1
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Schepers L, Jans I, Pot GK, Smilde AJ, Hofstra JM, de Roos NM. The Effect of Niacinamide Supplementation on Phosphate Concentrations in Dutch Dialysis Patients: A Randomized Crossover Trial. J Ren Nutr 2024:S1051-2276(24)00036-0. [PMID: 38492684 DOI: 10.1053/j.jrn.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 12/19/2023] [Accepted: 02/12/2024] [Indexed: 03/18/2024] Open
Abstract
OBJECTIVE Hyperphosphatemia is a common complication in patients with kidney failure, despite the use of phosphate binders. Vitamin B3, either in the form of niacin or niacinamide (NAM), shows potential as "add-on" treatment to reduce serum phosphate concentrations in this population. NAM seems to lack many of the side effects that are observed with niacin. The aim of this study was to investigate whether NAM is an effective and acceptable treatment in reducing serum phosphate concentrations in patients with kidney failure. METHODS DiaNia was a double-blind placebo-controlled randomized crossover trial, comparing NAM (250-500 mg/day) to placebo as "add-on" treatment to an individual treatment with approved phosphate binders for 12 weeks in patients receiving hemodialysis. The primary outcome was serum phosphate concentrations, and the secondary outcomes were platelet counts as well as drop-outs due to side effects. Data were analyzed using both per-protocol and intention-to-treat analyses. RESULTS Mean age of the per-protocol population (n = 26) was 63.6 ± 17.2 years and 53.8% were men. NAM treatment significantly reduced serum phosphate with 0.59 mg/dL (p = .03). Linear mixed-effects models demonstrated superiority of 12 weeks NAM over 12 weeks placebo with a between-treatment difference of 0.77 mg/dL (95% CI 0.010, 1.43; P = .03). Similar results, although not significant, were found in the intention-to-treat population. We found no between-treatment differences in platelet counts and during the NAM treatment we observed 3 drop-outs due to side effects (8.6%). CONCLUSION NAM is effective in reducing serum phosphate concentrations in patients with kidney failure receiving hemodialysis. In addition, NAM is well-tolerated and seems not to increase the risk of thrombocytopenia. Thus, NAM can be valuable as "add-on" treatment to combat hyperphosphatemia in patients with kidney failure. However, more research in larger populations is needed to confirm this.
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Affiliation(s)
- Lara Schepers
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
| | - Inez Jans
- Department of Nutrition and Dietetics, Hospital Gelderse Vallei, Ede, the Netherlands, Nutrition & Healthcare Alliance, Ede, The Netherlands
| | - Gerda K Pot
- Nutrition & Healthcare Alliance, Ede, The Netherlands
| | - Arend-Jan Smilde
- Department of Nephrology, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Julia M Hofstra
- Department of Nephrology, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Nicole M de Roos
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands.
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2
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Pierre VC, Wilharm RK. Design Principles and Applications of Selective Lanthanide-Based Receptors for Inorganic Phosphate. Front Chem 2022; 10:821020. [PMID: 35198539 PMCID: PMC8859545 DOI: 10.3389/fchem.2022.821020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/11/2022] [Indexed: 01/07/2023] Open
Abstract
Phosphate is an anion of both environmental and medical significance. The increase in phosphate levels in surface waters due primarily to run-offs from fertilized agricultural fields causes widespread eutrophication and increasingly large dead-zones. Hyperphosphatemia, a condition in which blood phosphate levels are elevated, is a primary cause of increased mortality and morbidity in chronic or advanced kidney disease. Resolving both of these issues require, in part, new technology that could selectively sequester phosphate in water at neutral pH. The high hydration energy of phosphate, which prevents organic receptors from functioning in water with sufficient affinity, can be overcome via coordination to a hard metal ion. The hardness, oxophilicity and lability of lanthanide ions make them excellent candidates for the design of high affinity phosphate receptors. In this perspective, we discuss how the principles of lanthanide coordination chemistry can be exploited to design sensitive and selective receptors for phosphate. Unlike many supramolecular systems, these hosts do not recognize their anionic guests via directed electrostatic and hydrogen bonding interactions. Instead, the selectivity of our fluxional receptors is governed entirely by acid-base chemistry and electrostatic forces. Parameters that affect the affinity and selectivity of the receptors include the basicities of the coordinating ligand and of the targeted anion, the acidity of the lanthanide ion, and the geometry of the ligand. Uniquely, their affinity for phosphate can be readily tuned by orders of magnitude either by peripheral interactions or by the lanthanide ion itself without affecting their exquisite selectivity over competing anions such as bicarbonate and chloride.
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Ahmed S, Rahman T, Ripon MSH, Rashid HU, Kashem T, Md Ali MS, Khor BH, Khosla P, Karupaiah T, Daud ZAM. A Food Frequency Questionnaire for Hemodialysis Patients in Bangladesh (BDHD-FFQ): Development and Validation. Nutrients 2021; 13:4521. [PMID: 34960076 PMCID: PMC8707927 DOI: 10.3390/nu13124521] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022] Open
Abstract
Diet is a recognized risk factor and cornerstone for chronic kidney disease (CKD) management; however, a tool to assess dietary intake among Bangladeshi dialysis patients is scarce. This study aims to validate a prototype Bangladeshi Hemodialysis Food Frequency Questionnaire (BDHD-FFQ) against 3-day dietary recall (3DDR) and corresponding serum biomarkers. Nutrients of interest were energy, macronutrients, potassium, phosphate, iron, sodium and calcium. The BDHD-FFQ, comprising 132 food items, was developed from 606 24-h recalls and had undergone face and content validation. Comprehensive facets of relative validity were ascertained using six statistical tests (correlation coefficient, percent difference, paired t-test, cross-quartiles classification, weighted kappa, and Bland-Altman analysis). Overall, the BDHD-FFQ showed acceptable to good correlations (p < 0.05) with 3DDR for the concerned nutrients in unadjusted and energy-adjusted models, but this correlation was diminished when adjusted for other covariates (age, gender, and BMI). Phosphate and potassium intake, estimated by the BDHD-FFQ, also correlated well with the corresponding serum biomarkers (p < 0.01) when compared to 3DDR (p > 0.05). Cross-quartile classification indicated that <10% of patients were incorrectly classified. Weighted kappa statistics showed agreement with all but iron. Bland-Altman analysis showed positive mean differences were observed for all nutrients when compared to 3DDR, whilst energy, carbohydrates, fat, iron, sodium, and potassium had percentage data points within the limit of agreement (mean ± 1.96 SD), above 95%. In summary, the BDHD-FFQ demonstrated an acceptable relative validity for most of the nutrients as four out of the six statistical tests fulfilled the cut-off standard in assessing dietary intake of CKD patients in Bangladesh.
