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Bartz-Kurycki M, Dream S. Surgical Management of Secondary and Tertiary Hyperparathyroidism. Surg Clin North Am 2024; 104:825-835. [PMID: 38944502 DOI: 10.1016/j.suc.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Secondary hyperparathyroidism (SHPT) often arises from kidney disease and is characterized by elevated parathyroid hormone (PTH) levels. The reported optimal PTH level to balance the compensatory physiologic response in SHPT with the pathologic morbidity and mortality has changed over time with our evolving understanding. Parathyroidectomy for kidney-related hyperparathyroidism requires consideration of the patient's dialysis status, potential for kidney transplantation, and medical history. Extent of parathyroidectomy and intraoperative decision-making requires consideration to maximize cure with the risk of permanent hypoparathyroidism. Parathyroidectomy for kidney-related hyperparathyroidism can provide a reduction in morbidity, mortality, and improved kidney allograft function and survival.
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Affiliation(s)
- Marisa Bartz-Kurycki
- Surgical Services, James A. Haley Veterans Hospital, 13000 Bruce B. Downs Boulevard, Tampa, FL 33612, USA; Department of Surgery, University of South Florida, Tampa, FL, USA. https://twitter.com/MarisaBK6
| | - Sophie Dream
- Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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Thiem U, Lenz J, Haller MC, Pasch A, Smith ER, Cejka D. The effect of parathyroid hormone lowering by etelcalcetide therapy on calcification propensity and calciprotein particles in hemodialysis patients. Clin Kidney J 2024; 17:sfae097. [PMID: 38919277 PMCID: PMC11197474 DOI: 10.1093/ckj/sfae097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Indexed: 06/27/2024] Open
Abstract
Background This study investigated whether parathyroid hormone (PTH) lowering with etelcalcetide, and the consequent effects on mineral and bone metabolism, could improve serum calcification propensity (T50 time) and decrease calciprotein particle (CPP) load in hemodialysis patients with secondary hyperparathyroidism. Methods In this single-arm, prospective, dose-escalation proof-of-principle study, hemodialysis patients received etelcalcetide at 2.5 mg/dialysis session with increments of 2.5 mg every 4 weeks to a maximum dose of 15 mg three times a week or until a pre-specified safety endpoint was reached, followed by an 8-week wash-out phase. Results Out of 36 patients recruited (81% male, 62 ± 13 years), 16 patients completed the study per protocol with a mean maximum tolerated dose of etelcalcetide of 9.5 ± 2.9 mg/dialysis session. With escalating doses of etelcalcetide, PTH and serum calcium levels significantly decreased (P < 0.0001). While there was no significant change in T50 times or serum phosphate levels, etelcalcetide did yield significant and consistent reductions in serum levels of endogenous calciprotein monomers [-35.4 (-44.4 to -26.5)%, P < 0.0001], primary [-22.4 (-34.5 to -10.3)%, P < 0.01] and secondary CPP [-29.1 (-45.7 to -12.4)%, P < 0.01], an effect that was reversed after therapy withdrawal. Serum levels of osteoclastic markers significantly decreased with escalating doses of etelcalcetide, while levels of the osteoblastic marker remained stable. Conclusions Lowering of PTH with etelcalcetide did not result in statistically significant changes in T50. By contrast, homogenous reductions in serum levels of calciprotein monomers, primary and secondary CPP were observed.
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Affiliation(s)
- Ursula Thiem
- Department of Medicine III - Nephrology, Hypertension, Transplantation Medicine, Rheumatology, Geriatrics, Ordensklinikum Linz - Elisabethinen Hospital, Linz, Austria
| | - Jakob Lenz
- Department of Medicine III - Nephrology, Hypertension, Transplantation Medicine, Rheumatology, Geriatrics, Ordensklinikum Linz - Elisabethinen Hospital, Linz, Austria
| | - Maria C Haller
- Department of Medicine III - Nephrology, Hypertension, Transplantation Medicine, Rheumatology, Geriatrics, Ordensklinikum Linz - Elisabethinen Hospital, Linz, Austria
- CeMSIIS - Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University Vienna, Vienna, Austria
| | - Andreas Pasch
- Calciscon AG, Biel, Switzerland
- Lindenhofspital Bern, Bern, Switzerland
- Department of Physiology and Pathophysiology, Johannes Kepler University Linz, Linz, Austria
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia
| | - Daniel Cejka
- Department of Medicine III - Nephrology, Hypertension, Transplantation Medicine, Rheumatology, Geriatrics, Ordensklinikum Linz - Elisabethinen Hospital, Linz, Austria
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Petrović M, Brković V, Baralić M, Marić I, Petković N, Stanković S, Lalić N, Stanisavljević D, Đukanović L, Ležaić V. Comparative Analysis of Vascular Calcification Risk Factors in Pre-Hemodialysis and Prevalent Hemodialysis Adult Patients: Insights into Calcification Biomarker Associations and Implications for Intervention Strategies in Chronic Kidney Disease. Diagnostics (Basel) 2024; 14:824. [PMID: 38667470 PMCID: PMC11049133 DOI: 10.3390/diagnostics14080824] [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: 02/11/2024] [Revised: 04/06/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
This retrospective study aimed to compare risk factors for vascular calcification (VC) between pre-hemodialysis (HD) and prevalent HD adult patients while investigating associations with calcification biomarkers. Baseline data from 30 pre-HD and 85 HD patients were analyzed, including iPTH, vitamin D, FGF 23, fetuin-A, sclerostin, and VC scores (Adragao method). Prevalence of VC was similar in both groups, but HD patients had more frequent VC scores ≥ 6. Pre-HD patients were older, with higher prevalence of hypertension and less frequent use of calcium phosphate binders. Both groups showed similar patterns of hyperphosphatemia, low vitamin D, and iPTH. Fetuin-A and sclerostin levels were higher in pre-HD, while FGF 23 was elevated in HD patients. Higher VC risk in pre-HD patients was associated with male gender, older age, lower fetuin-A and higher sclerostin, lower ferritin, and no vitamin D treatment, while in HD patients with higher sclerostin, FGF 23 and urea, and lower iPTH. Conclusion: Biomarkers could be measurable indicators of biological processes underlying VC in CKD patients that may serve as a potential guide for considering personalized therapeutic approaches. Further studies are needed to elucidate the underlying pathways.
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Affiliation(s)
- Marko Petrović
- Department of Nephrology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.P.); (M.B.)
| | - Voin Brković
- Department of Nephrology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.P.); (M.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia (L.Đ.)
| | - Marko Baralić
- Department of Nephrology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.P.); (M.B.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia (L.Đ.)
| | - Ivko Marić
- Special Hospital for Internal Diseases, 11550 Lazarevac, Serbia
| | - Nenad Petković
- Fresenius Medical Care Dialysis Center, 76230 Šamac, Bosnia and Herzegovina
| | - Sanja Stanković
- Centre for Medical Biochemistry, University Clinical Centre of Serbia, 11000 Belgrade, Serbia;
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Nataša Lalić
- Uromedica Polyclinic Belgrade, 11000 Belgrade, Serbia
| | | | - Ljubica Đukanović
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia (L.Đ.)
| | - Višnja Ležaić
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia (L.Đ.)
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Gu Z, Yang X, Wang Y, Gao J. Effects of denosumab on bone mineral density and bone metabolism in patients with end-stage renal disease: A systematic review and meta-analysis. Hemodial Int 2023; 27:352-363. [PMID: 37264758 DOI: 10.1111/hdi.13098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/25/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The effects of denosumab on bone mineral density (BMD) and metabolism in patients with end-stage renal disease (ESRD) remain controversial. Hence, we performed a systematic review and meta-analysis of observational studies. METHODS The MEDLINE, EMBASE, and Cochrane Library databases were searched in June 2022 to identify studies that evaluated the risk of denosumab-associated hypocalcemia and changes in bone metabolism, changes in BMD from baseline to post-treatment in patients with ESRD. FINDINGS Twelve studies with 348 participants were included. The pooled incidence of hypocalcemia during denosumab treatment was 35.0% (95% confidence interval [CI], 25%-46%; I2 = 63.6%). There were no significant changes in either the serum calcium or phosphate levels from the baseline to post-treatment period; the mean differences were 0.04 mg/dL (95% CI, -0.12 to 0.20 mg/dL) and -0.39 mg/dL (95% CI, -0.89 to 0.12 mg/dL). We found significant changes in the alkaline phosphatase and parathyroid hormone levels; the standardized mean differences were -2.98 (95% CI, -5.36 to -0.59) and -3.12 (95% CI: -4.94 to -1.29), respectively. Denosumab may increase BMD, with mean differences of 9.10% (95% CI: 4.07%-14.13%) and 9.00% (95% CI: 5.93%-12.07%) for the femoral neck and lumbar spine, respectively. DISCUSSION Denosumab increased the BMDs of the lumbar spine and femoral neck in patients with ESRD. The onset of hypocalcemia must be carefully monitored during denosumab administration.
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Affiliation(s)
- Zhaoyan Gu
- Department of Endocrinology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Xuhui Yang
- Department of Oncology, The Fifth Medical Center, Chinese PLA General Hospital and Chinese PLA Medical School, Beijing, People's Republic of China
| | - Yan Wang
- Chaoyang 1st Sanitarium for Retired Cadres of Beijing Garrison of the Chinese PLA, Beijing, People's Republic of China
| | - Jianjun Gao
- Department of Nephrology, The Chinese PLA Strategic Support Force Characteristic Medical Center, Beijing, People's Republic of China
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Magbri A, El-Magbri M, Hernandez PA. Get-up and Go: Adynamic Bone Disease in Chronic Kidney Disease Patient. ARCHIVES OF PHARMACY PRACTICE 2023. [DOI: 10.51847/suxosrek5t] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Bone Disease in Chronic Kidney Disease and Kidney Transplant. Nutrients 2022; 15:nu15010167. [PMID: 36615824 PMCID: PMC9824497 DOI: 10.3390/nu15010167] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022] Open
Abstract
Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) comprises alterations in calcium, phosphorus, parathyroid hormone (PTH), Vitamin D, and fibroblast growth factor-23 (FGF-23) metabolism, abnormalities in bone turnover, mineralization, volume, linear growth or strength, and vascular calcification leading to an increase in bone fractures and vascular disease, which ultimately result in high morbidity and mortality. The bone component of CKD-MBD, referred to as renal osteodystrophy, starts early during the course of CKD as a result of the effects of progressive reduction in kidney function which modify the tight interaction between mineral, hormonal, and other biochemical mediators of cell function that ultimately lead to bone disease. In addition, other factors, such as osteoporosis not apparently dependent on the typical pathophysiologic abnormalities resulting from altered kidney function, may accompany the different varieties of renal osteodystrophy leading to an increment in the risk of bone fracture. After kidney transplantation, these bone alterations and others directly associated or not with changes in kidney function may persist, progress or transform into a different entity due to new pathogenetic mechanisms. With time, these alterations may improve or worsen depending to a large extent on the restoration of kidney function and correction of the metabolic abnormalities developed during the course of CKD. In this paper, we review the bone lesions that occur during both CKD progression and after kidney transplant and analyze the factors involved in their pathogenesis as a means to raise awareness of their complexity and interrelationship.
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Lee DY, Yoo DK, Han SY, Lee K, Lee Y, Teopiz KM, Mansur RB, Rosenblat JD, McIntyre RS. Association between depressive symptoms and bone density in elderly patients with non-dialysis dependent chronic kidney disease. J Affect Disord 2022; 319:549-554. [PMID: 36113692 DOI: 10.1016/j.jad.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/04/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Depression is a disease that is commonly accompanied by elderly chronic kidney disease (CKD) patients, but when the two diseases are accompanied, etiology or combination are not well known. We aimed to evaluate the etiology of CKD and comorbid depression by investigating bone disorders that are observed in persons affected by both CKD and depression. METHODS We conducted a cross-sectional study with a total of 646 patients with CKD. We compared the sociodemographic factors, kidney function, markers for CKD-Mineral and Bone Disorder (CKD-MBD) and bone mineral density according to the depressive symptoms. We conducted a univariate and multivariate logistic regression analysis to calculate odd ratios (95 % confidence interval) between depressive symptoms and low bone mineral density. RESULTS Individuals with CKD and depressive symptoms were associated with lower level of education attained, living alone, exercising less, low 24-hour urine phosphorus, and low bone density. Depressive symptoms were significantly associated with low bone density in lowest parts (1.55 [1.06-2.29]) and in total hip (1.72 [1.17-2.53]) even after adjusting for diabetes mellitus, hypertension, kidney function, proteinuria, age, sex, smoking, and body mass index. LIMITATIONS A cross-sectional design was used in this study and the bone biopsy for diagnosis of CKD-MBD was not done because of invasiveness and practical difficulties. CONCLUSION Low bone density was associated with depressive symptoms in elderly patients with non-dialysis chronic kidney disease.
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Affiliation(s)
- Dong-Young Lee
- Department of Internal Medicine, Veterans Healthcare Service Medical Center, Seoul, Republic of Korea
| | - Dong Kyun Yoo
- Department of Internal Medicine, Veterans Healthcare Service Medical Center, Seoul, Republic of Korea
| | - Sang Youb Han
- Department of Internal Medicine, Inje University College of Medicine, Ilsan-Paik Hospital, Goyang, Gyeonggi, Republic of Korea
| | - Kangbaek Lee
- Yonsei Miso Dental Clinic, Seongnam, Gyeonggi, Republic of Korea
| | - Young Lee
- Veterans Medical Research Institute, Veterans Healthcare Service Medical Center, Seoul, Republic of Korea
| | - Kayla M Teopiz
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University of Health Network, Toronto, Ontario, Canada
| | - Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University of Health Network, Toronto, Ontario, Canada; Braxia Health, Mississauga, Ontario, Canada; Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University of Health Network, Toronto, Ontario, Canada; Braxia Health, Mississauga, Ontario, Canada; Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University of Health Network, Toronto, Ontario, Canada; Braxia Health, Mississauga, Ontario, Canada; Department of Psychiatry, University of Toronto, Ontario, Canada.
