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Molina P, Molina MD, Carrero JJ, Escudero V, Torralba J, Castro-Alonso C, Beltrán S, Vizcaíno B, González-Moya M, Kanter J, Sancho-Calabuig A, Bover J, Górriz JL. Sevelamer Use and Mortality in People with Chronic Kidney Disease Stages 4 and 5 Not on Dialysis. J Clin Med 2023; 12:7631. [PMID: 38137700 PMCID: PMC10743559 DOI: 10.3390/jcm12247631] [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: 11/01/2023] [Revised: 11/27/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Rationale and objective: Data suggest that non-calcium-based binders, and specifically sevelamer, may lead to lower rates of death when compared with calcium-based binders in end-stage renal disease (ESRD) patients. However, the association between sevelamer use and mortality for those with non-dialysis-dependent chronic kidney disease (NDD-CKD) patients has been uncertain. Study design: Our research is presented in a prospective cohort study. Setting and participants: A total of 966 participants with NDD-CKD stages 4-5 were enrolled in the PECERA study from 12 centers in Spain. Exposure: The participants were treated with sevelamer. Outcome: This study yielded all-cause and cardiovascular mortality outcomes. Analytical approach: We conducted an association analysis between mortality and sevelamer use with time-dependent Cox proportional hazards models. Results: After a median follow-up of 29 months (IQR: 13-36 months), death occurred in 181 participants (19%), with cardiovascular (n = 95, 53%) being the leading cause of death. In a multivariable model, the adjusted hazard ratios (HRs) for patients under sevelamer treatment were 0.44 (95% CI, 0.22 to 0.88) and 0.37 (95% CI, 0.18 to 0.75) for all-cause and cardiovascular mortality, respectively, compared with those of untreated patients. Limitations: Some limitations include potential confusion via indication bias; causal statements about these associations cannot be made due to the observational nature of this study. Conclusions: In this prospective NDD-CKD cohort study, the administration of sevelamer was independently associated with lower all-cause and cardiovascular mortality, suggesting that non-calcium-based phosphate binders might be the first-line therapy for phosphate lowering in this population. Further interventional studies clarifying the risks and benefits of phosphate binders in NDD-CKD are warranted.
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Affiliation(s)
- Pablo Molina
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
- Department of Medicine, Universitat de València, 46010 Valencia, Spain;
| | - Mariola D. Molina
- Department of Mathematics, Universidad de Alicante, 03690 Sant Vicent del Raspeig, Spain;
| | - Juan J. Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, SE-171 77 Stockholm, Sweden;
| | - Verónica Escudero
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
| | - Javier Torralba
- Department of Nephrology, Hospital General Universitario, 03010 Alicante, Spain;
| | - Cristina Castro-Alonso
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
| | - Sandra Beltrán
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
| | - Belén Vizcaíno
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
- Department of Medicine, Universitat de València, 46010 Valencia, Spain;
| | - Mercedes González-Moya
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
- Department of Medicine, Universitat de València, 46010 Valencia, Spain;
| | - Julia Kanter
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
| | - Asunción Sancho-Calabuig
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
- Department of Medicine, Universitat de València, 46010 Valencia, Spain;
| | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain;
| | - José L. Górriz
- Department of Medicine, Universitat de València, 46010 Valencia, Spain;
- Department of Nephrology, Hospital Clínico Universitario, Fundación para la Investigación del Hospital Clínico de la Comunidad Valenciana, 46010 Valencia, Spain
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Torregrosa JV, Bover J, Rodríguez Portillo M, González Parra E, Dolores Arenas M, Caravaca F, González Casaus ML, Martín-Malo A, Navarro-González JF, Lorenzo V, Molina P, Rodríguez M, Cannata Andia J. Recommendations of the Spanish Society of Nephrology for the management of mineral and bone metabolism disorders in patients with chronic kidney disease: 2021 (SEN-MM). Nefrologia 2023; 43 Suppl 1:1-36. [PMID: 37202281 DOI: 10.1016/j.nefroe.2023.03.003] [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: 02/17/2022] [Accepted: 03/26/2022] [Indexed: 05/20/2023] Open
Abstract
As in 2011, when the Spanish Society of Nephrology (SEN) published the Spanish adaptation to the Kidney Disease: Improving Global Outcomes (KDIGO) universal Guideline on Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD), this document contains an update and an adaptation of the 2017 KDIGO guidelines to our setting. In this field, as in many other areas of nephrology, it has been impossible to irrefutably answer many questions, which remain pending. However, there is no doubt that the close relationship between the CKD-MBD/cardiovascular disease/morbidity and mortality complex and new randomised clinical trials in some areas and the development of new drugs have yielded significant advances in this field and created the need for this update. We would therefore highlight the slight divergences that we propose in the ideal objectives for biochemical abnormalities in the CKD-MBD complex compared to the KDIGO suggestions (for example, in relation to parathyroid hormone or phosphate), the role of native vitamin D and analogues in the control of secondary hyperparathyroidism and the contribution of new phosphate binders and calcimimetics. Attention should also be drawn to the adoption of important new developments in the diagnosis of bone abnormalities in patients with kidney disease and to the need to be more proactive in treating them. In any event, the current speed at which innovations are taking place, while perhaps slower than we might like, globally drives the need for more frequent updates (for example, through Nefrología al día).
