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Ferraro S, Biganzoli G, Calcaterra V, Zuccotti G, Biganzoli EM, Plebani M. Fibroblast growth factor 23: translating analytical improvement into clinical effectiveness for tertiary prevention in chronic kidney disease. Clin Chem Lab Med 2022; 60:1694-1705. [PMID: 36008874 DOI: 10.1515/cclm-2022-0635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/22/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Fibroblast growth factor 23 (FGF23) plays a key role in the pathophysiology of chronic kidney disease (CKD) and of the associated cardiovascular diseases, ranking on the crossroads of several evolving areas with a relevant impact on the health-care system (ageing, treatment of CKD and prevention from cardiovascular and renal events). In this review, we will critically appraise the overall issues concerning the clinical usefulness of FGF23 determination in CKD, focusing on the analytical performances of the methods, aiming to assess whether and how the clinical introduction of FGF23 may promote cost-effective health care policies in these patients. CONTENT Our comprehensive critical appraisal of the literature revealed that we are currently unable to establish the clinical usefulness of FGF23 measured by ELISA in CKD, as stability issues and suboptimal analytical performances are the major responsible for the release of misleading results. The meta-analytical approach has failed to report unambiguous evidence in face of the wide heterogeneity of the results from single studies. SUMMARY AND OUTLOOK Our review has largely demonstrated that the clinical usefulness depends on a thorough analytical validation of the assay. The recent introduction of chemiluminescent intact-FGF23 (iFGF23) assays licensed for clinical use, after passing a robust analytical validation, has allowed the actual assessment of preliminary risk thresholds for cardiovascular and renal events and is promising to capture the iFGF23 clinically relevant changes as a result of a therapeutic modulation. In this perspective, the analytical optimization of FGF23 determination may allow a marriage between physiology and epidemiology and a merging towards clinical outcomes.
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Affiliation(s)
- Simona Ferraro
- Endocrinology Laboratory Unit, "Luigi Sacco" University Hospital, Milan, Italy
| | - Giacomo Biganzoli
- Medical Statistics Unit, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, University of Milan, Milan, Italy
| | - Valeria Calcaterra
- Department of Internal Medicine, University of Pavia, Pavia, Italy.,Pediatric Department, "V. Buzzi" Children's Hospital, Milan, Italy
| | - Gianvincenzo Zuccotti
- Pediatric Department, "V. Buzzi" Children's Hospital, Milan, Italy.,Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Elia Mario Biganzoli
- Medical Statistics Unit, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, University of Milan, Milan, Italy
| | - Mario Plebani
- Department of Medicine-DIMED, University of Padova, Padova, Italy
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2
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Udomkarnjananun S, Phannajit J, Takkavatakarn K, Tumkosit M, Kingpetch K, Avihingsanon Y, Praditpornsilpa K, Eiam-Ong S, Susantitaphong P. Effects of Phosphate Binders on Bone Biomarkers and Bone Density in Hemodialysis Patients. Nephrology (Carlton) 2022; 27:441-449. [PMID: 35044029 DOI: 10.1111/nep.14022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/04/2022] [Accepted: 01/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUNDS The incidences of osteoporosis, fracture, and vascular calcification increase concordantly with the progression of chronic kidney disease (CKD). CKD-mineral bone disease (CKD-MBD) induced by hyperphosphatemia is a major pathophysiologic mechanism. The effects of phosphate binders on bone turnover biomarkers and bone mineral density (BMD) in hemodialysis patients are still inconclusive. Our aim is to demonstrate the effects of these phosphate binders on different aspects of CKD-MBD. METHODS We conducted a prospective cohort of 65 hemodialysis patients to investigate the effect of 12-month monotherapy of phosphate binders composing calcium-based phosphate binders (CPB) or non-calcium-based phosphate binders (NCPB), including sevelamer and lanthanum, on bone turnover biomarkers and BMD changes. The performance of bone turnover biomarkers to predict low BMD was attentively determined. RESULTS When compared with CPB, NCPB use was associated with higher levels of bone turnover biomarkers. NCPB was also associated with lower BMD at lumbar and distal radius. Total procollagen type 1 N-terminal propeptide (P1NP), bone-specific alkaline phosphatase (BALP), and tartrate-resistant acid phosphatase 5b (TRAP5b) provided the best performance for diagnosing low BMD in hemodialysis patients. CONCLUSIONS Switching from CPB to NCPB might increase bone biomarkers and prevent the development of adynamic bone disease. On the contrary, NCPB should be cautiously used in hemodialysis patients who already had low BMD. P1NP, BALP, and TRAP5b could be used to guide the appropriate management, including anti-resorptive and anabolic medications, and predict low BMD in hemodialysis patients treated with phosphate binders. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jeerath Phannajit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Monravee Tumkosit
- Department of Radiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kanaungnit Kingpetch
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Basutkar RS, Varghese R, Mathew NK, Sankar Indira P, Viswanathan B, Sivasankaran P. Systematic review and meta-analysis of potential pleiotropic effects of sevelamer in chronic kidney disease: Beyond phosphate control. Nephrology (Carlton) 2021; 27:337-354. [PMID: 34882904 DOI: 10.1111/nep.14011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 11/26/2022]
Abstract
Sevelamer, has been shown to have many pleiotropic actions on lipid panel, various inflammatory markers, and blood glucose levels in chronic kidney disease patients. We conducted a systematic review and meta-analysis to compare these pleiotropic effects of sevelamer to other phosphate binders used in chronic kidney disease patients. The relevant randomized controlled trials published from 1 January 2001 to 31 November 2019 on the following databases: Cochrane Central Register of Controlled Trials published in The Cochrane Library, PubMed, Scopus and Google Scholar were identified. All the included studies were independently assessed for eligibility and risk of bias. The modified data extraction form of Cochrane was used. This review included 44 studies for qualitative analysis and 28 reports for quantitative analysis. A meta-analysis of three studies (n = 180) showed that glycated haemoglobin had significantly decreased in sevelamer-treated patients (MD: 0.5%; p = <.001). Compared with calcium-based phosphate binders, sevelamer showed a significant reduction in low-density lipoprotein (MD: -19.43 mg/dL; p = <.001) and total cholesterol (MD: -19.98 mg/dL; p < .001). A significant increase in high-density lipoprotein (MD: 1.29 mg/dL; p = .05) was also prominent in sevelamer treated patients. However, we were not able to observe a significant change in other biochemical parameters such as TG, CRP, hs-CRP, FGF-23, IL-6 and albumin as, no statistically significant difference was observed.
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Affiliation(s)
- Roopa Satyanarayan Basutkar
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | - Resia Varghese
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | - Nina Kallanthanath Mathew
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | - Prithika Sankar Indira
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | | | - Ponnusankar Sivasankaran
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
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Role and Treatment of Insulin Resistance in Patients with Chronic Kidney Disease: A Review. Nutrients 2021; 13:nu13124349. [PMID: 34959901 PMCID: PMC8707041 DOI: 10.3390/nu13124349] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 01/11/2023] Open
Abstract
Patients with chronic kidney disease (CKD) and dialysis have higher mortality than those without, and cardiovascular disease (CVD) is the main cause of death. As CVD is caused by several mechanisms, insulin resistance plays an important role in CVD. This review summarizes the importance and mechanism of insulin resistance in CKD and discusses the current evidence regarding insulin resistance in patients with CKD and dialysis. Insulin resistance has been reported to influence endothelial dysfunction, plaque formation, hypertension, and dyslipidemia. A recent study also reported an association between insulin resistance and cognitive dysfunction, non-alcoholic fatty liver disease, polycystic ovary syndrome, and malignancy. Insulin resistance increases as renal function decrease in patients with CKD and dialysis. Several mechanisms increase insulin resistance in patients with CKD, such as chronic inflammation, oxidative stress, obesity, and mineral bone disorder. There is the possibility that insulin resistance is the potential future target of treatment in patients with CKD.
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Takkavatakarn K, Wuttiputhanun T, Phannajit J, Praditpornsilpa K, Eiam-Ong S, Susantitaphong P. Effectiveness of fibroblast growth factor 23 lowering modalities in chronic kidney disease: a systematic review and meta-analysis. Int Urol Nephrol 2021; 54:309-321. [PMID: 33797709 DOI: 10.1007/s11255-021-02848-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/25/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The heightened fibroblast growth factor 23 (FGF23) level in patients with chronic kidney disease (CKD) is associated with increased cardiovascular disease and mortality. We performed a systematic review and meta-analysis to synthesize the available strategies to reduce FGF23 in CKD patients. METHODS We conducted a meta-analysis by searching the databases of MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) and single-arm studies that examined the effects of dietary phosphate restriction, phosphate binders, iron supplements, calcimimetics, parathyroidectomy, dialysis techniques, and the outcome of preservation of residual renal function (RRF) on FGF23 levels in CKD patients. Random-effects model meta-analyses were used to compute changes in the outcome of interests. RESULTS A total of 41 articles (7590 patients), comprising 36 RCTs, 5 prospective studies were included in this meta-analysis. Dietary phosphate restriction less than 800 mg per day yielded insignificant effect on FGF23 reduction. Interestingly sevelamer, lanthanum, iron-based phosphate binders, and iron supplement significantly lowered FGF23 levels. In CKD patients with secondary hyperparathyroidism, calcimimetics prescription could significantly reduce FGF23 levels, while surgical parathyroidectomy had no significant effect. In dialysis patients, preservation of RRF and hemoperfusion as well as hemodiafiltration provided a significant decrease in FGF23 levels. CONCLUSIONS The present meta-analysis demonstrated that non-calcium-based phosphate binders including sevelamer, lanthanum, and iron-based phosphate binders, iron supplements, calcimimetics, hemoperfusion, and preservation of RRF could effectively reduce FGF23 in CKD patients.
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Affiliation(s)
- Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Thunyatorn Wuttiputhanun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Jeerath Phannajit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand.
- Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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6
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Zhou C, Shi Z, Ouyang N, Ruan X. Hyperphosphatemia and Cardiovascular Disease. Front Cell Dev Biol 2021; 9:644363. [PMID: 33748139 PMCID: PMC7970112 DOI: 10.3389/fcell.2021.644363] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/08/2021] [Indexed: 12/12/2022] Open
Abstract
Hyperphosphatemia or even serum phosphate levels within the “normal laboratory range” are highly associated with increased cardiovascular disease risk and mortality in the general population and patients suffering from chronic kidney disease (CKD). As the kidney function declines, serum phosphate levels rise and subsequently induce the development of hypertension, vascular calcification, cardiac valvular calcification, atherosclerosis, left ventricular hypertrophy and myocardial fibrosis by distinct mechanisms. Therefore, phosphate is considered as a promising therapeutic target to improve the cardiovascular outcome in CKD patients. The current therapeutic strategies are based on dietary and pharmacological reduction of serum phosphate levels to prevent hyperphosphatemia in CKD patients. Large randomized clinical trials with hard endpoints are urgently needed to establish a causal relationship between phosphate excess and cardiovascular disease (CVD) and to determine if lowering serum phosphate constitutes an effective intervention for the prevention and treatment of CVD.
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Affiliation(s)
- Chao Zhou
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengyu Shi
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Nan Ouyang
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiongzhong Ruan
- John Moorhead Research Laboratory, Centre for Nephrology, University College London (UCL) Medical School, London, United Kingdom.,Centre for Lipid Research and Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Institute for Viral Hepatitis, Department of Infectious Diseases, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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7
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Mace ML, Olgaard K, Lewin E. New Aspects of the Kidney in the Regulation of Fibroblast Growth Factor 23 (FGF23) and Mineral Homeostasis. Int J Mol Sci 2020; 21:E8810. [PMID: 33233840 PMCID: PMC7699902 DOI: 10.3390/ijms21228810] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 02/07/2023] Open
Abstract
The bone-derived hormone fibroblast growth factor 23 (FGF23) acts in concert with parathyroid hormone (PTH) and the active vitamin D metabolite calcitriol in the regulation of calcium (Ca) and phosphate (P) homeostasis. More factors are being identified to regulate FGF23 levels and the endocrine loops between the three hormones. The present review summarizes the complex regulation of FGF23 and the disturbed FGF23/Klotho system in chronic kidney disease (CKD). In addition to the reduced ability of the injured kidney to regulate plasma levels of FGF23, several CKD-related factors have been shown to stimulate FGF23 production. The high circulating FGF23 levels have detrimental effects on erythropoiesis, the cardio-vascular system and the immune system, all contributing to the disturbed system biology in CKD. Moreover, new factors secreted by the injured kidney and the uremic calcified vasculature play a role in the mineral and bone disorder in CKD and create a vicious pathological crosstalk.
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Affiliation(s)
- Maria L. Mace
- Department of Nephrology, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; (K.O.); (E.L.)
| | - Klaus Olgaard
- Department of Nephrology, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; (K.O.); (E.L.)
| | - Ewa Lewin
- Department of Nephrology, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; (K.O.); (E.L.)
- Department of Nephrology, Herlev Hospital, University of Copenhagen, 2730 Herlev, Denmark
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8
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Rodelo-Haad C, Pendón-Ruiz de Mier MV, Díaz-Tocados JM, Martin-Malo A, Santamaria R, Muñoz-Castañeda JR, Rodríguez M. The Role of Disturbed Mg Homeostasis in Chronic Kidney Disease Comorbidities. Front Cell Dev Biol 2020; 8:543099. [PMID: 33282857 PMCID: PMC7688914 DOI: 10.3389/fcell.2020.543099] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 10/09/2020] [Indexed: 12/19/2022] Open
Abstract
Some of the critical mechanisms that mediate chronic kidney disease (CKD) progression are associated with vascular calcifications, disbalance of mineral metabolism, increased oxidative and metabolic stress, inflammation, coagulation abnormalities, endothelial dysfunction, or accumulation of uremic toxins. Also, it is widely accepted that pathologies with a strong influence in CKD progression are diabetes, hypertension, and cardiovascular disease (CVD). A disbalance in magnesium (Mg) homeostasis, more specifically hypomagnesemia, is associated with the development and progression of the comorbidities mentioned above, and some mechanisms might explain why low serum Mg is associated with negative clinical outcomes such as major adverse cardiovascular and renal events. Furthermore, it is likely that hypomagnesemia causes the release of inflammatory cytokines and C-reactive protein and promotes insulin resistance. Animal models have shown that Mg supplementation reverses vascular calcifications; thus, clinicians have focused on the potential benefits that Mg supplementation may have in humans. Recent evidence suggests that Mg reduces coronary artery calcifications and facilitates peripheral vasodilation. Mg may reduce vascular calcification by direct inhibition of the Wnt/β-catenin signaling pathway. Furthermore, Mg deficiency worsens kidney injury induced by an increased tubular load of phosphate. One important consequence of excessive tubular load of phosphate is the reduction of renal tubule expression of α-Klotho in moderate CKD. Low Mg levels worsen the reduction of Klotho induced by the tubular load of phosphate. Evidence to support clinical translation is yet insufficient, and more clinical studies are required to claim enough evidence for decision-making in daily practice. Meanwhile, it seems reasonable to prevent and treat Mg deficiency. This review aims to summarize the current understanding of Mg homeostasis, the potential mechanisms that may mediate the effect of Mg deficiency on CKD progression, CVD, and mortality.
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Affiliation(s)
- Cristian Rodelo-Haad
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Nephrology Service, Reina Sofia University Hospital, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
| | - M Victoria Pendón-Ruiz de Mier
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Nephrology Service, Reina Sofia University Hospital, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
| | - Juan Miguel Díaz-Tocados
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain.,University of Córdoba, Córdoba, Spain
| | - Alejandro Martin-Malo
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Nephrology Service, Reina Sofia University Hospital, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
| | - Rafael Santamaria
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Nephrology Service, Reina Sofia University Hospital, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
| | - Juan Rafael Muñoz-Castañeda
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Nephrology Service, Reina Sofia University Hospital, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
| | - Mariano Rodríguez
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain.,University of Córdoba, Córdoba, Spain.,Nephrology Service, Reina Sofia University Hospital, Córdoba, Spain.,Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
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Yuan Q, Xie Y, Peng Z, Wang J, Zhou Q, Xiao X, Wang W, Huang L, Tang W, Li X, Zhang L, Wang F, Zhao MH, Tao L, He K, Wanggou S, Xu H. Urinary magnesium predicts risk of cardiovascular disease in Chronic Kidney Disease stage 1-4 patients. Clin Nutr 2020; 40:2394-2400. [PMID: 33160701 DOI: 10.1016/j.clnu.2020.10.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 12/23/2022]
Abstract
Observational studies on dietary or circulating magnesium and risk of cardiovascular disease (CVD) in Chronic Kidney Disease (CKD) stage 1-4 have reported no-to-modest inverse associations. 24 h Urinary magnesium concentration (24 h UMg), an indicator of intestinal magnesium absorption, may provide better insight into the connection of CKD progression. We examined 3179 participants aged 18-74 years with CKD stage 1-4 in the Chinese Cohort Study of Chronic Kidney Disease (C-STRIDE) study, a prospective population-based cohort study. Data were analysed using Spearman rank-order correlation coefficients for all comparisons. We also performed a time-to-event analysis of the data using the Kaplan-Meier survival model, Cox proportional hazard model and competing risk Fine and Gray subdistribution hazard model. During a median follow-up of 4.19 years (interquartile range, 3.43-5.09 years), when modelling end-stage renal disease (ESRD), CVD and death, 24 h UMg was associated with risk of CVD (HR, 1.612 (95% CI, 1.056-2.460)), while no significant association with ESRD and death endpoints could be detected. 24 h UMg risk variants display a modest association with CVD in CKD stage 1-4 patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03041987. Registered January 1, 2012. (retrospectively registered) (https://www.clinicaltrials.gov/ct2/show/NCT03041987?term=Chinese+Cohort+Study+of+Chronic+Kidney+Disease+%28C-STRIDE%29&rank=1).
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Affiliation(s)
- Qiongjing Yuan
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Yanyun Xie
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Zhangzhe Peng
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Jinwei Wang
- Renal Division, Department of Medicine, Peking University First Hospital, China; Institute of Nephrology, Peking University, China; Key Laboratory of Renal Disease, Ministry of Health of China, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, 100034, China
| | - Qiaoling Zhou
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Xiangcheng Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Wei Wang
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Ling Huang
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Wenbin Tang
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Xiaozhao Li
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Luxia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, China; Institute of Nephrology, Peking University, China; Key Laboratory of Renal Disease, Ministry of Health of China, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, 100034, China; Center for Data Science in Health and Medicine, Peking University, Beijing, China
| | - Fang Wang
- Renal Division, Department of Medicine, Peking University First Hospital, China; Institute of Nephrology, Peking University, China; Key Laboratory of Renal Disease, Ministry of Health of China, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, 100034, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, China; Institute of Nephrology, Peking University, China; Key Laboratory of Renal Disease, Ministry of Health of China, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, 100034, China; Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Lijian Tao
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Kevin He
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Siyi Wanggou
- Department of Neurosurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Hui Xu
- Department of Nephrology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China.