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Affiliation(s)
- Shakil Ahmed
- Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Sonapur 3814, Bangladesh; (S.A.); (M.S.H.R.)
| | - Tanjina Rahman
- Institute of Nutrition and Food Science, University of Dhaka, Dhaka 1000, Bangladesh;
| | - Md Sajjadul Haque Ripon
- Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, Sonapur 3814, Bangladesh; (S.A.); (M.S.H.R.)
| | - Harun-Ur Rashid
- Kidney Foundation Hospital and Research Institute, Dhaka 1216, Bangladesh; (H.-U.R.); (T.K.)
| | - Tasnuva Kashem
- Kidney Foundation Hospital and Research Institute, Dhaka 1216, Bangladesh; (H.-U.R.); (T.K.)
| | - Mohammad Syafiq Md Ali
- Department of Nutrition Sciences, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Kuantan 25200, Pahang, Malaysia;
| | - Ban-Hock Khor
- Faculty of Food Science and Nutrition, Universiti Malaysia Sabah, Kota Kinabalu 88400, Sabah, Malaysia;
| | - Pramod Khosla
- Department of Nutrition and Food Science, Wayne State University, Detroit, MI 48202, USA;
| | - Tilakavati Karupaiah
- School of Biosciences, Taylors’ University, Subang Jaya 47500, Selangor, Malaysia;
| | - Zulfitri Azuan Mat Daud
- Department of Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
- Research Center of Excellence (RCoE) Nutrition and Non-Communicable Diseases, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
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4
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Wilharm RK, Huang SY, Gugger IJ, Pierre VC. A Walk Across the Lanthanide Series: Trend in Affinity for Phosphate and Stability of Lanthanide Receptors from La(III) to Lu(III). Inorg Chem 2021; 60:15808-15817. [PMID: 34618431 DOI: 10.1021/acs.inorgchem.1c02462] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The trend in affinity of two 1,2-hydroxypyridinonate lanthanide(III) receptors-LnIII-2,2-Li-HOPO and LnIII-3,3-Gly-HOPO (LnIII = LaIII, PrIII, NdIII, SmIII, EuIII, GdIII, TbIII, DyIII, HoIII, ErIII, TmIII, YbIII, and LuIII)-for phosphate across the series was investigated by luminescence spectroscopy via competition against the central europium(III) analog. Regardless of the ligand, the rare earth receptors display a steep and continuous increase in affinity for their phosphate guest across the series, with the later lanthanides displaying the highest affinity for the oxyanion. This trend mirrors that of the stability of the lanthanide receptors, which also increases significantly and continuously from LaIII to LuIII. For these two ligands, the ionic radius of a rare earth, a parameter directly linked to its Lewis acidity, correlates strongly with its affinity for anions, regardless of whether that anion is the one coordinating it (in this case the 1,2-hydroxypyridinonate ligand) or the guest targeted by the lanthanide receptor (in this case phosphate). These observations are indicative of a lack of steric hindrance for coordination of phosphate. Advantageously, increased efficacy of the lanthanide receptor comes with increased stability. The remarkably high stability of LuIII-2,2-Li-HOPO, combined with its high affinity for phosphate, makes it a particularly promising candidate for translational application to medical or environmental sequestration of phosphate since the higher stability will further reduce the risk of the rare earth leaching during anion separation. The unusually large difference in stability between lanthanide complexes (the LuIII complex of 2,2-Li-HOPO is at least 7 orders of magnitude more stable than the LaIII one) bodes well for potential applications in rare earth separation.
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Affiliation(s)
- Randall K Wilharm
- Department of Chemistry, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Sheng-Yin Huang
- Department of Chemistry, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Isabel J Gugger
- Department of Chemistry, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Valérie C Pierre
- Department of Chemistry, University of Minnesota, Minneapolis, Minnesota 55455, United States
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5
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Vermue IJM, Begum R, Castilho M, Rookmaaker MB, Masereeuw R, Bouten CVC, Verhaar MC, Cheng C. Renal Biology Driven Macro- and Microscale Design Strategies for Creating an Artificial Proximal Tubule Using Fiber-Based Technologies. ACS Biomater Sci Eng 2021; 7:4679-4693. [PMID: 34490771 PMCID: PMC8512683 DOI: 10.1021/acsbiomaterials.1c00408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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Chronic kidney disease
affects one in six people worldwide. Due
to the scarcity of donor kidneys and the complications associated
with hemodialysis (HD), a cell-based bioartificial kidney (BAK) device
is desired. One of the shortcomings of HD is the lack of active transport
of solutes that would normally be performed by membrane transporters
in kidney epithelial cells. Specifically, proximal tubule (PT) epithelial
cells play a major role in the active transport of metabolic waste
products. Therefore, a BAK containing an artificial PT to actively
transport solutes between the blood and the filtrate could provide
major therapeutic advances. Creating such an artificial PT requires
a biocompatible tubular structure which supports the adhesion and
function of PT-specific epithelial cells. Ideally, this scaffold should
structurally replicate the natural PT basement membrane which consists
mainly of collagen fibers. Fiber-based technologies such as electrospinning
are therefore especially promising for PT scaffold manufacturing.
This review discusses the use of electrospinning technologies to generate
an artificial PT scaffold for ex vivo/in
vivo cellularization. We offer a comparison of currently
available electrospinning technologies and outline the desired scaffold
properties required to serve as a PT scaffold. Discussed also are
the potential technologies that may converge in the future, enabling
the effective and biomimetic incorporation of synthetic PTs in to
BAK devices and beyond.
