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Panichi V, Rosati A, Mangione EA, Incognito F, Mattei S, Cupisti A. Serum alkaline phosphatase is a strong predictor of mortality in ESKD patients: analysis of the RISCAVID cohort. J Nephrol 2024:10.1007/s40620-024-01956-1. [PMID: 38913269 DOI: 10.1007/s40620-024-01956-1] [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: 01/09/2024] [Accepted: 04/06/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Mortality in hemodialysis (HD) patients remains unacceptably high compared with that of the general population and despite the continuous improvement of dialysis techniques. This study aimed to assess the role of alkaline phosphatase serum levels on cardiovascular and overall mortality in the RISCAVID study cohort through a long follow-up period, looking for associations with known risk factors for poor outcome. METHODS In June 2004, a prospective observational study was started focusing on the cardiovascular risk in hemodialysis patients who lived in the north-west area of Tuscany (RISCAVID, "RISchio CArdiovascolare nei pazienti afferenti all'Area Vasta In Dialisi"). The RISCAVID cohort included 572 prevalent patients on maintenance HD for at least three months. Morbid or fatal events were prospectively recorded at 6-month intervals for a follow up time of 216 months. RESULTS In univariable Cox regression analysis, dialysis technique, Geriatric Nutritional Risk Index, peripheral vascular disease, and intact parathyroid hormone and total calcium serum levels were significantly associated with baseline alkaline phosphatase serum levels. Cox multivariable analysis showed that elevated serum alkaline phosphatase levels (the highest quartile), advanced age, dialysis vintage, type of vascular access, Geriatric Nutritional Risk Index, C-reactive protein and calcium serum levels, history of cardiovascular disease and peripheral vascular disease were independent predictors of overall mortality in maintenance HD patients. The fourth quartile of alkaline phosphatase was associated with all-cause 10-year mortality (HR: 1.47; 95% CI: 1.177-1.834) with a 47% increase with respect to the 1st, 2nd, and 3rd quartiles. This was also observed for 18-year all-cause mortality. CONCLUSIONS Adjusted proportional analysis showed the alkaline phosphatase value to be an independent and powerful predictor of overall mortality in the hemodialysis population.
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Affiliation(s)
- Vincenzo Panichi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
- Nephrology, Transplants and Dialysis Unit, AOUP, Pisa, Italy.
| | - Alberto Rosati
- Nephrology and Dialysis Unit, San Giovanni di Dio Hospital, Florence, Italy
| | | | | | - Silvia Mattei
- Nephrology, Transplants and Dialysis Unit, AOUP, Pisa, Italy
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Nephrology, Transplants and Dialysis Unit, AOUP, Pisa, Italy
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Torres JA, Holznecht N, Asplund DA, Amarlkhagva T, Kroes BC, Rebello J, Agrawal S, Weimbs T. A combination of β-hydroxybutyrate and citrate ameliorates disease progression in a rat model of polycystic kidney disease. Am J Physiol Renal Physiol 2024; 326:F352-F368. [PMID: 38095025 PMCID: PMC11207547 DOI: 10.1152/ajprenal.00205.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 02/15/2024] Open
Abstract
Our research has shown that interventions producing a state of ketosis are highly effective in rat, mouse, and cat models of polycystic kidney disease (PKD), preventing and partially reversing cyst growth and disease progression. The ketone β-hydroxybutyrate (BHB) appears to underlie this effect. In addition, we have demonstrated that naturally formed microcrystals within kidney tubules trigger a renoprotective response that facilitates tubular obstruction clearance in healthy animals but, alternatively, leads to cyst formation in PKD. The administration of citrate prevents microcrystal formation and slows PKD progression. Juvenile Cy/+ rats, a nonorthologous PKD model, were supplemented from 3 to 8 wk of age with water containing titrated BHB, citrate, or in combination to find minimal effective and optimal dosages, respectively. Adult rats were given a reduced BHB/citrate combination or equimolar control K/NaCl salts from 8 to 12 wk of age. In addition, adult rats were placed in metabolic cages following BHB, citrate, and BHB/citrate administration to determine the impact on mineral, creatinine, and citrate excretion. BHB or citrate alone effectively ameliorates disease progression in juvenile rats, decreasing markers of cystic disease and, in combination, producing a synergistic effect. BHB/citrate leads to partial disease regression in adult rats with established cystic disease, inhibiting cyst formation and kidney injury. BHB/citrate confers benefits via multiple mechanisms, increases creatinine and citrate excretion, and normalizes mineral excretion. BHB and citrate are widely available and generally recognized as safe compounds and, in combination, exhibit high promise for supporting kidney health in polycystic kidney disease.NEW & NOTEWORTHY Combining β-hydroxybutyrate (BHB) and citrate effectively slows and prevents cyst formation and expansion in young Cy/+ rats using less BHB and citrate than when used alone, demonstrating synergy. In adult rats, the combination causes a partial reversal of existing disease, reducing cyst number and cystic area, preserving glomerular health, and decreasing markers of kidney injury. Our results suggest a safe and feasible strategy for supporting kidney health in polycystic kidney disease (PKD) using a combination of BHB and citrate.
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Affiliation(s)
- Jacob A Torres
- Department of Molecular, Cellular, and Developmental Biology, University of California-Santa Barbara, Santa Barbara, California, United States
| | - Nickolas Holznecht
- Department of Molecular, Cellular, and Developmental Biology, University of California-Santa Barbara, Santa Barbara, California, United States
| | - David A Asplund
- Department of Molecular, Cellular, and Developmental Biology, University of California-Santa Barbara, Santa Barbara, California, United States
| | - Tselmeg Amarlkhagva
- Department of Molecular, Cellular, and Developmental Biology, University of California-Santa Barbara, Santa Barbara, California, United States
| | - Bradley C Kroes
- Department of Molecular, Cellular, and Developmental Biology, University of California-Santa Barbara, Santa Barbara, California, United States
| | - Juliette Rebello
- Department of Molecular, Cellular, and Developmental Biology, University of California-Santa Barbara, Santa Barbara, California, United States
| | - Shagun Agrawal
- Department of Molecular, Cellular, and Developmental Biology, University of California-Santa Barbara, Santa Barbara, California, United States
| | - Thomas Weimbs
- Department of Molecular, Cellular, and Developmental Biology, University of California-Santa Barbara, Santa Barbara, California, United States
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Lalayiannis AD, Soeiro EMD, Moysés RMA, Shroff R. Chronic kidney disease mineral bone disorder in childhood and young adulthood: a 'growing' understanding. Pediatr Nephrol 2024; 39:723-739. [PMID: 37624528 PMCID: PMC10817832 DOI: 10.1007/s00467-023-06109-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/06/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023]
Abstract
Chronic kidney disease (CKD) mineral and bone disorder (MBD) comprises a triad of biochemical abnormalities (of calcium, phosphate, parathyroid hormone and vitamin D), bone abnormalities (turnover, mineralization and growth) and extra-skeletal calcification. Mineral dysregulation leads to bone demineralization causing bone pain and an increased fracture risk compared to healthy peers. Vascular calcification, with hydroxyapatite deposition in the vessel wall, is a part of the CKD-MBD spectrum and, in turn, leads to vascular stiffness, left ventricular hypertrophy and a very high cardiovascular mortality risk. While the growing bone requires calcium, excess calcium can deposit in the vessels, such that the intake of calcium, calcium- containing medications and high calcium dialysate need to be carefully regulated. Normal physiological bone mineralization continues into the third decade of life, many years beyond the rapid growth in childhood and adolescence, implying that skeletal calcium requirements are much higher in younger people compared to the elderly. Much of the research into the link between bone (de)mineralization and vascular calcification in CKD has been performed in older adults and these data must not be extrapolated to children or younger adults. In this article, we explore the physiological changes in bone turnover and mineralization in children and young adults, the pathophysiology of mineral bone disease in CKD and a potential link between bone demineralization and vascular calcification.
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Affiliation(s)
- Alexander D Lalayiannis
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK.
| | | | - Rosa M A Moysés
- Sao Paulo University Faculty of Medicine, Universidade de Sao Paulo Faculdade de Medicina, São Paulo, Brazil
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
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4
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Xiong L, Chen QQ, Cheng Y, Lan YS, Yang JB, Wen XQ, Xie X, Kang T, Wu WH, Ou S. The relationship between coronary artery calcification and bone metabolic markers in maintenance hemodialysis patients. BMC Nephrol 2023; 24:238. [PMID: 37582785 PMCID: PMC10428586 DOI: 10.1186/s12882-023-03286-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/31/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND To study the influencing factors for coronary artery calcification (CAC) in maintenance hemodialysis (MHD) patients and the relationship between CAC and bone metabolism markers and to attempt to find a reliable marker linking vascular calcification and bone metabolism in MHD patients. METHODS A total of 123 patients were enrolled. CAC was assessed by multislice spiral computed tomography (MSCT), and the CAC score (CACS) was evaluated using the Agaston method. Routine laboratory parameters, including triglycerides (TG), total cholesterol (TC), glucose (Glu), calcium (Ca), phosphorus (P), magnesium (Mg), etc., were measured. Serum markers of bone metabolism, such as alkaline phosphatase(ALP), calcitonin (CT), 25-hydroxy vitamin D [25-(OH)D], intact parathyroid hormone (iPTH), total type I procollagen amino-terminal peptide (tPINP), N-terminal mid-fragment of osteocalcin (N-MID OC), and β-type I collagen crosslinked carboxyl-terminal peptide (β-CTX), were also measured. RESULTS Among 123 MHD patients, 37 patients (30.08%) did not have CAC, and 86 patients (69.92%) had CAC, including 41 patients (47.67%) with mild calcification and 45 patients (52.33%) with moderate to severe calcification. Age, Body Mass Index(BMI), the prevalence of hypertension and diabetes mellitus, TC, Glu, P, and Ca×P in the calcification group were higher than those in the noncalcification group, whereas Mg, iPTH, tPINP, N-MID OC, and β-CTX were lower than those in the noncalcified group (P < 0.05). Compared with the mild calcification group (0 0.05). A logistic regression model was used to evaluate the influencing factors for CAC. The results showed that age, BMI, TC, Glu, P, and Ca×P were risk factors for CAC and its severity in MHD patients, whereas diabetes mellitus, Mg, and N-MID OC were protective factors for CAC in MHD patients. In addition, N-MID OC was a protective factor for the severity of CAC. After adjusting for the corresponding confounding factors, the results of the risk factors were consistent, and N-MID OC was still an independent protective factor for CAC and its severity. CONCLUSIONS Elevated serum P and Ca×P were independent risk factors for CAC in MHD patients, and serum Mg may be an independent protective factor for CAC. CAC was closely related to abnormal bone metabolism and bone metabolic markers in MHD patients. Relatively low bone turnover can promote the occurrence and development of CAC. N-MID OC may be a reliable bone metabolic marker linking vascular calcification and bone metabolism in MHD patients.
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Affiliation(s)
- Lin Xiong
- Department of Nephrology, The Affiliated Hospital of Southwest Medical University, 25th Taiping Street, Luzhou, 646000, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
| | - Qi-Qi Chen
- Department of Nephrology, The Affiliated Hospital of Southwest Medical University, 25th Taiping Street, Luzhou, 646000, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
| | - Yong Cheng
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Sichuan, China;, China
| | - Yong-Shu Lan
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Sichuan, China;, China
| | - Jian-Bo Yang
- Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Sichuan, China;, China
- Academician (Expert) Workstation of Sichuan Province, Luzhou, Sichuan, China
| | - Xiang-Qiong Wen
- Department of Nephrology, The Affiliated Hospital of Southwest Medical University, 25th Taiping Street, Luzhou, 646000, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
| | - Xin Xie
- Department of Nephrology, The Affiliated Hospital of Southwest Medical University, 25th Taiping Street, Luzhou, 646000, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
| | - Ting Kang
- Department of Nephrology, The Affiliated Hospital of Southwest Medical University, 25th Taiping Street, Luzhou, 646000, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
| | - Wei-Hua Wu
- Department of Nephrology, The Affiliated Hospital of Southwest Medical University, 25th Taiping Street, Luzhou, 646000, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
| | - Santao Ou
- Department of Nephrology, The Affiliated Hospital of Southwest Medical University, 25th Taiping Street, Luzhou, 646000, Sichuan, China.
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China.
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Hiramitsu T, Hasegawa Y, Futamura K, Okada M, Goto N, Narumi S, Watarai Y, Tominaga Y, Ichimori T. Maximal parathyroid gland diameter as a predictive factor for autograft-dependent recurrent secondary hyperparathyroidism after total parathyroidectomy. Front Endocrinol (Lausanne) 2023; 14:1175237. [PMID: 37396185 PMCID: PMC10311438 DOI: 10.3389/fendo.2023.1175237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Following total parathyroidectomy (PTx), transcervical thymectomy, and forearm autograft for secondary hyperparathyroidism (SHPT), recurrent SHPT can occur in the autografted forearm. However, few studies have investigated the factors contributing to re-PTx due to autograft-dependent recurrent SHPT before the completion of the initial PTx. Methods A total of 770 patients who had autografted parathyroid fragments derived from only one of the resected parathyroid glands (PTGs) and who had undergone successful initial total PTx and transcervical thymectomy-defined by serum intact parathyroid hormone level < 60 pg/mL on postoperative day 1-between January 2001 and December 2022 were included in this retrospective cohort study. Factors contributing to re-PTx due to graft-dependent recurrent SHPT before the completion of the initial PTx were investigated using multivariate Cox regression analysis. Receiver operating characteristic (ROC) curve analysis was performed to obtain the optimal maximum diameter of PTG for autograft. Results Univariate analysis showed that dialysis vintage and maximum diameter and weight of the PTG for autograft were significant factors contributing to graft-dependent recurrent SHPT. However, multivariate analysis revealed that dialysis vintage (P=0.010; hazard ratio [HR], 0.995; 95% confidence interval [CI], 0.992-0.999) and the maximum diameter of the PTG for autograft (P=0.046; HR, 1.107; 95% CI, 1.002-1.224) significantly contributed to graft-dependent recurrent SHPT. ROC curve analysis showed that < 14 mm was the optimal maximum diameter of PTG for autograft (area under the curve, 0.628; 95% CI, 0.551-0.705). Conclusions The dialysis vintage and maximum diameter of PTG for autograft may contribute to re-PTx due to autograft-dependent recurrent SHPT, which can be prevented by using PTGs with a maximum diameter of < 14 mm for autograft.
