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Liu D, Yang F, Zhang S, Guo Z, Peng S. Significance of changes in FGF23 levels in childhood primary nephrotic syndrome and children who progress to end‑stage renal disease. Exp Ther Med 2023; 26:390. [PMID: 37456167 PMCID: PMC10347369 DOI: 10.3892/etm.2023.12089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023] Open
Abstract
Fibroblast growth factor 23 (FGF23) is an important phosphaturic hormone, yet few studies have focused on FGF23 in children with primary nephrotic syndrome (PNS) and children who progressed to end-stage renal disease (ESRD). This cross-sectional study investigated the significance of changes in FGF23 levels in childhood PNS and children who progressed to ESRD. Of the 41 children included in the study, 17 had PNS with proteinuria and normal renal function (PNS group), 4 had ESRD (ESRD group), and 20 were healthy (control group). Following corticosteroid treatment, patients with PNS and proteinuria entered the remission phase. Serum levels of FGF23, phosphate, parathyroid hormone (PTH), 25-hydroxyvitamin D (25-OH-D), and calcium were measured. It was found that FGF23 levels in the PNS and ESRD groups were higher than those in the control group, while serum 25-OH-D levels were lower. Serum PTH levels increased significantly in the ESRD group. In the control group, FGF23 levels were negatively correlated with serum PTH and positively correlated with serum 25-OH-D. FGF23 levels were positively correlated with serum calcium and corrected calcium levels in children with PNS during the remission phase. Increased FGF23 levels in children with PNS, particularly in children who progressed to ESRD. It was also confirmed that serum FGF23 levels begin to rise in children with PNS prior to Stage 1 chronic kidney disease. These findings indicated that increased FGF23 levels may be associated with the progression and severity of nephrosis in children, and that serum FGF23 levels were useful for early detection of abnormal mineral metabolism in children with PNS.
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Affiliation(s)
- Ding Liu
- Department of Pediatrics, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, P.R. China
| | - Fang Yang
- Department of Pediatrics, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, P.R. China
| | - Sui Zhang
- Department of Pediatrics, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, P.R. China
| | - Zhiqiang Guo
- Department of Pediatrics, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, P.R. China
| | - Shuting Peng
- Department of Pediatrics, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, P.R. China
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2
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Pons-Belda OD, Alonso-Álvarez MA, González-Rodríguez JD, Mantecón-Fernández L, Santos-Rodríguez F. Mineral Metabolism in Children: Interrelation between Vitamin D and FGF23. Int J Mol Sci 2023; 24:ijms24076661. [PMID: 37047636 PMCID: PMC10094813 DOI: 10.3390/ijms24076661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 03/29/2023] [Accepted: 04/01/2023] [Indexed: 04/05/2023] Open
Abstract
Fibroblast growth factor 23 (FGF23) was identified at the turn of the century as the long-sought circulating phosphatonin in human pathology. Since then, several clinical and experimental studies have investigated the metabolism of FGF23 and revealed its relevant pathogenic role in various diseases. Most of these studies have been performed in adult individuals. However, the mineral metabolism of the child is, to a large extent, different from that of the adult because, in addition to bone remodeling, the child undergoes a specific process of endochondral ossification responsible for adequate mineralization of long bones’ metaphysis and growth in height. Vitamin D metabolism is known to be deeply involved in these processes. FGF23 might have an influence on bones’ growth as well as on the high and age-dependent serum phosphate concentrations found in infancy and childhood. However, the interaction between FGF23 and vitamin D in children is largely unknown. Thus, this review focuses on the following aspects of FGF23 metabolism in the pediatric age: circulating concentrations’ reference values, as well as those of other major variables involved in mineral homeostasis, and the relationship with vitamin D metabolism in the neonatal period, in vitamin D deficiency, in chronic kidney disease (CKD) and in hypophosphatemic disorders.
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Affiliation(s)
| | | | | | | | - Fernando Santos-Rodríguez
- Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
- Department of Medicine, Faculty of Medicine, University of Oviedo, 33003 Oviedo, Spain
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3
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Kubota M, Hamasaki Y, Hashimoto J, Aoki Y, Kawamura T, Saito A, Yuasa R, Muramatsu M, Komaba H, Toyoda M, Fukagawa M, Shishido S, Sakai K. Fibroblast growth factor 23-Klotho and mineral metabolism in the first year after pediatric kidney transplantation: A single-center prospective study. Pediatr Transplant 2023; 27:e14440. [PMID: 36471536 DOI: 10.1111/petr.14440] [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: 04/27/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of fibroblast growth factor 23 (FGF23) levels in mineral metabolism before and after kidney transplantation in pediatric patients is poorly understood. METHODS We prospectively evaluated 24 patients under 18 years of age (4.5 [3.3-9.8] years) who underwent living kidney transplantation between July 2016 and March 2018, and measured intact FGF23 and serum αKlotho levels, and other parameters of mineral metabolism before and after transplantation (Day 7, 1 and 4 months, and 1 year). Relationships between parameters were examined by linear analysis. RESULTS FGF23 level was 440.8 [63.4-5916.3] pg/ml pre-transplant and decreased significantly to 37.1 [16.0-71.5] pg/ml at Day 7 post-transplant (-91.6%, p < .001). Thereafter, it remained at normal levels until 1 year. αKlotho level was 785 [568-1292] pg/ml pre-transplant and remained low at Day 7 and 1 month post-transplant, with an increasing trend at 4 months. Post-transplant phosphorus levels were significantly decreased compared with pre-transplant, with a lowest level of 1.7 [1.3-2.9] mg/dl, -5.7 [-6.8, -3.8] SD at Day 4, followed by gradual recovery. Phosphorus levels and the ratio of tubular maximum phosphate reabsorption were significantly and negatively associated with pre-transplant FGF23 until 4 months of post-transplant. Pre-transplant αKlotho was negatively associated with pre-transplant FGF23 but not FGF23 or other parameters after transplantation. CONCLUSION FGF23 in pediatric kidney transplant patients decreased rapidly after transplantation and associated with post-transplant hypophosphatemia and increased phosphorus excretion. Post-transplant αKlotho was low early post-transplant but tended to increase subsequently. Post-transplant αKlotho was unaffected by pre-transplant FGF23 or other factors, suggesting pre-transplant chronic kidney disease status has no effect.
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Affiliation(s)
- Mai Kubota
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Junya Hashimoto
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Yujiro Aoki
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Takeshi Kawamura
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Akinobu Saito
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Rena Yuasa
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Masaki Muramatsu
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Masao Toyoda
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Seichiro Shishido
- Department of Pediatric Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Ken Sakai
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
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Abreu ALCS, Soeiro EMD, Bedram LG, de Andrade MC, 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] [MESH Headings] [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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5
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Vanderstraeten K, De Pauw R, Knops N, Bouts A, Cransberg K, El Amouri A, Raes A, Prytuła A. Body mass index is associated with hyperparathyroidism in pediatric kidney transplant recipients. Pediatr Nephrol 2021; 36:977-986. [PMID: 33034742 DOI: 10.1007/s00467-020-04796-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/01/2020] [Accepted: 09/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hyperparathyroidism persists in up to 50% of pediatric kidney transplant recipients. The aims of this study were to describe the evolution of parathyroid hormone (PTH) in the first year after transplantation and to identify factors associated with hyperparathyroidism. METHODS This retrospective study included children who underwent kidney transplantation at the University Hospitals of Ghent, Leuven, Rotterdam, or Amsterdam. Data from 149 patients were collected before and up to 12 months after transplantation. Severe hyperparathyroidism was defined as PTH 2-fold above the reference value. Factors associated with hyperparathyroidism and severe hyperparathyroidism were identified using multivariate logistic regression analysis. RESULTS Before transplantation, 97 out of 137 patients (71%) had hyperparathyroidism. The probability of hyperparathyroidism and severe hyperparathyroidism declined from 0.49 and 0.17 to 0.29 and 0.09 at 3 and 12 months after transplantation, respectively. BMI SDS (β: 0.509; p = 0.011; 95% CI: 1.122-2.468), eGFR (β: - 0.227; p = 0.030; 95% CI: 0.649-0.978), and pre-transplant hyperparathyroidism (β: 1.149; p = 0.039; 95% CI: 1.062-9.369) were associated with hyperparathyroidism 12 months after transplantation. Pre-transplant hyperparathyroidism (β: 2.115; p = 0.044; 95% CI: 1.055-65.084), defined as intact parathormone (iPTH) levels > 65 ng/l (6.9 pmol/l) or 1-84 PTH > 58 ng/l (6.2 pmol/l), was associated with severe hyperparathyroidism at 3 months. Only eGFR (β: - 0.488; p = 0.010; 95% CI: 0.425-0.888) was inversely associated with severe hyperparathyroidism at 9 months after transplantation. CONCLUSIONS Allograft function remains the main determinant of severe hyperparathyroidism after transplantation. Our findings emphasize the importance of BMI and pre-transplant PTH control.