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10
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Florenzano P, Jimenez M, Ferreira CR, Nesterova G, Roberts MS, Tella SH, Fernandez de Castro L, Gafni RI, Wolf M, Jüppner H, Gales B, Wesseling-Perry K, Markovich D, Gahl WA, Salusky IB, Collins MT. Nephropathic Cystinosis: A Distinct Form of CKD-Mineral and Bone Disorder that Provides Novel Insights into the Regulation of FGF23. J Am Soc Nephrol 2020; 31:2184-2192. [PMID: 32631973 DOI: 10.1681/asn.2019111172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 05/18/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The rare lysosomal storage disease nephropathic cystinosis presents with renal Fanconi syndrome that evolves in time to CKD. Although biochemical abnormalities in common causes of CKD-mineral and bone disorder have been defined, it is unknown if persistent phosphate wasting in nephropathic cystinosis is associated with a biochemical mineral pattern distinct from that typically observed in CKD-mineral and bone disorder. METHODS We assessed and compared determinants of mineral homeostasis in patients with nephropathic cystinosis across the predialysis CKD spectrum to these determinants in age- and CKD stage-matched patients, with causes of CKD other than nephropathic cystinosis. RESULTS The study included 50 patients with nephropathic cystinosis-related CDK and 97 with CKD from other causes. All major aspects of mineral homeostasis were differentially effected in patients with CKD stemming from nephropathic cystinosis versus other causes. Patients with nephropathic cystinosis had significantly lower percent tubular reabsorption of phosphate and fibroblast growth factor-23 (FGF23) at all CKD stages, and lower blood phosphate in CKD stages 3-5. Linear regression analyses demonstrated lower FGF23 levels in nephropathic cystinosis participants at all CKD stages when corrected for eGFR and age, but not when adjusted for serum phosphate. CONCLUSIONS Nephropathic cystinosis CKD patients have mineral abnormalities that are distinct from those in CKD stemming from other causes. Persistently increased urinary phosphate excretion maintains serum phosphate levels within the normal range, thus protecting patients with nephropathic cystinosis from elevations of FGF23 during early CKD stages. These findings support the notion that phosphate is a significant driver of increased FGF23 levels in CKD and that mineral abnormalities associated with CKD are likely to vary depending on the underlying renal disease.
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Affiliation(s)
- Pablo Florenzano
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland .,Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Macarena Jimenez
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlos R Ferreira
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Galina Nesterova
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Mary Scott Roberts
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland
| | - Sri Harsha Tella
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland
| | - Luis Fernandez de Castro
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina
| | - Harald Jüppner
- Endocrine Unit and Pediatric Nephrology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Barbara Gales
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Katherine Wesseling-Perry
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Daniela Markovich
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - William A Gahl
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Isidro B Salusky
- Division of Nephrology, Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland
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11
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Ketteler M, Sprague SM, Covic AC, Rastogi A, Spinowitz B, Rakov V, Walpen S, Floege J. Effects of sucroferric oxyhydroxide and sevelamer carbonate on chronic kidney disease-mineral bone disorder parameters in dialysis patients. Nephrol Dial Transplant 2020; 34:1163-1170. [PMID: 29846719 PMCID: PMC6603395 DOI: 10.1093/ndt/gfy127] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Indexed: 12/15/2022] Open
Abstract
Background Treatment of hyperphosphataemia is the primary goal of chronic kidney disease–mineral and bone disorder (CKD-MBD) management. This post hoc analysis of a randomized, Phase 3 study evaluated the effects of 1-year treatment with the phosphate binders sucroferric oxyhydroxide or sevelamer carbonate (‘sevelamer’) on CKD-MBD indices among dialysis patients with hyperphosphataemia. Methods After a 2- to 4-week washout from previous phosphate binders, 1059 patients were randomized 2:1 to sucroferric oxyhydroxide 1.0–3.0 g/day (n = 710) or sevelamer 2.4–14.4 g/day (n = 349) for up to 24 weeks. Eligible patients enrolled in a 28-week extension. This post hoc analysis was performed for patients who completed ≥1 year of continuous treatment (n = 549). As the treatment groups showed similar CKD-MBD outcomes, the data were pooled for this analysis. Results Phosphate-binder therapy was associated with significant and sustained 30% reductions in serum phosphorus (P < 0.001). Median intact fibroblast growth factor-23 (FGF-23) also significantly decreased (P < 0.001) by 64% over 1 year. Intact parathyroid hormone decreased significantly after 24 weeks (P < 0.001), but levels returned to near baseline values by Week 52; minimal changes in serum calcium were observed. Of the bone resorption markers evaluated, tartrate-resistant acid phosphatase 5b (TRAP5b) decreased significantly (P < 0.001), whereas CTx increased transiently but returned to baseline levels by Week 52. The bone formation markers bone-specific alkaline phosphatase and osteocalcin both increased over 1 year of treatment. Conclusions Overall, 1 year of sucroferric oxyhydroxide or sevelamer treatment significantly reduced serum FGF-23, which has been associated with clinical benefit in patients with CKD. The trend towards increased bone formation marker levels indicates a beneficial effect on bone metabolism.
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Affiliation(s)
- Markus Ketteler
- Klinikum Coburg and KfH-Dialysis Center, Coburg, Germany.,School of Medicine, University of Split, Split, Croatia
| | - Stuart M Sprague
- NorthShore University Health System, University of Chicago, Pritzker School of Medicine, Evanston, IL, USA
| | - Adrian C Covic
- Gr.T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Anjay Rastogi
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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12
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Ruospo M, Palmer SC, Natale P, Craig JC, Vecchio M, Elder GJ, Strippoli GFM. Phosphate binders for preventing and treating chronic kidney disease-mineral and bone disorder (CKD-MBD). Cochrane Database Syst Rev 2018; 8:CD006023. [PMID: 30132304 PMCID: PMC6513594 DOI: 10.1002/14651858.cd006023.pub3] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Phosphate binders are used to reduce positive phosphate balance and to lower serum phosphate levels for people with chronic kidney disease (CKD) with the aim to prevent progression of chronic kidney disease-mineral and bone disorder (CKD-MBD). This is an update of a review first published in 2011. OBJECTIVES The aim of this review was to assess the benefits and harms of phosphate binders for people with CKD with particular reference to relevant biochemical end-points, musculoskeletal and cardiovascular morbidity, hospitalisation, and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs of adults with CKD of any GFR category comparing a phosphate binder to another phosphate binder, placebo or usual care to lower serum phosphate. Outcomes included all-cause and cardiovascular death, myocardial infarction, stroke, adverse events, vascular calcification and bone fracture, and surrogates for such outcomes including serum phosphate, parathyroid hormone (PTH), and FGF23. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess evidence certainty. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised MD (SMD) for continuous outcomes. MAIN RESULTS We included 104 studies involving 13,744 adults. Sixty-nine new studies were added to this 2018 update.Most placebo or usual care controlled studies were among participants with CKD G2 to G5 not requiring dialysis (15/25 studies involving 1467 participants) while most head to head studies involved participants with CKD G5D treated with dialysis (74/81 studies involving 10,364 participants). Overall, seven studies compared sevelamer with placebo or usual care (667 participants), seven compared lanthanum to placebo or usual care (515 participants), three compared iron to placebo or usual care (422 participants), and four compared calcium to placebo or usual care (278 participants). Thirty studies compared sevelamer to calcium (5424 participants), and fourteen studies compared lanthanum to calcium (1690 participants). No study compared iron-based binders to calcium. The remaining studies evaluated comparisons between sevelamer (hydrochloride or carbonate), sevelamer plus calcium, lanthanum, iron (ferric citrate, sucroferric oxyhydroxide, stabilised polynuclear iron(III)-oxyhydroxide), calcium (acetate, ketoglutarate, carbonate), bixalomer, colestilan, magnesium (carbonate), magnesium plus calcium, aluminium hydroxide, sucralfate, the inhibitor of phosphate absorption nicotinamide, placebo, or usual care without binder. In 82 studies, treatment was evaluated among adults with CKD G5D treated with haemodialysis or peritoneal dialysis, while in 22 studies, treatment was evaluated among participants with CKD G2 to G5. The duration of study follow-up ranged from 8 weeks to 36 months (median 3.7 months). The sample size ranged from 8 to 2103 participants (median 69). The mean age ranged between 42.6 and 68.9 years.Random sequence generation and allocation concealment were low risk in 25 and 15 studies, respectively. Twenty-seven studies reported low risk methods for blinding of participants, investigators, and outcome assessors. Thirty-one studies were at low risk of attrition bias and 69 studies were at low risk of selective reporting bias.In CKD G2 to G5, compared with placebo or usual care, sevelamer, lanthanum, iron and calcium-based phosphate binders had uncertain or inestimable effects on death (all causes), cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. Sevelamer may lead to constipation (RR 6.92, CI 2.24 to 21.4; low certainty) and lanthanum (RR 2.98, CI 1.21 to 7.30, moderate certainty) and iron-based binders (RR 2.66, CI 1.15 to 6.12, moderate certainty) probably increased constipation compared with placebo or usual care. Lanthanum may result in vomiting (RR 3.72, CI 1.36 to 10.18, low certainty). Iron-based binders probably result in diarrhoea (RR 2.81, CI 1.18 to 6.68, high certainty), while the risks of other adverse events for all binders were uncertain.In CKD G5D sevelamer may lead to lower death (all causes) (RR 0.53, CI 0.30 to 0.91, low certainty) and induce less hypercalcaemia (RR 0.30, CI 0.20 to 0.43, low certainty) when compared with calcium-based binders, and has uncertain or inestimable effects on cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. The finding of lower death with sevelamer compared with calcium was present when the analysis was restricted to studies at low risk of bias (RR 0.50, CI 0.32 to 0.77). In absolute terms, sevelamer may lower risk of death (all causes) from 210 per 1000 to 105 per 1000 over a follow-up of up to 36 months, compared to calcium-based binders. Compared with calcium-based binders, lanthanum had uncertain effects with respect to all-cause or cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification and probably had reduced risks of treatment-related hypercalcaemia (RR 0.16, CI 0.06 to 0.43, low certainty). There were no head-to-head studies of iron-based binders compared with calcium. The paucity of placebo-controlled studies in CKD G5D has led to uncertainty about the effects of phosphate binders on patient-important outcomes compared with placebo.It is uncertain whether the effects of binders on clinically-relevant outcomes were different for patients who were and were not treated with dialysis in subgroup analyses. AUTHORS' CONCLUSIONS In studies of adults with CKD G5D treated with dialysis, sevelamer may lower death (all causes) compared to calcium-based binders and incur less treatment-related hypercalcaemia, while we found no clinically important benefits of any phosphate binder on cardiovascular death, myocardial infarction, stroke, fracture or coronary artery calcification. The effects of binders on patient-important outcomes compared to placebo are uncertain. In patients with CKD G2 to G5, the effects of sevelamer, lanthanum, and iron-based phosphate binders on cardiovascular, vascular calcification, and bone outcomes compared to placebo or usual care, are also uncertain and they may incur constipation, while iron-based binders may lead to diarrhoea.
