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Zilberman-Itskovich S, Algamal B, Azar A, Efrati S, Beberashvili I. Nutritional and Inflammatory Aspects of Low Parathyroid Hormone in Maintenance Hemodialysis Patients-A Longitudinal Study. J Ren Nutr 2024:S1051-2276(24)00094-3. [PMID: 38848802 DOI: 10.1053/j.jrn.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/11/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Low serum parathyroid hormone (PTH) is an accepted marker for adynamic bone disease which is characterized by increased morbidity and mortality in maintenance hemodialysis (MHD) patients. In light of the known cross-sectional associations between PTH and malnutrition-inflammation syndrome, we aimed to examine the longitudinal associations between PTH with changes in nutritional and inflammatory parameters and clinical outcomes in MHD patients with low PTH. METHODS This historical prospective and longitudinal study analyzed a clinical database at a single hemodialysis center, containing the medical records of 459 MHD patients (mean age of 71.4 ± 12.9 years old, 171 women), treated between the years 2007-2020. Bone turnover, nutritional and inflammatory marker levels were recorded at 0, 6, 12, 18, 24, 30, and 36 months followed by a median of 24 additional months of clinical observations. According to previous use of vitamin D analogs and/or calcium-sensing receptor agonists, the study participants were divided into treatment-related and disease-related groups. A linear mixed effects model was adjusted for baseline demographics and clinical parameters. RESULTS Of 459 MHD patients, 81 (17.6%) had PTH lower than 150pg/mL. Among them, 30 patients had treatment-related and 51 had disease-related low PTH. At baseline, MHD patients with treatment-related low PTH had a higher rate of diabetes compared to the disease-related group. In a linear mixed effects model, increased PTH over time was associated with decreased levels of alkaline phosphatase and C-reactive protein and with increased hemoglobin and albumin, but not the geriatric nutritional risk index at 3-year follow-up. The survival rate did not differ between the groups, with the risk of hospitalizations due to fractures being higher (HR: 4.04 with 95% CI: 1.51-10.8) in the disease-related group. Statistical significance of this association was abolished after adding C-reactive protein or alkaline phosphatase to the multivariate models. CONCLUSIONS Low serum PTH in MHD patients behaves differently depending on its cause, with a higher risk of fractures in the disease-related group. This association is dependent on inflammation. Our results should be verified in larger epidemiological studies.
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Affiliation(s)
- Shani Zilberman-Itskovich
- Nephrology Division, Yitzhak Shamir Medical Center, Zerifin, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Baker Algamal
- Nephrology Division, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Ada Azar
- Nutrition Department, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Shai Efrati
- Nephrology Division, Yitzhak Shamir Medical Center, Zerifin, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilia Beberashvili
- Nephrology Division, Yitzhak Shamir Medical Center, Zerifin, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Chan JP, Lung B, Donnelly M, Hashmi SZ, Bhatia N, Lee YP. Elevated Serum Alkaline Phosphatase is an Independent Predictor of Complications After Lumbar Spinal Fusion. World Neurosurg 2024:S1878-8750(24)00895-7. [PMID: 38810876 DOI: 10.1016/j.wneu.2024.05.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Alkaline phosphatase (ALP) is an enzyme which has been proven useful as a biomarker for bone turnover and inflammation. We hypothesized that high serum ALP levels are associated with increased complication rates following lumbar spinal fusion. METHODS Lumbar spinal fusion procedures from 2005 to 2019 were queried from the National Surgical Quality Improvement Program (NSQIP) database. Serum alkaline phosphatase levels were stratified into low <44 IU/L, normal 44-147 IU/L, and high >147 IU/L. A risk-adjusted multivariate logistic regression was used to analyze ALP as an independent risk factor for complications. RESULTS A total of 16,441 patients who underwent lumbar fusion procedures were included. Adjusted multivariate logistic regression analysis demonstrated that patients with a high serum ALP level had a significantly increased risk for developing septic shock (OR 4.68, 95% CI 1.83-11.97), pneumonia (OR 2.89, 95% CI 1.59-5.25), requiring a transfusion (OR 2.09, 95% CI 1.68-2.59), reoperation within 30 days (OR 1.68, 95% CI 1.12-2.52), readmission within 30 days (OR 1.60, 95% CI 1.16-2.21), increased length of stay (OR 1.87, 95% CI 1.49-2.36), and nonhome discharge (OR 2.18, 95% CI 1.80-2.66). CONCLUSIONS Elevated serum ALP in patients undergoing lumbar fusion procedures is associated with increased risk for multiple in-hospital complications as well as higher rates of readmission and reoperation.
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Affiliation(s)
- Justin P Chan
- University of California Irvine, Department of Orthopedic Surgery, Orange, California, USA.
| | - Brandon Lung
- University of California Irvine, Department of Orthopedic Surgery, Orange, California, USA
| | - Megan Donnelly
- University of California Irvine, Department of Orthopedic Surgery, Orange, California, USA
| | - Sohaib Z Hashmi
- University of California Irvine, Department of Orthopedic Surgery, Orange, California, USA
| | - Nitin Bhatia
- University of California Irvine, Department of Orthopedic Surgery, Orange, California, USA
| | - Yu-Po Lee
- University of California Irvine, Department of Orthopedic Surgery, Orange, California, USA
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Liu SH, Leonardo CJ, Loyst RA, Cerri-Droz P, Lung B, Zhu A, Wang ED. Elevated alkaline phosphatase independently predicts early postoperative complications in noninfectious revision total shoulder arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2081-2087. [PMID: 38532125 DOI: 10.1007/s00590-024-03902-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/07/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE This study investigates the association between preoperative serum alkaline phosphatase levels and 30 day postoperative complications following noninfectious revision total shoulder arthroplasty (TSA). We hypothesize that elevated alkaline phosphatase levels are significantly associated with an increased 30 day postoperative complication rate. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent noninfectious revision TSA from 2015 to 2022. The study population was divided into two groups based on preoperative serum alkaline phosphatase: normal (44-147 IU/L) and elevated (> 147 IU/L). Logistic regression analysis was conducted to investigate the relationship between elevated alkaline phosphatase levels and postoperative complications. RESULTS Compared to normal levels, elevated alkaline phosphatase was independently associated with a significantly greater likelihood of experiencing any complications (odds ratio [OR] 2.54, 95% confidence interval [CI] 1.41-4.55; P = .002), sepsis (OR 9.96, 95% CI 1.67-59.29; P = .012), blood transfusions (OR 3.77, 95% CI 1.48-9.61; P = .005), readmission (OR 3.65, 95% CI 1.48-9.01; P = .005), and length of stay > 2 days (OR 2.37, 95% CI 1.31-4.30; P = .004). CONCLUSIONS Elevated preoperative alkaline phosphatase was associated with a greater rate of early postoperative complications following noninfectious revision TSA. LEVEL OF EVIDENCE Level III; Retrospective Cohort Comparison; Prognosis Study.
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Affiliation(s)
- Steven H Liu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, 11794, USA.
| | | | - Rachel A Loyst
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, 11794, USA
| | - Patricia Cerri-Droz
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, 11794, USA
| | - Brandon Lung
- Department of Orthopaedics, University of California Irvine, Orange, CA, USA
| | - Andrew Zhu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, 11794, USA
| | - Edward D Wang
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, 11794, USA
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Yamamoto S, Jørgensen HS, Zhao J, Karaboyas A, Komaba H, Vervloet M, Mazzaferro S, Cavalier E, Bieber B, Robinson B, Evenepoel P, Fukagawa M. Alkaline Phosphatase and Parathyroid Hormone Levels: International Variation and Associations With Clinical Outcomes in the DOPPS. Kidney Int Rep 2024; 9:863-876. [PMID: 38765600 PMCID: PMC11101738 DOI: 10.1016/j.ekir.2024.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/26/2023] [Accepted: 01/02/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Secondary hyperparathyroidism (SHPT) increases the risk of fractures and cardiovascular (CV) disease in patients on hemodialysis (HD). The relationship between parathyroid hormone (PTH) and outcomes has been inconsistent, possibly due to variable bone responsiveness to PTH. The KDIGO guideline suggests monitoring total alkaline phosphatase (ALP), but the role of ALP versus PTH in the management of mineral and bone disorder (MBD) is not clear. Methods The analysis included 28,888 patients on HD in 9 countries in Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 3 to 7 (2005-2021). The primary exposures of interest were normalized ALP and PTH, which are raw values divided by facility upper normal limit, measured at study enrollment. Cox models were used to estimate hazard ratios of all-cause or CV mortality and any or hip fracture adjusted for potential confounders. Linear mixed models, adjusted for potential confounders, were employed to investigate the relationship between normalized ALP levels and patient characteristics. Results Normalized PTH showed a J-shaped association with all-cause or CV mortality, and a weak linear association with fracture. In contrast, normalized ALP showed a strong association with all outcomes. Factors associated with higher ALP levels after controlling for PTH included Black race, longer dialysis vintage, diabetes mellitus, hypocalcemia, hypophosphatemia, elevated C-reactive protein (CRP), and the use of cinacalcet. Conclusion Total ALP is a more robust exposure of adverse outcomes than PTH in patients on HD. PTH responsiveness is affected by race, primary renal disease, comorbidities, and mineral metabolism and therapy. Our results indicate that it may be useful to evaluate target organ response, rather than PTH alone when considering the consequences of (SHPT).
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Affiliation(s)
- Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Angelo Karaboyas
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Marc Vervloet
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Sandro Mazzaferro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU de Liège, Sart Tilman, Liège, Belgium
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Bruce Robinson
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
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Evenepoel P, Jørgensen HS, Bover J, Davenport A, Bacchetta J, Haarhaus M, Hansen D, Gracia-Iguacel C, Ketteler M, McAlister L, White E, Mazzaferro S, Vervloet M, Shroff R. Recommended calcium intake in adults and children with chronic kidney disease-a European consensus statement. Nephrol Dial Transplant 2024; 39:341-366. [PMID: 37697718 DOI: 10.1093/ndt/gfad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Indexed: 09/13/2023] Open
Abstract
Mineral and bone disorders (MBD) are common in patients with chronic kidney disease (CKD), contributing to significant morbidity and mortality. For several decades, the first-line approach to controlling hyperparathyroidism in CKD was by exogenous calcium loading. Since the turn of the millennium, however, a growing awareness of vascular calcification risk has led to a paradigm shift in management and a move away from calcium-based phosphate binders. As a consequence, contemporary CKD patients may be at risk of a negative calcium balance, which, in turn, may compromise bone health, contributing to renal bone disease and increased fracture risk. A calcium intake below a certain threshold may be as problematic as a high intake, worsening the MBD syndrome of CKD, but is not addressed in current clinical practice guidelines. The CKD-MBD and European Renal Nutrition working groups of the European Renal Association (ERA), together with the CKD-MBD and Dialysis working groups of the European Society for Pediatric Nephrology (ESPN), developed key evidence points and clinical practice points on calcium management in children and adults with CKD across stages of disease. These were reviewed by a Delphi panel consisting of ERA and ESPN working groups members. The main clinical practice points include a suggested total calcium intake from diet and medications of 800-1000 mg/day and not exceeding 1500 mg/day to maintain a neutral calcium balance in adults with CKD. In children with CKD, total calcium intake should be kept within the age-appropriate normal range. These statements provide information and may assist in decision-making, but in the absence of high-level evidence must be carefully considered and adapted to individual patient needs.
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Affiliation(s)
- Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Jordi Bover
- Department of Nephrology, University Hospital Germans Trias i Pujol, Barcelona, Catalonia, Spain
- REMAR-IGTP Group, Germans Trias i Pujol Research Institute, Can Ruti Campus, Barcelona, Catalonia, Spain
| | - Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Justine Bacchetta
- Pediatric Nephrology Rheumatology and Dermatology Unit, Reference Center for Rare Renal Diseases, ORKID and ERK-Net networks, Lyon University Hospital, Bron, France
- Lyon Est Medical School, INSERM1033 Research Unit, Claude Bernard Lyon 1 University, Lyon, France
| | - Mathias Haarhaus
- Division of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Diaverum Sweden, Malmö, Sweden
| | - Ditte Hansen
- Department of Nephrology, Copenhagen University Hospital-Herlev, Copenhagen
- Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Carolina Gracia-Iguacel
- Department of Renal Medicine, IIS-Fundación Jiménez Díaz UAM University Hospital, Madrid, Spain
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
| | - Louise McAlister
- Dietetic Team, UCL Great Ormond Street Hospital for Children and University College London, London, UK
| | - Emily White
- Dietetic Team, Royal Free Hospital, University College London, London, UK
| | - Sandro Mazzaferro
- Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marc Vervloet
- Amsterdam Cardiovascular Sciences, Amsterdam UMC, The Netherlands
- Department of Nephrology, Amsterdam UMC, The Netherlands
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children, London, UK
- Institute of Child Health, University College London, London, UK
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Fusaro M, Barbuto S, Gallieni M, Cossettini A, Re Sartò GV, Cosmai L, Cianciolo G, La Manna G, Nickolas T, Ferrari S, Bover J, Haarhaus M, Marino C, Mereu MC, Ravera M, Plebani M, Zaninotto M, Cozzolino M, Bianchi S, Messa P, Gregorini M, Gasperoni L, Agosto C, Aghi A, Tripepi G. Real-world usage of Chronic Kidney Disease - Mineral Bone Disorder (CKD-MBD) biomarkers in nephrology practices. Clin Kidney J 2024; 17:sfad290. [PMID: 38223338 PMCID: PMC10784916 DOI: 10.1093/ckj/sfad290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Indexed: 01/16/2024] Open
Abstract
Background Chronic kidney disease mineral bone disorder (CKD-MBD) is a condition characterized by alterations of calcium, phosphate, parathyroid hormone (PTH), and fibroblast growth factor 23 (FGF-23) metabolism that in turn promote bone disorders, vascular calcifications, and increase cardiovascular (CV) risk. Nephrologists' awareness of diagnostic, prognostic, and therapeutic tools to manage CKD-MBD plays a primary role in adequately preventing and managing this condition in clinical practice. Methods A national survey (composed of 15 closed questions) was launched to inquire about the use of bone biomarkers in the management of CKD-MBD patients by nephrologists and to gain knowledge about the implementation of guideline recommendations in clinical practice. Results One hundred and six Italian nephrologists participated in the survey for an overall response rate of about 10%. Nephrologists indicated that the laboratories of their hospitals were able to satisfy request of ionized calcium levels, 105 (99.1%) of both PTH and alkaline phosphatase (ALP), 100 (94.3%) of 25(OH)D, and 61 (57.5%) of 1.25(OH)2D; while most laboratories did not support the requests of biomarkers such as FGF-23 (intact: 88.7% and c-terminal: 93.4%), Klotho (95.3%; soluble form: 97.2%), tartrate-resistant acid phosphatase 5b (TRAP-5b) (92.5%), C-terminal telopeptide (CTX) (71.7%), and pro-collagen type 1 N-terminal pro-peptide (P1NP) (88.7%). As interesting data regarding Italian nephrologists' behavior to start treatment of secondary hyperparathyroidism (sHPT), the majority of clinicians used KDOQI guidelines (n = 55, 51.9%). In contrast, only 40 nephrologists (37.7%) relied on KDIGO guidelines, which recommended referring to values of PTH between two and nine times the upper limit of the normal range. Conclusion Results point out a marked heterogeneity in the management of CKD-MBD by clinicians as well as a suboptimal implementation of guidelines in Italian clinical practice.
