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Arroyo E, Leber CA, Burney HN, Li Y, Li X, Lu TS, Jones G, Kaufmann M, Ting SMS, Hiemstra TF, Zehnder D, Lim K. Epimeric vitamin D and cardiovascular structure and function in advanced CKD and after kidney transplantation. Nephrol Dial Transplant 2024; 39:264-276. [PMID: 37468453 PMCID: PMC10828205 DOI: 10.1093/ndt/gfad168] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND 25-hydroxyvitamin D can undergo C-3 epimerization to produce 3-epi-25(OH)D3. 3-epi-25(OH)D3 levels decline in chronic kidney disease (CKD), but its role in regulating the cardiovascular system is unknown. Herein, we examined the relationship between 3-epi-25(OH)D3, and cardiovascular functional and structural endpoints in patients with CKD. METHODS We examined n = 165 patients with advanced CKD from the Cardiopulmonary Exercise Testing in Renal Failure and After Kidney Transplantation (CAPER) study cohort, including those who underwent kidney transplant (KTR, n = 76) and waitlisted patients who did not (NTWC, n = 89). All patients underwent cardiopulmonary exercise testing and echocardiography at baseline, 2 months and 12 months. Serum 3-epi-25(OH)D3 was analyzed by liquid chromatography-tandem mass spectrometry. RESULTS Patients were stratified into quartiles of baseline 3-epi-25(OH)D3 (Q1: <0.4 ng/mL, n = 51; Q2: 0.4 ng/mL, n = 26; Q3: 0.5-0.7 ng/mL, n = 47; Q4: ≥0.8 ng/mL, n = 41). Patients in Q1 exhibited lower peak oxygen uptake [VO2Peak = 18.4 (16.2-20.8) mL/min/kg] compared with Q4 [20.8 (18.6-23.2) mL/min/kg; P = .009]. Linear mixed regression model showed that 3-epi-25(OH)D3 levels increased in KTR [from 0.47 (0.30) ng/mL to 0.90 (0.45) ng/mL] and declined in NTWC [from 0.61 (0.32) ng/mL to 0.45 (0.29) ng/mL; P < .001]. Serum 3-epi-25(OH)D3 was associated with VO2Peak longitudinally in both groups [KTR: β (standard error) = 2.53 (0.56), P < .001; NTWC: 2.73 (0.70), P < .001], but was not with left ventricular mass or arterial stiffness. Non-epimeric 25(OH)D3, 24,25(OH)2D3 and the 25(OH)D3:24,25(OH)2D3 ratio were not associated with any cardiovascular outcome (all P > .05). CONCLUSIONS Changes in 3-epi-25(OH)D3 levels may regulate cardiovascular functional capacity in patients with advanced CKD.
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Affiliation(s)
- Eliott Arroyo
- Division of Nephrology & Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cecilia A Leber
- Division of Nephrology & Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN, USA
| | - Heather N Burney
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yang Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tzong-shi Lu
- Renal Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Glenville Jones
- Department of Biomedical and Molecular Sciences and Medicine, Queen's University, Kingston, Ontario, Canada
| | - Martin Kaufmann
- Department of Biomedical and Molecular Sciences and Medicine, Queen's University, Kingston, Ontario, Canada
| | - Stephen M S Ting
- Department of Medicine, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK
| | - Thomas F Hiemstra
- Cambridge Clinical Trials Unit, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Daniel Zehnder
- Department of Nephrology
- Department of Acute Medicine, North Cumbria University Hospital National Health Service Trust, Carlisle, UK
| | - Kenneth Lim
- Division of Nephrology & Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Ginsberg C, Blackwell T, Cheng JH, Potok OA, Cauley JA, Ensrud KE, Hsu S, Kado DM, Orwoll E, Cawthon PM, Ix JH. The Vitamin D Metabolite Ratio Is Associated With Volumetric Bone Density in Older Men. J Clin Endocrinol Metab 2024; 109:e513-e521. [PMID: 37804103 PMCID: PMC10795912 DOI: 10.1210/clinem/dgad587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/08/2023] [Accepted: 10/02/2023] [Indexed: 10/08/2023]
Abstract
CONTEXT Serum 25-hydroxyvitamin D (25(OH)D) is the current marker of vitamin D adequacy, but its relationship with bone health has been inconsistent. The ratio of 24,25-dihydroxyvitamin D3 to 25(OH)D3 (vitamin D metabolite ratio or VMR) is a marker of vitamin D that has been associated with longitudinal changes in bone mineral density (BMD) and fracture risk. OBJECTIVE High-resolution peripheral quantitative computed tomography (HR-pQCT) provides information on bone health beyond standard dual-energy x-ray absorptiometry, in that it measures volumetric BMD (vBMD) as well bone strength. The relationship of the VMR with vBMD and bone strength remains unknown. METHODS We evaluated the associations of the VMR and 25(OH)D3 with vBMD and bone strength in the distal radius and tibia, assessed by HR-pQCT in 545 older men participating in the Osteoporotic Fractures in Men (MrOS) Study. Primary outcomes were vBMD and estimated failure load (EFL, a marker of bone strength) at the distal radius and tibia. RESULTS The mean age was 84 ± 4 years, 88.3% were White, and 32% had an estimated glomerular filtration rate <60 mL/min/1.73 m2. In adjusted models, each twofold higher VMR was associated with a 9% (3%, 16%) higher total vBMD and a 13% (5%, 21%) higher EFL at the distal radius. Results were similar at the distal tibia. 25(OH)D3 concentrations were not associated with any of the studied outcomes. CONCLUSION Among older men, a higher VMR was associated with greater vBMD and bone strength while 25(OH)D3 was not. The VMR may serve as a valuable marker of skeletal health in older men.
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Affiliation(s)
- Charles Ginsberg
- Division of Nephrology-Hypertension, University of California, San Diego, CA 92037, USA
| | - Terri Blackwell
- California Pacific Medical Center Research Institute, Department of Epidemiology, University of California, SanFrancisco, San Francisco, CA 94107, USA
| | - Jonathan H Cheng
- Division of Nephrology-Hypertension, University of California, San Diego, CA 92037, USA
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
| | - O Alison Potok
- Division of Nephrology-Hypertension, University of California, San Diego, CA 92037, USA
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
| | - Jane A Cauley
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Kristine E Ensrud
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN 55455, USA
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN 55417, USA
| | - Simon Hsu
- Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Deborah M Kado
- Department of Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Eric Orwoll
- Division of Endocrinology, Metabolism and Clinical Nutrition, Department of Medicine, Oregon Health and Sciences University, Portland, OR 97239, USA
| | - Peggy M Cawthon
- California Pacific Medical Center Research Institute, Department of Epidemiology, University of California, SanFrancisco, San Francisco, CA 94107, USA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California, San Diego, CA 92037, USA
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
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Germain MJ, Paul SK, Fadda G, Broumand V, Nguyen A, McGarvey NH, Gitlin MD, Bishop CW, Csomor P, Strugnell S, Ashfaq A. Real-world assessment: effectiveness and safety of extended-release calcifediol and other vitamin D therapies for secondary hyperparathyroidism in CKD patients. BMC Nephrol 2022; 23:362. [PMID: 36368937 PMCID: PMC9650892 DOI: 10.1186/s12882-022-02993-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Extended-release calcifediol (ERC), active vitamin D hormones and analogs (AVD) and nutritional vitamin D (NVD) are commonly used therapies for treating secondary hyperparathyroidism (SHPT) in adults with stage 3–4 chronic kidney disease (CKD) and vitamin D insufficiency (VDI). Their effectiveness for increasing serum total 25-hydroxyvitamin D (25D) and reducing elevated plasma parathyroid hormone (PTH), the latter of which is associated with increased morbidity and mortality, has varied across controlled clinical trials. This study aimed to assess real-world experience of ERC and other vitamin D therapies in reducing PTH and increasing 25D. Methods Medical records of 376 adult patients with stage 3–4 CKD and a history of SHPT and VDI from 15 United States (US) nephrology clinics were reviewed for up to 1 year pre- and post-ERC, NVD or AVD initiation. Key study variables included patient demographics, concomitant usage of medications and laboratory data. The mean age of the study population was 69.5 years, with gender and racial distributions representative of the US CKD population. Enrolled patients were grouped by treatment into three cohorts: ERC (n = 174), AVD (n = 55) and NVD (n = 147), and mean baseline levels were similar for serum 25D (18.8–23.5 ng/mL), calcium (Ca: 9.1–9.3 mg/dL), phosphorus (P: 3.7–3.8 mg/dL) and estimated glomerular filtration rate (eGFR: 30.3–35.7 mL/min/1.73m2). Mean baseline PTH was 181.4 pg/mL for the ERC cohort versus 156.9 for the AVD cohort and 134.8 pg/mL (p < 0.001) for the NVD cohort. Mean follow-up during treatment ranged from 20.0 to 28.8 weeks. Results Serum 25D rose in all cohorts (p < 0.001) during treatment. ERC yielded the highest increase (p < 0.001) of 23.7 ± 1.6 ng/mL versus 9.7 ± 1.5 and 5.5 ± 1.3 ng/mL for NVD and AVD, respectively. PTH declined with ERC treatment by 34.1 ± 6.6 pg/mL (p < 0.001) but remained unchanged in the other two cohorts. Serum Ca increased 0.2 ± 0.1 pg/mL (p < 0.001) with AVD but remained otherwise stable. Serum alkaline phosphatase remained unchanged. Conclusions Real-world clinical effectiveness and safety varied across the therapies under investigation, but only ERC effectively raised mean 25D (to well above 30 ng/mL) and reduced mean PTH levels without causing hypercalcemia.