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Affiliation(s)
| | - Jordi Bover
- Hospital Germans Trias i Pujol, Badalona, Spain
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Álvarez ES, Xipell M, Gallardo A, Astudillo E, Torregrosa JV. The 'Phosphorus Week': involvement of Spanish nephrologists in the control of phosphorus blood levels. Nefrologia 2023; 43:232-238. [PMID: 37442711 DOI: 10.1016/j.nefroe.2023.07.001] [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: 04/02/2021] [Accepted: 10/21/2021] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND The adequate control of phosphorus levels is a major concern for professionals involved in the care of patients with chronic kidney disease (CKD), since high phosphorus levels are directly related to an increase in mortality. OBJECTIVES To know the perception and involvement of Spanish nephrologists on the control of phosphorus levels, the so-called 'Phosphorus Week' was organized (November 13-17, 2017). METHODS All members of the Spanish Society of Nephrology were invited to participate in an online survey, which included questions on aspects related to phosphorus control in patients with advanced CKD (aCKD) (glomerular filtration rate <30 ml/min/1, 73 m2) and in the different modalities of renal replacement therapies [peritoneal dialysis (PD), hemodialysis (HD) and renal transplantation (KT)]. RESULTS 72 data entries were obtained in the survey with an inclusion of 7463 patients. Of them, 35.4% were on HD, 34.8% were KT, 24.2% had aCKD and 5.5% were on PD. The serum phosphorus level target for the four groups of patients was 4.5 mg/dl, with minimal variations depending on the area of the national territory. The patients with better control of phosphataemia were patients with KT (93.3% had phosphorus values <4.5 mg/dl), followed by patients with aCKD (65.6% with phosphorus <4.5 mg/dl). Only 53.6% of the patients on HD and 39.4% of those on PD reached the phosphorus goal <4.5 mg/dl. The group of patients on dialysis was the one in whom phosphorus binders prescribed the most (73.5% and 75.6% in HD and PD, respectively), being less frequent in patients with patients with aCKD (39.9%) and only 4.5 % in KT. CONCLUSIONS The objectives of the Spanish nephrologists are in line with those recommended by the national and international clinical guidelines; however, there is still a wide room for improvement to achieve these goals, especially in HD and PD patients.
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Affiliation(s)
| | | | - Anna Gallardo
- Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
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La «Semana del Fósforo»: implicación de la nefrología española en el control de los valores plasmáticos de fósforo. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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5
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Casado E, Bover J, Gómez-Alonso C, Navarro-González JF. Osteoporosis in chronic kidney disease: A essential challenge. Med Clin (Barc) 2021; 158:27-34. [PMID: 34154811 DOI: 10.1016/j.medcli.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Enrique Casado
- Servicio de Reumatología, Hospital Universitari Parc Taulí (UAB), Institut d'Investigació I3PT, Sabadell, Barcelona, España
| | - Jordi Bover
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, Barcelona, España; Red de Investigación Renal (REDinREN), Instituto de Salud Carlos III, Madrid, España; Chronic Kidney Disease-Mineral Bone Disorders (CKD-MBD) Working Group, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA).
