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Kim H, Lee EJ, Woo S, Rho S, Jung JY. Effect of Denosumab on Bone Health, Vascular Calcification, and Health-Related Quality of Life in Hemodialysis Patients with Osteoporosis: A Prospective Observational Study. J Clin Med 2024; 13:1462. [PMID: 38592300 PMCID: PMC10934499 DOI: 10.3390/jcm13051462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/26/2024] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Osteoporosis is common in hemodialysis (HD) patients, contributing to cardiovascular risks. Limited research exists on denosumab's efficacy in this group. Our study explores denosumab's effects on bone turnover markers (BTMs) and vascular calcification in chronic kidney disease-mineral bone disorder (CKD-MBD) patients. Methods: In a prospective single-center study, we investigated the effects of denosumab over 2 years on 30 HD patients from a cohort of 185. Annual assessments of bone mineral density (BMD), vascular calcification, and health-related quality of life (HRQL) were conducted and compared with an untreated group. Mineral and bone parameters were analyzed at specific intervals in the treatment group. Results: Denosumab notably raised femoral BMD in the initial year. Most bone turnover markers (BTMs) decreased, except for osteocalcin. Changes in T50 correlated with BTMs. Pre-denosumab supplementation of calcium and vitamin D helped manage mineral imbalances. Post denosumab, parathyroid hormone (PTH) levels increased initially, stabilizing after 3 months. No significant changes occurred in vascular calcification or HRQL. Conclusions: Denosumab exhibited varying effects on BMD improvement, with a stronger impact in the first year that diminished in the second year. Early PTH monitoring was crucial, and extending the administrative period may enhance BMD outcomes compared to the general population.
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Affiliation(s)
- Hyunsook Kim
- Department of Health Sciences and Technology, Gachon University, Incheon 21565, Republic of Korea;
| | - Eun Ju Lee
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea; (E.J.L.); (S.W.)
| | - Siyun Woo
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea; (E.J.L.); (S.W.)
| | - Sohee Rho
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea; (E.J.L.); (S.W.)
| | - Ji Yong Jung
- Department of Health Sciences and Technology, Gachon University, Incheon 21565, Republic of Korea;
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea; (E.J.L.); (S.W.)
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Kato K, Yaginuma T, Kobayashi A, Nakashima A, Ohkido I, Yokoo T. Long-term effects of denosumab on bone mineral density and turnover markers in patients undergoing hemodialysis. J Bone Miner Metab 2024; 42:264-270. [PMID: 38512458 PMCID: PMC10982096 DOI: 10.1007/s00774-024-01505-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/15/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Denosumab, a fully human anti-RANKL monoclonal antibody, is a widely used osteoporosis treatment that is increasingly being used in patients undergoing dialysis; however, its long-term efficacy and safety in these patients remain unknown. MATERIALS AND METHODS This observational study comprised individuals aged ≥ 20 years undergoing hemodialysis and receiving denosumab. After denosumab administration, we analyzed the long-term changes in bone mineral density (BMD) and levels of bone turnover markers (BTMs) and calcium. RESULTS The study included 45 patients who have been receiving denosumab for a median duration of 3.8 (interquartile range, 2.5-6.7) years. Tartrate-resistant acid phosphatase 5b (TRACP-5b) levels decreased from a median of 595 (434-778) mU/dL at baseline to 200 (141-430) mU/dL after 6 months of denosumab administration (P < 0.001) and remained low thereafter. Similarly, bone-specific alkaline phosphatase (BAP) levels decreased from a median of 18.2 (15.9-25.8) μg/L at baseline to 12.4 (9.9-15.6) μg/L after 6 months (P < 0.001) and remained low thereafter. Meanwhile, BMD, as assessed with dual energy X-ray absorptiometry and measured at the distal 1/3 of the radius, did not decrease (0.465 ± 0.112 g/cm2 at baseline vs. 0.464 ± 0.112 g/cm2 after administration; P = 0.616). Regarding hypocalcemia, corrected calcium levels reached were the lowest at 7 days after administration and normalized within 30 days. CONCLUSION The study showed long-term suppression of TRACP-5b and BAP levels and sustaining BMD after denosumab administration over an extended period in patients undergoing hemodialysis.
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Affiliation(s)
- Kazuhiko Kato
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo, Japan
| | | | - Arisa Kobayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akio Nakashima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
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Bird ST, Smith ER, Gelperin K, Jung TH, Thompson A, Kambhampati R, Lyu H, Zhao H, Zhao Y, Zhu Y, Easley O, Niak A, Wernecke M, Chillarige Y, Zemskova M, Kelman JA, Graham DJ. Severe Hypocalcemia With Denosumab Among Older Female Dialysis-Dependent Patients. JAMA 2024; 331:491-499. [PMID: 38241060 PMCID: PMC10799290 DOI: 10.1001/jama.2023.28239] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 12/27/2023] [Indexed: 01/22/2024]
Abstract
Importance Dialysis-dependent patients experience high rates of morbidity from fractures, yet little evidence is available on optimal treatment strategies. Chronic kidney disease-mineral and bone disorder is nearly universal in dialysis-dependent patients, complicating diagnosis and treatment of skeletal fragility. Objective To examine the incidence and comparative risk of severe hypocalcemia with denosumab compared with oral bisphosphonates among dialysis-dependent patients treated for osteoporosis. Design, Setting, and Participants Retrospective cohort study of female dialysis-dependent Medicare patients aged 65 years or older who initiated treatment with denosumab or oral bisphosphonates from 2013 to 2020. Clinical performance measures including monthly serum calcium were obtained through linkage to the Consolidated Renal Operations in a Web-Enabled Network database. Exposures Denosumab, 60 mg, or oral bisphosphonates. Main Outcomes and Measures Severe hypocalcemia was defined as total albumin-corrected serum calcium below 7.5 mg/dL (1.88 mmol/L) or a primary hospital or emergency department hypocalcemia diagnosis (emergent care). Very severe hypocalcemia (serum calcium below 6.5 mg/dL [1.63 mmol/L] or emergent care) was also assessed. Inverse probability of treatment-weighted cumulative incidence, weighted risk differences, and weighted risk ratios were calculated during the first 12 treatment weeks. Results In the unweighted cohorts, 607 of 1523 denosumab-treated patients and 23 of 1281 oral bisphosphonate-treated patients developed severe hypocalcemia. The 12-week weighted cumulative incidence of severe hypocalcemia was 41.1% with denosumab vs 2.0% with oral bisphosphonates (weighted risk difference, 39.1% [95% CI, 36.3%-41.9%]; weighted risk ratio, 20.7 [95% CI, 13.2-41.2]). The 12-week weighted cumulative incidence of very severe hypocalcemia was also increased with denosumab (10.9%) vs oral bisphosphonates (0.4%) (weighted risk difference, 10.5% [95% CI, 8.8%-12.0%]; weighted risk ratio, 26.4 [95% CI, 9.7-449.5]). Conclusions and Relevance Denosumab was associated with a markedly higher incidence of severe and very severe hypocalcemia in female dialysis-dependent patients aged 65 years or older compared with oral bisphosphonates. Given the complexity of diagnosing the underlying bone pathophysiology in dialysis-dependent patients, the high risk posed by denosumab in this population, and the complex strategies required to monitor and treat severe hypocalcemia, denosumab should be administered after careful patient selection and with plans for frequent monitoring.