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Hiramitsu T, Hasegawa Y, Futamura K, Okada M, Goto N, Narumi S, Watarai Y, Tominaga Y, Ichimori T. Treatment for secondary hyperparathyroidism focusing on parathyroidectomy. Front Endocrinol (Lausanne) 2023; 14:1169793. [PMID: 37152972 PMCID: PMC10159274 DOI: 10.3389/fendo.2023.1169793] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/07/2023] [Indexed: 05/09/2023] Open
Abstract
Secondary hyperparathyroidism (SHPT) is a major problem for patients with chronic kidney disease and can cause many complications, including osteodystrophy, fractures, and cardiovascular diseases. Treatment for SHPT has changed radically with the advent of calcimimetics; however, parathyroidectomy (PTx) remains one of the most important treatments. For successful PTx, removing all parathyroid glands (PTGs) without complications is essential to prevent persistent or recurrent SHPT. Preoperative imaging studies for the localization of PTGs, such as ultrasonography, computed tomography, and 99mTc-Sestamibi scintigraphy, and intraoperative evaluation methods to confirm the removal of all PTGs, including, intraoperative intact parathyroid hormone monitoring and frozen section diagnosis, are useful. Functional and anatomical preservation of the recurrent laryngeal nerves can be confirmed via intraoperative nerve monitoring. Total or subtotal PTx with or without transcervical thymectomy and autotransplantation can also be performed. Appropriate operative methods for PTx should be selected according to the patients' need for kidney transplantation. In the case of persistent or recurrent SHPT after the initial PTx, localization of the causative PTGs with autotransplantation is challenging as causative PTGs can exist in the neck, mediastinum, or autotransplanted areas. Additionally, the efficacy and cost-effectiveness of calcimimetics and PTx are increasingly being discussed. In this review, medical and surgical treatments for SHPT are described.
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Affiliation(s)
- Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
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Dominguez LJ, Veronese N, Ciriminna S, Pérez-Albela JL, Vásquez-López VF, Rodas-Regalado S, Di Bella G, Parisi A, Tagliaferri F, Barbagallo M. Association between Serum Magnesium and Fractures: A Systematic Review and Meta-Analysis of Observational Studies. Nutrients 2023; 15:nu15061304. [PMID: 36986033 PMCID: PMC10053795 DOI: 10.3390/nu15061304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/09/2023] Open
Abstract
Magnesium, an essential cation for numerous cellular processes, is a major component of bone. However, its relationship with the risk of fractures is still uncertain. The present systematic review and meta-analysis aim to investigate the impact of serum Mg on the risk of incident fractures. A systematic search was conducted using several databases including PubMed/Medline and Scopus from inception to 24 May 2022, including observational studies investigating serum Mg and the incidence of fractures considered as outcomes. Abstract and full-text screenings, data extractions, and risk of bias assessments were conducted by two investigators independently. Any inconsistencies were resolved by consensus with a third author. The Newcastle–Ottawa Scale was used to assess the study quality/risk of bias. Among 1332 records initially screened, 16 were retrieved as full-texts; of them, four papers were included in the systematic review with a total of 119,755 participants. We found that lower serum Mg concentrations were associated with a significantly higher risk of incident fractures (RR = 1.579; 95%CI: 1.216–2.051; p = 0.001; I2 = 46.9%). Our systematic review with meta-analysis suggests a strong association of serum Mg concentrations with incident fractures. Further research is needed to confirm our results among other populations and to assess whether serum Mg is potentially relevant in the prevention of fractures, which continue to increase and represent a significant health burden due to the associated disability.
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Affiliation(s)
- Ligia J. Dominguez
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, 90133 Palermo, Italy
- Faculty of Medicine and Surgery, Kore University of Enna, 94100 Enna, Italy
- Correspondence: or
| | - Nicola Veronese
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, 90133 Palermo, Italy
| | - Stefano Ciriminna
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, 90133 Palermo, Italy
| | | | | | | | - Giovanna Di Bella
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, 90133 Palermo, Italy
| | - Angela Parisi
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, 90133 Palermo, Italy
| | - Federica Tagliaferri
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, 90133 Palermo, Italy
| | - Mario Barbagallo
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, 90133 Palermo, Italy
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Serum OPG and RANKL Levels as Risk Factors for the Development of Cardiovascular Calcifications in End-Stage Renal Disease Patients in Hemodialysis. Life (Basel) 2023; 13:life13020454. [PMID: 36836810 PMCID: PMC9967106 DOI: 10.3390/life13020454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/19/2023] [Accepted: 01/29/2023] [Indexed: 02/09/2023] Open
Abstract
Cardiovascular calcifications (CVC) are frequently observed in chronic kidney disease (CKD) patients and contribute to their cardiovascular mortality. The aim of the present study was to investigate the impact of osteoprotegerin (OPG)/Receptor Activator of NF-κΒ (RANK)/RANK ligand (RANKL) pathway in the development and evolution of CVCs in hemodialysis patients. In total, 80 hemodialysis patients were assessed for the presence of vascular (abdominal aorta and muscular arteries) calcifications and results were correlated to serum OPG and RANKL levels and the OPG/RANKL ratio. Traditional cardiovascular risk factors and mineral bone disease parameters were also estimated. The presence of VCs was also evaluated 5 years after the initiation of the study, and results were correlated to the initial serum OPG levels. Age, diabetes mellitus, coronary artery disease and OPG levels (p < 0.001) were associated with VCs, whereas RANKL levels were not. Multivariate analysis though revealed that only OPG levels were significantly associated with abdominal aorta calcifications (p = 0.026), but they were not correlated with the progression of VCs. Serum OPG levels are positively and independently associated with VCs in HD patients, but not with their progression. RANKL levels did not show any associations, whereas further studies are needed to establish the significance of OPG/RANKL ratio.
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Oruc M, Mercan S, Bakan S, Kose S, Ikitimur B, Trabulus S, Altiparmak MR. Do trace elements play a role in coronary artery calcification in hemodialysis patients? Int Urol Nephrol 2023; 55:173-182. [PMID: 35854190 DOI: 10.1007/s11255-022-03303-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 07/07/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Abnormalities of trace elements have previously been linked to inflammatory processes in hemodialysis (HD) patients. We aimed to establish the trace element status of maintenance HD patients, to investigate the relationship between coronary artery calcification scores (CACs) and whole blood levels of trace elements. METHODS Patients undergoing HD in three times a week for > 6 months and age-and sex-matched controls were included from October 2015 to June 2016. Data were collected from patient files. All subjects' whole blood levels of trace elements were measured by Inductively Coupled Plasma Mass Spectrometry (ICP-MS). CACs for patients were assessed by multi-detector computed tomography. RESULTS The 35 patients (male, 60%) with a mean age of 45.7 ± 10.4 years and 35 controls were included. HD patients showed significantly lower levels of selenium and uranium and higher cadmium (Cd), cobalt, lithium, manganese, nickel, lead, platinum, tin, strontium, and thallium levels compared to controls. Coronary artery calcification (CAC) was present in 21 patients (60%), and median CACs were 14.2 (IQR 0-149). Patients with CACs > median were significantly older, had a higher prevalence of hypertension and lower ALP levels than patients with CACs ≤ median. No significant differences in whole blood levels of trace elements were found between patients with CACs > median and patients with CACs ≤ median. A near significance was noted in median whole blood levels of Cd between these groups (P = 0.096). According to multivariate analysis, age was the only independent determinant for CAC development. CONCLUSION Age is independently associated with coronary vascular calcification. High Cd levels might play a role in CAC development in HD patients.
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Affiliation(s)
- Meric Oruc
- Department of Nephrology, Kartal Dr Lutfi Kirdar City Hospital, 34865, Istanbul, Turkey.
| | - Selda Mercan
- Department of Science, Institute of Forensic Sciences and Legal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Selim Bakan
- Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sennur Kose
- Department of Nephrology, Istanbul Education and Research Hospital, Istanbul, Turkey
| | - Baris Ikitimur
- Department of Cardiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sinan Trabulus
- Department of Nephrology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mehmet Riza Altiparmak
- Department of Nephrology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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He L, Yang W, Yang P, Zhang X, Zhang A. Higher serum trimethylamine-N-oxide levels are associated with increased abdominal aortic calcification in hemodialysis patients. Ren Fail 2022; 44:2019-2027. [DOI: 10.1080/0886022x.2022.2145971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Lian He
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Wenling Yang
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Ping Yang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Xianhua Zhang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Aihua Zhang
- Department of Nephrology, Xuanwu Hospital Capital Medical University, Beijing, China
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Nagy E, Sobh MM, Abdalbary M, Elnagar S, Elrefaey R, Shabaka S, Elshabrawy N, Shemies R, Tawfik M, Santos CGS, Barreto FC, El-Husseini A. Is Adynamic Bone Always a Disease? Lessons from Patients with Chronic Kidney Disease. J Clin Med 2022; 11:jcm11237130. [PMID: 36498703 PMCID: PMC9736225 DOI: 10.3390/jcm11237130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022] Open
Abstract
Renal osteodystrophy (ROD) is a common complication of end-stage kidney disease that often starts early with loss of kidney function, and it is considered an integral part in management of patients with chronic kidney disease (CKD). Adynamic bone (ADB) is characterized by suppressed bone formation, low cellularity, and thin osteoid seams. There is accumulating evidence supporting increasing prevalence of ADB, particularly in early CKD. Contemporarily, it is not very clear whether it represents a true disease, an adaptive mechanism to prevent bone resorption, or just a transitional stage. Several co-players are incriminated in its pathogenesis, such as age, diabetes mellitus, malnutrition, uremic milieu, and iatrogenic factors. In the present review, we will discuss the up-to-date knowledge of the ADB and focus on its impact on bone health, fracture risk, vascular calcification, and long-term survival. Moreover, we will emphasize the proper preventive and management strategies of ADB that are pivotal issues in managing patients with CKD. It is still unclear whether ADB is always a pathologic condition or whether it can represent an adaptive process to suppress bone resorption and further bone loss. In this article, we tried to discuss this hard topic based on the available limited information in patients with CKD. More studies are needed to be able to clearly address this frequent ROD finding.
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Affiliation(s)
- Eman Nagy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mahmoud M. Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Sherouk Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Rabab Elrefaey
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Shimaa Shabaka
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Nehal Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Rasha Shemies
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Mona Tawfik
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt
| | - Cássia Gomes S. Santos
- Department of Internal Medicine, Division of Nephrology, Federal University of Paraná, Curitiba 80060-00, PR, Brazil
| | - Fellype C. Barreto
- Department of Internal Medicine, Division of Nephrology, Federal University of Paraná, Curitiba 80060-00, PR, Brazil
| | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40536-0298, USA
- Correspondence: ; Tel.: +1-859-218-0934; Fax: +1-859-323-0232
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Oka T, Sakaguchi Y, Isaka Y, Ishii H, Kabata D, Shintani A, Nakatani S, Morioka T, Mori K, Inaba M, Emoto M, Shoji T. Effects of alfacalcidol on cardiovascular outcomes according to alkaline phosphatase levels in the J-DAVID trial. Sci Rep 2022; 12:15463. [PMID: 36104443 PMCID: PMC9475027 DOI: 10.1038/s41598-022-19820-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
In the Japan Dialysis Active Vitamin D (J-DAVID) trial, oral alfacalcidol numerically, but not significantly, increased the risk of cardiovascular events among patients undergoing hemodialysis. Because the cardiovascular effect of alfacalcidol could be modulated by bone turnover status, this post-hoc analysis of the J-DAVID examined how alkaline phosphatase (ALP), a more precise marker of bone turnover than parathyroid hormone (PTH), modifies the impact of alfacalcidol. The J-DAVID was a 48-month, open-label, randomized controlled trial comparing oral alfacalcidol with no vitamin D receptor activators use in terms of cardiovascular events among 976 hemodialysis patients without secondary hyperparathyroidism. This post-hoc analysis included 959 patients with available data on baseline ALP. The median [25–75th percentile] baseline ALP level was 234 [183–296] U/L. In a Cox proportional hazards model, ALP did not significantly modify the effect of alfacalcidol on the rate of cardiovascular events or all-cause death (P for effect modification = 0.54 and 0.74, respectively). The effect of alfacalcidol on time-series changes in calcium, phosphate, and intact PTH were similar across ALP subgroups. In conclusion, oral alfacalcidol did not significantly affect cardiovascular outcomes irrespective of bone turnover status.
