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Kuang C, Shang J, Ma M, Huang S, Yan B, Zhong Y, Guan B, Gong J, Liu F, Chen L. Risk factors and clinical prediction models for osteoporosis in pre-dialysis chronic kidney disease patients. Ren Fail 2024; 46:2361802. [PMID: 38874080 PMCID: PMC11182074 DOI: 10.1080/0886022x.2024.2361802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 05/24/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Osteoporosis in pre-dialysis chronic kidney disease (CKD) patients has been overlooked, and the risk factors of osteoporosis in these patients have not been adequately studied. OBJECTIVE To identify risk factors for osteoporosis in pre-dialysis CKD patients and develop predictive models to estimate the likelihood of osteoporosis. METHODS Dual-energy X-ray absorptiometry was used to measure bone mineral density, and clinical examination results were collected from 326 pre-dialysis CKD patients. Binary logistic regression was employed to explore the risk factors associated with osteoporosis and develop predictive models. RESULTS In this cohort, 53.4% (n = 174) were male, 46.6% (n = 152) were female, and 21.8% (n = 71) were diagnosed with osteoporosis. Among those diagnosed with osteoporosis, 67.6% (n = 48) were female and 32.4% (n = 23) were male. Older age and low 25-(OH)-Vitamin D levels were identified as risk factors for osteoporosis in males. For females, older age, being underweight, higher bone alkaline phosphatase (NBAP), and advanced CKD (G5) were significant risk factors, while higher iPTH was protective. Older age, being underweight, and higher NBAP were risk factors for osteoporosis in the G1-4 subgroup. In the G5 subgroup, older age and higher NBAP increased the risk, while high 25-(OH)-Vitamin D or iPTH had protective effects. Nomogram models were developed to assess osteoporosis risk in pre-dialysis patients based on gender and renal function stage. CONCLUSION Risk factors for osteoporosis vary by gender and renal function stages. The nomogram clinical prediction models we constructed may aid in the rapid screening of patients at high risk of osteoporosis.
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Affiliation(s)
- Chaoying Kuang
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Jingjie Shang
- Nuclear Medicine, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Mingming Ma
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Shengling Huang
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Bing Yan
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Yuzhen Zhong
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Baozhang Guan
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Jian Gong
- Nuclear Medicine, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Fanna Liu
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
| | - Liangmei Chen
- Nephrology Department, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, Guangdong, China
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Fassio A, Andreola S, Gatti D, Pollastri F, Gatti M, Fabbrini P, Gambaro G, Ferraro PM, Caletti C, Rossini M, Viapiana O, Bixio R, Adami G. Long-Term Bone Mineral Density Changes in Kidney Transplant Recipients Treated with Denosumab: A Retrospective Study with Nonequivalent Control Group. Calcif Tissue Int 2024; 115:23-30. [PMID: 38730099 PMCID: PMC11153264 DOI: 10.1007/s00223-024-01218-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/16/2024] [Indexed: 05/12/2024]
Abstract
Data on the effectiveness of denosumab on osteoporosis after kidney transplantation are limited. We investigated the long-term bone mineral density (BMD) changes in kidney transplant recipients (KTRs) treated with denosumab compared to untreated KTRs. We enrolled KTRs treated with denosumab 60 mg/6 months for 4 years. An untreated group of sex and age-matched KTRs with a 1:1 ratio was included. The primary outcome was BMD changes assessed by Dual-energy X-ray Absorptiometry over 4 years. Data on serum creatinine, alkaline phosphatase (ALP), parathyroid hormone, and 25-hydroxyvitamin D were collected. All patients received oral cholecalciferol and calcium supplementation. 23 denosumab-treated KTRs were enrolled, and 23 untreated KTRs. The median time from transplant to the start of denosumab was 4 years (range 0:24). The denosumab group showed a significant increase from baseline in BMD at the lumbar spine (LS) (9.0 ± 10.7%, p < 0.001), and total hip (TH) (3.8 ± 7.9%, p = 0.041). The untreated group showed a significant decrease at all sites (- 3.0 ± 7%, p = 0.041 at the LS; - 6.3 ± 9.2%, p = 0.003 at the TH; - 6.7 ± 9.3%, p = 0.003 at the FN). The between-group differences in percent BMD changes were statistically significant at all sites. Similar results were found for the respective Z-scores. The ALP serum levels significantly decreased from baseline only in the denosumab group, with a significant between-group difference (p = 0.032). No significant differences in serum creatinine, hypocalcaemic events or acute graft rejection rates were observed. Four years of denosumab therapy were associated with increased BMD in KTRs, while untreated KTRs showed significant BMD losses at all sites.
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Affiliation(s)
- Angelo Fassio
- Rheumatology Unit, University of Verona, Verona, Italy.
- Rheumatology Unit, Policlinico GB Rossi, 37134, Verona, Italy.
| | | | - Davide Gatti
- Rheumatology Unit, University of Verona, Verona, Italy
| | | | - Matteo Gatti
- Rheumatology Unit, University of Verona, Verona, Italy
- Department of Nephrology and Dialysis, Ospedale Bassini, ASST Nord Milano-Cinisello Balsamo, Milan, Italy
| | - Paolo Fabbrini
- Department of Nephrology and Dialysis, Ospedale Bassini, ASST Nord Milano-Cinisello Balsamo, Milan, Italy
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Jørgensen HS, Lloret MJ, Lalayiannis AD, Shroff R, Evenepoel P. Ten tips on how to assess bone health in patients with chronic kidney disease. Clin Kidney J 2024; 17:sfae093. [PMID: 38817914 PMCID: PMC11137676 DOI: 10.1093/ckj/sfae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Indexed: 06/01/2024] Open
Abstract
Patients with chronic kidney disease (CKD) experience a several-fold increased risk of fracture. Despite the high incidence and the associated excess morbidity and premature mortality, bone fragility in CKD, or CKD-associated osteoporosis, remains a blind spot in nephrology with an immense treatment gap. Defining the bone phenotype is a prerequisite for the appropriate therapy of CKD-associated osteoporosis at the patient level. In the present review, we suggest 10 practical 'tips and tricks' for the assessment of bone health in patients with CKD. We describe the clinical, biochemical, and radiological evaluation of bone health, alongside the benefits and limitations of the available diagnostics. A bone biopsy, the gold standard for diagnosing renal bone disease, is invasive and not widely available; although useful in complex cases, we do not consider it an essential component of bone assessment in patients with CKD-associated osteoporosis. Furthermore, we advocate for the deployment of multidisciplinary expert teams at local, national, and potentially international level. Finally, we address the knowledge gaps in the diagnosis, particularly early detection, appropriate "real-time" monitoring of bone health in this highly vulnerable population, and emerging diagnostic tools, currently primarily used in research, that may be on the horizon of clinical practice.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Maria Jesús Lloret
- Department of Nephrology, Hospital Fundació Puigvert, Barcelona, Spain
- Institut de Recerca Sant-Pau (IR-Sant Pau), Barcelona, Spain
| | - Alexander D Lalayiannis
- Department of Pediatric Nephrology, Birmingham Women's and Children's Hospitals, Birmingham, UK
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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Maranduca MA, Cozma CT, Clim A, Pinzariu AC, Tudorancea I, Popa IP, Lazar CI, Moscalu R, Filip N, Moscalu M, Constantin M, Scripcariu DV, Serban DN, Serban IL. The Molecular Mechanisms Underlying the Systemic Effects Mediated by Parathormone in the Context of Chronic Kidney Disease. Curr Issues Mol Biol 2024; 46:3877-3905. [PMID: 38785509 PMCID: PMC11120161 DOI: 10.3390/cimb46050241] [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: 03/31/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
Chronic kidney disease (CKD) stands as a prominent non-communicable ailment, significantly impacting life expectancy. Physiopathology stands mainly upon the triangle represented by parathormone-Vitamin D-Fibroblast Growth Factor-23. Parathormone (PTH), the key hormone in mineral homeostasis, is one of the less easily modifiable parameters in CKD; however, it stands as a significant marker for assessing the risk of complications. The updated "trade-off hypothesis" reveals that levels of PTH spike out of the normal range as early as stage G2 CKD, advancing it as a possible determinant of systemic damage. The present review aims to review the effects exhibited by PTH on several organs while linking the molecular mechanisms to the observed actions in the context of CKD. From a diagnostic perspective, PTH is the most reliable and accessible biochemical marker in CKD, but its trend bears a higher significance on a patient's prognosis rather than the absolute value. Classically, PTH acts in a dichotomous manner on bone tissue, maintaining a balance between formation and resorption. Under the uremic conditions of advanced CKD, the altered intestinal microbiota majorly tips the balance towards bone lysis. Probiotic treatment has proven reliable in animal models, but in humans, data are limited. Regarding bone status, persistently high levels of PTH determine a reduction in mineral density and a concurrent increase in fracture risk. Pharmacological manipulation of serum PTH requires appropriate patient selection and monitoring since dangerously low levels of PTH may completely inhibit bone turnover. Moreover, the altered mineral balance extends to the cardiovascular system, promoting vascular calcifications. Lastly, the involvement of PTH in the Renin-Angiotensin-Aldosterone axis highlights the importance of opting for the appropriate pharmacological agent should hypertension develop.
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Affiliation(s)
- Minela Aida Maranduca
- Discipline of Physiology, Department of Morpho-Functional Sciences II, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.A.M.); (C.T.C.); (A.C.); (A.C.P.); (I.T.); (I.P.P.); (C.I.L.); (D.N.S.); (I.L.S.)
| | - Cristian Tudor Cozma
- Discipline of Physiology, Department of Morpho-Functional Sciences II, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.A.M.); (C.T.C.); (A.C.); (A.C.P.); (I.T.); (I.P.P.); (C.I.L.); (D.N.S.); (I.L.S.)
| | - Andreea Clim
- Discipline of Physiology, Department of Morpho-Functional Sciences II, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.A.M.); (C.T.C.); (A.C.); (A.C.P.); (I.T.); (I.P.P.); (C.I.L.); (D.N.S.); (I.L.S.)
| | - Alin Constantin Pinzariu
- Discipline of Physiology, Department of Morpho-Functional Sciences II, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.A.M.); (C.T.C.); (A.C.); (A.C.P.); (I.T.); (I.P.P.); (C.I.L.); (D.N.S.); (I.L.S.)
| | - Ionut Tudorancea
- Discipline of Physiology, Department of Morpho-Functional Sciences II, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.A.M.); (C.T.C.); (A.C.); (A.C.P.); (I.T.); (I.P.P.); (C.I.L.); (D.N.S.); (I.L.S.)
| | - Irene Paula Popa
- Discipline of Physiology, Department of Morpho-Functional Sciences II, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.A.M.); (C.T.C.); (A.C.); (A.C.P.); (I.T.); (I.P.P.); (C.I.L.); (D.N.S.); (I.L.S.)
| | - Cristina Iuliana Lazar
- Discipline of Physiology, Department of Morpho-Functional Sciences II, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.A.M.); (C.T.C.); (A.C.); (A.C.P.); (I.T.); (I.P.P.); (C.I.L.); (D.N.S.); (I.L.S.)
| | - Roxana Moscalu
- Division of Cell Matrix Biology & Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, UK;
| | - Nina Filip
- Discipline of Biochemistry, Department of Morpho-Functional Sciences II, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Mihaela Moscalu
- Department of Preventive Medicine and Interdisciplinarity, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihai Constantin
- Internal Medicine Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Dragos Viorel Scripcariu
- Department of Surgery, Grigore T. Popa University of Medicine and Pharmacy, 16 University Str., 700115 Iasi, Romania;
| | - Dragomir Nicolae Serban
- Discipline of Physiology, Department of Morpho-Functional Sciences II, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.A.M.); (C.T.C.); (A.C.); (A.C.P.); (I.T.); (I.P.P.); (C.I.L.); (D.N.S.); (I.L.S.)
| | - Ionela Lacramioara Serban
- Discipline of Physiology, Department of Morpho-Functional Sciences II, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.A.M.); (C.T.C.); (A.C.); (A.C.P.); (I.T.); (I.P.P.); (C.I.L.); (D.N.S.); (I.L.S.)
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Kato K, Nakashima A, Morishita M, Ohkido I, Yokoo T. Calcium-based phosphate binders and bone mineral density in patients undergoing hemodialysis: a retrospective cohort study. Clin Exp Nephrol 2024:10.1007/s10157-024-02493-8. [PMID: 38594468 DOI: 10.1007/s10157-024-02493-8] [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: 02/08/2024] [Accepted: 03/19/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Calcium supplements are commonly prescribed to prevent fractures in patients with osteoporosis. Nonetheless, they are generally eschewed in hemodialysis patients because they increase vascular calcification and induce cardiovascular disease. This retrospective cohort study aimed to investigate the effect of calcium-based phosphate binders (CBPB) on bone mineral density (BMD) in hemodialysis patients. METHODS Outpatients on dialysis who underwent BMD measurement from January to December 2017, whose data on BMD trends and CBPB administration were recorded over the next 4 years, were enrolled. Patients receiving anti-osteoporotic medications were excluded. The association between the presence and duration of CBPB administration and changes in BMD was evaluated. RESULTS The femoral neck's BMD decreased from 0.836 g/cm2 (0.702-0.952) to 0.764 g/cm2 (0.636-0.896) (P < 0.001) in the non-CBPB group (patients who never received CBPB over 4 years, n = 32). The CBPB group (n = 56) exhibited only a minute decrease from 0.833 g/cm2 (0.736-0.965) to 0.824 g/cm2 (0.706-0.939) (P = 0.004). Multivariate linear regression analysis revealed better BMD maintenance in the CBPB group [β-coefficient (95% CI): 0.033 (0.001-0.065); P = 0.046] than in the non-CBPB group. Additionally, the prolonged-CBPB administration group showed superior BMD preservation [β-coefficient (95% CI): 0.038 (0.001-0.076); P = 0.042]. CONCLUSION CBPB administration may be associated with BMD maintenance.
