patients is essential. Both noninvasive and invasive techniques for the assessment of bone quality are available.
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Affiliation(s)
- Kamyar Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, Kentucky, USA
| | - Mohamed Abdalbary
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
- Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Yahya Ahmad
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Elijah Kakani
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | | | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
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11
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Mineral and bone disorder in chronic kidney disease: pioneering studies. Kidney Int 2020; 98:807-811. [PMID: 32998807 DOI: 10.1016/j.kint.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 11/22/2022]
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12
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Proptosis in a child with chronic kidney disease: Answers. Pediatr Nephrol 2020; 35:789-791. [PMID: 31823042 DOI: 10.1007/s00467-019-04423-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
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13
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Hutchison AJ, Gokal R. Towards Tailored Dialysis Fluids in Capd the Role of Reduced Calcium and Magnesium in Dialysis Fluids. Perit Dial Int 2020. [DOI: 10.1177/089686089201200202] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Ram Gokal
- Renal Dialysis Unit Manchester Royal Infirmary Manchester, United Kingdom
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14
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Weinreich T, Ritz E, Passlick-Deetjen J, Colombi A, Echterhoff H, Geberth S, Mandelbaum A, Kiefer T, Mayer-Wehrstein R, Hild P, Leydig M, Birkner IL, Mielke G, Schillinger-Pokorny C, Nebel M, Rieden K. Long Term Dialysis with Low-Calcium Solution (1.0 Mmol/L) in Capd: Effects on Bone Mineral Metabolism. Perit Dial Int 2020. [DOI: 10.1177/089686089601600308] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Peritoneal dialysate solutions with conventionally high-calcium (Ca) concentrations (1.75 mmol/L) are now widely replaced by solutions with a lower, more physiological calcium content to prevent hypercalcemia in patients treated with oral calcium-containing phosphate binders and/or calcitriol. While there is still debate on how far the dialysate calcium should be lowered (1.25 mmol/L or less), little information is available concerning the effects of a long-term treatment with low-calcium solutions on secondary hyperparathyroidism and bone mineral metabolism in general. Design A prospective, randomized, controlled multicenter study to compare the effects of low-calcium (LCa, dialysate calcium 1.0 mmol/L) versus standard calcium dialysate solution (SCa, dialysate calcium 1.75 mmol/L)on bone mineral metabolism in continuous ambulatory peritoneal dialysis (CAPD) patients over 2 years of treatment. Setting Nephrology and dialysis units of primary and tertiary hospitals in Germany and Switzerland. Patients All CAPD patients in the participating centers between 18 and 80 years of age, stable on CAPD for at least 1 month, free of aluminum bone disease or prior parathyroidectomy were invited to enter the study. Sixty-four patients could be randomly allotted to LCa (n = 35) or SCa (n = 29) treatment in a 2-year protocol; 34 finished the study as planned. Interventions Calcium carbonate (CaCO3) was given as oral phosphate binder to maintain serum phosphate <2.0 mmol/L. If hypercalcemia supervened, CaCO3 was exchanged stepwise for aluminium hydroxide (AI(OH)3)’ until normocalcemia was obtained. Patients received calcitriol (0.25 μg/day per os) if parathyroid hormone (PTH) exceeded the upper limit of normal by a factor of 2 or more. Main Outcome Measures We assessed total and ionized serum calcium, phosphate, serum aluminum, alkaline phosphatase, osteocalcin, PTH (intact molecule), and phosphate binder intake at regular intervals. Measurements of bone mineral density and hand skeleton x-rays were obtained at the start and after 6 months and 2 years, respectively. Results With LCa, mean total and ionized serum calcium levels were within the normal range (total Ca: 2.0 2.6 mmol/L; ionized Ca: 1.19–1.32 mmol/L), but throughout the treatment period were significantly lower than with SCa. The incidence of hypercalcemia (>2.8 mmol/L) was three times higher in patients on SCa, despite the significantly higher amount of AI(OH)3 and less CaCO3 given in this group. In parallel, serum aluminum increased with SCa throughout the study, whereas it was slowly decreasing with LCa. Median PTH levels remained stable at about two times the upper limit of normal over the 2 years of study with LCa. However, 23% of the patients on LCa developed severe hyperparathyroidism, with PTH levels exceeding ten times the upper limit of normal compared to only 10.3% of the patients on SCa. With SCa, median PTH decreased towards near normal levels. Alkaline phosphatase and serum osteocalcin correlated positively with PTH levels. Bone mineral density was in the lower normal range in both groups a n d remained unchanged at the end of the study. Skeletal x-ray films showed only minor alterations in very few patients in both groups with no correlation to serum PTH or treatment modality. Conclusion In CAPD patients low-calcium dialysate solutions can be used successfully over prolonged periods of time with stable control of serum calcium. The risk of hypercalcemia resulting from calcium-containing phosphate binders and the need to use aluminum-containing phosphate binders is markedly diminished. However, there is a certain risk that severe secondary hyperparathyroidism with long-term LCa therapy will develop, even if normocalcemia is maintained. Thus, LCa dialysis requires closeand continuous monitoring of PTH and bone metabolism.
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Affiliation(s)
- Thomas Weinreich
- Department of Internal Medicine, Nephrology Unit, University Hospital, Zurich, Switzerland
| | | | | | - A. Colombi
- (Kantonsspital Luzern)Luzern, Switzerland
| | | | - S. Geberth
- (University of Heidelberg, Department of Nephrology), Heidelberg, Germany
| | - A. Mandelbaum
- (University of Heidelberg, Department of Nephrology), Heidelberg, Germany
| | - T. Kiefer
- (Robert -Bosch Krankenhaus Stuttgart), Stuttgart, Germany
| | | | - P. Hild
- (University Erlangen-Nürnberg, Städtisches Klinikum IV), N ürnberg, Germany
| | - M. Leydig
- (University Erlangen-Nürnberg, Städtisches Klinikum IV), N ürnberg, Germany
| | - I. Lubrich Birkner
- (University of Freiburg/Breisgau, Clinic for Internal Medicine), Freiburg/Breisgau, Germany
| | - G. Mielke
- (Kreiskrankenhaus Offenburg), Offenburg, Germany
| | | | - M. Nebel
- (Städtisches Krankenhaus Merheim), Köln, Germany
| | - K. Rieden
- (Krankenhaus Holweide), Köln, Germany
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15
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Shin SK, Kim DH, Kim HS, Shin KT, Ma KA, Kim SJ, Kwak YS, Ha SK, Sherrard DJ. Renal Osteodystrophy in Pre-Dialysis Patients: Ethnic Difference? Perit Dial Int 2020. [DOI: 10.1177/089686089901902s65] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The purpose of the present study is to investigate whether an ethnic difference exists in the incidence of renal osteodystrophy between Asian and Western countries in end-stage renal disease (ESRD) patients. We evaluated bone histology in 58 pre-dialysis patients (28 male, 30 female; mean age: 47.7 years). All patients had bone biopsies with quantitative histomorphometry and sero-logical parameters such as intact PTH, osteocalcin, total alkaline phosphatase, and basal and deferoxamine-stimulated serum aluminum levels. We observed that 91.4% of all evaluated patients showed renal osteodystrophy before the start of dialytic therapy. Mild osteitis fibrosa were observed in 21 patients (36.2%), severe osteitis fibrosa in 5 patients (8.6%), mixed lesions in 7 patients (12.1 %), osteomalacia in 6 patients (10.3%), aplastic bone disease in 14 patients (24.1%), and normal bone in 5 patients (8.6%). Among the bone histomorphometric parameters, fibrosis area rate (%) showed the best correlation with intact PTH, and osteocalcin and osteoid area rate (%) with total alkaline phosphatase. Aluminum-related bone disease was not observed. Among patients with aplastic bone disease, only 14.3% showed aluminum deposition of any significance (5% < stainable bone surface aluminum < 25%). In the diabetic patients, aplastic bone disease was most common, but no case was related to aluminum intoxication. In conclusion, the distribution of renal osteodystrophy in our study was different from that of Western countries in pre-dialysis patients. Our patients tended to have more mild-form osteitis fibrosa and normal findings, and less severe-form osteitis fibrosa and aplastic bone disease. Aluminum-related bone disease was not observed.
