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Shen Y. Mini review: A reevaluation of nutritional vitamin D in the treatment of chronic kidney disease. Medicine (Baltimore) 2023; 102:e35811. [PMID: 37904427 PMCID: PMC10615537 DOI: 10.1097/md.0000000000035811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/05/2023] [Indexed: 11/01/2023] Open
Abstract
Chronic kidney disease-mineral and bone disorder is a syndrome of mineral and bone metabolism abnormalities caused by chronic kidney disease. Osteoporosis is a systemic metabolic bone disease characterized by low bone mass, disruption of bone microstructure, increased brittleness, and a higher propensity for fractures. Both of these conditions significantly affect bone metabolism and substantially increase the risk of fractures. Nutritional vitamin D is an essential trace element in the human body and an important fat-soluble vitamin. One crucial physiological role of nutritional vitamin D is to achieve mineral-bone metabolism balance by regulating calcium homeostasis. This review summarized the metabolism of vitamin in normal population and its specificity in chronic kidney disease. Over the years, the understanding and application of vitamin D in patients with chronic renal failure is changing. As people pay more attention to hypercalcemia, vascular calcification, osteoporosis, nutritional vitamin D has come into people's attention again. More and more studies are discussing how to prescribe vitamin D supplementation in hemodialysis patients.
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Affiliation(s)
- Yingjing Shen
- Department of Nephrology, Shanghai Tianyou Hospital, Shanghai, China
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2
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Vervloet MG, Hsu S, de Boer IH. Vitamin D supplementation in people with chronic kidney disease. Kidney Int 2023; 104:698-706. [PMID: 37541585 DOI: 10.1016/j.kint.2023.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/08/2023] [Accepted: 07/13/2023] [Indexed: 08/06/2023]
Abstract
Vitamin D supplements have long been advocated for people with chronic kidney disease based on data from observational studies among the general population and people with chronic kidney disease. These data consistently suggested that higher circulating concentrations of 25-hydroxyvitamin D are associated with improved fracture, cardiovascular, cancer, and mortality outcomes. In the past few years, large clinical trials have been conducted to assess the effects of vitamin D supplements on a range of clinically relevant outcomes. Most of these studies were performed in the general population, but they also enrolled people with chronic kidney disease. Virtually all of these trials were negative and contradicted the observational data. In this review, the key observational data and clinical trials are summarized, and potential explanations for the discrepancies between these studies are discussed.
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Affiliation(s)
- Marc G Vervloet
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Division of Diabetes and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center (UMC), Amsterdam, the Netherlands.
| | - Simon Hsu
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Ian H de Boer
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, Washington, USA
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3
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Christodoulou M, Aspray TJ, Piec I, Washbourne C, Tang JCY, Fraser WD, Schoenmakers I. Early renal impairment affects hormonal regulators of calcium and bone metabolism and Wnt signalling and the response to vitamin D supplementation in healthy older adults. J Steroid Biochem Mol Biol 2023; 229:106267. [PMID: 36739953 DOI: 10.1016/j.jsbmb.2023.106267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 02/05/2023]
Abstract
Bone and renal metabolism are regulated by common factors and there is extensive cross-talk between these organs (the 'renal-bone-axis'). Ageing is associated with physiological changes including reduced bone mass, renal function and tissue sensitivity to regulatory hormones, impacting the renal-bone axis. We aimed to investigate the influence of estimated Glomerular Filtration Rate (eGFR) on plasma concentrations of vitamin D metabolites, Wnt signalling and bone metabolism in a dose ranging vitamin D3 RCT (12,000 IU, 24,000 IU, 48,000 IU/month for 1 year; n = 379, >70 y) with a baseline eGFR > 30 mL/min/1.73 m2. Participants were categorised on basis of eGFR (≥60 or mL/min/1.73 m2) based on 5 commonly used algorithms for eGFR. Differences between eGFR categories were tested with ANCOVA. Before supplementation commenced, a lower eGFR was associated with significantly higher concentrations of c-terminal and intact Fibroblast Growth Factor-23 (cFGF23; iFGF23), intact Parathyroid Hormone (iPTH) and Sclerostin (SOST) and lower Klotho, 1,25-dihydroxy Vitamin D (1,25(OH)2D) and Dickkopf-related Protein 1 (DKK1) concentrations. Differences between eGFR groups in 25-hydroxy Vitamin D (25(OH)D), 24,25-dihydroxy Vitamin D (24,25(OH)2D) and iPTH were only detected with eGFR based on Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Modification in Diet for Renal Disease (MDRD-4) algorithms. Differences in Bone Mineral Density and Content (BMD; BMC) and bone turnover markers were detected only with Cockcroft-Gault (CG). Pre- and post- supplementation comparisons showed differences in the response to supplementation by eGFR group. Plasma 25(OH)D, 24,25(OH)2D, 1,25(OH)2D and DKK1 increased and iPTH and C-terminal telopeptide (CTX) decreased in both groups. Plasma iFGF23, bone specific alkaline phosphatase (BAP) and Procollagen 1 intact N-terminal Propeptide (PINP) increased and phosphate decreased only in the group with eGFR ≥ 60 mL/min/1.73 m2. Findings were largely consistent across all eGFR algorithms. Post-supplementation, cFGF23, iFGF23, iPTH and SOST remained significantly higher in the lower eGFR group. Plasma 1,25(OH)2D and Klotho did no longer differ between eGFR groups. This was found for all eGFR algorithms, with the exception of iPTH and iFGF23, which were not significantly different with eGFR based on CG. Differences in BMD and BMC were detected with CKD-EPI-creatinine and MDRD-4 but not GC. This study showed that even a moderate decline in eGFR is associated with alterations in vitamin D metabolism, Wnt signalling and bone turnover markers. Renal function influenced the response to vitamin D supplementation. Supplementation increased Vitamin D metabolites in the group with moderate renal impairment to concentrations comparable to those found in the group with normal renal function. However, although CTX decreased, an increase in bone formation markers was not found in the group with eGFR 60 mL/min/1.73 m2. In conclusion, vitamin D supplementation had beneficial effects on markers of the renal-bone axis in older people with both normal and impaired renal function.
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Affiliation(s)
| | - Terence J Aspray
- University of Newcastle upon Tyne, Freeman hospital, Bone Clinic, UK
| | - Isabelle Piec
- University of East Anglia, Medical school, Norwich, UK
| | | | | | | | - Inez Schoenmakers
- University of East Anglia, Medical school, Norwich, UK; Formerly MRC Human Nutrition Research, Cambridge, UK
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4
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Shen Y. Role of nutritional vitamin D in chronic kidney disease-mineral and bone disorder: A narrative review. Medicine (Baltimore) 2023; 102:e33477. [PMID: 37026958 PMCID: PMC10082266 DOI: 10.1097/md.0000000000033477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/17/2023] [Indexed: 04/08/2023] Open
Abstract
Chronic kidney disease-mineral and bone disorder has complex and diverse clinical manifestations, including the simplest abnormalities of calcium, phosphorus and parathyroid hormone detected in blood, abnormalities of bone transformation and mineralization in bone, and calcification of blood vessels or other soft tissues detected on imaging. Patients with CKD-MBD combined low bone mineral density and fragility fractures are referred to as CKD-MBD with low bone mineral density. Vascular calcification refers to ectopic deposition of calcium phosphate in the blood vessel walls and heart valves. The degree of vascular calcification was inversely proportional to bone mineral density. The more severe the degree of vascular calcification, the lower the bone mineral density, and the higher the risk of death, indicating that the bone-vascular axis exists. Activation and alteration of the Wnt signaling pathway are central to the treatment of vascular diseases in uremia. Vitamin D supplementation can prevent secondary hyperparathyroidism, activate osteoblasts, relieve muscle weakness and myalgia, and reduce vascular calcification. Nutritional vitamin D may improve vascular calcification in uremia patients by regulating Wnt signaling pathway.
