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Hsu SN, Stephen LA, Dillon S, Milne E, Javaheri B, Pitsillides AA, Novak A, Millán JL, MacRae VE, Staines KA, Farquharson C. Increased PHOSPHO1 expression mediates cortical bone mineral density in renal osteodystrophy. J Endocrinol 2022; 254:153-167. [PMID: 35900032 PMCID: PMC9422252 DOI: 10.1530/joe-22-0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/25/2022] [Indexed: 11/08/2022]
Abstract
Patients with advanced chronic kidney disease (CKD) often present with skeletal abnormalities, a condition known as renal osteodystrophy (ROD). While tissue non-specific alkaline phosphatase (TNAP) and PHOSPHO1 are critical for bone mineralization, their role in the etiology of ROD is unclear. To address this, ROD was induced in both WT and Phospho1 knockout (P1KO) mice through dietary adenine supplementation. The mice presented with hyperphosphatemia, hyperparathyroidism, and elevated levels of FGF23 and bone turnover markers. In particular, we noted that in CKD mice, bone mineral density (BMD) was increased in cortical bone (P < 0.05) but decreased in trabecular bone (P < 0.05). These changes were accompanied by decreased TNAP (P < 0.01) and increased PHOSPHO1 (P < 0.001) expression in WT CKD bones. In P1KO CKD mice, the cortical BMD phenotype was rescued, suggesting that the increased cortical BMD of CKD mice was driven by increased PHOSPHO1 expression. Other structural parameters were also improved in P1KO CKD mice. We further investigated the driver of the mineralization defects, by studying the effects of FGF23, PTH, and phosphate administration on PHOSPHO1 and TNAP expression by primary murine osteoblasts. We found both PHOSPHO1 and TNAP expressions to be downregulated in response to phosphate and PTH. The in vitro data suggest that the TNAP reduction in CKD-MBD is driven by the hyperphosphatemia and/or hyperparathyroidism noted in these mice, while the higher PHOSPHO1 expression may be a compensatory mechanism. Increased PHOSPHO1 expression in ROD may contribute to the disordered skeletal mineralization characteristic of this progressive disorder.
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Affiliation(s)
- Shun-Neng Hsu
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian, UK
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Louise A Stephen
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian, UK
| | - Scott Dillon
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian, UK
| | - Elspeth Milne
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian, UK
| | - Behzad Javaheri
- Comparative Biomedical Sciences, The Royal Veterinary College, London, UK
| | | | - Amanda Novak
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian, UK
| | - Jose Luis Millán
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California, USA
| | - Vicky E MacRae
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian, UK
| | - Katherine A Staines
- Centre for Stress and Age-Related Disease, University of Brighton, Brighton, UK
| | - Colin Farquharson
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian, UK
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Sobh MM, Abdalbary M, Elnagar S, Nagy E, Elshabrawy N, Abdelsalam M, Asadipooya K, El-Husseini A. Secondary Osteoporosis and Metabolic Bone Diseases. J Clin Med 2022; 11:jcm11092382. [PMID: 35566509 PMCID: PMC9102221 DOI: 10.3390/jcm11092382] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/17/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023] Open
Abstract
Fragility fracture is a worldwide problem and a main cause of disability and impaired quality of life. It is primarily caused by osteoporosis, characterized by impaired bone quantity and or quality. Proper diagnosis of osteoporosis is essential for prevention of fragility fractures. Osteoporosis can be primary in postmenopausal women because of estrogen deficiency. Secondary forms of osteoporosis are not uncommon in both men and women. Most systemic illnesses and organ dysfunction can lead to osteoporosis. The kidney plays a crucial role in maintaining physiological bone homeostasis by controlling minerals, electrolytes, acid-base, vitamin D and parathyroid function. Chronic kidney disease with its uremic milieu disturbs this balance, leading to renal osteodystrophy. Diabetes mellitus represents the most common secondary cause of osteoporosis. Thyroid and parathyroid disorders can dysregulate the osteoblast/osteoclast functions. Gastrointestinal disorders, malnutrition and malabsorption can result in mineral and vitamin D deficiencies and bone loss. Patients with chronic liver disease have a higher risk of fracture due to hepatic osteodystrophy. Proinflammatory cytokines in infectious, autoimmune, and hematological disorders can stimulate osteoclastogenesis, leading to osteoporosis. Moreover, drug-induced osteoporosis is not uncommon. In this review, we focus on causes, pathogenesis, and management of secondary osteoporosis.
