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Sodium zirconium cyclosilicate and metabolic acidosis: Potential mechanisms and clinical consequences. Biomed Pharmacother 2023; 158:114197. [PMID: 36916426 DOI: 10.1016/j.biopha.2022.114197] [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: 09/06/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023] Open
Abstract
Metabolic acidosis is frequent in chronic kidney disease (CKD) and is associated with accelerated progression of CKD, hypercatabolism, bone disease, hyperkalemia, and mortality. Clinical guidelines recommend a target serum bicarbonate ≥ 22 mmol/L, but metabolic acidosis frequently remains undiagnosed and untreated. Sodium zirconium cyclosilicate (SZC) binds potassium in the gut and is approved to treat hyperkalemia. In clinical trials with a primary endpoint of serum potassium, SZC increased serum bicarbonate, thus treating CKD-associated metabolic acidosis. The increase in serum bicarbonate was larger in patients with more severe pre-existent metabolic acidosis, was associated to decreased serum urea and was maintained for over a year of SZC therapy. SZC also decreased serum urea and increased serum bicarbonate after switching from a potassium-binding resin in normokalemic individuals. Mechanistically, these findings are consistent with SZC binding the ammonium ion (NH4+) generated from urea by gut microbial urease, preventing its absorption and, thus, preventing the liver regeneration of urea and promoting the fecal excretion of H+. This mechanism of action may potentially result in benefits dependent on corrected metabolic acidosis (e.g., improved well-being, decreased catabolism, improved CKD mineral bone disorder, better control of serum phosphate, slower progression of CKD) and dependent on lower urea levels, such as decreased protein carbamylation. A roadmap is provided to guide research into the mechanisms and clinical consequences of the impact of SZC on serum bicarbonate and urate.
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Association of serum bicarbonate with graft survival and mortality in kidney transplant recipients. J Nephrol 2021; 35:619-627. [PMID: 34843097 DOI: 10.1007/s40620-021-01197-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Metabolic acidosis is an independent risk factor for kidney disease progression with a high prevalence after kidney transplantation (KTx). Remarkably, it is still unclear if there is an impact of metabolic acidosis on graft function and death after KTx. Thus, we wanted to investigate if serum bicarbonate is associated with long-term graft outcome and mortality after KTx. METHODS We performed a single-center retrospective study including adult de novo KTx patients between 1999 and 2015. Cox proportional hazard model was used to analyze a possible association between time-dependent serum bicarbonate measurements and graft failure or death. RESULTS Four hundred thirty KTRs were included in the analysis with a mean age of 50.9 ± 13.4 years. Mean observation time was 4.7 ± 2.8 years. Two hundred eighty-four (66%) patients were male and 318 (74%) had received a deceased donor kidney transplant. Mean bicarbonate and eGFR levels 1 year post-transplant amounted to 22.9 ± 3.1 mEq/L and 61 ± 26 ml/min/1.73 m2, respectively. Prevalence of metabolic acidosis was 31% 1 year after transplantation. Fourteen (3%) patients died and 31 (7%) suffered from graft failure. Higher bicarbonate levels were associated with significantly lower hazards for graft failure (Hazard Ratio (HR) = 0.88; 95% Confidence Interval (CI): 0.79-0.98) and mortality (HR = 0.79; 95% CI 0.66-0.93) after adjusting for potential confounders such as age, donor type and time-varying eGFR. CONCLUSIONS Our analysis showed that higher serum bicarbonate levels are positively associated with long-term graft and patient survival in kidney transplant recipients. Thus, serum bicarbonate may serve as a predictor and independent risk factor for graft and patient outcome after KTx as has been previously shown for patients with CKD.
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Gołębiowski T, Kusztal M, Konieczny A, Kuriata-Kordek M, Gawryś A, Augustyniak-Bartosik H, Letachowicz K, Zielińska D, Wiśniewska M, Krajewska M. Exhausted Capacity of Bicarbonate Buffer in Renal Failure Diagnosed Using Point of Care Analyzer. Diagnostics (Basel) 2021; 11:diagnostics11020226. [PMID: 33546171 PMCID: PMC7913213 DOI: 10.3390/diagnostics11020226] [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: 12/31/2020] [Revised: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Metabolic acidosis in patients with chronic kidney disease (CKD) is a common complication. A bicarbonate concentration in venous blood (V-HCO3-) is a key index for diagnosis and treatment initiation. The aim of our study is to evaluate usability of acid-base balance parameters of in blood taken simultaneously from peripheral artery and the vein. METHODS A total of 49 patients (median age 66 years [interquartile range IQR 45-75]), with CKD stage G4 or G5 were enrolled in this cross-sectional study. All patients were qualified for arteriovenous fistula creation in pre-dialysis period. The samples were taken during surgery, directly after dissection, and evaluated in a point of care testing analyzer. The arteriovenous difference in bicarbonate levels (Δ-HCO3-) was calculated. According to glomerular filtration rate (eGFR) the group was divided into Group A eGFR ≥ 10 mL/min/1.73 m2) and Group B eGFR < 10 mL/min/1.73 m2). RESULTS In Group A Δ-HCO3- was significantly higher compared to Group B. No such differences were observed in the case of V-HCO3-. Δ-HCO3- positively correlated with eGFR. The discriminative power of Δ-HCO3- for predicting eGFR < 10 mL/min/1.73 m2 was 0.72 (95% confidence interval [CI] = 0.551-0.88; p = 0.01) which provided 67% sensitivity and 75% specificity. The best cut-off was 0.5 mmol/L. CONCLUSIONS The Δ-HCO3- lower than 0.5 mmol/L may be used as predictor of exhaust buffer capacity. The value of this tool should be tested in larger population.
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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.); (M.K.-K.); (A.G.); (H.A.-B.); (K.L.); (D.Z.); (M.K.)
- Correspondence:
| | - Mariusz Kusztal
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (M.K.-K.); (A.G.); (H.A.-B.); (K.L.); (D.Z.); (M.K.)
| | - Andrzej Konieczny
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (M.K.-K.); (A.G.); (H.A.-B.); (K.L.); (D.Z.); (M.K.)
| | - Magdalena Kuriata-Kordek
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (M.K.-K.); (A.G.); (H.A.-B.); (K.L.); (D.Z.); (M.K.)
| | - Ada Gawryś
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (M.K.-K.); (A.G.); (H.A.-B.); (K.L.); (D.Z.); (M.K.)
| | - Hanna Augustyniak-Bartosik
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (M.K.-K.); (A.G.); (H.A.-B.); (K.L.); (D.Z.); (M.K.)
| | - Krzysztof Letachowicz
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (M.K.-K.); (A.G.); (H.A.-B.); (K.L.); (D.Z.); (M.K.)
| | - Dorota Zielińska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (M.K.-K.); (A.G.); (H.A.-B.); (K.L.); (D.Z.); (M.K.)
| | - Magdalena Wiśniewska
- Clinical Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, 70-214 Szczecin, Poland;
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.K.); (A.K.); (M.K.-K.); (A.G.); (H.A.-B.); (K.L.); (D.Z.); (M.K.)
