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Jung J, Lee KH, Park E, Park YS, Kang HG, Ahn YH, Ha IS, Kim SH, Cho H, Han KH, Cho MH, Choi HJ, Lee JH, Shin JI. Mineral bone disorder in children with chronic kidney disease: Data from the KNOW-Ped CKD (Korean cohort study for outcome in patients with pediatric chronic kidney disease) study. Front Pediatr 2023; 11:994979. [PMID: 36873652 PMCID: PMC9982157 DOI: 10.3389/fped.2023.994979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/24/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Children with chronic kidney disease (CKD) are at high risk of mineral bone disorder (MBD), which leads to fractures, growth retardation, and cardiovascular disease. We aimed to comprehensively understand the relationship between renal function and factors related to MBD and evaluate the prevalence and distribution characteristics of MBD, specifically among Korean patients from the KNOW-PedCKD cohort. METHODS From the baseline data of the KNOW-PedCKD cohort, we examined the prevalence and distribution of MBD in 431 Korean pediatric CKD patients, including the level of corrected total calcium, serum phosphate, serum alkaline phosphatase, serum intact parathyroid hormone (iPTH), fibroblast growth factor 23 (FGF-23), serum vitamin D, fractional excretion of phosphate (FEP), and bone densitometry Z-scores. RESULTS The median serum calcium level remained relatively normal regardless of the CKD stage. The levels of 1,25-dihydroxy vitamin D, urine calcium-to-creatinine ratio, and bone densitometry Z-score significantly decreased with advancing CKD stage, while those of serum phosphate, FGF-23, and FEP significantly increased with CKD stage. The prevalence of hyperphosphatemia (17.4%, 23.7%, and 41.2% from CKD stages 3b, 4, and 5, respectively) and hyperparathyroidism (37.3%, 57.4%, 55.3%, and 52.9% from CKD stages 3a, 3b, 4, and 5, respectively) significantly increased with the CKD stage. Prescriptions of medications, such as calcium supplements (39.1%, 42.1%, 82.4%), phosphate binders (39.1%, 43.4%, 82.4%), and active vitamin D (21.7%, 44.7%, and 64.7%) significantly increased with CKD stage 3b, 4, and 5, respectively. CONCLUSIONS The results demonstrated the prevalence and relationship of abnormal mineral metabolism and bone growth according to CKD stage in Korean pediatric CKD patients for the first time.
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Affiliation(s)
- Jiwon Jung
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University, College of Medicine, Seoul, Republic of Korea
| | - Keum Hwa Lee
- Department of Pediatrics, Severance Children's Hospital, College of Medicine, University of Yonsei, Seoul, Republic of Korea
| | - Eujin Park
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Young Seo Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University, College of Medicine, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University Children's Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Seong Heon Kim
- Department of Pediatrics, Seoul National University Children's Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Kyoung Hee Han
- Department of Pediatrics, School of Medicine, Jeju National University, Jeju, Republic of Korea
| | - Min Hyun Cho
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hyun Jin Choi
- National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Cheongju, Republic of Korea
| | - Joo Hoon Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University, College of Medicine, Seoul, Republic of Korea
| | - Jae Il Shin
- Department of Pediatrics, Severance Children's Hospital, College of Medicine, University of Yonsei, Seoul, Republic of Korea.,Institute of Kidney Disease Research, College of Medicine, Yonsei University, Seoul, Republic of Korea
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Fractional Excretion of Phosphate (FeP) Is Associated with End-Stage Renal Disease Patients with CKD 3b and 5. J Clin Med 2019; 8:jcm8071026. [PMID: 31336909 PMCID: PMC6678389 DOI: 10.3390/jcm8071026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/07/2019] [Accepted: 07/09/2019] [Indexed: 12/20/2022] Open
Abstract
