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Salcedo-Betancourt JD, Moe OW. The Effects of Acid on Calcium and Phosphate Metabolism. Int J Mol Sci 2024; 25:2081. [PMID: 38396761 PMCID: PMC10889523 DOI: 10.3390/ijms25042081] [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: 01/03/2024] [Revised: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
A variety of changes in mineral metabolism aiming to restore acid-base balance occur in acid loading and metabolic acidosis. Phosphate plays a key role in defense against metabolic acidosis, both as an intracellular and extracellular buffer, as well as in the renal excretion of excess acid in the form of urinary titratable acid. The skeleton acts as an extracellular buffer in states of metabolic acidosis, as the bone matrix demineralizes, leading to bone apatite dissolution and the release of phosphate, calcium, carbonate, and citrate into the circulation. The renal handling of calcium, phosphate and citrate is also affected, with resultant hypercalciuria, hyperphosphaturia and hypocitraturia.
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Affiliation(s)
- Juan D. Salcedo-Betancourt
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Orson W. Moe
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
- Department of Physiology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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2
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Qi L, Zhi B, Zhang J, Zhang L, Luo S, Zhang L. Defining Biventricular Abnormalities by Cardiac Magnetic Resonance in Pre-Dialysis Patients with Chronic Kidney Disease. KIDNEY DISEASES (BASEL, SWITZERLAND) 2023; 9:277-284. [PMID: 37900003 PMCID: PMC10601957 DOI: 10.1159/000529526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/30/2023] [Indexed: 10/31/2023]
Abstract
Introduction The aim of the study was to investigate biventricular structural and functional abnormalities in pre-dialysis patients across stages of chronic kidney disease (CKD) by cardiac magnetic resonance (CMR). Methods Fifty-one CKD patients with CMR exams were retrospectively analyzed. Patients were divided into three groups according to estimated glomerular filtration rate (eGFR): CKD 1 group (patients with normal eGFR≥90 mL/min/1.73 m2, n = 20), CKD 2-3 group (patients with eGFR< 90 to ≥30 mL/min/1.73 m2, n = 14), and CKD 4-5 group (patients with eGFR<30 mL/min/1.73 m2, n = 17). Twenty-one age- and sex-matched healthy controls (HC) were recruited. CMR-derived left ventricular (LV) and right ventricular (RV) structural and functional measures were compared. Association between CMR parameters and clinical measures was assessed. Results There was an increasing trend in RV mass index (RVMi) and LV mass index (LVMi) with the occurrence and development of CKD from HC group to CKD 4-5 group although no significant difference was observed between CKD 1 group and HC group. LV global radial strain and LV global circumferential strain dropped and native T1 value elevated significantly in CKD 4-5 group compared with the other three groups (all p < 0.05), while RV strain measures, RV ejection fraction, and LV ejection fraction showed no significant difference among 4 groups (all p > 0.05). Elevated LV end-diastolic volume index (β = 0.356, p = 0.016) and RV end-systolic volume index (β = 0.488, p = 0.001) were independently associated with RVMi. Increased systolic blood pressure (β = 0.309, p = 0.004), LV end-systolic volume index (β = 0.633, p < 0.001), and uric acid (β = 0.261, p = 0.013) were independently associated with LVMi. Meanwhile, serum phosphorus (β = 0.519, p = 0.001) was independently associated with native T1 value. Conclusion In pre-dialysis CKD patients, left and right ventricular remolding has occurred. RVMi and LVMi were the first changed CMR indexes in the development of CKD when eGFR began to drop. Because fluid volume overload was the independent risk factor for RVMi and LVMi increase, reasonable controlling fluid volume overload may slow down the progression of biventricular remolding and may reduce related cardiovascular disease risk.
