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Mattinzoli D, Molinari P, Romero-González G, Bover J, Cicero E, Pesce F, Abinti M, Conti C, Castellano G, Alfieri C. Is there a role in acute kidney injury for FGF23 and Klotho? Clin Kidney J 2023; 16:1555-1562. [PMID: 37779849 PMCID: PMC10539225 DOI: 10.1093/ckj/sfad093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Indexed: 10/03/2023] Open
Abstract
Cardio-renal syndrome is a clinical condition that has recently been well defined. In acute kidney disease, this interaction might trigger chronic processes determining the onset of cardiovascular events and the progression of chronic kidney disease. Moreover, the high mortality rate of acute kidney injury (AKI) is also linked to the fact that this condition is often complicated by dysfunctions of other organs such as lungs or heart, or is associated with septic episodes. In this context the role and the potential link between bone, heart and kidney is becoming an important topic of research. The aim of this review is to describe the cardiac alterations in the presence of AKI (cardiorenal syndrome type 3) and explore how bone can interact with heart and kidney in determining and influencing the trend of AKI in the short and long term. The main anomalies of mineral metabolism in patients with AKI will be reported, with specific reference to the alterations of fibroblast growth factor 23 and Klotho as a link between the bone-kidney-heart axis.
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Affiliation(s)
- Deborah Mattinzoli
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico, Milan, Italy
| | - Paolo Molinari
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico, Milan, Italy
- Post-Graduate School of Specialization in Nephrology, University of Milan, Milan, Italy
| | - Gregorio Romero-González
- Department of Nephrology, Germans Trias i Pujol University Hospital, Research Group on Renal Diseases (REMAR), Germans Trias i Pujol Research Institute, Badalona, Spain
| | - Jordi Bover
- Department of Nephrology, Germans Trias i Pujol University Hospital, Research Group on Renal Diseases (REMAR), Germans Trias i Pujol Research Institute, Badalona, Spain
| | - Elisa Cicero
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico, Milan, Italy
- Post-Graduate School of Specialization in Nephrology, University of Milan, Milan, Italy
| | - Francesco Pesce
- Nephrology, Dialysis and Transplantation Unit Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) University of Bari “Aldo Moro”
| | - Matteo Abinti
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico, Milan, Italy
- Post-Graduate School of Specialization in Nephrology, University of Milan, Milan, Italy
| | - Costanza Conti
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Policlinico, Milan, Italy
- Post-Graduate School of Specialization in Nephrology, 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
| | - Carlo 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
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Copur S, Demiray A, Basile C, Kanbay M. Endocrinological disorders in acute kidney injury: an often overlooked field of clinical research. J Nephrol 2023; 36:885-893. [PMID: 36652168 DOI: 10.1007/s40620-022-01554-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/05/2022] [Indexed: 01/19/2023]
Abstract
Acute kidney injury (AKI) is a common comorbidity, affecting approximately one in five hospitalized adults. The kidney is the site for the production, metabolism or excretion of most hormones, including the production of erythropoietin (EPO), the active form of vitamin D, renin, thrombopoietin, and the excretion of insulin, catecholamines, gastrin and many other hormones. Therefore, it is reasonable to say that AKI can have a considerable impact on the endocrine system. Although the effects of AKI on various parameters, including cardiovascular parameters, serum electrolytes and acid-base disorders, neuro-humoral mechanisms and neurological outcomes have been extensively studied, the endocrinological consequences of AKI are understudied. Thyroid dysfunction, mainly euthyroid sick syndrome, hypo/hyperglycemia, bone mineral disorders, changes in EPO and atrial natriuretic peptide (ANP) levels are commonly found in AKI. EPO, thyroxine and ANP administration have been evaluated as potential tools to prevent or treat AKI with varying success, while the effects of AKI on some key hormones, including cortisol and insulin, have never been studied. Aim of this narrative review is to illustrate what is known and what is not known about the endocrinological outcomes of AKI. Few clinical trials are ongoing: however, there is a clear need for large-scale randomized controlled trials investigating the endocrinological consequences of AKI.
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Affiliation(s)
- Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Atalay Demiray
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy.
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
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3
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Zhang L, Qin W. Research progress of fibroblast growth factor 23 in acute kidney injury. Pediatr Nephrol 2022:10.1007/s00467-022-05791-z. [PMID: 36416954 DOI: 10.1007/s00467-022-05791-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/19/2022] [Accepted: 10/11/2022] [Indexed: 11/24/2022]
Abstract
Fibroblast growth factor 23 (FGF23) is primarily produced in bones and mainly regulates calcium and phosphorus metabolism. The level of circulating FGF23 increases rapidly in the early stage of acute kidney injury (AKI). Recent studies have shown that FGF23 may serve as a biomarker for the diagnosis and poor prognosis of AKI. The mechanism of increased FGF23 in AKI may include increased production of FGF23, decreased renal clearance of FGF23, and some new regulatory factors, such as inflammation and glycerol 3-phosphate. However, the biological effects of elevated FGF23 in AKI are still unclear. It is also not known whether reducing the level of circulating FGF23 could alleviate AKI or its poor prognosis. Here, we review the pathophysiological mechanism and possible regulation of FGF23 in AKI and discuss the possibility of using FGF23 as a therapeutic target.
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Affiliation(s)
- Lina Zhang
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China.,Division of Nephrology, Henan Key Laboratory for Kidney Disease and Immunology, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Wei Qin
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China.