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Nagy E, Sobh MM, Abdalbary M, Elnagar S, Elrefaey R, Shabaka S, Elshabrawy N, Shemies R, Tawfik M, Santos CGS, Barreto FC, El-Husseini A. Is Adynamic Bone Always a Disease? Lessons from Patients with Chronic Kidney Disease. J Clin Med 2022; 11:jcm11237130. [PMID: 36498703 PMCID: PMC9736225 DOI: 10.3390/jcm11237130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022] Open
Abstract
Renal osteodystrophy (ROD) is a common complication of end-stage kidney disease that often starts early with loss of kidney function, and it is considered an integral part in management of patients with chronic kidney disease (CKD). Adynamic bone (ADB) is characterized by suppressed bone formation, low cellularity, and thin osteoid seams. There is accumulating evidence supporting increasing prevalence of ADB, particularly in early CKD. Contemporarily, it is not very clear whether it represents a true disease, an adaptive mechanism to prevent bone resorption, or just a transitional stage. Several co-players are incriminated in its pathogenesis, such as age, diabetes mellitus, malnutrition, uremic milieu, and iatrogenic factors. In the present review, we will discuss the up-to-date knowledge of the ADB and focus on its impact on bone health, fracture risk, vascular calcification, and long-term survival. Moreover, we will emphasize the proper preventive and management strategies of ADB that are pivotal issues in managing patients with CKD. It is still unclear whether ADB is always a pathologic condition or whether it can represent an adaptive process to suppress bone resorption and further bone loss. In this article, we tried to discuss this hard topic based on the available limited information in patients with CKD. More studies are needed to be able to clearly address this frequent ROD finding.
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Affiliation(s)
- Eman Nagy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mahmoud M. Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Sherouk Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Rabab Elrefaey
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Shimaa Shabaka
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Nehal Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Rasha Shemies
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mona Tawfik
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Cássia Gomes S. Santos
- Department of Internal Medicine, Division of Nephrology, Federal University of Paraná, Curitiba 80060-00, PR, Brazil
| | - Fellype C. Barreto
- Department of Internal Medicine, Division of Nephrology, Federal University of Paraná, Curitiba 80060-00, PR, Brazil
| | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40536-0298, USA
- Correspondence: ; Tel.: +1-859-218-0934; Fax: +1-859-323-0232
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Abdalbary M, Sobh M, Elnagar S, Elhadedy MA, Elshabrawy N, Abdelsalam M, Asadipooya K, Sabry A, Halawa A, El-Husseini A. Management of osteoporosis in patients with chronic kidney disease. Osteoporos Int 2022; 33:2259-2274. [PMID: 35748896 DOI: 10.1007/s00198-022-06462-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/31/2022] [Indexed: 12/19/2022]
Abstract
Patients with CKD have a 4-fivefold higher rate of fractures. The incidence of fractures increases with deterioration of kidney function. The process of skeletal changes in CKD patients is characterized by compromised bone strength because of deterioration of bone quantity and/or quality. The fractures lead to a deleterious effect on the quality of life and higher mortality in patients with CKD. The pathogenesis of bone loss and fracture is complex and multi-factorial. Renal osteodystrophy, uremic milieu, drugs, and systemic diseases that lead to renal failure all contribute to bone damage in CKD patients. There is no consensus on the optimal diagnostic method of compromised bone assessment in patients with CKD. Bone quantity and mass can be assessed by dual-energy x-ray absorptiometry (DXA) or quantitative computed tomography (QCT). Bone quality on the other side can be assessed by non-invasive methods such as trabecular bone score (TBS), high-resolution bone imaging methods, and invasive bone biopsy. Bone turnover markers can reflect bone remodeling, but some of them are retained by kidneys. Understanding the mechanism of bone loss is pivotal in preventing fracture in patients with CKD. Several non-pharmacological and therapeutic interventions have been reported to improve bone health. Controlling laboratory abnormalities of CKD-MBD is crucial. Anti-resorptive therapies are effective in improving BMD and reducing fracture risk, but there are uncertainties about safety and efficacy especially in advanced CKD patients. Accepting the prevalent of low bone turnover in patients with advanced CKD, the osteo-anabolics are possibly promising. Parathyroidectomy should be considered a last resort for intractable cases of renal hyperparathyroidism. There is a wide unacceptable gap in osteoporosis management in patients with CKD. This article is focusing on the updated management of CKD-MBD and osteoporosis in CKD patients. Chronic kidney disease deteriorates bone quality and quantity. The mechanism of bone loss mainly determines pharmacological treatment. DXA and QCT provide information about bone quantity, but assessing bone quality, by TBS, high-resolution bone imaging, invasive bone biopsy, and bone turnover markers, can guide us about the mechanism of bone loss.
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Affiliation(s)
- M Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA
| | - M Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - S Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M A Elhadedy
- Nephrology and Transplantation Unit, Mansoura Urology and Nephrology Center, Mansoura, Egypt
| | - N Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - K Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, USA
| | - A Sabry
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - A Halawa
- Sheffield Teaching Hospital, University of Liverpool, Liverpool, UK
| | - A El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA.
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg 2022; 276:e141-e176. [PMID: 35848728 DOI: 10.1097/sla.0000000000005522] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.
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El-Husseini A, Abdalbary M, Lima F, Issa M, Ahmed MT, Winkler M, Srour H, Davenport D, Wang G, Faugere MC, Malluche HH. Low Turnover Renal Osteodystrophy With Abnormal Bone Quality and Vascular Calcification in Patients With Mild-to-Moderate CKD. Kidney Int Rep 2022; 7:1016-1026. [PMID: 35570986 PMCID: PMC9091581 DOI: 10.1016/j.ekir.2022.02.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction Limited information is available on renal osteodystrophy (ROD) and vascular calcification (VC) during early chronic kidney disease (CKD). This study was designed to evaluate ROD and VC in 32 patients with CKD stages II to IV. Methods Patients underwent dual-energy X-ray absorptiometry (DXA) for assessment of bone mineral density (BMD) and trabecular bone score (TBS), thoracic computed tomography for VC scoring using the Agatston method, and anterior iliac crest bone biopsy for mineralized bone histology, histomorphometry, and Fourier transform infrared spectroscopy (FTIR). Classical and novel bone markers were determined in the blood. Results Mean estimated glomerular filtration rate (eGFR) was 44 ± 16 ml/min per 1.73 m2. Of the patients, 84% had low bone turnover. In Whites, eGFR correlated negatively with the turnover parameter activation frequency (Ac.f) (r -0.48, P = 0.019) and with parameters of bone formation. Most patients had VC (>80%) which correlated positively with levels of phosphorus, c-terminal fibroblast growth factor-23, and activin. Aortic calcifications (ACs) correlated negatively with bone formation rate (BFR) and Ac.f (rho -0.62, -0.61, P < 0.001). TBS correlated negatively with coronary calcification (rho -0.42, P = 0.019) and AC (rho -0.57, P = 0.001). These relationships remained after adjustment of age. The mineral-to-matrix ratio, an FTIR metric reflecting bone quality, was negatively related to Ac.f and positively related to AC. Conclusion Low bone turnover and VC are predominant in early stages of CKD. This is the first study demonstrating mineral abnormalities indicating reduced bone quality in these stages of CKD.
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Affiliation(s)
- Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Mohamed Abdalbary
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Florence Lima
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Mohamed Issa
- Department of Radiology, University of Kentucky, Lexington, Kentucky, USA
| | | | - Michael Winkler
- Department of Radiology, University of Kentucky, Lexington, Kentucky, USA
| | - Habib Srour
- Department of Anesthesia, University of Kentucky, Lexington, Kentucky, USA
| | - Daniel Davenport
- Division of Healthcare Outcomes & Optimal Patient Services, University of Kentucky, Lexington, Kentucky, USA
| | - Guodong Wang
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Marie-Claude Faugere
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Hartmut H. Malluche
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
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Fusaro M, Re Sartò GV, Gallieni M, Cosmai L, Messa P, Rossini M, Chiodini I, Plebani M, Evenepoel P, Harvey N, Ferrari S, Cannata-Andía J, Trombetti A, Brandi ML, Ketteler M, Nickolas TL, Cunningham J, Salam S, Della Rocca C, Scarpa A, Minisola S, Malberti F, Cetani F, Cozzolino M, Mazzaferro S, Morrone L, Tripepi G, Zaninotto M, Mereu MC, Ravera M, Cianciolo G, La Manna G, Aghi A, Giannini S, Dalle Carbonare L. Time for Revival of Bone Biopsy with Histomorphometric Analysis in Chronic Kidney Disease (CKD): Moving from Skepticism to Pragmatism. Nutrients 2022; 14:1742. [PMID: 35565717 PMCID: PMC9103887 DOI: 10.3390/nu14091742] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 12/04/2022] Open
Abstract
Bone Biopsy (BB) with histomorphometric analysis still represents the gold standard for the diagnosis and classification of different forms of renal osteodystrophy. Bone biopsy is the only technique able to provide comprehensive information on all bone parameters, measuring static and dynamic parameters of turnover, cortical and trabecular microarchitecture, and mineralization defects. In nephrological practice, bone biopsy yields relevant indications to support therapeutic choices in CKD, heavily impacting the management and prognosis of uremic patients. Unfortunately, the use of bone biopsy has decreased; a lack of expertise in performing and interpreting, perceived procedure invasiveness and pain, and reimbursement issues have all contributed to this decline. Nevertheless, both bone biomarkers and instrumental images cannot be considered reliable surrogates for histological findings, being insufficiently accurate to properly evaluate underlying mineral and bone disorders. This is a multidisciplinary position paper from the Nephrology and Osteoporosis Italian Scientific Societies with the purpose of restating the role of bone biopsy in CKD patient management and of providing strong solutions to allow diffusion of this technique in Italy, but potentially also in other countries. The Italian approach through the optimization and standardization of bone biopsy procedure, the construction of the Italian Hub and Spoke network, and a request for adjustment and national homogenization of reimbursement to the Italian Health Ministry has led the way to implement bone biopsy and to improve CKD patient management and prognosis.
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Affiliation(s)
- Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), 56124 Pisa, Italy
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Giulia Vanessa Re Sartò
- Post-Graduate School of Specialization in Nephrology, University of Milano, 20157 Milano, Italy; (G.V.R.S.); (M.G.)
| | - Maurizio Gallieni
- Post-Graduate School of Specialization in Nephrology, University of Milano, 20157 Milano, Italy; (G.V.R.S.); (M.G.)
- Department of Biomedical and Clinical Sciences, Università di Milano, 20157 Milano, Italy
- Nephrology Unit, ASST Fatebenefratelli Sacco, 20157 Milano, Italy;
| | - Laura Cosmai
- Nephrology Unit, ASST Fatebenefratelli Sacco, 20157 Milano, Italy;
| | - Piergiorgio Messa
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, 20157 Milano, Italy;
- Department of Clinical Sciences and Community Health, University of Milano, 20122 Milano, Italy
| | | | - Iacopo Chiodini
- Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, 20157 Milano, Italy;
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine, University of Padua, 35121 Padua, Italy; (M.P.); (M.Z.)
| | - Pieter Evenepoel
- Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven, B-3000 Leuven, Belgium;
| | - Nicholas Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton SO16 6YD, UK;
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Serge Ferrari
- Service des Maladies Osseuses, Département de Médecine, HUG, 1205 Geneva, Switzerland;
| | - Jorge Cannata-Andía
- Bone and Mineral Research Unit, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), REDinREN del ISCIII, Hospital Universitario Central de Asturias, Universidad de Oviedo, 33003 Oviedo, Spain;
| | - Andrea Trombetti
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland;
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy;
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, 70376 Stuttgart, Germany;
| | - Thomas L. Nickolas
- Division of Nephrology, Columbia University Irving Medical Center, New York, NY 10027, USA;
| | - John Cunningham
- Centre for Nephrology, The Royal Free Hospital and UCL Medical School, London WC1E 6BT, UK;
| | - Syazrah Salam
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield S10 2JF, UK;
| | - Carlo Della Rocca
- Department of Medico-Surgical Sciences and Biotechnology, Sapienza University, Polo Pontino, 00185 Rome, Italy;
| | - Aldo Scarpa
- ARC-Net Centre for Applied Research on Cancer, University and Hospital Trust of Verona, 37134 Verona, Italy;
- Department of Pathology and Diagnostics, University and Hospital Trust of Verona, 37134 Verona, Italy
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Fabio Malberti
- UO Nefrologia e Dialisi ASST Cremona, 26100 Cremona, Italy;
| | - Filomena Cetani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, San Paolo Hospital, University of Milan, 20142 Milan, Italy;
| | - Sandro Mazzaferro
- Nephrologic Unit, Department of Translational and Precision Medicine, University of Rome ‘La Sapienza’, 00185 Rome, Italy;
| | - Luigi Morrone
- Nephrology, Dialysis and Renal Transplantation Unit, University Hospital “Policlinico”, 70124 Bari, Italy;
| | - Giovanni Tripepi
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy;
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine, University of Padua, 35121 Padua, Italy; (M.P.); (M.Z.)
| | | | | | - Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; (G.C.); (G.L.M.)