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Affiliation(s)
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Patrizia Natale
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | | | - Grahame J Elder
- Westmead HospitalDepartment of Renal MedicineWestmeadNSWAustralia2145
- Garvan Institute of Medical ResearchOsteoporosis and Bone Biology DivisionDarlinghurstNSWAustralia2010
| | - Giovanni FM Strippoli
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Diaverum AcademyBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
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13
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Zhang W, Xu J, Li P, Gao X, Zhang W, Wang H, Tang B. Treatment of hyperphosphatemia based on specific interactions between phosphorus and Zr(iv) active centers of nano-MOFs. Chem Sci 2018; 9:7483-7487. [PMID: 30319748 PMCID: PMC6176778 DOI: 10.1039/c8sc02638f] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 07/20/2018] [Indexed: 12/24/2022] Open
Abstract
We describe a kind of Zr(iv)-based nano-MOF that is well suited for specific adsorption and selective fluorescence sensing of phosphate based on specific interactions between Zr(iv) and phosphate which provides a new approach for treatment of hyperphosphatemia.
Hyperphosphatemia is closely associated with the occurrence of multiple organ dysfunctions in patients with end-stage renal disease (ESRD). The application of phosphorus binders as an effective clinical approach for such diseases still suffers from serious side effects. Therefore, development of new phosphorus binders for the treatment of hyperphosphatemia remains a great challenge. Herein, we describe a kind of zirconium (Zr(iv))-based nano-MOF that is well suited for specific adsorption and selective fluorescence sensing of phosphate, and is based on the particular interactions between Zr(iv) and phosphate. The reduced levels of phosphate were quantitatively monitored using the MOF-based fluorescence nanosensor. Notably, the MOFs exhibit a greater reduction in phosphorus levels than commercially available phosphorus binders, and comparable therapeutic effects in the treatment of hyperphosphatemia of a mice model. Hence, the MOF acts as a promising medication for hyperphosphatemia by directly adsorbing phosphorus in the blood, which offers new perspectives in future applications of MOFs.
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Affiliation(s)
- Wei Zhang
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Jiheng Xu
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Ping Li
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Xiaonan Gao
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Wen Zhang
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Hui Wang
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
| | - Bo Tang
- College of Chemistry , Chemical Engineering and Materials Science , Collaborative Innovation Center of Functionalized Probes for Chemical Imaging in Universities of Shandong , Key Laboratory of Molecular and Nano Probes , Ministry of Education , Institute of Biomedical Sciences , Shandong Normal University , Jinan 250014 , P. R. China . ;
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14
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van den Broek DHN, Chang YM, Elliott J, Jepson RE. Prognostic importance of plasma total magnesium in a cohort of cats with azotemic chronic kidney disease. J Vet Intern Med 2018; 32:1359-1371. [PMID: 29704284 PMCID: PMC6060321 DOI: 10.1111/jvim.15141] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/10/2018] [Accepted: 03/28/2018] [Indexed: 12/28/2022] Open
Abstract
Background Hypomagnesemia is associated with increased mortality and renal function decline in humans with chronic kidney disease (CKD). Magnesium is furthermore inversely associated with fibroblast growth factor 23 (FGF23), an important prognostic factor in CKD in cats. However, the prognostic significance of plasma magnesium in cats with CKD is unknown. Objectives To explore associations of plasma total magnesium concentration (tMg) with plasma FGF23 concentration, all‐cause mortality, and disease progression in cats with azotemic CKD. Animals Records of 174 client‐owned cats with IRIS stage 2‐4 CKD. Methods Cohort study. Cats with azotemic CKD were identified from the records of two London‐based first opinion practices (1999–2013). Possible associations of baseline plasma tMg with FGF23 concentration and risks of death and progression were explored using, respectively, linear, Cox, and logistic regression. Results Plasma tMg (reference interval, 1.73–2.57 mg/dL) was inversely associated with plasma FGF23 when controlling for plasma creatinine and phosphate concentrations (partial correlation coefficient, −0.50; P < .001). Hypomagnesemia was observed in 12% (20/174) of cats, and independently associated with increased risk of death (adjusted hazard ratio, 2.74; 95% confidence interval [CI], 1.35–5.55; P = .005). The unadjusted associations of hypermagnesemia (prevalence, 6%; 11/174 cats) with survival (hazard ratio, 2.88; 95% CI, 1.54–5.38; P = .001), and hypomagnesemia with progressive CKD (odds ratio, 17.7; 95% CI, 2.04–154; P = .009) lost significance in multivariable analysis. Conclusions and Clinical Importance Hypomagnesemia was associated with higher plasma FGF23 concentrations and increased risk of death. Measurement of plasma tMg augments prognostic information in cats with CKD, but whether these observations are associations or causations warrants further investigation.
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Affiliation(s)
- D Hendrik N van den Broek
- Department of Clinical Science and Services, Royal Veterinary College, University of London, London, United Kingdom
| | - Yu-Mei Chang
- Research Support Office, Royal Veterinary College, University of London, London, United Kingdom
| | - Jonathan Elliott
- Department of Comparative Biomedical Sciences, Royal Veterinary College, University of London, London, United Kingdom
| | - Rosanne E Jepson
- Department of Clinical Science and Services, Royal Veterinary College, University of London, London, United Kingdom
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15
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Dzingarski D, Mladenovska K. Pharmacotherapy in chronic kidney disease hyperphosphatemia – effects on vascular calcification and bone health. MAKEDONSKO FARMACEVTSKI BILTEN 2017. [DOI: 10.33320/maced.pharm.bull.2017.63.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Hyperphosphatemia (HP) in patients with chronic kidney disease (CKD) leads to complications such as renal osteodistrophy, cardiovascular calcification and hemodynamic abnormalities, all of them having a serious impact on the survival rate and quality of life. Also, HP is a key pathogenic factor in the development of secondary hyperparathyroidism (SHPT) in CKD. Having in regard the significance of controlling serum phosphorus levels (Pi), in this paper, the needs and obstacles to successful pharmacological management of HP in CKD are presented, with an overview of major classes of phosphate binders (PBs) and other drugs affecting Pi level, such as active vitamin D sterols and calcimimetics (CMs). In addition, their effects on progression of cardiovascular calcification and bone health are elaborated. In this regard, a PubMed search was carried out to capture all abstracts and articles relevant to the topic of CKD, HP and mineral metabolism, bone disorders and vascular/valvular calcification (VC), published from January 2007 to August 2017. The search was limited to English language, with the search terms including drug name AND hyperphosphatemia or cardiovascular calcification or bone disorder. Comparative studies, clinical studies/trials and meta-analyses related to different classes/representatives of PBs, vitamin D analogues and CMs were reviewed and research data related to their efficacy and safety compared.
Keywords: chronic kidney disease, hyperphosphatemia, phosphate binders, active vitamin D sterols, calcimimetics, bone disorders, cardiovascular calcification
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Affiliation(s)
- Dimce Dzingarski
- Faculty of Pharmacy, University “Ss Cyril and Methodius”, Mother Theresa St. 47, 1000 Skopje, Republic of Macedonia
| | - Kristina Mladenovska
- Faculty of Pharmacy, University “Ss Cyril and Methodius”, Mother Theresa St. 47, 1000 Skopje, Republic of Macedonia
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16
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Kosk D, Kramer H, Luke A, Camacho P, Bovet P, Rhule JP, Forrester T, Wolf M, Sempos C, Melamed ML, Dugas LR, Cooper R, Durazo-Arvizu R. Dietary factors and fibroblast growth factor-23 levels in young adults with African ancestry. J Bone Miner Metab 2017; 35:666-674. [PMID: 27942978 PMCID: PMC5711483 DOI: 10.1007/s00774-016-0804-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 10/31/2016] [Indexed: 11/30/2022]
Abstract
Fibroblast growth factor-23 (FGF23), a phosphaturic hormone secreted mainly by osteocytes, maintains serum phosphate levels within a tight range by promoting phosphaturia. Previous studies have mainly focused on the link between FGF23 levels and dietary intake of phosphate, but other dietary factors may also influence FGF23 levels. This cross-sectional study pooled three populations of young adults with African ancestry (452 in Chicago, IL, USA; 477 in Victoria, Seychelles; and 482 in Kumasi, Ghana) with estimated glomerular filtration rate >80 ml/min/1.73 m2 to examine the association of dietary factors based on two 24-h recalls with FGF23 levels measured using a C-terminal assay. Linear regression was used to examine the association between log-transformed FGF23 levels and quartiles of calorie-adjusted dietary factors with adjustment for covariates. In the pooled sample of 1411 study participants, the mean age was 35.2 (6.2) years and 45.3% were male. Median plasma C-terminal FGF23 values in relative units (RU)/ml were 59.5 [interquartile range (IQR) 44.1, 85.3] in the USA, 43.2 (IQR 33.1, 57.9) in Seychelles, and 34.0 (IQR 25.2, 50.4) in Ghana. With adjustment for covariates, increasing quartiles of calcium and animal protein and decreasing quartiles of vegetable protein, fiber, and magnesium intake were associated with significantly higher FGF23 levels compared to the lowest quartile. After further adjustment for dietary factors, significant trends in FGF23 levels were noted only for quartiles of calcium, fiber, and magnesium intake (P < 0.001). Dietary factors other than phosphate are associated with FGF23 levels in young adults.
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Affiliation(s)
- Dominique Kosk
- Department of Public Health Sciences, Loyola University Chicago, 2160 First Avenue, Maywood, IL, 60153, USA
| | - Holly Kramer
- Department of Public Health Sciences, Loyola University Chicago, 2160 First Avenue, Maywood, IL, 60153, USA.