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Martin-Romero A, Perelló-Martínez J, Hidalgo-Santiago JC, Michan-Doña A, Bosco López Sáez J, Gómez-Fernández P. Effect of the administration of different forms of vitamin D on central blood pressure and aortic stiffness, and its implication in the reduction of albuminuria in chronic kidney disease. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2022; 34:311-321. [PMID: 35817704 DOI: 10.1016/j.arteri.2022.05.002] [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] [Received: 03/25/2022] [Revised: 04/24/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Vitamin D(vitD) participates in phospho-calcium metabolism and exerts multiple pleiotropic effects. There is tissue 1-α (OH)ase that converts 25-OH cholecalciferol (25 (OH) D) in calcitriol that exerts autocrine and paracrine effects. 25 (OH)D deficiency could limit these tissue effects of vitD. The administration of nutritional vitD and the activator of the vitD receptor, paricalcitol, may promote beneficial effects on vascular and renal function. The objective of this work was to study in subjects with chronic kidney disease (CKD) the effect that the administration of different forms of vitD has on arterial function and albuminuria, and the possible relationship between the modifications of these variables. PATIENTS AND METHODS We studied in 97 patients with CKD stages 3-4 the effect of the administration of cholecalciferol (group 2; n: 35) and paricalcitol (n: 31; group 3) on parameters derived from brachial blood pressure, aortic blood pressure and on aortic stiffness studied using carotid-femoral pulse velocity (Vpc-f), and on albuminuria. A group of patients with stages 3-4 CKD who did not receive vitD therapy served as a control group (n: 31; group 1). All parameters were studied at baseline and after the follow-up period which was 7 ± 2 months. RESULTS In the baseline phase, no differences were observed between the groups in brachial systolic blood pressure (bSBP), central systolic blood pressure (SBP), brachial pulse pressure (bPP), and central pulse pressure (pCP) or in aortic stiffness that was increased in all groups with a baseline Vpc-f value of 10.5 (9.2-12.1) m/sec. The baseline albuminuria value in the grouped patients was 229 (43-876) mg / g (median (interquartile range)), with no differences between the groups. Serum calcium and phosphorus increased significantly in those treated with cholecal-ciferol (native vitD) and paricalcitol (active vitD). Parathormone (PTH) values decreased in those treated with paricalcitol.bPP and cPP decreased in all groups treated with native and active vitD. No significant changes in bPP and cPP were observed in the control group. Vpc-f did not change significantly in any of the groups, although the variation was quantitatively greater in group 3 (11.2±2 vs. 10.7±1.6 (P=.06)). No differences were observed in the changes in Vpc-f between the groups when adjusted to the baseline values of estimated glomerular filtration rate (eGFR), albuminuria, PTH, vitD, brachial and central blood pressure parameters, and their changes with treatment.Those who received treatment with native and active vitD presented a significant decrease in albuminuria of 17% (group 2) and 21% (group 3) compared to a 16% increase in the untreated group (group 1) (P=.01). A decrease in albuminuria ≥30% was observed more frequently in the groups treated with some form of vitD (group 2: 23%; group 3: 45%) than in the control group (13%) (P=.03). The decrease in albuminuria observed in the groups treated with any of the forms of vitD did not vary when the baseline values of the biochemical parameters of phosphorus-calcium metabolism, those of arterial function (PPb, PPc, Vpc-f) or its modifications were introduced as covariates. There was no significant correlation between changes in Vpc-f and albuminuria. In logistic regression, changes in arterial function parameters were also not explanatory for the ≥30% decrease in albuminuria. CONCLUSIONS In patients with CKD stages 3-4, treated with RAS blockers and with residual albuminuria, the administration of or paricalcitol reduces brachial and aortic pulse pressures, and albuminuria. The decrease in albuminuria does not seem to be mediated, at least not decisively, by changes in central hemodynamics or aortic stiffness.
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Affiliation(s)
| | | | | | - Alfredo Michan-Doña
- Unidad de Medicina Interna, Hospital Universitario, Jerez de la Frontera, Cádiz, España
| | | | - Pablo Gómez-Fernández
- Unidad de Factores de Riesgo Vascular, Hospital Universitario, Jerez de la Frontera, Cádiz, España.
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Meshkini F, Soltani S, Clark CCT, Tam V, Meyre D, Toupchian O, Saraf-Bank S, Abdollahi S. The effect of vitamin D supplementation on serum levels of fibroblast growth factor- 23: A systematic review and meta-analysis of randomized controlled trials. J Steroid Biochem Mol Biol 2022; 215:106012. [PMID: 34710560 DOI: 10.1016/j.jsbmb.2021.106012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/18/2021] [Accepted: 10/21/2021] [Indexed: 12/29/2022]
Abstract
Previous studies of the effect of vtamin D on serum levels of fibroblast growth factor- 23 (FGF-23) have yeilded an inconsistent findings. This systematic review and meta-analysis of randomized controlled trials (RCTs) sought to investigate the effect of vitamin D supplementation on serum levels of FGF-23. PubMed, Scopus, ISI Web of Science, and the Cochrane Library were searched, from database inception to November 2020, for RCTs that evaluated the effects of native or active vitamin D supplementation on serum levels of FGF-23 in adults. Weighted mean difference (WMD) were calculated and random effects meta-analysis was used to estimate the overall effects. Twenty-seven trials were included in the meta-analysis. Supplementation with native vitamin D (23 studies, n = 2247 participants; weighted mean difference [WMD] = 0.5 pg/mL, 95 % CI: -0.52 to 1.51, P = 0.33; I2 = 29.9 %), and active vitamin D (5 studies, n = 342 participants, WMD = 29.45 pg/mL, 95 % CI: -3.9 to 62.81, P = 0.08; I2 = 99.3%) had no significant effects on serum FGF-23 concentration. In subgroup analyses, supplementation with ergocalciferol (3 studies, n = 205 participants; WMD = 18.27 pg/mL, 95 % CI: 5.36-31.17, P = 0.006), and daily dosing regimens (9 studies, n = 1374 participants; WMD = 0.41 pg/mL, 95 % CI: 0.22 to 0.59, P < 0.001) increased serum FGF-23 levels compared to control. Overall, our findings revealed no significan effect of vitamin D supplementation on serum FGF-23 concentration. However, further high quality, large-scale studies are needed to better elucidate this relationship.
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Affiliation(s)
- Fatemeh Meshkini
- Department of Biochemistry, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; Student Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Sepideh Soltani
- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Cain C T Clark
- Centre for Intelligent Healthcare, Coventry University, Coventry, CV1 5FB, UK
| | - Vivian Tam
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - David Meyre
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Omid Toupchian
- Department of Nutrition, School of Public Health, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Sahar Saraf-Bank
- Food Security Research Center, Department of Community Nutrition, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shima Abdollahi
- Department of Nutrition, School of Public Health, North Khorasan University of Medical Sciences, Bojnurd, Iran.
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Role and Treatment of Insulin Resistance in Patients with Chronic Kidney Disease: A Review. Nutrients 2021; 13:nu13124349. [PMID: 34959901 PMCID: PMC8707041 DOI: 10.3390/nu13124349] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 01/11/2023] Open
Abstract
Patients with chronic kidney disease (CKD) and dialysis have higher mortality than those without, and cardiovascular disease (CVD) is the main cause of death. As CVD is caused by several mechanisms, insulin resistance plays an important role in CVD. This review summarizes the importance and mechanism of insulin resistance in CKD and discusses the current evidence regarding insulin resistance in patients with CKD and dialysis. Insulin resistance has been reported to influence endothelial dysfunction, plaque formation, hypertension, and dyslipidemia. A recent study also reported an association between insulin resistance and cognitive dysfunction, non-alcoholic fatty liver disease, polycystic ovary syndrome, and malignancy. Insulin resistance increases as renal function decrease in patients with CKD and dialysis. Several mechanisms increase insulin resistance in patients with CKD, such as chronic inflammation, oxidative stress, obesity, and mineral bone disorder. There is the possibility that insulin resistance is the potential future target of treatment in patients with CKD.
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Christodoulou M, Aspray TJ, Schoenmakers I. Vitamin D Supplementation for Patients with Chronic Kidney Disease: A Systematic Review and Meta-analyses of Trials Investigating the Response to Supplementation and an Overview of Guidelines. Calcif Tissue Int 2021; 109:157-178. [PMID: 33895867 PMCID: PMC8273061 DOI: 10.1007/s00223-021-00844-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/22/2021] [Indexed: 12/13/2022]
Abstract
A large proportion of patients with chronic kidney disease (CKD) are vitamin D deficient (plasma 25-hydroxyvitamin D (25(OH)D) < 25 or 30 nmol/L per UK and US population guidelines) and this contributes to the development of CKD-mineral bone disease (CKD-MBD). Gaps in the evidence-base for the management of vitamin D status in relation to CKD-MBD are hindering the formulation of comprehensive guidelines. We conducted a systemic review of 22 RCTs with different forms of vitamin D or analogues with CKD-MBD related outcomes and meta-analyses for parathyroid hormone (PTH). We provide a comprehensive overview of current guidelines for the management of vitamin D status for pre-dialysis CKD patients. Vitamin D supplementation had an inconsistent effect on PTH concentrations and meta-analysis showed non- significant reduction (P = 0.08) whereas calcifediol, calcitriol and paricalcitol consistently reduced PTH. An increase in Fibroblast Growth Factor 23 (FGF23) with analogue administration was found in all 3 studies reporting FGF23, but was unaltered in 4 studies with vitamin D or calcifediol. Few RCTS reported markers of bone metabolism and variations in the range of markers prevented direct comparisons. Guidelines for CKD stages G1-G3a follow general population recommendations. For the correction of deficiency general or CKD-specific patient guidelines provide recommendations. Calcitriol or analogues administration is restricted to stages G3b-G5 and depends on patient characteristics. In conclusion, the effect of vitamin D supplementation in CKD patients was inconsistent between studies. Calcifediol and analogues consistently suppressed PTH, but the increase in FGF23 with calcitriol analogues warrants caution.
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Affiliation(s)
| | - Terence J Aspray
- University of Newcastle Upon Tyne, Freeman Hospital, Bone Clinic, Newcastle, UK
| | - Inez Schoenmakers
- Medical School, University of East Anglia, Norwich, UK.
- Department of Medicine, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
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Ginsberg C, Zelnick LR, Block GA, Chertow GM, Chonchol M, Hoofnagle A, Kestenbaum B, de Boer IH. Differential effects of phosphate binders on vitamin D metabolism in chronic kidney disease. Nephrol Dial Transplant 2020; 35:616-623. [PMID: 32160298 DOI: 10.1093/ndt/gfaa010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Phosphate binders are commonly used in the treatment of patients with hyperphosphatemia. While phosphate binders are used to lower phosphate, the effects of specific phosphate binder types on vitamin D metabolism are unknown. METHODS We performed a secondary analysis of the Phosphate Normalization Trial in which patients with moderate to advanced chronic kidney disease were randomized to receive either placebo, sevelamer carbonate, lanthanum carbonate or calcium acetate for 9 months. We evaluated changes in serum concentrations of vitamin D metabolites including 24,25-dihydroxyvitamin D3 [24,25(OH)2D3], 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], the ratio of 24,25(OH)2D3 to 25-hydroxyvitamin D [the vitamin D metabolite ratio (VMR)] and the ratio of serum 1,25(OH)2D to 25-hydroxyvitamin D. RESULTS Compared with placebo, randomization to the calcium acetate arm was associated with a 0.6 ng/mL (95% CI 0.2, 1) and 13.5 pg/ng (95% CI 5.5, 21.5) increase in 24,25(OH)2D and VMR, respectively, and a 5.2 pg/mL (95% CI 1.1, 9.4) reduction in 1,25(OH)2D. Randomization to sevelamer carbonate was associated with a 0.5 ng/mL (95% CI -0.9, -0.1) and 11.8 pg/ng (95% CI -20, -3.5) reduction in 24,25(OH)2D3 and VMR, respectively. There was no association of the sevelamer arm with the change in 1,25(OH)2D3, and randomization to lanthanum carbonate was not associated with a change in any of the vitamin D metabolites. CONCLUSION Administration of different phosphate binders to patients with moderate to severe CKD results in unique changes in vitamin D metabolism.
