1
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Sharma S, Mehta P, Patil A, Gupta SK, Rajender S, Chattopadhyay N. Meta-analyses of the quantitative computed tomography data in dialysis patients show differential impacts of renal failure on the trabecular and cortical bones. Osteoporos Int 2022; 33:1521-1533. [PMID: 35249146 DOI: 10.1007/s00198-022-06366-2] [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: 01/03/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
UNLABELLED Dialysis patients have compromised bone health that increases their fracture risk due to low bone mass and deterioration in bone microarchitecture. Through meta-analyses of published studies, we conclude that dialysis patients suffer from impaired compartmental bone parameters compared with healthy controls. INTRODUCTION We performed meta-analyses to determine the effect of chronic kidney disease (CKD) patients under dialysis on the trabecular and cortical parameters of radius and tibia. METHODS This is a meta-analysis of cross-sectional and prospective clinical studies. PubMed, Web of Science, Google Scholar, and Scopus were searched using various permutation combinations. Dialysis patients were compared with non-CKD healthy controls using quantitative computed tomography. High-resolution peripheral quantitative computed tomography (HR-pQCT) and pQCT data of dialysis patients were dissected from eligible studies for pooled analysis of each parameter. RESULTS Ten studies met the inclusion criteria that included data from 457 dialysis patients and 2134 controls. Pooled analysis showed a significant decrease (a) in total vBMD at distal radius [standard deviation of the mean (SDM) = -0.842, p = 0.000] and tibia (SMD = -0.705, p = 0.000) and (b) in cortical vBMD (SDM = -1.037, p = 0.000) at radius of dialysis patients compared with control. There were strong correlations between total vBMD and microarchitecture parameters at tibia in dialysis patients. CONCLUSIONS At radius and tibia, bone mass, microarchitecture, and geometry at trabecular and cortical envelopes displayed impairments in dialysis patients compared with control. Tibial vBMD may have diagnostic value in dialysis. HR-pQCT and pQCT may be used to further understand the compartmental bones response to CKD-induced loss at different stages of CKD.
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Affiliation(s)
- S Sharma
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - P Mehta
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - A Patil
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India
| | - S K Gupta
- Department of Endocrinology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow, India
| | - S Rajender
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India.
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India.
| | - N Chattopadhyay
- Division of Endocrinology and Centre for Research in Anabolic Skeletal Targets in Health and Illness (ASTHI), CSIR-Central Drug Research Institute, Sector 10, Jankipuram Extension, Sitapur Road, Lucknow, 226031, India.
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India.
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2
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Hasparyk UG, Vigil FMB, Bartolomei VS, Nunes VM, Simões e Silva AC. Chronic Kidney Disease-Mineral Bone Disease biomarkers in kidney transplant patients. Curr Med Chem 2022; 29:5230-5253. [DOI: 10.2174/0929867329666220318105856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 11/22/2022]
Abstract
Background:
Chronic Kidney Disease associated with Mineral Bone Disease (CKD-MBD) is frequent in kidney transplant patients. Post-transplantation bone disease is complex, especially in patients with pre-existing metabolic bone disorders that are further affected by immunosuppressive medications and changes in renal allograft function. Main biochemical abnormalities of mineral metabolism in kidney transplantation (KTx) include hypophosphatemia, hyperparathyroidism (HPTH), insufficiency or deficiency of vitamin D, and hypercalcemia.
Objective:
This review aimed to summarize the pathophysiology and main biomarkers of CKD-MBD in KTx.
Methods:
A comprehensive and non-systematic search in PubMed was independently made with an emphasis on biomarkers in mineral bone disease in KTx.
Results:
CKD-MBD can be associated with numerous factors including secondary HPTH, metabolic dysregulations before KTx, and glucocorticoids therapy in post-transplant subjects. Fibroblast growth factor 23 (FGF23) reaches normal levels after KTx with good allograft function, while calcium, vitamin D and phosphorus, ultimately, result in hypercalcemia, persistent vitamin D insufficiency, and hypophosphatemia respectively. As for PTH levels, there is an initial tendency of a significant decrease, followed by a raise due to secondary or tertiary HPTH. In regard to sclerostin levels, there is no consensus in the literature.
Conclusion:
KTx patients should be continuously evaluated for mineral homeostasis and bone status, both cases with successful kidney transplantation and those with reduced functionality. Additional research on CKD-MBD pathophysiology, diagnosis, and management is essential to guarantee long-term graft function, better prognosis, good quality of life, and reduced mortality for KTx patients.