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Affiliation(s)
- Steven T. Bird
- Office of Pharmacovigilance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | - Kate Gelperin
- Office of Pharmacovigilance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Tae Hyun Jung
- Division of Biometrics, Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Aliza Thompson
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Rekha Kambhampati
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Hai Lyu
- Acumen LLC, Burlingame, California
| | | | - Yueqin Zhao
- Division of Biometrics, Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | - Olivia Easley
- Division of General Endocrinology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Ali Niak
- Office of Pharmacovigilance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Marina Zemskova
- Division of General Endocrinology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | - David J. Graham
- Office of Pharmacovigilance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
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Kanagalingam T, Khan T, Sultan N, Cowan A, Thain J, Hoy C, Ledger S, Clemens KK. Reducing the risk of denosumab-induced hypocalcemia in patients with advanced chronic kidney disease: a quality improvement initiative. Arch Osteoporos 2023; 18:138. [PMID: 37985504 DOI: 10.1007/s11657-023-01341-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023]
Abstract
Denosumab can improve bone health in advanced kidney disease (CKD) but is associated with hypocalcemia. We created a clinical care pathway focused on the safe provision of denosumab in advanced CKD that reduced the risk of hypocalcemia by 37% at our hospital. Similar pathways could be adopted and tested in other centers. PURPOSE There is an increased risk of hypocalcemia with denosumab in advanced chronic kidney disease (CKD). We aimed to reduce the proportion of patients with advanced CKD who experienced denosumab-induced hypocalcemia at our center. METHODS We conducted a quality improvement (QI) project of patients with CKD stage 3b or less (i.e., estimated glomerular filtration rate <45 mL/min/1.73m2 including dialysis) who were part of the Osteoporosis and Bone Disease Program at St. Joseph's Health Care London (Canada) between December 2020 and January 2023. Our intervention was a clinical care pathway which optimized CKD mineral and bone disorder (CKD-MBD) and 25-hydroxyvitamin levels; provided calcium and vitamin D prophylaxis; promoted multidisciplinary communication between bone and kidney specialists; and carefully monitored calcium post-denosumab injection. Our primary outcome measure was the proportion of patients with hypocalcemia (defined by albumin-corrected serum calcium <1.9mmol/L) at 60 days. Process measures included the appropriate provision of calcium and vitamin D prophylaxis. Balance measures included the development of hypercalcemia and hyperphosphatemia following prophylaxis. We used plan-do-see-act cycles to study four tests of change and presented results using descriptive statistics and run charts. RESULTS There were 6 patients with advanced CKD treated with denosumab prior to the implementation of our care pathway (March 2015-October 2020; 83% receiving dialysis). At the time of their denosumab injection, 83% were using 500-1000 mg of calcium, and 83% used 1000-2000 IU of vitamin D3. Fifty percent developed denosumab-induced hypocalcemia. Following the implementation of our care pathway, 15 patients (40% receiving dialysis) were treated with denosumab. Ninety-three percent received calcium at a daily dose of 350 to 2250 mg and 87% received 1000-2000 IU of vitamin D3. Thirteen percent developed denosumab-induced hypocalcemia. There was no hypercalcemia or hyperphosphatemia. CONCLUSIONS A clinical care pathway focused on the safe provision of denosumab in advanced CKD reduced the risk of hypocalcemia in patients treated in our hospital. Similar pathways could be adopted and tested in other centers.
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Affiliation(s)
- Tharsan Kanagalingam
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Tayyab Khan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada
- St Joseph's Health Care London, London, ON, Canada
- Centre for Diabetes, Endocrinology, and Metabolism, St. Joseph's Hospital, PO BOX 5777, STN B, London, Ontario, N6A 4V2, Canada
| | - Nabil Sultan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
- Division of Nephrology, Western University, London, ON, Canada
| | - Andrea Cowan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
- Division of Nephrology, Western University, London, ON, Canada
| | - Jenny Thain
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- St Joseph's Health Care London, London, ON, Canada
- Division of Geriatrics, Western University, London, ON, Canada
| | - Cindy Hoy
- St Joseph's Health Care London, London, ON, Canada
| | | | - Kristin K Clemens
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
- Division of Endocrinology and Metabolism, Western University, London, ON, Canada.
- St Joseph's Health Care London, London, ON, Canada.
- Centre for Diabetes, Endocrinology, and Metabolism, St. Joseph's Hospital, PO BOX 5777, STN B, London, Ontario, N6A 4V2, Canada.
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
- Lawson Health Research Institute, London, ON, Canada.
- ICES, London, ON, Canada.
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Gu Z, Yang X, Wang Y, Gao J. Effects of denosumab on bone mineral density and bone metabolism in patients with end-stage renal disease: A systematic review and meta-analysis. Hemodial Int 2023; 27:352-363. [PMID: 37264758 DOI: 10.1111/hdi.13098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/25/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The effects of denosumab on bone mineral density (BMD) and metabolism in patients with end-stage renal disease (ESRD) remain controversial. Hence, we performed a systematic review and meta-analysis of observational studies. METHODS The MEDLINE, EMBASE, and Cochrane Library databases were searched in June 2022 to identify studies that evaluated the risk of denosumab-associated hypocalcemia and changes in bone metabolism, changes in BMD from baseline to post-treatment in patients with ESRD. FINDINGS Twelve studies with 348 participants were included. The pooled incidence of hypocalcemia during denosumab treatment was 35.0% (95% confidence interval [CI], 25%-46%; I2 = 63.6%). There were no significant changes in either the serum calcium or phosphate levels from the baseline to post-treatment period; the mean differences were 0.04 mg/dL (95% CI, -0.12 to 0.20 mg/dL) and -0.39 mg/dL (95% CI, -0.89 to 0.12 mg/dL). We found significant changes in the alkaline phosphatase and parathyroid hormone levels; the standardized mean differences were -2.98 (95% CI, -5.36 to -0.59) and -3.12 (95% CI: -4.94 to -1.29), respectively. Denosumab may increase BMD, with mean differences of 9.10% (95% CI: 4.07%-14.13%) and 9.00% (95% CI: 5.93%-12.07%) for the femoral neck and lumbar spine, respectively. DISCUSSION Denosumab increased the BMDs of the lumbar spine and femoral neck in patients with ESRD. The onset of hypocalcemia must be carefully monitored during denosumab administration.
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Affiliation(s)
- Zhaoyan Gu
- Department of Endocrinology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Xuhui Yang
- Department of Oncology, The Fifth Medical Center, Chinese PLA General Hospital and Chinese PLA Medical School, Beijing, People's Republic of China
| | - Yan Wang
- Chaoyang 1st Sanitarium for Retired Cadres of Beijing Garrison of the Chinese PLA, Beijing, People's Republic of China
| | - Jianjun Gao
- Department of Nephrology, The Chinese PLA Strategic Support Force Characteristic Medical Center, Beijing, People's Republic of China
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Abduelkarem AR, Guella A, Hamrouni AM, Hassanein MM, Nasr A, Rana O. Denosumab Use in Chronic Kidney Disease Associated Osteoporosis: A Narrative Review. Risk Manag Healthc Policy 2023; 16:1809-1813. [PMID: 37719685 PMCID: PMC10503558 DOI: 10.2147/rmhp.s426869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023] Open
Abstract
Chronic kidney disease (CKD) and hemodialysis (HD) patients have a high incidence of bone disease and increased fracture risk, making effective management of their bone health a clinical challenge. Denosumab, a human monoclonal antibody, has been investigated as a therapeutic option in this patient population. In this review, we summarize the current evidence on the efficacy and safety of denosumab in CKD and HD patients. A comprehensive search of the relevant literature was conducted, including randomized controlled trials, observational studies, and meta-analyses. The findings suggest that denosumab reduces the risk of fractures and improves bone mineral density in all stages of CKD. The results of this review support the use of denosumab as a promising option for managing bone disease in CKD and HD patients.