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Affiliation(s)
- Charles Ginsberg
- Division of Nephrology-Hypertension, University of California, San Diego, San Diego, CA, USA.,Division of Nephrology, Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Leila R Zelnick
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, WA, USA
| | | | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Anschutz Medical Center, Aurora, CO, USA
| | - Andrew Hoofnagle
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Bryan Kestenbaum
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, WA, USA
| | - Ian H de Boer
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, WA, USA.,VA Puget Sound Health Care System, Seattle, WA, USA
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Kalantar-Zadeh K, Hollenbeak CS, Arguello R, Snyder S, Ashfaq A. The cost-effectiveness of extended-release calcifediol versus paricalcitol for the treatment of secondary hyperparathyroidism in stage 3-4 CKD. J Med Econ 2020; 23:308-315. [PMID: 31726882 DOI: 10.1080/13696998.2019.1693385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aims: Patients with chronic kidney disease (CKD) not on dialysis frequently have vitamin D insufficiency (VDI) and secondary hyperparathyroidism (SHPT), which are associated with an increased risk of cardiovascular (CV) disease, fracture, CKD progression, and death. This study estimated the cost-effectiveness of extended-release calcifediol (ERC) vs paricalcitol for the treatment of patients with CKD stages 3-4 that have SHPT and VDI.Materials and methods: An economic analysis of SHPT treatments among a hypothetical cohort of 1,000 patients with CKD Stage 3 and 4 with SHPT and VDI was developed to estimate differences in the rates and costs of CV events, fractures, CKD stage progression, and mortality in patients treated with ERC and paricalcitol. A Markov model was developed with 1-year cycles and a 5-year time horizon from a US Medicare payer perspective with costs valued in 2017 US dollars.Results: The outcomes of the model were rates of clinical events, total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). Across a 1,000-person cohort, ERC was the dominant (less costly, more effective) treatment strategy when compared with paricalcitol. Treatment with ERC resulted in cost savings of $14.8 M (95% CI = -$10.0 M-$45.2 M) and an incremental gain of 340 QALYs (95% CI = 200-496) compared to treatment with paricalcitol.Limitations: Bridging biochemical levels to clinical outcomes may not represent real-world risk of the clinical events modeled. Future real-world outcomes of patients treated with ERC and paricalcitol may be used to evaluate the model results.Conclusions: This model demonstrated favorable short- and long-term clinical benefits associated with the use of ERC in patients with CKD Stage 3 and 4 with SHPT and VDI, suggesting ERC may be cost-effective from the Medicare perspective compared to paricalcitol.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Christopher S Hollenbeak
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, PA, USA
| | - Roy Arguello
- Health Economics and Outcomes Research, BluePath Solutions, Los Angeles, CA, USA
| | - Sophie Snyder
- Health Economics and Outcomes Research, BluePath Solutions, Los Angeles, CA, USA
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Vitamin D Metabolic Ratio and Risks of Death and CKD Progression. Kidney Int Rep 2019; 4:1598-1607. [PMID: 31891001 PMCID: PMC6933450 DOI: 10.1016/j.ekir.2019.08.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 12/28/2022] Open
Abstract
Introduction Assessment of impaired vitamin D metabolism is limited by lack of functional measures. CYP24A1-mediated vitamin D clearance, calculated as the ratio of serum 24,25-dihydroxyvitamin D3 to 25-hydroxyvitamin D3 (the vitamin D metabolic ratio, VDMR), is induced by 1,25-dihydroxyvitamin D and may assess tissue-level activity. We tested associations of the VDMR with risks of death and progression to end-stage renal disease (ESRD) in patients with chronic kidney disease (CKD). Methods We studied participants from the Chronic Renal Insufficiency Cohort (CRIC), which included a random subset of 1080 CRIC participants plus additional participants who experienced ESRD or died (case cohort study design). Serum 24,25-dihydroxyvitamin D3 and 25-hydroxyvitamin D3 was measured 1 year after enrollment. The primary outcomes included death and progression to ESRD. Using inverse probability weighting, we tested associations of VDMR (24,25[OH]2D3/25[OH]D3) with risks of death and ESRD, adjusting for demographics, comorbidity, and kidney function (estimated glomerular filtration rate [eGFR] and urine protein-to-creatinine ratio [PCR]). Results There were a total of 708 ESRD events and 650 deaths events over mean (SD) follow-up periods of 4.9 (2.9) years and 6.5 (2.5) years, respectively. Lower VDMR was associated with increased risk of ESRD prior to adjusting for kidney function (hazard ratio [HR], 1.80 per 20 pg/ng lower VDMR; 95% confidence interval [CI], 1.56–2.08), but not with adjustment for kidney function (HR, 0.94 per 20 pg/ng; 95% CI, 0.81–1.10). Lower VDMR was associated with modestly increased mortality risk, including adjustment for kidney function (HR, 1.18 per 20 pg/ng; 95% CI, 1.02–1.36). Conclusion Lower VDMR, a measure of CYP24A1-mediated vitamin D clearance, was significantly associated with all-cause mortality but not with progression to ESRD in patients with CKD.
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Lo C, Toyama T, Wang Y, Lin J, Hirakawa Y, Jun M, Cass A, Hawley CM, Pilmore H, Badve SV, Perkovic V, Zoungas S. Insulin and glucose-lowering agents for treating people with diabetes and chronic kidney disease. Cochrane Database Syst Rev 2018; 9:CD011798. [PMID: 30246878 PMCID: PMC6513625 DOI: 10.1002/14651858.cd011798.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diabetes is the commonest cause of chronic kidney disease (CKD). Both conditions commonly co-exist. Glucometabolic changes and concurrent dialysis in diabetes and CKD make glucose-lowering challenging, increasing the risk of hypoglycaemia. Glucose-lowering agents have been mainly studied in people with near-normal kidney function. It is important to characterise existing knowledge of glucose-lowering agents in CKD to guide treatment. OBJECTIVES To examine the efficacy and safety of insulin and other pharmacological interventions for lowering glucose levels in people with diabetes and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 February 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs looking at head-to-head comparisons of active regimens of glucose-lowering therapy or active regimen compared with placebo/standard care in people with diabetes and CKD (estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) were eligible. DATA COLLECTION AND ANALYSIS Four authors independently assessed study eligibility, risk of bias, and quality of data and performed data extraction. Continuous outcomes were expressed as post-treatment mean differences (MD). Adverse events were expressed as post-treatment absolute risk differences (RD). Dichotomous clinical outcomes were presented as risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS Forty-four studies (128 records, 13,036 participants) were included. Nine studies compared sodium glucose co-transporter-2 (SGLT2) inhibitors to placebo; 13 studies compared dipeptidyl peptidase-4 (DPP-4) inhibitors to placebo; 2 studies compared glucagon-like peptide-1 (GLP-1) agonists to placebo; 8 studies compared glitazones to no glitazone treatment; 1 study compared glinide to no glinide treatment; and 4 studies compared different types, doses or modes of administration of insulin. In addition, 2 studies compared sitagliptin to glipizide; and 1 study compared each of sitagliptin to insulin, glitazars to pioglitazone, vildagliptin to sitagliptin, linagliptin to voglibose, and albiglutide to sitagliptin. Most studies had a high risk of bias due to funding and attrition bias, and an unclear risk of detection bias.Compared to placebo, SGLT2 inhibitors probably reduce HbA1c (7 studies, 1092 participants: MD -0.29%, -0.38 to -0.19 (-3.2 mmol/mol, -4.2 to -2.2); I2 = 0%), fasting blood glucose (FBG) (5 studies, 855 participants: MD -0.48 mmol/L, -0.78 to -0.19; I2 = 0%), systolic blood pressure (BP) (7 studies, 1198 participants: MD -4.68 mmHg, -6.69 to -2.68; I2 = 40%), diastolic BP (6 studies, 1142 participants: MD -1.72 mmHg, -2.77 to -0.66; I2 = 0%), heart failure (3 studies, 2519 participants: RR 0.59, 0.41 to 0.87; I2 = 0%), and hyperkalaemia (4 studies, 2788 participants: RR 0.58, 0.42 to 0.81; I2 = 0%); but probably increase genital infections (7 studies, 3086 participants: RR 2.50, 1.52 to 4.11; I2 = 0%), and creatinine (4 studies, 848 participants: MD 3.82 μmol/L, 1.45 to 6.19; I2 = 16%) (all effects of moderate certainty evidence). SGLT2 inhibitors may reduce weight (5 studies, 1029 participants: MD -1.41 kg, -1.8 to -1.02; I2 = 28%) and albuminuria (MD -8.14 mg/mmol creatinine, -14.51 to -1.77; I2 = 11%; low certainty evidence). SGLT2 inhibitors may have little or no effect on the risk of cardiovascular death, hypoglycaemia, acute kidney injury (AKI), and urinary tract infection (low certainty evidence). It is uncertain whether SGLT2 inhibitors have any effect on death, end-stage kidney disease (ESKD), hypovolaemia, fractures, diabetic ketoacidosis, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, DPP-4 inhibitors may reduce HbA1c (7 studies, 867 participants: MD -0.62%, -0.85 to -0.39 (-6.8 mmol/mol, -9.3 to -4.3); I2 = 59%) but may have little or no effect on FBG (low certainty evidence). DPP-4 inhibitors probably have little or no effect on cardiovascular death (2 studies, 5897 participants: RR 0.93, 0.77 to 1.11; I2 = 0%) and weight (2 studies, 210 participants: MD 0.16 kg, -0.58 to 0.90; I2 = 29%; moderate certainty evidence). Compared to placebo, DPP-4 inhibitors may have little or no effect on heart failure, upper respiratory tract infections, and liver impairment (low certainty evidence). Compared to placebo, it is uncertain whether DPP-4 inhibitors have any effect on eGFR, hypoglycaemia, pancreatitis, pancreatic cancer, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, GLP-1 agonists probably reduce HbA1c (7 studies, 867 participants: MD -0.53%, -1.01 to -0.06 (-5.8 mmol/mol, -11.0 to -0.7); I2 = 41%; moderate certainty evidence) and may reduce weight (low certainty evidence). GLP-1 agonists may have little or no effect on eGFR, hypoglycaemia, or discontinuation due to adverse effects (low certainty evidence). It is uncertain whether GLP-1 agonists reduce FBG, increase gastrointestinal symptoms, or affect the risk of pancreatitis (very low certainty evidence).Compared to placebo, it is uncertain whether glitazones have any effect on HbA1c, FBG, death, weight, and risk of hypoglycaemia (very low certainty evidence).Compared to glipizide, sitagliptin probably reduces hypoglycaemia (2 studies, 551 participants: RR 0.40, 0.23 to 0.69; I2 = 0%; moderate certainty evidence). Compared to glipizide, sitagliptin may have had little or no effect on HbA1c, FBG, weight, and eGFR (low certainty evidence). Compared to glipizide, it is uncertain if sitagliptin has any effect on death or discontinuation due to adverse effects (very low certainty).For types, dosages or modes of administration of insulin and other head-to-head comparisons only individual studies were available so no conclusions could be made. AUTHORS' CONCLUSIONS Evidence concerning the efficacy and safety of glucose-lowering agents in diabetes and CKD is limited. SGLT2 inhibitors and GLP-1 agonists are probably efficacious for glucose-lowering and DPP-4 inhibitors may be efficacious for glucose-lowering. Additionally, SGLT2 inhibitors probably reduce BP, heart failure, and hyperkalaemia but increase genital infections, and slightly increase creatinine. The safety profile for GLP-1 agonists is uncertain. No further conclusions could be made for the other classes of glucose-lowering agents including insulin. More high quality studies are required to help guide therapeutic choice for glucose-lowering in diabetes and CKD.