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Affiliation(s)
- Kazuhiko Kato
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-Ku, Tokyo, 105-8461, Japan
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo, Japan
- Department of Nephrology, Morishita Memorial Hospital, Kanagawa, Japan
| | - Akio Nakashima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-Ku, Tokyo, 105-8461, Japan.
| | | | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-Ku, Tokyo, 105-8461, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi Minato-Ku, Tokyo, 105-8461, Japan
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Wang AYM, Tang TK, Yau YY, Lo WK. Impact of Parathyroidectomy Versus Oral Cinacalcet on Bone Mineral Density in Patients on Peritoneal Dialysis With Advanced Secondary Hyperparathyroidism: The PROCEED Pilot Randomized Trial. Am J Kidney Dis 2024; 83:456-466.e1. [PMID: 38040277 DOI: 10.1053/j.ajkd.2023.10.007] [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: 02/07/2023] [Revised: 10/21/2023] [Accepted: 10/22/2023] [Indexed: 12/03/2023]
Abstract
RATIONALE & OBJECTIVE Parathyroidectomy and calcimimetics have been used to reduce fracture risk in patients with kidney failure and advanced secondary hyperparathyroidism (SHPT), but direct comparisons of these treatment approaches have not been implemented. This pilot study compared their effects on bone mineral density (BMD) in this patient population. STUDY DESIGN A prospective pilot open-label randomized trial. SETTING & PARTICIPANTS 65 patients receiving maintenance peritoneal dialysis with advanced SHPT recruited from 2 university-affiliated hospitals in Hong Kong. INTERVENTIONS Total parathyroidectomy with forearm autografting versus oral cinacalcet treatment for 12 months. OUTCOME Prespecified secondary end points including changes in BMD z and T scores of femoral neck, lumbar spine, and distal radius 12 months after treatment initiation and also categorized as osteopenia or osteoporosis according to the World Health Organization. RESULTS Both total parathyroidectomy and cinacalcet significantly improved BMD of the lumbar spine and femoral neck over 12 months, but the total parathyroidectomy group had a greater increase than the cinacalcet-treated group (P<0.001). The proportion of study participants classified as having osteopenia/osteoporosis by femoral neck T-score fell from 78.2% to 51.7% in the total parathyroidectomy group (P<0.001) and from 65.7% to 52.0% in cinacalcet-treated group after 12 months (P=0.7). The proportion of participants with a T-score at the lumbar spine classified as osteopenia/osteoporosis fell from 53.1% to 31.0% in the total parathyroidectomy group (P=0.01) and from 59.4% to 53.8% with cinacalcet (P=0.3). No significant change was observed in BMD T or z score of the distal radius over 12 months with either intervention. LIMITATIONS Bone histology was not assessed, and the study duration was 12 months. CONCLUSIONS A large proportion of peritoneal dialysis patients with advanced SHPT had low bone densities and osteopenia/osteoporosis. Total parathyroidectomy increased the BMD of the lumbar spine and femoral neck and reduced osteopenia/osteoporosis more than oral cinacalcet. FUNDING Grants from academic (The University of Hong Kong Research) and not-for-profit (Hong Kong Society of Nephrology) entities. REGISTRATION Registered at Clinicaltrials.gov with study number NCT01447368. PLAIN-LANGUAGE SUMMARY It is not known whether oral cinacalcet and surgical parathyroidectomy differ in their effects on bone parameters in patients with advanced secondary hyperparathyroidism (SHPT) receiving peritoneal dialysis. This pilot randomized trial evaluated the effect of medical versus surgical therapy on bone mineral densities (BMD) as prespecified secondary study end points. The findings showed that a large proportion of peritoneal dialysis patients with advanced SHPT had low bone densities and osteopenia/osteoporosis. Parathyroidectomy increased the BMD of the lumbar spine and femoral neck more than cinacalcet over 12 months. Parathyroidectomy reduced the proportion of patients with osteopenia/osteoporosis at the lumbar spine and femoral neck more than cinacalcet after 12 months. Neither intervention led to an increase in the BMD of the distal radius over 12 months.
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Affiliation(s)
- Angela Yee-Moon Wang
- University Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong.
| | - Tak-Ka Tang
- University Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | | | - Wai Kei Lo
- Department of Medicine, Tung Wah Hospital, Hong Kong
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Pollock C, Moon JY, Ngoc Ha LP, Gojaseni P, Ching CH, Gomez L, Chan TM, Wu MJ, Yeo SC, Nugroho P, Bhalla AK. Framework of Guidelines for Management of CKD in Asia. Kidney Int Rep 2024; 9:752-790. [PMID: 38765566 PMCID: PMC11101746 DOI: 10.1016/j.ekir.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/29/2023] [Accepted: 12/11/2023] [Indexed: 05/22/2024] Open
Affiliation(s)
- Carol Pollock
- Kolling Institute of Medical Research, University of Sydney, St Leonards, New South Wales, Australia
| | - Ju-young Moon
- Kyung Hee University School of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Le Pham Ngoc Ha
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | | | | | - Lynn Gomez
- Asian Hospital and Medical Center, Muntinlupa City, Metro Manila, Philippines
| | - Tak Mao Chan
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Ming-Ju Wu
- Taichung Veterans General Hospital, Taichung City, Taiwan
| | | | | | - Anil Kumar Bhalla
- Department of Nephrology-Sir Ganga Ram Hospital Marg, New Delhi, Delhi, India
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Gao Y, Gao J, Wang Y, Gan H. Predicting Osteoporotic Fracture in Patients With Early-Stage Diabetic Kidney Disease Using a Radiomic Model: A Longitudinal Cohort Study. Endocr Pract 2024; 30:360-366. [PMID: 38185330 DOI: 10.1016/j.eprac.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/09/2024]
Abstract
OBJECTIVE There is an urgent need for effective predictive strategies to accurately evaluate the risk of fragility fractures in elderly patients in the early stages of diabetic kidney disease (DKD). METHODS This longitudinal cohort study included 715 older patients in the early stages of DKD diagnosed between January 2015 and August 2019. Patients were randomly allocated to a training cohort (n = 499) and a validation cohort (n = 216). The least absolute shrinkage and selection operator method was used to select key features for dual-energy x-ray absorptiometry-based radiomic analysis. A radiomic model was constructed using Cox proportional hazards regression. The performance of the radiomic model was compared with that of traditional fracture assessment tools through a receiver operating characteristic curve, calibration curve, and decision curve analysis. RESULTS Over a mean follow-up period of 4.72 ± 1.60 years, 65 participants (9.09%) experienced incident fragility fractures. Seventeen features were ultimately selected to create the radiomic model. The calibration plots of this model demonstrated satisfactory agreement between the observed and predicted outcomes. Moreover, the radiomic model outperformed traditional fracture assessment tools in both the training and validation cohorts according to the area under the receiver operating characteristic curve and decision curve analysis. CONCLUSIONS The novel radiomic model has demonstrated a more effective prediction of fragility fracture in elderly patients in the early stages of DKDcompared to traditional fracture assessment tools.
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Affiliation(s)
- Youyuan Gao
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Department of Nephrology, Chongqing University Fuling Hospital, Chongqing, China
| | - Jianya Gao
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunting Wang
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hua Gan
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Kim H, Lee EJ, Woo S, Rho S, Jung JY. Effect of Denosumab on Bone Health, Vascular Calcification, and Health-Related Quality of Life in Hemodialysis Patients with Osteoporosis: A Prospective Observational Study. J Clin Med 2024; 13:1462. [PMID: 38592300 PMCID: PMC10934499 DOI: 10.3390/jcm13051462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/26/2024] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Osteoporosis is common in hemodialysis (HD) patients, contributing to cardiovascular risks. Limited research exists on denosumab's efficacy in this group. Our study explores denosumab's effects on bone turnover markers (BTMs) and vascular calcification in chronic kidney disease-mineral bone disorder (CKD-MBD) patients. Methods: In a prospective single-center study, we investigated the effects of denosumab over 2 years on 30 HD patients from a cohort of 185. Annual assessments of bone mineral density (BMD), vascular calcification, and health-related quality of life (HRQL) were conducted and compared with an untreated group. Mineral and bone parameters were analyzed at specific intervals in the treatment group. Results: Denosumab notably raised femoral BMD in the initial year. Most bone turnover markers (BTMs) decreased, except for osteocalcin. Changes in T50 correlated with BTMs. Pre-denosumab supplementation of calcium and vitamin D helped manage mineral imbalances. Post denosumab, parathyroid hormone (PTH) levels increased initially, stabilizing after 3 months. No significant changes occurred in vascular calcification or HRQL. Conclusions: Denosumab exhibited varying effects on BMD improvement, with a stronger impact in the first year that diminished in the second year. Early PTH monitoring was crucial, and extending the administrative period may enhance BMD outcomes compared to the general population.
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Affiliation(s)
- Hyunsook Kim
- Department of Health Sciences and Technology, Gachon University, Incheon 21565, Republic of Korea;
| | - Eun Ju Lee
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea; (E.J.L.); (S.W.)
| | - Siyun Woo
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea; (E.J.L.); (S.W.)
| | - Sohee Rho
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea; (E.J.L.); (S.W.)
| | - Ji Yong Jung
- Department of Health Sciences and Technology, Gachon University, Incheon 21565, Republic of Korea;
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea; (E.J.L.); (S.W.)
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10
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Bover J, Gómez-Alonso C, Casado E, Rodríguez-García M, Lloret MJ, Castro-Alonso C, Gifre L, Henríquez-Palop F, Prior-Español Á, López de la Manzanara V, Láiz AM, Martínez-Ferrer À, Torregrosa JV, Cigarrán S, Górriz JL, Montomoli M, Panizo N, Costa E, Martínez-Laguna D, Rodríguez M, Navarro-González JF. Osteoporosis management in patients with chronic kidney disease (ERCOS Study): A challenge in nephrological care. Nefrologia 2024; 44:241-250. [PMID: 38531765 DOI: 10.1016/j.nefroe.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/07/2023] [Indexed: 03/28/2024] Open
Abstract
Fracture risk assessment in patients with chronic kidney disease (CKD) has been included in the CKD-MBD ("Chronic Kidney Disease-Mineral and Bone Disorders") complex in international and national nephrology guidelines, suggesting for the first time the assessment of bone mineral density (BMD) if the results can influence therapeutic decision-making. However, there is very little information on actual clinical practice in this population. The main objective of the ERCOS (ERC-Osteoporosis) study is to describe the profile of patients with CKD G3-5D with osteoporosis (OP) and/or fragility fractures treated in specialized nephrology, rheumatology and internal medicine clinics in Spain. Fifteen centers participated and 162 patients (mostly women [71.2%] postmenopausal [98.3%]) with a median age of 77 years were included. Mean estimated glomerular filtration rate (eGFR) was 36 mL/min/1.73 m2 and 38% of the included patients were on dialysis. We highlight the high frequency of prevalent fragility fractures [37.7%), mainly vertebral (52.5%) and hip (24.6%)], the disproportionate history of patients with glomerular disease compared to purely nephrological series (corticosteroids) and undertreatment for fracture prevention, especially in nephrology consultations. This study is an immediate call to action with the dissemination of the new, more proactive, clinical guidelines, and underlines the need to standardize a coordinated and multidisciplinary care/therapeutic approach to these patients in an efficient way to avoid current discrepancies and therapeutic nihilism.
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Affiliation(s)
- Jordi Bover
- Servicio de Nefrología, Hospital Universitari Germans Trias i Pujol, REMAR-IGTP Group, Can Ruti Campus, Badalona, Barcelona, Spain.
| | - Carlos Gómez-Alonso
- Unidad de Gestión Clínica de Metabolismo Óseo y Mineral, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Enrique Casado
- Servicio de Reumatología, Hospital Universitari Parc Taulí, Sabadell, Barcelona, Spain
| | - Minerva Rodríguez-García
- Unidad de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - María Jesús Lloret
- Servicio de Nefrología, Fundació Puigvert, Institut d'Investigació Biomèdica Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | - Cristina Castro-Alonso
- Servicio de Nefrología, Hospital Universitario Doctor Peset, Fundació per al Foment de la Investigació Sanitària i Biomèdica de la Comunitat Valenciana (FISABIO), Valencia, Spain
| | - Laia Gifre
- Servicio de Reumatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | - Águeda Prior-Español
- Servicio de Reumatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | | | - Ana María Láiz
- Servicio de Reumatología, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | | | - José Luis Górriz
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
| | - Marco Montomoli
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
| | - Nayara Panizo
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
| | - Ester Costa
- Servicio de Reumatología, Hospital Universitari Parc Taulí, Sabadell, Barcelona, Spain
| | | | - Mariano Rodríguez
- Servicio de Nefrología, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Juan F Navarro-González
- Unidad de Investigación y Servicio de Nefrología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Islas Canarias, Spain
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11
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Kato K, Yaginuma T, Kobayashi A, Nakashima A, Ohkido I, Yokoo T. Long-term effects of denosumab on bone mineral density and turnover markers in patients undergoing hemodialysis. J Bone Miner Metab 2024; 42:264-270. [PMID: 38512458 PMCID: PMC10982096 DOI: 10.1007/s00774-024-01505-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/15/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Denosumab, a fully human anti-RANKL monoclonal antibody, is a widely used osteoporosis treatment that is increasingly being used in patients undergoing dialysis; however, its long-term efficacy and safety in these patients remain unknown. MATERIALS AND METHODS This observational study comprised individuals aged ≥ 20 years undergoing hemodialysis and receiving denosumab. After denosumab administration, we analyzed the long-term changes in bone mineral density (BMD) and levels of bone turnover markers (BTMs) and calcium. RESULTS The study included 45 patients who have been receiving denosumab for a median duration of 3.8 (interquartile range, 2.5-6.7) years. Tartrate-resistant acid phosphatase 5b (TRACP-5b) levels decreased from a median of 595 (434-778) mU/dL at baseline to 200 (141-430) mU/dL after 6 months of denosumab administration (P < 0.001) and remained low thereafter. Similarly, bone-specific alkaline phosphatase (BAP) levels decreased from a median of 18.2 (15.9-25.8) μg/L at baseline to 12.4 (9.9-15.6) μg/L after 6 months (P < 0.001) and remained low thereafter. Meanwhile, BMD, as assessed with dual energy X-ray absorptiometry and measured at the distal 1/3 of the radius, did not decrease (0.465 ± 0.112 g/cm2 at baseline vs. 0.464 ± 0.112 g/cm2 after administration; P = 0.616). Regarding hypocalcemia, corrected calcium levels reached were the lowest at 7 days after administration and normalized within 30 days. CONCLUSION The study showed long-term suppression of TRACP-5b and BAP levels and sustaining BMD after denosumab administration over an extended period in patients undergoing hemodialysis.
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Affiliation(s)
- Kazuhiko Kato
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo, Japan
| | | | - Arisa Kobayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akio Nakashima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
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12
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Lloret MJ, Fusaro M, Jørgensen HS, Haarhaus M, Gifre L, Alfieri CM, Massó E, D'Marco L, Evenepoel P, Bover J. Evaluating Osteoporosis in Chronic Kidney Disease: Both Bone Quantity and Quality Matter. J Clin Med 2024; 13:1010. [PMID: 38398323 PMCID: PMC10889712 DOI: 10.3390/jcm13041010] [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: 12/30/2023] [Revised: 01/28/2024] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
Bone strength is determined not only by bone quantity [bone mineral density (BMD)] but also by bone quality, including matrix composition, collagen fiber arrangement, microarchitecture, geometry, mineralization, and bone turnover, among others. These aspects influence elasticity, the load-bearing and repair capacity of bone, and microcrack propagation and are thus key to fractures and their avoidance. In chronic kidney disease (CKD)-associated osteoporosis, factors traditionally associated with a lower bone mass (advanced age or hypogonadism) often coexist with non-traditional factors specific to CKD (uremic toxins or renal osteodystrophy, among others), which will have an impact on bone quality. The gold standard for measuring BMD is dual-energy X-ray absorptiometry, which is widely accepted in the general population and is also capable of predicting fracture risk in CKD. Nevertheless, a significant number of fractures occur in the absence of densitometric World Health Organization (WHO) criteria for osteoporosis, suggesting that methods that also evaluate bone quality need to be considered in order to achieve a comprehensive assessment of fracture risk. The techniques for measuring bone quality are limited by their high cost or invasive nature, which has prevented their implementation in clinical practice. A bone biopsy, high-resolution peripheral quantitative computed tomography, and impact microindentation are some of the methods established to assess bone quality. Herein, we review the current evidence in the literature with the aim of exploring the factors that affect both bone quality and bone quantity in CKD and describing available techniques to assess them.