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Pichone A, Gomes CP, Lima LFC, Moreira CA, Paranhos-Neto FDP, Madeira M, Lopes RT, Farias MLF, Leite Jr. M. Assessment of trabecular and cortical parameters using high-resolution peripheral quantitative computed tomography, histomorphometry and microCT of iliac crest bone core in hemodialysis patients. Bone Rep 2022; 16:101173. [PMID: 35198659 PMCID: PMC8850668 DOI: 10.1016/j.bonr.2022.101173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/28/2022] Open
Abstract
Patients with end-stage renal disease develop changes in bone quality and quantity, which can be assessed using different methods. This study aimed to compare and to correlate bone parameters obtained in vivo using high-resolution peripheral quantitative computed tomography (HR-pQCT) with those obtained by bone biopsy using histomorphometry and microcomputed tomography (microCT) analysis of the iliac crest core, and to evaluate if HR-pQCT is helpful in aiding with categorization of those with high turnover. Twenty hemodialysis patients, 13 females (7 postmenopausal), underwent bone biopsy from 2018 to 2020. The mean age was 48.5 ± 10.6 years, and the mean hemodialysis vintage was 15 years. Histomorphometry identified mineralization defects, low turnover, and high turnover in 65%, 45%, and 35% of the patients, respectively. The highest values of trabecular bone volume (BV/TV) were obtained by histomorphometry, while the highest values of cortical thickness (Ct.Th) were obtained by HR-pQCT at the distal tibia. Moderate correlations were found between BV/TV values obtained by microCT of the bone core and HR-pQCT at the distal radius (r = 0.531, p = 0.016) and at the distal tibia (r = 0.536, p = 0.015). BV/TV values obtained from the bone core by histomorphometry and microCT were also significantly correlated (r = 0.475, p = 0.04). Regarding Ct.Th, there was a strong correlation between the radius and tibia HR-pQCT (r = 0.800, p < 0.001), between bone core microCT and the distal radius HR-pQCT (r = 0.610, p < 0.01), as between histomorphometry and microCT (r = 0.899, p < 0.01). In groups classified by bone turnover, patients with high turnover presented lower BV/TV, Tb.N, Tb.Th, and Ct.Th than those with low turnover in peripheral sites using HR-pQCT. By this method, it was possible to identify low turnover from tibia BV/TV > 12,4% plus Tb.Sp ≤ 0.667 mm (AUC 0.810, 95% CI 0.575 to 0.948) and high turnover from total bone mineral density (BMD) ≤ 154.2 mg HA/cm3 (AUC 0.860, 95% CI 0.633 to 0.982, p < 0.001) and cortical BMD ≤ 691.6 mg HA/cm3 (AUC 0.840, 95% CI 0.609 to 0.963, p < 0.001). In conclusion, HR-pQCT had significant correlation with iliac crest bone in BV/TV and Ct.Th, which are known to provide bone strength. This method is quick and non-invasive and may be helpful in categorizing those with high versus low turnover in hemodialysis patients. Bone structure in hemodialysis patients can be assessed using different methods. There was correlation of BV/TV and Ct.Th between histomorphometry and bone core microCT. BV/TV and Ct.Th values obtained by radius HR-pQCT and bone core microCT were correlated. High turnover patients had lower BV/TV, Tb.N, Tb.Th, and Ct.Th by HR-pQCT. HR-pQCT was able to discriminate low and high turnover in hemodialysis patients.
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Affiliation(s)
- Alinie Pichone
- Division of Nephrology, HUCFF, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Corresponding author at: Hospital Universitario Clementino Fraga Filho – Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255/Serviço de nefrologia - sétimo andar, Rio de Janeiro, RJ 21941-617, Brazil.
| | - Carlos Perez Gomes
- Division of Nephrology, HUCFF, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luis Felipe Cardoso Lima
- Laboratory of Nuclear Instrumentation, COPPE, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Carolina Aguiar Moreira
- Division of Endocrinology (SEMPR), Internal Medicine Department of Federal University of Parana & Academic Research Center of Pro Renal Institute, Curitiba, Brazil
| | | | - Miguel Madeira
- Division of Endocrinology, HUCFF, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ricardo Tadeu Lopes
- Laboratory of Nuclear Instrumentation, COPPE, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Maurilo Leite Jr.
- Division of Nephrology, HUCFF, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Eremkina AK, Gorbacheva AM, Enenko VA, Litvinova EE, Mokrysheva NG. [Experience in using teriparatide for the treatment of postoperative hypoparathyroidism in hemodialysis patients]. PROBLEMY ENDOKRINOLOGII 2022; 68:30-39. [PMID: 36104963 DOI: 10.14341/probl13075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/18/2022] [Accepted: 05/30/2022] [Indexed: 01/01/2023]
Abstract
The frequency of chronic postoperative hypoparathyroidism after total parathyroidectomy for secondary and tertiary hyperparathyroidism in patients with end-stage renal failure, according to various authors, can reach 20% or more. Prescribing active metabolites of vitamin D and calcium it is not always sufficient for achievement of target goals. This dictates the need for replacement therapy with recombinant parathyroid hormone. Teriparatide is the only drug of this series approved by the American Food and Drug Administration (FDA) and registered in the Russian Federation. However, it is registered as an anabolic anti-osteoporotic drug and is not indicated for the treatment of chronic hypoparathyroidism. The use of teriparatide in postoperative hypoparathyroidism in patients receiving renal replacement therapy with programmed hemodialysis in the Russian Federation has not been previously studied. Data on this issue is also limited in foreign literature. However, it is a potential treatment option for hemodialysis patients with chronic hypoparathyroidism and severe bone disorders. In this article, we present 2 clinical cases of substitution and anabolic therapy with teriparatide in this cohort of patients.
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Alkaline Phosphatase: An Old Friend as Treatment Target for Cardiovascular and Mineral Bone Disorders in Chronic Kidney Disease. Nutrients 2022; 14:nu14102124. [PMID: 35631265 PMCID: PMC9144546 DOI: 10.3390/nu14102124] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022] Open
Abstract
Alkaline phosphatase (ALP) is an evolutionary conserved enzyme and widely used biomarker in clinical practice. Tissue-nonspecific alkaline phosphatase (TNALP) is one of four human isozymes that are expressed as distinct TNALP isoforms after posttranslational modifications, mainly in bone, liver, and kidney tissues. Beyond the well-known effects on bone mineralization, the bone ALP (BALP) isoforms (B/I, B1, B1x, and B2) are also involved in the pathogenesis of ectopic calcification. This narrative review summarizes the recent clinical investigations and mechanisms that link ALP and BALP to inflammation, metabolic syndrome, vascular calcification, endothelial dysfunction, fibrosis, cardiovascular disease, and mortality. The association between ALP, vitamin K, bone metabolism, and fracture risk in patients with chronic kidney disease (CKD) is also discussed. Recent advances in different pharmacological strategies are highlighted, with the potential to modulate the expression of ALP directly and indirectly in CKD–mineral and bone disorder (CKD-MBD), e.g., epigenetic modulation, phosphate binders, calcimimetics, vitamin D, and other anti-fracture treatments. We conclude that the significant evidence for ALP as a pathogenic factor and risk marker in CKD-MBD supports the inclusion of concrete treatment targets for ALP in clinical guidelines. While a target value below 120 U/L is associated with improved survival, further experimental and clinical research should explore interventional strategies with optimal risk–benefit profiles. The future holds great promise for novel drug therapies modulating ALP.
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Yang X, Zhao D, Yu F, Heidari AA, Bano Y, Ibrohimov A, Liu Y, Cai Z, Chen H, Chen X. An optimized machine learning framework for predicting intradialytic hypotension using indexes of chronic kidney disease-mineral and bone disorders. Comput Biol Med 2022; 145:105510. [DOI: 10.1016/j.compbiomed.2022.105510] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 11/03/2022]
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El-Husseini A, Abdalbary M, Lima F, Issa M, Ahmed MT, Winkler M, Srour H, Davenport D, Wang G, Faugere MC, Malluche H. Low turnover renal osteodystrophy with abnormal bone quality and vascular calcification in patients with mild to moderate CKD. Kidney Int Rep 2022; 7:1016-1026. [PMID: 35570986 PMCID: PMC9091581 DOI: 10.1016/j.ekir.2022.02.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction Limited information is available on renal osteodystrophy (ROD) and vascular calcification (VC) during early chronic kidney disease (CKD). This study was designed to evaluate ROD and VC in 32 patients with CKD stages II to IV. Methods Patients underwent dual-energy X-ray absorptiometry (DXA) for assessment of bone mineral density (BMD) and trabecular bone score (TBS), thoracic computed tomography for VC scoring using the Agatston method, and anterior iliac crest bone biopsy for mineralized bone histology, histomorphometry, and Fourier transform infrared spectroscopy (FTIR). Classical and novel bone markers were determined in the blood. Results Mean estimated glomerular filtration rate (eGFR) was 44 ± 16 ml/min per 1.73 m2. Of the patients, 84% had low bone turnover. In Whites, eGFR correlated negatively with the turnover parameter activation frequency (Ac.f) (r −0.48, P = 0.019) and with parameters of bone formation. Most patients had VC (>80%) which correlated positively with levels of phosphorus, c-terminal fibroblast growth factor-23, and activin. Aortic calcifications (ACs) correlated negatively with bone formation rate (BFR) and Ac.f (rho −0.62, −0.61, P < 0.001). TBS correlated negatively with coronary calcification (rho −0.42, P = 0.019) and AC (rho −0.57, P = 0.001). These relationships remained after adjustment of age. The mineral-to-matrix ratio, an FTIR metric reflecting bone quality, was negatively related to Ac.f and positively related to AC. Conclusion Low bone turnover and VC are predominant in early stages of CKD. This is the first study demonstrating mineral abnormalities indicating reduced bone quality in these stages of CKD.
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Chen TY, Yang J, Zuo L, Wang L, Wang LF. Relationship of abdominal aortic calcification with lumbar vertebral volumetric bone mineral density assessed by quantitative computed tomography in maintenance hemodialysis patients. Arch Osteoporos 2022; 17:24. [PMID: 35080671 PMCID: PMC8791896 DOI: 10.1007/s11657-022-01059-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 12/29/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION This cross-sectional study aimed to investigate the relationship between abdominal aortic calcification (AAC), which is a marker of vascular calcification, and volumetric bone mineral density (vBMD) by quantitative computed tomography (QCT) in maintenance hemodialysis (MHD) patients. METHODS All participants underwent lumbar vertebral vBMD measurement by QCT. Eight cross-sections were extracted sequentially and analyzed by ImageJ software to obtain the ratio of the calcified area to the abdominal aortic area (the calcification ratio). The AAC score was determined by the sum of the calcification ratios. The relationship between AAC and vBMD was analyzed using multivariate logistic regression. RESULTS Ninety MHD patients (58.89% male) with a mean age of 63.43 (standard deviation [SD] = 13.20) years were included in the study. AAC was present (AAC score > 0) in 93.33% of the patients. The 75th percentile of the AAC score corresponding to 119 was used as the cutoff point between the mild and severe groups. After full adjustment in the logistic model, AAC was found to be inversely associated with vBMD (odds ratio [OR], 0.970; 95% confidence interval [CI], 0.944 to 0.996; P = 0.025), and patients with osteoporosis had a significantly higher risk of severe AAC than those with normal bone mass (OR, 14.498; 95% CI, 1.507 to 139.486; P = 0.021). The independent inverse association was still stable after adjusting for variables measured at different time periods and using different cutoff points of the AAC score. CONCLUSION There was an independent inverse association between AAC and vBMD, and osteoporosis was significantly associated with severe AAC in patients with MHD.
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Affiliation(s)
- Tian-Yi Chen
- Department of Renal Medicine, Beijing Jishuitan Hospital, No. 68, Hui-South Road, Hui- Longguan Town, Changping District, 100096, Beijing, China.
| | - Jie Yang
- Department of Renal Medicine, Beijing Jishuitan Hospital, No. 68, Hui-South Road, Hui- Longguan Town, Changping District, 100096, Beijing, China
| | - Li Zuo
- Department of Renal Medicine, Peking University People's Hospital, Beijing, China
| | - Ling Wang
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Li-Fang Wang
- Clinical Epidemiology Research Center, Beijing Jishuitan Hospital, Beijing, China
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Kim H, Lee J, Lee KB, Kim YH, Hong N, Park JT, Han SH, Kang SW, Choi KH, Oh KH, Yoo TH. Low bone mineral density is associated with coronary arterial calcification progression and incident cardiovascular events in patients with chronic kidney disease. Clin Kidney J 2022; 15:119-127. [PMID: 35035942 PMCID: PMC8757420 DOI: 10.1093/ckj/sfab138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Indexed: 12/15/2022] Open
Abstract
Background Although it is well known that low bone mineral density (BMD) is associated with an increased risk of cardiovascular disease (CVD) and mortality in the general population, the prognostic role of bone mineral density (BMD) has not been established in the chronic kidney disease (CKD) population. Therefore we aimed to evaluate the association between BMD and the risk of CVD and cardiovascular mortality in patients with predialysis CKD. Methods This prospective cohort study was conducted with 1957 patients with predialysis CKD Stages 1–5. BMD was measured using dual-energy X-ray absorptiometry and coronary arterial calcification (CAC) scores were evaluated using coronary computed tomography. The primary outcome was a major adverse cardiovascular event (MACE). Results When patients were classified based on total hip BMD T-score tertiles stratified by sex, the lowest BMD tertile was significantly associated with an increased risk of MACE {hazard ratio 2.16 [95% confidence interval (CI) 1.25–3.74]; P = 0.006}. This association was also shown with BMD at the femur neck but not with BMD at lumbar spine. In the subgroup of 977 patients with follow-up CACs at their fourth year, 97 (9.9%) showed accelerated CAC progression (>50/year), and BMD was inversely associated with accelerated CAC progression even after adjusting for the baseline CAC score [odds ratio 0.75 (95% CI 0.58–0.99); P = 0.039]. In addition, baseline CAC was associated with an increased risk of MACEs after adjusting for total hip T-score. Conclusions Low BMD was significantly associated with CAC progression and MACEs in patients with predialysis CKD.