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Affiliation(s)
- Clement Lo
- Monash UniversityMonash Centre for Health Research and Implementation, School of Public Health and Preventive MedicineClaytonVICAustralia
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
| | - Tadashi Toyama
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
- Kanazawa University HospitalDivision of NephrologyKanazawaJapan
| | - Ying Wang
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Jin Lin
- Beijing Friendship Hospital, Capital Medical UniversityDepartment of Critical Care Medicine95 Yong‐An Road, Xuan Wu DistrictBeijingChina100050
| | - Yoichiro Hirakawa
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
| | - Min Jun
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Alan Cass
- Menzies School of Health ResearchPO Box 41096CasuarinaNTAustralia0811
| | - Carmel M Hawley
- Princess Alexandra HospitalDepartment of NephrologyIpswich RoadWoolloongabbaQLDAustralia4102
| | - Helen Pilmore
- Auckland HospitalDepartment of Renal MedicinePark RoadGraftonAucklandNew Zealand
- University of AucklandDepartment of MedicineGraftonNew Zealand
| | - Sunil V Badve
- St George HospitalDepartment of Renal MedicineKogarahNSWAustralia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Sophia Zoungas
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
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Oblak M, Mlinšek G, Kandus A, Buturović-Ponikvar J, Arnol M. Paricalcitol versus placebo for reduction of proteinuria in kidney transplant recipients: a double-blind, randomized controlled trial. Transpl Int 2018; 31:1391-1404. [PMID: 30062716 DOI: 10.1111/tri.13323] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/30/2018] [Accepted: 07/26/2018] [Indexed: 12/24/2022]
Abstract
Proteinuria after kidney transplantation is accompanied by an increased risk of graft failure. In this single-center, placebo-controlled, double-blind trial we studied whether vitamin D receptor activator paricalcitol might reduce proteinuria. Patients with urinary protein-to-creatinine ratio (UPCR) ≥20 mg/mmol despite optimization of the renin angiotensin aldosterone system (RAAS) blockade were randomly assigned to receive 24 weeks' treatment with 2 μg/day paricalcitol or placebo. Primary endpoint was change in UPCR, and main secondary endpoints were change in urinary albumin-to-creatinine ratio (UACR) and 24-h proteinuria. Analysis was by intention to treat. One hundred and sixty-eight patients undergo randomization, and 83 were allocated to paricalcitol, and 85 to placebo. Compared with baseline, UPCR declined in the paricalcitol group (-39%, 95% CI -45 to -31) but not in the placebo group (21%, 95% CI 9 to 35), with a between group difference of -49% (95% CI -57 to -41; P < 0.001). UACR and 24-h proteinuria decreased only on paricalcitol therapy and significantly differed between groups at end-of-treatment (P < 0.001). Paricalcitol was well tolerated but incidence of mild hypercalcemia was higher than in placebo. In conclusion, addition of 2 μg/day paricalcitol lowers residual proteinuria in kidney transplant recipients. Long-term studies are needed to determine if the reduction in proteinuria improves transplant outcomes (ClinicalTrials.gov, number NCT01436747).
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Affiliation(s)
- Manca Oblak
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gregor Mlinšek
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Aljoša Kandus
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jadranka Buturović-Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Arnol
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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van 't Erve TJ. Strategies to decrease oxidative stress biomarker levels in human medical conditions: A meta-analysis on 8-iso-prostaglandin F 2α. Redox Biol 2018; 17:284-296. [PMID: 29775960 PMCID: PMC6007822 DOI: 10.1016/j.redox.2018.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023] Open
Abstract
The widespread detection of elevated oxidative stress levels in many medical conditions has led to numerous efforts to design interventions to reduce its effects. Efforts have been wide-ranging, from dietary changes to administration of antioxidants, supplements, e.g., omega-3-fatty acids, and many medications. However, there is still no systemic assessment of the efficacy of treatments for oxidative stress reduction across a variety of medical conditions. The goal of this meta-analysis is, by combining multiple studies, to quantitate the change in the levels of the popular oxidative stress biomarker 8-iso-prostaglandin F2α (8-iso-PGF2α) after a variety of treatment strategies in human populations. Nearly 350 unique publications with 180 distinct strategies were included in the analysis. For each strategy, the difference between pre- or placebo and post-treatment levels calculated using Hedges' g value of effect. In general, administration of antibiotics, antihyperlipidemic agents, or changes in lifestyle (g = - 0.63, - 0.54, and 0.56) had the largest effect. Administration of supplements, antioxidants, or changes in diet (g = - 0.09, - 0.28, - 0.12) had small quantitative effects. To fully interpret the effectiveness of these treatments, comparisons to the increase in g value for each medical condition is required. For example, antioxidants in populations with coronary artery disease (CAD) reduce the 8-iso-PGF2α levels by g = - 0.34 ± 0.1, which is quantitatively considered a small effect. However, CAD populations, in comparison to healthy populations, have an increase in 8-iso-PGF2α levels by g = 0.38 ± 0.04; therefore, the overall reduction of 8-iso-PGF2α levels is ≈ 90% by this treatment in this specific medical condition. In conclusion, 8-iso-PGF2α levels can be reduced not only by antioxidants but by many other strategies. Not all strategies are equally effective at reducing 8-iso-PGF2α levels. In addition, the effectiveness of any strategy can be assessed only in relation to the medical condition investigated.
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Affiliation(s)
- Thomas J van 't Erve
- Immunity, Inflammation and Disease Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, 27709 NC, USA; Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, 27709 NC, USA.
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14
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Spoto B, Pizzini P, Cutrupi S, Tripepi G, Curatola G, Mallamaci F, Zoccali C. Vitamin D receptor activation by paricalcitol and insulin resistance in CKD. Nutr Metab Cardiovasc Dis 2018; 28:291-297. [PMID: 29307660 DOI: 10.1016/j.numecd.2017.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/26/2017] [Accepted: 11/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND AIMS The nature of the link (causal vs non-causal) between low 1,25-OH vitamin D and insulin resistance (IR) in patients with chronic kidney disease (CKD) remains elusive. We have now made a post hoc analysis of the effect of vitamin D receptor activation by paricalcitol on IR in the complete dataset of a double-blind, randomized, placebo controlled trial, the Paricalcitol and ENdothelial fuNction in chronic kidneY disease (PENNY). METHODS AND RESULTS Eighty-eight patients with stage 3-4 CKD were randomized (1:1) to receive 2 μg/day paricalcitol or matching placebo for 12 weeks. IR was measured by five IR indices: the homeostasis model assessment of insulin resistance (HOMA-IR), the quantitative insulin sensitivity check index (QUICKI), the McAuley index, the HOMA corrected for adiponectin (HOMA-AD) and the Leptin-adiponectin ratio (LAR). As compared to placebo, paricalcitol produced the expected small rise in serum calcium (+0.07 mmol/L, P = 0.01) and phosphate (+0.08 mmol/L, P = 0.034) and the expected parathyroid hormone suppression (-96 pg/ml, P < 0.001). However, the drug largely failed to affect the five indices of IR which remained unchanged both in the active and the placebo arm (paricalcitol vs placebo, P ranging from 0.25 to 0.62) and no effect modification of paricalcitol on IR by vitamin D or other parameters was registered. CONCLUSION Paricalcitol treatment for 12 weeks does not improve IR in patients with stage 3-4 CKD. Low vitamin D receptor activation is not a causal factor for IR in the CKD population.
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Affiliation(s)
- B Spoto
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - P Pizzini
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - S Cutrupi
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - G Tripepi
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - G Curatola
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - F Mallamaci
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy; Nephrology Dialysis and Renal Transplantation Unit, Reggio Calabria, Italy
| | - C Zoccali
- CNR-IFC, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy.
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15
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Fernandez-Fernandez B, Ortiz A. Paricalcitol and albuminuria: tread carefully. Lancet Diabetes Endocrinol 2018; 6:3-5. [PMID: 29104157 DOI: 10.1016/s2213-8587(17)30361-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 10/09/2017] [Indexed: 01/04/2023]
Affiliation(s)
- Beatriz Fernandez-Fernandez
- Nephrology and Hypertension Department, Instituto Investigación Sanitaria-Fundación Jiménez Díaz and School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain; Instituto Reina Sofia de Investigaciones Nefrologicas, Madrid, Spain; Red de Investigación Renal, 28040 Madrid, Spain
| | - Alberto Ortiz
- Nephrology and Hypertension Department, Instituto Investigación Sanitaria-Fundación Jiménez Díaz and School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain; Instituto Reina Sofia de Investigaciones Nefrologicas, Madrid, Spain; Red de Investigación Renal, 28040 Madrid, Spain.
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16
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Hallan S, Afkarian M, Zelnick LR, Kestenbaum B, Sharma S, Saito R, Darshi M, Barding G, Raftery D, Ju W, Kretzler M, Sharma K, de Boer IH. Metabolomics and Gene Expression Analysis Reveal Down-regulation of the Citric Acid (TCA) Cycle in Non-diabetic CKD Patients. EBioMedicine 2017; 26:68-77. [PMID: 29128444 PMCID: PMC5832558 DOI: 10.1016/j.ebiom.2017.10.027] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 10/27/2017] [Accepted: 10/28/2017] [Indexed: 01/17/2023] Open
Abstract
Chronic kidney disease (CKD) is a public health problem with very high prevalence and mortality. Yet, there is a paucity of effective treatment options, partly due to insufficient knowledge of underlying pathophysiology. We combined metabolomics (GCMS) with kidney gene expression studies to identify metabolic pathways that are altered in adults with non-diabetic stage 3-4 CKD versus healthy adults. Urinary excretion rate of 27 metabolites and plasma concentration of 33 metabolites differed significantly in CKD patients versus controls (estimate range-68% to +113%). Pathway analysis revealed that the citric acid cycle was the most significantly affected, with urinary excretion of citrate, cis-aconitate, isocitrate, 2-oxoglutarate and succinate reduced by 40-68%. Reduction of the citric acid cycle metabolites in urine was replicated in an independent cohort. Expression of genes regulating aconitate, isocitrate, 2-oxoglutarate and succinate were significantly reduced in kidney biopsies. We observed increased urine citrate excretion (+74%, p=0.00009) and plasma 2-oxoglutarate concentrations (+12%, p=0.002) in CKD patients during treatment with a vitamin-D receptor agonist in a randomized trial. In conclusion, urinary excretion of citric acid cycle metabolites and renal expression of genes regulating these metabolites were reduced in non-diabetic CKD. This supports the emerging view of CKD as a state of mitochondrial dysfunction.