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Affiliation(s)
- Ursula Gramiscelli Hasparyk
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Flávia Maria Borges Vigil
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Victória Soares Bartolomei
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Vitor Moreira Nunes
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Ana Cristina Simões e Silva
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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3
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Tasnim N, Dutta P, Nayeem J, Masud P, Ferdousi A, Ghosh AS, Hossain M, Rajia S, Kubra KT, Sakibuzzaman M, Khan AT. Osteoporosis, an Inevitable Circumstance of Chronic Kidney Disease: A Systematic Review. Cureus 2021; 13:e18488. [PMID: 34692259 PMCID: PMC8526087 DOI: 10.7759/cureus.18488] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 12/15/2022] Open
Abstract
Nowadays, chronic kidney disease (CKD) and osteoporosis have become crucial health-related issues globally. CKD-induced osteoporosis is a systemic disease characterized by the disruption of mineral, hormone, and vitamin homeostasis that elevates the likelihood of fracture. Here, we review recent studies on the association of CKD and osteoporosis. In particular, we focus on the pathogenesis of CKD-associated osteoporosis, including the homeostasis and pathways of several components such as parathyroid hormone, calcium, phosphate, vitamin D, fibroblast growth factor, and klotho, as well as abnormal bone mineralization, remodeling, and turnover. In addition, we explore the diagnostic tools and possible therapeutic approaches for the management and prevention of CKD-associated osteoporosis. Patients with CKD show higher osteoporosis prevalence, greater fracture rate, increased morbidity and mortality, and an elevated occurrence of hip fracture. We also rule out that increased severity of CKD is related to a more severe condition of osteoporosis. Furthermore, supplements such as calcium and vitamin D as well as lifestyle modifications such as exercise and cessation of smoking and alcohol help in fracture prevention. However, new approaches and advancements in treatment are needed to reduce the fracture risk in patients with CKD. Therefore, further collaborative multidisciplinary research is needed in this regard.
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Affiliation(s)
- Nishat Tasnim
- Internal Medicine, Sacramento Veterans Affairs Medical Center, Mather, USA
| | - Priyata Dutta
- Internal Medicine, Mymensingh Medical College, Mymensingh, BGD
| | - Jannatun Nayeem
- Internal Medicine, Cumilla Medical College and Hospital, Cumilla, BGD
| | - Parisha Masud
- Internal Medicine, Columbia University Medical Center, New York, USA
| | - Afsana Ferdousi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ammy S Ghosh
- Internal Medicine, Institute of Applied Health Sciences, Chittagong, BGD
| | - Maksuda Hossain
- Biodesign Institute Center for Immunotherapy, Vaccines and Virotherapy, Arizona State University, Tempe, USA
| | - Sultana Rajia
- Internal Medicine, Sher-E Bangla Medical College, Barishal, BGD
| | - Khadija T Kubra
- Internal Medicine, Bangladesh Medical College and Hospital, Dhaka, BGD
| | - Md Sakibuzzaman
- Internal Medicine, University of Mississippi Medical Center, Jackson, USA.,Experimental Pathology (Cancer Biology), Mayo Clinic, Rochester, USA.,Internal Medicine, Sir Salimullah Medical College, Dhaka, BGD.,Neuroscience, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Asma T Khan
- Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
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4
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The Vascular Circadian Clock in Chronic Kidney Disease. Cells 2021; 10:cells10071769. [PMID: 34359937 PMCID: PMC8306728 DOI: 10.3390/cells10071769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/29/2021] [Accepted: 07/09/2021] [Indexed: 12/11/2022] Open
Abstract
Chronic kidney disease is associated with extremely high cardiovascular mortality. The circadian rhythms (CR) have an impact on vascular function. The disruption of CR causes serious health problems and contributes to the development of cardiovascular diseases. Uremia may affect the master pacemaker of CR in the hypothalamus. A molecular circadian clock is also expressed in peripheral tissues, including the vasculature, where it regulates the different aspects of both vascular physiology and pathophysiology. Here, we address the impact of CKD on the intrinsic circadian clock in the vasculature. The expression of the core circadian clock genes in the aorta is disrupted in CKD. We propose a novel concept of the disruption of the circadian clock system in the vasculature of importance for the pathology of the uremic vasculopathy.
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5
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The Influence of Dietary Interventions on Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Nutrients 2021; 13:nu13062065. [PMID: 34208727 PMCID: PMC8235119 DOI: 10.3390/nu13062065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease is a health problem whose prevalence is increasing worldwide. The kidney plays an important role in the metabolism of minerals and bone health and therefore, even at the early stages of CKD, disturbances in bone metabolism are observed. In the course of CKD, various bone turnover or mineralization disturbances can develop including adynamic hyperparathyroid, mixed renal bone disease, osteomalacia. The increased risk of fragility fractures is present at any age in these patients. Nutritional treatment of patients with advanced stages of CKD is aiming at prevention or correction of signs, symptoms of renal failure, avoidance of protein-energy wasting (PEW), delaying or prevention of the occurrence of mineral/bone disturbances, and delaying the start of dialysis. The results of studies suggest that progressive protein restriction is beneficial with the progression of renal insufficiency; however, other aspects of dietary management of CKD patients, including changes in sodium, phosphorus, and energy intake, as well as the source of protein and lipids (animal or plant origin) should also be considered carefully. Energy intake must cover patients' energy requirement, in order to enable correct metabolic adaptation in the course of protein-restricted regimens and prevent negative nitrogen balance and protein-energy wasting.