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Affiliation(s)
- Hyoungnae Kim
- Division of Nephrology, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Joongyub Lee
- Prevention and Management Center, Inha University Hospital, Incheon, Korea
| | - Kyu-Beck Lee
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Yeong-Hoon Kim
- Department of Internal Medicine, Busan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Namki Hong
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Tak Park
- Department of Internal Medicine, Yonsei University, Institute of Kidney Disease Research, College of Medicine, Seoul, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Yonsei University, Institute of Kidney Disease Research, College of Medicine, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University, Institute of Kidney Disease Research, College of Medicine, Seoul, Korea
| | - Kyu Hun Choi
- Department of Internal Medicine, Yonsei University, Institute of Kidney Disease Research, College of Medicine, Seoul, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, Yonsei University, Institute of Kidney Disease Research, College of Medicine, Seoul, Korea
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Aaltonen L, Koivuviita N, Seppänen M, Kröger H, Tong X, Löyttyniemi E, Metsärinne K. Association between bone mineral metabolism and vascular calcification in end-stage renal disease. BMC Nephrol 2022; 23:12. [PMID: 34979983 PMCID: PMC8722315 DOI: 10.1186/s12882-021-02652-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
Background Development of vascular calcification is accelerated in patients with end-stage renal disease. In addition to traditional risk factors of cardiovascular disease (CVD) abnormal bone and mineral metabolism together with many other factors contribute to the excess cardiovascular burden in patients on dialysis. Aortic calcification score and coronary calcification score are predictive of CVD and mortality. The aim of this study was to evaluate the possible relationship between arterial calcification and bone metabolism. Methods Thirty two patients on dialysis were included. All patients underwent a bone biopsy to assess bone histomorphometry and a 18F-NaF PET scan. Fluoride activity was measured in the lumbar spine (L1 – L4) and at the anterior iliac crest. Arterial calcification scores were assessed by computerized tomography for quantification of coronary artery calcification score and lateral lumbar radiography for aortic calcification score. Results This study group showed high prevalence of arterial calcification and 59% had verified CVD. Both CAC and AAC were significantly higher in patients with verified CVD. Only 22% had low turnover bone disease. There was a weak association between fluoride activity, which reflects bone turnover, measured in the lumbar spine, and CAC and between PTH and CAC. There was also a weak association between erosion surfaces and AAC. No significant association was found between calcification score and any other parameter measured. Conclusions The results in this study highlight the complexity, when evaluating the link between bone remodeling and vascular calcification in patients with multiple comorbidities and extensive atherosclerosis. Several studies suggest an impact of bone turnover on development of arterial calcification and there is some evidence of reduced progression of vascular calcification with improvement in bone status. The present study indicates an association between vascular calcification and bone turnover, even though many parameters of bone turnover failed to show significance. In the presence of multiple other factors contributing to the development of calcification, the impact of bone remodeling might be diminished. Trial registration The study is registered in ClinicalTrials.gov protocol registration and result system, ID is NCT02967042. Date of registration is 17/11/2016.
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Affiliation(s)
- Louise Aaltonen
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland.
| | - Niina Koivuviita
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Marko Seppänen
- Turku PET Centre, University of Turku, Kiinamyllynkatu 4-8, 20521, Turku, Finland.,Department of Clinical Physiology, Nuclear Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit (KMRU) Institute of Clinical Medicine, University of Eastern Finland, POB 1627, Kuopio, Finland.,Kuopio University Hospital, Kuopio, Finland
| | - Xiaoyu Tong
- Kuopio Musculoskeletal Research Unit (KMRU) Institute of Clinical Medicine, University of Eastern Finland, POB 1627, Kuopio, Finland
| | - Eliisa Löyttyniemi
- Department of Biostatistics, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland
| | - Kaj Metsärinne
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
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Bone mass measurement by DXA should be interpreted with caution in the CKD population with vascular calcification. Bone Rep 2022; 16:101169. [PMID: 35146076 PMCID: PMC8819399 DOI: 10.1016/j.bonr.2022.101169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background KDIGO guidelines suggest the use of dual-energy X-ray absorptiometry (DXA) to assess bone mineral density (BMD) in patients with CKD 3a-5D. Previous studies have demonstrated an association between trabecular bone mass loss and coronary artery calcification (CAC) progression. This study aimed to prospectively investigate the relationship between BMD changes, quantified by DXA, and CAC progression in the non-dialyzed CKD population. Methods In this post hoc study, BMD by DXA was measured at the lumbar spine and total hip at baseline and 12-months. Patients were categorized according to BMD changes into 3 different groups: LOSS, UNCHANGED and GAIN. CAC quantification was obtained by multislice computed tomography at baseline and 12-months. Results 87 patients (55.6 ± 10.7 years, 62% males, 30% diabetic, eGFR = 39.2 ± 18.1 mL/min/1.73m2) were enrolled. CAC was found in 41 (47%) of the patients at baseline and CAC progression in 25 (64%) of them. Considering the lumbar spine and total hip BMD changes together, 24%, 48%, and 25% of the patients were in the LOSS, UNCHANGED and GAIN groups, respectively. Compared to the UNCHANGED or LOSS groups, the GAIN group had an increase in calcium score (p = 0.04) and a higher proportion of patients with CAC progression (p = 0.01). In the logistic regression analysis, CAC progression was 4.5 times more likely to be in the GAIN group. Conclusions The association between the increase in BMD values and the progression of vascular calcification was the result of two concomitant processes overlapping, leading to a misinterpretation of DXA results. Thus, the use of DXA for the evaluation of bone mass, especially at the lumbar spine, must be applied with restraint and its results very carefully interpreted in CKD patients. DXA should be interpreted with caution in the CKD population. Vascular calcification progression is highly prevalent among CKD patients. The increase of BMD values by DXA should be taken with restraint in CKD patients particularly in those with vascular calcification progression.
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Low bone turnover is associated with plain X-ray vascular calcification in predialysis patients. PLoS One 2021; 16:e0258284. [PMID: 34644326 PMCID: PMC8513829 DOI: 10.1371/journal.pone.0258284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/24/2021] [Indexed: 11/19/2022] Open
Abstract
Background Vascular calcification (VC) is a common finding in chronic kidney disease (CKD) patients and predicts subsequent cardiovascular morbidity and mortality in this population. Vascular calcification is linked to disordered mineral metabolism and has been associated with bone histomorphometry changes in CKD. However, data on predialysis patients is scarce. Methods A cross-sectional study was conducted on a cohort of 56 CKD patients not yet on dialysis, who underwent a transiliac bone biopsy for histomorphometric evaluation after double tetracycline labeling. Patients had no previous exposure to calcium salts, vitamin D agents, steroids or bisphosphonates. Vascular calcification was assessed at the time of biopsy, using Kauppila (plain X-ray of the lateral lumbar spine) and Adragão (plain X-ray of the pelvis and hands) scores. Results Vascular calcification was seen in two-thirds of the cohort. Subjects with VC were more likely to be male and have diabetes, and had significantly higher sclerostin and osteoprotegerin circulating levels than those without VC. The histomorphometric analysis showed that bone formation rate was significantly lower in VC compared to non-VC patients. In the multivariable logistic regression analysis, bone formation rate was independently associated with the presence of VC. Conclusions Vascular calcification is highly prevalent in predialysis patients, especially in those with diabetes. The independent association between bone formation rate and VC provides evidence of an important interaction between bone and vessel in CKD. Our results suggest that low bone turnover is a non-traditional risk factor for cardiovascular disease in predialysis patients.
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Rodrigues FG, Ormanji MS, Heilberg IP, Bakker SJL, de Borst MH. Interplay between gut microbiota, bone health and vascular calcification in chronic kidney disease. Eur J Clin Invest 2021; 51:e13588. [PMID: 33948936 PMCID: PMC8459296 DOI: 10.1111/eci.13588] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/30/2021] [Accepted: 05/01/2021] [Indexed: 02/06/2023]
Abstract
Deregulations in gut microbiota may play a role in vascular and bone disease in chronic kidney disease (CKD). As glomerular filtration rate declines, the colon becomes more important as a site of excretion of urea and uric acid, and an increased bacterial proteolytic fermentation alters the gut microbial balance. A diet with limited amounts of fibre, as well as certain medications (eg phosphate binders, iron supplementation, antibiotics) further contribute to changes in gut microbiota composition among CKD patients. At the same time, both vascular calcification and bone disease are common in patients with advanced kidney disease. This narrative review describes emerging evidence on gut dysbiosis, vascular calcification, bone demineralization and their interrelationship termed the 'gut-bone-vascular axis' in progressive CKD. The role of diet, gut microbial metabolites (ie indoxyl sulphate, p-cresyl sulphate, trimethylamine N-oxide (TMAO) and short-chain fatty acids (SCFA)), vitamin K deficiency, inflammatory cytokines and their impact on both bone health and vascular calcification are discussed. This framework may open up novel preventive and therapeutic approaches targeting the microbiome in an attempt to improve cardiovascular and bone health in CKD.
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Affiliation(s)
- Fernanda G Rodrigues
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Nutrition Post-Graduation Program, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Milene S Ormanji
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ita P Heilberg
- Nutrition Post-Graduation Program, Universidade Federal de São Paulo, São Paulo, Brazil.,Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Stephan J L Bakker
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Martin H de Borst
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Ott SM, Malluche HH, Jorgetti V, Elder GJ. Importance of bone turnover for therapeutic decisions in patients with CKD-MBD. Kidney Int 2021; 100:502-505. [PMID: 34420656 DOI: 10.1016/j.kint.2021.05.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 01/13/2023]
Abstract
Patients with chronic kidney disease-mineral and bone disorder (CKD-MBD) frequently have low bone formation rates. A recent review suggested that adynamic bone disease is not always associated with negative outcomes and therefore antiresorptive medications could be used more often. However, there is currently no evidence to support an improvement in fracture risk or mortality in patients with CKD-MBD and low bone turnover who are treated with antiresorptive medication. There is reasonable pathophysiological evidence suggesting that it may even be harmful.
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Affiliation(s)
- Susan M Ott
- Department of Medicine, University of Washington, Seattle, Washington, USA.
| | - Hartmut H Malluche
- Division of Nephrology Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Vanda Jorgetti
- Faculdade de Medicina, Hospital das Clínicas, Laboratório de Fisiopatologia Renal, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Grahame J Elder
- Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia; Osteoporosis and Bone Biology Division, Garvan Institute for Medical Research, Darlinghurst, New South Wales, Australia
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25
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Reducing the burden of cardiovascular disease in children with chronic kidney disease: prevention vs. damage limitation. Pediatr Nephrol 2021; 36:2537-2544. [PMID: 34143301 DOI: 10.1007/s00467-021-05102-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
Cardiovascular disease (CVD) is a life-limiting condition in patients with chronic kidney disease (CKD) and is rapidly progressive, especially in those with stage 5 CKD and on dialysis. Cardiovascular mortality, although reducing, remains at least 30 times higher than in the general pediatric population. The American Heart Association guidelines for cardiovascular risk reduction in high-risk pediatric patients has stratified pediatric CKD patients in the "high risk" category for the development of CVD, with associated pathological and/or clinical evidence for manifest coronary disease before 30 years of age. While improving patient survival is a key priority, other patient-related outcomes, such as psychosocial development, quality of life and growth are of major importance to children and their caregivers. Once vascular damage or calcification has developed, there are no data to suggest that they can be reversed. Treatments such as intensified dialysis and transplantation may attenuate the progression of subclinical cardiovascular disease, but no treatment to date has shown that the inexorable progression of CVD in CKD can be reversed. Thus, our management must focus on early diagnosis and robust preventative strategies to give our patients the best chance of optimal cardiovascular health and survival. In this review, the pathophysiology and importance of preventing the development of CVD in CKD is discussed.
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26
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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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García-Bello JA, Gómez-Díaz RA, Contreras-Rodríguez A, Sánchez-Barbosa L, Mondragón-González R, Gallardo-Montoya JM, Wacher NH. Endothelial dysfunction in children with chronic kidney disease. Nefrologia 2021; 41:436-445. [PMID: 36165112 DOI: 10.1016/j.nefroe.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/17/2020] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Cardiovascular disease (CVD) is the main cause of death in children with chronic kidney disease (CKD). Inflammation and endothelial dysfunction (ED) are found in the majority of these patients and are factors associated to CVD. Flow mediated dilatation (FMD) is a surrogate marker validated for evaluating ED. Our objective was to identify risk factors associated to ED in children with CKD. MATERIALS AND METHODS Children 2-16 years of age were studied. Clinical information and biochemical variables were gathered, including intact parathyroid hormone (iPTH), interleukins 6 and 1b, high sensitivity C reactive protein (hsCRP), reduced glutathione, nitric oxide, malondialdehyde and homocysteine. FMD was measured, and considered altered if <7%. RESULTS Included were 129 patients aged 13.1 ± 2.6 years. FMD < 7% was found in 69 (52.7%). Patients with altered FMD had higher levels of triglycerides and hsCRP than those with normal FMD (145.5 mg/dl vs. 120.0 mg/dl, P = .042, y 1.24 U/L vs. 0.55 U/L, P = .007, respectively), as well as higher frequency of low iPTH (19.1% vs. 4.9%, P = .036). Levels of hsCRP correlated significantly with FMD (Rho = -0.28, P = .003). Patients with low iPTH (OR = 4.41, 95%CI 1.13-17.27, P = .033) and increased hsCRP (OR = 2.89, 95%CI 1.16-7.17, P = .022) had higher adjusted risk of having FMD < 7%. CONCLUSIONS Hypertriglyceridemia, inflammation and low iPTH associated significantly with altered FMD. They are frequent, treatable risk factors for CVD.
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Affiliation(s)
- Juan Antonio García-Bello
- División de Investigación, Unidad Médica de Alta Especialidad Hospital de Gineco Obstetricia No. 3, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Rita A Gómez-Díaz
- Unidad de Investigación Médica en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico.
| | - Alicia Contreras-Rodríguez
- Servicio de Radiodiagnóstico, Unidad Médica de Alta Especialidad Hospital de Cardiología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Lorena Sánchez-Barbosa
- Coordinación de Unidades Médicas de Alta Especialidad, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Rafael Mondragón-González
- Unidad de Investigación Médica en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Juan Manuel Gallardo-Montoya
- Enfermedades Nefrológicas, Unidad Médica de Alta Especialidad Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Niels H Wacher
- Unidad de Investigación Médica en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
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28
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Differentiating the causes of adynamic bone in advanced chronic kidney disease informs osteoporosis treatment. Kidney Int 2021; 100:546-558. [PMID: 34102219 DOI: 10.1016/j.kint.2021.04.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022]
Abstract
Patients with chronic kidney disease (CKD) have an increased fracture risk because of impaired bone quality and quantity. Low bone mineral density predicts fracture risk in all CKD stages, including advanced CKD (CKD G4-5D). Pharmacological therapy improves bone mineral density and reduces fracture risk in moderate CKD. Its efficacy in advanced CKD remains to be determined, although pilot studies suggest a positive effect on bone mineral density. Currently, antiresorptive agents are the most commonly prescribed drugs for the prevention and therapy of osteoporosis. Their use in advanced CKD has been limited by the lack of large clinical trials and fear of causing kidney dysfunction and adynamic bone disease. In recent decades, adynamic bone disease has evolved as the most predominant form of renal osteodystrophy, commonly associated with poor outcomes, including premature mortality and progression of vascular calcification. Evolving evidence indicates that reduction of bone turnover by parathyroidectomy or pharmacological therapies, such as calcimimetics and antiresorptive agents, are not associated with premature mortality or accelerated vascular calcification in CKD. In contrast, chronic inflammation, oxidative stress, malnutrition, and diabetes can induce low bone turnover and associate with poor prognosis. Thus, the conditions causing suppression of bone turnover rather than the low bone turnover per se may account for the perceived association with outcomes. Anabolic treatment, in contrast, has been suggested to improve turnover and bone mass in patients with advanced CKD and low bone turnover; however, uncertainty about safety even exceeds that of antiresorptive agents. Here, we critically review the pathophysiological concept of adynamic bone disease and discuss the effect of low bone turnover on the safety and efficacy of anti-osteoporosis pharmacotherapy in advanced CKD.