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Singh NP, Panwar V, Aggarwal NP, Chhabra SK, Gupta AK, Ganguli A. Regulation of Calcium Homeostasis in Acute Kidney Injury: A Prospective Observational Study. Indian J Crit Care Med 2022; 26:302-306. [PMID: 35519919 PMCID: PMC9015928 DOI: 10.5005/jp-journals-10071-24124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Maintaining homeostasis is an integral part of all physiological processes both in health and disease including critically ill patients and may impact clinical outcomes. The present study was designed to assess prevalence of serum calcium, phosphate, vitamin-D3, FGF-23, and PTH levels abnormalities in AKI. Patients and methods Single-center, prospective, observational study in a tertiary care hospital. Patients meeting KDIGO criteria for AKI were included. Paired blood samples were drawn from eligible patients—first sample within 24 hours of AKI diagnosis and second after 5 days or at time of hospital discharge, whichever was earlier for measuring serum calcium (albumin corrected), phosphate, PTH, 25(OH)Vit-D, and FGF-23 levels. Clinical outcomes analyzed included survival status, utilization of RRT, and hospital stay. Results Of the 50 patients with AKI, about three-fourths were males. Mean age of the participants was 57.32 ± 11.47 years. Around half of patients had hypocalcemia and four-fifths had low serum phosphate. Nearly 82% had low 25(OH)Vit-D and 52% cases had high PTH level. Patients who underwent RRT had numerically higher but not significant serum calcium and PTH levels. FGF-23 levels (pg/mL) were significantly higher in patients on RRT (81.70 ± 17.30 vs non-RRT, 72.43 ± 20.27, p = 0.049), nonsurvivors (87.96 ± 18.82 vs survivors 57.11 ± 15.19, p = 0.045), and those hospitalized for time of stay above median (109.67 ± 26.97 vs below median 70.27 ± 20.43, p = 0.046). Among all the bone and mineral parameters analyzed high FGF23 levels were consistently linked with poor clinical outcomes in AKI. Conclusion The present study found high prevalence of calcium and phosphate disorders in AKI with dysregulated phosphate homeostasis as evidenced from elevated FGF-23 levels linked with morbidity and mortality in AKI. How to cite this article Singh NP, Panwar V, Aggarwal NP, Chhabra SK, Gupta AK, Ganguli A. Regulation of Calcium Homeostasis in Acute Kidney Injury: A Prospective Observational Study. Indian J Crit Care Med 2022;26(3):302–306.
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Affiliation(s)
- Narinder Pal Singh
- Faculty of Medicine and Health Sciences, SGT Medical College Hospital and Research Institute, Gurugram, Haryana, India
- Narinder Pal Singh, Faculty of Medicine and Health Sciences, SGT Medical College Hospital and Research Institute, Gurugram, Haryana, India, Phone: +91 9868446621, e-mail:
| | - Vikrant Panwar
- Department of Gastroenterology, Artemis Institute of Health Sciences, Gurugram, Haryana, India
| | - Neeru P Aggarwal
- Department of Nephrology, Max Super Speciality Hospital, Ghaziabad, Uttar Pradesh, India
| | - Satish K Chhabra
- Department of Nephrology, Max Super Speciality Hospital, Patparganj, New Delhi, India
| | - Anish K Gupta
- Faculty of Medicine and Health Sciences, SGT Medical College Hospital and Research Institute, Gurugram, Haryana, India
| | - Anirban Ganguli
- Department of Nephrology, Georgetown University, Washington, DC, United States of America
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FGF23 ameliorates ischemia-reperfusion induced acute kidney injury via modulation of endothelial progenitor cells: targeting SDF-1/CXCR4 signaling. Cell Death Dis 2021; 12:409. [PMID: 33866326 PMCID: PMC8053200 DOI: 10.1038/s41419-021-03693-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 01/09/2023]
Abstract
The levels of fibroblast growth factor 23 (FGF23) rapidly increases after acute kidney injury (AKI). However, the role of FGF23 in AKI is still unclear. Here, we observe that pretreatment with FGF23 protein into ischemia-reperfusion induced AKI mice ameliorates kidney injury by promoting renal tubular regeneration, proliferation, vascular repair, and attenuating tubular damage. In vitro assays demonstrate that SDF-1 induces upregulation of its receptor CXCR4 in endothelial progenitor cells (EPCs) via a non-canonical NF-κB signaling pathway. FGF23 crosstalks with the SDF-1/CXCR4 signaling and abrogates SDF-1-induced EPC senescence and migration, but not angiogenesis, in a Klotho-independent manner. The downregulated pro-angiogenic IL-6, IL-8, and VEGF-A expressions after SDF-1 infusion are rescued after adding FGF23. Diminished therapeutic ability of SDF-1-treated EPCs is counteracted by FGF23 in a SCID mouse in vivo AKI model. Together, these data highlight a revolutionary and important role that FGF23 plays in the nephroprotection of IR-AKI.
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6
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Graidis S, Papavramidis TS, Papaioannou M. Vitamin D and Acute Kidney Injury: A Two-Way Causality Relation and a Predictive, Prognostic, and Therapeutic Role of Vitamin D. Front Nutr 2021; 7:630951. [PMID: 33748167 PMCID: PMC7969500 DOI: 10.3389/fnut.2020.630951] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Acute kidney injury (AKI) constitutes a multi-factorially caused condition, which significantly affects kidney function and can lead to elevated risk of morbidity and mortality. Given the rising scientific evidence regarding vitamin D's (VitD's) multisystemic role, the connection between AKI and VitD is currently being studied, and the complex relation between them has started to be unraveled. Methods: A systematic review had been conducted to identify the pathogenetic relation of VitD and AKI and the potential role of VitD as a biomarker and therapeutic–renoprotective factor. Results: From 792 articles, 74 articles were identified that fulfilled the inclusion criteria. Based on these articles, it has been found that not only can VitD disorders (VitD deficiency or toxicity) cause AKI but, also, AKI can lead to great disruption in the metabolism of VitD. Moreover, it has been found that VitD serves as a novel biomarker for prediction of the risk of developing AKI and for the prognosis of AKI's severity. Finally, animal models showed that VitD can both ameliorate AKI and prevent its onset, suggesting its renoprotective effect. Conclusion: There is a complex two-way pathogenetic relation between VitD disorders and AKI, while, concomitantly, VitD serves as a potential novel predictive–prognostic biomarker and a treatment agent in AKI therapy.
