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van der Vaart A, Bakker SJL, Laverman GD, van Dijk PR, de Borst MH. NT-proBNP Mediates the Association Between FGF23 and All-Cause Mortality in Individuals With Type 2 Diabetes. J Am Heart Assoc 2023; 12:e031873. [PMID: 38014662 PMCID: PMC10727346 DOI: 10.1161/jaha.123.031873] [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: 07/20/2023] [Accepted: 09/27/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND FGF23 (fibroblast growth factor 23) is associated with a higher mortality risk in type 2 diabetes, but the mechanism is unclear. We aimed to study whether NT-proBNP (N-terminal pro-brain natriuretic peptide) mediates the association between FGF23 and mortality. METHODS AND RESULTS We analyzed C-terminal FGF23 and NT-proBNP levels in 399 patients with type 2 diabetes. Cox regression analyses were performed, followed by mediation analyses using Structural Equation Modeling. During follow-up of 9.2 [7.6-11.3] years, 117 individuals died. FGF23 was associated with all-cause mortality, independent of potential confounders (fully adjusted hazard ratio [HR], 2.32 [95% CI, 1.21-4.43], P=0.01). The association was lost upon further adjustment for NT-proBNP (HR, 1.84; 95% CI, 0.91-3.73). NT-proBNP accounted for 26% of the mediation effect between FGF23 and all-cause mortality. CONCLUSIONS These findings suggest that a higher FGF23 level is associated with increased mortality in individuals with type 2 diabetes through an effect on volume homeostasis.
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Affiliation(s)
- Amarens van der Vaart
- Department of Internal Medicine, Division of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
- Department of Internal Medicine, Division of EndocrinologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Stephan J. L. Bakker
- Department of Internal Medicine, Division of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Gozewijn D. Laverman
- Division of Nephrology, Department of Internal MedicineZiekenhuisgroep TwenteHengeloThe Netherlands
| | - Peter R. van Dijk
- Department of Internal Medicine, Division of EndocrinologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Martin H. de Borst
- Department of Internal Medicine, Division of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
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Hodson EM, Cooper TE. Altered dietary salt intake for preventing diabetic kidney disease and its progression. Cochrane Database Syst Rev 2023; 1:CD006763. [PMID: 36645291 PMCID: PMC9841968 DOI: 10.1002/14651858.cd006763.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND There is strong evidence that our current consumption of salt is a major factor in the development of increased blood pressure (BP) and that a reduction in our salt intake lowers BP, whether BP levels are normal or raised initially. Effective control of BP in people with diabetes lowers the risk of strokes, heart attacks and heart failure and slows the progression of chronic kidney disease (CKD) in people with diabetes. This is an update of a review first published in 2010. OBJECTIVES To evaluate the effect of altered salt intake on BP and markers of cardiovascular disease and of CKD in people with diabetes. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) of altered salt intake in individuals with type 1 and type 2 diabetes. Studies were included when there was a difference between low and high sodium intakes of at least 34 mmol/day. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies and resolved differences by discussion. We calculated mean effect sizes as mean difference (MD) and 95% confidence intervals (CI) using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Thirteen RCTs (313 participants), including 21 comparisons (studies), met our inclusion criteria. One RCT (two studies) was added to this review update. Participants included 99 individuals with type 1 diabetes and 214 individuals with type 2 diabetes. Two RCTs (four studies) included some participants with reduced overall kidney function. The remaining studies either reported that participants with reduced glomerular filtration rate (GFR) were excluded from the study or only included participants with microalbuminuria and normal GFR. Five studies used a parallel study