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Affiliation(s)
- Li Qi
- Department of Radiology, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Beibei Zhi
- Department of Radiology, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Jun Zhang
- Department of Radiology, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Lingyan Zhang
- Department of Radiology, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Song Luo
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Longjiang Zhang
- Department of Radiology, Jinling Hospital, Nanjing Medical University, Nanjing, China
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Wang Y, Zhou J, Zou Y, Chen X, Liu L, Qi W, Huang X, Chen C, Liu NN. Fungal commensalism modulated by a dual-action phosphate transceptor. Cell Rep 2022; 38:110293. [PMID: 35081357 DOI: 10.1016/j.celrep.2021.110293] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 11/01/2021] [Accepted: 12/30/2021] [Indexed: 02/07/2023] Open
Abstract
Successful host colonization by fungi in fluctuating niches requires response and adaptation to multiple environmental stresses. However, our understanding about how fungal species thrive in the gastrointestinal (GI) ecosystem by combing multifaceted nutritional stress with respect to homeostatic host-commensal interactions is still in its infancy. Here, we discover that depletion of the phosphate transceptor Pho84 across multiple fungal species encountered a substantial cost in gastrointestinal colonization. Mechanistically, Pho84 enhances the gastrointestinal commensalism via a dual-action activity, coordinating both phosphate uptake and TOR activation by induction of the transcriptional regulator Try4 and downstream commensalism-related transcription. As such, Pho84 promotes Candida albicans commensalism, but this does not translate into enhanced pathogenicity. Thus, our study uncovers a specific nutrient-dependent dual-action regulatory pathway for Pho84 on fungal commensalism.
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Affiliation(s)
- Yuanyuan Wang
- The Center for Microbes, Development, and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai 200031, China; The University of Chinese Academy of Sciences, Beijing, China; The Nanjing Unicorn Academy of Innovation, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Nanjing 211135, China
| | - Jia Zhou
- State Key Laboratory of Oncogenes and Related Genes, Center for Single-Cell Omics, School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yun Zou
- The Center for Microbes, Development, and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai 200031, China; The University of Chinese Academy of Sciences, Beijing, China; The Nanjing Unicorn Academy of Innovation, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Nanjing 211135, China
| | - Xiaoqing Chen
- The Center for Microbes, Development, and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai 200031, China; The University of Chinese Academy of Sciences, Beijing, China
| | - Lin Liu
- State Key Laboratory of Oncogenes and Related Genes, Center for Single-Cell Omics, School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Wanjun Qi
- Division of Infectious Diseases, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA
| | - Xinhua Huang
- The Center for Microbes, Development, and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai 200031, China
| | - Changbin Chen
- The Center for Microbes, Development, and Health, Key Laboratory of Molecular Virology and Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai 200031, China; The Nanjing Unicorn Academy of Innovation, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Nanjing 211135, China.
| | - Ning-Ning Liu
- State Key Laboratory of Oncogenes and Related Genes, Center for Single-Cell Omics, School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
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McCullough PA. Phosphate Control: The Next Frontier in Dialysis Cardiovascular Mortality. Cardiorenal Med 2021; 11:123-132. [PMID: 34120113 DOI: 10.1159/000516286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is a major cause of death in patients with chronic kidney disease (CKD) on dialysis. Mortality rates are still unacceptably high even though they have fallen in the past 2 decades. Hyperphosphatemia (elevated serum phosphate levels) is seen in almost all patients with advanced CKD and is by far the largest remaining modifiable contributor to CKD mortality. SUMMARY Phosphate retention drives multiple physiological mechanisms linked to increased risk of CVD. Fibroblast growth factor 23 and parathyroid hormone (PTH) levels, both of which have been suggested to have direct pathogenic CV effects, increase in response to phosphate retention. Phosphate, calcium, and PTH levels are linked in a progressively worsening cycle. Maladaptive upregulation of phosphate absorption is also likely to occur further exacerbating hyperphosphatemia. Even higher phosphate levels within the normal range may be a risk factor for vascular calcification and, thus, CV morbidity and mortality. A greater degree of phosphate control is important to reduce the risk of CV morbidity and mortality. Improved phosphate control and regular monitoring of phosphate levels are guideline-recommended, established clinical practices. There are several challenges with the current phosphate management approaches in patients with CKD on dialysis. Dietary restriction of phosphate and thrice-weekly dialysis alone are insufficient/unreliable to reduce phosphate to <5.5 mg/dL. Even with the addition of phosphate binders, the only pharmacological treatment currently indicated for hyperphosphatemia, the majority of patients are unable to achieve and maintain phosphate levels <5.5 mg/dL (or more normal levels) [PhosLo® gelcaps (calcium acetate): 667 mg (prescribing information), 2011, VELPHORO®: (Sucroferric oxyhydroxide) (prescribing information), 2013, FOSRENAL®: (Lanthanum carbonate) (prescribing information), 2016, AURYXIA®: (Ferric citrate) tablets (prescribing information), 2017, RENVELA®: (Sevelamer carbonate) (prescribing information), 2020, RealWorld dynamix. Dialysis US: Spherix Global Insights, 2019]. Phosphate binders do not target the primary pathway of phosphate absorption (paracellular), have limited binding capacity, and bind nonspecifically [PhosLo® gelcaps (calcium acetate): 667 mg (prescribing information). 2013, VELPHORO®: (Sucroferric oxyhydroxide) (prescribing information), 2013, FOSRENAL®: (Lanthanum carbonate) (prescribing information), 2016, AURYXIA®: (Ferric citrate) tablets (prescribing information), 2017, RENVELA®: (Sevelamer carbonate) (prescribing information) 2020]. Key Messages: Despite current phosphate management strategies, most patients on dialysis are unable to consistently achieve target phosphate levels, indicating a need for therapeutic innovations [RealWorld dynamix. Dialysis US: Spherix Global Insights, 2019]. Given a growing evidence base that the dominant mechanism of phosphate absorption is the intestinal paracellular pathway, new therapies are investigating ways to reduce phosphate levels by blocking absorption through the paracellular pathway.