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Affiliation(s)
- Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
- Department of Medicine, University of Padova, Padova, Italy
| | - Simona Barbuto
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Maurizio Gallieni
- Department of Biomedical and Clinical Sciences ‘Luigi Sacco’, Università di Milano, Milano, Italy
- Post-Graduate School of Specialization in Nephrology, University of Milano, Milano, Italy
- Division of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Fatebenefratelli-Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Althea Cossettini
- Post-Graduate School of Specialization in Nephrology, University of Milano, Milano, Italy
| | | | - Laura Cosmai
- Division of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale (ASST) Fatebenefratelli-Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Thomas Nickolas
- Department of Medicine, Division of Nephrology, Columbia University, New York, NY, USA
| | - Serge Ferrari
- Service des Maladies Osseuses, Département de Médecine, HUG, Geneva, Switzerland
| | - Jordi Bover
- Servicio de Nefrología, Hospital Universitario Germans Trias i Pujol, Badalona (Barcelona), Spain
| | - Mathias Haarhaus
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Carmela Marino
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Reggio Calabria, Italy
| | | | - Maura Ravera
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, 16132 Genoa, Italy
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, University of Milan, ASST Santi Paolo e Carlo, Milan, Italy
| | - Stefano Bianchi
- Department of Internal Medicine, Nephrology and Dialysis Complex Operative Unit, Livorno, Italy
| | - Piergiorgio Messa
- Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Lorenzo Gasperoni
- Nephrology and Dialysis Unit, Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - Caterina Agosto
- Pediatric Pain and Palliative Care Service, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | | | - Giovanni Tripepi
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Reggio Calabria, Italy
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Sinkler MA, Benedick A, Kavanagh M, Vallier HA. Functional Outcomes After High-Energy Lisfranc Injuries. Foot Ankle Int 2023; 44:960-967. [PMID: 37341124 DOI: 10.1177/10711007231181121] [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] [Indexed: 06/22/2023]
Abstract
BACKGROUND Midfoot fractures and dislocations are infrequent and functional outcomes following Lisfranc injuries have not been well described. The purpose of this project was to explore functional outcomes following operative treatment of high-energy Lisfranc injury. METHODS A retrospective cohort of 46 adults with tarsometatarsal fractures and dislocations treated at a single Level 1 trauma center were reviewed. Demographic, medical, social, and injury features of these patients and their injuries were recorded. Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA) surveys were collected after mean 8.7 years' follow-up. Multiple linear regression was performed to identify independent predictors of outcome. RESULTS Forty-six patients with mean age 39.7 years completed functional outcome surveys. Mean SMFA scores were 29.3 (dysfunction) and 32.6 (bothersome). Mean FFI scores were 43.1 (pain), 43.0 (disability), and 21.7 (activity), with a mean total score of 35.9. FFI pain scores were worse than published values for fractures of the plafond (33, P = .04), distal tibia (33, P = .04), and talus (25.3, P = .001). Lisfranc injury patients reported worse disability (43.0 vs 29, P = .008) and total FFI scores (35.9 vs 26, P = .02) compared with distal tibia fractures. Tobacco smoking was an independent predictor of worse FFI (P < .05) and SMFA emotion and bothersome scores (P < .04). Chronic renal disease was a predictor of worse FFI disability (P = .04) and SMFA subcategory scores (P < .04). Male sex was associated with better scores in all SMFA categories (P < .04). Age, obesity, or open injury did not affect functional outcomes. CONCLUSION Patients reported worse pain by FFI after Lisfranc injury compared to other injuries about the foot and ankle. Tobacco smoking, female sex, and preexisting chronic renal disease are predictive of worse functional outcome scores, warranting further study in a larger sample, as well as counseling of long-term consequences of this injury. LEVEL OF EVIDENCE Level IV, retrospective, prognostic.
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Affiliation(s)
- Margaret A Sinkler
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Alex Benedick
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Michael Kavanagh
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Heather A Vallier
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Cejka D, Wakolbinger-Habel R, Zitt E, Fahrleitner-Pammer A, Amrein K, Dimai HP, Muschitz C. [Diagnosis and treatment of osteoporosis in patients with chronic kidney disease : Joint guidelines of the Austrian Society for Bone and Mineral Research (ÖGKM), the Austrian Society of Physical and Rehabilitation Medicine (ÖGPMR) and the Austrian Society of Nephrology (ÖGN)]. Wien Med Wochenschr 2023; 173:299-318. [PMID: 36542221 PMCID: PMC10516794 DOI: 10.1007/s10354-022-00989-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
DEFINITION AND EPIDEMIOLOGY Chronic kidney disease (CKD): abnormalities of kidney structure or function, present for over 3 months. Staging of CKD is based on GFR and albuminuria (not graded). Osteoporosis: compromised bone strength (low bone mass, disturbance of microarchitecture) predisposing to fracture. By definition, osteoporosis is diagnosed if the bone mineral density T‑score is ≤ -2.5. Furthermore, osteoporosis is diagnosed if a low-trauma (inadequate trauma) fracture occurs, irrespective of the measured T‑score (not graded). The prevalence of osteoporosis, osteoporotic fractures and CKD is increasing worldwide (not graded). PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENT OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER (CKD-MBD): Definition of CKD-MBD: a systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following: abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; renal osteodystrophy; vascular calcification (not graded). Increased, normal or decreased bone turnover can be found in renal osteodystrophy (not graded). Depending on CKD stage, routine monitoring of calcium, phosphorus, alkaline phosphatase, PTH and 25-OH-vitamin D is recommended (2C). Recommendations for treatment of CKD-MBD: Avoid hypercalcemia (1C). In cases of hyperphosphatemia, lower phosphorus towards normal range (2C). Keep PTH within or slightly above normal range (2D). Vitamin D deficiency should be avoided and treated when diagnosed (1C). DIAGNOSIS AND RISK STRATIFICATION OF OSTEOPOROSIS IN CKD Densitometry (using dual X‑ray absorptiometry, DXA): low T‑score correlates with increased fracture risk across all stages of CKD (not graded). A decrease of the T‑score by 1 unit approximately doubles the risk for osteoporotic fracture (not graded). A T-score ≥ -2.5 does not exclude osteoporosis (not graded). Bone mineral density of the lumbar spine measured by DXA can be increased and therefore should not be used for the diagnosis or monitoring of osteoporosis in the presence of aortic calcification, osteophytes or vertebral fracture (not graded). FRAX can be used to aid fracture risk estimation in all stages of CKD (1C). Bone turnover markers can be measured in individual cases to monitor treatment (2D). Bone biopsy may be considered in individual cases, especially in patients with CKD G5 (eGFR < 15 ml/min/1.73 m2) or CKD 5D (dialysis). SPECIFIC TREATMENT OF OSTEOPOROSIS IN PATIENTS WITH CKD Hypocalcemia should be treated and serum calcium normalized before initiating osteoporosis therapy (1C). CKD G1-G2 (eGFR ≥ 60 ml/min/1.73 m2): treat osteoporosis as recommended for the general population (1A). CKD G3-G5D (eGFR < 60 ml/min/1.73 m2 to dialysis): treat CKD-MBD first before initiating osteoporosis treatment (2C). CKD G3 (eGFR 30-59 ml/min/1.73 m2) with PTH within normal limits and osteoporotic fracture and/or high fracture risk according to FRAX: treat osteoporosis as recommended for the general population (2B). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) with osteoporotic fracture (secondary prevention): Individualized treatment of osteoporosis is recommended (2C). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) and high fracture risk (e.g. FRAX score > 20% for a major osteoporotic fracture or > 5% for hip fracture) but without prevalent osteoporotic fracture (primary prevention): treatment of osteoporosis may be considered and initiated individually (2D). CKD G4-5D (eGFR < 30 ml/min/1.73 m2 to dialysis): Calcium should be measured 1-2 weeks after initiation of antiresorptive therapy (1C). PHYSICAL MEDICINE AND REHABILITATION Resistance training prioritizing major muscle groups thrice weekly (1B). Aerobic exercise training for 40 min four times per week (1B). Coordination and balance exercises thrice weekly (1B). Flexibility exercise 3-7 times per week (1B).
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Affiliation(s)
- Daniel Cejka
- Abteilung für Innere Medizin III, Nieren- und Hochdruckerkrankungen, Transplantationsmedizin, Rheumatologie, Akutgeriatrie, Ordensklinikum Linz – Krankenhaus der Elisabethinen, Fadingerstr. 1, 4020 Linz, Österreich
| | - Robert Wakolbinger-Habel
- Department of Physical and Rehabilitation Medicine (PRM), Vienna Healthcare Group – Clinic Donaustadt, Langobardenstr. 122, 1220 Wien, Österreich
| | - Emanuel Zitt
- Department of Internal Medicine 3 (Nephrology and Dialysis), Feldkirch Academic Teaching Hospital, Feldkirch, Österreich
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Österreich
- Agency for Preventive and Social Medicine (aks), Bregenz, Österreich
| | - Astrid Fahrleitner-Pammer
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Hans Peter Dimai
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Christian Muschitz
- Medical Department II – VINFORCE, St. Vincent Hospital Vienna (Barmherzige Schwestern Krankenhaus Wien), Stumpergasse 13, 1060 Wien, Österreich
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9
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Xue X, Li JX, Wang JW, Lin LM, Cheng H, Deng DF, Xu WC, Zhao Y, Zou XR, Yuan J, Zhang LX, Zhao MH, Wang XQ. Association between alkaline phosphatase/albumin ratio and the prognosis in patients with chronic kidney disease stages 1-4: results from a C-STRIDE prospective cohort study. Front Med (Lausanne) 2023; 10:1215318. [PMID: 37799589 PMCID: PMC10548241 DOI: 10.3389/fmed.2023.1215318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/11/2023] [Indexed: 10/07/2023] Open
Abstract
Background The alkaline phosphatase-to-albumin ratio (APAR) has been demonstrated to be a promising non-invasive biomarker for predicting prognosis in certain diseases. However, the relationship between APAR and prognosis in non-dialysis chronic kidney disease (CKD) patients remains unclear. This study aims to identify the association between APAR and prognosis among CKD stages 1-4 in China. Methods Patients with CKD stages 1-4 were consecutively recruited from 39 clinical centers in China from 2011 to 2016. New occurrences of end-stage kidney disease (ESKD), major adverse cardiovascular and cerebrovascular events, and all-cause deaths were the outcome events of this study. Subdistribution hazard competing risk and Cox proportional hazards regression models were adopted. Results A total of 2,180 participants with baseline APAR values were included in the analysis. In the primary adjusted analyses, higher APAR level [per 1-standard deviation (SD) increase in natural logarithm transformed (ln-transformed) APAR] was associated with 33.5% higher risk for all-cause deaths [adjusted hazard ratio (HR) 1.335, 95% confidence interval (CI) 1.068-1.670]. In addition, there was evidence for effect modification of the association between APAR and ESKD by baseline estimated glomerular filtration rate (eGFR) (P interaction < 0.001). A higher APAR level (per 1-SD increase in ln-transformed APAR) was associated with a greater risk of ESKD among participants with eGFR ≥ 60 ml/min/1.73 m2 (adjusted SHR 1.880, 95% CI 1.260-2.810) but not in eGFR < 60 ml/min/1.73 m2. Conclusion Higher APAR levels in patients with CKD stages 1-4 seemed to be associated with an increased risk of all-cause death. Thus, APAR appears to be used in risk assessment for all-cause death among patients with CKD stages 1-4.
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Affiliation(s)
- Xue Xue
- The First Clinical Medical School, Hubei University of Chinese Medicine, Wuhan, China
| | - Jia-Xuan Li
- School of Clinical Traditional Chinese Medicine, Hubei University of Chinese Medicine, Wuhan, China
| | - Jin-Wei Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, National Health Commission of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - La-Mei Lin
- Department of Nephrology, Affiliated Hospital of Hubei University of Chinese Medicine, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
| | - Hong Cheng
- Department of Nephrology, Affiliated Hospital of Hubei University of Chinese Medicine, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
| | - Dan-Fang Deng
- Department of Nephrology, Affiliated Hospital of Hubei University of Chinese Medicine, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
| | - Wen-Cheng Xu
- Department of Nephrology, Affiliated Hospital of Hubei University of Chinese Medicine, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
| | - Yu Zhao
- Department of Nephrology, Affiliated Hospital of Hubei University of Chinese Medicine, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
| | - Xin-Rong Zou
- Department of Nephrology, Affiliated Hospital of Hubei University of Chinese Medicine, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
| | - Jun Yuan
- Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Lu-Xia Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, National Health Commission of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
- National Institute of Health Data Science at Peking University, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, National Health Commission of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Qin Wang
- Department of Nephrology, Affiliated Hospital of Hubei University of Chinese Medicine, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Hubei Key Laboratory of Theory and Application Research of Liver and Kidney in Traditional Chinese Medicine, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
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10
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Jørgensen HS, Evenepoel P, Komaba H, Mazzaferro S, Vervloet M, Cavalier E, Fukagawa M. Response to Letter to the Editor From Sumi et al: "Lower Bone Turnover and Skeletal PTH Responsiveness in Japanese Compared to European Patients Receiving Hemodialysis". J Clin Endocrinol Metab 2023; 108:e42-e43. [PMID: 36469693 PMCID: PMC9931179 DOI: 10.1210/clinem/dgac698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, 3000 Leuven, Belgium
- Department of Renal Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Pieter Evenepoel
- Correspondence: Pieter Evenepoel, MD, PhD, Department of Medicine, Division of Nephrology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara 259–1193, Japan
| | - Sandro Mazzaferro
- Nephrology Unit at Policlinico Umberto I Hospital, 00185 Rome, Italy
- Department of Translation and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Marc Vervloet
- Department of Nephrology, Amsterdam University Medical Center, 1081 HV Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, 1081 HV Amsterdam, The Netherlands
| | - Etienne Cavalier
- Department of Biochemistry, Université de Liège, 4000 Liège, Belgium
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara 259–1193, Japan
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11
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Lung BE, Kim M, McLellan M, Callan K, Wang ED, McMaster W, Yang S, So DH. Alkaline Phosphatase is an Independent Risk Factor for Periprosthetic Fractures in Total Joint Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202302000-00007. [PMID: 36763725 PMCID: PMC10566914 DOI: 10.5435/jaaosglobal-d-22-00129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 01/06/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Serum alkaline phosphatase (ALP) is a biomarker for chronic low-grade inflammation along with hepatobiliary and bone disorders. High abnormal ALP levels in blood have been associated with metabolic bone disease and high bone turnover. METHODS All primary total hip and knee arthroplasties from 2005 to 2019 were queried from the National Surgical Quality Improvement Program database. Patients with available serum ALP levels were included and stratified to low (<44 IU/L), normal (44 to 147 IU/L), and high (>147 IU/L). A risk-adjusted multivariate logistic regression was used to analyze ALP as an independent risk factor of complications. RESULTS The analysis included 324,592 patients, consisting of 11,427 low ALP, 305,977 normal ALP, and 7,188 high preoperative ALP level patients undergoing total joint arthroplasty. Adjusted multivariate logistic regression analysis showed high ALP level patients had an overall increased risk of readmission within 30 days of surgery compared with the control group (odds ratio [OR], 1.69; P < 0.01). High ALP patients also had an increased risk of postoperative periprosthetic fracture (OR, 1.6), postoperative wound infection (OR, 1.81), pneumonia (OR, 2.24), renal insufficiency (OR, 2.39), cerebrovascular disease (OR, 2.2), postoperative bleeding requiring transfusion (OR, 1.83), sepsis (OR, 2.35), length of stay > 2 days (OR, 1.47), Clostridium difficile infection (OR, 2.07), and discharge to a rehab facility (OR, 1.41) (all P < 0.05). A low ALP level was also associated with increased postoperative bleeding transfusion risk (OR, 1.12; P < 0.01) and developing a deep vein thrombosis (OR, 1.25; P = 0.03). CONCLUSION Abnormal serum ALP levels in patients undergoing primary total joint arthroplasty are associated with increased postoperative periprosthetic fracture risk and medical complications requiring increased length of stay and discharge to a rehabilitation facility.