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Affiliation(s)
- Yingjing Shen
- Department of Nephrology, Shanghai Tianyou Hospital, Shanghai, China
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5
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Bover J, Massó E, Gifre L, Alfieri C, Soler-Majoral J, Fusaro M, Calabia J, Rodríguez-Pena R, Rodríguez-Chitiva N, López-Báez V, Sánchez-Baya M, da Silva I, Aguilar A, Bustos MC, Rodrigues N, Chávez-Iñiguez JS, Romero-González G, Valdivielso JM, Molina P, Górriz JL. Vitamin D and Chronic Kidney Disease Association with Mineral and Bone Disorder: An Appraisal of Tangled Guidelines. Nutrients 2023; 15:nu15071576. [PMID: 37049415 PMCID: PMC10097233 DOI: 10.3390/nu15071576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
Chronic kidney disease (CKD) is a highly prevalent condition worldwide in which the kidneys lose many abilities, such as the regulation of vitamin D (VD) metabolism. Moreover, people with CKD are at a higher risk of multifactorial VD deficiency, which has been extensively associated with poor outcomes, including bone disease, cardiovascular disease, and higher mortality. Evidence is abundant in terms of the association of negative outcomes with low levels of VD, but recent studies have lowered previous high expectations regarding the beneficial effects of VD supplementation in the general population. Although controversies still exist, the diagnosis and treatment of VD have not been excluded from nephrology guidelines, and much data still supports VD supplementation in CKD patients. In this narrative review, we briefly summarize evolving controversies and useful clinical approaches, underscoring that the adverse effects of VD derivatives must be balanced against the need for effective prevention of progressive and severe secondary hyperparathyroidism. Guidelines vary, but there seems to be general agreement that VD deficiency should be avoided in CKD patients, and it is likely that one should not wait until severe SHPT is present before cautiously starting VD derivatives. Furthermore, it is emphasized that the goal should not be the complete normalization of parathyroid hormone (PTH) levels. New developments may help us to better define optimal VD and PTH at different CKD stages, but large trials are still needed to confirm that VD and precise control of these and other CKD-MBD biomarkers are unequivocally related to improved hard outcomes in this population.
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Affiliation(s)
- Jordi Bover
- Department of Nephrology, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, 08916 Badalona, Spain
| | - Elisabet Massó
- Department of Nephrology, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, 08916 Badalona, Spain
| | - Laia Gifre
- Rheumatology Service, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain
| | - Carlo Alfieri
- Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Jordi Soler-Majoral
- Department of Nephrology, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, 08916 Badalona, Spain
| | - Maria Fusaro
- National Research Council (CNR), 56124 Pisa, Italy
- Department of Medicine, University of Padua, 35128 Padova, Italy
| | - Jordi Calabia
- Department of Nephrology, University Hospital Josep Trueta, 17007 Girona, Spain
| | - Rosely Rodríguez-Pena
- Department of Nephrology, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, 08916 Badalona, Spain
| | - Néstor Rodríguez-Chitiva
- Department of Nephrology, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, 08916 Badalona, Spain
| | - Víctor López-Báez
- Department of Nephrology, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, 08916 Badalona, Spain
| | - Maya Sánchez-Baya
- Department of Nephrology, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, 08916 Badalona, Spain
| | - Iara da Silva
- Department of Nephrology, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, 08916 Badalona, Spain
| | - Armando Aguilar
- Department of Nephrology, Instituto Mexicano del Seguro Social, Hospital General de Zona No. 2, Tuxtla Gutiérrez 29000, Mexico
| | - Misael C Bustos
- Department of Nephrology, Pontificia Catholic University of Chile, Santiago 8331150, Chile
| | - Natacha Rodrigues
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, 1649-028 Lisboa, Portugal
| | - Jonathan S Chávez-Iñiguez
- Department of Nephrology, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara 44280, Mexico
- Centro Universitario de Ciencias de la Salud CUCS, Guadalajara University, Guadalajara 44340, Mexico
| | - Gregorio Romero-González
- Department of Nephrology, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol, Can Ruti Campus, 08916 Badalona, Spain
| | - José Manuel Valdivielso
- Grupo de Investigación Traslacional Vascular y Renal, Instituto de Investigación Biomédica IRBlleida, 25198 Lleida, Spain
| | - Pablo Molina
- Department of Nephrology, Hospital Universitario Dr Peset, Universitat de València Fisabio, 46017 Valencia, Spain
| | - José L Górriz
- Department of Nephrology, University Hospital Clínico, INCLIVA, Valencia University, 46010 Valencia, Spain
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Grant WB, Al Anouti F, Boucher BJ, Fakhoury HMA, Moukayed M, Pilz S, Al-Daghri NM. Evidence That Increasing Serum 25(OH)D Concentrations to 30 ng/mL in the Kingdom of Saudi Arabia and the United Arab Emirates Could Greatly Improve Health Outcomes. Biomedicines 2023; 11:biomedicines11040994. [PMID: 37189612 DOI: 10.3390/biomedicines11040994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Accumulating evidence supports the potential protective effects of vitamin D against chronic diseases such as Alzheimer’s disease, autoimmune diseases, cancers, cardiovascular disease (ischaemic heart disease and stroke), type 2 diabetes, hypertension, chronic kidney disease, stroke, and infectious diseases such as acute respiratory tract diseases, COVID-19, influenza, and pneumonia, as well as adverse pregnancy outcomes. The respective evidence is based on ecological and observational studies, randomized controlled trials, mechanistic studies, and Mendelian randomization studies. However, randomized controlled trials on vitamin D supplementation have largely failed to show benefits, probably due to poor design and analysis. In this work, we aim to use the best available evidence on the potential beneficial effects of vitamin D to estimate the expected reduction in incidence and mortality rates of vitamin D-related diseases in the Kingdom of Saudi Arabia and the United Arab Emirates if minimum serum 25(OH)D concentrations were to be raised to 30 ng/mL. Estimated reductions by 25% for myocardial infarction incidence, 35% for stroke incidence, 20 to 35% for cardiovascular disease mortality, and 35% for cancer mortality rates depicted a promising potential for raising serum 25(OH)D. Methods to increase serum 25(OH)D concentrations at the population level could include food fortification with vitamin D3, vitamin D supplementation, improved dietary vitamin D intake, and sensible sun exposure.
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7
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Pistis KD, Westerberg PA, Qureshi AR, Beshara S, Sterner G, Bárány P, Linde T. The effect of high-dose vitamin D supplementation on hepcidin-25 and erythropoiesis in patients with chronic kidney disease. BMC Nephrol 2023; 24:20. [PMID: 36698076 PMCID: PMC9875529 DOI: 10.1186/s12882-022-03014-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 11/21/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Hepcidin is considered to play a central role in the pathophysiology of renal anemia. Recent studies in healthy individuals have demonstrated a suppressive effect of vitamin D (VD) on the expression of hepcidin. In this post-hoc analysis based on a randomized controlled study, we evaluated the effect of supplementing chronic kidney disease (CKD) patients (stage G3-G4) with a high daily dose of native VD on serum levels of hepcidin-25, the hepcidin/ferritin ratio, as well as on markers of erythropoiesis. METHODS Patients with CKD stage G3-G4 included in a double blind, randomized, placebo (PBO) controlled study with available hepcidin measurements were analyzed. Study subjects received either 8000 international units (IU) of cholecalciferol daily or PBO for 12 weeks. We evaluated the change in markers of hepcidin expression, erythropoiesis, and iron status from baseline to week 12 and compared the change between the groups. RESULTS Eighty five patients completed the study. Calcitriol, but not 25-hydroxyvitamin D (25(OH) D), was inversely correlated with serum levels of hepcidin-25 (rho = -0,38; p = < 0, 01 and rho = -0,02; p = 0, 89, respectively) at baseline. Supplementation with VD significantly raised the serum concentration of serum 25(OH)D in the treatment group (from 54 (39-71) to 156 (120-190) nmol/L; p = < 0, 01)) but had no effect on any of the markers of hepcidin, erythropoiesis, or iron status in the entire cohort. However, we did observe an increase in hemoglobin (HB) levels and transferrin saturation (TSAT) as compared to the PBO group in a subgroup of patients with low baseline 25(OH)D levels (< 56 nmol/L). In contrast, in patients with high baseline 25(OH)D values (≥ 56 nmol/L), VD supplementation associated with a decrease in HB levels and TSAT (p = 0,056) within the VD group in addition to a decrease in hepcidin levels as compared to the PBO group. CONCLUSION High-dose VD supplementation had no discernible effect on markers of hepcidin or erythropoiesis in the entire study cohort. However, in patients with low baseline 25(OH)D levels, high-dose VD supplementation associated with beneficial effects on erythropoiesis and iron availability. In contrast, in patients with elevated baseline 25(OH)D levels, high-dose VD supplementation resulted in a decrease in hepcidin levels, most likely due to a deterioration in iron status.
