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Nasr RY, Othman MAL. Calcineurin inhibitor-induced pain syndrome (CIPS) affects the hips in a renal transplant recipient: A case report. Radiol Case Rep 2024; 19:4024-4028. [PMID: 39091342 PMCID: PMC11292245 DOI: 10.1016/j.radcr.2024.06.015] [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] [Received: 01/26/2024] [Revised: 05/31/2024] [Accepted: 06/03/2024] [Indexed: 08/04/2024] Open
Abstract
Calcineurin inhibitor-induced pain syndrome is a rare but debilitating complication of organ transplantation. This case report describes a man in his forties who developed bilateral hip pain, an atypical presentation of calcineurin inhibitor-induced pain syndrome, after undergoing renal transplantation. Initially, avascular necrosis was suspected as a potential cause of pain. The initial radiographs revealed no abnormalities. However, high trough levels of calcineurins and subsequent magnetic resonance imaging of the hip revealed bilateral symmetric bone marrow edema, which was consistent with calcineurin inhibitor-induced pain syndrome. Adjustments made to the immunosuppressive regimen and multidisciplinary management resulted in an improvement in the patient's symptoms. This case report emphasizes the importance of adopting a comprehensive approach to post-transplantation pain management. Moreover, this report emphasizes the importance of considering the diagnosis of calcineurin inhibitor-induced pain syndrome while investigating and managing post-transplantation patients presenting with hip pain. Clinicians need a high index of suspicion for calcineurin inhibitor-induced pain syndrome, thereby contributing to enhanced post-transplantation care and outcomes while improving the quality of life of transplant recipients experiencing musculoskeletal pain.
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Affiliation(s)
- Ranim Y. Nasr
- Department of Radiology, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Maram AL Othman
- Department of Radiology, King Faisal Specialist Hospital and Research center, Riyadh, Saudi Arabia
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2
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Courbebaisse M, Bourmaud A, Souberbielle JC, Sberro-Soussan R, Moal V, Le Meur Y, Kamar N, Albano L, Thierry A, Dantal J, Danthu C, Moreau K, Morelon E, Heng AE, Bertrand D, Arzouk N, Perrin P, Morin MP, Rieu P, Presne C, Grimbert P, Ducloux D, Büchler M, Le Quintrec M, Ouali N, Pernin V, Bouvier N, Durrbach A, Alamartine E, Randoux C, Besson V, Hazzan M, Pages J, Colas S, Piketty ML, Friedlander G, Prié D, Alberti C, Thervet E. Nonskeletal and skeletal effects of high doses versus low doses of vitamin D 3 in renal transplant recipients: Results of the VITALE (VITamin D supplementation in renAL transplant recipients) study, a randomized clinical trial. Am J Transplant 2023; 23:366-376. [PMID: 36695682 DOI: 10.1016/j.ajt.2022.12.007] [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: 09/09/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 01/11/2023]
Abstract
Vitamin D sufficiency is associated with a reduced risk of fractures, diabetes mellitus, cardiovascular events, and cancers, which are frequent complications after renal transplantation. The VITALE (VITamin D supplementation in renAL transplant recipients) study is a multicenter double-blind randomized trial, including nondiabetic adult renal transplant recipients with serum 25-hydroxy vitamin D (25(OH) vitamin D) levels of <30 ng/mL, which is randomized 12 to 48 months after transplantation to receive high (100 000 IU) or low doses (12 000 IU) of cholecalciferol every 2 weeks for 2 months and then monthly for 22 months. The primary outcome was a composite endpoint, including diabetes mellitus, major cardiovascular events, cancer, and death. Of 536 inclusions (50.8 [13.7] years, 335 men), 269 and 267 inclusions were in the high-dose and low-dose groups, respectively. The serum 25(OH) vitamin D levels increased by 23 versus 6 ng/mL in the high-dose and low-dose groups, respectively (P < .0001). In the intent-to-treat analysis, 15% versus 16% of the patients in the high-dose and low-dose groups, respectively, experienced a first event of the composite endpoint (hazard ratio, 0.94 [0.60-1.48]; P = .78), whereas 1% and 4% of patients in the high-dose and low-dose groups, respectively, experienced an incident symptomatic fracture (odds ratio, 0.24 [0.07-0.86], P = .03). The incidence of adverse events was similar between the groups. After renal transplantation, high doses of cholecalciferol are safe but do not reduce extraskeletal complications (trial registration: ClinicalTrials.gov; identifier: NCT01431430).