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Affiliation(s)
- Karen Vanderstraeten
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Rani De Pauw
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Noël Knops
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Antonia Bouts
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Karlien Cransberg
- Department of Pediatric Nephrology, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Amina El Amouri
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Ann Raes
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Agnieszka Prytuła
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
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6
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Mosca M, Lion-Lambert M, Bienaimé F, Berthaud R, Dorval G, Garcelon N, Dehoux L, Krid S, Charbit M, Rabant M, Niaudet P, Salomon R, Bacchetta J, Boyer O. Association between 25(OH) vitamin D and graft survival in renal transplanted children. Pediatr Transplant 2020; 24:e13809. [PMID: 32845557 DOI: 10.1111/petr.13809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND In children, vitamin D deficiency is common after renal transplantation. Besides promoting bone and muscle development, vitamin D has immunomodulatory effects, which could protect kidney allografts. The purpose of this study was to assess the association between vitamin D status and the occurrence of renal rejection. METHODS We studied a retrospective cohort of 123 children, who were transplanted at a single institution between September 2008 and April 2019. Patients did not receive vitamin D supplementation systematically. In addition, factors influencing vitamin D status were analyzed using univariate and multivariate analyses. RESULTS Median 25-hydroxy-vitamin D (25-OH-D) concentration was close to reference values at the time of transplantation (30 ng/mL (min-max 5-100)), but rapidly decreased within the first 3 months to 19 ng/mL (min-max 3-91) (P < .001). The overall acute rejection rate was 7%. The clinical rejection rate (5% vs 9%), subclinical rejection (12% vs 36%), and borderline changes (21% vs 28%) were not statistically different during the follow-up between the 3-month 25-OH-D < 20 ng/mL and 3-month 25-OH-D > 20 ng/mL groups. There was a correlation between the 25-OH-D levels and PTH concentration at 3 months (r = -.2491, P = .01), but no correlation between the 3-month 25-OH-D and the season of the year (F = 0.19, P = .90; F = 1.34, P = .27, respectively). Multivariate analyses revealed that age and mGFR at 3 months, were independent predictors of mGFR at 12 months. CONCLUSION Our data show that vitamin D deficiency can develop rapidly after transplantation; vitamin D levels at 3 months are not associated with lower mGFR or a higher rejection rate at 1 year in children as opposed to adult recipients.
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Affiliation(s)
- Mélodie Mosca
- Centre de Référence des Maladies Rénales Rares, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,Centre de Référence des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Mathilde Lion-Lambert
- Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Hôpital Necker-Enfants malades, Paris, France.,Université de Paris, Paris, France
| | - Frank Bienaimé
- Université de Paris, Paris, France.,Service d'Explorations Fonctionnelles, Hôpital Necker-Enfants malades, Paris, France.,Institut Necker-Enfants malades, Paris, France
| | - Romain Berthaud
- Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Hôpital Necker-Enfants malades, Paris, France.,Université de Paris, Paris, France.,Institut Imagine, Paris, France
| | - Guillaume Dorval
- Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Hôpital Necker-Enfants malades, Paris, France.,Université de Paris, Paris, France.,Institut Imagine, Paris, France
| | | | - Laurène Dehoux
- Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Hôpital Necker-Enfants malades, Paris, France
| | - Saoussen Krid
- Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Hôpital Necker-Enfants malades, Paris, France
| | - Marina Charbit
- Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Hôpital Necker-Enfants malades, Paris, France
| | - Marion Rabant
- Laboratoire d'Anatomie et de Cytologie Pathologiques, Hôpital Necker-Enfants malades, APHP, Paris, France
| | - Patrick Niaudet
- Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Hôpital Necker-Enfants malades, Paris, France.,Université de Paris, Paris, France
| | - Rémi Salomon
- Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Hôpital Necker-Enfants malades, Paris, France.,Université de Paris, Paris, France.,Institut Imagine, Paris, France
| | - Justine Bacchetta
- Centre de Référence des Maladies Rénales Rares, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,Centre de Référence des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
| | - Olivia Boyer
- Service de Néphrologie Pédiatrique, Centre de référence MARHEA, Hôpital Necker-Enfants malades, Paris, France.,Université de Paris, Paris, France.,Institut Imagine, Paris, France
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7
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Delucchi Á, Toro L, Alzamora R, Barrientos V, González M, Andaur R, León P, Villanueva F, Galindo M, Las Heras F, Montecino M, Moena D, Lazcano A, Pinto V, Salas P, Reyes ML, Mericq V, Michea L. Glucocorticoids Decrease Longitudinal Bone Growth in Pediatric Kidney Transplant Recipients by Stimulating the FGF23/FGFR3 Signaling Pathway. J Bone Miner Res 2019; 34:1851-1861. [PMID: 31099911 DOI: 10.1002/jbmr.3761] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 05/05/2019] [Accepted: 05/11/2019] [Indexed: 12/11/2022]
Abstract
Renal transplantation (RTx) is an effective therapy to improve clinical outcomes in pediatric patients with terminal chronic kidney disease. However, chronic immunosuppression with glucocorticoids (GCs) reduces bone growth and BMD. The mechanisms causing GC-induced growth impairment have not been fully clarified. Fibroblast growth factor 23 (FGF23) is a peptide hormone that regulates phosphate homeostasis and bone growth. In pathological conditions, FGF23 excess or abnormal FGF receptors (FGFR) activity leads to bone growth impairment. Experimental data indicate that FGF23 expression is induced by chronic GC exposure. Therefore, we hypothesize that GCs impair bone growth by increasing FGF23 expression, which has direct effects on bone growth plate. In a post hoc analysis of a multicentric randomized clinical trial of prepubertal RTx children treated with early GC withdrawal or chronic GC treatment, we observed that GC withdrawal was associated with improvement in longitudinal growth and BMD, and lower plasma FGF23 levels as compared with a chronic GC group. In prepubertal rats, GC-induced bone growth retardation correlated with increased plasma FGF23 and bone FGF23 expression. Additionally, GC treatment decreased FGFR1 expression whereas it increased FGFR3 expression in mouse tibia explants. The GC-induced bone growth impairment in tibiae explants was prevented by blockade of FGF23 receptors using either a pan-FGFR antagonist (PD173074), a C-terminal FGF23 peptide (FGF23180-205) which blocks the binding of FGF23 to the FGFR-Klotho complex or a specific FGFR3 antagonist (P3). Finally, local administration of PD173074 into the tibia growth plate ameliorated cartilage growth impairment in GC-treated rats. These results show that GC treatment partially reduces longitudinal bone growth via upregulation of FGF23 and FGFR3 expression, thus suggesting that the FGF23/Klotho/FGFR3 axis at the growth plate could be a potential therapeutic target for the management of GC-induced growth impairment in children.
