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Liu X, Liu Y, Zheng P, Xie X, Li Z, Yang R, Jin L, Mei Z, Chen P, Zhou L. Effects of active vitamin D analogs and calcimimetic agents on PTH and bone mineral biomarkers in hemodialysis patients with SHPT: a network meta-analysis. Eur J Clin Pharmacol 2024; 80:1555-1569. [PMID: 39002024 DOI: 10.1007/s00228-024-03730-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 07/06/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVE Active vitamin D analogs and calcimimetic agents are primary drugs for patients with secondary hyperparathyroidism. Due to the different pharmacological mechanisms, they have different effects on the level of parathyroid hormone, serum calcium, phosphorus, and bone turnover biomarkers. This study aimed to evaluate the active vitamin D analogs and calcimimetic agents in hemodialysis patients with secondary hyperparathyroidism. METHODS We included randomized clinical trials of hemodialysis patients with secondary hyperparathyroidism, comparing active vitamin D analogs to calcimimetic agents or placebo/control. The primary outcome was the change of PTH level from baseline to end-up. The secondary outcome was the change in serum calcium, phosphorus, calcium-phosphorus product, and bone turnover biomarkers. A network meta-analysis method was applied to complete this study. The forest plots reflected statistical differences in the outcomes between active vitamin D analogs and calcimimetic agents. The SUCRA result presented the ranking of impact on the outcomes. RESULTS Twenty-one randomized clinical trials with 4653 patients were included in this network meta-analysis. Global and splitting-node inconsistencies provided no evidence of inconsistency in this study. There was no statistical difference between two active vitamin D analogs and three calcimimetic agents in the PTH, and phosphorus levels changed. Considering serum calcium level, compared with placebo, calcitriol (9.73, 3.09 to 16.38) and paricalcitol (9.74, 3.87 to 15.60) increase serum calcium. However, cinacalcet (- 1.94, - 3.72 to - 0.15) and etelcalcetide (- 7.80, - 11.80 to - 3.80) reduced the serum calcium, even a joint use of cinacalcet with active vitamin D analogs (- 5.83, - 9.73 to - 1.93). Three calcimimetic agents decreased calcium levels much more than calcitriol and paricalcitol. The same type of drugs was not distinct, with each one affecting the change in calcium level. Cinacalcet reduced calcium-phosphorus product much more than paricalcitol (- 3.66, - 6.72 to - 0.60). Evocalcet decreased calcium-phosphorus product more than cinacalcet (- 5.64, - 8.91 to - 2.37), calcitriol (- 9.36, - 14.81 to - 3.92), and paricalcitol (- 9.30, - 13.78 to - 4.82). Compared with paricalcitol, cinacalcet significantly increases the level of ALP (24.50, 23.05 to 25.95) and bALP (0.67, 0.03 to 1.31). The incidence of gastrointestinal disorders in cinacacet (29.35, 1.71 to 504.98) and etelcalcetide (20.92, 1.20 to 365.68) was notably higher than in paricalcitol. Etelcalcetide (0.71, 0.53 to 0.96) and evocalcet (0.46, 0.33 to 0.64) presented a lower rate of gastrointestinal disorders than cinacalcet. Cinacalcet ranked first in adverse gastrointestinal, nervous, and respiratory reactions. CONCLUSION The same kinds of agents perform similar efficacy on the level of PTH, serum calcium, phosphorus, and calcium-phosphorus product. Paricalcitol did not lead to more hypercalcemia than calcitriol. The calcium decrease induced by cinacalcet was not settled even by associating it with active vitamin D analogs. Cinacalcet and evocalcet were superior to calcitriol and paricacitol in reducing calcium-phosphorus product. Calcimimetics induced more gastrointestinal disorders than active vitamin D analogs, especially cinacalcet.
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Affiliation(s)
- Xing Liu
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Yichen Liu
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Peimin Zheng
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Xun Xie
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Zhouzhou Li
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Rui Yang
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Lie Jin
- Lishui Central Hospital, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, Zhejiang, China
| | - Ziwei Mei
- Lishui Central Hospital, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, Zhejiang, China
| | - Peipei Chen
- Lishui Central Hospital, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, Zhejiang, China
| | - Limei Zhou
- Lishui Central Hospital, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, Zhejiang, China.
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2
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Turner ME, Beck L, Hill Gallant KM, Chen Y, Moe OW, Kuro-o M, Moe S, Aikawa E. Phosphate in Cardiovascular Disease: From New Insights Into Molecular Mechanisms to Clinical Implications. Arterioscler Thromb Vasc Biol 2024; 44:584-602. [PMID: 38205639 PMCID: PMC10922848 DOI: 10.1161/atvbaha.123.319198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Hyperphosphatemia is a common feature in patients with impaired kidney function and is associated with increased risk of cardiovascular disease. This phenomenon extends to the general population, whereby elevations of serum phosphate within the normal range increase risk; however, the mechanism by which this occurs is multifaceted, and many aspects are poorly understood. Less than 1% of total body phosphate is found in the circulation and extracellular space, and its regulation involves multiple organ cross talk and hormones to coordinate absorption from the small intestine and excretion by the kidneys. For phosphate to be regulated, it must be sensed. While mostly enigmatic, various phosphate sensors have been elucidated in recent years. Phosphate in the circulation can be buffered, either through regulated exchange between extracellular and cellular spaces or through chelation by circulating proteins (ie, fetuin-A) to form calciprotein particles, which in themselves serve a function for bulk mineral transport and signaling. Either through direct signaling or through mediators like hormones, calciprotein particles, or calcifying extracellular vesicles, phosphate can induce various cardiovascular disease pathologies: most notably, ectopic cardiovascular calcification but also left ventricular hypertrophy, as well as bone and kidney diseases, which then propagate phosphate dysregulation further. Therapies targeting phosphate have mostly focused on intestinal binding, of which appreciation and understanding of paracellular transport has greatly advanced the field. However, pharmacotherapies that target cardiovascular consequences of phosphate directly, such as vascular calcification, are still an area of great unmet medical need.
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Affiliation(s)
- Mandy E. Turner
- Division of Cardiovascular Medicine, Department of Medicine, Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Laurent Beck
- Nantes Université, CNRS, Inserm, l’institut du thorax, F-44000 Nantes, France
| | - Kathleen M Hill Gallant
- Department of Food Science and Nutrition, University of Minnesota, St. Paul, Minnesota, USA
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yabing Chen
- Department of Pathology, University of Alabama at Birmingham
- Research Department, Veterans Affairs Birmingham Medical Center, Birmingham, AL, USA
| | - Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Physiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Makoto Kuro-o
- Division of Anti-aging Medicine, Center for Molecular Medicine, Jichi Medical University 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Sharon Moe
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Elena Aikawa
- Division of Cardiovascular Medicine, Department of Medicine, Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Center for Excellence in Vascular Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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3
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Karbowska M, Pawlak K, Sieklucka B, Domaniewski T, Lebkowska U, Zawadzki R, Pawlak D. Dose-dependent exposure to indoxyl sulfate alters AHR signaling, sirtuins gene expression, oxidative DNA damage, and bone mineral status in rats. Sci Rep 2024; 14:2583. [PMID: 38297036 PMCID: PMC10831046 DOI: 10.1038/s41598-024-53164-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 01/29/2024] [Indexed: 02/02/2024] Open
Abstract
Indoxyl sulfate (IS), an agonist of aryl hydrocarbon receptors (AhR), can accumulate in patients with chronic kidney disease, but its direct effect on bone is not clear. The present study investigated the effect of chronic exposure to low (100 mg/kg b.w.; 100 IS) and high (200 mg/kg b.w.; 200 IS) dose of IS on bone AhR pathway, sirtuins (SIRTs) expression, oxidative DNA damage and bone mineral status in Wistar rats. The accumulation of IS was observed only in trabecular bone tissue in both doses. The differences were observed in the bone parameters, depending on the applied IS dose. The exposure to 100 IS increased AhR repressor (AhRR)-CYP1A2 gene expression, which was associated with SIRT-1, SIRT-3 and SIRT-7 expression. At the low dose group, the oxidative DNA damage marker was unchanged in the bone samples, and it was inversely related to the abovementioned SIRTs expression. In contrast, the exposure to 200 IS reduced the expression of AhRR, CYP1A, SIRT-3 and SIRT-7 genes compared to 100 IS. The level of oxidative DNA damage was higher in trabecular bone in 200 IS group. Femoral bone mineral density was decreased, and inverse relations were noticed between the level of trabecular oxidative DNA damage and parameters of bone mineral status. In conclusion, IS modulates AhR-depending signaling affecting SIRTs expression, oxidative DNA damage and bone mineral status in a dose dependent manner.
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Affiliation(s)
- Malgorzata Karbowska
- Department of Pharmacodynamics, Medical University of Bialystok, Białystok, Poland.
| | - Krystyna Pawlak
- Department of Monitored Pharmacotherapy, Medical University of Bialystok, Białystok, Poland
| | - Beata Sieklucka
- Department of Pharmacodynamics, Medical University of Bialystok, Białystok, Poland
| | - Tomasz Domaniewski
- Department of Monitored Pharmacotherapy, Medical University of Bialystok, Białystok, Poland
| | - Urszula Lebkowska
- Department of Radiology, Medical University of Bialystok, Białystok, Poland
| | - Radoslaw Zawadzki
- Department of Radiology, Medical University of Bialystok, Białystok, Poland
| | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, Białystok, Poland
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4
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Yang Y, Liang W, Gong W, Li S, Chen S, Yang Z, Kuang C, Zhong Y, Yang D, Liu F. Establishment and evaluation of a nomogram prediction model for the risk of vascular calcification in stage 5 chronic kidney disease patients. Sci Rep 2024; 14:1025. [PMID: 38200088 PMCID: PMC10781805 DOI: 10.1038/s41598-023-48275-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/24/2023] [Indexed: 01/12/2024] Open
Abstract
Vascular calcification (VC) is a common complication of chronic kidney disease (CKD) that has a detrimental effect on patients' survival and prognosis. The aim of this study was to develop and validate a practical and reliable prediction model for VC in CKD5 patients. The medical records of 544 CKD5 patients were reviewed retrospectively. Multivariate logistic regression analysis was used to identify the independent risk factors for vascular calcification in patients with CKD5 and then created a nomogram prediction model. The area under the receiver operating characteristic curve (AUC), Hosmer-Lemeshow test, and decision curve analysis (DCA) were used to assess model performance. The patients were split into groups with normal and high serum uric acid levels, and the factors influencing these levels were investigated. Age, BUN, SUA, P and TG were independent risk factors for vascular calcification in CKD5 patients in the modeling group (P < 0.05). In the internal validation, the results of model showed that the AUC was 0.917. No significant divergence between the predicted probability of the nomogram and the actual incidence rate (x2 = 5.406, P = 0.753) was revealed by the calibration plot and HL test, thus confirming that the calibration was satisfactory. The external validation also showed good discrimination (AUC = 0.973). The calibration chart and HL test also demonstrated good consistency. Besides, the correlation analysis of serum uric acid levels in all CKD5 patients revealed that elevated uric acid levels may be related to gender, BUN, P, and TG.
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Affiliation(s)
- Yan Yang
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Jinan University, 613 W. Huangpu Avenue, Guangzhou, 510632, Guangdong, China
- Department of General Practice, Puning People's Hospital, Puning, 515300, Guangdong, China
| | - Wenxue Liang
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Jinan University, 613 W. Huangpu Avenue, Guangzhou, 510632, Guangdong, China
| | - Wenyu Gong
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Jinan University, 613 W. Huangpu Avenue, Guangzhou, 510632, Guangdong, China
| | - Shishi Li
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Jinan University, 613 W. Huangpu Avenue, Guangzhou, 510632, Guangdong, China
| | - Sining Chen
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Jinan University, 613 W. Huangpu Avenue, Guangzhou, 510632, Guangdong, China
| | - Zhiqian Yang
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Jinan University, 613 W. Huangpu Avenue, Guangzhou, 510632, Guangdong, China
| | - Chaoying Kuang
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Jinan University, 613 W. Huangpu Avenue, Guangzhou, 510632, Guangdong, China
| | - Yuzhen Zhong
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Jinan University, 613 W. Huangpu Avenue, Guangzhou, 510632, Guangdong, China
| | - Demao Yang
- Department of General Practice, Puning People's Hospital, Puning, 515300, Guangdong, China.
| | - Fanna Liu
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Jinan University, 613 W. Huangpu Avenue, Guangzhou, 510632, Guangdong, China.
