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Balsamello C, Mas MM, Rombolà G, Floreani R, Costantino ML, Casagrande G. Same therapy, same calcium mobilization? Exploring calcium exchange across body compartments using a patient-specific predictive model. Artif Organs 2024. [PMID: 38837387 DOI: 10.1111/aor.14800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/09/2024] [Accepted: 05/15/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Comprehensive, patient-specific models are essential to study calcium deposition and mobilization during dialysis. We aim to develop tools to support clinical prescriptions with a more accurate approach for the prediction of calcium mobilization while also considering major electrolytes and catabolites. METHODS We modified a multi-solute model predicting patient-specific dialysis response by incorporating a calcium buffer to represent bone exchanges. Data from four centers, involving 127 patients with six sessions each, were utilized. For each patient, three sessions were allocated for model training (ID123), while the remaining sessions were for validation (PRED456). The normalized root mean square error (nRMSE%) was used to evaluate both descriptive and predictive accuracy. Correlations between initial data and calcium exchanges were also assessed. RESULTS The overall nRMSE% for ID123 was 3.92%. For PRED456, it was 3.46% (ranging from a minimum of 1.17% for [Na+] to a maximum of 6.62% for [urea]). The median nRMSE% for plasma calcium varied between 1.13 and 8.32 for SHD sessions, depending on whether Ca_dialysis fluid (Cad) was ≥ or <1.50 mmol/L, respectively. For HDF sessions, the range was between 2.90 and 5.89. A significant and moderate correlation was found between overall calcium removal and the buffer balance. The most robust correlation observed was between the amount of calcium administered via post-dilution fluid and the overall calcium removal in the dialysis filter. CONCLUSIONS Identical therapy settings do not uniformly affect calcium mobilization, and our approach offers insight into calcium distribution across body compartments. This understanding will enhance clinical prescription practices.
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Affiliation(s)
- Carlo Balsamello
- Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milan, Italy
| | - Mar Martinez Mas
- Columbia University in the City of New York, New York, New York, USA
| | - Giuseppe Rombolà
- Nephrology and Dialysis Unit, Multimedica Clinica San Giuseppe, Milan, Italy
| | | | - Maria Laura Costantino
- Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milan, Italy
| | - Giustina Casagrande
- Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milan, Italy
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2
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Jørgensen HS, Lloret MJ, Lalayiannis AD, Shroff R, Evenepoel P. Ten tips on how to assess bone health in patients with chronic kidney disease. Clin Kidney J 2024; 17:sfae093. [PMID: 38817914 PMCID: PMC11137676 DOI: 10.1093/ckj/sfae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Indexed: 06/01/2024] Open
Abstract
Patients with chronic kidney disease (CKD) experience a several-fold increased risk of fracture. Despite the high incidence and the associated excess morbidity and premature mortality, bone fragility in CKD, or CKD-associated osteoporosis, remains a blind spot in nephrology with an immense treatment gap. Defining the bone phenotype is a prerequisite for the appropriate therapy of CKD-associated osteoporosis at the patient level. In the present review, we suggest 10 practical 'tips and tricks' for the assessment of bone health in patients with CKD. We describe the clinical, biochemical, and radiological evaluation of bone health, alongside the benefits and limitations of the available diagnostics. A bone biopsy, the gold standard for diagnosing renal bone disease, is invasive and not widely available; although useful in complex cases, we do not consider it an essential component of bone assessment in patients with CKD-associated osteoporosis. Furthermore, we advocate for the deployment of multidisciplinary expert teams at local, national, and potentially international level. Finally, we address the knowledge gaps in the diagnosis, particularly early detection, appropriate "real-time" monitoring of bone health in this highly vulnerable population, and emerging diagnostic tools, currently primarily used in research, that may be on the horizon of clinical practice.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Maria Jesús Lloret
- Department of Nephrology, Hospital Fundació Puigvert, Barcelona, Spain
- Institut de Recerca Sant-Pau (IR-Sant Pau), Barcelona, Spain
| | - Alexander D Lalayiannis
- Department of Pediatric Nephrology, Birmingham Women's and Children's Hospitals, Birmingham, UK
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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3
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Lalayiannis AD, Soeiro EMD, Moysés RMA, Shroff R. Chronic kidney disease mineral bone disorder in childhood and young adulthood: a 'growing' understanding. Pediatr Nephrol 2024; 39:723-739. [PMID: 37624528 PMCID: PMC10817832 DOI: 10.1007/s00467-023-06109-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/06/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023]
Abstract