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; (G.C.); (G.L.M.)
| | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padua, 35128 Padua, Italy; (A.A.); (S.G.)
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padua, 35128 Padua, Italy; (A.A.); (S.G.)
| | - Luca Dalle Carbonare
- Section of Internal Medicine, Department of Medicine, University of Verona, 37134 Verona, Italy;
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13
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Barra ABL, Roque-da-Silva AP, Canziani MEF, Lugon JR, Strogoff-de-Matos JP. Characteristics and predictors of mortality on haemodialysis in Brazil: a cohort of 5,081 incident patients. BMC Nephrol 2022; 23:77. [PMID: 35196997 PMCID: PMC8864821 DOI: 10.1186/s12882-022-02705-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/10/2022] [Indexed: 11/23/2022] Open
Abstract
Background Although Brazil has one of the largest populations on haemodialysis (HD) in the world, data regarding patients’ characteristics and the variables associated with risk of death are scanty. Methods This is a retrospective analysis of all adult patients who initiated on maintenance HD at 23 dialysis centres in Brazil between 2012 and 2017. Patients were censored after 60 months of follow-up or at the end of 2019. Results A total of 5,081 patients were included in the analysis. The median age was 59 years, 59.4% were men, 37.5% had diabetes as the cause of kidney failure. Almost 70% had a central venous catheter (CVC) as the initial vascular access, about 60% started dialysis in the hospital, and fluid overload (FO) by bioimpedance assessment was seen in 45% of patients. The 60-month survival rate was 51.4%. In the Cox regression analysis, being older (P<0.0001), starting dialysis in the hospital (P=0.016), having diabetes as the cause of kidney failure (P=0.001), high alkaline phosphatase (P=0.005), CVC as first vascular access (P=0.023), and FO (P<0.0001) were associated with higher death risk, whereas higher body mass index (P=0.015), haemoglobin (P=0.004), transferrin saturation (P=0.002), and serum albumin (P<0.0001) were associated with better survival. The same variables, except initial CVC use (P=0.14), were associated with death risk in an analysis of subdistribution proportional hazards ratio including the competing outcomes. Conclusions The present study gives an overview of a large HD population in a developing country and identifies the main predictors of mortality, including some potentially modifiable ones, such as unplanned initiation of dialysis in the hospital and fluid overload. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02705-x.
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Affiliation(s)
- Ana Beatriz Lesqueves Barra
- Postgraduation Program in Medical Sciences, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil.,Fresenius Medical Care Brazil, Rio de Janeiro, Brazil
| | - Ana Paula Roque-da-Silva
- Postgraduation Program in Medical Sciences, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil
| | | | - Jocemir R Lugon
- Postgraduation Program in Medical Sciences, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil.,Nephrology Division, Department of Medicine, Universidade Federal Fluminense, Av. Marquês do Paraná 303, 2 andar, Niterói, Rio de Janeiro, Zip Code 24033-900, Brazil
| | - Jorge Paulo Strogoff-de-Matos
- Postgraduation Program in Medical Sciences, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil. .,Nephrology Division, Department of Medicine, Universidade Federal Fluminense, Av. Marquês do Paraná 303, 2 andar, Niterói, Rio de Janeiro, Zip Code 24033-900, Brazil.
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14
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Ferreira AC, Cotovio P, Aires I, Mendes M, Navarro D, Silva C, Caeiro F, Salvador R, Correia B, Cabral G, Nolasco F, Ferreira A. The Role of Bone Volume, FGF23 and Sclerostin in Calcifications and Mortality; a Cohort Study in CKD Stage 5 Patients. Calcif Tissue Int 2022; 110:215-224. [PMID: 34477944 DOI: 10.1007/s00223-021-00910-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
Chronic kidney disease-mineral and bone disorder has been associated with increasing morbid-mortality. The aim of this study was to determine the prevalence and phenotype of bone disease before transplantation and to correlate FGF23 and sclerostin levels with bone histomorphometry, and study possible associations between FGF23, sclerostin, and bone histomorphometry with cardiovascular disease and mortality. We performed a cross-sectional cohort study of a sample of 84 patients submitted to renal transplant, which were prospectively followed for 12 months. Demographic, clinical, and echocardiographic data were collected, laboratory evaluation, bone biopsy, and X-ray of the pelvis and hands were performed. Patient and graft survival were recorded. We diagnosed low bone turnover in 16 patients (19.5%); high bone turnover in 22 patients (26.8%); osteomalacia in 1 patient (1.2%), and mixed renal osteodystrophy in 3 patients (3.7%). At the end of 12 months, 5 patients had graft failure (5.9%), 4 had a cardiovascular event (4.8%), and 4 died. Age was associated with low remodeling disease, whereas high BALP and phosphorus and low sclerostin with high turnover disease. Sclerostin was a risk factor for isolated low bone volume. High BALP, low phosphorus, and low FGF23 were risk factors for abnormal mineralization. FGF23 appears as an independent factor for severity of vascular calcifications and for cardiovascular events, whereas the presence of valve calcifications was associated with low volume and with turnover deviations. Sclerostin was associated a higher HR for death. Sclerostin and FGF23 seemed to provide higher cardiovascular risk, as well as low bone volume, which associated with extra-osseous calcifications.
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Affiliation(s)
- Ana Carina Ferreira
- Nephrology Department, Hospital Curry Cabral|CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal.
- Nova Medical School, Lisbon, Portugal.
| | - Patrícia Cotovio
- Nephrology Department, Hospital Curry Cabral|CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
| | - Inês Aires
- Nephrology Department, Hospital Curry Cabral|CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Marco Mendes
- Nephrology Department, Hospital Curry Cabral|CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
| | - David Navarro
- Nephrology Department, Hospital Curry Cabral|CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
| | - Cecília Silva
- Nephrology Department, Hospital Curry Cabral|CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
| | - Fernando Caeiro
- Nephrology Department, Hospital Curry Cabral|CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
| | - Rute Salvador
- CEDOC, Tissue Repair and Inflammation Lab, Lisbon, Portugal
| | - Bruna Correia
- CEDOC, Tissue Repair and Inflammation Lab, Lisbon, Portugal
| | | | - Fernando Nolasco
- Nephrology Department, Hospital Curry Cabral|CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Aníbal Ferreira
- Nephrology Department, Hospital Curry Cabral|CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
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15
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Yajima A, Tsuchiya K, Burr DB, Murata T, Nakamura M, Inaba M, Tominaga Y, Tanizawa T, Nakayama T, Ito A, Nitta K. Micropetrosis in hemodialysis patients. Bone Rep 2021; 15:101150. [PMID: 34926729 PMCID: PMC8649646 DOI: 10.1016/j.bonr.2021.101150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/06/2021] [Accepted: 11/15/2021] [Indexed: 01/03/2023] Open
Abstract
Micropetrosis develops as a result of stagnation of calcium, phosphorus and bone fluid, which appears as highly mineralized bone area in the osteocytic perilacunar/canalicular system regardless of bone turnover of the patients. And microcracks are predisposed to increase in these areas, which leads to increased bone fragility. However, micropetrosis of hemodialysis (HD) patients has not been discussed at all. Micropetrosis area per bone area (Mp.Ar/B·Ar) and osteocyte number per micropetrosis area (Ot.N/Mp.Ar) were measured in nine HD patients with renal hyperparathyroidism (Group I), twelve patients with hypoparathyroidism within 1 year after the treatment of renal hyperparathyroidism (Group II) and seven patients suffering from hypoparathyroidism for over two years (Group III). And bone mineral density (BMD) and tissue mineral density (TMD) were calculated using μCT to evaluate bone mineral content of iliac bone of the patients. These parameters were compared among the three groups. Only Mp.Ar/B·Ar was statistically greater in Group II and III compared to Group I in the parameters of bone mineral content and micropetrosis. However, the other parameters were not statistically different among the three groups. In long-term HD patients, BMD and TMD may be modified by the causes of renal insufficiency and the treatment of renal bone disease. We concluded that Mp.Ar/B·Ar was greater in patients with long-term hypoparathyroidism than both those with short-term hypoparathyroidism and with renal hyperparathyroidism. Special attention should be paid to avoid long-term hypoparathyroidism of the patients from the view point of increased fracture risk caused by increased micropetrosis area.
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Affiliation(s)
- Aiji Yajima
- Department of Anatomy, Cell Biology and Physiology, Indiana University, School of Medicine, Indianapolis, IN, USA.,Department of Urology, Tokyo Teishin Hospital, Tokyo, Japan.,Department of Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Ken Tsuchiya
- Department of Blood Purification, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - David B Burr
- Department of Anatomy, Cell Biology and Physiology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Taro Murata
- Department of Urology, Tokyo Teishin Hospital, Tokyo, Japan
| | - Masaki Nakamura
- Department of Nephrology and Urology, NTT East Kanto Hospital, Tokyo, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshihiro Tominaga
- Department of Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | | | | | - Akemi Ito
- Ito Bone Histomorphometry Institute, Niigata, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
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16
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Bucharles SGE, Carmo LPDFD, Carvalho AB, Jorgetti V. Diagnosis of bone abnormalities in CKD-MBD (Imaging and bone biopsy). J Bras Nefrol 2021; 43:621-627. [PMID: 34910795 PMCID: PMC8823924 DOI: 10.1590/2175-8239-jbn-2021-s103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/11/2021] [Indexed: 12/03/2022] Open
Affiliation(s)
| | | | | | - Vanda Jorgetti
- Universidade de São Paulo, Pathophysiology Laboratory (LIM-16), Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, SP, Brazil
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17
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Hernandes FR, Goldenstein P, Custódio MR. Treatment of Hyperparathyroidism (SHPT). J Bras Nefrol 2021; 43:645-649. [PMID: 34910799 PMCID: PMC8823921 DOI: 10.1590/2175-8239-jbn-2021-s107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/01/2021] [Indexed: 11/21/2022] Open
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18
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Roy S, Reddy SN, Garcha AS, Vantipalli P, Patel SS, Ur Rahman E, Adapa S. Successful Treatment of Calciphylaxis in a Young Female With End-Stage Renal Disease on Peritoneal Dialysis With Parathyroidectomy, Intensification of Dialysis, and Sodium Thiosulphate-A Case Report and Literature Review. J Investig Med High Impact Case Rep 2021; 9:23247096211060580. [PMID: 34845938 PMCID: PMC8637396 DOI: 10.1177/23247096211060580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Calcific uremic arteriolopathy, commonly referred to as “calciphylaxis,” is a rare life-threatening condition observed in patients with chronic kidney disease and end-stage renal disease on dialysis. This results in necrotic, ischemic, tender dermal lesions anywhere in the body, but mainly on the abdominal wall and lower extremities, where subcutaneous tissue is abundant. Histologically, it is defined by calcification in dermal capillaries, arterioles, and subcutaneous adipose tissues. It can occur in all advanced stages of chronic kidney disease as well as end-stage renal disease patients on hemodialysis or peritoneal dialysis. Our case highlights a successful case of calciphylaxis in a young female patient who underwent parathyroidectomy and intensification of peritoneal dialysis regimen along with the infusion of sodium thiosulphate injection resulting in complete resolution of the lesion in 3 months. With limited evidence of treatment options and increased frequency of this condition in a dialysis patient, our case highlights the key aspects of calciphylaxis management in a young end-stage renal disease patient who didn’t need a change of dialysis modality. We also review the risk factors and current practiced management options of this condition in our article.
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Affiliation(s)
- Sasmit Roy
- University of Virginia, Charlottesville, USA
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19
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Neto R, Pereira L, Magalhães J, Quelhas-Santos J, Martins S, Carvalho C, Frazão JM. Sclerostin and DKK1 circulating levels associate with low bone turnover in patients with chronic kidney disease Stages 3 and 4. Clin Kidney J 2021; 14:2401-2408. [PMID: 34754436 PMCID: PMC8572981 DOI: 10.1093/ckj/sfab081] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/17/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Disordered mineral and bone metabolism is a common complication of chronic kidney disease (CKD). Bone biopsy remains the gold standard tool for evaluating renal osteodystrophy (ROD), but it is an invasive procedure. Despite a growing interest in the ability of newer bone biomarkers to discriminate between different forms of ROD, data on pre-dialysis patients are scarce. METHODS A cross-sectional study was conducted in a cohort of 56 patients with CKD Stages 3 and 4. Participants underwent a transiliac bone biopsy after a course of double tetracycline labelling. Circulating levels of Wnt signalling inhibitors sclerostin and Dickkopf-1 (DKK1), soluble receptor activator of nuclear factor-κB ligand (sRANKL) and osteoprotegerin were measured and correlated with histomorphometric analysis results. RESULTS Most patients had abnormal bone histology and low-turnover bone disease was the predominant form of ROD. Characteristics associated with high bone turnover were worse renal function, lower serum calcium and higher intact parathyroid hormone and fibroblast growth factor-23 levels. Patients with low bone turnover, on the other hand, presented with higher sclerostin along with lower DKK1 and sRANKL levels. In the multivariable logistic regression analysis, sclerostin and DKK1 levels were independently associated with low-turnover bone disease. CONCLUSIONS Our results suggest that circulating levels of Wnt signalling inhibitors sclerostin and DKK1 are predictive of low-turnover bone disease in patients not yet on dialysis. Further research is needed to assess the performance of these bone turnover biomarkers, compared with histomorphometric analysis, in the diagnosis and treatment monitoring of ROD.