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Affiliation(s)
- Peter A McCullough
- Baylor University Medical Center, Dallas, Texas, USA.,Department of Internal Medicine, Texas A & M College of Medicine, Baylor Heart and Vascular Institute, Dallas, Texas, USA.,Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas, USA
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Bacchetta J, Bernardor J, Garnier C, Naud C, Ranchin B. Hyperphosphatemia and Chronic Kidney Disease: A Major Daily Concern Both in Adults and in Children. Calcif Tissue Int 2021; 108:116-127. [PMID: 31996964 DOI: 10.1007/s00223-020-00665-8] [Citation(s) in RCA: 15] [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: 11/21/2019] [Accepted: 01/20/2020] [Indexed: 12/19/2022]
Abstract
Hyperphosphatemia is common in chronic kidney disease (CKD). Often seen as the "silent killer" because of its dramatic effect on vascular calcifications, hyperphosphatemia explains, at least partly, the onset of the complex mineral and bone disorders associated with CKD (CKD-MBD), together with hypocalcemia and decreased 1-25(OH)2 vitamin D levels. The impact of CKD-MBD may be immediate with abnormalities of bone and mineral metabolism with secondary hyperparathyroidism and increased FGF23 levels, or delayed with poor growth, bone deformities, fractures, and vascular calcifications, leading to increased morbidity and mortality. The global management of CKD-MBD has been detailed in international guidelines for adults and children, however, with difficulties to obtain an agreement on the ideal PTH targets. The clinical management of hyperphosphatemia is a daily challenge for nephrologists and pediatric nephrologists, notably because of the phosphate overload in occidental diets that is mainly due to the phosphate "hidden" in food additives. The management begins with a dietary restriction of phosphate intake, and is followed by the use of calcium-based and non-calcium-based phosphate binders, and/or the intensification of dialysis. The objective of this review is to provide an overview of the pathophysiology of hyperphosphatemia in CKD, with a focus on its deleterious effects and a description of the clinical management of hyperphosphatemia in a more global setting of CKD-MBD.
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Affiliation(s)
- Justine Bacchetta
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France.
- Université de Lyon, Lyon, France.
- INSERM 1033 Research Unit, Lyon, France.
| | - Julie Bernardor
- Unité de Néphrologie pédiatrique, Hôpital L'Archet, CHU de Nice, Nice, France
| | - Charlotte Garnier
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
| | - Corentin Naud
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
| | - Bruno Ranchin
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
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6
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Mosca M, Bernardor J, Lemoine S, Bertholet-Thomas A, Bacchetta J. Rare diseases of phosphate and calcium metabolism: Crossing glances between nephrology and endocrinology. ANNALES D'ENDOCRINOLOGIE 2020; 82:30-35. [PMID: 33316222 DOI: 10.1016/j.ando.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Rare diseases of phosphate/calcium metabolism correspond to a wide and heterogeneous spectrum of diseases. Recent knowledge in physiology and genetics has made it possible to better characterize them and to propose attractive therapeutic approaches based on the underlying pathophysiology. These diseases are often at the interface between nephrology and endocrinology. In this spirit of a multidisciplinary care, each specialty can bring its own critical point of view and its own specificities to improve patient care. The objective of this manuscript is to "read" with a nephrologist's point of view the main frameworks of diseases of phosphate/calcium metabolism, to illustrate the three crucial messages of nephro-protection sent to endocrinologists. First, calciuria must be interpreted both in absolute value (concentration hypercalciuria) and in ratio (flow hypercalciuria). Second, renal monitoring of therapies inducing hypercalciuria on kidneys with normal renal function (e.g. active vitamin D analogs or teriparatide) should be systematic. Last, hyperphosphatemia, often latent in hypoparathyroidism and pseudo-hypoparathyroidism, should be detected and at least benefit from dietary measures, in the context of Western diets rich in phosphate hidden in food additives.