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Affiliation(s)
- Maria J Lloret
- Nephrology Department, Fundació Puigvert, Cartagena 340-350, 08025 Barcelona, Spain
- Institut de Recerca Sant Pau (IR-Sant-Pau), 08025 Barcelona, Spain
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology, 56124 Pisa, Italy
- Department of Medicine, University of Padua, 35128 Padua, Italy
| | - Hanne S Jørgensen
- Institute of Clinical Medicine, Aarhus University, 8000 Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Mathias Haarhaus
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden
- Diaverum AB, Hyllie Boulevard 53, 215 37 Malmö, Sweden
| | - Laia Gifre
- Rheumatology Department, University Hospital Germans Trias I Pujol, Universitat Autònoma de Barcelona, 08193 Badalona, Spain
| | - Carlo M Alfieri
- Unit of Nephrology Dialysis and Renal Transplantation Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Elisabet Massó
- Nephrology Department, University Hospital Germans Trias I Pujol, REMAR-IGTP Group, Research Institute Germans Trias I Pujol (IGTP), Universitat Autònoma de Barcelona, 08193 Badalona, Spain
| | - Luis D'Marco
- Grupo de Investigación en Enfermedades Cardiorenales y Metabólicas, Departamento de Medicina y Cirugía, Facultad de Ciencias de la Salud, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
| | - Pieter Evenepoel
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias I Pujol, REMAR-IGTP Group, Research Institute Germans Trias I Pujol (IGTP), Universitat Autònoma de Barcelona, 08193 Badalona, Spain
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13
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Teh JW, Mac Gearailt C, Lappin DWP. Post-Transplant Bone Disease in Kidney Transplant Recipients: Diagnosis and Management. Int J Mol Sci 2024; 25:1859. [PMID: 38339137 PMCID: PMC10856017 DOI: 10.3390/ijms25031859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
Kidney transplantation is the preferred gold standard modality of treatment for kidney failure. Bone disease after kidney transplantation is highly prevalent in patients living with a kidney transplant and is associated with high rates of hip fractures. Fractures are associated with increased healthcare costs, morbidity and mortality. Post-transplant bone disease (PTBD) includes renal osteodystrophy, osteoporosis, osteonecrosis and bone fractures. PTBD is complex as it encompasses pre-existing chronic kidney disease-mineral bone disease and compounding factors after transplantation, including the use of immunosuppression and the development of de novo bone disease. After transplantation, the persistence of secondary and tertiary hyperparathyroidism, renal osteodystrophy, relative vitamin D deficiency and high levels of fibroblast growth factor-23 contribute to post-transplant bone disease. Risk assessment includes identifying both general risk factors and kidney-specific risk factors. Diagnosis is complex as the gold standard bone biopsy with double-tetracycline labelling to diagnose the PTBD subtype is not always readily available. Therefore, alternative diagnostic tools may be used to aid its diagnosis. Both non-pharmacological and pharmacological therapy can be employed to treat PTBD. In this review, we will discuss pathophysiology, risk assessment, diagnosis and management strategies to manage PTBD after kidney transplantation.
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Affiliation(s)
- Jia Wei Teh
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - Conall Mac Gearailt
- Department of Rheumatology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - David W. P. Lappin
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
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14
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Evenepoel P, Jørgensen HS, Bover J, Davenport A, Bacchetta J, Haarhaus M, Hansen D, Gracia-Iguacel C, Ketteler M, McAlister L, White E, Mazzaferro S, Vervloet M, Shroff R. Recommended calcium intake in adults and children with chronic kidney disease-a European consensus statement. Nephrol Dial Transplant 2024; 39:341-366. [PMID: 37697718 DOI: 10.1093/ndt/gfad185] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Indexed: 09/13/2023] Open
Abstract
Mineral and bone disorders (MBD) are common in patients with chronic kidney disease (CKD), contributing to significant morbidity and mortality. For several decades, the first-line approach to controlling hyperparathyroidism in CKD was by exogenous calcium loading. Since the turn of the millennium, however, a growing awareness of vascular calcification risk has led to a paradigm shift in management and a move away from calcium-based phosphate binders. As a consequence, contemporary CKD patients may be at risk of a negative calcium balance, which, in turn, may compromise bone health, contributing to renal bone disease and increased fracture risk. A calcium intake below a certain threshold may be as problematic as a high intake, worsening the MBD syndrome of CKD, but is not addressed in current clinical practice guidelines. The CKD-MBD and European Renal Nutrition working groups of the European Renal Association (ERA), together with the CKD-MBD and Dialysis working groups of the European Society for Pediatric Nephrology (ESPN), developed key evidence points and clinical practice points on calcium management in children and adults with CKD across stages of disease. These were reviewed by a Delphi panel consisting of ERA and ESPN working groups members. The main clinical practice points include a suggested total calcium intake from diet and medications of 800-1000 mg/day and not exceeding 1500 mg/day to maintain a neutral calcium balance in adults with CKD. In children with CKD, total calcium intake should be kept within the age-appropriate normal range. These statements provide information and may assist in decision-making, but in the absence of high-level evidence must be carefully considered and adapted to individual patient needs.
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Affiliation(s)
- Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Jordi Bover
- Department of Nephrology, University Hospital Germans Trias i Pujol, Barcelona, Catalonia, Spain
- REMAR-IGTP Group, Germans Trias i Pujol Research Institute, Can Ruti Campus, Barcelona, Catalonia, Spain
| | - Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Justine Bacchetta
- Pediatric Nephrology Rheumatology and Dermatology Unit, Reference Center for Rare Renal Diseases, ORKID and ERK-Net networks, Lyon University Hospital, Bron, France
- Lyon Est Medical School, INSERM1033 Research Unit, Claude Bernard Lyon 1 University, Lyon, France
| | - Mathias Haarhaus
- Division of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Diaverum Sweden, Malmö, Sweden
| | - Ditte Hansen
- Department of Nephrology, Copenhagen University Hospital-Herlev, Copenhagen
- Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Carolina Gracia-Iguacel
- Department of Renal Medicine, IIS-Fundación Jiménez Díaz UAM University Hospital, Madrid, Spain
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
| | - Louise McAlister
- Dietetic Team, UCL Great Ormond Street Hospital for Children and University College London, London, UK
| | - Emily White
- Dietetic Team, Royal Free Hospital, University College London, London, UK
| | - Sandro Mazzaferro
- Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marc Vervloet
- Amsterdam Cardiovascular Sciences, Amsterdam UMC, The Netherlands
- Department of Nephrology, Amsterdam UMC, The Netherlands
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children, London, UK
- Institute of Child Health, University College London, London, UK
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15
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Fusaro M, Barbuto S, Gallieni M, Cossettini A, Re Sartò GV, Cosmai L, Cianciolo G, La Manna G, Nickolas T, Ferrari S, Bover J, Haarhaus M, Marino C, Mereu MC, Ravera M, Plebani M, Zaninotto M, Cozzolino M, Bianchi S, Messa P, Gregorini M, Gasperoni L, Agosto C, Aghi A, Tripepi G. Real-world usage of Chronic Kidney Disease - Mineral Bone Disorder (CKD-MBD) biomarkers in nephrology practices. Clin Kidney J 2024; 17:sfad290. [PMID: 38223338 PMCID: PMC10784916 DOI: 10.1093/ckj/sfad290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Indexed: 01/16/2024] Open
Abstract
Background Chronic kidney disease mineral bone disorder (CKD-MBD) is a condition characterized by alterations of calcium, phosphate, parathyroid hormone (PTH), and fibroblast growth factor 23 (FGF-23) metabolism that in turn promote bone disorders, vascular calcifications, and increase cardiovascular (CV) risk. Nephrologists' awareness of diagnostic, prognostic, and therapeutic tools to manage CKD-MBD plays a primary role in adequately preventing and managing this condition in clinical practice. Methods A national survey (composed of 15 closed questions) was launched to inquire about the use of bone biomarkers in the management of CKD-MBD patients by nephrologists and to gain knowledge about the implementation of guideline recommendations in clinical practice. Results One hundred and six Italian nephrologists participated in the survey for an overall response rate of about 10%. Nephrologists indicated that the laboratories of their hospitals were able to satisfy request of ionized calcium levels, 105 (99.1%) of both PTH and alkaline phosphatase (ALP), 100 (94.3%) of 25(OH)D, and 61 (57.5%) of 1.25(OH)2D; while most laboratories did not support the requests of biomarkers such as FGF-23 (intact: 88.7% and c-terminal: 93.4%), Klotho (95.3%; soluble form: 97.2%), tartrate-resistant acid phosphatase 5b (TRAP-5b) (92.5%), C-terminal telopeptide (CTX) (71.7%), and pro-collagen type 1 N-terminal pro-peptide (P1NP) (88.7%). As interesting data regarding Italian nephrologists' behavior to start treatment of secondary hyperparathyroidism (sHPT), the majority of clinicians used KDOQI guidelines (n = 55, 51.9%). In contrast, only 40 nephrologists (37.7%) relied on KDIGO guidelines, which recommended referring to values of PTH between two and nine times the upper limit of the normal range. Conclusion Results point out a marked heterogeneity in the management of CKD-MBD by clinicians as well as a suboptimal implementation of guidelines in Italian clinical practice.
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Affiliation(s)
- Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
- Department of Medicine, University of Padova, Padova, Italy
| | - Simona Barbuto
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Maurizio Gallieni
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, Università di Milano, Milano, Italy
- Post-Graduate School of Specialization in Nephrology, University of Milano, Milano, Italy
- Division of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Fatebenefratelli-Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Althea Cossettini
- Post-Graduate School of Specialization in Nephrology, University of Milano, Milano, Italy
| | | | - Laura Cosmai
- Division of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Fatebenefratelli-Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Thomas Nickolas
- Department of Medicine, Division of Nephrology, Columbia University, New York, NY, USA
| | - Serge Ferrari
- Service des Maladies Osseuses, Département de Médecine, HUG, Geneva, Switzerland
| | - Jordi Bover
- Servicio de Nefrología, Hospital Universitario Germans Trias i Pujol, Badalona (Barcelona), Spain
| | - Mathias Haarhaus
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Carmela Marino
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Reggio Calabria, Italy
| | | | - Maura Ravera
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, 16132 Genoa, Italy
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, Milan, Italy
| | - Stefano Bianchi
- Department of Internal Medicine, Nephrology and Dialysis Complex Operative Unit, Livorno, Italy
| | - Piergiorgio Messa
- Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Lorenzo Gasperoni
- Nephrology and Dialysis Unit, Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - Caterina Agosto
- Pediatric Pain and Palliative Care Service, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | | | - Giovanni Tripepi
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Reggio Calabria, Italy
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16
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Cejka D, Wakolbinger-Habel R, Zitt E, Fahrleitner-Pammer A, Amrein K, Dimai HP, Muschitz C. [Diagnosis and treatment of osteoporosis in patients with chronic kidney disease : Joint guidelines of the Austrian Society for Bone and Mineral Research (ÖGKM), the Austrian Society of Physical and Rehabilitation Medicine (ÖGPMR) and the Austrian Society of Nephrology (ÖGN)]. Wien Med Wochenschr 2023; 173:299-318. [PMID: 36542221 PMCID: PMC10516794 DOI: 10.1007/s10354-022-00989-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
DEFINITION AND EPIDEMIOLOGY Chronic kidney disease (CKD): abnormalities of kidney structure or function, present for over 3 months. Staging of CKD is based on GFR and albuminuria (not graded). Osteoporosis: compromised bone strength (low bone mass, disturbance of microarchitecture) predisposing to fracture. By definition, osteoporosis is diagnosed if the bone mineral density T‑score is ≤ -2.5. Furthermore, osteoporosis is diagnosed if a low-trauma (inadequate trauma) fracture occurs, irrespective of the measured T‑score (not graded). The prevalence of osteoporosis, osteoporotic fractures and CKD is increasing worldwide (not graded). PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENT OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER (CKD-MBD): Definition of CKD-MBD: a systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following: abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; renal osteodystrophy; vascular calcification (not graded). Increased, normal or decreased bone turnover can be found in renal osteodystrophy (not graded). Depending on CKD stage, routine monitoring of calcium, phosphorus, alkaline phosphatase, PTH and 25-OH-vitamin D is recommended (2C). Recommendations for treatment of CKD-MBD: Avoid hypercalcemia (1C). In cases of hyperphosphatemia, lower phosphorus towards normal range (2C). Keep PTH within or slightly above normal range (2D). Vitamin D deficiency should be avoided and treated when diagnosed (1C). DIAGNOSIS AND RISK STRATIFICATION OF OSTEOPOROSIS IN CKD Densitometry (using dual X‑ray absorptiometry, DXA): low T‑score correlates with increased fracture risk across all stages of CKD (not graded). A decrease of the T‑score by 1 unit approximately doubles the risk for osteoporotic fracture (not graded). A T-score ≥ -2.5 does not exclude osteoporosis (not graded). Bone mineral density of the lumbar spine measured by DXA can be increased and therefore should not be used for the diagnosis or monitoring of osteoporosis in the presence of aortic calcification, osteophytes or vertebral fracture (not graded). FRAX can be used to aid fracture risk estimation in all stages of CKD (1C). Bone turnover markers can be measured in individual cases to monitor treatment (2D). Bone biopsy may be considered in individual cases, especially in patients with CKD G5 (eGFR < 15 ml/min/1.73 m2) or CKD 5D (dialysis). SPECIFIC TREATMENT OF OSTEOPOROSIS IN PATIENTS WITH CKD Hypocalcemia should be treated and serum calcium normalized before initiating osteoporosis therapy (1C). CKD G1-G2 (eGFR ≥ 60 ml/min/1.73 m2): treat osteoporosis as recommended for the general population (1A). CKD G3-G5D (eGFR < 60 ml/min/1.73 m2 to dialysis): treat CKD-MBD first before initiating osteoporosis treatment (2C). CKD G3 (eGFR 30-59 ml/min/1.73 m2) with PTH within normal limits and osteoporotic fracture and/or high fracture risk according to FRAX: treat osteoporosis as recommended for the general population (2B). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) with osteoporotic fracture (secondary prevention): Individualized treatment of osteoporosis is recommended (2C). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) and high fracture risk (e.g. FRAX score > 20% for a major osteoporotic fracture or > 5% for hip fracture) but without prevalent osteoporotic fracture (primary prevention): treatment of osteoporosis may be considered and initiated individually (2D). CKD G4-5D (eGFR < 30 ml/min/1.73 m2 to dialysis): Calcium should be measured 1-2 weeks after initiation of antiresorptive therapy (1C). PHYSICAL MEDICINE AND REHABILITATION Resistance training prioritizing major muscle groups thrice weekly (1B). Aerobic exercise training for 40 min four times per week (1B). Coordination and balance exercises thrice weekly (1B). Flexibility exercise 3-7 times per week (1B).