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5
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Magagnoli L, Cozzolino M, Caskey FJ, Evans M, Torino C, Porto G, Szymczak M, Krajewska M, Drechsler C, Stenvinkel P, Pippias M, Dekker FW, de Rooij ENM, Wanner C, Chesnaye NC, Jager KJ. Association between CKD-MBD and mortality in older patients with advanced CKD-results from the EQUAL study. Nephrol Dial Transplant 2023; 38:2562-2575. [PMID: 37230954 PMCID: PMC10615632 DOI: 10.1093/ndt/gfad100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Chronic kidney disease-mineral and bone disorder (CKD-MBD) is a common complication of CKD; it is associated with higher mortality in dialysis patients, while its impact in non-dialysis patients remains mostly unknown. We investigated the associations between parathyroid hormone (PTH), phosphate and calcium (and their interactions), and all-cause, cardiovascular (CV) and non-CV mortality in older non-dialysis patients with advanced CKD. METHODS We used data from the European Quality study, which includes patients aged ≥65 years with estimated glomerular filtration rate ≤20 mL/min/1.73 m2 from six European countries. Sequentially adjusted Cox models were used to assess the association between baseline and time-dependent CKD-MBD biomarkers and all-cause, CV and non-CV mortality. Effect modification between biomarkers was also assessed. RESULTS In 1294 patients, the prevalence of CKD-MBD at baseline was 94%. Both PTH [adjusted hazard ratio (aHR) 1.12, 95% confidence interval (CI) 1.03-1.23, P = .01] and phosphate (aHR 1.35, 95% CI 1.00-1.84, P = .05), but not calcium (aHR 1.11, 95% CI 0.57-2.17, P = .76), were associated with all-cause mortality. Calcium was not independently associated with mortality, but modified the effect of phosphate, with the highest mortality risk found in patients with both hypercalcemia and hyperphosphatemia. PTH level was associated with CV mortality, but not with non-CV mortality, whereas phosphate was associated with both CV and non-CV mortality in most models. CONCLUSIONS CKD-MBD is very common in older non-dialysis patients with advanced CKD. PTH and phosphate are independently associated with all-cause mortality in this population. While PTH level is only associated with CV mortality, phosphate seems to be associated with both CV and non-CV mortality.
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Affiliation(s)
- Lorenza Magagnoli
- University of Milan, Department of Health Sciences, Milan, Italy
- ASST Santi Paolo e Carlo, Renal Division, Milan, Italy
| | - Mario Cozzolino
- University of Milan, Department of Health Sciences, Milan, Italy
- ASST Santi Paolo e Carlo, Renal Division, Milan, Italy
| | - Fergus J Caskey
- University of Bristol, Population Health Sciences, Bristol, UK
- North Bristol NHS Trust, Renal Unit, Bristol, UK
| | - Marie Evans
- Karolinska Institutet, Department of Clinical Intervention and Technology (CLINTEC), Stockholm, Sweden
| | - Claudia Torino
- Istituto di Fisiologia Clinica Consiglio Nazionale delle Ricerche (IFC-CNR), Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria, Italy (IT)
| | - Gaetana Porto
- G.O.M., Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Maciej Szymczak
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Wroclaw, Poland
| | - Magdalena Krajewska
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Wroclaw, Poland
| | | | - Peter Stenvinkel
- Karolinska Institutet, Department of Clinical Intervention and Technology (CLINTEC), Stockholm, Sweden
| | - Maria Pippias
- University of Bristol, Population Health Sciences, Bristol, UK
- North Bristol NHS Trust, Renal Unit, Bristol, UK
| | - Friedo W Dekker
- Leiden University Medical Center, Department of Clinical Epidemiology, Leiden, The Netherlands
| | - Esther N M de Rooij
- Leiden University Medical Center, Department of Clinical Epidemiology, Leiden, The Netherlands
| | - Christoph Wanner
- University Hospital Würzburg, Division of Nephrology, Würzburg, Germany
| | - Nicholas C Chesnaye
- Amsterdam UMC location AMC, Medical Informatics, ERA Registry, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
| | - Kitty J Jager
- Amsterdam UMC location AMC, Medical Informatics, ERA Registry, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
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6
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Yari Z. Review of Isoflavones and Their Potential Clinical Impacts on Cardiovascular and Bone Metabolism Markers in Peritoneal Dialysis Patients. Prev Nutr Food Sci 2022; 27:347-353. [PMID: 36721750 PMCID: PMC9843715 DOI: 10.3746/pnf.2022.27.4.347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 01/03/2023] Open
Abstract
Cardiovascular disease is the most important cause of mortality in patients with chronic kidney disease, including patients undergoing peritoneal dialysis. Oxidative stress, systemic and vascular inflammation, and lipid abnormalities are important causes of cardiovascular disease in these patients. Bone disorders are also a common complication in dialysis patients and can lead to bone fractures, decreased quality of life, vascular calcification, cardiovascular disease, and increased mortality. Studies in non-uremic populations have shown that soy isoflavones have beneficial effects on oxidative stress, inflammation, lipid abnormalities, and markers of bone metabolism; however, very few studies in this field have been conducted with peritoneal dialysis patients. This paper reviews the key data regarding the effects of soy isoflavones on cardiovascular disease and bone markers and discusses the role of this nutraceutical in preventing and managing the complications of peritoneal dialysis.
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Affiliation(s)
- Zahra Yari
- Department of Nutrition Research, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran 19839-63113, Iran,
Correspondence to Zahra Yari, E-mail:
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7
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Leto G, Tartaglione L, Rotondi S, Pasquali M, Maddaloni E, Mignogna C, D'Onofrio L, Zampetti S, Carlone A, Muci ML, Mastroluca D, Fassino V, Buzzetti R, Mazzaferro S. Diastolic Pressure and ACR Are Modifiable Risk Factors of Arterial Stiffness in T2DM Without Cardiovascular Disease. J Clin Endocrinol Metab 2022; 107:e3857-e3865. [PMID: 35595474 DOI: 10.1210/clinem/dgac291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Indexed: 11/19/2022]
Abstract
AIM To evaluate early, before the onset of cardiovascular events and of chronic renal insufficiency, the association between chronic kidney disease (CKD)-mineral bone disorder (MBD) biomarkers and vascular stiffness [Cardio Ankle Vascular Index (CAVI)] in the course of type 2 diabetes (T2DM). METHOD We evaluated 174 T2DM patients [median age 56 years; male/female (M/F) 100/74] with diabetes duration < 10 years and without decreased estimated glomerular filtration rate (eGFR; ≥60 mL/min/1.73 m2) or macrovascular complications. Thirty-four age-matched healthy subjects [M/F 13/21; age 53.5 (50.0-57.7) years; eGFR 107.5 (97.0-119.7) mL/ min1.73 m2] served as local reference control for CAVI (pathological: ≥8) and the novel CKD-MBD biomarkers. RESULTS Albumin-to-creatinine ratio (ACR) averaged 8.5 mg/g (5.6-17.2) with 12.6% of the patients showing pathologic values, indicative of incipient diabetic nephropathy. Serum parathyroid hormone, fibroblast growth factor 23, and sclerostin were higher while 1,25-dihydroxyvitamin D and Klotho were lower than a control group. CAVI was normal (<8) in only 54% and correlated positively with age (P < 0.001), hemoglobin 1A1c (P = 0.036), and systolic (P = 0.021) and diastolic blood pressure (DBP) (P = 0.001) and negatively correlated with 25-hydroxyvitamin D (P = 0.046). In multivariate analysis, age, DBP, ACR, and serum Klotho were independent positive predictors of CAVI. CONCLUSION In the absence of overt cardiovascular disease and of chronic renal insufficiency, CAVI is frequently pathologic in T2DM. DBP and ACR are modifiable risk factors of vascular stiffness in T2DM, thus warranting optimal assessment.
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Affiliation(s)
- Gateano Leto
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Lida Tartaglione
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
- Nephrology and Dialysis Unit, San Giovanni Evangelista Hospital, Tivoli, Italy
| | - Silverio Rotondi
- Nephrology and Dialysis Unit, ICOT Hospital, Polo Pontino Sapienza University of Rome, Rome, Italy
| | | | - Ernesto Maddaloni
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Carmen Mignogna
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Luca D'Onofrio
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Simona Zampetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Angela Carlone
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Maria Luisa Muci
- Nephrology and Dialysis Unit, ICOT Hospital, Polo Pontino Sapienza University of Rome, Rome, Italy
| | - Daniela Mastroluca
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Valeria Fassino
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Raffaella Buzzetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Sandro Mazzaferro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
- Nephrology Unit, Policlinico Umberto I, Rome, Italy
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8
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Okasha KM, Aboufreikha MH, Elrefaey W, Ashmawy MM, Mourad H, Elsebaey MA, Elnaggar MH, Mashaal RG, Metwally S, Mashal SSA, Shalaby NA, Elhoseny SA, Alkassas A, Elbarbary M, Shoeib O, Ali DA, Baiomy N, Alnabawy SM. Association of Serum Osteoprotegerin Level With Myocardial Injury and Cardiovascular Calcification in Chronic Kidney Disease Patients. Front Med (Lausanne) 2022; 9:814970. [PMID: 35814784 PMCID: PMC9257085 DOI: 10.3389/fmed.2022.814970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 05/26/2022] [Indexed: 11/17/2022] Open
Abstract
Background Chronic kidney disease has emerged as a significant independent risk factor for cardiovascular disease. Cardiovascular calcification is an active process involving a complex interaction of inducers and inhibitors. High sensitivity cardiac troponin T assay detects troponin T with higher sensitivity and precision at an earlier point of time than the conventional assays, and is associated with poor outcomes. Serum osteoprotegerin is classed as an inhibitory factor for cardiovascular calcification. It is involved in the pathological processes of vascular damage and linked to the excess cardiovascular morbidity. The aim of the present study was to evaluate the extent of cardiovascular calcification and serum high sensitivity cardiac troponin T level, and their association with serum osteoprotegerin level in patients with chronic kidney disease stages 3-5. Methods 90 chronic kidney disease patients were enrolled in this study, and they were divided into two groups: group (1) included 45 non-dialysis-dependent chronic kidney disease patients (stages 3-5) and group (2) included 45 chronic hemodialysis patients. Each group further subdivided according to the presence of cardiovascular calcification into subgroup A and B. Vascular calcifications were assessed by lateral lumbar, pelvis and hands X-ray radiographs. Valvular calcification was assessed by echocardiography. Serum cardiac troponin T was measured by high sensitivity assay and serum osteoprotegerin was measured by ELISA. Results Cardiovascular calcification distribution was 22.2% in group (1) and 33.3% in group (2). Serum osteoprotegerin and troponin T in calcification groups (1A and 2A) were significantly higher than non-calcification groups (1B and 2B; P < 0.001). Osteoprotegerin correlated positively with high sensitivity cardiac troponin T (rs = 0.72, P < 0.001). cardiovascular calcification correlated positively with osteoprotegerin, troponin T, and phosphorus. osteoprotegerin and phosphorus were significant independent predictors of cardiovascular calcification at cut-off values ≥4.6 ng/L and ≥6.95 mg/dl, respectively (P < 0.001). Serum phosphorus and creatinine were independent predictors of osteoprotegerin (P < 0.001 and 0.048, respectively). Conclusion Osteoprotegerin is strongly associated with cardiovascular calcification and high sensitivity cardiac troponin T. In addition, there is a positive association between calcification and troponin T. This suggests a role for osteoprotegerin in the pathogenesis and risk stratification of cardiovascular calcification and myocardial injury in chronic kidney disease patients with a potential role as a therapeutic target.
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Affiliation(s)
- Kamal M. Okasha
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Waleed Elrefaey
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Medhat M. Ashmawy
- Cardiovascular Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Heba Mourad
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohamed A. Elsebaey
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohammed H. Elnaggar
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Raghda Gabr Mashaal
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Sama Metwally
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Neveen A. Shalaby
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Shireen Ali Elhoseny
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amr Alkassas
- Cardiovascular Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohammed Elbarbary
- Cardiovascular Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Osama Shoeib
- Cardiovascular Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Dina A. Ali
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Nivin Baiomy
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Sherein M. Alnabawy
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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9
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Inactivation of Osteoblast PKC Signaling Reduces Cortical Bone Mass and Density and Aggravates Renal Osteodystrophy in Mice with Chronic Kidney Disease on High Phosphate Diet. Int J Mol Sci 2022; 23:ijms23126404. [PMID: 35742850 PMCID: PMC9223847 DOI: 10.3390/ijms23126404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/01/2022] [Accepted: 06/06/2022] [Indexed: 02/05/2023] Open
Abstract
Chronic kidney disease (CKD) frequently leads to hyperphosphatemia and hyperparathyroidism, mineral bone disorder (CKD-MBD), ectopic calcifications and cardiovascular mortality. PTH activates the osteoanabolic Gαs/PKA and the Gαq/11/PKC pathways in osteoblasts, the specific impact of the latter in CKD-MBD is unknown. We generated osteoblast specific Gαq/11 knockout (KO) mice and established CKD-MBD by subtotal nephrectomy and dietary phosphate load. Bone morphology was assessed by micro-CT, osteoblast function by bone planar scintigraphy at week 10 and 22 and by histomorphometry. Osteoblasts isolated from Gαq/11 KO mice increased cAMP but not IP3 in response to PTH 1-34, demonstrating the specific KO of the PKC signaling pathway. Osteoblast specific Gαq/11 KO mice exhibited increased serum calcium and reduced bone cortical thickness and mineral density at 24 weeks. CKD Gαq/11 KO mice had similar bone morphology compared to WT, while CKD Gαq/11-KO on high phosphate diet developed decreased metaphyseal and diaphyseal cortical thickness and area, as well as a reduction in trabecular number. Gαq/11-KO increased bone scintigraphic tracer uptake at week 10 and mitigated tracer uptake in CKD mice at week 22. Histological bone parameters indicated similar trends. Gαq/11-KO in osteoblast modulates calcium homeostasis, bone formation rate, bone morphometry, and bone mineral density. In CKD and high dietary phosphate intake, osteoblast Gαq/11/PKC KO further aggravates mineral bone disease.