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Affiliation(s)
| | - Per-Anton Westerberg
- grid.8993.b0000 0004 1936 9457Medical Sciences, Uppsala University, Uppsala, Sweden ,grid.460356.20000 0004 0449 0385Department of Medicine, Åland’s Central Hospital, 22100 Mariehamn, Finland
| | - Abdul Rashid Qureshi
- grid.4714.60000 0004 1937 0626Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Soheir Beshara
- grid.4714.60000 0004 1937 0626Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Sterner
- grid.411843.b0000 0004 0623 9987Renal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Peter Bárány
- grid.4714.60000 0004 1937 0626Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Torbjörn Linde
- grid.8993.b0000 0004 1936 9457Medical Sciences, Uppsala University, Uppsala, Sweden
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Barbuto S, Perrone V, Veronesi C, Dovizio M, Zappulo F, Vetrano D, Giannini S, Fusaro M, Ancona DD, Barbieri A, Ferrante F, Lena F, Palcic S, Re D, Rizzi FV, Cogliati P, Soro M, Esposti LD, Cianciolo G. Real-World Analysis of Outcomes and Economic Burden in Patients with Chronic Kidney Disease with and without Secondary Hyperparathyroidism among a Sample of the Italian Population. Nutrients 2023; 15:nu15020336. [PMID: 36678208 PMCID: PMC9867108 DOI: 10.3390/nu15020336] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/06/2023] [Accepted: 01/06/2023] [Indexed: 01/12/2023] Open
Abstract
This real-world analysis evaluated the clinical and economic burden of non-dialysis-dependent CKD patients with and without secondary hyperparathyroidism (sHPT) in Italy. An observational retrospective study was conducted using administrative databases containing a pool of healthcare entities covering 2.45 million health-assisted individuals. Adult patients with hospitalization discharge diagnoses for CKD stages 3, 4, and 5 were included from 1 January 2012 to 31 March 2015 and stratified using the presence/absence of sHPT. Of the 5710 patients, 3119 were CKD-only (62%) and 1915 were CKD + sHPT (38%). The groups were balanced using Propensity Score Matching (PSM). Kaplan-Meier curves revealed that progression to dialysis and cumulative mortality had a higher incidence in the CKD + sHPT versus CKD-only group in CKD stage 3 patients and the overall population. The total direct healthcare costs/patient at one-year follow-up were significantly higher in CKD + sHPT versus CKD-only patients (EUR 8593 vs. EUR 5671, p < 0.001), mostly burdened by expenses for drugs (EUR 2250 vs. EUR 1537, p < 0.001), hospitalizations (EUR 4628 vs. EUR 3479, p < 0.001), and outpatient services (EUR 1715 vs. EUR 654, p < 0.001). These findings suggest that sHPT, even at an early CKD stage, results in faster progression to dialysis, increased mortality, and higher healthcare expenditures, thus indicating that timely intervention can ameliorate the management of CKD patients affected by sHPT.
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Affiliation(s)
- Simona Barbuto
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Valentina Perrone
- CliCon S.r.l., Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy
| | - Chiara Veronesi
- CliCon S.r.l., Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy
| | - Melania Dovizio
- CliCon S.r.l., Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy
| | - Fulvia Zappulo
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Daniele Vetrano
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Sandro Giannini
- Clinica Medica 1, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), 56124 Pisa, Italy
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | | | | | - Fulvio Ferrante
- UOC Farmacia, Ufficio di Farmacovigilanza, ASL Frosinone, 03100 Frosinone, Italy
| | - Fabio Lena
- U.O.C. Politiche del Farmaco, USL Toscana Sud Est, 58100 Grosseto, Italy
| | - Stefano Palcic
- SC Farmacia Ospedaliera e Territoriale—Area Giuliana, Azienda Sanitaria Universitaria Integrata Giuliano-Isontina (ASUGI), 34128 Trieste, Italy
| | - Davide Re
- Servizio Farmaceutico Territoriale, ASL Teramo, 64100 Teramo, Italy
| | | | | | | | - Luca Degli Esposti
- CliCon S.r.l., Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy
- Correspondence:
| | - Giuseppe Cianciolo
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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9
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Ketteler M, Bover J, Mazzaferro S. Treatment of secondary hyperparathyroidism in non-dialysis CKD: an appraisal 2022s. Nephrol Dial Transplant 2022; 38:1397-1404. [PMID: 35977397 DOI: 10.1093/ndt/gfac236] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Indexed: 11/12/2022] Open
Abstract
The situation of secondary hyperparathyroidism (sHPT) in CKD patients not on dialysis (ND-CKD) is probably best characterised by the KDIGO CKD-MBD Update 2017 guideline 4.2.1 stating that the optimal PTH levels is not known in these stages. Furthermore, new caution became recommended with regard to the routine use of active vitamin D analogues in early CKD stages and moderate sHPT phenotypes, due to their potential risks for hypercalcaemia and hyperphosphataemia aggravation. Nevertheless, there is still a substantial clinical need to prevent the development of parathyroid gland autonomy with its associated consequences of bone and vascular damage including fracture risks and cardiovascular events. Therefore, we now attempt to review the current guideline-based and clinical practice management of sHPT in ND-CKD including their strengths and weaknesses, favouring individualised approaches respecting calcium and phosphate homeostasis. We further comment on extended-release calcifediol (ERC) as a new differential therapeutic option now also available in Europe, and on a potentially novel understanding of a required vitamin D saturation in more advanced CKD stages. There is no doubt, however, that knowledge gaps will remain in this issue unless powerful RCTs with hard and meaningful endpoints are performed.
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Affiliation(s)
- Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias i Pujol (HGiTP), Badalona (Barcelona), Catalonia, Spain.,REMAR-IGTP Group, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Badalona (Barcelona), Catalonia, Spain
| | - Sandro Mazzaferro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
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Vitamin D and the Kidney: Two Players, One Console. Int J Mol Sci 2022; 23:ijms23169135. [PMID: 36012412 PMCID: PMC9409427 DOI: 10.3390/ijms23169135] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 01/08/2023] Open
Abstract
Vitamin D belongs to the group of liposoluble steroids mainly involved in bone metabolism by modulating calcium and phosphorus absorption or reabsorption at various levels, as well as parathyroid hormone production. Recent evidence has shown the extra-bone effects of vitamin D, including glucose homeostasis, cardiovascular protection, and anti-inflammatory and antiproliferative effects. This narrative review provides an overall view of vitamin D’s role in different settings, with a special focus on chronic kidney disease and kidney transplant.
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Meshkini F, Soltani S, Clark CCT, Tam V, Meyre D, Toupchian O, Saraf-Bank S, Abdollahi S. The effect of vitamin D supplementation on serum levels of fibroblast growth factor- 23: A systematic review and meta-analysis of randomized controlled trials. J Steroid Biochem Mol Biol 2022; 215:106012. [PMID: 34710560 DOI: 10.1016/j.jsbmb.2021.106012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/18/2021] [Accepted: 10/21/2021] [Indexed: 12/29/2022]
Abstract
Previous studies of the effect of vtamin D on serum levels of fibroblast growth factor- 23 (FGF-23) have yeilded an inconsistent findings. This systematic review and meta-analysis of randomized controlled trials (RCTs) sought to investigate the effect of vitamin D supplementation on serum levels of FGF-23. PubMed, Scopus, ISI Web of Science, and the Cochrane Library were searched, from database inception to November 2020, for RCTs that evaluated the effects of native or active vitamin D supplementation on serum levels of FGF-23 in adults. Weighted mean difference (WMD) were calculated and random effects meta-analysis was used to estimate the overall effects. Twenty-seven trials were included in the meta-analysis. Supplementation with native vitamin D (23 studies, n = 2247 participants; weighted mean difference [WMD] = 0.5 pg/mL, 95 % CI: -0.52 to 1.51, P = 0.33; I2 = 29.9 %), and active vitamin D (5 studies, n = 342 participants, WMD = 29.45 pg/mL, 95 % CI: -3.9 to 62.81, P = 0.08; I2 = 99.3%) had no significant effects on serum FGF-23 concentration. In subgroup analyses, supplementation with ergocalciferol (3 studies, n = 205 participants; WMD = 18.27 pg/mL, 95 % CI: 5.36-31.17, P = 0.006), and daily dosing regimens (9 studies, n = 1374 participants; WMD = 0.41 pg/mL, 95 % CI: 0.22 to 0.59, P < 0.001) increased serum FGF-23 levels compared to control. Overall, our findings revealed no significan effect of vitamin D supplementation on serum FGF-23 concentration. However, further high quality, large-scale studies are needed to better elucidate this relationship.
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Affiliation(s)
- Fatemeh Meshkini
- Department of Biochemistry, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; Student Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Sepideh Soltani
- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Cain C T Clark
- Centre for Intelligent Healthcare, Coventry University, Coventry, CV1 5FB, UK
| | - Vivian Tam
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - David Meyre
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Omid Toupchian
- Department of Nutrition, School of Public Health, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Sahar Saraf-Bank
- Food Security Research Center, Department of Community Nutrition, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shima Abdollahi
- Department of Nutrition, School of Public Health, North Khorasan University of Medical Sciences, Bojnurd, Iran.