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Affiliation(s)
- Daniel Cejka
- Abteilung für Innere Medizin III, Nieren- und Hochdruckerkrankungen, Transplantationsmedizin, Rheumatologie, Akutgeriatrie, Ordensklinikum Linz – Krankenhaus der Elisabethinen, Fadingerstr. 1, 4020 Linz, Österreich
| | - Robert Wakolbinger-Habel
- Department of Physical and Rehabilitation Medicine (PRM), Vienna Healthcare Group – Clinic Donaustadt, Langobardenstr. 122, 1220 Wien, Österreich
| | - Emanuel Zitt
- Department of Internal Medicine 3 (Nephrology and Dialysis), Feldkirch Academic Teaching Hospital, Feldkirch, Österreich
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Österreich
- Agency for Preventive and Social Medicine (aks), Bregenz, Österreich
| | - Astrid Fahrleitner-Pammer
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Hans Peter Dimai
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Christian Muschitz
- Medical Department II – VINFORCE, St. Vincent Hospital Vienna (Barmherzige Schwestern Krankenhaus Wien), Stumpergasse 13, 1060 Wien, Österreich
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17
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Levy-Schousboe K, Marckmann P, Frimodt-Møller M, Peters CD, Kjærgaard KD, Jensen JD, Strandhave C, Sandstrøm H, Hitz MF, Langdahl B, Vestergaard P, Brasen CL, Schmedes A, Madsen JS, Jørgensen NR, Frøkjær JB, Frandsen NE, Petersen I, Hansen D. Vitamin K supplementation and bone mineral density in dialysis: results of the double-blind, randomized, placebo-controlled RenaKvit trial. Nephrol Dial Transplant 2023; 38:2131-2142. [PMID: 36460034 PMCID: PMC10539208 DOI: 10.1093/ndt/gfac315] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Vitamin K deficiency is highly prevalent in patients on dialysis and may contribute to their low bone mineral density (BMD) and increased risk of fracture. This study investigated the effect of menaquinone-7 (MK-7) supplementation on BMD in patients on chronic dialysis. METHODS In a multicentre, double-blind, placebo-controlled intervention trial, 123 patients on chronic dialysis were randomised to a daily oral supplement of either MK-7 360 µg or placebo for 2 years. BMD of the distal radius (1/3, mid, ultradistal and total), femoral neck, lumbar spine (L1-L4) and whole body was assessed by dual-energy X-ray absorptiometry. Serum levels of vitamin K1 and MK-7 and plasma levels of total osteocalcin, dephosphorylated-uncarboxylated matrix Gla protein and protein induced by vitamin K absence II were measured to assess vitamin K status. RESULTS After 2 years, an accelerated BMD loss of the 1/3 distal radius was found with MK-7 supplementation {mean difference of changes relative to placebo -0.023 g/cm2 [95% confidence interval (CI) -0.039 to -0.008]}, whereas the decrease in lumbar spine BMD seen in the placebo group was prevented [mean difference of changes between groups 0.050 g/cm2 (95% CI 0.015-0.085)]. No significant effects were observed at the remaining skeletal sites. Vitamin K status strongly improved in MK-7-supplemented participants. CONCLUSION Compared with placebo, an accelerated BMD loss of the 1/3 distal radius was found after 2 years of MK-7 supplementation, whereas a decline in lumbar spine BMD was prevented. As such, MK-7 supplementation might modify BMD site-specifically in patients on dialysis. In aggregate, our findings do not support MK-7 supplementation to preserve bone in patients on dialysis.
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Affiliation(s)
| | - Peter Marckmann
- Department of Medicine Sønderborg-Tønder, Hospital Sønderjylland, Sønderborg, Denmark
| | - Marie Frimodt-Møller
- Steno Diabetes Center, Copenhagen, Denmark
- Department of Nephrology, Herlev University Hospital, Copenhagen, Denmark
| | - Christian D Peters
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Krista D Kjærgaard
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jens D Jensen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Hanne Sandstrøm
- Department of Radiology, Zealand University Hospital, Roskilde, Denmark
| | - Mette F Hitz
- Department of Medicine, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Vestergaard
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Claus L Brasen
- Department of Biochemistry and Immunology, Lillebælt Hospital, University Hospital of Southern Denmark, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Anne Schmedes
- Department of Biochemistry and Immunology, Lillebælt Hospital, University Hospital of Southern Denmark, Denmark
| | - Jonna S Madsen
- Department of Biochemistry and Immunology, Lillebælt Hospital, University Hospital of Southern Denmark, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Niklas R Jørgensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Jens B Frøkjær
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels E Frandsen
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Inge Petersen
- Open Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - Ditte Hansen
- Department of Nephrology, Herlev University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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18
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Newman CL, Surowiec RK, Swallow EA, Metzger CE, Kim J, Tomaschke AA, Chen NX, Allen MR, Wallace JM, Moe SM, Wu YC, Niziolek PJ. Assessing cortical bone porosity with MRI in an animal model of chronic kidney disease. Bone 2023; 173:116808. [PMID: 37207990 PMCID: PMC11167728 DOI: 10.1016/j.bone.2023.116808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/07/2023] [Accepted: 05/15/2023] [Indexed: 05/21/2023]
Abstract
Chronic kidney disease (CKD) is characterized by secondary hyperparathyroidism and an increased risk of hip fractures predominantly related to cortical porosity. Unfortunately, bone mineral density measurements and high-resolution peripheral computed tomography (HR-pQCT) imaging have shortcomings that limit their utility in these patients. Ultrashort echo time magnetic resonance imaging (UTE-MRI) has the potential to overcome these limitations by providing an alternative assessment of cortical porosity. The goal of the current study was to determine if UTE-MRI could detect changes in porosity in an established rat model of CKD. Cy/+ rats (n = 11), an established animal model of CKD-MBD, and their normal littermates (n = 12) were imaged using microcomputed tomography (microCT) and UTE-MRI at 30 and 35 weeks of age (which approximates late-stage kidney disease in humans). Images were obtained at the distal tibia and the proximal femur. Cortical porosity was assessed using the percent porosity (Pore%) calculated from microCT imaging and the porosity index (PI) calculated from UTE-MRI. Correlations between Pore% and PI were also calculated. Cy/+ rats had higher Pore% than normal rats at both skeletal sites at 35 weeks (tibia = 7.13 % +/- 5.59 % vs. 0.51 % +/- 0.09 %, femur = 19.99 % +/- 7.72 % vs. 2.72 % +/- 0.32 %). They also had greater PI at the distal tibia at 30 weeks of age (0.47 +/- 0.06 vs. 0.40 +/- 0.08). However, Pore% and PI were only correlated in the proximal femur at 35 weeks of age (ρ = 0.929, Spearman). These microCT results are consistent with prior studies in this animal model utilizing microCT imaging. The UTE-MRI results were inconsistent, resulting in variable correlations with microCT imaging, which may be related to suboptimal bound and pore water discrimination at higher magnetic field strengths. Nevertheless, UTE-MRI may still provide an additional clinical tool to assess fracture risk without using ionizing radiation in CKD patients.
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Affiliation(s)
- Christopher L Newman
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States of America.
| | - Rachel K Surowiec
- Department of Biomedical Engineering, Indiana University-Purdue University, Indianapolis, Indianapolis, IN, United States of America
| | | | - Corinne E Metzger
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, United States of America
| | - Jieun Kim
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, United States of America
| | - Andrew A Tomaschke
- Department of Biomedical Engineering, Indiana University-Purdue University, Indianapolis, Indianapolis, IN, United States of America
| | - Neal X Chen
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Matthew R Allen
- Department of Biomedical Engineering, Indiana University-Purdue University, Indianapolis, Indianapolis, IN, United States of America; Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America; Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Joseph M Wallace
- Department of Biomedical Engineering, Indiana University-Purdue University, Indianapolis, Indianapolis, IN, United States of America
| | - Sharon M Moe
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Yu-Chien Wu
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Paul J Niziolek
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States of America
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19
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Lafage-Proust MH. Bone and Chronic Kidney Disease. Semin Musculoskelet Radiol 2023; 27:463-470. [PMID: 37748470 DOI: 10.1055/s-0043-1770353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Chronic kidney disease (CKD) induces mineral and bone disorders (CKD-MBD) that affect calcium and phosphate metabolism. This review links pathophysiology, histologic aspects, and radiologic signs. CKD leads to bone lesions, namely renal osteodystrophy, which may combine low or high bone remodeling, impaired mineralization, and bone loss. CKD-MBD also comprises vascular calcifications, which, together with bone disease, lead to a high risk of cardiovascular events and osteoporotic fractures that increase both morbidity and mortality. Osteoporosis assessment is based on screening for classic risk factors and CKD-related factors (disease duration/severity, transplantation history, dialysis vintage). Treatment of mineral disorders may combine serum phosphate lowering drugs, natural vitamin D or its 1-α derivatives, or calcium-sensing receptor agonists. Treatment of osteoporosis is conventional in mild to moderate stages but more complex in severe CKD because evidence about the efficacy and safety of anti-osteoporosis drugs is scant.
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Affiliation(s)
- Marie-Hélène Lafage-Proust
- INSERM U1059 SAINBIOSE Université Jean Monnet, Saint-Etienne, France
- Service de Rhumatologie, CHU Saint-Etienne, Saint-Etienne, France
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20
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Ozawa M, Hirawa N, Haze T, Haruna A, Kawano R, Komiya S, Ohki Y, Suzuki S, Kobayashi Y, Fujiwara A, Saka S, Hanaoka M, Mitsuhashi H, Yamaguchi S, Ohnishi T, Tamura K. The implication of calf circumference and grip strength in osteoporosis and bone mineral density among hemodialysis patients. Clin Exp Nephrol 2023; 27:365-373. [PMID: 36574105 PMCID: PMC10023647 DOI: 10.1007/s10157-022-02308-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/02/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chronic kidney disease-mineral and bone disorder (CKD-MBD), nutritional status, and uremia management have been emphasized for bone management in hemodialysis patients. Nevertheless, valuable data on the importance of muscle mass in bone management are limited, including whether conventional management alone can prevent osteoporosis. Thus, the importance of muscle mass and strength, independent of the conventional management in osteoporosis prevention among hemodialysis patients, was evaluated. METHODS Patients with a history of hemodialysis 6 months or longer were selected. We assessed the risk for osteoporosis associated with calf circumference or grip strength using multivariable adjustment for indices of CKD-MBD, nutrition, and dialysis adequacy. Moreover, the associations between bone mineral density (BMD), calf circumference, grip strength, and bone metabolic markers were also evaluated. RESULTS A total of 136 patients were included. The odds ratios (95% confidence interval) for osteoporosis at the femoral neck were 1.25 (1.04-1.54, P < 0.05) and 1.08 (1.00-1.18, P < 0.05) per 1 cm shorter calf circumference or 1 kg weaker grip strength, respectively. Shorter calf circumference was significantly associated with a lower BMD at the femoral neck and lumbar spine (P < 0.001). Weaker grip strength was also associated with lower BMD at the femoral neck (P < 0.01). Calf circumference or grip strength was negatively correlated with bone metabolic marker values. CONCLUSION Shorter calf circumference or weaker grip strength was associated with osteoporosis risk and lower BMD among hemodialysis patients, independent of the conventional therapies.
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Affiliation(s)
- Moe Ozawa
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Japan
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Nobuhito Hirawa
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Japan.
| | - Tatsuya Haze
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Japan
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- YCU Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Yokohama, Japan
| | - Aiko Haruna
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Japan
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Rina Kawano
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Japan
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shiro Komiya
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Japan
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuki Ohki
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Japan
| | - Shota Suzuki
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Japan
| | - Yusuke Kobayashi
- YCU Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Yokohama, Japan
| | - Akira Fujiwara
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Japan
| | - Sanae Saka
- Department of Nephrology and Hypertension, Yokohama City University Medical Center, 4-57, Urafune-Cho, Minami-Ku, Yokohama, Japan
| | - Masaaki Hanaoka
- Kamiooka Jinsei Clinic, Kousaikai Medical Corporation, Yokohama, Japan
| | | | - Satoshi Yamaguchi
- Yokohama Jinsei Hospital, Kousaikai Medical Corporation, Yokohama, Japan
| | - Toshimasa Ohnishi
- Kamiooka Jinsei Clinic, Kousaikai Medical Corporation, Yokohama, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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21
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Kim H, Kim AJ, Ro H, Chang JH, Lee HH, Chung W, Jung JY. Serum calcification propensity and its association with biochemical parameters and bone mineral density in hemodialysis patients. Kidney Res Clin Pract 2023; 42:262-271. [PMID: 36328988 PMCID: PMC10085723 DOI: 10.23876/j.krcp.22.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/20/2022] [Accepted: 06/03/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND T50 is a novel serum-based marker that assesses the propensity for calcification in serum. A shorter T50 indicates a greater propensity to calcify and has been associated with cardiovascular disease and mortality among patients with chronic kidney disease. The factors associated with T50 and the correlation between T50 and bone mineral density (BMD) are unknown in hemodialysis (HD) patients. METHODS This cross-sectional study included 184 patients undergoing HD. Individuals were grouped into tertiles of T50 to compare the demographic and disease indicators of the tertiles. Linear regression was used to evaluate the association between T50 and hip and spinal BMD in a multivariate model. RESULTS Mineral and inflammatory parameters, including serum phosphate (r = -0.156, p = 0.04), albumin (r = 0.289, p < 0.001), and high-sensitivity C-reactive protein (r = -0.224, p = 0.003) levels, were associated with T50. We found a weak association between T50 and BMD in the total hip area in the unadjusted model (β = 0.030, p = 0.04) but did not find a statistically significant association with the total hip (β = 0.017, p = 0.12), femoral neck (β = -0.001, p = 0.96), or spinal BMD (β = 0.019, p = 0.33) in multivariable-adjusted models. CONCLUSION T50 was moderately associated with mineral and inflammatory parameters but did not conclusively establish an association with BMD in HD patients. Broad-scale future studies should determine whether T50 can provide insights into BMD beyond traditional risk factors in this population.