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Affiliation(s)
- Stein Hallan
- Center for Renal Translational Medicine/Institute for Metabolomic Medicine, University of California San Diego, San Diego, CA, United States; Department of Clinical and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Nephrology, St. Olav Hospital, Trondheim, Norway.
| | - Maryam Afkarian
- Kidney Research Institute, University of Washington, Seattle, WA, United States; Division of Nephrology, Department of Medicine, University of California, Davis, CA, United States
| | - Leila R Zelnick
- Kidney Research Institute, University of Washington, Seattle, WA, United States; Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Bryan Kestenbaum
- Kidney Research Institute, University of Washington, Seattle, WA, United States; Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Shoba Sharma
- University of Texas Health San Antonio, San Antonio, TX, United States
| | - Rintaro Saito
- Center for Renal Translational Medicine/Institute for Metabolomic Medicine, University of California San Diego, San Diego, CA, United States
| | - Manjula Darshi
- Center for Renal Translational Medicine/Institute for Metabolomic Medicine, University of California San Diego, San Diego, CA, United States
| | - Gregory Barding
- Northwest Metabolomics Research Center, University of Washington, Seattle, WA, United States
| | - Daniel Raftery
- Northwest Metabolomics Research Center, University of Washington, Seattle, WA, United States
| | - Wenjun Ju
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, United States; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, United States
| | - Matthias Kretzler
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, United States; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, United States
| | - Kumar Sharma
- Center for Renal Translational Medicine/Institute for Metabolomic Medicine, University of California San Diego, San Diego, CA, United States; Department of Nephrology and Hypertension, Veterans Administration San Diego HealthCare System, San Diego, CA, United States
| | - Ian H de Boer
- Kidney Research Institute, University of Washington, Seattle, WA, United States; Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, United States
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17
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Molina P, Carrero JJ, Bover J, Chauveau P, Mazzaferro S, Torres PU. Vitamin D, a modulator of musculoskeletal health in chronic kidney disease. J Cachexia Sarcopenia Muscle 2017; 8:686-701. [PMID: 28675610 PMCID: PMC5659055 DOI: 10.1002/jcsm.12218] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 04/04/2017] [Accepted: 04/20/2017] [Indexed: 02/06/2023] Open
Abstract
The spectrum of activity of vitamin D goes beyond calcium and bone homeostasis, and growing evidence suggests that vitamin D contributes to maintain musculoskeletal health in healthy subjects as well as in patients with chronic kidney disease (CKD), who display the combination of bone metabolism disorder, muscle wasting, and weakness. Here, we review how vitamin D represents a pathway in which bone and muscle may interact. In vitro studies have confirmed that the vitamin D receptor is present on muscle, describing the mechanisms whereby vitamin D directly affects skeletal muscle. These include genomic and non-genomic (rapid) effects, regulating cellular differentiation and proliferation. Observational studies have shown that circulating 25-hydroxyvitamin D levels correlate with the clinical symptoms and muscle morphological changes observed in CKD patients. Vitamin D deficiency has been linked to low bone formation rate and bone mineral density, with an increased risk of skeletal fractures. The impact of low vitamin D status on skeletal muscle may also affect muscle metabolic pathways, including its sensitivity to insulin. Although some interventional studies have shown that vitamin D may improve physical performance and protect against the development of histological and radiological signs of hyperparathyroidism, evidence is still insufficient to draw definitive conclusions.
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Affiliation(s)
- Pablo Molina
- Department of NephrologyHospital Universitario Doctor PesetValenciaSpain
- REDinRENMadridSpain
- Department of MedicineUniversitat de ValènciaValenciaSpain
| | - Juan J. Carrero
- Division of Renal MedicineCLINTEC, Karolinska InstitutetStockholmSweden
| | - Jordi Bover
- REDinRENMadridSpain
- Department of NephrologyFundació PuigvertBarcelonaSpain
- IIB Sant PauBarcelonaSpain
| | - Philippe Chauveau
- Service de Néphrologie Transplantation DialyseCentre Hospitalier Universitaire de Bordeaux et Aurad‐AquitaineBordeauxFrance
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric SciencesSapienza University of RomeRomeItaly
| | - Pablo Ureña Torres
- Department of Nephrology and DialysisClinique du Landy, Ramsay‐Générale de SantéSaint OuenParisFrance
- Department of Renal PhysiologyNecker Hospital, University of Paris DescartesParisFrance
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Hu X, Shang J, Yuan W, Zhang S, Jiang Y, Zhao B, Duan Y, Xiao J, Zhao Z. Effects of paricalcitol on cardiovascular outcomes and renal function in patients with chronic kidney disease : A meta-analysis. Herz 2017; 43:518-528. [PMID: 28835982 DOI: 10.1007/s00059-017-4605-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 07/16/2017] [Accepted: 07/16/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Paricalcitol, a selective activator of the vitamin D receptor (VDR), influences calcium and phosphorus homeostasis and bone metabolism. Whether paricalcitol reduces cardiovascular risk and protects renal function remains unclear. To systematically evaluate this in patients with chronic kidney disease (CKD), we conducted a meta-analysis of published randomized controlled trials (RCTs). METHODS We searched MEDLINE, Embase, the Cochrane Library, and reference lists for RCTs comparing paricalcitol with placebo in stage 2-5 CKD (including pre-dialysis and renal replacement patients). The Cochrane quality assessment method was used to evaluate study quality. Results were summarized as risk ratios (RRs) for dichotomous outcomes or mean differences (MD) for continuous outcomes. RESULTS We included 21 studies comprising 1894 patients. Compared to placebo, paricalcitol reduced the risk of cardiovascular events (RR 0.55; 95% CI 0.35-0.87; p = 0.01), but the RR of hypercalcemia associated with paricalcitol was 6.50 (95% CI 3.21-13.15; p < 0.00001). Paricalcitol cannot significantly change systolic blood pressure and cardiac structure. Although proteinuria reduction was achieved more frequently with paricalcitol (RR 1.51; 95% CI 1.25-1.82; p < 0.0001), it did not significantly reduce proteinuria level compared to placebo. Paricalcitol could not protect renal function to delay CKD progression, since it reduced the glomerular filtration rate (MD -3.15; 95% CI -4.35--1.96; p < 0.0001) and elevated serum creatinine (MD 0.93; 95% CI 0.10-0.68; p = 0.008). CONCLUSION Paricalcitol reduces the risk of cardiovascular events in CKD patients but increases the risk of hypercalcemia and cannot improve cardiac structure. Meanwhile, it cannot significantly reduce proteinuria level or protect renal function.
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Affiliation(s)
- X Hu
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China
| | - J Shang
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China
| | - W Yuan
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China
| | - S Zhang
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China
| | - Y Jiang
- Emergency Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - B Zhao
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Y Duan
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - J Xiao
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China
| | - Z Zhao
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China.
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19
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Caravaca F, Caravaca-Fontán F, Azevedo L, Luna E. Changes in renal function after discontinuation of vitamin D analogues in advanced chronic kidney disease. Nefrologia 2017; 38:179-189. [PMID: 28676189 DOI: 10.1016/j.nefro.2017.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/25/2017] [Accepted: 05/22/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In routine clinical practice, the prescription of vitamin D analogues (VDA) in patients with chronic kidney disease (CKD) is often associated with a decline of the estimated renal function. The reason for this is not fully understood. AIMS To analyse the effects of VDA discontinuation in advanced CKD and to determine the factors associated with changes in renal function. MATERIAL AND METHODS Retrospective cohort study of adult patients with advanced CKD. The case subgroup was treated with VDA and this medication was discontinued at baseline (the first visit). The control subgroup was not treated with VDA and they were selected according to comparability principles for CKD progression by propensity score matching. The primary outcome measure was a change to both the estimated glomerular filtration rate (MDRD-GFR) and the measured glomerular filtration rate (mGFR by combined creatinine and urea clearances). Baseline parameters related to mineral metabolism and creatinine generation were analysed as potential determinants of renal function changes. RESULTS The study sample consisted of 67 cases and 67 controls. Renal function improved in 67% of cases and worsened in 72% of controls (p<0.0001). Changes in MDRD-GFR for the case subgroup and the control subgroup were +0.455±0.997 vs. -0.436±1.103ml/min/1.73 m2/month (p<0.0001), respectively. Total creatinine excretion was slightly higher in cases than in controls but the difference was not significant. According to multivariate logistic and linear regression analyses, baseline total serum calcium was one of the best determinants of both renal function recovery (Odds ratio=3.49; p=0.001), and of the extent of renal function recovery (beta=0.276; p=0.001). CONCLUSIONS Discontinuation of VDA treatment in CKD patients is associated with significant recovery of estimated renal function. The extent of these changes is mainly associated with baseline total serum calcium.
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Affiliation(s)
| | | | - Lilia Azevedo
- Servicio de Nefrología, Hospital Infanta Cristina, Badajoz, España
| | - Enrique Luna
- Servicio de Nefrología, Hospital Infanta Cristina, Badajoz, España
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20
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Snelson M, Clarke RE, Coughlan MT. Stirring the Pot: Can Dietary Modification Alleviate the Burden of CKD? Nutrients 2017; 9:nu9030265. [PMID: 28287463 PMCID: PMC5372928 DOI: 10.3390/nu9030265] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/27/2017] [Accepted: 03/06/2017] [Indexed: 02/06/2023] Open
Abstract
Diet is one of the largest modifiable risk factors for chronic kidney disease (CKD)-related death and disability. CKD is largely a progressive disease; however, it is increasingly appreciated that hallmarks of chronic kidney disease such as albuminuria can regress over time. The factors driving albuminuria resolution remain elusive. Since albuminuria is a strong risk factor for GFR loss, modifiable lifestyle factors that lead to an improvement in albuminuria would likely reduce the burden of CKD in high-risk individuals, such as patients with diabetes. Dietary therapy such as protein and sodium restriction has historically been used in the management of CKD. Evidence is emerging to indicate that other nutrients may influence kidney health, either through metabolic or haemodynamic pathways or via the modification of gut homeostasis. This review focuses on the role of diet in the pathogenesis and progression of CKD and discusses the latest findings related to the mechanisms of diet-induced kidney disease. It is possible that optimizing diet quality or restricting dietary intake could be harnessed as an adjunct therapy for CKD prevention or progression in susceptible individuals, thereby reducing the burden of CKD.