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Affiliation(s)
- Abduelmula R Abduelkarem
- Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
- Research Institute for Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Adnane Guella
- Department of Nephrology, University Hospital Sharjah, Sharjah, United Arab Emirates
| | - Amar M Hamrouni
- Department of Pharmaceutical Sciences, College of Pharmacy, Al Ain University, Al Ain, United Arab Emirates
| | - Mohammed M Hassanein
- Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
| | - Ahmed Nasr
- Pharmacy Department, University Hospital Sharjah, Sharjah, United Arab Emirates
| | - Owais Rana
- Department of Internal Medicine, University Hospital Sharjah, Sharjah, United Arab Emirates
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Abdalbary M, Sobh M, Elnagar S, Elhadedy MA, Elshabrawy N, Abdelsalam M, Asadipooya K, Sabry A, Halawa A, El-Husseini A. Management of osteoporosis in patients with chronic kidney disease. Osteoporos Int 2022; 33:2259-2274. [PMID: 35748896 DOI: 10.1007/s00198-022-06462-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/31/2022] [Indexed: 12/19/2022]
Abstract
Patients with CKD have a 4-fivefold higher rate of fractures. The incidence of fractures increases with deterioration of kidney function. The process of skeletal changes in CKD patients is characterized by compromised bone strength because of deterioration of bone quantity and/or quality. The fractures lead to a deleterious effect on the quality of life and higher mortality in patients with CKD. The pathogenesis of bone loss and fracture is complex and multi-factorial. Renal osteodystrophy, uremic milieu, drugs, and systemic diseases that lead to renal failure all contribute to bone damage in CKD patients. There is no consensus on the optimal diagnostic method of compromised bone assessment in patients with CKD. Bone quantity and mass can be assessed by dual-energy x-ray absorptiometry (DXA) or quantitative computed tomography (QCT). Bone quality on the other side can be assessed by non-invasive methods such as trabecular bone score (TBS), high-resolution bone imaging methods, and invasive bone biopsy. Bone turnover markers can reflect bone remodeling, but some of them are retained by kidneys. Understanding the mechanism of bone loss is pivotal in preventing fracture in patients with CKD. Several non-pharmacological and therapeutic interventions have been reported to improve bone health. Controlling laboratory abnormalities of CKD-MBD is crucial. Anti-resorptive therapies are effective in improving BMD and reducing fracture risk, but there are uncertainties about safety and efficacy especially in advanced CKD patients. Accepting the prevalent of low bone turnover in patients with advanced CKD, the osteo-anabolics are possibly promising. Parathyroidectomy should be considered a last resort for intractable cases of renal hyperparathyroidism. There is a wide unacceptable gap in osteoporosis management in patients with CKD. This article is focusing on the updated management of CKD-MBD and osteoporosis in CKD patients. Chronic kidney disease deteriorates bone quality and quantity. The mechanism of bone loss mainly determines pharmacological treatment. DXA and QCT provide information about bone quantity, but assessing bone quality, by TBS, high-resolution bone imaging, invasive bone biopsy, and bone turnover markers, can guide us about the mechanism of bone loss.
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Affiliation(s)
- M Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA
| | - M Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - S Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M A Elhadedy
- Nephrology and Transplantation Unit, Mansoura Urology and Nephrology Center, Mansoura, Egypt
| | - N Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - K Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, USA
| | - A Sabry
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - A Halawa
- Sheffield Teaching Hospital, University of Liverpool, Liverpool, UK
| | - A El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA.
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Smout D, Jørgensen HS, Cavalier E, Evenepoel P. Clinical utility of bone turnover markers in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:332-338. [PMID: 35703216 DOI: 10.1097/mnh.0000000000000798] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The burden of fractures is very high in patients with chronic kidney disease (CKD). It is increasingly recognized that knowledge of bone turnover is of paramount importance in guiding mineral metabolism and osteoporosis therapy in CKD. Bone histomorphometry is the gold standard to assess bone turnover, but is seldomly performed in clinical practice. Bone turnover markers (BTMs) may be the long awaited noninvasive diagnostic that may help to close the therapeutic gap in patients with advanced CKD presenting with bone fragility. RECENT FINDINGS Mounting evidence indicates that BTMs may be useful in skeletal and nonskeletal risk stratification, in guiding mineral metabolism and osteoporosis therapy, and in monitoring the therapeutic response. SUMMARY BTMs provide information that is complementary to other clinical tests. It may be envisioned that in the near future, the assessment of nonkidney cleared BTMs may become part of routine clinical evaluation and monitoring of bone health in CKD patients, integrated with clinical risk factors, imaging data and, eventually, bone histomorphometry. Panels of BTMs will likely be more informative than single markers, and the same might hold true for trends as opposed to single time point data.
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Affiliation(s)
- Dieter Smout
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Hanne S Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven
- Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liege, CHU de Liege, Liege, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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9
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Effects of bone turnover status on the efficacy and safety of denosumab among haemodialysis patients. Sci Rep 2022; 12:7781. [PMID: 35546172 PMCID: PMC9095701 DOI: 10.1038/s41598-022-12029-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/04/2022] [Indexed: 11/08/2022] Open
Abstract
Denosumab is reported to increase bone mineral density (BMD) among haemodialysis patients; however, hypocalcaemia is a serious adverse effect among chronic kidney disease (CKD) patients. Identifying which patients will show greater improvement in BMD is important. We enrolled 84 haemodialysis patients with osteoporosis in our study. 28 patients initiated denosumab treatment between October 2019 and October 2020. We assessed BMD changes and investigated the association between baseline bone turnover marker (BTM) levels and 6-month changes in BMD after denosumab treatment. BMD was increased at 6 months in denosumab-treated patients compared with patients not treated with denosumab (lumbar spine: 5.34% vs. - 0.49%; total hip: 2.43% vs. - 0.47%). Bone-specific alkaline phosphatase (BAP) and tartrate-resistant acid phosphatase-5b (TRACP-5b) at baseline were independently associated with increased BMD in the total hip (BAP: β = 0.472, p value = 0.004; TRACP-5b: β = 0.433, p value = 0.008) and lumbar spine (BAP: β = 0.591, p value = 0.001; TRACP-5b: β = 0.613, p value = 0.0008). BAP and TRACP-5b were also independent predictors of hypocalcaemic events (OR [95% CI] 1.747 [1.084-4.604] and 1.006 [1.000-1.015], respectively). BTMs may be associated with increased BMD and hypocalcaemic events after denosumab treatment. BTM measurement may be useful for assessing the effect of denosumab on BMD; however, careful monitoring of serum calcium levels is needed.
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10
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Barreto FC, Bucharles SGE, Jorgetti V. Treatment of Osteoporosis in Chronic Kidney Disease. J Bras Nefrol 2021; 43:654-659. [PMID: 34910801 PMCID: PMC8823917 DOI: 10.1590/2175-8239-jbn-2021-s109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/18/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Fellype Carvalho Barreto
- Universidade Federal do Paraná, Internal Medicine Department, Service of Nephrology, Curitiba, PR, Brazil.,Universidade Federal do Paraná, Hospital de Clínicas, Service of Nephrology, Curitiba, PR, Brazil
| | | | - Vanda Jorgetti
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Pathophysiology Laboratory (LIM-16), São Paulo, SP, Brazil
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11
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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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12
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Jang SM, Anam S, Pringle T, Lahren P, Infante S. Contrasting PTH Response of Denosumab Use in Dialysis Patients: A Report of 2 Cases. PHARMACY 2020; 8:E59. [PMID: 32244607 PMCID: PMC7355881 DOI: 10.3390/pharmacy8020059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 02/07/2023] Open
Abstract
A common complication of end-stage renal disease (ESRD) is mineral and bone disorder. Yet, many anti-osteoporotic drugs are contraindicated in ESRD patients. Denosumab, a monoclonal antibody, does not require renal dose adjustment. However, its use is uncertain due to a lack of safety and efficacy of data in this population. Two hemodialysis patient cases of contrasting responses in parathyroid hormone (PTH) after denosumab administration were observed. Patient 1, a 62-years-old male received denosumab 60 mg at Day 0. His calcium decreased from 8.8 mg/dL to 6.8 mg/dL on Day 30. The PTH level increased from 265 pg/mL to 372 pg/mL after 30 days. Calcium and PTH levels approached normal range after increasing doses of vitamin D/calcium supplements, and calcitriol. Patient 2, a 72-years-old male on hemodialysis also received denosumab 60 mg on Day 0. His baseline calcium and PTH were 9.2 mg/dL and 420 pg/mL, respectively. On Day 30, his calcium level decreased (6.8 mg/dL) but, PTH level drastically increased (>5,000 pg/mL). Denosumab commonly causes hypocalcemia and hyperparathyroidism since it inhibits osteoclast activation, reduces calcium release from bone and increases PTH levels as a compensatory mechanism. With a wait-and-watch approach, Patient 2's levels approached the normal range (calcium 9.6 mg/dL and PTH 274 pg/mL at Day 90).
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Affiliation(s)
- Soo Min Jang
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA 92350, USA;
- Loma Linda University Kidney Center, Loma Linda, CA 92354, USA; (T.P.); (P.L.)
| | | | - Tara Pringle
- Loma Linda University Kidney Center, Loma Linda, CA 92354, USA; (T.P.); (P.L.)
| | - Paul Lahren
- Loma Linda University Kidney Center, Loma Linda, CA 92354, USA; (T.P.); (P.L.)
| | - Sergio Infante
- Loma Linda University Kidney Center, Loma Linda, CA 92354, USA; (T.P.); (P.L.)