design, and 16 used a cross-over design. Studies were at high risk of bias for most criteria. Random sequence generation and allocation concealment were adequate in only three and two studies, respectively. One study was at low risk of bias for blinding of participants and outcome assessment, but no studies were at low risk for selective reporting. Twelve studies reported non-commercial funding sources, three reported conflicts of interest, and eight reported adequate washout between interventions in cross-over studies. The median net reduction in 24-hour urine sodium excretion (24-hour UNa) in seven long-term studies (treatment duration four to 12 weeks) was 76 mmol (range 51 to 124 mmol), and in 10 short-term studies (treatment duration five to seven days) was 187 mmol (range 86 to 337 mmol). Data were only available graphically in four studies. In long-term studies, reduced sodium intake may lower systolic BP (SBP) by 6.15 mm Hg (7 studies: 95% CI -9.27 to -3.03; I² = 12%), diastolic BP (DBP) by 3.41 mm Hg (7 studies: 95% CI -5.56 to -1.27; I² = 41%) and mean arterial pressure (MAP) by 4.60 mm Hg (4 studies: 95% CI -7.26 to -1.94; I² = 28%). In short-term studies, low sodium intake may reduce SBP by 8.43 mm Hg (5 studies: 95% CI -14.37 to -2.48; I² = 88%), DBP by 2.95 mm Hg (5 studies: 95% CI -4.96 to -0.94; I² = 70%) and MAP by 2.37 mm Hg (9 studies: 95% CI -4.75 to -0.01; I² = 65%). There was considerable heterogeneity in most analyses but particularly among short-term studies. All analyses were considered to be of low certainty evidence. SBP, DBP and MAP reductions may not differ between hypertensive and normotensive participants or between individuals with type 1 or type 2 diabetes. In hypertensive participants, SBP, DBP and MAP may be reduced by 6.45, 3.15 and 4.88 mm Hg, respectively, while in normotensive participants, they may be reduced by 8.43, 2.95 and 2.15 mm Hg, respectively (all low certainty evidence). SBP, DBP and MAP may be reduced by 7.35, 3.04 and 4.30 mm Hg, respectively, in participants with type 2 diabetes and by 7.35, 3.20, and 0.08 mm Hg, respectively, in participants with type 1 diabetes (all low certainty evidence). Eight studies provided measures of urinary protein excretion before and after salt restriction; four reported a reduction in urinary albumin excretion with salt restriction. Pooled analyses showed no changes in GFR (12 studies: MD -1.87 mL/min/1.73 m², 95% CI -5.05 to 1.31; I² = 32%) or HbA1c (6 studies: MD -0.62, 95% CI -1.49 to 0.26; I² = 95%) with salt restriction (low certainty evidence). Body weight was reduced in studies lasting one to two weeks but not in studies lasting for longer periods (low certainty evidence). Adverse effects were reported in only one study; 11% and 21% developed postural hypotension on the low-salt diet and the low-salt diet combined with hydrochlorothiazide, respectively. AUTHORS' CONCLUSIONS This systematic review shows an important reduction in SBP and DBP in people with diabetes with normal GFR during short periods of salt restriction, similar to that obtained with single drug therapy for hypertension. These data support the international recommendations that people with diabetes with or without hypertension or evidence of kidney disease should reduce salt intake to less than 5 g/day (2 g sodium).
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Affiliation(s)
- Elisabeth M Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Tess E Cooper
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
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Acute cardiac overload does not induce cardiac or skeletal expression of fibroblast growth factor 23 in rats. Cardiovasc Endocrinol Metab 2021; 10:204-209. [PMID: 34765890 PMCID: PMC8575438 DOI: 10.1097/xce.0000000000000249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/05/2021] [Indexed: 12/05/2022]
Abstract
Elevated fibroblast growth factor 23 (FGF23) is associated with cardiovascular events, particularly heart failure. Although FGF23 has been reported to induce cardiac hypertrophy, recent studies demonstrated that cardiac hypertrophy and myocardial infarction induce FGF23 production by cardiomyocytes. We aimed to explore whether acute cardiac overload increases cardiac and skeletal FGF23 expression and circulating FGF23 levels.