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Affiliation(s)
- Ricardo Neto
- Institute for Innovation and Health Research (I3S), Institute of Biomedical Engineering (INEB), Nephrology and Infectious Diseases Research Group, University of Porto, Porto, Portugal
- Department of Nephrology, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Luciano Pereira
- Institute for Innovation and Health Research (I3S), Institute of Biomedical Engineering (INEB), Nephrology and Infectious Diseases Research Group, University of Porto, Porto, Portugal
- Department of Nephrology, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Juliana Magalhães
- Institute for Innovation and Health Research (I3S), Institute of Biomedical Engineering (INEB), Nephrology and Infectious Diseases Research Group, University of Porto, Porto, Portugal
| | | | - Sandra Martins
- Department of Clinical Pathology, Centro Hospitalar Universitário São João, Porto, Portugal
- EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal
| | - Catarina Carvalho
- Institute for Innovation and Health Research (I3S), Institute of Biomedical Engineering (INEB), Nephrology and Infectious Diseases Research Group, University of Porto, Porto, Portugal
| | - João Miguel Frazão
- Institute for Innovation and Health Research (I3S), Institute of Biomedical Engineering (INEB), Nephrology and Infectious Diseases Research Group, University of Porto, Porto, Portugal
- Department of Nephrology, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
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20
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Bone Biopsy for Histomorphometry in Chronic Kidney Disease (CKD): State-of-the-Art and New Perspectives. J Clin Med 2021; 10:jcm10194617. [PMID: 34640633 PMCID: PMC8509646 DOI: 10.3390/jcm10194617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 01/31/2023] Open
Abstract
The use of bone biopsy for histomorphometric analysis is a quantitative histological examination aimed at obtaining quantitative information on bone remodeling, structure and microarchitecture. The labeling with tetracycline before the procedure also allows for a dynamic analysis of the osteoblastic activity and mineralization process. In the nephrological setting, bone biopsy is indicated to confirm the diagnosis of subclinical or focal osteomalacia and to characterize the different forms of renal osteodystrophy (ROD). Even if bone biopsy is the gold standard for the diagnosis and specific classification of ROD, the use of this approach is very limited. The main reasons for this are the lack of widespread expertise in performing or interpreting bone biopsy results and the cost, invasiveness and potential pain associated with the procedure. In this regard, the sedation, in addition to local anesthesia routinely applied in Italian protocol, significantly reduces pain and ameliorates the pain perception of patients. Concerning the lack of widespread expertise, in Italy a Hub/Spokes model is proposed to standardize the analyses, optimizing the approach to CKD patients and reducing the costs of the procedure. In addition, new tools offer the possibility to evaluate the osteogenic potential or the ability to form bone under normal and pathological conditions, analyzing mesenchymal stem cells and their ability to differentiate in the osteogenic lineage. In the same way, circulating microRNAs are suggested as a tool for exploring osteogenic potential. The combination of different diagnostic approaches and the optimization of the bioptic procedure represent a concrete solution to spread the use of bone biopsy and optimize CKD patient management.
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21
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Zhou L, Wang Z, Wang Z, Zhu J, Feng Y, Zhang D, Shen C, Ye X, Zhu J, Wei P, Mei J, Zhang J. Effect of heparinization on promoting angiogenesis of decellularized kidney scaffolds. J Biomed Mater Res A 2021; 109:1979-1989. [PMID: 33822474 DOI: 10.1002/jbm.a.37190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 12/26/2020] [Accepted: 03/24/2021] [Indexed: 12/30/2022]
Abstract
Native decellularized extracellular matrix provides an adequate platform for tissues and organs and promotes the development of organogenesis and tissue remodeling. However, thrombosis poses a great challenge that hinders the transplantation for a substantial organ in vivo. Therefore, anticoagulation and re-reendothelialization of organ biological scaffolds are the primary concerns to be addressed before orthotopic transplantation. Herein, a heparinized decellularized kidney scaffold (HEP-DKSs) was prepared using end-point attachment technology, followed by binding the vascular endothelial growth factor (VEGF) to greatly improve the hemocompatibility and angiogenesis of DKSs. Based on the anticoagulant, co-culture of human umbilical vein endothelial cells, and subcapsular transplantation of kidney experiments, HEP-VEGF-DKSs are shown to reduce platelet adhesion, which is crucial for subsequent vascularization and slow release of heparin and VEGF, suggesting its ability of improve neovascularization. Taken together, these data indicated an optimal anticoagulation function of HEP-VEGF-DKSs and the potential of vascularization for regeneration of whole decellularized kidney.
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Affiliation(s)
- Lebin Zhou
- Anatomy Department, Wenzhou Medical University, Wenzhou, China
- Department of Emergency, People's Hospital of Yueqing, Wenzhou, China
| | - Zhiyi Wang
- Department of General Practice, The Second Affliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhibin Wang
- Institute of Bioscaffold Transplantation and Immunology, Wenzhou Medical University, Wenzhou, China
| | - Junyi Zhu
- Department of Hand Surgery and Peripheral Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yulu Feng
- Department of Emergency, People's Hospital of Yueqing, Wenzhou, China
| | - Deming Zhang
- Key Laboratory of 3D Printing Process and Equipment of Zhejiang Province, School of Mechanical Engineering, Zhejiang University, Hangzhou, China
| | - Chenfang Shen
- Department of General Practice, The Second Affliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaoting Ye
- Department of General Practice, The Second Affliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jieyang Zhu
- Department of General Practice, The Second Affliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peng Wei
- Department of Hand and Repair Reconstruction Surgical, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Jin Mei
- Anatomy Department, Wenzhou Medical University, Wenzhou, China
- Institute of Bioscaffold Transplantation and Immunology, Wenzhou Medical University, Wenzhou, China
| | - Jianse Zhang
- Anatomy Department, Wenzhou Medical University, Wenzhou, China
- Institute of Bioscaffold Transplantation and Immunology, Wenzhou Medical University, Wenzhou, China
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22
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Nascimento Junior CP, Arap SS, Custodio MR, Massoni Neto LM, Brescia MDG, Moyses RMA, Jorgetti V, Montenegro FLDM. Parathyroid hormone levels after parathyroidectomy for secondary hyperparathyroidism. ACTA ACUST UNITED AC 2021; 67:230-234. [PMID: 34231767 DOI: 10.1590/1806-9282.67.02.20200609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/26/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The parathormone level after parathyroidectomy in dialysis patients are of interest. Low levels may require cryopreserved tissue implantation; however, the resection is necessary in case of recurrence. We analyzed post parathyroidectomy parathormone levels in renal hyperparathyroidism. METHODS Prospective observation of postoperative parathormone levels over defined periods in a cohort of dialysis patients that underwent total parathyroidectomy and immediate forearm autograft from 2008 to 2010, at a single tertiary care hospital. RESULTS Of 33 patients, parathormone levels until 36 months could be divided into four patterns. Patients with stable function (Pattern 1) show relatively constant levels after two months (67% of the cases). Early function and later failure (Pattern 2) were an initial function with marked parathormone reduction before one year (18%). Graft recurrence (Pattern 3) showed a progressive increase of parathormone in four cases (12%). Complete graft failure (Pattern 4) was a nonfunctioning implant at any period, which was observed in one patient (3%). Parathormone levels of Pattern 3 became statistically different of Pattern 1 at 36 months. CONCLUSIONS Patients that underwent the total parathyroidectomy and autograft present four different graft function patterns with a possible varied therapeutic management.
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Affiliation(s)
| | - Sergio Samir Arap
- Universidade de São Paulo, Serviço de Cirurgia de Cabeça e Pescoço - São Paulo (SP), Brasil
| | - Melani Ribeiro Custodio
- Universidade de São Paulo, Departamento de Clínica Médica, Serviço de Nefrologia - São Paulo (SP), Brasil
| | | | | | - Rosa Maria Affonso Moyses
- Universidade de São Paulo, Departamento de Clínica Médica, Serviço de Nefrologia - São Paulo (SP), Brasil
| | - Vanda Jorgetti
- Universidade de São Paulo, Departamento de Clínica Médica, Serviço de Nefrologia - São Paulo (SP), Brasil
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Sprague SM, Martin KJ, Coyne DW. Phosphate Balance and CKD-Mineral Bone Disease. Kidney Int Rep 2021; 6:2049-2058. [PMID: 34386654 PMCID: PMC8343779 DOI: 10.1016/j.ekir.2021.05.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/10/2021] [Indexed: 12/29/2022] Open
Abstract
Chronic kidney disease-mineral bone disorder (CKD-MBD) is a common comorbidity in patients with CKD. Characterized by laboratory abnormalities, bone abnormality, and vascular calcification, CKD-MBD encompasses a group of mineral and hormone disturbances that are strongly associated with increased cardiovascular (CV) morbidity and mortality. Abnormal serum phosphate concentrations are an independent risk factor for CV morbidity and mortality, and overall mortality. Phosphate retention plays a central role in initiating and driving many other disturbances in CKD-MBD (e.g., increased parathyroid hormone and fibroblast growth factor 23 concentrations, hypocalcemia, low vitamin D) that are also linked to increased CV risk. Thus, effective phosphate control is a logical therapeutic target for CKD-MBD treatment. Current phosphate management strategies (dietary restrictions, dialysis, phosphate binders) are insufficient to consistently achieve and maintain target phosphate concentrations in patients on dialysis. Phosphate binders reduce available phosphate for intestinal absorption but do not impair the dominant phosphate absorption pathway. Novel therapies that consider new mechanistic understandings of intestinal phosphate absorption are needed. One such therapy is tenapanor, a targeted sodium-hydrogen exchanger isoform 3 inhibitor that has been shown to reduce serum phosphate concentrations in multiple clinical trials. Tenapanor has a novel mechanism of action that reduces intestinal phosphate absorption in the primary paracellular phosphate absorption pathway.
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Affiliation(s)
- Stuart M. Sprague
- Division of Nephrology and Hypertension, NorthShore University Health System, Evanston, IL, USA
| | | | - Daniel W. Coyne
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
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24
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González-Casaus ML, Fernández-Calle P, Buño Soto A. Should clinical laboratories adapt to the reality of chronic kidney disease in the determination of parathyroid hormone? ADVANCES IN LABORATORY MEDICINE 2021; 2:332-351. [PMID: 37362408 PMCID: PMC10197458 DOI: 10.1515/almed-2021-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/15/2021] [Indexed: 06/28/2023]
Abstract
Objectives The contribution of the clinical laboratory to diagnostics is increasingly important since a great deal of clinical decisions rely on laboratory test results. Content Parathyroid hormone (PTH) measurement presents a considerable analytical variability due to the heterogeneity of its circulating forms and the antigenic configuration of the different assays commercially available. Such variability may have an impact on pathological conditions associated with significant increases in circulating PTH, as it is the case of chronic kidney disease (CKD). Summary Despite the recent identification of new molecules involved in bone and mineral disorders associated with CKD, such as klotho or the fibroblastic factor 23 (FGF23), nephrologists still base their clinical decisions on PTH concentrations. The problem is that unawareness of these analytical considerations may cause errors in the clinical interpretation of test results. Outlook This systematic review addresses these issues from the clinical laboratory perspective and proposes new approaches related to PTH method selection and result expression. These new strategies will help laboratory medicine specialists and nephrologist better determine the status of CKD patients.
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Affiliation(s)
| | | | - Antonio Buño Soto
- Department of Laboratory Medicine, Hospital Universitario La Paz, Madrid, Spain
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25
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Pawlak K, Sieklucka B, Pawlak D. Paracrine Kynurenic Pathway Activation in the Bone of Young Uremic Rats Can Antagonize Anabolic Effects of PTH on Bone Turnover and Strength through the Disruption of PTH-Dependent Molecular Signaling. Int J Mol Sci 2021; 22:6563. [PMID: 34207309 PMCID: PMC8234704 DOI: 10.3390/ijms22126563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 01/02/2023] Open
Abstract
Secondary hyperparathyroidism and abnormalities in tryptophan (TRP) metabolism are commonly observed in chronic kidney disease (CKD). The present study aimed to establish potential interactions between endogenous parathyroid hormone (PTH) and activation of the bone kynurenine (KYN) pathway in relation to bone turnover and strength in young rats after one month (CKD-1) and three months (CKD-3) of experimental CKD. TRP, KYN, KYN/TRP ratio and bone turnover markers (BTMs) were measured in trabecular and cortical bone tissue. Expression of aryl hydrocarbon receptor (AhR) and the genes involved in osteogenesis was determined in femoral bone. Biomechanical testing of femoral diaphysis and femoral neck was also performed. Activation of the KYN pathway in trabecular bone during CKD development intensified the expression of genes related to osteogenesis, which led to a decrease in cyclic adenosine monophosphate (cAMP) and BTMs levels, resulting in a stiffer and mechanically weaker femoral neck. In contrast, reduction of the KYN pathway in cortical bone allowed to unblock the PTH-dependent anabolic activating transcription factor 4/parathyroid hormone 1 receptor (PTH1R/ATF4) axis, led to cAMP accumulation, better bone turnover and strength in the course of CKD development. In summary, the paracrine KYN pathway in bone can interfere with the anabolic effects of PTH on bone through disrupting PTH-dependent molecular signaling.
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Affiliation(s)
- Krystyna Pawlak
- Department of Monitored Pharmacotherapy, Medical University of Bialystok, Mickiewicza 2C, 15-222 Bialystok, Poland
| | - Beata Sieklucka
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2C, 15-222 Bialystok, Poland; (B.S.); (D.P.)
| | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2C, 15-222 Bialystok, Poland; (B.S.); (D.P.)