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12
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Dusso AS, Bauerle KT, Bernal-Mizrachi C. Non-classical Vitamin D Actions for Renal Protection. Front Med (Lausanne) 2021; 8:790513. [PMID: 34950686 PMCID: PMC8688743 DOI: 10.3389/fmed.2021.790513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022] Open
Abstract
Chronic Kidney Disease (CKD), a disorder that affects 11% of the world's population, is characterized by an acceleration in skeletal, immune, renal, and cardiovascular aging that increases the risk of cardiovascular mortality by 10- to 20-fold, compared to that in individuals with normal renal function. For more than two decades, the progressive impairment in renal capacity to maintain normal circulating levels of the hormonal form of vitamin D (1,25-dihydroxyvitamin D or calcitriol) was considered the main contributor to the reduced survival of CKD patients. Accordingly, calcitriol administration was the treatment of choice to attenuate the progression of secondary hyperparathyroidism (SHPT) and its adverse impact on bone health and vascular calcification. The development of calcitriol analogs, designed to mitigate the resistance to calcitriol suppression of PTH associated with CKD progression, demonstrated survival benefits unrelated to the control of SHPT or skeletal health. The exhaustive search for the pathophysiology behind survival benefits associated with active vitamin D analogs has identified novel anti-inflammatory, anti-hypertensive, anti-aging actions of the vitamin D endocrine system. A major paradigm shift regarding the use of calcitriol or active vitamin D analogs to improve survival in CKD patients emerged upon demonstration of a high prevalence of vitamin D (not calcitriol) deficiency at all stages of CKD and, more significantly, that maintaining serum levels of the calcitriol precursor, 25(OH)vitamin D, above 23 ng/ml delayed CKD progression. The cause of vitamin D deficiency in CKD, however, is unclear since vitamin D bioactivation to 25(OH)D occurs mostly at the liver. Importantly, neither calcitriol nor its analogs can correct vitamin D deficiency. The goals of this chapter are to present our current understanding of the pathogenesis of vitamin D deficiency in CKD and of the causal link between defective vitamin D bioactivation to calcitriol and the onset of molecular pathways that promote CKD progression independently of the degree of SHPT. An understanding of these mechanisms will highlight the need for identification of novel sensitive biomarkers to assess the efficacy of interventions with vitamin D and/or calcitriol(analogs) to ameliorate CKD progression in a PTH-independent manner.
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Affiliation(s)
- Adriana S. Dusso
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Kevin T. Bauerle
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
- Department of Medicine, VA Medical Center, St. Louis, MO, United States
| | - Carlos Bernal-Mizrachi
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
- Department of Medicine, VA Medical Center, St. Louis, MO, United States
- Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, MO, United States
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13
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Bover J, Gunnarsson J, Csomor P, Kaiser E, Cianciolo G, Lauppe R. Impact of nutritional vitamin D supplementation on parathyroid hormone and 25-hydroxyvitamin D levels in non-dialysis chronic kidney disease: a meta-analysis. Clin Kidney J 2021; 14:2177-2186. [PMID: 34603696 PMCID: PMC8483691 DOI: 10.1093/ckj/sfab035] [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: 09/08/2020] [Accepted: 01/11/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Secondary hyperparathyroidism (SHPT) is a common and major complication in chronic kidney disease (CKD), reflecting the increase of parathyroid hormone (PTH) in response to reduced vitamin D signalling and hypocalcaemia. This meta-analysis evaluated the impact of nutritional vitamin D (NVD) (cholecalciferol or ergocalciferol) on SHPT-related biomarkers. METHODS A systematic literature search was performed in PubMed to identify relevant randomized control trials to be included in the meta-analysis. Fixed- and random-effects models were used to pool study-level results. Effects were studied within NVD study arms and relative to control groups (placebo/no treatment); the former in order to identify the effect of actively altering biomarkers levels. RESULTS Reductions in PTH from supplementation with NVD were small when observed within the NVD study arms (pooled reduction: 10.5 pg/mL) and larger when compared with placebo/no treatment (pooled reduction: 49.7 pg/mL). NVD supplementation increased levels of 25-hydroxyvitamin D [25(OH)D] in both analyses (increase within NVD study arm: 20.6 ng/mL, increase versus placebo/no treatment: 26.9 ng/mL). While small and statistically non-significant changes in phosphate and fibroblast growth factor 23 were observed, NVD supplementation caused calcium levels to increase when compared with placebo/no treatment (increase: 0.23 mg/dL). CONCLUSIONS Our results suggest that supplementation with NVD can be used to increase 25(OH)D to a certain extent, while the potential of NVD to actively reduce PTH in non-dialysis-CKD patients with SHPT is limited.
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Affiliation(s)
- Jordi Bover
- Fundació Puigvert, Servicio de Nefrología, IIB Sant Pau, REDinREN, Barcelona, Spain
| | | | | | | | - Giuseppe Cianciolo
- Nephrology Dialysis and Kidney Transplantation Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Malpighi Hospital, Bologna, Italy
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14
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Gregg LP, Bossola M, Ostrosky-Frid M, Hedayati SS. Fatigue in CKD: Epidemiology, Pathophysiology, and Treatment. Clin J Am Soc Nephrol 2021; 16:1445-1455. [PMID: 33858827 PMCID: PMC8729574 DOI: 10.2215/cjn.19891220] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Fatigue is a commonly reported and debilitating symptom among patients with CKD, yet little is known about its epidemiology, pathogenesis, and treatment. Various measurement tools have been used in published studies to identify and quantify fatigue. These include several single-item measures embedded in longer questionnaires for assessing depression, quality of life, or symptom burden in patients with kidney disease. Approximately 70% of patients with CKD report fatigue, with up to 25% reporting severe symptoms. Patient-reported fatigue is associated with death, dialysis initiation, and hospitalization among individuals with CKD. The pathophysiology is multifactorial and likely includes decreased oxygen delivery and increased reliance on anaerobic metabolism, thus generating lactic acidosis in response to exertion; the effects of chronic metabolic acidosis and hyperphosphatemia on skeletal muscle myocytes; protein-energy wasting and sarcopenia; and depression. Physical activity has been shown to improve fatigue in some small but promising trials, and so should be recommended, given the additional benefits of exercise. Targeting higher hemoglobin levels with erythropoiesis-stimulating agents may improve fatigue, but potential adverse cardiovascular effects preclude their use to solely treat fatigue without the presence of another indication. Current guidelines recommend cautious individualization of hemoglobin targets for those at low cardiovascular risk who still experience fatigue or functional limitation despite a hemoglobin level of 10 g/dl. Sodium bicarbonate supplementation for the treatment of metabolic acidosis may also improve functional status. Selective serotonin reuptake inhibitors have not been consistently shown to improve fatigue in patients with kidney disease, but an ongoing trial will evaluate the effect of alternative antidepressant drug and behavioral activation therapy on fatigue in patients with CKD. Overall, more research is needed to further clarify underlying mechanisms of fatigue and identify effective, targeted treatments for patients with CKD.
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Affiliation(s)
- L. Parker Gregg
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Division of Nephrology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, Texas
| | - Maurizio Bossola
- Haemodialysis Unit, Fondazione Policlinico Universitario “Agostino Gemelli,” Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - S. Susan Hedayati
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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15
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Christodoulou M, Aspray TJ, Schoenmakers I. Vitamin D Supplementation for Patients with Chronic Kidney Disease: A Systematic Review and Meta-analyses of Trials Investigating the Response to Supplementation and an Overview of Guidelines. Calcif Tissue Int 2021; 109:157-178. [PMID: 33895867 PMCID: PMC8273061 DOI: 10.1007/s00223-021-00844-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/22/2021] [Indexed: 12/13/2022]
Abstract
A large proportion of patients with chronic kidney disease (CKD) are vitamin D deficient (plasma 25-hydroxyvitamin D (25(OH)D) < 25 or 30 nmol/L per UK and US population guidelines) and this contributes to the development of CKD-mineral bone disease (CKD-MBD). Gaps in the evidence-base for the management of vitamin D status in relation to CKD-MBD are hindering the formulation of comprehensive guidelines. We conducted a systemic review of 22 RCTs with different forms of vitamin D or analogues with CKD-MBD related outcomes and meta-analyses for parathyroid hormone (PTH). We provide a comprehensive overview of current guidelines for the management of vitamin D status for pre-dialysis CKD patients. Vitamin D supplementation had an inconsistent effect on PTH concentrations and meta-analysis showed non- significant reduction (P = 0.08) whereas calcifediol, calcitriol and paricalcitol consistently reduced PTH. An increase in Fibroblast Growth Factor 23 (FGF23) with analogue administration was found in all 3 studies reporting FGF23, but was unaltered in 4 studies with vitamin D or calcifediol. Few RCTS reported markers of bone metabolism and variations in the range of markers prevented direct comparisons. Guidelines for CKD stages G1-G3a follow general population recommendations. For the correction of deficiency general or CKD-specific patient guidelines provide recommendations. Calcitriol or analogues administration is restricted to stages G3b-G5 and depends on patient characteristics. In conclusion, the effect of vitamin D supplementation in CKD patients was inconsistent between studies. Calcifediol and analogues consistently suppressed PTH, but the increase in FGF23 with calcitriol analogues warrants caution.