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Magagnoli L, Galassi A, Cozzolino M. Beyond vessels and bones: can CKD-MBD treatment improve uremic subjects' minds? Nephrol Dial Transplant 2022; 37:2039-2041. [PMID: 35544125 DOI: 10.1093/ndt/gfac176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lorenza Magagnoli
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, Milan, Italy
| | - Andrea Galassi
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, Milan, Italy
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, Milan, Italy
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11
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Ureña Torres PA, Souberbielle JC, Solal MC. Bone Fragility in Chronic Kidney Disease Stage 3 to 5: The Use of Vitamin D Supplementation. Metabolites 2022; 12:metabo12030266. [PMID: 35323709 PMCID: PMC8953916 DOI: 10.3390/metabo12030266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/10/2022] [Accepted: 03/17/2022] [Indexed: 12/02/2022] Open
Abstract
Frequently silent until advanced stages, bone fragility associated with chronic kidney disease-mineral and bone disease (CKD-MBD) is one of the most devastating complications of CKD. Its pathophysiology includes the reduction of active vitamin D metabolites, phosphate accumulation, decreased intestinal calcium absorption, renal alpha klotho production, and elevated fibroblast growth factor 23 (FGF23) levels. Altogether, these factors contribute firstly to secondary hyperparathyroidism, and ultimately, to micro- and macrostructural bone changes, which lead to low bone mineral density and an increased risk of fracture. A vitamin D deficiency is common in CKD patients, and low circulating 25(OH)D levels are invariably associated with high serum parathyroid hormone (PTH) levels as well as with bone mineralization defects, such as osteomalacia in case of severe forms. It is also associated with a variety of non-skeletal diseases, including cardiovascular disease, diabetes mellitus, multiple sclerosis, cancer, and reduced immunological response. Current international guidelines recommend supplementing CKD patients with nutritional vitamin D as in the general population; however, there is no randomized clinical trial (RCT) evaluating the effect of vitamin D (or vitamin D+calcium) supplementation on the risk of fracture in the setting of CKD. It is also unknown what level of circulating 25(OH)D would be sufficient to prevent bone abnormalities and fractures in these patients. The impact of vitamin D supplementation on other surrogate endpoints, including bone mineral density and bone-related circulating biomarkers (PTH, FGF23, bone-specific alkaline phosphatase, sclerostin) has been evaluated in several RTCs; however, the results were not always translated into an improvement in long-term outcomes, such as reduced fracture risk. This review provides a brief and comprehensive update on CKD-related bone fragility and the use of natural vitamin D supplementation in these patients.
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Affiliation(s)
- Pablo Antonio Ureña Torres
- Department of Dialysis AURA Nord Saint Ouen, 12, Rue Anselme, 93400 Saint Ouen, France
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, 75015 Paris, France;
- Correspondence: (P.A.U.T.); (M.C.S.)
| | - Jean Claude Souberbielle
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, 75015 Paris, France;
| | - Martine Cohen Solal
- Bioscar INSERM U1132, Department of Rheumatology, Université de Paris, Hôpital Lariboisière, 75010 Paris, France
- Correspondence: (P.A.U.T.); (M.C.S.)
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12
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Díaz-De la Cruz EN, Cerrillos-Gutiérrez JI, García-Sánchez A, Prado-Nevárez CG, Andrade-Sierra J, Jalomo-Martínez B, Banda-López A, Rojas-Campos E, Miranda-Díaz AG. The Influence of Sevelamer Hydrochloride and Calcium Carbonate on Markers of Inflammation and Oxidative Stress in Hemodialysis at Six Months of Follow-Up. Front Med (Lausanne) 2021; 8:714205. [PMID: 34901050 PMCID: PMC8655244 DOI: 10.3389/fmed.2021.714205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Patients with end-stage renal disease (ESRD) present alterations in mineral and bone metabolism. Hyperphosphatemia in ESRD is considered an independent risk factor for cardiovascular disease (CVD), increasing morbidity, and mortality. Sevelamer hydrochloride is a calcium-free, non-absorbable phosphate-chelating polymer. Calcium carbonate chelator is helpful in controlling serum phosphate levels. There is insufficient information on the influence of sevelamer hydrochloride and calcium carbonate on the behavior of oxidative stress (OS) markers and inflammation in patients on hemodialysis (HD). A randomized open clinical trial was carried out on patients to evaluate sevelamer hydrochloride and calcium carbonate influence at 6 months of study follow-up. Levels of oxidants (LPO, NO, and 8-isoprostanes), antioxidants (SOD and TAC), oxidative DNA damage (8-OHdG and hOGG1), pro-inflammatory cytokines (IL-6 and TNF-α), and inflammation markers (ferritin and C-reactive protein) were measured with colorimetric and ELISA methods. We found a significant increase in oxidants LPO and NO, and antioxidants SOD and TAC, and downregulation of IL-6 and TNF-α. Ferritin decrease at 6 months follow-up in the sevelamer hydrochloride group. Increase in C-reactive protein was found in the group of patients treated with calcium carbonate. In conclusion, we found an oxidative state imbalance with increase in LPO and NO oxidants. The activity of the antioxidant enzymes (SOD and TAC) was also found to increase, suggesting a compensatory effect in the face of increase in oxidants. The same phenomenon was observed with increase in the oxidative damage marker to DNA and the increase in the DNA repair enzyme, suggesting a compensatory effect. Pro-inflammatory cytokines were predominantly downregulated by TNF-α in the group that ingested sevelamer hydrochloride in the final determination at 6 months of follow-up. Serum ferritin levels decreased significantly at the end of follow-up in patients on HD in the sevelamer hydrochloride group. The management of hyperphosphatemia with sevelamer hydrochloride appears to have obvious anti-inflammatory and antioxidant benefits.
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Affiliation(s)
| | - José Ignacio Cerrillos-Gutiérrez
- Department of Nephrology and Organ Transplant Unit, National Western Medical Centre, Mexican Institute of Social Security, Specialties Hospital, Guadalajara, Mexico
| | - Andrés García-Sánchez
- Department of Physiology, University Health Sciences Center, Universidad de Guadalajara, Guadalajara, Mexico
| | - Carlos Gerardo Prado-Nevárez
- Department of Nephrology and Organ Transplant Unit, National Western Medical Centre, Mexican Institute of Social Security, Specialties Hospital, Guadalajara, Mexico
| | - Jorge Andrade-Sierra
- Department of Nephrology and Organ Transplant Unit, National Western Medical Centre, Mexican Institute of Social Security, Specialties Hospital, Guadalajara, Mexico
| | - Basilio Jalomo-Martínez
- Department of Nephrology and Organ Transplant Unit, National Western Medical Centre, Mexican Institute of Social Security, Specialties Hospital, Guadalajara, Mexico
| | - Adriana Banda-López
- Department of Nephrology and Organ Transplant Unit, National Western Medical Centre, Mexican Institute of Social Security, Specialties Hospital, Guadalajara, Mexico
| | - Enrique Rojas-Campos
- Department of Nephrology and Organ Transplant Unit, National Western Medical Centre, Mexican Institute of Social Security, Specialties Hospital, Guadalajara, Mexico
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Cozzolino M, Galassi A, Ciceri P. Phosphate binders in dialysis: better satisfied than sorry. Clin Kidney J 2021; 14:1859-1860. [PMID: 34345407 PMCID: PMC8323148 DOI: 10.1093/ckj/sfab093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/17/2021] [Indexed: 12/11/2022] Open
Abstract
High serum phosphate levels have been associated with increased morbidity and mortality in dialysis patients. Nephrologists routinely counteract the positive phosphate balance in dialysis patients through nutritional counselling, stronger phosphate removal by dialysis and prescription of phosphate binders. An individualized choice of phosphate binders is a desirable option to improve the poor adherence with these medications' prescription that has been associated with hyperphosphataemia.
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Affiliation(s)
- Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
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14
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Fusaro M, Holden R, Lok C, Iervasi G, Plebani M, Aghi A, Gallieni M, Cozzolino M. Phosphate and bone fracture risk in chronic kidney disease patients. Nephrol Dial Transplant 2021; 36:405-412. [PMID: 31620773 DOI: 10.1093/ndt/gfz196] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/29/2019] [Indexed: 01/25/2023] Open
Abstract
In chronic kidney disease (CKD), phosphate homoeostasis plays a central role in the development of mineral and bone disorder (MBD) together with decreased serum calcium and elevated serum parathyroid hormone, fibroblast growth factor 23 and sclerostin levels. Today there are only a few data exploring the direct role of abnormal phosphate homoeostasis and hyperphosphataemia in the development of CKD-MBD. On the other hand, several studies have looked at the link between hyperphosphataemia and cardiovascular morbidity and mortality in CKD, but there is a lack of evidence to indicate that lowering phosphate levels improves cardiovascular outcomes in this population. Furthermore, the impact of liberalizing phosphate targets on CKD-MBD progression and bone fracture is currently not known. In this review we discuss the central role of phosphate in the pathogenesis of CKD-MBD and how it may be associated with fracture risk, both in hyper- and hypophosphataemia.
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Affiliation(s)
- Maria Fusaro
- National Research Council, Institute of Clinical Physiology, Pisa, Italy.,Department of Medicine, University of Padova, Padova, Italy
| | - Rachel Holden
- Department of Medicine, Division of Nephrology, Queen's University, Kingston, Ontario, Canada
| | - Charmaine Lok
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Giorgio Iervasi
- National Research Council, Institute of Clinical Physiology, Pisa, Italy
| | - Mario Plebani
- Department of Medicine, Laboratory Medicine Unit, University of Padova, Padova, Italy
| | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Maurizio Gallieni
- Department of Biomedical and Clinical Sciences 'L. Sacco', Nephrology and Dialysis Unit, ASST Fatebenefratelli-Sacco, Università di Milano, Milan, Italy
| | - Mario Cozzolino
- Department of Health Sciences, ASST Santi Paolo and Carlo, University of Milan and Renal Division, Milan, Italy
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15
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Tinti F, Lai S, Noce A, Rotondi S, Marrone G, Mazzaferro S, Di Daniele N, Mitterhofer AP. Chronic Kidney Disease as a Systemic Inflammatory Syndrome: Update on Mechanisms Involved and Potential Treatment. Life (Basel) 2021; 11:419. [PMID: 34063052 PMCID: PMC8147921 DOI: 10.3390/life11050419] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/26/2021] [Accepted: 05/01/2021] [Indexed: 02/07/2023] Open
Abstract
Chronic kidney disease (CKD) is characterized by manifestations and symptoms involving systemic organs and apparatus, associated with elevated cardiovascular morbidity and mortality, bone disease, and other tissue involvement. Arterial hypertension (AH), diabetes mellitus (DM), and dyslipidemia, with glomerular or congenital diseases, are the traditional risk factors recognized as the main causes of progressive kidney dysfunction evolving into uremia. Acute kidney injury (AKI) has recently been considered an additional risk factor for the worsening of CKD or the development of CKD de novo. Evidence underlies the role of systemic inflammation as a linking factor between AKI and CKD, recognizing the role of inflammation in AKI evolution to CKD. Moreover, abnormal increases in oxidative stress (OS) and inflammatory status in CKD seem to exert an important pathogenetic role, with significant involvement in the clinical management of this condition. With our revision, we want to focus on and update the inflammatory mechanisms responsible for the pathologic conditions associated with CKD, with particular attention on the development of AKI and AKI-CKD de novo, the alteration of calcium-phosphorus metabolism with bone disease and CKD-MBD syndrome, the status of malnutrition and malnutrition-inflammation complex syndrome (MICS) and protein-energy wasting (PEW), uremic sarcopenia, the status of OS, and the different inflammatory pathways, highlighting a new approach to CKD. The depth comprehension of the mechanisms underlying the development of inflammation in CKD may present new possible therapeutic approaches in CKD and hopefully improve the management of correlated morbidities and provide a reduction in associated mortality.
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Affiliation(s)
- Francesca Tinti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Silvia Lai
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Annalisa Noce
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
| | - Silverio Rotondi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Giulia Marrone
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
- PhD School of Applied Medical, Surgical Sciences, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy
| | - Sandro Mazzaferro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Nicola Di Daniele
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
| | - Anna Paola Mitterhofer
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
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16
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Bover J, Ureña-Torres P, Cozzolino M, Rodríguez-García M, Gómez-Alonso C. The Non-invasive Diagnosis of Bone Disorders in CKD. Calcif Tissue Int 2021; 108:512-527. [PMID: 33398414 DOI: 10.1007/s00223-020-00781-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Abnormal bone metabolism is an integral part of the chronic kidney disease-mineral bone disorder (CKD-MBD). For several reasons, the difficult bone compartment was neglected for some time, but there has been renewed interest as a result of the conception of bone as a new endocrine organ, the increasing recognition of the cross-talk between bone and vessels, and, especially, the very high risk of osteoporotic fractures (and associated mortality) demonstrated in patients with CKD. Therefore, it has been acknowledged in different guidelines that action is needed in respect of fracture risk assessment and the diagnosis and treatment of osteoporosis in the context of CKD and CKD-MBD, even beyond renal osteodystrophy. These updated guidelines clearly underline the need to improve a non-invasive approach to these bone disorders in order to guide treatment decisions aimed at not only controlling CKD-MBD but also decreasing the risk of fracture. In this report, we review the current role of the most often clinically used or promising biochemical circulating biomarkers such as parathyroid hormone, alkaline phosphatases, and other biochemical markers of bone activity as alternatives to some aspects of bone histomorphometry. We also mention the potential role of classic and new imaging techniques for CKD patients. Information on many aspects is still scarce and heterogeneous, but many of us consider that it is indeed time for action, recognizing our definitely limited ability to base certain treatment decisions only on our current non-comprehensive knowledge.