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Affiliation(s)
- Sug Kyun Shin
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Do Hun Kim
- Department of Nephrology and Clinical Pathology, 1 School of Medicine, Ajou University, Suwon
| | - Heung Su Kim
- Department of Nephrology and Clinical Pathology, 1 School of Medicine, Ajou University, Suwon
| | - Kyu Tae Shin
- Department of Nephrology and Clinical Pathology, 1 School of Medicine, Ajou University, Suwon
| | - Kyung Ae Ma
- Department of Nephrology and Clinical Pathology, 1 School of Medicine, Ajou University, Suwon
| | - Sung Jung Kim
- Department of Nephrology and Clinical Pathology, 1 School of Medicine, Ajou University, Suwon
| | - Youn Sik Kwak
- Department of Nephrology and Clinical Pathology, 1 School of Medicine, Ajou University, Suwon
| | - Seung Kyu Ha
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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16
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Anwar N, Hutchison AJ, Gokal R. Comparison of Renal Osteodystrophy in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis and Hemodialysis. Perit Dial Int 2020. [DOI: 10.1177/089686089301302s113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Nisar Anwar
- Department of Renal Medicine, Manchester Royal Infirmary; Manchester, U. K
| | | | - Ram Gokal
- Department of Renal Medicine, Manchester Royal Infirmary; Manchester, U. K
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17
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Buijsen CG, Struijk DG, Huijgen HJ, Boeschoten EW, Wilmink JM. Can Low-Calcium Peritoneal Dialysis Solution Safely Replace the Standard Calcium Solution in the Majority of Chronic Peritoneal Dialysis Patients? Perit Dial Int 2020. [DOI: 10.1177/089686089601600512] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate the use of low-calcium solution as the standard solution in chronic peritoneal dialysis patients. Design Prospective long-term follow-up study over a one-year period. Setting University hospital. Interventions The change of the calcium concentration of the dialysate from 1.75 mmollL to 1.25 mmollL. Main Outcome Measures Serum calcium and phosphorus concentration and intact parathyroid hormone (iPTH). Patients Fifty normo and hypercalcemic patients using the standard 1.75 mmollL calcium solution. Results Serum ionized calcium (iCa) decreased significantly during the first six months, resulting in a significant increment of iPTH (baselinevalue: 0.9 79, median 9.4 pmollL; at six months: 1.1 -111, median 20.6 pmollL; p < 0.05). In 28 patients completing the study, iPTH remained significantly elevated, despite high normal iCa. At similar changes of iCa, patients with baseline iPTH > 20 pmollL showed a significantly higher increase in iPTH than patients with low iPTH (24.0 vs 5.0; p < 0.01), despite a more than doubled dose of alfacalcidol and calcium carbonate (mean dose of 1580 increased to 3277 mg/day). During the follow-up, 21 episodes of hypercalcemia were observed. Phosphorus control was adequate. Conclusions Low-calcium solution cannot be used as a standard solution, especially in patients with iPTH levels indicating mild or severe hyperparathyroidism, because in these patients iPTH may rise further.
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Affiliation(s)
- Coby G.M. Buijsen
- Departments of Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Dirk G. Struijk
- Departments of Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Henk J. Huijgen
- Clinical Chemistry, Academic Medical Center, Amsterdam, the Netherlands
| | - Els W. Boeschoten
- Departments of Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Joep M. Wilmink
- Departments of Medicine, Academic Medical Center, Amsterdam, the Netherlands
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18
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19
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Duncan R, Cochrane T, Bhalla C, Michael J, Richards NT, Adu D. Low Calcium Dialysate and Hyperparathyroidism. Perit Dial Int 2020. [DOI: 10.1177/089686089601601s101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A low calcium dialysate reduces hypercalcemia from calcium-containing phosphate binders and makes phosphate control possible without the use of aluminum salts. We asked whether this might, however, lead to hyperparathyroidism. We prospectively studied serum concentrations of parathyroid hormone levels (by an immunoreactive intact molecule assay) in 173 patients on continuous ambulatory peritoneal dialysis (CAPD) who were started on a low calcium dialysate (Ca2+ 1.25 or 1.00 mmol/L) because of hypercalcemia. Median follow-up was 13.2 months (range 1 -28). Initial serum parathyroid hormone was [median (range)]: 70 (5 -1043) ng/L pre low calcium dialysate, and this rose to 130(5 -914) ng/LatO 6 months; 130 (5 -1030) ng/Lat 6 -12 months; 170 (170 1400) ng/L at 12 -18 months; and 130 (5 -1200) ng/L at 18 24 months (p = 0.0006). Twenty-two patients required a parathyroidectomy because of a sustained rise in parathyroid hormone that was not responsive to alfacalcidol and hypercalcemia. Initial serum parathyroid hormone was significantly higher in these patients at 359 (5 1073) ng/L as compared to a level of 69.5 (6 1147) ng/L in patients who did not have a parathyroidectomy (p = 0.0009). There was a significant sustained fall in mean serum corrected calcium from 2.77 (2.37 3.51) mmol/L to 2.53 (1.39 3.20) mmol/L at three months (p = 0.0006), a nonsignificant rise in mean serum alkaline phosphate from 179 (47 -1858) mmol/L to 191 (55 -1821) mmol/L (p = 0.15), and a fall in mean serum phosphate levels from 1.87 (0.59–3.18) mmol/L to 1.68 (0.45–3.6) mmol/L (p = 0.76). Our data suggest that the benefits of a low calcium dialysate in CAPD patients are balanced by an increased risk of hyperparathyroidism, and that this risk is higher in patients with an initially high serum parathyroid hormone level.
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Affiliation(s)
- Rachel Duncan
- Queen Elizabeth Hospital, Birmingham, United Kingdom
| | | | - Carol Bhalla
- Queen Elizabeth Hospital, Birmingham, United Kingdom
| | | | | | - Dwomoa Adu
- Queen Elizabeth Hospital, Birmingham, United Kingdom
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20
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Ni LH, Yuan C, Song KY, Wang XC, Chen SJ, Wang LT, Zhang YX, Liu H, Liu BC, Tang RN. Efficacy and safety of cinacalcet and active vitamin D in the treatment of secondary hyperparathyroidism in patients with chronic kidney disease: a network meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:322. [PMID: 31475192 DOI: 10.21037/atm.2019.05.84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background We conducted a network meta-analysis (NMA) to evaluate the efficacy and safety of cinacalcet, active vitamin D and cinacalcet plus active vitamin D in the treatment of secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD). Methods A systematic literature search was performed using the Cochrane Library, PubMed, EMBASE, Web of Science, Google Scholar, China National Knowledge Internet (CNKI) and Wanfang databases. In total, eight randomized controlled trials (RCTs) with 1,443 patients were eligible for this meta-analysis. Pairwise meta-analysis was performed to evaluate the compliance of intact parathyroid hormone (iPTH), Ca, P, etc., and the mortality and safety of cinacalcet plus active vitamin D and active vitamin D alone. Then, NMA was used to estimate the safety and efficacy of the administration of active vitamin D and different drugs in the control group. Results The results of the pairwise meta-analysis revealed that compared with active vitamin D monotherapy, cinacalcet plus active vitamin D did not improve the survival of patients but significantly improved the blood calcium compliance rate [relative risk (RR) =1.82, 95% confidence interval (CI): 1.51-2.21, P<0.00001]. Furthermore, it is worth noting that compared with the corresponding incidence with other treatments, the incidence of vomiting was significantly increased with cinacalcet plus active vitamin D treatment (RR =2.07, 95% CI: 1.18-3.65, P=0.01). Through direct and indirect comparisons, the NMA revealed the following results: (I) compared with oral or intravenous (IV) administration of vitamin D, the solely oral administration of active vitamin D increased mortality, and (II) cinacalcet monotherapy increased the risk of hypocalcemia, and that risk was even higher for cinacalcet plus active vitamin D. However, the results should be treated with caution because the prediction interval (PrI) crossed the invalid line. Conclusions This pairwise meta-analysis and NMA provided a comprehensive analysis of the currently utilized CKD-SHPT treatment interventions. This network identified some highly ranked interventions through analyses that were included in a small number of trials; these interventions merit further examination on a larger scale in the context of well-designed RCTs.