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Affiliation(s)
- Mahmoud M. Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Mohamed Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40506, USA
| | - Sherouk Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Eman Nagy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Nehal Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Mostafa Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Kamyar Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, KY 40506, USA;
| | - Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40506, USA
- Correspondence: ; Tel.: +1-859-218-0934
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Inaba M, Une Y, Ikejiri K, Kanda H, Fukagawa M, Akizawa T. Dose-Response of Tenapanor in Patients With Hyperphosphatemia Undergoing Hemodialysis in Japan—a Phase 2 Randomized Trial. Kidney Int Rep 2021; 7:177-188. [PMID: 35155857 PMCID: PMC8820999 DOI: 10.1016/j.ekir.2021.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 11/03/2021] [Accepted: 11/08/2021] [Indexed: 12/18/2022] Open
Abstract
Introduction Simplified, but effective, hyperphosphatemia treatments with novel mechanisms of action, tolerable safety profiles, and low pill burden are needed for patients undergoing hemodialysis. Tenapanor is a calcium (Ca)-free, nonmetal, nonpolymeric drug that reduces phosphate absorption by selectively inhibiting intestinal sodium-hydrogen exchanger 3. As the serum phosphorus (P) level-lowering effect of tenapanor has not been evaluated in Japanese patients with hyperphosphatemia undergoing hemodialysis, we evaluated its efficacy and safety in this population. Methods This was a multicenter, phase 2, double-blind, placebo-controlled, parallel-group, dose-finding study. Change in serum P level from baseline at week 6 was the primary end point. Results Overall, 207 patients were randomized to 5 groups (placebo [n = 41] and tenapanor 5-mg taken twice daily [BID] [n = 42], 10-mg BID [n = 41], 30-mg BID [n = 42], and 30-mg BID dose-titration [n = 41]) and treated for 6 weeks. Mean changes from baseline at week 6 in serum P level were 0.64, −0.93, −1.36, −1.92, and −1.99 mg/dl in the placebo and tenapanor groups, respectively. Serum P level was significantly decreased from baseline in all tenapanor groups compared with placebo (P < 0.001, for each dose). Diarrhea was the most frequent drug-related adverse event (AE) with an incidence of 9.8%, 50.0%, 65.9%, 76.2%, and 65.9% in the respective placebo and tenapanor groups. Conclusion In Japanese patients undergoing hemodialysis, tenapanor was found to have a dose-responsive, serum P level-lowering effect. Diarrhea was the most frequent drug-related AE; most cases were mild and generally tolerable. Tenapanor may become a first-in-class therapeutic agent for patients with hyperphosphatemia.
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Bone Mineral Density and Aortic Calcification: Evidence for a Bone-vascular Axis After Kidney Transplantation. Transplantation 2021; 105:231-239. [PMID: 32568501 DOI: 10.1097/tp.0000000000003226] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic kidney disease mineral and bone disorders (CKD-MBD) and vascular calcification are often seen in kidney transplantation recipients (KTR). This study focused on the bone-vascular axis hypothesis, the pathophysiological mechanisms driving both bone loss and vascular calcification, supported by an association between lower bone mineral density (BMD) and higher risk of vascular calcification. METHODS KTR referred for a dual-energy X-ray absorptiometry procedure within 6 mo after transplantation were included in a cross-sectional study (2004-2014). Areal BMD was measured at the proximal femur, and abdominal aortic calcification (AAC) was quantified (8-points score) from lateral single-energy images of the lumbar spine. Patients were divided into 3 AAC categories (negative-AAC: AAC 0; low-AAC: AAC 1-3; and high-AAC: AAC 4-8). Multivariable-adjusted multinomial logistic regression models were performed to study the association between BMD and AAC. RESULTS We included 678 KTR (51 ± 13 y old, 58% males), 366 (54%) had BMD disorders, and 266 (39%) had detectable calcification. High-AAC was observed in 9%, 11%, and 25% of KTR with normal BMD, osteopenia, and osteoporosis, respectively (P < 0.001). Higher BMD (T-score, continuous) was associated with a lower risk of high-AAC (odds ratio 0.61, 95% confidence interval 0.42-0.88; P = 0.008), independent of age, sex, body mass index, estimated glomerular filtration rate, and immunosuppressive therapy. KTR with normal BMD were less likely to have high-AAC (odds ratio 0.24, 95% confidence interval 0.08-0.72; P = 0.01). CONCLUSIONS BMD disorders are highly prevalent in KTR. The independent inverse association between BMD and AAC may provide evidence to point toward the existence, while highlighting the clinical and epidemiological relevance, of a bone-vascular axis after kidney transplantation.