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Affiliation(s)
| | - Terence J Aspray
- University of Newcastle Upon Tyne, Freeman Hospital, Bone Clinic, Newcastle, UK
| | - Inez Schoenmakers
- Medical School, University of East Anglia, Norwich, UK.
- Department of Medicine, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
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16
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Ketteler M, Ambühl P. Where are we now? Emerging opportunities and challenges in the management of secondary hyperparathyroidism in patients with non-dialysis chronic kidney disease. J Nephrol 2021; 34:1405-1418. [PMID: 34170509 PMCID: PMC8494658 DOI: 10.1007/s40620-021-01082-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022]
Abstract
Abstract Rising levels of parathyroid hormone (PTH) are common in patients with chronic kidney disease (CKD) not on dialysis and are associated with an elevated risk of morbidity (including progression to dialysis) and mortality. However, there are several challenges for the clinical management of secondary hyperparathyroidism (SHPT) in this population. While no recognised target level for PTH currently exists, it is accepted that patients with non-dialysis CKD should receive early and regular monitoring of PTH from CKD stage G3a. However, studies indicate that adherence to monitoring recommendations in non-dialysis CKD may be suboptimal. SHPT is linked to vitamin D [25(OH)D] insufficiency in non-dialysis CKD, and correction of low 25(OH)D levels is a recognised management approach. A second challenge is that target 25(OH)D levels are unclear in this population, with recent evidence suggesting that the level of 25(OH)D above which suppression of PTH progressively diminishes may be considerably higher than that recommended for the general population. Few therapeutic agents are licensed for use in non-dialysis CKD patients with SHPT and optimal management remains controversial. Novel approaches include the development of calcifediol in an extended-release formulation, which has been shown to increase 25(OH)D gradually and provide a physiologically-regulated increase in 1,25(OH)2D that can reliably lower PTH in CKD stage G3–G4 without clinically meaningful increases in serum calcium and phosphate levels. Additional studies would be beneficial to assess the comparative effects of available treatments, and to more clearly elucidate the overall benefits of lowering PTH in non-dialysis CKD, particularly in terms of hard clinical outcomes. Graphic abstract ![]()
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Affiliation(s)
- Markus Ketteler
- Allgemeine Innere Medizin und Nephrologie, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
| | - Patrice Ambühl
- Institut für Nephrologie, Stadtspital Waid und Triemli Zürich, Zurich, Switzerland
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17
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Galassi A, Ciceri P, Porata G, Iatrino R, Boni Brivio G, Fasulo E, Magagnoli L, Stucchi A, Frittoli M, Cara A, Cozzolino M. Current treatment options for secondary hyperparathyroidism in patients with stage 3 to 4 chronic kidney disease and vitamin D deficiency. Expert Opin Drug Saf 2021; 20:1333-1349. [PMID: 33993809 DOI: 10.1080/14740338.2021.1931117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Secondary hyperparathyroidism (SHPT) represents a complication of chronic kidney disease (CKD). Vitamin D system is altered since early CKD, and vitamin D deficiency is an established trigger of SHPT. Although untreated SHPT may degenerate into tertiary hyperparathyroidism with detrimental consequences in advanced CKD, best treatments for counteracting SHPT from stage 3 CKD are still debated. Enthusiasm on prescription of vitamin D receptor activators (VDRA) in non-dialysis renal patients, has been mitigated by the risk of low bone turnover and positive calcium-phosphate balance. Nutritional vitamin D is now suggested as first-line therapy to treat SHPT with low 25(OH)D insufficiency. However, no high-grade evidence supports the best choice between ergocalciferol, cholecalciferol, and calcifediol (in its immediate or extended-release formulation).Areas covered: The review discusses available data on safety and efficacy of nutritional vitamin D, VDRA and nutritional therapy in replenishing 25(OH)D deficiency and counteracting SHPT in non-dialysis CKD patients.Expert opinion: Best treatment for low 25(OH)D and SHPT remains unknown, due to incomplete understanding of the best homeostatic, as mutable, adaptation of mineral metabolism to CKD progression. Nutritional vitamin D and nutritional therapy appear safest interventions, whenever contextualized with single-patient characteristics. VDRA should be restricted to uncontrolled SHPT by first-line therapy.
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Affiliation(s)
- Andrea Galassi
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and Fondazione D'Amico per La Ricerca Sulle Malattie Renali, Milan, Italy
| | - Giulia Porata
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy
| | | | - Giulia Boni Brivio
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy.,Department of Health and Science, University of Milan, Milan, Italy
| | - Eliana Fasulo
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy
| | - Lorenza Magagnoli
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy.,Department of Health and Science, University of Milan, Milan, Italy
| | - Andrea Stucchi
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy
| | - Michela Frittoli
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy.,Department of Health and Science, University of Milan, Milan, Italy
| | - Anila Cara
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy.,Department of Health and Science, University of Milan, Milan, Italy
| | - Mario Cozzolino
- Renal and Dialysis Unit, ASST Santi Paolo E Carlo, Milan, Italy.,Department of Health and Science, University of Milan, Milan, Italy
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18
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Karimi E, Bitarafan S, Mousavi SM, Zargarzadeh N, Mokhtari P, Hawkins J, Meysamie A, Koohdani F. The effect of vitamin D supplementation on fibroblast growth factor-23 in patients with chronic kidney disease: A systematic review and meta-analysis. Phytother Res 2021; 35:5339-5351. [PMID: 33928687 DOI: 10.1002/ptr.7139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 03/30/2021] [Accepted: 04/10/2021] [Indexed: 12/28/2022]
Abstract
This is a meta-analysis of randomized controlled trials (RCTs) investigating the effects of oral vitamin D supplementation on serum fibroblast growth factor-23 (FGF23) concentrations in patients with chronic kidney disease (CKD). Manuscripts were extracted from PubMed/MEDLINE, Scopus, and ISI Web of Science through February 2020. Subgroup analyses, sensitivity analysis, and meta-regression assessments were performed. A total of eight clinical trials with nine treatment arms were included in the final analysis. The pooled results showed no significant changes in circulating FGF23 following vitamin D supplementation compared to the control group (Standardized mean difference (SMD): 0.24; 95% confidence intervals (CIs): -0.03 to 0.50, p > 0.05). Subgroup analyses found that studies which had participants with a body mass index (BMI) higher than 25 kg/m2 , with an intervention duration shorter than 15 weeks, using phosphate binder medications, and trials that were on both patients with CKD undergoing hemodialysis and patients without hemodialysis treatment produced significant increases in FGF23 when concentration compared with the control group. This meta-analysis provides evidence that vitamin D supplementation does not have a significant effect on plasma FGF23 levels. However, further high-quality trials are required to identify the influence of oral vitamin D supplementation on FGF23 levels in patients with CKD.
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Affiliation(s)
- Elmira Karimi
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sama Bitarafan
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Mousavi
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nikan Zargarzadeh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Pari Mokhtari
- Department of Nutrition and Integrative Physiology, College of Health, University of Utah, Salt Lake City, Utah, USA
| | - Jessie Hawkins
- Integrative Health, Franklin School of Integrative Health Sciences, Franklin, Tennessee, USA
| | - Alipasha Meysamie
- Department of Community Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Fariba Koohdani
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
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19
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Cianciolo G, Cappuccilli M, Tondolo F, Gasperoni L, Zappulo F, Barbuto S, Iacovella F, Conte D, Capelli I, La Manna G. Vitamin D Effects on Bone Homeostasis and Cardiovascular System in Patients with Chronic Kidney Disease and Renal Transplant Recipients. Nutrients 2021; 13:1453. [PMID: 33922902 PMCID: PMC8145016 DOI: 10.3390/nu13051453] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/14/2021] [Accepted: 04/22/2021] [Indexed: 12/25/2022] Open
Abstract
Poor vitamin D status is common in patients with impaired renal function and represents one main component of the complex scenario of chronic kidney disease-mineral and bone disorder (CKD-MBD). Therapeutic and dietary efforts to limit the consequences of uremia-associated vitamin D deficiency are a current hot topic for researchers and clinicians in the nephrology area. Evidence indicates that the low levels of vitamin D in patients with CKD stage above 4 (GFR < 15 mL/min) have a multifactorial origin, mainly related to uremic malnutrition, namely impaired gastrointestinal absorption, dietary restrictions (low-protein and low-phosphate diets), and proteinuria. This condition is further worsened by the compromised response of CKD patients to high-dose cholecalciferol supplementation due to the defective activation of renal hydroxylation of vitamin D. Currently, the literature lacks large and interventional studies on the so-called non-calcemic activities of vitamin D and, above all, the modulation of renal and cardiovascular functions and immune response. Here, we review the current state of the art of the benefits of supplementation with native vitamin D in various clinical settings of nephrological interest: CKD, dialysis, and renal transplant, with a special focus on the effects on bone homeostasis and cardiovascular outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplantation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.C.); (M.C.); (F.T.); (L.G.); (F.Z.); (S.B.); (F.I.); (D.C.); (I.C.)