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Affiliation(s)
- Ángela Delucchi
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,Division of Nephrology, Clínica Alemana de Santiago, Santiago, Chile
| | - Luis Toro
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada, Hospital Clínico Universidad de Chile, Santiago, Chile.,Clinica Las Condes, Santiago, Chile
| | - Rodrigo Alzamora
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Nucleus of Ion Channel-Associated Diseases (MiNICAD), Santiago, Chile
| | - Victor Barrientos
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Magdalena González
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Rodrigo Andaur
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Pablo León
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Francisco Villanueva
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Mario Galindo
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Institute on Immunology and Immunotherapy (MIII), Santiago, Chile
| | - Facundo Las Heras
- Clinica Las Condes, Santiago, Chile.,Department of Anatomic Pathology, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Martín Montecino
- Institute of Biomedical Sciences, Faculty of Medicine and Faculty of Life Sciences, Universidad Andrés Bello, Santiago, Chile.,FONDAP Center for Genome Regulation, Universidad Andres Bello, Santiago, Chile
| | - Daniel Moena
- Institute of Biomedical Sciences, Faculty of Medicine and Faculty of Life Sciences, Universidad Andrés Bello, Santiago, Chile.,FONDAP Center for Genome Regulation, Universidad Andres Bello, Santiago, Chile
| | - Andrea Lazcano
- Division of Nephrology, Clínica Alemana de Santiago, Santiago, Chile.,Division of Nephrology, Hospital de Niños Roberto del Río, Santiago, Chile
| | - Viola Pinto
- Clinica Las Condes, Santiago, Chile.,Pediatric Nephrology Unit, Hospital Doctor Exequiel González Cortés, Santiago, Chile
| | - Paulina Salas
- Pediatric Nephrology Unit, Hospital Doctor Exequiel González Cortés, Santiago, Chile
| | - María Loreto Reyes
- Pediatric Endocrinology Unit, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Verónica Mericq
- Clinica Las Condes, Santiago, Chile.,Institute of Maternal and Child Research, Universidad de Chile, Santiago, Chile
| | - Luis Michea
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile.,Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Institute on Immunology and Immunotherapy (MIII), Santiago, Chile
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8
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Short stature in advanced pediatric CKD is associated with faster time to reduced kidney function after transplant. Pediatr Nephrol 2019; 34:897-905. [PMID: 30627858 PMCID: PMC6424594 DOI: 10.1007/s00467-018-4165-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 10/11/2018] [Accepted: 11/30/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Among children who receive a kidney transplant, short stature is associated with a more complicated post-transplant course and increased mortality. Short stature prior to transplant may reflect the accumulated risk of multiple factors during chronic kidney disease (CKD); however, its relationship with post-transplant kidney function has not been well characterized. METHODS In the Chronic Kidney Disease in Children (CKiD) cohort restricted to children who received a kidney transplant, short stature (i.e., growth failure) was defined as age-sex-specific height < 3rd percentile. The outcome was time to estimated glomerular filtration rate (eGFR) < 45 ml/min/1.73 m2 after transplant. Parametric survival models, including adjustment for disease severity, socioeconomic status (SES), and parental height by inverse probability weighting, described the relative times to eGFR< 45 ml/min/1.73 m2. RESULTS Of 138 children (median CKD duration at transplant: 13 years), 20% (28) had short stature before the transplant. The median time to eGFR < 45 ml/min/1.73 m2 after kidney transplantation was 6.6 years and those with short stature had a significantly faster time to the poor outcome (log-rank p value 0.004). Children with short stature tended to have lower SES, nephrotic proteinuria, higher blood pressure, and lower mid-parental height before transplant. After adjusting for these variables, children with growth failure had 40% shorter time to eGFR < 45 ml/min/1.73 m2 than those with normal stature (relative time 0.60, 95%CI 0.32, 1.03). CONCLUSIONS Short stature was associated with a faster time to low kidney function after transplant. SES, disease severity, and parental height partially explained the association. Clinicians should be aware of the implications of growth failure on the outcome of this unique population, while continued attempts are made to define modifiable factors that contribute to this association.
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9
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Abstract
PURPOSE OF REVIEW Despite metabolic improvements following kidney transplantation, transplant recipients still often suffer from complex mineral and bone disease after transplantation. RECENT FINDINGS The pathophysiology of post-transplant disease is unique, secondary to underlying pre-transplant mineral and bone disease, immunosuppression, and changing kidney function. Changes in modern immunosuppression regimens continue to alter the clinical picture. Modern management includes reducing cumulative steroid exposure and correcting the biochemical abnormalities in mineral metabolism. While bone mineral density screening appears to help predict fracture risk and anti-osteoporotic therapy appears to have a positive effect on bone mineral density, more data regarding specific treatment is necessary. Patients with mineral and bone disease after kidney transplantation require special care in order to properly manage and mitigate their mineral and bone disease. Recent changes in clinical management of transplant patients may also be changing the implications on patients' mineral and bone disease.
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Affiliation(s)
- Ariella M Altman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University HealthSystem, University of Chicago Medical School, 2650 Ridge Avenue, Evanston, IL, 60201, USA.
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10
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van Londen M, Aarts BM, Sanders JSF, Hillebrands JL, Bakker SJL, Navis G, de Borst MH. Tubular maximum phosphate reabsorption capacity in living kidney donors is independently associated with one-year recipient GFR. Am J Physiol Renal Physiol 2018; 314:F196-F202. [PMID: 28978532 DOI: 10.1152/ajprenal.00287.2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The donor glomerular filtration rate (GFR) measured before kidney donation is a strong determinant of recipient graft outcome. No tubular function markers have been identified that can similarly be used in donors to predict recipient outcomes. In the present study we investigated whether the pre-donation tubular maximum reabsorption capacity of phosphate (TmP-GFR), which may be considered a functional tubular marker in healthy kidney donors, is associated with recipient GFR at 1 yr after transplantation, a key determinant of long-term outcome. We calculated the pre-donation TmP-GFR from serum and 24-h urine phosphate and creatinine levels in 165 kidney donors, and recipient 125I-iothalamate GFR and eGFR (CKD-EPI) at 12 mo after transplantation. Kidney donors were 51 ± 10 yr old, 47% were men, and mean GFR was 118 ± 26 ml/min. The donor TmP-GFR was associated with recipient GFR 12 mo after transplantation (GFR 6.0 ml/min lower per 1 mg/dl decrement of TmP-GFR), which persisted after multivariable adjustment for donor age, sex, pre-donation GFR, and blood pressure and other potential confounders. Results were highly similar when eGFR at 12 mo was taken as the outcome. Tubular damage markers kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin were low and not associated with recipient GFR. A lower donor TmP-GFR before donation, which may be considered to represent a functional measure of tubular phosphate reabsorption capacity, is independently associated with a lower recipient GFR 1 yr after transplantation. These data are the first to link donor tubular phosphate reabsorption with recipient GFR post-transplantation.
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Affiliation(s)
| | | | | | - Jan-Luuk Hillebrands
- Department of Medical Biology and Pathology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | | | - Gerjan Navis
- Department of Internal Medicine, Division of Nephrology
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11
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Tranæus Lindblad Y, Olauson H, Vavilis G, Hammar U, Herthelius M, Axelsson J, Bárány P. The FGF23-Klotho axis and cardiac tissue Doppler imaging in pediatric chronic kidney disease-a prospective cohort study. Pediatr Nephrol 2018; 33:147-157. [PMID: 28795324 PMCID: PMC5700222 DOI: 10.1007/s00467-017-3766-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/13/2017] [Accepted: 07/14/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Chronic kidney disease-associated mineral bone disorder (CKD-MBD) is common in pediatric kidney disease patients and a risk factor for future cardiovascular disease (CVD). Fibroblast growth factor-23 (FGF23) and Klotho are novel key players in CKD-MBD, and has been suggested to be involved in the development of CVD. METHODS This prospective cohort study included 74 pediatric patients; 31 with CKD (age range 0.8-18.8 years, glomerular filtration rate (GFR) range 9-68 mL/min/1.73 m2) and 43 transplanted patients (CKD-T; age range 3.3-17.7 years, GFR range 10-99 mL/min/1.73 m2) examined annually for 3 years. We assessed longitudinal patterns and predictors of FGF23 and soluble Klotho, as well as associations to cardiac remodeling and function using echocardiographic pulse wave Doppler (PWD) and color-coded tissue Doppler imaging (cc-TDI). RESULTS The prevalence of high FGF23 levels (≥95th percentile) was 60% in CKD and 42% in CKD-T patients, despite a low prevalence of hyperphosphatemia and normal Klotho levels. Low GFR at baseline was a predictor for high mean log FGF23 during follow-up in CKD and CKD-T patients (β = -0.2, p < 0.001). A high log FGF23 z-score longitudinally was borderline significantly associated with elevated left ventricular mass index (LVMI) in CKD patients (β = 1.8, p = 0.06). In addition, high log FGF23 (β = -0.43, p = 0.01) and low log Klotho (β = 0.44, p = 0.006) over time were associated with a worse left ventricular diastolic function (cc-TDI e'/a') in CKD-T patients. CONCLUSIONS In pediatric CKD and CKD-T patients, the FGF23 level increase and Klotho level decrease with progressing renal failure, despite well-controlled phosphate levels. Following adjustments, both high FGF23 and low Klotho levels were strongly associated with a worse left ventricular diastolic function longitudinally. The potential role of FGF23 and Klotho in cardiac morbidity in pediatric CKD requires further investigation.