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Affiliation(s)
- IJsbrand M Vermue
- Department of Nephrology and Hypertension, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands
| | - Runa Begum
- Department of Nephrology and Hypertension, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands
| | - Miguel Castilho
- Department of Orthopaedics, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands.,Regenerative Medicine Center Utrecht, 3508 GA Utrecht, The Netherlands.,Department of Biomedical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Maarten B Rookmaaker
- Department of Nephrology and Hypertension, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands
| | - Rosalinde Masereeuw
- Regenerative Medicine Center Utrecht, 3508 GA Utrecht, The Netherlands.,Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, 3584 CS Utrecht, The Netherlands
| | - Carlijn V C Bouten
- Department of Biomedical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands.,Institute for Complex Molecular Systems (ICMS), Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands
| | - Caroline Cheng
- Department of Nephrology and Hypertension, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands.,Experimental Cardiology, Department of Cardiology, Thorax Center, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
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6
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St-Jules DE, Woolf K, Goldfarb DS, Pompeii ML, Li H, Wang C, Mattoo A, Marcum ZA, Sevick MA. Feasibility and Acceptability of mHealth Interventions for Managing Hyperphosphatemia in Patients Undergoing Hemodialysis. J Ren Nutr 2021; 31:403-410. [DOI: 10.1053/j.jrn.2020.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 06/25/2020] [Accepted: 07/26/2020] [Indexed: 11/11/2022] Open
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7
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St-Jules DE, Rozga MR, Handu D, Carrero JJ. Effect of Phosphate-Specific Diet Therapy on Phosphate Levels in Adults Undergoing Maintenance Hemodialysis: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol 2020; 16:107-120. [PMID: 33380474 PMCID: PMC7792658 DOI: 10.2215/cjn.09360620] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/07/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Hyperphosphatemia is a persistent problem in individuals undergoing maintenance hemodialysis, which may contribute to vascular and bone complications. In some dialysis centers, dietitians work with patients to help them manage serum phosphate. Given the regularity of hyperphosphatemia in this population and constraints on kidney dietitian time, the authors aimed to evaluate the evidence for this practice. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS There was a systematic review and meta-analysis of clinical trials. MEDLINE, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, and other databases were searched for controlled trials published from January 2000 until November 2019 in the English language. Included studies were required to examine the effect of phosphate-specific diet therapy provided by a dietitian on serum phosphate in individuals on hemodialysis. Risk of bias and certainty of evidence were assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) method. RESULTS Of the 8054 titles/abstracts identified, 168 articles were reviewed, and 12 clinical trials (11 randomized, one nonrandomized) were included. Diet therapy reduced serum phosphate compared with controls in all studies, reaching statistical significance in eight studies, although overall certainty of evidence was low, primarily due to randomization issues and deviations from protocol. Monthly diet therapy (20-30 minutes) significantly lowered serum phosphate in patients with persistent hyperphosphatemia for 4-6 months, without compromising nutrition status (mean difference, -0.87 mg/dl; 95% confidence interval, -1.40 to -0.33 mg/dl), but appeared unlikely to maintain these effects if discontinued. Unfortunately, trials were too varied in design, setting, and approach to appropriately pool in meta-analysis, and were too limited in number to evaluate the timing, dose, and strategy of phosphate-specific diet therapy. CONCLUSIONS There is low-quality evidence that monthly diet therapy by a dietitian appears to be a safe and efficacious treatment for persistent hyperphosphatemia in patients on HD.
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Affiliation(s)
| | - Mary R. Rozga
- Evidence Analysis Center, Academy of Nutrition and Dietetics, Chicago, Illinois
| | - Deepa Handu
- Evidence Analysis Center, Academy of Nutrition and Dietetics, Chicago, Illinois
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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8
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Farfan-Ruiz AC, Czikk D, Leidecker J, Ramsay T, McCormick B, Wilson K, Zimmerman D. Multidisciplinary Team versus a "Phosphate-Counting" App for Serum Phosphate Control: A Randomized Controlled Trial. KIDNEY360 2020; 2:290-297. [PMID: 35373021 PMCID: PMC8740993 DOI: 10.34067/kid.0007132020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/14/2020] [Indexed: 02/04/2023]
Abstract
Background Hyperphosphatemia is almost universal in well-nourished patients with ESKD treated with dialysis due to an imbalance between dietary intake and phosphate removal via residual kidney function and dialysis. Although food phosphate content can vary dramatically between meals, the current standard is to prescribe a fixed dose of phosphate binder that may not match meal phosphate intake. The primary objective of our study was to determine if the use of an app that matches phosphate binder dose with food phosphate content would be associated with an improvement in serum phosphate and a reduction in calcium carbonate intake compared with the multidisciplinary renal team. Methods Eighty patients with ESKD treated with peritoneal dialysis at a tertiary care hospital in Canada were randomized to the standard of care for serum phosphate management (multidisciplinary renal team) versus the OkKidney app. Serum phosphate was measured at baseline and then monthly for 3 months with adjustments to phosphate management as deemed necessary by the multidisciplinary team (control) or the phosphate binder multiplier in the OkKidney app (intervention) on the basis of the laboratory values. The primary analysis was an unpaired t test of the serum phosphate at study completion. Results The participants were 56 (±14) years old, and 54% were men; the most common cause of ESKD was diabetes mellitus. The serum phosphate values were 1.96 (0.41) and 1.85 (0.44) mmol/L in the control and intervention groups, respectively, at the end of 3 months (P=0.30). The median elemental daily dose of calcium carbonate did not differ between the groups at study completion (587 mg [309-928] versus 799 mg [567-1183], P=0.29). Conclusions The OkKidney app was associated with similar but not superior serum phosphate control to the standard of care, which included renal dietician support. Clinical Trial registry name and registration number US National Library Medicine ClinicalTrials.gov, NCT01643486.
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Affiliation(s)
- Ana Cecilia Farfan-Ruiz
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Czikk
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Leidecker
- Kidney Research Centre of the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tim Ramsay
- Methods Centre, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Brendan McCormick
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada,Kidney Research Centre of the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kumanan Wilson
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Deborah Zimmerman
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada,Kidney Research Centre of the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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9
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Milazi M, Douglas C, Bonner A. A bundled phosphate control intervention (4Ds) for adults with end-stage kidney disease receiving haemodialysis: A cluster randomized controlled trial. J Adv Nurs 2020; 77:1345-1356. [PMID: 33277736 DOI: 10.1111/jan.14700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/18/2020] [Accepted: 11/13/2020] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the effectiveness of a bundled self-management intervention (taking control of your phosphate with the 4Ds) to improve phosphate control among adults receiving haemodialysis. BACKGROUND Hyperphosphataemia occurs in end-stage kidney disease and is managed by diet, drinks, drugs (phosphate binder medication), and dialysis (the 4Ds). Adherence to the 4Ds is challenging for patients. DESIGN A pragmatic cluster randomized controlled trial with repeated measures. METHODS Participants were adults receiving haemodialysis with high serum phosphate (>1.6 mmol/L for at least 3 months) recruited between August 2017 -May 2018. Cluster randomization was according to haemodialysis treatment shifts. The 'teach-back' intervention was designed to improve phosphate control. Expected outcomes were reduced serum phosphate and increased knowledge of phosphate in end-stage kidney disease, self-efficacy and adherence to diet, drugs, and dialysis. RESULTS There were no differences between groups at baseline. Both groups had similar mean serum phosphate over time; at three months, 46% of the intervention group achieved reductions that met the target serum phosphate level compared with 33% of the control group. There were significant improvements in knowledge of phosphate in end-stage kidney disease, self-efficacy and adherence to diet, drugs, and dialysis (missing) in the intervention group compared with control group. CONCLUSION The 4Ds, a bundled self-management intervention, was effective in improving patient confidence and adherence to phosphate control methods. IMPACT The 4Ds intervention bundles together four essential strategies for preventing and controlling hyperphosphataemia in end-stage kidney disease. TRIAL REGISTRATION ACTRN12617000703303 Registered 16/05/2017.