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26
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Pimentel A, Ureña-Torres P, Bover J, Luis Fernandez-Martín J, Cohen-Solal M. Bone Fragility Fractures in CKD Patients. Calcif Tissue Int 2021; 108:539-550. [PMID: 33219822 PMCID: PMC8052229 DOI: 10.1007/s00223-020-00779-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/04/2020] [Indexed: 12/14/2022]
Abstract
Chronic kidney diseases (CKD) are associated with mineral and bone diseases (MBD), including pain, bone loss, and fractures. Bone fragility related to CKD includes the risk factors observed in osteoporosis in addition to those related to CKD, resulting in a higher risk of mortality related to fractures. Unawareness of such complications led to a poor management of fractures and a lack of preventive approaches. The current guidelines of the Kidney Disease Improving Global Outcomes (KDIGO) recommend the assessment of bone mineral density if results will impact treatment decision. In addition to bone density, circulating biomarkers of mineral, serum bone turnover markers, and imaging techniques are currently available to evaluate the fracture risk. The purpose of this review is to provide an overview of the epidemiology and pathogenesis of CKD-associated bone loss. The contribution of the current tools and other techniques in development are discussed. We here propose a current view of how to better predict bone fragility and the therapeutic options in CKD.
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Affiliation(s)
| | - Pablo Ureña-Torres
- AURA Paris-Nord, Saint-Ouen, France
- Necker Hospital, University of Paris Descartes, Department of Renal Physiology, Paris, France
| | - Jordi Bover
- Fundació Puigvert, Universitat Autònoma, IIB Sant Pau, REDinREN, Nephrology Department, Barcelona, Catalonia, Spain
| | - Jose Luis Fernandez-Martín
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), REDinREN del ISCIII, Hospital Universitario Central de Asturias. Universidad de Oviedo, Bone and Mineral Research Unit, Oviedo, Asturias, Spain
| | - Martine Cohen-Solal
- INSERM U1132 & Université de Paris, Hôpital Lariboisière, Department of Rheumatology, Paris, France.
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27
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Truyts C, Custodio M, Pecoit-Filho R, Moraes TPD, Jorgetti V. Cardiovascular mortality in peritoneal dialysis: the impact of mineral disorders. J Bras Nefrol 2021; 43:182-190. [PMID: 33576763 PMCID: PMC8257281 DOI: 10.1590/2175-8239-jbn-2020-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 11/04/2020] [Indexed: 12/14/2022] Open
Abstract
Introduction: Mineral and bone disorders (MBD) are associated with higher mortality in
dialysis patients. The main guidelines related to the subject, Kidney
Disease Outcomes Quality Initiative (KDOQI) and Kidney Disease: Improving
Global Outcomes (KDIGO), were elaborated based on published information from
hemodialysis participants. The aim of our study was to evaluate the impact
of calcium (Ca), phosphorus (P), and parathyroid hormone (PTH) (according to
guideline ranges from KDOQI and KDIGO) on the cardiovascular mortality of
peritoneal dialysis (PD) patients. Methods: We used the BRAZPDII database, an observational multi-centric prospective
study, which assessed participants on PD between December 2004 and January
2011. Amongst 9,905 participants included in this database, we analyzed 4424
participants who were on PD for at least 6 months. The appropriate
confounding variables were entered into the model. Serum levels of Ca, P,
and PTH were the variables of interest for the purposes of the current
study. Results: We found a significant association between high P serum levels, categorized
by KDOQI and KDIGO (P above 5.5 mg/dL), and cardiovascular survival
(p < 0.01). Likewise, a compelling association was
found between lower levels of PTH, categorized by guidelines (KDOQI and
KDIGO - PTH less than 150 pg/mL, p < 0.01), and
cardiovascular survival. Conclusion: In conclusion, levels of P above and PTH below the values proposed by KDOQI
and KDIGO were associated with cardiovascular mortality in PD patients.
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Affiliation(s)
- César Truyts
- Universidade de São Paulo, Laboratório de Fisiopatologia Renal, São Paulo, SP, Brasil
| | - Melani Custodio
- Universidade de São Paulo, Laboratório de Fisiopatologia Renal, São Paulo, SP, Brasil
| | - Roberto Pecoit-Filho
- Pontifícia Universidade Católica do Paraná, Faculdade de Medicina, Curitiba, PR, Brasil
| | | | - Vanda Jorgetti
- Universidade de São Paulo, Laboratório de Fisiopatologia Renal, São Paulo, SP, Brasil
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28
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Lalayiannis AD, Crabtree NJ, Ferro CJ, Askiti V, Mitsioni A, Biassoni L, Kaur A, Sinha MD, Wheeler DC, Duncan ND, Popoola J, Milford DV, Long J, Leonard MB, Fewtrell M, Shroff R. Routine serum biomarkers, but not dual-energy X-ray absorptiometry, correlate with cortical bone mineral density in children and young adults with chronic kidney disease. Nephrol Dial Transplant 2020; 36:1872-1881. [DOI: 10.1093/ndt/gfaa199] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Indexed: 12/18/2022] Open
Abstract
Abstract
Background. Biomarkers and dual-energy X-ray absorptiometry (DXA) are thought to be poor predictors of bone mineral density (BMD). The Kidney Disease: Improving Global Outcomes guidelines suggest using DXA if the results will affect patient management, but this has not been studied in children or young adults in whom bone mineral accretion continues to 30 years of age. We studied the clinical utility of DXA and serum biomarkers against tibial cortical BMD (CortBMD) measured by peripheral quantitative computed tomography, expressed as Z-score CortBMD, which predicts fracture risk.
Methods. This was a cross-sectional multicentre study in 26 patients with CKD4 and 5 and 77 on dialysis.
Results. Significant bone pain that hindered activities of daily living was present in 58%, and 10% had at least one low-trauma fracture. CortBMD and cortical mineral content Z-scores were lower in dialysis compared with CKD patients (P = 0.004 and P = 0.02). DXA BMD hip and lumbar spine Z-scores did not correlate with CortBMD or biomarkers. CortBMD was negatively associated with parathyroid hormone (PTH; r = −0.44, P < 0.0001) and alkaline phosphatase (ALP; r = −0.22, P = 0.03) and positively with calcium (Ca; r = 0.33, P = 0.001). At PTH <3 times upper limit of normal, none of the patients had a CortBMD below −2 SD (odds ratio 95% confidence interval 7.331 to infinity). On multivariable linear regression PTH (β = −0.43 , P < 0.0001), ALP (β = −0.36, P < 0.0001) and Ca (β = 0.21, P = 0.005) together predicted 57% of variability in CortBMD. DXA measures did not improve this model.
Conclusions. Taken together, routinely used biomarkers, PTH, ALP and Ca, but not DXA, are moderate predictors of cortical BMD. DXA is not clinically useful and should not be routinely performed in children and young adults with CKD 4–5D.
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Affiliation(s)
- Alexander D Lalayiannis
- Great Ormond St Hospital for Children NHS Foundation Trust, University College London Institute of Child Health, London, UK
| | - Nicola J Crabtree
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - Charles J Ferro
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Lorenzo Biassoni
- Great Ormond St Hospital for Children NHS Foundation Trust, University College London Institute of Child Health, London, UK
| | - Amrit Kaur
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Manish D Sinha
- Evelina Children’s Hospital, Guy’s & St Thomas' NHS Foundation Trust, London, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Neill D Duncan
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| | - Joyce Popoola
- Department of Nephrology and Transplantation, George’s University Hospital NHS Foundation Trust, London, UK
| | - David V Milford
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - Jin Long
- Stanford University, Palo Alto, CA, USA
| | | | - Mary Fewtrell
- Great Ormond St Hospital for Children NHS Foundation Trust, University College London Institute of Child Health, London, UK
| | - Rukshana Shroff
- Great Ormond St Hospital for Children NHS Foundation Trust, University College London Institute of Child Health, London, UK
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29
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The cut-off values of handgrip strength and lean mass index for sarcopenia among patients on peritoneal dialysis. Nutr Metab (Lond) 2020; 17:84. [PMID: 33062032 PMCID: PMC7542899 DOI: 10.1186/s12986-020-00506-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/23/2020] [Indexed: 11/30/2022] Open
Abstract
Background Sarcopenia is common and contributes to a high risk of mortality among general population. There is no consensus regarding the cut-off values for sarcopenia in terms of mortality among chronic kidney disease patients. This study aimed to explore and validate cut-off points of handgrip strength (HGS) and lean mass index (LMI) for estimating the risk of mortality in peritoneal dialysis (PD) patients. Methods This single-center prospective cohort study enrolled 1089 incident PD patients between October 2002 and July 2019. All patients were followed until death, transfer to hemodialysis, receiving renal transplantation or the end date of study (December 2019). All participants were randomly sampled to development cohort (70% participants) and validation cohort (30% participants), matched by gender and diabetes. Lean body mass was calculated by using the equation published by our center. Cubic spline regression analysis was used to examine the relationship between HGS or LMI values and mortality, and explore the cut-off points after adjusting for age, diabetes, cardiovascular disease and serum albumin in the development cohort. The derived cut-off values were verified by the agreement rate for predicting mortality and then compared with cut-off values from various clinical guidelines in the validation cohort. Results All 1089 patients were followed up with the median of 36.0 (18.0, 71.0) months. In the development cohort, cut-off points for predicting the higher mortality were derived as 24.5 kg and 14 kg of HGS for males and females, 16.7 kg/m2 and 13.8 kg/m2 of LMI for males and females respectively. In the validation cohort, these cut-off values significantly predicted worse outcomes, with HR 1.96 (1.35, 2.84) of HGS and HR 1.76 (1.26, 2.47) of LMI for all-cause mortality after multivariate adjustment. The newly derived cut-off points of HGS have numerically higher prognostic values in all-cause mortality compared with those from current clinical guidelines, and agreement rates of HGS were 65.2 versus 62.5–64.6 respectively. Conclusions The derived cut-off values of HGS and LMI have sufficient and better prognostic value in predicting all-cause mortality in PD patients compared with the cut-off values in the existing guidelines. These cut-off values are only validated in a single population, thus limiting the generalizability.
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30
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Hsu CY, Chen LR, Chen KH. Osteoporosis in Patients with Chronic Kidney Diseases: A Systemic Review. Int J Mol Sci 2020; 21:E6846. [PMID: 32961953 PMCID: PMC7555655 DOI: 10.3390/ijms21186846] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) is associated with the development of mineral bone disorder (MBD), osteoporosis, and fragility fractures. Among CKD patients, adynamic bone disease or low bone turnover is the most common type of renal osteodystrophy. The consequences of CKD-MBD include increased fracture risk, greater morbidity, and mortality. Thus, the goal is to prevent the occurrences of fractures by means of alleviating CKD-induced MBD and treating subsequent osteoporosis. Changes in mineral and humoral metabolism as well as bone structure develop early in the course of CKD. CKD-MBD includes abnormalities of calcium, phosphorus, PTH, and/or vitamin D; abnormalities in bone turnover, mineralization, volume, linear growth, or strength; and/or vascular or other soft tissue calcification. In patients with CKD-MBD, using either DXA or FRAX to screen fracture risk should be considered. Biomarkers such as bALP and iPTH may assist to assess bone turnover. Before initiating an antiresorptive or anabolic agent to treat osteoporosis in CKD patients, lifestyle modifications, such as exercise, calcium, and vitamin D supplementation, smoking cessation, and avoidance of excessive alcohol intake are important. Managing hyperphosphatemia and SHPT are also crucial. Understanding the complex pathogenesis of CKD-MBD is crucial in improving one's short- and long-term outcomes. Treatment strategies for CKD-associated osteoporosis should be patient-centered to determine the type of renal osteodystrophy. This review focuses on the mechanism, evaluation and management of patients with CKD-MBD. However, further studies are needed to explore more details regarding the underlying pathophysiology and to assess the safety and efficacy of agents for treating CKD-MBD.
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Affiliation(s)
- Chia-Yu Hsu
- Department of Rehabilitation Medicine, Ten-Chan General Hospital, Zhongli, Taoyuan 320, Taiwan;
- Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan 320, Taiwan
| | - Li-Ru Chen
- Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei 104, Taiwan;
- Department of Mechanical Engineering, National Chiao-Tung University, Hsinchu 300, Taiwan
| | - Kuo-Hu Chen
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan
- Department of Medicine, School of Medicine, Tzu-Chi University, Hualien 970, Taiwan
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31
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Soeiro EMD, Castro L, Menezes R, Elias RM, Dos Reis LM, Jorgetti V, Moysés RMA. Association of parathormone and alkaline phosphatase with bone turnover and mineralization in children with CKD on dialysis: effect of age, gender, and race. Pediatr Nephrol 2020; 35:1297-1305. [PMID: 32157445 DOI: 10.1007/s00467-020-04499-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Studies investigating bone histology in children with chronic kidney disease (CKD) are scarce. METHODS Forty-two patients, mean age 11.3 ± 4.3 years with stage 5 CKD on dialysis, underwent double tetracycline labeling bone biopsy and the relationship between clinical features, biochemical markers, and bone densitometry (DXA) was investigated. RESULTS Low bone turnover was present in 59% of patients, abnormal mineralization in 29%, and low bone volume in 7%. Higher bone formation rate was found in non-Caucasian patients, whereas abnormal mineralization occurred in older and shorter children. We found no impact of gender and etiology of renal disease in our population. Parathormone (PTH) and alkaline phosphatase (AP) showed positive associations with bone turnover. ROC curve analysis showed a fair performance of biomarkers to predict TMV status. PTH < 2 times ULN independently associated with low bone turnover (RR 5.62, 95% CI 1.01-31.24; p = 0.049), in a model adjusted for race, calcitriol dosage, and calcium. It was also associated with abnormal mineralization (RR 1.35, 95% CI 1.04-1.75; p = 0.025), in a model adjusted for BMD scores, AP, age, and calcitriol. PTH and AP significantly predicted turnover and mineralization defect, although with low specificity and sensitivity, reaching a maximum value of 64% and 67%, respectively. CONCLUSIONS While PTH and AP were associated with turnover and mineralization, we recognize the limitation of their performance to clearly distinguish high from low/normal bone turnover and normal from abnormal mineralization. Our results reinforce the need to expand knowledge about renal osteodystrophy in pediatric population through prospective bone biopsy studies. Graphical abstract.