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The Influence of Dietary Interventions on Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Nutrients 2021; 13:nu13062065. [PMID: 34208727 PMCID: PMC8235119 DOI: 10.3390/nu13062065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease is a health problem whose prevalence is increasing worldwide. The kidney plays an important role in the metabolism of minerals and bone health and therefore, even at the early stages of CKD, disturbances in bone metabolism are observed. In the course of CKD, various bone turnover or mineralization disturbances can develop including adynamic hyperparathyroid, mixed renal bone disease, osteomalacia. The increased risk of fragility fractures is present at any age in these patients. Nutritional treatment of patients with advanced stages of CKD is aiming at prevention or correction of signs, symptoms of renal failure, avoidance of protein-energy wasting (PEW), delaying or prevention of the occurrence of mineral/bone disturbances, and delaying the start of dialysis. The results of studies suggest that progressive protein restriction is beneficial with the progression of renal insufficiency; however, other aspects of dietary management of CKD patients, including changes in sodium, phosphorus, and energy intake, as well as the source of protein and lipids (animal or plant origin) should also be considered carefully. Energy intake must cover patients' energy requirement, in order to enable correct metabolic adaptation in the course of protein-restricted regimens and prevent negative nitrogen balance and protein-energy wasting.
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Bushinsky DA, Chertow GM, Cheng S, Deng H, Kopyt N, Martin KJ, Rastogi A, Ureña-Torres P, Vervloet M, Block GA. One-year safety and efficacy of intravenous etelcalcetide in patients on hemodialysis with secondary hyperparathyroidism. Nephrol Dial Transplant 2020; 35:1769-1778. [PMID: 30859218 PMCID: PMC7538239 DOI: 10.1093/ndt/gfz039] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 01/21/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Secondary hyperparathyroidism (sHPT), a common complication of chronic kidney disease, is characterized by elevated serum parathyroid hormone (PTH). Etelcalcetide is an intravenous calcimimetic that increases sensitivity of the calcium-sensing receptor to calcium and decreases PTH secretion. This open-label extension (OLE) trial evaluated the long-term effects of etelcalcetide for sHPT treatment in patients receiving hemodialysis. METHODS This 52-week, multicenter, single-arm OLE enrolled patients from three parent trials: two randomized, double-blind, placebo-controlled trials and one open-label, single-arm, 'switch' study from cinacalcet to etelcalcetide. The primary endpoint was to investigate the nature, frequency, severity and relation to treatment of all adverse events (AEs) reported throughout the trial. Secondary endpoints included the proportion of patients with >30% reduction from baseline in PTH and the percentage change from baseline in PTH, albumin-corrected calcium (Ca), phosphate (P) and the calcium-phosphate product (Ca × P).ClinicalTrials.gov identifier: NCT01785875; Amgen study: 20120231. RESULTS Overall, 89.8% of the patients experienced one or more treatment-emergent AE. The most common were decreased blood Ca (43.3%), diarrhea (10.8%), vomiting (10.4%) and nausea (9.6%); symptomatic hypocalcemia occurred in 3.7% of the patients. Approximately 68% of patients achieved >30% reduction in PTH, and ∼56% achieved PTH ≤300 pg/mL. Mean percent changes from baseline ranged from -25.4% to -26.1% for PTH, -8.3% to -9.1% for Ca, -3.6% to -4.1% for P and -12.0% to -12.6% for Ca × P. CONCLUSIONS Etelcalcetide effectively lowered PTH and its effect was sustained, while no new safety concerns emerged over a 1-year treatment period.