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Affiliation(s)
- Molly Milazi
- School of Nursing, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Kidney Health Service, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Clint Douglas
- School of Nursing, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Nursing Chair, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Ann Bonner
- Kidney Health Service, Metro North Hospital and Health Service, Brisbane, Queensland, Australia.,School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia
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10
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Murali KM, Lonergan M. Breaking the adherence barriers: Strategies to improve treatment adherence in dialysis patients. Semin Dial 2020; 33:475-485. [DOI: 10.1111/sdi.12925] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | - Maureen Lonergan
- Department of Nephrology Wollongong Hospital Wollongong NSW Australia
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11
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HD-FFQ to Detect Nutrient Deficiencies and Toxicities for a Multiethnic Asian Dialysis Population. Nutrients 2020. [PMCID: PMC7352606 DOI: 10.3390/nu12061585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A rapid and reliable tool appropriate to quantifying macronutrient and micronutrient intakes in diets consumed by Malaysian hemodialysis (HD) patients is lacking. We aimed to develop and validate a novel HD-food frequency questionnaire (HD-FFQ) to assess habitual nutritional intakes of HD patients with diverse ethnic backgrounds. This study was conducted in three phases. In Phase I, a HD-FFQ comprising 118 food items was developed using 3-day diet recalls (3DDR) from 388 HD patients. Phase II was the face and content validation using the Scale-Content Validity Index (S-CVI). After successfully developing the FFQ, Phase III tested relative validation against a reference method, the 3DDR. Results from Phase III showed that the mean difference for absolute intakes of nutrients assessed by HD-FFQ and 3DDR were significant (p < 0.05). However, there was a significant correlation between the HD-FFQ and reference method ranging from 0.35–0.47 (p < 0.05). Cross-quartile classification showed that <10% of patients were grossly misclassified. In conclusion, the HD-FFQ has an acceptable relative validity in assessing and ranking the dietary intake of the HD patients in Malaysia.
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12
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Floege J. Phosphate binders in chronic kidney disease: an updated narrative review of recent data. J Nephrol 2019; 33:497-508. [PMID: 31865608 DOI: 10.1007/s40620-019-00689-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/17/2019] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease (CKD) is frequently accompanied by hyperphosphatemia. High serum phosphate usually requires dietary measures, adequate dialysis prescription and/or phosphate binders. For this narrative review a PubMed searched was undertaken to identify new publications on phosphate binders that had been published between January 2015 and July 2019. The present review summarizes this most recent information on dietary measures and their problems in treating hyperphosphatemia in CKD patients, overall effects of phosphate binders on cardiovascular mortality and morbidity, adherence to phosphate binder therapy as well as new data on specific aspects of the various phosphate binders on the market: calcium-containing phosphate binders, polymeric phosphate binders (sevelamer, bixalomer, colestilan), magnesium-containing phosphate binders, lanthanum carbonate, ferric citrate, sucroferric oxyhydroxide, and new compounds in development, in particular drugs targeting intestinal phosphate transporters.
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Affiliation(s)
- Jürgen Floege
- Department of Nephrology and Clinical Immunology, University Hospital, Rheinisch Westfälische Technische Hochschule (RWTH), Pauwelsstr. 30, 52057, Aachen, Germany.
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13
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Abstract
Allowing dialysis patients to eat during the treatment is controversial. It is, therefore, no surprise that practices and policies with respect to intradialytic food consumption vary considerably from unit to unit and from country to country. Those who defend the position of feeding during dialysis reason that intradialytic meals offer a supervised and effective therapy for protein-energy wasting. Those who take the opposite view argue that intradialytic food intake should be avoided for the following three reasons. First, interventional studies show that eating during dialysis causes a clinically significant reduction in systemic blood pressure during the postprandial period and elevates the risk of symptomatic intradialytic hypotension; the latter is associated with increased mortality risk. Second, clinical studies have shown that eating during dialysis interferes with the adequacy of the delivered dialysis, whereas eating 2-3 h before the dialysis session has no impact on the efficiency of the subsequent dialysis treatment. And third, randomized studies show that eating during dialysis focus on the positive outcomes but do not adequately balance this potential benefit against the risk of intradialytic hemodynamic instability and poor quality of delivered dialysis. Even after half a century of providing long-term dialysis, definitive randomized trials that balance risks and benefits of eating during dialysis are missing. These knowledge gaps require randomized trials. Since there is a real possibility of harm with eating during dialysis, we caution that instead of encouraging the widespread use of intradialytic meals, practices and policies should focus on adequate nutrient intake during the interdialytic interval.
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Affiliation(s)
- Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
| | - Panagiotis Georgianos
- Division of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Kritmetapak K, Dumrongsukit S, Jinchai J, Wongprommek P. Pseudohyperphosphatemia in a patient with relapsed multiple myeloma after bone marrow transplantation: A case report. Clin Case Rep 2019; 7:1426-1429. [PMID: 31360504 PMCID: PMC6637355 DOI: 10.1002/ccr3.2264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/10/2019] [Accepted: 05/28/2019] [Indexed: 11/11/2022] Open
Abstract
Pseudohyperphosphatemia is a laboratory artifact characterized by falsely elevated serum phosphate mostly due to paraprotein interference on the conventional automated analyzer. Clinician recognition of this phenomenon and pre-analytical preparation, including dilution or protein precipitation, can obviate unnecessary therapy and potentially unveil the diagnosis of paraproteinemia especially related to multiple myeloma.