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Affiliation(s)
- Emilia M D Soeiro
- Laboratório de Investigação Médica 16, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Faculdade Pernambucana de Saúde, Recife, Brazil.,Instituto de Medicina Integral de Pernambuco, Recife, Brazil
| | | | | | - Rosilene M Elias
- Laboratório de Investigação Médica 16, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luciene M Dos Reis
- Laboratório de Investigação Médica 16, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vanda Jorgetti
- Laboratório de Investigação Médica 16, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Rosa M A Moysés
- Laboratório de Investigação Médica 16, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. .,LIM 16-Nephrology Department, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455, 3° andar, sala 3342, São Paulo, SP, 01246-903, Brazil.
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32
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Gołębiowski T, Kusztal M, Konieczny A, Letachowicz K, Gawryś A, Skolimowska B, Ostrowska B, Zmonarski S, Janczak D, Krajewska M. Disability of Dialysis Patients and the Condition of Blood Vessels. J Clin Med 2020; 9:E1806. [PMID: 32531965 PMCID: PMC7356767 DOI: 10.3390/jcm9061806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 01/31/2023] Open
Abstract
The number of elderly hemodialysis patients is constantly increasing worldwide. This population has a high burden of comorbid conditions, which impair daily activities. The aim of the study was to analyze problems of disability in hemodialysis patients in the context of cardiovascular (CV) complications and vascular condition. In this cross-sectional study, 129 patients (mean age 64.5) were enrolled. The degree of disability in Barthel index (Bi) and 10-year cardiovascular risk (QRISK®3) were assessed. A Mobil-O-Graph monitor was used for measuring hemodynamic parameters. Only 6.2% of patients were professionally active, 19% used a wheelchair for transport, and 16% used crutches. More than half (51%) were independent in everyday activities reaching 80-100 points on Bi. The rest, with Bi < 80, were considered as dependent. The most common causes of disability were CV complications. The independent group (80-100 points) was characterized by significantly lower pulse wave velocity (PWV) and lower QRISK®3 compared to dependent patients. The degree of disability negatively correlated with age, PWV, and QRISK®3. Multivariate logistic regression revealed that disability (Bi < 80) was independently associated with CV events in the past adjusted odds ratio (adj.OR) 4.83 (95% confidence interval (95% CI): 1.74-13.41) and higher PWV adj.OR 1.45 (95% CI: 1.15-1.82). Our results indicate that CV diseases are the most important cause of functional impairment.
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Affiliation(s)
- Tomasz Gołębiowski
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Mariusz Kusztal
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Andrzej Konieczny
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Krzysztof Letachowicz
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Ada Gawryś
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Beata Skolimowska
- Department of Occupational Therapy, University School of Physical Education in Wroclaw, 51-612 Wroclaw, Poland; (B.S.); (B.O.)
| | - Bożena Ostrowska
- Department of Occupational Therapy, University School of Physical Education in Wroclaw, 51-612 Wroclaw, Poland; (B.S.); (B.O.)
| | - Sławomir Zmonarski
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
| | - Dariusz Janczak
- Department of Vascular, General and Transplantation Surgery, Wroclaw Medical University, 50-556 Wroclaw, Poland;
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (K.L.); (A.G.); (S.Z.); (M.K.)
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Matias PJ, Laranjinha I, Azevedo A, Raimundo A, Navarro D, Jorge C, Aires I, Mendes M, Ferreira C, Amaral T, Gil C, Ferreira A. Bone fracture risk factors in prevalent hemodialysis patients. J Bone Miner Metab 2020; 38:205-212. [PMID: 31489503 DOI: 10.1007/s00774-019-01041-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 07/31/2019] [Indexed: 12/21/2022]
Abstract
Bone fractures are an important cause of morbidity and mortality in hemodialysis (HD) patients. The aim of this study was to quantify the incidence of fractures in a cohort of prevalent HD patients and evaluate its relationship with possible risk factors. We performed a retrospective analysis of 341 patients, since they started HD (median of 51 months). Demographic, clinical, and biochemical parameters as well as vascular calcifications (VC) were evaluated. Fifty-seven episodes of fracture were identified with a median HD vintage of 47 months (incidence rate of 31 per 1000 person-years). Age (p < 0.001), female gender (p < 0.001), lower albumin (p = 0.02), and higher VC score (p < 0.001) were independently associated with increased risk of fracture, while active vitamin D therapy (p = 0.03) was associated with decreased risk. A significantly higher risk of incident fracture was also associated with higher values of bone-specific alkaline phosphatase (bALP) (p = 0.01) and intact parathyroid hormone (iPTH) levels either < 300 pg/mL (p = 0.02) or > 800 pg/mL (p < 0.001) compared with 300-800 pg/mL. In conclusion, bone fracture incidence in HD patients is high and its risk increases with age, female gender, lower serum albumin, and with the presence of more VC. Prevalent HD patients with low or high iPTH levels or increased bALP also had a higher fracture risk. Therapy with active vitamin D seems to have a protective role. Assessment of fracture risk and management in dialysis patients at greatest risk requires further study.
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Affiliation(s)
- Patrícia João Matias
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal.
- Dialysis Unit, Dialverca, Forte da Casa, Portugal.
- NIDAN, Lisbon, Portugal.
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal.
| | - Ivo Laranjinha
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal
| | - Ana Azevedo
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
| | - Ana Raimundo
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- NIDAN, Lisbon, Portugal
| | - David Navarro
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- NIDAN, Lisbon, Portugal
| | - Cristina Jorge
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
| | - Inês Aires
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal
| | - Marco Mendes
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- NIDAN, Lisbon, Portugal
| | - Carina Ferreira
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal
| | - Tiago Amaral
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
| | - Célia Gil
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
| | - Aníbal Ferreira
- Dialysis Unit, Nephrocare Vila Franca de Xira, Praça Bartolomeu Dias, lote 3 r/c, 2600-063, Vila Franca de Xira, Portugal
- Dialysis Unit, Dialverca, Forte da Casa, Portugal
- NIDAN, Lisbon, Portugal
- Faculdade de Ciências Médicas, NOVA Medical School, Lisbon, Portugal
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Lalayiannis A, Crabtree N, Fewtrell M, Biassoni L, Milford D, Ferro C, Shroff R. Assessing bone mineralisation in children with chronic kidney disease: what clinical and research tools are available? Pediatr Nephrol 2020; 35:937-957. [PMID: 31240395 PMCID: PMC7184042 DOI: 10.1007/s00467-019-04271-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/19/2019] [Accepted: 04/26/2019] [Indexed: 12/11/2022]
Abstract
Mineral and bone disorder in chronic kidney disease (CKD-MBD) is a triad of biochemical imbalances of calcium, phosphate, parathyroid hormone and vitamin D, bone abnormalities and soft tissue calcification. Maintaining optimal bone health in children with CKD is important to prevent long-term complications, such as fractures, to optimise growth and possibly also to prevent extra-osseous calcification, especially vascular calcification. In this review, we discuss normal bone mineralisation, the pathophysiology of dysregulated homeostasis leading to mineralisation defects in CKD and its clinical consequences. Bone mineralisation is best assessed on bone histology and histomorphometry, but given the rarity with which this is performed, we present an overview of the tools available to clinicians to assess bone mineral density, including serum biomarkers and imaging such as dual-energy X-ray absorptiometry and peripheral quantitative computed tomography. We discuss key studies that have used these techniques, their advantages and disadvantages in childhood CKD and their relationship to biomarkers and bone histomorphometry. Finally, we present recommendations from relevant guidelines-Kidney Disease Improving Global Outcomes and the International Society of Clinical Densitometry-on the use of imaging, biomarkers and bone biopsy in assessing bone mineral density. Given low-level evidence from most paediatric studies, bone imaging and histology remain largely research tools, and current clinical management is guided by serum calcium, phosphate, PTH, vitamin D and alkaline phosphatase levels only.
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Affiliation(s)
- A.D. Lalayiannis
- Nephrology Department Great Ormond St. Hospital for Children NHS Foundation Trust and University College London Institute of Child Health, London, UK
| | - N.J. Crabtree
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - M. Fewtrell
- Nephrology Department Great Ormond St. Hospital for Children NHS Foundation Trust and University College London Institute of Child Health, London, UK
| | - L. Biassoni
- Nephrology Department Great Ormond St. Hospital for Children NHS Foundation Trust and University College London Institute of Child Health, London, UK
| | - D.V. Milford
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - C.J. Ferro
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R. Shroff
- Nephrology Department Great Ormond St. Hospital for Children NHS Foundation Trust and University College London Institute of Child Health, London, UK
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Bellorin-Font E, Vasquez-Rios G, Martin KJ. Controversies in the Management of Secondary Hyperparathyroidism in Chronic Kidney Disease. Curr Osteoporos Rep 2019; 17:333-342. [PMID: 31485996 DOI: 10.1007/s11914-019-00533-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Secondary hyperparathyroidism is a frequent complication of chronic kidney disease that begins early in the course of renal insufficiency as an adaptive response to maintain mineral homeostasis. This complex disorder affects the bone, leading to an increase in fracture risk and is associated with increased risks of vascular calcification and mortality. PURPOSE OF REVIEW: In this review, we examine the different strategies available to manage secondary hyperparathyroidism. Particularly, we focus on the adequate control of serum phosphorus by restricting intake and the use of phosphate binders, correction of hypocalcemia while minimizing calcium burden, and reduction in PTH levels through the use of vitamin D sterols and calcimimetics. RECENT FINDINGS: It was observed that although numerous agents directed at the correction of these abnormalities have demonstrated effectiveness on biochemical markers, there is still a relative scarcity of studies demonstrating treatment effectiveness as measured by hard clinical outcomes. In addition, most agents have side effects that may limit their use, even in patients in which the treatment has demonstrated efficacy in controlling these parameters. There is still controversy as to what therapeutic regimens to choose for a particular patient and what parameter should be used to follow their effects, including outcomes, side effects, pill burden, and costs, among others. In the present article, we analyze controversial aspects of the different therapeutic agents available. Although many tools and regimens are available, no one by itself is enough for an adequate management of the patient. But rather, combined therapy and individualization of approaches are recommended for better results. We suggest that new studies analyzing the effectiveness of therapeutic approaches to the management of secondary hyperparathyroidism should be directed not only to controlling parathyroid hormone levels but also to the evaluation of long-term outcomes, based on modification of morbidity, mortality, and end organ impact, while reducing side effects and controlling costs, among others.
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Affiliation(s)
- Ezequiel Bellorin-Font
- Division of Nephrology and Hypertension, Saint Louis University, Saint Louis, MO, 63110, USA
| | - George Vasquez-Rios
- Division of Nephrology and Hypertension, Saint Louis University, Saint Louis, MO, 63110, USA
| | - Kevin J Martin
- Division of Nephrology and Hypertension, Saint Louis University, Saint Louis, MO, 63110, USA.
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Kakani E, Elyamny M, Ayach T, El‐Husseini A. Pathogenesis and management of vascular calcification in CKD and dialysis patients. Semin Dial 2019; 32:553-561. [DOI: 10.1111/sdi.12840] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Elijah Kakani
- Division of Hospital Medicine University of Kentucky Lexington KY USA
| | - Mohamed Elyamny
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
| | - Taha Ayach
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
| | - Amr El‐Husseini
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
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Jean G, Chazot C. Complications et prises en charge thérapeutiques des anomalies du métabolisme phosphocalcique de l’insuffisance rénale chronique. Nephrol Ther 2019; 15:242-258. [DOI: 10.1016/j.nephro.2019.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Keronen S, Martola L, Finne P, Burton IS, Kröger H, Honkanen E. Changes in Bone Histomorphometry after Kidney Transplantation. Clin J Am Soc Nephrol 2019; 14:894-903. [PMID: 31088851 PMCID: PMC6556726 DOI: 10.2215/cjn.09950818] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 04/02/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Over the past decade, the management of CKD-mineral and bone disorder has changed substantially, altering the pattern of bone disease in CKD. We aimed to evaluate the natural history of kidney bone disease in contemporary kidney transplant recipients and patients on dialysis. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS Sixty one patients on dialysis who were referred to kidney transplantation participated in this prospective cohort study during November 2009 and December 2010. We performed baseline bone biopsies while the patients were on dialysis and repeated the procedure in 56 patients at 2 years after kidney transplantation or 2 years after baseline if transplantation was not performed. Measurements of mineral metabolism and bone turnover, as well as dual energy x-ray absorptiometry scans, were obtained concurrently. RESULTS A total of 37 out of 56 participants received a kidney transplant, of which 27 underwent successful repeat bone biopsy. The proportion of patients with high bone turnover declined from 63% at baseline to 19% at 2 years after kidney transplantation, whereas the proportion of those with low bone turnover increased from 26% to 52%. Of 19 participants remaining on dialysis after 2 years, 13 underwent successful repeat biopsy. The proportion of patients remaining on dialysis with high bone turnover decreased from 69% to 31%, and low bone turnover increased from 8% to 38%. Abnormal bone mineralization increased in transplant recipients from 33% to 44%, but decreased in patients remaining on dialysis from 46% to 15%. Trabecular bone volume showed little change after transplantation, but low bone volume increased in patients remaining on dialysis. Bone mineral density did not correlate with histomorphometric findings. CONCLUSIONS Bone turnover decreased over time both in patients remaining on dialysis and in kidney transplant recipients. Bone mineral density and bone biomarkers were not associated with bone metabolism changes detected in bone biopsy specimens.