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McMahon EJ, Campbell KL, Bauer JD, Mudge DW, Kelly JT. Altered dietary salt intake for people with chronic kidney disease. Cochrane Database Syst Rev 2021; 6:CD010070. [PMID: 34164803 PMCID: PMC8222708 DOI: 10.1002/14651858.cd010070.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Evidence indicates that reducing dietary salt may reduce the incidence of heart disease and delay decline in kidney function in people with chronic kidney disease (CKD). This is an update of a review first published in 2015. OBJECTIVES To evaluate the benefits and harms of altering dietary salt for adults with CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 6 October 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials comparing two or more levels of salt intake in adults with any stage of CKD. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility, conducted risk of bias evaluation and evaluated confidence in the evidence using GRADE. Results were summarised using random effects models as risk ratios (RR) for dichotomous outcomes or mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included 21 studies (1197 randomised participants), 12 in the earlier stages of CKD (779 randomised participants), seven in dialysis (363 randomised participants) and two in post-transplant (55 randomised participants). Selection bias was low in seven studies, high in one and unclear in 13. Performance and detection biases were low in four studies, high in two, and unclear in 15. Attrition and reporting biases were low in 10 studies, high in three and unclear in eight. Because duration of the included studies was too short (1 to 36 weeks) to test the effect of salt restriction on endpoints such as death, cardiovascular events or CKD progression, changes in salt intake on blood pressure and other secondary risk factors were examined. Reducing salt by mean -73.51 mmol/day (95% CI -92.76 to -54.27), equivalent to 4.2 g or 1690 mg sodium/day, reduced systolic/diastolic blood pressure by -6.91/-3.91 mm Hg (95% CI -8.82 to -4.99/-4.80 to -3.02; 19 studies, 1405 participants; high certainty evidence). Albuminuria was reduced by 36% (95% CI 26 to 44) in six studies, five of which were carried out in people in the earlier stages of CKD (MD -0.44, 95% CI -0.58 to -0.30; 501 participants; high certainty evidence). The evidence is very uncertain about the effect of lower salt intake on weight, as the weight change observed (-1.32 kg, 95% CI -1.94 to -0.70; 12 studies, 759 participants) may have been due to fluid volume, lean tissue, or body fat. Lower salt intake may reduce extracellular fluid volume in the earlier stages of CKD (-0.87 L, 95% CI -1.17 to -0.58; 3 studies; 187 participants; low certainty evidence). The evidence is very uncertain about the effect of lower salt intake on reduction in antihypertensive dose (RR 2.45, 95% CI 0.98 to 6.08; 8 studies; 754 participants). Lower salt intake may lead to symptomatic hypotension (RR 6.70, 95% CI 2.40 to 18.69; 6 studies; 678 participants; moderate certainty evidence). Data were sparse for other types of adverse events. AUTHORS' CONCLUSIONS We found high certainty evidence that salt reduction reduced blood pressure in people with CKD, and albuminuria in people with earlier stage CKD in the short-term. If such reductions could be maintained long-term, this effect may translate to clinically significant reductions in CKD progression and cardiovascular events. Research into the long-term effects of sodium-restricted diet for people with CKD is warranted.
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Affiliation(s)
- Emma J McMahon
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Brisbane, Australia
| | - Katrina L Campbell
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
- Healthcare Excellence and Innovation, Metro North Hospital and Health Service, Herston, Australia
| | - Judith D Bauer
- School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, Australia
| | - David W Mudge
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Woolloongabba, Australia
| | - Jaimon T Kelly
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
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Freundlich M, Gamba G, Rodriguez-Iturbe B. Fibroblast growth factor 23-Klotho and hypertension: experimental and clinical mechanisms. Pediatr Nephrol 2021; 36:3007-3022. [PMID: 33230698 PMCID: PMC7682775 DOI: 10.1007/s00467-020-04843-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/07/2020] [Accepted: 10/23/2020] [Indexed: 12/11/2022]
Abstract
Hypertension (HTN) and chronic kidney disease (CKD) are increasingly recognized in pediatric patients and represent risk factors for cardiovascular morbidity and mortality later in life. In CKD, enhanced tubular sodium reabsorption is a leading cause of HTN due to augmented extracellular fluid volume expansion. The renin-angiotensin-aldosterone system (RAAS) upregulates various tubular sodium cotransporters that are also targets of the hormone fibroblast growth factor 23 (FGF23) and its co-receptor Klotho. FGF23 inhibits the activation of 1,25-dihydroxyvitamin D that is a potent suppressor of renin biosynthesis. Here we review the complex interactions and disturbances of the FGF23-Klotho axis, vitamin D, and the RAAS relevant to blood pressure regulation and discuss the therapeutic strategies aimed at mitigating their pathophysiologic contributions to HTN.