| | - Carlos Gómez-Alonso
- Unidad de Gestión Clínica de Metabolismo Óseo y Mineral, ISPA, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Juan F Navarro-González
- Red de Investigación Renal (REDinREN), Instituto de Salud Carlos III, Madrid, España; Chronic Kidney Disease-Mineral Bone Disorders (CKD-MBD) Working Group, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA); Servicio de Nefrología y Unidad de Investigación, Hospital Universitario Nuestra Señora de la Candelaria, Instituto de Tecnologías Biomédicas, Universidad de La Laguna, San Cristóbal de La Laguna, Santa Cruz de Tenerife, España
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Bover J, Aguilar A, Arana C, Molina P, Lloret MJ, Ochoa J, Berná G, Gutiérrez-Maza YG, Rodrigues N, D'Marco L, Górriz JL. Clinical Approach to Vascular Calcification in Patients With Non-dialysis Dependent Chronic Kidney Disease: Mineral-Bone Disorder-Related Aspects. Front Med (Lausanne) 2021; 8:642718. [PMID: 34095165 PMCID: PMC8171667 DOI: 10.3389/fmed.2021.642718] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/12/2021] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is associated with a very high morbimortality, mainly from cardiovascular origin, and CKD is currently considered in the high- or very high risk- cardiovascular risk category. CKD-mineral and bone disorders (CKD-MBDs), including vascular and/or valvular calcifications, are also associated with these poor outcomes. Vascular calcification (VC) is very prevalent (both intimal and medial), even in non-dialysis dependent patients, with a greater severity and more rapid progression. Simple X-ray based-scores such as Adragão's (AS) are useful prognostic tools and AS (even AS based on hand-X-ray only) may be superior to the classic Kauppila's score when evaluating non-dialysis CKD patients. Thus, in this mini-review, we briefly review CKD-MBD-related aspects of VC and its complex pathophysiology including the vast array of contributors and inhibitors. Furthermore, although VC is a surrogate marker and is not yet considered a treatment target, we consider that the presence of VC may be relevant in guiding therapeutic interventions, unless all patients are treated with the mindset of reducing the incidence or progression of VC with the currently available armamentarium. Avoiding phosphate loading, restricting calcium-based phosphate binders and high doses of vitamin D, and avoiding normalizing (within the normal limits for the assay) parathyroid hormone levels seem logical approaches. The availability of new drugs and future studies, including patients in early stages of CKD, may lead to significant improvements not only in patient risk stratification but also in attenuating the accelerated progression of VC in CKD.
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Affiliation(s)
- Jordi Bover
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Armando Aguilar
- Department of Nephrology, Instituto Mexicano del Seguro Social, Hospital General de Zona No. 2, Tuxtla Gutiérrez, Mexico
| | - Carolt Arana
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Pablo Molina
- Department of Nephrology, Hospital Universitario Dr Peset, Universidad de Valencia, REDinREN, Valencia, Spain
| | - María Jesús Lloret
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Jackson Ochoa
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Gerson Berná
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Yessica G. Gutiérrez-Maza
- Department of Nephrology, Instituto Mexicano del Seguro Social, Hospital General de Zona No. 2, Tuxtla Gutiérrez, Mexico
| | - Natacha Rodrigues
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, Lisboa, Portugal
| | - Luis D'Marco
- Servicio de Nefrología, Hospital Clínico Universitario, INCLIVA, Universidad de Valencia, Valencia, Spain
| | - José L. Górriz
- Servicio de Nefrología, Hospital Clínico Universitario, INCLIVA, Universidad de Valencia, Valencia, Spain
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Bover J, Ureña-Torres P, Mateu S, DaSilva I, Gràcia S, Sánchez-Baya M, Arana C, Fayos L, Guirado L, Cozzolino M. Evidence in chronic kidney disease-mineral and bone disorder guidelines: is it time to treat or time to wait? Clin Kidney J 2020; 13:513-521. [PMID: 32905295 PMCID: PMC7467585 DOI: 10.1093/ckj/sfz187] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/02/2019] [Indexed: 12/18/2022] Open
Abstract
Chronic kidney disease-mineral and bone disorder (CKD-MBD) is one of the many important complications associated with CKD and may at least partially explain the extremely high morbidity and mortality among CKD patients. The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline document was based on the best information available at that time and was designed not only to provide information but also to assist in decision-making. In addition to the international KDIGO Work Group, which included worldwide experts, an independent Evidence Review Team was assembled to ensure rigorous review and grading of the existing evidence. Based on the evidence from new clinical trials, an updated Clinical Practice Guideline was published in 2017. In this review, we focus on the conceptual and practical evolution of clinical guidelines (from eMinence-based medicine to eVidence-based medicine and 'living' guidelines), highlight some of the current important CKD-MBD-related changes, and underline the poor or extremely poor level of evidence present in those guidelines (as well as in other areas of nephrology). Finally, we emphasize the importance of individualization of treatments and shared decision-making (based on important ethical considerations and the 'best available evidence'), which may prove useful in the face of the uncertainty over the decision whether 'to treat' or 'to wait'.