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Affiliation(s)
- Marie Courbebaisse
- Paris University; Physiology Department, European Georges-Pompidou Hospital, APHP; INSERM U1151. Paris, France.
| | - Aurelie Bourmaud
- APHP.Nord-Université de Paris, Hôpital Universitaire Robert Debré, Unité d'Epidémiologie Clinique, Inserm, CIC 1426, F-75019 Paris, France; Université de Paris, ECEVE UMR 1123, INSERM. F-75010 Paris, France
| | - Jean-Claude Souberbielle
- Service des explorations fonctionnelles hôpital Necker-Enfants Malades, DMU Biophygen, GHU Centre Université de Paris APHP. Paris, France
| | - Rebecca Sberro-Soussan
- Université de Paris; Service de Transplantation Rénale et Néphrologie, Hôpital Necker Enfant Malades, APHP. Paris, France
| | - Valérie Moal
- Aix-Marseille Université - AP-HM - Hôpital Conception - Centre de Néphrologie et Transplantation Rénale. Marseille, France
| | - Yannick Le Meur
- Department of Nephrology, CHU de Brest; UMR1227, Lymphocytes B et Autoimmunité, Université de Brest, Inserm, Labex IGO. Brest, France
| | - Nassim Kamar
- Department of Nephrology, Dialysis and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR -BMT, University Paul Sabatier. Toulouse, France
| | - Laetitia Albano
- Service de Transplantation Rénale, CHU de Nice. Nice, France
| | - Antoine Thierry
- Service de Néphrologie, INSERM U1082 et Fédération Hospitalo-Universitaire BIOSUPORT. Poitiers, France
| | - Jacques Dantal
- CRTI (Centre de Recherche en Transplantation et Immunologie) INSERM UMR1064, Université de Nantes, Centre Hospitalier Universitaire de Nantes. Nantes, France
| | - Clément Danthu
- Department of Nephrology, Limoges University hospital; UMR INSERM 1092, RESINFIT, Limoges University hospital 2. Limoges, France
| | - Karine Moreau
- Unité de transplantation rénale, Hôpital Pellegrin, CHU de Bordeaux. Bordeaux, France
| | - Emmanuel Morelon
- Service de transplantation, néphrologie et immunologie clinique, Hôpital Edouard Herriot, Hospices Civils de Lyon; INSERM U1111, Université Claude Bernard Lyon1. Lyon, France
| | - Anne-Elisabeth Heng
- Service de Néphrologie, Dialyse, Transplantation, CHU de Clermont-Ferrand; Université Clermont Auvergne. F-63000 Clermont-Ferrand, France
| | - Dominique Bertrand
- Nephrology, dialysis and kidney transplantation, Rouen University Hospital. Rouen, France
| | - Nadia Arzouk
- Service de Transplantation Rénale, hôpital La Pitié-Salpétrière, APHP. Paris, France
| | - Peggy Perrin
- Department of Nephrology and Transplantation, Strasbourg University Hospital; Fédération de Médecine Translationnelle, INSERM U1109, LabEx TRANSPLANTEX. Strasbourg, France
| | | | - Philippe Rieu
- Division of Nephrology, Reims university hospital, CRNS UMR 7369 MEDyC laboratory. Reims, France
| | - Claire Presne
- Nephrology Internal Medicine Dialysis Transplantation Department, Amiens University Hospital. Amiens France
| | - Philippe Grimbert
- Nephrology and Transplant Department, CHU Henri-Mondor, APHP; Université Paris Est Créteil, INSERM U955. Paris, France
| | - Didier Ducloux
- Department of Nephrology, CHU Besançon. Besançon, France
| | - Matthias Büchler
- Department of Nephrology and Transplantation, CHU Tours; University of Tours, EA4245 Transplantation, Immunology, Inflammation; FHU SUPORT. Tours, France
| | | | - Nacéra Ouali
- Nephrology department, SINRA, Hôpital Tenon. Paris, France
| | - Vincent Pernin
- University of Montpellier, Department of Nephrology, Dialysis and Transplantation, Montpellier University hospital; Institute for Regenerative Medicine & Biotherapy (IRMB), INSERM U1183. Montpellier, France
| | - Nicolas Bouvier
- Service de Néphrologie-Dialyse-Transplantation, CHU Caen Normandie; Université de Caen Normandie. Caen, France
| | - Antoine Durrbach
- Université Paris Saclay, France; INSERM UMR 1186, Gustave Roussy. Villejuif, France; Nephrology Department, Bicêtre Hospital APHP. Le Kremlin-Bicêtre, France
| | - Eric Alamartine
- CHU de Saint Etienne et CIRI - INSERM U1111 - CNRS UMR5308 - ENS Lyon/UCBL1/Université St Etienne. Saint Etienne, France
| | - Christine Randoux
- Service de Néphrologie, CHU Bichat Claude Bernard, APHP.Nord. Paris, France
| | - Virginie Besson
- Service de Néphrologie-Dialyse-transplantation, CHU d'Angers. Angers, France
| | - Marc Hazzan
- Université de Lille, INSERM, CHU Lille, U1286 - Infinite - Institute for Translational Research in Inflammation. F-59000 Lille, France
| | - Justine Pages
- APHP.Nord-Université de Paris, Hôpital Universitaire Robert Debré, Unité d'Epidémiologie Clinique, INSERM, CIC 1426. F-75019 Paris, France
| | - Sandra Colas
- Unité de Recherche Clinique Necker-Cochin, APHP. Paris, France
| | - Marie-Liesse Piketty
- Service des explorations fonctionnelles hôpital Necker-Enfants Malades, DMU Biophygen, GHU Centre Université de Paris APHP. Paris, France
| | | | - Dominique Prié
- Université de Paris; INSERM U1151, service des explorations fonctionnelles hôpital Necker-Enfants Malades, DMU Biophygen, GHU Centre Université de Paris APHP. Paris, France
| | - Corinne Alberti