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Affiliation(s)
| | - Sophon Dumrongsukit
- Department of Medicine, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand
| | - Jittirat Jinchai
- Department of Medicine, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand
| | - Panibud Wongprommek
- Division of Nephrology, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand
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15
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Hjemås BJ, Bøvre K, Mathiesen L, Lindstrøm JC, Bjerknes K. Interventional study to improve adherence to phosphate binder treatment in dialysis patients. BMC Nephrol 2019; 20:178. [PMID: 31101020 PMCID: PMC6525353 DOI: 10.1186/s12882-019-1334-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 04/12/2019] [Indexed: 01/28/2023] Open
Abstract
Background Adherence to phosphate binder treatment is important to prevent high serum phosphate level in chronic dialysis patients. We therefore wanted to investigate patient knowledge, beliefs about and adherence to phosphate binders among these patients and assess whether one-to-one pharmacist-led education and counselling enhance adherence and lead to changes in serum phosphate levels. Methods A descriptive, interventional, single arm, pre-post study was performed at a hospital in Norway, including chronic dialysis patients aged 18 years or more using phosphate binders. The primary end-point was change in the proportion of patients with serum phosphate below 1.80 mmol/L and the secondary end-points included change in the patient’s knowledge, beliefs and adherence after the intervention measured by completion of questionnaires ‘Patient Knowledge’, Medication Adherence Report Scale (MARS− 5) and Beliefs about Medicines Questionnaire (BMQ). Data was collected both prior to and after one-to-one pharmacist-led education and counselling about their phosphate binders. Other medicines used by the patient was also registered. Results A total of 69 patients were enrolled in the study. After intervention, the probability of serum phosphate being below the target threshold 1.80 mmol/L (5.58 mg/dL) increased, although no significant change in mean serum phosphate levels was seen. On the other hand, the knowledge regarding phosphate binder treatment and the patients’ beliefs about the necessity of the treatment increased, while the concerns decreased (BMQ). This effect did not lead to increase in self-reported adherence measured by MARS-5. However the scores were high before the intervention. Conclusions Short term one-to-one individualized pharmacist-led education and counselling about phosphate binders increased the probability of serum phosphate concentrations being below the target threshold level 1.80 mmol/L (5.58 mg/dL), although not statistically significant. However, it did not decrease the mean serum phosphate level or increase the patients’ self-reported adherence. The patients increased their knowledge about the phosphate binder and their understanding of adherence, and were less concerned about the side effects of the medication. Trial registration ISRCTN52852596, registered 11 April 2019. The trial was registered retrospectively.
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Affiliation(s)
- Bodil Jahren Hjemås
- Hospital Pharmacies Enterprise, South Eastern Norway, Stenersgate 1, PB. 79, 0050, Oslo, Norway.
| | - Katrine Bøvre
- Hospital Pharmacies Enterprise, South Eastern Norway, Stenersgate 1, PB. 79, 0050, Oslo, Norway
| | - Liv Mathiesen
- Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
| | - Jonas Christoffer Lindstrøm
- Health Services Research Units, Akershus University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kathrin Bjerknes
- Hospital Pharmacies Enterprise, South Eastern Norway, Stenersgate 1, PB. 79, 0050, Oslo, Norway
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16
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Creatine is a Conditionally Essential Nutrient in Chronic Kidney Disease: A Hypothesis and Narrative Literature Review. Nutrients 2019; 11:nu11051044. [PMID: 31083291 PMCID: PMC6567063 DOI: 10.3390/nu11051044] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/23/2019] [Accepted: 05/08/2019] [Indexed: 12/15/2022] Open
Abstract
To accommodate the loss of the plethora of functions of the kidneys, patients with chronic kidney disease require many dietary adjustments, including restrictions on the intake of protein, phosphorus, sodium and potassium. Plant-based foods are increasingly recommended as these foods contain smaller amounts of saturated fatty acids, protein and absorbable phosphorus than meat, generate less acid and are rich in fibers, polyunsaturated fatty acids, magnesium and potassium. Unfortunately, these dietary recommendations cannot prevent the occurrence of many symptoms, which typically include fatigue, impaired cognition, myalgia, muscle weakness, and muscle wasting. One threat coming with the recommendation of low-protein diets in patients with non-dialysis-dependent chronic kidney disease (CKD) and with high-protein diets in patients with dialysis-dependent CKD, particularly with current recommendations towards proteins coming from plant-based sources, is that of creatine deficiency. Creatine is an essential contributor in cellular energy homeostasis, yet on a daily basis 1.6–1.7% of the total creatine pool is degraded. As the average omnivorous diet cannot fully compensate for these losses, the endogenous synthesis of creatine is required for continuous replenishment. Endogenous creatine synthesis involves two enzymatic steps, of which the first step is a metabolic function of the kidney facilitated by the enzyme arginine:glycine amidinotransferase (AGAT). Recent findings strongly suggest that the capacity of renal AGAT, and thus endogenous creatine production, progressively decreases with the increasing degree of CKD, to become absent or virtually absent in dialysis patients. We hypothesize that with increasing degree of CKD, creatine coming from meat and dairy in food increasingly becomes an essential nutrient. This phenomenon will likely be present in patients with CKD stages 3, 4 and 5, but will likely be most pronouncedly present in patients with dialysis-dependent CKD, because of the combination of lowest endogenous production of creatine and unopposed losses of creatine into the dialysate. It is likely that these increased demands for dietary creatine are not sufficiently met. The result of which, may be a creatine deficiency with important contributions to the sarcopenia, fatigue, impaired quality of life, impaired cognition, and premature mortality seen in CKD.