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Affiliation(s)
- Li-Hua Ni
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Cheng Yuan
- Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan 430071, China
| | - Kai-Yun Song
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Xiao-Chen Wang
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Si-Jie Chen
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Li-Ting Wang
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Yu-Xia Zhang
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Hong Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Bi-Cheng Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Ri-Ning Tang
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China.,Nanjing Lishui People's Hospital, Zhongda Hospital Lishui Branch, Nanjing 210009, China
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21
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Lip A, Warias A, Shamseddin MK, Thomson B, Wijeratne DT. Effect of Bisphosphonates on Bone Health in Adult Renal Transplant Patients: Beyond the First Year Posttransplant-A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2019; 6:2054358119858014. [PMID: 31263566 PMCID: PMC6595663 DOI: 10.1177/2054358119858014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 04/22/2019] [Indexed: 12/24/2022] Open
Abstract
Background: Bone mineral density (BMD) decreases postrenal transplantation. Evidence
demonstrating the effects of bisphosphonates on BMD and fracture risk beyond
1-year posttransplant is sparse in existing literature, but remains
essential to enhance clinical outcomes in this population. Objective: Our study aimed to systematically review and meta-analyze the current
literature on the use of any bisphosphonate in the adult renal transplant
population beyond the first year of renal transplant to determine its effect
on BMD and fracture incidence. Design: We conducted a systematic review and meta-analysis of primary research
literature that included full-text, English-language, original randomized
clinical trials (RCTs) and observational studies. Setting: Patient data were primarily captured in an outpatient setting across various
studies. Patients: Our population of interest was patients older than 18 years who received
deceased/living donor kidney transplantation and any bisphosphonate with a
follow-up greater than 12 months posttransplantation. Measurements: The primary outcome was change in BMD from baseline. Secondary outcomes were
the incidence of fractures and effects of other confounders on bone
health. Methods: We included RCTs and observational studies that satisfied our inclusion
criteria. Each study was analyzed for risk of bias and data were
extrapolated to analyze for overall statistical significance accounting for
heterogeneity of studies. Results: Sixteen studies (N = 1762) were analyzed. The follow-up ranged from 12 to 98
months. There was a nonsignificant improvement in BMD with bisphosphonate
treatment persisting into the second and third years posttransplant at the
lumbar spine. The calculated standardized mean BMD difference was −0.29
(−0.75 to 0.17), P = .22. Only 5 studies reported a total
of 43 new fractures. Prednisone (P < .01), low body
weight (P < .001), low body mass index
(P < .01), and male gender (P <
.05) correlated with reduced lumbar and femoral BMD. Limitations: Limitations of this review include the use of BMD as a surrogate outcome, the
bias of the included studies, and the incomplete reporting data in numerous
analyzed studies. Conclusions: We demonstrate no statistically significant benefit of bisphosphonate
treatment on BMD beyond the first year postrenal transplantation. Despite
heterogeneity of treatment, a differential nonsignificant improvement in
lumbar spine BMD was consistent and may be clinically relevant. Trial Registration: PROSPERO CRD42019125593
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Affiliation(s)
- Alyssa Lip
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Ashley Warias
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - M Khaled Shamseddin
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Benjamin Thomson
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - D Thiwanka Wijeratne
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
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Eroglu E, Kontas ME, Kocyigit I, Kontas O, Donmez H, Kucuk A, Sipahioglu MH, Tokgoz B, Oymak O. Brown tumor of the thoracic spine presenting with paraplegia in a patient with peritoneal dialysis. CEN Case Rep 2019; 8:227-232. [PMID: 31089951 DOI: 10.1007/s13730-019-00398-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 04/18/2019] [Indexed: 11/26/2022] Open
Abstract
Secondary and tertiary hyperparathyroidism is an important problem of chronic kidney disease. Brown tumor is a benign, unusual, reactive lesion as a result of disturbed bone remodeling, from long-standing increase in parathyroid hormone level. Brown tumors may cause morbidity due to pressure symptoms on neural structures and spontaneous bone fractures. Herein, we presented a peritoneal dialysis patient with tertiary hyperparathyroidism under calcand calcitriol treatment for 4 years due to refusing of the parathyroidectomy operation. She admitted to hospital for sudden onset back pain with difficulty in gait and walking, and imaging studies showed an expansile mass lesion in the thoracic spine. She was operated for mass and diagnosed with brown tumor. After operation, she lost the ability of walking than become paraplegic and she underwent rehabilitation program. Preventive measures including calcitriol and cinacalcet may cause a modest decrease in parathyroid hormone levels but it should be remembered for the development of bone complications such as brown tumor formation in patients with moderate elevated PTH levels, especially those with tertiary hyperparathyroidism. Parathyroidectomy should be performed without delay in these cases.
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Affiliation(s)
- Eray Eroglu
- Division of Nephrology, Department of Internal Medicine, Erciyes University Medical Faculty, 38039, Kayseri, Turkey.
| | - Mustafa Eymen Kontas
- Department of Internal Medicine, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Ismail Kocyigit
- Division of Nephrology, Department of Internal Medicine, Erciyes University Medical Faculty, 38039, Kayseri, Turkey
| | - Olgun Kontas
- Department of Pathology, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Halil Donmez
- Department of Radiology, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Ahmet Kucuk
- Department of Neurosurgery, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Murat Hayri Sipahioglu
- Division of Nephrology, Department of Internal Medicine, Erciyes University Medical Faculty, 38039, Kayseri, Turkey
| | - Bulent Tokgoz
- Division of Nephrology, Department of Internal Medicine, Erciyes University Medical Faculty, 38039, Kayseri, Turkey
| | - Oktay Oymak
- Division of Nephrology, Department of Internal Medicine, Erciyes University Medical Faculty, 38039, Kayseri, Turkey
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Yajima A, Tsuchiya K, Burr DB, Minner DE, Condon KW, Miller CA, Satoh S, Inaba M, Nakayama T, Tanizawa T, Ito A, Nitta K. Osteocytic perilacunar/canalicular turnover in hemodialysis patients with high and low serum PTH levels. Bone 2018; 113:68-76. [PMID: 29738853 DOI: 10.1016/j.bone.2018.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 04/16/2018] [Accepted: 05/02/2018] [Indexed: 01/30/2023]
Abstract
Osteocytic perilacunar/canalicular turnover in hemodialysis patients has not yet been reported. Osteocyte lacunae in lamellar bone and woven bone were classified as eroded surface-, osteoid surface-, and quiescent surface-predominant osteocyte lacunae (ES-Lc, OS-Lc, QS-Lc, respectively) in 55 hemodialysis patients with either high- (n = 45) or low- (n = 10) parathyroid hormone levels, and 19 control subjects without chronic kidney disease. We calculated the area and number of ES-Lc, OS-Lc, and QS-Lc. The mineralized surface on the osteocyte lacunar walls was measured in each group, and compared among the three groups. The shapes of the osteocyte lacunar walls were validated by backscattered electron microscopy. While the number of ES-Lc per bone area (N.ES-Lc/B.Ar) was higher than the number of OS-Lc per bone area (N.OS-Lc/B.Ar) in all groups, N.ES-Lc/B.Ar and N.OS-Lc/B.Ar were greater in high-parathyroid hormone group than in low-parathyroid hormone and control groups. The total volume of ES-Lc per bone area (ES-Lc.Ar/B.Ar) was greater than the total volume of OS-Lc per bone area (OS-Lc.Ar/B.Ar) in both parathyroid hormone groups. However, both lacunar erosion and lacunar formation increased proportionally, suggesting that global coupling between them was maintained. N.ES-Lc/B.Ar was higher in woven bone than in lamellar bone. The rate of OS-Lc stained by tetracycline hydrochloride, the mineralized lacunar surface and the mean area of OS-Lc with Tc obtained from both parathyroid hormone groups were greater than those in the control group. We conclude that osteocytic perilacunar/canalicular turnover is increased in hemodialysis patients with high parathyroid hormone levels. Osteocytic perilacunar/canalicular turnover depends, at least in part, on serum parathyroid hormone level. However, the ideal PTH level for osteocytic perilacunar/canalicular turnover could not be determined but osteocytic osteolysis was predominant in both the high- and low-PTH groups in this study. Thus, attention should be paid to bone loss from the viewpoint of osteocytic perilacunar/canalicular turnover in hemodialysis patients.