Chronic kidney disease (CKD) mineral and bone disorder (MBD) comprises a triad of biochemical abnormalities (of calcium, phosphate, parathyroid hormone and vitamin D), bone abnormalities (turnover, mineralization and growth) and extra-skeletal calcification. Mineral dysregulation leads to bone demineralization causing bone pain and an increased fracture risk compared to healthy peers. Vascular calcification, with hydroxyapatite deposition in the vessel wall, is a part of the CKD-MBD spectrum and, in turn, leads to vascular stiffness, left ventricular hypertrophy and a very high cardiovascular mortality risk. While the growing bone requires calcium, excess calcium can deposit in the vessels, such that the intake of calcium, calcium- containing medications and high calcium dialysate need to be carefully regulated. Normal physiological bone mineralization continues into the third decade of life, many years beyond the rapid growth in childhood and adolescence, implying that skeletal calcium requirements are much higher in younger people compared to the elderly. Much of the research into the link between bone (de)mineralization and vascular calcification in CKD has been performed in older adults and these data must not be extrapolated to children or younger adults. In this article, we explore the physiological changes in bone turnover and mineralization in children and young adults, the pathophysiology of mineral bone disease in CKD and a potential link between bone demineralization and vascular calcification.
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Affiliation(s)
- Alexander D Lalayiannis
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK.
| | | | - Rosa M A Moysés
- Sao Paulo University Faculty of Medicine, Universidade de Sao Paulo Faculdade de Medicina, São Paulo, Brazil
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
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4
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Mak RH, Iyengar A, Lai WM, McAlister L, Oliveira EA, Xu H, Yap HK, Shroff R. Nutrition in Children With Chronic Kidney Disease: How to Thrive? J Ren Nutr 2023; 33:S49-S55. [PMID: 37558172 DOI: 10.1053/j.jrn.2023.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/21/2023] [Accepted: 07/23/2023] [Indexed: 08/11/2023] Open
Abstract
The nutritional status and management of children with chronic kidney disease (CKD) are complex and require a combined pediatric nephrology team work approach with physicians, nutritionists, nurses, and physical/occupational therapists. Prospective observational studies such as Children with CKD in the US, the 4C study in Europe and the International Pediatric Peritoneal Dialysis Network have advanced the field. However, most recommendations and guidelines from international task forces such as Kidney Diseases Improving Global Outcomes and Pediatric Renal Nutrition Taskforce are opinion-based rather than evidence-based. There is exciting ongoing research to improve nutrition in children with CKD to help them thrive.
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Affiliation(s)
- Robert H Mak
- Division of Pediatric Nephrology, Rady Children's Hospital, University of California San Diego, La Jolla.
| | - Arpana Iyengar
- Department of Pediatric Nephrology, St John's National Academy of Health Sciences, Bangalore, India
| | - Wai Ming Lai
- Paediatric Nephrology Center, Hong Kong Children's Hospital, Hong Kong
| | | | - Eduardo A Oliveira
- Department of Pediatrics, School of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Hong Xu
- Department of Pediatric Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Hui Kim Yap
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rukshana Shroff
- Division of Paediatric Nephrology, Institute of Child Health, London, United Kingdom
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5
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Pontán F, Hauta-Alus H, Valkama S, Rosendahl J, Enlund-Cerullo M, Andersson S, Mäkitie O, Holmlund-Suila E. Alkaline Phosphatase and Hyperphosphatasemia in Vitamin D Trial in Healthy Infants and Toddlers. J Clin Endocrinol Metab 2023; 108:e1082-e1091. [PMID: 37061810 DOI: 10.1210/clinem/dgad208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/16/2023] [Accepted: 04/12/2023] [Indexed: 04/17/2023]
Abstract
CONTEXT Childhood hyperphosphatasemia is usually transient and may be associated with infections. It remains less well known how hyperphosphatasemia is related to growth and bone mineralization. OBJECTIVE We explored alkaline phosphatase (ALP) concentrations and prevalence of hyperphosphatasemia, and their association with vitamin D, growth, infections, and bone parameters in healthy children. METHODS The study was a secondary analysis of a vitamin D intervention trial. Participants received vitamin D3 10 or 30 µg daily from age 2 weeks to 2 years. Children with data on ALP at 12 and/or 24 months (n = 813, girls 51.9%) were included. Anthropometrics and bone parameters were measured at 12 and 24 months. Infections were recorded prospectively by the parents. RESULTS Boys had higher ALP than girls at 12 months (median [IQR] 287 [241-345] U/L vs 266 [218-341] U/L; P = .02). At 24 months concentrations were lower than at 12 months (240 [202-284]; P < .001) but without sex difference. The prevalence of hyperphosphatasemia (ALP > 1000 U/L) at 12 months was 5.3% and at 24 months 0.6%. Body size, growth rate, and bone mineral content associated positively with ALP, while vitamin D intervention had no effect. Infants with hyperphosphatasemia were smaller than infants with ALP ≤ 1000 U/L. Hyperphosphatasemia was not associated with previous infections. CONCLUSION Approximately 5% of infants had hyperphosphatasemia at 12 months, but <1% at 24 months. ALP concentrations and hyperphosphatasemia were associated with sex, anthropometry, and bone mineralization. Infections did not contribute to hyperphosphatasemia.