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29
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Fathala AL, Alkulaybi S, Khawaji A, Alomari A, Almuhaideb A. The association between low bone mineral density and coronary artery calcification in osteoporotic and non-osteoporotic patients in a tertiary center in Saudi Arabia. Ann Saudi Med 2021; 41:101-108. [PMID: 33818146 PMCID: PMC8020646 DOI: 10.5144/0256-4947.2021.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) and osteoporosis are major health-care concerns worldwide. The evidence is contradictory on whether a relationship exists between low bone mineral density (BMD) determined by dual-energy absorptiometry (DXA scan) and coronary artery calcification (CAC) measured by computed tomography. Currently, there are no data on patients from Saudi Arabia. OBJECTIVE Examine the relationship between CAC and BMD in both genders and study the influence of traditional coronary artery disease (CAD) risk factors and osteoporosis. DESIGN Retrospective, cross-sectional, analytical. SETTING Single tertiary care center. PATIENTS AND METHODS We searched radiology databases for patients who underwent both DXA and CAC score scanning within six months of each other. The inclusion criterion was an absence of any history of CAD. MAIN OUTCOME MEASURE Association between osteoporosis and CAC. SAMPLE SIZE 195 (34 osteoporosic, 161 normal BMD or osteopenic) RESULTS: Most of the study population (57.4%) were females. The mean age of all patients was 63.6 (10.1) years. Participants with CAC scores of 0 were significantly younger than those who had CAC scores >0. The presence of diabetes mellitus, hypertension, and hypercholesterolemia was higher in patients with CAC scores >0. CAC score and other CAD risk factors were not significantly different between the osteoporotic and nonosteoporotic groups, except for body mass index. A high CAC score (>100) was present in 28%, 20%, 11%, and 30% of participants with no osteoporosis, osteoporosis of the lumbar spine, osteoporosis of the femoral neck, and participants with osteoporosis of both the lumbar spine and femoral neck, respectively (P=.762), suggesting there is no association between CAC and the presence of osteoporosis. CONCLUSIONS Osteoporosis is not associated with higher CAC scores in Saudi Arabia and CAD risk factors are not significantly prevalent in osteoporosis. It appears that CAC and osteoporosis are independent age-related diseases that share common risk factors. LIMITATIONS Single-center, retrospective. CONFLICT OF INTEREST None.
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Affiliation(s)
- Ahmed L Fathala
- From the Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Sami Alkulaybi
- From the Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulrahman Khawaji
- From the Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdelghafour Alomari
- From the Department of Family Medicine, Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ahmed Almuhaideb
- From the Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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30
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Endothelial dysfunction in children with chronic kidney disease. Nefrologia 2021. [PMID: 33602566 DOI: 10.1016/j.nefro.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Cardiovascular disease is the main cause of death in children with chronic kidney disease. Inflammation and endothelial dysfunction are found in the majority of these patients and are factors associated to cardiovascular disease. Flow mediated dilatation (FMD) is a surrogate marker validated for evaluating endothelial dysfunction. Our objective was to identify risk factors associated to endothelial dysfunction in children with chronic kidney disease. MATERIALS AND METHODS Children 2-16 years of age were studied. Clinical information and biochemical variables were gathered, including intact parathyroid hormone (iPTH), interleukins 6 and 1β, high sensitivity C reactive protein (hsCRP), reduced glutathione, nitric oxide, malondialdehyde and homocysteine. FMD was measured, and considered altered if<7%. RESULTS Included were 129 patients aged 13.1±2.6 years. FMD<7% was found in 69 (52.7%). Patients with altered FMD had higher levels of triglycerides and hsCRP than those with normal FMD (145.5 vs. 120.0mg/dL, P=.042, and 1.24 vs. 0.55U/L, P=.007, respectively), as well as higher frequency of low iPTH (19.1 vs. 4.9%, P=.036). Levels of hsCRP correlated significantly with FMD (Rho=-0.28, P=.003). Patients with low iPTH (OR 4.41, 95% CI 1.13-17.27, P=.033) and increased hsCRP (OR 2.89, 95% CI 1.16-7.17, P=.022) had higher adjusted risk of having FMD<7%. CONCLUSIONS Hypertriglyceridemia, inflammation and low iPTH associated significantly with altered FMD. They are frequent, treatable risk factors for cardiovascular disease.
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31
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Hildebrand S, Cunningham J. Is there a role for bisphosphonates in vascular calcification in chronic kidney disease? Bone 2021; 142:115751. [PMID: 33188959 DOI: 10.1016/j.bone.2020.115751] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 10/28/2020] [Accepted: 11/09/2020] [Indexed: 01/15/2023]
Abstract
Theoretically bisphosphonates could accelerate or retard vascular calcification. In subjects with low GFR, the position is further confounded by a combination of uncertain pharmacokinetics (GI absorption is poor and inconsistent at all levels of renal function and the effect of low GFR generally is to increase bioavailability) and a highly variable skeletal substrate with extremes of turnover that increase unpredictably further. Although bisphosphonates reduce bone formation by 70-90% in subjects with normal GFR and reduce the ability of bone to buffer exogenous calcium fluxes, in bisphosphonate treated postmenopausal women accelerated vascular calcification has not been documented. The kidneys assist with this buffering, but the capacity to modulate calcium excretion declines as GFR falls, increasing the risk of hypercalcaemia in the event of high calcium influx. In the ESRD patient, decreased buffering capacity substantially increases the risk of transient hypercalcaemia, especially in the setting of dialysis, and as such may promote vascular calcification which is highly prevalent in the CKD population. Low bone turnover may thus be less of a vascular problem in patients with preserved renal function and a bigger problem when the GFR is low. In patients with stage 4 and 5 CKD, adynamic bone disease associates with the severity and progression of arterial calcification, including coronary artery calcification, and further suppression of bone turnover by a bisphosphonate might exacerbate an already high predisposition to vascular calcification. No convincing signal of harm has emerged from clinical studies thus far. For example 51 individuals with CKD stage 3-4 treated with either alendronate 70 mg per week or placebo for 18 months showed no difference in the rate of vascular calcifications. Conversely an observational study of women with stage 3-4 CKD with pre-existing cardiovascular disease found an increased risk of mortality with a hazard ratio of 1.22 (1.04-1.42) in those given bisphosphonates. Direct suppression of vascular calcification by bisphosphonates is probably confined to etidronate - treatment of soft tissue calcification was a recognized indication for this drug and etidronate markedly reduced progression of vascular calcification in CKD patients. Bisphosphonates are analogues of pyrophosphate, a potent calcification inhibitor in bone and soft tissue. Thus the efficacy of etidronate as treatment for soft tissue calcification brought with it a problematic tendency to cause osteomalacia. In contrast, conventional doses of nitrogen-containing bisphosphonates fail to yield circulating concentrations sufficient to exert direct anti-calcifying effects, at least in patients with good renal function and studies using alendronate and ibandronate have yielded inconsistent vascular outcomes.
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Affiliation(s)
- S Hildebrand
- Centre for Nephrology, Royal Free Hospital, London, UK.
| | - J Cunningham
- Centre for Nephrology, Royal Free Hospital, London, UK
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32
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Elias RM, Moe S, Moysés RMA. Skeletal and cardiovascular consequences of a positive calcium balance during hemodialysis. J Bras Nefrol 2020; 43:539-550. [PMID: 33107900 PMCID: PMC8940101 DOI: 10.1590/2175-8239-jbn-2020-0098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/23/2020] [Indexed: 11/22/2022] Open
Abstract
Patients on hemodialysis are exposed to calcium via the dialysate at least three times a week. Changes in serum calcium vary according to calcium mass transfer during dialysis, which is dependent on the gradient between serum and dialysate calcium concentration (d[Ca]) and the skeleton turnover status that alters the ability of bone to incorporate calcium. Although underappreciated, the d[Ca] can potentially cause positive calcium balance that leads to systemic organ damage, including associations with mortality, myocardial dysfunction, hemodynamic tolerability, vascular calcification, and arrhythmias. The pathophysiology of these adverse effects includes serum calcium changes, parathyroid hormone suppression, and vascular calcification through indirect and direct effects. Some organs are more susceptible to alterations in calcium homeostasis. In this review, we discuss the existing data and potential mechanisms linking the d[Ca] to calcium balance with consequent dysfunction of the skeleton, myocardium, and arteries.
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Affiliation(s)
- Rosilene M Elias
- Universidade de São Paulo, Hospital das Clínicas, Departamento de Medicina, Divisão de Nefrologia, São Paulo, SP, Brasil.,Universidade Nove de Julho, São Paulo, SP, Brasil
| | - Sharon Moe
- Indiana University School of Medicine, Department of Medicine, Division of Nephrology, Indianapolis, Indiana, USA.,Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA
| | - Rosa M A Moysés
- Universidade de São Paulo, Hospital das Clínicas, Departamento de Medicina, Divisão de Nefrologia, São Paulo, SP, Brasil
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33
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Trabecular bone score may indicate chronic kidney disease-mineral and bone disorder (CKD-MBD) phenotypes in hemodialysis patients: a prospective observational study. BMC Nephrol 2020; 21:299. [PMID: 32711466 PMCID: PMC7382149 DOI: 10.1186/s12882-020-01944-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 07/12/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In the general population, the trabecular bone score (TBS) represents the bone microarchitecture and predicts fracture risk independent of bone mineral density (BMD). A few studies reported that TBS is significantly reduced in dialysis patients. Chronic kidney disease-mineral and bone disorder (CKD-MBD) are accompanied by increased fracture risk, cardiovascular morbidity, and mortality. We investigated whether TBS is associated with comorbidity related to CKD-MBD or frailty in hemodialysis patients. METHODS In this prospective observational study, TBS was obtained using the TBS iNsight software program (Med-Imaps) with BMD dual energy x-ray absorptiometry (DXA) images (L1-L4) from prevalent hemodialysis patients. A Tilburg frailty indicator was used to evaluate frailty, and hand grip strength and bio-impedance (InBody) were measured. A patient-generated subjective global assessment (PG-SGA) was used for nutritional assessment. The history of cardiovascular events (CVE) and demographic, clinical, laboratory, and biomarker data were collated. We then followed up patients for the occurrence of CKD-MBD related complications. RESULTS We enrolled 57 patients in total. The mean age was 56.8 ± 15.9 years (50.9% female). Prevalence of Diabetes mellitus (DM) was 40.4% and CVE was 36.8%. Mean TBS was 1.44 ± 0.10. TBS significantly reduced in the CVE group (1.38 ± 0.08 vs. 1.48 ± 0.10, p < 0.001). Multivariable regression analysis was conducted adjusting for age, sex, dialysis vintage, DM, CVE, albumin, intact parathyroid hormone, fibroblast growth factor 23, handgrip strength, and phosphate binder dose. Age (ß = - 0.030; p = 0.001) and CVE (ß = - 0.055; p = 0.024) were significant predictors of TBS. During the follow up period after TBS measurements (about 20 months), four deaths, seven incident fractures, and six new onset CVE were recorded. Lower TBS was associated with mortality (p = 0.049) or new onset fracture (p = 0.007, by log-rank test). CONCLUSION Lower TBS was independently associated with increased age and CVE prevalence in hemodialysis patients. Mortality and fracture incidence were significantly higher in patients with lower TBS values. These findings suggest that TBS may indicate a phenotype of frailty and also a CKD-MBD phenotype reciprocal to CVE.
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34
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Iseri K, Dai L, Chen Z, Qureshi AR, Brismar TB, Stenvinkel P, Lindholm B. Bone mineral density and mortality in end-stage renal disease patients. Clin Kidney J 2020; 13:307-321. [PMID: 32699616 PMCID: PMC7367137 DOI: 10.1093/ckj/sfaa089] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Indexed: 12/17/2022] Open
Abstract
Osteoporosis characterized by low bone mineral density (BMD) as assessed by dual-energy X-ray absorptiometry (DXA) is common among end-stage renal disease (ESRD) patients and associates with high fracture incidence and high all-cause mortality. This is because chronic kidney disease-mineral bone disorders (CKD-MBDs) promote not only bone disease (osteoporosis and renal dystrophy) but also vascular calcification and cardiovascular disease. The disturbed bone metabolism in ESRD leads to 'loss of cortical bone' with increased cortical porosity and thinning of cortical bone rather than to loss of trabecular bone. Low BMD, especially at cortical-rich bone sites, is closely linked to CKD-MBD, vascular calcification and poor cardiovascular outcomes. These effects appear to be largely mediated by shared mechanistic pathways via the 'bone-vascular axis' through which impaired bone status associates with changes in the vascular wall. Thus, bone is more than just the scaffolding that holds the body together and protects organs from external forces but is-in addition to its physical supportive function-also an active endocrine organ that interacts with the vasculature by paracrine and endocrine factors through pathways including Wnt signalling, osteoprotegerin (OPG)/receptor activator of nuclear factor-κB (RANK)/RANK ligand system and the Galectin-3/receptor of advanced glycation end products axis. The insight that osteogenesis and vascular calcification share many similarities-and the knowledge that vascular calcification is a cell-mediated active rather than a passive mineralization process-suggest that low BMD and vascular calcification ('vascular ossification') to a large extent represent two sides of the same coin. Here, we briefly review changes of BMD in ESRD as observed using different DXA methods (central and whole-body DXA) at different bone sites for BMD measurements, and summarize recent knowledge regarding the relationships between 'low BMD' and 'fracture incidence, vascular calcification and increased mortality' in ESRD patients, as well as potential 'molecular mechanisms' underlying these associations.