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Affiliation(s)
- David A Bushinsky
- Department of Medicine, Division of Nephrology, University of Rochester School of Medicine, Rochester, NY, USA
| | - Glenn M Chertow
- Department of Medicine, Division of Nephrology, Stanford University, Stanford, CA, USA
| | - Sunfa Cheng
- Clinical Development, Amgen Inc., Thousand Oaks, CA, USA
| | - Hongjie Deng
- Biostatistics, Amgen Inc., Thousand Oaks, CA, USA
| | - Nelson Kopyt
- Department of Medicine, Division of Nephrology, Lehigh Valley Hospital, Allentown, PA, USA
| | - Kevin J Martin
- Department of Internal Medicine, Division of Nephrology, Saint Louis University School of Medicine, St Louis, MO, USA
| | - Anjay Rastogi
- Department of Medicine, Division of Nephrology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Pablo Ureña-Torres
- Department of Nephrology and Dialysis, Ramsay-Générale de Santé, Clinique du Landy, Saint Ouen, France and Necker Hospital, University of Paris Descartes, Paris, France
| | - Marc Vervloet
- Department of Nephrology and Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, The Netherlands
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Potential protective effect of leptin and uncoupling protein-2 genes polymorphism in Egyptian patients with chronic kidney disease. Int Urol Nephrol 2020; 52:2153-2160. [PMID: 32720029 DOI: 10.1007/s11255-020-02567-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Kidney disease is a serious public health problem worldwide. It is the fifth top-ranking cause of death in Egypt, causing approximately 3.98% of all deaths. This study's objective was to examine whether an association exists between leptin (- 2548G/A) and uncoupling protein-2 45 bp I/D genes, individually and collectively, in CKD and progression to ESRD. METHODS One hundred patients (69 males, 31 females) aged (47.1 ± 16.11 years) with ESRD, 40 patients (19 males, 21 females) aged (43.15 ± 10.00 years with CKD, and 50 healthy controls (23 males, 27 females) aged (37.84 ± 1.95 years) were enrolled. Polymerase chain reaction (PCR) was employed to measure variation in gene expression among the study groups. The frequency of single nucleotide polymorphisms (SNP) genotypes were identified in controls, CKD and ESRD patients. RESULTS Leptin genotypes were associated with lower CKD incidence in control versus study subjects (95% CI = (0.08-0.63), P = 0.01) with risk value equal to 0.22 < 1, G/A genotype was significantly lower in CKD than ESRD groups. There was no correlation between UCP-2 I/D genotype and CKD (P = 0.27). There was no correlation between the UCP-2 gene and the progression to ESRD. CONCLUSIONS This study suggests that, Leptin - 2548G/A gene may be a promising marker for early detection of ESRD in Egyptian patients. G/A genotype might inhibit the development of CKD to ESRD.
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Waziri B, Duarte R, Naicker S. Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD): Current Perspectives. Int J Nephrol Renovasc Dis 2019; 12:263-276. [PMID: 31920363 PMCID: PMC6935280 DOI: 10.2147/ijnrd.s191156] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/13/2019] [Indexed: 02/06/2023] Open
Abstract
Despite the availability of global and regional guidelines to curtail the adverse clinical outcomes associated with chronic kidney disease–mineral and bone disorder (CKD-MBD), most CKD patients are still affected by the consequences of abnormalities of CKD-MBD. This important clinical complication of CKD continues to be studied, in order to improve the understanding and management of CKD-MBD. Some notable discoveries include the role of fibroblast growth factor 23 (FGF23) in the pathogenesis of CKD-MBD, leading to a shift from the previous well-established classic trade-off hypothesis to the updated trade-off hypothesis. More recently, there has been a shift from the treatment of CKD-MBD based on a single level of biomarkers to serial measurements of calcium, phosphate and parathyroid hormone (PTH). Furthermore, some clinical trials have emerged after the 2009 Kidney Disease-Improving Global Outcomes (KDIGO) Guidelines, leading to the 2017 KDIGO updated recommendations. Hence, this review gives an overview of the rapidly evolving trends in CKD-MBD, linking the past and current concepts of CKD-MBD.
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Affiliation(s)
- Bala Waziri
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Medicine, Ibrahim Badamasi Babangida Specialist Hospital, Minna, Nigeria
| | - Raquel Duarte
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Saraladevi Naicker
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Li C, Chen XM, Li Y, Zhou YL, Yan JN, Du XG. Factors and Outcome of Renal Osteodystrophy-Associated Initial Fragility Fracture in End-Stage Renal Disease Patients. KIDNEY DISEASES (BASEL, SWITZERLAND) 2019; 5:118-125. [PMID: 31019925 DOI: 10.1159/000494924] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 10/29/2018] [Indexed: 01/09/2023]
Abstract
Background Renal osteodystrophy has caused increased risk of fragility fracture in end-stage renal disease (ESRD) patients. However, risk factors and outcome of ESRD patients with fragility fracture remain uncharacterized. We aimed to assess these parameters in ESRD patients. Summary This retrospective case-control study analyzed 354 ESRD patients (initial fragility fracture [FF] group, n = 59; control group, n = 295). Pre-dialysis blood hemoglobin, serum albumin, lipid, calcium, phosphorus, alkaline phosphatase (ALP), and intact parathyroid hormone (iPTH) were collected. All procedures performed involving human participants were in accordance with the ethical standards of the institutional committee of The First Affiliated Hospital of Chongqing Medical University (IRB approval number 216-82), and informed consent was obtained from all participants. There were higher prevalence rates of primary hypertension and diabetes, higher serum ALP, corrected calcium, and lower serum total cholesterol, low-density lipoprotein, lipoprotein-α, and iPTH in the FF group. Fractures were more likely to occur in the higher level of corrected calcium as well as in the lower iPTH group. High corrected calcium (p = 0.010, OR = 11.308, 95% CI: 1.770-72.242) and serum ALP (p = 0.000, OR = 1.007, 95% CI: 1.004-1.011) were independent risk factors of fragility fracture. The incidence of all-cause mortality and cardiovascular (CV) events in ESRD patients with fragility fracture was higher than in those without fracture. Key Messages Patients with hypertension, diabetes, excessive suppression of PTH, and poor nutritional status are more prone to fractures. Serum corrected calcium and ALP were independent risk factors of fragility fracture. Patients with initial fragility fracture had more CV events and higher mortality.