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Affiliation(s)
- Freja Pontán
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - Helena Hauta-Alus
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
- Population Health Unit, Finnish Institute for Health and Welfare (THL), 00300 Helsinki, Finland
- Clinical Medicine Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, 90014 Oulu, Finland
| | - Saara Valkama
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
| | - Jenni Rosendahl
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
| | - Maria Enlund-Cerullo
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
- Institute of Genetics, Folkhälsan Research Center, 00290 Helsinki, Finland
| | - Sture Andersson
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - Outi Mäkitie
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
- Institute of Genetics, Folkhälsan Research Center, 00290 Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden
- Department of Clinical Genetics, Karolinska University Hospital, 171 77 Stockholm, Sweden
| | - Elisa Holmlund-Suila
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
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6
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Lalayiannis AD, Crabtree NJ, Ferro CJ, Wheeler DC, Duncan ND, Smith C, Popoola J, Varvara A, Mitsioni A, Kaur A, Sinha MD, Biassoni L, McGuirk SP, Mortensen KH, Milford DV, Long J, Leonard MD, Fewtrell M, Shroff R. Bone Mineral Density and Vascular Calcification in Children and Young Adults With CKD 4 to 5 or on Dialysis. Kidney Int Rep 2022; 8:265-273. [PMID: 36815116 PMCID: PMC9939315 DOI: 10.1016/j.ekir.2022.10.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 10/11/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction Older adults with chronic kidney disease (CKD) can have low bone mineral density (BMD) with concurrent vascular calcification. Mineral accrual by the growing skeleton may protect young people with CKD from extraosseous calcification. Our hypothesis was that children and young adults with increasing BMD do not develop vascular calcification. Methods This was a multicenter longitudinal study in children and young people (5-30 years) with CKD stages 4 to 5 or on dialysis. BMD was assessed by tibial peripheral quantitative computed tomography (pQCT) and lumbar spine dual-energy X-ray absorptiometry (DXA). The following cardiovascular imaging tests were undertaken: cardiac computed tomography for coronary artery calcification (CAC), ultrasound for carotid intima media thickness z-score (cIMTz), pulse wave velocity z-score (PWVz), and carotid distensibility for arterial stiffness. All measures are presented as age-adjusted and sex-adjusted z-scores. Results One hundred participants (median age 13.82 years) were assessed at baseline and 57 followed up after a median of 1.45 years. Trabecular BMD z-score (TrabBMDz) decreased (P = 0.01), and there was a nonsignificant decrease in cortical BMD z-score (CortBMDz) (P = 0.09). Median cIMTz and PWVz showed nonsignificant increase (P = 0.23 and P = 0.19, respectively). The annualized increase in TrabBMDz (ΔTrabBMDz) was an independent predictor of cIMTz increase (R 2 = 0.48, β = 0.40, P = 0.03). Young people who demonstrated statural growth (n = 33) had lower ΔTrabBMDz and also attenuated vascular changes compared with those with static growth (n = 24). Conclusion This hypothesis-generating study suggests that children and young adults with CKD or on dialysis may develop vascular calcification even as their BMD increases. A presumed buffering capacity of the growing skeleton may offer some protection against extraosseous calcification.