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Affiliation(s)
- Brandon E. Lung
- From the UC Irvine Department of Orthopaedic Surgery, Orange, CA (Dr. Lung, McLellan, Callan, Dr. McMaster, Dr. Yang, and Dr. So) and the Stony Brook Department of Orthopaedic Surgery, Stony Brook, NY (Kim, and Dr. Wang)
| | - Matthew Kim
- From the UC Irvine Department of Orthopaedic Surgery, Orange, CA (Dr. Lung, McLellan, Callan, Dr. McMaster, Dr. Yang, and Dr. So) and the Stony Brook Department of Orthopaedic Surgery, Stony Brook, NY (Kim, and Dr. Wang)
| | - Maddison McLellan
- From the UC Irvine Department of Orthopaedic Surgery, Orange, CA (Dr. Lung, McLellan, Callan, Dr. McMaster, Dr. Yang, and Dr. So) and the Stony Brook Department of Orthopaedic Surgery, Stony Brook, NY (Kim, and Dr. Wang)
| | - Kylie Callan
- From the UC Irvine Department of Orthopaedic Surgery, Orange, CA (Dr. Lung, McLellan, Callan, Dr. McMaster, Dr. Yang, and Dr. So) and the Stony Brook Department of Orthopaedic Surgery, Stony Brook, NY (Kim, and Dr. Wang)
| | - Edward D. Wang
- From the UC Irvine Department of Orthopaedic Surgery, Orange, CA (Dr. Lung, McLellan, Callan, Dr. McMaster, Dr. Yang, and Dr. So) and the Stony Brook Department of Orthopaedic Surgery, Stony Brook, NY (Kim, and Dr. Wang)
| | - William McMaster
- From the UC Irvine Department of Orthopaedic Surgery, Orange, CA (Dr. Lung, McLellan, Callan, Dr. McMaster, Dr. Yang, and Dr. So) and the Stony Brook Department of Orthopaedic Surgery, Stony Brook, NY (Kim, and Dr. Wang)
| | - Steven Yang
- From the UC Irvine Department of Orthopaedic Surgery, Orange, CA (Dr. Lung, McLellan, Callan, Dr. McMaster, Dr. Yang, and Dr. So) and the Stony Brook Department of Orthopaedic Surgery, Stony Brook, NY (Kim, and Dr. Wang)
| | - David H. So
- From the UC Irvine Department of Orthopaedic Surgery, Orange, CA (Dr. Lung, McLellan, Callan, Dr. McMaster, Dr. Yang, and Dr. So) and the Stony Brook Department of Orthopaedic Surgery, Stony Brook, NY (Kim, and Dr. Wang)
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12
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Sinkler MA, Pennacchio CA, Kotchman HM, Vallier HA. Association of Chronic Kidney Disease and Complications Following Acute Torsional Ankle Fracture. Foot Ankle Int 2022; 43:1569-1576. [PMID: 36254721 DOI: 10.1177/10711007221127026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although chronic kidney disease (CKD) has been associated with poor outcomes following traumatic fractures, there is a scarcity of literature describing the effect on outcomes of ankle fractures. We will examine the impact of CKD on clinical outcomes following torsional ankle fracture, including complications and unplanned surgical procedures. METHODS A retrospective review of 1981 adult patients with torsional ankle fractures treated at a level 1 trauma center was performed to identify patients with CKD based on glomerular filtration rate. Demographic, injury, and treatment-related characteristics were collected. Outcomes included any unplanned procedure: implant removal, debridement, revision, arthrodesis, and amputation; in addition to complications of superficial infection, deep infection, and implant irritation. Patients with CKD were matched with patients without CKD by propensity score matching. Univariate comparisons between groups were conducted using chi-square and Mann-Whitney U tests. RESULTS 136 patients (68 with CKD and 68 without CKD) were analyzed. Of the 68 patients with CKD, the mean stage of disease was 3.7 with 24% on dialysis for a mean length of 4.1 years. Patients without CKD were more likely to undergo primary ORIF (100% vs 54%, P < .001). Thirty-five percent of patients with CKD had surgical complications vs 19% in the cohort without (P = .07). Patients with open fractures, dislocation, and chronic kidney disease were, respectively, 5.19, 3.77, and 3.91 times more likely to have any complication (P = .02, P = .05, P = .05). Patients with CKD were more likely to undergo unplanned arthrodesis (P = .01). Only dislocation was an independent predictor for unplanned procedure (odds ratio = 5.08, P = .026). CONCLUSION Following torsional ankle fracture, CKD is associated with increased likelihood of having a complication or an unplanned arthrodesis. Open fractures and dislocation at time of injury are also associated with complications. Our findings encourage caution about surgical treatment of ankle fractures in patients with CKD. LEVEL OF EVIDENCE Level III, retrospective, comparative, prognostic.
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Affiliation(s)
- Margaret A Sinkler
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Halle M Kotchman
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Heather A Vallier
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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13
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Evenepoel P, Jørgensen HS, Komaba H, Mazzaferro S, Vervloet M, Cavalier E, Fukagawa M. Lower Bone Turnover and Skeletal PTH Responsiveness in Japanese Compared to European Patients on Hemodialysis. J Clin Endocrinol Metab 2022; 107:e4350-e4359. [PMID: 36068939 DOI: 10.1210/clinem/dgac522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Parathyroid hormone (PTH) treatment targets for patients receiving hemodialysis (HD) are lower in Japan than in Europe. Whether this translates to lower bone turnover is unknown and could depend on skeletal PTH responsiveness. OBJECTIVE This study investigates whether skeletal PTH responsiveness is better preserved in Japanese vs European patients receiving HD. METHODS This is a post hoc analysis of data from 2 prospective cohort studies, using a case-control design. Patients receiving chronic intermittent HD therapy were eligible for inclusion. Participating Belgian and Japanese patients (n = 374) were matched 1:1 by age (59 ± 12 years), sex (66% male), diabetes (34%), and dialysis duration (39 months [22-63 months]). PTH, bone-specific alkaline phosphatase (BALP), and tartrate-resistant acid phosphatase isoform 5b (TRAP5b) were measured centrally in Liège, Belgium. RESULTS Japanese patients had lower levels of iPTH (207 vs 268 pg/mL; P < .001), BALP (15.3 vs 24.5 μg/L; P < .001), and TRAP5b (3.35 vs 5.79 U/L; P < .001). Linear regression analyses revealed lower levels of bone turnover markers for any given level of PTH in Japanese vs Belgian patients, indicating lower skeletal PTH responsiveness. Consistently, bone turnover markers were significantly lower in Japanese vs Belgian patients when stratifying or matching according to PTH levels. Male sex, obesity, and hyperphosphatemia were the main determinants of the bone turnover marker/PTH ratios. CONCLUSION Japanese patients receiving HD have lower bone turnover than their European counterparts, even at similar PTH levels. The rationale for the current regional differences in PTH treatment targets remains obscure and deserves further attention.
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Affiliation(s)
- Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, 3000 Leuven, Belgium
- Department of Medicine, Division of Nephrology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, 3000 Leuven, Belgium
- Department of Renal Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara 259-1193, Japan
| | - Sandro Mazzaferro
- Nephrology Unit at Policlinico Umberto I Hospital, 00185 Rome, Italy
- Department of Translation and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Marc Vervloet
- Department of Nephrology, Amsterdam University Medical Center, 1081 HV Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, 1081 HV Amsterdam, the Netherlands
| | - Etienne Cavalier
- Department of Biochemistry, Université de Liège, 4000 Liège, Belgium
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara 259-1193, Japan
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14
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Abdalbary M, Sobh M, Elnagar S, Elhadedy MA, Elshabrawy N, Abdelsalam M, Asadipooya K, Sabry A, Halawa A, El-Husseini A. Management of osteoporosis in patients with chronic kidney disease. Osteoporos Int 2022; 33:2259-2274. [PMID: 35748896 DOI: 10.1007/s00198-022-06462-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/31/2022] [Indexed: 12/19/2022]
Abstract
Patients with CKD have a 4-fivefold higher rate of fractures. The incidence of fractures increases with deterioration of kidney function. The process of skeletal changes in CKD patients is characterized by compromised bone strength because of deterioration of bone quantity and/or quality. The fractures lead to a deleterious effect on the quality of life and higher mortality in patients with CKD. The pathogenesis of bone loss and fracture is complex and multi-factorial. Renal osteodystrophy, uremic milieu, drugs, and systemic diseases that lead to renal failure all contribute to bone damage in CKD patients. There is no consensus on the optimal diagnostic method of compromised bone assessment in patients with CKD. Bone quantity and mass can be assessed by dual-energy x-ray absorptiometry (DXA) or quantitative computed tomography (QCT). Bone quality on the other side can be assessed by non-invasive methods such as trabecular bone score (TBS), high-resolution bone imaging methods, and invasive bone biopsy. Bone turnover markers can reflect bone remodeling, but some of them are retained by kidneys. Understanding the mechanism of bone loss is pivotal in preventing fracture in patients with CKD. Several non-pharmacological and therapeutic interventions have been reported to improve bone health. Controlling laboratory abnormalities of CKD-MBD is crucial. Anti-resorptive therapies are effective in improving BMD and reducing fracture risk, but there are uncertainties about safety and efficacy especially in advanced CKD patients. Accepting the prevalent of low bone turnover in patients with advanced CKD, the osteo-anabolics are possibly promising. Parathyroidectomy should be considered a last resort for intractable cases of renal hyperparathyroidism. There is a wide unacceptable gap in osteoporosis management in patients with CKD. This article is focusing on the updated management of CKD-MBD and osteoporosis in CKD patients. Chronic kidney disease deteriorates bone quality and quantity. The mechanism of bone loss mainly determines pharmacological treatment. DXA and QCT provide information about bone quantity, but assessing bone quality, by TBS, high-resolution bone imaging, invasive bone biopsy, and bone turnover markers, can guide us about the mechanism of bone loss.
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Affiliation(s)
- M Abdalbary
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA
| | - M Sobh
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - S Elnagar
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M A Elhadedy
- Nephrology and Transplantation Unit, Mansoura Urology and Nephrology Center, Mansoura, Egypt
| | - N Elshabrawy
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - M Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - K Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, USA
| | - A Sabry
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - A Halawa
- Sheffield Teaching Hospital, University of Liverpool, Liverpool, UK
| | - A El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, 800 Rose Street, Room MN-560, Lexington, KY, 40536-0298, USA.
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15
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Serum alkaline phosphatase and infection-related mortality in hemodialysis patients: ten-year outcomes of the Q-cohort study. Clin Exp Nephrol 2022; 26:1119-1129. [PMID: 35927603 DOI: 10.1007/s10157-022-02255-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND High serum alkaline phosphatase (ALP) levels are associated with excess all-cause and cardiovascular mortality in patients undergoing hemodialysis (HD). However, the long-term relationship between serum ALP levels and infection-related mortality remains unclear. METHODS A total of 3502 maintenance HD patients were registered in the Q-Cohort Study, an observational cohort study in Japan. The primary outcome was infection-related mortality during a 10-year follow-up period. The covariate of interest was serum ALP levels at baseline. The association between serum ALP levels and infection-related mortality was calculated using a Cox proportional hazards model and a Fine-Gray subdistribution hazards model with non-infection-related death as a competing risk. RESULTS During the follow-up period, 446 patients died of infection. According to their baseline serum ALP levels, the patients were categorized into sex-specific quartiles (Q1-Q4). Compared with patients in the lowest serum ALP quartile (Q1), those in the highest quartile (Q4) had a significantly higher multivariable-adjusted hazard ratio (HR) of 1.70 [95% confidence interval (CI) 1.24-2.32] for infection-related mortality. Furthermore, the HR for every 50 U/L increase in serum ALP levels was 1.24 (95% CI 1.12-1.36) for infection-related mortality. These associations remained consistent in the competing risk model: subdistribution HR, 1.47; 95% CI 1.07-2.03 for Q4 compared with Q1. CONCLUSION Higher serum ALP levels were significantly associated with a higher risk of infection-related mortality in patients undergoing HD.
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Smout D, Jørgensen HS, Cavalier E, Evenepoel P. Clinical utility of bone turnover markers in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:332-338. [PMID: 35703216 DOI: 10.1097/mnh.0000000000000798] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The burden of fractures is very high in patients with chronic kidney disease (CKD). It is increasingly recognized that knowledge of bone turnover is of paramount importance in guiding mineral metabolism and osteoporosis therapy in CKD. Bone histomorphometry is the gold standard to assess bone turnover, but is seldomly performed in clinical practice. Bone turnover markers (BTMs) may be the long awaited noninvasive diagnostic that may help to close the therapeutic gap in patients with advanced CKD presenting with bone fragility. RECENT FINDINGS Mounting evidence indicates that BTMs may be useful in skeletal and nonskeletal risk stratification, in guiding mineral metabolism and osteoporosis therapy, and in monitoring the therapeutic response. SUMMARY BTMs provide information that is complementary to other clinical tests. It may be envisioned that in the near future, the assessment of nonkidney cleared BTMs may become part of routine clinical evaluation and monitoring of bone health in CKD patients, integrated with clinical risk factors, imaging data and, eventually, bone histomorphometry. Panels of BTMs will likely be more informative than single markers, and the same might hold true for trends as opposed to single time point data.
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Affiliation(s)
- Dieter Smout
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Hanne S Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven
- Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liege, CHU de Liege, Liege, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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Alkaline Phosphatase: An Old Friend as Treatment Target for Cardiovascular and Mineral Bone Disorders in Chronic Kidney Disease. Nutrients 2022; 14:nu14102124. [PMID: 35631265 PMCID: PMC9144546 DOI: 10.3390/nu14102124] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022] Open
Abstract
Alkaline phosphatase (ALP) is an evolutionary conserved enzyme and widely used biomarker in clinical practice. Tissue-nonspecific alkaline phosphatase (TNALP) is one of four human isozymes that are expressed as distinct TNALP isoforms after posttranslational modifications, mainly in bone, liver, and kidney tissues. Beyond the well-known effects on bone mineralization, the bone ALP (BALP) isoforms (B/I, B1, B1x, and B2) are also involved in the pathogenesis of ectopic calcification. This narrative review summarizes the recent clinical investigations and mechanisms that link ALP and BALP to inflammation, metabolic syndrome, vascular calcification, endothelial dysfunction, fibrosis, cardiovascular disease, and mortality. The association between ALP, vitamin K, bone metabolism, and fracture risk in patients with chronic kidney disease (CKD) is also discussed. Recent advances in different pharmacological strategies are highlighted, with the potential to modulate the expression of ALP directly and indirectly in CKD–mineral and bone disorder (CKD-MBD), e.g., epigenetic modulation, phosphate binders, calcimimetics, vitamin D, and other anti-fracture treatments. We conclude that the significant evidence for ALP as a pathogenic factor and risk marker in CKD-MBD supports the inclusion of concrete treatment targets for ALP in clinical guidelines. While a target value below 120 U/L is associated with improved survival, further experimental and clinical research should explore interventional strategies with optimal risk–benefit profiles. The future holds great promise for novel drug therapies modulating ALP.