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Copur S, Sag AA, Afsar B, Rossignol P, Covic A, Kanbay M. Complications of metabolic acidosis and alkalinizing therapy in chronic kidney disease patients: a clinician-directed organ-specific primer. Int Urol Nephrol 2020; 52:2311-2320. [PMID: 32661618 DOI: 10.1007/s11255-020-02563-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/29/2020] [Indexed: 01/09/2023]
Abstract
Chronic kidney disease is prevalent, affecting more than one in ten adults. In this population, metabolic acidosis is considered a key underlying pathophysiological feature, tying together bone mineral disorders, sarcopenia, insulin resistance, vascular calcification, pro-inflammatory and pro-thrombotic states. This review aims to address the paucity of literature on alkalinizing agents, a promising treatment option that has known adverse effects.
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Affiliation(s)
- Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Alan A Sag
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, USA
| | - Baris Afsar
- Division of Nephrology, Department of Internal Medicine, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Patrick Rossignol
- Université de Lorraine, INSERM CIC-P 1433, CHRU de Nancy, INSERM U1116, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Adrian Covic
- Department of Nephrology, Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, 34010, Istanbul, Turkey.
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Successful correction of metabolic acidosis is difficult to achieve in chronic kidney disease. Nefrologia 2019; 40:328-335. [PMID: 31862183 DOI: 10.1016/j.nefro.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/13/2019] [Accepted: 09/16/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Metabolic acidosis (MA) is a common complication of chronic kidney disease (CKD) and is associated with numerous adverse effects, which is why its correction is highly recommended. Oral sodium bicarbonate is the current treatment of choice. OBJECTIVES To describe the prevalence of MA in advanced CKD patients and to determine the clinical and biochemical characteristics associated with its successful correction. MATERIAL AND METHODS Retrospective, observational cohort study in adult patients with CKD stage 4-5. The inclusion criteria were: not being treated with alkali therapy at the time of inclusion, and to have at least three consecutive glomerular filtration rate (GFR) measurements and biochemical parameters during a minimum follow-up period of 3 months. Incident patients with serum bicarbonate<22 mEq/l were included in the follow-up study and treated with oral sodium bicarbonate. Correction was considered successful when more than half of the samples and the mean bicarbonate levels during individual follow-up were≥22 mEq/l. RESULTS The study group consisted of 969 patients (age 65±14 years, 507 males) with a mean GFR of 14.8±4.5ml/min/1.73 m2. At baseline, 530 patients (55%) had serum bicarbonate<22mEq/l. They were treated with sodium bicarbonate and followed for 15 months. Satisfactory correction of MA was only achieved in 133 patients (25%). By multivariate logistic regression analysis, the main characteristics of patients with adequate control of MA were: age (OR=1.03; 95% CI 1.01 - 1.05), baseline GFR (OR=1.07; 1.02 - 1.12), and treatment with proton-pump inhibitors (OR=1.61; 95% CI 1.06 - 2.44). Patients who achieved successful correction of MA showed slower CKD progression (-1.67±3.71 vs -4.36±4.56ml/min/1.73 m2/year, P<.0001), and lower average serum potassium concentration (5.1±0.5 vs 5.3±0.5, P<.0001) than those who did not. However, there were no differences in the hospitalisation or mortality rate. CONCLUSION MA is a common complication of advanced CKD but difficult to manage with current therapies. Due to the significant potential benefit of controlling MA, new, more effective therapies should be further researched.
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Bicarbonate : de la physiologie aux applications thérapeutiques pour tout clinicien. Nephrol Ther 2018; 14:13-23. [DOI: 10.1016/j.nephro.2017.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 02/22/2017] [Indexed: 11/17/2022]
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Lima GAC, de Paula Paranhos-Neto F, Silva LC, de Mendonça LMC, Delgado AG, Leite M, Gomes CP, Farias MLF. Bone Density Is Directly Associated With Glomerular Filtration and Metabolic Acidosis but Do Not Predict Fragility Fractures in Men With Moderate Chronic Kidney Disease. J Clin Densitom 2016; 19:146-53. [PMID: 24709549 DOI: 10.1016/j.jocd.2014.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 01/22/2014] [Indexed: 01/10/2023]
Abstract
Hyperparathyroidism, vitamin D deficiency, increased fibroblast growth factor-23 (FGF-23), and metabolic acidosis promote bone fragility in chronic kidney disease (CKD). Although useful in predicting fracture risk in the general population, the role of dual-energy X-ray absorptiometry (DXA) in CKD remains uncertain. This cross-sectional study included 51 men aged 50-75 yr with moderate CKD. The stage 4 CKD patients had higher levels of parathyroid hormone (p<0.001), FGF-23 (p=0.029), and lowest 25-hydroxyvitamin D (p=0.016), bicarbonate (p<0.001), total femur (p=0.003), and femoral neck (p=0.011) T-scores compared with stage 3 CKD patients. Total femur and femoral neck T-scores were directly correlated with serum bicarbonate (p=0.003, r=0.447 and p=0.005, r=0.427, respectively) and estimated glomerular filtration rate (p=0.024, r=0.325 and p=0.003, r=0.313, respectively) but were not significantly associated with parathyroid hormone, 25-hydroxyvitamin D, or FGF-23. Only 3.9% of the participants had osteoporosis on DXA scan, whereas 31.4% reported a low-impact fracture. Our data point to a pivotal role of metabolic acidosis for bone impairment and to the inadequacy of DXA to evaluate bone fragility in CKD patients.