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Affiliation(s)
- Ylva Tranæus Lindblad
- Division of Pediatrics, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden. .,Astrid Lindgren Children's Hospital, Huddinge BUMM, Paradistorget 4, 5tr, S-141 47, Huddinge, Sweden. .,Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden.
| | - Hannes Olauson
- 0000 0004 1937 0626grid.4714.6Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Georgios Vavilis
- 0000 0000 9241 5705grid.24381.3cDivision of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf Hammar
- 0000 0004 1937 0626grid.4714.6Institute of Environmental Medicine and Unit of Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Maria Herthelius
- 0000 0004 1937 0626grid.4714.6Division of Pediatrics, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden ,0000 0000 9241 5705grid.24381.3cDepartment of Pediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Axelsson
- 0000 0000 9241 5705grid.24381.3cDepartment of Immunology, Karolinska University Hospital, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Peter Bárány
- 0000 0004 1937 0626grid.4714.6Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden ,0000 0000 9241 5705grid.24381.3cDepartment of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
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12
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Coskun Y, Paydas S, Balal M, Soyupak S, Kara E. Bone Disease and Serum Fibroblast Growth Factor-23 Levels in Renal Transplant Recipients. Transplant Proc 2017; 48:2040-5. [PMID: 27569941 DOI: 10.1016/j.transproceed.2016.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 04/19/2016] [Accepted: 05/04/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Posttransplantation bone disease develops commonly and results in important complications. In this study, we aimed to investigate the relationship between bone diseases and serum fibroblast growth factor-23 (FGF-23) in renal transplant recipients. METHODS This study was conducted in 106 kidney transplant recipients (KTrs; group G1) and 30 patients with chronic kidney disease (group G2). Patients with fever, heart failure, angina pectoris, acute renal failure, malignant disease, or any gastrointestinal disease were excluded. KTrs were treated with triple immunosuppressive drugs including glucocorticoids. Complete blood count (CBC), blood urea nitrogen (BUN), creatinine, glomerular filtration rate (GFR, Modification of Diet in Renal Disease [MDRD] formula), lipid profile, calcium (Ca), phosphorous (P), parathormone (PTH), 25OHD3, serum levels of tacrolimus/cyclosporine, and intact FGF-23 were measured. Bone mineral density (BMD) was measured with dual energy X-ray absorptiometry. RESULTS The mean patient age was 40.1 ± 11.1 years and 39.2 ± 11.3 years in G1 and G2, respectively (P > .05). In G1 and G2, 76 and 15 patients were male, respectively. Compared with the G2 patients, G1 patients had lower body mass index (BMI), serum glucose levels, P, Mg, and Ca·P (P < .05 for all). T scores of the lumbar vertebrae/femur were -1.82 ± 0.99/-1.34 ± 0.89 and -1.13 ± 1.34/-0.51 ± 1.18 in G1 and G2 patients, respectively (P < .05 for all). The incidences of osteopenia/osteoporosis in the lumbar spine and femur were 50.9%/27.4% and 57.5%/10.4% in G1 and 16.6%/23.3%, and 40%/3.3% in G2. There were positive correlations between BMD and BMI, the time elapsed after renal transplantation, and GFR. In our study, a statistically significant relationship was found between lipid parameters and BMD, PTH, and 250HD3 levels, as well as use of corticosteroid and calcineurin inhibitors (P < .05 for all). In G1 and G2, BMD of the lumbar spine in patients with serum creatinine >1.5 mg/dL was lower than that in patients with serum creatinine <1.5 mg/dL. CONCLUSION The association between age and BMD was found only in the femur of KTrs. No relationship was observed between serum FGF-23 levels and BMD values. In both groups, the BMD T score of the lumbar spine was lower compared to the BMD T score of the femur and in patients with serum creatinine >1.5 mg/dL. In long-term follow-up of renal transplantation by as much as 58 months, the incidence of bone disease such as osteoporosis/osteopenia was as high as 67% and was also higher than that of nontransplant patients with similar GFR. In addition to decreased renal function, dyslipidemia, inflammation, and continuing hypophosphatemia were also accompanied by decreased BMD as in cardiovascular disease in KTrs.
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Affiliation(s)
- Y Coskun
- Department of Internal Medicine and Nephrology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - S Paydas
- Department of Internal Medicine and Nephrology, Cukurova University Faculty of Medicine, Adana, Turkey.
| | - M Balal
- Department of Internal Medicine and Nephrology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - S Soyupak
- Department of Radiology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - E Kara
- Department of Public Health, Cukurova University Faculty of Medicine, Adana, Turkey
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13
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Portale AA, Wolf MS, Messinger S, Perwad F, Jüppner H, Warady BA, Furth SL, Salusky IB. Fibroblast Growth Factor 23 and Risk of CKD Progression in Children. Clin J Am Soc Nephrol 2016; 11:1989-1998. [PMID: 27561289 PMCID: PMC5108188 DOI: 10.2215/cjn.02110216] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/25/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Plasma fibroblast growth factor 23 (FGF23) concentrations increase early in the course of CKD in children. High FGF23 levels associate with progression of CKD in adults. Whether FGF23 predicts CKD progression in children is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We tested the hypothesis that high plasma FGF23 is an independent risk factor for CKD progression in 419 children, aged 1-16 years, enrolled in the Chronic Kidney Disease in Children (CKiD) cohort study. We measured plasma FGF23 concentrations at baseline and determined GFR annually using plasma disappearance of iohexol or the CKiD study estimating equation. We analyzed the association of baseline FGF23 with risk of progression to the composite end point, defined as start of dialysis or kidney transplantation or 50% decline from baseline GFR, adjusted for demographics, baseline GFR, proteinuria, other CKD-specific factors, and other mineral metabolites. RESULTS At enrollment, median age was 11 years [interquartile range (IQR), 8-15], GFR was 44 ml/min per 1.73 m2 (IQR, 33-57), and FGF23 was 132 RU/ml (IQR, 88-200). During a median follow-up of 5.5 years (IQR, 3.5-6.6), 32.5% of children reached the progression end point. Higher FGF23 concentrations were independently associated with higher risk of the composite outcome (fully adjusted hazard ratio, 2.52 in the highest versus lowest FGF23 tertile; 95% confidence interval, 1.44 to 4.39, P=0.002; fully adjusted hazard ratio, 1.33 per doubling of FGF23; 95% confidence interval, 1.13 to 1.56, P=0.001). The time to progression was 40% shorter for participants in the highest compared with the lowest FGF23 tertile. In contrast, serum phosphorus, vitamin D metabolites, and parathyroid hormone did not consistently associate with progression in adjusted analyses. CONCLUSIONS High plasma FGF23 is an independent risk factor for CKD progression in children.
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Affiliation(s)
- Anthony A. Portale
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Myles S. Wolf
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Shari Messinger
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Farzana Perwad
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Harald Jüppner
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bradley A. Warady
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Susan L. Furth
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Isidro B. Salusky
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California
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14
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Seifert ME, Ashoor IF, Chiang ML, Chishti AS, Dietzen DJ, Gipson DS, Janjua HS, Selewski DT, Hruska KA. Fibroblast growth factor-23 and chronic allograft injury in pediatric renal transplant recipients: a Midwest Pediatric Nephrology Consortium study. Pediatr Transplant 2016; 20:378-87. [PMID: 26880121 PMCID: PMC4818682 DOI: 10.1111/petr.12682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2016] [Indexed: 11/30/2022]
Abstract
The chronic kidney disease-mineral bone disorder (CKD-MBD) produces fibroblast growth factor-23 (FGF-23) and related circulating pathogenic factors that are strongly associated with vascular injury and declining kidney function in native CKD. Similarly, chronic renal allograft injury (CRAI) is characterized by vascular injury and declining allograft function in transplant CKD. We hypothesized that circulating CKD-MBD factors could serve as non-invasive biomarkers of CRAI. We conducted a cross-sectional, multicenter case-control study. Cases (n = 31) had transplant function >20 mL/min/1.73 m(2) and biopsy-proven CRAI. Controls (n = 31) had transplant function >90 mL/min/1.73 m(2) and/or a biopsy with no detectable abnormality in the previous six months. We measured plasma CKD-MBD factors at a single time point using ELISA. Median (range) FGF23 levels were over twofold higher in CRAI vs. controls [106 (10-475) pg/mL vs. 45 (8-91) pg/mL; p < 0.001]. FGF23 levels were inversely correlated with transplant function (r(2) = -0.617, p < 0.001). Higher FGF23 levels were associated with increased odds of biopsy-proven CRAI after adjusting for transplant function, clinical, and demographic factors [OR (95% CI) 1.43 (1.23, 1.67)]. Relationships between additional CKD-MBD factors and CRAI were attenuated in multivariable models. Higher FGF23 levels were independently associated with biopsy-proven CRAI in children.