- Department of Internal Medicine Nephrology Division, Loma Linda University School of Medicine, Loma Linda, CA 92350, USA
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13
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Tsvetov G, Amitai O, Shochat T, Shimon I, Akirov A, Diker-Cohen T. Denosumab-induced hypocalcemia in patients with osteoporosis: can you know who will get low? Osteoporos Int 2020; 31:655-665. [PMID: 31838550 DOI: 10.1007/s00198-019-05261-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/05/2019] [Indexed: 02/08/2023]
Abstract
UNLABELLED Hypocalcemia was reported at low rates (0.05-1.7%) in denosumab-treated postmenopausal women with osteoporosis. This real-life study shows a 7.4% rate of denosumab-induced hypocalcemia in community-dwelling osteoporotic men and women. Pretreatment serum calcium and creatinine levels are major predictors for this complication. Serum-calcium monitoring may help to identify and prevent severe hypocalcemia. PURPOSE RCTs have reported a 0.05-1.7% rate of hypocalcemia in denosumab-treated postmenopausal women with osteoporosis, but long-term real-life data are lacking. We assessed the rate of hypocalcemia in osteoporotic community-dwelling patients treated with denosumab. METHODS A retrospective analysis was conducted based on medical records (2010-2018) from a large HMO. An albumin-adjusted serum calcium concentration lower than 8.5 mg/dL was defined as hypocalcemia. RESULTS We included 2005 patients (93% women, mean age 76 ± 9 years). Hypocalcemia developed during treatment in 149 patients (7.4%; 1% less than 8 mg/dL): in 66 after 0.5-1 years; 48 after 1-2 years; 35 after > 2 years. On comparison of the hypocalcemic and normocalcemic patients, the strongest predictors of hypocalcemia were pretreatment levels of albumin-adjusted serum calcium (9.1 ± 0.4 vs. 9.4 ± 0.5 mg/dL, respectively; p < 0.05) and creatinine (0.9 ± 0.5 vs. 0.8 ± 0.3 mg/dL, respectively; p < 0.05). The hypocalcemia rate increased in parallel to a decrease in eGFR (p = 0.032 for the difference between eGFR ranges). Baseline calcium level ≤ 9.31 mg/dL predicted hypocalcemia with a sensitivity of 77% and specificity of 56%. A model of (- 2)*calcium + creatinine predicted hypocalcemia (3.7% when lower and 17.1% when higher than - 17.4). Gender, age, 25-hydroxyvitamin-D, parathyroid hormone, alkaline phosphatase, and whether denosumab was given as first or advanced line of osteoporotic therapy had no predictive value. CONCLUSION Real-life rates of denosumab-induced hypocalcemia are higher than previously reported. Hypocalcemia might develop after each dose of denosumab in ongoing treatment. Adequate calcium and vitamin D supplementation are needed. Serum calcium monitoring is advised in high-risk patients for early detection of severe hypocalcemia.
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Affiliation(s)
- G Tsvetov
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Amitai
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Clalit Healthcare Services, Petah-Tikva, Israel
| | - T Shochat
- Statistical Consulting Unit, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel
| | - I Shimon
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Akirov
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - T Diker-Cohen
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Department of Medicine A, Rabin Medical Center - Beilinson Hospital, 39 Jabotinski St., 4941492, Petah Tikva, Israel.
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14
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Kunizawa K, Hiramatsu R, Hoshino J, Mizuno H, Ozawa Y, Sekine A, Kawada M, Sumida K, Hasegawa E, Yamanouchi M, Hayami N, Suwabe T, Sawa N, Ubara Y, Takaichi K. Denosumab for dialysis patients with osteoporosis: A cohort study. Sci Rep 2020; 10:2496. [PMID: 32051451 PMCID: PMC7016112 DOI: 10.1038/s41598-020-59143-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 01/24/2020] [Indexed: 11/22/2022] Open
Abstract
Evidence for the efficacy of denosumab in HD patients is limited. Accordingly, here we report a study on the safety and efficacy of denosumab in these patients. We prospectively followed 324 patients (121 HD and 203 non-HD patients) receiving denosumab between June 2013 and May 2018, assessing changes in bone mineral density (BMD) and bone metabolic markers, and noting side-effects. Annual changes in BMD at the lumbar spine in HD and non-HD patients from baseline were, respectively, 6.7 ± 11.1% and 7.5 ± 10.2% (p = 0.60), those at the femoral neck were 4.3 ± 7.9% and 3.1 ± 9.5% (p = 0.32), and those at the distal radius were −0.5 ± 6.4% and 0.2 ± 13.0% (p = 0.66). The prevalence of hypocalcemia (<8.5 mg/dL) was significantly higher in HD than in non-HD patients (35.6% vs 5.4%, p < 0.001). The median elapsed time between the first injection of denosumab and the occurrence of hypocalcemia was 7 days in HD patients. The decrease of serum calcium was greater in patients with higher TRACP5b, corticosteroid use, and those without CaCO3 supplementation. Our study suggests that denosumab was equally as effective in HD as non-HD patients. However, careful hypocalcemia monitoring, for at least 4 weeks, is recommended for HD patients.
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Affiliation(s)
- Kyohei Kunizawa
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan.,Department of Nephrology, Kyorin University, Tokyo, Japan
| | | | - Junichi Hoshino
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan. .,Nephrology Center, Toranomon Hospital, Tokyo, Japan. .,The Okinaka Memorial Institute for Medical Research, Tokyo, Japan.
| | | | - Yuko Ozawa
- Nephrology Center, Toranomon Hospital, Tokyo, Japan
| | | | | | - Keiichi Sumida
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | | | | | - Noriko Hayami
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Tatsuya Suwabe
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan.,The Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Kenmei Takaichi
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan.,Nephrology Center, Toranomon Hospital, Tokyo, Japan.,The Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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15
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Pratt RM, West ML, Tennankore KK. Use of denosumab to treat refractory hypercalcemia in a peritoneal dialysis patient with immobilization and tertiary hyperparathyroidism. Perit Dial Int 2020; 40:103-106. [DOI: 10.1177/0896860819880095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypercalcemia due to excess parathyroid hormone (PTH) production is a common condition among patients with end-stage renal disease (ESRD), often referred to as tertiary hyperparathyroidism. There are limited effective medical treatment options currently available for such patients. Denosumab is a monoclonal antibody that inhibits osteoclast activation, thereby reducing calcium release from bones. Denosumab has been used to treat medically-refractory hypercalcemia in non-ESRD patients with hyperparathyroidism. Denosumab has also been used to treat non-PTH-mediated hypercalcemia in patients with advanced chronic kidney disease and ESRD. In this case report, we describe the use of denosumab to successfully treat a case of medically refractory hypercalcemia due to immobilization in a patient on peritoneal dialysis with severe underlying tertiary hyperparathyroidism. In spite of persistently elevated PTH, hypercalcemia quickly resolved after a single dose of denosumab. The patient subsequently developed temporary hypocalcemia requiring medical intervention. Our case report, which is the first described use of denosumab for treatment of hypercalcemia in the setting of tertiary hyperparathyroidism in a peritoneal dialysis patient, adds to the body of literature suggesting denosumab is a useful therapeutic agent in patients with ESRD. Issues with post-treatment electrolyte management and other therapeutic considerations are also discussed.