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Affiliation(s)
- Guilherme Alcantara Cunha Lima
- Division of Endocrinology, Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil.
| | - Francisco de Paula Paranhos-Neto
- Division of Endocrinology, Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
| | - Luciana Colonese Silva
- Division of Endocrinology, Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
| | - Laura Maria Carvalho de Mendonça
- Division of Rheumatology, Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
| | - Alvimar Gonçalves Delgado
- Division of Nephrology, Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
| | - Maurilo Leite
- Division of Nephrology, Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
| | - Carlos Perez Gomes
- Division of Nephrology, Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
| | - Maria Lucia Fleiuss Farias
- Division of Endocrinology, Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
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Witham MD, Band MM, Littleford RC, Avenell A, Soiza RL, McMurdo MET, Sumukadas D, Ogston SA, Lamb EJ, Hampson G, McNamee P. Does oral sodium bicarbonate therapy improve function and quality of life in older patients with chronic kidney disease and low-grade acidosis (the BiCARB trial)? Study protocol for a randomized controlled trial. Trials 2015; 16:326. [PMID: 26231610 PMCID: PMC4522127 DOI: 10.1186/s13063-015-0843-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 07/01/2015] [Indexed: 12/24/2022] Open
Abstract
Background Metabolic acidosis is more common with advancing chronic kidney disease, and has been associated with impaired physical function, impaired bone health, accelerated decline in kidney function and increased vascular risk. Although oral sodium bicarbonate is widely used to correct metabolic acidosis, there exist potential risks of therapy including worsening hypertension and fluid overload. Little trial evidence exists to decide whether oral bicarbonate therapy is of net benefit in advanced chronic kidney disease, particularly in older people who are most commonly affected, and in whom physical function, quality of life and vascular health are at least as important outcomes as decline in renal function. Methods/Design BiCARB is a multi-centre, double-blind, placebo controlled, randomised trial evaluating the clinical and cost-effectiveness of oral sodium bicarbonate in the management of older people with chronic kidney disease and severely reduced glomerular filtration rate (GFR) who have a mild degree of metabolic acidosis. The trial will recruit 380 patients from renal, Medicine for the Elderly, and primary care services across centres in the United Kingdom. Male and female patients aged 60 years and older with an estimated glomerular filtration rate of <30 mL/min/1.73 m2, not on dialysis, and with serum bicarbonate concentrations <22 mmol/L will be eligible for participation. The primary clinical outcome for the trial is the between-group difference in the Short Physical Performance Battery score at 12 months. Secondary outcomes include muscle strength, quality of life measured using the EQ-5D score and KDQoL tools, cost effectiveness, renal function, presence of albuminuria and blood pressure. Markers of bone turnover (25-hydroxyvitamin D, 1,25-hydroxyvitamin D, tartrate-resistant acid phosphatase-5b and bone-specific alkaline phosphatase) and vascular health (B-type natriuretic peptide) will be measured. Participants will receive a total of 24 months of either bicarbonate or placebo. The results will provide the first robust test of the overall clinical and cost-effectiveness of this commonly used therapy in older patients with severely reduced kidney function. Trial registration www.isrctn.com; ISRCTN09486651, registered 17 February 2012
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Affiliation(s)
- Miles D Witham
- Medical Research Institute, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Margaret M Band
- Tayside Clinical Trials Unit, University of Dundee / NHS Tayside, Dundee, UK.
| | | | - Alison Avenell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
| | - Roy L Soiza
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
| | - Marion E T McMurdo
- Medical Research Institute, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Deepa Sumukadas
- Medical Research Institute, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Simon A Ogston
- Epidemiology and Biostatistics Unit, University of Dundee, Dundee, UK.
| | - Edmund J Lamb
- Department of Clinical Biochemistry, East Kent NHS Trust, Canterbury, UK.
| | - Geeta Hampson
- Department of Chemical Pathology, Guy's and St Thomas' Hospitals, London, UK.
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK.
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Urinary ammonia and long-term outcomes in chronic kidney disease. Kidney Int 2015; 88:137-45. [DOI: 10.1038/ki.2015.52] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/23/2014] [Accepted: 01/02/2015] [Indexed: 12/16/2022]
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Experimental application of Lactobacillus fermentum CCM 7421 in combination with chlorophyllin in dogs. Appl Microbiol Biotechnol 2015; 99:8681-90. [DOI: 10.1007/s00253-015-6724-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/20/2015] [Accepted: 05/25/2015] [Indexed: 12/31/2022]
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de-Brito Ashurst I, O'Lone E, Kaushik T, McCafferty K, Yaqoob MM. Acidosis: progression of chronic kidney disease and quality of life. Pediatr Nephrol 2015; 30:873-9. [PMID: 25085611 DOI: 10.1007/s00467-014-2873-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 05/23/2014] [Accepted: 05/30/2014] [Indexed: 11/25/2022]
Abstract
Metabolic acidosis (MA) is relatively common in patients with chronic kidney disease (CKD) particularly in stages 4 and 5. It is assumed to play a contributory role in the development of several complications including bone disease, skeletal muscle wasting, altered protein synthesis, and degradation. Recent evidence also suggests that even mild acidosis might play a role in progressive glomerular filtration rate loss. Experimental and clinical studies suggest that correction of acidosis by alkali therapy attenuates these complications and improves quality of life. Despite several recent small and single-center studies supporting this notion, more robust evidence is required with regard to the long-term benefits of alkali therapy, type of alkali supplements, and the optimal level of serum bicarbonate.
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Affiliation(s)
- Ione de-Brito Ashurst
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, Cardiovascular Biological Research Unit and William Harvey Research Institute, London, UK
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Sánchez-Canel JJ, Hernández-Jaras J, Pons-Prades R. A randomized controlled study on the effects of acetate-free biofiltration on organic anions and acid-base balance in hemodialysis patients. Ther Apher Dial 2014; 19:63-72. [PMID: 25256567 DOI: 10.1111/1744-9987.12180] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Metabolic acidosis correction is achieved by the transfer of bicarbonate and other buffer anions in dialysis. The aim of this study was to evaluate changes in the main anions of intermediary metabolism on standard hemodiafiltration (HDF) and on acetate-free biofiltration (AFB). A prospective, in-center, crossover study was carried out with 22 patients on maintenance dialysis. Patients were randomly assigned to start with 12 successive sessions of standard HDF with bicarbonate (34 mmol/L) and acetate dialysate (3 mmol/L) or 12 successive sessions of AFB without base in the dialysate. Acetate increased significantly during the standard HDF session from 0.078 ± 0.062 mmol/L to 0.156 ± 0.128 mmol/L (P < 0.05) and remained unchanged at 0.044 ± 0.034 mmol and 0.055 ± 0.028 mmol/L in AFB modality. Differences in the acetate levels were observed at two hours (P < 0.005), at the end (P < 0.005) and thirty minutes after the session between HDF and AFB (P < 0.05). There were significantly more patients above the normal range in HDF group than AFB group (68.1% vs 4.5% P < 0.005) postdialysis and 30 minutes later. Serum lactate and pyruvate concentrations decreased during the sessions without differences between modalities. Citrate decreased only in the AFB group (P < 0.05). Acetoacetate and betahydroxybutyrate increased in both modalities, but the highest betahydroxybutyrate values were detected in HDF (P < 0.05). The sum of postdialysis unusual measured organic anions (OA) were higher in HDF compared to AFB (P < 0.05). AFB achieves an optimal control of acid-base equilibrium through a bicarbonate substitution fluid. It also prevents hyperacetatemia and restores internal homeostasis with less production of intermediary metabolites.