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17
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Aigner C, Cejka D, Sliber C, Fraunschiel M, Sunder-Plassmann G, Gaggl M. Oral Sodium Bicarbonate Supplementation Does Not Affect Serum Calcification Propensity in Patients with Chronic Kidney Disease and Chronic Metabolic Acidosis. Kidney Blood Press Res 2019; 44:188-199. [PMID: 31067546 DOI: 10.1159/000498975] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 01/23/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death in patients with chronic kidney disease (CKD) and metabolic acidosis might accelerate vascular calcification. The T50 calcification inhibition test (T50-test) is a global functional test analyzing the overall propensity of calcification in serum, and low T50-time is associated with progressive aortic stiffening and with all-cause mortality in non-dialysis CKD, dialysis, and transplant patients. Low serum bicarbonate is associated with a short T50-time and alkali supplementation could be a simple modifier of calcification propensity. The aim of this study was to investigate the short-term effect of oral sodium bicarbonate supplementation on T50-time in CKD patients. MATERIAL AND METHODS The SoBic-study is an ongoing randomized-controlled trial in CKD-G3 and G4 patients with chronic metabolic acidosis (serum HCO3- ≤21 mmol/L), in which patients are randomized to either achieve serum HCO3- levels of 24 ± 1 mmol/L (intervention group) or 20 ± 1 mmol/L (rescue group). The effect of bicarbonate treatment on T50-time was assessed. RESULTS The study cohort consisted of 35 (14 female) patients aged 57 (±15) years, and 18 were randomized to the intervention group. The mean T50-time was 275 (± 64) min. After 4 weeks, the mean change of T50-time was 4 (±69) min in the intervention group and 18 min (±56) in the rescue group (β = -25; 95% CI: -71 to 22; p = 0.298). Moreover, change of serum bicarbonate in individual patients was not associated with change in T50-time, analyzed by regression analysis. Change of serum phosphate had a significant impact on change of T50-time (β = -145; 95% CI: -237 to -52). CONCLUSION Oral sodium bicarbonate supplementation showed no effect on T50-time in acidotic CKD patients.
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Affiliation(s)
- Christof Aigner
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Daniel Cejka
- Department of Medicine III, Nephrology, Hypertension, Transplantation and Rheumatology, Ordensklinikum Linz at Krankenhaus der Elisabethinen, Linz, Austria
| | - Christopher Sliber
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria.,Department of Medicine, Sana Klinikum Offenbach, Offenbach, Germany
| | - Melanie Fraunschiel
- ITSC - IT Systems & Communications, Section IT4Science, Medical University of Vienna, Vienna, Austria
| | - Gere Sunder-Plassmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Martina Gaggl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria,
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A Novel Heterozygous Deletion Variant in KLOTHO Gene Leading to Haploinsufficiency and Impairment of Fibroblast Growth Factor 23 Signaling Pathway. J Clin Med 2019; 8:jcm8040500. [PMID: 31013726 PMCID: PMC6517886 DOI: 10.3390/jcm8040500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 03/31/2019] [Accepted: 04/08/2019] [Indexed: 11/24/2022] Open
Abstract
Hyperphosphatemia is commonly present in end-stage renal disease. Klotho (KL) is implicated in phosphate homeostasis since it acts as obligate co-receptor for the fibroblast growth factor 23 (FGF23), a major phosphaturic hormone. We hypothesized that genetic variation in the KL gene might be associated with alterations in phosphate homeostasis resulting in hyperphosphatemia. We performed sequencing for determining KL gene variants in a group of resistant hyperphosphatemic dialysis patients. In a 67-year-old female, blood DNA sequencing revealed a heterozygous deletion of a T at position 1041 (c.1041delT) in exon 2. This variation caused a frameshift with substitution of isoleucine for phenylalanine and introduction of a premature termination codon (p.Ile348Phefs*28). cDNA sequencing showed absence of deletion-carrier transcripts in peripheral blood mononuclear cells suggesting degradation of these through a nonsense-mediated RNA decay pathway. Experiments in vitro showed that p.Ile348Phefs*28 variant impaired FGF23 signaling pathway, indicating a functional inactivation of the gene. In the patient, serum levels of KL were 2.9-fold lower than the mean level of a group of matched dialysis subjects, suggesting a compromise in the circulating protein concentration due to haploinsufficiency. These findings provide a new loss-of-function variant in the human KL gene, suggesting that genetic determinants might be associated to clinical resistant hyperphosphatemia.
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19
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Murali KM, Mullan J, Roodenrys S, Hassan HC, Lambert K, Lonergan M. Strategies to improve dietary, fluid, dialysis or medication adherence in patients with end stage kidney disease on dialysis: A systematic review and meta-analysis of randomized intervention trials. PLoS One 2019; 14:e0211479. [PMID: 30695068 PMCID: PMC6350978 DOI: 10.1371/journal.pone.0211479] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/18/2018] [Indexed: 12/21/2022] Open
Abstract
Background In patients with end stage kidney disease (ESKD) on dialysis, treatment non-adherence is common and results in poor health outcomes. However, the clinical benefits of interventions to improve adherence in dialysis patients are difficult to evaluate since trialled interventions and reported outcomes are highly diverse/ heterogeneous. This review summarizes existing literature on randomized controlled trials (RCTs) evaluating adherence interventions in ESKD patients focusing on the intervention category, outcome efficacy and persistence of benefit beyond the intervention. Methods We performed electronic database searches in Medline, Embase & Cochrane CENTRAL upto 1st July 2018 for RCTs evaluating interventions to improve diet, fluid, medication or dialysis adherence in ESKD patients. Study characteristics including category of interventions, outcomes, efficacy and follow-up were assessed. Meta-analysis was used to compute pooled estimates of the effects on the commonest reported outcome measures. Results From 1311 citations, we included 36 RCTs (13 cluster-randomized trials), recruiting a total of 3510 dialysis patients (mean age 55.1 ± 5.8 years, males 58.1%). Overall risk of bias was ‘high’ for 24 and of ‘some concern’ for 12 studies. Most interventions (33 trials, 92%) addressed patient related factors, and included educational/cognitive (N = 11), behavioural / counselling (N = 4), psychological/affective (N = 4) interventions or a combination (N = 14) of the above. A majority of (28/36) RCTs showed improvement in some reported outcomes. Surrogate measures like changes in phosphate (N = 19) and inter-dialytic weight gain (N = 15) were the most common reported outcomes and both showed significant improvement in the meta-analysis. Sixteen trials reported follow-up (1–12 months) beyond intervention and the benefits waned or were absent in nine trials within 12 months post-intervention. Conclusions Interventions to improve treatment adherence result in modest short-term benefits in surrogate outcome measures in dialysis patients, but significant improvements in trial design and outcome reporting are warranted to identify strategies that would achieve meaningful and sustainable clinical benefits. Limitations Poor methodological quality of trials. Frequent use of surrogate outcomes measures. Low certainly of evidence.