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Affiliation(s)
- Alexander D. Lalayiannis
- Pediatric Nephrology, Birmingham Women’s and Children’s Hospitals, National Health Service Foundation Trust, Birmingham, UK; University College London Great Ormond Street Hospital Institute of Child Health, London, UK
- Nephrology, Birmingham Children’s Hospital, Birmingham, UK
- Correspondence: Alexander D. Lalayiannis, Nephrology Department, Birmingham Women's and Children's Hospitals NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Nicola J. Crabtree
- Densitometry Department, Birmingham Women’s and Children’s Hospitals National Health Service, Foundation Trust, Birmingham, UK
| | | | - David C. Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Neill D. Duncan
- Imperial College Healthcare National Health Service Trust, Renal and Transplant Center, London, UK
| | - Colette Smith
- Institute of Global Helath, University College London, London, UK
| | - Joyce Popoola
- St. George’s University Hospital National Health Service Foundation Trust, London, UK
| | - Askiti Varvara
- Department of Pediatric Nephrology, “P & A Kyriakou” Children’s Hospital, Athens, Greece
| | - Andromachi Mitsioni
- Department of Pediatric Nephrology, “P & A Kyriakou” Children’s Hospital, Athens, Greece
| | - Amrit Kaur
- Pediatric Nephrology, Manchester University National Health Service Foundation Trust, Manchester, UK
| | - Manish D. Sinha
- Pediatric Nephrology, Evelina Children’s Hospital, London, UK
| | - Lorenzo Biassoni
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | - Simon P. McGuirk
- Radiology Department, Birmingham Women’s and Children’s Hospitals National Health Service Foundation Trust, Birmingham, UK
| | - Kristian H. Mortensen
- Department of Cardiac Imaging, University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | | | - Jin Long
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Mary D. Leonard
- Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Mary Fewtrell
- University College London Great Ormond Street Institute of Child Health, Population Policy and Practice, Childhood Nutrition Research Center, London, UK
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
- Great Ormond Street Hospital, London, UK
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7
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Shroff R, Lalayiannis AD, Fewtrell M, Schmitt CP, Bayazit A, Askiti V, Jankauskiene A, Bacchetta J, Silva S, Goodman N, McAlister L, Biassoni L, Crabtree N, Rahn A, Fischer DC, Heuser A, Kolevica A, Eisenhauer A. Naturally occurring stable calcium isotope ratios are a novel biomarker of bone calcium balance in chronic kidney disease. Kidney Int 2022; 102:613-623. [DOI: 10.1016/j.kint.2022.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/10/2022] [Accepted: 04/18/2022] [Indexed: 11/28/2022]
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8
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Lalayiannis AD, Ferro CJ, Wheeler DC, Duncan ND, Smith C, Popoola J, Askiti V, Mitsioni A, Kaur A, Sinha MD, McGuirk SP, Mortensen KH, Milford DV, Shroff R. The burden of subclinical cardiovascular disease in children and young adults with chronic kidney disease and on dialysis. Clin Kidney J 2022; 15:287-294. [PMID: 35145643 PMCID: PMC8824782 DOI: 10.1093/ckj/sfab168] [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: 04/23/2021] [Indexed: 11/14/2022] Open
Abstract
Background Cardiovascular disease (CVD) is a common cause of morbidity and mortality even in young
people with chronic kidney disease (CKD). We examined structural and functional CV
changes in patients ˂30 years of age with CKD Stages 4 and 5 and on dialysis. Methods A total of 79 children and 21 young adults underwent cardiac computed tomography for
coronary artery calcification (CAC), ultrasound for carotid intima-media thickness
(cIMT), carotid–femoral pulse wave velocity (cfPWV) and echocardiography. Differences in
structural (CAC, cIMT z-score, left ventricular mass index) and
functional (carotid distensibility z-score and cfPWV
z-score) measures were examined between CKD Stages 4 and 5 and dialysis
patients. Results Overall, the cIMT z-score was elevated [median 2.17 (interquartile
range 1.14–2.86)] and 10 (10%) had CAC. A total of 16/23 (69.5%) patients with CKD
Stages 4 and 5 and 68/77 (88.3%) on dialysis had at least one structural or functional
CV abnormality. There was no difference in the prevalence of structural abnormalities in
CKD or dialysis cohorts, but functional abnormalities were more prevalent in patients on
dialysis (P < 0.05). The presence of more than one structural abnormality was
associated with a 4.5-fold increased odds of more than one functional abnormality (95%
confidence interval 1.3–16.6; P < 0.05). Patients with structural and functional
abnormalities [cIMT z-score >2 standard deviation (SD) or
distensibility <−2 SD) had less carotid dilatation (lumen:wall cross-sectional area
ratio) compared with those with normal cIMT and distensibility. Conclusions There is a high burden of subclinical CVD in young CKD patients, with a greater
prevalence of functional abnormalities in dialysis compared with CKD patients.