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Bales AM, Moysés RMA, dos Reis LM, Graciolli FG, Hung J, Martins Castro MC, Elias RM. Correction of metabolic acidosis in hemodialysis: consequences on serum leptin and mineral metabolism. Int Urol Nephrol 2014; 47:177-82. [PMID: 25252843 DOI: 10.1007/s11255-014-0844-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 09/10/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE Hyperleptinemia and metabolic acidosis (MA) are frequently observed in patients on hemodialysis (HD). While the role of leptin in patients on HD is not completely understood, HD only partially corrects MA. Both leptin and acidosis have effect on bone disease. The goal of the present study was to evaluate the effects of MA correction on chronic kidney disease-mineral and bone disorder laboratory parameters and leptin levels. METHODS Forty-eight patients on HD, aged 43±19 years, were prospectively studied. Individual adjustments in the bicarbonate dialysate concentration were made to maintain pre-dialysis concentration≥22 mEq/l. Blood gas analysis was done monthly for 4 months (M1-M4). RESULTS From M0 to M4, serum albumin increased (from 3.5 ±0.3 to 4.0±0.3 g/l, p<0.0001) while β2 microglobulin decreased (from 27.6±8.3 to 25.8±6.8 µg/ml, p=0.025). Serum leptin decreased in all but three patients, as well as leptin/adiponectin ratio (p<0.0001). There was a decrease in ionized serum calcium (from 5.0±0.5 to 4.7±0.5 mg/dl, p =0.002) and an increase in parathyroid hormone (PTH) [from 191 (85, 459) to 446 pg/ml (212, 983), p<0.0001] and in serum phosphate (from 5.4±1.4 to 5.8±1.1 mg/dl, p=0.048). CONCLUSION MA correction in HD patients can decrease leptin, an atherogenic marker. The impact of such treatment extends to uremic bone disease, as decrease in serum calcium and increase in PTH. However, this could be an undesirable effect because it may aggravate a secondary hyperparathyroidism. Whether the reduction in leptin levels has impact on outcomes in patients on hemodialysis deserves further investigation.
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Affiliation(s)
- Alessandra M Bales
- Division of Nephrology, Hospital das Clinicas da FMUSP - Disciplina de Nefrologia, Universidade de São Paulo, Rua Dr. Enéas de Carvalho Aguiar 255, 7º andar, São Paulo, SP, CEP 05403-000, Brazil
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Kuragano T, Furuta M, Yahiro M, Kida A, Otaki Y, Hasuike Y, Matsumoto A, Nakanishi T. Acetate free citrate-containing dialysate increase intact-PTH and BAP levels in the patients with low intact-PTH. BMC Nephrol 2013; 14:18. [PMID: 23327614 PMCID: PMC3583681 DOI: 10.1186/1471-2369-14-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 01/11/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recently, acetate-free citrate containing dialysate (A(-)D) was developed. We have already reported about the significant effect of A(-)D on metabolic acidosis, anemia, and malnutrition in maintenance hemodialysis (MHD) patients. In this study, we compared the effect of A(-)D and acetate containing dialysate (A(+)D) on serum calcium and intact-parathyroid hormone (int-PTH) levels. METHOD Single session study: Seventeen patients were treated with A(+)D in one session and also treated with A(-)D in another session. Serum levels of pH, HCO3-, total (t)-calcium, ionized (i)-calcium, and int-PTH were evaluated at the beginning and the end of each session. Cross over study: A total of 29 patients with MHD were treated with A(+)D for 4 months, switched to A(-)D for next 4 months, and returned to A(+)D for the final 4 months. RESULTS In single session study, serum i-calcium and t-calcium levels significantly increased, and int-PTH levels decreased after HD with A(+)D, whereas HD with A(-)D did not affect iCa and int-PTH. In cross over study, if all patients were analyzed, there was no significant difference in serum int-PTH or bone alkaline phosphatase (BAP) levels during each study period. In contrast, in the patients with low int-PTH (<60 pg/mL), serum levels of int-PTH and BAP were significantly increased during the A(-)D, without significant changes in serum t-calcium or i-calcium levels. CONCLUSION A(-)D containing citrate could affect calcium and PTH levels, and, in 4 month period of crossover study, increased int-PTH levels pararelled with increasing BAP levels, exclusively in MHD patients with low int-PTH levels.
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Affiliation(s)
- Takahiro Kuragano
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
- Takahiro Kuragano, 1-1, Mukogawa cho, 663-8501, Nishinomiya, Japan
| | | | - Mana Yahiro
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
| | - Aritoshi Kida
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshinaga Otaki
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yukiko Hasuike
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Takeshi Nakanishi
- Department of Internal Medicine Division of kidney and Dialysis, Hyogo College of Medicine, Nishinomiya, Japan
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Kraut JA, Madias NE. Consequences and therapy of the metabolic acidosis of chronic kidney disease. Pediatr Nephrol 2011; 26:19-28. [PMID: 20526632 PMCID: PMC2991191 DOI: 10.1007/s00467-010-1564-4] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 04/22/2010] [Accepted: 05/04/2010] [Indexed: 01/18/2023]
Abstract
Metabolic acidosis is common in patients with chronic kidney disease (CKD), particularly once the glomerular filtration rate (GFR) falls below 25 ml/min/1.73 m(2). It is usually mild to moderate in magnitude with the serum bicarbonate concentration ([HCO(3)(-)]) ranging from 12 to 23 mEq/l. Even so, it can have substantial adverse effects, including development or exacerbation of bone disease, growth retardation in children, increased muscle degradation with muscle wasting, reduced albumin synthesis with a predisposition to hypoalbuminemia, resistance to the effects of insulin with impaired glucose tolerance, acceleration of the progression of CKD, stimulation of inflammation, and augmentation of β(2)-microglobulin production. Also, its presence is associated with increased mortality. The administration of base to patients prior to or after initiation of dialysis leads to improvement in many of these adverse effects. The present recommendation by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) is to raise serum [HCO(3)(-)] to ≥ 22 mEq/l, whereas Caring for Australians with Renal Impairment (CARI) recommends raising serum [HCO(3)(-)] to >22 mEq/l. Base administration can potentially contribute to volume overload and exacerbation of hypertension as well as to metastatic calcium precipitation in tissues. However, sodium retention is less when given as sodium bicarbonate and sodium chloride intake is concomitantly restricted. Results from various studies suggest that enhanced metastatic calcification is unlikely with the pH values achieved during conservative base administration, but the clinician should be careful not to raise serum [HCO(3)(-)] to values outside the normal range.