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Affiliation(s)
- Hyunsook Kim
- Department of Health Sciences and Technology, Gachon University, Incheon, Republic of Korea
| | - Ae Jin Kim
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Han Ro
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Jae Hyun Chang
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Hyun Hee Lee
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Wookyung Chung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Ji Yong Jung
- Department of Health Sciences and Technology, Gachon University, Incheon, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
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22
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Duarte MP, Ribeiro HS, Neri SGR, Almeida LS, Oliveira JS, Viana JL, Lima RM. Prevalence of low bone mineral density (T-score ≤ - 2.5) in the whole spectrum of chronic kidney disease: a systematic review and meta-analysis. Osteoporos Int 2023; 34:467-477. [PMID: 36370217 DOI: 10.1007/s00198-022-06598-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
The prevalence of low bone mineral density (LBMD) in people with chronic kidney disease (CKD) remains unknown. We identified a high prevalence of LBMD in CKD population. Thus, public health strategies should include efforts to prevent, early detect, and manage LBMD in CKD patients, especially in patients undergoing kidney replacement therapy. Mineral and bone disorders are common among patients with CKD, which affects bone mineral density. We conducted a systematic review and meta-analysis to estimate the prevalence of low bone mineral density (LBMD) in adults with CKD. We searched MEDLINE, EMBASE, Web of Science, CINAHL, and LILACS databases from inception to February 2021. Observational studies that reported the prevalence of LBMD in adults with CKD stages 3a-5D were included. The LBMD was defined according to the World Health Organization criterion (T-score ≤ - 2.5). Random-effect model meta-analyses were used to estimate the pooled prevalence of LBMD. Meta-regressions and subgroup analyses were conducted for stages of CKD, dialysis modality, gender, bone sites and morphology, and geographical region. This study was registered in PROSPERO, number CRD42020211077. One-hundred and fifty-three studies with 78,092 patients were included. The pooled global prevalence of LBMD in CKD was 24.5% (95% CI, 21.3 - 27.8%). Subgroup analyses indicated a higher prevalence of LBMD in dialysis patients (30%, 95% CI 25 - 35%) compared with non-dialysis CKD patients (12%, 95% CI 8 - 16%), cortical bone sites (28%, 95% CI 23 - 35%) relative to trabecular sites (19%, 95% CI 14 - 24%), while similar estimates in the European and the Asiatic continents (26%, 95% CI 21 - 30% vs 25%, 95% CI 21 - 29). The prevalence of LBMD in CKD patients is high, particularly in those undergoing dialysis and in cortical bone sites. Therefore, efforts to early diagnosis and management strategies should be implemented in clinical routine for an epidemiological control of LBMD in CKD patients.
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Affiliation(s)
- Marvery P Duarte
- Faculty of Physical Education, University of Brasilia, Brasília, Brazil.
| | - Heitor S Ribeiro
- Faculty of Physical Education, University of Brasilia, Brasília, Brazil
- Research Center in Sports Sciences and Human Development, CIDESD, University of Maia, Maia, Portugal
| | - Silvia G R Neri
- Faculty of Physical Education, University of Brasilia, Brasília, Brazil
| | - Lucas S Almeida
- Faculty of Physical Education, University of Brasilia, Brasília, Brazil
| | - Juliana S Oliveira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - João L Viana
- Research Center in Sports Sciences and Human Development, CIDESD, University of Maia, Maia, Portugal
| | - Ricardo M Lima
- Faculty of Physical Education, University of Brasilia, Brasília, Brazil
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23
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Suh SH, Oh TR, Choi HS, Yang EM, Kim CS, Bae EH, Ma SK, Oh KH, Hyun YY, Sung S, Kim SW. Bone Mineral Density and All-Cause Mortality in Patients with Nondialysis Chronic Kidney Disease: Results from KNOW-CKD Study. J Clin Med 2023; 12:jcm12051850. [PMID: 36902637 PMCID: PMC10003778 DOI: 10.3390/jcm12051850] [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: 01/18/2023] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Despite the clear association between low BMD and all-cause mortality in the general population, the association has not been validated in patients with nondialysis CKD. To investigate the association of low BMD with all-cause mortality in this population, a total of 2089 patients with nondialysis CKD at stages 1 to predialysis 5 were categorized into normal BMD (T-score ≥ -1.0), osteopenia (-2.5 < T-score < -1.0), and osteoporosis (T-score ≤ - 2.5) by the BMD at femoral neck. The study outcome was all-cause mortality. Kaplan-Meier curve depicted a significantly increased number of all-cause death events in the subjects with osteopenia or osteoporosis during the follow-up period compared with subjects with normal BMD. Cox regression models demonstrated that osteoporosis, but not osteopenia, was significantly associated with an increased risk of all-cause mortality (adjusted hazard ratio 2.963, 95% confidence interval 1.655 to 5.307). Smoothing curve fitting model visualized a clear inverse correlation between BMD T-score and the risk of all-cause mortality. Even after recategorizing the subjects by BMD T-scores at total hip or lumbar spine, the result was similar to the primary analyses. Subgroup analyses revealed that the association was not significantly modified by clinical contexts, such as age, gender, body mass index, estimated glomerular filtration rate, and albuminuria. In conclusion, low BMD is associated with an increased risk of all-cause mortality in patients with nondialysis CKD. This emphasizes that the routine measurement of BMD by DXA may confer an additional benefit beyond the prediction of fracture risk in this population.
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Affiliation(s)
- Sang Heon Suh
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
| | - Tae Ryom Oh
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
| | - Hong Sang Choi
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
| | - Eun Mi Yang
- Department of Pediatrics, Chonnam National University Medical School, Gwangju 61469, Republic of Korea
- Department of Pediatrics, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
| | - Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Young Youl Hyun
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Republic of Korea
| | - Suah Sung
- Department of Internal Medicine, Eulji Medical Center, Eulji University, Seoul 01830, Republic of Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
- Correspondence: ; Tel.: +82-62-225-6271
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Sumi H, Shiizaki K, Tominaga N. Letter to the Editor From Sumi et al.: "Lower Bone Turnover and Skeletal PTH Responsiveness in Japanese Compared to European Patients Receiving Hemodialysis". J Clin Endocrinol Metab 2023; 108:e40-e41. [PMID: 36469590 DOI: 10.1210/clinem/dgac696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Hirofumi Sumi
- Division of Nephrology and Hypertension, Kawasaki Municipal Tama Hospital, Tama-ku, Kawasaki, Kanagawa 214-8525, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
| | - Kazuhiro Shiizaki
- Department of Nephrology, Yurina Medical Park, Nogi-machi, Shimotsuga, Tochigi 329-0111, Japan
| | - Naoto Tominaga
- Division of Nephrology and Hypertension, Kawasaki Municipal Tama Hospital, Tama-ku, Kawasaki, Kanagawa 214-8525, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan
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Bone Disease in Chronic Kidney Disease and Kidney Transplant. Nutrients 2022; 15:nu15010167. [PMID: 36615824 PMCID: PMC9824497 DOI: 10.3390/nu15010167] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022] Open
Abstract
Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) comprises alterations in calcium, phosphorus, parathyroid hormone (PTH), Vitamin D, and fibroblast growth factor-23 (FGF-23) metabolism, abnormalities in bone turnover, mineralization, volume, linear growth or strength, and vascular calcification leading to an increase in bone fractures and vascular disease, which ultimately result in high morbidity and mortality. The bone component of CKD-MBD, referred to as renal osteodystrophy, starts early during the course of CKD as a result of the effects of progressive reduction in kidney function which modify the tight interaction between mineral, hormonal, and other biochemical mediators of cell function that ultimately lead to bone disease. In addition, other factors, such as osteoporosis not apparently dependent on the typical pathophysiologic abnormalities resulting from altered kidney function, may accompany the different varieties of renal osteodystrophy leading to an increment in the risk of bone fracture. After kidney transplantation, these bone alterations and others directly associated or not with changes in kidney function may persist, progress or transform into a different entity due to new pathogenetic mechanisms. With time, these alterations may improve or worsen depending to a large extent on the restoration of kidney function and correction of the metabolic abnormalities developed during the course of CKD. In this paper, we review the bone lesions that occur during both CKD progression and after kidney transplant and analyze the factors involved in their pathogenesis as a means to raise awareness of their complexity and interrelationship.
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Advancement in the Treatment of Osteoporosis and the Effects on Bone Healing. J Clin Med 2022; 11:jcm11247477. [PMID: 36556093 PMCID: PMC9781093 DOI: 10.3390/jcm11247477] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
Osteoporosis (OP) is a major global health concern, with aging being one of the most important risk factors. Osteoarthritis (OA) is also an age-related disorder. Patients with OP and/or OA may be treated surgically for fractures or when their quality of life is impaired. Poor bone quality due to OP can seriously complicate the stability of a bone fixation construct and/or surgical fracture treatment. This review summarizes the current knowledge on the pathophysiology of normal and osteoporotic bone healing, the effect of a bone fracture on bone turnover markers, the diagnosis of a low bone mineral density (BMD) before surgical intervention, and the effect of available anti-osteoporosis treatment. Interventions that improve bone health may enhance the probability of favorable surgical outcomes. Fracture healing and the treatment of atypical femoral fractures are also discussed.
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Schini M, Vilaca T, Gossiel F, Salam S, Eastell R. Bone Turnover Markers: Basic Biology to Clinical Applications. Endocr Rev 2022; 44:417-473. [PMID: 36510335 PMCID: PMC10166271 DOI: 10.1210/endrev/bnac031] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 11/26/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
Bone turnover markers (BTMs) are used widely, in both research and clinical practice. In the last 20 years, much experience has been gained in measurement and interpretation of these markers, which include commonly used bone formation markers bone alkaline phosphatase, osteocalcin, and procollagen I N-propeptide; and commonly used resorption markers serum C-telopeptides of type I collagen, urinary N-telopeptides of type I collagen and tartrate resistant acid phosphatase type 5b. BTMs are usually measured by enzyme-linked immunosorbent assay or automated immunoassay. Sources contributing to BTM variability include uncontrollable components (e.g., age, gender, ethnicity) and controllable components, particularly relating to collection conditions (e.g., fasting/feeding state, and timing relative to circadian rhythms, menstrual cycling, and exercise). Pregnancy, season, drugs, and recent fracture(s) can also affect BTMs. BTMs correlate with other methods of assessing bone turnover, such as bone biopsies and radiotracer kinetics; and can usefully contribute to diagnosis and management of several diseases such as osteoporosis, osteomalacia, Paget's disease, fibrous dysplasia, hypophosphatasia, primary hyperparathyroidism, and chronic kidney disease-mineral bone disorder.
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Affiliation(s)
- Marian Schini
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Tatiane Vilaca
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Fatma Gossiel
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Syazrah Salam
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Richard Eastell
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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28
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Aleksova J, Ebeling PR, Milat F, Elder GJ. DXA-derived advanced hip analysis and the trabecular bone score in end-stage kidney disease secondary to type 1 diabetes. Eur J Endocrinol 2022; 187:883-892. [PMID: 36315195 DOI: 10.1530/eje-22-0687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/31/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Patients with end-stage kidney disease (ESKD) caused by type 1 diabetes mellitus (T1DM) have a heightened fracture risk. Bone mineral density (BMD) may predict fracture less accurately in ESKD than in patients with chronic kidney disease (CKD) stages 1-3b or the general population. Alternate, readily available imaging modalities are needed to improve ESKD fracture risk assessment. This study aimed to assess dual-energy X-ray absorptiometry (DXA)-derived BMD, the trabecular bone score (TBS) and advanced hip analysis parameters in patients with ESKD due to T1DM and to compare their results with those of patients with ESKD from other causes. METHODS We compared the DXA-derived TBS, hip cortical thickness (CT) and femoral neck (FN) buckling ratio (BR), an index of FN stability, of patients with T1DM and ESKD undergoing simultaneous pancreas kidney transplantation, patients with ESKD from other causes receiving kidney transplants and population reference ranges. RESULTS Of 227 patients with ESKD, 28% had T1DM and 65% were male. Compared with other ESKD patients, patients with T1DM were younger (42 ± 7.7 vs 51 ± 13.8 years), had shorter dialysis duration (24.4 ± 21 vs 42.6 ± 40 months), had higher HbA1c (7.9 ± 1.57% vs 5.4 ± 0.95%) and had lower BMI (25 ± 6 vs 27 ± 5 kg/m2). They had lower spine, hip and UD radius BMD Z-scores (all P ≤ 0.001), TBS (1.33 ± 0.12 vs 1.36 ± 0.12; P = 0.05), CT at the FN (P = 0.03), calcar (P = 0.006) and shaft (P < 0.001) and higher BR (10.1±7.1 vs 7.7±4; P = 0.006). All ESKD parameters were lower than population-based reference ranges (P < 0.001). Adjusting for age, sex, dialysis vintage and weight, prevalent vertebral fractures in patients with T1DM and ESKD were associated with higher BR (odds ratio (OR): 3.27 (95% CI: 1.19-8.92), P = 0.002) and lower FN CT (OR: 3.70 (95% CI: 1.13-12.50)). CONCLUSION Patients with ESKD and T1DM have reduced TBS, reduced CT and increased BR compared with other ESKD patients. Prospective study of these parameters is warranted to determine their utility in fracture risk prediction and management. SIGNIFICANCE STATEMENT Patients with ESKD and T1DM have an elevated fracture risk due to decreased bone strength. As an adjunct to BMD, evaluating dual-energy X-ray absorptiometry parameters that incorporate structural change may have greater value in patients with ESKD and T1DM than in the general population. In this study, patients with ESKD due to T1DM had lower BMD, lower trabecular bone scores, more severe loss of CT and higher BR than other patients with ESKD and people from the general population. Both lower CT and higher BR were associated with prevalent vertebral fractures in patients with T1DM and ESKD. Changes to these parameters should be evaluated for incident fracture prediction.