Longitudinal studies are required to test these hypothesis-generating data and define
the trajectory of CV changes in CKD.
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Affiliation(s)
- Alexander D Lalayiannis
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | - Charles J Ferro
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Neill D Duncan
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| | - Colette Smith
- Institute of Global Health, University College London, London, UK
| | - Joyce Popoola
- Department of Nephrology and Transplantation, St. George's University Hospital NHS Foundation Trust, London, UK
| | | | | | - Amrit Kaur
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Manish D Sinha
- Evelina Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Simon P McGuirk
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Kristian H Mortensen
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | - David V Milford
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
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9
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Abreu ALCS, Soeiro EMD, Bedram LG, Andrade MCD, Lopes R. Brazilian guidelines for chronic kidney disease-mineral and bone metabolism disorders in children and adolescents. J Bras Nefrol 2021; 43:680-692. [PMID: 34910806 PMCID: PMC8823923 DOI: 10.1590/2175-8239-jbn-2021-s114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/09/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Emília Maria Dantas Soeiro
- Universidade Federal de Pernambuco, Recife, PE, Brazil.,Instituto de Medicina Integral Professor Fernando Figueira - IMIP, Recife, PE, Brazil
| | | | | | - Renata Lopes
- Universidade Federal de São Paulo, São Paulo, SP, Brazil
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10
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Fischer DC, Smith C, De Zan F, Bacchetta J, Bakkaloglu SA, Agbas A, Anarat A, Aoun B, Askiti V, Azukaitis K, Bayazit A, Bulut IK, Canpolat N, Borzych-Dużałka D, Duzova A, Habbig S, Krid S, Licht C, Litwin M, Obrycki L, Paglialonga F, Rahn A, Ranchin B, Samaille C, Shenoy M, Sinha MD, Spasojevic B, Stefanidis CJ, Vidal E, Yilmaz A, Fischbach M, Schaefer F, Schmitt CP, Shroff R. Hemodiafiltration Is Associated With Reduced Inflammation and Increased Bone Formation Compared With Conventional Hemodialysis in Children: The HDF, Hearts and Heights (3H) Study. Kidney Int Rep 2021; 6:2358-2370. [PMID: 34514197 PMCID: PMC8418977 DOI: 10.1016/j.ekir.2021.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 06/21/2021] [Indexed: 01/02/2023] Open
Abstract
Background Patients on dialysis have a high burden of bone-related comorbidities, including fractures. We report a post hoc analysis of the prospective cohort study HDF, Hearts and Heights (3H) to determine the prevalence and risk factors for chronic kidney disease-related bone disease in children on hemodiafiltration (HDF) and conventional hemodialysis (HD). Methods The baseline cross-sectional analysis included 144 children, of which 103 (61 HD, 42 HDF) completed 12-month follow-up. Circulating biomarkers of bone formation and resorption, inflammatory markers, fibroblast growth factor-23, and klotho were measured. Results Inflammatory markers interleukin-6, tumor necrosis factor-α, and high-sensitivity C-reactive protein were lower in HDF than in HD cohorts at baseline and at 12 months (P < .001). Concentrations of bone formation (bone-specific alkaline phosphatase) and resorption (tartrate-resistant acid phosphatase 5b) markers were comparable between cohorts at baseline, but after 12-months the bone-specific alkaline phosphatase/tartrate-resistant acid phosphatase 5b ratio increased in HDF (P = .004) and was unchanged in HD (P = .44). On adjusted analysis, the bone-specific alkaline phosphatase/tartrate-resistant acid phosphatase 5b ratio was 2.66-fold lower (95% confidence interval, −3.91 to −1.41; P < .0001) in HD compared with HDF. Fibroblast growth factor-23 was comparable between groups at baseline (P = .52) but increased in HD (P < .0001) and remained unchanged in HDF (P = .34) at 12 months. Klotho levels were similar between groups and unchanged during follow-up. The fibroblast growth factor-23/klotho ratio was 3.86-fold higher (95% confidence interval, 2.15–6.93; P < .0001) after 12 months of HD compared with HDF. Conclusion Children on HDF have an attenuated inflammatory profile, increased bone formation, and lower fibroblast growth factor-23/klotho ratios compared with those on HD. Long-term studies are required to determine the effects of an improved bone biomarker profile on fracture risk and cardiovascular health.