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Affiliation(s)
- Satu Keronen
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland;
| | - Leena Martola
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Patrik Finne
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Inari S Burton
- Kuopio Musculoskeletal Research Unit, University of Eastern Finland, Kuopio, Finland; and
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit, University of Eastern Finland, Kuopio, Finland; and.,Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Eero Honkanen
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Laowalert S, Khotavivattana T, Wattanachanya L, Luangjarmekorn P, Udomkarnjananun S, Katavetin P, Eiam‐Ong S, Praditpornsilpa K, Susantitaphong P. Bone turnover markers predict type of bone histomorphometry and bone mineral density in Asian chronic haemodialysis patients. Nephrology (Carlton) 2019; 25:163-171. [DOI: 10.1111/nep.13593] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/25/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Suthanit Laowalert
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Tanatorn Khotavivattana
- Center of Excellence in Natural Products Chemistry, Department of ChemistryFaculty of Science, Chulalongkorn University Bangkok Thailand
| | - Lalita Wattanachanya
- Division of Endocrinology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Pobe Luangjarmekorn
- Department of OrthopedicsChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Pisut Katavetin
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Somchai Eiam‐Ong
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
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Barreto FDC, Costa CRVD, Reis LMD, Custódio MR. Bone biopsy in nephrology practice. ACTA ACUST UNITED AC 2018; 40:366-374. [PMID: 30525179 PMCID: PMC6534004 DOI: 10.1590/2175-8239-jbn-2017-0012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 07/09/2018] [Indexed: 12/12/2022]
Abstract
Renal osteodystrophy (ROD), a group of metabolic bone diseases secondary to chronic kidney disease (CKD), still represents a great challenge to nephrologists. Its management is tailored by the type of bone lesion - of high or low turnover - that cannot be accurately predicted by serum biomarkers of bone remodeling available in daily clinical practice, mainly parathyroid hormone (PTH) and alkaline phosphatase (AP). In view of this limitation, bone biopsy followed by bone quantitative histomorphometry, the gold-standard method for the diagnosis of ROD, is still considered of paramount importance. Bone biopsy has also been recommended for evaluation of osteoporosis in the CKD setting to help physicians choose the best anti-osteoporotic drug. Importantly, bone biopsy is the sole diagnostic method capable of providing dynamic information on bone metabolism. Trabecular and cortical bones may be analyzed separately by evaluating their structural and dynamic parameters, thickness and porosity, respectively. Deposition of metals, such as aluminum and iron, on bone may also be detected. Despite of these unique characteristics, the interest on bone biopsy has declined over the last years and there are currently few centers around the world specialized on bone histomorphometry. In this review, we will discuss the bone biopsy technique, its indications, and the main information it can provide. The interest on bone biopsy should be renewed and nephrologists should be capacitated to perform it as part of their training during medical residency.
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Affiliation(s)
| | | | - Luciene Machado Dos Reis
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clinicas, Laboratório de Fisiopatologia Renal São Paulo, SP, Brasil
| | - Melani Ribeiro Custódio
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clinicas, Laboratório de Fisiopatologia Renal São Paulo, SP, Brasil
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Sánchez-González C, Gonzalez-Casaus ML, Sellares VL, Albalate M, Torregrosa JV, Mas S, Ortiz A, Rodriguez M, Gonzalez-Parra E. Higher Proportion of Non-1-84 PTH Fragments in Peritoneal Dialysis Patients Compared to Hemodialysis Patients Using Solutions Containing 1.75 mmol/l Calcium. Front Physiol 2018; 9:1643. [PMID: 30524306 PMCID: PMC6262178 DOI: 10.3389/fphys.2018.01643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/30/2018] [Indexed: 11/13/2022] Open
Abstract
Background: The prevalence of low- turnover bone disease (LTBD) in peritoneal dialysis (PD) patients is higher than in hemodialysis (HD) patients. LTBD patients may be at risk for vascular calcification, and cardiovascular disease. Current therapy for chronic kidney disease metabolic bone disorders (CKD-MBD) is guided by biochemical parameters, as bone biopsy is not used in routine clinical care. Methods: We assessed intact PTH (iPTH: 1-84PTH plus non-1-84PTH), 1-84PTH, and the 1-84PTH/non-1-84PTH ratio in 129 hemodialysis and 73 PD prevalent patients dialyzed with solutions containing 1.75 mmol/L calcium. Results: Hemodialysis and PD patients presented similar iPTH and tCa values and prevalence of putative LTBD as defined according to KDOQI iPTH cut-off levels or 1-84 PTH levels. However, iCa accounted for a higher percentage of tCa in PD (53%) than in hemodialysis (39%) p < 0.001, and the 1-84PTH/non-1-84PTH ratio was lower in PD than in hemodialysis patients (0.44 ± 0.12) vs. (0.60 ± 0.10), p < 0.001. The prevalence of putative LTBD when using the coexistence of 1-84PTH/non-1-84PTH ratio < 1.0 and iPTH < 420 pg/m, was higher in PD than in hemodialysis patients (73 vs. 16% respectively, p < 0.001). In a multivariate logistic regression analysis, dialysis modality was the main determinant of the 1-84PTH/non-1-84PTH ratio. Conclusion: Solutions containing 1.75 mmol/L calciums are associated to a higher proportion of non-1-84PTH fragments in PD than in HD patients. Different analytical criteria result in widely different estimates of LTBD prevalence, thus impairing the ability of clinicians to optimize therapy for CKD-MBD.
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Affiliation(s)
| | | | | | | | | | - Sebastian Mas
- Unidad de Diálsis IIS Fundación Jiménez Díaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Alberto Ortiz
- REDINREN, Madrid, Spain
- Unidad de Diálsis IIS Fundación Jiménez Díaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mariano Rodriguez
- REDINREN, Madrid, Spain
- Nefrología y Unidad de Investigación, Hospital Universitario Reina Sofia, Córdoba, Spain
| | - Emilio Gonzalez-Parra
- REDINREN, Madrid, Spain
- Unidad de Diálsis IIS Fundación Jiménez Díaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
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Damasiewicz MJ, Nickolas TL. Rethinking Bone Disease in Kidney Disease. JBMR Plus 2018; 2:309-322. [PMID: 30460334 PMCID: PMC6237213 DOI: 10.1002/jbm4.10117] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/05/2018] [Accepted: 10/03/2018] [Indexed: 12/17/2022] Open
Abstract
Renal osteodystrophy (ROD) is the bone component of chronic kidney disease mineral and bone disorder (CKD-MBD). ROD affects bone quality and strength through the numerous hormonal and metabolic disturbances that occur in patients with kidney disease. Collectively these disorders in bone quality increase fracture risk in CKD patients compared with the general population. Fractures are a serious complication of kidney disease and are associated with higher morbidity and mortality compared with the general population. Furthermore, at a population level, fractures are at historically high levels in patients with end-stage kidney disease (ESKD), whereas in contrast the general population has experienced a steady decline in fracture incidence rates. Based on these findings, it is clear that a paradigm shift is needed in our approach to diagnosing and managing ROD. In clinical practice, our ability to diagnose ROD and initiate antifracture treatments is impeded by the lack of accurate noninvasive methods that identify ROD type. The past decade has seen advances in the noninvasive measurement of bone quality and strength that have been studied in kidney disease patients. Below we review the current literature pertaining to the epidemiology, pathology, diagnosis, and management of ROD. We aim to highlight the pressing need for a greater awareness of this condition and the need for the implementation of strategies that prevent fractures in kidney disease patients. Research is needed for more accurate noninvasive assessment of ROD type, clinical studies of existing osteoporosis therapies in patients across the spectrum of kidney disease, and the development of CKD-specific treatments. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
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Affiliation(s)
- Matthew J Damasiewicz
- Department of NephrologyMonash HealthClaytonAustralia
- Department of MedicineMonash UniversityClaytonAustralia
| | - Thomas L Nickolas
- Columbia University Medical CenterDepartment of MedicineDivision of NephrologyNew YorkNYUSA
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Soliman M, Hassan W, Yaseen M, Rao M, Sawaya BP, El-Husseini A. PTH assays in dialysis patients: Practical considerations. Semin Dial 2018; 32:9-14. [PMID: 30168196 DOI: 10.1111/sdi.12743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Parathyroid hormone (PTH) 1-84 is the main biologically active hormone produced by the parathyroid cells. Circulating PTH molecules include the whole PTH 1-84 along with amino (N) and carboxyl (C) terminal fragments. While PTH is the best available noninvasive biomarker to assess bone turnover in dialysis patients, the biological roles of individual circulating PTH fragments are still not completely known. The understanding that there is an enormous variation in the target specificity of currently available PTH assays for different circulating forms of PTH has led to the evolution of assays from first to second then third generation. With a reduction in kidney function, there is a preferential increase in circulating C fragments and non-PTH 1-84 forms, resulting in a decrease in the ratio of PTH 1-84/non-PTH 1-84. However, there are also substantial differences in between-assay measurements, with several fold variations in results. Targets based on multiples of the upper limit of normal (ULN) should be used rather than PTH ranges using absolute iPTH values. To date, the second-generation PTH remains the most widely used assay. Current guidelines recommend following iPTH trends rather than absolute values. Herein, we highlight problems and challenges in PTH assays/measurements and their interpretations in dialysis patients.
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Affiliation(s)
- Mohanad Soliman
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Waleed Hassan
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Maria Yaseen
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Madhumathi Rao
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - B Peter Sawaya
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
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Ruospo M, Palmer SC, Natale P, Craig JC, Vecchio M, Elder GJ, Strippoli GFM. Phosphate binders for preventing and treating chronic kidney disease-mineral and bone disorder (CKD-MBD). Cochrane Database Syst Rev 2018; 8:CD006023. [PMID: 30132304 PMCID: PMC6513594 DOI: 10.1002/14651858.cd006023.pub3] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Phosphate binders are used to reduce positive phosphate balance and to lower serum phosphate levels for people with chronic kidney disease (CKD) with the aim to prevent progression of chronic kidney disease-mineral and bone disorder (CKD-MBD). This is an update of a review first published in 2011. OBJECTIVES The aim of this review was to assess the benefits and harms of phosphate binders for people with CKD with particular reference to relevant biochemical end-points, musculoskeletal and cardiovascular morbidity, hospitalisation, and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 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 We included randomised controlled trials (RCTs) or quasi-RCTs of adults with CKD of any GFR category comparing a phosphate binder to another phosphate binder, placebo or usual care to lower serum phosphate. Outcomes included all-cause and cardiovascular death, myocardial infarction, stroke, adverse events, vascular calcification and bone fracture, and surrogates for such outcomes including serum phosphate, parathyroid hormone (PTH), and FGF23. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess evidence certainty. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised MD (SMD) for continuous outcomes. MAIN RESULTS We included 104 studies involving 13,744 adults. Sixty-nine new studies were added to this 2018 update.Most placebo or usual care controlled studies were among participants with CKD G2 to G5 not requiring dialysis (15/25 studies involving 1467 participants) while most head to head studies involved participants with CKD G5D treated with dialysis (74/81 studies involving 10,364 participants). Overall, seven studies compared sevelamer with placebo or usual care (667 participants), seven compared lanthanum to placebo or usual care (515 participants), three compared iron to placebo or usual care (422 participants), and four compared calcium to placebo or usual care (278 participants). Thirty studies compared sevelamer to calcium (5424 participants), and fourteen studies compared lanthanum to calcium (1690 participants). No study compared iron-based binders to calcium. The remaining studies evaluated comparisons between sevelamer (hydrochloride or carbonate), sevelamer plus calcium, lanthanum, iron (ferric citrate, sucroferric oxyhydroxide, stabilised polynuclear iron(III)-oxyhydroxide), calcium (acetate, ketoglutarate, carbonate), bixalomer, colestilan, magnesium (carbonate), magnesium plus calcium, aluminium hydroxide, sucralfate, the inhibitor of phosphate absorption nicotinamide, placebo, or usual care without binder. In 82 studies, treatment was evaluated among adults with CKD G5D treated with haemodialysis or peritoneal dialysis, while in 22 studies, treatment was evaluated among participants with CKD G2 to G5. The duration of study follow-up ranged from 8 weeks to 36 months (median 3.7 months). The sample size ranged from 8 to 2103 participants (median 69). The mean age ranged between 42.6 and 68.9 years.Random sequence generation and allocation concealment were low risk in 25 and 15 studies, respectively. Twenty-seven studies reported low risk methods for blinding of participants, investigators, and outcome assessors. Thirty-one studies were at low risk of attrition bias and 69 studies were at low risk of selective reporting bias.In CKD G2 to G5, compared with placebo or usual care, sevelamer, lanthanum, iron and calcium-based phosphate binders had uncertain or inestimable effects on death (all causes), cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. Sevelamer may lead to constipation (RR 6.92, CI 2.24 to 21.4; low certainty) and lanthanum (RR 2.98, CI 1.21 to 7.30, moderate certainty) and iron-based binders (RR 2.66, CI 1.15 to 6.12, moderate certainty) probably increased constipation compared with placebo or usual care. Lanthanum may result in vomiting (RR 3.72, CI 1.36 to 10.18, low certainty). Iron-based binders probably result in diarrhoea (RR 2.81, CI 1.18 to 6.68, high certainty), while the risks of other adverse events for all binders were uncertain.In CKD G5D sevelamer may lead to lower death (all causes) (RR 0.53, CI 0.30 to 0.91, low certainty) and induce less hypercalcaemia (RR 0.30, CI 0.20 to 0.43, low certainty) when compared with calcium-based binders, and has uncertain or inestimable effects on cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. The finding of lower death with sevelamer compared with calcium was present when the analysis was restricted to studies at low risk of bias (RR 0.50, CI 0.32 to 0.77). In absolute terms, sevelamer may lower risk of death (all causes) from 210 per 1000 to 105 per 1000 over a follow-up of up to 36 months, compared to calcium-based binders. Compared with calcium-based binders, lanthanum had uncertain effects with respect to all-cause or cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification and probably had reduced risks of treatment-related hypercalcaemia (RR 0.16, CI 0.06 to 0.43, low certainty). There were no head-to-head studies of iron-based binders compared with calcium. The paucity of placebo-controlled studies in CKD G5D has led to uncertainty about the effects of phosphate binders on patient-important outcomes compared with placebo.It is uncertain whether the effects of binders on clinically-relevant outcomes were different for patients who were and were not treated with dialysis in subgroup analyses. AUTHORS' CONCLUSIONS In studies of adults with CKD G5D treated with dialysis, sevelamer may lower death (all causes) compared to calcium-based binders and incur less treatment-related hypercalcaemia, while we found no clinically important benefits of any phosphate binder on cardiovascular death, myocardial infarction, stroke, fracture or coronary artery calcification. The effects of binders on patient-important outcomes compared to placebo are uncertain. In patients with CKD G2 to G5, the effects of sevelamer, lanthanum, and iron-based phosphate binders on cardiovascular, vascular calcification, and bone outcomes compared to placebo or usual care, are also uncertain and they may incur constipation, while iron-based binders may lead to diarrhoea.