- Division of Nephrology and Hypertension, Department of Public Health Sciences and Medicine, Loyola University Chicago, Maywood, IL, USA.
| | - Amy Luke
- Department of Public Health Sciences, Loyola University Chicago, 2160 First Avenue, Maywood, IL, 60153, USA
| | - Pauline Camacho
- Division of Endocrinology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Pascal Bovet
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
- Ministry of Health, Victoria, Republic of Seychelles
| | - Jacob Plange Rhule
- Department of Physiology, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Terrence Forrester
- University of West Indies Solutions for Developing Countries, University of the West Indies Mona, Kingston, Jamaica
| | - Myles Wolf
- Division of Nephrology and Hypertension, Department of Medicine, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Chris Sempos
- National Institutes of Health Office of Dietary Supplements, Bethesda, MD, USA
| | - Michal L Melamed
- Department of Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Lara R Dugas
- Department of Public Health Sciences, Loyola University Chicago, 2160 First Avenue, Maywood, IL, 60153, USA
| | - Richard Cooper
- Department of Public Health Sciences, Loyola University Chicago, 2160 First Avenue, Maywood, IL, 60153, USA
| | - Ramon Durazo-Arvizu
- Department of Public Health Sciences, Loyola University Chicago, 2160 First Avenue, Maywood, IL, 60153, USA
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17
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Apetrii M, Covic A, Massy ZA. Magnesium supplementation: A consideration in dialysis patients. Semin Dial 2017; 31:11-14. [PMID: 29063671 DOI: 10.1111/sdi.12653] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Even though disorders of magnesium (Mg) balance are common in dialyzed patients, this cation is often neglected. Many factors interfere with serum magnesium including diet, medications (eg, antacids or phosphate binders), and the dialysis prescription. Mg supplementation may help reduce serum phosphate concentration, PTH, and interfere with vascular calcification and bone mineralization. It could also decrease the all-cause and cardiovascular mortalities, although the results of current studies are conflicting. As with many other variables that influence hard endpoints in nephrology, additional research directly targeting the role of Mg supplementation in dialyzed patients are required. Nevertheless, a current risk/benefit assessment suggests that supplementation of Mg targeting high normal serum levels may represent a plausible option to improve the outcome of dialysis patients.
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Affiliation(s)
- Mugurel Apetrii
- Department of Nephrology, University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Romania
| | - Adrian Covic
- Department of Nephrology, University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Romania
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré Hospital, APHP, Boulogne Billancourt/Paris, France.,Inserm U1018, UVSQ, Université Paris-Saclay, Villejuif, France
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Ma L, Zhao S, Li Z. Effects of parathyroidectomy on bone metabolism in haemodialysis patients with secondary hyperparathyroidism. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:527-534. [PMID: 28741963 DOI: 10.1080/00365513.2017.1354256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the outcome of bone metabolism and bone mineral density (BMD) in haemodialysis patients after parathyroidectomy (PTX). METHODS A total of 31 haemodialysis patients with secondary hyperparathyroidism (SHPT) were treated with PTX. BMD of lumbar spine (LS) and femoral neck (FN) was determined by dual energy X-ray absorptiometry. RESULTS Parathyroidectomy ledds to significant decrease of serum β-crosslaps (β-CTX), osteocalcin (OC) and procollagen type I amino-terminal propeptide (PINP) while serum sclerostin (SOST) increased after surgery. BMD was markedly improved in both LS and FN after PTX. Z-scores analysis further confirmed that PTX significantly benefited bone metabolism in haemodialysis patients, which well correlated with the improvement of serum iPTH and OC. CONCLUSIONS Parathyroidectomy leads to significant improvement of serum OC, PINP, β-CTX and SOST, which may beneficially modify calcium-phosphorus metabolism and BMD in haemodialysis patients with SHPT.
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Affiliation(s)
- Lijie Ma
- a Department of Nephrology , Beijing Chaoyang Hospital, Capital Medical University , Beijing , China
| | - Sumei Zhao
- a Department of Nephrology , Beijing Chaoyang Hospital, Capital Medical University , Beijing , China
| | - Zhongxin Li
- b Department of Nephrology , Beijing Lu He Hospital, Capital Medical University , Beijing , China
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Gungor O, Kocyigit I, Yilmaz MI, Sezer S. Role of vascular calcification inhibitors in preventing vascular dysfunction and mortality in hemodialysis patients. Semin Dial 2017; 31:72-81. [DOI: 10.1111/sdi.12616] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Ozkan Gungor
- Department of Nephrology; Faculty of Medicine; Kahramanmaraş Sütçü İmam University; Kahramanmaras Turkey
| | - Ismail Kocyigit
- Department of Nephrology; Erciyes University Faculty of Medicine; Kayseri Turkey
| | | | - Siren Sezer
- Department of Nephrology; Faculty of Medicine; Baskent University; Ankara Turkey
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Misra PS, Nessim SJ. Clinical aspects of magnesium physiology in patients on dialysis. Semin Dial 2017; 30:438-445. [PMID: 28609017 DOI: 10.1111/sdi.12613] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Magnesium balance is infrequently discussed in the dialysis population, and the clinical consequences of derangements in magnesium homeostasis are incompletely understood. There is an association between hypomagnesemia and adverse outcomes including increases in cardiovascular disease and mortality, while elevated magnesium levels have also been linked with complications such as osteomalacia. In this review, we discuss the features of magnesium physiology relevant to dialysis patients and provide an updated summary of the literature linking magnesium derangements with bone disease, cardiovascular disease, sudden cardiac death, and mortality.
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Affiliation(s)
- Paraish S Misra
- Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Sharon J Nessim
- Division of Nephrology, Jewish General Hospital, McGill University, Montreal, QC, Canada
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Dhondup T, Qian Q. Electrolyte and Acid-Base Disorders in Chronic Kidney Disease and End-Stage Kidney Failure. Blood Purif 2017; 43:179-188. [PMID: 28114143 DOI: 10.1159/000452725] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The kidneys play a pivotal role in the regulation of electrolyte and acid-base balance. With progressive loss of kidney function, derangements in electrolytes and acid-base inevitably occur and contribute to poor patient outcomes. As chronic kidney disease (CKD) has become a worldwide epidemic, medical providers are increasingly confronted with such problems. Adequate diagnosis and treatment will minimize complications and can potentially be lifesaving. In this review, we discuss the current understanding of the disease process, clinical presentation, diagnosis and treatment strategies, integrating up-to-date knowledge in the field. Although electrolyte and acid-base derangements are significant causes of morbidity and mortality in CKD and end-stage renal disease patients, they can be effectively managed through a timely institution of combined preventive measures and pharmacological therapy. Exciting advances and several upcoming outcome trials will provide further information to guide treatment and improve patient outcomes.
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Affiliation(s)
- Tsering Dhondup
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, College of Medicine, Rochester, MN, USA
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Clinical features of CKD-MBD in Japan: cohort studies and registry. Clin Exp Nephrol 2016; 21:9-20. [PMID: 27942882 DOI: 10.1007/s10157-016-1367-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 11/29/2016] [Indexed: 12/29/2022]
Abstract
Randomized controlled trials (RCTs) are essential for evidence-based medicine; however, cohort studies and registries provide an important information about risk factors and, hence, shed light on the target of laboratory parameters. The uniqueness of the current Japanese CKD-MBD guidelines lies in the lower target range of intact parathyroid hormone levels than those used in other countries, which is based on analyses of the nationwide Japan Renal Data Registry. Cohort studies were also useful in exploring risk factors of renal outcome in predialysis patients. It was revealed that low vitamin D status (very prevalent in Japan) and high fibroblast growth factor 23 (FGF23) levels predict poor renal outcome. The reported association of FGF23 levels with left ventricular hypertrophy (LVH) and heart failure observed in cohort studies may support the idea of adding the 4th component of CKD-MBD, namely, "LVH" to the three original components. When it is not feasible to conduct RCTs regarding intervention, we have no choice but to rely on observational studies with sophisticated analysis methods, such as facility-level analysis and marginal structural model minimizing indication bias. Observational studies conducted in Japan revealed that the side effects of medications for CKD-MBD, resultant compliance, and effective doses in terms of hard outcome in Japanese patients were found to be different from those in other countries. For example, the MBD-5D study confirmed the benefit of cinacalcet in terms of mortality despite its median dose of only 25 mg/day. These data are very helpful for future guidelines specific to Japanese patients with CKD.
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Melamed ML, Buttar RS, Coco M. CKD-Mineral Bone Disorder in Stage 4 and 5 CKD: What We Know Today? Adv Chronic Kidney Dis 2016; 23:262-9. [PMID: 27324680 PMCID: PMC5034723 DOI: 10.1053/j.ackd.2016.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 01/20/2016] [Accepted: 03/29/2016] [Indexed: 11/11/2022]
Abstract
Patients with CKD stages 4 and 5 experience biochemical derangements associated with CKD-mineral bone disorder. Some of the key abnormalities are hyperparathyroidism, hyperphosphatemia, hypocalcemia, and metabolic acidosis. We review the available treatments for these conditions and the evidence behind the treatments. We conclude that there is greater evidence for treating hyperphosphatemia than hyperparathyroidism. Treatment of metabolic acidosis in small clinical trials appears to be safe. We caution the reader about side effects associated with some of these treatments that differ in patients with CKD Stages 4 and 5 compared with patients on dialysis. The use of cinacalcet has been associated with hyperphosphatemia in patients with functioning kidneys. Activated vitamin D therapy has been associated with elevated creatinine levels, which may or may not be a reflection of true decrement in kidney function. Finally, the use of non-calcium-containing phosphate binders may be associated with improved clinical outcomes in patients; however, many more clinical trials are needed in this important area of medicine.