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Affiliation(s)
| | - Colette Smith
- Pediatric Nephrology Unit, Institute of Global Health, University College London, London, UK
| | - Francesca De Zan
- Pediatric Nephrology Unit, University College London Great Ormond Street Hospital for Children and Institute of Child Health, London, UK
| | - Justine Bacchetta
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Bron, France
| | | | - Ayse Agbas
- Pediatric Nephrology Unit, Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Ali Anarat
- Pediatric Nephrology Unit, Cukurova University, Adana, Turkey
| | - Bilal Aoun
- Pediatric Nephrology Unit, Armand Trousseau Hospital, Paris, France
| | - Varvara Askiti
- Pediatric Nephrology Unit, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, Greece
| | - Karolis Azukaitis
- Pediatric Nephrology Unit, Clinic of Pediatrics, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Aysun Bayazit
- Pediatric Nephrology Unit, Cukurova University, Adana, Turkey
| | - Ipek Kaplan Bulut
- Pediatric Nephrology Unit, Ege University Faculty of Medicine, Izmir, Turkey
| | - Nur Canpolat
- Pediatric Nephrology Unit, Cerrahpasa School of Medicine, Istanbul, Turkey
| | | | - Ali Duzova
- Pediatric Nephrology Unit, Hacettepe University, Ankara, Turkey
| | - Sandra Habbig
- Pediatric Nephrology Unit, University Hospital Cologne, Cologne, Germany
| | - Saoussen Krid
- Pediatric Nephrology Unit, Hôpital Necker-Enfants Malades, Paris, France
| | - Christoph Licht
- Pediatric Nephrology Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mieczyslaw Litwin
- Pediatric Nephrology Unit, Children's Memorial Health Institute, Warsaw, Poland
| | - Lukasz Obrycki
- Pediatric Nephrology Unit, Children's Memorial Health Institute, Warsaw, Poland
| | - Fabio Paglialonga
- Pediatric Nephrology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anja Rahn
- Department of Pediatrics, Rostock University Medical Centre, Rostock, Germany
| | - Bruno Ranchin
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Bron, France
| | - Charlotte Samaille
- Service de Néphrologie Pédiatrique, Centre Hospitalier Universitaire Lille, Lille, France
| | - Mohan Shenoy
- Pediatric Nephrology Unit, Royal Manchester Children's Hospital, Manchester, UK
| | - Manish D Sinha
- Pediatric Nephrology Unit, Kings College London Evelina London Children's Hospital, London, UK
| | | | | | - Enrico Vidal
- Division of Pediatrics, Department of Medicine, University of Udine, Udine, Italy
| | - Alev Yilmaz
- Pediatric Nephrology Unit, Istanbul University, Faculty of Medicine, Istanbul, Turkey
| | | | - Franz Schaefer
- Pediatric Nephrology Unit, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Claus Peter Schmitt
- Pediatric Nephrology Unit, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Rukshana Shroff
- Pediatric Nephrology Unit, University College London Great Ormond Street Hospital for Children and Institute of Child Health, London, UK
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11
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Bakkaloglu SA, Bacchetta J, Lalayiannis AD, Leifheit-Nestler M, Stabouli S, Haarhaus M, Reusz G, Groothoff J, Schmitt CP, Evenepoel P, Shroff R, Haffner D. Bone evaluation in paediatric chronic kidney disease: clinical practice points from the European Society for Paediatric Nephrology CKD-MBD and Dialysis working groups and CKD-MBD working group of the ERA-EDTA. Nephrol Dial Transplant 2021; 36:413-425. [PMID: 33245331 DOI: 10.1093/ndt/gfaa210] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Indexed: 11/13/2022] Open
Abstract
Mineral and bone disorder (MBD) is widely prevalent in children with chronic kidney disease (CKD) and is associated with significant morbidity. CKD may cause disturbances in bone remodelling/modelling, which are more pronounced in the growing skeleton, manifesting as short stature, bone pain and deformities, fractures, slipped epiphyses and ectopic calcifications. Although assessment of bone health is a key element in the clinical care of children with CKD, it remains a major challenge for physicians. On the one hand, bone biopsy with histomorphometry is the gold standard for assessing bone health, but it is expensive, invasive and requires expertise in the interpretation of bone histology. On the other hand, currently available non-invasive measures, including dual-energy X-ray absorptiometry and biomarkers of bone formation/resorption, are affected by growth and pubertal status and have limited sensitivity and specificity in predicting changes in bone turnover and mineralization. In the absence of high-quality evidence, there are wide variations in clinical practice in the diagnosis and management of CKD-MBD in childhood. We present clinical practice points (CPPs) on the assessment of bone disease in children with CKD Stages 2-5 and on dialysis based on the best available evidence and consensus of experts from the CKD-MBD and Dialysis working groups of the European Society for Paediatric Nephrology and the CKD-MBD working group of the European Renal Association-European Dialysis and Transplant Association. These CPPs should be carefully considered by treating physicians and adapted to individual patients' needs as appropriate. Further areas for research are suggested.