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Affiliation(s)
- Spyridon Graidis
- Laboratory of Biological Chemistry, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodosios S Papavramidis
- 1st Propedeutic Department of Surgery, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Papaioannou
- Laboratory of Biological Chemistry, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Hu PP, Bao JF, Li A. Roles for fibroblast growth factor-23 and α-Klotho in acute kidney injury. Metabolism 2021; 116:154435. [PMID: 33220250 DOI: 10.1016/j.metabol.2020.154435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/08/2020] [Accepted: 11/13/2020] [Indexed: 12/21/2022]
Abstract
Acute kidney injury is a global disease with high morbidity and mortality. Recent studies have revealed that the fibroblast growth factor-23-α-Klotho axis is closely related to chronic kidney disease, and has multiple biological functions beyond bone-mineral metabolism. However, although dysregulation of fibroblast growth factor-23-α-Klotho has been observed in acute kidney injury, the role of fibroblast growth factor-23-α-Klotho in the pathophysiology of acute kidney injury remains largely unknown. In this review, we describe recent findings regarding fibroblast growth factor-23-α-Klotho, which is mainly involved in inflammation, oxidative stress, and hemodynamic disorders. Further, based on these recent results, we put forth novel insights regarding the relationship between the fibroblast growth factor-23-α-Klotho axis and acute kidney injury, which may provide new therapeutic targets for treating acute kidney injury.
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Affiliation(s)
- Pan-Pan Hu
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, China; Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, 510005 Guangzhou, China
| | - Jing-Fu Bao
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, China; Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, 510005 Guangzhou, China
| | - Aiqing Li
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, China; Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, 510005 Guangzhou, China.
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8
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Fayed A, Radwan WA, Amin M, Gamal A. Prediction of mortality and need for renal replacement therapy in patients of acute kidney injury using fibroblast growth factor 23. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2020; 30:1044-1051. [PMID: 31696842 DOI: 10.4103/1319-2442.270259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute kidney injury (AKI) occurs in up to 50% of patients admitted to the intensive care units. Fibroblast growth factor 23 (FGF23), which plays an important role in regulating phosphate, rises early in AKI. Few studies were conducted to correlate the level of FGF23 and adverse outcomes in AKI. The study was conducted on 30 participants with AKI, which was defined according to AKI network criteria, admitted to the Critical Care Department, Kasr El Aini Hospital, Cairo University between July 2016 and May 2017, and serum FGF23 was measured within 24 h of AKI onset to correlate the level of FGF23 with mortality and need for renal replacement therapy (RRT). Enrollment FGF23 levels were significantly higher among patients who died than in the survival group (mean level: 544.2 vs. 59.3 pg/mL, P = 0.004). Furthermore, FGF23 levels were significantly higher in patients who needed RRT than in other participants (mean level: 529.5 vs. 285.11 pg/mL, P = 0.04). There was a statistically significant positive relationship between FGF23 level and sequential organ failure assessment score (P = 0.03). In patients with AKI, higher FGF23 levels are associated with increased risk of mortality and need for RRT.
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Affiliation(s)
- Ahmed Fayed
- Department of Internal Medicine, Nephrology Unit, Kasr Al Aini School of Medicine, Cairo University, Cairo, Egypt
| | - Waheed Ahmed Radwan
- Department of Critical Care, Kasr El Aini School of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Amin
- Department of Critical Care, Kasr El Aini School of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Gamal
- Department of Critical Care, Kasr El Aini School of Medicine, Cairo University, Cairo, Egypt
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9
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Chen LS, Singh RJ. Utilities of traditional and novel biomarkers in the management of acute kidney injury. Crit Rev Clin Lab Sci 2019. [DOI: 10.1080/10408363.2019.1689916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Li-Sheng Chen
- Research and Development Directorate (J-9), Defense Health Agency, Silver Spring, MD, USA
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10
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Bär L, Stournaras C, Lang F, Föller M. Regulation of fibroblast growth factor 23 (FGF23) in health and disease. FEBS Lett 2019; 593:1879-1900. [PMID: 31199502 DOI: 10.1002/1873-3468.13494] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 12/19/2022]
Abstract
Fibroblast growth factor 23 (FGF23) is mainly produced in the bone and, upon secretion, forms a complex with a FGF receptor and coreceptor αKlotho. FGF23 can exert several endocrine functions, such as inhibiting renal phosphate reabsorption and 1,25-dihydroxyvitamin D3 production. Moreover, it has paracrine activities on several cell types, including neutrophils and hepatocytes. Klotho and Fgf23 deficiencies result in pathologies otherwise encountered in age-associated diseases, mainly as a result of hyperphosphataemia-dependent calcification. FGF23 levels are also perturbed in the plasma of patients with several disorders, including kidney or cardiovascular diseases. Here, we review mechanisms controlling FGF23 production and discuss how FGF23 regulation is perturbed in disease.
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Affiliation(s)
- Ludmilla Bär
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Christos Stournaras
- Institute of Biochemistry, University of Crete Medical School, Heraklion, Greece
| | - Florian Lang
- Institute of Physiology, University of Tübingen, Germany
| | - Michael Föller
- Institute of Physiology, University of Hohenheim, Stuttgart, Germany
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11
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Abstract
Acute kidney injury (AKI) is associated with many of the same mineral metabolite abnormalities that are observed in chronic kidney disease. These include increased circulating levels of the osteocyte-derived, vitamin D-regulating hormone, fibroblast growth factor 23 (FGF23), and decreased renal expression of klotho, the co-receptor for FGF23. Recent data have indicated that increased FGF23 and decreased klotho levels in the blood and urine could serve as novel predictive biomarkers of incident AKI, or as novel prognostic biomarkers of adverse outcomes in patients with established AKI. In addition, because FGF23 and klotho exert numerous classic as well as off-target effects on a variety of organ systems, targeting their dysregulation in AKI may represent a unique opportunity for therapeutic intervention. We review the pathophysiology, kinetics, and regulation of FGF23 and klotho in animal and human studies of AKI, and we discuss the challenges and opportunities involved in targeting FGF23 and klotho therapeutically.
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Affiliation(s)
- Marta Christov
- Department of Medicine, New York Medical College, Valhalla, NY.