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Affiliation(s)
- Michal L Melamed
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
| | - Rupinder Singh Buttar
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Maria Coco
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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Bover J, Ureña-Torres P, Lloret MJ, Ruiz-García C, DaSilva I, Diaz-Encarnacion MM, Mercado C, Mateu S, Fernández E, Ballarin J. Integral pharmacological management of bone mineral disorders in chronic kidney disease (part I): from treatment of phosphate imbalance to control of PTH and prevention of progression of cardiovascular calcification. Expert Opin Pharmacother 2016; 17:1247-58. [DOI: 10.1080/14656566.2016.1182155] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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Matias PJ, Jorge C, Azevedo A, Laranjinha I, Navarro D, Mendes M, Amaral T, Ferreira C, Aires I, Gil C, Stuard S, Ferreira A. Calcium Acetate/Magnesium Carbonate and Cardiovascular Risk Factors in Chronic Hemodialysis Patients. Nephron Clin Pract 2016; 132:317-26. [PMID: 27023929 DOI: 10.1159/000444421] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 02/02/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM Calcium acetate/magnesium carbonate (CaMg) is a recent phosphate binder that has been shown to have protective cardiovascular (CV) effects in animal models. The aim of this study was to evaluate the relationship between CaMg therapy and CV risk markers like pulse pressure (PP), left ventricular mass index (LVMI) and valvular calcifications compared to sevelamer or no phosphate binder (NPB) therapy in chronic hemodialysis (HD) patients. METHODS We performed a 48-month prospective study in 138 HD patients under hemodiafiltration with a dialysate Mg concentration of 0.5 mmol/l. Patients underwent treatment with CaMg or sevelamer for at least 36 months or NPB therapy. Demographic, clinical, biochemical and echocardiographic parameters were evaluated at baseline and after a 48-month period. RESULTS At the end of the study, patients who had taken CaMg showed a significant reduction in PP (p < 0.001), LVMI (p = 0.003), aortic (p = 0.004) and mitral valve calcifications (p = 0.03) compared with NPB patients. Patients under CaMg showed a significant reduction of PP (p < 0.001), LVMI (p = 0.01) and aortic valve calcifications (p = 0.02) compared to sevelamer patients. In a multivariable analysis, CaMg therapy was negatively associated with progression of LVMI (p = 0.02) and aortic valve calcifications (p = 0.01). Patients under CaMg showed higher serum Mg levels (0.93 ± 0.14 mmol/l) compared to patients under sevelamer (0.87 ± 0.13) or NPB patients (0.82 ± 0.12; p < 0.001). CONCLUSIONS In prevalent HD patients, the use of CaMg over 48 months was associated with a reduction of PP and LVMI and with a stabilization of aortic valve calcifications. These protective and promising results of this new phosphate binder need to be confirmed in randomized controlled studies.
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de Roij van Zuijdewijn CLM, Grooteman MPC, Bots ML, Blankestijn PJ, Steppan S, Büchel J, Groenwold RHH, Brandenburg V, van den Dorpel MA, ter Wee PM, Nubé MJ, Vervloet MG. Serum Magnesium and Sudden Death in European Hemodialysis Patients. PLoS One 2015; 10:e0143104. [PMID: 26600017 PMCID: PMC4658157 DOI: 10.1371/journal.pone.0143104] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/30/2015] [Indexed: 12/18/2022] Open
Abstract
Despite suggestions that higher serum magnesium (Mg) levels are associated with improved outcome, the association with mortality in European hemodialysis (HD) patients has only scarcely been investigated. Furthermore, data on the association between serum Mg and sudden death in this patient group is limited. Therefore, we evaluated Mg in a post-hoc analysis using pooled data from the CONvective TRAnsport STudy (CONTRAST, NCT00205556), a randomized controlled trial (RCT) evaluating the survival risk in dialysis patients on hemodiafiltration (HDF) compared to HD with a mean follow-up of 3.1 years. Serum Mg was measured at baseline and 6, 12, 24 and 36 months thereafter. Cox proportional hazards models, adjusted for confounders using inverse probability weighting, were used to estimate hazard ratios (HRs) of baseline serum Mg on all-cause mortality, cardiovascular mortality, non-cardiovascular mortality and sudden death. A generalized linear mixed model was used to investigate Mg levels over time. Out of 714 randomized patients, a representative subset of 365 (51%) were analyzed in the present study. For every increase in baseline serum Mg of 0.1 mmol/L, the HR for all-cause mortality was 0.85 (95% CI 0.77–94), the HR for cardiovascular mortality 0.73 (95% CI 0.62–0.85) and for sudden death 0.76 (95% CI 0.62–0.93). These findings did not alter after extensive correction for potential confounders, including treatment modality. Importantly, no interaction was found between serum phosphate and serum Mg. Baseline serum Mg was not related to non-cardiovascular mortality. Mg decreased slightly but statistically significant over time (Δ -0.011 mmol/L/year, 95% CI -0.017 to -0.009, p = 0.03). In short, serum Mg has a strong, independent association with all-cause mortality, cardiovascular mortality and sudden death in European HD patients. Serum Mg levels decrease slightly over time.
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Affiliation(s)
- Camiel L. M. de Roij van Zuijdewijn
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
- Institute for Cardiovascular Research, VU University Medical Center (ICaR-VU), VU University Medical Center, Amsterdam, the Netherlands
- * E-mail:
| | - Muriel P. C. Grooteman
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
- Institute for Cardiovascular Research, VU University Medical Center (ICaR-VU), VU University Medical Center, Amsterdam, the Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter J. Blankestijn
- Department of Nephrology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Sonja Steppan
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Janine Büchel
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Rolf H. H. Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Vincent Brandenburg
- Department of Cardiology and Vascular Medicine, University Hospital Aachen, Aachen, Germany
| | | | - Piet M. ter Wee
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
- Institute for Cardiovascular Research, VU University Medical Center (ICaR-VU), VU University Medical Center, Amsterdam, the Netherlands
| | - Menso J. Nubé
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
- Institute for Cardiovascular Research, VU University Medical Center (ICaR-VU), VU University Medical Center, Amsterdam, the Netherlands
| | - Marc G. Vervloet
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
- Institute for Cardiovascular Research, VU University Medical Center (ICaR-VU), VU University Medical Center, Amsterdam, the Netherlands
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Zoccali C, Mallamaci F, Cannata-Andía J. Phosphate Binders and Clinical Outcomes in Patients with Stage 5D Chronic Kidney Disease. Semin Dial 2015; 28:587-93. [PMID: 26278591 DOI: 10.1111/sdi.12416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Knowledge informing the prescription and the choice of phosphate binders in end stage kidney disease (ESKD) patients has a weak evidentiary base. To date, no placebo-controlled trial based on meaningful clinical endpoints (death, cardiovascular events, bone fractures) has been performed to test the efficacy of these drugs. By the same token, we still lack solid proof that noncalcium binders afford better clinical outcomes as compared with calcium-based binders. Without proper trials, clinical decisions about the treatment of hyperphosphatemia rest on experience and contingent clinical judgment. The use of huge doses of calcium-based binders typically prescribed in the nineties now appears unwarranted. The relationship between phosphate and the risk of death is U shaped and moderate hyperphosphatemia carries just a mild-to-moderate risk excess and may not be seen as a compelling indication for the prescription of phosphate binders. Placebo-controlled randomized clinical trials assessing whether non-calcium and calcium-based binders reduce the risk of death and cardiovascular disease events in ESKD patients remain a public health priority.
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Affiliation(s)
- Carmine Zoccali
- CNR-IFC Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal c/o Ospedali Riuniti, Reggio Cal, Italy
| | - Francesca Mallamaci
- CNR-IFC Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal c/o Ospedali Riuniti, Reggio Cal, Italy.,Nephrology, Transplantation and Hypertension Division, Ospedali Riuniti, Reggio Cal, Italy
| | - Jorge Cannata-Andía
- Bone and Mineral Research Unit, Reina Sofia Research Institute of the Hospital, Universitario Central de Asturias.,Department of Medicine, University of Oviedo, Oviedo, Spain
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Iguchi A, Watanabe Y, Iino N, Kazama JJ, Iesato H, Narita I. Serum magnesium concentration is inversely associated with fibroblast growth factor 23 in haemodialysis patients. Nephrology (Carlton) 2015; 19:667-71. [PMID: 24899171 DOI: 10.1111/nep.12287] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2014] [Indexed: 12/22/2022]
Abstract
AIM Fibroblast growth factor 23 is reported to be a pivotal regulator for the chronic kidney disease-mineral bone disorders, working in coordinated ways with phosphate, calcium, and parathyroid hormone. However, whether there is a relationship between fibroblast growth factor 23 and magnesium is currently unclear. To address this, we performed a cross-sectional observational study in haemodialysis patients. METHODS We measured the serum levels of fibroblast growth factor 23, magnesium and other factors that are implicated in chronic kidney disease-mineral bone disorders in 225 haemodialysis patients. RESULTS Simple correlation analysis showed that fibroblast growth factor 23 was not correlated with magnesium. However, upon multiple regression analysis, a significant negative correlation was found between fibroblast growth factor 23 and magunesium (b = -0.164, P = 0.0020). Moreover, the levels of fibroblast growth factor 23 in patients treated with magnesium oxide had significantly lower levels than those without magnesium oxide. CONCLUSION We speculate that the magnesium is a potential regulator of fibroblast growth factor 23 levels in haemodialysis patients. Our data suggest that follow-up studies to elucidate the molecular mechanisms that underlie this relationship are warranted.
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Affiliation(s)
- Akira Iguchi
- Department of Internal Medicine, Ojiya General Hospital, Niigata, Japan
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Rodríguez M, Rodríguez-Ortiz ME. Advances in pharmacotherapy for secondary hyperparathyroidism. Expert Opin Pharmacother 2015; 16:1703-16. [DOI: 10.1517/14656566.2015.1061994] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Contemporary management of phosphorus retention in chronic kidney disease: a review. Clin Exp Nephrol 2015; 19:985-99. [DOI: 10.1007/s10157-015-1126-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 05/14/2015] [Indexed: 12/18/2022]
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Abstract
Magnesium fulfils important roles in multiple physiological processes. Accordingly, a tight regulation of magnesium homeostasis is essential. Dysregulated magnesium serum levels, in particular hypomagnesaemia, are common in patients with chronic kidney disease (CKD) and have been associated with poor clinical outcomes. In cell culture studies as well as in clinical situations magnesium levels were associated with vascular calcification, cardiovascular disease and altered bone-mineral metabolism. Magnesium has also been linked to diseases such as metabolic syndrome, diabetes, hypertension, fatigue and depression, all of which are common in CKD. The present review summarizes and discusses the latest clinical data on the impact of magnesium and possible effects of higher levels on the health status of patients with CKD, including an outlook on the use of magnesium-based phosphate-binding agents in this context.