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6
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Budin C, Staniloaie D, Vasile D, Ilco A, Balan DG, Popa CC, Stiru O, Tulin A, Enyedi M, Miricescu D, Georgescu DE, Georgescu TF, Badiu DC, Mihai DA. Hypocalcemia: A possible risk factor for anastomotic leak in digestive surgery. Exp Ther Med 2021; 21:523. [PMID: 33815596 PMCID: PMC8014963 DOI: 10.3892/etm.2021.9955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/18/2021] [Indexed: 11/22/2022] Open
Abstract
Anastomotic leaks (ALs) remain the most severe complication in digestive surgery, as well as the most consumptive in terms of human and financial resources. There is an abundance of international research which has focused on identifying and correcting risk factors, and on individualized surgical management as well. The most frequent risk factors are male sex, obesity, diabetes, advanced malignant disease, ASA score, perioperative blood loss or perioperative transfusion, long operation time, emergency operation and altered nutritional status. The aim of the present study was to measure the preoperative serum calcium level and to find a possible correlation between calcium levels and the risk of AL occurrence. A retrospective analysis of medical records for 122 patients who underwent surgical gut resection with anastomosis for different pathologies was carried out. Preoperative serum calcium level and the occurrence of AL was noted. The results revealed that the average value of total blood calcium was 8.78 mg/dl, without a significant difference in sex groups. Hypocalcemia was identified in 44 patients (36.1%). AL was identified in 8 patients (6.6%), with a statistically insignificant difference between male and female patients. The average value of blood calcium in the AL patient group was 8.07 mg/dl, while in patients without AL the average value was 8.83 mg/dl. Hypocalcemia, defined as a serum calcium level below 8.5 mg/dl, was observed in 7 of the 8 patients presenting with AL (87.5%) and 37 patients who did not present with AL (32.5%), a significant difference with which to consider and include hypocalcemia in the group of risk factors for AL (P=0.001). In conclusion, preoperative low serum calcium level can represent a risk factor for AL in digestive surgery.
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Affiliation(s)
- Constantin Budin
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Daniel Staniloaie
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Danut Vasile
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Alexandru Ilco
- Department of General Surgery, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Daniela-Gabriela Balan
- Department of Physiology, Faculty of Dental Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Cristian Constantin Popa
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Ovidiu Stiru
- Department of Cardiovascular Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Cardiovascular Surgery, 'Prof. Dr. C.C. Iliescu' Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Adrian Tulin
- Department of Anatomy, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, 'Prof. Dr. Agrippa Ionescu' Clinical Emergency Hospital, 011356 Bucharest, Romania
| | - Mihaly Enyedi
- Department of Anatomy, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Radiology, 'Victor Babes' Private Medical Clinic, 030303 Bucharest, Romania
| | - Daniela Miricescu
- Department of Biochemistry, Faculty of Dental Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Dragos Eugen Georgescu
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Teodor Florin Georgescu
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Dumitru Cristinel Badiu
- Department of General Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of General Surgery, 'Bagdasar-Arseni' Clinical Emergency Hospital, 041915 Bucharest, Romania
| | - Doina-Andrada Mihai
- Department of Diabetes, Nutrition and Metabolic Diseases, Prof. N.C. Paulescu National Institute of Diabetes, Nutrition and Metabolic Disease, 020021 Bucharest, Romania.,Department of Diabetes, Nutrition and Metabolic Diseases, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
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7
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Mace ML, Gravesen E, Nordholm A, Egstrand S, Morevati M, Nielsen C, Kjaer A, Behets G, D'Haese P, Olgaard K, Lewin E. Chronic Kidney Disease-Induced Vascular Calcification Impairs Bone Metabolism. J Bone Miner Res 2021; 36:510-522. [PMID: 33301619 PMCID: PMC7988613 DOI: 10.1002/jbmr.4203] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/21/2020] [Accepted: 10/23/2020] [Indexed: 12/31/2022]
Abstract
An association between lower bone mineral density (BMD) and presence of vascular calcification (VC) has been reported in several studies. Chronic kidney disease (CKD) causes detrimental disturbances in the mineral balance, bone turnover, and development of severe VC. Our group has previously demonstrated expression of Wnt inhibitors in calcified arteries of CKD rats. Therefore, we hypothesized that the CKD-induced VC via this pathway signals to bone and induces bone loss. To address this novel hypothesis, we developed a new animal model using isogenic aorta transplantation (ATx). Severely calcified aortas from uremic rats were transplanted into healthy rats (uremic ATx). Transplantation of normal aortas into healthy rats (normal ATx) and age-matched rats (control) served as control groups. Trabecular tissue mineral density, as measured by μCT, was significantly lower in uremic ATx rats compared with both control groups. Uremic ATx rats showed a significant upregulation of the mineralization inhibitors osteopontin and progressive ankylosis protein homolog in bone. In addition, we found significant changes in bone mRNA levels of several genes related to extracellular matrix, bone turnover, and Wnt signaling in uremic ATx rats, with no difference between normal ATx and control. The bone histomorphometry analysis showed significant lower osteoid area in uremic ATx compared with normal ATx along with a trend toward fewer osteoblasts as well as more osteoclasts in the erosion lacunae. Uremic ATx and normal ATx had similar trabecular number and thickness. The bone formation rate did not differ between the three groups. Plasma biochemistry, including sclerostin, kidney, and mineral parameters, were similar between all three groups. ex vivo cultures of aorta from uremic rats showed high secretion of the Wnt inhibitor sclerostin. In conclusion, the presence of VC lowers BMD, impairs bone metabolism, and affects several pathways in bone. The present results prove the existence of a vasculature to bone tissue cross-talk. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Maria L Mace