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Affiliation(s)
- Jeffrey A. Kraut
- Medical and Research Services, VHAGLA Healthcare System, UCLA Membrane Biology Laboratory, Los Angeles, CA USA ,Division of Nephrology, VHAGLA Healthcare System, Los Angeles, USA ,David Geffen School of Medicine, Los Angeles, CA USA
| | - Nicolaos E. Madias
- Division of Nephrology, Department of Medicine, St. Elizabeth’s Medical Center, 736 Cambridge St., Boston, MA 02135 USA ,Department of Medicine, Tufts University School of Medicine, Boston, MA USA
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HernáNdez-Jaras J, Torregrosa De Juan E, Pons-Prades R, RÍus-Peris A, Fenollosa-Segarra M. Switching from Three Times a Week to Short Daily Online Hemodiafiltration: Effects on Acid-Base Balance. Int J Artif Organs 2008; 31:237-43. [DOI: 10.1177/039139880803100307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims This study examines the effect of a change from the standard 4–5 hours 3 times a week of online hemodiafiltration (OL-HDF) to 2–2.5 hours daily (6 times a week) OL-HDF, on acid-base balance, and attempts assess the modifications of acid-base parameters, ionic concentration, and electrical charges of albumin and phosphate available for diffusion and convection mechanisms across the membrane and subsequent infusion. Methods In 18 patients on online HDF, blood gas, electrolytes (Na, K, Cl), lactate, phosphate, albumin, apparent strong ion difference (SIDa), effective strong ion difference (SIDe), strong ion gap (SIG), anion gap (AG), and bicarbonate and pH time-averaged concentration (TAC) and time-averaged deviation (TAD) variables were evaluated at baseline, and 1, 3, 6, 9, and 12 months after patients were switched to daily OL-HDF. Additionally, in 12 patients, the same parameters measured simultaneously at dialyzer inlet, outlet, and after reinfusion were studied. Results Throughout the study, weekly single-pool Kt/V, equilibrated Kt/V, and TAC urea remained constant. However, standard Kt/V increased and TAD urea decreased on daily OL-HDF. There were no statistical differences during the time span of 12 months in pH, cations (Na, K), anions (Cl, HCO–3 AG, and lactate), or SIDa, SIDe, and SIG pre-HDF; while pH and HCO3– TAD decreased from 0.02 and 1.02 ± 0.74 mEq/L, to 0.01 and 0.64 ± 0.52 mEq/L, respectively (p<0.01). Net albumin charge and AG increased significantly at dialyzer outlet and decreased after reinfusion. Conclusions We did not observe changes in the acid-base balance in patients who switched from 3 times a week to short daily OL-HDF. The main benefit observed was a lower pH and bicarbonate TAD. This shows a better physiology for daily OL-HDF.
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Affiliation(s)
| | | | - R. Pons-Prades
- Department of Nephrology, Hospital General, Castellón - Spain
| | - A. RÍus-Peris
- Department of Nephrology, Hospital General, Castellón - Spain
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Noh US, Yi JH, Han SW, Kim HJ. Varying Dialysate Bicarbonate Concentrations in Maintenance Hemodialysis Patients Affect Post-dialysis Alkalosis but not Pre-dialysis Acidosis. Electrolyte Blood Press 2007; 5:95-101. [PMID: 24459507 PMCID: PMC3894521 DOI: 10.5049/ebp.2007.5.2.95] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Accepted: 10/01/2007] [Indexed: 12/04/2022] Open
Abstract
This study aimed to assess the effects of different dialysate bicarbonate concentrations in correcting acid-base imbalance in 53 stable hemodialysis patients in a university-hemodialysis unit. Three different bicarbonate concentrations were assigned, i.e. 25 mEq/L in 10, 30 mEq/L in 30, and 35 mEq/L in 13 patients. Blood gas analyses from arterial line blood samples before and after dialysis in the mid-week were performed for the determination of pH and serum bicarbonate (HCO3-) concentration. The mean values of predialysis arterial HCO3- were mildly acidotic in all 3 groups, but not significantly different among them, whereas those of post-dialysis arterial HCO3- were alkalotic, especially in the group of 35 mEq/L as compared with the other two groups. The mean blood pH was not significantly different among the 3 groups. As expected, there was a positive correlation between pre-dialysis pH and post-dialysis pH (r=0.45, p=0.001), and pre-dialysis HCO3- and post-dialysis HCO3- (r=0.58, p=0.000), but with a negative correlation between pre-dialysis HCO3- and the increment of intradialytic HCO3- following hemodialysis (r=-0.46, p=0.001). In conclusion, this study shows that the impact of conventional dialysate bicarbonate concentrations ranging from 25 to 35 mEq/L is not quite different on the mild degree of predialysis acidemia, but the degree of postdialysis alkalemia is more prominent in higher bicarbonate concentrations. Base supply by hemodialysis alone does not seem to be the main factor to determine the predialysis acidosis in end-stage renal disease patients on chronic maintenance hemodialysis.
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Affiliation(s)
- U-Seok Noh
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Joo-Hark Yi
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Sang-Woong Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Ho-Jung Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
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Stabellini G, Minola E, Dolci C, Moscheni C, Calastrini C, Lumare E, Tartaglia G, Carinci F, Vertemati M. Glycosaminoglycan, collagen, and glycosidase changes in human osteoblasts treated with interleukin 1, and osteodystrophy. Biomed Pharmacother 2007; 61:686-92. [PMID: 17561366 DOI: 10.1016/j.biopha.2007.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Accepted: 04/20/2007] [Indexed: 11/27/2022] Open
Abstract
Normal bone homeostasis involves a balance between osteoblast and osteoclast action, regulated by hormones and cytokine stimuli. Hemodialysis patients appear to have increased production of interleukin-1 (IL-1), interleukin-6 (IL-6) and glycosaminoglycans (GAG) in serum. IL-1 plays a role in the synthesis, degradation and degree of sulphatation of ECM components such as glycosaminoglycans. Also, continuous changes in the ECM involve enzymes such as beta-N-acetyl-d-glucosaminidase (beta-NAG) and beta-d-glucuronidase (beta-GLU) which act on different GAG classes and collagen fibers. We examined the effects of IL-1alpha on ECM synthesis and the related enzymes in human uremic osteoblast cultures. We also measured the levels of IL-1beta, and IL-6 and alkaline phosphatase activity. In biopsies of uremic bone there was less ECM deposition than resorption associated with changes in osteoblast morphology. In vitro osteoblast proliferation was higher (P< or =0.01), and extracellular GAG lower (P< or =0.01) than in controls. The enzyme beta-NAG was high (P< or =0.05) but there were no noteworthy changes in beta-GLU. ELISA of the medium indicated spontaneous production of IL-1beta and IL-6, which significantly increased after IL-1alpha treatment compared to controls. IL-1alpha reduced alkaline phosphatase activity (P< or =0.01) in uremic osteoblast cultures. IL-1 acts on osteoblasts with decreases in GAG synthesis and alkaline phosphatase activity, while beta-NAG increases. This lead to a reduction in the organic component in ECM and its mineralization, and to changes in the regulation of cytokine activity by GAG. The enzymatic breakdown might be facilitated by metabolic acidosis and failed osteoblast differentiation; these factors could be correlated with different degrees of osteodystrophy.