- APHP.Nord-Université de Paris, Hôpital Universitaire Robert Debré, Unité d'Epidémiologie Clinique, Inserm, CIC 1426, F-75019 Paris, France; Université de Paris, ECEVE UMR 1123, INSERM. F-75010 Paris, France
| | - Eric Thervet
- Paris University; Nephrology Department, European Georges-Pompidou Hospital, APHP; INSERM UMR 970, Paris Cardiovascular Research Center. Paris, France
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3
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Molinari P, Alfieri CM, Mattinzoli D, Campise M, Cervesato A, Malvica S, Favi E, Messa P, Castellano G. Bone and Mineral Disorder in Renal Transplant Patients: Overview of Pathology, Clinical, and Therapeutic Aspects. Front Med (Lausanne) 2022; 9:821884. [PMID: 35360722 PMCID: PMC8960161 DOI: 10.3389/fmed.2022.821884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/08/2022] [Indexed: 12/25/2022] Open
Abstract
Renal transplantation (RTx) allows us to obtain the resolution of the uremic status but is not frequently able to solve all the metabolic complications present during end-stage renal disease. Mineral and bone disorders (MBDs) are frequent since the early stages of chronic kidney disease (CKD) and strongly influence the morbidity and mortality of patients with CKD. Some mineral metabolism (MM) alterations can persist in patients with RTx (RTx-p), as well as in the presence of complete renal function recovery. In those patients, anomalies of calcium, phosphorus, parathormone, fibroblast growth factor 23, and vitamin D such as bone and vessels are frequent and related to both pre-RTx and post-RTx specific factors. Many treatments are present for the management of post-RTx MBD. Despite that, the guidelines that can give clear directives in MBD treatment of RTx-p are still missed. For the future, to obtain an ever-greater individualisation of therapy, an increase of the evidence, the specificity of international guidelines, and more uniform management of these anomalies worldwide should be expected. In this review, the major factors related to post-renal transplant MBD (post-RTx-MBD), the main mineral metabolism biochemical anomalies, and the principal treatment for post-RTx MBD will be reported.
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Affiliation(s)
- Paolo Molinari
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Carlo Maria Alfieri
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- *Correspondence: Carlo Maria Alfieri ;
| | - Deborah Mattinzoli
- Renal Research Laboratory Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Mariarosaria Campise
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Angela Cervesato
- Department of Nephrology, Clinical and Translational Sciences, Università degli Studi della Campania L.Vanvitelli, Naples, Italy
| | - Silvia Malvica
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Evaldo Favi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of General Surgery, Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giuseppe Castellano
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Cianciolo G, Cappuccilli M, Tondolo F, Gasperoni L, Zappulo F, Barbuto S, Iacovella F, Conte D, Capelli I, La Manna G. Vitamin D Effects on Bone Homeostasis and Cardiovascular System in Patients with Chronic Kidney Disease and Renal Transplant Recipients. Nutrients 2021; 13:1453. [PMID: 33922902 PMCID: PMC8145016 DOI: 10.3390/nu13051453] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/14/2021] [Accepted: 04/22/2021] [Indexed: 12/25/2022] Open
Abstract
Poor vitamin D status is common in patients with impaired renal function and represents one main component of the complex scenario of chronic kidney disease-mineral and bone disorder (CKD-MBD). Therapeutic and dietary efforts to limit the consequences of uremia-associated vitamin D deficiency are a current hot topic for researchers and clinicians in the nephrology area. Evidence indicates that the low levels of vitamin D in patients with CKD stage above 4 (GFR < 15 mL/min) have a multifactorial origin, mainly related to uremic malnutrition, namely impaired gastrointestinal absorption, dietary restrictions (low-protein and low-phosphate diets), and proteinuria. This condition is further worsened by the compromised response of CKD patients to high-dose cholecalciferol supplementation due to the defective activation of renal hydroxylation of vitamin D. Currently, the literature lacks large and interventional studies on the so-called non-calcemic activities of vitamin D and, above all, the modulation of renal and cardiovascular functions and immune response. Here, we review the current state of the art of the benefits of supplementation with native vitamin D in various clinical settings of nephrological interest: CKD, dialysis, and renal transplant, with a special focus on the effects on bone homeostasis and cardiovascular outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplantation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.C.); (M.C.); (F.T.); (L.G.); (F.Z.); (S.B.); (F.I.); (D.C.); (I.C.)