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Affiliation(s)
- Michael E. Seifert
- Department of Pediatrics, Division of Pediatric Nephrology, Southern Illinois University, Springfield, IL
,Department of Pediatrics, Washington University, St. Louis, MO
| | - Isa F. Ashoor
- Division of Nephrology, Children’s Hospital of New Orleans, New Orleans, LA
| | - Myra L. Chiang
- Department of Pediatrics, West Virginia University, Charleston, WV
| | - Aftab S. Chishti
- Division of Nephrology, Hypertension & Renal Transplantation, University of Kentucky, Lexington, KY
| | | | - Debbie S. Gipson
- Division of Nephrology, C.S. Mott Children’s Hospital and University of Michigan, Ann Arbor, MI
| | - Halima S. Janjua
- Center for Pediatric Nephrology, Cleveland Clinic Children’s Hospital and Case Western Reserve University, Cleveland, OH
| | - David T. Selewski
- Division of Nephrology, C.S. Mott Children’s Hospital and University of Michigan, Ann Arbor, MI
| | - Keith A. Hruska
- Department of Pediatrics, Washington University, St. Louis, MO
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15
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Abstract
Dysregulated phosphate metabolism is a common consequence of chronic kidney disease, and is characterized by a high circulating level of fibroblast growth factor (FGF)-23, hyperparathyroidism, and hyperphosphataemia. Kidney transplantation can elicit specific alterations to phosphate metabolism that evolve over time, ranging from severe hypophosphataemia (<0.5 mmol/l) to hyperphosphataemia (>1.50 mmol/l) and high FGF-23 levels. The majority of renal transplant recipients develop hypophosphataemia during the first 3 months after transplantation as a consequence of relatively slow adaptation of FGF-23 and parathyroid hormone levels to restored renal function, and the influence of immunosuppressive drugs. By 3-12 months after transplantation, phosphate homeostasis is at least partially restored in the majority of recipients, which is paralleled by a substantially reduced risk of cardiovascular-associated morbidity and mortality compared with the pre-transplantation setting. Many renal transplant recipients, however, exhibit persistent abnormalities in phosphate homeostasis, which is often due to multifactorial causes, and may contribute to adverse outcomes on the cardiovascular system, kidney, and bone. Dietary and pharmacologic interventions might improve phosphate homeostasis in renal transplant recipients, but additional insight into the pathophysiology of transplantation-associated abnormalities in phosphate homeostasis is needed to further optimize disease management and improve prognosis for renal transplant recipients.
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16
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Ebbert K, Chow J, Krempien J, Matsuda-Abedini M, Dionne J. Vitamin D insufficiency and deficiency in pediatric renal transplant recipients. Pediatr Transplant 2015; 19:492-8. [PMID: 26011664 DOI: 10.1111/petr.12527] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 11/28/2022]
Abstract
Vitamin D deficiency is prevalent in the pediatric CKD population. Recognizing that renal transplant recipients have CKD, we assessed the prevalence of vitamin D insufficiency and deficiency in pediatric renal transplant recipients, compared to a healthy pediatric population. We prospectively studied 25(OH)D levels in 29 pediatric renal transplant recipients and 45 control patients over one yr. The overall prevalence of vitamin D insufficiency and deficiency was common in both populations, at 76% (95% CI: 61, 87%) in the pediatric renal transplant recipients and 91% (95% CI: 80, 98%) in the control group. In the paired renal transplant samples, the mean 25(OH)D level was 52.3 ± 17.9 nmol/L in the winter and 65.6 ± 18.8 nmol/L in the summer (95% CI diff.: 3.9, 22.7), in keeping with a significant seasonal difference. The mean dietary intake of vitamin D in the renal transplant recipients, assessed by three-day dietary record, was 5.7 μg/day, with a vitamin D intake below the EAR in the majority. We did not find an association between vitamin D intake and 25(OH)D levels in this study, likely due to the low dietary intake of vitamin D within the transplant population, identifying a potential area for intervention and improvement.
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Affiliation(s)
- Kirsten Ebbert
- Department of Pediatrics, B.C. Children's Hospital, Vancouver, BC, Canada
| | - Josephine Chow
- Division of Nephrology, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Jennifer Krempien
- Division of Nephrology, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Mina Matsuda-Abedini
- Division of Nephrology, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Janis Dionne
- Division of Nephrology, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
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17
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Bonthuis M, Busutti M, van Stralen KJ, Jager KJ, Baiko S, Bakkaloğlu S, Battelino N, Gaydarova M, Gianoglio B, Parvex P, Gomes C, Heaf JG, Podracka L, Kuzmanovska D, Molchanova MS, Pankratenko TE, Papachristou F, Reusz G, Sanahuja MJ, Shroff R, Groothoff JW, Schaefer F, Verrina E. Mineral metabolism in European children living with a renal transplant: a European society for paediatric nephrology/european renal association-European dialysis and transplant association registry study. Clin J Am Soc Nephrol 2015; 10:767-75. [PMID: 25710805 DOI: 10.2215/cjn.06200614] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 01/13/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Data on mineral metabolism in pediatric renal transplant recipients largely arise from small single-center studies. In adult patients, abnormal mineral levels are related to a higher risk of graft failure. This study used data from the European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry to study the prevalence and potential determinants of mineral abnormalities, as well as the predictive value of a disturbed mineral level on graft survival in a large cohort of European pediatric renal transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study included 1237 children (0-17 years) from 10 European countries, who had serum calcium, phosphorus, and parathyroid hormone measurements from 2000 onward. Abnormalities of mineral metabolism were defined according to European guidelines on prevention and treatment of renal osteodystrophy in children on chronic renal failure. RESULTS Abnormal serum phosphorus levels were observed in 25% (14% hypophosphatemia and 11% hyperphosphatemia), altered serum calcium in 30% (19% hypocalcemia, 11% hypercalcemia), and hyperparathyroidism in 41% of the patients. A longer time since transplantation was associated with a lower risk of having mineral levels above target range. Serum phosphorus levels were inversely associated with eGFR, and levels above the recommended targets were associated with a higher risk of graft failure independently of eGFR. CONCLUSIONS Abnormalities in mineral metabolism are common after pediatric renal transplantation in Europe and are associated with graft dysfunction.
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Affiliation(s)
- Marjolein Bonthuis
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Marco Busutti
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Karlijn J van Stralen
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material.
| | - Kitty J Jager
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Sergey Baiko
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Sevcan Bakkaloğlu
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Nina Battelino
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Maria Gaydarova
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Bruno Gianoglio
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Paloma Parvex
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Clara Gomes
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - James G Heaf
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Ludmila Podracka
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Dafina Kuzmanovska
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Maria S Molchanova
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Tatiana E Pankratenko
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Fotios Papachristou
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - György Reusz
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Maria José Sanahuja
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Rukshana Shroff
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Jaap W Groothoff
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Franz Schaefer
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Enrico Verrina
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
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18
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Seifert ME, Mannon RB. Modernization of Chronic Allograft Injury Research: Better Biomarkers, Better Studies, Better Outcomes. CLINICAL TRANSPLANTS 2015; 31:211-225. [PMID: 28514583 PMCID: PMC6437558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Despite dramatic improvements in acute rejection rates and short-term allograft survival, long-term allograft survival remains unchanged in the modern era, largely due to chronic allograft injury, a progressive disease that is common across all solid organ transplantation but has no proven treatment. Studies of novel diagnostic and therapeutic strategies for chronic allograft injury have been relatively sparse, in part due to the time and expense required to conduct traditional long-term clinical studies of a variably progressive disease. In this article, we review the pathophysiology of chronic allograft injury, including recent insights into key mechanisms of the disease. We discuss the barriers to progress in chronic allograft injury research and present alternative approaches to study design that could accelerate improvements in diagnosis, prevention, or treatment of the disease. We integrate these approaches with emerging biomarkers and surrogate endpoints into a model clinical study of chronic renal allograft injury, providing a framework for modern study design in solid organ transplantation.