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Affiliation(s)
- Karumathil M. Murali
- Department of Nephrology, Wollongong Hospital, Wollongong, NSW, Australia
- * E-mail:
| | - Judy Mullan
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), University of Wollongong, Wollongong, NSW, Australia
| | - Steven Roodenrys
- School of Psychology, University of Wollongong, Wollongong, NSW, Australia
| | - Hicham C. Hassan
- Department of Nephrology, Wollongong Hospital, Wollongong, NSW, Australia
| | - Kelly Lambert
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), University of Wollongong, Wollongong, NSW, Australia
| | - Maureen Lonergan
- Department of Nephrology, Wollongong Hospital, Wollongong, NSW, Australia
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20
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Fang YW, Leu JG, Tsai MH, Liou HH. Higher Intra-Dialysis Serum Phosphorus Reduction Ratio as a Predictor of Mortality in Patients on Long-Term Hemodialysis. Med Sci Monit 2019; 25:691-699. [PMID: 30674864 PMCID: PMC6354640 DOI: 10.12659/msm.913137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Rapid shifting between extracellular and intracellular phosphorus can occur during dialysis sessions, which can cause aberrant intracellular signaling in long-term hemodialysis (LTHD) patients. However, the effect of these intra-dialysis fluctuations of phosphorus on clinical outcomes has not been examined. Therefore, we investigated the relationship between intradialysis serum phosphorus reduction ratio (IDSPRR) and mortality in LTHD patients. Material/Methods This was a retrospective, observational cohort study to assess the predictive power of IDSPRR (>0.63 vs. ≤0.63) on mortality in a total of 805 LTHD patients. All these fatal events were analyzed using the Cox proportional hazards regression model. Results After multivariable analysis, baseline IDSPRR higher than 0.63 was significantly predictive of all-cause mortality (hazard ratio [HR]: 1.58; 95% confidence interval [CI]: 1.10–2.26), but not for cardiovascular (CV) mortality (HR: 1.41; 95% CI: 0.91–2.18). However, when time-varied IDSPRRs were applied, a value greater than 0.63 was not only significantly predictive of all-cause mortality (HR: 1.74, 95% CI: 1.16–2.63), but also CV mortality (HR: 2.04, 95% CI: 1.23–3.40). Conclusions High IDSPRR (>0.63) is independently associated with increased all-cause and CV mortality, which shows the negative effect of rapid intracellular phosphorus-shifting on LTHD patients.
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Affiliation(s)
- Yu-Wei Fang
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,Fu-Jen Catholic University School of Medicine, Taipei, Taiwan
| | - Jyh-Gang Leu
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,Fu-Jen Catholic University School of Medicine, Taipei, Taiwan
| | - Ming-Hsein Tsai
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,Fu-Jen Catholic University School of Medicine, Taipei, Taiwan.,Division of Biostatistics, Institutes of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hung-Hsiang Liou
- Division of Nephrology, Department of Internal Medicine, Hsin-Jen Hospital, New Taipei City, Taipei, Taiwan
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21
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Abstract
BACKGROUND AND AIMS The efficacy of phosphate binders is difficult to be estimated clinically. This study analyzes the changes in serum phosphate and urinary phosphate excretion after the prescription of phosphate binders (PB) in patients with chronic kidney disease stage 4-5 pre-dialysis, and the usefulness of the ratio between total urinary phosphate and protein catabolic rate (Pu/PCR) for estimating the efficacy of PB. METHODS This retrospective observational cohort study included adult chronic kidney disease patients. Biochemical parameters were determined baseline and after 45-60 days on a low phosphate diet plus PB ("binder" subgroup=260 patients) or only with dietary advice ("control" subgroup=79 patients). RESULTS Phosphate load (total urinary excretion) per unit of renal function (Pu/GFR) was the best parameter correlated with serum phosphate levels (R2=0.61). Mean±SD level of Pu/PCR was 8.2±2.3mg of urinary phosphate per each g of estimated protein intake. After treatment with PB, serum phosphate levels decreased by 11%, urinary phosphate 22%, protein catabolic rate 7%, and Pu/PCR 15%. In the control subgroup, Pu/PCR increased by 20%. Urinary phosphate and urea nitrogen excretion correlated strongly, both baseline and after PB or dietary advice. CONCLUSIONS The proposed parameter Pu/PCR may reflect the rate of intestinal phosphate absorption, and therefore, its variations after PB prescription may be a useful tool for estimating the pharmacological efficacy of these drugs.
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Affiliation(s)
| | | | - Lilia Azevedo
- Servicio de Nefrología, Hospital Infanta Cristina, Badajoz, España
| | - Enrique Luna
- Servicio de Nefrología, Hospital Infanta Cristina, Badajoz, España
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22
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Schumacher SP, Schurgers LJ, Vervloet MG, Neradova A. Influence of pH and phosphate concentration on the phosphate binding capacity of five contemporary binders. An in vitro study. Nephrology (Carlton) 2018; 24:221-226. [PMID: 29479762 PMCID: PMC6585603 DOI: 10.1111/nep.13245] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2018] [Indexed: 11/26/2022]
Abstract
AIM Hyperphosphataemia is associated with increased mortality and morbidity in end stage renal disease. Despite phosphate binder therapy, a large proportion of patients do not reach the treatment target. In five contemporary binders we explored the influence of pH and phosphate concentration on phosphate binding. This interaction could be of relevance in clinical practice. METHODS Phosphate binding was quantified in vitro in 25 mL of purified water containing phosphate concentrations of 10, 15 and 20 mM and baseline pH values of 3.0 or 6.0, with a binder over 6 h. Lanthanum carbonate, calcium acetate/magnesium carbonate, sevelamer carbonate, calcium carbonate and sucroferric oxyhydroxide, 67 mg of each, were used. The experiments were performed in duplicate. The primary outcome was the difference in the amount of bound phosphate for each binder after 6 h in solutions at two different pH values. Secondary outcomes were the influence of phosphate concentration on phosphate binding, next to binding patterns and phosphate binder saturation. RESULTS AND CONCLUSION In this specific in vitro setting, lanthanum carbonate, sevelamer carbonate, calcium carbonate and sucroferric oxyhydroxide bound more phosphate in the solution with baseline pH of 3.0. Differences however were small except for lanthanum carbonate. Calcium acetate/magnesium carbonate was most effective in a solution with baseline pH of 6.0. All phosphate binders bound more phosphate in solutions with higher concentrations of phosphate. Sevelamer carbonate, calcium acetate/magnesium carbonate and sucroferric oxyhydroxide bound most phosphate in the first hour and reached maximum binding capacity in less than 6 h.