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Affiliation(s)
- Mélodie Mosca
- Centre de référence des maladies rares du calcium et du phosphore, centre de référence des maladies rénales rares, filières de santé maladies rares OSCAR, ORKID et ERKNet, service de néphrologie rhumatologie et dermatologie pédiatriques, hôpital femme mère enfant, Bron, France
| | - Julie Bernardor
- INSERM 1033, prévention des maladies osseuses, Lyon, France; Service de néphrologie pédiatrique, CHU de Nice, hôpital Archet, Nice, France
| | - Sandrine Lemoine
- Service d'exploration fonctionnelle rénale, centre de référence des maladies rares du calcium et du phosphore, centre de référence des maladies rénales rares, filières de santé maladies rares OSCAR et ORKID, département de néphrologie, hôpital Edouard-Herriot, Lyon, France; Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France
| | - Aurélia Bertholet-Thomas
- Centre de référence des maladies rares du calcium et du phosphore, centre de référence des maladies rénales rares, filières de santé maladies rares OSCAR, ORKID et ERKNet, service de néphrologie rhumatologie et dermatologie pédiatriques, hôpital femme mère enfant, Bron, France; INSERM 1033, prévention des maladies osseuses, Lyon, France
| | - Justine Bacchetta
- Centre de référence des maladies rares du calcium et du phosphore, centre de référence des maladies rénales rares, filières de santé maladies rares OSCAR, ORKID et ERKNet, service de néphrologie rhumatologie et dermatologie pédiatriques, hôpital femme mère enfant, Bron, France; INSERM 1033, prévention des maladies osseuses, Lyon, France; Faculté de Médecine Lyon Est, Université de Lyon, Lyon, France.
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Hannedouche T, Fouque D, Joly D. Complications métaboliques en insuffisance rénale chronique : hyperphosphatémie, hyperkaliémie et anémie. Nephrol Ther 2018; 14:6S17-6S25. [DOI: 10.1016/s1769-7255(18)30647-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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8
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Turner ME, White CA, Hopman WM, Ward EC, Jeronimo PS, Adams MA, Holden RM. Impaired Phosphate Tolerance Revealed With an Acute Oral Challenge. J Bone Miner Res 2018; 33:113-122. [PMID: 28914962 DOI: 10.1002/jbmr.3294] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/28/2017] [Accepted: 09/13/2017] [Indexed: 01/01/2023]
Abstract
Elevated serum phosphate is consistently linked with cardiovascular disease (CVD) events and mortality in the setting of normal and impaired kidney function. However, serum phosphate does not often exceed the upper limit of normal until glomerular filtration rate (GFR) falls below 30 mL/min/m2 . It was hypothesized that the response to an oral, bioavailable phosphate load will unmask impaired phosphate tolerance, a maladaptation not revealed by baseline serum phosphate concentrations. In this study, rats with varying kidney function as well as normo-phosphatemic human subjects, with inulin-measured GFR (13.2 to 128.3mL/min), received an oral phosphate load. Hormonal and urinary responses were evaluated over 2 hours. Results revealed that the more rapid elevation of serum phosphate was associated with subjects and rats with higher levels of kidney function, greater responsiveness to acute changes in parathyroid hormone (PTH), and significantly more urinary phosphate at 2 hours. In humans, increases in urinary phosphate to creatinine ratio did not correlate with baseline serum phosphate concentrations but did correlate strongly to early increase of serum phosphate. The blunted rise in serum phosphate in rats with CKD was not the result of altered absorption. This result suggests acute tissue deposition may be altered in the setting of kidney function impairment. Early recognition of impaired phosphate tolerance could translate to important interventions, such as dietary phosphate restriction or phosphate binders, being initiated at much higher levels of kidney function than is current practice. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Mandy E Turner
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Canada
| | | | - Wilma M Hopman
- Clinical Research Centre, Kingston General Hospital, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - Emilie C Ward
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Canada
| | - Paul S Jeronimo
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Canada
| | - Michael A Adams
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Canada
| | - Rachel M Holden
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Canada.,Department of Medicine, Queen's University, Kingston, Canada
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Vervloet MG, Sezer S, Massy ZA, Johansson L, Cozzolino M, Fouque D. The role of phosphate in kidney disease. Nat Rev Nephrol 2016; 13:27-38. [PMID: 27867189 DOI: 10.1038/nrneph.2016.164] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The importance of phosphate homeostasis in chronic kidney disease (CKD) has been recognized for decades, but novel insights - which are frequently relevant to everyday clinical practice - continue to emerge. Epidemiological data consistently indicate an association between hyperphosphataemia and poor clinical outcomes. Moreover, compelling evidence suggests direct toxicity of increased phosphate concentrations. Importantly, serum phosphate concentration has a circadian rhythm that must be considered when interpreting patient phosphate levels. Detailed understanding of dietary sources of phosphate, including food additives, can enable phosphate restriction without risking protein malnutrition. Dietary counselling provides an often underestimated opportunity to target the increasing exposure to dietary phosphate of both the general population and patients with CKD. In patients with secondary hyperparathyroidism, bone can be an important source of serum phosphate, and adequate appreciation of this fact should impact treatment. Dietary and pharmotherapeutic interventions are efficacious strategies to lower phosphate intake and serum concentration. However, strong evidence that targeting serum phosphate improves patient outcomes is currently lacking. Future studies are, therefore, required to investigate the effects of modern dietary and pharmacological interventions on clinically meaningful end points.