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Affiliation(s)
- Cai Li
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xue-Mei Chen
- Emergency Department, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yin Li
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of Nephrology and Endocrinology, The People's Hospital of Tongliang District, Chongqing, China
| | - Yan-Lin Zhou
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jia-Ni Yan
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Gang Du
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Beto J, Bhatt N, Gerbeling T, Patel C, Drayer D. Overview of the 2017 KDIGO CKD-MBD Update: Practice Implications for Adult Hemodialysis Patients. J Ren Nutr 2018; 29:2-15. [PMID: 30150095 DOI: 10.1053/j.jrn.2018.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/06/2018] [Accepted: 05/25/2018] [Indexed: 01/10/2023] Open
Abstract
Renal dietitians play a pivotal role in the ongoing management of chronic kidney disease in patients on hemodialysis. Awareness of changes to clinical practice guidelines that may impact laboratory parameters associated with chronic kidney disease-mineral and bone disorder is important for optimal patient care. In this article, the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update recommendations related to the treatment of secondary hyperparathyroidism in adults on hemodialysis are reviewed and treatment implications for renal dietitians discussed. Specific attention is given to the integration of updated recommendations such as the use of calcimimetics as part of a combination approach to the existing treatment paradigm. Renal dietitians can directly apply the updated clinical recommendations in the evaluation of diet composition; food additives; medication adherence challenges with phosphate binder type and use and serial monitoring of phosphorus, calcium, and parathyroid hormone levels to inform clinical decisions on treatment options for patients.
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Affiliation(s)
- Judith Beto
- Research Associate, Division of Nephrology and Hypertension, Loyola University of Chicago, Maywood, Illinois.
| | - Nisha Bhatt
- US Medical Leader Nephrology, Medical Affairs, Amgen Inc., Thousand Oaks, California
| | - Teresa Gerbeling
- Renal Dietitian Coordinator, Dialysis Center of Lincoln, Lincoln, Nebraska
| | - Chhaya Patel
- Nutrition Program Manager, Divisional Lead RD, ORCA Division, DaVita Inc., Denver, Colorado
| | - Debra Drayer
- Senior Regional Medical Liaison Nephrology, Amgen Inc., Thousand Oaks, California
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Estrogen Deficiency Leads to Further Bone Loss in the Mandible of CKD Mice. PLoS One 2016; 11:e0148804. [PMID: 26886008 PMCID: PMC4757532 DOI: 10.1371/journal.pone.0148804] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 01/22/2016] [Indexed: 02/05/2023] Open
Abstract
Background Chronic kidney disease (CKD) has been regarded as a grave public health problem. Estrogen is a critical factor for both renal protection and bone remodeling. Our previous study demonstrated that CKD impairs the healing of titanium implants. The aim of this study was to investigate the effects of estrogen deficiency on the mandibular bone in CKD mice. Methods Forty eleven-week-old female C57BL mice were used in this study. Uremia and estrogen deficiency were induced by 5/6 nephrectomy and ovariectomy (OVX), respectively. After 8 weeks, the mice were sacrificed, and their mandibles were collected for micro-CT analysis and histological examination. Results All the mice survived the experimental period. Serum measurements confirmed a significant increase in BUN in the CKD group that was further increased by OVX. OVX led to significant decreases in both the BV/TV and cortical thickness of the mandibular bone in CKD mice. Conclusion In summary, our findings indicate that estrogen deficiency leads to further mandibular bone loss in CKD mice.