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Affiliation(s)
- Michael Freundlich
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Gerardo Gamba
- grid.9486.30000 0001 2159 0001Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico ,grid.416850.e0000 0001 0698 4037Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Bernardo Rodriguez-Iturbe
- grid.416850.e0000 0001 0698 4037Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico ,grid.419172.80000 0001 2292 8289Department of Nephrology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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Humalda JK, Yeung SMH, Geleijnse JM, Gijsbers L, Riphagen IJ, Hoorn EJ, Rotmans JI, Vogt L, Navis G, Bakker SJL, de Borst MH. Effects of Potassium or Sodium Supplementation on Mineral Homeostasis: A Controlled Dietary Intervention Study. J Clin Endocrinol Metab 2020; 105:5854371. [PMID: 32506135 PMCID: PMC7365698 DOI: 10.1210/clinem/dgaa359] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/03/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Although dietary potassium and sodium intake may influence calcium-phosphate metabolism and bone health, the effects on bone mineral parameters, including fibroblast growth factor 23 (FGF23), are unclear. OBJECTIVE Here, we investigated the effects of potassium or sodium supplementation on bone mineral parameters. DESIGN, SETTING, PARTICIPANTS We performed a post hoc analysis of a dietary controlled randomized, blinded, placebo-controlled crossover trial. Prehypertensive individuals not using antihypertensive medication (n = 36) received capsules containing potassium chloride (3 g/d), sodium chloride (3 g/d), or placebo. Linear mixed-effect models were used to estimate treatment effects. RESULTS Potassium supplementation increased plasma phosphate (from 1.10 ± 0.19 to 1.15 ± 0.19 mmol/L, P = 0.004), in line with an increase in tubular maximum of phosphate reabsorption (from 0.93 ± 0.21 to 1.01 ± 0.20 mmol/L, P < 0.001). FGF23 decreased (114.3 [96.8-135.0] to 108.5 [93.5-125.9] RU/mL, P = 0.01), without change in parathyroid hormone and 25-hydroxy vitamin D3. Fractional calcium excretion decreased (from 1.25 ± 0.50 to 1.11 ± 0.46 %, P = 0.03) without change in plasma calcium. Sodium supplementation decreased both plasma phosphate (from 1.10 ± 0.19 to 1.06 ± 0.21 mmol/L, P = 0.03) and FGF23 (from 114.3 [96.8-135.0] to 108.7 [92.3-128.1] RU/mL, P = 0.02). Urinary and fractional calcium excretion increased (from 4.28 ± 1.91 to 5.45 ± 2.51 mmol/24 hours, P < 0.001, and from 1.25 ± 0.50 to 1.44 ± 0.54 %, P = 0.004, respectively). CONCLUSIONS Potassium supplementation led to a decrease in FGF23, which was accompanied by increase in plasma phosphate and decreased calcium excretion. Sodium supplementation reduced FGF23, but this was accompanied by decrease in phosphate and increase in fractional calcium excretion. Our results indicate distinct effects of potassium and sodium intake on bone mineral parameters, including FGF23. CLINICAL TRIAL REGISTRATION NUMBER NCT01575041.