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Affiliation(s)
- Marc G Vervloet
- Department of Nephrology, VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands.,Institute for Cardiovascular Research (ICaR-VU), VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - Siren Sezer
- Department of Nephrology, Baskent University Hospital, 5. Sok No:48, 06490 Bahcelievler, Ankara, Turkey
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré Hospital, Paris-Ile-de-France-Ouest University (UVSQ), 9 Avenue Charles de Gaulle, 92104 Boulogne Billancourt cedex, France.,INSERM U1018, Team 5, Centre de recherche en épidémiologie et santé des populations (CESP), University Paris Saclay (UVSQ), Villejuif, France
| | - Lina Johansson
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Mario Cozzolino
- Renal Division, Ospedale Santi Paolo e Carlo, Presidio San Paolo, Università di Milano, via di Rudinì, 8-20142, Milan, Italy
| | - Denis Fouque
- Department of Nephrology, University Lyon, UCBL, Carmen, Centre Hospitalier Lyon SUD, Pierre-Bénite, F-69495, France
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Abstract
Serum phosphorus levels stay relatively constant through the influence of multiple factors-such as parathyroid hormone, fibroblast growth factor 23, and vitamin D-on the kidney, bone, and digestive system. Whereas normal serum phosphorus ranges between 3 mg/dL to 4.5 mg/dL, large cross-sectional studies have shown that even people with normal kidney function are sometimes found to have levels ranging between 1.6 mg/dL and 6.2 mg/dL. While this may partially be due to diet and the factors mentioned above, total understanding of these atypical ranges of serum phosphorus remains uncertain. Risks for bone disease are high in people aged 50 and older, and this group comprises a large proportion of people who also have chronic kidney disease. Consuming diets low in calcium and high in phosphorus, especially foods with phosphate additives, further exacerbates bone turnover. Existing bone disease increases the risk for high serum phosphorus, and higher serum phosphorus has been associated with increased adverse events and cardiovascular-related mortality both in people with chronic kidney disease and in those with no evidence of disease. Once kidney function has deteriorated to end-stage disease (Stage 5), maintaining normal serum phosphorus requires dietary restrictions, phosphate-binding medications, and dialysis. Even so, normal serum phosphorus remains elusive in many patients with Stage 5 kidney disease, and researchers are testing novel targets that may inhibit intestinal transport of phosphorus to achieve better phosphate control. Protecting and monitoring bone health should also aid in controlling serum phosphorus as kidney disease advances.