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Affiliation(s)
- Jasna Aleksova
- Hudson Institute for Medical Research
- Department of Medicine, Monash University
- Department of Endocrinology, Monash Health
| | - Peter R Ebeling
- Department of Medicine, Monash University
- Department of Endocrinology, Monash Health
| | - Frances Milat
- Hudson Institute for Medical Research
- Department of Medicine, Monash University
- Department of Endocrinology, Monash Health
| | - Grahame J Elder
- Department of Renal Medicine, Westmead Hospital
- Skeletal Biology Program, Garvan Institute of Medical Research
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29
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Burstad KM, Cladis DP, Vorland CJ, Wastney ME, Biruete A, Dominguez JM, O'Neill KD, Chen NX, Moe SM, Hill Gallant KM. Acute High Dietary Phosphorus Following Low-Phosphorus Diet Acclimation Does Not Enhance Intestinal Fractional Phosphorus Absorption in Nephrectomized Male Rats. JBMR Plus 2022; 6:e10698. [PMID: 36530183 PMCID: PMC9751657 DOI: 10.1002/jbm4.10698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/05/2022] [Accepted: 10/27/2022] [Indexed: 05/21/2024] Open
Abstract
Dietary phosphorus restriction and phosphorus binders are commonly prescribed for patients with chronic kidney disease (CKD). However, occurrences of non-adherence to these interventions are common. As low-phosphorus (LP) diets have been consistently experimentally shown in vitro to increase intestinal phosphorus absorption efficiency, a bout of non-adherence to diet or binders may cause an unintended consequence of enhanced intestinal phosphorus absorption. Thus, we aimed to determine the effect of a single bout of high-phosphorus (HP) intake after acclimation to a LP diet. Male Sprague Dawley rats with 5/6 nephrectomy (n = 36) or sham operation (n = 36) were block-randomized to 1 of 3 diets: LP (0.1% P w/w), HP (1.2%), or LP followed by acute HP (LPHP 0.1% then 1.2%). Phosphorus absorption tests were conducted using 33P radioisotope administrated by oral gavage or intravenously (iv). Although the overall two-way ANCOVA model for intestinal fractional phosphorus absorption was non-significant, exploratory comparisons showed intestinal fractional phosphorus absorption efficiency tended to be higher in rats in the LP compared with HP or LPHP groups. Rats in the HP or LPHP groups had higher plasma phosphorus compared with rats in the LP group, but the LPHP group was not different from the HP group. Gene expression of the major intestinal phosphate transporter, NaPi-2b, was lower in the jejunum of rats in the LPHP group compared with rats in the HP group but not different in the duodenum. These results demonstrate that an acute HP load after acclimation to a LP diet does not lead to enhanced intestinal fractional phosphorus absorption efficiency in 5/6 nephrectomized male rats. These data provide evidence against the notion that dietary phosphorus restriction or binder use adversely increases absorption efficiency after a single instance of dietary or binder non-adherence. However, other adverse consequences of fluctuating dietary phosphorus intake cannot be ruled out. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Kendal M Burstad
- Department of Food Science and NutritionUniversity of MinnesotaSaint PaulMNUSA
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
| | - Dennis P Cladis
- Department of Food Science and NutritionUniversity of MinnesotaSaint PaulMNUSA
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
| | - Colby J Vorland
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
- Department of Applied Health ScienceIndiana University School of Public Health‐BloomingtonBloomingtonINUSA
| | - Meryl E Wastney
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
| | - Annabel Biruete
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
- Department of Nutrition and DieteticsIndiana University‐Purdue University IndianapolisIndianapolisINUSA
| | - James M Dominguez
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
| | - Kalisha D O'Neill
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
| | - Neal X Chen
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
| | - Sharon M Moe
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
- Department of Anatomy and Cell BiologyIndiana University School of MedicineIndianapolisINUSA
- Department of MedicineRoudebush Veterans Affairs Medicine CenterIndianapolisINUSA
| | - Kathleen M Hill Gallant
- Department of Food Science and NutritionUniversity of MinnesotaSaint PaulMNUSA
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
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Metzger CE, Newman CL, Tippen SP, Golemme NT, Chen NX, Moe SM, Allen MR. Cortical porosity occurs at varying degrees throughout the skeleton in rats with chronic kidney disease. Bone Rep 2022; 17:101612. [PMID: 36035656 PMCID: PMC9411579 DOI: 10.1016/j.bonr.2022.101612] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/03/2022] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
Cortical porosity develops in chronic kidney disease (CKD) and increases with progressing disease. Cortical porosity is likely a prominent contributor to skeletal fragility/fracture. The degree to which cortical porosity occurs throughout the skeleton is not fully known. In this study, we assessed cortical bone porosity via micro-computed tomography at multiple skeletal sites in rats with progressive chronic kidney disease. We hypothesized that cortical porosity would occur in long bones throughout the body, but to a lesser degree in flat bones and irregular bones. Porosity was measured, using micro-CT, at 17 different skeletal sites in 6 male rats with CKD. Varying degrees of porosity were seen throughout the skeleton with higher porosity in flat and irregular bone (i.e. parietal bone, mandible) vs. long bones (p = 0.01) and in non-weightbearing bones vs. weightbearing bones (p = 0.01). Porosity was also higher in proximal sites vs. distal sites in long bones (p < 0.01 in all comparisons). There was large heterogeneity in porosity within skeletal sites across rats and within the same rat across skeletal sites. Correlations showed cortical porosity of the proximal tibia was positively associated with porosity at the other sites with the strongest correlation to the parietal bone and the weakest to the ulna. Overall, our data demonstrates varying and significant cortical bone porosity across the skeleton of animals with chronic kidney disease. These data point to careful selection of skeletal sites to assess porosity in pre-clinical studies and the potential for fractures at multiple skeletal sites in patients with CKD.
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Affiliation(s)
- Corinne E. Metzger
- Department of Anatomy, Cell Biology, and Physiology, Indianapolis, IN, USA, 46202
| | | | - Samantha P. Tippen
- Department of Anatomy, Cell Biology, and Physiology, Indianapolis, IN, USA, 46202
| | - Natalie T. Golemme
- Department of Anatomy, Cell Biology, and Physiology, Indianapolis, IN, USA, 46202
| | - Neal X. Chen
- Department of Medicine, Indiana University School of Medicine, Indianapolis 46202, IN, USA
| | - Sharon M. Moe
- Department of Medicine, Indiana University School of Medicine, Indianapolis 46202, IN, USA
| | - Matthew R. Allen
- Department of Anatomy, Cell Biology, and Physiology, Indianapolis, IN, USA, 46202
- Department of Medicine, Indiana University School of Medicine, Indianapolis 46202, IN, USA
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis 46202, IN, USA
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31
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Evenepoel P, Jørgensen HS, Komaba H, Mazzaferro S, Vervloet M, Cavalier E, Fukagawa M. Lower Bone Turnover and Skeletal PTH Responsiveness in Japanese Compared to European Patients on Hemodialysis. J Clin Endocrinol Metab 2022; 107:e4350-e4359. [PMID: 36068939 DOI: 10.1210/clinem/dgac522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Parathyroid hormone (PTH) treatment targets for patients receiving hemodialysis (HD) are lower in Japan than in Europe. Whether this translates to lower bone turnover is unknown and could depend on skeletal PTH responsiveness. OBJECTIVE This study investigates whether skeletal PTH responsiveness is better preserved in Japanese vs European patients receiving HD. METHODS This is a post hoc analysis of data from 2 prospective cohort studies, using a case-control design. Patients receiving chronic intermittent HD therapy were eligible for inclusion. Participating Belgian and Japanese patients (n = 374) were matched 1:1 by age (59 ± 12 years), sex (66% male), diabetes (34%), and dialysis duration (39 months [22-63 months]). PTH, bone-specific alkaline phosphatase (BALP), and tartrate-resistant acid phosphatase isoform 5b (TRAP5b) were measured centrally in Liège, Belgium. RESULTS Japanese patients had lower levels of iPTH (207 vs 268 pg/mL; P < .001), BALP (15.3 vs 24.5 μg/L; P < .001), and TRAP5b (3.35 vs 5.79 U/L; P < .001). Linear regression analyses revealed lower levels of bone turnover markers for any given level of PTH in Japanese vs Belgian patients, indicating lower skeletal PTH responsiveness. Consistently, bone turnover markers were significantly lower in Japanese vs Belgian patients when stratifying or matching according to PTH levels. Male sex, obesity, and hyperphosphatemia were the main determinants of the bone turnover marker/PTH ratios. CONCLUSION Japanese patients receiving HD have lower bone turnover than their European counterparts, even at similar PTH levels. The rationale for the current regional differences in PTH treatment targets remains obscure and deserves further attention.
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Affiliation(s)
- Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, 3000 Leuven, Belgium
- Department of Medicine, Division of Nephrology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, 3000 Leuven, Belgium
- Department of Renal Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara 259-1193, Japan
| | - Sandro Mazzaferro
- Nephrology Unit at Policlinico Umberto I Hospital, 00185 Rome, Italy
- Department of Translation and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Marc Vervloet
- Department of Nephrology, Amsterdam University Medical Center, 1081 HV Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, 1081 HV Amsterdam, the Netherlands
| | - Etienne Cavalier
- Department of Biochemistry, Université de Liège, 4000 Liège, Belgium
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara 259-1193, Japan
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32
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Pediatric CKD-MBD: existing and emerging treatment approaches. Pediatr Nephrol 2022; 37:2599-2614. [PMID: 35038008 DOI: 10.1007/s00467-021-05265-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 12/13/2022]
Abstract
The effects of bone and mineral metabolism on skeletal formation, as well as vascular and soft tissue calcifications, define chronic kidney disease-metabolic bone disease (CKD-MBD). Treatment recommendations center on establishing adequate vitamin D status, phosphate control through diet restriction and phosphate binders, and the use of vitamin D analogs for specific indications. Several emerging bone-promoting therapies have now been studied in adults with CKD, including bisphosphonates and denosumab. These approaches are associated with improved bone mass and, in some cases, decreased fracture rates in adults with CKD-MBD and are of potential interest for some children with CKD-MBD. In children with CKD and immobilization and/or muscle weakness, bisphosphonates appear to be an effective treatment to increase bone mass; baseline assessment and careful monitoring of bone density and/or bone biopsy findings are important in consideration of any new bone therapies for children with CKD-MBD.
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Abdalbary M, Sobh M, Elnagar S, Elhadedy MA, Elshabrawy N, Abdelsalam M, Asadipooya K, Sabry A, Halawa A, El-Husseini A. Management of osteoporosis in patients with chronic kidney disease. Osteoporos Int 2022; 33:2259-2274. [PMID: 35748896 DOI: 10.1007/s00198-022-06462-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/31/2022] [Indexed: 12/19/2022]
Abstract
Patients with CKD have a 4-fivefold higher rate of fractures. The incidence of fractures increases with deterioration of kidney function. The process of skeletal changes in CKD patients is characterized by compromised bone strength because of deterioration of bone quantity and/or quality. The fractures lead to a deleterious effect on the quality of life and higher mortality in patients with CKD. The pathogenesis of bone loss and fracture is complex and multi-factorial. Renal osteodystrophy, uremic milieu, drugs, and systemic diseases that lead to renal failure all contribute to bone damage in CKD patients. There is no consensus on the optimal diagnostic method of compromised bone assessment in patients with CKD. Bone quantity and mass can be assessed by dual-energy x-ray absorptiometry (DXA) or quantitative computed tomography (QCT). Bone quality on the other side can be assessed by non-invasive methods such as trabecular bone score (TBS), high-resolution bone imaging methods, and invasive bone biopsy. Bone turnover markers can reflect bone remodeling, but some of them are retained by kidneys. Understanding the mechanism of bone loss is pivotal in preventing fracture in patients with CKD. Several non-pharmacological and therapeutic interventions have been reported to improve bone health. Controlling laboratory abnormalities of CKD-MBD is crucial. Anti-resorptive therapies are effective in improving BMD and reducing fracture risk, but there are uncertainties about safety and efficacy especially in advanced CKD patients. Accepting the prevalent of low bone turnover in patients with advanced CKD, the osteo-anabolics are possibly promising. Parathyroidectomy should be considered a last resort for intractable cases of renal hyperparathyroidism. There is a wide unacceptable gap in osteoporosis management in patients with CKD. This article is focusing on the updated management of CKD-MBD and osteoporosis in CKD patients. Chronic kidney disease deteriorates bone quality and quantity. The mechanism of bone loss mainly determines pharmacological treatment. DXA and QCT provide information about bone quantity, but assessing bone quality, by TBS, high-resolution bone imaging, invasive bone biopsy, and bone turnover markers, can guide us about the mechanism of bone loss.
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Affiliation(s)
- M Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA
| | - M Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - S Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M A Elhadedy
- Nephrology and Transplantation Unit, Mansoura Urology and Nephrology Center, Mansoura, Egypt
| | - N Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - K Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, USA
| | - A Sabry
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - A Halawa
- Sheffield Teaching Hospital, University of Liverpool, Liverpool, UK
| | - A El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA.
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Jørgensen HS, Borghs H, Heye S, Smout D, Claes K, Evenepoel P. Vascular calcification of the abdominal aorta has minimal impact on lumbar spine bone density in patients with chronic kidney disease. Bone 2022; 162:116482. [PMID: 35787485 DOI: 10.1016/j.bone.2022.116482] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Herman Borghs
- Center for Metabolic Bone Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Sam Heye
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium; Department of Radiology, Jessa Ziekenhuis, Hasselt, Belgium
| | - Dieter Smout
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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Alkaline Phosphatase: An Old Friend as Treatment Target for Cardiovascular and Mineral Bone Disorders in Chronic Kidney Disease. Nutrients 2022; 14:nu14102124. [PMID: 35631265 PMCID: PMC9144546 DOI: 10.3390/nu14102124] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022] Open
Abstract
Alkaline phosphatase (ALP) is an evolutionary conserved enzyme and widely used biomarker in clinical practice. Tissue-nonspecific alkaline phosphatase (TNALP) is one of four human isozymes that are expressed as distinct TNALP isoforms after posttranslational modifications, mainly in bone, liver, and kidney tissues. Beyond the well-known effects on bone mineralization, the bone ALP (BALP) isoforms (B/I, B1, B1x, and B2) are also involved in the pathogenesis of ectopic calcification. This narrative review summarizes the recent clinical investigations and mechanisms that link ALP and BALP to inflammation, metabolic syndrome, vascular calcification, endothelial dysfunction, fibrosis, cardiovascular disease, and mortality. The association between ALP, vitamin K, bone metabolism, and fracture risk in patients with chronic kidney disease (CKD) is also discussed. Recent advances in different pharmacological strategies are highlighted, with the potential to modulate the expression of ALP directly and indirectly in CKD–mineral and bone disorder (CKD-MBD), e.g., epigenetic modulation, phosphate binders, calcimimetics, vitamin D, and other anti-fracture treatments. We conclude that the significant evidence for ALP as a pathogenic factor and risk marker in CKD-MBD supports the inclusion of concrete treatment targets for ALP in clinical guidelines. While a target value below 120 U/L is associated with improved survival, further experimental and clinical research should explore interventional strategies with optimal risk–benefit profiles. The future holds great promise for novel drug therapies modulating ALP.