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Eva Gravesen
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anders Nordholm
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Nephrology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Soeren Egstrand
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Nephrology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Marya Morevati
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Carsten Nielsen
- Department of Clinical Physiology, Nuclear Medicine and PET and Cluster for Molecular Imaging, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine and PET and Cluster for Molecular Imaging, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Geert Behets
- Department of Biomedical Sciences, Laboratory of Pathophysiology, University of Antwerp, Antwerp, Belgium
| | - Patrick D'Haese
- Department of Biomedical Sciences, Laboratory of Pathophysiology, University of Antwerp, Antwerp, Belgium
| | - Klaus Olgaard
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ewa Lewin
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Nephrology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
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8
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Haffner D, Leifheit-Nestler M. CKD-MBD post kidney transplantation. Pediatr Nephrol 2021; 36:41-50. [PMID: 31858226 DOI: 10.1007/s00467-019-04421-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/28/2019] [Accepted: 11/12/2019] [Indexed: 12/22/2022]
Abstract
Complications of chronic kidney disease-associated mineral and bone disorders (CKD-MBD) are frequently observed in pediatric kidney transplant recipients and are associated with high morbidity, including growth failure, leg deformities, bone pain, fractures, osteonecrosis, and vascular calcification. Post-transplant CKD-MBD is mainly due to preexisting renal osteodystrophy and cardiovascular changes at the time of transplantation, glucocorticoid treatment, and reduced graft function. In addition, persistent elevated levels of parathyroid hormone (PTH) and fibroblast growth factor 23 may cause hypophosphatemia, resulting in impaired bone mineralization. Patient monitoring should include assessment of growth, leg deformities, and serum levels of calcium, phosphate, magnesium, alkaline phosphatase, 25-hydroxyvitamin D, and PTH. Therapy should primarily focus on regular physical activity, preservation of transplant function, and steroid-sparing immunosuppressive protocols. In addition, adequate monitoring and treatment of vitamin D and mineral metabolism including vitamin D supplementation, oral phosphate, and/or magnesium supplementation, in case of persistent hypophosphatemia/hypomagnesemia, and treatment with active vitamin D in cases of persistent secondary hyperparathyroidism. The latter should be done using the minimum PTH-suppressive dosages aiming at the recommended CKD stage-dependent PTH target range. Finally, treatment with recombinant human growth hormone should be considered in patients lacking catch-up growth within the first year after transplantation.
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Affiliation(s)
- Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Paediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Maren Leifheit-Nestler
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Paediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,Paediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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9
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Tabibzadeh N, Karaboyas A, Robinson BM, Csomor PA, Spiegel DM, Evenepoel P, Jacobson SH, Ureña-Torres PA, Fukagawa M, Al Salmi I, Liang X, Pisoni RL, Young EW. The risk of medically uncontrolled secondary hyperparathyroidism depends on parathyroid hormone levels at haemodialysis initiation. Nephrol Dial Transplant 2021; 36:160-169. [PMID: 33068419 PMCID: PMC7771977 DOI: 10.1093/ndt/gfaa195] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Optimal parathyroid hormone (PTH) control during non-dialysis chronic kidney disease (ND-CKD) might decrease the subsequent risk of parathyroid hyperplasia and uncontrolled secondary hyperparathyroidism (SHPT) on dialysis. However, the evidence for recommending PTH targets and therapeutic strategies is weak for ND-CKD. We evaluated the patient characteristics, treatment patterns and PTH control over the first year of haemodialysis (HD) by PTH prior to HD initiation. METHODS We studied 5683 incident HD patients from 21 countries in Dialysis Outcomes and Practice Patterns Study Phases 4-6 (2009-18). We stratified by PTH measured immediately prior to HD initiation and reported the monthly prescription prevalence of active vitamin D and calcimimetics over the first year of HD and risk of PTH >600 pg/mL after 9-12 months on HD. RESULTS The 16% of patients with PTH >600 pg/mL prior to HD initiation were more likely to be prescribed active vitamin D and calcimimetics during the first year of HD. The prevalence of PTH >600 pg/mL 9-12 months after start of HD was greater for patients who initiated HD with PTH >600 (29%) versus 150-300 (7%) pg/mL (adjusted risk difference: 19%; 95% confidence interval : 15%, 23%). The patients with sustained PTH >600 pg/mL after 9-12 months on HD were younger, more likely to be black, and had higher serum phosphorus and estimated glomerular filtration rates at HD initiation. CONCLUSIONS Increased PTH before HD start predicted a higher PTH level 9-12 months later, despite greater use of active vitamin D and calcimimetics. More targeted PTH control during ND-CKD may influence outcomes during HD, raising the need for PTH target guidelines in these patients.