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Affiliation(s)
- Matthew Snelson
- Glycation, Nutrition and Metabolism Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne 3004, Australia.
| | - Rachel E Clarke
- Glycation, Nutrition and Metabolism Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne 3004, Australia.
- Department of Physiology, Monash University, Clayton 3800, Australia.
| | - Melinda T Coughlan
- Glycation, Nutrition and Metabolism Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne 3004, Australia.
- Department of Diabetes, Central Clinical School, Monash University, Alfred Medical Research and Education Precinct, Melbourne 3004, Australia.
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21
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Spoto B, Pisano A, Zoccali C. Insulin resistance in chronic kidney disease: a systematic review. Am J Physiol Renal Physiol 2016; 311:F1087-F1108. [DOI: 10.1152/ajprenal.00340.2016] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 09/28/2016] [Indexed: 01/07/2023] Open
Abstract
Insulin resistance (IR) is an early metabolic alteration in chronic kidney disease (CKD) patients, being apparent when the glomerular filtration rate is still within the normal range and becoming almost universal in those who reach the end stage of kidney failure. The skeletal muscle represents the primary site of IR in CKD, and alterations at sites beyond the insulin receptor are recognized as the main defect underlying IR in this condition. Estimates of IR based on fasting insulin concentration are easier and faster but may not be adequate in patients with CKD because renal insufficiency reduces insulin catabolism. The hyperinsulinemic euglycemic clamp is the gold standard for the assessment of insulin sensitivity because this technique allows a direct measure of skeletal muscle sensitivity to insulin. The etiology of IR in CKD is multifactorial in nature and may be secondary to disturbances that are prominent in renal diseases, including physical inactivity, chronic inflammation, oxidative stress, vitamin D deficiency, metabolic acidosis, anemia, adipokine derangement, and altered gut microbiome. IR contributes to the progression of renal disease by worsening renal hemodynamics by various mechanisms, including activation of the sympathetic nervous system, sodium retention, and downregulation of the natriuretic peptide system. IR has been solidly associated with intermediate mechanisms leading to cardiovascular (CV) disease in CKD including left ventricular hypertrophy, vascular dysfunction, and atherosclerosis. However, it remains unclear whether IR is an independent predictor of mortality and CV complications in CKD. Because IR is a modifiable risk factor and its reduction may lower CV morbidity and mortality, unveiling the molecular mechanisms responsible for the pathogenesis of CKD-related insulin resistance is of importance for the identification of novel therapeutic targets aimed at reducing the high CV risk of this condition.
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Affiliation(s)
- Belinda Spoto
- Consiglio Nazionale delle Ricerche-Istituto di Fisiologia Clinica, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio di Calabria, Italy
| | - Anna Pisano
- Consiglio Nazionale delle Ricerche-Istituto di Fisiologia Clinica, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio di Calabria, Italy
| | - Carmine Zoccali
- Consiglio Nazionale delle Ricerche-Istituto di Fisiologia Clinica, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio di Calabria, Italy
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22
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Keyzer CA, van Breda GF, Vervloet MG, de Jong MA, Laverman GD, Hemmelder MH, Janssen WMT, Lambers Heerspink HJ, Kwakernaak AJ, Bakker SJL, Navis G, de Borst MH. Effects of Vitamin D Receptor Activation and Dietary Sodium Restriction on Residual Albuminuria in CKD: The ViRTUE-CKD Trial. J Am Soc Nephrol 2016; 28:1296-1305. [PMID: 27856633 DOI: 10.1681/asn.2016040407] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/11/2016] [Indexed: 12/26/2022] Open
Abstract
Reduction of residual albuminuria during single-agent renin-angiotensin-aldosterone blockade is accompanied by improved cardiorenal outcomes in CKD. We studied the individual and combined effects of the vitamin D receptor activator paricalcitol (PARI) and dietary sodium restriction on residual albuminuria in CKD. In a multicenter, randomized, placebo (PLAC)-controlled, crossover trial, 45 patients with nondiabetic CKD stages 1-3 and albuminuria >300 mg/24 h despite ramipril at 10 mg/d and BP<140/90 mmHg were treated for four 8-week periods with PARI (2 μg/d) or PLAC, each combined with a low-sodium (LS) or regular sodium (RS) diet. We analyzed the treatment effect by linear mixed effect models for repeated measurements. In the intention-to-treat analysis, albuminuria (geometric mean) was 1060 (95% confidence interval, 778 to 1443) mg/24 h during RS + PLAC and 990 (95% confidence interval, 755 to 1299) mg/24 h during RS + PARI (P=0.20 versus RS + PLAC). LS + PLAC reduced albuminuria to 717 (95% confidence interval, 512 to 1005) mg/24 h (P<0.001 versus RS + PLAC), and LS + PARI reduced albuminuria to 683 (95% confidence interval, 502 to 929) mg/24 h (P<0.001 versus RS + PLAC). The reduction by PARI beyond the effect of LS was nonsignificant (P=0.60). In the per-protocol analysis restricted to participants with ≥95% compliance with study medication, PARI did provide further albuminuria reduction (P=0.04 LS + PARI versus LS + PLAC). Dietary adherence was good as reflected by urinary excretion of 174±64 mmol Na+ per day in the combined RS groups and 108±61 mmol Na+ per day in the LS groups (P<0.001). In conclusion, moderate dietary sodium restriction substantially reduced residual albuminuria during fixed dose angiotensin-converting enzyme inhibition. The additional effect of PARI was small and nonsignificant.
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Affiliation(s)
| | - G Fenna van Breda
- Department of Nephrology and Institute for Cardiovascular Research, Vrije University Medical Centre, Amsterdam, The Netherlands
| | - Marc G Vervloet
- Department of Nephrology and Institute for Cardiovascular Research, Vrije University Medical Centre, Amsterdam, The Netherlands
| | | | - Gozewijn D Laverman
- Department of Internal Medicine, Division of Nephrology, Zorggroep Twente Hospital, Almelo, The Netherlands
| | - Marc H Hemmelder
- Department of Internal Medicine, Division of Nephrology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands; and
| | - Wilbert M T Janssen
- Department of Internal Medicine, Division of Nephrology, Martini Hospital Groningen, Groningen, The Netherlands
| | - Hiddo J Lambers Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | | | - Gerjan Navis
- Department of Internal Medicine, Division of Nephrology and
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23
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Grübler MR, Gaksch M, Kienreich K, Verheyen N, Schmid J, Ó Hartaigh B, Richtig G, Scharnagl H, Meinitzer A, Fahrleitner-Pammer A, März W, Tomaschitz A, Pilz S. Effects of vitamin D supplementation on glycated haemoglobin and fasting glucose levels in hypertensive patients: a randomized controlled trial. Diabetes Obes Metab 2016; 18:1006-12. [PMID: 27334070 DOI: 10.1111/dom.12709] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/08/2016] [Accepted: 06/12/2016] [Indexed: 12/26/2022]
Abstract
AIM To investigate the efficacy of vitamin D supplementation on glycaemic control. METHODS The Styrian Vitamin D Hypertension Trial was a single-centre, double-blind, placebo-controlled study conducted between 2011 and 2014 at the Medical University of Graz, Austria. We enrolled 200 people with arterial hypertension and 25-hydroxyvitamin D [25(OH)D] concentrations <30 ng/mL. Study participants were randomized to receive either 2800 IU of vitamin D or placebo per day for 8 weeks. The present study was a post hoc analysis that incorporated an analysis of covariance (ancova) approach, while adjusting for baseline differences. RESULTS A total of 185 participants [mean ± standard deviation age, 60.1 ± 11.3 years; 47% women; mean 25(OH)D 21.2 ± 5.6 ng/mL, mean glycated haemoglobin (HbA1c) 44.8 ± 11.8 mmol/mol and mean body mass index 30.4 ± 5.4 kg/m(2) ] completed the trial. ancova showed a mean treatment effect [95% confidence interval (CI)] on HbA1c of -3.52 (-6.7 to -0.34) mmol/mol (p = .045). There was no difference in fasting glucose -4.7 mg/dL (95% CI -16.3 to 6.9; p = .426). CONCLUSIONS Vitamin D supplementation in obese hypertensive patients with low 25(OH)D reduces HbA1c levels. This finding warrants further investigation into potential vitamin D effects on glucose homeostasis.
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Affiliation(s)
- M R Grübler
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Graz, Austria.
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland.
| | - M Gaksch
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Graz, Austria
| | - K Kienreich
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Graz, Austria
| | - N Verheyen
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - J Schmid
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - B Ó Hartaigh
- Department of Radiology, Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York
| | - G Richtig
- Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Graz, Austria
| | - H Scharnagl
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - A Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - A Fahrleitner-Pammer
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Graz, Austria
| | - W März
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
- Synlab Academy, Synlab Services GmbH, Mannheim, Germany
- Medical Clinic V (Nephrology, Hypertensiology, Rheumatology, Endocrinolgy, Diabetology), Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - A Tomaschitz
- Department of Cardiology, Medical University of Graz, Graz, Austria
- Specialist Clinic for Rehabilitation Bad Aussee, Bad Aussee, Austria
| | - S Pilz
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Medical University of Graz, Graz, Austria
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
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24
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de Boer IH, Zelnick L, Afkarian M, Ayers E, Curtin L, Himmelfarb J, Ikizler TA, Kahn SE, Kestenbaum B, Utzschneider K. Impaired Glucose and Insulin Homeostasis in Moderate-Severe CKD. J Am Soc Nephrol 2016; 27:2861-71. [PMID: 26823551 DOI: 10.1681/asn.2015070756] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 12/08/2015] [Indexed: 12/16/2022] Open
Abstract
Kidney disease leads to clinically relevant disturbances in glucose and insulin homeostasis, but the pathophysiology in moderate-severe CKD remains incompletely defined. In a cross-sectional study of 59 participants with nondiabetic CKD (mean eGFR =37.6 ml/min per 1.73 m(2)) and 39 healthy control subjects, we quantified insulin sensitivity, clearance, and secretion and glucose tolerance using hyperinsulinemic-euglycemic clamp and intravenous and oral glucose tolerance tests. Participants with CKD had lower insulin sensitivity than participants without CKD (mean[SD] 3.9[2.0] versus 5.0 [2.0] mg/min per µU/ml; P<0.01). Insulin clearance correlated with insulin sensitivity (r=0.72; P<0.001) and was also lower in participants with CKD than controls (876 [226] versus 998 [212] ml/min; P<0.01). Adjustment for physical activity, diet, fat mass, and fatfree mass in addition to demographics and smoking partially attenuated associations of CKD with insulin sensitivity (adjusted difference, -0.7; 95% confidence interval, -1.4 to 0.0 mg/min per µU/ml) and insulin clearance (adjusted difference, -85; 95% confidence interval, -160 to -10 ml/min). Among participants with CKD, eGFR did not significantly correlate with insulin sensitivity or clearance. Insulin secretion and glucose tolerance did not differ significantly between groups, but 65% of participants with CKD had impaired glucose tolerance. In conclusion, moderate-severe CKD associated with reductions in insulin sensitivity and clearance that are explained, in part, by differences in lifestyle and body composition. We did not observe a CKD-specific deficit in insulin secretion, but the combination of insulin resistance and inadequate augmentation of insulin secretion led to a high prevalence of impaired glucose tolerance.