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Affiliation(s)
- Jordi Bover
- Department of Nephrology, Fundació Puigvert and Universitat Autònoma, IIB Sant Pau, REDinREN, C. Cartagena 340-350, 08025, Barcelona, Catalonia, Spain.
| | - Pablo Ureña-Torres
- Department of Dialysis, AURA Nord Saint Ouen and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Minerva Rodríguez-García
- Unidad de Gestión Clínica de Nefrología, Hospital Universitario Central de Asturias, REDinREN, Universidad de Oviedo, Oviedo, Spain
| | - Carlos Gómez-Alonso
- Unidad de Gestión Clínica de Metabolismo Óseo y Mineral, Instituto de Investigación Sanitaria del Principado de Asturias, Hospital Universitario Central de Asturias, Oviedo, Spain
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17
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Mazzaferro S, Bagordo D, De Martini N, Pasquali M, Rotondi S, Tartaglione L, Stenvinkel P. Inflammation, Oxidative Stress, and Bone in Chronic Kidney Disease in the Osteoimmunology Era. Calcif Tissue Int 2021; 108:452-460. [PMID: 33388898 PMCID: PMC7778498 DOI: 10.1007/s00223-020-00794-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022]
Abstract
Bone is not only a mineralized and apparently non-vital structure that provides support for locomotion and protection to inner organs. An increasing number of studies are unveiling new biologic functions and connections to other systems, giving the rise to new fields of research, such as osteoimmunology. The bone marrow niche, a new entity in bone physiology, seems to represent the site where a complex crosstalk between bone and immune/inflammatory responses takes place. An impressive interplay with the immune system is realized in bone marrow, with reciprocal influences between bone cells and haematopoietic cells. In this way, systemic chronic inflammatory diseases realize a crosstalk with bone, resulting in bone disease. Thus, pathogenetic links between chronic kidney disease-mineral bone disorders and osteoporosis, cardiovascular disease, and ageing are common. The aim of this narrative review is to provide a general view of the progresses in the field of bone research and their potential clinical implications, with emphasis on the links with inflammation and the connections to osteoimmunology and chemokines.
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Affiliation(s)
- Sandro Mazzaferro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
- Nephrology Unit, Policlinico Umberto I, Rome, Italy.
| | - Domenico Bagordo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Natalia De Martini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | | | - Silverio Rotondi
- Nephrology and Dialysis Unit, ICOT Hospital, Polo Pontino Sapienza University of Rome, Rome, Italy
| | - Lida Tartaglione
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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18
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Cozzolino M, Galassi A, Ciceri P. Do we need new phosphate binders in dialysis? Clin Kidney J 2021; 14:474-475. [PMID: 33626110 PMCID: PMC7886565 DOI: 10.1093/ckj/sfaa246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 11/28/2022] Open
Abstract
Patients affected by chronic kidney disease (CKD) have a greater risk of mortality than the general population. Fatal cardiovascular events are the most frequent cause of death in CKD patients, especially in the late stages of disease. Derangement of mineral metabolism and hyperphosphataemia are currently accepted as pivotal triggers of these vascular complications. Phosphate binders represent the common strategy to counteract hyperphosphataemia in dialysis patients. Several studies have reported a reduction in mortality risk in dialysis patients receiving phosphate binders compared with untreated patients, independent of the class of binder prescribed.
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Affiliation(s)
- Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Depart. of Health Sciences, University of Milan, Milan, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Depart. of Health Sciences, University of Milan, Milan, Italy
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, Milan, Italy
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Itano Y, Kato S, Tsuboi M, Kasuga H, Tsuruta Y, Sato F, Hishida M, Ishimoto T, Kosugi T, Ando M, Kuwatsuka Y, Maruyama S. A Prospective, Randomized Clinical Trial of Etelcalcetide in Patients Receiving Hemodialysis With Secondary Hyperparathyroidism (the DUET Trial). Kidney Int Rep 2020; 5:2168-2177. [PMID: 33305109 PMCID: PMC7710846 DOI: 10.1016/j.ekir.2020.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/05/2020] [Accepted: 09/08/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION The clinical trial on the Development of a treatment strategy for chronic kidney disease‒mineral and bone disorder by a mUltilateral mechanism of ETelcalcetide hydrochloride, or the DUET trial, was designed to determine the efficacy of etelcalcetide, an intravenous calcimimetic, for control of secondary hyperparathyroidism (SHPT). METHODS Eligible SHPT maintenance hemodialysis patients (n = 124) were randomized (1:1:1) for inclusion in the DUET trial, a 12-week, multicenter, open-label, parallel-group study (jRCTs041180108), and assigned to either an etelcalcetide + active vitamin D group (group E+D), an etelcalcetide + oral calcium preparation group (group E+Ca), or a control group (group C). The primary endpoint was number of patients with a 50% reduction from baseline of intact parathyroid hormone (iPTH) levels, and iPTH levels ≤ 240 pg/mL at 12 weeks after start of the trial. RESULTS The proportion of patients reaching the primary endpoint (95% confidence interval [CI]) was 90.0% (76.3%-97.2%) in group E+D, 56.8% (39.5%-72.9%) in group E+Ca, and 19.5% (8.8%-34.9%) in group C. Etelcalcetide treatment led to a significant increase in the number of patients achieving the endpoint (odds ratio, 13.4; 95% CI, 5.10-35.3) on logistic regression analysis, with iPTH, corrected serum calcium, and phosphate at baseline as covariates. Significantly more patients achieved the endpoint in group E+D compared with group E+Ca (odds ratio, 6.35; 95% CI, 1.79-22.48). There were fewer hypocalcemic visits in group E+D compared with group E+Ca (P = 0.018), yet the former group was prone to hyperphosphatemia. CONCLUSION Etelcalcetide showed good control of iPTH for maintenance hemodialysis patients with SHPT. Active vitamin D was useful in correcting hypocalcemia, but the oral calcium preparation was superior for suppression of hyperphosphatemia.
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Affiliation(s)
- Yuya Itano
- Department of Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Sawako Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | | | | | | | | | - Manabu Hishida
- Department of Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takuji Ishimoto
- Department of Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tomoki Kosugi
- Department of Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masahiko Ando
- Department of Advanced Medicine, Nagoya University Hospital, Aichi, Japan
| | - Yachiyo Kuwatsuka
- Department of Advanced Medicine, Nagoya University Hospital, Aichi, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
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Cianciolo G, La Manna G, Capelli I, Gasperoni L, Galassi A, Ciceri P, Cozzolino M. The role of activin: the other side of chronic kidney disease-mineral bone disorder? Nephrol Dial Transplant 2020; 36:966-974. [PMID: 32940690 DOI: 10.1093/ndt/gfaa203] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Indexed: 12/21/2022] Open
Abstract
Chronic kidney disease-mineral bone disorder (CKD-MBD) plays a pivotal role in the excess of cardiovascular morbidity and mortality associated with CKD. There is now a growing awareness that pathways involved in CKD-MBD, like canonical Wnt signalling, are activated from the earliest stages of CKD, playing a role in the development of adynamic bone disease with unknown consequences on vasculature. These changes occur before the classic changes in mineral metabolism: secondary hyperparathyroidism, calcitriol deficiency and hyperphosphataemia. Furthermore, vascular calcification is frequently associated and evolves with decreased bone mineral density and deranged bone turnover, while bone and arterial mineralization share common pathways. Therefore, results of clinical trials focused on mineral bone disorder, aimed at preserving bone and cardiovascular health, are considered unsatisfactory. In order to identify more effective therapeutic strategies, it is necessary to clarify the pathways modulating the cross-talk between bone and vasculature and identify new mediators involved in the pathogenesis of CKD-MBD. Much attention has been paid recently to the role of the transforming growth factor-beta superfamily members in renal disease, and in particular of activin A (ActA). Preclinical studies demonstrate an upgrade of ActA signalling in kidney, skeleton, vasculature and heart during CKD. This supports the idea that an endocrine factor produced in the kidney during renal disease, in addition to promoting the progression of kidney damage, deranges other organs' homoeostasis and participates in CKD-MBD. In this review, we analyse the contribution of ActA to kidney fibrosis and inflammation as well as its role in the development of CKD-MBD.
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Affiliation(s)
- Giuseppe Cianciolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Irene Capelli
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Lorenzo Gasperoni
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Andrea Galassi
- Department of Health Sciences, Renal Division, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Paola Ciceri
- Department of Nephrology, Dialysis and Renal Transplant, Renal Research Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
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Cardoso DF, Marques EA, Leal DV, Ferreira A, Baker LA, Smith AC, Viana JL. Impact of physical activity and exercise on bone health in patients with chronic kidney disease: a systematic review of observational and experimental studies. BMC Nephrol 2020; 21:334. [PMID: 32770949 PMCID: PMC7414574 DOI: 10.1186/s12882-020-01999-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 07/31/2020] [Indexed: 12/13/2022] Open
Abstract
Background Chronic Kidney Disease (CKD) patients frequently develop life-impairing bone mineral disorders. Despite the reported impact of exercise on bone health, systematic reviews of the evidence are lacking. This review examines the association of both physical activity (PA) and the effects of different exercise interventions with bone outcomes in CKD. Methods English-language publications in EBSCO, Web of Science and Scopus were searched up to May 2019, from which observational and experimental studies examining the relation between PA and the effect of regular exercise on bone-imaging or -outcomes in CKD stage 3–5 adults were included. All data were extracted and recorded using a spreadsheet by two review authors. The evidence quality was rated using the Cochrane risk of bias tool and a modified Newcastle-Ottawa scale. Results Six observational (4 cross-sectional, 2 longitudinal) and seven experimental (2 aerobic-, 5 resistance-exercise trials) studies were included, with an overall sample size of 367 and 215 patients, respectively. Judged risk of bias was low and unclear in most observational and experimental studies, respectively. PA was positively associated with bone mineral density at lumbar spine, femoral neck and total body, but not with bone biomarkers. Resistance exercise seems to improve bone mass at femoral neck and proximal femur, with improved bone formation and inhibited bone resorption observed, despite the inconsistency of results amongst different studies. Conclusions There is partial evidence supporting (i) a positive relation of PA and bone outcomes, and (ii) positive effects of resistance exercise on bone health in CKD. Prospective population studies and long-term RCT trials exploring different exercise modalities measuring bone-related parameters as endpoint are currently lacking.
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Affiliation(s)
- Daniela F Cardoso
- Research Center in Sports Sciences, Health Sciences and Human Development, CIDESD, University Institute of Maia, Av. Carlos Oliveira Campos - Castelo da Maia, 4475-690, Maia, Portugal
| | - Elisa A Marques
- Research Center in Sports Sciences, Health Sciences and Human Development, CIDESD, University Institute of Maia, Av. Carlos Oliveira Campos - Castelo da Maia, 4475-690, Maia, Portugal
| | - Diogo V Leal
- Research Center in Sports Sciences, Health Sciences and Human Development, CIDESD, University Institute of Maia, Av. Carlos Oliveira Campos - Castelo da Maia, 4475-690, Maia, Portugal
| | - Aníbal Ferreira
- Department of Nephrology, Curry Cabral Hospital, Lisbon, Portugal
| | - Luke A Baker
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alice C Smith
- Leicester Kidney Lifestyle Team, Department of Health Sciences, University of Leicester, Leicester, UK
| | - João L Viana
- Research Center in Sports Sciences, Health Sciences and Human Development, CIDESD, University Institute of Maia, Av. Carlos Oliveira Campos - Castelo da Maia, 4475-690, Maia, Portugal.
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Bover J, Ureña-Torres P, Mateu S, DaSilva I, Gràcia S, Sánchez-Baya M, Arana C, Fayos L, Guirado L, Cozzolino M. Evidence in chronic kidney disease-mineral and bone disorder guidelines: is it time to treat or time to wait? Clin Kidney J 2020; 13:513-521. [PMID: 32905295 PMCID: PMC7467585 DOI: 10.1093/ckj/sfz187] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/02/2019] [Indexed: 12/18/2022] Open
Abstract
Chronic kidney disease-mineral and bone disorder (CKD-MBD) is one of the many important complications associated with CKD and may at least partially explain the extremely high morbidity and mortality among CKD patients. The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline document was based on the best information available at that time and was designed not only to provide information but also to assist in decision-making. In addition to the international KDIGO Work Group, which included worldwide experts, an independent Evidence Review Team was assembled to ensure rigorous review and grading of the existing evidence. Based on the evidence from new clinical trials, an updated Clinical Practice Guideline was published in 2017. In this review, we focus on the conceptual and practical evolution of clinical guidelines (from eMinence-based medicine to eVidence-based medicine and 'living' guidelines), highlight some of the current important CKD-MBD-related changes, and underline the poor or extremely poor level of evidence present in those guidelines (as well as in other areas of nephrology). Finally, we emphasize the importance of individualization of treatments and shared decision-making (based on important ethical considerations and the 'best available evidence'), which may prove useful in the face of the uncertainty over the decision whether 'to treat' or 'to wait'.