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20
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Shoji T, Nakatani S, Kabata D, Mori K, Shintani A, Yoshida H, Takahashi K, Ota K, Fujii H, Ueda S, Nishi S, Nakatani T, Yoshiyama M, Goto K, Hamada T, Imanishi M, Ishimura E, Kagitani S, Kato Y, Kumeda Y, Maekawa K, Matsumura T, Nagayama H, Obi Y, Ohno Y, Sai Y, Sakurai M, Sasaki S, Shidara K, Shoji S, Tsujimoto Y, Yamakawa K, Yasuda H, Yodoi S, Inaba M, Emoto M. Comparative Effects of Etelcalcetide and Maxacalcitol on Serum Calcification Propensity in Secondary Hyperparathyroidism: A Randomized Clinical Trial. Clin J Am Soc Nephrol 2021; 16:599-612. [PMID: 33685864 PMCID: PMC8092049 DOI: 10.2215/cjn.16601020] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/22/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Vitamin D receptor activators and calcimimetics (calcium-sensing receptor agonists) are two major options for medical treatment of secondary hyperparathyroidism. A higher serum calcification propensity (a shorter T50 value) is a novel surrogate marker of calcification stress and mortality in patients with CKD. We tested a hypothesis that a calcimimetic agent etelcalcetide is more effective in increasing T50 value than a vitamin D receptor activator maxacalcitol. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A randomized, multicenter, open-label, blinded end point trial with active control was conducted in patients with secondary hyperparathyroidism undergoing hemodialysis in Japan. Patients were randomly assigned to receive intravenous etelcalcetide 5 mg thrice weekly (etelcalcetide group) or intravenous maxacalcitol 5 or 10 µg thrice weekly (maxacalcitol group). The primary, secondary, and tertiary outcomes were changes in T50 value, handgrip strength, and score of the Dementia Assessment Sheet for Community-Based Integrated Care System from baseline to 12 months, respectively. RESULTS In total, 425 patients from 23 dialysis centers were screened for eligibility, 326 patients were randomized (etelcalcetide, n=167; control, n=159), and 321 were included in the intention-to-treat analysis (median age, 66 years; 113 women [35%]). The median (interquartile range) of T50 value was changed from 116 minutes (interquartile range, 90-151) to 131 minutes (interquartile range, 102-176) in the maxacalcitol group, whereas it was changed from 123 minutes (interquartile range, 98-174) to 166 minutes (interquartile range, 127-218) in the etelcalcetide group. The increase in T50 value was significantly greater in the etelcalcetide group (difference in change, 20 minutes; 95% confidence interval, 7 to 34 minutes; P=0.004). No significant between-group difference was found in the change in handgrip strength or in the Dementia Assessment Sheet for Community-Based Integrated Care System score. CONCLUSIONS Etelcalcetide was more effective in increasing T50 value than maxacalcitol among patients on hemodialysis with secondary hyperparathyroidism. There was no difference in handgrip strength or cognition between the two drugs. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER VICTORY; UMIN000030636 and jRCTs051180156.
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Affiliation(s)
- Tetsuo Shoji
- Department of Vascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan,Vascular Science Center for Translational Research, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinya Nakatani
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Katsuhito Mori
- Department of Nephrology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hisako Yoshida
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kanae Takahashi
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Keiko Ota
- Center for Clinical Research and Innovation, Osaka City University Hospital, Osaka, Japan
| | - Hisako Fujii
- Department of Drug and Food Evaluation, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinichiro Ueda
- Department of Clinical Pharmacology and Therapeutics, University of the Ryukyus, Okinawa, Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tatsuya Nakatani
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Minoru Yoshiyama
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Masaaki Inaba
- Vascular Science Center for Translational Research, Osaka City University Graduate School of Medicine, Osaka, Japan,Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan,Department of Nephrology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masanori Emoto
- Vascular Science Center for Translational Research, Osaka City University Graduate School of Medicine, Osaka, Japan,Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan,Department of Nephrology, Osaka City University Graduate School of Medicine, Osaka, Japan
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Bacchetta J, Bernardor J, Garnier C, Naud C, Ranchin B. Hyperphosphatemia and Chronic Kidney Disease: A Major Daily Concern Both in Adults and in Children. Calcif Tissue Int 2021; 108:116-127. [PMID: 31996964 DOI: 10.1007/s00223-020-00665-8] [Citation(s) in RCA: 15] [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: 11/21/2019] [Accepted: 01/20/2020] [Indexed: 12/19/2022]
Abstract
Hyperphosphatemia is common in chronic kidney disease (CKD). Often seen as the "silent killer" because of its dramatic effect on vascular calcifications, hyperphosphatemia explains, at least partly, the onset of the complex mineral and bone disorders associated with CKD (CKD-MBD), together with hypocalcemia and decreased 1-25(OH)2 vitamin D levels. The impact of CKD-MBD may be immediate with abnormalities of bone and mineral metabolism with secondary hyperparathyroidism and increased FGF23 levels, or delayed with poor growth, bone deformities, fractures, and vascular calcifications, leading to increased morbidity and mortality. The global management of CKD-MBD has been detailed in international guidelines for adults and children, however, with difficulties to obtain an agreement on the ideal PTH targets. The clinical management of hyperphosphatemia is a daily challenge for nephrologists and pediatric nephrologists, notably because of the phosphate overload in occidental diets that is mainly due to the phosphate "hidden" in food additives. The management begins with a dietary restriction of phosphate intake, and is followed by the use of calcium-based and non-calcium-based phosphate binders, and/or the intensification of dialysis. The objective of this review is to provide an overview of the pathophysiology of hyperphosphatemia in CKD, with a focus on its deleterious effects and a description of the clinical management of hyperphosphatemia in a more global setting of CKD-MBD.
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Affiliation(s)
- Justine Bacchetta
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France.
- Université de Lyon, Lyon, France.
- INSERM 1033 Research Unit, Lyon, France.
| | - Julie Bernardor
- Unité de Néphrologie pédiatrique, Hôpital L'Archet, CHU de Nice, Nice, France
| | - Charlotte Garnier
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
| | - Corentin Naud
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
| | - Bruno Ranchin
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
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Winder MB, Mason DL, Rangaswami J, Asif A, Vachharajani TJ, Mathew RO. Racial differences in the relationship between high-normal 25-hydroxy vitamin d and parathyroid hormone levels in early stage chronic kidney disease. J Bras Nefrol 2021; 43:34-40. [PMID: 33022030 PMCID: PMC8061959 DOI: 10.1590/2175-8239-jbn-2020-0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/23/2020] [Indexed: 12/03/2022] Open
Abstract
AIM Current guidelines do not address between-person variability in markers of bone and mineral metabolism across subgroups of patients, nor delineate treatment strategies based upon such factors. METHODS A cross sectional study was carried out to analyze data from 20,494 United States Veterans and verify the variability of Vitamin D (25(OH)D) and parathyroid hormone (PTH) levels across race and stage of chronic kidney disease. RESULTS PTH levels were higher in Black Americans (BA) than White Americans (WA) at all levels of 25(OH)D and across eGFR strata. There was a progressive decline in PTH levels from the lowest (25(OH)D < 20) to highest quartile (25(OH)D >=40) in both BA (134.4 v 90 pg/mL, respectively) and WA (112.5 v 71.62 pg/mL) (p<0.001 for all comparisons). CONCLUSION In this analysis, higher than normal 25(OH)D levels were well tolerated and associated with lower parathyroid hormone values in both blacks and whites. Black Americans had higher PTH values at every level of eGFR and 25(OH)D levels suggesting a single PTH target is not appropriate.