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18
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Fusaro M, Re Sartò GV, Gallieni M, Cosmai L, Messa P, Rossini M, Chiodini I, Plebani M, Evenepoel P, Harvey N, Ferrari S, Cannata-Andía J, Trombetti A, Brandi ML, Ketteler M, Nickolas TL, Cunningham J, Salam S, Della Rocca C, Scarpa A, Minisola S, Malberti F, Cetani F, Cozzolino M, Mazzaferro S, Morrone L, Tripepi G, Zaninotto M, Mereu MC, Ravera M, Cianciolo G, La Manna G, Aghi A, Giannini S, Dalle Carbonare L. Time for Revival of Bone Biopsy with Histomorphometric Analysis in Chronic Kidney Disease (CKD): Moving from Skepticism to Pragmatism. Nutrients 2022; 14:1742. [PMID: 35565717 PMCID: PMC9103887 DOI: 10.3390/nu14091742] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 12/04/2022] Open
Abstract
Bone Biopsy (BB) with histomorphometric analysis still represents the gold standard for the diagnosis and classification of different forms of renal osteodystrophy. Bone biopsy is the only technique able to provide comprehensive information on all bone parameters, measuring static and dynamic parameters of turnover, cortical and trabecular microarchitecture, and mineralization defects. In nephrological practice, bone biopsy yields relevant indications to support therapeutic choices in CKD, heavily impacting the management and prognosis of uremic patients. Unfortunately, the use of bone biopsy has decreased; a lack of expertise in performing and interpreting, perceived procedure invasiveness and pain, and reimbursement issues have all contributed to this decline. Nevertheless, both bone biomarkers and instrumental images cannot be considered reliable surrogates for histological findings, being insufficiently accurate to properly evaluate underlying mineral and bone disorders. This is a multidisciplinary position paper from the Nephrology and Osteoporosis Italian Scientific Societies with the purpose of restating the role of bone biopsy in CKD patient management and of providing strong solutions to allow diffusion of this technique in Italy, but potentially also in other countries. The Italian approach through the optimization and standardization of bone biopsy procedure, the construction of the Italian Hub and Spoke network, and a request for adjustment and national homogenization of reimbursement to the Italian Health Ministry has led the way to implement bone biopsy and to improve CKD patient management and prognosis.
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Affiliation(s)
- Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), 56124 Pisa, Italy
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Giulia Vanessa Re Sartò
- Post-Graduate School of Specialization in Nephrology, University of Milano, 20157 Milano, Italy; (G.V.R.S.); (M.G.)
| | - Maurizio Gallieni
- Post-Graduate School of Specialization in Nephrology, University of Milano, 20157 Milano, Italy; (G.V.R.S.); (M.G.)
- Department of Biomedical and Clinical Sciences, Università di Milano, 20157 Milano, Italy
- Nephrology Unit, ASST Fatebenefratelli Sacco, 20157 Milano, Italy;
| | - Laura Cosmai
- Nephrology Unit, ASST Fatebenefratelli Sacco, 20157 Milano, Italy;
| | - Piergiorgio Messa
- Unit of Nephrology, Dialysis and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, 20157 Milano, Italy;
- Department of Clinical Sciences and Community Health, University of Milano, 20122 Milano, Italy
| | | | - Iacopo Chiodini
- Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, 20157 Milano, Italy;
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine, University of Padua, 35121 Padua, Italy; (M.P.); (M.Z.)
| | - Pieter Evenepoel
- Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven, B-3000 Leuven, Belgium;
| | - Nicholas Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton SO16 6YD, UK;
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Serge Ferrari
- Service des Maladies Osseuses, Département de Médecine, HUG, 1205 Geneva, Switzerland;
| | - Jorge Cannata-Andía
- Bone and Mineral Research Unit, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), REDinREN del ISCIII, Hospital Universitario Central de Asturias, Universidad de Oviedo, 33003 Oviedo, Spain;
| | - Andrea Trombetti
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland;
| | - Maria Luisa Brandi
- Department of Surgery and Translational Medicine, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy;
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, 70376 Stuttgart, Germany;
| | - Thomas L. Nickolas
- Division of Nephrology, Columbia University Irving Medical Center, New York, NY 10027, USA;
| | - John Cunningham
- Centre for Nephrology, The Royal Free Hospital and UCL Medical School, London WC1E 6BT, UK;
| | - Syazrah Salam
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield S10 2JF, UK;
| | - Carlo Della Rocca
- Department of Medico-Surgical Sciences and Biotechnology, Sapienza University, Polo Pontino, 00185 Rome, Italy;
| | - Aldo Scarpa
- ARC-Net Centre for Applied Research on Cancer, University and Hospital Trust of Verona, 37134 Verona, Italy;
- Department of Pathology and Diagnostics, University and Hospital Trust of Verona, 37134 Verona, Italy
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Fabio Malberti
- UO Nefrologia e Dialisi ASST Cremona, 26100 Cremona, Italy;
| | - Filomena Cetani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, San Paolo Hospital, University of Milan, 20142 Milan, Italy;
| | - Sandro Mazzaferro
- Nephrologic Unit, Department of Translational and Precision Medicine, University of Rome ‘La Sapienza’, 00185 Rome, Italy;
| | - Luigi Morrone
- Nephrology, Dialysis and Renal Transplantation Unit, University Hospital “Policlinico”, 70124 Bari, Italy;
| | - Giovanni Tripepi
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy;
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine, University of Padua, 35121 Padua, Italy; (M.P.); (M.Z.)
| | | | | | - Giuseppe Cianciolo
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; (G.C.); (G.L.M.)
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy; (G.C.); (G.L.M.)
| | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padua, 35128 Padua, Italy; (A.A.); (S.G.)
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padua, 35128 Padua, Italy; (A.A.); (S.G.)
| | - Luca Dalle Carbonare
- Section of Internal Medicine, Department of Medicine, University of Verona, 37134 Verona, Italy;
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Hagiwara K, Sakamoto A, Sasaki K, Kanatani A, Kimura M, Kaneko T, Takahashi S, Yamada Y, Nakagawa T. Higher serum alkaline phosphatase value indicates the need for bone mineral density testing in non-metastatic prostate cancer patients undergoing androgen deprivation therapy. Jpn J Clin Oncol 2022; 52:73-80. [PMID: 34542155 DOI: 10.1093/jjco/hyab147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/01/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Osteoporosis is a well-known adverse effect of androgen deprivation therapy for prostate cancer. This study aimed to reveal the factors associated with the diagnosis of osteoporosis in prostate cancer patients undergoing androgen deprivation therapy. METHODS This retrospective cross-sectional study included 106 prostate cancer patients treated with androgen deprivation therapy. Patients with bone metastasis at the initiation of androgen deprivation therapy and those with castration-resistant prostate cancer were excluded. Bone mineral density was measured at the lumbar spine and femoral neck using dual-energy X-ray absorptiometry. Osteoporosis was defined as bone mineral density equal to or below either -2.5 SD or 70% of the mean in young adults. The association between clinicopathological variables and bone mineral density or diagnosis of osteoporosis was investigated. RESULTS Thirty-six (34%) patients were found to have osteoporosis. The incidence of osteoporosis increased in a stepwise manner depending on the duration of androgen deprivation therapy. Multivariate logistic regression analysis identified a longer duration of androgen deprivation therapy (months, odd's ratio = 1.017, P = 0.006), lower body mass index (kg/m2, odd's ratio = 0.801, P = 0.005) and higher serum alkaline phosphatase value (U/l, odd's ratio 1.007, P = 0.014) as the factors independently associated with the diagnosis of osteoporosis. Eleven out of 50 (22%), 14 out of 35 (40%) and 11 out of 20 patients (55%) were osteoporotic in the patients with serum alkaline phosphatase values <238 U/l, 238-322 U/l and >322 U/l, respectively (P = 0.022). CONCLUSIONS Osteoporosis is common in prostate cancer patients undergoing androgen deprivation therapy; furthermore, its incidence increases depending on the duration of androgen deprivation therapy. Bone mineral density testing should be considered for all patients on androgen deprivation therapy, especially for those with a lower body mass index and higher serum alkaline phosphatase value.
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Affiliation(s)
- Kanade Hagiwara
- Department of Urology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Akihiko Sakamoto
- Department of Urology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Kenichi Sasaki
- Department of Urology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Atsushi Kanatani
- Department of Urology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Masaki Kimura
- Department of Urology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Tomoyuki Kaneko
- Department of Urology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Sayuri Takahashi
- Department of Urology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Yukio Yamada
- Department of Urology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Tohru Nakagawa
- Department of Urology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
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20
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Alfieri C, Mattinzoli D, Messa P. Tertiary and Postrenal Transplantation Hyperparathyroidism. Endocrinol Metab Clin North Am 2021; 50:649-662. [PMID: 34774239 DOI: 10.1016/j.ecl.2021.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients who have undergone kidney transplantation (KTx) (KTxps) are a distinctive population characterized by the persistence of some metabolic anomalies present during end-stage renal disease. Mineral metabolism (MM) parameters are frequently altered after KTx. These alterations involve calcium, phosphorus, vitamin D, and parathormone (PTH) disarrangements. At present, there is little consensus about the correct monitoring and management of PTH disorders in KTxps. This article presents the prevalence and epidemiologic and clinical impact of post-KTx hyper-PTH. The principal biochemical and instrumental investigations and the therapeutic options for these conditions are also reported.
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Affiliation(s)
- Carlo Alfieri
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Via Commenda 15, Milan 20122, Italy; Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono, 7, Milan 20122, Italy
| | - Deborah Mattinzoli
- Renal Research Laboratory Fondazione IRCCS Ca' Granda Ospedale Policlinico, Via Pace 9, Milan 20122, Italy
| | - Piergiorgio Messa
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Via Commenda 15, Milan 20122, Italy; Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono, 7, Milan 20122, Italy.
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21
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Zhang X, Chen Y, Zhang C, Zhang X, Xia T, Han J, Song S, Xu C, Chen F. Effects of icariin on the fracture healing in young and old rats and its mechanism. PHARMACEUTICAL BIOLOGY 2021; 59:1245-1255. [PMID: 34511043 PMCID: PMC8439244 DOI: 10.1080/13880209.2021.1972121] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/06/2021] [Accepted: 08/19/2021] [Indexed: 06/13/2023]
Abstract
CONTEXT Icariin has attracted increasing attention because of its wide variety of pharmacological effects. OBJECTIVE This study investigates whether icariin could promote fracture healing in young and old rats and its mechanisms. MATERIALS AND METHODS A Wistar rat model for the tibia fracture in relatively young and old rats, respectively, was established. The rats were divided into four groups: model group, L-icariin (50 mg/kg icariin), M-icariin (100 mg/kg icariin) and H-icariin (200 mg/kg icariin), and intragastric administration of icariin was performed for 10 days or 20 days. In addition, isolated and cultured rat bone mesenchymal stem cells (rBMSCs) from young and old rats were cultured with 5% and 20% of icariin-containing serum, respectively, then cell viability and alkaline phosphatase (ALP) activity were measured. RESULTS Icariin administration induced the expression of Runx2, Osterix, BMP-2, p-Smad5 and osteocalcin secretion (young rats: model: 2.50 ± 0.71; L-icariin: 10.10 ± 1.55; M-icariin: 24.95 ± 2.19; H-icariin: 36.80 ± 2.26; old rats: model: 1.55 ± 0.49; L-icariin:6.55 ± 0.50; M-icariin: 15.00 ± 0.85; H-icariin:20.50 ± 2.27) at the fracture site, and increased the levels of bone formation markers (OC, BAP, NTX-1 and CTX-1) in a dose-dependent manner. In vitro, icariin treatment promoted rBMSC viability, increased ALP activity and the expression of BMP-2/Smad5/Runx2 pathway proteins. DISCUSSION AND CONCLUSIONS Icariin may accelerate fracture healing by activating the BMP-2/Smad5/Runx2 pathway in relatively young and old rats. The research on the mechanism of icariin to promote fracture healing can provide a theoretical basis for the clinical application and promotion of icariin.
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Affiliation(s)
- Xiaoyun Zhang
- Clinical Medical School, Jiangxi University of Traditional Chinese Medicine, Nanchang, China
- Department of Orthopedics, Ruikang Hospital Affiliated with Guangxi University of Chinese Medicine, Nanning, China
| | - Yueping Chen
- Department of Orthopedics, Ruikang Hospital Affiliated with Guangxi University of Chinese Medicine, Nanning, China
| | - Chi Zhang
- Department of Orthopedics, Ruikang Hospital Affiliated with Guangxi University of Chinese Medicine, Nanning, China
| | - Xuan Zhang
- Department of Orthopedics, Ruikang Hospital Affiliated with Guangxi University of Chinese Medicine, Nanning, China
| | - Tian Xia
- Department of Orthopedics, Ruikang Hospital Affiliated with Guangxi University of Chinese Medicine, Nanning, China
| | - Jie Han
- Department of Orthopedics, Ruikang Hospital Affiliated with Guangxi University of Chinese Medicine, Nanning, China
| | - Shilei Song
- Department of Orthopedics, Ruikang Hospital Affiliated with Guangxi University of Chinese Medicine, Nanning, China
| | - Canhong Xu
- Department of Orthopedics, Ruikang Hospital Affiliated with Guangxi University of Chinese Medicine, Nanning, China
| | - Feng Chen
- Department of Orthopedics, Ruikang Hospital Affiliated with Guangxi University of Chinese Medicine, Nanning, China
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Evenepoel P, Cunningham J, Ferrari S, Haarhaus M, Javaid MK, Lafage-Proust MH, Prieto-Alhambra D, Torres PU, Cannata-Andia J. Diagnosis and management of osteoporosis in chronic kidney disease stages 4 to 5D: a call for a shift from nihilism to pragmatism. Osteoporos Int 2021; 32:2397-2405. [PMID: 34129059 DOI: 10.1007/s00198-021-05975-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/21/2021] [Indexed: 12/22/2022]
Abstract
The European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) CKD-MBD working group, in collaboration with the Committee of Scientific Advisors of the International Osteoporosis Foundation, published a position paper for the diagnosis and management of osteoporosis in patients with CKD stages 4-5D (eGFR < 30 ml/min 1.73 m2). The present article reports and summarizes the main recommendations included in this 2021 document. The following areas are reviewed: diagnosis of osteoporosis; risk factors for fragility fractures; fracture risk assessment; intervention thresholds for pharmacological intervention; general and pharmacological management of osteoporosis; monitoring of treatment, and systems of care, all in patients with CKD stages 4-5D. Guidance is provided for clinicians caring for CKD stages 4-5D patients with osteoporosis, allowing for a pragmatic individualized diagnostic and therapeutic approach as an alternative to current variations in care and treatment nihilism.
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Affiliation(s)
- P Evenepoel
- Division of Nephrology, University Hospitals Leuven, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - J Cunningham
- Centre for Nephrology, Royal Free Campus, UCL Medical School, Rowland Hill Street, London, NW3 2PF, UK
| | - S Ferrari
- Service of Bone diseases, Geneva university Hospital Switzerland, Rue Gabrielle-Perret-Gentil 4, 1205, Genève, Switzerland
| | - M Haarhaus
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet,, Karolinska University Hospital, Solna, Sweden
| | - M K Javaid
- NDORMS, University of Oxford, Windmill Road, Oxford, OX3 7HE, UK
| | | | - D Prieto-Alhambra
- CSM-NDORMS, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - P U Torres
- AURA Nord Saint Ouen, 108 bis, avenue Gabriel Péri, 93400, Saint Ouen, France
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - J Cannata-Andia
- Bone and Mineral Research Unit (ISPA) (REDinREN), Hospital Universitario Central Asturias, Oviedo University, Asturias, Spain
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Jia XY, Wei K, Chen J, Xi LH, Kong XL, Wei Y, Wang L, Wang ZS, Liu YP, Liang LM, Xu DM. Association of plasma neutrophil gelatinase-associated lipocalin with parameters of CKD-MBD in maintenance hemodialysis patients. J Bone Miner Metab 2021; 39:1058-1065. [PMID: 34392464 DOI: 10.1007/s00774-021-01248-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 06/30/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Neutrophil gelatinase-associated lipocalin (NGAL) is not only a biomarker of kidney injury but also a bone-derived factor involved in metabolism. We aimed to explore relationships between plasma NGAL and chronic kidney disease-mineral bone disorder (CKD-MBD) parameters in maintenance hemodialysis (MHD) patients. MATERIALS AND METHODS First, a cross sectional observational study, including 105 MHD patients, was conducted to explore relationships between plasma NGAL levels and CKD-MBD parameters. Second, impact of parathyroidectomy and auto-transplantation (PTX + AT) on plasma NGAL was investigated in 12 MHD patients with severe secondary hyperparathyroidism (SHPT). RESULTS According to Spearman correlation analysis, plasma NGAL levels were positively correlated with female (r = 0.243, P = 0.012), vintage (r = 0.290, P = 0.003), Klotho (r = 0.234, P = 0.016), calcium(Ca) (r = 0.332, P = 0.001), alkaline phosphatase (ALP) (r = 0.401, P < 0.001) and intact parathyroid hormone (iPTH) (r = 0.256, P = 0.008); while inversely correlated with albumin(Alb) (r = - 0.201, P = 0.039). After adjusting for age, sex, vintage, Alb and all parameters of CKD-MBD(Ca, P, lg(ALP), lg(iPTH), Klotho and fibroblast growth factor 23(FGF23)), lg(NGAL) were positively correlated with Ca (r = 0.481, P < 0.001), P (r = 0.336, P = 0.037), lg(ALP) (r = 0.646, P < 0.001) in Partial correlation analysis; further multiple linear regression analysis showed same positive associations between lg(NGAL) and Ca (β = 0.330, P = 0.002), P (β = 0.218, P = 0.037), lg(ALP) (β = 0.671, P < 0.001). During the 4-7 days after PTX + AT, plasma NGAL decreased from 715.84 (578.73, 988.14) to 688.42 (660.00, 760.26) ng/mL (P = 0.071), Klotho increased from 496.45 (341.73, 848.30) to 1138.25 (593.87, 2009.27) pg/mL (P = 0.099). CONCLUSION Plasma NGAL levels were positively associated with ALP in MHD patients; and downtrends were shown after PTX + AT in patients with severe SHPT. These findings suggest that NGAL is a participant in CKD-MBD under MHD condition.