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Affiliation(s)
- Jordi Bover
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Pablo Ureña-Torres
- Department of Dialysis, AURA Nord Saint Ouen, Saint Ouen and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Silvia Mateu
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Iara DaSilva
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Silvia Gràcia
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Maya Sánchez-Baya
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Carolt Arana
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Leonor Fayos
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Lluis Guirado
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Mario Cozzolino
- Renal Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
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Cianciolo G, De Pascalis A, Gasperoni L, Tondolo F, Zappulo F, Capelli I, Cappuccilli M, La Manna G. The Off-Target Effects, Electrolyte and Mineral Disorders of SGLT2i. Molecules 2020; 25:molecules25122757. [PMID: 32549243 PMCID: PMC7355461 DOI: 10.3390/molecules25122757] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 12/21/2022] Open
Abstract
The sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a relatively new class of antidiabetic drugs that, in addition to emerging as an effective hypoglycemic treatment, have been shown to improve, in several trials, both renal and cardiovascular outcomes. In consideration of the renal site of action and the associated osmotic diuresis, a negative sodium balance has been postulated during SGLT2i administration. Although it is presumable that sodium and water depletion may contribute to some positive actions of SGLT2i, evidence is far from being conclusive and the real physiologic effects of SGLT2i on sodium remain largely unknown. Indeed, no study has yet investigated how SGLT2i change sodium balance in the long term and especially the pathways through which the natriuretic effect is expressed. Furthermore, recently, several experimental studies have identified different pathways, not directly linked to tubular sodium handling, which could contribute to the renal and cardiovascular benefits associated with SGLT2i. These compounds may also modulate urinary chloride, potassium, magnesium, phosphate, and calcium excretion. Some changes in electrolyte homeostasis are transient, whereas others may persist, suggesting that the administration of SGLT2i may affect mineral and electrolyte balances in exposed subjects. This paper will review the evidence of SGLT2i action on sodium transporters, their off-target effects and their potential role on kidney protection as well as their influence on electrolytes and mineral homeostasis.
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Affiliation(s)
- Giuseppe Cianciolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40100 Bologna, Italy; (G.C.); (L.G.); (F.T.); (F.Z.); (I.C.); (M.C.)
| | | | - Lorenzo Gasperoni
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40100 Bologna, Italy; (G.C.); (L.G.); (F.T.); (F.Z.); (I.C.); (M.C.)
| | - Francesco Tondolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40100 Bologna, Italy; (G.C.); (L.G.); (F.T.); (F.Z.); (I.C.); (M.C.)
| | - Fulvia Zappulo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40100 Bologna, Italy; (G.C.); (L.G.); (F.T.); (F.Z.); (I.C.); (M.C.)
| | - Irene Capelli
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40100 Bologna, Italy; (G.C.); (L.G.); (F.T.); (F.Z.); (I.C.); (M.C.)
| | - Maria Cappuccilli
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40100 Bologna, Italy; (G.C.); (L.G.); (F.T.); (F.Z.); (I.C.); (M.C.)
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40100 Bologna, Italy; (G.C.); (L.G.); (F.T.); (F.Z.); (I.C.); (M.C.)
- Correspondence: ; Tel.: +39-051-214-3255; Fax: +39-051-340-871
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Ting IW, Yeh HC, Huang HC, Chiang HY, Chu PL, Kuo CC. Joint Longitudinal Low Calcium High Phosphorus Trajectory Associates with Accelerated Progression, Acute Coronary Syndrome and Mortality in Chronic Kidney Disease. Sci Rep 2020; 10:9682. [PMID: 32541796 PMCID: PMC7296014 DOI: 10.1038/s41598-020-66577-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
The effects of long-term disturbance of the mineral metabolism on patients with chronic kidney disease (CKD) are unclear. We investigated whether the longitudinal Ca-P (joint calcium and phosphorus) trajectories are associated with incident end-stage renal disease (ESRD), acute coronary syndrome (ACS), and all-cause mortality in patients with CKD. We conducted a prospective cohort study by using data from a 13-year multidisciplinary pre-ESRD care registry. The final study population consisted of 4,237 CKD patients aged 20–90 years with data gathered from 2003 to 2015. Individuals’ Ca-P trajectories were defined using group-based multi-trajectory modeling into three distinct patterns: reference, moderately abnormal, and severely abnormal. Times to ESRD, ACS, and death were analyzed using multiple Cox regression. Compared with those with a “reference” Ca-P trajectory, the adjusted hazard ratios (aHRs) (95% confidence interval [CI]) for incidental ESRD were 5.92 (4.71–7.44) and 15.20 (11.85–19.50) for “moderately abnormal” and “severely abnormal” Ca-P trajectories, respectively. The corresponding aHRs for ACS were 1.94 (1.49–2.52) and 3.18 (2.30–4.39), and for all-cause mortality, they were 1.88 (1.64–2.16) and 2.46 (2.05–2.96) for “moderately abnormal” and “severely abnormal” Ca-P trajectories, respectively. For outcomes of progression to ESRD, the detrimental effects of abnormal Ca-P trajectories were more substantial in patients with CKD stage 3 than those with CKD stage 4 or 5 (p-value for interaction < 0.001). Future studies should validate reliable longitudinal cut-offs of serum phosphorus and consider the “lowering phosphorus— the lower the better, the earlier the better” approach to phosphorus control in CKD.
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Affiliation(s)
- I-Wen Ting
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Hung-Chieh Yeh
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.,Big Data Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Han-Chun Huang
- Big Data Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Hsiu-Yin Chiang
- Big Data Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Pei-Lun Chu
- Department of Internal Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei, Taiwan.,School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan
| | - Chin-Chi Kuo
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan. .,Big Data Center, China Medical University Hospital, China Medical University, Taichung, Taiwan.
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25
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Effects of isoflavones on bone turnover markers in peritoneal dialysis patients: a randomized controlled trial. Int Urol Nephrol 2020; 52:1367-1376. [PMID: 32488754 DOI: 10.1007/s11255-020-02523-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study was to investigate the effects of soy isoflavones on serum markers of bone formation and resorption in peritoneal dialysis (PD) patients. METHODS In this randomized, double-blind, placebo-controlled trial, 40 PD patients were randomly assigned to either the soy isoflavone or the placebo group. The patients in the soy isoflavone group received 100 mg soy isoflavones daily for 8 weeks, whereas the placebo group received corresponding placebos. At baseline and the end of the 8th week, 7 ml of blood was obtained from each patient after a 12- to 14-h fast and serum concentrations of bone formation markers (osteocalcin and bone alkaline phosphatase), bone resorption markers [N-telopeptide and receptor activator of nuclear factor kappa B ligand (RANKL)], and osteoprotegerin as an inhibitor of bone resorption were measured. RESULTS Serum N-telopeptide concentration decreased significantly up to 27% in the soy isoflavone group at the end of week 8 compared to baseline (P = 0.003). Also, serum RANKL concentration reduced significantly up to 17% in the soy isoflavone group at the end of week 8 compared to baseline (P = 0.03). These bone resorption markers did not significantly change in the placebo group during the study. There were no significant differences between the two groups in mean changes of serum osteocalcin, bone alkaline phosphatase, and osteoprotegerin. CONCLUSION This study indicates that daily administration of 100 mg soy isoflavone supplement to PD patients reduces serum N-telopeptide and RANKL which are two bone resorption markers. CLINICALTRIALS.GOV: NCT03773029, 2018.
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Cozzolino M, Cianciolo G, Podestà MA, Ciceri P, Galassi A, Gasperoni L, La Manna G. Current Therapy in CKD Patients Can Affect Vitamin K Status. Nutrients 2020; 12:nu12061609. [PMID: 32486167 PMCID: PMC7352600 DOI: 10.3390/nu12061609] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/15/2022] Open
Abstract
Chronic kidney disease (CKD) patients have a higher risk of cardiovascular (CVD) morbidity and mortality compared to the general population. The links between CKD and CVD are not fully elucidated but encompass both traditional and uremic-related risk factors. The term CKD-mineral and bone disorder (CKD-MBD) indicates a systemic disorder characterized by abnormal levels of calcium, phosphate, PTH and FGF-23, along with vitamin D deficiency, decreased bone mineral density or altered bone turnover and vascular calcification. A growing body of evidence shows that CKD patients can be affected by subclinical vitamin K deficiency; this has led to identifying such a condition as a potential therapeutic target given the specific role of Vitamin K in metabolism of several proteins involved in bone and vascular health. In other words, we can hypothesize that vitamin K deficiency is the common pathogenetic link between impaired bone mineralization and vascular calcification. However, some of the most common approaches to CKD, such as (1) low vitamin K intake due to nutritional restrictions, (2) warfarin treatment, (3) VDRA and calcimimetics, and (4) phosphate binders, may instead have the opposite effects on vitamin K metabolism and storage in CKD patients.
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Affiliation(s)
- Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, 20142 Milan, Italy; (M.C.); (M.A.P.); (A.G.)
| | - Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola Hospital, University of Bologna, 40126 Bologna, Italy; (G.C.); (L.G.)
| | - Manuel Alfredo Podestà
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, 20142 Milan, Italy; (M.C.); (M.A.P.); (A.G.)
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, 20142 Milan, Italy; (M.C.); (M.A.P.); (A.G.)
| | - Lorenzo Gasperoni
- Nephrology, Dialysis and Renal Transplant Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola Hospital, University of Bologna, 40126 Bologna, Italy; (G.C.); (L.G.)
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola Hospital, University of Bologna, 40126 Bologna, Italy; (G.C.); (L.G.)
- Correspondence: ; Tel.: +39-051214-3255
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Mazzaferro S, De Martini N, Rotondi S, Tartaglione L, Ureña-Torres P, Bover J, Pasquali M. Bone, inflammation and chronic kidney disease. Clin Chim Acta 2020; 506:236-240. [PMID: 32275989 DOI: 10.1016/j.cca.2020.03.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 01/04/2023]
Abstract
Increasing knowledge on inflammatory mediators and bone metabolism highlights the relationship between inflammation and bone disease. During acute illness, inflammatory cells and cytokines modulate bone cells activity so as to mobilize calcium seemingly to supply the metabolic requirements for immune response. In case of long lasting, chronic inflammatory states a condition of maladaptive, smouldering inflammation is realized and negatively affects calcium bone balance. Aging, now nicknamed inflammaging, is regarded as a chronic inflammatory condition, characterized by increased circulating inflammatory cytokines, that contributes to the development of osteoporosis, cardiovascular diseases and chronic kidney disease. In patients with renal insufficiency, the development of bone and mineral disorders (so called CKD-MBD "syndrome") is now a recognized pathogenic factor for the seemingly accelerated process of aging and for the increased risk of cardiovascular death in these patients. The adaptive changes in mineral and bone metabolism developing in the early stages of chronic kidney disease could represent a hypothetical model of accelerated aging, osteoporosis and cardiovascular disease.
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Affiliation(s)
- Sandro Mazzaferro
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
| | - Natalia De Martini
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
| | | | - Lida Tartaglione
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
| | - Pablo Ureña-Torres
- AURA Nord Saint Ouen, Saint Ouen, France; Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France.
| | - Jordi Bover
- Fundació Puigvert, Department of Nephrology, IIB Sant Pau, Universitat Autònoma, RedinRen, Barcelona, Catalonia, Spain.
| | - Marzia Pasquali
- Azienda Ospedaliero-Universitaria Policlinico Umberto I, Roma, Italy.
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Roggeri A, Conte F, Rossi C, Cozzolino M, Zocchetti C, Roggeri DP. Cinacalcet adherence in dialysis patients with secondary hyperparathyroidism in Lombardy Region: clinical implications and costs. Drugs Context 2020; 9:dic-2020-1-1. [PMID: 32273898 PMCID: PMC7111129 DOI: 10.7573/dic.2020-1-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/01/2020] [Accepted: 03/06/2020] [Indexed: 01/16/2023] Open
Abstract
Background Patients on dialysis often have secondary hyperparathyroidism (SHPT), a disorder associated with renal osteodystrophy, progressive vascular calcification, cardiovascular disease, and death. The objective of this retrospective observational study was to evaluate, in dialysis patients with SHPT, the impact of different levels of adherence to cinacalcet therapy on hospitalisations and direct healthcare costs charged to the Lombardy Regional Health Service (Italy). Methods Data recorded in the administrative databases on all citizens undergoing dialysis between 1 January 2011 and 31 December 2011 were selected. For the aim of this study, patients with SHPT already on dialysis in the first 6 months of 2009 who had been treated with cinacalcet for at least 365 days were selected and retrospectively analysed through to end of 2012. Healthcare resource utilisation, cinacalcet adherence, and costs for medication, hospitalisations, and diagnostic/therapeutic procedures were estimated. Results A total of 994 patients were identified (mean age 63.0 years, females 43.5%). The first patient tertile had an adherence to cinacalcet of <64.1%, whereas the third had an adherence of over 91.5%. Patients in the third adherence tertile experienced fewer all-causes hospitalisations than those in the first tertile (-19.2%; p=0.01423), fractures (-37.1%; p=0.59422), cardiovascular disease (-23.8%; p=0.04025), and sepsis (-32.3%; p=0.01386). The increase in costs for cinacalcet-adherent patients is almost completely offset by the reduction in costs for hospitalisations. Conclusions The results of the analysis suggest that there may be some correlation between a high level of cinacalcet adherence and a decrease in hospitalisations.