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Affiliation(s)
- Stefan P Schumacher
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Leon J Schurgers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, University Maastricht, Maastricht, The Netherlands
| | - Marc G Vervloet
- Department of Nephrology, VU University Medical Center, Amsterdam, The Netherlands.,Institute for Cardiovascular Research VU, ICaR-VU, Amsterdam, The Netherlands
| | - Aegida Neradova
- Department of Nephrology, VU University Medical Center, Amsterdam, The Netherlands
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23
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A Review of Phosphate Binders in Chronic Kidney Disease: Incremental Progress or Just Higher Costs? Drugs 2017; 77:1155-1186. [DOI: 10.1007/s40265-017-0758-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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24
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Piccoli GB, Moio MR, Fois A, Sofronie A, Gendrot L, Cabiddu G, D'Alessandro C, Cupisti A. The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach. Nutrients 2017; 9:E372. [PMID: 28394304 PMCID: PMC5409711 DOI: 10.3390/nu9040372] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/17/2017] [Accepted: 03/31/2017] [Indexed: 12/25/2022] Open
Abstract
The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients' lives. In the early years of dialysis, potassium was identified as "the killer", and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the "third era" finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the "magic numbers" of nutritional requirements (calories: 30-35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on "conventional" thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of "vascular healthy" food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Maria Rita Moio
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Antioco Fois
- Nefrologia, Ospedale Brotzu, 09100 Cagliari, Italy.
| | - Andreea Sofronie
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
| | - Lurlinys Gendrot
- Nephrologie, Centre Hospitalier le Mans, Avenue Roubillard, 72000 Le Mans, France.
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25
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Imtiaz R, Hawken S, McCormick BB, Leung S, Hiremath S, Zimmerman DL. Diabetes Mellitus and Younger Age Are Risk Factors for Hyperphosphatemia in Peritoneal Dialysis Patients. Nutrients 2017; 9:E152. [PMID: 28218647 PMCID: PMC5331583 DOI: 10.3390/nu9020152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 01/27/2017] [Accepted: 02/13/2017] [Indexed: 02/02/2023] Open
Abstract
Hyperphosphatemia has been associated with adverse outcomes in patients with end stage kidney disease (ESKD). The purpose of this study was to determine risk factors for hyperphosphatemia in ESKD patients treated with peritoneal dialysis (PD). This information will be used to develop a patient specific phosphate binder application to facilitate patient self-management of serum phosphate. Adult PD patients documented their food, beverage, and phosphate binder intake for three days using a dietitian developed food journal. Phosphate content of meals was calculated using the ESHA Food Processor SQL Software (ESHA Research, Salem, UT, USA). Clinic biochemistry tests and an adequacy assessment (Baxter Adequest program) were done. Univariate logistic regression was used to determine predictors of serum phosphate >1.78 mmol/L. A multivariable logistic regression model was then fit including those variables that achieved a significance level of p < 0.20 in univariate analyses. Sixty patients (38 men, 22 women) completed the protocol; they were 60 ± 17 years old, 50% had a history of diabetes mellitus (DM) and 33% had hyperphosphatemia (PO₄ > 1.78 mmol/L). In univariate analysis, the variables associated with an increased risk of hyperphosphatemia with a p-value < 0.2 were male gender (p = 0.13), younger age (0.07), presence of DM (0.005), higher dose of calcium carbonate (0.08), higher parathyroid serum concentration (0.08), lower phosphate intake (0.03), lower measured glomerular filtration rate (0.15), higher phosphate excretion (0.11), and a higher body mass index (0.15). After multivariable logistic regression analysis, younger age (odds ratio (OR) 0.023 per decade, 95% confidence interval (CI) 0.00065 to 0.455; p = 0.012), presence of diabetes (OR 11.40, 95 CI 2.82 to 61.55; p = 0.0003), and measured GFR (OR 0.052 per mL/min decrease; 95% CI 0.0025 to 0.66) were associated with hyperphosphatemia. Our results support that younger age and diabetes mellitus are significant risk factors for hyperphosphatemia. These findings warrant further investigation to determine the potential mechanisms that predispose younger patients and those with DM to hyperphosphatemia.
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Affiliation(s)
- Rameez Imtiaz
- Department of Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada.
| | - Steven Hawken
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON K1Y 4E9, Canada.
| | - Brendan B McCormick
- Department of Medicine, Division of Nephrology, Ottawa Hospital, University of Ottawa, Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON K1H 7W9, Canada.
| | - Simon Leung
- Ottawa Hospital Academic Family Health Team, Ottawa Hospital, Ottawa, ON K1Y 4K7, Canada.
| | - Swapnil Hiremath
- Department of Medicine, Division of Nephrology, Ottawa Hospital, University of Ottawa, Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON K1H 7W9, Canada.
| | - Deborah L Zimmerman
- Department of Medicine, Division of Nephrology, Ottawa Hospital, University of Ottawa, Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON K1H 7W9, Canada.
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26
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Chen NC, Hsu CY, Chen CL. The Strategy to Prevent and Regress the Vascular Calcification in Dialysis Patients. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9035193. [PMID: 28286773 PMCID: PMC5329685 DOI: 10.1155/2017/9035193] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 01/17/2017] [Indexed: 12/31/2022]
Abstract
The high prevalence of arterial calcification in end-stage renal disease (ESRD) is far beyond the explanation by common cardiovascular risk factors such as aging, diabetes, hypertension, and dyslipidemia. The finding relies on the fact that vascular and valvular calcifications are predictors of cardiovascular diseases and mortality in persons with chronic renal failure. In addition to traditional cardiovascular risk factors such as diabetes mellitus and blood pressure control, other ESRD-related risks such as phosphate retention, excess calcium, and prolonged dialysis time also contribute to the development of vascular calcification. The strategies are to reverse "calcium paradox" and lower vascular calcification by decreasing procalcific factors including minimization of inflammation (through adequate dialysis and by avoiding malnutrition, intravenous labile iron, and positive calcium and phosphate balance), correction of high and low bone turnover, and restoration of anticalcification factor balance such as correction of vitamin D and K deficiency; parathyroid intervention is reserved for severe hyperparathyroidism. The role of bone antiresorption therapy such as bisphosphonates and denosumab in vascular calcification in high-bone-turnover disease remains unclear. The limited data on sodium thiosulfate are promising. However, if calcification is to be targeted, ensure that bone health is not compromised by the treatments.
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Affiliation(s)
- Nai-Ching Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
| | - Chih-Yang Hsu
- Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chien-Liang Chen
- Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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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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