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MESH Headings
- Aged
- Bone Remodeling
- Bone and Bones/metabolism
- Bone and Bones/physiopathology
- Chelating Agents/therapeutic use
- Chronic Kidney Disease-Mineral and Bone Disorder/epidemiology
- Chronic Kidney Disease-Mineral and Bone Disorder/metabolism
- Chronic Kidney Disease-Mineral and Bone Disorder/physiopathology
- Chronic Kidney Disease-Mineral and Bone Disorder/therapy
- Disease Progression
- Female
- Humans
- Intestinal Absorption
- Kidney/metabolism
- Kidney/physiopathology
- Kidney Failure, Chronic/epidemiology
- Kidney Failure, Chronic/metabolism
- Kidney Failure, Chronic/physiopathology
- Kidney Failure, Chronic/therapy
- Male
- Phosphorus, Dietary/administration & dosage
- Phosphorus, Dietary/blood
- Phosphorus, Dietary/metabolism
- Prevalence
- Recommended Dietary Allowances
- Renal Dialysis
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/physiopathology
- Renal Insufficiency, Chronic/therapy
- Risk Factors
- Treatment Outcome
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Sherman RA. Hyperphosphatemia in Dialysis Patients: Beyond Nonadherence to Diet and Binders. Am J Kidney Dis 2015; 67:182-6. [PMID: 26508681 DOI: 10.1053/j.ajkd.2015.07.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/22/2015] [Indexed: 01/10/2023]
Abstract
Hyperphosphatemia in dialysis patients is routinely attributed to nonadherence to diet, prescribed phosphate binders, or both. The role of individual patient variability in other determinants of phosphate control is not widely recognized. In a manner that cannot be explained by dialysis parameters or serum phosphate levels, dialytic removal of phosphate may vary by >400mg per treatment. Similarly, enteral phosphate absorption, unexplained by diet or vitamin D intake, may differ by ≥250mg/d among patients. Binder efficacy also varies among patients, with 2-fold differences reported. One or more elements of this triple threat-varying dialytic removal, phosphate absorption, and phosphate binding-may account for hyperphosphatemia in dialysis patients rather than nonadherence to therapy. Just as the cause(s) of hyperphosphatemia may vary, so too may an individual patient's response to different therapeutic interventions.
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Affiliation(s)
- Richard A Sherman
- Division of Nephrology, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
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12
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Abstract
PURPOSE OF REVIEW Disturbances in calcium-phosphate homeostasis play an important role in children with chronic kidney disease, and not only cause renal osteodystrophy but also result in increased cardiovascular morbidity and mortality. This review outlines the current aspects in the pathogenesis, diagnostic approach and treatment of renal osteodystrophy. RECENT FINDINGS The pathogenesis of renal osteodystrophy is under strong influence of the fibroblast growth factor 23/Klotho system, which is able to enhance phosphate excretion and reduce calcitriol synthesis in the kidney. Fibroblast growth factor 23 increases tissue calcinosis and is cardiotoxic, and is independently associated with mortality. Despite improvement in diagnostic imaging (bone density measurements), determination of biomarkers, mainly parathyroid hormone, still plays a central role. New treatment options resulted in improved bone health and also a reduction in mortality was achieved in adults with calcium-free phosphate binders. Substitution of active and inactive vitamin D is important and also has a beneficial effect on proteinuria. SUMMARY Knowledge about the biochemical and molecular mechanisms of renal osteodystrophy is increasing dramatically and has an impact not only to bone health but also overall morbidity and mortality. This will ultimately translate into further improved diagnostic approaches and novel treatment options.
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Ohnishi R, Segawa H, Ohmoto T, Sasaki S, Hanazaki A, Mori A, Ikuta K, Furutani J, Kawakami E, Tatsumi S, Hamada Y, Miyamoto KI. Effect of dietary components on renal inorganic phosphate (Pi) excretion induced by a Pi-depleted diet. THE JOURNAL OF MEDICAL INVESTIGATION 2014; 61:162-70. [DOI: 10.2152/jmi.61.162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ritsuko Ohnishi
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Hiroko Segawa
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Tomoyo Ohmoto
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Shohei Sasaki
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Ai Hanazaki
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Ayaka Mori
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Kayo Ikuta
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Junya Furutani
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Eri Kawakami
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Sawako Tatsumi
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Yasuhiro Hamada
- Department of Therapeutic Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Ken-ichi Miyamoto
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
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Ohnishi R, Segawa H, Ohmoto T, Sasaki S, Hanazaki A, Mori A, Ikuta K, Furutani J, Kawakami E, Tatsumi S, Hamada Y, Miyamoto KI. <b>Effect of dietary components on renal inorganic </b><b>phosphate (Pi) excretion induced by a Pi-depleted diet</b>. THE JOURNAL OF MEDICAL INVESTIGATION 2000. [DOI: 10.2152/jmi.40.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ritsuko Ohnishi
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Hiroko Segawa
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Tomoyo Ohmoto
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Shohei Sasaki
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Ai Hanazaki
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Ayaka Mori
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Kayo Ikuta
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Junya Furutani
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Eri Kawakami
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Sawako Tatsumi
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Yasuhiro Hamada
- Department of Therapeutic Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| | - Ken-ichi Miyamoto
- Department of Molecular Nutrition, Institution of Health Biosciences, the University of Tokushima Graduate School
| |
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