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Affiliation(s)
- Ryan M Pratt
- Division of Nephrology, Department of Medicine, Dalhousie University, Nova Scotia, Canada
- Queen Elizabeth II Health Sciences Center, Nova Scotia, Canada
| | - Michael L West
- Division of Nephrology, Department of Medicine, Dalhousie University, Nova Scotia, Canada
| | - Karthik K Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University, Nova Scotia, Canada
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16
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Polyzos SA, Makras P, Tournis S, Anastasilakis AD. Off-label uses of denosumab in metabolic bone diseases. Bone 2019; 129:115048. [PMID: 31454537 DOI: 10.1016/j.bone.2019.115048] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/14/2019] [Accepted: 08/23/2019] [Indexed: 01/16/2023]
Abstract
Denosumab (Dmab), a monoclonal antibody against the receptor activator of nuclear factor-κB (RANK) ligand (RANKL) which substantially suppresses osteoclast activity, has been approved for the treatment of common metabolic bone diseases, including postmenopausal osteoporosis, male osteoporosis, and glucocorticoid-induced osteoporosis, in which the pathway of the RANK/RANKL/osteoprotegerin is dysregulated. However, the imbalance of RANKL/RANK/osteoprotegerin is also implicated in the pathogenesis of several other rare metabolic bone diseases, including Juvenile Paget disease, fibrous dysplasia, Hajdu Cheney syndrome and Langerhans cell histiocytosis, thus rendering Dmab a potential treatment option for these diseases. Dmab has been also administered off-label in selected patients (e.g., with Paget's disease, osteogenesis imperfecta, aneurysmal bone cysts) due to contraindications or unresponsiveness to standard treatment, such as bisphosphonates. Moreover, Dmab was administered to improve hypercalcemia induced by various diseases, including primary hyperparathyroidism, tuberculosis and immobilization. The aim of this review is to summarize existing evidence on off-label uses of Dmab in metabolic bone diseases and provide opinion for or against its use, which should be always considered on an individual basis.
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Affiliation(s)
- Stergios A Polyzos
- First Department of Pharmacology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Polyzois Makras
- Department of Endocrinology and Diabetes and Department of Medical Research, 251 Hellenic Air Force General Hospital, Athens, Greece
| | - Symeon Tournis
- Laboratory for Research of the Musculoskeletal System "Th. Garofalidis", National and Kapodistrian University of Athens, KAT Hospital, Athens, Greece
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17
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Iseri K, Watanabe M, Yoshikawa H, Mitsui H, Endo T, Yamamoto Y, Iyoda M, Ryu K, Inaba T, Shibata T. Effects of Denosumab and Alendronate on Bone Health and Vascular Function in Hemodialysis Patients: A Randomized, Controlled Trial. J Bone Miner Res 2019; 34:1014-1024. [PMID: 30690785 DOI: 10.1002/jbmr.3676] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 12/26/2018] [Accepted: 01/11/2019] [Indexed: 12/11/2022]
Abstract
Mineral and bone disorders including osteoporosis are common in dialysis patients and contribute to increased morbimortality. However, whether denosumab and alendronate are effective and safe treatments in hemodialysis patients is not known. Thus, we conducted a prospective, three-center study of 48 hemodialysis patients who were diagnosed as having osteoporosis and had not received anti-osteoporotic agents previously. Participants were randomized to either denosumab or intravenous alendronate, and all subjects received elemental calcium and calcitriol during the initial 2 weeks. The primary endpoint was the percent change in lumbar spine bone mineral density (LSBMD) at 12 months of treatment. The secondary endpoints included the following: change in BMD at other sites; change of serum bone turnover markers (BTM), coronary artery calcium score (CACS), ankle-brachial pressure index (ABI), brachial-ankle pulse wave velocity (baPWV), flow mediated dilation (FMD), and intima-media thickness at the carotid artery (CA-IMT); change from day 0 to day 14 in serum levels of Ca and P; time course of serum calcium (Ca), phosphorus (P), and intact parathyroid hormone (i-PTH); new fractures; and adverse events. Initial supplementation with elemental calcium and calcitriol markedly ameliorated the decrease of serum corrected calcium (cCa) levels induced by denosumab during the first 2 weeks, whereas serum cCa levels in the alendronate group were increased. Denosumab and alendronate markedly decreased serum levels of BTM and increased LSBMD at 12 months compared with baseline. However, no significant differences were found in the changes in LSBMD between the two groups. The serum cCa, P, and i-PTH levels in the two groups were maintained within the appropriate range. In contrast to the anti-osteoporotic effects, no significant differences after 12 months of treatment were found in the CACS, CA-IMT, ABI, baPWV, and FMD compared with pretreatment in both groups. Denosumab and alendronate treatment improved LSBMD, reduced BTM, and appeared to be safe in hemodialysis patients with osteoporosis. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Ken Iseri
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.,Nephrology Center, Makita General Hospital, Tokyo, Japan
| | - Makoto Watanabe
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.,Nephrology Center, Makita General Hospital, Tokyo, Japan
| | | | - Hisao Mitsui
- Hanedaoozora Dialysis Clinic, Tokyo, Japan.,Adachimotoki Jin Dialysis Clinic, Tokyo, Japan
| | | | | | - Masayuki Iyoda
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Kakei Ryu
- Clinical Pharmacology, Pharmacology, Showa University School of Medicine, Tokyo, Japan
| | - Taro Inaba
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takanori Shibata
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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18
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Abstract
PURPOSE OF REVIEW Patients with chronic kidney disease have a high risk of fractures and no established treatments that have been shown to prevent the bone disease. The physiology of renal osteodystrophy is complex and recently more factors have been found that complicate the mineral metabolism. The recognition that vascular calcifications are related to bone disease has made treatment even more challenging. RECENT FINDINGS The most exciting new findings relate to the signaling pathways that are seen in kidney disease and how they cause abnormalities in bone physiology. In particular, wnt and activin signaling pathways are seen early in the course of renal disease. The bones react by increasing FGF-23, which targets both renal phosphate secretion and a variety of other systemic effects. Secreted klotho is another newly described hormone with effects on several systems.Clinical studies have focused on treatments for hyperparathyroidism and phosphate, and frustrating limitations of the treatments used for ordinary osteoporosis. SUMMARY Treatment of bone disease in patients with chronic kidney disease is challenging, and understanding the physiological pathways could lead to novel therapies.
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19
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Bover J, Ureña-Torres P, Laiz Alonso AM, Torregrosa JV, Rodríguez-García M, Castro-Alonso C, Górriz JL, Benito S, López-Báez V, Lloret Cora MJ, Cigarrán S, DaSilva I, Sánchez-Bayá M, Mateu Escudero S, Guirado L, Cannata-Andía J. Osteoporosis, densidad mineral ósea y complejo CKD-MBD (II): implicaciones terapéuticas. Nefrologia 2019; 39:227-242. [DOI: 10.1016/j.nefro.2018.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 09/13/2018] [Accepted: 10/31/2018] [Indexed: 12/23/2022] Open
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20
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Miyaoka D, Imanishi Y, Ohara M, Hayashi N, Nagata Y, Yamada S, Mori K, Emoto M, Inaba M. Impaired residual renal function predicts denosumab-induced serum calcium decrement as well as increment of bone mineral density in non-severe renal insufficiency. Osteoporos Int 2019; 30:241-249. [PMID: 30187112 DOI: 10.1007/s00198-018-4688-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 08/26/2018] [Indexed: 12/27/2022]
Abstract
UNLABELLED Denosumab treatment of osteoporotic patients, except those with severe renal insufficiency, reduced cCa levels. Low baseline cCa, low estimated glomerular filtration rate, and high bone turnover increased the risk of lower cCa, while increasing bone mineral density. Pretreatment with antiresorptive agents was beneficial in reducing the risk of hypocalcemia. INTRODUCTION Although denosumab-induced hypocalcemia has been frequently observed in patients with chronic kidney disease (CKD) stages 4-5D being treated with denosumab for osteoporosis, few studies have assessed the risk factors for serum-corrected calcium (cCa) reductions in patients with non-severe renal insufficiency. This study assessed the risk factors for reduced cCa concentration following denosumab administration and analyzed factors predictive of changes in bone mineral density (BMD). METHODS Seventy-seven osteoporotic patients, not including those with CKD stages 4-5D, were treated with 60 mg denosumab once every 6 months. Biochemical parameters and BMD were analyzed from prior to the initial dose until 1 month after the second dose. RESULTS Following the first administration of denosumab, cCa levels decreased, reaching a minimum on day 7. Multiple linear regression analyses showed that baseline cCa, estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2, tartrate-resistant acid phosphatase-5b (TRACP-5b), and bone alkaline phosphatase (BAP) or pretreatment with antiresorptive agents were significant factors independently associated with the absolute reduction in cCa from baseline to day 7 (ΔcCa0-7 days). ΔcCa0-7 days after the second dose of denosumab was significantly lower than that after the first dose. After 6 months of denosumab treatment, both LS-BMD and FN-BMD significantly increased from baseline. LS-BMD and FN-BMD correlated significantly with baseline TRACP-5b or BAP and eGFR, respectively. CONCLUSIONS Both low eGFR and high bone turnover were independent risk factors for denosumab-induced cCa decrement, and for increases in BMD. Pretreatment with antiresorptive agents may reduce the risk of hypocalcemia.