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Affiliation(s)
- Ian H de Boer
- Division of Nephrology and Kidney Research Institute and Veterans Affairs Puget Sound Health Care System, Seattle, Washington; and
| | - Leila Zelnick
- Division of Nephrology and Kidney Research Institute and
| | | | - Ernest Ayers
- Division of Nephrology and Kidney Research Institute and
| | - Laura Curtin
- Division of Nephrology and Kidney Research Institute and
| | | | - T Alp Ikizler
- Division of Nephrology and Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Steven E Kahn
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; and Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, Washington
| | | | - Kristina Utzschneider
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; and Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, Washington
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25
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Zhang Q, Li M, Zhang T, Chen J. Effect of Vitamin D Receptor Activators on Glomerular Filtration Rate: A Meta-Analysis and Systematic Review. PLoS One 2016; 11:e0147347. [PMID: 26812502 PMCID: PMC4727919 DOI: 10.1371/journal.pone.0147347] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 12/31/2015] [Indexed: 11/26/2022] Open
Abstract
Background Vitamin D receptor activators (VDRAs) can protect against mineral bone disease, but they are reported to elevate serum creatinine (SCr) and may also reduce glomerular filtration rate (GFR). Methods We conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) to evaluate the effect of VDRAs on kidney function and adverse events. MEDLINE, EMBASE, the Cochrane Controlled Trials Register were searched for RCTs that evaluate vitamin D receptor activators (alfacalcidol, calcitriol, doxercalciferol, falecalcitriol, maxacalcitol and paricalcitol) up to March 2015. Results We included 31 studies, all of which were performed between 1976 and 2015, which enrolled 2621 patients. Patients receiving VDRAs had lower eGFR (weighted mean difference WMD -1.29 mL/min /1.73 m2, 95% CI -2.42 to -0.17) and elevated serum creatinine (WMD 7.03 μmol/L, 95% CI 0.61 to 13.46) in sensitivity analysis excluding studies with dropout rate more than 30%. Subgroup analysis of the 5 studies that not use SCr-based measures did not indicated lower GFR in the VDRAs group(WMD -0.97 mL/min/1.73 m2, 95% CI -4.85 to 2.92). Compared with control groups, there was no difference in all-cause mortality (relative risk RR 1.41, 95% CI 0.58 to 3.80), cardiovascular disease (RR 0.84, 95% CI 0.42 to 1.71), and severe adverse events (RR 1.15, 95% CI 0.75 to 1.77) for the VDRAs groups. Episodes of hypercalcemia (RR 3.29, 95% CI 2.02 to 5.38) were more common in the VDRAs group than in the control group. Conclusions Administration of VDRAs increased serum creatinine levels. Subgroup analysis of studies that did not use SCr-based measures did not indicate a lower GFR in the VDRA group. Future studies with non-SCr-based measures are needed to assess whether the mild elevations of serum creatinine are of clinical significance.
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Affiliation(s)
- Qian Zhang
- Division of Nephrology, Huashan Hospital and Huashan Hospital North, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ming Li
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital Affiliated to Tongji University, Shanghai, China
| | - Tiansong Zhang
- Department of TCM, Jing’an District centre hospital of Shanghai, Shanghai, China
| | - Jing Chen
- Division of Nephrology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- * E-mail:
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Protective Effects of Paricalcitol on Peritoneal Remodeling during Peritoneal Dialysis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:468574. [PMID: 26605330 PMCID: PMC4641933 DOI: 10.1155/2015/468574] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 09/10/2015] [Accepted: 10/01/2015] [Indexed: 11/17/2022]
Abstract
Peritoneal dialysis (PD) is associated with structural and functional alterations of the peritoneal membrane, consisting of fibrosis, angiogenesis, and loss of ultrafiltration capacity. Vitamin D receptor activation (VDRA) plays an important role in mineral metabolism and inflammation, but also antiangiogenic and antifibrotic properties have been reported. Therefore, the effects of active vitamin D treatment on peritoneal function and remodeling were investigated. Rats were either kept naïve to PDF exposure or daily exposed to 10 mL PDF and were treated for five or seven weeks with oral paricalcitol or vehicle control. Non-PDF-exposed rats showed no peritoneal changes upon paricalcitol treatment. Paricalcitol reduced endogenous calcitriol but did not affect mineral homeostasis. However, upon PDF exposure, loss of ultrafiltration capacity ensued which was fully rescued by paricalcitol treatment. Furthermore, PD-induced ECM thickening was significantly reduced and omental PD-induced angiogenesis was less pronounced upon paricalcitol treatment. No effect of paricalcitol treatment on total amount of peritoneal cells, peritoneal leukocyte composition, and epithelial to mesenchymal transition (EMT) was observed. Our data indicates that oral VDRA reduces tissue remodeling during chronic experimental PD and prevents loss of ultrafiltration capacity. Therefore, VDRA is potentially relevant in the prevention of treatment technique failure in PD patients.
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Sarathy H, Pramanik V, Kahn J, Abramowitz MK, Meier K, Kishore P, Melamed ML. The effects of short-term vitamin D supplementation on glucose metabolism in dialysis patients: a systematic review and meta-analysis. Int Urol Nephrol 2015; 47:537-49. [PMID: 25636811 DOI: 10.1007/s11255-015-0909-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/02/2015] [Indexed: 12/26/2022]
Abstract
PURPOSE We tested whether short-term vitamin D supplementation improves insulin resistance in patients with kidney disease, a condition with little intrinsic vitamin D activity. METHODS PubMed, EMBASE and CENTRAL were searched for relevant observational studies and randomized clinical trials (RCTs). Random-effects models were employed for meta-analysis, and effect sizes were summarized as standardized mean difference (SMD) with 95% confidence intervals. Separate analyses were done for RCTs and non-randomized intervention studies (NRIS). RESULTS Seventeen studies (5 RCTs and 12 NRIS) were included. The meta-analysis population (n = 131) was mostly middle aged (40-50 years), male and non-diabetic, and on hemodialysis. The duration (4-12 weeks) and type of supplementation varied between studies. Among RCTs, compared to placebo, vitamin D supplementation was associated with significant decrease in fasting glucose [SMD -1.13, (-2.11 to -0.11)] and PTH levels [SMD -1.50, (-2.95 to -0.04)] but no difference in fasting insulin levels [SMD 1.32, (-0.15 to 2.79)]. Among NRIS, there was only a significant decrease in PTH levels [SMD -1.68, (-2.55 to -0.82)] between pre- and post-vitamin D treatment levels. CONCLUSIONS Short-term (4-12 weeks) supplementation with vitamin D is associated with lower fasting glucose levels in ESRD with no change in fasting insulin levels. However, the findings from this study are limited by the studies that were used in the meta-analysis, which were mostly small, used multiple different vitamin D compounds and dosing regimens, and had large heterogeneity, and funnel plots showed that there was a dearth of studies with null or negative finding. Therefore, larger RCTs need to be performed to answer this important clinical question.
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Affiliation(s)
- Harini Sarathy
- Department of Internal Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, NY, USA
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Ivarsson KM, Clyne N, Almquist M, Akaberi S. Hyperparathyroidism and new onset diabetes after renal transplantation. Transplant Proc 2015; 46:145-50. [PMID: 24507041 DOI: 10.1016/j.transproceed.2013.07.076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 07/30/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Secondary hyperparathyroidism persists after renal transplantation in a substantial number of patients. Primary hyperparathyroidism and secondary hyperparathyroidism are both associated with abnormalities in glucose metabolism, such as insufficient insulin release and glucose intolerance. The association of hyperparathyroidism and diabetes after renal transplantation has, as far as we know, not been studied. Our aim was to investigate whether hyperparathyroidism is associated with new-onset diabetes mellitus after transplantation (NODAT) during the first year posttransplantation. STUDY DESIGN In a retrospective study, we analyzed data on patient characteristics, treatment details, and parathyroid hormone (PTH) in 245 adult nondiabetic patients who underwent renal transplantation between January 2000 and June 2011. RESULTS The first year cumulative incidence of NODAT was 15%. The first serum PTH value after transplantation was above normal range in 74% of the patients. In multiple logistic regression analysis, PTH levels above twice normal range (>13.80 pmol/L) were significantly associated with NODAT (odds ratio [OR], 4.25; 95% confidence interval [CI], 1.13-15.92; P = .03) compared with PTH within normal range (≤6.9 pmol/L). Age between 45 and 65 years (OR, 2.80; 95% CI, 1.07-7.36; P = .04) compared with age <45 years was also associated with NODAT. CONCLUSION We found a strong association between hyperparathyroidism and NODAT in the first year after renal transplantation. Both conditions are common and have a negative impact on graft and patient survivals. Our results should be confirmed in prospective studies.
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Affiliation(s)
- K M Ivarsson
- Department of Nephrology, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - N Clyne
- Department of Nephrology, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - M Almquist
- Department of Surgery, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - S Akaberi
- Department of Nephrology, Clinical Sciences Lund, Lund University, Lund, Sweden.
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Sprague SM, Silva AL, Al-Saghir F, Damle R, Tabash SP, Petkovich M, Messner EJ, White JA, Melnick JZ, Bishop CW. Modified-release calcifediol effectively controls secondary hyperparathyroidism associated with vitamin D insufficiency in chronic kidney disease. Am J Nephrol 2015; 40:535-45. [PMID: 25572630 DOI: 10.1159/000369939] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 11/13/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND/AIMS Vitamin D insufficiency drives secondary hyperparathyroidism (SHPT) and is associated with increased cardiovascular mortality in patients with chronic kidney disease (CKD). SHPT is poorly addressed by current vitamin D repletion options. The present study evaluated a novel investigational vitamin D repletion therapy: a modified-release (MR) formulation of calcifediol designed to raise serum 25-hydroxyvitamin D in a gradual manner to minimize the induction of CYP24 and, thereby, improve the SHPT control. METHODS This randomized, double-blind, placebo-controlled trial evaluated MR calcifediol in CKD subjects (n = 78) with plasma intact parathyroid hormone (iPTH) >70 pg/ml and serum total 25-hydroxyvitamin D <30 ng/ml. Subjects received daily treatment for six weeks with oral MR calcifediol (30, 60 or 90 µg) or a placebo. RESULTS More than 90% of subjects treated with MR calcifediol achieved serum 25-hydroxyvitamin D levels ≥30 ng/ml versus 3% of subjects treated with placebo (p < 0.0001). Mean plasma iPTH decreased from baseline (140.3 pg/ml) by 20.9 ± 6.2% (SE), 32.8 ± 5.7 and 39.3 ± 4.3% in the 30, 60 and 90 µg dose groups, respectively, and increased 17.2 ± 7.8% in the pooled placebo group (p < 0.005). No clinically significant safety concerns arose during MR calcifediol treatment. CONCLUSION Oral MR calcifediol appears safe and highly effective in treating SHPT associated with vitamin D insufficiency in CKD.