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Affiliation(s)
- Ken Iseri
- Department of Clinical Science, Intervention and Technology, Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Division of Nephrology, Showa University School of Medicine, Tokyo, Japan
| | - Lu Dai
- Department of Clinical Science, Intervention and Technology, Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - Zhimin Chen
- Department of Clinical Science, Intervention and Technology, Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Abdul Rashid Qureshi
- Department of Clinical Science, Intervention and Technology, Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - Torkel B Brismar
- Department of Clinical Science, Intervention and Technology, Division of Medical Imaging and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Karolinska University Hospital, Huddinge, Sweden
| | - Peter Stenvinkel
- Department of Clinical Science, Intervention and Technology, Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Department of Clinical Science, Intervention and Technology, Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden
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Pereira L, Frazão JM. The bone-vessel axis in chronic kidney disease: An update on biochemical players and its future role in laboratory medicine. Clin Chim Acta 2020; 508:221-227. [PMID: 32422129 DOI: 10.1016/j.cca.2020.05.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 03/31/2020] [Accepted: 05/11/2020] [Indexed: 12/16/2022]
Abstract
Vascular wall calcification (VC) is highly prevalent in patients with chronic kidney disease (CKD). In CKD, VC is more frequent and severe than in the general population and it is associated with increased cardiovascular mortality and morbidity. In the last years, laboratory and clinical evidence have drawn the attention to the relationship between bone disease and VC in CKD patients, leading to the concept of a bone-vessel or bone-vascular axis. It means that disorders of bone volume and bone turnover may influence the risk of VC and ultimately the high risk of cardiovascular mortality. In fact, a higher burden of VC has been associated to low bone volume and low bone turnover in hemodialysis (HD) patients with renal osteodystrophy characterized by histomorphometric evaluation of bone biopsies. The molecular mechanisms underlying the regulation of bone cells and vascular cells in CKD are poorly understood. In this review, we discuss relevant evidence linking bone disorders and VC in CKD and also rising molecular players involved in this bone-vascular axis. Indeed, accumulating data is available for two proposed systems: receptor activator for nuclear factor kB (RANK)/ RANK ligand (RANKL)/osteoprotegerin (OPG) system and inhibitors of Wnt signaling - mainly sclerostin. Although they are promising biochemical markers linking bone formation and bone reabsorption with VC, there is a long way to go as long evidence from laboratory studies is often divergent to the clinical data as will be discussed. Future prospective studies are needed in order to evaluate the role of these biochemical players as useful clinical markers for VC, bone volume and perhaps bone turnover.
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Affiliation(s)
- Luciano Pereira
- Institute of Investigation and Innovation in Health, University of Porto, Portugal; INEB - National Institute of Biomedical Engineering, University of Porto, Portugal; Department of Nephrology, São João Hospital Center, Porto, Portugal
| | - João M Frazão
- Institute of Investigation and Innovation in Health, University of Porto, Portugal; INEB - National Institute of Biomedical Engineering, University of Porto, Portugal; Department of Nephrology, São João Hospital Center, Porto, Portugal.
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Aaltonen L, Koivuviita N, Seppänen M, Tong X, Kröger H, Löyttyniemi E, Metsärinne K. Correlation between 18F-Sodium Fluoride positron emission tomography and bone histomorphometry in dialysis patients. Bone 2020; 134:115267. [PMID: 32058018 DOI: 10.1016/j.bone.2020.115267] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/03/2020] [Accepted: 02/09/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The diagnosis of renal osteodystrophy is challenging. Bone biopsy is the gold standard, but it is invasive and limited to one site of the skeleton. The ability of biomarkers to estimate the underlying bone pathology is limited. 18F-Sodium Fluoride positron emission tomography (18F-NaF PET) is a noninvasive quantitative imaging technique that allows assessment of regional bone turnover at clinically relevant sites. The hypothesis of this study was, that 18F-NaF PET correlates with bone histomorphometry in dialysis patients and could act as a noninvasive diagnostic tool in this patient group. METHODS This was a cross-sectional diagnostic test study. 26 dialysis patients with biochemical abnormalities indicating mineral and bone disorder were included. All the participants underwent a 18F-NaF PET scan and a bone biopsy. Fluoride activity in the PET scan was measured in the lumbar spine and at the anterior iliac crest. Dynamic and static histomorphometric parameters of the bone biopsy were assessed. As histomorphometric markers for bone turnover we used bone formation rate per bone surface (BFR/BS) and activation frequency per year (Ac.f). RESULTS There was a statistically significant correlation between fluoride activity in the 18F-NaF PET scan and histomorphometric parameters such as bone formation rate, activation frequency and osteoclast and osteoblast surfaces and mineralized surfaces. 18F-NaF PET's sensitivity to recognize low turnover in respect to non-low turnover was 76% and specificity 78%. Because of the small number of patients with high turnover, we were unable to demonstrate significant predictive value in this group. CONCLUSIONS A clear correlation between histomorphometric parameters and fluoride activity in the 18F-NaF PET scan was established. 18F-NaF PET may possibly be a noninvasive diagnostic tool in dialysis patients with low turnover bone disease, but further research is needed.
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Affiliation(s)
- Louise Aaltonen
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, Turku 20521, Finland.
| | - Niina Koivuviita
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, Turku 20521, Finland
| | - Marko Seppänen
- Department of Clinical Physiology, Nuclear Medicine and Turku PET Centre, University of Turku, Kiinamyllynkatu 4-8, Turku 20521, Finland
| | - Xiaoyu Tong
- Kuopio Musculoskeletal Research Unit (KMRU), Institute of Clinical Medicine, University of Eastern Finland, POB 1627, Kuopio, Finland
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit (KMRU), Institute of Clinical Medicine, University of Eastern Finland, POB 1627, Kuopio, Finland; Kuopio University Hospital, Kuopio, Finland
| | - Eliisa Löyttyniemi
- Department of Biostatistics, University of Turku, Kiinamyllynkatu 10, 20014 Turku, Finland
| | - Kaj Metsärinne
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, Turku 20521, Finland
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Costa LR, Carvalho AB, Bittencourt AL, Rochitte CE, Canziani MEF. Cortical unlike trabecular bone loss is not associated with vascular calcification progression in CKD patients. BMC Nephrol 2020; 21:121. [PMID: 32252657 PMCID: PMC7137513 DOI: 10.1186/s12882-020-01756-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 03/05/2020] [Indexed: 11/17/2022] Open
Abstract
Background Vascular calcification progression has been associated with the loss of trabecular bone in chronic kidney disease (CKD) patients. There are few data evaluating the relationship between cortical bone loss and vascular calcification in this population. The aim of this study was to prospectively evaluate the association between changes in cortical bone density and coronary artery calcification (CAC) progression in non-dialyzed CKD patients. Methods Changes of cortical and trabecular bone, and changes of calcium score, were analyzed using vertebral tomographic images from a prospective study. Automatic delineation of the cortical bone layer was performed by Image J software, and trabecular bone was determined by selecting a region of interest using Vitrea 2® software. Cortical and trabecular bone density (BD) were expressed in Hounsfield Units (HU), and coronary artery calcium score in Agatston Units (AU). Results Seventy asymptomatic patients [57.8 ± 10.2 years, 63% males, 20% diabetic, estimated glomerular filtration rate (eGFR) = 37.3 (24.8–51.3) mL/min/1.73m2] were followed for 24 months. The mean cortical and trabecular BD did not change over time. While 49 patients lost either bone, 29 (41%) patients lost cortical [− 4.4%/year (ranging from − 7.15 to − 0.5)] and 39 (56%) lost trabecular bone [− 3.15%/year (− 13.7 to − 0.25)]. There was no association between cortical and trabecular BD changes (p = 0.12). CAC was observed in 33 (46%) patients at baseline, and 30 (91%) of them showed CAC progression. While an inverse correlation between trabecular bone and calcium score changes was observed (p = 0.001), there was no correlation between cortical bone and calcium score changes (p = 0.34). Conclusion CKD patients experience either cortical or trabecular bone loss over time, but these changes do not take place simultaneously in all patients. Cortical, unlike trabecular bone loss, is not associated with vascular calcification progression in these patients.
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Affiliation(s)
- Larissa R Costa
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 282 - Vila Clementino, São Paulo, SP, 04039-000, Brazil.
| | - Aluizio B Carvalho
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 282 - Vila Clementino, São Paulo, SP, 04039-000, Brazil
| | - Amandha L Bittencourt
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 282 - Vila Clementino, São Paulo, SP, 04039-000, Brazil
| | - Carlos E Rochitte
- Heart Institute of the University of São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44 - Pacaembu, São Paulo, SP, 05403-900, Brazil
| | - Maria Eugênia F Canziani
- Nephrology Division of Federal University of São Paulo, Rua Pedro de Toledo, 282 - Vila Clementino, São Paulo, SP, 04039-000, Brazil
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Goto K, Goto S, Fujii H, Watanabe K, Kono K, Nishi S. Effects of lanthanum carbonate on bone markers and bone mineral density in incident hemodialysis patients. J Bone Miner Metab 2019; 37:1075-1082. [PMID: 31214836 DOI: 10.1007/s00774-019-01018-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 06/03/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Recent clinical studies demonstrated the favorable effects of calcium-free phosphate binders on mortality and vascular calcification in hemodialysis (HD) patients. The aim of the present study was to investigate the effects of a calcium-free phosphate binder, lanthanum carbonate (LC), on bone metabolic markers and bone mineral density (BMD), compared with those of calcium carbonate (CC), in subjects new to HD. MATERIALS AND METHODS The present study included 65 subjects from our previous randomized controlled trial (LC group, N = 31; CC group, N = 34). We investigated the effects of LC on serum intact parathyroid hormone (iPTH), osteocalcin (OC), bone-specific alkaline phosphatase (BAP), tartrate-resistant acid phosphatase 5b (TRACP-5b), sclerostin levels, and BMD, compared with those of CC in patients new to HD at baseline and at 12 and 18 months. RESULTS Serum OC levels at 18 months were significantly higher in the LC group than in the CC group. During the study period, serum BAP and TRACP-5b and iPTH levels tended to be higher in the LC group than in the CC group. At 18 months, the percentage of low bone turnover, based on a serum BAP cutoff value, was significantly lower in the LC group than in the CC group. There were no significant differences in the lumbar and femoral BMD between the two groups. CONCLUSIONS The results of the present study suggest that LC has potential in preventing low bone turnover, in comparison to CC, in patients new to HD.
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Affiliation(s)
- Kimihiko Goto
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Shunsuke Goto
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hideki Fujii
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Kentaro Watanabe
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Keiji Kono
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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Gueiros APS, Gueiros JEDB, Nóbrega KT, Calado EB, da Matta MC, Torres LC, Souza ASR, Casarini DE, de Carvalho AB. Effect of spironolactone on the progression of coronary calcification in peritoneal dialysis patients: a pilot study. J Bras Nefrol 2019; 41:345-355. [PMID: 31419271 PMCID: PMC6788848 DOI: 10.1590/2175-8239-jbn-2019-0009] [Citation(s) in RCA: 4] [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: 01/11/2019] [Accepted: 04/21/2019] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION There is evidence that aldosterone plays a role in the pathogenesis of vascular calcification. The aim of this study was to evaluate the effect of spironolactone, a mineralocorticoid receptor antagonist, on the progression of coronary calcification (CC) in peritoneal dialysis patients and to identify the factors involved in this progression. METHODS Thirty-three patients with a coronary calcium score (CCS) ≥ 30, detected through multi-detector computed tomography (MDCT) and expressed in Agatston units, were randomly assigned to a group receiving 25mg spironolactone per day for 12 months (spironolactone group) and a control group not receiving this drug. The primary outcome was a percentage change in CCS from baseline to end of the study (relative progression), when a further MDCT was conducted. Patients who had progression of CC were compared with those who did not progress. RESULTS Sixteen patients, seven in the spironolactone group and nine in the control group, concluded the study. The relative progression of the CCS was similar in both groups, 17.2% and 27.5% in the spironolactone and control groups respectively. Fifty-seven percent of the treated patients and 67% of those in the control group presented progression in the CC scores (p = 0.697). Progressor patients differed from non-progressors because they presented higher levels of calcium and low-density lipoprotein cholesterol and lower levels of albumin. CONCLUSION In peritoneal dialysis patients, spironolactone did not attenuate the progression of CC. However, large-scale studies are needed to confirm this observation. Disorders of mineral metabolism and dyslipidemia are involved in the progression of CC.
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Affiliation(s)
- Ana Paula Santana Gueiros
- Instituto de Medicina Integral Professor
Fernando FigueiraServiço de NefrologiaRecifePEBrasilInstituto de Medicina Integral Professor
Fernando Figueira, Serviço de Nefrologia, Recife, PE, Brasil.
| | - José Edevanilson de Barros Gueiros
- Instituto de Medicina Integral Professor
Fernando FigueiraServiço de NefrologiaRecifePEBrasilInstituto de Medicina Integral Professor
Fernando Figueira, Serviço de Nefrologia, Recife, PE, Brasil.
| | - Karina Tavares Nóbrega
- Instituto de Medicina Integral Professor
Fernando FigueiraServiço de RadiologiaRecifePEBrasilInstituto de Medicina Integral Professor
Fernando Figueira, Serviço de Radiologia, Recife, PE, Brasil.
| | - Eveline Barros Calado
- Instituto de Medicina Integral Professor
Fernando FigueiraServiço de RadiologiaRecifePEBrasilInstituto de Medicina Integral Professor
Fernando Figueira, Serviço de Radiologia, Recife, PE, Brasil.
| | - Marina Cadena da Matta
- Instituto de Medicina Integral Professor
Fernando FigueiraDepartamento de Pesquisa ClínicaRecifePEBrasilInstituto de Medicina Integral Professor
Fernando Figueira, Departamento de Pesquisa Clínica, Recife, PE,
Brasil.
| | - Leuridan Cavalcante Torres
- Instituto de Medicina Integral Professor
Fernando FigueiraDepartamento de Pesquisa ClínicaRecifePEBrasilInstituto de Medicina Integral Professor
Fernando Figueira, Departamento de Pesquisa Clínica, Recife, PE,
Brasil.
| | - Alex Sandro Rolland Souza
- Instituto de Medicina Integral Professor
Fernando FigueiraDepartamento de Pesquisa ClínicaRecifePEBrasilInstituto de Medicina Integral Professor
Fernando Figueira, Departamento de Pesquisa Clínica, Recife, PE,
Brasil.
| | - Dulce Elena Casarini
- Universidade Federal de São PauloSão PauloSPBrasilUniversidade Federal de São Paulo, Disciplina
de Nefrologia, São Paulo, SP, Brasil.
| | - Aluizio Barbosa de Carvalho
- Universidade Federal de São PauloSão PauloSPBrasilUniversidade Federal de São Paulo, Disciplina
de Nefrologia, São Paulo, SP, Brasil.