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Affiliation(s)
- Nahid Tabibzadeh
- Renal Physiology Department, APHP Hôpital Bichat, Université de Paris, INSERM, Paris, France
| | | | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - David M Spiegel
- Clinical Development, Relypsa Inc., Vifor Pharma Group Company, Redwood City, CA, USA
| | - Pieter Evenepoel
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology and Immunology, Laboratory of Nephrology, KU Leuven, Leuven, Belgium
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Pablo-Antonio Ureña-Torres
- Department of Dialysis, AURA Nord Saint Ouen, Saint-Ouen, France
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Issa Al Salmi
- Department of Renal Medicine, Royal Hospital, Muscat, Oman
| | - Xinling Liang
- Department of Nephrology, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | | | - Eric W Young
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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10
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Ljubičić J, Pešić A, Marinković N, Kravljača M. Prevalence and risk factors for coronary artery disease in patients on chronic hemodialysis. MEDICINSKI PODMLADAK 2021. [DOI: 10.5937/mp72-34597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction: Cardiovascular diseases (CVD) represent the leading cause of morbidity and mortality (46 - 60%) among patients with chronic kidney disease (CKD). Three methods are used for kidney function replacement in patients with end-stage renal disease: hemodialysis, pertioneal dialysis and kidney transplantation. About 40% of the dialysis population develop coronary artery disease (CAD) due to chronic metabolic and inflammatory disorders. Risk factors for developing CAD in this group of patients include chronic anemia, secondary hyperparathyroidism, chronic inflammation, insulin resistance and volume overload. Aim: To determine the impact of metabolic and inflammatory disorders in developing CAD in patients with CKD that are chronically treated with hemodialysis. Material and methods: This case-control study included 115 patients with end-stage renal disease that were treated in Hemodialysis ward, Clinic for Nephrology, University Clinical Centre of Serbia. Data were collected for the period from January 2015 to December 2020. Elective coronarography was used to determine the presence and the characteristics of CAD. We also analyzed patient's laboratory findings, their demographic and clinical characteristics, as well as primary renal disease that led to the development of CKD in these patients. Additional parameters used in this study included the presence of Diabetes mellitus (DM) and duration of hemodialysis. Results: Coronary artery disease was diagnosed in 19 out of 115 patients (16.5%). Patients with CAD had a significantly higher levels of serum calcium (2.3 to 2.2 mmol/L) (p = 0.039), while other laboratory parameters did not show significant correlation. Most of the patients with CAD were male (16 of 19 patients, 84.3%, p = 0.01), while 31.6% (6 of 19 patients) with CAD were diagnosed with Diabetes mellitus (p = 0.009). Conclusion: The presence of Diabetes mellitus, higher calcium level, as well as male gender signicifantly increase the risk of developing CAD in patients chronically treated with hemodialysis.
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11
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The Association between the Activin A Serum Level and Carotid Intima-Media Thickness in Chronic Kidney Disease Patients. Int J Nephrol 2020; 2020:8893653. [PMID: 33294228 PMCID: PMC7700056 DOI: 10.1155/2020/8893653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/18/2020] [Accepted: 10/25/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction Chronic kidney disease (CKD) is associated with high mortality rates, mainly as a result of cardiovascular complications. Meanwhile, recent studies have suggested a role of a homodimer protein called activin A in chronic kidney disease-mineral and bone disorder (CKD-MBD) conditions that may exist in the vascular calcification and osteolytic process. Ultrasound examination of the carotid intima-media thickness (cIMT) is a noninvasive method to assess vascular calcification. This study aimed to analyze the relationship between the activin A serum level and cIMT in patients with CKD at Mohammad Hoesin Hospital, Palembang, Indonesia. Methods We conducted a hospital-based, cross-sectional study of consecutive CKD patients at the Department of Internal Medicine, Mohammad Hoesin Hospital, from July to November 2019. The level of activin A was measured by enzyme-linked immunosorbent assay. Meanwhile, cIMT measurements were collected by B-mode ultrasound imaging. Results A total of 55 patients with CKD were included in this investigation. The median serum activin A level in these patients was 236.17 (116.33–283) pg/mL, while the median cIMT was 0.8 (0.6–1.45) mm. A relationship between the serum activin A level and cIMT (r = 0.449; p = 0.001) was observed. During multivariate analysis with linear regression, triglyceride (p = 0.049), phosphate (p = 0.005), and activin A (p = 0.020) serum levels were factors associated with cIMT. Conclusion In this study, a relationship between the activin A serum level and cIMT in patients with CKD was identified. Vascular calcification should be screened for in all CKD patients by the measurement of cIMT.
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12
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Covic AC, Sprague SM, Rastogi A, Ketteler M, Walpen S, Perrin A, Floege J. Characteristics of Patients Who Achieve Serum Phosphorus Control on Sucroferric Oxyhydroxide or Sevelamer Carbonate: A post hoc Analysis of a Phase 3 Study. Nephron Clin Pract 2020; 144:428-439. [PMID: 32585670 DOI: 10.1159/000507258] [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] [Received: 09/16/2019] [Accepted: 03/14/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Control of hyperphosphatemia in patients on dialysis remains a major challenge. OBJECTIVE This study evaluated predictors of serum phosphorus (sP) control among dialysis patients treated with noncalcium, oral phosphate binder therapy in a phase 3 clinical trial. METHODS Post hoc analyses were performed using data for patients with hyperphosphatemia who received 52 weeks of treatment with sucroferric oxyhydroxide (SFOH) or sevelamer carbonate (sevelamer). Patients were categorized into those who achieved sP control (n = 302; defined as sP ≤ 5.5 mg/dL at week 52), and those with uncontrolled sP (n = 195; sP >5.5 mg/dL at week 52). Because SFOH and sevelamer have previously demonstrated similar effects on chronic kidney disease-mineral-bone disorder parameters in this study, the treatment groups were pooled. RESULTS Average age at baseline was higher among sP-controlled versus sP-uncontrolled patients (56.9 vs. 53.4 years; p = 0.005). Baseline sP levels were significantly lower among sP-controlled versus sP-uncontrolled patients (7.30 vs. 7.85 mg/dL; p < 0.001), and sP reductions from baseline were significantly greater in the sP-controlled group (-2.89 vs. -0.99 mg/dL at week 52; p < 0.001). Logistic regression analysis identified higher baseline sP levels (odds ratio [OR] = 0.86, 95% confidence interval [CI]: 0.765-0.960), no concomitant active vitamin D therapy use (OR = 0.51, 95% CI: 0.328-0.804), and higher body mass index at baseline (OR = 0.96, 95% CI: 0.937-0.992) as significant predictors of uncontrolled sP. CONCLUSION This analysis indicates that sP control may be more challenging in younger patients with high sP levels. Closer monitoring and management of serum phosphorus levels may be required in this population.