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Affiliation(s)
- Aiji Yajima
- Department of Anatomy and Cell Biology, Indiana University, School of Medicine, Indianapolis, IN, USA; Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan.
| | - Ken Tsuchiya
- Department of Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - David B Burr
- Department of Anatomy and Cell Biology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Daniel E Minner
- Department of Integrated Nanosystems Development Institute, Indiana University, Purdue University, Indianapolis, IN, USA
| | - Keith W Condon
- Department of Anatomy and Cell Biology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Caroline A Miller
- Department of Anatomy and Cell Biology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Shigeru Satoh
- Center for Kidney Disease and Transplantation, Akita University Hospital, Akita, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | | | - Akemi Ito
- Ito Bone Histomorphometry Institute, Niigata, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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Cannella G, Messa P. Pathogenesis and Treatment of Secondary Hyperparathyroidism in Chronic Renal Disease. Int J Artif Organs 2018. [DOI: 10.1177/039139889902200101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- G. Cannella
- Nefrologia, Dialisi e Trapianto Renale Ospedale S. Martino, Genova
| | - P. Messa
- Nefrologia, Dialisi e Trapianto Renale Ospedale S. Maria della Misericordia, Udine - Italy
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25
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Couttenye MM, D'Haese PC, De Broe ME. What Considerations Should we Give to Adynamic Bone Disease? Int J Artif Organs 2018. [DOI: 10.1177/039139889802101102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M. M. Couttenye
- Department of Nephrology-Hypertension, University of Antwerp - Belgium
| | - P. C. D'Haese
- Department of Nephrology-Hypertension, University of Antwerp - Belgium
| | - M. E. De Broe
- Department of Nephrology-Hypertension, University of Antwerp - Belgium
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Abstract
When renal disease develops, mineral and vitamin D homeostasis is disrupted, resulting in diverse modifications in bone cells, bone structure and the rate of bone turnover. In end stage renal failure (ESRF) when patients require chronic maintenance dialysis, nearly all of them have abnormal bone histology known as renal osteodystrophy (ROD). Moreover, survival rates of patients on dialysis have increased because of therapeutic improvement and the resultant increase in duration of dialysis has led to a further rise in renal osteodystrophy. Because metabolic bone disease can produce fractures, bone pain, and deformities late in the course of the disease, prevention and early treatment are essential. Serum PTH and various bone markers are commonly used to assess bone changes in ESRF patients, but the diagnosis of underlying bone disease is still rather uncertain. To date, bone biopsy is the most powerful and informative diagnostic tool to provide precise information on the type and severity of renal osteodystrophy, and on the presence and amount of aluminum and strontium deposited in the bone. Bone biopsy is not only useful in clinical settings but also in research to assess the effects of therapies on bone. Although considered an invasive procedure, bone biopsy has been proven to be safe and free from major complications, but the operator's experience and skill is important in further minimizing morbidity. Alternatives to bone biopsy continue to be sought, but the non-invasive bone markers have not been proven to be sufficient in diagnostic performance related to bone turnover, mineralization process and bone cell abnormality. Hence, transiliac bone biopsy remains the gold standard for the diagnosis of renal osteodystrophy.
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Affiliation(s)
- G B Spasovski
- Department of Nephrology, Clinical Center Skopje, University of Skopje--Macedonia.
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Friedl C, Zitt E. Vitamin D prohormone in the treatment of secondary hyperparathyroidism in patients with chronic kidney disease. Int J Nephrol Renovasc Dis 2017; 10:109-122. [PMID: 28546765 PMCID: PMC5436758 DOI: 10.2147/ijnrd.s97637] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Secondary hyperparathyroidism (sHPT) represents the adaptive and very often, finally, maladaptive response of the organism to control the disturbed homeostasis of calcium, phosphorus, and vitamin D metabolism caused by declining renal function in chronic kidney disease (CKD). sHPT leads to cardiovascular and extravascular calcifications and is directly linked to an increased risk of cardiovascular morbidity and mortality as well as excess all-cause mortality. Vitamin D plays an important role in the development of sHPT. CKD patients are characterized by a high prevalence of hypovitaminosis D. Supplementation with both vitamin D prohormones cholecalciferol and ergocalciferol enables the achievement and maintenance of a normal vitamin D status when given in adequate doses over an appropriate treatment period. In patients with earlier stages of CKD, sHPT is influenced by and can be successfully treated with vitamin D prohormone supplementation, whereas in patients with very late stages of CKD and those requiring dialysis, treatment with prohormones seems to be of limited efficacy. This review gives an overview of the pathogenesis of sHPT, summarizes vitamin D metabolism, and discusses the existing literature regarding the role of vitamin D prohormone in the treatment of sHPT in patients with CKD.
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Affiliation(s)
- Claudia Friedl
- Department of Internal Medicine, Clinical Division of Nephrology, Medical University of Graz, Graz
| | - Emanuel Zitt
- Department of Nephrology and Dialysis, Feldkirch Academic Teaching Hospital, Feldkirch, Austria
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Hudson JQ. Secondary Hyperparathyroidism in Chronic Kidney Disease: Focus on Clinical Consequences and Vitamin D Therapies. Ann Pharmacother 2016; 40:1584-93. [PMID: 16912241 DOI: 10.1345/aph.1g724] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To assess vitamin D–based treatment approaches for secondary hyperparathyroidism and its complications. Data Sources: A literature search was performed using MEDLINE (1990–February 28, 2006). Key words used were chronic kidney disease and vitamin D to identify relevant papers published in English. Study Selection and Data Extraction: From the database of articles generated, 48 papers were identified. Titles and abstracts were examined to identify those directly related to the objective. Discussion was expanded through the bibliographies of cited articles. Data Synthesis: The increasing prevalence of chronic kidney disease (CKD) in the US indicates an urgent need for treatment strategies to delay or prevent disease progression. Abnormalities in phosphorus and calcium homeostasis, vitamin D levels, and the subsequent development of secondary hyperparathyroidism (SHPT) are secondary complications of CKD associated with increased morbidity and mortality. Management options include dietary phosphorus restriction, phosphate binders and/or calcium supplementation, vitamin D supplementation, and calcimimetics. Vitamin D supplementation has received increased attention given the prevalence of vitamin D deficiency in patients with CKD and the beneficial effect of correcting this deficiency. Conclusions: Early identification and intervention appropriate to the stage of CKD are likely to improve patient outcomes. Improved knowledge of interactions between vitamin D and vitamin D receptors has led to the development of vitamin D analogs and calcimimetics, which offer benefits in the management of SHPT. Integrating available treatment options into practice to achieve optimal therapeutic goals of SHPT based on the stage of CKD is a significant challenge for pharmacists managing patients with CKD.
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Affiliation(s)
- Joanna Q Hudson
- Department of Clinical Pharmacy, The University of Tennessee, Memphis, TN 38163-0001, USA.