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Affiliation(s)
- Giordano Stabellini
- Human Morphology Department, University of Milan, Via Mangiagalli 31, 20133 Milan, Italy.
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Roderick P, Willis NS, Blakeley S, Jones C, Tomson C. Correction of chronic metabolic acidosis for chronic kidney disease patients. Cochrane Database Syst Rev 2007; 2007:CD001890. [PMID: 17253467 PMCID: PMC7045985 DOI: 10.1002/14651858.cd001890.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Metabolic acidosis is a feature of chronic kidney disease (CKD) due to the reduced capacity of the kidney to synthesise ammonia and excrete hydrogen ions. It has adverse consequences on protein and muscle metabolism, bone turnover and the development of renal osteodystrophy. Metabolic acidosis may be corrected by oral bicarbonate supplementation or in dialysis patients by increasing the bicarbonate concentration in dialysate fluid. OBJECTIVES To examine the benefits and harms of treating metabolic acidosis in patients with CKD, both prior to reaching end-stage renal disease (ESRD) or whilst on renal replacement therapy (RRT), with sodium bicarbonate or increasing the bicarbonate concentration of dialysate. SEARCH STRATEGY We searched CENTRAL (The Cochrane Library, issue 4 2005), Cochrane Renal Group's specialised register (October 2005), MEDLINE (1966 - October 2005) and EMBASE (1980 - October 2005). SELECTION CRITERIA Randomised controlled trials (RCTs), crossover RCTs and quasi-RCTs investigating the correction of chronic metabolic acidosis in adults or children with CKD. DATA COLLECTION AND ANALYSIS Outcomes were analysed using relative risk (RR) and weighted mean difference (MD) for continuous measures. MAIN RESULTS We identified three trials in adult dialysis patients (n = 117). There were insufficient data for most outcomes for meta-analysis. In all three trials acidosis improved in the intervention group though there was variation in achieved bicarbonate level. There was no evidence of effect on blood pressure or sodium levels. Some measures of nutritional status/protein metabolism (e.g. SGA, NP NA) were significantly improved by correction in the one trial that looked in these in detail. There was heterogeneity of the effect on serum albumin in two trials. Serum PTH fell significantly in the two trials that estimated this, there was no significant effect on calcium or phosphate though both fell after correction. Complex bone markers were assessed in one study, with some evidence for a reduction in bone turnover in those with initial high bone turnover and an increase in low turnover patients. The studies were underpowered to assess clinical outcomes, in the one study that did there was some evidence for a reduction in hospitalisation after correction. AUTHORS' CONCLUSIONS The evidence for the benefits and risks of correcting metabolic acidosis is very limited with no RCTs in pre-ESRD patients, none in children, and only three small trials in dialysis patients. These trials suggest there may be some beneficial effects on both protein and bone metabolism but the trials were underpowered to provide robust evidence.
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Affiliation(s)
- P Roderick
- University of Southampton, School of Medicine, Community Clinical Sciences, Level C, South Academic Block, Southampton General Hospital, Southampton, UK, S016 6YD.
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Brewster UC, Ciampi MA, Abu-Alfa AK, Reilly RF. Long-term comparison of sevelamer hydrochloride to calcium-containing phosphate binders. Nephrology (Carlton) 2006; 11:142-6. [PMID: 16669977 DOI: 10.1111/j.1440-1797.2006.00544.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM In patients with end-stage renal disease (ESRD), hyperphosphataemia and an elevated calcium-phosphorus (Ca-P) product contribute to morbidity and mortality. Suggested target goals for serum phosphorus concentration and calcium-phosphorus product have recently been lowered. As a result, long-term comparative studies of the efficacy of phosphate binders are critical. This study compares the long-term efficacy of sevelamer hydrochloride to calcium-containing binders (CCB). METHODS A retrospective chart review was conducted in 30 patients receiving sevelamer hydrochloride for >1 years and 25 patients receiving CCB. RESULTS Patients on sevelamer hydrochloride had lower serum bicarbonate concentration than those on CCB, 18.6 +/- 2.7 versus 20.3 +/- 1.8 mmol/L (P = 0.0017). Serum phosphorus concentration was higher in patients on sevelamer hydrochloride compared to CCB 2.10 +/- 0.87 versus 1.74 +/- 0.28 mmol/L (P = 0.0013), as was the Ca-P product 4.97 +/- 0.94 mmol2L2 (62.1 +/- 11.8 mg2/dL2) versus 3.97 +/- 1.18 mmol2/L2 (49.7 +/- 14.7 mg2/dL2), P = 0.0009). Only 36% of patients on sevelamer hydrochloride compared with 68% on CCB (P = 0.015) met the serum phosphorus goal of < or =1.78 mmol/L. CONCLUSION Patients on sevelamer hydrochloride for >1 years compared to those on CCB had a lower serum bicarbonate concentration, a higher serum phosphorus concentration and a higher Ca-P product. Clinicians should balance the increase in calcium load with CCB versus the cost and effectiveness of sevelamer hydrochloride in choosing a phosphate binder for ESRD patients.
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Affiliation(s)
- Ursula C Brewster
- Yale University School of Medicine, Section of Nephrology, New Haven, Connecticut, USA
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Mathur RP, Dash SC, Gupta N, Prakash S, Saxena S, Bhowmik D. Effects of correction of metabolic acidosis on blood urea and bone metabolism in patients with mild to moderate chronic kidney disease: a prospective randomized single blind controlled trial. Ren Fail 2006; 28:1-5. [PMID: 16526312 DOI: 10.1080/08860220500461187] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND There are no controlled trials on the efficacy of oral bicarbonate therapy in patients with mild to moderate chronic kidney disease (CKD). This prospective randomized controlled study was done to evaluate the effects of correction of metabolic acidosis on renal functions and bone metabolism in this group of patients. PATIENTS AND METHODS Forty patients were randomized to treatment with oral bicarbonate or placebo for a period of 3 months. Investigations at baseline included venous pH, bicarbonate, renal functions, serum iPTH, and bone radiology. The treatment group (Group B) received daily oral sodium bicarbonate therapy at a dose of 1.2 mEq/kg of body weight. Their venous blood pH and bicarbonate levels were estimated weekly to keep blood pH near 7.36 and bicarbonate at 22-26 mEq/L by adjusting the dose of sodium bicarbonate. At the end of 3 months, all the tests were repeated in both groups. RESULTS After oral bicarbonate therapy (OBT), there was a significant decline in the rise of blood urea level in Group B associated with a sense of well-being in 50% patients. The rise in parathormone (PTH) was six times the baseline value in Group A and only 1.5 times baseline value in Group B, although not statistically significant. There was no significant change in total calcium, phosphorus, alkaline phosphatase, creatinine, total protein, or albumin levels. CONCLUSION Correction of metabolic acidosis in patients with moderate CKD attenuates the rise in blood urea and PTH, which might prevent the deleterious long-term consequences of secondary hyperparathyroidism.