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Affiliation(s)
- D Miyaoka
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Y Imanishi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - M Ohara
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - N Hayashi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Y Nagata
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - S Yamada
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - K Mori
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - M Emoto
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - M Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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21
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Thongprayoon C, Acharya P, Acharya C, Chenbhanich J, Bathini T, Boonpheng B, Sharma K, Wijarnpreecha K, Ungprasert P, Gonzalez Suarez ML, Cheungpasitporn W. Hypocalcemia and bone mineral density changes following denosumab treatment in end-stage renal disease patients: a meta-analysis of observational studies. Osteoporos Int 2018; 29:1737-1745. [PMID: 29713798 DOI: 10.1007/s00198-018-4533-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/11/2018] [Indexed: 02/06/2023]
Abstract
The incidence of hypocalcemia and bone mineral density (BMD) changes in end-stage renal disease (ESRD) patients on denosumab remains unclear. We performed this meta-analysis to assess the incidence of denosumab-associated hypocalcemia and effects of denosumab on BMD in ESRD patients. A literature search was conducted using MEDLINE, EMBASE, and Cochrane Database from inception through November 2017 to identify studies evaluating incidence of denosumab-associated hypocalcemia and changes in serum calcium, phosphate, alkaline phosphatase (ALP), parathyroid hormone (PTH), and BMD from baseline to post-treatment course of denosumab in ESRD patients. Study results were pooled and analyzed using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42017081074). Six observational studies with a total of 84 ESRD patients were enrolled. The pooled estimated incidence of hypocalcemia during denosumab treatment was 42% (95% CI 29-55%, I2 = 0%). Hypocalcemia occurred approximately 7 to 20 days after the first dose and reached nadir of low calcium levels in the first 2 weeks up to 2 months. However, there were no significant changes in serum calcium or phosphate from baseline to post-treatment course (≥ 3 months after treatment) with mean differences [MDs] of 0.20 mg/dL (95% CI, - 0.30 to 0.69 mg/dL) and - 0.10 mg/dL (95% CI, - 0.70 to 0.49 mg/dL). There were significant reductions in ALP and PTH levels with standardized mean differences (SMDs) of - 0.65 (95% CI - 1.13 to - 0.16) and - 1.89 (95% CI - 3.44 to - 0.34), respectively. There were significant increases in T-scores with MDs of 0.39 (95% CI 0.10 to 0.69) and 0.79 (95% CI 0.60 to 0.98) for lumbar spine and femoral neck, respectively. Our study demonstrates the estimated incidence of denosumab-associated hypocalcemia in dialysis patients of 42%. From baseline to post-treatment course, although there are no differences in serum calcium and phosphate, our findings suggest significant reductions in ALP and PTH and a significant increase in BMD. Currently, denosumab should not be considered as the treatment of choice in ESRD patients until more safety and efficacy data are available.
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Affiliation(s)
- C Thongprayoon
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY, USA
| | - P Acharya
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Mississippi, 2500 N. State St., Jackson, MS, 39216, USA
| | - C Acharya
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Mississippi, 2500 N. State St., Jackson, MS, 39216, USA
| | - J Chenbhanich
- Department of Internal Medicine, Metrowest Medical Center, Framingham, MA, USA
| | - T Bathini
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY, USA
| | - B Boonpheng
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - K Sharma
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY, USA
| | - K Wijarnpreecha
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY, USA
| | - P Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - M L Gonzalez Suarez
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Mississippi, 2500 N. State St., Jackson, MS, 39216, USA
| | - W Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Mississippi, 2500 N. State St., Jackson, MS, 39216, USA.
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22
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Hamano T. Mineral and bone disorders in conventional hemodialysis: Challenges and solutions. Semin Dial 2018; 31:592-598. [PMID: 29900589 DOI: 10.1111/sdi.12729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite the advent of cinacalcet and noncalcium-containing phosphate binders, controlling the progression of vascular calcification (VC) is still challenging. Recent reports demonstrate that carbamylation driven by high urea concentration aggravates VC, suggesting the importance of adequate dialysis in retarding its progression. Theoretically, other promising measures include the use of iron-based phosphate binders, vitamin K, and magnesium supplements, which should be investigated in future randomized controlled trials (RCTs), ideally with hard outcomes. While incidence of hip fracture in patients on dialysis is decreasing in the United States and Japan (possibly owing to better control of PTH levels by cinacalcet) it remains much higher than that in the general population. Many drugs used in the treatment of osteoporosis, including bisphosphonate, raloxifene, denosumab, and teriparatide can, under specific conditions, increase bone mineral density (BMD), which is associated with a lower fracture rate. However, the efficacy of these drugs in reducing the fracture rate remains to be proven in hemodialysis (HD) patients, given their adverse effects such as severe hypocalcemia and resultant worsening of secondary hyperparathyroidism. Some clinical studies have shown that cinacalcet, lanthanum carbonate, and sevelamer reduce mortality in elderly patients on HD, suggesting the benefits of reducing PTH and serum phosphate levels. However, the target ranges of PTH and phosphate levels are based solely on observational studies. This is also the case when treating low PTH levels by decreasing vitamin D or calcium load. RCTs with hard clinical endpoints comparing different targets are necessary in the future.
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Affiliation(s)
- Takayuki Hamano
- Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Osaka, Japan
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23
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Przedlacki J, Buczyńska-Chyl J, Koźmiński P, Niemczyk E, Wojtaszek E, Gieglis E, Żebrowski P, Podgórzak A, Wściślak J, Wieliczko M, Matuszkiewicz-Rowińska J. The utility of FRAX® in predicting bone fractures in patients with chronic kidney disease on hemodialysis: a two-year prospective multicenter cohort study. Osteoporos Int 2018; 29:1105-1115. [PMID: 29411069 DOI: 10.1007/s00198-018-4406-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 01/23/2018] [Indexed: 01/05/2023]
Abstract
UNLABELLED We assessed the FRAX® method in 718 hemodialyzed patients in estimating increased risk of bone major and hip fractures. Over two prospective years, statistical analysis showed that FRAX® enables a better assessment of bone major fracture risk in these patients than any of its components and other risk factors considered in the analysis. INTRODUCTION Despite the generally increased risk of bone fractures among patients with end-stage renal disease, no prediction models for identifying individuals at particular risk have been developed to date. The goal of this prospective, multicenter observational study was to assess the usefulness of the FRAX® method in comparison to all its elements considered separately, selected factors associated with renal disease and the history of falls, in estimating increased risk of low-energy major bone and hip fractures in patients undergoing chronic hemodialysis. METHODS The study included a total of 1068 hemodialysis patients, who were followed for 2 years, and finally, 718 of them were analyzed. The risk analysis included the Polish version of the FRAX® calculator (without bone mineral density), dialysis vintage, mineral metabolism disorders (serum calcium, phosphate, and parathyroid hormone), and the number of falls during the last year before the study. RESULTS Over 2 years, low-energy 30 major bone fractures were diagnosed and 13 of hip fractures among them. Area under the curve for FRAX® was 0.76 (95% CI 0.69-0.84) for major fractures and 0.70 (95% CI 0.563-0.832) for hip fractures. The AUC for major bone fractures was significantly higher than for all elements of the FRAX® calculator. In logistic regression analysis FRAX® was the strongest independent risk factor of assessment of the major bone fracture risk. CONCLUSIONS FRAX® enables a better assessment of major bone fracture risk in ESRD patients undergoing hemodialysis than any of its components and other risk factors considered in the analysis.