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Affiliation(s)
- Jordi Bover
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Pablo Ureña-Torres
- Department of Dialysis, AURA Nord Saint Ouen, Saint Ouen and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Silvia Mateu
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Iara DaSilva
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Silvia Gràcia
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Maya Sánchez-Baya
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Carolt Arana
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Leonor Fayos
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Lluis Guirado
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Mario Cozzolino
- Renal Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
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Bover J, Cozzolino M. Small steps towards the potential of 'preventive' treatment of early phosphate loading in chronic kidney disease patients. Clin Kidney J 2019; 12:673-677. [PMID: 31584564 PMCID: PMC6768463 DOI: 10.1093/ckj/sfz082] [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: 05/27/2019] [Indexed: 12/31/2022] Open
Abstract
Few clinical studies have investigated the value of phosphate (P)-lowering therapies in early chronic kidney disease (CKD) patients in whom hyperphosphataemia has not yet clearly developed and they report conflicting and even unexpected results. In this issue of Clinical Kidney Journal, de Krijger et al. found that sevelamer carbonate (4.8 g/day for 8 weeks) did not induce a significant reduction of pulse wave velocity (PWV) and that fibroblast growth factor 23 (FGF23) did not decrease despite a decline in 24-h urine P excretion. To some extent these findings challenge the concept that 'preventive' P binder therapy to lower FGF23 is a useful approach, at least over this short period of time. Interestingly, in a subgroup of patients with absent or limited abdominal vascular calcification, treatment did result in a statistically significant reduction in adjusted PWV, suggesting that PWV is amenable to improvement in this subset. Interpretation of the scarce and heterogeneous observations described in early CKD remains difficult and causality and/or the possibility of 'preventive' treatment may not yet be completely disregarded. Moreover, de Krijger et al. contribute to the identification of new sources of bias and methodological issues that may lead to more personalized treatments, always bearing in mind that not all patients and not all P binders are equal.
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Affiliation(s)
- Jordi Bover
- Fundació Puigvert, Department of Nephrology and Cardiology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Mario Cozzolino
- Renal Unit, San Paolo Hospital and San Carlo Hospital, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
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9
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Bover J, Ureña P, Aguilar A, Mazzaferro S, Benito S, López-Báez V, Ramos A, daSilva I, Cozzolino M. Alkaline Phosphatases in the Complex Chronic Kidney Disease-Mineral and Bone Disorders. Calcif Tissue Int 2018; 103:111-124. [PMID: 29445837 DOI: 10.1007/s00223-018-0399-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/29/2018] [Indexed: 12/16/2022]
Abstract
Alkaline phosphatases (APs) remove the phosphate (dephosphorylation) needed in multiple metabolic processes (from many molecules such as proteins, nucleotides, or pyrophosphate). Therefore, APs are important for bone mineralization but paradoxically they can also be deleterious for other processes, such as vascular calcification and the increasingly known cross-talk between bone and vessels. A proper balance between beneficial and harmful activities is further complicated in the context of chronic kidney disease (CKD). In this narrative review, we will briefly update the complexity of the enzyme, including its different isoforms such as the bone-specific alkaline phosphatase or the most recently discovered B1x. We will also analyze the correlations and potential discrepancies with parathyroid hormone and bone turnover and, most importantly, the valuable recent associations of AP's with cardiovascular disease and/or vascular calcification, and survival. Finally, a basic knowledge of the synthetic and degradation pathways of APs promises to open new therapeutic strategies for the treatment of the CKD-Mineral and Bone Disorder (CKD-MBD) in the near future, as well as for other processes such as sepsis, acute kidney injury, inflammation, endothelial dysfunction, metabolic syndrome or, in diabetes, cardiovascular complications. However, no studies have been done using APs as a primary therapeutic target for clinical outcomes, and therefore, AP's levels cannot yet be used alone as an isolated primary target in the treatment of CKD-MBD. Nonetheless, its diagnostic and prognostic potential should be underlined.