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Affiliation(s)
- Rajendra P Mathur
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
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Abstract
Metabolic acidosis is noted in the majority of patients with chronic kidney disease (CKD) when glomerular filtration rate (GFR) decreases to less than 20% to 25% of normal, although as many as 20% of individuals can have acid-base parameters close to or within the normal range. Acidosis generally is mild to moderate in degree, with plasma bicarbonate concentrations ranging from 12 to 22 mEq/L (mmol/L), and it is rare to see values less than 12 mEq/L (mmol/L) in the absence of an increased acid load. Degree of acidosis approximately correlates with severity of renal failure and usually is more severe at a lower GFR. The metabolic acidosis can be of the high-anion-gap variety, although anion gap can be normal or only moderately increased even with stage 4 to 5 CKD. Several adverse consequences have been associated with metabolic acidosis, including muscle wasting, bone disease, impaired growth, abnormalities in growth hormone and thyroid hormone secretion, impaired insulin sensitivity, progression of renal failure, and exacerbation of beta 2 -microglobulin accumulation. Administration of base aimed at normalization of plasma bicarbonate concentration might be associated with certain complications, such as volume overload, exacerbation of hypertension, and facilitation of vascular calcifications. Whether normalization of plasma bicarbonate concentrations in all patients is desirable therefore requires additional study. In the present review, we describe clinical and laboratory characteristics of metabolic acidosis, discuss potential adverse effects, and address benefits and complications of therapy.
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Affiliation(s)
- Jeffrey A Kraut
- Division of Nephrology, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, CA 90073, USA.
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Kraut JA, Madias NE. Opinion: What Unique Acid-Base Considerations Exist in Dialysis Patients? Semin Dial 2004. [DOI: 10.1111/j.0894-0959.2004.17344.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Boling EP. Secondary osteoporosis: underlying disease and the risk for glucocorticoid-induced osteoporosis. Clin Ther 2004; 26:1-14. [PMID: 14996513 DOI: 10.1016/s0149-2918(04)90001-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2003] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic diseases of many organ systems require long-term (>or=1 year) treatment with glucocorticoids. Owing to the catabolic activity of glucocorticoid therapy, osteoporosis is a potential complication. OBJECTIVES This review discusses glucocorticoid-induced bone loss and the factors, including underlying disease, that increase the risk for osteoporosis. Therapeutic options for the prevention and treatment of glucocorticoid-induced osteoporosis (GIO) also are reviewed. METHODS A review of the English-language literature was conducted using the MEDLINE database and proceedings from scientific meetings. Search terms including glucocorticoid-induced osteoporosis, bone loss, and fracture were used to refine the search, and preference was given to studies published after 1990. RESULTS Long-term glucocorticoid treatment causes bone loss that is most precipitous in the first 6 months. Patients treated with glucocorticoids have additional risk factors for bone loss and osteoporosis that are associated with their primary disease. Chronic diseases can cause changes in bone metabolism, leading to bone loss in addition to that induced by glucocorticoids alone. Bone loss can be minimized through proper nutrition, weight-bearing exercise, calcium and vitamin D supplementation, and, where indicated, bisphosphonate treatment. The American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis guidelines recommend bisphosphonates for minimizing bone loss and fracture risk in patients at risk for GIO. Risedronate is indicated for the prevention and treatment of GIO, and alendronate is indicated for its treatment. Both risedronate and alendronate increase bone mineral density in patients at risk for GIO. Risedronate significantly reduces the incidence of vertebral fractures after 1 year of treatment (P<0.05). The effectiveness and tolerability of the bisphosphonates have not been established in pregnant women or pediatric patients. CONCLUSIONS Men and women initiating long-term glucocorticoid treatment and those with GIO should be concomitantly treated with effective osteoporosis therapy to reduce fracture risk and counseled on preventive lifestyle changes.
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Affiliation(s)
- Eugene P Boling
- Department of Medicine, Loma Linda University, Rancho Cucamonga, California, USA.
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Blair D, Bigelow C, Sweet SJ. Nutritional effects of delivered bicarbonate dose in maintenance hemodialysis patients. J Ren Nutr 2003; 13:205-11. [PMID: 12874745 DOI: 10.1016/s1051-2276(03)00092-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Metabolic acidosis is common in patients with end-stage renal disease (ESRD). Studies suggest that correction of acidosis may improve nutritional status and patient outcomes. The purpose of this study was to examine the effects of increasing delivered bicarbonate dose from 35 mmol/L to 39 mmol/L with respect to nutrition-related outcomes in maintenance hemodialysis patients (MHD). DESIGN AND SETTING This was a longitudinal, observational study conducted at 4 dialysis centers in western Massachusetts. Patients were followed for 6 months after change in bicarbonate dose protocol. PATIENTS The study sample consisted of 248 patients who had been on MHD for at least 1 year on the standard bicarbonate dialysate of 35 mmol/L without oral bicarbonate supplements. MAIN OUTCOME MEASURES Measures of interest included predialysis serum bicarbonate, albumin, hemoglobin, potassium, phosphorus, calcium, and parathyroid hormone (iPTH), as well as protein catabolic rate (nPCR). A subset of patients (n = 35) was examined for changes via Subjective Global Assessment (SGA). RESULTS Serum bicarbonate improved significantly from baseline (21.7 +/- 2.8 mmol/L; mean +/- SD) at 3 months (23.3 +/- 3.3) and 6 months (23.1 +/- 3.3) (P <.0001). Phosphorus decreased from 6.0 +/- 2.0 mmol/L at baseline to 5.7 +/- 1.7 mmol/L (P =.02) at 6 months, although calcium, iPTH, and potassium remained relatively stable. Serum bicarbonate was inversely and significantly correlated with nPCR at baseline (r = -0.23; P <.05) and 3 months (r = -0.22; P <.05). The nPCR decreased significantly (P =.001) from baseline (0.99 +/- 0.26) at 6 months (0.93 +/- 0.23), whereas the serum albumin and SGA scores did not differ. CONCLUSION Increasing delivered bicarbonate dose improves serum bicarbonate and may decrease catabolism. Further study is needed to confirm the potential nutritional benefits.