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Affiliation(s)
- Michael E Seifert
- Department of Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Roslyn B Mannon
- Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL
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19
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McGregor R, Li G, Penny H, Lombardi G, Afzali B, Goldsmith DJ. Vitamin D in renal transplantation - from biological mechanisms to clinical benefits. Am J Transplant 2014; 14:1259-70. [PMID: 24840071 PMCID: PMC4441280 DOI: 10.1111/ajt.12738] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 03/04/2014] [Accepted: 03/05/2014] [Indexed: 01/25/2023]
Abstract
Recent developments in our understanding of vitamin D show that it plays a significant role in immunological health, uniquely occupying both an anti-microbial and immunoregulatory niche. Vitamin D deficiency is widespread amongst renal transplant recipients (RTRs), thus providing one patho-mechanism that may influence the achievement of a successful degree of immunosuppression. It may also influence the development of the infectious, cardiovascular and neoplastic complications seen in RTRs. This review examines the biological roles of vitamin D in the immune system of relevance to renal transplantation (RTx) and evaluates whether vitamin D repletion may be relevant in determining immunologically-related clinical outcomes in RTRs, (including graft survival, cardiovascular disease and cancer). While there are plausible biological and epidemiological reasons to undertake vitamin D repletion in RTRs, there are few randomized-controlled trials in this area. Based on the available literature, we cannot at present categorically make the case for routine measurement and repletion of vitamin D in clinical practice but we do suggest that this is an area in urgent need of further randomized controlled level evidence.
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Affiliation(s)
- R McGregor
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
- National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College LondonLondon, UK
| | - G Li
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
| | - H Penny
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
| | - G Lombardi
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
- National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College LondonLondon, UK
| | - B Afzali
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
- National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College LondonLondon, UK
- Guy's and St Thomas' NHS Foundation TrustLondon, UK
| | - DJ Goldsmith
- Medical Research Council Centre for Transplantation, King's College LondonLondon, UK
- National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College LondonLondon, UK
- Guy's and St Thomas' NHS Foundation TrustLondon, UK
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20
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[Mineral and bone disorders in renal transplantation]. Nephrol Ther 2013; 9:461-70. [PMID: 24176653 DOI: 10.1016/j.nephro.2013.07.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 07/23/2013] [Accepted: 07/26/2013] [Indexed: 11/22/2022]
Abstract
The deregulation of bone and mineral metabolism during chronic kidney disease (CKD) is a daily challenge for physicians, its management aiming at decreasing the risk of both fractures and vascular calcifications. Renal transplantation in the context of CKD, with pre-existing renal osteodystrophy as well as nutritional impairment, chronic inflammation, hypogonadism and corticosteroids exposure, represents a major risk factor for bone impairment in the post-transplant period. The aim of this review is therefore to provide an update on the pathophysiology of mineral and bone disorders after renal transplantation.
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FGF23 and mineral metabolism in the early post-renal transplantation period. Pediatr Nephrol 2013; 28:2207-15. [PMID: 23852336 PMCID: PMC3796035 DOI: 10.1007/s00467-013-2547-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 05/08/2013] [Accepted: 06/07/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The relationship between fibroblast growth factor 23 (FGF23) and vitamin D production and catabolism post-renal transplantation has not been characterized. METHODS Circulating creatinine, calcium, phosphorus, albumin, parathyroid hormone, FGF23, and 1,25(OH)2 vitamin D (calcitriol) values were obtained pre-transplantation, daily post-operatively for 5 days, and at 6 months post-transplantation in 44 patients aged 16.4 ± 0.4 years undergoing renal transplantation at UCLA from 1 August 2005 through to 30 April 2007. 25(OH) Vitamin D and 24,25(OH)2 vitamin D concentrations were obtained at baseline and on post-operative days 5 and 180, and urinary concentrations of creatinine, phosphorus, and FGF23 were measured on post-operative days 1, 3, 5, and 180. RESULTS Circulating phosphate concentrations declined more rapidly and the fractional excretion of phosphorus was higher in the first week post-transplantation in subjects with higher FGF23 values. Fractional excretion of FGF23 was low at all time-points. Circulating 1,25(OH)2 vitamin D levels rose more rapidly and were consistently higher in patients with lower FGF23 values; however, 25(OH) vitamin D and 24,25(OH)2 vitamin D values were unrelated to FGF23 concentrations. CONCLUSIONS Inhibition of renal 1α-hydroxylase, rather than stimulation of 24-hydroxylase, may primarily contribute to the relationship between FGF23 values and calcitriol. The rapid decline in FGF23 levels post-transplantation in our patient cohort was not mediated solely by the filtration of intact FGF23 by the new kidney.
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Sánchez Fructuoso AI, Maestro ML, Pérez-Flores I, Valero R, Rafael S, Veganzones S, Calvo N, De la Orden V, De la Flor JC, Valga F, Vidaurreta M, Fernández-Pérez C, Barrientos A. Serum level of fibroblast growth factor 23 in maintenance renal transplant patients. Nephrol Dial Transplant 2013; 27:4227-35. [PMID: 23144073 DOI: 10.1093/ndt/gfs409] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The discovery of fibroblast growth factor 23 (FGF23) provides a new conceptual framework that improves our understanding of the pathogenesis of post-transplant bone disease. Excess FGF23 is produced in the early post-transplant period; levels return to normal in the months following transplant. However, few manuscripts discuss FGF23 levels in stable long-term renal transplant recipients. METHODS We performed a cross-sectional observational study of 279 maintenance kidney recipients with chronic kidney disease (CKD) Stages 1-4 and stable allograft function who had received their transplant at least 12 months previously. We calculated the estimated GFR (eGFR) using the MDRD4 equation. RESULTS FGF23, parathyroid hormone (PTH) and phosphorus values were higher in more advanced stages, while the serum calcitriol levels and the phosphate reabsorption rate were lower. A significant inverse correlation was found between eGFR and FGF23 (r = -0.487; P < 0.001), PTH (r = -0.444; P < 0.001), serum phosphate levels (r = -0.315; P < 0.001) and fractional excretion of magnesium (r = -0.503; P < 0.001). Multivariable analysis showed that increased time on corticosteroids (P < 0.001), PTH (P < 0.001), serum phosphate (P = 0.003), decreased serum calcitriol (P = 0.049) and estimated glomerular filtration (P = 0.003) rate were associated with high FGF23 levels. In contrast with pre-transplant patients and first year post-transplant patients, higher FGF23 values were not correlated with increased phosphate excretion. An elevated phosphate reabsorption rate was associated with decreased PTH (P < 0.001) and calciuria (P = 0.028) and increased serum calcitriol (P = 0.009), plasma bicarbonate (P = 0.024) and estimated glomerular filtration (P = 0.003). CONCLUSIONS Serum FGF23 concentrations remain increased in long-term kidney graft recipients, even in the early stages of CKD. It remains to be seen whether measures aimed at reducing serum levels of PTH and phosphate and/or corticosteroid doses might help to lower serum FGF23 and whether this will improve kidney recipient outcomes.