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Affiliation(s)
| | - Ferruccio Conte
- Department of Health Sciences, Renal Division, University of Milan, San Paolo Hospital, Milan, Italy
| | | | - Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, San Paolo Hospital, Milan, Italy
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Piccoli GB, Trabace T, Chatrenet A, Carranza de La Torre CA, Gendrot L, Nielsen L, Fois A, Santagati G, Saulnier P, Panocchia N. New Intravenous Calcimimetic Agents: New Options, New Problems. An Example on How Clinical, Economical and Ethical Considerations Affect Choice of Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1238. [PMID: 32075103 PMCID: PMC7068561 DOI: 10.3390/ijerph17041238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/10/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Dialysis treatment is improving, but several long-term problems remain unsolved, including metabolic bone disease linked to chronic kidney disease (CKD-MBD). The availability of new, efficacious but expensive drugs (intravenous calcimimetic agents) poses ethical problems, especially in the setting of budget limitations. METHODS Reasons of choice, side effects, biochemical trends were discussed in a cohort of 15 patients (13% of the dialysis population) who stared treatment with intravenous calcimimetics in a single center. All patients had previously been treated with oral calcimimetic agents; dialysis efficacy was at target in 14/15; hemodiafiltration was employed in 10/15. Median Charlson Comorbidity Index was 8. The indications were discussed according to the principlist ethics (beneficience, non maleficience, justice and autonomy). Biochemical results were analyzed to support the clinical-ethical choices. RESULTS In the context of a strict clinical and biochemical surveillance, the lack of side effects ensured "non-maleficence"; efficacy was at least similar to oral calcimimetic agents, but tolerance was better. Autonomy was respected through a shared decision-making model; all patients appreciated the reduction of the drug burden, and most acknowledged better control of their biochemical data. The ethical conflict resides in the balance between the clinical "beneficience, non-maleficience" advantage and "justice" (economic impact of treatment, potentially in attrition with other resources, since the drug is expensive and included in the dialysis bundle). The dilemma is more relevant when a patient's life expectancy is short (economic impact without clear clinical advantages), or when non-compliance is an issue (unclear advantage if the whole treatment is not correctly taken). CONCLUSIONS In a context of person-centered medicine, autonomy, beneficence and non-maleficence should weight more than economic justice. While ethical discussions are not aimed at finding "the right answer" but asking "the right questions", this example can raise awareness of the importance of including an ethical analysis in the choice of "economically relevant" drugs.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Tiziana Trabace
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Antoine Chatrenet
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | | | - Lurlinys Gendrot
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Louise Nielsen
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Antioco Fois
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Giulia Santagati
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Patrick Saulnier
- Statistical laboratory, University of Angers, 49035 Angers, France;
| | - Nicola Panocchia
- Nephrology Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy;
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Ureña Torres PA, Cohen-Solal M. Not all hyperphosphataemias should be treated. Nephrol Dial Transplant 2020; 34:1077-1079. [PMID: 30403809 DOI: 10.1093/ndt/gfy308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Pablo Antonio Ureña Torres
- Department of Nephrology and Dialysis, Clinique du Landy, Ramsay-Générale de Santé, Paris, France.,Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Martine Cohen-Solal
- Department of Rheumatology, INSERM U1132 & USPC Paris-Diderot, Hôpital Lariboisière, Paris, France
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Bouquegneau A, Evenepoel P, Paquot F, Malaise O, Cavalier E, Delanaye P. Sclerostin within the chronic kidney disease spectrum. Clin Chim Acta 2019; 502:84-90. [PMID: 31866333 DOI: 10.1016/j.cca.2019.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 01/08/2023]
Abstract
Sclerostin is sometimes presented as a promising biomarker in assessing bone health both in the general population and chronic kidney disease patients. However, it is still unclear whether it has any true added value compared to existing bone biomarkers in predicting bone turnover and/or bone density in chronic kidney disease patients. A wealth of papers has been published to evaluate the association between sclerostin and vascular calcifications development or even as prognostic biomarker for mortality, but often with conflicting results. Standardization and harmonization of analytical techniques is a prerequisite to advance clinical knowledge in sclerostin.
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Affiliation(s)
- Antoine Bouquegneau
- Department of Nephrology-Dialysis-Transplantation, University Hospital of Liege (ULg CHU), Liege, Belgium.
| | - Peter Evenepoel
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - François Paquot
- Department of Nephrology-Dialysis-Transplantation, University Hospital of Liege (ULg CHU), Liege, Belgium
| | - Olivier Malaise
- Department of Rheumatology, University Hospital of Liege (ULg CHU), Liege, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University Hospital of Liege (ULg CHU), Liege, Belgium
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University Hospital of Liege (ULg CHU), Liege, Belgium
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Therapeutic Effect of Iron Citrate in Blocking Calcium Deposition in High Pi-Calcified VSMC: Role of Autophagy and Apoptosis. Int J Mol Sci 2019; 20:ijms20235925. [PMID: 31775364 PMCID: PMC6928632 DOI: 10.3390/ijms20235925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 11/23/2019] [Accepted: 11/23/2019] [Indexed: 11/23/2022] Open
Abstract
In chronic kidney disease (CKD), the first cause of mortality is cardiovascular disease induced mainly by vascular calcification (VC). Recently, iron-based phosphate binders have been proposed in advanced CKD to treat hyperphosphatemia. We studied the effect of iron citrate (iron) on the progression of calcification in high-phosphate (Pi) calcified VSMC. Iron arrested further calcification when added on days 7–15 in the presence of high Pi (1.30 ± 0.03 vs 0.61 ± 0.02; OD/mg protein; day 15; Pi vs Pi + Fe, p < 0.01). We next investigated apoptosis and autophagy. Adding iron to high-Pi-treated VSMC, on days 7–11, decreased apoptotic cell number (17.3 ± 2.6 vs 11.6 ± 1.6; Annexin V; % positive cells; day 11; Pi vs Pi + Fe; p < 0.05). The result was confirmed thorough analysis of apoptotic nuclei both in VSMCs and aortic rings treated on days 7–15 (3.8 ± 0.2 vs 2.3 ± 0.3 and 4.0 ± 0.3 vs 2.2 ± 0.2; apoptotic nuclei; arbitrary score; day 15; Pi vs Pi + Fe; VSMCs and aortic rings; p < 0.05). Studying the prosurvival axis GAS6/AXL, we found that iron treatment on days 9–14 counteracted protein high-Pi-stimulated down-regulation and induced its de novo synthesis. Moreover, iron added on days 9–15 potentiated autophagy, as detected by an increased number of autophagosomes with damaged mitochondria and an increase in autophagic flux. Highlighting the effect of iron on apoptosis, we demonstrated its action in blocking the H2O2-induced increase in calcification added both before high Pi treatment and when the calcification was already exacerbated. In conclusion, we demonstrate that iron arrests further high Pi-induced calcium deposition through an anti-apoptotic action and the induction of autophagy on established calcified VSMC.
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Mazzaferro S, Pasquali M. Direct bone effects of calcimimetics in chronic kidney disease? Kidney Int 2019; 95:1012-1014. [PMID: 31010472 DOI: 10.1016/j.kint.2019.01.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 12/12/2022]
Abstract
Calcimimetics are widely used in patients on dialysis to treat secondary hyperparathyroidism. Our current view is that bone effects are only indirect through parathyroid hormone suppression. However, because bone cells express the calcium-sensing receptor, direct calcium-sensing receptor-mediated effects are also possible. New experimental data demonstrate direct anabolic bone actions of calcimimetics, independent of parathyroid hormone suppression. Because these effects could be clinically useful, further studies are necessary to confirm the validity of this observation.
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Affiliation(s)
- Sandro Mazzaferro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy; Ospedale Universitario Policlinico Umberto I, Rome, Italy.
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Mazzaferro S, Cianciolo G, De Pascalis A, Guglielmo C, Urena Torres PA, Bover J, Tartaglione L, Pasquali M, La Manna G. Bone, inflammation and the bone marrow niche in chronic kidney disease: what do we know? Nephrol Dial Transplant 2019; 33:2092-2100. [PMID: 29733407 DOI: 10.1093/ndt/gfy115] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023] Open
Abstract
Recent improvements in our understanding of physiology have altered the way in which bone is perceived: no longer is it considered as simply the repository of divalent ions, but rather as a sophisticated endocrine organ with potential extraskeletal effects. Indeed, a number of pathologic conditions involving bone in different ways can now be reconsidered from a bone-centred perspective. For example, in metabolic bone diseases like osteoporosis (OP) and renal osteodystrophy (ROD), the association with a worse cardiovascular outcome can be tentatively explained by the possible derangements of three recently discovered bone hormones (osteocalcin, fibroblast growth factor 23 and sclerostin) and a bone-specific enzyme (alkaline phosphatase). Further, in recent years the close link between bone and inflammation has been better appreciated and a wide range of chronic inflammatory states (from rheumatoid arthritis to ageing) are being explored to discover the biochemical changes that ultimately lead to bone loss and OP. Also, it has been acknowledged that the concept of the bone-vascular axis may explain, for example, the relationship between bone metabolism and vessel wall diseases like atherosclerosis and arteriosclerosis, with potential involvement of a number of cytokines and metabolic pathways. A very important discovery in bone physiology is the bone marrow (BM) niche, the functional unit where stem cells interact, exchanging signals that impact on their fate as bone-forming cells or immune-competent haematopoietic elements. This new element of bone physiology has been recognized to be dysfunctional in diabetes (so-called diabetic mobilopathy), with possible clinical implications. In our opinion, ROD, the metabolic bone disease of renal patients, will in the future probably be identified as a cause of BM niche dysfunction. An integrated view of bone, which includes the BM niche, now seems necessary in order to understand the complex clinical entity of chronic kidney disease-mineral and bone disorders and its cardiovascular burden. Bone is thus becoming a recurrently considered paradigm for different inter-organ communications that needs to be considered in patients with complex diseases.
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Affiliation(s)
- Sandro Mazzaferro
- Department of Cardiovascular Respiratory Nephrologic Geriatric and Anesthetic Sciences, Sapienza University of Rome, Rome, Italy.,Nephrology Unit, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy
| | - Giuseppe Cianciolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Antonio De Pascalis
- Nephrology, Dialysis and Renal Transplant Unit, Vito Fazzi Hospital, Lecce, Italy
| | - Chiara Guglielmo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
| | - Pablo A Urena Torres
- Ramsay-Générale de Santé, Clinique du Landy, Department of Nephrology and Dialysis and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Jordi Bover
- Fundació Puigvert, Department of Nephrology IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Lida Tartaglione
- Department of Cardiovascular Respiratory Nephrologic Geriatric and Anesthetic Sciences, Sapienza University of Rome, Rome, Italy
| | - Marzia Pasquali
- Nephrology Unit, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy
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Abstract
INTRODUCTION Chronic kidney disease patients often also present protein-calorie malnutrition, and it is a powerful predictor of morbidity and mortality. In this article, causes and management are shown, highlighting oral and parenteral nutritional supplementation, especially during dialysis process.
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Rottembourg J, Ureña-Torres P, Toledano D, Gueutin V, Hamani A, Coldefy O, Hebibi H, Guincestre T, Emery C. Factors associated with parathyroid hormone control in haemodialysis patients with secondary hyperparathyroidism treated with cinacalcet in real-world clinical practice: Mimosa study. Clin Kidney J 2019; 12:871-879. [PMID: 31807302 PMCID: PMC6885690 DOI: 10.1093/ckj/sfz021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Indexed: 12/19/2022] Open
Abstract
Background Secondary hyperparathyroidism (SHPT) is frequent in haemodialysis (HD) patients. Oral cinacalcet-hydrochloride (HCl) decreases parathyroid hormone (PTH); however, real-life PTH data, according to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, are still lacking. Our goal is to assess the percentage of cinacalcet-HCl-treated HD patients with controlled SHPT (PTH <9× upper limit of the normal range) after 12 months (M12) of treatment. Methods This is a retrospective observational study in HD patients with SHPT treated by cinacalcet-HCl between 2005 and 2015 and dialysed in seven French HD centres using the same database (Hemodial™). Results The study included 1268 patients with a mean (standard deviation) follow-up of 21 ± 12 months. Their mean dialysis vintage was 4.3 ± 5.6 years. PTH values were available and exploitable at M12 in 50% of them (645 patients). Among these patients, 58.9% had controlled (mean PTH of 304 ± 158 pg/mL) and 41.1% uncontrolled SHPT (mean PTH of 1084 ± 543) at M12. At the baseline, patients with controlled SHPT were older (66 ± 15 versus 61 ± 17 years), and had lower PTH (831 ± 346 versus 1057 ± 480 pg/mL) and calcaemia (2.18 ± 0.2 versus 2.22 ± 0.19 mmol/L) than uncontrolled patients. In multivariate analysis, these three factors still remained significantly associated with controlled SHPT. Conclusion In this real-life study, 41.1% of HD patients with SHPT treated with cinacalcet-HCl remained with a PTH above the KDIGO recommended target after 12 months of treatment. Apart from the possibility of non-compliance, the severity of SHPT appears to be a major factor determining the response to cinacalcet-HCl treatment, reinforcing the importance of treating SHPT at earlier stages.