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5
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Sella S, Bonfante L, Fusaro M, Neri F, Plebani M, Zaninotto M, Aghi A, Innico G, Tripepi G, Michielin A, Prandini T, Calò LA, Giannini S. Efficacy of weekly administration of cholecalciferol on parathyroid hormone in stable kidney-transplanted patients with CKD stage 1-3. Clin Chem Lab Med 2020; 59:343-351. [PMID: 32374278 DOI: 10.1515/cclm-2020-0282] [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: 03/08/2020] [Accepted: 04/10/2020] [Indexed: 11/15/2022]
Abstract
Objectives Kidney transplant (KTx) recipients frequently have deficient or insufficient levels of serum vitamin D. Few studies have investigated the effect of cholecalciferol in these patients. We evaluated the efficacy of weekly cholecalciferol administration on parathyroid hormone (PTH) levels in stable KTx patients with chronic kidney disease stage 1-3. Methods In this retrospective cohort study, 48 stable KTx recipients (37 males, 11 females, aged 52 ± 11 years and 26 months post-transplantation) were treated weekly with oral cholecalciferol (7500-8750 IU) for 12 months and compared to 44 untreated age- and gender-matched recipients. Changes in levels of PTH, 25(OH) vitamin D (25[OH]D), serum calcium, phosphate, creatinine and estimated glomerular filtration rate (eGFR) were measured at baseline, 6 and 12 months. Results At baseline, clinical characteristics were similar between treated and untreated patients. Considering the entire cohort, 87 (94.6%) were deficient in vitamin D and 64 (69.6%) had PTH ≥130 pg/mL. Serum calcium, phosphate, creatinine and eGFR did not differ between groups over the follow-up period. However, 25(OH)D levels were significantly higher at both 6 (63.5 vs. 30.3 nmol/L, p < 0.001) and 12 months (69.4 vs. 30 nmol/L, p < 0.001) in treated vs. untreated patients, corresponding with a significant reduction in PTH at both 6 (112 vs. 161 pg/mL) and 12 months (109 vs. 154 pg/mL) in treated vs. untreated patients, respectively (p < 0.001 for both). Conclusions Weekly administration of cholecalciferol can significantly and stably reduce PTH levels, without any adverse effects on serum calcium and renal function.
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Affiliation(s)
- Stefania Sella
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Luciana Bonfante
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Padova, Italy
| | - Maria Fusaro
- National Research Council, Institute of Clinical Physiology, Pisa, Italy
| | - Flavia Neri
- Department of Surgery, Renal and Pancreas Transplant Unit, University of Padova, Padova, Italy
| | - Mario Plebani
- Department of Medicine, Laboratory Medicine Unit, University of Padova, Padova, Italy
| | - Martina Zaninotto
- Department of Medicine, Laboratory Medicine Unit, University of Padova, Padova, Italy
| | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Georgie Innico
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Padova, Italy
| | - Giovanni Tripepi
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR, Institute of Biomedicine, Reggio Calabria, Italy
| | - Alberto Michielin
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Tancredi Prandini
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Lorenzo A Calò
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Padova, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
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6
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Capelli I, Cianciolo G, Gasperoni L, Galassi A, Ciceri P, Cozzolino M. Nutritional vitamin D in CKD: Should we measure? Should we treat? Clin Chim Acta 2019; 501:186-197. [PMID: 31770508 DOI: 10.1016/j.cca.2019.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 02/08/2023]
Abstract
Vitamin Ddeficiency is frequently present in patients affected by chronic kidney disease (CKD). Experimental studies demonstrated that Vitamin D may play a role in the pathophysiology of diseases beyond mineral bone disorders in CKD (CKD-MBD). Unfortunately, the lack of large and interventional studies focused on the so called "non-classic" effects of 25(OH) Vitamin D supplementation in CKD patients, doesn't permit to conclude definitely about the beneficial effects of this supplementation in clinical practice. In conclusion, treatment of nutritional vitamin D deficiency in CKD may play a central role in both bone homeostasis and cardiovascular outcomes, but there is not clear evidence to support one formulation of nutritional vitamin D over another in CKD.
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Affiliation(s)
- Irene Capelli
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Cianciolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Lorenzo Gasperoni
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy.
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7
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Giannini S, Mazzaferro S, Minisola S, De Nicola L, Rossini M, Cozzolino M. Raising awareness on the therapeutic role of cholecalciferol in CKD: a multidisciplinary-based opinion. Endocrine 2018; 59:242-259. [PMID: 28726185 PMCID: PMC5846860 DOI: 10.1007/s12020-017-1369-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 06/27/2017] [Indexed: 12/19/2022]
Abstract
Vitamin D is recognized to play an essential role in health and disease. In kidney disease, vitamin D analogs have gained recognition for their involvement and potential therapeutic importance. Nephrologists are aware of the use of oral native vitamin D supplementation, however, uncertainty still exists with regard to the use of this treatment option in chronic kidney disease as well as clinical settings related to chronic kidney disease, where vitamin D supplementation may be an appropriate therapeutic choice. Two consecutive meetings were held in Florence in July and November 2016 comprising six experts in kidney disease (N = 3) and bone mineral metabolism (N = 3) to discuss a range of unresolved issues related to the use of cholecalciferol in chronic kidney disease. The panel focused on the following six key areas where issues relating to the use of oral vitamin D remain controversial: (1) vitamin D and parathyroid hormone levels in the general population, (2) cholecalciferol in chronic kidney disease, (3) vitamin D in cardiovascular disease, (4) vitamin D and renal bone disease, (5) vitamin D in rheumatological diseases affecting the kidney, (6) vitamin D and kidney transplantation.