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Affiliation(s)
- Xiao-Yan Jia
- Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, No.16766, Jingshi Road, Jinan, 250014, China
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Provincial Insititute of Nephrology, Jinan, China
| | - Kai Wei
- Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, No.16766, Jingshi Road, Jinan, 250014, China
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Provincial Insititute of Nephrology, Jinan, China
| | - Juan Chen
- Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, No.16766, Jingshi Road, Jinan, 250014, China
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Provincial Insititute of Nephrology, Jinan, China
| | - Lin-He Xi
- Department of Plastic and Reconstructive Surgery, Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Xiang-Lei Kong
- Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, No.16766, Jingshi Road, Jinan, 250014, China
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Provincial Insititute of Nephrology, Jinan, China
| | - Yong Wei
- Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, No.16766, Jingshi Road, Jinan, 250014, China
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Provincial Insititute of Nephrology, Jinan, China
| | - Li Wang
- Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, No.16766, Jingshi Road, Jinan, 250014, China
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Provincial Insititute of Nephrology, Jinan, China
| | - Zun-Song Wang
- Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, No.16766, Jingshi Road, Jinan, 250014, China
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Provincial Insititute of Nephrology, Jinan, China
| | - Yi-Peng Liu
- Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, No.16766, Jingshi Road, Jinan, 250014, China
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Provincial Insititute of Nephrology, Jinan, China
| | - Li-Ming Liang
- Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, No.16766, Jingshi Road, Jinan, 250014, China
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Jinan, China
- Shandong Provincial Insititute of Nephrology, Jinan, China
| | - Dong-Mei Xu
- Department of Nephrology, The First Affiliated Hospital of Shandong First Medical University, No.16766, Jingshi Road, Jinan, 250014, China.
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Jinan, China.
- Shandong Provincial Insititute of Nephrology, Jinan, China.
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Lower Geriatric Nutritional Risk Index ( GNRI) Is Associated with Higher Risk of Fractures in Patients Undergoing Hemodialysis. Nutrients 2021; 13:nu13082847. [PMID: 34445007 PMCID: PMC8400213 DOI: 10.3390/nu13082847] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/14/2021] [Accepted: 08/17/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Although malnutrition and bone fracture are both major complications in patients undergoing hemodialysis, their association has not been clarified. The aim of our study was to clarify the association between the geriatric nutritional risk index (GNRI), an indicator of nutritional status, and the incidence of bone fractures in patients undergoing hemodialysis. Methods: We included 1342 registered patients undergoing hemodialysis and performed a post hoc analysis. We divided patients into the high GNRI group (≥92), considered to have a low risk of malnutrition, and the low GNRI group (<92), considered to have a high risk of malnutrition. Fracture-free survival in the low and high GNRI groups was evaluated by the Kaplan–Meier method. Cox proportional hazards models were used to identify the risk factors for fractures requiring hospitalization. All results were stratified by sex. Results: New bone fractures developed in 108 (8.0%) patients in 5 years of follow-up. Bone fractures occurred more frequently in the low GNRI group compared with the high GNRI group (HR: 3.51, 95% CI: 1.91–6.42, p < 0.01 in males; HR: 2.47, 95% CI: 1.52–4.03, p < 0.01 in females). A low GNRI was significantly associated with an increased incidence of bone fractures, even after adjustment for covariates. However, the serum levels of calcium, phosphate, parathyroid hormone, and alkaline phosphatase were not associated with the incidence of bone fractures. Conclusions: A low GNRI is an independent risk factor for bone fractures in patients undergoing hemodialysis. Early intervention for the low GNRI group may be important in preventing the occurrence of fractures.
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Differentiating the causes of adynamic bone in advanced chronic kidney disease informs osteoporosis treatment. Kidney Int 2021; 100:546-558. [PMID: 34102219 DOI: 10.1016/j.kint.2021.04.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022]
Abstract
Patients with chronic kidney disease (CKD) have an increased fracture risk because of impaired bone quality and quantity. Low bone mineral density predicts fracture risk in all CKD stages, including advanced CKD (CKD G4-5D). Pharmacological therapy improves bone mineral density and reduces fracture risk in moderate CKD. Its efficacy in advanced CKD remains to be determined, although pilot studies suggest a positive effect on bone mineral density. Currently, antiresorptive agents are the most commonly prescribed drugs for the prevention and therapy of osteoporosis. Their use in advanced CKD has been limited by the lack of large clinical trials and fear of causing kidney dysfunction and adynamic bone disease. In recent decades, adynamic bone disease has evolved as the most predominant form of renal osteodystrophy, commonly associated with poor outcomes, including premature mortality and progression of vascular calcification. Evolving evidence indicates that reduction of bone turnover by parathyroidectomy or pharmacological therapies, such as calcimimetics and antiresorptive agents, are not associated with premature mortality or accelerated vascular calcification in CKD. In contrast, chronic inflammation, oxidative stress, malnutrition, and diabetes can induce low bone turnover and associate with poor prognosis. Thus, the conditions causing suppression of bone turnover rather than the low bone turnover per se may account for the perceived association with outcomes. Anabolic treatment, in contrast, has been suggested to improve turnover and bone mass in patients with advanced CKD and low bone turnover; however, uncertainty about safety even exceeds that of antiresorptive agents. Here, we critically review the pathophysiological concept of adynamic bone disease and discuss the effect of low bone turnover on the safety and efficacy of anti-osteoporosis pharmacotherapy in advanced CKD.
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26
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Kang SH, Do JY, Kim JC. Association Between Alkaline Phosphatase and Muscle Mass, Strength, or Physical Performance in Patients on Maintenance Hemodialysis. Front Med (Lausanne) 2021; 8:657957. [PMID: 34079810 PMCID: PMC8165237 DOI: 10.3389/fmed.2021.657957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 04/21/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: Alkaline phosphatase (ALP) is an indicator for checking liver or bone disorders, but recent studies have shown the possibility of an additive indicator beyond the simple mineral-bone status in dialysis patients. The aim of the study was to evaluate the ALP level and various indicators for malnutrition, physical performance, or hospitalization in patients on hemodialysis (HD). Methods: This study was an observational study (n = 84). We included all patients undergoing HD with the following criteria: age ≥ 20 years, duration of dialysis ≥ 6 months, ability to ambulate without an assistive device, ability to communicate with the interviewer, and no hospitalization within the last 3 months before enrollment. Furthermore, none of the patients had liver disease. We recommended abstinence of alcohol for ≥ 1 month for the duration of the study. The patients were divided into tertiles based on the ALP level. Muscle mass [appendicular muscle mass index using dual-energy X-ray absorptiometry (ASM/Ht2), thigh muscle area index using computed tomography (TMA/Ht2)], strength [handgrip strength (HGS)], and physical performance [gait speed (GS), sit-to-stand for 30-s test (STS30), 6-min walk test (6-MWT), or Short Physical Performance Battery test (SPPB)] were evaluated. The number of hospitalizations was also evaluated. Results: The ALP level in the low, middle, and high tertiles was 50.5 ± 7.5, 69.8 ± 5.4, and 113.3 ± 47.3 IU/l, respectively. The high tertile group showed the poorest trends in ASM/Ht2, TMA/Ht2, HGS, GS, STS30, and 6-MWT compared to the other tertile groups. Logistic regression analysis showed that the high tertile group for low HGS, low GS, or low SPPB had a higher odds ratio compared to the other tertiles. Subgroup analyses according to age, sex and diabetes mellitus showed similar trends as in the total cohort. Hospitalization-free survival rates after 300 days in the high tertile and the other tertiles were 53.8 and 77.2%, respectively (P = 0.105). Conclusion: The present study demonstrated that ALP is associated with muscle mass, strength, and physical performance in patients on maintenance HD. In addition, the trend showed better hospitalization-free survival in the low or middle tertiles than in the high tertile. ALP can be considered as a simple and useful indicator to detect malnutrition, physical performance, or hospitalization in patients on HD.
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Affiliation(s)
- Seok Hui Kang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, South Korea
| | - Jun Young Do
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, South Korea
| | - Jun Chul Kim
- Division of Nephrology, Department of Internal Medicine, CHA Gumi Medical Center, CHA University, Gumi, South Korea
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Evenepoel P, Cunningham J, Ferrari S, Haarhaus M, Javaid MK, Lafage-Proust MH, Prieto-Alhambra D, Torres PU, Cannata-Andia J. European Consensus Statement on the diagnosis and management of osteoporosis in chronic kidney disease stages G4-G5D. Nephrol Dial Transplant 2021; 36:42-59. [PMID: 33098421 DOI: 10.1093/ndt/gfaa192] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Indexed: 12/16/2022] Open
Abstract
Controlling the excessive fracture burden in patients with chronic kidney disease (CKD) Stages G4-G5D remains an impressive challenge. The reasons are 2-fold. First, the pathophysiology of bone fragility in patients with CKD G4-G5D is complex and multifaceted, comprising a mixture of age-related (primary male/postmenopausal), drug-induced and CKD-related bone abnormalities. Second, our current armamentarium of osteoporosis medications has not been developed for, or adequately studied in patients with CKD G4-G5D, partly related to difficulties in diagnosing osteoporosis in this specific setting and fear of complications. Doubts about the optimal diagnostic and therapeutic approach fuel inertia in daily clinical practice. The scope of the present consensus paper is to review and update the assessment and diagnosis of osteoporosis in patients with CKD G4-G5D and to discuss the therapeutic interventions available and the manner in which these can be used to develop management strategies for the prevention of fragility fracture. As such, it aims to stimulate a cohesive approach to the management of osteoporosis in patients with CKD G4-G5D to replace current variations in care and treatment nihilism.
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Affiliation(s)
- Pieter Evenepoel
- Department of Nephrology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - John Cunningham
- Centre for Nephrology, UCL Medical School, Royal Free Campus, London, UK
| | - Serge Ferrari
- Service of Bone Diseases, Geneva University Hospital, Switzerland
| | - Mathias Haarhaus
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Diaverum Sweden, Stockholm, Sweden
| | | | | | | | - Pablo Ureña Torres
- Department of Dialysis, AURA Nord Saint Ouen, Saint Ouen, France.,Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Jorge Cannata-Andia
- Bone and Mineral Research Unit (ISPA) (REDinREN), Hospital Universitario Central Asturias, Oviedo University, Spain
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Xie L, Hu X, Li W, Ouyang Z. A retrospective study of end-stage kidney disease patients on maintenance hemodialysis with renal osteodystrophy-associated fragility fractures. BMC Nephrol 2021; 22:23. [PMID: 33430788 PMCID: PMC7802139 DOI: 10.1186/s12882-020-02224-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/23/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Nephropathy associated metabolic disorder induces high incidence of fragility fracture in end-stage renal disease (ESRD) patients. As the risk factors and prognosis of fragility fracture in ESRD patients are unclear, more research is needed. This study aimed to evaluate various risk factors for ESRD-related fragility fractures, explore factors affecting the prognosis of patients with such fractures, and provide information for prevention and treatment of renal osteopathy to improve the prognosis of patients. METHODS In this retrospective case-control study, the case notes of 521 ESRD patients who received maintenance dialysis for at least 3 months were examined. Finally, 44 patients diagnosed with fragility fractures were assigned to the fragility fracture (FF) group and 192 patients were included in the control group (CG). Demographic information, underlying diseases, nutritional, bone metabolism, and renal function parameters, along with the number and causes of any deaths, were recorded for multiple statistical analysis. RESULTS The FF group had increased incidences of essential hypertension and diabetes mellitus and higher serum calcium, corrected calcium, alkaline phosphatase, and hemoglobin levels. Immunoreactive parathyroid hormone (iPTH), total cholesterol (TC), and low density lipoprotein (LDL) levels were higher in the CG. Multivariate Cox regression analysis revealed that fragility fracture was an independent risk factor for all-cause mortality in ESRD patients (P < .001, RR: 4.877, 95% CI: 2.367-10.013). CONCLUSIONS Essential hypertension and diabetes, high serum calcium and alkaline phosphatase levels, and reduced iPTH levels were risk factors for fragility fracture in ESRD patients. Maintaining iPTH and serum TC levels may protect against fragility fractures in them. Fragility fractures may yield poor prognosis and shorter lifespan. The presence of fragility fracture was an independent predictor of all-cause death in ESRD patients.
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Affiliation(s)
- Lihua Xie
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, P.R. China
| | - Xuantao Hu
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Changsha, 410011, Hunan, P.R. China
| | - Wenzhao Li
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Changsha, 410011, Hunan, P.R. China.
| | - Zhengxiao Ouyang
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Changsha, 410011, Hunan, P.R. China.
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Dusceac R, Niculescu DA, Dobre R, Sorohan MC, Caragheorgheopol A, Tacu C, David C, Poiana C. Bone turnover correlates with bone quantity but not bone microarchitecture in chronic hemodialysis. J Bone Miner Metab 2020; 38:597-604. [PMID: 32144577 DOI: 10.1007/s00774-020-01094-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION In chronic hemodialysis, high-turnover bone disease was associated with decreased bone mineral density (BMD), poor bone quality (chemical and structural), and increased fracture risk. Our aim was to correlate bone turnover markers (BTMs) with bone microarchitecture measured by trabecular bone score (TBS) before and after correction for BMD. MATERIALS AND METHODS We measured lumbar spine (LS), femoral neck, and 1/3 radius BMD and LS TBS by dual X-ray absorptiometry in 81 patients on permanent hemodialysis. Bone turnover was assessed using serum parathyroid hormone, osteocalcin, C-terminal crosslaps of type 1 collagen, procollagen 1 N-terminal propeptide (P1NP), and alkaline phosphatase (ALP). No patient had any partial or total parathyroidectomy and no previous or current treatment with anti-osteoporotic drugs. RESULTS All BTMs correlated significantly with each other. Univariate regressions showed significant negative correlations between BTMs and BMD (best r = - 0.53, between P1NP and 1/3 radius Z-score) or BTMs and TBS (best r = - 0.27, p < 0.05 between ALP and TBS T-score). TBS correlated significantly with BMD at all three sites (best r = 0.5, between LS BMD and TBS T-score). Multivariate regression showed that TBS, crude or adjusted, correlated with LS BMD. No model retained any of the BTMs as independent variables due to the better prediction of BMD and multicollinearity. CONCLUSION We showed a progressively impaired bone microarchitecture with increasing bone turnover in chronic hemodialysis. However, this correlation is no longer present when controlling for bone mass. This suggests that impaired bone microarchitecture and increased fracture risk are dependent upon factors other than high bone turnover.