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Pavlov SB, Kumechko MV, Litvinova OB, Babenko NM, Goncharova AV. BONE REGULATORY MECHANISMS DESTRUCTION IN EXPERIMENTAL CHRONIC KIDNEY DISEASE. ACTA ACUST UNITED AC 2016; 62:54-9. [PMID: 29569886 DOI: 10.15407/fz62.03.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of our study was to investigate the role of intercellular
mediators – interleukin-1 receptor antagonist (IL-1 RA),
interleukin-17 (IL-17), receptor activator of nuclear factor kB
ligand (RANKL) and osteoprotegerin in the mechanisms of
metabolic regulation of renal and bone tissue on model of violations
of bone remodeling in chronic kidney disease (CKD).
It was found a significant increase in the content of cytokines
IL-1 RA (4,207 ± 0,546 pg/ml), IL-17 (33,944 ± 0,938 pg/
ml), osteoprotegerin (28,338 ± 1,223 pg/ml) and RANKL
(0,184 ± 0,018 pmol/l) in the serum of animals in violation
of bone remodeling in CKD compared with the contents of
the studied cytokines in animals in the control group (2,529
± 0,132 pg/ml, 28,166 ± 0,526 pg/ml, 21,588 ± 0,763 pg/ml
and 0,131 ± 0,006 pmol/l, respectively) (P<0.05). The obtained
correlations reflect the relationship between regulation of bone
remodeling and the development of inflammation in CKD.
The imbalance between pro- and anti-inflammatory cytokine
plays an important role both in the development of CKD and
in processes of bone remodeling.
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Zhang S, Guo Y, Zou H, Sun N, Zhao D, Liu W, Dong Y, Cheng G, Yuan Q. Effect of estrogen deficiency on the fixation of titanium implants in chronic kidney disease mice. Osteoporos Int 2015; 26:1073-80. [PMID: 25366374 DOI: 10.1007/s00198-014-2952-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 10/27/2014] [Indexed: 02/05/2023]
Abstract
UNLABELLED We established a chronic kidney disease (CKD) mouse model with estrogen deficiency and inserted titanium implants into the femur of such mice to investigate the fixation of the implants. Both the histomorphometry and implant resistance indicated that estrogen deficiency impaired the fixation of titanium implants inserted into such mice. INTRODUCTION CKD has been regarded as a worldwide public health problem. Estrogen is a critical factor for both renal protection and bone remodeling. A previous study demonstrated that CKD impairs the early healing of titanium implants. However, the combined effect of estrogen deficiency and CKD on the fixation of titanium implants is largely unknown. METHODS Forty 9-week-old female C57BL mice were randomly divided into sham, ovariectomy (OVX), CKD, and CKD + OVX groups. Uremia and estrogen deficiency were induced by 5/6 nephrectomy and OVX, respectively. Experimental titanium implants were inserted into the distal end of the femur. Bone-implant contact (BIC) ratio and bone volume (BV/TV) around the implants were histomorphometrically analyzed. The fixation strength of the implant was measured by a biomechanical push-in resistance test. RESULTS Serum measurement confirmed a significant increase in serum blood urea nitrogen (BUN) in the CKD group, which was further increased by OVX. Estrogen deficiency led to significant decreases in the BIC ratio, BV/TV, and the push-in resistance in CKD animals. There was a significant interaction between the effects of OVX and CKD, with OVX exacerbating the effects of CKD on BIC ratio and push-in resistance. CONCLUSIONS The results indicated that estrogen deficiency exerts a synergistic effect with CKD and further impairs the fixation of titanium implants in CKD mice.
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Affiliation(s)
- S Zhang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, 14 Third Section, Renmin Nan Road, 610041, Chengdu, China
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Alharthi AA, Kamal NM, Abukhatwah MW, Sherief LM. Cinacalcet in pediatric and adolescent chronic kidney disease: a single-center experience. Medicine (Baltimore) 2015; 94:e401. [PMID: 25590845 PMCID: PMC4602555 DOI: 10.1097/md.0000000000000401] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Cinacalcet, a calcimimetic drug, has been shown to be efficacious in adult chronic kidney disease (CKD) patients; however, it was not fully studied in pediatric CKD patients. We aimed at assessing the effect of cinacalcet on intact parathyroid hormone (iPTH) secretion in children with CKD-4/5 with iPTH consistently ≥ 300 pg/mL refractory to conventional treatment. This is a prospective cohort analysis of 28 children with uncontrolled hyper-parathyroidism secondary to stage 4 and 5 CKD admitted to a tertiary center during the period from April 2012 to April 2014. Twenty-eight patients with CKD-4/5 were assessed prospectively regarding bone biochemistry, renal ultrasonography, serum iPTH level, and medications. Patients were classified into 3 groups: group 1, 6 patients with CKD-4 on supplemental and supportive therapy; group 2, 6 patients with CKD-5 on hemodialysis and; group 3, 16 patients with CKD-5 on automated peritoneal dialysis. Patients were between the ages of 9 months and 18 years on commencing cinacalcet at doses of 0.5 to 1.5 mg/kg. All patients showed at least a 60% reduction in iPTH (60%-97%). Highly significant reduction in iPTH and serum alkaline phosphatase levels was detected post-cinacalcet. The serum calcium (Ca), phosphate (P), and Ca × P product were unaffected. Treatment was well tolerated with no hypophosphatemia, hypocalcemia, or other adverse effects almost in all patients. Cinacalcet use was proven safe for all pediatric and adolescent patients with CKD-4/5 during the study period, and at the same time most of the patients reached the suggested iPTH target values.