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, KY; Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
| | - Sanjeev Gupta
- Department of Medicine, New York Medical College, Valhalla, NY
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
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Renal ischemia-reperfusion injury impairs renal calcium, magnesium, and phosphate handling in mice. Pflugers Arch 2019; 471:901-914. [PMID: 30685787 DOI: 10.1007/s00424-019-02255-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/04/2019] [Accepted: 01/10/2019] [Indexed: 01/04/2023]
Abstract
Fibroblast growth factor 23 (FGF23) levels are elevated in patients with acute kidney injury (AKI). The consequences on renal Ca2+, Mg2+, and Pi regulatory mechanisms are unknown. We hypothesized that renal ischemia-reperfusion (I/R) injury alters the expression of important renal Ca2+, Mg2+, and Pi transport proteins. I/R injury was induced in male C57BL/6 mice by clamping both renal arteries for 27 min. Mice were investigated 18 h later. The mRNA and protein levels of renal Ca2+, Mg2+, and Pi transport proteins were measured by RT-qPCR and western blot analysis. I/R injury-induced hyperphosphatemia and hypermagnesemia were paralleled by a decrease in glomerular filtration rate and an increase in the fractional excretion of Ca2+, Mg2+, and Pi. I/R injury affected the fibroblast growth factor 23 (FGF23)-klotho-vitamin D axis by increasing plasma levels of FGF23 and downregulation of renal klotho expression. Plasma levels of PTH and 1,25-dihydroxyvitamin D3 were unchanged. Further, downregulation of key genes for paracellular reabsorption of Ca2+ and Mg2+ (claudin (Cldn)2, Cldn10b, Cldn16, Cldn19) and for active transcellular transport of Ca2+, Mg2+, and Pi (calbindin-D28K, Ncx1, Pmca4, Cnnm2, Trpm7, NaPi-2a, and NaPi-2c) was observed. However, renal expression of Trpv5 and Trpv6 was increased. In vitro studies support a direct effect of proinflammatory cytokines on the mRNA expression of Cldn16, Cldn19, and Trpv6. Our findings indicate that renal I/R injury increases FGF23 blood levels independent of PTH and 1,25-dihydroxyvitamin D3. This increase is associated with hypermagnesemia, hyperphosphatemia, and increased or decreased expression of specific renal Ca2+, Mg2+, and Pi transporters, respectively.
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Abstract
Aims: This study aimed to assess whether neutrophil gelatinase-associated lipocalin (NGAL) and fibroblast growth factor 23 (FGF23) could be reliable biomarkers for early diagnosis of contrast-induced nephropathy (CIN). Methods: 202 patients who underwent percutaneous coronary intervention (PCI) were included in the research. All subjects were divided into CIN group and non-CIN group. Serum NGAL and FGF23 were evaluated before and 0, 1, and 2 days after PCI. Serum levels of these two markers were compared intra-group and among groups. Receiver-operating characteristic (ROC) analysis and logistic regression models were conducted to assess the diagnostic performance of NGAL and FGF23 in detecting CIN. Results: When compared with baseline values, serum levels of both NGAL and FGF23 in all subjects increased after PCI, and the values peaked 1 day after PCI, but the changing was greater in CIN group. There were obvious differences between two groups in serum NGAL after 1, 2 days, and similar differences present in serum FGF23 after 1 day. ROC analysis showed that the area under the curve (AUC) of relative values (percent change from the baseline) in NGAL after 1 day was 0.899 (95% CI: 0.834–0.964, p = .000), the optimum cutoff was 49% (sensitivity = 80%, specificity = 92.4%). And the AUC in FGF23 was 0.814 (95% CI: 0.733–0.894, p = .000), the optimum cutoff was 20% (sensitivity = 73.3%, specificity = 87.6%). Both serum NGAL and serum FGF23 could improve the clinical models in identifying CIN. Conclusions: NGAL and FGF23 may have certain value in early diagnosis of CIN.
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Affiliation(s)
- Huihui Li
- a Department of Nephropathy , Xiangya Hospital Central-South University , Changsha , Hunan 410008 , China
| | - Zaixin Yu
- b Department of Cardiology , Xiangya Hospital Central-South University , Changsha , Hunan 410008 , China
| | - Lu Gan
- a Department of Nephropathy , Xiangya Hospital Central-South University , Changsha , Hunan 410008 , China
| | - Ling Peng
- a Department of Nephropathy , Xiangya Hospital Central-South University , Changsha , Hunan 410008 , China
| | - Qiaoling Zhou
- a Department of Nephropathy , Xiangya Hospital Central-South University , Changsha , Hunan 410008 , China
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14
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Toro L, Barrientos V, León P, Rojas M, Gonzalez M, González-Ibáñez A, Illanes S, Sugikawa K, Abarzúa N, Bascuñán C, Arcos K, Fuentealba C, Tong AM, Elorza AA, Pinto ME, Alzamora R, Romero C, Michea L. Erythropoietin induces bone marrow and plasma fibroblast growth factor 23 during acute kidney injury. Kidney Int 2018; 93:1131-1141. [PMID: 29395333 DOI: 10.1016/j.kint.2017.11.018] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 10/26/2017] [Accepted: 11/09/2017] [Indexed: 12/13/2022]
Abstract
It is accepted that osteoblasts/osteocytes are the major source for circulating fibroblast growth factor 23 (FGF23). However, erythropoietic cells of bone marrow also express FGF23. The modulation of FGF23 expression in bone marrow and potential contribution to circulating FGF23 has not been well studied. Moreover, recent studies show that plasma FGF23 may increase early during acute kidney injury (AKI). Erythropoietin, a kidney-derived hormone that targets erythropoietic cells, increases in AKI. Here we tested whether an acute increase of plasma erythropoietin induces FGF23 expression in erythropoietic cells of bone marrow thereby contributing to the increase of circulating FGF23 in AKI. We found that erythroid progenitor cells of bone marrow express FGF23. Erythropoietin increased FGF23 expression in vivo and in bone marrow cell cultures via the homodimeric erythropoietin receptor. In experimental AKI secondary to hemorrhagic shock or sepsis in rodents, there was a rapid increase of plasma erythropoietin, and an induction of bone marrow FGF23 expression together with a rapid increase of circulating FGF23. Blockade of the erythropoietin receptor fully prevented the induction of bone marrow FGF23 and partially suppressed the increase of circulating FGF23. Finally, there was an early increase of both circulating FGF23 and erythropoietin in a cohort of patients with severe sepsis who developed AKI within 48 hours of admission. Thus, increases in plasma erythropoietin and erythropoietin receptor activation are mechanisms implicated in the increase of plasma FGF23 in AKI.