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Affiliation(s)
- Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH University of Aachen, Pauwelsstr. 30, 52057, Aachen, Germany,
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Abstract
Sevelamer carbonate (Renvela(®)), a buffered form of sevelamer hydrochloride (Renagel(®)), is an orally administered non-absorbed phosphate-binding anion exchange resin used in the treatment of hyperphosphataemia in chronic kidney disease (CKD). In the EU, sevelamer carbonate is approved in adult CKD patients who require dialysis and in those who do not require dialysis with serum phosphate levels ≥ 1.78 mmol/L, whereas in the USA sevelamer carbonate is approved in adult CKD patients who require dialysis. Sevelamer carbonate and sevelamer hydrochloride achieved similar reductions in serum phosphate levels in randomized comparative trials in patients with CKD receiving haemodialysis; sevelamer carbonate also reduced serum phosphate levels in noncomparative studies in CKD patients not requiring dialysis. The most common adverse events with sevelamer carbonate are gastrointestinal in nature. Sevelamer has pleiotropic effects, such as improving the serum lipid profile and attenuating endothelial and cardiovascular risk factors in CKD. All formulations of sevelamer have markedly higher acquisition costs than calcium-based phosphate binders. Cost-effectiveness analyses focusing specifically on sevelamer carbonate have not been conducted, and those based on clinical trial data with sevelamer hydrochloride have provided both favourable and unfavourable results compared with calcium-based phosphate binders, reflecting heterogeneity between modelled analyses in terms of data sources, assumptions, comparators, geographical regions, type of costs included and other factors. Although well-designed studies evaluating the impact of phosphate binders on hard clinical endpoints appear to be warranted, sevelamer carbonate may be particularly useful for the treatment of patients at risk of metabolic acidosis (offering advantages over sevelamer hydrochloride in this regard) and for individuals requiring treatment with a phosphate binding agent that does not contain aluminium or calcium.
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Abstract
Cardiovascular complications are the leading cause of death in patients with chronic kidney disease (CKD). Abundant experimental evidence suggests a physiological role of magnesium in cardiovascular function, and clinical evidence suggests a role of the cation in cardiovascular disease in the general population. The role of magnesium in CKD-mineral and bone disorder, and in particular its impact on cardiovascular morbidity and mortality in patients with CKD, is however not well understood. Experimental studies have shown that magnesium inhibits vascular calcification, both by direct effects on the vessel wall and by indirect, systemic effects. Moreover, an increasing number of epidemiologic studies in patients with CKD have shown associations of serum magnesium levels with intermediate and hard outcomes, including vascular calcification, cardiovascular events and mortality. Intervention trials in these patients conducted to date have had small sample sizes and have been limited to the study of surrogate parameters, such as arterial stiffness, vascular calcification and atherosclerosis. Randomized controlled trials are clearly needed to determine the effects of magnesium supplementation on hard outcomes in patients with CKD.
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Cannata-Andía JB, Martin KJ. The challenge of controlling phosphorus in chronic kidney disease. Nephrol Dial Transplant 2015; 31:541-7. [PMID: 25770169 DOI: 10.1093/ndt/gfv055] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 01/30/2015] [Indexed: 01/26/2023] Open
Abstract
The pathogenesis and management of chronic kidney disease-mineral bone disorders (CKD-MBD) has experienced major changes, but the control of serum phosphorus at all stages of CKD still seems to be a key factor to improve clinical outcomes. High serum phosphorus is the most important uremia-related, non-traditional risk factor associated with vascular calcification in CKD patients and in the general population. Phosphorus may also be one of the key elements linking vascular calcification with low bone turnover. The main hormones and factors that contribute to the kidney regulation of phosphorus and calcium include parathyroid hormone, FGF-23, klotho and 1,25-dihydroxyvitamin D (1,25(OH)2D). Serum phosphorus did not start rising until CKD 3b in contrast with the earlier changes observed with fibroblast growth factor-23 (FGF-23), Klotho, calcitriol and parathyroid hormone (PTH). Despite FGF-23 and PTH having synergic effects regarding phosphorus removal, they have opposite effects on 1,25(OH)2D3. At the same stages of CKD in which phosphorus retention appears to occur, calcium retention also occurs. As phosphorus accumulation is associated with poor outcomes, an important question without a clear answer is at which level-range should serum phosphorus be maintained at different stages of CKD to improve clinical outcomes. There are four main strategies to manage phosphate homeostasis; phosphorus dietary intake, administration of phosphate binder agents, effective control of hyperparathyroidism and to ensure in the CKD 5D setting, an adequate scheme of dialysis. Despite all the available strategies, and the introduction of new phosphate binder agents in the market, controlling serum phosphorus remains challenging, and hyperphosphatemia continues to be extremely common in CKD 5 patients. Furthermore, despite phosphate binding agents having proved to be effective in reducing serum phosphorus, their ultimate effects on clinical outcomes remain controversial. Thus, we still need well-designed, large-scale, placebo-controlled studies to definitively prove that the reduction of serum phosphorus by phosphate binders improves clinical outcomes.
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Affiliation(s)
- Jorge B Cannata-Andía
- Bone and Mineral Research Unit, Hospital Universitario Central de Asturias, Instituto Reina Sofía de Investigación, REDinREN del ISCIII, University of Oviedo, Asturias, Spain
| | - Kevin J Martin
- Division of Nephrology, Saint Louis University School of Medicine, St. Louis, MO, USA
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Sakaguchi Y, Fujii N, Shoji T, Hayashi T, Rakugi H, Iseki K, Tsubakihara Y, Isaka Y. Magnesium modifies the cardiovascular mortality risk associated with hyperphosphatemia in patients undergoing hemodialysis: a cohort study. PLoS One 2014; 9:e116273. [PMID: 25545498 PMCID: PMC4278867 DOI: 10.1371/journal.pone.0116273] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 12/08/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In vitro studies have shown inhibitory effects of magnesium (Mg) on phosphate-induced calcification of vascular smooth muscle cells, raising the possibility that maintaining a high Mg level may be useful for reducing cardiovascular risks of patients with hyperphosphatemia. We examined how serum Mg levels affect the association between serum phosphate levels and the risk of cardiovascular mortality in patients undergoing hemodialysis. METHODS A nationwide register-based cohort study was conducted using database of the Renal Data Registry of the Japanese Society for Dialysis Therapy in 2009. We identified 142,069 patients receiving in-center hemodialysis whose baseline serum Mg and phosphate levels were available. Study outcomes were one-year cardiovascular and all-cause mortality. Serum Mg levels were categorized into three groups (lower, <2.7 mg/dL; intermediate, ≥2.7, <3.1 mg/dL; and higher, ≥3.1 mg/dL). RESULTS During follow-up, 11,401 deaths occurred, out of which 4,751 (41.7%) were ascribed to cardiovascular disease. In multivariable analyses, an increase in serum phosphate levels elevated the risk of cardiovascular mortality in the lower- and intermediate-Mg groups, whereas no significant risk increment was observed in the higher-Mg group. Moreover, among patients with serum phosphate levels of ≥6.0 mg/dL, the cardiovascular mortality risk significantly decreased with increasing serum Mg levels (adjusted odds ratios [95% confidence intervals] of the lower-, intermediate-, and higher-Mg groups were 1.00 (reference), 0.81 [0.66-0.99], and 0.74 [0.56-0.97], respectively.). An interaction between Mg and phosphate on the risk of cardiovascular mortality was statistically significant (P = 0.03). CONCLUSION Serum Mg levels significantly modified the mortality risk associated with hyperphosphatemia in patients undergoing hemodialysis.
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Affiliation(s)
- Yusuke Sakaguchi
- Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Naohiko Fujii
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Tatsuya Shoji
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Terumasa Hayashi
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Hiromi Rakugi
- Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Kunitoshi Iseki
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Yoshiharu Tsubakihara
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Yoshitaka Isaka
- Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
- * E-mail:
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Abstract
PURPOSE OF REVIEW The review focuses on the rationale and evidence behind management strategies for hyperphosphatemia in patients with chronic kidney disease (CKD). RECENT FINDINGS Optimal management of phosphate in CKD remains an area of uncertainty, but multiple studies now point to a clinical benefit from the use of phosphate binders. Evidence of improved survival is particularly strong with sevelamer, though it remains unclear whether the absence of calcium or other properties of sevelamer are responsible for this relationship. Newer agents, such as iron-based binders or niacin compounds to inhibit phosphorus absorption, may have additional benefits which will be better defined with additional experience. A reduced pill count may be a particularly beneficial characteristic of newer agents, and has been associated with improved response to therapy. Increased use of frequent, nocturnal hemodialysis is an additional tool to help ameliorate phosphate control. Data on the reduction of fibroblast growth factor 23 through use of phosphate binders remain weak. SUMMARY An improved understanding of phosphate regulation and the development of new therapeutic agents have reinvigorated a once stagnant field, but significant changes to practice cannot yet be justified. There is increasing support for using sevelamer in place of calcium-based binders, though economic practicability remains challenging.
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Galassi A, Cupisti A, Santoro A, Cozzolino M. Phosphate balance in ESRD: diet, dialysis and binders against the low evident masked pool. J Nephrol 2014; 28:415-29. [PMID: 25245472 DOI: 10.1007/s40620-014-0142-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 09/11/2014] [Indexed: 12/11/2022]
Abstract
Phosphate metabolism is crucial in the pathophysiology of secondary hyperparathyroidism and vascular calcification. High phosphate levels have been consistently associated with unfavorable outcomes in dialysis patients, but several limitations are still hampering a resolutive definition of the optimal targets of phosphate serum levels to be achieved in this cohort. Nonetheless, hyperphosphatemia is a late marker of phosphate overload in humans. Clinical nephrologists routinely counteract the positive phosphate balance in dialysis patients through nutritional counseling, stronger phosphate removal by dialysis and prescription of phosphate binders. However, the superiority against placebo of phosphate control by diet, dialysis or binders in terms of survival has never been tested in dedicated randomized controlled trials. The present review discusses this conundrum with particular emphasis on the rationale supporting the value of a simultaneous intervention against phosphate overload in dialysis patients via the improvement of dietary intakes, dialysis efficiency and an individualized choice of phosphate binders.