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Affiliation(s)
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Patrizia Natale
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | | | - Grahame J Elder
- Westmead HospitalDepartment of Renal MedicineWestmeadNSWAustralia2145
- Garvan Institute of Medical ResearchOsteoporosis and Bone Biology DivisionDarlinghurstNSWAustralia2010
| | - Giovanni FM Strippoli
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Diaverum AcademyBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
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Time to rethink the use of bone biopsy to prevent fractures in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2018; 27:243-250. [DOI: 10.1097/mnh.0000000000000418] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Long-term effects of low calcium dialysates on the serum calcium levels during maintenance hemodialysis treatments: A systematic review and meta-analysis. Sci Rep 2018; 8:5310. [PMID: 29593281 PMCID: PMC5871761 DOI: 10.1038/s41598-018-23658-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 03/19/2018] [Indexed: 01/11/2023] Open
Abstract
Hypercalcemia and hyperparathyroidism in patients receiving maintenance hemodialysis (MHD) can cause the progression of cardiovascular diseases (CVD) and mineral bone disorders (MBD). The KDIGO recommends the dialysates with a calcium (Ca) concentration of 1.25–1.5 mmol/L for MHD treatments, but the optimal concentration remains controversial. Here, we conducted a systematic review and a meta-analysis of seven randomized controlled trials examining a total of 622 patients to investigate the optimal concentration for MHD for 6 months or longer. The dialysates with a low Ca concentration (1.125 or 1.25 mmol/L) significantly lowered the serum Ca and raised the intact parathyroid hormone levels by 0.52 mg/dL (95% confidence interval, 0.20–0.85) and 39.59 pg/mL (14.80–64.38), respectively, compared with a high Ca concentration (1.50 or 1.75 mmol/L). Three studies showed that a low concentration was preferred for lowering arterial calcifications or atherosclerosis in different arteries, but one study showed that coronary arterial calcifications increased with a low concentration. Two studies showed contradictory outcomes in terms of MBD. Our meta-analysis showed that a dialysate with a low Ca concentration lowered the serum Ca levels in patients receiving long-term MHD, but further studies are needed to determine the optimal Ca concentration in terms of CVD and MBD.
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Salam S, Gallagher O, Gossiel F, Paggiosi M, Khwaja A, Eastell R. Diagnostic Accuracy of Biomarkers and Imaging for Bone Turnover in Renal Osteodystrophy. J Am Soc Nephrol 2018; 29:1557-1565. [PMID: 29555831 DOI: 10.1681/asn.2017050584] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 02/13/2018] [Indexed: 11/03/2022] Open
Abstract
Background Renal osteodystrophy is common in advanced CKD, but characterization of bone turnover status can only be achieved by histomorphometric analysis of bone biopsy specimens (gold standard test). We tested whether bone biomarkers and high-resolution peripheral computed tomography (HR-pQCT) parameters can predict bone turnover status determined by histomorphometry.Methods We obtained fasting blood samples from 69 patients with CKD stages 4-5, including patients on dialysis, and 68 controls for biomarker analysis (intact parathyroid hormone [iPTH], procollagen type 1 N-terminal propeptide [PINP], bone alkaline phosphatase [bALP], collagen type 1 crosslinked C-telopeptide [CTX], and tartrate-resistant acid phosphatase 5b [TRAP5b]) and scanned the distal radius and tibia of participants by HR-pQCT. We used histomorphometry to evaluate bone biopsy specimens from 43 patients with CKD.Results Levels of all biomarkers tested were significantly higher in CKD samples than control samples. For discriminating low bone turnover, bALP, intact PINP, and TRAP5b had an areas under the receiver operating characteristic curve (AUCs) of 0.82, 0.79, and 0.80, respectively, each significantly better than the iPTH AUC of 0.61. Furthermore, radius HR-pQCT total volumetric bone mineral density and cortical bone volume had AUCs of 0.81 and 0.80, respectively. For discriminating high bone turnover, iPTH had an AUC of 0.76, similar to that of all other biomarkers tested.Conclusions The biomarkers bALP, intact PINP, and TRAP5b and radius HR-pQCT parameters can discriminate low from nonlow bone turnover. Despite poor diagnostic accuracy for low bone turnover, iPTH can discriminate high bone turnover with accuracy similar to that of the other biomarkers, including CTX.
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Affiliation(s)
- Syazrah Salam
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom; and .,Academic Unit of Bone Metabolism and.,Mellanby Centre for Bone Research, Medical School, University of Sheffield, Sheffield, United Kingdom
| | - Orla Gallagher
- Mellanby Centre for Bone Research, Medical School, University of Sheffield, Sheffield, United Kingdom
| | - Fatma Gossiel
- Academic Unit of Bone Metabolism and.,Mellanby Centre for Bone Research, Medical School, University of Sheffield, Sheffield, United Kingdom
| | - Margaret Paggiosi
- Academic Unit of Bone Metabolism and.,Mellanby Centre for Bone Research, Medical School, University of Sheffield, Sheffield, United Kingdom
| | - Arif Khwaja
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom; and
| | - Richard Eastell
- Academic Unit of Bone Metabolism and.,Mellanby Centre for Bone Research, Medical School, University of Sheffield, Sheffield, United Kingdom
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Ureña-Torres PA, Cozzolino M, Bover J. [Utilization of alfacalcidol and active vitamin D analogs in chronic kidney disease]. Nephrol Ther 2018; 14:189-200. [PMID: 29545131 DOI: 10.1016/j.nephro.2017.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/01/2017] [Accepted: 03/16/2017] [Indexed: 01/22/2023]
Abstract
Secondary hyperparathyroidism (SHPT) is one of the most frequent and deleterious complication of chronic kidney disease (CKD). SHPT is also one of the principal components of the now called CKD-mineral and bone disorders (MBD) syndrome. It is usually prevented and treated by vitamin D derivatives. However, the rationale for the prescription of vitamin D sterols in those patients is still a matter of hotly debates, mainly because of unsatisfactory results from numerous observational and not well-controlled studies. Scanty clinical data on head-to-head comparisons between the multiple vitamin D sterols are currently available. Moreover, there is crescent expectations on nutritional vitamin D, as well as vitamin D receptor activators (VDRA), regarding their putative pleiotropic effects even in CKD patients, and the promising effects of VDRA against proteinuria and myocardial hypertrophy in diabetic CKD cohorts. Nevertheless, additional randomized controlled trials (RCT) are needed to answer to many open questions and incertitude considering the effect of nutritional vitamin D and VDRA on hard end points including the risk of skeletal fractures and of mortality in CKD patients. RCT comparing VDRA to calcimimetics in the control of SHPT are also needed in dialysis patients. The present review will visit these open questions that nephrologists should ask before starting a treatment by nutritional vitamin D or VDRA.
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Affiliation(s)
- Pablo Antonio Ureña-Torres
- Ramsay générale de santé, service de néphrologie et dialyse, clinique du Landy, 23, rue du Landy, 93400 Saint-Ouen, France; Department of renal physiology, Necker hospital, university of Paris Descartes, 75015 Paris, France.
| | - Mario Cozzolino
- Renal division, San Paolo hospital, Depart of health sciences, University of Milan, Milan, Italie
| | - Jordi Bover
- Fundació Puigvert, Department of nephrology, C./Cartagena 340-350, 08025 Barcelona, Espagne
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Chiang C. The use of bone turnover markers in chronic kidney disease-mineral and bone disorders. Nephrology (Carlton) 2018; 22 Suppl 2:11-13. [PMID: 28429547 DOI: 10.1111/nep.13014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Bone turnover markers assist in fracture risk prediction, management and monitoring of osteoporosis in patients without chronic kidney disease (CKD). The use in CKD-mineral bone disorder (MBD) has been limited as many of these markers and breakdown products are renally excreted, including the most commonly used and well standardized procollagen type I N propeptide and C-terminal cross-linking telopeptide of type I collagen. Of the markers unaffected by renal function, bone specific alkaline phosphatase is associated with mortality and fracture rate in CKD subjects and is now available on several automated analysers. When used in combination with PTH, bone specific alkaline phosphatase as a bone formation marker correlated well with bone biopsy histomorphometry in predicting adynamic bone disease. Tartrate-resistant acid phosphatase 5b is a resorption marker that is under development for automation. Both high and low bone turnover in CKD-MBD patients are associated with increased fracture and mortality risk. Bone biopsy as the gold standard to differentiate between adynamic bone disease and osteitis fibrosa is limited by availability and cost. Appropriate use of bone turnover markers is vital in the decision to commence anti-resorptive agents, and to monitor efficacy in order to avoid over suppression of bone turnover, which may lead to stress fractures. Further efforts are required to develop markers unaffected by renal function with standardized cut-off values and fracture as well as vascular calcification end-points.
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Affiliation(s)
- Cherie Chiang
- Department of Pathology, Royal Melbourne Hospital.,Department of Endocrinology, Department of Pathology, Austin Hospital.,University of Melbourne, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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Fülöp T, Koch CA, Farah Musa AR, Clark CM, Gharaibeh KA, Lengvársky Z, Hamrahian M, Pitman KT, Dixit MP. Targeted surgical parathyroidectomy in end-stage renal disease patients and long-term metabolic control: A single-center experience in the current era. Hemodial Int 2018; 22:394-404. [PMID: 29446565 DOI: 10.1111/hdi.12639] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The long-term results of surgical parathyroidectomy (PTX) in end-stage renal disease (ESRD) patients are less well known in the modern era of newer activated vitamin-D analogs, calcimimetics and intraoperative monitoring of parathyroid hormone (PTH). METHODS We performed a retrospective chart review of all ESRD patients undergoing PTX at the University of Mississippi Medical Center between January 2005 and August 2011, with follow-up data as available up to 4 years. All PTXs were performed with intraoperative second-generation PTH monitoring and targeted gland size reduction. RESULTS The cohort (N = 37) was relatively young with a mean (±SD) age of 48.4 ± 13.9. 94.6% of the subjects were African American and 59.5% female. Preoperatively, 45.9% received cinacalcet (CNC) at a mean dose of 63.5 ± 20.9 mg. The size of the largest removed glands measured 1.7 ± 0.8 cm and almost all (94.6%) glands had hyperplasia on histology. The mean length of inpatient stay was 5.5 ± 2.4 days. Preoperative calcium/phosphorus measured 9.6 ± 1.2/6.6 ± 1.7 mg/dL with PTH concentrations of 1589 ± 827 pg/mL. Postoperative PTH values measured 145.4 ± 119.2 pg/mL. Preoperative PTH strongly correlated (P < 0.0001) with both alkaline phosphatase (ALP) levels (r: 0.596) and the number of inpatient days (r: 0.545), but not with CNC administration. Independent predictors for the duration of hospitalization were preoperative ALP (beta 0.469; P = 0.001) and age (beta -0.401; P = 0.005) (R2 0.45); for postoperative hypocalcemia, age (beta: -0.321; P = 0.006) and preoperative PTH (beta: 0.431; P = 0.036) were significant in linear regression models with stepwise selection. CONCLUSION Gland-sparing PTX achieved acceptable control of ESRD-associated hyperparathyroidism in most patients from a socioeconomically challenged, underserved population of the United States.
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Affiliation(s)
- Tibor Fülöp
- Division of Nephrology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Christian A Koch
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA.,G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi, USA.,Cancer Institute, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Abdeen R Farah Musa
- Division of Nephrology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Christopher M Clark
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Kamel A Gharaibeh
- Division of Nephrology, Diabetes and Metabolism, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Zsolt Lengvársky
- Department of Mathematics, Louisiana State University Shreveport, Shreveport, Louisiana, USA
| | | | - Karen T Pitman
- Johns Hopkins Department of Otolaryngology, Milton J. Dance Jr. Head and Neck Center, Baltimore, Maryland, USA
| | - Mehul P Dixit
- Division of Pediatric Nephrology, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
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