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Affiliation(s)
- Luis Toro
- Instituto de Ciencias Biomedicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Division of Nephrology, Department of Medicine, Hospital Clinico Universidad de Chile, Santiago, Chile; Centro de Investigacion Clinica Avanzada, Hospital Clinico Universidad de Chile, Santiago, Chile
| | - Víctor Barrientos
- Instituto de Ciencias Biomedicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Pablo León
- Instituto de Ciencias Biomedicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Macarena Rojas
- Instituto de Ciencias Biomedicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Magdalena Gonzalez
- Instituto de Ciencias Biomedicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Alvaro González-Ibáñez
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile; Center for Biomedical Research, Faculty of Biological Sciences and Faculty of Medicine, Universidad Andrés Bello, Santiago, Chile
| | - Sebastián Illanes
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universidad de los Andes, Santiago, Chile
| | | | - Néstor Abarzúa
- Instituto de Ciencias Biomedicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - César Bascuñán
- Instituto de Ciencias Biomedicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Katherine Arcos
- Instituto de Ciencias Biomedicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Carlos Fuentealba
- Instituto de Ciencias Biomedicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Ana María Tong
- Clinical Laboratory, Hospital Clinico Universidad de Chile, Santiago, Chile
| | - Alvaro A Elorza
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile; Center for Biomedical Research, Faculty of Biological Sciences and Faculty of Medicine, Universidad Andrés Bello, Santiago, Chile
| | | | - Rodrigo Alzamora
- Instituto de Ciencias Biomedicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Millennium Nucleus of Ion Channel-Associated Diseases (MiNICAD), Santiago, Chile
| | - Carlos Romero
- Critical Care Unit, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Luis Michea
- Instituto de Ciencias Biomedicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Division of Nephrology, Department of Medicine, Hospital Clinico Universidad de Chile, Santiago, Chile; Millennium Institute on Immunology and Immunotherapy, Santiago, Chile.
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15
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Lim AKH. Transient secondary hyperparathyroidism in acute kidney injury. Intern Med J 2017; 46:857-8. [PMID: 27405896 DOI: 10.1111/imj.13095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 02/04/2016] [Indexed: 12/31/2022]
Affiliation(s)
- A K H Lim
- Department of General Medicine, Monash Health, Melbourne, Victoria, Australia.,Department of Nephrology, Monash Health, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University Department of Medicine, Monash Health, Melbourne, Victoria, Australia
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Leaf DE, Christov M, Jüppner H, Siew E, Ikizler TA, Bian A, Chen G, Sabbisetti VS, Bonventre JV, Cai X, Wolf M, Waikar SS. Fibroblast growth factor 23 levels are elevated and associated with severe acute kidney injury and death following cardiac surgery. Kidney Int 2016; 89:939-48. [PMID: 26924052 DOI: 10.1016/j.kint.2015.12.035] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 11/24/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
Fibroblast growth factor 23 (FGF23) is elevated in chronic kidney disease and associated with increased mortality, but data on FGF23 in humans with acute kidney injury (AKI) are limited. Here we tested whether FGF23 levels rise early in the course of AKI following cardiac surgery and if higher postoperative FGF23 levels are independently associated with severe AKI and adverse outcomes. Plasma C-terminal FGF23 (cFGF23) levels were measured preoperatively, at the end of cardiopulmonary bypass, and on postoperative days 1 and 3 in 250 patients undergoing cardiac surgery. We also measured intact FGF23, parathyroid hormone, phosphate, and vitamin D metabolites in a subgroup of 18 patients with severe AKI and 18 matched non-AKI controls. Beginning at the end of cardiopulmonary bypass, cFGF23 levels were significantly and consistently higher in patients who developed AKI compared with those who did not. The early increase in cFGF23 predated changes in other mineral metabolites. The levels of intact FGF23 also increased in patients who developed severe AKI, but the magnitude was lower than cFGF23. In analyses adjusted for age, preoperative eGFR, and cardiopulmonary bypass time, higher cFGF23 levels at the end of cardiopulmonary bypass were significantly associated with greater risk of severe AKI and the need for renal replacement therapy or death. Thus, cFGF23 levels rise early in AKI following cardiac surgery and are independently associated with adverse postoperative outcomes.
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Affiliation(s)
- David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Marta Christov
- Endocrine Unit and Pediatric Nephrology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Medicine, New York Medical College, Valhalla, NY
| | - Harald Jüppner
- Endocrine Unit and Pediatric Nephrology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Edward Siew
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Guanhua Chen
- Department of Biostatistics, Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Venkata S Sabbisetti
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joseph V Bonventre
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Xuan Cai
- Division of Nephrology, Department of Medicine and Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Myles Wolf
- Division of Nephrology, Department of Medicine and Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sushrut S Waikar
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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17
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Shiao CC, Wu PC, Huang TM, Lai TS, Yang WS, Wu CH, Lai CF, Wu VC, Chu TS, Wu KD. Long-term remote organ consequences following acute kidney injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:438. [PMID: 26707802 PMCID: PMC4699348 DOI: 10.1186/s13054-015-1149-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute kidney injury (AKI) has been a global health epidemic problem with soaring incidence, increased long-term risks for multiple comorbidities and mortality, as well as elevated medical costs. Despite the improvement of patient outcomes following the advancements in preventive and therapeutic strategies, the mortality rates among critically ill patients with AKI remain as high as 40–60 %. The distant organ injury, a direct consequence of deleterious systemic effects, following AKI is an important explanation for this phenomenon. To date, most evidence of remote organ injury in AKI is obtained from animal models. Whereas the observations in humans are from a limited number of participants in a relatively short follow-up period, or just focusing on the cytokine levels rather than clinical solid outcomes. The remote organ injury is caused with four underlying mechanisms: (1) “classical” pattern of acute uremic state; (2) inflammatory nature of the injured kidneys; (3) modulating effect of AKI of the underlying disease process; and (4) healthcare dilemma. While cytokines/chemokines, leukocyte extravasation, oxidative stress, and certain channel dysregulation are the pathways involving in the remote organ damage. In the current review, we summarized the data from experimental studies to clinical outcome studies in the field of organ crosstalk following AKI. Further, the long-term consequences of distant organ-system, including liver, heart, brain, lung, gut, bone, immune system, and malignancy following AKI with temporary dialysis were reviewed and discussed.