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Affiliation(s)
- Jordi Bover
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain.
| | - Pablo Ureña
- Department of Nephrology and Dialysis, Clinique du Landy and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Armando Aguilar
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Benito
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Víctor López-Báez
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Alejandra Ramos
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Iara daSilva
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Mario Cozzolino
- Laboratory of Experimental Nephrology, Renal Division,San Paolo Hospital, DiSS University of Milan, Milan, Italy
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10
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Shen J, Zhang N, Lin YN, Xiang P, Liu XB, Shan PF, Hu XY, Zhu W, Tang YL, Webster KA, Cai R, Schally AV, Wang J, Yu H. Regulation of Vascular Calcification by Growth Hormone-Releasing Hormone and Its Agonists. Circ Res 2018; 122:1395-1408. [PMID: 29618597 DOI: 10.1161/circresaha.117.312418] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
RATIONALE Vascular calcification (VC) is a marker of the severity of atherosclerotic disease. Hormones play important roles in regulating calcification; estrogen and parathyroid hormones exert opposing effects, the former alleviating VC and the latter exacerbating it. To date no treatment strategies have been developed to regulate clinical VC. OBJECTIVE The objective of this study was to investigate the effect of growth hormone-releasing hormone (GHRH) and its agonist (GHRH-A) on the blocking of VC in a mouse model. METHODS AND RESULTS Young adult osteoprotegerin-deficient mice were given daily subcutaneous injections of GHRH-A (MR409) for 4 weeks. Significant reductions in calcification of the aortas of MR409-treated mice were paralleled by markedly lower alkaline phosphatase activity and a dramatic reduction in the expression of transcription factors, including the osteogenic marker gene Runx2 and its downstream factors, osteonectin and osteocalcin. The mechanism of action of GHRH-A was dissected in smooth muscle cells isolated from human and mouse aortas. Calcification of smooth muscle cells induced by osteogenic medium was inhibited in the presence of GHRH or MR409, as evidenced by reduced alkaline phosphatase activity and Runx2 expression. Inhibition of calcification by MR409 was partially reversed by MIA602, a GHRH antagonist, or a GHRH receptor-selective small interfering RNA. Treatment with MR409 induced elevated cytosolic cAMP and its target, protein kinase A which in turn blocked nicotinamide adenine dinucleotide phosphate oxidase activity and reduced production of reactive oxygen species, thus blocking the phosphorylation of nuclear factor κB (p65), a key intermediate in the ligand of receptor activator for nuclear factor-κ B-Runx2/alkaline phosphatase osteogenesis program. A protein kinase A-selective small interfering RNA or the chemical inhibitor H89 abolished these beneficial effects of MR409. CONCLUSIONS GHRH-A controls osteogenesis in smooth muscle cells by targeting cross talk between protein kinase A and nuclear factor κB (p65) and through the suppression of reactive oxygen species production that induces the Runx2 gene and alkaline phosphatase. Inflammation-mediated osteogenesis is thereby blocked. GHRH-A may represent a new pharmacological strategy to regulate VC.
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Affiliation(s)
- Jian Shen
- From the Departments of Cardiology (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
- Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, PR China (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
| | - Ning Zhang
- From the Departments of Cardiology (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
- Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, PR China (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
| | - Yi-Nuo Lin
- From the Departments of Cardiology (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
- Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, PR China (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
| | - PingPing Xiang
- From the Departments of Cardiology (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
- Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, PR China (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
| | - Xian-Bao Liu
- From the Departments of Cardiology (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
- Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, PR China (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
| | | | - Xin-Yang Hu
- From the Departments of Cardiology (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
- Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, PR China (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
| | - Wei Zhu
- From the Departments of Cardiology (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
- Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, PR China (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
| | - Yao-Liang Tang
- Vascular Biology Center, Georgia Regents University, Augusta (Y.-l.T.)
| | - Keith A Webster
- Department of Molecular and Cellular Pharmacology and the Vascular Biology Institute (K.A.W., R.C., A.V.S.)
| | - Renzhi Cai
- Department of Molecular and Cellular Pharmacology and the Vascular Biology Institute (K.A.W., R.C., A.V.S.)