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Affiliation(s)
- Roxana Dusceac
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania.
| | - Ramona Dobre
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Madalina Cristina Sorohan
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Andra Caragheorgheopol
- Research Laboratory, C. I. Parhon National Institute of Endocrinology, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
| | - Catalin Tacu
- Diaverum Dialysis Center, 2N Industiilor blvd, 032895, Bucharest, Romania
| | - Cristiana David
- Department of Nephrology, Carol Davila University of Medicine and Pharmacy, 13 Vitan-Barzesti rd, 042122, Bucharest, Romania
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 34-38 Aviatorilor blvd, 011863, Bucharest, Romania
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30
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Chen Z, Zhang X, Han F, Xie X, Hua Z, Huang X, Lindholm B, Haarhaus M, Stenvinkel P, Qureshi AR, Chen J. High alkaline phosphatase and low intact parathyroid hormone associate with worse clinical outcome in peritoneal dialysis patients. Perit Dial Int 2020; 41:236-243. [PMID: 32363998 DOI: 10.1177/0896860820918131] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Alkaline phosphatase (ALP) is used as a biomarker to monitor the chronic kidney disease-mineral bone disorder (CKD-MBD) and high levels of parathyroid hormone (PTH) that were reported to be related to increased mortality in CKD patients. Therefore, we conducted this longitudinal cohort study to evaluate the relations between ALP and intact PTH (iPTH) and the associations with all-cause and cardiovascular mortality in peritoneal dialysis (PD) patients. METHODS In 1276 incident PD patients (median age 50 years, 56% males), baseline serum ALP, iPTH, and metabolic biomarkers potentially linked to CKD-MBD were analyzed in relation to mortality during follow-up period of up to 60 months. All-cause and cardiovascular mortality risk of ALP and iPTH were analyzed with competing-risks regression models with transplantation as competing risk adjusting for all covariates. RESULTS After adjustments for confounders by logistic regression model, older age, higher change level to levels of iPTH, S-albumin, calcium, alanine transaminase (ALT), and lower level of phosphorus were associated with higher ALP level (>79 U/L), and female gender, non-diabetes mellitus, younger age, lower calcium, higher ALT, total bilirubin, phosphorus, and ALP were associated with higher iPTH level (>300 pg/mL). During 60 months (median 44 months) of follow-up, the all-cause mortality rate was 16%, and 91 (46%) of the 199 deaths were caused by cardiovascular disease. In competing-risks regression analysis, "high ALP + low iPTH" was independently associated with all-cause and cardiovascular mortality after adjustment for age, gender, presence of diabetes, and cardiovascular disease, the calendar year of recruitment and vitamin D therapy in PD patients. The subhazard ratio (sHR) of group "high ALP + low iPTH" was 1.96 times and 3.35 times higher than sHR of group "low ALP + high iPTH" for all-cause mortality and cardiovascular mortality, respectively. CONCLUSIONS The combination of high ALP and low iPTH was independently associated with increased all-cause and cardiovascular mortality in PD patients, suggesting that ALP and iPTH have the potential to predict clinical outcomes and might be useful risk assessment tools in PD patients. Further studies exploring the observed association between combination of ALP with iPTH and mortality are warranted.
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Affiliation(s)
- Zhimin Chen
- Kidney Disease Center, 1st Affiliated Hospital College of Medicine, 12377Zhejiang University, Hangzhou, China.,Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Xiaohui Zhang
- Kidney Disease Center, 1st Affiliated Hospital College of Medicine, 12377Zhejiang University, Hangzhou, China
| | - Fei Han
- Kidney Disease Center, 1st Affiliated Hospital College of Medicine, 12377Zhejiang University, Hangzhou, China
| | - Xishao Xie
- Kidney Disease Center, 1st Affiliated Hospital College of Medicine, 12377Zhejiang University, Hangzhou, China
| | - Zhou Hua
- Kidney Disease Center, 1st Affiliated Hospital College of Medicine, 12377Zhejiang University, Hangzhou, China.,Renal Department, People's Hospital of Suichang County, Lishui, China
| | - Xiaohan Huang
- Kidney Disease Center, 1st Affiliated Hospital College of Medicine, 12377Zhejiang University, Hangzhou, China
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Mathias Haarhaus
- Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Division of Renal Medicine and Baxter Novum, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Jianghua Chen
- Kidney Disease Center, 1st Affiliated Hospital College of Medicine, 12377Zhejiang University, Hangzhou, China
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Efficacy of Ultrasound-guided Radiofrequency Ablation of Parathyroid Hyperplasia: Single Session vs. Two-Session for Effect on Hypocalcemia. Sci Rep 2020; 10:6206. [PMID: 32277134 PMCID: PMC7148367 DOI: 10.1038/s41598-020-63299-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/28/2020] [Indexed: 12/18/2022] Open
Abstract
To evaluate safety and efficacy of one- vs. two-session radiofrequency ablation (RFA) of parathyroid hyperplasia for patients with secondary hyperparathyroidism (SHPT) and to compare the outcome of both methods on hypocalcemia. Patients with secondary hyperparathyroidism underwent ultrasound guided RFA of parathyroid hyperplasia. Patients were alternately assigned to either group 1 (n = 28) with RFA of all 4 glands in one session or group 2 (n = 28) with RFA of 2 glands in a first session and other 2 glands in a second session. Serum parathyroid hormone (PTH), calcium, phosphorus and alkaline phosphatase (ALP) values were measured at a series of time points after RFA. RFA parameters, including operation duration and ablation time and hospitalization length and cost, were compared between the two groups. Mean PTH decreased in group 1 from 1865.18 ± 828.93 pg/ml to 145.72 ± 119.27 pg/ml at 1 day after RFA and in group 2 from 2256.64 ± 1021.72 pg/ml to 1388.13 ± 890.15 pg/ml at 1 day after first RFA and to 137.26 ± 107.12 pg/ml at 1 day after second RFA. Group 1's calcium level decreased to 1.79 ± 0.31 mmol/L at day 1 after RFA and group 2 decreased to 1.89 ± 0.26 mmol/L at day 1 after second session RFA (P < 0.05). Multivariate analysis showed that hypocalcemia was related to serum ALP. Patients with ALP ≥ 566 U/L had lower calcium compared to patients with ALP < 566 U/L up to a month after RFA (P < 0.05). Group 1's RFA time and hospitalization were shorter and had lower cost compared with Group 2. US-guided RFA of parathyroid hyperplasia is a safe and effective method for treating secondary hyperparathyroidism. Single-session RFA was more cost-effective and resulted in a shorter hospital stay compared to two sessions. However, patients with two-session RFA had less hypocalcemia, especially those with high ALP.
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32
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Cohen-Solal M, Funck-Brentano T, Ureña Torres P. Bone fragility in patients with chronic kidney disease. Endocr Connect 2020; 9:R93-R101. [PMID: 32168473 PMCID: PMC7219138 DOI: 10.1530/ec-20-0039] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/13/2020] [Indexed: 11/23/2022]
Abstract
Mineral and bone diseases (MBD) are predominant in patients with chronic kidney disease (CKD) and lead to several bone manifestations, from pain to skeletal fractures. Cumulative traditional clinical risk factors, such as age and gender, in addition to those related to CKD, enhance the risk of comorbidity and mortality related to fractures. Despite great advances in understanding MBD in CKD, clinical and biological targets are lacking, which leads to under-management of fractures. Optimal PTH control results in a net improvement in defining the levels of bone remodeling. In addition, circulating biomarkers such as bone-specific alkaline phosphatase and cross-linked collagen type I peptide will also provide additional information about remodeling rate, bone mineralization and the evaluation of fracture risk. Imaging techniques identify patients at risk by measurement of bone mineral density by DEXA or by high peripheral QCT, which allow the discrimination of trabecular and cortical bone. Here, we have reviewed the literature related to epidemiology and the pathophysiological role of mineral and biochemical factors involved in CKD-MBD with a special focus on fracture risk. We also provide an algorithm that could be used for the management of bone diseases and to guide treatment decisions. Finally, the combined expertise of clinicians from various disciplines is crucial for the best prevention of fractures.
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Affiliation(s)
- Martine Cohen-Solal
- Department of Skeletal Diseases, INSERM U1132 & Université de Paris, Hôpital Lariboisière, Paris, France
- Correspondence should be addressed to M Cohen-Solal:
| | - Thomas Funck-Brentano
- Department of Skeletal Diseases, INSERM U1132 & Université de Paris, Hôpital Lariboisière, Paris, France
| | - Pablo Ureña Torres
- AURA Nord, Saint Ouen, France
- Department of Renal Physiology, Necker Hospital, Université de Paris, Paris, France
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Zhang Y, Lu Y, Feng S, Zhan Z, Shen H. Evaluation of laboratory parameters and symptoms after parathyroidectomy in dialysis patients with secondary hyperparathyroidism. Ren Fail 2020; 41:921-929. [PMID: 31573378 PMCID: PMC6781481 DOI: 10.1080/0886022x.2019.1666724] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objectives: The aim of the study was to evaluate the laboratory parameters and symptoms after parathyroidectomy (PTX) in dialysis patients with secondary hyperparathyroidism (SHPT), and to briefly analyze the different therapeutic effects of the three surgical methods. Methods: A total of 182 dialysis patients who underwent PTX between February 2012 and January 2018 at the Second Affiliated Hospital of Soochow University were included in this study and followed for 12 months. Laboratory parameters such as calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), and intact parathyroid hormone (iPTH) were measured before and after operation. According to the follow-up time and type of operation, we calculated the percentage of laboratory indicators reaching the recommended range of the KDIGO guidelines after surgery. We also analyzed the improvement of bone pain and pruritus, as well as surgical complications. Results: After the operation, the levels of iPTH, Ca, and P decreased significantly at each time point. ALP increased at the first postoperative week and gradually decreased to normal range after 3 months. Symptoms, such as bone pain and pruritus, were significantly relieved. According to the follow-up time and three surgical methods (subtotal parathyroidectomy, total parathyroidectomy, total parathyroidectomy plus autologous transplantation), we found that the ratio of each laboratory parameter reaching the recommended range of KDIGO guidelines was significantly different. Conclusion: PTX is a safe and effective therapy for treating SHPT that is refractory to medical therapies and accompanied by related signs and symptoms in dialysis patients. All three operative techniques were effective in controlling SHPT.
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Affiliation(s)
- Yi Zhang
- Department of Nephrology, The Second Affiliated Hospital of Soochow University , Suzhou , China
| | - Ying Lu
- Department of Nephrology, The Second Affiliated Hospital of Soochow University , Suzhou , China
| | - Sheng Feng
- Department of Nephrology, The Second Affiliated Hospital of Soochow University , Suzhou , China
| | - Zhoubing Zhan
- Department of Nephrology, The Second Affiliated Hospital of Soochow University , Suzhou , China
| | - Huaying Shen
- Department of Nephrology, The Second Affiliated Hospital of Soochow University , Suzhou , China
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Beberashvili I, Samogalska O, Azar A, Stav K, Efrati S. Nutritional Status and Mortality Predictability for Time-Varying Serum Alkaline Phosphatase in Hemodialysis Patients: A Longitudinal Study. J Ren Nutr 2020; 30:452-461. [PMID: 31980325 DOI: 10.1053/j.jrn.2019.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 10/06/2019] [Accepted: 10/13/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Higher serum alkaline phosphatase (sALP) levels associate with a poor prognosis in maintenance hemodialysis patients. However, little is known about the meaning of lower sALP in this population. We hypothesized that lower sALP concentrations may express nutritional status and survival accordingly. METHODS A retrospective, longitudinal cohort study of a clinical database containing the medical records of 554 patients (367 men and 187 women, mean age 67.6 ± 14.2 years) receiving maintenance hemodialysis from November 2007 to July 2018 in a single center was conducted. sALP, nutritional, bone turnover, and inflammatory marker levels were recorded at 0, 6, 12, 18, 24, 30,and 36 months followed by 58 additional months of clinical observations. RESULTS The median sALP level was 90.0 (71.0-125.8) U/L. In a linear mixed effects model adjusted for baseline demographics and clinical parameters, each 1.0 U/L increase above the mean sALP at baseline was associated with 0.7% slower rate of decline in geriatric nutritional risk index per 3 years (P = .02 for sALP × time interaction). sALP remained associated with the rate of change in geriatric nutritional risk index, even after controlling for C-reactive protein and intact parathyroid hormone levels. For each 1.0 U/L increase in sALP over time, the fully adjusted all-cause mortality hazard ratio using Cox models with the time-varying risk effect was 0.996 (95% confidence interval 0.993-1.000, P = .04). CONCLUSIONS Increasing longitudinal levels of sALP associate with improved nutritional status and lower mortality rates. sALP can be used as an integrated marker, combining the properties of the nutritional marker, the marker of mineral-bone disease and inflammation, according to its levels.
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Affiliation(s)
- Ilia Beberashvili
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Oleksandra Samogalska
- Department of Internal Medicine "E", Assaf Harofeh Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ada Azar
- Nutrition Department, Assaf Harofeh Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kobi Stav
- Urology Department, Assaf Harofeh Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Efrati
- Nephrology Division, Assaf Harofeh Medical Center, Zerifin, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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USTA M, ERSOY A, ERSOY C, GÖKSEL G. Chronic kidney disease presenting with bilateral spontaneous femoral neck fracture: A case report. TURKISH JOURNAL OF INTERNAL MEDICINE 2019. [DOI: 10.46310/tjim.632048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Leonard MB, Wehrli FW, Ziolkowski SL, Billig E, Long J, Nickolas TL, Magland JF, Nihtianova S, Zemel BS, Herskovitz R, Rajapakse CS. A multi-imaging modality study of bone density, bone structure and the muscle - bone unit in end-stage renal disease. Bone 2019; 127:271-279. [PMID: 31158505 DOI: 10.1016/j.bone.2019.05.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 01/10/2023]
Abstract
End stage renal disease (ESRD) is associated with sarcopenia and skeletal fragility. The objectives of this cross-sectional study were to (1) characterize body composition, bone mineral density (BMD) and bone structure in hemodialysis patients compared with controls, (2) assess whether DXA areal BMD (aBMD) correlates with peripheral quantitative CT (pQCT) measures of volumetric BMD (vBMD), cortical dimensions and MRI measures of trabecular microarchitecture, and (3) determine the magnitude of bone deficits in ESRD after adjustment for muscle mass. Thirty ESRD participants, ages 25 to 64 years, were compared with 403 controls for DXA and pQCT outcomes and 104 controls for MRI outcomes; results were expressed as race- and sex- specific Z-scores relative to age. DXA appendicular lean mass index (ALMI kg/m2) and total hip, femoral neck, ultradistal and 1/3rd radius aBMD were significantly lower in ESRD, vs. controls (all p < 0.01). pQCT trabecular vBMD (p < 0.01), cortical vBMD (p < 0.001) and cortical thickness (due to a greater endosteal circumference, p < 0.02) and MRI measures of trabecular number, trabecular thickness, and whole bone stiffness were lower (all p < 0.01) in ESRD, vs. controls. ALMI was positively associated with total hip, femoral neck, ultradistal radius and 1/3rd radius aBMD and with tibia cortical thickness (R = 0.46 to 0.64). Adjustment for ALMI significantly attenuated bone deficits at these sites: e.g. mean femoral neck aBMD was 0.79 SD lower in ESRD, compared with controls and this was attenuated to 0.33 with adjustment for ALMI. In multivariate models within the dialysis participants, pQCT trabecular vBMD and cortical area Z-scores were significant and independently (all p < 0.02) associated with DXA femoral neck, total hip, and ultradistal radius aBMD Z-scores. Cortical vBMD (p = 0.01) and cortical area (p < 0.001) Z-scores were significantly and independently associated with 1/3rd radius areal aBMD Z-scores (R2 = 0.62). These data demonstrate that DXA aBMD captures deficits in trabecular and cortical vBMD and cortical area. The strong associations with ALMI, as an index of skeletal muscle, highlight the importance of considering the role of sarcopenia in skeletal fragility in patients with ESRD.