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Affiliation(s)
- Adrian C Covic
- Nephrology Clinic and Dialysis and Transplantation Center, Grigore T. Popa University of Medicine and Pharmacy, Iași, Romania,
| | - Stuart M Sprague
- NorthShore University Health System, University of Chicago, Pritzker School of Medicine, Evanston, Illinois, USA
| | - Anjay Rastogi
- Division of Nephrology, University of California, Los Angeles, California, USA
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Sebastian Walpen
- Department of Medical Affairs, Vifor Pharma, Glattbrugg, Switzerland
| | - Amandine Perrin
- Department of Biometrics, Vifor Pharma, Glattbrugg, Switzerland
| | - Jürgen Floege
- Division of Nephrology, RWTH University Hospital Aachen, Aachen, Germany
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13
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Behrmann A, Zhong D, Li L, Cheng SL, Mead M, Ramachandran B, Sabaeifard P, Goodarzi M, Lemoff A, Kronenberg HM, Towler DA. PTH/PTHrP Receptor Signaling Restricts Arterial Fibrosis in Diabetic LDLR -/- Mice by Inhibiting Myocardin-Related Transcription Factor Relays. Circ Res 2020; 126:1363-1378. [PMID: 32160132 PMCID: PMC7524585 DOI: 10.1161/circresaha.119.316141] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 03/11/2020] [Indexed: 12/24/2022]
Abstract
RATIONALE The PTH1R (PTH [parathyroid hormone]/PTHrP [PTH-related protein] receptor) is expressed in vascular smooth muscle (VSM) and increased VSM PTH1R signaling mitigates diet-induced arteriosclerosis in LDLR-/- mice. OBJECTIVE To study the impact of VSM PTH1R deficiency, we generated mice SM22-Cre:PTH1R(fl/fl);LDLR-/- mice (PTH1R-VKO) and Cre-negative controls. METHODS AND RESULTS Immunofluorescence and Western blot confirmed PTH1R expression in arterial VSM that was reduced by Cre-mediated knockout. PTH1R-VKO cohorts exhibited increased aortic collagen accumulation in vivo, and VSM cultures from PTH1R-VKO mice elaborated more collagen (2.5-fold; P=0.01) with elevated Col3a1 and Col1a1 expression. To better understand these profibrotic responses, we performed mass spectrometry on nuclear proteins extracted from Cre-negative controls and PTH1R-VKO VSM. PTH1R deficiency reduced Gata6 but upregulated the MADS (MCM1, Agamous, Deficiens, and Srf DNA-binding domain)-box transcriptional co-regulator, Mkl-1 (megakaryoblastic leukemia [translocation] 1). Co-transfection assays (Col3a1 promoter-luciferase reporter) confirmed PTH1R-mediated inhibition and Mkl-1-mediated activation of Col3a1 transcription. Regulation mapped to a conserved hybrid CT(A/T)6GG MADS-box cognate in the Col3a1 promoter. Mutations of C/G in this motif markedly reduced Col3a1 transcriptional regulation by PTH1R and Mkl-1. Upregulation of Col3a1 and Col1a1 in PTH1R-VKO VSM was inhibited by small interfering RNA targeting Mkl1 and by treatment with the Mkl-1 antagonist CCG1423 or the Rock (Rho-associated coiled-coil containing protein kinase)-2 inhibitor KD025. Chromatin precipitation demonstrated that VSM PTH1R deficiency increased Mkl-1 binding to Col3a1 and Col1a1, but not TNF, promoters. Proteomic studies of plasma extracellular vesicles and VSM from PTH1R-VKO mice identified C1r (complement component 1, r) and C1s (complement component 1, s), complement proteins involved in vascular collagen metabolism, as potential biomarkers. VSM C1r protein and C1r message were increased with PTH1R deficiency, mediated by Mkl-1-dependent transcription and inhibited by CCG1423 or KD025. CONCLUSIONS PTH1R signaling restricts collagen production in the VSM lineage, in part, via Mkl-1 regulatory circuits that control collagen gene transcription. Strategies that maintain homeostatic VSM PTH1R signaling, as reflected in extracellular vesicle biomarkers of VSM PTH1R/Mkl-1 action, may help mitigate arteriosclerosis and vascular fibrosis.