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Affiliation(s)
- Jelmer K Humalda
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, RB Groningen, the Netherlands
| | - Stanley M H Yeung
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, RB Groningen, the Netherlands
| | - Johanna M Geleijnse
- Division of Human Nutrition and Health, Wageningen University, HB Wageningen, the Netherlands
| | - Lieke Gijsbers
- Division of Human Nutrition and Health, Wageningen University, HB Wageningen, the Netherlands
| | - Ineke J Riphagen
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, RB Groningen, the Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, CA Rotterdam, The Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center, RC Leiden, the Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, DD Amsterdam Zuidoost, the Netherlands
| | - Gerjan Navis
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, RB Groningen, the Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, RB Groningen, the Netherlands
| | - Martin H de Borst
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, RB Groningen, the Netherlands
- Correspondence and Reprint Requests: Martin H. de Borst, MD, PhD, Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands. E-mail:
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Yeung SMH, Bakker SJL, Laverman GD, De Borst MH. Fibroblast Growth Factor 23 and Adverse Clinical Outcomes in Type 2 Diabetes: a Bitter-Sweet Symphony. Curr Diab Rep 2020; 20:50. [PMID: 32857288 PMCID: PMC7455586 DOI: 10.1007/s11892-020-01335-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Fibroblast growth factor 23 (FGF23) is a key phosphate-regulating hormone that has been associated with adverse outcomes in patients with chronic kidney disease (CKD). Emerging data suggest that FGF23 plays a specific role in type 2 diabetes, partly independent of kidney function. We aimed to summarize current literature on the associations between FGF23 and outcomes in patients with type 2 diabetes with or without CKD. RECENT FINDINGS Several cohort studies have shown strong associations between plasma FGF23 and cardiovascular outcomes in diabetic CKD. Moreover, recent data suggest that FGF23 are elevated and may also be a risk factor for cardiovascular disease and mortality in type 2 diabetes patients without CKD, although the magnitude of the association is smaller than in CKD patients. Diabetes-related factors may influence plasma FGF23 levels, and a higher FGF23 levels seem to contribute to a higher cardiovascular and mortality risk in patients with type 2 diabetes. Although this risk may be relevant in diabetic individuals with preserved kidney function, it is strongly accentuated in diabetic nephropathy. Future studies should clarify if FGF23 is merely a disease severity marker or a contributor to adverse outcomes in type 2 diabetes and establish if antidiabetic medication can modify FGF23 levels.
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Affiliation(s)
- Stanley M. H. Yeung
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands
| | - Stephan J. L. Bakker
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands
| | - Gozewijn D. Laverman
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente Hospital, Almelo and Hengelo, the Netherlands
| | - Martin H. De Borst
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands
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8
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Ter Maaten JM, Voors AA, Damman K, van der Meer P, Anker SD, Cleland JG, Dickstein K, Filippatos G, van der Harst P, Hillege HL, Lang CC, Metra M, Navis G, Ng L, Ouwerkerk W, Ponikowski P, Samani NJ, van Veldhuisen DJ, Zannad F, Zwinderman AH, de Borst MH. Fibroblast growth factor 23 is related to profiles indicating volume overload, poor therapy optimization and prognosis in patients with new-onset and worsening heart failure. Int J Cardiol 2018; 253:84-90. [PMID: 29306478 DOI: 10.1016/j.ijcard.2017.10.010] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 09/03/2017] [Accepted: 10/02/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Fibroblast growth factor (FGF) 23 is a hormone that increases urinary phosphate excretion and regulates renal sodium reabsorption and plasma volume. We studied the role of plasma FGF23 in therapy optimization and outcomes in patients with new-onset and worsening heart failure (HF). METHODS We measured plasma C-terminal FGF23 levels at baseline in 2399 of the 2516 patients included in the BIOlogy Study to Tailored Treatment in Chronic HF (BIOSTAT-CHF) trial. The association between FGF23 and outcome was evaluated by Cox regression analysis adjusted for potential confounders. RESULTS Median FGF23 was 218.0 [IQR: 117.1-579.3] RU/ml; patients with higher FGF23 levels had a worse NYHA class, more signs of congestion, and were less likely to use an ACE-inhibitor (ACEi) or angiotensin receptor blocker (ARBs) at baseline (all P<0.01). Higher FGF23 levels were independently associated with higher BNP, lower eGFR, the presence of oedema and atrial fibrillation (all P<0.001). In addition, higher FGF23 was independently associated with impaired uptitration of ACEi/ARBs after 3months, but not of beta-blockers. In multivariable Cox regression analysis, FGF23 was independently associated with all-cause mortality (hazard ratio: 1.17 (1.09-1.26) per log increase, P<0.001), and the combined endpoint of all-cause mortality and HF hospitalization (1.15 (1.08-1.22) per log increase, P<0.001). CONCLUSIONS In patients with new-onset and worsening HF, higher plasma FGF23 levels were independently associated with volume overload, less successful uptitration of ACEi/ARBs and an increased risk of all-cause mortality and HF hospitalization.