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Wu PY, Chen SC, Lin YC, Chen PC, Chung WS, Huang YC, Wu PH, Tsai YC, Huang JC, Chiu YW, Chang JM. Role of Fracture Risk Assessment Tool and Bone Turnover Markers in Predicting All-Cause and Cardiovascular Mortality in Hemodialysis Patients. Front Med (Lausanne) 2022; 9:891363. [PMID: 35463031 PMCID: PMC9021425 DOI: 10.3389/fmed.2022.891363] [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: 03/07/2022] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background Fracture Risk Assessment Tool (FRAX) and bone turnover markers (BTMs) predict fractures in the general population. However, the role of FRAX and BTMs in predicting mortality remains uncertain in hemodialysis (HD) patients. Methods One hundred and sixty-four HD patients stratified by low or high risk of 10-year fracture probability using FRAX. High risk of fracture was defined as 10-year probability of hip fracture ≥3% or major osteoporotic fracture ≥20%. The association of high risk of fracture and BTMs with all-cause mortality and cardiovascular (CV) mortality were evaluated using multivariate-adjusted Cox regression analysis. Results Eighty-five (51.8%) patients were classified as high risk of fracture based on FRAX among 164 HD patients. During a mean follow-up period of 3.5 ± 1.0 years, there were 39 all-cause deaths and 23 CV deaths. In multivariate-adjusted Cox regression, high risk of fracture based on FRAX was independently associated with all-cause mortality [hazard ratio (HR): 2.493, 95% confidence interval (CI): 1.026–6.056, p = 0.044) but not with CV mortality (HR: 2.129, 95% CI: 0.677–6.700, p = 0.196). There were no associations between BTMs and mortality risk. Furthermore, lower geriatric nutritional risk index (GNRI) was significantly associated with increased CV mortality (HR: 0.888, 95% CI: 0.802–0.983, p = 0.022) after adjusting by confounding variables. Conclusion High risk of fracture using FRAX was an independent predictor of all-cause mortality in patients undergoing HD. FRAX, rather than BTMs, has an important role of prognostic significance in HD patients.
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Affiliation(s)
- Pei-Yu Wu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Szu-Chia Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Ching Lin
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Doctoral Degree Program of Toxicology, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Chih Chen
- Department of Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Shiuan Chung
- Department of Radiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Radiology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ya-Chin Huang
- Department of Preventive Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Occupational & Environmental Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ping-Hsun Wu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chun Tsai
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jiun-Chi Huang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Wen Chiu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jer-Ming Chang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Sobh MM, Abdalbary M, Elnagar S, Nagy E, Elshabrawy N, Abdelsalam M, Asadipooya K, El-Husseini A. Secondary Osteoporosis and Metabolic Bone Diseases. J Clin Med 2022; 11:jcm11092382. [PMID: 35566509 PMCID: PMC9102221 DOI: 10.3390/jcm11092382] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/17/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023] Open
Abstract
Fragility fracture is a worldwide problem and a main cause of disability and impaired quality of life. It is primarily caused by osteoporosis, characterized by impaired bone quantity and or quality. Proper diagnosis of osteoporosis is essential for prevention of fragility fractures. Osteoporosis can be primary in postmenopausal women because of estrogen deficiency. Secondary forms of osteoporosis are not uncommon in both men and women. Most systemic illnesses and organ dysfunction can lead to osteoporosis. The kidney plays a crucial role in maintaining physiological bone homeostasis by controlling minerals, electrolytes, acid-base, vitamin D and parathyroid function. Chronic kidney disease with its uremic milieu disturbs this balance, leading to renal osteodystrophy. Diabetes mellitus represents the most common secondary cause of osteoporosis. Thyroid and parathyroid disorders can dysregulate the osteoblast/osteoclast functions. Gastrointestinal disorders, malnutrition and malabsorption can result in mineral and vitamin D deficiencies and bone loss. Patients with chronic liver disease have a higher risk of fracture due to hepatic osteodystrophy. Proinflammatory cytokines in infectious, autoimmune, and hematological disorders can stimulate osteoclastogenesis, leading to osteoporosis. Moreover, drug-induced osteoporosis is not uncommon. In this review, we focus on causes, pathogenesis, and management of secondary osteoporosis.
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Affiliation(s)
- Mahmoud M. Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Mohamed Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40506, USA
| | - Sherouk Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Eman Nagy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Nehal Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Mostafa Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura 35516, Egypt; (M.M.S.); (M.A.); (S.E.); (E.N.); (N.E.); (M.A.)
| | - Kamyar Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, KY 40506, USA;
| | - Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY 40506, USA
- Correspondence: ; Tel.: +1-859-218-0934
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Fusaro M, Re Sartò GV, Gallieni M, Cosmai L, Messa P, Rossini M, Chiodini I, Plebani M, Evenepoel P, Harvey N, Ferrari S, Cannata-Andía J, Trombetti A, Brandi ML, Ketteler M, Nickolas TL, Cunningham J, Salam S, Della Rocca C, Scarpa A, Minisola S, Malberti F, Cetani F, Cozzolino M, Mazzaferro S, Morrone L, Tripepi G, Zaninotto M, Mereu MC, Ravera M, Cianciolo G, La Manna G, Aghi A, Giannini S, Dalle Carbonare L. Time for Revival of Bone Biopsy with Histomorphometric Analysis in Chronic Kidney Disease (CKD): Moving from Skepticism to Pragmatism. Nutrients 2022; 14:1742. [PMID: 35565717 PMCID: PMC9103887 DOI: 10.3390/nu14091742] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 12/04/2022] Open
Abstract
Bone Biopsy (BB) with histomorphometric analysis still represents the gold standard for the diagnosis and classification of different forms of renal osteodystrophy. Bone biopsy is the only technique able to provide comprehensive information on all bone parameters, measuring static and dynamic parameters of turnover, cortical and trabecular microarchitecture, and mineralization defects. In nephrological practice, bone biopsy yields relevant indications to support therapeutic choices in CKD, heavily impacting the management and prognosis of uremic patients. Unfortunately, the use of bone biopsy has decreased; a lack of expertise in performing and interpreting, perceived procedure invasiveness and pain, and reimbursement issues have all contributed to this decline. Nevertheless, both bone biomarkers and instrumental images cannot be considered reliable surrogates for histological findings, being insufficiently accurate to properly evaluate underlying mineral and bone disorders. This is a multidisciplinary position paper from the Nephrology and Osteoporosis Italian Scientific Societies with the purpose of restating the role of bone biopsy in CKD patient management and of providing strong solutions to allow diffusion of this technique in Italy, but potentially also in other countries. The Italian approach through the optimization and standardization of bone biopsy procedure, the construction of the Italian Hub and Spoke network, and a request for adjustment and national homogenization of reimbursement to the Italian Health Ministry has led the way to implement bone biopsy and to improve CKD patient management and prognosis.
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Affiliation(s)
- Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), 56124 Pisa, Italy
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Giulia Vanessa Re Sartò
- Post-Graduate School of Specialization in Nephrology, University of Milano, 20157 Milano, Italy; (G.V.R.S.); (M.G.)
| | - Maurizio Gallieni
- Post-Graduate School of Specialization in Nephrology, University of Milano, 20157 Milano, Italy; (G.V.R.S.); (M.G.)
- Department of Biomedical and Clinical Sciences, Università di Milano, 20157 Milano, Italy
- Nephrology Unit, ASST Fatebenefratelli Sacco, 20157 Milano, Italy;
| | - Laura Cosmai
- Nephrology Unit, ASST Fatebenefratelli Sacco, 20157 Milano, Italy;
| | - Piergiorgio Messa
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, 20157 Milano, Italy;
- Department of Clinical Sciences and Community Health, University of Milano, 20122 Milano, Italy
| | | | - Iacopo Chiodini
- Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, 20157 Milano, Italy;
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine, University of Padua, 35121 Padua, Italy; (M.P.); (M.Z.)
| | - Pieter Evenepoel
- Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven, B-3000 Leuven, Belgium;
| | - Nicholas Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton SO16 6YD, UK;
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Serge Ferrari
- Service des Maladies Osseuses, Département de Médecine, HUG, 1205 Geneva, Switzerland;
| | - Jorge Cannata-Andía
- Bone and Mineral Research Unit, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), REDinREN del ISCIII, Hospital Universitario Central de Asturias, Universidad de Oviedo, 33003 Oviedo, Spain;
| | - Andrea Trombetti
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland;
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy;
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, 70376 Stuttgart, Germany;
| | - Thomas L. Nickolas
- Division of Nephrology, Columbia University Irving Medical Center, New York, NY 10027, USA;
| | - John Cunningham
- Centre for Nephrology, The Royal Free Hospital and UCL Medical School, London WC1E 6BT, UK;
| | - Syazrah Salam
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield S10 2JF, UK;
| | - Carlo Della Rocca
- Department of Medico-Surgical Sciences and Biotechnology, Sapienza University, Polo Pontino, 00185 Rome, Italy;
| | - Aldo Scarpa
- ARC-Net Centre for Applied Research on Cancer, University and Hospital Trust of Verona, 37134 Verona, Italy;
- Department of Pathology and Diagnostics, University and Hospital Trust of Verona, 37134 Verona, Italy
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Fabio Malberti
- UO Nefrologia e Dialisi ASST Cremona, 26100 Cremona, Italy;
| | - Filomena Cetani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, San Paolo Hospital, University of Milan, 20142 Milan, Italy;
| | - Sandro Mazzaferro
- Nephrologic Unit, Department of Translational and Precision Medicine, University of Rome ‘La Sapienza’, 00185 Rome, Italy;
| | - Luigi Morrone
- Nephrology, Dialysis and Renal Transplantation Unit, University Hospital “Policlinico”, 70124 Bari, Italy;
| | - Giovanni Tripepi
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy;
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine, University of Padua, 35121 Padua, Italy; (M.P.); (M.Z.)
| | | | | | - Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; (G.C.); (G.L.M.)
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; (G.C.); (G.L.M.)
| | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padua, 35128 Padua, Italy; (A.A.); (S.G.)
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padua, 35128 Padua, Italy; (A.A.); (S.G.)
| | - Luca Dalle Carbonare
- Section of Internal Medicine, Department of Medicine, University of Verona, 37134 Verona, Italy;
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Yang X, Zhao D, Yu F, Heidari AA, Bano Y, Ibrohimov A, Liu Y, Cai Z, Chen H, Chen X. An optimized machine learning framework for predicting intradialytic hypotension using indexes of chronic kidney disease-mineral and bone disorders. Comput Biol Med 2022; 145:105510. [DOI: 10.1016/j.compbiomed.2022.105510] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 11/03/2022]
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Keronen S, Martola L, Finne P, Burton IS, Tong XF, Kröger H, Honkanen E. Bone volume, mineral density, and fracture risk after kidney transplantation. PLoS One 2022; 17:e0261686. [PMID: 35349587 PMCID: PMC8963906 DOI: 10.1371/journal.pone.0261686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 12/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background
Disordered mineral metabolism reverses incompletely after kidney transplantation in numerous patients. Post-transplantation bone disease is a combination of pre-existing chronic kidney disease and mineral disorder and often evolving osteoporosis. These two frequently overlapping conditions increase the risk of post-transplantation fractures.
Material and methods
We studied the prevalence of low bone volume in bone biopsies obtained from kidney transplant recipients who were biopsied primarily due to the clinical suspicion of persistent hyperparathyroidism between 2000 and 2015 at the Hospital District of Helsinki and Uusimaa. Parameters of mineral metabolism, results of dual-energy x-ray absorptiometry scans, and the history of fractures were obtained concurrently.
One hundred nine bone biopsies taken at a median of 31 (interquartile range, IQR, 18–70) months after transplantation were included in statistical analysis. Bone turnover was classified as high in 78 (72%) and normal/low in 31 (28%) patients. The prevalence of low bone volume (n = 47, 43%) was higher among patients with low/normal turnover compared to patients with high turnover [18 (58%) vs. 29 (37%), P = 0.05]. Thirty-seven fragility fractures in 23 (21%) transplant recipients corresponding to fracture incidence 15 per 1000 person-years occurred during a median follow-up 9.1 (IQR, 6.3–12.1) years. Trabecular bone volume did not correlate with incident fractures. Accordingly, low bone mineral density at the lumbar spine correlated with low trabecular bone volume, but not with incident fractures. The cumulative corticosteroid dose was an important determinant of low bone volume, but not of incident fractures.
Conclusions
Despite the high prevalence of trabecular bone loss among kidney transplant recipients, the number of fractures was limited. The lack of association between trabecular bone volume and fractures suggests that the bone cortical compartment and quality are important determinants of bone strength and post-transplantation fracture.
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Affiliation(s)
- Satu Keronen
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- * E-mail:
| | - Leena Martola
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Patrik Finne
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Inari S. Burton
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
| | - Xiaoyu F. Tong
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
- Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Eero Honkanen
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Lateral spine dual-energy X-ray absorptiometry and the risk of fragility fractures in long-term kidney graft recipients. Clin Exp Nephrol 2022; 26:724-732. [PMID: 35304690 DOI: 10.1007/s10157-022-02210-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/06/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Although the prevalence of osteoporosis and fractures in the first 6-12 months post-renal transplantation is high, little is known about the utility of bone mineral density (BMD) to predict fractures in long-term kidney graft recipients. Lateral spine dual-energy X-ray absorptiometry (DXA) scanning is a reliable tool for measuring glucocorticoid-induced and age-related bone loss in the elderly population. However, little is known about the utility of lateral spine DXA for patients with chronic kidney diseases. This study aimed to analyze the utility of lateral spine BMD for fragility fractures in long-term kidney graft recipients. METHODS A total of 357 stable kidney transplant recipients for a minimum of 1 year after kidney transplantation underwent DXA measurements at several sites, including the lateral spine between January 2017 and December 2018. We collected data on new incident fractures from the patients' medical records. RESULTS The median post-transplantation time at baseline DXA measurement was 12.6 years. During the median follow-up period of 3.5 years, 41 (11.4%) fractures occurred. The lateral spine BMDs were independently associated with fractures (adjusted hazard ratio 0.076; 95% confidence interval 0.012-0.42, p = 0.003). The cumulative incidence rate of fractures was significantly higher in the lower lateral spine BMD group (< 0.471 g/cm2, optimal cut-off value by receiver operating characteristic curve) than in the higher lateral spine BMD group (23.4 vs. 7.4%, adjusted hazard ratio 4.92; 95% confidence interval 2.33-10.74, p < 0.001). CONCLUSION Lateral lumbar spine BMD can be used to predict the risk of fragility fractures in long-term kidney graft recipients.
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Molinari P, Alfieri CM, Mattinzoli D, Campise M, Cervesato A, Malvica S, Favi E, Messa P, Castellano G. Bone and Mineral Disorder in Renal Transplant Patients: Overview of Pathology, Clinical, and Therapeutic Aspects. Front Med (Lausanne) 2022; 9:821884. [PMID: 35360722 PMCID: PMC8960161 DOI: 10.3389/fmed.2022.821884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/08/2022] [Indexed: 12/25/2022] Open
Abstract
Renal transplantation (RTx) allows us to obtain the resolution of the uremic status but is not frequently able to solve all the metabolic complications present during end-stage renal disease. Mineral and bone disorders (MBDs) are frequent since the early stages of chronic kidney disease (CKD) and strongly influence the morbidity and mortality of patients with CKD. Some mineral metabolism (MM) alterations can persist in patients with RTx (RTx-p), as well as in the presence of complete renal function recovery. In those patients, anomalies of calcium, phosphorus, parathormone, fibroblast growth factor 23, and vitamin D such as bone and vessels are frequent and related to both pre-RTx and post-RTx specific factors. Many treatments are present for the management of post-RTx MBD. Despite that, the guidelines that can give clear directives in MBD treatment of RTx-p are still missed. For the future, to obtain an ever-greater individualisation of therapy, an increase of the evidence, the specificity of international guidelines, and more uniform management of these anomalies worldwide should be expected. In this review, the major factors related to post-renal transplant MBD (post-RTx-MBD), the main mineral metabolism biochemical anomalies, and the principal treatment for post-RTx MBD will be reported.