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MESH Headings
- Animals
- Aorta/metabolism
- Aorta/pathology
- Atherosclerosis/genetics
- Atherosclerosis/metabolism
- Atherosclerosis/pathology
- Cells, Cultured
- Collagen Type I/genetics
- Collagen Type I/metabolism
- Collagen Type I, alpha 1 Chain
- Collagen Type III/genetics
- Collagen Type III/metabolism
- Diabetes Mellitus/genetics
- Diabetes Mellitus/metabolism
- Diabetes Mellitus/pathology
- Diet, High-Fat
- Disease Models, Animal
- Fibrosis
- Humans
- Male
- Mice, Inbred C57BL
- Mice, Knockout
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/pathology
- Parathyroid Hormone/metabolism
- Rats
- Receptor, Parathyroid Hormone, Type 1/deficiency
- Receptor, Parathyroid Hormone, Type 1/genetics
- Receptor, Parathyroid Hormone, Type 1/metabolism
- Receptors, LDL/deficiency
- Receptors, LDL/genetics
- Signal Transduction
- Trans-Activators/genetics
- Trans-Activators/metabolism
- Transcription, Genetic
- Vascular Remodeling
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Affiliation(s)
- Abraham Behrmann
- Internal Medicine – Endocrine Division, UT Southwestern Medical Center, Dallas, TX 75390
| | - Dalian Zhong
- Internal Medicine – Endocrine Division, UT Southwestern Medical Center, Dallas, TX 75390
| | - Li Li
- Internal Medicine – Endocrine Division, UT Southwestern Medical Center, Dallas, TX 75390
| | - Su-Li Cheng
- Internal Medicine – Endocrine Division, UT Southwestern Medical Center, Dallas, TX 75390
| | - Megan Mead
- Internal Medicine – Endocrine Division, UT Southwestern Medical Center, Dallas, TX 75390
| | - Bindu Ramachandran
- Internal Medicine – Endocrine Division, UT Southwestern Medical Center, Dallas, TX 75390
| | - Parastoo Sabaeifard
- Internal Medicine – Endocrine Division, UT Southwestern Medical Center, Dallas, TX 75390
| | | | - Andrew Lemoff
- Biochemistry, UT Southwestern Medical Center, Dallas, TX 75390
| | - Henry M. Kronenberg
- Endocrine Unit, Massachusetts General Hospital & Harvard Medical School, Boston, MA 02114
| | - Dwight A. Towler
- Internal Medicine – Endocrine Division, UT Southwestern Medical Center, Dallas, TX 75390
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14
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Lower Serum Fibroblast Growth Factor 21 Levels are Associated with Normal Lumbar Spine Bone Mineral Density in Hemodialysis Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17061938. [PMID: 32188054 PMCID: PMC7143095 DOI: 10.3390/ijerph17061938] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 12/11/2022]
Abstract
Recent evidence has indicated that fibroblast growth factor 21 (FGF21) regulates longitudinal bone growth, with increased FGF21 levels leading to bone loss. The present study evaluated the relationship between bone mineral density (BMD) and serum FGF21 levels in patients undergoing hemodialysis (HD). We analyzed blood samples from 95 patients undergoing HD and measured BMD using dual-energy X-ray absorptiometry of the lumbar vertebrae (L2–L4). Serum FGF21 concentrations were determined using a commercially available enzyme-linked immunosorbent assay kit. Thirteen (11.6%) patients were found to have osteoporosis, 27 (28.4%) osteopenia, and 57 patients had normal BMD. Advanced age and decreased body mass index, height, body weight, waist circumference, and triglyceride level were associated with lower lumbar T-scores, as were increased alkaline phosphatase, urea reduction rate, fractional clearance index for urea, and FGF21 levels. Low log-FGF21, increased body mass index, increased pre-HD body weight, and increased logarithmically transformed triglycerides (log-TG) were found to be significantly and independently associated with lumbar BMD by multivariate forward stepwise linear regression analysis with adjustment for significant confounders. We conclude that high serum FGF21 level is negatively associated with BMD in patients undergoing HD.
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15
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Ketteler M, Sprague SM, Covic AC, Rastogi A, Spinowitz B, Rakov V, Walpen S, Floege J. Effects of sucroferric oxyhydroxide and sevelamer carbonate on chronic kidney disease-mineral bone disorder parameters in dialysis patients. Nephrol Dial Transplant 2020; 34:1163-1170. [PMID: 29846719 PMCID: PMC6603395 DOI: 10.1093/ndt/gfy127] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Indexed: 12/15/2022] Open
Abstract
Background Treatment of hyperphosphataemia is the primary goal of chronic kidney disease–mineral and bone disorder (CKD-MBD) management. This post hoc analysis of a randomized, Phase 3 study evaluated the effects of 1-year treatment with the phosphate binders sucroferric oxyhydroxide or sevelamer carbonate (‘sevelamer’) on CKD-MBD indices among dialysis patients with hyperphosphataemia. Methods After a 2- to 4-week washout from previous phosphate binders, 1059 patients were randomized 2:1 to sucroferric oxyhydroxide 1.0–3.0 g/day (n = 710) or sevelamer 2.4–14.4 g/day (n = 349) for up to 24 weeks. Eligible patients enrolled in a 28-week extension. This post hoc analysis was performed for patients who completed ≥1 year of continuous treatment (n = 549). As the treatment groups showed similar CKD-MBD outcomes, the data were pooled for this analysis. Results Phosphate-binder therapy was associated with significant and sustained 30% reductions in serum phosphorus (P < 0.001). Median intact fibroblast growth factor-23 (FGF-23) also significantly decreased (P < 0.001) by 64% over 1 year. Intact parathyroid hormone decreased significantly after 24 weeks (P < 0.001), but levels returned to near baseline values by Week 52; minimal changes in serum calcium were observed. Of the bone resorption markers evaluated, tartrate-resistant acid phosphatase 5b (TRAP5b) decreased significantly (P < 0.001), whereas CTx increased transiently but returned to baseline levels by Week 52. The bone formation markers bone-specific alkaline phosphatase and osteocalcin both increased over 1 year of treatment. Conclusions Overall, 1 year of sucroferric oxyhydroxide or sevelamer treatment significantly reduced serum FGF-23, which has been associated with clinical benefit in patients with CKD. The trend towards increased bone formation marker levels indicates a beneficial effect on bone metabolism.