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Bisson SK, Ung RV, Picard S, Valade D, Agharazii M, Larivière R, Mac-Way F. High calcium, phosphate and calcitriol supplementation leads to an osteocyte-like phenotype in calcified vessels and bone mineralisation defect in uremic rats. J Bone Miner Metab 2019; 37:212-223. [PMID: 29603070 DOI: 10.1007/s00774-018-0919-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 02/20/2018] [Indexed: 11/26/2022]
Abstract
A link between vascular calcification and bone anomalies has been suggested in chronic kidney disease (CKD) patients with low bone turnover disease. We investigated the vascular expression of osteocyte markers in relation to bone microarchitecture and mineralization defects in a model of low bone turnover CKD rats with vascular calcification. CKD with vascular calcification was induced by 5/6 nephrectomy followed by high calcium and phosphate diet, and vitamin D supplementation (Ca/P/VitD). CKD + Ca/P/VitD group (n = 12) was compared to CKD + normal diet (n = 12), control + normal diet (n = 8) and control + Ca/P/VitD supplementation (n = 8). At week 6, tibia, femurs and the thoracic aorta were analysed by Micro-Ct, histomorphometry and for expression of osteocyte markers. High Ca/P/VitD treatment induced vascular calcification only in CKD rats, suppressed serum parathyroid hormone levels and led to higher sclerostin, DKK1 and FGF23 serum levels. Expression of sclerostin, DKK1 and DMP1 but not FGF23 were increased in calcified vessels from CKD + Ca/P/VitD rats. Despite low parathyroid hormone levels, tibia bone cortical thickness was significantly lower in CKD + Ca/P/VitD rats as compared to control rats fed a normal diet, which is likely the result of radial growth impairment. Finally, Ca/P/VitD treatment in CKD rats induced a bone mineralization defect, which is likely explained by the high calcitriol dose. In conclusion, Ca/P/VitD supplementation in CKD rats induces expression of osteocyte markers in vessels and bone mineralisation anomalies. Further studies should evaluate the mechanisms of high dose calcitriol-induced bone mineralisation defects in CKD.
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Affiliation(s)
- Sarah-Kim Bisson
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Roth-Visal Ung
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Sylvain Picard
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Danika Valade
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Mohsen Agharazii
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Richard Larivière
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada
| | - Fabrice Mac-Way
- Endocrinology and Nephrology Axis, Faculty and Department of Medicine, L'Hôtel-Dieu de Québec Hospital, CHU de Québec Research Center, Université Laval, 10 McMahon, Quebec City, QC, G1R 2J6, Canada.
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Barreto FDC, Costa CRVD, Reis LMD, Custódio MR. Bone biopsy in nephrology practice. ACTA ACUST UNITED AC 2018; 40:366-374. [PMID: 30525179 PMCID: PMC6534004 DOI: 10.1590/2175-8239-jbn-2017-0012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 07/09/2018] [Indexed: 12/12/2022]
Abstract
Renal osteodystrophy (ROD), a group of metabolic bone diseases secondary to chronic kidney disease (CKD), still represents a great challenge to nephrologists. Its management is tailored by the type of bone lesion - of high or low turnover - that cannot be accurately predicted by serum biomarkers of bone remodeling available in daily clinical practice, mainly parathyroid hormone (PTH) and alkaline phosphatase (AP). In view of this limitation, bone biopsy followed by bone quantitative histomorphometry, the gold-standard method for the diagnosis of ROD, is still considered of paramount importance. Bone biopsy has also been recommended for evaluation of osteoporosis in the CKD setting to help physicians choose the best anti-osteoporotic drug. Importantly, bone biopsy is the sole diagnostic method capable of providing dynamic information on bone metabolism. Trabecular and cortical bones may be analyzed separately by evaluating their structural and dynamic parameters, thickness and porosity, respectively. Deposition of metals, such as aluminum and iron, on bone may also be detected. Despite of these unique characteristics, the interest on bone biopsy has declined over the last years and there are currently few centers around the world specialized on bone histomorphometry. In this review, we will discuss the bone biopsy technique, its indications, and the main information it can provide. The interest on bone biopsy should be renewed and nephrologists should be capacitated to perform it as part of their training during medical residency.
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Affiliation(s)
| | | | - Luciene Machado Dos Reis
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clinicas, Laboratório de Fisiopatologia Renal São Paulo, SP, Brasil
| | - Melani Ribeiro Custódio
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clinicas, Laboratório de Fisiopatologia Renal São Paulo, SP, Brasil
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Sprague SM, Ketteler M, Covic AC, Floege J, Rakov V, Walpen S, Rastogi A. Long-term efficacy and safety of sucroferric oxyhydroxide in African American dialysis patients. Hemodial Int 2018; 22:480-491. [PMID: 29656600 DOI: 10.1111/hdi.12663] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/21/2018] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Sucroferric oxyhydroxide (SFOH) is a non-calcium, iron-based phosphate binder that demonstrated sustained serum phosphorus (sP) control, good tolerability, and lower pill burden, vs. sevelamer carbonate ("sevelamer"), in a Phase 3 study conducted in dialysis patients with hyperphosphatemia. This analysis evaluates the efficacy and safety of SFOH and sevelamer among African American (AA) patients participating in the trial. METHODS Post hoc analysis of a 24-week, Phase 3, open-label trial (NCT01324128) and its 28-week extension study (NCT01464190). Patients were randomized 2:1 to SFOH (1.0-3.0 g/day) or sevelamer (2.4-14.4 g/day) for up to 52 weeks. FINDINGS Of 549 patients who completed the Phase 3 study and extension, 100 (18.2%) AA patients were eligible for efficacy analysis (SFOH, n = 48; sevelamer, n = 52). sP concentrations decreased rapidly and comparably with both treatments by Week 8 (mean ± standard deviation change from baseline: -1.9 ± 1.9 mg/dL for SFOH and -2.2 ± 1.8 mg/dL for sevelamer). These reductions were maintained for 52 weeks (-2.1 ± 2.6 and -2.1 ± 1.6 mg/dL) and achieved with a lower mean pill burden (3.4 ± 1.4 vs. 7.6 ± 2.9 tablets/day) with SFOH vs. sevelamer. Treatment adherence rates (adherence within 70%-120% of expected medication intake) were 79.2% with SFOH and 59.6% with sevelamer. The proportion of patients reporting serious adverse events (AEs) was 27.7% with SFOH and 30.7% with sevelamer. More patients withdrew due to treatment-emergent AEs with SFOH vs. sevelamer (18.5% vs. 8.0%). The most common AEs with both treatments were gastrointestinal-related: diarrhea and discolored feces with SFOH, and nausea, vomiting, and constipation with sevelamer. DISCUSSION SFOH is an efficacious and well-tolerated treatment for hyperphosphatemia in AA dialysis patients, with a lower pill burden and an improved adherence rate vs. sevelamer. These findings were consistent with the wider US patient population and the overall study population.
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Affiliation(s)
| | | | - Adrian C Covic
- 'Gr.T. Popa' University of Medicine and Pharmacy, Iasi, Romania
| | | | | | | | - Anjay Rastogi
- University of California, Los Angeles, California, USA
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Yadav AK, Kumar V, Kumar V, Banerjee D, Gupta KL, Jha V. The Effect of Vitamin D Supplementation on Bone Metabolic Markers in Chronic Kidney Disease. J Bone Miner Res 2018; 33:404-409. [PMID: 29044707 DOI: 10.1002/jbmr.3314] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/10/2017] [Accepted: 10/14/2017] [Indexed: 01/20/2023]
Abstract
Use of active forms of vitamin D is advocated in patients with chronic kidney disease (CKD) for treatment of mineral bone disease because of the presumption that native forms of vitamin D would not undergo significant activation to calcitriol, the most active biological form of vitamin D. We present secondary analysis looking at bone turnover in subjects who completed the randomized, double blind, placebo-controlled trial investigating the effect of cholecalciferol supplementation on vascular function in nondiabetic CKD stage G3-G4 and vitamin D ≤20 ng/mL (Clinical Trials Registry of India: CTRI/2013/05/003648). Patients were randomized (1:1) to receive either two directly observed oral doses of 300,000 IU of cholecalciferol or matching placebo at baseline and 8 weeks. Of the 120 subjects enrolled, 58 in the cholecalciferol group and 59 in the placebo group completed the study. At 16 weeks, the serum 25(OH)D and 1,25(OH)2 D levels increased in the cholecalciferol group but not in the placebo group (between-group difference in mean change: 23.40 ng/mL; 95% CI, 19.76 to 27.06; p < 0.001, and 14.98 pg/mL; 95% CI, 4.48 to 27.18; p = 0.007, respectively). Intact parathyroid hormone (iPTH) decreased in the cholecalciferol group (between-group difference in mean change -100.73 pg/mL (95% CI, -150.50 to -50.95; p < 0.001). Serum total and bone-specific alkaline phosphatase (SAP, BAP) and serum C-terminal cross-linked collagen type I telopeptides (CTX-1) were significantly reduced in cholecalciferol group (between group difference for change in mean: -20.25 U/L; 95% CI, -35.14 to -5.38 U/L; p = 0.008 for SAP; -12.54 U/L; 95% CI, -22.09 to -2.98 U/L; p = 0.013 for BAP; and -0.21 ng/mL; 95% CI, -0.38 to -0.05 ng/mL; p = 0.05 for CTX-1). Correlation analysis showed significant correlation of Δ25(OH)D with ΔiPTH (r = -0.409, p < 0.0001), Δ1,25(OH)2 D (r = 0.305, p = 0.001), ΔSAP (r = -0.301, p = 0.002), ΔBAP (r = -0.264, p = 0.004), and ΔCTX-1 (r = -0.210, p = 0.0230). Cholecalciferol supplementation corrects vitamin D deficiency and is effective in lowering serum intact parathyroid hormone and bone turnover markers in early stages of CKD. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Ashok Kumar Yadav
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Kumar
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vinod Kumar
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals National Health Service (NHS) Foundation Trust.,Molecular and Clinical Sciences Research Institute, St Georges, University of London, UK
| | - Krishan Lal Gupta
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivekanand Jha
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.,The George Institute for Global Health, New Delhi, India.,George Institute for Global Health, University of Oxford, Oxford, UK
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Kaesler N, Verhulst A, De Maré A, Deck A, Behets GJ, Hyusein A, Evenepoel P, Floege J, Marx N, Babler A, Kramer I, Kneissel M, Kramann R, Weis D, D'Haese PC, Brandenburg VM. Sclerostin deficiency modifies the development of CKD-MBD in mice. Bone 2018; 107:115-123. [PMID: 29175269 DOI: 10.1016/j.bone.2017.11.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 11/20/2017] [Accepted: 11/20/2017] [Indexed: 01/16/2023]
Abstract
UNLABELLED Sclerostin is a soluble antagonist of canonical Wnt signaling and a strong inhibitor of bone formation. We present experimental data on the role of sclerostin in chronic kidney disease - bone mineral disorder (CKD-MBD). METHODS We performed 5/6 nephrectomies in 36-week-old sclerostin-deficient (SOST-/-) B6-mice and in C57BL/6J wildtype (WT) mice. Animals received a high phosphate diet for 11weeks. The bones were analyzed by high-resolution micro-computed tomography (μCT) and quantitative bone histomorphometry. Aortic tissue was analyzed regarding the extent of vascular calcification. RESULTS All nephrectomized mice had severe renal failure, and parathyroid hormone was highly increased compared to corresponding sham animals. All SOST-/- animals revealed the expected high bone mass phenotype. Overall, the bone compartment in WT and SOST-/- mice responded similarly to nephrectomy. In uremic WT animals, μCT data at both the distal femur and lumbar spine revealed significantly increased trabecular volume compared to non-uremic WTs. In SOST-/- mice, the differences between trabecular bone volume were less pronounced when comparing uremic with sham animals. Cortical thickness and cortical bone density at the distal femur decreased significantly and comparably in both genotypes after 5/6 nephrectomy compared to sham animals (cortical bone density -18% and cortical thickness -32%). Overall, 5/6 nephrectomy and concomitant hyperparathyroidism led to a genotype-independent loss of cortical bone volume and density. Overt vascular calcification was not detectable in either of the genotypes. CONCLUSION Renal osteodystrophy changes were more pronounced in WT mice than in SOST-/- mice. The high bone mass phenotype of sclerostin deficiency was detectable also in the setting of chronic renal failure with severe secondary hyperparathyroidism.