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Affiliation(s)
- Chih-Chung Shiao
- Division of Nephrology, Department of Internal Medicine, Saint Mary's Hospital Luodong, 160 Chong-Cheng South Road, Luodong, Yilan, 265, Taiwan.,Saint Mary's Medicine, Nursing and Management College, 160 Chong-Cheng South Road, Luodong, Yilan, 265, Taiwan
| | - Pei-Chen Wu
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital, 92, Sec. 2, Zhongshan N. Road, Taipei, 10449, Taiwan
| | - Tao-Min Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, 579, Sec. 2, Yunlin Road, Douliu City, Yunlin County, 640, Taiwan
| | - Tai-Shuan Lai
- Department of Internal Medicine, National Taiwan University Hospital, Bei-Hu Branch, 87 Neijiang Street, Taipei, 108, Taiwan
| | - Wei-Shun Yang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Hisn-Chu Branch, No.25, Lane 442, Sec. 1, Jingguo Road, Hsin-Chu City, 300, Taiwan
| | - Che-Hsiung Wu
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chun-Fu Lai
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan.
| | - Tzong-Shinn Chu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan
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18
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Neyra JA, Moe OW, Hu MC. Fibroblast growth factor 23 and acute kidney injury. Pediatr Nephrol 2015; 30:1909-18. [PMID: 25480729 PMCID: PMC4458234 DOI: 10.1007/s00467-014-3006-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/03/2014] [Accepted: 11/04/2014] [Indexed: 02/07/2023]
Abstract
Fibroblast growth factor 23 (FGF23), which is produced in bone, participates in the maintenance of phosphate metabolism and can serve as a biomarker for adverse cardiovascular outcomes in patients with chronic kidney disease and end-stage renal disease. Circulating FGF23 rapidly increases after acute kidney injury (AKI), preceding other known markers such as neutrophil gelatinase-associated lipocalin and serum creatinine. The increase in FGF23 in AKI appears to be independent of parathyroid hormone, vitamin D signaling pathways, and dietary phosphate. The potential mechanisms include: (1) increased production of FGF23 in the bone by yet-to-be-identified factors; (2) ectopic production of FGF23 by injured renal tubules; and (3) decreased renal clearance of circulating FGF23. Circulating FGF23 determined by intact FGF23 enzyme-linked immunosorbent assay (ELISA) is a more reliable biomarker of AKI than FGF23 C-terminal ELISA (a mixed readout of C-terminal fragment and intact FGF23). Given that FGF23 can be ectopically expressed in differentiated renal tubules and iron modulates FGF23 metabolism, an effect of iron on FGF23 expression in renal tubules is conceivable but remains to be confirmed. More clinical and experimental studies are required to validate the use of circulating FGF23 as a biomarker for the early identification of AKI and prediction of short- and long-term adverse outcomes post-AKI. More importantly, the biologic effect of increased FGF23 in AKI needs to be defined.
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Affiliation(s)
- Javier A Neyra
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-885, USA
| | - Orson W Moe
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-885, USA
- Department of Physiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-885, USA
| | - Ming Chang Hu
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-885, USA.
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-885, USA.
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19
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Abstract
PURPOSE OF REVIEW To review the emerging literature on changes in fibroblast growth factor 23 (FGF23) levels in the setting of acute kidney injury (AKI). RECENT FINDINGS Studies suggest that FGF23 levels are elevated in patients with AKI and correlate with increased risk of death or need for dialysis in adults, or prolonged ventilation time and higher fluid gain in children. Animal studies have shown that the cause behind this FGF23 increase is multifactorial and includes increased production in bone and decreased clearance, but not vitamin D or parathyroid hormone (PTH) activated pathways. Interestingly, FGF23 levels are found to be mildly elevated even in hospitalized patients without kidney injury, although this observation may be limited to only c-terminal FGF23 fragments. The prognostic implications of an elevated FGF23 value in patients with AKI need to be confirmed in larger cohorts and evaluated for long-term outcomes such as the development of new chronic kidney disease (CKD) or CKD progression, as well as cardiovascular disease, similar to the studies of FGF23 in the prevalent CKD population. SUMMARY FGF23 levels are elevated in patients with AKI and are associated with morbidity and mortality in small human studies. Mechanistic work in animals suggests that the elevation is independent of PTH or vitamin D signaling pathways. Much work remains to understand the physiology behind FGF23 elevation and the long-term effects of FGF23 in AKI.
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Wu V, Wu P, Wu C, Huang T, Chang C, Tsai P, Ko W, Chen L, Wang C, Chu T, Wu K. The impact of acute kidney injury on the long-term risk of stroke. J Am Heart Assoc 2014; 3:e000933. [PMID: 25027018 PMCID: PMC4310379 DOI: 10.1161/jaha.114.000933] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 06/16/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND The incidence of acute kidney injury (AKI) requiring dialysis in hospitalized patients is increasing; however, information on the long-term incidence of stroke in patients surviving to discharge after recovering from AKI after dialysis has not been reported. METHODS AND RESULTS Patients that survived after recovery from dialysis-requiring AKI during index hospitalizations from 1999 to 2008 were identified in nationwide administrative registries. The risk of de novo stroke and death were analyzed with time-varying Cox proportional hazard models. The results were validated by a critical care database. We enrolled 4315 patients in the AKI-recovery group (men, 57.7%; mean age, 62.8±16.8 years) and matched 4315 control subjects as the non-AKI group by propensity scores. After a median follow-up period of 3.36 years, the incident stroke rate was 15.6 per 1000 person-years. The AKI-recovery group had higher risk (hazard ratio: 1.25; P=0.037) and higher severity of stroke events than the non-AKI group, regardless of progression to subsequent chronic kidney disease. The rate of incident stroke was not statistically different in those with diabetes alone (without AKI) and in those with AKI alone (without diabetes) after hospital discharge (P=0.086). Furthermore, the risk of mortality in the AKI-recovery group was higher than in the non-AKI group (hazard ratio: 2.4; P<0.001). CONCLUSIONS The patients who recovered from AKI had a higher incidence of developing incident stroke and mortality than the patients without AKI, and the impact was similar to diabetes. Our results suggest that a public health initiative is needed to enhance postdischarge follow-up of renal function and to control the subsequent incidence of stroke among patients who recover from AKI after dialysis.