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23
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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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Yasin A, Liu D, Chau L, Madrenas J, Filler G. Fibroblast growth factor-23 and calcium phosphate product in young chronic kidney disease patients: a cross-sectional study. BMC Nephrol 2013; 14:39. [PMID: 23413976 PMCID: PMC3598245 DOI: 10.1186/1471-2369-14-39] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 02/13/2013] [Indexed: 01/09/2023] Open
Abstract
Background Fibroblast growth factor-23 (FGF-23), a novel marker of bone disease in chronic kidney disease (CKD) has been shown to correlate with vascular calcifications. We aimed to describe the effect of the calcium phosphate product (Ca*P) on FGF-23 concentrations in children and young adults without confounding cardiovascular disease. Methods Pediatric and young adult patients with CKD stages I-V were recruited in this cross sectional study to measure FGF-23, cystatin C, vitamin D-metabolites and other serum markers of bone metabolism. FGF-23 levels were determined with an enzyme-linked immunosorbent assay. The association between FGF-23 and (Ca*P) was assessed using non-parametric methods. Patients were divided into two age groups, less than 13 years of age and greater than 13 years of age. Results This cross-sectional study measured serum FGF-23, in 81 patients (42 females, 51.9%) at London Health Sciences Centre, aged 2 to 25 years, with various stages of CKD (Cystatin C estimated glomerular filtration rate, eGFR=10.7-213.0 ml/min). For the whole entire group of patients, FGF-23 levels were found to correlate significantly with age (Spearman r= 0.26, p=0.0198), Cystatin C eGFR (Spearman r=−0.40 p=0.0002), CKD stage (Spearman r=0.457, p<0.0001), PTH (Spearman r=0.330, p=0.0039), ionized calcium (Spearman r=−0.330, p=0.0049), CysC (Spearman r= 0.404, p=0.0002) and 1,25-dihydroxyvitamin D (Spearman r=−0.345, p=0.0034) concentrations. No significant correlation was found between FGF-23 levels and calcium phosphate product (Spearman r= 0.164, p=0.142). Upon classification of patients into two age groups, less than 13 years of age and more than 13 years of age, correlational results differed significantly. FGF-23 correlated with CysC eGFR( Spearman r= −0.633, p<0.0001), CKD stage (Spearman r=0.731, p<0.0001), phosphate (Spearman r= 0.557, p<0.0001), calcium phosphate product (Spearman r=0.534, p<0.0001), 125(OH)2 Vit D (Spearman r=−0.631, p<0.0001), PTH (Spearman r= 0.475, p=0.0017) and ionized calcium (Spearman r= −0.503, p=0.0015) only in the older group. The relationship between FGF-23 and Ca*P for the older group could be expressed by the exponential model FGF-23= 38.15 e0.4625Ca*P. Conclusion Abnormal values of FGF-23 in adolescents and young adults with CKD correlate with Ca* P in the absence of vascular calcifications, and may serve as a biomarker for the risk of cardiovascular calcifications.
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Affiliation(s)
- Abeer Yasin
- Department of Pediatrics, Children's Hospital, London Health Science Center, University of Western Ontario, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada
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Bacchetta J, Sea JL, Chun RF, Lisse TS, Wesseling-Perry K, Gales B, Adams JS, Salusky IB, Hewison M. Fibroblast growth factor 23 inhibits extrarenal synthesis of 1,25-dihydroxyvitamin D in human monocytes. J Bone Miner Res 2013; 28:46-55. [PMID: 22886720 PMCID: PMC3511915 DOI: 10.1002/jbmr.1740] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 07/10/2012] [Accepted: 08/02/2012] [Indexed: 01/03/2023]
Abstract
Vitamin D is a potent stimulator of monocyte innate immunity, and this effect is mediated via intracrine conversion of 25-hydroxyvitamin D (25OHD) to 1,25-dihydroxyvitamin D (1,25(OH)(2) D). In the kidney, synthesis of 1,25(OH)(2) D is suppressed by fibroblast growth factor 23 (FGF23), via transcriptional suppression of the vitamin D-activating enzyme 1α-hydroxylase (CYP27B1). We hypothesized that FGF23 also suppresses CYP27B1 in monocytes, with concomitant effects on intracrine responses to 1,25(OH)(2) D. Healthy donor peripheral blood mononuclear cell monocytes (PBMCm) and peritoneal dialysate monocyte (PDm) effluent from kidney disease patients were assessed at baseline to confirm the presence of mRNA for FGF23 receptors (FGFRs), with Klotho and FGFR1 being more strongly expressed than FGFR2/3/4 in both cell types. Immunohistochemistry showed coexpression of Klotho and FGFR1 in PBMCm and PDm, with this effect being enhanced following treatment with FGF23 in PBMCm but not PDm. Treatment with FGF23 activated mitogen-activated protein kinase (MAPK) and protein kinase B (Akt) pathways in PBMCm, demonstrating functional FGFR signaling in these cells. FGF23 treatment of PBMCm and PDm decreased expression of mRNA for CYP27B1. In PBMCm this was associated with downregulation of 25OHD to 1,25(OH)(2) D metabolism, and concomitant suppression of intracrine induced 24-hydroxylase (CYP24A1) and antibacterial cathelicidin (LL37). FGF23 suppression of CYP27B1 was particularly pronounced in PBMCm treated with interleukin-15 to stimulate synthesis of 1,25(OH)(2) D. These data indicate that FGF23 can inhibit extra-renal expression of CYP27B1 and subsequent intracrine responses to 1,25(OH)(2) D in two different human monocyte models. Elevated expression of FGF23 may therefore play a crucial role in defining immune responses to vitamin D and this, in turn, may be a key determinant of infection in patients with chronic kidney disease (CKD).
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Affiliation(s)
- Justine Bacchetta
- UCLA Orthopaedic Hospital, Department of Orthopaedic Surgery, Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, 90095, USA
- Department of Pediatrics, David Geffen School of Medicine, University of California at Los Angeles
| | - Jessica L Sea
- UCLA Orthopaedic Hospital, Department of Orthopaedic Surgery, Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, 90095, USA
| | - Rene F Chun
- UCLA Orthopaedic Hospital, Department of Orthopaedic Surgery, Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, 90095, USA
| | - Thomas S Lisse
- UCLA Orthopaedic Hospital, Department of Orthopaedic Surgery, Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, 90095, USA
| | | | - Barbara Gales
- Department of Pediatrics, David Geffen School of Medicine, University of California at Los Angeles
| | - John S. Adams
- UCLA Orthopaedic Hospital, Department of Orthopaedic Surgery, Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, 90095, USA
| | - Isidro B Salusky
- Department of Pediatrics, David Geffen School of Medicine, University of California at Los Angeles
| | - Martin Hewison
- UCLA Orthopaedic Hospital, Department of Orthopaedic Surgery, Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, 90095, USA
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Wan M, Smith C, Shah V, Gullet A, Wells D, Rees L, Shroff R. Fibroblast growth factor 23 and soluble klotho in children with chronic kidney disease. Nephrol Dial Transplant 2012. [PMID: 23180879 DOI: 10.1093/ndt/gfs411] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Fibroblast growth factor 23 (FGF23), a bone-derived phosphaturic hormone, is elevated in chronic kidney disease (CKD). There are scarce data on the levels of its essential co-receptor klotho, and longitudinal changes in FGF23 levels are also unknown. METHODS We examined FGF23 and soluble klotho (s-klotho) levels over 1 year in 154 children with CKD Stages 1-5 (CKD1-5), were on dialysis or who have received a transplantation. RESULTS In children with CKD1-5 and who were receiving dialysis, FGF23 correlated inversely with the estimated glomerular filtration rate (eGFR) (P < 0.001), whereas a decrease in s-klotho was observed with a lower eGFR (P = 0.01). There was no correlation between FGF23 and serum phosphate (P) or parathyroid hormone (PTH) in our cohort wherein 89 and 66%, respectively, had normal levels. FGF23 increased by 6-fold over a 12-month period in children with eGFR of 15-29 mL/min/1.73 m(2), with an overall 5% annual increase in the CKD1-5 and dialysis cohort. High FGF23 levels were seen with high calcium (Ca) levels (P < 0.001). FGF23 levels were high when 25-hydroxyvitamin D [25(OH)D] and 1,25-dihydroxyvitamin D [1,25(OH)(2)D] were deficient (P = 0.05 and P < 0.001, respectively). s-klotho levels correlated positively with 25(OH)D (P < 0.001) and negatively with PTH (P = 0.04) and age (P = 0.03). Multivariate regression analysis demonstrated a strong relationship between FGF23 and eGFR, whereas the association between s-klotho and eGFR as observed in univariate analysis was lost following the adjustment of confounders. In transplanted patients, FGF23 correlated with eGFR (P = 0.02) and 25(OH)D (P = 0.05). CONCLUSIONS This study shows increasing FGF23 and reduced s-klotho levels with progressive renal failure even in a population of children with well-controlled P levels. Novel associations between FGF23 and serum Ca as well as 25(OH)D warrant further investigation.