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Krishnasamy R, Hawley CM, Johnson DW. An update on bone imaging and markers in chronic kidney disease. Expert Rev Endocrinol Metab 2016; 11:455-466. [PMID: 30058917 DOI: 10.1080/17446651.2016.1239527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Bone disorders in chronic kidney disease (CKD) are associated with heightened risks of fractures, vascular calcification, poor quality of life and mortality compared to the general population. However, diagnosis and management of these disorders in CKD are complex and appreciably limited by current diagnostic modalities. Areas covered: Bone histomorphometry remains the gold standard for diagnosis but is not widely utilised and lacks feasibility as a monitoring tool. In practice, non-invasive imaging and biochemical markers are preferred to guide therapeutic decisions. Expert commentary: This review aims to summarize the risk factors for, and spectrum of bone disease in CKD, as well as appraise the clinical utility of dual energy X-ray densitometry, peripheral quantitative computed tomography, high-resolution peripheral quantitative computed tomography, and bone turnover markers.
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Affiliation(s)
- Rathika Krishnasamy
- a Department of Nephrology , Nambour General Hospital , Nambour , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
| | - Carmel M Hawley
- b Department of Nephrology , Princess Alexandra Hospital , Brisbane , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
- d Department of Nephrology , Translation Research Institute , Brisbane , Australia
| | - David W Johnson
- b Department of Nephrology , Princess Alexandra Hospital , Brisbane , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
- d Department of Nephrology , Translation Research Institute , Brisbane , Australia
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Melek E, Aynacı S, Atmış B, Yöntem A, Uğuz A, Bayazıt AK. A rare manifestation of renal osteodystrophy in a non-compliant child on hemodialysis: Answers. Pediatr Nephrol 2016; 31:1451-3. [PMID: 25966786 DOI: 10.1007/s00467-015-3124-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 04/14/2015] [Accepted: 04/27/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Engin Melek
- Department of Pediatric Nephrology, Cukurova University, Adana, Turkey.
| | - Sercan Aynacı
- Department of Pediatric Nephrology, Cukurova University, Adana, Turkey
| | - Bahriye Atmış
- Department of Pediatric Nephrology, Cukurova University, Adana, Turkey
| | - Ahmet Yöntem
- Department of Pediatric Nephrology, Cukurova University, Adana, Turkey
| | - Aysun Uğuz
- Department of Pathology, Cukurova University, Adana, Turkey
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Cao Z, Liu D, Zhang Q, Sun X, Li Y. Aluminum Chloride Induces Osteoblasts Apoptosis via Disrupting Calcium Homeostasis and Activating Ca(2+)/CaMKII Signal Pathway. Biol Trace Elem Res 2016; 169:247-53. [PMID: 26138010 DOI: 10.1007/s12011-015-0417-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 06/17/2015] [Indexed: 12/16/2022]
Abstract
Aluminum promotes osteoblast (OB) apoptosis. Apoptosis is induced by the disordered calcium homeostasis. Therefore, to investigate the relationship between Al-induced OB apoptosis and calcium homeostasis, calvarium OBs from neonatal rats (3-4 days) were cultured and exposed to 0.048-mg/mL Al(3+) or 0.048-mg/mL Al(3+) combined with 5 μM BAPTA-AM (OBs were pretreated with 5 μM BAPTA-AM for 1 h, then added 0.048 mg/mL Al(3+)), respectively. Then OB apoptosis rate, intracellular calcium ions concentration ([Ca(2+)]i), mRNA expression level of calmodulin (CaM), and protein expression levels of CaM and p-CaMKII in OBs were examined. The result showed that AlCl3 increased OB apoptosis rate, and [Ca(2+)]i and p-CaMKII expression levels and decreased CaM expression levels, whereas BAPTA-AM relieved the effects. These results proved that AlCl3 induced OB apoptosis by disrupting the intracellular Ca(2+) homeostasis and activating the Ca(2+)/CaMKII signal pathway. Our findings can provide new insights for revealing the apoptosis mechanism of OBs exposed to AlCl3.
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Affiliation(s)
- Zheng Cao
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, 150030, China
| | - Dawei Liu
- Heilongjiang Province Hospital, Harbin, 150036, China
- School Basic Medical Sciences, Heilongjiang University of Chinese Medicine, Harbin, 150040, China
| | - Qiuyue Zhang
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, 150030, China
| | - Xudong Sun
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, 150030, China
| | - Yanfei Li
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, 150030, China.
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Tanaka M, Komaba H, Itoh K, Matsushita K, Matshushita K, Hamada Y, Fujii H, Fukagawa M. The whole-PTH/intact-PTH ratio is a useful predictor of severity of secondary hyperparathyroidism. NDT Plus 2015; 1:iii59-iii62. [PMID: 25983976 PMCID: PMC4421130 DOI: 10.1093/ndtplus/sfn089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Accepted: 02/29/2008] [Indexed: 11/23/2022] Open
Abstract
Background. The newer parathyroid hormone (PTH) assay, whole-PTH, uses an antibody that binds the region harbouring the first amino acid, making it specific for the complete molecule, 1–84-PTH. Especially among dialysis patients, it has been reported that the level of whole-PTH can be calculated as ∼60% of their intact-PTH value. In addition, since 1–84-PTH is part of intact-PTH, the whole-PTH/intact-PTH ratio should not theoretically exceed 1. However, an abnormally high 1–84-PTH/intact-PTH ratio is reported in a few patients with parathyroid carcinoma, primary hyperparathyroidism and secondary hyperparathyroidism. In this study, we examined the correlation between the 1–84-PTH/intact-PTH ratio and the severity of hyperparathyroidism in patients on haemodialysis (HD). Patients and methods. The study population comprised 196 HD patients (males 113, females 83, age 67.4 ± 13.6 years, HD period 8.1 ± 7.3 years; mean ± SD). The whole-PTH/intact-PTH ratio was compared in patients with high PTH levels (intact-PTH ≥300 pg/ ml; high PTH group, n = 32), moderate PTH levels (intact-PTH >150–<300 pg/ml; moderate PTH group, n = 50) and low PTH levels (intact-PTH <150 pg/ml; low PTH group, n = 114). The ratio was also compared in 25 patients with at least one enlarged gland >0.5 cm3 suggesting nodular hyperplasia, as determined by power Doppler ultrasonography (hyperplasia group) with seven patients without enlarged gland (non-hyperplasia group) and six patients who had undergone total parathyroidectomy (post-PTx group). Results. The whole-PTH/intact-PTH ratio of the high PTH group (0.68 ± 0.1) was significantly higher than those of the moderate (0.61 ± 0.1, P < 0.001) and low (0.52 ± 0.1, P < 0.001) groups. Moreover, the ratio was significantly higher in the hyperplasia group (0.70 ± 0.1) than those in the non-hyperplasia group (0.59 ± 0.1, P < 0.05) and post-PTx group (0.456 ± 0.12, P < 0.001). Conclusions. The whole-PTH/intact-PTH ratio correlated with the severity of hyperparathyroidism. Our results suggest that the ratio might be a useful predictor of severity of secondary hyperparathyroidism in HD patients.