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Affiliation(s)
- Jozine M Ter Maaten
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
| | - Kevin Damman
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology & Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - John G Cleland
- National Heart & Lung Institute, Royal Brompton & Harefield hospitals, Imperial College, London, UK
| | - Kenneth Dickstein
- University of Bergen, Bergen, Norway; University of Stavanger, Stavanger, Norway
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Heart Failure Unit, Athens University Hospital Attikon, Athens, Greece
| | - Pim van der Harst
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Hans L Hillege
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital & Medical School, Dundee, UK
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy
| | - Gerjan Navis
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Leong Ng
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK; NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Wouter Ouwerkerk
- Department of Epidemiology, Biostatistics & Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Poland and Cardiology Department, Military Hospital, Wroclaw, Poland
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK; NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Faiez Zannad
- Inserm CIC1433, Université de Lorrain, CHU de Nancy, Nancy, France
| | - Aeilko H Zwinderman
- Department of Epidemiology, Biostatistics & Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Martin H de Borst
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Courbebaisse M, Lanske B. Biology of Fibroblast Growth Factor 23: From Physiology to Pathology. Cold Spring Harb Perspect Med 2018; 8:a031260. [PMID: 28778965 PMCID: PMC5932574 DOI: 10.1101/cshperspect.a031260] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Fibroblast growth factor (FGF)23 is a phosphaturic hormone produced by osteocytes and osteoblasts that binds to FGF receptors in the presence of the transmembrane protein αKlotho. FGF23 mainly targets the renal proximal tubule to inhibit calcitriol production and the expression of the sodium/phosphate cotransporters NaPi2a and NaPi2c, thus inhibiting renal phosphate reabsorption. FGF23 also acts on the parathyroid glands to inhibit parathyroid hormone synthesis and secretion. FGF23 regulation involves many systemic and local factors, among them calcitriol, phosphate, and parathyroid hormone. Increased FGF23 is primarily observed in rare acquired or genetic disorders, but chronic kidney disease is associated with a reactional increase in FGF23 to combat hyperphosphatemia. However, high FGF23 levels induce left ventricular hypertrophy (LVH) and are associated with an increased risk of mortality. In this review, we describe FGF23 physiology and the pathological consequences of high or low FGF23 levels.