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Affiliation(s)
- A Galassi
- Department of Medicine, Renal and Dialysis Unit, Desio Hospital, Desio, Italy,
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A magnesium based phosphate binder reduces vascular calcification without affecting bone in chronic renal failure rats. PLoS One 2014; 9:e107067. [PMID: 25229549 PMCID: PMC4167554 DOI: 10.1371/journal.pone.0107067] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 08/07/2014] [Indexed: 11/19/2022] Open
Abstract
The alternative phosphate binder calcium acetate/magnesium carbonate (CaMg) effectively reduces hyperphosphatemia, the most important inducer of vascular calcification, in chronic renal failure (CRF). In this study, the effect of low dose CaMg on vascular calcification and possible effects of CaMg on bone turnover, a persistent clinical controversy, were evaluated in chronic renal failure rats. Adenine-induced CRF rats were treated daily with 185 mg/kg CaMg or vehicle for 5 weeks. The aortic calcium content and area% calcification were measured to evaluate the effect of CaMg. To study the effect of CaMg on bone remodeling, rats underwent 5/6th nephrectomy combined with either a normal phosphorus diet or a high phosphorus diet to differentiate between possible bone effects resulting from either CaMg-induced phosphate deficiency or a direct effect of Mg. Vehicle or CaMg was administered at doses of 185 and 375 mg/kg/day for 8 weeks. Bone histomorphometry was performed. Aortic calcium content was significantly reduced by 185 mg/kg/day CaMg. CaMg ameliorated features of hyperparathyroid bone disease. In CRF rats on a normal phosphorus diet, the highest CaMg dose caused an increase in osteoid area due to phosphate depletion. The high phosphorus diet combined with the highest CaMg dose prevented the phosphate depletion and thus the rise in osteoid area. CaMg had no effect on osteoblast/osteoclast or dynamic bone parameters, and did not alter bone Mg levels. CaMg at doses that reduce vascular calcification did not show any harmful effect on bone turnover.
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de Francisco ÁL, Rodriguez M. Does mild hypermagnesemia increase risk of PTH oversuppression? Kidney Int 2014; 86:212. [DOI: 10.1038/ki.2014.147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Vo TM, Disthabanchong S. Are there ways to attenuate arterial calcification and improve cardiovascular outcomes in chronic kidney disease? World J Cardiol 2014; 6:216-226. [PMID: 24944752 PMCID: PMC4062121 DOI: 10.4330/wjc.v6.i5.216] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 04/18/2014] [Accepted: 04/19/2014] [Indexed: 02/06/2023] Open
Abstract
The risk of cardiovascular mortality among patients with end-stage renal disease is several times higher than general population. Arterial calcification, a marker of atherosclerosis and a predictor of cardiovascular mortality, is common in chronic kidney disease (CKD). The presence of traditional cardiovascular risk factors such as diabetes, hypertension, hyperlipidemia, and advanced age cannot fully explain the high prevalence of atherosclerosis and arterial calcification. Other factors specific to CKD such as hyperphosphatemia, excess of calcium, high dose active vitamin D and prolonged dialysis vintage play important roles in the development of arterial calcification. Due to the significant health risk, it is prudent to attempt to lower arterial calcification burden in CKD. Treatment of hyperlipidemia with statin has failed to lower atherosclerotic and arterial calcification burden. Data on diabetes and blood pressure controls as well as smoking cessation on cardiovascular outcomes in CKD population are limited. Currently available treatment options include non-calcium containing phosphate binders, low dose active vitamin D, calcimimetic agent and perhaps bisphosphonates, vitamin K and sodium thiosulfate. Preliminary data on bisphosphonates, vitamin K and sodium thiosulfate are encouraging but larger studies on efficacy and outcomes are needed.
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Nastou D, Fernández-Fernández B, Elewa U, González-Espinoza L, González-Parra E, Sanchez-Niño MD, Ortiz A. Next-Generation Phosphate Binders: Focus on Iron-Based Binders. Drugs 2014; 74:863-77. [DOI: 10.1007/s40265-014-0224-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Locatelli F, Del Vecchio L, Violo L, Pontoriero G. Phosphate binders for the treatment of hyperphosphatemia in chronic kidney disease patients on dialysis: a comparison of safety profiles. Expert Opin Drug Saf 2014; 13:551-61. [PMID: 24702470 DOI: 10.1517/14740338.2014.907791] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Hyperphosphatemia is common in the late stages of chronic kidney disease (CKD) and is associated with elevated parathormone levels, abnormal bone mineralization, extraosseous calcification and increased risk of cardiovascular events and death. Several classes of oral phosphate binders are available to help control phosphorus levels. Although effective at lowering serum phosphorus, they all have safety issues that need to be considered when selecting which one to use. AREAS COVERED This paper reviews the use of phosphate binders in patients with CKD on dialysis, with a focus on safety and tolerability. In addition to the more established agents, a new resin-based phosphate binder, colestilan, is discussed. EXPERT OPINION Optimal phosphate control is still an unmet need in CKD. Nonetheless, we now have an extending range of phosphate binders available. Aluminium has potentially serious toxic risks. Calcium-based binders are still very useful but can lead to hypercalcemia and/or positive calcium balance and cardiovascular calcification. No long-term data are available for the new calcium acetate/magnesium combination product. Lanthanum is an effective phosphate binder, but there is insufficient evidence about possible long-term effects of tissue deposition. The resin-based binders, colestilan and sevelamer, appear to have profiles that would lead to less vascular calcification, and the main adverse events seen with these agents are gastrointestinal effects.
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Affiliation(s)
- Francesco Locatelli
- Alessandro Manzoni Hospital, Department of Nephrology Dialysis , Via dell'Eremo 9, 23900 Lecco , Italy +39 0341 489850 ; +39 0341 489860 ;
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43
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Abstract
PURPOSE OF REVIEW Disturbances in calcium-phosphate homeostasis play an important role in children with chronic kidney disease, and not only cause renal osteodystrophy but also result in increased cardiovascular morbidity and mortality. This review outlines the current aspects in the pathogenesis, diagnostic approach and treatment of renal osteodystrophy. RECENT FINDINGS The pathogenesis of renal osteodystrophy is under strong influence of the fibroblast growth factor 23/Klotho system, which is able to enhance phosphate excretion and reduce calcitriol synthesis in the kidney. Fibroblast growth factor 23 increases tissue calcinosis and is cardiotoxic, and is independently associated with mortality. Despite improvement in diagnostic imaging (bone density measurements), determination of biomarkers, mainly parathyroid hormone, still plays a central role. New treatment options resulted in improved bone health and also a reduction in mortality was achieved in adults with calcium-free phosphate binders. Substitution of active and inactive vitamin D is important and also has a beneficial effect on proteinuria. SUMMARY Knowledge about the biochemical and molecular mechanisms of renal osteodystrophy is increasing dramatically and has an impact not only to bone health but also overall morbidity and mortality. This will ultimately translate into further improved diagnostic approaches and novel treatment options.
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44
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Abstract
Disturbances in phosphate homeostasis are common in patients with chronic kidney disease. As kidney function declines, circulating concentrations of phosphate and the phosphate-regulatory hormone, fibroblast growth factor (FGF)-23, rise progressively. Higher serum levels of phosphate and FGF-23 are associated with an increased risk of adverse outcomes, including all-cause mortality and cardiovascular events. The associations between higher FGF-23 levels and adverse cardiovascular outcomes are generally independent of serum phosphate levels, and might be strongest for congestive heart failure. Higher serum phosphate levels are also modestly associated with an increased risk of cardiovascular events even after accounting for FGF-23 levels. This observation suggests that FGF-23 and phosphate might promote distinct mechanisms of cardiovascular toxicity. Indeed, animal models implicate high serum phosphate as a mechanism of vascular calcification and endothelial dysfunction, whereas high levels of FGF-23 are implicated in left ventricular hypertrophy. These seemingly distinct, but perhaps additive, adverse effects of phosphate on the vasculature and FGF-23 on the heart suggest that future population-level and individual-level interventions will need to simultaneously target these molecules to reduce the risk of associated cardiovascular events.
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Galassi A, Cozzolino M. Magnesium: a renewed player of vascular ageing in diabetic CKD patients? Clin Kidney J 2014; 7:93-6. [PMID: 25852855 PMCID: PMC4377787 DOI: 10.1093/ckj/sfu011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 02/05/2014] [Indexed: 12/24/2022] Open
Affiliation(s)
- Andrea Galassi
- Renal and Dialysis Unit, Department of Medicine , Desio Hospital , Desio , Italy
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division , San Paolo Hospital, University of Milan , Milan , Italy
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46
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Sherman RA. Briefly Noted. Semin Dial 2014. [DOI: 10.1111/sdi.12160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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47
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Locatelli F, Del Vecchio L. Optimal phosphate control: still an unmet need in chronic kidney disease patients. Expert Opin Pharmacother 2013; 15:307-9. [DOI: 10.1517/14656566.2014.860446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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48
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Abstract
There is growing interest in the role of fibroblast growth factor 23 (FGF23) in various diseases of disordered mineral metabolism. In chronic kidney disease (CKD), where biochemical evidence of mineral disturbances is especially common, FGF23 measurement has been advocated as an early and sensitive marker for CKD-related bone disease. In this setting, FGF23 analysis may also improve the discrimination of risk of adverse renal and cardiovascular outcomes and aid targeting of those patients that are likely to benefit from interventions. Nonetheless, while the physiological relevance of FGF23 in the control of mineral metabolism is now firmly established, relatively little attention has been paid to important preanalytical and analytical aspects of FGF23 measurement that may impact on its clinical utility. Here we review these issues and discuss the suitability of FGF23 testing strategies for routine clinical practice. The current ‘state-of-the-art’ enzyme-linked immunosorbent assay methods for FGF23 measurement show poor agreement due to differences in FGF23 fragment detection, antibody specificity and calibration. Such analytical variability does not permit direct comparison of FGF23 measurements made with different assays and is likely to at least in part account for some of the inconsistencies noted between observational studies. From a clinical perspective, the lack of concordance has implications for the development of standardized reference intervals and clinical decision limits. Finally, the inherent assay-dependent biological variability of plasma FGF23 concentration can further complicate the interpretation of results and the design of FGF23-based testing protocols. Currently, it would be premature to consider incorporating FGF23 measurements into standard testing repertoires.
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Affiliation(s)
- Edward R Smith
- Department of Renal Medicine, Eastern Health Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia
| | - Lawrence P McMahon
- Department of Renal Medicine, Eastern Health Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia
| | - Stephen G Holt
- Department of Renal Medicine, Eastern Health Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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