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Affiliation(s)
- Paolo Molinari
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Carlo Maria Alfieri
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- *Correspondence: Carlo Maria Alfieri ;
| | - Deborah Mattinzoli
- Renal Research Laboratory Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Mariarosaria Campise
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Angela Cervesato
- Department of Nephrology, Clinical and Translational Sciences, Università degli Studi della Campania L.Vanvitelli, Naples, Italy
| | - Silvia Malvica
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Evaldo Favi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of General Surgery, Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giuseppe Castellano
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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43
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Ebeling PR, Nguyen HH, Aleksova J, Vincent AJ, Wong P, Milat F. Secondary Osteoporosis. Endocr Rev 2022; 43:240-313. [PMID: 34476488 DOI: 10.1210/endrev/bnab028] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 02/07/2023]
Abstract
Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria 3011, Australia
| | - Jasna Aleksova
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
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44
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El-Husseini A, Abdalbary M, Lima F, Issa M, Ahmed MT, Winkler M, Srour H, Davenport D, Wang G, Faugere MC, Malluche H. Low turnover renal osteodystrophy with abnormal bone quality and vascular calcification in patients with mild to moderate CKD. Kidney Int Rep 2022; 7:1016-1026. [PMID: 35570986 PMCID: PMC9091581 DOI: 10.1016/j.ekir.2022.02.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction Limited information is available on renal osteodystrophy (ROD) and vascular calcification (VC) during early chronic kidney disease (CKD). This study was designed to evaluate ROD and VC in 32 patients with CKD stages II to IV. Methods Patients underwent dual-energy X-ray absorptiometry (DXA) for assessment of bone mineral density (BMD) and trabecular bone score (TBS), thoracic computed tomography for VC scoring using the Agatston method, and anterior iliac crest bone biopsy for mineralized bone histology, histomorphometry, and Fourier transform infrared spectroscopy (FTIR). Classical and novel bone markers were determined in the blood. Results Mean estimated glomerular filtration rate (eGFR) was 44 ± 16 ml/min per 1.73 m2. Of the patients, 84% had low bone turnover. In Whites, eGFR correlated negatively with the turnover parameter activation frequency (Ac.f) (r −0.48, P = 0.019) and with parameters of bone formation. Most patients had VC (>80%) which correlated positively with levels of phosphorus, c-terminal fibroblast growth factor-23, and activin. Aortic calcifications (ACs) correlated negatively with bone formation rate (BFR) and Ac.f (rho −0.62, −0.61, P < 0.001). TBS correlated negatively with coronary calcification (rho −0.42, P = 0.019) and AC (rho −0.57, P = 0.001). These relationships remained after adjustment of age. The mineral-to-matrix ratio, an FTIR metric reflecting bone quality, was negatively related to Ac.f and positively related to AC. Conclusion Low bone turnover and VC are predominant in early stages of CKD. This is the first study demonstrating mineral abnormalities indicating reduced bone quality in these stages of CKD.
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45
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Tsuji K, Kitamura M, Chiba K, Muta K, Yokota K, Okazaki N, Osaki M, Mukae H, Nishino T. Comparison of bone microstructures via high-resolution peripheral quantitative computed tomography in patients with different stages of chronic kidney disease before and after starting hemodialysis. Ren Fail 2022; 44:381-391. [PMID: 35220856 PMCID: PMC8890516 DOI: 10.1080/0886022x.2022.2043375] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Chronic kidney disease (CKD) negatively affects bone strength; however, the osteoporotic conditions in patients with CKD are not fully understood. Moreover, the changes in bone microstructure between pre-dialysis and dialysis are unknown. High-resolution peripheral quantitative computed tomography (HR-pQCT) reveals the three-dimensional microstructures of the bone. We aimed to evaluate bone microstructures in patients with different stages of CKD. This study included 119 healthy men and 40 men admitted to Nagasaki University Hospital for inpatient education or the initiation of hemodialysis. The distal radius and tibia were scanned with HR-pQCT. Patient clinical characteristics and bone microstructures were evaluated within 3 months of initiation of hemodialysis (in patients with CKD stage 5 D), patients with CKD stage 4–5, and healthy volunteers. Cortical bone parameters were lower in the CKD group than in healthy controls. Tibial cortical and trabecular bone parameters (cortical thickness, cortical area, trabecular volumetric bone mineral density, trabecular-bone volume fraction, and trabecular thickness) differed between patients with CKD stage 5 D and those with CKD stage 4–5 (p < 0.01). These differences were also observed between patients with CKD stage 5 and those with CKD stage 5 D (p < 0.017), but not between patients with CKD stage 4 and those with CKD stage 5, suggesting that the bone microstructure rapidly changed at the start of hemodialysis. Patients with CKD stage 5 D exhibited tibial microstructural impairment compared with those with CKD stage 4–5. HR-pQCT is useful for elucidation of the pathology of bone microstructures in patients with renal failure.
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Affiliation(s)
- Kiyokazu Tsuji
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Mineaki Kitamura
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ko Chiba
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kumiko Muta
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuaki Yokota
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Narihiro Okazaki
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Makoto Osaki
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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46
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Lee SE, Park JH, Kim KA, Choi HS. Discordance in Bone Mineral Density between the Lumbar Spine and Femoral Neck Is Associated with Renal Dysfunction. Yonsei Med J 2022; 63:133-140. [PMID: 35083898 PMCID: PMC8819412 DOI: 10.3349/ymj.2022.63.2.133] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/12/2021] [Accepted: 10/23/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Bone mineral density (BMD) determined by dual-energy X-ray absorptiometry is considered a gold standard for diagnosing osteoporosis. Some people show discordance in BMD values measured at the femur and that at the lumbar spine (LS). The aim of the present study was to investigate whether differences in BMD T-scores between the LS and femur neck (FN) are associated with renal dysfunction in the general population of Korea. MATERIALS AND METHODS We analyzed national data for 17306 adults from the Korean National Health and Nutrition Examination Survey conducted between 2008 and 2011. BMD T-score differences between LS and FN (termed BMD offset) were calculated by subtracting FN T-scores from LS T-scores. Diminished renal function was defined as estimated glomerular filtration rates (eGFR) less than 60 mL/min/1.73 m². RESULTS Among those aged ≥50 years, BMD offset was negatively associated with eGFR levels. Additionally, eGFR levels decreased linearly across increasing BMD offset quartiles. Men and women with an offset of >1.5 showed a 4.79-times and 2.51-times higher risk of renal dysfunction, respectively, compared to individuals with an offset of ≤0, after adjusting for age, body mass index, educational level, current smoking, and physical activity. In contrast, there was little evidence of an association between renal dysfunction and BMD offset in subjects aged <50 years. CONCLUSION Discordance between LS and FN BMDs was significantly associated with renal dysfunction in subjects aged ≥50 years. When assessing bone health in older chronic kidney disease patients, physicians should consider the possibility of BMD discordance between LS and FN.
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Affiliation(s)
- Seung Eun Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Ju-Hyun Park
- Department of Statistics, Dongguk University, Seoul, Korea
| | - Kyoung-Ah Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Han Seok Choi
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea.
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47
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Poiana C, Dusceac R, Niculescu DA. Utility of Trabecular Bone Score (TBS) in Bone Quality and Fracture Risk Assessment in Patients on Maintenance Dialysis. Front Med (Lausanne) 2022; 8:782837. [PMID: 35127749 PMCID: PMC8810536 DOI: 10.3389/fmed.2021.782837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/21/2021] [Indexed: 12/26/2022] Open
Abstract
Maintenance dialysis is associated with almost universal changes in bone metabolism collectively known as chronic kidney disease—mineral and bone disorder (CKD-MBD). These are accompanied in various proportions by bone loss and altered bone quality that led to an increased risk of fracture. Osteoporosis, age-related or postmenopausal, a condition that often coexists with CKD, is also a leading cause of fracture. Dual-energy X-ray densitometry (DXA) is the main tool for assessing the bone quantity and bone loss and the associated fracture risk. It has been validated in both CKD-MBD and osteoporosis. Trabecular bone score (TBS) is a DXA-derived algorithm for the evaluation of bone microarchitecture, and its clinical value has been repeatedly demonstrated in large cohorts of osteoporotic patients. However, its utility in patients on maintenance dialysis has not been conclusively shown. Published studies showed a lower TBS score and implicitly an altered bone microarchitecture in patients on maintenance dialysis, even after adjusting for various variables. Moreover, FRAX-based fracture risk is higher after adjusting for TBS, showing promise on an algorithm better estimating the clinical fracture risk in dialysis patients. However, TBS has not been demonstrated to independently predict clinical fractures in prospective studies on dialysis patients. Also, aortic calcifications and altered fluid balance could significantly affect TBS score and could hamper the widespread clinical use in patients on maintenance dialysis. In this mini-review, we focus on the benefits and pitfalls of TBS in the management of CKD-MBD and fracture risk assessment in patients on maintenance dialysis.
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Affiliation(s)
- Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Pituitary and Neuroendocrine Disorders, C. I. Parhon National Institute of Endocrinology, Bucharest, Romania
- *Correspondence: Catalina Poiana
| | - Roxana Dusceac
- Department of Pituitary and Neuroendocrine Disorders, C. I. Parhon National Institute of Endocrinology, Bucharest, Romania
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Pituitary and Neuroendocrine Disorders, C. I. Parhon National Institute of Endocrinology, Bucharest, Romania
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48
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Kim H, Lee J, Lee KB, Kim YH, Hong N, Park JT, Han SH, Kang SW, Choi KH, Oh KH, Yoo TH. Low bone mineral density is associated with coronary arterial calcification progression and incident cardiovascular events in patients with chronic kidney disease. Clin Kidney J 2022; 15:119-127. [PMID: 35035942 PMCID: PMC8757420 DOI: 10.1093/ckj/sfab138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Indexed: 12/15/2022] Open
Abstract
Background Although it is well known that low bone mineral density (BMD) is associated with an increased risk of cardiovascular disease (CVD) and mortality in the general population, the prognostic role of bone mineral density (BMD) has not been established in the chronic kidney disease (CKD) population. Therefore we aimed to evaluate the association between BMD and the risk of CVD and cardiovascular mortality in patients with predialysis CKD. Methods This prospective cohort study was conducted with 1957 patients with predialysis CKD Stages 1–5. BMD was measured using dual-energy X-ray absorptiometry and coronary arterial calcification (CAC) scores were evaluated using coronary computed tomography. The primary outcome was a major adverse cardiovascular event (MACE). Results When patients were classified based on total hip BMD T-score tertiles stratified by sex, the lowest BMD tertile was significantly associated with an increased risk of MACE {hazard ratio 2.16 [95% confidence interval (CI) 1.25–3.74]; P = 0.006}. This association was also shown with BMD at the femur neck but not with BMD at lumbar spine. In the subgroup of 977 patients with follow-up CACs at their fourth year, 97 (9.9%) showed accelerated CAC progression (>50/year), and BMD was inversely associated with accelerated CAC progression even after adjusting for the baseline CAC score [odds ratio 0.75 (95% CI 0.58–0.99); P = 0.039]. In addition, baseline CAC was associated with an increased risk of MACEs after adjusting for total hip T-score. Conclusions Low BMD was significantly associated with CAC progression and MACEs in patients with predialysis CKD.
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Affiliation(s)
- Hyoungnae Kim
- Division of Nephrology, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Joongyub Lee
- Prevention and Management Center, Inha University Hospital, Incheon, Korea
| | - Kyu-Beck Lee
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Yeong-Hoon Kim
- Department of Internal Medicine, Busan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Namki Hong
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Tak Park
- Department of Internal Medicine, Yonsei University, Institute of Kidney Disease Research, College of Medicine, Seoul, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Yonsei University, Institute of Kidney Disease Research, College of Medicine, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University, Institute of Kidney Disease Research, College of Medicine, Seoul, Korea
| | - Kyu Hun Choi
- Department of Internal Medicine, Yonsei University, Institute of Kidney Disease Research, College of Medicine, Seoul, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, Yonsei University, Institute of Kidney Disease Research, College of Medicine, Seoul, Korea
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49
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Jaques DA, Henderson S, Davenport A. OUP accepted manuscript. Clin Kidney J 2022; 15:1188-1195. [PMID: 35664286 PMCID: PMC9155216 DOI: 10.1093/ckj/sfac034] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Scott Henderson
- UCL Department of Nephrology, Royal Free Hospital, University College London, London, UK
| | - Andrew Davenport
- UCL Department of Nephrology, Royal Free Hospital, University College London, London, UK
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50
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Bone mass measurement by DXA should be interpreted with caution in the CKD population with vascular calcification. Bone Rep 2022; 16:101169. [PMID: 35146076 PMCID: PMC8819399 DOI: 10.1016/j.bonr.2022.101169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background KDIGO guidelines suggest the use of dual-energy X-ray absorptiometry (DXA) to assess bone mineral density (BMD) in patients with CKD 3a-5D. Previous studies have demonstrated an association between trabecular bone mass loss and coronary artery calcification (CAC) progression. This study aimed to prospectively investigate the relationship between BMD changes, quantified by DXA, and CAC progression in the non-dialyzed CKD population. Methods In this post hoc study, BMD by DXA was measured at the lumbar spine and total hip at baseline and 12-months. Patients were categorized according to BMD changes into 3 different groups: LOSS, UNCHANGED and GAIN. CAC quantification was obtained by multislice computed tomography at baseline and 12-months. Results 87 patients (55.6 ± 10.7 years, 62% males, 30% diabetic, eGFR = 39.2 ± 18.1 mL/min/1.73m2) were enrolled. CAC was found in 41 (47%) of the patients at baseline and CAC progression in 25 (64%) of them. Considering the lumbar spine and total hip BMD changes together, 24%, 48%, and 25% of the patients were in the LOSS, UNCHANGED and GAIN groups, respectively. Compared to the UNCHANGED or LOSS groups, the GAIN group had an increase in calcium score (p = 0.04) and a higher proportion of patients with CAC progression (p = 0.01). In the logistic regression analysis, CAC progression was 4.5 times more likely to be in the GAIN group. Conclusions The association between the increase in BMD values and the progression of vascular calcification was the result of two concomitant processes overlapping, leading to a misinterpretation of DXA results. Thus, the use of DXA for the evaluation of bone mass, especially at the lumbar spine, must be applied with restraint and its results very carefully interpreted in CKD patients. DXA should be interpreted with caution in the CKD population. Vascular calcification progression is highly prevalent among CKD patients. The increase of BMD values by DXA should be taken with restraint in CKD patients particularly in those with vascular calcification progression.
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