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Affiliation(s)
| | - Hirotaka Komaba
- Division of Nephrology and Kidney Center , Kobe University School of Medicine , Kobe , Japan
| | - Kazuko Itoh
- Department of Nephrology, Akebono Clinic, Kumamoto
| | | | | | - Yasuhiro Hamada
- Division of Nephrology and Kidney Center , Kobe University School of Medicine , Kobe , Japan
| | - Hideki Fujii
- Division of Nephrology and Kidney Center , Kobe University School of Medicine , Kobe , Japan
| | - Masafumi Fukagawa
- Division of Nephrology and Kidney Center , Kobe University School of Medicine , Kobe , Japan
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Zuckier LS, Martineau P. Altered Biodistribution of Radiopharmaceuticals Used in Bone Scintigraphy. Semin Nucl Med 2015; 45:81-96. [DOI: 10.1053/j.semnuclmed.2014.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Low parathyroid hormone levels in patients who underwent/would undergo hemodialysis result in bone graft failure after posterolateral fusion. Spine (Phila Pa 1976) 2014; 39:327-31. [PMID: 24299716 DOI: 10.1097/brs.0000000000000132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case series. OBJECTIVE To reveal the association between levels of parathyroid hormone (PTH) and outcome of bone fusion in patients who underwent/would undergo hemodialysis. SUMMARY OF BACKGROUND DATA Among the different bone lesions observed in patients who underwent/would undergo hemodialysis, adynamic bone disease is regarded as a factor associated with bone graft failure because of severely reduced bone turnover. Although PTH levels reflect the pathological findings of bone lesions in patients who underwent/would undergo hemodialysis, the relationship between PTH levels and the outcome of bone fusion in patients who underwent/would undergo hemodialysis has not been investigated. METHODS Patients who underwent/would undergo hemodialysis (n = 48) with lumbar spine lesion underwent posterolateral spinal fusion with instrumentation. The outcome of bone fusion was assessed radiographically 12 months after surgery, and sensitivity and specificity were determined using preoperative PTH levels as the standard. RESULTS A significant difference in PTH levels was observed between the good fusion (mean, 235.4 pg/mL) and poor fusion (mean, 100.0 pg/mL) groups. The intersection of the sensitivity and specificity plots, generated using preoperative PTH levels, was 150 pg/mL, and the area under the receiver operating characteristic curve was 0.72. CONCLUSION Low PTH levels are a risk factor for bone graft failure in patients who underwent/would undergo hemodialysis. Accordingly, PTH level can be a useful predictor of the outcome of bone fusion. LEVEL OF EVIDENCE 4.
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Yousaf F, Charytan C. Review of cinacalcet hydrochloride in the management of secondary hyperparathyroidism. Ren Fail 2013; 36:131-8. [DOI: 10.3109/0886022x.2013.832319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Abstract
Childhood and adolescence are crucial times for the development of a healthy skeletal and cardiovascular system. Disordered mineral and bone metabolism accompany chronic kidney disease (CKD) and present significant obstacles to optimal bone strength, final adult height, and cardiovascular health. Early increases in bone and plasma fibroblast growth factor 23 (FGF23) are associated with early defects in skeletal mineralization. Later in the course of CKD, secondary hyperparathyroidism--caused by a combination of declining calcitriol values and phosphate retention--results in high-turnover renal osteodystrophy whereas increased levels of both phosphate and FGF23 contribute to cardiovascular disease. Treatment of hyperphosphatemia and secondary hyperparathyroidism improves high-turnover bone disease but fails to correct defects in skeletal mineralization. Because overtreatment may result in adynamic bone disease, growth failure, hypercalcemia, and progression of cardiovascular calcifications, therapy therefore must be titrated carefully to maintain optimal serum biochemical parameters according to stage of CKD. Newer therapeutic agents and new treatment paradigms may suppress serum PTH levels effectively while limiting intestinal calcium absorption and skeletal FGF23 stimulation and may provide future therapeutic alternatives for children with CKD.
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Affiliation(s)
- Katherine Wesseling-Perry
- Department of Pediatrics, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA 90095, USA.
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37
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de Oliveira RB, Graciolli FG, dos Reis LM, Cancela ALE, Cuppari L, Canziani ME, Carvalho AB, Jorgetti V, Moyses RMA. Disturbances of Wnt/ -catenin pathway and energy metabolism in early CKD: effect of phosphate binders. Nephrol Dial Transplant 2013; 28:2510-7. [DOI: 10.1093/ndt/gft234] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Ueyama T, Yamamoto Y, Ueda K, Yajima A, Maeda Y, Yamashita Y, Ito T, Tsuruo Y, Ichinose M. Is gastrectomy-induced high turnover of bone with hyperosteoidosis and increase of mineralization a typical osteomalacia? PLoS One 2013; 8:e65685. [PMID: 23776526 PMCID: PMC3679169 DOI: 10.1371/journal.pone.0065685] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 04/26/2013] [Indexed: 11/19/2022] Open
Abstract
Gastrectomy (GX) is thought to result in osteomalacia due to deficiencies in Vitamin D and Ca. Using a GX rat model, we showed that GX induced high turnover of bone with hyperosteoidosis, prominent increase of mineralization and increased mRNA expression of both osteoclast-derived tartrate-resistant acid phosphatase 5b and osteocalcin. The increased 1, 25(OH)2D3 level and unchanged PTH and calcitonin levels suggested that conventional bone and Ca metabolic pathways were not involved or changed in compensation. Thus, GX-induced bone pathology was different from a typical osteomalacia. Gene expression profiles through microarray analysis and data mining using Ingenuity Pathway Analysis indicated that 612 genes were up-regulated and 1,097 genes were down-regulated in the GX bone. These genes were related functionally to connective tissue development, skeletal and muscular system development and function, Ca signaling and the role of osteoblasts, osteoclasts and chondrocytes. Network analysis indicated 9 genes (Aldehyde dehydrogenase 1 family, member A1; Aquaporin 9; Interleukin 1 receptor accessory protein; Very low density lipoprotein receptor; Periostin, osteoblast specific factor; Aggrecan; Gremlin 1; Angiopoietin-like 4; Wingless-type MMTV integration site family, member 10B) were hubs connected with tissue development and immunological diseases. These results suggest that chronic systemic inflammation might underlie the GX-induced pathological changes in bone.
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Affiliation(s)
- Takashi Ueyama
- Department of Anatomy and Cell Biology, Wakayama Medical University Graduate School of Medicine, Wakayama, Japan.
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Wesseling-Perry K, Jüppner H. The osteocyte in CKD: new concepts regarding the role of FGF23 in mineral metabolism and systemic complications. Bone 2013; 54:222-9. [PMID: 23079136 PMCID: PMC3582844 DOI: 10.1016/j.bone.2012.10.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 10/01/2012] [Accepted: 10/04/2012] [Indexed: 12/23/2022]
Abstract
The identification of elevated circulating levels of the osteocytic protein fibroblast growth factor 23 (FGF23) in patients with chronic kidney disease (CKD), along with recent data linking these values to the pathogenesis of secondary hyperparathyroidism and to systemic complications, has changed the approach to the pathophysiology and treatment of disordered bone and mineral metabolism in renal failure. It now appears that osteocyte biology is altered very early in the course of CKD and these changes have implications for bone biology, as well as for progressive cardiovascular and renal disease. Since circulating FGF23 values are influenced by therapies used to treat secondary hyperparathyroidism, the effects of different therapeutic paradigms on FGF23 have important implications for mineral metabolism as well as for morbidity and mortality. Further studies are critically needed to identify the initial trigger for abnormalities of skeletal mineralization and turnover as well as the potential effects that current therapeutic options may have on osteocyte biology.
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Yajima A, Inaba M, Tominaga Y, Tanaka M, Otsubo S, Nitta K, Ito A, Satoh S. Impact of Lanthanum Carbonate on Cortical Bone in Dialysis Patients with Adynamic Bone Disease. Ther Apher Dial 2013; 17 Suppl 1:41-8. [DOI: 10.1111/1744-9987.12038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Indexed: 01/01/2023]
Affiliation(s)
| | - Masaaki Inaba
- Department of Metabolism; Endocrinology and Molecular Medicine; Osaka City University Graduate School of Medicine; Abeno-ku; Osaka
| | - Yoshihiro Tominaga
- Department of Endocrine Surgery; Nagoya Second Red Cross Hospital; Aichi
| | | | | | - Kosaku Nitta
- Department of Medicine; Tokyo Women's Medical University; Tokyo
| | - Akemi Ito
- Ito Bone Histomorphometry Institute; Niigata; Japan
| | - Shigeru Satoh
- Division of Renal Replacement Therapeutic Science; Akita University School of Medicine; Akita
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Do WS, Park JK, Park MI, Kim HS, Kim SH, Lee DH. Bisphosphonate-induced Severe Hypocalcemia - A Case Report -. J Bone Metab 2012; 19:139-45. [PMID: 24524045 PMCID: PMC3780919 DOI: 10.11005/jbm.2012.19.2.139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 09/18/2012] [Accepted: 10/17/2012] [Indexed: 12/30/2022] Open
Abstract
Bisphosphonate generally seems to be safe, but hypocalcemia may occasionally develop in the course of bisphosphonate treatment. Hypocalcemia induced by bisphosphonate is usually mild and asymptomatic, but unrecognized or poorly treated hypocalcemia can lead to life-threatening state. A 78-year-old woman who had a history of hip arthroplasty and intravenous zoledronate treatment for femur neck fracture was presented to emergency department with altered mental status. It turned out that her symptom was due to severe hypocalcemia which was caused by intravenous zoledronate treatment. She also had renal dysfunction. She was treated by intravenous calcium gluconate and calcitriol administration. This case supports the need for evaluation of renal dysfunction, vitamin D deficiency and parathyroid gland dysfunction before bisphosphonate treatment and accurate monitoring of plasma calcium and creatinine levels. In addition, vitamin D and calcium supply during treatment with bisphosphonate is mandatory.