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Affiliation(s)
- Debra Blair
- Renal Dietitian, Fresenius Medical Care-Western Mass. Kidney Center, Springfield, MA 01103, USA
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Kovacic V, Roguljic L, Kovacic V. Metabolic acidosis of chronically hemodialyzed patients. Am J Nephrol 2003; 23:158-64. [PMID: 12649614 DOI: 10.1159/000070205] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2003] [Accepted: 02/20/2003] [Indexed: 11/19/2022]
Abstract
Metabolic acidosis is a condition that is commonly encountered in both chronic renal failure and in end-stage renal disease. Metabolic acidosis is associated with many adverse effects: negative nitrogen balance, increased protein decomposition, anorexia, fatigue, bone lesions, impaired function of the cardiovascular system, impaired function of the gastrointestinal system, hormonal disturbances, insulin resistance, hyperkalemia, altered gluconeogenesis and triglyceride metabolism, increased progression of chronic renal failure, and growth retardation in children. Even 'minor' degrees of metabolic acidosis are deleterious. Metabolic acidosis of end-stage renal patients could be successfully corrected with bicarbonate hemodialysis and with peroral bicarbonate-containing phosphate binders, i.e. calcium carbonate. Bicarbonate powder compared with bicarbonate solutions has some advantages and enables a stabile composition of electrolytes. 'High' dialysate bicarbonate (40- 42 mmol/l) is a safe, well-tolerated and useful tool for better correction of the metabolic acidosis and must become a standard of hemodialysis treatment. Measured postdialysis blood bicarbonate concentration should be obtained at least every month and correction of metabolic acidosis by maintaining serum bicarbonate >or=22 mmol/l should be a goal of the management of patients undergoing chronic hemodialysis.
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Stabellini G, Calastrini C, Pezzetti F, DeMattei M, Dellavia C, Moscheni C, Pellati A, Bedani P, Vertemati M, Bodo-Lumare M. Chick embryo back skin organ and fibroblast cultures. Extracellular matrix changes induced by dialysate fluid and uraemic toxins in relation to proliferation and differentiation processes. Pathology 2003. [DOI: 10.1080/0031302031000123218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lopez I, Aguilera-Tejero E, Felsenfeld AJ, Estepa JC, Rodriguez M. Direct effect of acute metabolic and respiratory acidosis on parathyroid hormone secretion in the dog. J Bone Miner Res 2002; 17:1691-700. [PMID: 12211440 DOI: 10.1359/jbmr.2002.17.9.1691] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Because both metabolic (Met Acid) and respiratory acidosis (Resp Acid) have diverse effects on mineral metabolism, it has been difficult to establish whether acidosis directly affects parathyroid hormone (PTH) secretion. Our goal was to determine whether acute Met Acid and Resp Acid directly affected PTH secretion. Three groups of dogs were studied: control, acute Met Acid induced by HCl infusion, and acute Resp Acid induced by hypoventilation. EDTA was infused to prevent acidosis-induced increases in ionized calcium, but more EDTA was needed in Met Acid than in Resp Acid. The PTH response to EDTA-induced hypocalcemia was evaluated also. Magnesium needed to be infused in groups receiving EDTA to prevent hypomagnesemia. The half-life of intact PTH (iPTH) was determined during hypocalcemia when PTH was measured after parathyroidectomy. During normocalcemia, PTH values were greater (p < 0.05) in Met Acid (92 +/- 19 pg/ml) and Resp Acid (77 +/- 22 pg/ml) than in controls (27 +/- 5 pg/ml); the respective pH values were 7.23 +/- 0.01, 7.24 +/- 0.01, and 7.39 +/- 0.02. The maximal PTH response to hypocalcemia was greater (p < 0.05) in Met Acid (443 +/- 54 pg/ml) than in Resp Acid (267 +/- 37 pg/ml) and controls (262 +/- 48 pg/ml). The half-life of PTH was greater (p < 0.05) in Met Acid than in controls, but the PTH secretion rate also was greater (p < 0.05) in Met Acid than in the other two groups. In conclusion, (1) both acute Met Acid and Resp Acid increase PTH secretion when the ionized calcium concentration is normal; (2) acute Met Acid may increase the bone efflux of calcium more than Resp Acid; (3) acute Met Acid acts as a secretogogue for PTH secretion because it enhances the maximal PTH response to hypocalcemia.
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Affiliation(s)
- Ignacio Lopez
- Departamento de Medicina y Cirugía Animal, Universidad de Córdoba, Spain
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Abstract
There are a number of pathologies that are associated with the development of renal failure. Once renal function has deteriorated beyond a point where life is not sustainable without dialysis, new sets of pathologic processes develop. These are, in part, related to the continuation of poor renal function and to the process of dialysis itself. This article addresses the processes that are believed to be due to dialysis, among which are disorders of bone, deposition of metals and amyloid within a number of tissues, and local problems such as inflammation and tumors related to the dialysis site.
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Affiliation(s)
- A J Freemont
- Department of Osteoarticular Pathology, The Medical School, University of Manchester, United Kingdom.
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Abstract
Severe acidemia (blood pH < 7.1 to 7.2) suppresses myocardial contractility, predisposes to cardiac arrhythmias, causes venoconstriction, and can decrease total peripheral vascular resistance and blood pressure, reduce hepatic blood flow, and impair oxygen delivery. These alterations in organ function can contribute to increased morbidity and mortality. Although it seemed logical to administer sodium bicarbonate to attenuate acidemia and therefore lessen the impact on cardiac function, the routine use of bicarbonate in the treatment of the most common causes of severe acidemia, diabetic ketoacidosis, lactic acidosis, and cardiac arrest, has been an issue of great controversy. Studies of animals and patients with these disorders have reported conflicting data on the benefits of bicarbonate, showing both beneficial and detrimental effects. Alternative alkalinizing agents, tris-hydroxymethyl aminomethane and Carbicarb, have shown some promise in studies of animals and humans, and reevaluation of these buffers in the treatment of severe acidemic states seems warranted. The potential value of base therapy in the treatment of severe acidemia remains an important issue, and further studies are required to determine which patients should be administered base therapy and what base should be used.
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Affiliation(s)
- J A Kraut
- Division of Nephrology, Veterans Administration Greater Los Angeles Health Care System, Los Angeles, CA 90073, USA.
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