- Divisions of Hematology/Oncology, Department of Medicine (R.C., A.V.S.)
- Miller School of Medicine, University of Miami, FL; and Endocrine, Polypeptide and Cancer Institute, Veterans Affairs Medical Center, Miami, FL (R.C., A.V.S.)
| | - Andrew V Schally
- Department of Molecular and Cellular Pharmacology and the Vascular Biology Institute (K.A.W., R.C., A.V.S.)
- Divisions of Hematology/Oncology, Department of Medicine (R.C., A.V.S.)
- Miller School of Medicine, University of Miami, FL; and Endocrine, Polypeptide and Cancer Institute, Veterans Affairs Medical Center, Miami, FL (R.C., A.V.S.)
| | - Jian'an Wang
- From the Departments of Cardiology (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
- Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, PR China (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
| | - Hong Yu
- From the Departments of Cardiology (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
- Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, PR China (J.S., N.Z., Y.-N.L., P.P.X., X.-b.L., X.-y.H., W.Z., J.W., H.Y.)
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Bover J, Górriz JL, Ureña-Torres P, Lloret MJ, Ruiz-García C, daSilva I, Chang P, Rodríguez M, Ballarín J. Detección de las calcificaciones cardiovasculares: ¿una herramienta útil para el nefrólogo? Nefrologia 2016; 36:587-596. [DOI: 10.1016/j.nefro.2016.05.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/19/2016] [Indexed: 12/12/2022] Open
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Bover J, Ureña-Torres P, Górriz JL, Lloret MJ, da Silva I, Ruiz-García C, Chang P, Rodríguez M, Ballarín J. Cardiovascular calcifications in chronic kidney disease: Potential therapeutic implications. Nefrologia 2016; 36:597-608. [PMID: 27595517 DOI: 10.1016/j.nefro.2016.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/19/2016] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular (CV) calcification is a highly prevalent condition at all stages of chronic kidney disease (CKD) and is directly associated with increased CV and global morbidity and mortality. In the first part of this review, we have shown that CV calcifications represent an important part of the CKD-MBD complex and are a superior predictor of clinical outcomes in our patients. However, it is also necessary to demonstrate that CV calcification is a modifiable risk factor including the possibility of decreasing (or at least not aggravating) its progression with iatrogenic manoeuvres. Although, strictly speaking, only circumstantial evidence is available, it is known that certain drugs may modify the progression of CV calcifications, even though a direct causal link with improved survival has not been demonstrated. For example, non-calcium-based phosphate binders demonstrated the ability to attenuate the progression of CV calcification compared with the liberal use of calcium-based phosphate binders in several randomised clinical trials. Moreover, although only in experimental conditions, selective activators of the vitamin D receptor seem to have a wider therapeutic margin against CV calcification. Finally, calcimimetics seem to attenuate the progression of CV calcification in dialysis patients. While new therapeutic strategies are being developed (i.e. vitamin K, SNF472, etc.), we suggest that the evaluation of CV calcifications could be a diagnostic tool used by nephrologists to personalise their therapeutic decisions.
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Affiliation(s)
- Jordi Bover
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España.
| | - Pablo Ureña-Torres
- Departamento de Nefrología y Diálisis, Clinique du Landy, París, Francia; Departamento de Fisiología Renal, Hospital Necker, Universidad de París Descartes, París, Francia
| | - José Luis Górriz
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Valencia, España
| | - María Jesús Lloret
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - Iara da Silva
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - César Ruiz-García
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - Pamela Chang
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - Mariano Rodríguez
- Servicio de Nefrología, Hospital Universitario Reina Sofía, IMIBIC, Universidad de Córdoba, Córdoba, España
| | - José Ballarín
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
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