Background: The perturbation of phosphate homeostasis portends unfavorable outcomes in chronic kidney disease (CKD). However, the absence of randomized clinical trials (RCT) fuels the discussion of whether phosphate or some other phosphorous-related factor(s) such as fibroblast growth factor 23 (FGF-23) mediates the cardiovascular and systemic toxicity. We herein test whether the fractional excretion of phosphate (FeP) as a marker of renal stress to excrete phosphorous predicts unfavorable outcomes in CKD patients. Methods: Retrospective, cross-sectional observational study. For current analysis, an historical cohort of 407 records of CKD stage 3b-5 patients attending between January 2010 and October 2015 at the Nephrology Unit of Solofra (AV), Italy were utilized. Demographic, clinical, laboratory, and outcome data were identified through the subjects’ medical records. We tested whether quartiles of FeP are associated with the risk of CKD progression or all causes of death. Parametric as well as non-parametric tests, linear and logistic regression, as well as survival analysis were utilized. Results: Overall, we investigated middle-age (mean 66.0, standard deviation 12.3 years) men and women (male 43%) with CKD stage 3b to 5 (creatinine clearance 32.0 (13.3) mL/min). Older age, lower diastolic blood pressure, poor renal function, as well as higher serum phosphate were associated with FeP. Patients with higher FeP were at an increased risk of starting dialysis or dying (hazard ratio 2.40; 95% confidence interval (1.44, 3.99)). Notably, when the two endpoints were analyzed separately, FeP was associated with renal but not all-cause survival. Conclusion: FeP is associated with ESRD, but not all-cause mortality risk in a large cohort of moderate to advanced CKD patients. Future efforts are required to validate FeP as a marker of nephron stress and risk factor for CKD progression in this high-risk population.
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De Nicola L, Provenzano M, Chiodini P, Borrelli S, Russo L, Bellasi A, Santoro D, Conte G, Minutolo R. Epidemiology of low-proteinuric chronic kidney disease in renal clinics. PLoS One 2017; 12:e0172241. [PMID: 28212407 PMCID: PMC5315278 DOI: 10.1371/journal.pone.0172241] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 02/01/2017] [Indexed: 12/29/2022] Open
Abstract
CKD patients with low-grade proteinuria (LP) are common in nephrology clinics. However, prevalence, characteristics, and the competing risks of ESRD and death as the specific determinants, are still unknown. We analyzed epidemiological features of LP status in a prospective cohort of 2,340 patients with CKD stage III-V referred from ≥6 months in 40 nephrology clinics in Italy. LP status was defined as proteinuria <0.5 g/24h according to current KDIGO guidelines. Patients with higher proteinuria constituted the control group (CON). LP patients were 54.5% of the whole cohort. As compared to CON, LP were older (70.0±12.1 vs 65.4±14.1 y), and less likely to be male (55.8 vs 62.0%) and diabetic (27.6 vs 34.1%), and had hypertension as the most common cause of CKD (39.8%). They had higher eGFR (34.8±13.5 vs 26.8±13.2 mL/min/1.73m2) and hemoglobin (12.7±1.7 vs 12.3±1.7 g/dL), while systolic blood pressure (137±18 vs 140±18 mmHg) and serum phosphorus (3.7±0.8 vs 3.9±0.8 mg/dL) were lower [P<0.001 for all comparisons]. Over a median follow-up of 48 months, an inverse relative risk of ESRD and death was observed in LP (death>>ESRD; P = 0.002) versus CON (ESRD>>death; P<0.0001). Modifiable risk factors were also different in LP, with smoking, lower hemoglobin, and proteinuria being associated with higher mortality risk while lower BMI and higher phosphorus predicting ESRD at multivariable Cox analyses [P<0.05 for all]. Therefore, in nephrology clinics, LP patients are the majority and show distinctive basal features. More important, they are more exposed to death than ESRD and do present specific modifiable determinants of either outcome; indeed, in LP, while smoking plays a role for mortality, lower BMI and higher phosphorus levels -even if in the normal range- are predictors of ESRD. These data support the need to further study the low proteinuric CKD population to guide management.