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Xiong Y, Li J, Sun S, Han M, Liao R, Li Y, Wang L, Lin L, Liu Q, Su B. Association of mineral content outside of bone with coronary artery calcium and 1-year cardiovascular prognosis in maintenance hemodialysis patients. Artif Organs 2019; 43:988-1001. [PMID: 30932185 PMCID: PMC6850757 DOI: 10.1111/aor.13461] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/12/2019] [Accepted: 03/18/2019] [Indexed: 02/05/2023]
Abstract
Coronary artery calcifications (CACs) are common among maintenance hemodialysis (MHD) patients and associated with increased morbidity and mortality due to cardiovascular events. The insight into chronic kidney disease‐mineral and bone disorder (CKD‐MBD) established a correlation between dysregulated mineral metabolism and CACs. This study aimed to identify the association of mineral content outside of bone (MCOB) with CACs and cardiovascular events in MHD patients. In the pilot prospective study with no intervention, patients underwent body composition assessment by body composition monitor after hemodialysis and computed tomography examination using the Agatston scoring method simultaneously within a week. The primary end point included cardiovascular events and cardiovascular death. Correlations and receiver operating characteristic analysis elucidated the associations of MCOB with CACs; multivariate analysis assessed the cardiovascular risk for groups with different MCOB. One hundred three eligible patients with an average age of 48 (35‐63) years old were enrolled and followed up to 12 (11‐12.5) months, among which 52.4% had detectable CACs at baseline. MCOB showed an inverse correlation with Agatston score and significantly discriminated the patients with Agatston score > 0 (AUC = 0.737; P < 0.001) and 400 (AUC = 0.733; P < 0.001). MCOB ≤ 9.2657 mg/kg was an independent risk factor for CACs (OR = 4.853; P = 0.044) and strong predictor for cardiovascular morbidity and mortality (HR = 10.108; P = 0.042), as well as rehospitalization (HR = 2.689; P = 0.004). MCOB inversely correlated with the presence and extent of CACs, and could discriminate Agatston score > 0 and 400, which also presented as an independent indicator for CKD‐MBD and 1‐year cardiovascular prognosis in adult MHD patients. Additional studies are required for identifying this issue.
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Affiliation(s)
- Yuqin Xiong
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiameng Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Si Sun
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Mei Han
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Ruoxi Liao
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Yupei Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Liya Wang
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Liping Lin
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang Liu
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
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Isaksson E, Ivarsson K, Akaberi S, Muth A, Prütz KG, Clyne N, Sterner G, Almquist M. Total versus subtotal parathyroidectomy for secondary hyperparathyroidism. Surgery 2018; 165:142-150. [PMID: 30413319 DOI: 10.1016/j.surg.2018.04.076] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/06/2018] [Accepted: 04/15/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND It remains unclear whether total or subtotal parathyroidectomy for secondary hyperparathyroidism yields the best outcomes. We investigated mortality, cardiovascular events, hip fracture, and recurrent parathyroidectomy after total versus subtotal parathyroidectomy in patients on renal replacement therapy. METHODS Using the Swedish Renal Registry, the surgical registry for thyroid and parathyroid surgery, and the National Inpatient Registry, we identified patients who underwent parathyroidectomy between 1991 and 2013. We calculated the risk of outcome after total versus subtotal parathyroidectomy using COX's regression, adjusting for age, sex, cause of renal disease, time with a functioning graft before and after parathyroidectomy, Charlson comorbidity index, year of surgery, prevalent cardiovascular disease, time on dialysis, renal transplantation at parathyroidectomy, and treatment with calcimimetics before parathyroidectomy. RESULTS There were 824 patients who underwent parathyroidectomy, 388 total and 436 subtotal. There was no difference in mortality or risk of incident hip fracture between groups. Comparing the subtotal with the total parathyroidectomy, the adjusted hazard ratio (95% confidence interval) for cardiovascular events was 0.43 (0.25-0.72) and for recurrent parathyroidectomy 3.33 (1.33-8.32). CONCLUSION There was a higher risk of cardiovascular events in patients after total parathyroidectomy compared with subtotal parathyroidectomy, but a lower risk of recurrent parathyroidectomy.
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Affiliation(s)
- Elin Isaksson
- Lund University, Faculty of Medicine, Department of Clinical Sciences, Nephrology, Malmö, Sweden
| | - Kerstin Ivarsson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Shahriar Akaberi
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Andreas Muth
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Karl-Göran Prütz
- Director, Swedish Renal Registry, Helsingborg Hospital, Department of Internal Medicine, Helsingborg, Sweden
| | - Naomi Clyne
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Gunnar Sterner
- Lund University, Faculty of Medicine, Department of Clinical Sciences, Nephrology, Malmö, Sweden
| | - Martin Almquist
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden.
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The unexpected presence of iron in bone biopsies of hemodialysis patients. Int Urol Nephrol 2018; 50:1907-1912. [PMID: 30136087 DOI: 10.1007/s11255-018-1936-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/06/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Bone biopsy defines classical diseases that constitute the renal osteodystrophy. There is a recent concern regarding other histological findings that are not appreciated by using the turnover, mineralization, and volume (TMV) classification. Iron (Fe) overload has been considered a new challenge and the real significance of the presence of this metal in bones is not completely elucidated. Therefore, the main goal of the current study was to not only to identify bone Fe, but also correlate its presence with demographic, and biochemical characteristics. METHODS This is a cross-sectional analysis of bone biopsies performed in 604 patients on dialysis from 2010 to 2014 in a tertiary academic Hospital. RESULTS Histomorphometric findings revealed the presence of Fe in 29.1%. Fe was associated with higher levels of serum ferritin and serum calcium. No TMV status was related to Fe bone overload. CONCLUSION Our study has highlighted that the presence of Fe in one-third of bone samples has unknown clinical significance. The lack of other contemporary bone biopsy study reporting Fe prevents us from comparison. The findings presented here should be specifically addressed in a future research and will require attention prior to implementation of any clinical guideline. If any proposed treatment, however, would change the bone Fe-related morbidity is undetermined.
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Ruospo M, Palmer SC, Natale P, Craig JC, Vecchio M, Elder GJ, Strippoli GFM. Phosphate binders for preventing and treating chronic kidney disease-mineral and bone disorder (CKD-MBD). Cochrane Database Syst Rev 2018; 8:CD006023. [PMID: 30132304 PMCID: PMC6513594 DOI: 10.1002/14651858.cd006023.pub3] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Phosphate binders are used to reduce positive phosphate balance and to lower serum phosphate levels for people with chronic kidney disease (CKD) with the aim to prevent progression of chronic kidney disease-mineral and bone disorder (CKD-MBD). This is an update of a review first published in 2011. OBJECTIVES The aim of this review was to assess the benefits and harms of phosphate binders for people with CKD with particular reference to relevant biochemical end-points, musculoskeletal and cardiovascular morbidity, hospitalisation, and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs of adults with CKD of any GFR category comparing a phosphate binder to another phosphate binder, placebo or usual care to lower serum phosphate. Outcomes included all-cause and cardiovascular death, myocardial infarction, stroke, adverse events, vascular calcification and bone fracture, and surrogates for such outcomes including serum phosphate, parathyroid hormone (PTH), and FGF23. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess evidence certainty. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised MD (SMD) for continuous outcomes. MAIN RESULTS We included 104 studies involving 13,744 adults. Sixty-nine new studies were added to this 2018 update.Most placebo or usual care controlled studies were among participants with CKD G2 to G5 not requiring dialysis (15/25 studies involving 1467 participants) while most head to head studies involved participants with CKD G5D treated with dialysis (74/81 studies involving 10,364 participants). Overall, seven studies compared sevelamer with placebo or usual care (667 participants), seven compared lanthanum to placebo or usual care (515 participants), three compared iron to placebo or usual care (422 participants), and four compared calcium to placebo or usual care (278 participants). Thirty studies compared sevelamer to calcium (5424 participants), and fourteen studies compared lanthanum to calcium (1690 participants). No study compared iron-based binders to calcium. The remaining studies evaluated comparisons between sevelamer (hydrochloride or carbonate), sevelamer plus calcium, lanthanum, iron (ferric citrate, sucroferric oxyhydroxide, stabilised polynuclear iron(III)-oxyhydroxide), calcium (acetate, ketoglutarate, carbonate), bixalomer, colestilan, magnesium (carbonate), magnesium plus calcium, aluminium hydroxide, sucralfate, the inhibitor of phosphate absorption nicotinamide, placebo, or usual care without binder. In 82 studies, treatment was evaluated among adults with CKD G5D treated with haemodialysis or peritoneal dialysis, while in 22 studies, treatment was evaluated among participants with CKD G2 to G5. The duration of study follow-up ranged from 8 weeks to 36 months (median 3.7 months). The sample size ranged from 8 to 2103 participants (median 69). The mean age ranged between 42.6 and 68.9 years.Random sequence generation and allocation concealment were low risk in 25 and 15 studies, respectively. Twenty-seven studies reported low risk methods for blinding of participants, investigators, and outcome assessors. Thirty-one studies were at low risk of attrition bias and 69 studies were at low risk of selective reporting bias.In CKD G2 to G5, compared with placebo or usual care, sevelamer, lanthanum, iron and calcium-based phosphate binders had uncertain or inestimable effects on death (all causes), cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. Sevelamer may lead to constipation (RR 6.92, CI 2.24 to 21.4; low certainty) and lanthanum (RR 2.98, CI 1.21 to 7.30, moderate certainty) and iron-based binders (RR 2.66, CI 1.15 to 6.12, moderate certainty) probably increased constipation compared with placebo or usual care. Lanthanum may result in vomiting (RR 3.72, CI 1.36 to 10.18, low certainty). Iron-based binders probably result in diarrhoea (RR 2.81, CI 1.18 to 6.68, high certainty), while the risks of other adverse events for all binders were uncertain.In CKD G5D sevelamer may lead to lower death (all causes) (RR 0.53, CI 0.30 to 0.91, low certainty) and induce less hypercalcaemia (RR 0.30, CI 0.20 to 0.43, low certainty) when compared with calcium-based binders, and has uncertain or inestimable effects on cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. The finding of lower death with sevelamer compared with calcium was present when the analysis was restricted to studies at low risk of bias (RR 0.50, CI 0.32 to 0.77). In absolute terms, sevelamer may lower risk of death (all causes) from 210 per 1000 to 105 per 1000 over a follow-up of up to 36 months, compared to calcium-based binders. Compared with calcium-based binders, lanthanum had uncertain effects with respect to all-cause or cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification and probably had reduced risks of treatment-related hypercalcaemia (RR 0.16, CI 0.06 to 0.43, low certainty). There were no head-to-head studies of iron-based binders compared with calcium. The paucity of placebo-controlled studies in CKD G5D has led to uncertainty about the effects of phosphate binders on patient-important outcomes compared with placebo.It is uncertain whether the effects of binders on clinically-relevant outcomes were different for patients who were and were not treated with dialysis in subgroup analyses. AUTHORS' CONCLUSIONS In studies of adults with CKD G5D treated with dialysis, sevelamer may lower death (all causes) compared to calcium-based binders and incur less treatment-related hypercalcaemia, while we found no clinically important benefits of any phosphate binder on cardiovascular death, myocardial infarction, stroke, fracture or coronary artery calcification. The effects of binders on patient-important outcomes compared to placebo are uncertain. In patients with CKD G2 to G5, the effects of sevelamer, lanthanum, and iron-based phosphate binders on cardiovascular, vascular calcification, and bone outcomes compared to placebo or usual care, are also uncertain and they may incur constipation, while iron-based binders may lead to diarrhoea.