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Affiliation(s)
- Marie Courbebaisse
- Division of Bone and Mineral Research OMII, Harvard School of Dental Medicine, Boston, Massachusetts 02115
- Paris Descartes University, Paris 75006, France
| | - Beate Lanske
- Division of Bone and Mineral Research OMII, Harvard School of Dental Medicine, Boston, Massachusetts 02115
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
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Mattinzoli D, Ikehata M, Tsugawa K, Alfieri CM, Dongiovanni P, Trombetta E, Valenti L, Puliti A, Lazzari L, Messa P. FGF23 and Fetuin-A Interaction in the Liver and in the Circulation. Int J Biol Sci 2018; 14:586-598. [PMID: 29904273 PMCID: PMC6001652 DOI: 10.7150/ijbs.23256] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/02/2018] [Indexed: 12/24/2022] Open
Abstract
Recently it has been demonstrated that Fetuin-A, an anti-inflammatory protein synthesized by the liver, is produced also in bone by an FGF23-regulated pathway. FGF23 has been also demonstrated to induce inflammatory cytokine production in the liver. This study aimed to explore if FGF23 plays a role in the Fetuin-A production in the liver cells too and the possible relationships with FGF23 pro-inflammatory effects. FGF23 and Fetuin-A were studied in liver, kidney and in plasma with immunochemistry, immunoprecipitation, western blot, chromatin immunoprecipitation, duolink, ELISA, qrtPCR methodology. FGF23 is produced, but not secreted by the liver cells. In hepatocytes and circulation, FGF23 was present only strictly linked to Fetuin-A, while Fetuin-A was found also in unbounded form. No link was observed in the kidney. FGF23 up to 600 pg/ml stimulates, while, at higher concentrations, reduces Fetuin-A expression. Notably, overall the range of concentrations, FGF23 stimulates Fetuin-A promoter, TNFα and IL6 expression. In the nucleus, FGF23 seems to act as a direct transcription factor of Fetuin-A promoter. These results suggest that FGF23 played a direct regulatory role in Fetuin-A expression in liver cells with a biphasic effect: Fetuin-A progressively increases when FGF23 increases up to 400-600 pg/mL, and declines at higher FGF23 concentrations. These results lead us to hypothesize: a) a possible epigenetic post-transcriptional regulation; b) a possible counter-regulatory effect of FGF23 induced inflammatory cytokines (TNFα/ NF-κB mechanism). This study could add an additional key for the interpretation of the possible mechanisms linking FGF23, Fetuin-A and inflammation in CKD patients and suggests a role for FGF23 as transcription factor.
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Affiliation(s)
- Deborah Mattinzoli
- Renal Research Laboratory Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Masami Ikehata
- Renal Research Laboratory Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Koji Tsugawa
- Renal Research Laboratory Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Carlo M Alfieri
- Renal Research Laboratory Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.,Unit of Nephrology, Dialysis and Renal transplant Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Dongiovanni
- Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Trombetta
- Flow Cytometry and Experimental Hepatology Service, Clinical Chemistry and Microbiology Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Valenti
- Department of pathophysiology and transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi di Milano, Italy
| | - Aldamaria Puliti
- DiNOGMI, University of Genoa, Italy.,Medical Genetics Unit, Istituto Giannina Gaslini, Italy
| | - Lorenza Lazzari
- Cell Factory Unit of Cell Therapy and Cryobiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Renal Research Laboratory Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.,Unit of Nephrology, Dialysis and Renal transplant Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi di Milano, Italy
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Hu JW, Wang Y, Chu C, Mu JJ. Effect of Salt Intervention on Serum Levels of Fibroblast Growth Factor 23 (FGF23) in Chinese Adults: An Intervention Study. Med Sci Monit 2018; 24:1948-1954. [PMID: 29608553 PMCID: PMC5898259 DOI: 10.12659/msm.906489] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Fibroblast growth factor 23 (FGF23), a prominent regulator of phosphate and calcium metabolism, regulates sodium excretion in distal tubules through sodium-chloride cotransporter. This effect regulates blood pressure. Salt intake exerts effects on serum levels of FGF23 in mice. The aim of this study was to explore whether salt intervention affects serum concentrations of FGF23 in Chinese adults. Material/Methods We enrolled 44 participants from Lantian, a rural community of Shaanxi, China. All participants were maintained on a three-day normal diet, which was sequentially followed by a seven-day low-Na+ diet and seven-day high-Na+ diet. Serum FGF23 concentrations were assessed by ELISA. Results Serum FGF23 concentrations elevated during low-salt diet compared with levels at baseline (66.20±44.21 pg/mL versus 86.77±53.74 pg/mL, p<0.05) and remarkably decreased when changed from low to high salt intake (86.77±53.74 pg/mL versus 49.26±42.67 pg/mL, p<0.001). Responses of FGF23 to salt intervention were more prominent in normotensive, older than 60 years, BMI <24 kg/m2 and salt-resistant individuals. Furthermore, a significant inverse correlation was observed between 24-hour urinary sodium and serum concentrations of FGF23 after adjusting age, sex, BMI and hypertension status. Conclusions Dietary salt intervention significantly affects serum FGF23 in Chinese adults.