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Affiliation(s)
- Abdulla A Alharthi
- From the Faculty of Medicine, Taif University, Al Hada Armed Forces Hospital, Taif, KSA (AAA); Faculty of Medicine, Cairo University, Cairo, Egypt, Al Hada Armed Forces Hospital, Taif, KSA (NMK); Al Hada Armed Forces Hospital, Taif, KSA (MWA); and Faculty of Medicine, Zagazig University, Egypt (LMS)
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Osorio A, Ortega E, Torres JM, Sanchez P, Ruiz-Requena E. Mineral-bone metabolism markers in young hemodialysis patients. Clin Biochem 2011; 44:1425-8. [DOI: 10.1016/j.clinbiochem.2011.08.1143] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 07/28/2011] [Accepted: 08/28/2011] [Indexed: 10/17/2022]
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Abstract
PURPOSE OF REVIEW Renal osteodystrophy is a complex disorder of bone associated with chronic kidney disease (CKD). Disturbances in mineral metabolism, which include, phosphate retention, hypocalcemia, vitamin D deficiency, and hyperparathyroidism develop early in the progression of CKD. The Kidney Disease: Improving Global Outcomes (KDIGO) has proposed a new classification system to understand the complex pathophysiology in mineral metabolism and bone disease. Understanding this pathophysiology has become especially important, as recent evidence has suggested that disordered mineral metabolism is associated with increased cardiovascular mortality and morbidity in patients with CKD. RECENT FINDINGS This review discusses the effect of these disturbances on the skeleton and how they result in altered bone structure and turnover. The degree of hyperparathyroidism appears to affect bone turnover; however, bone biopsies appear to be the only definitive method to specifically diagnose the bone lesion. SUMMARY This review will assist the clinician in the early identification of patients at risk of renal osteodystrophy. Therapeutic strategies could then be employed to prevent and correct these disturbances in mineral metabolism and, thus, avoid patient morbidity.
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Affiliation(s)
- Stuart M Sprague
- NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, Illinois, USA.
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Isaksson H, Turunen MJ, Rieppo L, Saarakkala S, Tamminen IS, Rieppo J, Kröger H, Jurvelin JS. Infrared spectroscopy indicates altered bone turnover and remodeling activity in renal osteodystrophy. J Bone Miner Res 2010; 25:1360-6. [PMID: 20200925 DOI: 10.1002/jbmr.10] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Renal osteodystrophy alters metabolic activity and remodeling rate of bone and also may lead to different bone composition. The objective of this study was to characterize the composition of bone in high-turnover renal osteodystrophy patients by means of Fourier transform infrared spectroscopic imaging (FTIRI). Iliac crest biopsies from healthy bone (n = 11) and patients with renal osteodystrophy (ROD, n = 11) were used in this study. The ROD samples were from patients with hyperparathyroid disease. By using FTIRI, phosphate-to-amide I ratio (mineral-to-matrix ratio), carbonate-to-phosphate ratio, and carbonate-to-amide I ratio (turnover rate/remodeling activity), as well as the collagen cross-link ratio (collagen maturity), were quantified. Histomorphometric analyses were conducted for comparison. The ROD samples showed significantly lower carbonate-to-phosphate (p < .01) and carbonate-to-amide I (p < .001) ratios. The spatial variation across the trabeculae highlighted a significantly lower degree of mineralization (p < .05) at the edges of the trabeculae in the ROD samples than in normal bone. Statistically significant linear correlations were found between histomorphometric parameters related to bone-remodeling activity and number of bone cells and FTIRI-calculated parameters based on carbonate-to-phosphate and carbonate-to-amide I ratios. Hence the results suggested that FTIRI parameters related to carbonate may be indicative of turnover and remodeling rate of bone.