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Affiliation(s)
- Vin‐Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (V.C.W., C.H.C., T.S.C., K.D.W.)
| | - Pei‐Chen Wu
- Department of Internal Medicine, Da‐Chien General Hospital, Miaoli City, Taiwan (P.C.W.)
| | - Che‐Hsiung Wu
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan (C.H.W.)
| | - Tao‐Min Huang
- Yun‐Lin Branch, National Taiwan University Hospital, Taipei, Taiwan (T.M.H.)
| | - Chia‐Hsuin Chang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (V.C.W., C.H.C., T.S.C., K.D.W.)
| | - Pi‐Ru Tsai
- Department of Traumatology and Surgery, National Taiwan University Hospital, Taipei, Taiwan (P.R.T., W.J.K.)
| | - Wen‐Je Ko
- Department of Traumatology and Surgery, National Taiwan University Hospital, Taipei, Taiwan (P.R.T., W.J.K.)
| | - Likwang Chen
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan (L.C.)
| | - Cheng‐Yi Wang
- Department of Internal Medicine, and Medical Research Center, Cardinal Tien Hospital, School of Medicine, Fu Jen Catholic University, Xindian Dist New Taipei City, Taiwan (C.Y.W.)
| | - Tzong‐Shinn Chu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (V.C.W., C.H.C., T.S.C., K.D.W.)
| | - Kwan‐Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (V.C.W., C.H.C., T.S.C., K.D.W.)
| | - The National Taiwan University Study Group on Acute Renal Failure (NSARF) Group
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (V.C.W., C.H.C., T.S.C., K.D.W.)
- Yun‐Lin Branch, National Taiwan University Hospital, Taipei, Taiwan (T.M.H.)
- Department of Traumatology and Surgery, National Taiwan University Hospital, Taipei, Taiwan (P.R.T., W.J.K.)
- Department of Internal Medicine, Da‐Chien General Hospital, Miaoli City, Taiwan (P.C.W.)
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan (C.H.W.)
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan (L.C.)
- Department of Internal Medicine, and Medical Research Center, Cardinal Tien Hospital, School of Medicine, Fu Jen Catholic University, Xindian Dist New Taipei City, Taiwan (C.Y.W.)
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21
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Wu VC, Wu CH, Huang TM, Wang CY, Lai CF, Shiao CC, Chang CH, Lin SL, Chen YY, Chen YM, Chu TS, Chiang WC, Wu KD, Tsai PR, Chen L, Ko WJ. Long-term risk of coronary events after AKI. J Am Soc Nephrol 2014; 25:595-605. [PMID: 24503241 DOI: 10.1681/asn.2013060610] [Citation(s) in RCA: 245] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The incidence rate of AKI in hospitalized patients is increasing. However, relatively little attention has been paid to the association of AKI with long-term risk of adverse coronary events. Our study investigated hospitalized patients who recovered from de novo dialysis-requiring AKI between 1999 and 2008 using patient data collected from inpatient claims from Taiwan National Health Insurance. We used Cox regression with time-varying covariates to adjust for subsequent CKD and ESRD after discharge. Results were further validated by analysis of a prospectively constructed database. Among 17,106 acute dialysis patients who were discharged, 4869 patients recovered from dialysis-requiring AKI (AKI recovery group) and were matched with 4869 patients without AKI (non-AKI group). The incidence rates of coronary events were 19.8 and 10.3 per 1000 person-years in the AKI recovery and non-AKI groups, respectively. AKI recovery associated with higher risk of coronary events (hazard ratio [HR], 1.67; 95% confidence interval [95% CI], 1.36 to 2.04) and all-cause mortality (HR, 1.67; 95% CI, 1.57 to 1.79) independent of the effects of subsequent progression to CKD and ESRD. The risk levels of de novo coronary events after hospital discharge were similar in patients with diabetes alone and patients with AKI alone (P=0.23). Our results reveal that AKI with recovery associated with higher long-term risks of coronary events and death in this cohort, suggesting that AKI may identify patients with high risk of future coronary events. Enhanced postdischarge follow-up of renal function of patients who have recovered from temporary dialysis may be warranted.
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Affiliation(s)
- Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine
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Plasma FGF23 levels increase rapidly after acute kidney injury. Kidney Int 2013; 84:776-85. [PMID: 23657144 PMCID: PMC3766419 DOI: 10.1038/ki.2013.150] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 01/22/2013] [Accepted: 02/22/2013] [Indexed: 12/19/2022]
Abstract
Emerging evidence suggests that fibroblast growth factor 23 (FGF23) levels are elevated in patients with acute kidney injury (AKI). In order to determine how early this increase occurs we used a murine folic acid nephropathy model and found that plasma FGF23 levels increased significantly from baseline already after 1 hour of AKI, with an 18-fold increase at 24 hours. Similar elevations of FGF23 levels were found when AKI was induced in mice with osteocyte-specific parathyroid hormone receptor ablation or the global deletion of parathyroid hormone or vitamin D receptor, indicating that the increase in FGF23 was independent of parathyroid hormone and vitamin D signaling. Furthermore, FGF23 levels increased to a similar extent in wild-type mice maintained on normal or phosphate-depleted diets prior to induction of AKI, indicating that the marked FGF23 elevation is at least partially independent of dietary phosphate. Bone production of FGF23 was significantly increased in AKI. The half-life of intravenously administered recombinant FGF23 was only modestly increased. Consistent with the mouse data, plasma FGF23 levels rose 15.9-fold by 24 hours following cardiac surgery in patients who developed AKI. The levels were significantly higher than in those without postoperative AKI. Thus, circulating FGF23 levels rise rapidly during AKI in rodents and humans. In mice this increase is independent of established modulators of FGF23 secretion.