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Affiliation(s)
- Mandy Wan
- Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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The Transplant Recipient and Issues in Bone Metabolism. Clin Rev Bone Miner Metab 2012. [DOI: 10.1007/s12018-011-9118-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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van Husen M, Lehnhardt A, Fischer AK, Brinkert F, Loos S, Oh J, Kemper MJ. Fibroblast growth factor 23 and calcium phosphate homeostasis after pediatric renal transplantation. Pediatr Transplant 2012; 16:443-50. [PMID: 22554017 DOI: 10.1111/j.1399-3046.2012.01702.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
FGF23 is a circulating factor regulating TPR and is increased in CKD. After RT, it seems to induce phosphorus wasting in adults. Data on FGF23 after PRT are scarce. Parameters of bone metabolism including calcium, phosphate, 25-(OH) vitamin D, 1,25-(OH)(2) vitamin D, alkaline phosphatase, PTH, and FGF23 were analyzed in 57 children after PRT and 11 controls. Median time after PRT was 25.9 (range 2-135) months. eGFR after PRT ranged from 15 to 175 mL/min/1.73 qm. Mean (±s.e.) FGF23 and PTH levels were significantly elevated compared with controls (146 ± 30 vs. 43 ± 3 ng/L, p = 0.001 and 182 ± 42 vs. 74 ± 18 ng/L, p = 0.004, respectively). Highest FGF23 levels were found in children with an eGFR below 60 mL/min*1.73 sqm (280 ± 69 vs. 62 ± 5 ng/L, p = 0.001), but significantly elevated values were already present in CKD2T. In a multivariate analysis, eGFR, PTH, calcium, and phosphate were significantly associated with FGF23. In a subgroup of 17 patients (29.8%) with persistent hypophosphatemia, phosphate levels were significantly associated with FGF23 and not with PTH. FGF23 is increased in children after PRT, especially in patients with chronic allograft dysfunction, and seems to be a more sensitive marker of dysregulated calcium phosphate homeostasis than PTH.
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Affiliation(s)
- Michael van Husen
- Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Siomou E, Stefanidis CJ. FGF-23 in children with CKD: a new player in the development of CKD-mineral and bone disorder. Nephrol Dial Transplant 2012; 27:4259-62. [PMID: 22848110 DOI: 10.1093/ndt/gfs315] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Disturbances in mineral and bone metabolism in children with chronic kidney disease (CKD) lead to specific abnormalities of skeletal homeostasis called CKD-mineral and bone disorder (CKD-MBD). These disturbances should be diagnosed and managed appropriately to prevent bone deformities and disturbed growth. Changes in the vitamin D and parathyroid hormone (PTH), and the subsequent alterations in calcium (Ca) and phosphate (P) homeostasis are considered responsible for the development of CKD-MBD. Recently, a phosphaturic hormone, the fibroblast growth factor-23 (FGF-23), has been reported as a key regulator of P and vitamin D metabolism. A number of recent studies in paediatric populations have documented that the FGF-23 levels are increased early in CKD, before any abnormalities in serum Ca, P or PTH are apparent. The elevated FGF-23 levels result in a negative P balance to maintain P homeostasis, inducing phosphaturia, independently of PTH, and suppressing vitamin D synthesis. Therefore, the bone-kidney-parathyroid endocrine axis mediated by FGF-23 should be a novel therapeutic target in clinical practice, even in early stages of CKD in children.
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Affiliation(s)
- Ekaterini Siomou
- Department of Child Health, Medical School, University of Ioannina, Ioannina, Greece.
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Filler G, Liu D, Sharma AP, Grimmer J. Are fibroblast growth factor 23 concentrations in renal transplant patients different from non-transplanted chronic kidney disease patients? Pediatr Transplant 2012; 16:73-7. [PMID: 22121948 DOI: 10.1111/j.1399-3046.2011.01613.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To compare the pattern of serum FGF23 levels in pediatric renal transplant recipients and GFR-matched controls. We performed a cross-sectional matched pair study in 19 stable pediatric renal transplant recipients and 19 GFR-matched controls with native CKD. After assessment for normal distribution, demographic and bone metabolism parameters were compared with Student's t-test, Wilcoxon's matched pairs (for non-normal distribution) test, and correlation analysis. The groups were comparable for anthropometric parameters, cystatin C eGFR (71.10 ± 37.28 vs. 76.11 ± 26.80 mL/min/1.73 m(2) ), cystatin C, urea, creatinine, intact PTH, pH, CRP, alkaline phosphatase, phosphate, calcium, ionized calcium, FGF-23 (63.44 [IQR 38.42, 76.29], 49.92 [IQR 42.48, 76.97]), albumin, and urinary calcium/creatinine ratio. The renal transplant patients had significantly lower 25-(OH) vitamin D levels (66.63 ± 17.54 vs. 91.42 ± 29.16 ng/mL), and higher 1,25-(OH)(2) vitamin D levels (95.78 ± 34.54 vs. 67.11 ± 35.90 pm). FGF-23 levels correlated negatively with cystatin C eGFR (r = -0.3571, p = 0.02770) and positively with PTH (r = 0.5063, p = 0.0026), but not with serum phosphate (r = 0.2651, p = 0.1077). We conclude that the increase in FGF23 levels with GFR decline in pediatric renal transplant patients remains similar to that in the patients with CKD. The relationship between FGF23 and serum vitamin D needs further evaluation.
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Affiliation(s)
- Guido Filler
- Department of Pediatrics, Children's Hospital, London Health Science Centre, University of Western Ontario, London, ON, Canada.
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Sampaio MS, Molnar MZ, Kovesdy CP, Mehrotra R, Mucsi I, Sim JJ, Krishnan M, Nissenson AR, Kalantar-Zadeh K. Association of pretransplant serum phosphorus with posttransplant outcomes. Clin J Am Soc Nephrol 2011; 6:2712-21. [PMID: 21959597 DOI: 10.2215/cjn.06190611] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Serum phosphorus levels are associated with mortality, cardiovascular disease, and renal function loss in individuals with and without chronic kidney disease. The association of pretransplant serum phosphorus levels with transplant outcomes is not clear. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data of the Scientific Registry of Transplant Recipients (SRTR) up to June 2007 were linked to the database (2001 through 2006) of one of the U.S.-based large dialysis organizations (DaVita). The selected 9384 primary kidney recipients were divided into five groups according to pretransplant serum phosphorus levels (mg/dl): <3.5, 3.5 to <5.5 (reference group), 5.5 to <7.5, 7.5 to <9.5, and ≥9.5. Unadjusted and multivariate adjusted risks for transplant outcomes were compared. RESULTS Patients were 48 ± 14 years old and included 37% women and 27% African Americans. After multivariate adjustment, all-cause and cardiovascular death hazard ratios were 2.44 (95% confidence interval: 1.28 to 4.65) and 3.63 (1.13 to 11.64), respectively, in recipients in the ≥9.5 group; allograft loss hazard ratios were 1.42 (1.04 to 1.95) and 2.36 (1.33 to 4.17) in recipients with 7.5 to >9.5 and ≥9.5, respectively. No significant association with delayed graft function was found. CONCLUSIONS Pretransplant phosphorus levels 7.5 to <9.5 mg/dl and ≥9.5 mg/dl were associated with increased risk of functional graft failure and increased risk of all-cause and cardiovascular deaths, respectively, when compared with 3.5 to <5.5 mg/dl. Additional studies are needed to examine whether more aggressive control of pretransplant serum phosphorus may improve posttransplant outcomes.
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Affiliation(s)
- Marcelo S Sampaio
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California 90509-2910, USA
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Schmitt CP, Mehls O. Mineral and bone disorders in children with chronic kidney disease. Nat Rev Nephrol 2011; 7:624-34. [PMID: 21947120 DOI: 10.1038/nrneph.2011.139] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
As children with chronic kidney disease (CKD) have a long lifespan, optimal control of bone and mineral homeostasis is essential not only for the prevention of debilitating skeletal complications and for achieving adequate growth but also for preserving long-term cardiovascular health. As the growing skeleton is highly dynamic and at particular risk of deterioration, close control of bone and mineral homeostasis is required in children with CKD. However, assessment of bone disease is hampered by the limited validity of biochemical parameters-major controversy exists on key issues such as parathyroid hormone target ranges and the lack of useful imaging techniques. The role of newly discovered factors in bone and mineral homeostasis, such as fibroblast growth factor 23, is not yet established. Even though scientific evidence is limited in children with CKD, ergocalciferol or cholecalciferol supplementation and the use of calcium-free phosphate binders is recommended. The new drug cinacalcet is highly promising; however, pediatric experience is still limited to observational data and the effect of cinacalcet on longitudinal growth and pubertal development is unknown. Randomized, controlled trials are underway, including studies of cinacalcet pharmacokinetics and pharmacodynamics in infants.
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Affiliation(s)
- Claus Peter Schmitt
- Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, INF 430, University of Heidelberg, 69120 Heidelberg, Germany.
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