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Affiliation(s)
- Luca De Nicola
- Nephrology Unit at Second University of Naples, Naples, Italy
- * E-mail:
| | | | - Paolo Chiodini
- Medical Statistics Unit at Second University of Naples, Naples, Italy
| | - Silvio Borrelli
- Nephrology Unit at Second University of Naples, Naples, Italy
| | - Luigi Russo
- Nephrology Unit at University Federico II in Naples, Naples, Italy
| | | | | | - Giuseppe Conte
- Nephrology Unit at Second University of Naples, Naples, Italy
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Bover J, Ureña-Torres P, Górriz JL, Lloret MJ, da Silva I, Ruiz-García C, Chang P, Rodríguez M, Ballarín J. Cardiovascular calcifications in chronic kidney disease: Potential therapeutic implications. Nefrologia 2016; 36:597-608. [PMID: 27595517 DOI: 10.1016/j.nefro.2016.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/19/2016] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular (CV) calcification is a highly prevalent condition at all stages of chronic kidney disease (CKD) and is directly associated with increased CV and global morbidity and mortality. In the first part of this review, we have shown that CV calcifications represent an important part of the CKD-MBD complex and are a superior predictor of clinical outcomes in our patients. However, it is also necessary to demonstrate that CV calcification is a modifiable risk factor including the possibility of decreasing (or at least not aggravating) its progression with iatrogenic manoeuvres. Although, strictly speaking, only circumstantial evidence is available, it is known that certain drugs may modify the progression of CV calcifications, even though a direct causal link with improved survival has not been demonstrated. For example, non-calcium-based phosphate binders demonstrated the ability to attenuate the progression of CV calcification compared with the liberal use of calcium-based phosphate binders in several randomised clinical trials. Moreover, although only in experimental conditions, selective activators of the vitamin D receptor seem to have a wider therapeutic margin against CV calcification. Finally, calcimimetics seem to attenuate the progression of CV calcification in dialysis patients. While new therapeutic strategies are being developed (i.e. vitamin K, SNF472, etc.), we suggest that the evaluation of CV calcifications could be a diagnostic tool used by nephrologists to personalise their therapeutic decisions.
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Affiliation(s)
- Jordi Bover
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España.
| | - Pablo Ureña-Torres
- Departamento de Nefrología y Diálisis, Clinique du Landy, París, Francia; Departamento de Fisiología Renal, Hospital Necker, Universidad de París Descartes, París, Francia
| | - José Luis Górriz
- Servicio de Nefrología, Hospital Universitario Dr. Peset, Valencia, España
| | - María Jesús Lloret
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - Iara da Silva
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - César Ruiz-García
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - Pamela Chang
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
| | - Mariano Rodríguez
- Servicio de Nefrología, Hospital Universitario Reina Sofía, IMIBIC, Universidad de Córdoba, Córdoba, España
| | - José Ballarín
- Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, España
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Zoccali C, Mallamaci F. Moderator's view: Phosphate binders in chronic kidney disease patients: a clear 'No' at the moment, but stay tuned. Nephrol Dial Transplant 2015; 31:196-9. [PMID: 26681749 DOI: 10.1093/ndt/gfv404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Particularly because the risk of harm cannot be safely excluded, the use of phosphate binders in chronic kidney disease (CKD) patients demands caution. Yet, the clinical inertia concerning phosphate burden is unjustified. Inorganic, phosphate esters added to preserve food represent an important component of dietary phosphate load. These compounds are easily absorbable and have a measurable effect on serum phosphate, and therefore their use should be avoided in CKD patients. The ongoing CKD Optimal management with Binders and NicotinamidE (COMBINE) study, applying chelation by phosphate binders and intestinal Na-P channel blockade by nicotinamide, will establish whether this combination may effectively reduce serum phosphate and fibroblast growth factor 23 in pre-dialysis CKD patients and produce improvements in surrogate measures of cardiovascular and renal damages. On the other hand, the ANSWER study will ascertain whether phosphate reduction by sevelamer carbonate may have an antiproteinuric effect in CKD patients with residual proteinuria despite effective blockade of the renin-angiotensin system. At this stage of knowledge, the use of phosphate binders in pre-dialysis CKD patients cannot be recommended. Ongoing studies will tell us whether the application of these drugs may have beneficial health effects in CKD patients at the pre-dialysis stage.
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Affiliation(s)
- Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, Reggio Calabria, Italy Nephrology, Hypertension and Renal Transplantation Unit, Ospedali Riuniti, Reggio Calabria, Italy
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