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Affiliation(s)
- Won-Seok Do
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jin-Kyung Park
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Myung-Il Park
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Hyeong-Seok Kim
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Sung-Ho Kim
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Duk-Hyun Lee
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
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Coco M, Pullman J, Cohen HW, Lee S, Shapiro C, Solorzano C, Greenstein S, Glicklich D. Effect of risedronate on bone in renal transplant recipients. J Am Soc Nephrol 2012; 23:1426-37. [PMID: 22797188 DOI: 10.1681/asn.2011060623] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Bisphosphonates may prevent or treat the bone loss promoted by the immunosuppressive regimens used in renal transplantation. Risedronate is a commonly used third-generation amino-bisphosphonate, but little is known about its effects on the bone health of renal transplant recipients. We randomly assigned 42 new living-donor kidney recipients to either 35 mg of risedronate weekly or placebo for 12 months. We obtained bone biopsies at the time of renal transplant and after 12 months of protocol treatment. Treatment with risedronate did not affect bone mineral density (BMD) in the overall cohort. In subgroup analyses, it tended to preserve BMD in female participants but did not significantly affect the BMD of male participants. Risedronate did associate with increased osteoid volume and trabecular thickness in male participants, however. There was no evidence for the development of adynamic bone disease. In summary, further study is needed before the use of prophylactic bisphosphonates to attenuate bone loss can be recommended in renal transplant recipients.
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Affiliation(s)
- Maria Coco
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
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Jiang JQ, Lin S, Xu PC, Zheng ZF, Jia JY. Serum osteoprotegerin measurement for early diagnosis of chronic kidney disease-mineral and bone disorder. Nephrology (Carlton) 2011; 16:588-94. [PMID: 21649792 DOI: 10.1111/j.1440-1797.2011.01481.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Chronic kidney disease-mineral and bone disorder (CKD-MBD) has been proposed to be the replacement of renal osteodystrophy by the Organization of Kidney Disease: Improving Global Outcomes since 2005 because the mineral disorder is not confined to the skeleton in CKD. Accordingly, laboratory and imaging tests have been emphasized for the clinical assessment of patients with CKD besides renal biopsy. The objective of the current study was to investigate whether osteoprotegerin (OPG) could be made a useful biomarker for early diagnosis of CKD-MBD. METHODS Sixty pre-dialysis patients with CKD 1-5 were enrolled in this study. The serum calcium, phosphorus, blood urea nitrogen, creatinine, alkaline phosphatase, Osteocalcin, Calcitonin, intact parathyroid hormone and OPG were measured. Bone mineral densities of the lumbar spine (L2-L4), femoral neck, Ward's triangle and trochanter were measured by dual-energy X-ray absorptiometry. RESULTS Among all measured serum bone metabolism indexes, the changing of serum OPG level happened at the earliest time (CKD 3) and its correlation coefficient with estimated glomerular filtration rate (eGFR) was also the highest (r = -0.601, P = 0.001). In the multivariable analysis that included sex, age and eGFR as controlling factors, the serum OPG correlated with the bone mineral density (BMD) of Ward's triangle (r = -0.390, P = 0.041). CONCLUSION Serum OPG may be a useful biomarker for early diagnosis of CKD-MBD.
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Affiliation(s)
- Jian-Qing Jiang
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
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Mitchell E, Frisbie S, Sarkar B. Exposure to multiple metals from groundwater-a global crisis: geology, climate change, health effects, testing, and mitigation. Metallomics 2011; 3:874-908. [PMID: 21766119 DOI: 10.1039/c1mt00052g] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This paper presents an overview of the global extent of naturally occurring toxic metals in groundwater. Adverse health effects attributed to the toxic metals most commonly found in groundwater are reviewed, as well as chemical, biochemical, and physiological interactions between these metals. Synergistic and antagonistic effects that have been reported between the toxic metals found in groundwater and the dietary trace elements are highlighted, and common behavioural, cultural, and dietary practices that are likely to significantly modify health risks due to use of metal-contaminated groundwater are reviewed. Methods for analytical testing of samples containing multiple metals are discussed, with special attention to analytical interferences between metals and reagents. An overview is presented of approaches to providing safe water when groundwater contains multiple metallic toxins.
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Mirza MA, Karlsson MK, Mellström D, Orwoll E, Ohlsson C, Ljunggren O, Larsson TE. Serum fibroblast growth factor-23 (FGF-23) and fracture risk in elderly men. J Bone Miner Res 2011; 26:857-64. [PMID: 20928885 DOI: 10.1002/jbmr.263] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A normal mineral metabolism is integral for skeletal development and preservation of bone integrity. Fibroblast growth factor 23 (FGF-23) is a bone-derived circulating factor that decreases serum concentrations of inorganic phosphorous (P(i)) and 1,25-dihydroxyvitamin D(3) [1,25(OH)(2)D(3)]. Increased FGF-23 expression is a direct or indirect culprit in several skeletal disorders; however, the relation between FGF-23 and fracture risk remains undetermined. We evaluated the prospective relation between serum intact FGF-23 (measured by a two-site monoclonal antibody ELISA) and fracture risk employing the Swedish part of the population-based Osteoporotic Fractures in Men Study (MrOS; n = 2868; mean age 75.4 ± 3.2 years; median follow-up period 3.35 years). The incidence of at least one validated fracture after baseline was 20.4 per 1000 person-years. FGF-23 was directly related to the overall fracture risk [age-adjusted hazard ratio (HR) per SD increase = 1.20, 95% confidence interval (CI) 1.03-1.40] and vertebral fracture risk (HR = 1.33, 95% CI 1.02-1.75). Spline models revealed a nonlinear relation between FGF-23 and fracture risk, with the strongest relation at FGF-23 levels above 55.7 pg/mL. FGF-23 levels above 55.7 pg/mL also were associated with an increased risk for hip and nonvertebral fractures (HR = 2.30, 95% CI 1.16-4.58, and HR = 1.63, 95% CI 1.01-2.63, respectively). These relations remained essentially unaltered after adjustment for bodymass index (BMI), bone mineral density (BMD), glomerular filtration rate, 25(OH)(2)D(3), parathyroid hormone (PTH), and other fracture risk factors. In conclusion, FGF-23 is a novel predictor of fracture risk in elderly men.
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Affiliation(s)
- Majd Ai Mirza
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden.
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Hruska KA, Mathew S. The roles of the skeleton and phosphorus in the CKD mineral bone disorder. Adv Chronic Kidney Dis 2011; 18:98-104. [PMID: 21406294 DOI: 10.1053/j.ackd.2011.01.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 01/04/2011] [Accepted: 01/06/2011] [Indexed: 12/18/2022]
Abstract
The CKD mineral bone disorder is a new term coined to describe the multiorgan system failure that is a major component of the excess cardiovascular mortality and morbidity complicating decreased kidney function. This syndrome embodies new discoveries of organ-to-organ communication including the skeletal hormone fibroblast growth factor-23 (FGF-23), which signals the status of skeletal mineral deposition to the kidney. The CKD mineral bone disorder begins with mild decreases in kidney function (stage 2 CKD) affecting the skeleton, as marked by increased FGF-23 secretion. At this stage, the stimulation of cardiovascular risk has begun and the increases in FGF-23 levels are strongly predictive of cardiovascular events. Later in CKD, hyperphosphatemia ensues when FGF-23 and hyperparathyroidism are no longer sufficient to maintain phosphate excretion. Hyperphosphatemia has been shown to be a direct stimulus to several cell types including vascular smooth muscle cells migrating to the neointima of atherosclerotic plaques. Phosphorus stimulates FGF-23 secretion by osteocytes and expression of the osteoblastic transcriptome, thereby increasing extracellular matrix mineralization in atherosclerotic plaques, hypertrophic cartilage, and skeletal osteoblast surfaces. In CKD, the skeleton positively contributes to hyperphosphatemia through excess bone resorption and inhibition of matrix mineralization. Thus, through the action of phosphorus, FGF-23, and other newly discovered skeletal hormones, such as osteocalcin, the skeleton plays an important role in the occurrence of cardiovascular morbidity in CKD.