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Affiliation(s)
- Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Sandro Mazzaferro
- Department of Cardiovascular Respiratory Nephrologic Anesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
| | - Luca De Nicola
- Division of Nephrology, Second University of Naples, Naples, Italy
| | - Maurizio Rossini
- Department of Medicine, Rheumatology Unit, University of Verona, Verona, Italy
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division and Laboratory of Experimental Nephrology, San Paolo Hospital, University of Milan, Milan, Italy.
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8
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Sarno G, Nappi R, Altieri B, Tirabassi G, Muscogiuri E, Salvio G, Paschou SA, Ferrara A, Russo E, Vicedomini D, Vincenzo C, Vryonidou A, Della Casa S, Balercia G, Orio F, De Rosa P. Current evidence on vitamin D deficiency and kidney transplant: What's new? Rev Endocr Metab Disord 2017; 18:323-334. [PMID: 28281103 DOI: 10.1007/s11154-017-9418-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Kidney transplant is the treatment of choice for end-stage chronic kidney disease. Kidneys generate 1,25-dihydroxyvitamin D (calcitriol) from 25-hydroxyvitamin D (calcidiol) for circulation in the blood to regulate calcium levels. Transplant patients with low calcidiol levels have an increased risk of metabolic and endocrine problems, cardiovascular disease, type 2 diabetes mellitus, poor graft survival, bone disorders, cancer, and mortality rate. The recommended calcidiol level after transplant is at least 30 ng/mL (75 nmol/L), which could require 1000-3000 IU/d vitamin D3 to achieve. Vitamin D3 supplementation studies have found improved endothelial function and acute rejection episodes. However, since kidney function may still be impaired, raising calcidiol levels may not lead to normal calcitriol levels. Thus, supplementation with calcitriol or an analog, alfacalcidiol, is often employed. Some beneficial effects found include possible improved bone health and reduced risk of chronic allograft nephropathy and cancer.
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Affiliation(s)
- Gerardo Sarno
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy.
| | - Riccardo Nappi
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
- Nephrology and Dialisys Unit - "Santa Maria della Misericordia" Hospital, ASUIUD - Udine, Udine, Italy
| | - Barbara Altieri
- Institute of Medical Pathology, Division of Endocrinology and Metabolic Diseases, Catholic University, Rome, Italy
| | - Giacomo Tirabassi
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | | | - Gianmaria Salvio
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Stavroula A Paschou
- Division of Endocrinology and Diabetes, "Aghia Sophia" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristide Ferrara
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Enrico Russo
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Daniela Vicedomini
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Cerbone Vincenzo
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, Athens, Greece
| | - Silvia Della Casa
- Institute of Medical Pathology, Division of Endocrinology and Metabolic Diseases, Catholic University, Rome, Italy
| | - Giancarlo Balercia
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Francesco Orio
- Endocrinology, Department of Sports Science and Wellness, "Parthenope" University Naples, Naples, Italy
| | - Paride De Rosa
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
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9
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Ziff OJ, Penny H, Frame S, Cronin A, Goldsmith D. Impact of seasonality on the dynamics of native Vitamin D repletion in long-term renal transplant patients. Clin Kidney J 2017; 10:411-418. [PMID: 28616220 PMCID: PMC5466087 DOI: 10.1093/ckj/sfw136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 11/14/2016] [Indexed: 01/06/2023] Open
Abstract
Background: Renal transplant recipients (RTRs) are often Vitamin D (VitD) depleted as a result of both chronic kidney disease and mandated sun avoidance behaviours. Repleting VitD may be warranted, but how, and for how long, is unknown, as is the impact of seasonality on the success of repletion. We investigated the impact of seasonality on VitD status following VitD repletion in a large cohort of stable, long-term RTRs. Methods: Serum 25-hydroxyvitamin D [25(OH)D] concentrations and bone biochemistry parameters were analysed from 102 VitD repletion courses in 98 RTRs that had undergone VitD repletion. Repletion was delivered over 6 months with either 240 000 IU colecalciferol if pre-repletion serum VitD was between 20 and 50 nmol/L, or with 360 000 IU if VitD was <20 nmol/L. Twelve months post-repletion 25(OH)D and parathyroid hormone (PTH) were available for 75 patients. Results: At baseline, 25(OH)D was 20.1 ± 1.0 nmol/L, increasing to 65.4 ± 1.8 nmol/L following repletion (+7.55 nmol/L/month, P < 0.0001). Twelve months post-repletion and after no further VitD administration, 25(OH)D fell to 35.4 ± 1.8 nmol/L (14.2 ± 0.7 ng/mL; −2.50 nmol/L/month, P < 0.0001). PTH followed the opposite trend with baseline, repletion-end and post-repletion values being 144.2 ± 12.0, 109.6 ± 7.5 and 129.2 ± 11.4 ng/L, respectively. VitD repletion during the summer was associated with significantly higher at repletion-end 25(OH)D compared with any other time of year [summer 80.9 ± 4.0, autumn 64.1 ± 3.0 (P = 0.002), winter 48.9 ± 3.0 (P <0.001), spring 63.8 ± 2.5 nmol/L (P <0.001)]. There was no hypercalcaemia during repletion and renal transplant function remained stable without any evidence of allograft rejection. Conclusions: VitD repletion can safely and effectively be achieved in the majority of chronic stable RTRs using a 6-month bolus intermediate-dose schedule. Winter repletion is associated with an inadequate response in 25(OH)D; however, all patients experience a post-repletion fall towards deficiency in the absence of maintenance supplementation, irrespective of the season of repletion.