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Affiliation(s)
- J Przedlacki
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland.
| | | | | | - E Niemczyk
- Department of Internal Diseases, John Paul II Western Hospital, Grodzisk Mazowiecki, Poland
- Fresenius Dialysis Center, Płońsk, Poland
| | - E Wojtaszek
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - E Gieglis
- Fresenius Dialysis Center, Otwock, Poland
| | - P Żebrowski
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - A Podgórzak
- Department of Nephrology, Mazovia Regional Hospital, Siedlce, Poland
| | - J Wściślak
- Department of Nephrology, Mazovia Regional Hospital, Siedlce, Poland
| | - M Wieliczko
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - J Matuszkiewicz-Rowińska
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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24
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Denosumab for Male Hemodialysis Patients with Low Bone Mineral Density: A Case-Control Study. Int J Nephrol 2017; 2017:6218129. [PMID: 28912972 PMCID: PMC5585574 DOI: 10.1155/2017/6218129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/13/2017] [Accepted: 07/20/2017] [Indexed: 01/16/2023] Open
Abstract
Denosumab increases bone mineral density (BMD) in patients not receiving hemodialysis therapy. However, limited data are available in the literature concerning the use of denosumab in hemodialysis patients. We treated male hemodialysis patients with low radius BMD with denosumab therapy for 1 year and evaluated its effect on radius BMD. Seventeen patients were treated with denosumab 60 mg every 6 months, and 20 patients were not treated with denosumab (control group). At seven days, the mean corrected calcium level decreased from 9.2 ± 0.5 mg to 8.5 ± 0.5 mg (P < 0.01), and mean serum phosphorus decreased from 5.0 ± 1.3 mg/dl to 4.2 ± 0.9 mg/dl (P < 0.01). At 1 month, the corrected calcium and serum phosphorus levels were 9.2 ± 0.9 mg/dl and 4.0 ± 1.1 mg/dl, respectively. At 1 year, BMD increased by 2.6% ± 4.4% in the denosumab group and decreased by 4.5% ± 7.7% in the control group (P < 0.001). In our observational study, denosumab therapy represents an effective treatment for male dialysis patients with low BMD.
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25
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Gielen E, Bergmann P, Bruyère O, Cavalier E, Delanaye P, Goemaere S, Kaufman JM, Locquet M, Reginster JY, Rozenberg S, Vandenbroucke AM, Body JJ. Osteoporosis in Frail Patients: A Consensus Paper of the Belgian Bone Club. Calcif Tissue Int 2017; 101:111-131. [PMID: 28324124 PMCID: PMC5498589 DOI: 10.1007/s00223-017-0266-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/02/2017] [Indexed: 12/11/2022]
Abstract
In this consensus paper, the Belgian Bone Club aims to provide a state of the art on the epidemiology, diagnosis, and management of osteoporosis in frail individuals, including patients with anorexia nervosa, patients on dialysis, cancer patients, persons with sarcopenia, and the oldest old. All these conditions may indeed induce bone loss that is superimposed on physiological bone loss and often remains under-recognized and under-treated. This is of particular concern because of the major burden of osteoporotic fractures in terms of morbidity, mortality, and economic cost. Therefore, there is an urgent need to appreciate bone loss associated with these conditions, as this may improve diagnosis and management of bone loss and fracture risk in clinical practice.
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Affiliation(s)
- E Gielen
- Gerontology and Geriatrics, Department of Clinical and Experimental Medicine, KU Leuven & Center for Metabolic Bone Diseases, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - P Bergmann
- Department of Radioisotopes, CHU Brugmann, Université Libre de Bruxelles, Bruxelles, Belgium
| | - O Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liège, CHU de Liège, Liège, Belgium
| | - E Cavalier
- Department of Clinical Chemistry, UnilabLg, CIRM, University of Liège, CHU de Liège, Liège, Belgium
| | - P Delanaye
- Department of Nephrology, Dialysis, Transplantation, University of Liège, CHU de Liège, Liège, Belgium
| | - S Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - J-M Kaufman
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - M Locquet
- Department of Public Health, Epidemiology and Health Economics, University of Liège, CHU de Liège, Liège, Belgium
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, CHU de Liège, Liège, Belgium
| | - S Rozenberg
- Department of Gynaecology-Obstetrics, Université Libre de Bruxelles, Bruxelles, Belgium
| | - A-M Vandenbroucke
- Clinical Department of Internal Medicine, UZ Leuven, Leuven, Belgium
| | - J-J Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Bruxelles, Belgium
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26
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Molecular Abnormalities Underlying Bone Fragility in Chronic Kidney Disease. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3485785. [PMID: 28421193 PMCID: PMC5380833 DOI: 10.1155/2017/3485785] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 02/28/2017] [Accepted: 03/13/2017] [Indexed: 02/08/2023]
Abstract
Prevention of bone fractures is one goal of therapy for patients with chronic kidney disease-mineral and bone disorder (CKD-MBD), as indicated by the Kidney Disease: Improving Global Outcomes guidelines. CKD patients, including those on hemodialysis, are at higher risk for fractures and fracture-related death compared to people with normal kidney function. However, few clinicians focus on this issue as it is very difficult to estimate bone fragility. Additionally, uremia-related bone fragility has a more complicated pathological process compared to osteoporosis. There are many uremia-associated factors that contribute to bone fragility, including severe secondary hyperparathyroidism, skeletal resistance to parathyroid hormone, and bone mineralization disorders. Uremia also aggravates bone volume loss, disarranges microarchitecture, and increases the deterioration of material properties of bone through abnormal bone cells or excess oxidative stress. In this review, we outline the prevalence of fractures, the interaction of CKD-MBD with osteoporosis in CKD patients, and discuss possible factors that exacerbate the mechanical properties of bone.
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27
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Znorko B, Oksztulska-Kolanek E, Michałowska M, Kamiński T, Pawlak K. Does the OPG/RANKL system contribute to the bone-vascular axis in chronic kidney disease? A systematic review. Adv Med Sci 2017; 62:52-64. [PMID: 28189120 DOI: 10.1016/j.advms.2016.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/20/2016] [Accepted: 08/29/2016] [Indexed: 02/07/2023]
Abstract
Vascular calcification (VC) is highly prevalent in patients with chronic kidney disease (CKD) and is strongly associated with cardiovascular mortality and morbidity. Accumulating evidence over the past decade has challenged the hypothesis of close interaction between bone and VC what raises the possibility of a common underlying pathophysiological mechanism. Lately, bone regulatory proteins such as: osteoprotegerin (OPG) and Receptor Activator for Nuclear Factor κB Ligand (RANKL) has attracted attention of researchers as a possible key mediators of bone-vascular calcification imbalance. The literature search was carried out using the MEDLINE/PubMed database and a combination of keywords and MeSH terms, and only papers published since January 2005 to July 2016 were selected. The search resulted in 562 potential articles. After selection according to the eligibility criteria, 107 studies fulfilled were included (102 full texts and 5 was case reports). OPG and RANKL plays essential role in the regulation of bone metabolism and may be regarded as a possible link between VC, bone and mineral metabolism in CKD patients. Further studies are required to determine the diagnostic significance of these proteins in evaluation of progression and severity of VC process in CKD patients. Finally, the efficacy and safety, especially in regard to VC, of anti-RANKL therapy in CKD patients requires well-designed prospective, randomized trials.
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Affiliation(s)
- Beata Znorko
- Department of Monitored Pharmacotherapy, Medical University of Bialystok, Bialystok, Poland
| | - Ewa Oksztulska-Kolanek
- Department of Monitored Pharmacotherapy, Medical University of Bialystok, Bialystok, Poland
| | | | - Tomasz Kamiński
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Krystyna Pawlak
- Department of Monitored Pharmacotherapy, Medical University of Bialystok, Bialystok, Poland.