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Affiliation(s)
- Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America; Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America.
| | - Felix W Wehrli
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Susan L Ziolkowski
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Erica Billig
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jin Long
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Thomas L Nickolas
- Department of Medicine, Columbia University, New York, NY, United States of America
| | - Jeremy F Magland
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Snejana Nihtianova
- Susanne M. Glasscock School of Continuing Studies, Rice University, Houston, TX, United States of America
| | - Babette S Zemel
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Rita Herskovitz
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Chamith S Rajapakse
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States of America; Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States of America
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Bucharles SGE, Barreto FC, Riella MC. The impact of cinacalcet in the mineral metabolism markers of patients on dialysis with severe secondary hyperparathyroidism. J Bras Nefrol 2019; 41:336-344. [PMID: 31419274 PMCID: PMC6788853 DOI: 10.1590/2175-8239-jbn-2018-0219] [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: 01/11/2018] [Accepted: 04/24/2019] [Indexed: 11/22/2022] Open
Abstract
Introduction: Treating secondary hyperparathyroidism (SHPT), a common condition associated
with death in patients with chronic kidney disease, is a challenge for
nephrologists. Calcimimetics have allowed the introduction of drug therapies
no longer based on phosphate binders and active vitamin D. This study aimed
to assess the safety and effectiveness of cinacalcet in managing chronic
dialysis patients with severe SHPT. Methods: This retrospective study included 26 patients [age: 52 ± 12 years; 55%
females; time on dialysis: 54 (4-236) months] on hemodialysis (N = 18) or
peritoneal dialysis (N = 8) with severe SHPT (intact parathyroid hormone
(iPTH) level > 600 pg/mL) and hyperphosphatemia and/or persistent
hypercalcemia treated with cinacalcet. The patients were followed for 12
months. Their serum calcium (Ca), phosphorus (P), alkaline phosphatase
(ALP), and iPTH levels were measured at baseline and on days 30, 60, 90,
180, and 365. Results: Patients with hyperphosphatemia (57.7%), hypercalcemia (23%), or both (19.3%)
with iPTH > 600 pg/mL were prescribed cinacalcet. At the end of the
study, decreases were observed in iPTH (1348 ± 422 vs. 440 ±
210 pg/mL; p < 0.001), Ca (9.5 ± 1.0 vs. 9.1
± 0.6 mg/dl; p = 0.004), P (6.0 ± 1.3 vs. 4.9
± 1.1 mg/dl; p < 0.001), and ALP (202 ±
135 vs. 155 ± 109 IU/L; p = 0.006) levels. Adverse
events included hypocalcemia (26%) and digestive problems (23%). At the end
of the study, 73% of the patients were on active vitamin D and cinacalcet.
Three (11.5%) patients on peritoneal dialysis did not respond to therapy
with cinacalcet, and their iPTH levels were never below 800 pg/mL. Conclusion: Cinacalcet combined with traditional therapy proved safe and effective and
helped manage the mineral metabolism of patients with severe SHPT.
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Prasad B, Ferguson T, Tangri N, Ng CY, Nickolas TL. Association of Bone Mineral Density With Fractures Across the Spectrum of Chronic Kidney Disease: The Regina CKD-MBD Study. Can J Kidney Health Dis 2019; 6:2054358119870539. [PMID: 31467681 PMCID: PMC6704416 DOI: 10.1177/2054358119870539] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 07/01/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Recent studies have demonstrated that measurement of areal bone mineral density by dual-energy x-ray absorptiometry (DXA) predicts fractures in patients with chronic kidney disease (CKD). However, whether fracture risk prediction through bone mineral density (BMD) is enhanced due to the assessment of biochemical markers of chronic kidney disease and mineral and bone disease (CKD-MBD) or clinical risk factors is not clear. We hypothesized that in a select cohort of patients managed in a CKD clinic, that combining T-Scores with biochemical markers would optimize fracture discrimination than using DXA alone. Objective: To examine the relationships among BMD, biochemical markers of CKD-MBD, and fracture risk across Kidney Disease Improving Global Outcomes (KDIGO) glomerular filtration rate (GFR) categories G3a to G5. Design: Retrospective study. Setting: Patients were recruited from the multidisciplinary CKD clinic, Regina General Hospital, Canada. Patients: A total of 374 patients who received a DXA scan upon initial referral to Regina Multidisciplinary CKD Program from January 31, 2001 to January 31, 2010, were included in this study. The patients were followed for a total of 5 years. Methods: We conducted a retrospective review of 374 consecutive patients who underwent DXA imaging at the point of entry into our multidisciplinary CKD program. Areal BMD, T- and Z-Scores were obtained at the lumbar spine, total hip, mean of left and right femoral neck, and the one-third radius. We collected data on demographic, cross-sectional biochemical markers of mineral metabolism and fractures (identified through self-reported questionnaires, hospital electronic medical records, and physician billing records). We were able to gather data on 8/11 variables of Fracture Risk Assessment (FRAX) tool. Results: In our cohort, 14.3% of GFR categories G3a and G3b, 15.7% of GFR category G4, and 19.7% of GFR category G5 experienced a clinical fracture during the study period. On multivariate analysis, each decline of 1.0 SD in total hip BMD T-Score was associated with a significant increase in the risk of fracture (OR = 1.46, 95% confidence interval [CI], 1.12-1.89). Adding CKD-MBD markers and clinical risk factors did not further contribute to the model. Low BMD was the only independent risk factor for fracture in patients with CKD. Limitations: Self-reporting by patients and administrative records were used to identify fractures. We did not perform spine imaging to ascertain morphometric vertebral fractures. We were unable to gather all 11 variables of FRAX score and information on ethnicity. We were unable to capture site of fracture (hips, spine, etc) from billing records. Albumin excretion rates were not collected at baseline. Treatment of the underlying bone disease with pharmacotherapeutic agents may have attenuated patients’ fracture risk and thus underestimated the association between BMD and future fracture. Conclusions: Our findings confirm that BMD predicts fracture. The addition of cross-sectional CKD-MBD parameters and clinical risk factors to BMD did not add to fracture prediction. Prospective studies should investigate the utility of longitudinal biochemical markers on improving fracture risk assessment.
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Affiliation(s)
- Bhanu Prasad
- Section of Nephrology, Department of Medicine, Regina Qu'Appelle Health Region, SK, Canada
| | | | | | - Chee Yong Ng
- Department of Renal Medicine, Changi General Hospital, Singapore
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Sumida K, Molnar MZ, Potukuchi PK, Thomas F, Lu JL, Obi Y, Rhee CM, Streja E, Yamagata K, Kalantar-Zadeh K, Kovesdy CP. Prognostic significance of pre-end-stage renal disease serum alkaline phosphatase for post-end-stage renal disease mortality in late-stage chronic kidney disease patients transitioning to dialysis. Nephrol Dial Transplant 2019; 33:264-273. [PMID: 28064159 DOI: 10.1093/ndt/gfw412] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 10/25/2016] [Indexed: 12/20/2022] Open
Abstract
Background Higher serum alkaline phosphatase (ALP) levels have been associated with excess mortality in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) and end-stage renal disease (ESRD). However, little is known about the impact of late-stage NDD-CKD ALP levels on outcomes after dialysis initiation. Methods Among 17 732 US veterans who transitioned to dialysis between October 2007 and September 2011, we examined the association of serum ALP levels averaged over the last 6 months of the pre-ESRD transition period ('prelude period') with all-cause, cardiovascular and infection-related mortality following dialysis initiation, using Cox (for all-cause mortality) and competing risk (for cause-specific mortality) regressions adjusted for demographics, comorbidities, medications, estimated glomerular filtration rate and serum albumin levels over the 6-month prelude period, and vascular access type at dialysis initiation. Results During a median follow-up of 2.0 (interquartile range, 1.1-3.2) years following dialysis initiation, a total of 9196 all-cause deaths occurred. Higher ALP levels were incrementally associated with higher all-cause, cardiovascular and infection-related mortality. Compared with patients in the lowest ALP quartile (<66.0 U/L), those in the highest quartile (≥111.1 U/L) had multivariable-adjusted hazard/subhazard ratios (95% confidence interval) of 1.42 (1.34-1.51), 1.43 (1.09-1.88) and 1.39 (1.09-1.78) for all-cause, cardiovascular and infection-related mortality, respectively. The associations remained consistent in various subgroups and after further adjustment for liver enzymes, serum phosphorus and intact parathyroid hormone levels. Conclusions Higher pre-ESRD serum ALP levels are independently associated with higher post-ESRD mortality risk. Further studies are warranted to determine if interventions that lower pre-ESRD ALP levels reduce mortality in incident dialysis patients.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan.,Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z Molnar
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Praveen K Potukuchi
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jun Ling Lu
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
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Bone mineral density, bone turnover markers, and incident fractures in de novo kidney transplant recipients. Kidney Int 2019; 95:1461-1470. [DOI: 10.1016/j.kint.2018.12.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/12/2018] [Accepted: 12/13/2018] [Indexed: 11/20/2022]
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Wakasugi M, Kazama JJ, Kikuchi K, Yasuda K, Wada A, Hamano T, Masakane I, Narita I. Hemodialysis Product and Hip Fracture in Hemodialysis Patients: A Nationwide Cohort Study in Japan. Ther Apher Dial 2019; 23:507-517. [PMID: 30941869 DOI: 10.1111/1744-9987.12807] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/08/2019] [Accepted: 04/01/2019] [Indexed: 12/25/2022]
Abstract
Some have raised concerns that longer and more frequent hemodialysis (HD) would be associated with bone fractures due to excess phosphate removal. We examined the effects of hemodialysis product (HDP) on hip fracture incidence among Japanese HD patients using registry data of the Japanese Society for Dialysis Therapy. During a 1-year study period, 1411 hip fractures occurred among 135 984 patients. After adjusting for demographic and clinical factors, patients with a high HDP did not show a significant risk of hip fracture. Interestingly, patients with polycystic kidney disease had a lower risk of hip fracture. Our findings did not support the hypothesis that patients undergoing longer and more frequent HD would face a higher risk of hip fracture than those undergoing shorter and less frequent HD. Polycystic kidney disease was identified as a new significant factor for hip fracture; relative to glomerulonephritis, this condition was associated with a lower risk of hip fracture.
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Affiliation(s)
- Minako Wakasugi
- Division of Comprehensive Geriatrics in Community, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Junichiro J Kazama
- Departments of Nephrology and Hypertension, Fukushima Medical University, Fukushima, Japan
| | - Kan Kikuchi
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Kaoru Yasuda
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Atsushi Wada
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Takayuki Hamano
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Ikuto Masakane
- Committee of Renal Data Registry, Japanese Society for Dialysis Therapy, Tokyo, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
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Li C, Chen XM, Li Y, Zhou YL, Yan JN, Du XG. Factors and Outcome of Renal Osteodystrophy-Associated Initial Fragility Fracture in End-Stage Renal Disease Patients. KIDNEY DISEASES (BASEL, SWITZERLAND) 2019; 5:118-125. [PMID: 31019925 DOI: 10.1159/000494924] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 10/29/2018] [Indexed: 01/09/2023]
Abstract
Background Renal osteodystrophy has caused increased risk of fragility fracture in end-stage renal disease (ESRD) patients. However, risk factors and outcome of ESRD patients with fragility fracture remain uncharacterized. We aimed to assess these parameters in ESRD patients. Summary This retrospective case-control study analyzed 354 ESRD patients (initial fragility fracture [FF] group, n = 59; control group, n = 295). Pre-dialysis blood hemoglobin, serum albumin, lipid, calcium, phosphorus, alkaline phosphatase (ALP), and intact parathyroid hormone (iPTH) were collected. All procedures performed involving human participants were in accordance with the ethical standards of the institutional committee of The First Affiliated Hospital of Chongqing Medical University (IRB approval number 216-82), and informed consent was obtained from all participants. There were higher prevalence rates of primary hypertension and diabetes, higher serum ALP, corrected calcium, and lower serum total cholesterol, low-density lipoprotein, lipoprotein-α, and iPTH in the FF group. Fractures were more likely to occur in the higher level of corrected calcium as well as in the lower iPTH group. High corrected calcium (p = 0.010, OR = 11.308, 95% CI: 1.770-72.242) and serum ALP (p = 0.000, OR = 1.007, 95% CI: 1.004-1.011) were independent risk factors of fragility fracture. The incidence of all-cause mortality and cardiovascular (CV) events in ESRD patients with fragility fracture was higher than in those without fracture. Key Messages Patients with hypertension, diabetes, excessive suppression of PTH, and poor nutritional status are more prone to fractures. Serum corrected calcium and ALP were independent risk factors of fragility fracture. Patients with initial fragility fracture had more CV events and higher mortality.
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Affiliation(s)
- Cai Li
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xue-Mei Chen
- Emergency Department, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yin Li
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of Nephrology and Endocrinology, The People's Hospital of Tongliang District, Chongqing, China
| | - Yan-Lin Zhou
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jia-Ni Yan
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Gang Du
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Imbalance of osteoprotegerin/receptor activator of nuclear factor-κB ligand and oxidative stress in patients with obstructive sleep apnea-hypopnea syndrome. Chin Med J (Engl) 2019; 132:25-29. [PMID: 30628956 PMCID: PMC6629297 DOI: 10.1097/cm9.0000000000000046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with a higher prevalence of osteoporosis. However, the underlying mechanisms linking OSAHS with bone loss are still unclear. The aim of this study was to investigate the changes of receptor activator of nuclear factor-κB ligand (RANKL, an osteoclastogenesis-promoting factor) and osteoprotegerin (OPG, the decoy receptor for RANKL), oxidative stress and bone metabolism markers in OSAHS, in order to understand the potential mechanisms underlying bone loss in OSAHS patients. Methods: Forty-eight male patients with OSAHS, confirmed by polysomnography (PSG) study, were enrolled. Twenty male subjects who were confirmed as not having OSAHS served as the controls. The subjects’ bone mineral density (BMD) was assessed in lumbar spine and femoral neck using dual-energy X-ray absorptiometry (DXA). Blood samples were collected from all subjects for measurement of RANKL, OPG, the bone formation marker bone-specific alkaline phosphatase (BAP), the bone resorption marker tartrate-resistant acid phosphatase 5b (TRAP-5b), and total antioxidant capacity (TAOC). Results: The BMD and the T-score of the femoral neck and the lumbar spine were significantly lower in OSAHS patients as compared to the control group (P < 0.05). The serum level of BAP was significantly decreased in the OSAHS group (15.62 ± 5.20 μg/L) as compared to the control group (18.83 ± 5.50 μg/L, t = −2.235, P < 0.05), while the levels of TRAP-5b did not differ between the two groups (t = −1.447, P > 0.05). The serum level of OPG and the OPG/RANKL ratio were lower in the OSAHS group compared to the control group (both P < 0.05). TAOC level was also decreased significantly in the OSAHS group (P < 0.05). Correlation analysis showed that the TAOC level was positively correlated with BAP in the OSAHS group (r = 0.248, P = 0.04), but there were no correlations between TAOC and the BMD or the T-scores. The correlations between the level of OPG (or the OPG/RANKL ratio) and BMD or TAOC did not reach significance. Conclusion: In OSAHS patients, lower levels of TAOC were associated with decreased bone formation, suggesting a role of oxidative stress in bone loss, while the role of OPG/RANKL imbalance in bone metabolism in OSAHS needs further evaluation.