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Affiliation(s)
- Hanna Isaksson
- Department of Physics and Mathematics, University of Eastern Finland, Kuopio, Finland.
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Mahan JD, Ferris ME. Case-Based Education at the 2009 Pediatric Nephrology Fellows Conference. Ren Fail 2010; 32:14-20. [DOI: 10.3109/08860220903474428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John D. Mahan
- Pediatric Residency Program/Pediatric Nephrology Fellowship Program, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Maria E. Ferris
- Department of Pediatrics/Renal Replacement Therapies Program, University of North Caroline School of Medicine, Chapel Hill, North Carolina, USA
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Abstract
Chronic kidney disease (CKD) is a complex disease affecting more than 20 million individuals in the United States. Progression of CKD is associated with a number of serious complications, including increased incidence of cardiovascular disease, hyperlipidemia, anemia, and metabolic bone disease. CKD patients should be assessed for the presence of these complications and receive optimal treatment to reduce their morbidity and mortality. A multidisciplinary approach is required to accomplish this goal.
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Abstract
Calcimimetics reduce serum levels of parathyroid hormone (PTH) and calcium, with a leftward shift in the set-point for calcium-regulated PTH secretion. The aim of this publication is to review the data available for calcimimetics in primary, secondary and tertiary hyperparathyroidism (HPT). Parathyroidectomy (PTX) is currently the only curative treatment for primary HPT, and recommended for patients with moderate-to-severe disease, as defined by a 2002 National Institute's of Health summary statement. In general, patients with primary HPT not meeting these surgical criteria, as well as those with contraindication or refusal for surgery, are monitored for signs and symptoms of primary HPT. There are currently no non-surgical therapies approved for use in primary HPT, although bisphosphonates are used in some patients, in an effort to control serum calcium levels. Calcimimetics decrease PTH and calcium levels and are a potential alternative for patients contraindicated for PTX, or who have failed previous PTX and have recurrent primary HPT. Secondary HPT develops early in chronic kidney disease and is present virtually in all patients with end-stage renal disease (ESRD). Secondary HPT is a progressive disease and is associated with several systemic complications, including renal osteodystrophy, soft tissue and vascular calcifications, and adverse cardiovascular outcomes. In ESRD patients, calcimimetics were shown to simultaneously reduce PTH, calcium, phosphate and calcium x phosphate product. In addition, observational analyses of use of calcimimetics in the ESRD population have shown a reduction of important clinical outcomes. In renal allograft recipients with tertiary HPT and hypercalcaemia, calcimimetics are a promising treatment option to control the parameters of calcium phosphate metabolism and may be a valid alternative to PTX. Based on its unique mechanism of action, the calcimimetic cinacalcet may play a role in the medical treatment of primary and tertiary forms of HPT, in addition to the registered indication for the treatment of secondary HPT.
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Affiliation(s)
- R P Wüthrich
- Clinic for Nephrology, University Hospital of Zürich, Switzerland.
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Moe SM, Drüeke T, Lameire N, Eknoyan G. Chronic kidney disease-mineral-bone disorder: a new paradigm. Adv Chronic Kidney Dis 2007; 14:3-12. [PMID: 17200038 DOI: 10.1053/j.ackd.2006.10.005] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Disturbances in mineral and bone metabolism are prevalent in chronic kidney disease (CKD) and an important cause of morbidity, decreased quality of life, and extraskeletal calcification that have been associated with increased cardiovascular mortality. These disturbances have traditionally been termed renal osteodystrophy and classified on the basis of bone biopsy. Kidney Disease: Improving Global Outcomes (KDIGO) recently sponsored a Controversies Conference to evaluate this definition. The recommendations were that (1) the term renal osteodystrophy be used exclusively to define alterations in bone morphology associated with CKD and (2) the term CKD-mineral and bone disorder (CKD-MBD) be used to describe the broader clinical syndrome that develops as a systemic disorder of mineral and bone metabolism as a result of CKD. CKD-MBD is manifested by an abnormality of any one or a combination of the following: laboratory-abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; bone-changes in bone turnover, mineralization, volume, linear growth, or strength; and calcification-vascular or other soft-tissue calcification. The pathogenesis and clinical manifestations of these components of CKD-MBD are described in detail in this issue of Advances in Chronic Kidney Disease.
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Affiliation(s)
- Sharon M Moe
- Indiana University School of Medicine and Roudebush VAMC, Indianapolis, IN 46202, USA.
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