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Affiliation(s)
- Oliver J Ziff
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Institute of Cardiovascular Sciences, University College London, London, UK
| | - Hugo Penny
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sharon Frame
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Antonia Cronin
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David Goldsmith
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
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10
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Taweesedt PT, Disthabanchong S. Mineral and bone disorder after kidney transplantation. World J Transplant 2015; 5:231-242. [PMID: 26722650 PMCID: PMC4689933 DOI: 10.5500/wjt.v5.i4.231] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/11/2015] [Accepted: 10/27/2015] [Indexed: 02/05/2023] Open
Abstract
After successful kidney transplantation, accumulated waste products and electrolytes are excreted and regulatory hormones return to normal levels. Despite the improvement in mineral metabolites and mineral regulating hormones after kidney transplantation, abnormal bone and mineral metabolism continues to present in most patients. During the first 3 mo, fibroblast growth factor-23 (FGF-23) and parathyroid hormone levels decrease rapidly in association with an increase in 1,25-dihydroxyvitamin D production. Renal phosphate excretion resumes and serum calcium, if elevated before, returns toward normal levels. FGF-23 excess during the first 3-12 mo results in exaggerated renal phosphate loss and hypophosphatemia occurs in some patients. After 1 year, FGF-23 and serum phosphate return to normal levels but persistent hyperparathyroidism remains in some patients. The progression of vascular calcification also attenuates. High dose corticosteroid and persistent hyperparathyroidism are the most important factors influencing abnormal bone and mineral metabolism in long-term kidney transplant (KT) recipients. Bone loss occurs at a highest rate during the first 6-12 mo after transplantation. Measurement of bone mineral density is recommended in patients with estimated glomerular filtration rate > 30 mL/min. The use of active vitamin D with or without bisphosphonate is effective in preventing early post-transplant bone loss. Steroid withdrawal regimen is also beneficial in preservation of bone mass in long-term. Calcimimetic is an alternative therapy to parathyroidectomy in KT recipients with persistent hyperparathyroidism. If parathyroidectomy is required, subtotal to near total parathyroidectomy is recommended. Performing parathyroidectomy during the waiting period prior to transplantation is also preferred in patients with severe hyperparathyroidism associated with hypercalcemia.
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11
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Wong J, Tan MZW, Chandran M. Fifty shades of gray: Bone disease in renal transplantation. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815611808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Kidney transplantation is the renal replacement therapy of choice for patients with end stage renal disease. Advances in technology, surgical techniques and pharmacotherapy have improved renal allograft survival. Increasingly, we are seeing long term side effects related to renal transplantation, bone disease being a major one amongst them. Renal transplant patients have a higher risk of fragility fractures even when compared to those who remain on dialysis. This is likely to be related to pre-existing underlying bone disease and the emergence of new metabolic bone problems post-transplant. Conditions such as persistent hyperparathyroidism and the use of certain immunosuppressive agents have a deleterious effect on the post renal transplant bone. Remarkable advances in the field of metabolic bone research have been made in the last decade and newer imaging techniques, biomarkers and therapeutic options are now available for osteoporosis in the general population. Interest is being focused on attempting to extrapolate these new discoveries to the management of bone disease post renal transplant. This review will briefly describe the metabolic bone changes that occur after transplantation and will provide an update on the currently available investigative options and therapeutic strategies for the management of post renal transplant bone disease.