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Zitt E, Jäger C, Rosenkranz AR, Eigner M, Kodras K, Kovarik J, Graf H, Pétavy F, Horn S, Watschinger B. Effective use of cinacalcet for the treatment of secondary hyperparathyroidism in Austrian dialysis patients--results of the Austrian cohort of the ECHO study. Wien Klin Wochenschr 2011; 123:45-52. [PMID: 21253777 DOI: 10.1007/s00508-010-1515-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 11/18/2010] [Indexed: 01/27/2023]
Abstract
BACKGROUND Despite extensive use of standard therapy for secondary hyperparathyroidism (sHPT) in dialysis patients, still most patients do not achieve the recommended treatment targets. In a pan-European observational study (ECHO), the effectiveness of the calcimimetic cinacalcet for the treatment of sHPT was evaluated in real-world clinical practice. A sub-analysis of the entire Austrian study cohort is presented. METHODS Adult dialysis patients who had initiated cinacalcet therapy were included. Data on biochemical parameters of bone and mineral metabolism (intact parathyroid hormone [iPTH], calcium [Ca] and phosphorus [P]) and concurrent medication were collected 6 months prior to the initiation of cinacalcet, at initiation (baseline) and after up to 12 months of active treatment. RESULTS A total of 320 patients (mean age (±SD): 56 (±14) years) from 34 Austrian dialysis centres were enrolled. At baseline, patients presented with elevated serum iPTH (median 605 pg/ml) and hyperphosphataemia (median 2.1 mmol/l). After 12 months of cinacalcet treatment, serum iPTH (median percentage change -48%), calcium (-2%) and phosphorus (-6%) decreased. The greatest iPTH reduction (-66%) was found in patients with most severe sHPT (>800 pg/ml at baseline). The proportion of patients achieving the recommended NKF/K-DOQI(™) treatment targets increased from baseline to month 12 for iPTH (3-36%) and phosphorus (24 to 39%) and remained stable for calcium (51 to 50%), respectively. No patient had all 3 parameters simultaneously within NKF/K-DOQI(™) treatment targets at baseline, while 7% of patients achieved this treatment goal after 12 months. During the study the use of the phosphate binder sevelamer remained fairly stable, while the relative percentage use of calcium-based phosphate binders increased and the usage of aluminium-containing binders decreased; vitamin D analogue use remained stable. CONCLUSION Additional use of cinacalcet improved biochemical parameters of bone and mineral metabolism and enabled more patients to achieve and maintain the KDOQI(™) treatment targets for serum iPTH, calcium and phosphorus.
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Affiliation(s)
- Emanuel Zitt
- Department of Nephrology and Dialysis, LKH Feldkirch, Feldkirch, Austria.
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Cejka D, Herberth J, Branscum AJ, Fardo DW, Monier-Faugere MC, Diarra D, Haas M, Malluche HH. Sclerostin and Dickkopf-1 in renal osteodystrophy. Clin J Am Soc Nephrol 2010; 6:877-82. [PMID: 21164019 DOI: 10.2215/cjn.06550810] [Citation(s) in RCA: 189] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES The serum proteins sclerostin and Dickkopf-1 (Dkk-1) are soluble inhibitors of canonical wnt signaling and were recently identified as components of parathyroid hormone (PTH) signal transduction. This study investigated the associations between sclerostin and Dkk-1 with histomorphometric parameters of bone turnover, mineralization, and volume in stage 5 chronic kidney disease patients on dialysis (CKD-5D). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a cross-sectional study, 60 CKD-5D patients underwent bone biopsies followed by histomorphometry. Levels of sclerostin, Dkk-1, and intact PTH (iPTH) were determined in blood. RESULTS Serum levels of sclerostin and iPTH correlated negatively. In unadjusted analyses, sclerostin correlated negatively with histomorphometric parameters of turnover, osteoblastic number, and function. In adjusted analyses, sclerostin remained a strong predictor of parameters of bone turnover and osteoblast number. An observed correlation between sclerostin and cancellous bone volume was lost in regression analyses. Sclerostin was superior to iPTH for the positive prediction of high bone turnover and number of osteoblasts. In contrast, iPTH was superior to sclerostin for the negative prediction for high bone turnover and had similar predictive values than sclerostin for the number of osteoblasts. Serum levels of Dkk-1 did not correlate with iPTH or with any histomorphometric parameter. CONCLUSIONS Our data describe a promising role for serum measurements of sclerostin in addition to iPTH in the diagnosis of high bone turnover in CKD-5D patients, whereas measurements of Dkk-1 do not seem to be useful for this purpose.
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Affiliation(s)
- Daniel Cejka
- Division of Nephrology, Medical University Vienna, Vienna, Austria
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Wagner SE, Burch JB, Bottai M, Pinney SM, Puett R, Porter D, Vena JE, Hébert JR. Hypertension and hematologic parameters in a community near a uranium processing facility. ENVIRONMENTAL RESEARCH 2010; 110:786-97. [PMID: 20889151 PMCID: PMC2978648 DOI: 10.1016/j.envres.2010.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 08/16/2010] [Accepted: 09/10/2010] [Indexed: 05/03/2023]
Abstract
BACKGROUND Environmental uranium exposure originating as a byproduct of uranium processing can impact human health. The Fernald Feed Materials Production Center functioned as a uranium processing facility from 1951 to 1989, and potential health effects among residents living near this plant were investigated via the Fernald Medical Monitoring Program (FMMP). METHODS Data from 8216 adult FMMP participants were used to test the hypothesis that elevated uranium exposure was associated with indicators of hypertension or changes in hematologic parameters at entry into the program. A cumulative uranium exposure estimate, developed by FMMP investigators, was used to classify exposure. Systolic and diastolic blood pressure and physician diagnoses were used to assess hypertension; and red blood cells, platelets, and white blood cell differential counts were used to characterize hematology. The relationship between uranium exposure and hypertension or hematologic parameters was evaluated using generalized linear models and quantile regression for continuous outcomes, and logistic regression or ordinal logistic regression for categorical outcomes, after adjustment for potential confounding factors. RESULTS Of 8216 adult FMMP participants 4187 (51%) had low cumulative uranium exposure, 1273 (15%) had moderate exposure, and 2756 (34%) were in the high (>0.50 Sievert) cumulative lifetime uranium exposure category. Participants with elevated uranium exposure had decreased white blood cell and lymphocyte counts and increased eosinophil counts. Female participants with higher uranium exposures had elevated systolic blood pressure compared to women with lower exposures. However, no exposure-related changes were observed in diastolic blood pressure or hypertension diagnoses among female or male participants. CONCLUSIONS Results from this investigation suggest that residents in the vicinity of the Fernald plant with elevated exposure to uranium primarily via inhalation exhibited decreases in white blood cell counts, and small, though statistically significant, gender-specific alterations in systolic blood pressure at entry into the FMMP.
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Affiliation(s)
- Sara E Wagner
- College of Public Health, Department of Epidemiology and Biostatistics, Paul D. Coverdell Center for Biomedical and Health Sciences, University of Georgia, 500 D.W. Brooks Drive, Athens, GA 30602-7396, USA.
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