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23
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Leaf DE, Wolf M, Waikar SS, Chase H, Christov M, Cremers S, Stern L. FGF-23 levels in patients with AKI and risk of adverse outcomes. Clin J Am Soc Nephrol 2012; 7:1217-23. [PMID: 22700885 PMCID: PMC3408118 DOI: 10.2215/cjn.00550112] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 04/26/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Fibroblast growth factor 23 plays an important role in regulating phosphate and vitamin D homeostasis. Elevated levels of fibroblast growth factor 23 are independently associated with mortality in patients with CKD and ESRD. Whether fibroblast growth factor 23 levels are elevated and associated with adverse outcomes in patients with AKI has not been studied. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study had 30 participants with AKI, which was defined as an increase in serum creatinine ≥ 0.3 mg/dl or ≥ 50% from baseline, and 30 controls from the general hospital wards and intensive care units. Plasma levels of C-terminal fibroblast growth factor 23 and vitamin D metabolites were measured within 24 hours of AKI onset and 5 days later. The composite endpoint was death or need for renal replacement therapy. RESULTS Enrollment fibroblast growth factor 23 levels were significantly higher among participants with AKI than controls (median [interquartile range]=1471 [224-2534] versus 263 [96-574] RU/ml, P=0.003). Enrollment fibroblast growth factor 23 correlated negatively with 25-hydroxyvitamin D (r=-0.43, P<0.001) and 1,25-dihydroxyvitamin D (r=-0.39, P=0.003) and positively with phosphate (r=0.32, P=0.02) and parathyroid hormone (r=0.37, P=0.005). Among participants with AKI, enrollment fibroblast growth factor 23 (but not other serum parameters) was significantly associated with the composite endpoint, even after adjusting for age and enrollment serum creatinine (11 events; adjusted odds ratio per 1 SD higher ln[fibroblast growth factor 23]=13.73, 95% confidence interval=1.75-107.50). CONCLUSIONS Among patients with AKI, fibroblast growth factor 23 levels are elevated and associated with greater risk of death or need for renal replacement therapy.
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Affiliation(s)
- David E Leaf
- Division of Nephrology, Columbia University, New York, New York, USA.
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24
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Zhang M, Hsu R, Hsu CY, Kordesch K, Nicasio E, Cortez A, McAlpine I, Brady S, Zhuo H, Kangelaris KN, Stein J, Calfee CS, Liu KD. FGF-23 and PTH levels in patients with acute kidney injury: A cross-sectional case series study. Ann Intensive Care 2011; 1:21. [PMID: 21906363 PMCID: PMC3224491 DOI: 10.1186/2110-5820-1-21] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 06/14/2011] [Indexed: 01/22/2023] Open
Abstract
Background Fibroblast growth factor-23 (FGF-23), a novel regulator of mineral metabolism, is markedly elevated in chronic kidney disease and has been associated with poor long-term outcomes. However, whether FGF-23 has an analogous role in acute kidney injury is unknown. The goal of this study was to measure FGF-23 levels in critically ill patients with acute kidney injury to determine whether FGF-23 levels were elevated, as in chronic kidney disease. Methods Plasma FGF-23 and intact parathyroid hormone (PTH) levels were measured in 12 patients with acute kidney injury and 8 control subjects. Results FGF-23 levels were significantly higher in acute kidney injury cases than in critically ill subjects without acute kidney injury, with a median FGF-23 level of 1948 RU/mL (interquartile range (IQR), 437-4369) in cases compared with 252 RU/mL (IQR, 65-533) in controls (p = 0.01). No correlations were observed between FGF-23 and severity of acute kidney injury (defined by the Acute Kidney Injury Network criteria); among patients with acute kidney injury, FGF-23 levels were higher in nonsurvivors than survivors (median levels of 4446 RU/mL (IQR, 3455-5443) versus 544 RU/mL (IQR, 390-1948; p = 0.02). Severe hyperparathyroidism (defined as intact PTH >250 mg/dL) was present in 3 of 12 (25%) of the acute kidney injury subjects versus none of the subjects without acute kidney injury, although this result did not meet statistical significance. Conclusions We provide novel data that demonstrate that FGF-23 levels are elevated in acute kidney injury, suggesting that FGF-23 dysregulation occurs in acute kidney injury as well as chronic kidney disease. Further studies are needed to define the short- and long-term clinical effects of dysregulated mineral metabolism in acute kidney injury patients.
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Affiliation(s)
- Maryann Zhang
- Division of Nephrology, Department of Medicine, University of California, San Francisco, CA, USA.
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25
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Wolf M. Forging forward with 10 burning questions on FGF23 in kidney disease. J Am Soc Nephrol 2010; 21:1427-35. [PMID: 20507943 DOI: 10.1681/asn.2009121293] [Citation(s) in RCA: 227] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The discovery of fibroblast growth factor 23 (FGF23) as the causal factor in the pathogenesis of rare forms of hypophosphatemic rickets is rapidly reshaping our understanding of disordered mineral metabolism in chronic kidney disease (CKD). Excessive production of FGF23 by osteocytes is an appropriate compensation to help maintain normal phosphorus metabolism in these patients. Beginning in early CKD, progressive increases in levels of FGF23 enhance phosphaturia on a per-nephron basis and inhibit calcitriol production, thereby contributing centrally to the predominant phosphorus phenotype of predialysis kidney disease: normal serum phosphate, increased fractional excretion of phosphate, and calcitriol deficiency. A proliferation of studies linking phosphorus and now FGF23 excess to adverse renal and cardiovascular outcomes in patients with CKD is setting the stage for novel clinical trials that could ultimately bring FGF23 testing into the clinic. Ten burning questions must be addressed to galvanize FGF23 research further in CKD.
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Affiliation(s)
- Myles Wolf
- Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB, C-221, Room 819, Miami, FL 33136, USA.
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