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Affiliation(s)
- Nadine Kaesler
- Department of Nephrology, University Hospital of the RWTH Aachen, Germany.
| | - Anja Verhulst
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Wilrijk, Belgium
| | - Annelies De Maré
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Wilrijk, Belgium
| | - Annika Deck
- Department of Cardiology, University Hospital of the RWTH Aachen, Germany
| | - Geert J Behets
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Wilrijk, Belgium
| | - Ayshe Hyusein
- Department of Nephrology, University Hospital of the RWTH Aachen, Germany
| | - Pieter Evenepoel
- Department of Immunology and Microbiology, Laboratory of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Jürgen Floege
- Department of Nephrology, University Hospital of the RWTH Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, University Hospital of the RWTH Aachen, Germany
| | - Anne Babler
- Helmholtz Institute for Biomedical Engineering, Biointerface Laboratory, 52074 Aachen, Germany
| | - Ina Kramer
- Musculoskeletal Disease Area, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Michaela Kneissel
- Musculoskeletal Disease Area, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Rafael Kramann
- Department of Nephrology, University Hospital of the RWTH Aachen, Germany
| | - Daniel Weis
- Department of Nephrology, University Hospital of the RWTH Aachen, Germany
| | - Patrick C D'Haese
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Wilrijk, Belgium
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Cozzolino M. Achieve Your Goals Together. The Easy and Reasonable Way to Treat Chronic Kidney Disease-Mineral Bone Disorder. Blood Purif 2017; 45:71-72. [PMID: 29241204 DOI: 10.1159/000485233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 11/13/2017] [Indexed: 12/26/2022]
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44
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Molnar AO, Sood MM. Predicting in a predicament: Stroke and hemorrhage risk prediction in dialysis patients with atrial fibrillation. Semin Dial 2017; 31:37-47. [PMID: 28699181 DOI: 10.1111/sdi.12637] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Whether to anticoagulate dialysis patients with atrial fibrillation is a common clinical dilemma with limited high-quality data to inform decision-making. While the efficacy and safety of anticoagulation for stroke prevention in dialysis patients with atrial fibrillation has long been debated and remains unclear, the more upstream issue of stroke risk assessment from atrial fibrillation has received relatively little attention. In the general population, a handful of risk scores to help predict stroke and hemorrhage risk in the setting of atrial fibrillation are widely validated and applied in clinical practice. But are they applicable to the dialysis population? The most commonly used stroke risk scores, CHADS2 and CHA2DS2-VASC, have limited validation in the dialysis population, and when validated, have shown poor performance (c-statistics <0.70). Stroke risk scores derived in the general atrial fibrillation population may perform poorly in dialysis patients for a number of reasons. Dialysis patients have unique stroke risk factors, such as chronic inflammation and vascular calcification, and a much higher competing risk of death, none of which are accounted for in current risk scores. Further complicating the dilemma of anticoagulation is hemorrhage risk, which is known to be exceedingly high in dialysis patients. Currently available hemorrhage risk scores, such as HAS-BLED, have not been validated in dialysis patients and will likely underestimate hemorrhage risk. Moving forward, risk tools specific to the dialysis population are needed to accurately assess and balance stroke and hemorrhage risks in dialysis patients with atrial fibrillation.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada.,Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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45
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Cozzolino M, Galassi A, Conte F, Mangano M, Di Lullo L, Bellasi A. Treatment of secondary hyperparathyroidism: the clinical utility of etelcalcetide. Ther Clin Risk Manag 2017; 13:679-689. [PMID: 28615947 PMCID: PMC5461056 DOI: 10.2147/tcrm.s108490] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Secondary hyperparathyroidism (SHPT), a very frequent, severe, and worsening complication of chronic kidney disease, is characterized by high serum parathyroid hormone (PTH), parathyroid gland hyperplasia, and disturbances in mineral metabolism. Clinically, SHPT shows renal osteodystrophy, vascular calcification, cardiovascular damage, and fatal outcome. Calcium-sensing receptor (CaSR) is the main physiological regulator of PTH secretion; its activation by calcium rapidly inhibits PTH. Another important player in regulating mineral metabolism is vitamin D receptor (VDR), which is under the influence of vitamin D and influences the intestinal absorption of calcium and phosphate, PTH gene expression, and bone calcium mobilization. Serum phosphate levels influence fibroblast growth factor 23 (FGF-23) production, a phosphatonin that modulates serum phosphate reabsorption, PTH synthesis, and vitamin D production. Current therapeutic approaches consist of 1) phosphate intake control by diet or phosphate binders, 2) vitamin D by VDR activation, and 3) calcimimetic agents that activate CaSR. Recently, a new long-acting peptide (etelcalcetide) belonging to the calcimimetics class was approved for intravenous use in hemodialysis patients with SHPT. Etelcalcetide binds directly to CaSR, by a sulfide bond, inhibiting the production and secretion of PTH by parathyroid glands. After intravenous administration in rats, etelcalcetide is quickly distributed to the tissues and eliminated by kidneys, while in uremic animals the nonrenal excretion is only 1.2%. In hemodialysis patients, the treatment itself is the main route of elimination. Etelcalcetide in hemodialysis patients with SHPT was more effective than placebo and cinacalcet, with a PTH reduction of >30% in 76% of patients with etelcalcetide versus 10% with placebo. Particular attention was paid to the safety of the drug; the most common adverse event was asymptomatic blood calcium reduction, similar to cinacalcet, while gastrointestinal symptoms were less frequent. This promising new drug available for better control of SHPT will, together with drugs already in use, optimize the treatment to normalize the biochemical parameters.
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Affiliation(s)
- Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan
| | - Andrea Galassi
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan
| | - Ferruccio Conte
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan
| | - Michela Mangano
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan
| | - Luca Di Lullo
- U.O.C. Nefrologia e Dialisi, Ospedale L. Parodi Delfino, Colleferro, Roma
| | - Antonio Bellasi
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan
- Sant’Anna Hospital, ASST-Lariana, Como, Italy
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46
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Demian MN, Lam NN, Mac-Way F, Sapir-Pichhadze R, Fernandez N. Opportunities for Engaging Patients in Kidney Research. Can J Kidney Health Dis 2017; 4:2054358117703070. [PMID: 28491336 PMCID: PMC5406191 DOI: 10.1177/2054358117703070] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 01/26/2017] [Indexed: 01/03/2023] Open
Abstract
Purpose: The purpose of this review is to provide a summary of the rationale for engaging patients in research as well as to review the established and envisioned advantages and strategies for patient-researcher partnerships. The authors of this article, which include a patient and 4 researchers in kidney disease, discuss the expected benefits and opportunities for patient engagement in their respective research programs. The 4 research programs span the spectrum of kidney disease and focus on enhancing bone health, increasing living donor kidney transplants, improving medication adherence, and preventing kidney transplant rejection. Sources of Information: The sources of information for this review include published studies on the topics of patient engagement and the 4 research programs of the new investigators. Key Findings: (1) Patient, health care provider, and researcher partnerships can contribute useful insights capable of enhancing research in kidney disease. (2) Regardless of the research program, there are various strategies and opportunities for engagement of patients with lived experience across the various stages of research in kidney disease. (3) Envisioned advantages of patient-researcher partnerships include: targeting patient-identified research priorities, integrating patients’ experiential knowledge, improving study design and feasibility through patient-researcher input, facilitating dissemination of research findings to other patients, effectively responding to patient concerns about studies, and inspiring researchers to conduct their research. Limitations: The limitations of the current review include the relative scarcity of literature on patient engagement within the field of kidney disease. Implications: The findings of the current review suggest that it will be important for future studies to identify optimal strategies for patient engagement in setting research priorities, study design, participant recruitment, execution of research projects, and knowledge dissemination and translation.
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Affiliation(s)
- Maryam N Demian
- Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Ngan N Lam
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Fabrice Mac-Way
- Division of Nephrology, Department of Medicine, Laval University, Quebec City, Québec, Canada
| | - Ruth Sapir-Pichhadze
- Division of Nephrology, Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Nicolas Fernandez
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Québec, Canada
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47
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Zoccali C, Vanholder R, Massy ZA, Ortiz A, Sarafidis P, Dekker FW, Fliser D, Fouque D, Heine GH, Jager KJ, Kanbay M, Mallamaci F, Parati G, Rossignol P, Wiecek A, London G. The systemic nature of CKD. Nat Rev Nephrol 2017; 13:344-358. [PMID: 28435157 DOI: 10.1038/nrneph.2017.52] [Citation(s) in RCA: 242] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The accurate definition and staging of chronic kidney disease (CKD) is one of the major achievements of modern nephrology. Intensive research is now being undertaken to unravel the risk factors and pathophysiologic underpinnings of this disease. In particular, the relationships between the kidney and other organs have been comprehensively investigated in experimental and clinical studies in the last two decades. Owing to technological and analytical limitations, these links have been studied with a reductionist approach focusing on two organs at a time, such as the heart and the kidney or the bone and the kidney. Here, we discuss studies that highlight the complex and systemic nature of CKD. Energy balance, innate immunity and neuroendocrine signalling are highly integrated biological phenomena. The diseased kidney disrupts such integration and generates a high-risk phenotype with a clinical profile encompassing inflammation, protein-energy wasting, altered function of the autonomic and central nervous systems and cardiopulmonary, vascular and bone diseases. A systems biology approach to CKD using omics techniques will hopefully enable in-depth study of the pathophysiology of this systemic disease, and has the potential to unravel critical pathways that can be targeted for CKD prevention and therapy.
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Affiliation(s)
- Carmine Zoccali
- CNR-IFC Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension Unit, Ospedali Riuniti 89124 Reggio Calabria, Italy
| | - Raymond Vanholder
- Ghent University Hospital, Department of Nephrology, Department of Internal Medicine, University Hospital Gent, De Pintelaan 185, B9000 Ghent, Belgium
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré Hospital, Assistance Publique Hôpitaux de Paris, 9 Avenue Charles de Gaulle, 92100 Boulogne-Billancourt, Paris.,University of Paris Ouest-Versailles-Saint-Quentin-en-Yvelines (UVSQ), 55 Avenue de Paris, 78000 Versailles, France.,Inserm U-1018, Centre de recherche en épidémiologie et santé des populations (CESP), Equipe 5, Hôpital Paul-Brousse, 16 avenue Paul Vaillant-Couturier, 94807 Villejuif Cedex, France.,Paris-Sud University (PSU), 15 Rue Georges Clemenceau, 91400 Orsay, France.,French-Clinical Research Infrastructure Network (F-CRIN), Pavillon Leriche 2è étage CHU de Toulouse, Place Dr Baylac TSA40031, 31059 TOULOUSE Cedex 3, France
| | - Alberto Ortiz
- Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Av. Reyes Católicos, 2, 28040 Madrid, Spain
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Thessaloniki, Konstantinoupoleos 49, Thessaloniki 546 42, Greece
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Danilo Fliser
- Department Internal Medicine IV-Renal and Hypertensive Disease-Saarland University Medical Centre Kirrberger Straß 66421 Homburg, Saar, Germany
| | - Denis Fouque
- Université de Lyon, UCBL, Carmen, Department of Nephrology, Centre Hospitalier Lyon-Sud, F-69495 Pierre Bénite, France
| | - Gunnar H Heine
- Department Internal Medicine IV-Renal and Hypertensive Disease-Saarland University Medical Centre Kirrberger Straß 66421 Homburg, Saar, Germany
| | - Kitty J Jager
- European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, Department of Medical Informatics, Meibergdreef 9, 1105 AZ Amsterdam-Zuidoost, The Netherlands
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine,Koç University, Rumelifeneri Yolu 34450 Sarıyer Istanbul, Turkey
| | - Francesca Mallamaci
- CNR-IFC Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension Unit, Ospedali Riuniti 89124 Reggio Calabria, Italy.,Nephrology, Dialysis and Transplantation Unit Ospedali Riuniti, 89124 Reggio Calabria Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano &Department of Medicine and Surgery, University of Milan-Bicocca, Piazzale Brescia 20, Milan 20149, Italy
| | - Patrick Rossignol
- French-Clinical Research Infrastructure Network (F-CRIN), Pavillon Leriche 2è étage CHU de Toulouse, Place Dr Baylac TSA40031, 31059 TOULOUSE Cedex 3, France.,Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Cardiovascular and Renal Clinical Trialists (INI-CRCT), Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 rue Morvan, 54500 Vandoeuvre-les-Nancy, France.,Inserm U1116, Faculté de Médecine, Bâtiment D 1er étage, 9 avenue de la forêt de Haye - BP 184, 54500 Vandœuvre-lès-Nancy Cedex, France.,CHU Nancy, Département de Cardiologie, Institut Lorrain du Cœur et des Vaisseaux, 5 Rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.,Université de Lorraine, 34 Cours Léopold, 54000 Nancy, France
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Francuska 20/24 Street, Pl-40-027 Katowice, Poland
| | - Gerard London
- INSERM U970, Hopital Européen Georges Pompidou, 20 Rue Leblanc, 75015 Paris, France
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Osteoporosis, bone mineral density and CKD–MBD: treatment considerations. J Nephrol 2017; 30:677-687. [DOI: 10.1007/s40620-017-0404-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/08/2017] [Indexed: 02/07/2023]
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49
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Stratégies visant à réduire la phosphatémie dans la maladie rénale chronique. Nephrol Ther 2017; 13 Suppl 1:S95-S101. [DOI: 10.1016/j.nephro.2017.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/09/2017] [Accepted: 01/17/2017] [Indexed: 12/15/2022]
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50
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Bover J, Górriz JL, Ureña-Torres P, Lloret MJ, Ruiz-García C, daSilva I, Chang P, Rodríguez M, Ballarín J. Detección de las calcificaciones cardiovasculares: ¿una herramienta útil para el nefrólogo? Nefrologia 2016; 36:587-596. [DOI: 10.1016/j.nefro.2016.05.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/19/2016] [Indexed: 12/12/2022] Open
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