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Affiliation(s)
- Jiunn Wong
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Manju Chandran
- Department of Endocrinology, Singapore General Hospital, Singapore
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12
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Sgambat K, Moudgil A. Optimization of Bone Health in Children before and after Renal Transplantation: Current Perspectives and Future Directions. Front Pediatr 2014; 2:13. [PMID: 24605319 PMCID: PMC3932433 DOI: 10.3389/fped.2014.00013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 02/11/2014] [Indexed: 11/29/2022] Open
Abstract
The accrual of healthy bone during the critical period of childhood and adolescence sets the stage for lifelong skeletal health. However, in children with chronic kidney disease (CKD), disturbances in mineral metabolism and endocrine homeostasis begin early on, leading to alterations in bone turnover, mineralization, and volume, and impairing growth. Risk factors for CKD-mineral and bone disorder (CKD-MBD) include nutritional vitamin D deficiency, secondary hyperparathyroidism, increased fibroblast growth factor 23 (FGF-23), altered growth hormone and insulin-like growth factor-1 axis, delayed puberty, malnutrition, and metabolic acidosis. After kidney transplantation, nutritional vitamin D deficiency, persistent hyperparathyroidism, tertiary FGF-23 excess, hypophosphatemia, hypomagnesemia, immunosuppressive therapy, and alteration of sex hormones continue to impair bone health and growth. As function of the renal allograft declines over time, CKD-MBD associated changes are reactivated, further impairing bone health. Strategies to optimize bone health post-transplant include healthy diet, weight-bearing exercise, correction of vitamin D deficiency and acidosis, electrolyte abnormalities, steroid avoidance, and consideration of recombinant human growth hormone therapy. Other drug therapies have been used in adult transplant recipients, but there is insufficient evidence for use in the pediatric population at the present time. Future therapies to be explored include anti-FGF-23 antibodies, FGF-23 receptor blockers, and treatments targeting the colonic microbiota by reduction of generation of bacterial toxins and adsorption of toxic end products that affect bone mineralization.
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Affiliation(s)
| | - Asha Moudgil
- Children National Medical Center, Washington, DC, USA
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13
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Alshayeb HM, Josephson MA, Sprague SM. CKD-mineral and bone disorder management in kidney transplant recipients. Am J Kidney Dis 2012; 61:310-25. [PMID: 23102732 DOI: 10.1053/j.ajkd.2012.07.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 07/09/2012] [Indexed: 12/11/2022]
Abstract
Kidney transplantation, the most effective treatment for the metabolic abnormalities of chronic kidney disease (CKD), only partially corrects CKD-mineral and bone disorders. Posttransplantation bone disease, one of the major complications of kidney transplantation, is characterized by accelerated loss of bone mineral density and increased risk of fractures and osteonecrosis. The pathogenesis of posttransplantation bone disease is multifactorial and includes the persistent manifestations of pretransplantation CKD-mineral and bone disorder, peritransplantation changes in the fibroblast growth factor 23-parathyroid hormone-vitamin D axis, metabolic perturbations such as persistent hypophosphatemia and hypercalcemia, and the effects of immunosuppressive therapies. Posttransplantation fractures occur more commonly at peripheral than central sites. Although there is significant loss of bone density after transplantation, the evidence linking posttransplantation bone loss and subsequent fracture risk is circumstantial. Presently, there are no prospective clinical trials that define the optimal therapy for posttransplantation bone disease. Combined pharmacologic therapy that targets multiple components of the disordered pathways has been used. Although bisphosphonate or calcitriol therapy can preserve bone mineral density after transplantation, there is no evidence that these agents decrease fracture risk. Moreover, bisphosphonates pose potential risks for adynamic bone disease.
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Affiliation(s)
- Hala M Alshayeb
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL, USA
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14
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Sgambat K, Tuchman S, Ryan L, Wood R, Moudgil A. Low bone mineral density and nutritional vitamin D deficiency in pediatric renal transplant recipients: Assessment of risk factors and response to oral vitamin D therapy. Pediatr Transplant 2011; 15:790-7. [PMID: 21895903 DOI: 10.1111/j.1399-3046.2011.01571.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
VitD deficiency and bone disease are common after Tx. Prevalence and risk factors for low VitD and BMD and response to VitD therapy were investigated in pediatric renal Tx recipients. 25-hydroxy VitD levels of 71 Tx were compared to 54 healthy AA children. DXA of 44 Tx were compared to 47 AA controls. Of Tx, 59% were AA. Majority (59.1%) of Tx were VitD deficient (23.9%) or insufficient (35.2%). Prevalence of low VitD levels was double in AA (73.9%) vs. non-AA Tx (37.7%), (p = 0.003). Low VitD among Tx was associated with AA ethnicity (p < 0.01), winter (p < 0.05), older age (p < 0.05), males (p < 0.05) and time <6 months post Tx (p < 0.05). Tx with low VitD were treated with oral ergocalciferol or cholecalciferol (23 each); 13% treated with ergocalciferol vs. 82.6% treated with cholecalciferol achieved repletion (p < 0.0001). Of 36 Tx with whole body DXA, 19.5% had BMD (z < -1) after height adjustment. AA Tx had 3.4-fold higher risk of low BMD vs. controls (p < 0.05). Low VitD and BMD are prevalent in children after renal Tx. Better repletion of VitD is achieved with cholecalciferol.
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Affiliation(s)
- Kristen Sgambat
- Department of Nephrology, Children's National Medical Center Emergency Medicine, Children's National Medical Center, Washington, DC 20010, USA
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15
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Di Rosa M, Malaguarnera M, Nicoletti F, Malaguarnera L. Vitamin D3: a helpful immuno-modulator. Immunology 2011; 134:123-39. [PMID: 21896008 DOI: 10.1111/j.1365-2567.2011.03482.x] [Citation(s) in RCA: 290] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The active metabolite of vitamin D, 1α, 25-dihydroxyvitamin D3 [1,25(OH)(2) D3], is involved in calcium and phosphate metabolism and exerts a large number of biological effects. Vitamin D3 inhibits parathyroid hormone secretion, adaptive immunity and cell proliferation, and at the same time promotes insulin secretion, innate immunity and stimulates cellular differentiation. The role of vitamin D3 in immunoregulation has led to the concept of a dual function as both as an important secosteroid hormone for the regulation of body calcium homeostasis and as an essential organic compound that has been shown to have a crucial effect on the immune responses. Altered levels of vitamin D3 have been associated, by recent observational studies, with a higher susceptibility of immune-mediated disorders and inflammatory diseases. This review reports the new developments with specific reference to the metabolic and signalling mechanisms associated with the complex immune-regulatory effects of vitamin D3 on immune cells.