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Affiliation(s)
- Stuart M Sprague
- NorthShore University Health System-University of Chicago, Pritzker School of Medicine, Evanston, Ill., USA
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Messa P, Curreri M, Regalia A, Alfieri CM. Vitamin D and the cardiovascular system: an overview of the recent literature. Am J Cardiovasc Drugs 2014; 14:1-14. [PMID: 24122604 DOI: 10.1007/s40256-013-0047-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Since the discovery that the enzyme catalyzing the synthesis of the most active natural vitamin D metabolite(calcitriol) and the vitamin D-specific receptor (VDR)were expressed in a wide range of tissues and organs, not only involved in the mineral metabolism (MM), there has been increasing interest on the putative ‘non classical’ roles of vitamin D metabolites, particularly on their possible effects on the cardiovascular (CV) system. These hypothetical CV effects of vitamin D gained particular interesting the nephrology field, given the high prevalence of CV disease in patients affected by either acute or chronic kidney diseases. However, notwithstanding a huge amount of experimental data suggesting a possible protective role of vitamin D on the CV system, the conclusions of two recent meta-analyses from the Cochrane group and a recent statement from the Institute of Medicine, based on a complete revision of the available data, concluded that there is no clear evidence for a role of vitamin D other than that strictly associated with bone health. However, a continuous and increasing flow of new studies still continues to add information on this topic. In the present review, we have tried to critically address the data added on this topicin the last 2 years, considering separately the experimental,observational, and intervention studies that have appeared in PubMed in the last 2 years, discussing the data providing proof, pro or contra, the involvement of vitamin D in CV disease, both in the absence or presence of kidney function impairment.
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The authors reply. Kidney Int 2014; 85:212-3. [PMID: 24380909 DOI: 10.1038/ki.2013.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Affiliation(s)
- Anand Vaidya
- Metabolism Clinical and Experimental, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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de Boer IH, Thadhani R. Vitamin D deficiency: consequence or cause of CKD? Clin J Am Soc Nephrol 2013; 8:1844-6. [PMID: 24135217 DOI: 10.2215/cjn.09480913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Ian H de Boer
- Division of Nephrology, and Kidney Research Institute, Departments of Medicine and Epidemiology, University of Washington, Seattle, Washington, †Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Brown JM, Secinaro K, Williams JS, Vaidya A. Evaluating hormonal mechanisms of vitamin D receptor agonist therapy in diabetic kidney disease: the VALIDATE-D study. BMC Endocr Disord 2013; 13:33. [PMID: 23971740 PMCID: PMC3765219 DOI: 10.1186/1472-6823-13-33] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 08/22/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Insufficient vitamin D status and increased renin-angiotensin system (RAS) activity have been associated with renal-vascular disease and nephropathy in diabetes. Accumulating evidence indicates that vitamin D receptor (VDR) activation lowers unfavorable RAS activity; however, more human intervention studies evaluating whether this mechanism could influence diabetic kidney disease are needed. We previously reported that both vitamin D levels and genetic variation at the VDR predict human RAS activity, and that vitamin D therapy can lower RAS activity in non-diabetics. The VALIDATE-D study is a randomized, placebo-controlled, intervention study designed to extend these findings by evaluating whether direct VDR activation in diabetes lowers circulating and local renal-vascular tissue RAS activity (Aims 1 and 2) in a manner similar to the action of ACE inhibitors (Aim 3). METHODS/DESIGN Forty subjects with type 2 diabetes, microalbuminuria, and without chronic kidney disease will be recruited to undergo detailed assessment of the RAS before and after randomization to calcitriol 0.75 mcg/day or placebo. Primary analyses will evaluate whether calcitriol therapy reduces circulating and renal-vascular tissue-RAS activity in comparison to placebo. All subjects will thereafter be treated with lisinopril and followed for 3.5 months to evaluate whether combination therapy (calcitriol + lisinopril vs. placebo + lisinopril) additively or synergistically improves renal-vascular function, and lowers proteinuria. DISCUSSION The VALIDATE-D study is the first human intervention study to evaluate whether direct VDR activation can lower the human RAS in diabetes, compared to the effect of an ACE inhibitor, and whether this mechanism can translate to clinically relevant endpoints for diabetic kidney disease. The outcomes of VALIDATE-D will have major implications for the recommendation of vitamin D supplementation for the primary prevention of kidney complications in diabetes. TRIAL REGISTRATION ClinicalTrials.gov, NCT01635062.
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Affiliation(s)
- Jenifer M Brown
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, 221 Longwood Ave, RFB, Boston, MA 02115, USA
| | - Kristina Secinaro
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, 221 Longwood Ave, RFB, Boston, MA 02115, USA
| | - Jonathan S Williams
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, 221 Longwood Ave, RFB, Boston, MA 02115, USA
| | - Anand Vaidya
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, 221 Longwood Ave, RFB, Boston, MA 02115, USA
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de Borst MH, Hajhosseiny R, Tamez H, Wenger J, Thadhani R, Goldsmith DJA. Active vitamin D treatment for reduction of residual proteinuria: a systematic review. J Am Soc Nephrol 2013; 24:1863-71. [PMID: 23929770 DOI: 10.1681/asn.2013030203] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Despite renin-angiotensin-aldosterone system blockade, which retards progression of CKD by reducing proteinuria, many patients with CKD have residual proteinuria, an independent risk factor for disease progression. We aimed to address whether active vitamin D analogs reduce residual proteinuria. We systematically searched for trials published between 1950 and September of 2012 in the Medline, Embase, and Cochrane Library databases. All randomized controlled trials of vitamin D analogs in patients with CKD that reported an effect on proteinuria with sample size≥50 were selected. Mean differences of proteinuria change over time and odds ratios for reaching ≥15% proteinuria decrease from baseline to last measurement were synthesized under a random effects model. From 907 citations retrieved, six studies (four studies with paricalcitol and two studies with calcitriol) providing data for 688 patients were included in the meta-analysis. Most patients (84%) used an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker throughout the study. Active vitamin D analogs reduced proteinuria (weighted mean difference from baseline to last measurement was -16% [95% CI, -13% to -18%]) compared with controls (+6% [95% CI, 0% to +12%]; P<0.001). Proteinuria reduction was achieved more commonly in patients treated with an active vitamin D analog (204/390 patients) than control patients (86/298 patients; OR, 2.72 [95% CI, 1.82 to 4.07]; P<0.001). Thus, active vitamin D analogs may further reduce proteinuria in CKD patients in addition to current regimens. Future studies should address whether vitamin D therapy also retards progressive renal functional decline.
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Affiliation(s)
- Martin H de Borst
- Division of Nephrology, Department of Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Abstract
Vitamin D compounds may have extraskeletal functions. Chronic kidney disease (CKD) offers an opportunity to investigate these actions, as vitamin D deficiency is prevalent in this population and actions of vitamin D such as those on the heart and glucose metabolism are highly relevant. However, recent randomized controlled trials have tempered enthusiasm. We appraise a trial by de Boer et al. that addresses effects of paricalcitol on glucose metabolism in CKD, and offer perspectives on future trials.
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Larsen T, Mose FH, Bech JN, Pedersen EB. Effect of paricalcitol on renin and albuminuria in non-diabetic stage III-IV chronic kidney disease: a randomized placebo-controlled trial. BMC Nephrol 2013; 14:163. [PMID: 23889806 PMCID: PMC3729723 DOI: 10.1186/1471-2369-14-163] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 07/19/2013] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Vitamin D receptor activators reduce albuminuria, and may improve survival in chronic kidney disease (CKD). Animal studies suggest that these pleiotropic effects of vitamin D may be mediated by suppression of renin. However, randomized trials in humans have yet to establish this relationship. METHODS In a randomized, placebo-controlled, double-blinded crossover study, the effect of oral paricalcitol (2 μg/day) was investigated in 26 patients with non-diabetic, albuminuric stage III-IV CKD. After treatment, plasma concentrations of renin (PRC), angiotensin II (AngII) and aldosterone (Aldo) were measured. GFR was determined by 51Cr-EDTA clearance. Assessment of renal NO dependency was performed by infusion of NG-monomethyl-L-arginine (L-NMMA). Albumin excretion rate (AER) was analyzed in 24-h urine and during 51Cr-EDTA clearance. RESULTS Paricalcitol did not alter plasma levels of renin, AngII, Aldo, or urinary excretion of sodium and potassium. A modest reduction of borderline significance was observed in AER, and paricalcitol abrogated the albuminuric response to L-NMMA. CONCLUSIONS In this randomized, placebo-controlled trial paricalcitol only marginally decreased AER and did not alter circulating levels of renin, AngII or Aldo. The abrogation of the rise in albumin excretion by paricalcitol during NOS blockade may indicate that favourable modulation of renal NO dependency could be involved in mediating reno-protection and survival benefits in CKD. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01136564.
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Pilz S, Kienreich K, Rutters F, de Jongh R, van Ballegooijen AJ, Grübler M, Tomaschitz A, Dekker JM. Role of vitamin D in the development of insulin resistance and type 2 diabetes. Curr Diab Rep 2013; 13:261-70. [PMID: 23264189 DOI: 10.1007/s11892-012-0358-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Vitamin D deficiency is mainly a consequence of insufficient sunlight induced vitamin D production in the skin and has been associated with various chronic diseases including type 2 diabetes. Experimental data have shown that vitamin D is important for glucose induced insulin secretion, improves insulin resistance, and exerts anti-inflammatory actions. Epidemiological studies have largely documented that a poor vitamin D status is associated with higher risk of insulin resistance and type 2 diabetes. The majority of randomized controlled trials (RCTs) in healthy or prediabetic individuals have, however, failed to demonstrate relevant vitamin D effects on insulin resistance or diabetes incidence. In patients with type 2 diabetes, a few RCTs reported some moderate effects of vitamin D on glycemic control and insulin resistance. While these findings warrant further in-depth studies, the current evidence is insufficient to recommend vitamin D supplementation for the prevention or treatment of type 2 diabetes.
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Affiliation(s)
- Stefan Pilz
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre Amsterdam, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
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