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Affiliation(s)
- Marquita B. Winder
- Columbia Veterans Affairs Health Care System, Columbia, SC, United States
| | | | | | - Arif Asif
- Jersey Shore University Medical Center, Hackensack-Meridian School of Medicine, Neptune, NJ, United States
| | - Tushar J. Vachharajani
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Glickman Urological & Kidney Institute, Department of Nephrology & Hypertension, Cleveland, OH, United States
| | - Roy O. Mathew
- Columbia Veterans Affairs Health Care System, Columbia, SC, United States
- University of South Carolina, School of Medicine, Columbia, SC, United States
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23
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Hyder R, Sprague SM. Secondary Hyperparathyroidism in a Patient with CKD. Clin J Am Soc Nephrol 2020; 15:1041-1043. [PMID: 32461217 PMCID: PMC7341786 DOI: 10.2215/cjn.13411119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Ryyan Hyder
- NorthShore University Health System-Pritzker School of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Stuart M Sprague
- NorthShore University Health System-Pritzker School of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois
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24
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Intermittent cholecalciferol supplementation in children and teenagers followed in pediatric nephrology: data from a prospective single-center single-arm open trial. Eur J Pediatr 2020; 179:661-669. [PMID: 31873802 DOI: 10.1007/s00431-019-03553-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 12/24/2022]
Abstract
Vitamin D deficiency is frequent in pediatric nephrology. The 2017 European guidelines recommend keeping 25OH vitamin D (25-D) levels within the 75-120 nmol/L range, ideally with daily supplementation. Intermittent supplementation with D3 has also been proposed. We aimed to assess the influence of our local protocol of intermittent vitamin D supplementation on the evolution of 25-D levels between baseline and 2 months. VITATOL is a prospective single-center study performed in our tertiary unit in children and teenagers followed for chronic kidney disease (CKD), kidney transplantation, or stable chronic nephrotic syndrome with 25-D levels below 75 nmol/L. Intermittent oral cholecalciferol (100,000 IU) was administered depending on baseline vitamin D levels and body weight. The primary outcome was the change in 25-D levels between baseline and 2 months. Secondary outcomes were the evolution of the main mineral biomarkers. Thirty-seven patients were included. Two months after beginning supplementation, corresponding to a median(min-max) of 46 (14-79) days after the last dose of vitamin D, 25-D levels increased from 50 to 76 nmol/L (p < 0.001), 18 patients having 25-D levels within the target range and 2 above. All patients displayed 25-D levels above 50 nmol/L. There were no significant changes in phosphate, PTH, alkaline phosphatase, and FGF23 levels before and after supplementation. Calcium levels increased from 2.39 to 2.44 mmol/L (p = 0.017), but no differences in calciuria and urinary calcium/creatinine ratio were observed.Conclusion: This vitamin D supplementation protocol using intermittent moderate doses of cholecalciferol seems efficient in 54% of cases, with neither significant overdose nor hypercalciuria. What is Known: • Vitamin D deficiency is frequent in pediatric nephrology. • The 2017 European guidelines recommend keeping 25OH vitamin D levels within the 75-120 nmol/L range ideally with daily supplementation, but intermittent supplementation with D3 has also been proposed. What is New: • We assessed the influence of a local protocol of intermittent vitamin D supplementation on the evolution of 25-D levels between baseline and 2 months in children and teenagers followed in pediatric nephrology. • The intermittent cholecalciferol supplementation protocol seems efficient in 54% of cases, with neither significant overdose nor hypercalciuria.
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Restrepo-Valencia CA, Aguirre-Arango JV, Musso CG. Effectiveness of Native Vitamin D Therapy in Patients with Chronic Kidney Disease Stage 3 and Hypovitaminosis D in Colombia, South America. Int J Nephrol Renovasc Dis 2019; 12:241-250. [PMID: 31827333 PMCID: PMC6902866 DOI: 10.2147/ijnrd.s214194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 11/21/2019] [Indexed: 01/25/2023] Open
Abstract
Introduction: In a high percentage of patients with chronic kidney disease (CKD) low levels of vitamin D are detected. The purpose of this study was to evaluate if the native vitamin D therapy (cholecalciferol) in the patients with stage 3 and hypovitaminosis D allows to modify markers of bone and mineral metabolism once normal serum levels have been achieved. MATERIALS AND METHODS From an initial base of 297 patients with CKD and hypovitaminosis D, those with normal or high levels of PTH were chosen for therapy with native vitamin D. The initial administered dose was 1000 IU/day, with adjustments every 4 months of 1000 IU (maximum 4000 IU/day, according to RDA and IOM), until achieving serum levels of 25 hydroxyvitamin D greater than 30 ng/mL and lower than 80 ng/mL. The variables calcium, phosphorus, intact parathormone (iPTH), creatinine and glomerular filtration rate (GFR) were also evaluated every 4 months. RESULTS The total number of patients included in this study was 170. Seventy-three patients were excluded along the follow-up: 17 non-responders (never achieved the projected serum levels of vitamin D), and 56 for not completing one year of follow-up. A total of 97 patients were finally included. In 82 patients, follow-up was achieved for 12 months (G1) and in 38 patients for 24 months (G2). In 15 patients despite achieving satisfactory levels of vitamin D at 12 months, it was not possible to obtain adequate levels of iPTH for their GFR according to K/DOQI 2003 guidelines and they were called refractory to therapy (G3). In both groups 1 and 2, a non-significant tendency to increase calcium and serum phosphorus was observed. iPTH decreased significantly at 12 and 24 months follow-up. In group 3, we opted at 12 months for conversion to calcitriol, with a significant reduction in iPTH values. In this group, the initial value of GFR was close to 30 mL/min, and its fall in time more significant than the other two groups to CKD stage 4. CONCLUSION Cholecalciferol with adjustment in its dose, and obtaining normal serum levels is an excellent therapeutic alternative for the treatment of patients with CKD stage 3, and hypovitaminosis D. In the group of patients with GFR close to 30 mL/min, or lower values (stage 4), and with the presence of secondary hyperparathyroidism, the use of active form of vitamin D (calcitriol, paricalcitol) is recommended as the first therapeutic alternative.
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Affiliation(s)
| | | | - Carlos G Musso
- Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
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26
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Capelli I, Cianciolo G, Gasperoni L, Galassi A, Ciceri P, Cozzolino M. Nutritional vitamin D in CKD: Should we measure? Should we treat? Clin Chim Acta 2019; 501:186-197. [PMID: 31770508 DOI: 10.1016/j.cca.2019.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 02/08/2023]
Abstract
Vitamin Ddeficiency is frequently present in patients affected by chronic kidney disease (CKD). Experimental studies demonstrated that Vitamin D may play a role in the pathophysiology of diseases beyond mineral bone disorders in CKD (CKD-MBD). Unfortunately, the lack of large and interventional studies focused on the so called "non-classic" effects of 25(OH) Vitamin D supplementation in CKD patients, doesn't permit to conclude definitely about the beneficial effects of this supplementation in clinical practice. In conclusion, treatment of nutritional vitamin D deficiency in CKD may play a central role in both bone homeostasis and cardiovascular outcomes, but there is not clear evidence to support one formulation of nutritional vitamin D over another in CKD.
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Affiliation(s)
- Irene Capelli
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Cianciolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Lorenzo Gasperoni
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy.
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27
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Cholecalciferol supplementation increases FGF23 in peritoneal dialysis patients with hypovitaminosis D: a randomized clinical trial. J Nephrol 2019; 32:645-659. [DOI: 10.1007/s40620-019-00599-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/07/2019] [Indexed: 02/07/2023]
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28
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Lu CL, Yeih DF, Hou YC, Jow GM, Li ZY, Liu WC, Zheng CM, Lin YF, Shyu JF, Chen R, Huang CY, Lu KC. The Emerging Role of Nutritional Vitamin D in Secondary Hyperparathyroidism in CKD. Nutrients 2018; 10:nu10121890. [PMID: 30513912 PMCID: PMC6316278 DOI: 10.3390/nu10121890] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/22/2018] [Accepted: 11/23/2018] [Indexed: 12/18/2022] Open
Abstract
In chronic kidney disease (CKD), hyperphosphatemia induces fibroblast growth factor-23 (FGF-23) expression that disturbs renal 1,25-dihydroxy vitamin D (1,25D) synthesis; thereby increasing parathyroid hormone (PTH) production. FGF-23 acts on the parathyroid gland (PTG) to increase 1α-hydroxylase activity and results in increase intra-gland 1,25D production that attenuates PTH secretion efficiently if sufficient 25D are available. Interesting, calcimimetics can further increase PTG 1α-hydroxylase activity that emphasizes the demand for nutritional vitamin D (NVD) under high PTH status. In addition, the changes in hydroxylase enzyme activity highlight the greater parathyroid 25-hydroxyvitmain D (25D) requirement in secondary hyperparathyroidism (SHPT); the higher proportion of oxyphil cells as hyperplastic parathyroid progression; lower cytosolic vitamin D binding protein (DBP) content in the oxyphil cell; and calcitriol promote vitamin D degradation are all possible reasons supports nutritional vitamin D (NVD; e.g., Cholecalciferol) supplement is crucial in SHPT. Clinically, NVD can effectively restore serum 25D concentration and prevent the further increase in PTH level. Therefore, NVD might have the benefit of alleviating the development of SHPT in early CKD and further lowering PTH in moderate to severe SHPT in dialysis patients.
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Affiliation(s)
- Chien-Lin Lu
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan.