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28
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Uehara A, Yazawa M, Kawata A, Hachisuka R, Shibagaki Y. Denosumab for treatment of immobilization-related hypercalcemia in a patient with end-stage renal disease. CEN Case Rep 2017; 6:111-114. [PMID: 28509133 DOI: 10.1007/s13730-017-0254-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 02/12/2017] [Indexed: 11/28/2022] Open
Abstract
The efficacy and safety of denosumab for the treatment of immobilization-related hypercalcemia in end-stage renal disease remain uncertain. We describe the case of a hemodialysis patient with immobilization-related hypercalcemia who was successfully treated with denosumab. A 79-year-old man admitted for hemodialysis after sustaining an acute kidney injury developed immobilization-related hypercalcemia due to the impairment resulting from an acute myocardial infarction, acute heart failure, and catheter-related bloodstream infection. After admission, the patient's corrected serum calcium rose to 12.9 from 8.8 mg/dL. A bisphosphonate (alendronate) was administered, but it was ineffective. Subsequently, treatment with denosumab proved to be effective and his corrected serum calcium level declined to 9.3 mg/dL within 1 week. Hypocalcemia, which is an adverse effect of denosumab, was prevented using active vitamin D and calcium supplementation, and his calcium level stabilized. Thus, our case demonstrates that denosumab is a viable therapeutic option for dialysis patients experiencing immobilization-related hypercalcemia.
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Affiliation(s)
- Atsuko Uehara
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa, 216-8511, Japan.
| | - Masahiko Yazawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa, 216-8511, Japan
| | - Atsumi Kawata
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa, 216-8511, Japan
| | - Rina Hachisuka
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa, 216-8511, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa, 216-8511, Japan
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29
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Optimal management of bone mineral disorders in chronic kidney disease and end stage renal disease. Curr Opin Nephrol Hypertens 2016; 25:120-6. [PMID: 26785065 DOI: 10.1097/mnh.0000000000000203] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW The review summarizes recent studies on chronic kidney disease-mineral bone disorders, with a focus on new developments in disease management. RECENT FINDINGS The term chronic kidney disease-mineral bone disorder has come to describe an increasingly complex network of alterations in minerals and skeletal disorders that contribute to the significant cardiovascular morbidity and mortality seen in patients with chronic kidney disease and end stage renal disease. Clinical studies continue to suggest associations with clinical outcomes, yet current clinical trials have failed to support causality. Variability in practice exists as current guidelines for management of mineral bone disorders are often based on weak evidence. Recent studies implicate novel pathways for therapeutic intervention in clinical trials. SUMMARY Mineral bone disorders in chronic kidney disease arise from alterations in a number of molecules in an increasingly complex physiological network interconnecting bone and the cardiovascular system. Despite extensive associations with improved outcomes in a number of molecules, clinical trials have yet to prove causality and there is an absence of new therapies available to improve patient outcomes. Additional clinical trials that can incorporate the complexity of mineral bone disorders, and with the ability to intervene on more than one pathway, are needed to advance patient care.
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30
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Festuccia F, Jafari MT, Moioli A, Fofi C, Barberi S, Amendola S, Sciacchitano S, Punzo G, Menè P. Safety and efficacy of denosumab in osteoporotic hemodialysed patients. J Nephrol 2016; 30:271-279. [PMID: 27394428 DOI: 10.1007/s40620-016-0334-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 06/28/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS In elderly subjects, renal insufficiency and osteoporosis often coexist with high risk of fracture and elevated socio-economic burden. Today a large number of effective anti-osteoporotic drugs are available but generally they are contraindicated in patients with chronic kidney disease (CKD) because of their progressive accumulation. Denosumab, instead, does not require dose adjustments for different degrees of renal impairment so it can be a valid treatment in osteoporotic patients with CKD. Limited data are available in the literature concerning the use of denosumab in hemodialysis (HD). The aim of our study was, therefore, to study the efficacy and tolerability of this drug in this particular subset of patients. METHODS We retrospectively reviewed the charts of 12 osteoporotic HD patients who received a single 60-mg subcutaneous dose of denosumab every 6 months for an observation period of 24 months. Serum electrolyte, markers of bone turnover and quantitative ultrasound (QUS) were evaluated. RESULTS Over 24 months, we observed a gradual improvement of bone metabolism: β-CrossLaps from 2567.08 ± 1264 to 1492.5 ± 1182.5 pg/ml; bone alkaline phosphatase (BALP) from 33.5 ± 28.8 to 11.8 ± 3.7 mcg/l, and of QUS index (T-score from -5.33 ± 1.58 to -4.84 ± 1.2; risk of fracture from 13.9 ± 4.7 to 11.07 ± 5.3 %). Few cases of hypocalcemia were detected, more significant after the first and second injection, but with careful monitoring of serum calcium and rapid therapy adjustment we could easily manage serum Ca levels. CONCLUSIONS Our pilot experience highlights the safety and efficacy of denosumab in the treatment of osteoporosis in HD patients, potentially supporting its use to reduce the burden of fractures in this patient population.
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Affiliation(s)
- Francescaromana Festuccia
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy. .,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Maryam Tayefeh Jafari
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Alessandra Moioli
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy. .,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Claudia Fofi
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy.,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Simona Barberi
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy.,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Stefano Amendola
- Section of Endocrinology and Diabetology, Ospedale Israelitico, Rome, Italy
| | - Salvatore Sciacchitano
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy.,Laboratory of Biomedical Research, Niccolò Cusano University Foundation, Rome, Italy
| | - Giorgio Punzo
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy.,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Paolo Menè
- Nephrology and Dialysis Unit, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy.,Division of Nephrology, Sant'Andrea University Hospital, Via di Grottarossa 1035-1039, 00189, Rome, Italy
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31
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Morrone LF, Bolasco P, Camerini C, Cianciolo G, Cupisti A, Galassi A, Mazzaferro S, Russo D, Russo L, Cozzolino M. Vitamin D in patients with chronic kidney disease: a position statement of the Working Group "Trace Elements and Mineral Metabolism" of the Italian Society of Nephrology. J Nephrol 2016; 29:305-328. [PMID: 27062486 DOI: 10.1007/s40620-016-0305-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/30/2016] [Indexed: 02/07/2023]
Abstract
In the late 1970s, calcitriol was introduced into clinical practice for the management of secondary renal hyperparathyroidism in chronic kidney disease (CKD). Since then, the use of calcifediol or other native forms of vitamin D was largely ignored until the publication of the 2009 Kidney Disease Improving Global Outcomes (KDIGO) recommendations. The guidelines suggested that measurement of circulating levels of 25(OH)D (calcifediol) and its supplementation were to be performed on the same basis as for the general population. This indication was based on the fact that the precursors of active vitamin D had provided to CKD patients considerable benefits in survival, mainly due to their pleiotropic effects on the cardiovascular system. However, despite the long-term use of various classes of vitamin D in CKD, a clear definition is still lacking concerning the most appropriate time for initiation of therapy, the best compound to prescribe (active metabolites or analogs), the proper dosage, and the most suitable duration of therapy. The aim of this position statement is to provide and critically appraise the current plentiful evidence on vitamin D in different clinical settings related to CKD, particularly focusing on outcomes, monitoring and treatment-associated risks. However, it should be taken in account that position statements are meant to provide guidance; therefore, they are not to be considered prescriptive for all patients and, importantly, they cannot replace the judgment of clinicians.
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Affiliation(s)
- Luigi Francesco Morrone
- Nephrology, Dialysis and Renal Transplantation Unit, University Hospital "Policlinico", Bari, Italy.
| | - Pergiorgio Bolasco
- Territorial Unit of Nephrology and Dialysis-ASL 8 of Cagliari, Cagliari, Italy
| | - Corrado Camerini
- Operative Unit of Nephrology, AO Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Giuseppe Cianciolo
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna, Italy
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Sandro Mazzaferro
- Department of Cardiovascular Respiratory Nephrologic Anesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Domenico Russo
- Department of Public Health, Unit of Nephrology and Hypertension, University of Naples Federico II, Naples, Italy
| | - Luigi Russo
- Department of Public Health, Unit of Nephrology and Hypertension, University of Naples Federico II, Naples, Italy
| | - Mario Cozzolino
- Renal Division and Laboratory of Experimental Nephrology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
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Monge Rafael P, Arias M, Fernández-Fresnedo G. Severe hypocalcemia following denosumab injection in patient with chronic kidney disease. Nefrologia 2016; 36:446-8. [PMID: 27012438 DOI: 10.1016/j.nefro.2016.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/01/2016] [Accepted: 02/15/2016] [Indexed: 11/16/2022] Open
Affiliation(s)
- Pilar Monge Rafael
- Servicio de Endocrinología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Manuel Arias
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Gema Fernández-Fresnedo
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España.
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