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Affiliation(s)
- Sevcan A Bakkaloglu
- Department of Paediatric Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Justine Bacchetta
- Department of Paediatric Nephrology, Rheumatology and Dermatology, University Children's Hospital, Lyon, France
| | - Alexander D Lalayiannis
- Renal Unit, UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK
| | - Maren Leifheit-Nestler
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | - Stella Stabouli
- First Department of Paediatrics, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Mathias Haarhaus
- Division of Renal Medicine and Baxter Novum, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Diaverum AB, Stockholm, Sweden
| | - George Reusz
- First Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Jaap Groothoff
- Department of Paediatric Nephrology, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Claus Peter Schmitt
- Division of Paediatric Nephrology, Center for Paediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Pieter Evenepoel
- Department of Microbiology and Immunology, Laboratory of Nephrology, KU Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK
| | - Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
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12
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Lalayiannis AD, Fewtrell M, Biassoni L, Silva S, Goodman N, Shroff R, Crabtree NJ. Studying bone mineral density in young people: The complexity of choosing a pQCT reference database. Bone 2021; 143:115713. [PMID: 33122089 DOI: 10.1016/j.bone.2020.115713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/07/2020] [Accepted: 10/24/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Many chronic illnesses affect bone health, and commonly lead to mineralization abnormalities in young people. As cortical and trabecular bone may be differentially affected in certain diseases, an imaging technique that allows for detailed study of the bone structure is required. Peripheral quantitative computed tomography (pQCT) overcomes the limitations of dual energy X-ray absorptiometry (DXA) and is perhaps more widely available for use in research than bone biopsy. However, in contrast to DXA, where there are large reference datasets, this is not the case for pQCT. METHODS Fifty-five children and young adults aged 7 to 30 years had the non-dominant tibia scanned at the 3% & 4% sites for trabecular bone mineral density and the 38% site for cortical bone mineral density and bone mineral content. Image acquisition and analysis was undertaken according to the protocols of two of the largest reference datasets for tibial pQCT. The Z-scores generated were compared to examine the differences between protocols and the differences from the expected median of zero in a healthy population. RESULTS The trabecular bone mineral density Z-scores generated by the two protocols were similar. The same was true for cortical mineral content Z-scores at the 38% site. Cortical bone mineral density was significantly different between protocols and likely affected by differences in the ethnicity of our cohort compared to the reference datasets. Only one reference dataset extended from childhood to young adulthood. Only trabecular bone mineral density, periosteal and endosteal circumference Z-scores from one methodology were not significantly biased when tested for deviation of the median from zero. CONCLUSIONS pQCT is a useful tool for studying trabecular and cortical compartments separately but, there are variations in pQCT scanning protocols, analysis methodology, and a paucity of reference data. Reference datasets may not be generalizable to local study populations, even when analysed using identical analysis protocols.
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Affiliation(s)
- A D Lalayiannis
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK.
| | - M Fewtrell
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK
| | - L Biassoni
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK
| | - S Silva
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK
| | - N Goodman
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK
| | - R Shroff
- UCL Great Ormond Street Hospital Institute of Child Health, London, UK
| | - N J Crabtree
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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