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van der Plas WY, Engelsman AF, Umakanthan M, Mather A, Sidhu SB, Delbridge LW, Pollock C, Waugh D, Sywak MS, Kruijff S. Treatment strategy of end stage renal disease-related hyperparathyroidism before, during, and after the era of calcimimetics. Surgery 2018; 165:135-141. [PMID: 30413324 DOI: 10.1016/j.surg.2018.04.092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/03/2018] [Accepted: 04/07/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Since 2004, end-stage renal disease related hyperparathyroidism patients are treated mainly with cinacalcet, which ceased to be subsidized through the Australian Pharmaceutical Benefits Scheme in 2015. We aimed to investigate the impact of these changes on the treatment strategy in the Australian end-stage renal disease population. METHODS The following groups were formed according to the date of parathyroidectomy: A, before calcimimetics; B, during the era of calcimimetics; and C, after cinacalcet removal by the Australian Pharmaceutical Benefits Scheme. The primary outcome was time from start of dialysis to parathyroidectomy. Regression analysis was used to examine trends in parathyroidectomy rates. RESULTS Between 1998 and 2016, 195 parathyroidectomies were performed. Median time to referral was 69 (33-123), 67 (31-110) and 44 (23-102) months for groups A, B, and C, respectively (P = .55). Parathyroidectomy rates increased throughout the years (CI 0.09-1.13, R2=0.27, P = .02). A trend toward a dip in parathyroidectomy rates was seen during the era of cinacalcet (P = .08). Median preoperative parathyroid hormone levels increased significantly (842 [418-1,553] versus 1,040 [564-1,810] versus 1,350 [1,037-1,923] pg/mL, for groups A, B, and C, respectively [P < .01]). CONCLUSION Parathyroidectomy rates seem to vary according to the availability of cinacalcet. This change in treatment strategy is accompanied with increased preoperative parathyroid hormone levels, reflecting delayed surgery and increased disease severity.
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Affiliation(s)
- Willemijn Y van der Plas
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Anton F Engelsman
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia; Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marille Umakanthan
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - Amanda Mather
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - Stan B Sidhu
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Leigh W Delbridge
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Carol Pollock
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - David Waugh
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - Mark S Sywak
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Schelto Kruijff
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
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Tan J, Li Y, Wu Z, Zhao J. Risk of hip fracture in patients on dialysis or kidney transplant: a meta-analysis of 14 cohort studies. Ther Clin Risk Manag 2018; 14:1747-1755. [PMID: 30288044 PMCID: PMC6159787 DOI: 10.2147/tcrm.s171970] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Purpose We aimed to conduct a meta-analysis of published cohort studies to evaluate the risk of hip fracture in patients undergoing dialysis or kidney transplantation (KT). Methods We identified relevant studies by searching PubMed, EMBASE and Google Scholar databases from their inception to December 31, 2017. Cohort studies evaluating risk of hip fractures in patients undergoing dialysis or KT were considered included. The methodological quality of the cohort studies was assessed using the modified Newcastle-Ottawa scale. Results In our meta-analysis of 14 retrospective cohort studies, a total of more than 1.5 million patients undergoing dialysis or KT were included, of whom more than 30,000 had hip fractures. After the merger, the proportion of hip fractures was 1.92% (95% CI, 1.38%−2.46%) with significant heterogeneity (I2=99.9%, P=0.000) in all patients, and the incidence rate of hip fractures (per 1,000 person-years) was 8.95 (95% CI, 4.05–13.85) with significant heterogeneity (I2=99.9%, P=0.000). The pooled relative risks (RR) value for dialysis patients compared with the general population were 6.35 (95% CI, 4.53–8.88) for male and 5.57 (95% CI, 4.44–6.99) for female. The pooled RR value for hemodialysis (HD) patients compared with peritoneal dialysis (PD) patients was 1.39 (95% CI, 1.13–1.70) with no heterogeneity (I2=0.0%, P=0.763). Conclusion In conclusion, the present meta-analysis reveals that about 2% of dialysis or KT patients go on to sustain a hip fracture during follow-up, with the overall hip fracture incidence rates being 8.95 per 1,000 person-years. The overall risk of hip fracture was more than 5-fold higher in dialysis patients than in the general population. Among patients on PD, HD, and KT, HD and KT patients had the highest and the lowest risk of hip fractures, respectively.
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Affiliation(s)
- Jiachang Tan
- Department of Bone and Soft Tissue Surgery, Affiliated Tumor Hospital, Guangxi Medical University, Nanning 530021, People's Republic of China
| | - Yuping Li
- The First Clinical Medical College, Guangxi Medical University, Nanning 530021, People's Republic of China
| | - Zhenjie Wu
- Department of Bone and Soft Tissue Surgery, Affiliated Tumor Hospital, Guangxi Medical University, Nanning 530021, People's Republic of China
| | - Jinmin Zhao
- Department of Orthopaedics Trauma and Hand Surgery, The First Affiliated Hospital, Guangxi Medical University, Nanning 530021, People's Republic of China,
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潘 健, 胡 海, 张 炜, 陈 进, 窦 献. [Value of serum alkaline phosphatase for predicting 2-year fracture in patients with chronic kidney disease on dialysis]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:1095-1099. [PMID: 30377117 PMCID: PMC6744186 DOI: 10.12122/j.issn.1673-4254.2018.09.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To explore the value of baseline serum alkaline phosphatase (ALP) for predicting 2-year fracture in patients with chronic kidney disease (CKD) on maintenance dialysis. METHODS A total of 139 patients with CKD undergoing maintenance dialysis in our hospital were enrolled in this study. According to the median serum ALP level, the patients were divided into high ALP and low ALP groups. The demographic and clinical data of the patients including dialysis duration, serum calcium level, serum phosphorus level, and serum intact parathyroid hormone level were recorded, and their bone mineral density of the femur and the lumbar spine was measured using dual energy X-ray absorptiometry. The patients were followed up for 2 years and fracture events were recorded. The risk factors of fracture were analyzed using logistic regression analysis, and their predictive value for fracture was analyzed using receiver-operating characteristic (ROC) curve. RESULTS The mean baseline serum ALP level was 132.55±167.68 U/L in these patients, significantly higher than that in the normal population (t=2.816, P=0.006). Baseline serum ALP level was negatively correlated with the bone mineral density of the lumbar spine (r=-0.203, P=0.006) and the femur (r=-0.196, P=0.021). Fractures occurred in 21 (15.1%) of the patients during the 2-year follow-up, and the fracture rate was significantly higher in patients with high ALP levels. Logistic regression analysis identified serum ALP level as an independent risk factor of fracture (OR: 1.010, P=0.001, 95%CI: 1.004-1.016). The areas under the ROC curve were 0.900 and 0.768 for serum ALP level and intact parathyroid hormone level in predicting 2-year fractures, respectively. CONCLUSIONS Serum ALP may serve as a good indicator for predicting 2-year fractures in patients with CKD on maintenance dialysis.
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Affiliation(s)
- 健怡 潘
- />南方医科大学顺德医院//佛山市顺德区第一人民医院,广东 佛山 528300Department of Nephrology, Shunde Hospital of Southern Medical University/Shunde First People's Hospital, Foshan 528300, China
| | - 海棠 胡
- />南方医科大学顺德医院//佛山市顺德区第一人民医院,广东 佛山 528300Department of Nephrology, Shunde Hospital of Southern Medical University/Shunde First People's Hospital, Foshan 528300, China
| | - 炜 张
- />南方医科大学顺德医院//佛山市顺德区第一人民医院,广东 佛山 528300Department of Nephrology, Shunde Hospital of Southern Medical University/Shunde First People's Hospital, Foshan 528300, China
| | - 进忠 陈
- />南方医科大学顺德医院//佛山市顺德区第一人民医院,广东 佛山 528300Department of Nephrology, Shunde Hospital of Southern Medical University/Shunde First People's Hospital, Foshan 528300, China
| | - 献蕊 窦
- />南方医科大学顺德医院//佛山市顺德区第一人民医院,广东 佛山 528300Department of Nephrology, Shunde Hospital of Southern Medical University/Shunde First People's Hospital, Foshan 528300, China
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Iwasaki Y, Yamato H, Fukagawa M. TGF-Beta Signaling in Bone with Chronic Kidney Disease. Int J Mol Sci 2018; 19:E2352. [PMID: 30103389 PMCID: PMC6121599 DOI: 10.3390/ijms19082352] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 07/30/2018] [Accepted: 08/08/2018] [Indexed: 01/05/2023] Open
Abstract
Transforming growth factor (TGF)-β signaling is not only important in skeletal development, but also essential in bone remodeling in adult bone. The bone remodeling process involves integrated cell activities induced by multiple stimuli to balance bone resorption and bone formation. TGF-β plays a role in bone remodeling by coordinating cell activities to maintain bone homeostasis. However, mineral metabolism disturbance in chronic kidney disease (CKD) results in abnormal bone remodeling, which leads to ectopic calcification in CKD. High circulating levels of humoral factors such as parathyroid hormone, fibroblast growth factor 23, and Wnt inhibitors modulate bone remodeling in CKD. Several reports have revealed that TGF-β is involved in the production and functions of these factors in bone. TGF-β may act as a factor that mediates abnormal bone remodeling in CKD.
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Affiliation(s)
- Yoshiko Iwasaki
- Department of Health Sciences, Oita University of Nursing and Health Sciences, Oita 870-1163, Japan.
| | - Hideyuki Yamato
- Division of Nephrology and Metabolism, Tokai University School of Medicine, Kanagawa 259-119, Japan.
| | - Masafumi Fukagawa
- Division of Nephrology and Metabolism, Tokai University School of Medicine, Kanagawa 259-119, Japan.
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Gosmanova EO, Gosmanov AR. Novel Approaches for Assessment of Bone Turnover in CKD: Is New Always Better? J Am Soc Nephrol 2018; 29:2443. [PMID: 30061452 DOI: 10.1681/asn.2018050561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Elvira O Gosmanova
- Department of Medicine, Stratton Veterans Affairs Medical Center, Albany, New York; and Divisions of.,Nephrology and
| | - Aidar R Gosmanov
- Department of Medicine, Stratton Veterans Affairs Medical Center, Albany, New York; and Divisions of .,Endocrinology, Albany Medical College, Albany, New York
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49
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Bover J, Ureña P, Aguilar A, Mazzaferro S, Benito S, López-Báez V, Ramos A, daSilva I, Cozzolino M. Alkaline Phosphatases in the Complex Chronic Kidney Disease-Mineral and Bone Disorders. Calcif Tissue Int 2018; 103:111-124. [PMID: 29445837 DOI: 10.1007/s00223-018-0399-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/29/2018] [Indexed: 12/16/2022]
Abstract
Alkaline phosphatases (APs) remove the phosphate (dephosphorylation) needed in multiple metabolic processes (from many molecules such as proteins, nucleotides, or pyrophosphate). Therefore, APs are important for bone mineralization but paradoxically they can also be deleterious for other processes, such as vascular calcification and the increasingly known cross-talk between bone and vessels. A proper balance between beneficial and harmful activities is further complicated in the context of chronic kidney disease (CKD). In this narrative review, we will briefly update the complexity of the enzyme, including its different isoforms such as the bone-specific alkaline phosphatase or the most recently discovered B1x. We will also analyze the correlations and potential discrepancies with parathyroid hormone and bone turnover and, most importantly, the valuable recent associations of AP's with cardiovascular disease and/or vascular calcification, and survival. Finally, a basic knowledge of the synthetic and degradation pathways of APs promises to open new therapeutic strategies for the treatment of the CKD-Mineral and Bone Disorder (CKD-MBD) in the near future, as well as for other processes such as sepsis, acute kidney injury, inflammation, endothelial dysfunction, metabolic syndrome or, in diabetes, cardiovascular complications. However, no studies have been done using APs as a primary therapeutic target for clinical outcomes, and therefore, AP's levels cannot yet be used alone as an isolated primary target in the treatment of CKD-MBD. Nonetheless, its diagnostic and prognostic potential should be underlined.
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Affiliation(s)
- Jordi Bover
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain.
| | - Pablo Ureña
- Department of Nephrology and Dialysis, Clinique du Landy and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Armando Aguilar
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Benito
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Víctor López-Báez
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Alejandra Ramos
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Iara daSilva
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Mario Cozzolino
- Laboratory of Experimental Nephrology, Renal Division,San Paolo Hospital, DiSS University of Milan, Milan, Italy
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50
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Ureña-Torres PA, Vervloet M, Mazzaferro S, Oury F, Brandenburg V, Bover J, Cavalier E, Cohen-Solal M, Covic A, Drüeke TB, Hindié E, Evenepoel P, Frazão J, Goldsmith D, Kazama JJ, Cozzolino M, Massy ZA. Novel insights into parathyroid hormone: report of The Parathyroid Day in Chronic Kidney Disease. Clin Kidney J 2018; 12:269-280. [PMID: 30976408 PMCID: PMC6452197 DOI: 10.1093/ckj/sfy061] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease (CKD) is often associated with a mineral and bone disorder globally described as CKD-Mineral and Bone Disease (MBD), including renal osteodystrophy, the latter ranging from high bone turnover, as in case of secondary hyperparathyroidism (SHPT), to low bone turnover. The present article summarizes the important subjects that were covered during ‘The Parathyroid Day in Chronic Kidney Disease’ CME course organized in Paris in September 2017. It includes the latest insights on parathyroid gland growth, parathyroid hormone (PTH) synthesis, secretion and regulation by the calcium-sensing receptor, vitamin D receptor and fibroblast growth factor 23 (FGF23)–Klotho axis, as well as on parathyroid glands imaging. The skeletal action of PTH in early CKD stages to the steadily increasing activation of the often downregulated PTH receptor type 1 has been critically reviewed, emphasizing that therapeutic strategies to decrease PTH levels at these stages might not be recommended. The effects of PTH on the central nervous system, in particular cognitive functions, and on the cardiovascular system are revised, and the reliability and exchangeability of second- and third-generation PTH immunoassays discussed. The article also reviews the different circulating biomarkers used for the diagnosis and monitoring of CKD-MBD, including PTH and alkaline phosphatases isoforms. Moreover, it presents an update on the control of SHPT by vitamin D compounds, old and new calcimimetics, and parathyroidectomy. Finally, it covers the latest insights on the persistence and de novo occurrence of SHPT in renal transplant recipients.
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Affiliation(s)
- Pablo A Ureña-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
| | - Marc Vervloet
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), VU University Medical Center, Amsterdam, The Netherlands
| | - Sandro Mazzaferro
- Department of Cardiovascular Respiratory Nephrologic Anaesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Franck Oury
- INEM, Centre de Mdecine Moléculaire Faculté de Médecine Paris Descartes, Sorbonne, Paris Cité Bâtiment Leriche, France
| | - Vincent Brandenburg
- Department of Cardiology, University Hospital RWTH Aachen, Pauwelsstraße, Aachen, Germany
| | - Jordi Bover
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350 Barcelona, Spain
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU Sart-Tilman, Liège, Belgium
| | - Martine Cohen-Solal
- INSERM U1132 & USPC Paris-Diderot, Department of Rheumatology, Hôpital Lariboisière, Paris, France
| | - Adrian Covic
- Department of Nephrology, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Romania
| | - Tilman B Drüeke
- Inserm Unit 1018, CESP, Team 5, Paul Brousse Hospital, Villejuif/Paris, France
| | - Elif Hindié
- Nuclear Medicine, University of Bordeaux, Haut-Lévêque Hospital, Pessac, France
| | - Pieter Evenepoel
- Department of Medicine, Division of Nephrology, University Hospital Leuven, Leuven, Belgium.,Dienst nefrologie, Universitair Ziekenhuis Gasthuisberg, Herestraat, Leuven, Belgium
| | - João Frazão
- Institute of Investigation and Innovation in Health, University of Porto, Porto, Portugal.,INEB-National Institute of Biomedical Engineer, University of Porto, Porto, Portugal.,Department of Nephrology, São João Hospital Center, Porto, Portugal.,School of Medicine of University of Porto, Porto, Portugal
| | | | - Junichiro James Kazama
- Department of Nephrology and Hypertension, Fukushima Medical University, 1 Hikarigaoka, Fukushima 960-1247, Japan
| | - Mario Cozzolino
- Renal Division, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré University Medical Center, APHP, University of Paris Ouest (UVSQ), Boulogne Billancourt/Paris, France
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