- Division of Nephrology, Department of Medicine, Fu Jen Catholic University Hospital, School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan.
| | - Dong-Feng Yeih
- Division of Cardiology, Department of Medicine, Fu Jen Catholic University Hospital, School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan.
| | - Yi-Chou Hou
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan.
- Division of Nephrology, Department of Medicine, Cardinal-Tien Hospital, School of Medicine, Fu Jen Catholic University, New Taipei City 23155, Taiwan.
| | - Guey-Mei Jow
- Division of Nephrology, Department of Medicine, Fu Jen Catholic University Hospital, School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan.
| | - Zong-Yu Li
- Division of Nephrology, Department of Medicine, Fu Jen Catholic University Hospital, School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan.
| | - Wen-Chih Liu
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan.
- Division of Nephrology, Department of Internal Medicine, Tungs' Taichung MetroHarbor Hospital, Taichung City 433, Taiwan.
| | - Cai-Mei Zheng
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan.
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, New Taipei City 235, Taiwan.
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11103, Taiwan.
| | - Yuh-Feng Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan.
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, New Taipei City 235, Taiwan.
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11103, Taiwan.
| | - Jia-Fwu Shyu
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan.
- Department of Biology and Anatomy, National Defense Medical Center, Taipei 114, Taiwan.
| | - Remy Chen
- Kidney Dialysis Center, Kamifukuoka General Hospital, Saitama 356, Japan.
| | - Chung-Yu Huang
- Department of Medicine, Show-Chwan Memorial Hospital, Changhua 50008, Taiwan.
| | - Kuo-Cheng Lu
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan.
- Division of Nephrology, Department of Medicine, Fu Jen Catholic University Hospital, School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan.
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Özkan G, Güzel S, Atar RV, Fidan Ç, Kara SP, Ulusoy Ş. Elevated serum levels of procollagen C-proteinase enhancer-1 in patients with chronic kidney disease is associated with a declining glomerular filtration rate. Nephrology (Carlton) 2018; 24:938-942. [PMID: 30393914 DOI: 10.1111/nep.13521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Procollagen C-proteinase enhancer-1 (PCPE-1) is a 55 kDa glycoprotein, which increases the activity of procollagen C-proteinases that break down C-terminal propeptides. Studies have shown that PCPE-1 is involved in the fibrotic process that occurs in various tissues and organs. Our review of the literature revealed no data concerning the relation between PCPE-1 and chronic kidney disease (CKD). The purpose of this study was to determine PCPE-1 levels in CKD. METHODS One hundred thirty-one CKD patients and 34 healthy controls were included in our study. Demographic data were recorded, and routine biochemical tests were performed. Blood specimens were collected for PCPE-1 investigation. Demographic data, biochemical test results and PCPE-1 levels were compared between the control and patient groups. Parameters affecting PCPE-1 levels in our patient group were assessed. RESULTS Procollagen C-proteinase enhancer-1 levels were significantly higher in our patient group compared to the control group. Parameters affecting PCPE-1 elevation in the patient group were identified as systolic blood pressure, blood urea nitrogen, phosphorus, haemoglobin, intact parathormone levels, glomerular filtration rate and body mass index. CONCLUSION We determined high PCPE-1 levels in CKD patients. PCPE-1 levels being negatively correlated with glomerular filtration rate suggests that PCPE-1 may be associated with progression in CKD patients.
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Affiliation(s)
- Gülsüm Özkan
- Department of Nephrology, Namık Kemal University, School of Medicine, Tekirdağ, Turkey
| | - Savaş Güzel
- Department of Biochemistry, Namık Kemal University, School of Medicine, Tekirdağ, Turkey
| | - Reşit V Atar
- Department of Internal Medicine, Namık Kemal University, School of Medicine, Tekirdağ, Turkey
| | - Çiğdem Fidan
- Department of Biochemistry, Namık Kemal University, School of Medicine, Tekirdağ, Turkey
| | - Sonat P Kara
- Department of Internal Medicine, Namık Kemal University, School of Medicine, Tekirdağ, Turkey
| | - Şükrü Ulusoy
- Department of Nephrology, Karadeniz Technical University, School of Medicine, Trabzon, Turkey
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Abstract
Chronic kidney disease mineral and bone disorder (MBD) encompasses changes in mineral ion and vitamin D metabolism that are widespread in the setting of chronic kidney disease and end-stage renal disease. MBD components associate with cardiovascular disease in many epidemiologic studies. Through impacts on hypertension, activation of the renin-angiotensin-aldosterone system, vascular calcification, endothelial function, and cardiac remodeling and conduction, MBD may be a direct and targetable cause of cardiovascular disease. However, assessment and treatment of MBD is rife with challenges owing to biological tensions between its many components, such as calcium and phosphorus with their regulatory hormones fibroblast growth factor 23 and parathyroid hormone; fibroblast growth factor 23 with its co-receptor klotho; and vitamin D with control of calcium and phosphorus. These complex interactions between MBD components hinder the simple translation to clinical trials, which ultimately are needed to prove the benefits of treating MBD. Deeper investigation using precision medicine tools and principles, including genomics and individualized risk assessment and therapy, may help move the field closer toward clinical applications. This review provides a high-level overview of conventional and precision epidemiology in MBD, potential mechanisms of cardiovascular disease pathogenesis, and guiding therapeutic principles for established and emerging treatments.
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Affiliation(s)
- Joseph Lunyera
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC.
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Lodebo BT, Shah A, Kopple JD. Is it Important to Prevent and Treat Protein-Energy Wasting in Chronic Kidney Disease and Chronic Dialysis Patients? J Ren Nutr 2018; 28:369-379. [DOI: 10.1053/j.jrn.2018.04.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/30/2018] [Accepted: 04/05/2018] [Indexed: 01/05/2023] Open
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32
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Chemouny JM, Sannier A, Hanouna G, Champion L, Vrtovsnik F, Daugas E. Malakoplakia as a cause of severe hypercalcemia through ectopic 25-hydroxyvitamin D3 1-alpha-hydroxylase expression: A case report. Medicine (Baltimore) 2018; 97:e12090. [PMID: 30290590 PMCID: PMC6200547 DOI: 10.1097/md.0000000000012090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Malakoplakia is a rare disease characterized by the presence of nongranulomatous macrophage infiltration. In most cases, it affects the urinary tract. Malakoplakia can cause acute kidney injury when it is localized in the kidneys. PATIENT CONCERNS Here, we report the case of a 65-year-old female patient with renal malakoplakia responsible for hypercalcemia. During her initial assessment, she was also diagnosed 25-OH vitamin D insufficiency, for which she was prescribed oral cholecalciferol. Three months later, she developed severe hypercalcemia with normal 25-OH vitamin D and parathyroid hormone levels and high 1,25-dihydroxyvitamin D levels. DIAGNOSES After a superimposed granulomatous disease was excluded, malakoplakia cells were suspected to be responsible for the abnormal 25-hydroxyvitamin D3 1-alpha-hydroxylase activity, which was confirmed by immunohistochemistry. INTERVENTIONS Cholecalciferol was stopped, the patient was rehydrated with intravenous physiological saline, and prednisone was initiated to decrease the enzyme activity. OUTCOMES Six months later, she displayed normal serum calcium, 25-OH vitamin D and 1,25-dihydroxyvitamin D levels. LESSONS This case illustrates that malakoplakia may exhibit ectopic 25-hydroxyvitamin D3 1-alpha-hydroxylase activity and cause severe hypercalcemia upon vitamin D supplementation. Therefore, such supplementation should not be given in malakoplakia patients without an actual deficiency and requires careful monitoring of serum calcium.
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Affiliation(s)
- Jonathan Maurice Chemouny
- Service de Néphrologie, Hôpital Bichat-Claude Bernard, AP-HP, DHU Fire
- INSERM, Centre de Recherche sur l’Inflammation
- Université Paris Diderot, Sorbonne Paris Cité
| | - Aurélie Sannier
- Université Paris Diderot, Sorbonne Paris Cité
- Laboratoire d’anatomopathologie et de cytologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Guillaume Hanouna
- Service de Néphrologie, Hôpital Bichat-Claude Bernard, AP-HP, DHU Fire
- INSERM, Centre de Recherche sur l’Inflammation
| | | | - Francois Vrtovsnik
- Service de Néphrologie, Hôpital Bichat-Claude Bernard, AP-HP, DHU Fire
- INSERM, Centre de Recherche sur l’Inflammation
- Université Paris Diderot, Sorbonne Paris Cité
| | - Eric Daugas
- Service de Néphrologie, Hôpital Bichat-Claude Bernard, AP-HP, DHU Fire
- INSERM, Centre de Recherche sur l’Inflammation
- Université Paris Diderot, Sorbonne Paris Cité
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