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Affiliation(s)
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Patrizia Natale
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | | | - Grahame J Elder
- Westmead HospitalDepartment of Renal MedicineWestmeadNSWAustralia2145
- Garvan Institute of Medical ResearchOsteoporosis and Bone Biology DivisionDarlinghurstNSWAustralia2010
| | - Giovanni FM Strippoli
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Diaverum AcademyBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
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Pichler G, Haller MC, Kainz A, Wolf M, Redon J, Oberbauer R. Prognostic value of bone- and vascular-derived molecular biomarkers in hemodialysis and renal transplant patients: a systematic review and meta-analysis. Nephrol Dial Transplant 2018; 32:1566-1578. [PMID: 28025385 DOI: 10.1093/ndt/gfw387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 09/26/2016] [Indexed: 12/24/2022] Open
Abstract
Background Patients undergoing hemodialysis and kidney graft recipients are high-risk populations for cardiovascular and all-cause mortality. Fibroblast growth factor 23 (FGF23), osteoprotegerin (OPG), RANK ligand, osteopontin (OPN), Klotho protein and bone morphogenetic protein-7 (BMP-7) are bone- and vascular-derived molecular biomarkers that have been shown to be associated with cardiovascular surrogate end points; however, currently available data on the prognostic value of these biomarkers is inconsistent. The aim of the present study was to conduct a systematic review and meta-analysis in order to summarize the available evidence on the association of molecular biomarkers with mortality in individuals undergoing hemodialysis and renal transplant patients. Methods Two databases (MEDLINE and Embase) were systematically searched. Studies were eligible if the association of biomarker and mortality was reported as time-to-event data [hazard Ratio (HR)] or as effect size with a fixed time of follow-up [odds Ratio (OR)]. Abstracted HRs were converted onto a standard scale of effect and combined using a random effects model. Results From a total of 1170 studies identified in initial searches, 21 met the inclusion criteria. In hemodialysis patients, comparing the lower third with the upper third of baseline FGF23 distribution, pooled HRs (95% confidence intervals) were 1.94 (1.47, 2.56) for all-cause mortality and 2.4 (1.64, 3.51) for cardiovascular mortality. For the same comparison of baseline OPG distribution, pooled HRs were 1.8 (0.95, 3.39) for all-cause mortality and 2.53 (1.29, 4.94) for cardiovascular mortality. Reported risk estimates of RANK ligand, OPN, Klotho protein and BMP-7 were not suitable for pooling; however, only Klotho protein was significantly related to mortality. For kidney graft recipients, four studies that investigated the relationship of FGF23 and OPG with mortality were identified, all of which reported a significant association. Conclusions In hemodialysis patients, FGF23 is a predictor of all-cause and cardiovascular mortality, whereas the predictive value of OPG is restricted to cardiovascular mortality. Further studies are needed in order to gain insight into the prognostic value of these biomarkers in renal transplant recipients.
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Affiliation(s)
- Gernot Pichler
- Area of Cardiometabolic and Renal Risk, Institute for Biomedical Research INCLIVA, Valencia, Spain.,Hypertension Unit, Department of Internal Medicine, University Hospital Clínico of Valencia, Valencia, Spain.,Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Maria C Haller
- Center for Medical Statistics, Informatics and Intelligent Systems (CeMSIIS), Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria.,Department of Nephrology and Hypertension Diseases, Transplantation Medicine and Rheumatology, Krankenhaus Elisabethinen, Linz, Austria.,Methods Support Team European Renal Best Practice, Ghent University Hospital, Ghent, Belgium
| | - Alexander Kainz
- Center for Medical Statistics, Informatics and Intelligent Systems (CeMSIIS), Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria
| | - Myles Wolf
- Division of Nephrology, Department of Medicine and Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Josep Redon
- Area of Cardiometabolic and Renal Risk, Institute for Biomedical Research INCLIVA, Valencia, Spain.,CIBER Physiopathology of Obesity and Nutrition (CIBEROBN), Institute of Health Carlos III, Madrid, Spain
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
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Chen Z, Sun J, Haarhaus M, Barany P, Wennberg L, Ripsweden J, Brismar TB, Lindholm B, Wernerson A, Söderberg M, Stenvinkel P, Qureshi AR. Bone mineral density of extremities is associated with coronary calcification and biopsy-verified vascular calcification in living-donor renal transplant recipients. J Bone Miner Metab 2017; 35:536-543. [PMID: 27913900 DOI: 10.1007/s00774-016-0788-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 09/12/2016] [Indexed: 12/21/2022]
Abstract
Chronic kidney disease (CKD) mineral and bone disorders (CKD-MBD) may lead to low bone mineral density (BMD) and vascular calcification (VC), but links to the latter are unclear. Here we investigated associations between BMD, coronary artery calcium (CAC) scores, and histological signs of VC in end-stage renal disease (ESRD) patients undergoing living-donor kidney transplantation (LD-Rtx). In 66 ESRD patients (median age 45 years, 68% males), BMD (by dual-energy X-ray absorptiometry, DXA), CAC score (by computed tomography, CT; n = 54), and degree of VC score (graded by histological examination of epigastric artery specimens collected at LD-Rtx; n = 55) were assessed at the time of LD-Rtx. Of the patients, 26% had osteopenia and 7% had osteoporosis. Of those undergoing artery biopsy, 16% had extensive VC, and of those undergoing CT 28% had high CAC score (>100 Agatston units). CAC scores correlated with BMD of legs and pelvis. BMDs of leg and pelvic sub-regions were significantly lower in patients with extensive VC. In multivariate regression analysis adjusted for age and gender, lower BMD of leg sub-region was associated with CAC score >100 AUs and extensive VC, and patients with extensive VC had significantly higher CAC score. Both high CAC and extensive VC were independently predicted by low BMD of legs. Low BMD has the potential to identify ESRD patients at risk of vascular calcification.
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Affiliation(s)
- Zhimin Chen
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, M-99 Karolinska University Hospital, Huddinge, CLINTEC, SE-141 86, Stockholm, Sweden
- Kidney Disease Center, 1st Affiliated Hospital College of Medicine, Zhejiang University, Hangzhou, China
| | - Jia Sun
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, M-99 Karolinska University Hospital, Huddinge, CLINTEC, SE-141 86, Stockholm, Sweden
| | - Mathias Haarhaus
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, M-99 Karolinska University Hospital, Huddinge, CLINTEC, SE-141 86, Stockholm, Sweden
| | - Peter Barany
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, M-99 Karolinska University Hospital, Huddinge, CLINTEC, SE-141 86, Stockholm, Sweden
| | - Lars Wennberg
- Transplantation Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Jonaz Ripsweden
- Radiology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | | | - Bengt Lindholm
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, M-99 Karolinska University Hospital, Huddinge, CLINTEC, SE-141 86, Stockholm, Sweden
| | - Annika Wernerson
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, M-99 Karolinska University Hospital, Huddinge, CLINTEC, SE-141 86, Stockholm, Sweden
| | - Magnus Söderberg
- Pathology, Drug Safety and Metabolism, AstraZeneca, Mölndal, Sweden
| | - Peter Stenvinkel
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, M-99 Karolinska University Hospital, Huddinge, CLINTEC, SE-141 86, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Divisions of Renal Medicine and Baxter Novum, Karolinska Institutet, M-99 Karolinska University Hospital, Huddinge, CLINTEC, SE-141 86, Stockholm, Sweden.
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46
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Adragao T, Ferreira A, Frazao JM, Papoila AL, Pinto I, Monier-Faugere MC, Malluche HH. Higher mineralized bone volume is associated with a lower plain X-Ray vascular calcification score in hemodialysis patients. PLoS One 2017; 12:e0179868. [PMID: 28686736 PMCID: PMC5501435 DOI: 10.1371/journal.pone.0179868] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 06/04/2017] [Indexed: 11/19/2022] Open
Abstract
Background and objectives In dialysis patients, there is an increasing evidence that altered bone metabolism is associated with cardiovascular calcifications. The main objective of this study was to analyse, in hemodialysis patients, the relationships between bone turnover, mineralization and volume, evaluated in bone biopsies, with a plain X-ray vascular calcification score. Design, setting, participants and measurements In a cross-sectional study, bone biopsies and evaluation of vascular calcifications were performed in fifty hemodialysis patients. Cancellous bone volume, mineralized bone volume, osteoid volume, activation frequency, bone formation rate/bone surface, osteoid thickness and mineralization lag time were determined by histomorphometry. Vascular calcifications were assessed by the simple vascular calcification score (SVCS) in plain X-Ray of pelvis and hands and, for comparison, by the Agatston score in Multi-Slice Computed Tomography (MSCT). Results SVCS≥3 was present in 20 patients (40%). Low and high bone turnover were present in 54% and 38% of patients, respectively. Low bone volume was present in 20% of patients. In multivariable analysis, higher age (p = 0.015) and longer hemodialysis duration (p = 0.017) were associated with SVCS≥3. Contrary to cancellous bone volume, the addition to this model of mineralized bone volume (OR = 0.863; 95%CI: 0.766, 0.971; p = 0.015), improved the performance of the model. For each increase of 1% in mineralized bone volume there was a 13.7% decrease in the odds of having SVCS≥3 (p = 0.015). An Agatston score>400 was observed in 80% of the patients with a SVCS≥3 versus 4% of patients with a SVCS<3, (p<0.001). Conclusion Higher mineralized bone volume was associated with a lower plain X-ray vascular calcification. This study corroborates the hypothesis of the existence of a link between bone and vessel and reinforces the clinical utility of this simple and inexpensive vascular calcification score in dialysis patients.
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Affiliation(s)
- Teresa Adragao
- Nephrology Department, Santa Cruz Hospital, Lisbon, Portugal
- * E-mail:
| | - Anibal Ferreira
- Nephrology Department, Curry Cabral Hospital, Lisbon, Portugal
| | - Joao M. Frazao
- Nephrology Department, S Joao Hospital, Medical School and Nephrology Research and Development Unit, University of Porto, Porto, Portugal
| | - Ana Luisa Papoila
- CEAUL, CEDOC, Nova Medical School/FCM, New University, Lisbon, Portugal
| | | | - Marie-Claude Monier-Faugere
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, United States of America
| | - Hartmut H. Malluche
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, United States of America
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Abstract
PURPOSE OF REVIEW The term renal osteodystrophy has been used to describe a wide variety of bone problems facing patients with chronic kidney disease (CKD). Here, we review the history of the use of this term. RECENT FINDINGS Bone disease resulting from CKD was first noticed in 1890. The term "renal osteodystrophy" was used to define the bone disease in 1942. Since then, important discoveries have increased our knowledge of the complexities of bone physiology in these patients. At the same time, secular changes in the disease have occurred. The terms used to describe the bone histological findings have changed as well, reflecting new understanding of the physiological processes. However, since different investigators used the terms in different ways, the need to standardize the nomenclature has become increasingly important. Ongoing international collaboration about nosography will allow more optimal communication among scientists and clinicians as we continue to make new discoveries.
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Affiliation(s)
- Susan M Ott
- University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
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48
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Abstract
Cardiovascular disease is the main cause of early death in the settings of chronic kidney disease (CKD), type 2 diabetes mellitus (T2DM), and ageing. Cardiovascular events can be caused by an imbalance between promoters and inhibitors of mineralization, which leads to vascular calcification. This process is akin to skeletal mineralization, which is carefully regulated and in which isozymes of alkaline phosphatase (ALP) have a crucial role. Four genes encode ALP isozymes in humans. Intestinal, placental and germ cell ALPs are tissue-specific, whereas the tissue-nonspecific isozyme of ALP (TNALP) is present in several tissues, including bone, liver and kidney. TNALP has a pivotal role in bone calcification. Experimental overexpression of TNALP in the vasculature is sufficient to induce vascular calcification, cardiac hypertrophy and premature death, mimicking the cardiovascular phenotype often found in CKD and T2DM. Intestinal ALP contributes to the gut mucosal defence and intestinal and liver ALPs might contribute to the acute inflammatory response to endogenous or pathogenic stimuli. Here we review novel mechanisms that link ALP to vascular calcification, inflammation, and endothelial dysfunction in kidney and cardiovascular diseases. We also discuss new drugs that target ALP, which have the potential to improve cardiovascular outcomes without inhibiting skeletal mineralization.
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49
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Ohtake T, Kobayashi S. Impact of vascular calcification on cardiovascular mortality in hemodialysis patients: clinical significance, mechanisms and possible strategies for treatment. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0094-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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50
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Chen Z, Qureshi AR, Ripsweden J, Wennberg L, Heimburger O, Lindholm B, Barany P, Haarhaus M, Brismar TB, Stenvinkel P. Vertebral bone density associates with coronary artery calcification and is an independent predictor of poor outcome in end-stage renal disease patients. Bone 2016; 92:50-57. [PMID: 27519971 DOI: 10.1016/j.bone.2016.08.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 07/06/2016] [Accepted: 08/08/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Chronic kidney disease-mineral bone disorder (CKD-MBD) is a major complication of end-stage renal disease (ESRD). Reduced bone mineral density (BMD) is associated with vascular calcification. Here we investigated associations between vertebral bone density (VBD) and coronary artery calcification (CAC), quantified by cardiac computed tomography (CT), and BMD quantified by dual-energy X-ray absorptiometry (DXA), and their relations with mortality. METHODS In 231 ESRD patients (median age 56years, 63% males) comprising incident dialysis patients, prevalent peritoneal dialysis patients and recipients of living donor kidney transplant, VBD (Hounsfield units, HUs) and CAC scores (Agatston units, AUs) were quantified by cardiac CT, and, in 143 of the patients, BMD was measured by DXA of total body. Metabolic and inflammation biomarkers potentially linked to CKD-MBD were also analysed. RESULTS Patients with low tertile of VBD were older and had more often cardiovascular disease (CVD), and higher HbA1c (non-diabetics), interleukin-6 and CAC score. Low VBD was independently associated with higher CAC score (>100 AUs) after adjustment for age, gender, diabetes, CVD, inflammation and cohorts. In Cox proportional hazards analysis, low VBD was independently associated with all-cause mortality after adjustment for age, gender, diabetes, CVD, inflammation and subjective global assessment (SGA). The root mean-squared error of prediction (RMSE) showed a good degree of association between VBD and BMD evaluated from DXA. In receiver-operator characteristics curve (ROC) analysis, lower VBD was more strongly associated with higher CAC score and all-cause mortality than BMD evaluated from DXA. CONCLUSIONS While assessments of BMD by DXA and CT showed good degree of agreement, associations of high CAC, and mortality, with low VBD were stronger than those based on low BMD by DXA. The strong independent associations of low VBD with high CAC score and increased mortality risk suggest that VBD may serve as an important prognosticator in ESRD patients.
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Affiliation(s)
- Zhimin Chen
- Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Kidney Disease Center, 1st Affiliated Hospital College of Medicine, Zhejiang University, Hangzhou, China
| | - Abdul Rashid Qureshi
- Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Jonaz Ripsweden
- Division of Medical Imaging and Technology, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Radiology, Karolinska University Hospital, Huddinge, Sweden
| | - Lars Wennberg
- Division of Transplantation Surgery, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olof Heimburger
- Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Barany
- Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Mathias Haarhaus
- Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Torkel B Brismar
- Division of Medical Imaging and Technology, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Radiology, Karolinska University Hospital, Huddinge, Sweden
| | - Peter Stenvinkel
- Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
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