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16
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Di Rosa M, Malaguarnera M, Nicoletti F, Malaguarnera L. Vitamin D3: a helpful immuno-modulator. Immunology 2011. [PMID: 21896008 DOI: 10.1111/j.1365-2567.2011.03482.x.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The active metabolite of vitamin D, 1α, 25-dihydroxyvitamin D3 [1,25(OH)(2) D3], is involved in calcium and phosphate metabolism and exerts a large number of biological effects. Vitamin D3 inhibits parathyroid hormone secretion, adaptive immunity and cell proliferation, and at the same time promotes insulin secretion, innate immunity and stimulates cellular differentiation. The role of vitamin D3 in immunoregulation has led to the concept of a dual function as both as an important secosteroid hormone for the regulation of body calcium homeostasis and as an essential organic compound that has been shown to have a crucial effect on the immune responses. Altered levels of vitamin D3 have been associated, by recent observational studies, with a higher susceptibility of immune-mediated disorders and inflammatory diseases. This review reports the new developments with specific reference to the metabolic and signalling mechanisms associated with the complex immune-regulatory effects of vitamin D3 on immune cells.
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17
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Unal A, Kocyigit I, Sipahioglu MH, Tokgoz B, Kavuncuoglu F, Oymak O, Utas C. Loss of bone mineral density in renal transplantation recipients. Transplant Proc 2011; 42:3550-3. [PMID: 21094813 DOI: 10.1016/j.transproceed.2010.07.106] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Accepted: 07/26/2010] [Indexed: 10/18/2022]
Abstract
AIM This study investigated the prevalence and contributing factors of loss of bone mineral density after renal transplantation among Turkish patients. PATIENTS AND METHODS The study included 70 subjects, namely 50 males and 20 females of overall mean age of 36.94 ± 10.09 years. We measured femoral neck mineral density by dual-energy X-ray absorptiometry (DEXA). A T score above -1 was defined as a normal bone mineral density compared with T scores of -1.0 to -2.5 or below -2.5 which were defined as either osteopenia or osteoporosis, respectively. RESULTS At a median duration of 23 months after renal transplantation, osteopenia or osteoporosis was observed among 30 (42.9%) or 30 (42.9%) of the 70 patients, respectively. The mean body mass index (BMI) value was significantly higher among the normal than the osteoporotic group: 27.59 ± 4.66 kg/m(2) vs 24.18 ± 3.57 kg/m(2), respectively. However, no significant differences occurred in terms of BMI among the other groups. The amount of proteinuria was significantly lower in the normal than the osteopenic or osteoporotic group: (12.5 (range, 10.0-20.0); 105.0 (10.0-2800.0) or 215.5 (10.0-1880.0) mg/d (P = .001 and .004, respectively). In contrast, there was no significant difference between the amounts of proteinuria displayed by the osteopenic group and the osteoporotic group (P < .05)]. These patient groups showed no difference in age, gender, donor source, cause of end-stage renal disease (ESRD), pretransplant dialysis modality, duration of dialysis, use of a vitamin D preparation, immunosuppressive regimen, posttransplantation period, levels of iPTH or 25 hydroxy vitamin D3 (25OH vit D), exposure to tacrolimus or cyclosporine (CyA), calcium × phosphate product, serum albumin and hemoglobin content, creatinine clearance, or serum bicarbonate concentrations (P > .05). The T scores of the femoral neck correlated with BMI (r: 0.415; P = .001), 25OH vit D level (r: 0.268, P = .026), creatinine clearance (r: 0.273, P = .022), and serum glucose level (r: 0.349, P = .003). It inversely correlated with the amount of proteinuria (r: -0.263, P = .028), serum alkaline phosphatase level (r: -0.329, P = .005), and serum magnesium concentration (r: -0.252, P = .035). Upon multivariate analysis, BMI and 25OH vit D level were observed to be independent risk factors for loss of femoral mineral density. CONCLUSION Loss of bone mineral density is a common complication that correlates with low BMI values and decreased 25OH vit D levels as major risk factors for this problem.
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Affiliation(s)
- A Unal
- Erciyes University Medical School, Department of Nephrology, Kayseri, 38039 Turkey.
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18
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Hyperparathyroidism and Vitamin D Deficiency Predispose to Bone Loss in Renal Transplant Recipients. Transplantation 2009; 88:678-83. [DOI: 10.1097/tp.0b013e3181b27c4d] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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