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Affiliation(s)
- Jia-Wen Hu
- Department of Cardiology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland).,Key Laboratory of Molecular Cardiology of Shaanxi Province, Xi'an, Shaanxi, China (mainland)
| | - Yang Wang
- Department of Cardiology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland).,Key Laboratory of Molecular Cardiology of Shaanxi Province, Xi'an, Shaanxi, China (mainland)
| | - Chao Chu
- Department of Cardiology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland).,Key Laboratory of Molecular Cardiology of Shaanxi Province, Xi'an, Shaanxi, China (mainland)
| | - Jian-Jun Mu
- Department of Cardiology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi, China (mainland).,Key Laboratory of Molecular Cardiology of Shaanxi Province, Xi'an, Shaanxi, China (mainland)
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The effect of nephrectomy on Klotho, FGF-23 and bone metabolism. Int Urol Nephrol 2017; 49:681-688. [PMID: 28130714 PMCID: PMC5357491 DOI: 10.1007/s11255-017-1519-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 01/17/2017] [Indexed: 01/12/2023]
Abstract
Background Increased concentration of fibroblast growth factor 23 (FGF-23) and decreased levels of soluble Klotho (sKL) are linked to negative clinical outcomes among patients with chronic kidney disease and acute kidney injury. Therefore, it is reasonable to hypothesize that GFR reduction caused by nephrectomy might alter mineral metabolism and induces adverse consequences. Whether nephrectomy due to urological indications causes derangements in FGF-23 and sKL has not been studied. The aim of the study was to evaluate the effect of acute GFR decline due to unilateral nephrectomy on bone metabolism, FGF-23 and sKL levels. Methods This is a prospective, single-centre observational study of patients undergoing nephrectomy due to urological indications. Levels of C-terminal FGF-23 (c-FGF-23), sKL and bone turnover markers [β-crosslaps (CTX), bone-specific alkaline phosphatase (bALP) and tartrate-resistant acid phosphatase 5b (TRAP 5b)] were measured before and after surgery (5 ± 2 days). Results Twenty-nine patients were studied (14 females, age 63.0 ± 11.6, eGFR 87.3 ± 19.2 ml/min/1.73 m2). After surgery, eGFR significantly declined (p < 0.0001). Nephrectomy significantly decreased sKL level [709.8 (599.9–831.2) vs. 583.0 (411.7–752.6) pg/ml, p < 0.001] and did not change c-FGF-23 concentration [70.5 (49.8–103.3) vs. 77.1 (60.5–109.1) RU/ml, p = 0.9]. Simultaneously, alterations in bone turnover markers were observed. Serum concentration of CTX increased [0.49 (0.4–0.64) vs. 0.59 (0.46–0.85) ng/ml, p = 0.001], while bALP and TRAP 5b decreased [23.6 (18.8–31.4) vs. 17.9 (15.0–22.0) U/l, p < 0.0001 and 3.3 (3.0–3.7) vs. 2.8 (2.3–3.2) U/l, p < 0.001, respectively]. Conclusions Nephrectomy among patients with preserved renal function before surgery does not increase c-FGF-23 but reduces sKL. Moreover, nephrectomy results in derangements in bone turnover markers in short-term follow-up. These changes may participate in pathogenesis of bone disease after nephrectomy.
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