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Affiliation(s)
- Markus Ketteler
- Klinikum Coburg and KfH-Dialysis Center, Coburg, Germany.,School of Medicine, University of Split, Split, Croatia
| | - Stuart M Sprague
- NorthShore University Health System, University of Chicago, Pritzker School of Medicine, Evanston, IL, USA
| | - Adrian C Covic
- Gr.T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Anjay Rastogi
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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16
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Haffner D, Leifheit-Nestler M. Treatment of hyperphosphatemia: the dangers of aiming for normal PTH levels. Pediatr Nephrol 2020; 35:485-491. [PMID: 31823044 DOI: 10.1007/s00467-019-04399-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/30/2019] [Accepted: 10/14/2019] [Indexed: 12/14/2022]
Abstract
Secondary hyperparathyroidism is part of the complex of chronic kidney disease-associated mineral and bone disorders (CKD-MBD) and is linked with high bone turnover, ectopic calcification, and increased cardiovascular mortality. Therefore, measures for CKD-MBD aim at lowering PTH levels, but there is no general consensus on optimal PTH target values. This manuscript is part of a pros and cons debate for keeping PTH levels within the normal range in children with CKD, focusing on the cons. We conclude that a modest increase in PTH most likely represents an appropriate adaptive response to declining kidney function in patients with CKD stages 2-5D, due to phosphaturic effects and increasing bone resistance. There is no evidence for strictly keeping PTH levels within the normal range in CKD patients with respect to bone health and cardiovascular outcome. In addition, the potentially adverse effects of PTH-lowering measures, such as active vitamin D and calcimimetics, must be taken into account. We suggest that PTH values of 1-2 times the upper normal limit (ULN) may be acceptable in children with CKD stage 2-3, and that PTH levels of 1.7-5 times UNL may be optimal in patients with CKD stage 4-5D. However, standard care of CKD-MBD in children relies on a combination of different measures in which the observation of PTH levels is only a small part of, and trends in PTH levels rather than absolute target values should determine treatment decisions in patients with CKD as recommended by the 2017 KDIGO guidelines.
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Affiliation(s)
- Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Pediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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17
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Rroji M, Figurek A, Spasovski G. Should We Consider the Cardiovascular System While Evaluating CKD-MBD? Toxins (Basel) 2020; 12:toxins12030140. [PMID: 32106499 PMCID: PMC7150959 DOI: 10.3390/toxins12030140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/12/2020] [Accepted: 02/20/2020] [Indexed: 12/25/2022] Open
Abstract
Cardiovascular (CV) disease is highly prevalent in the population with chronic kidney disease (CKD), where the risk of CV death in early stages far exceeds the risk of progression to dialysis. The presence of chronic kidney disease-mineral and bone disorder (CKD-MBD) has shown a strong correlation with CV events and mortality. As a non-atheromatous process, it could be partially explained why standard CV disease-modifying drugs do not provide such an impact on CV mortality in CKD as observed in the general population. We summarize the potential association of CV comorbidities with the older (parathyroid hormone, phosphate) and newer (FGF23, Klotho, sclerostin) CKD-MBD biomarkers.
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Affiliation(s)
- Merita Rroji
- University Department of Nephrology, Faculty of Medicine, University of Medicine Tirana, Tirana 1001, Albania
- Correspondence:
| | - Andreja Figurek
- Institute of Anatomy, University of Zurich, Zurich 8057, Switzerland;
| | - Goce Spasovski
- University Department of Nephrology, Medical Faculty, University of Skopje, Skopje 1000, North Macedonia;
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18
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Lalayiannis A, Crabtree N, Fewtrell M, Biassoni L, Milford D, Ferro C, Shroff R. Assessing bone mineralisation in children with chronic kidney disease: what clinical and research tools are available? Pediatr Nephrol 2020; 35:937-957. [PMID: 31240395 PMCID: PMC7184042 DOI: 10.1007/s00467-019-04271-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/19/2019] [Accepted: 04/26/2019] [Indexed: 12/11/2022]
Abstract
Mineral and bone disorder in chronic kidney disease (CKD-MBD) is a triad of biochemical imbalances of calcium, phosphate, parathyroid hormone and vitamin D, bone abnormalities and soft tissue calcification. Maintaining optimal bone health in children with CKD is important to prevent long-term complications, such as fractures, to optimise growth and possibly also to prevent extra-osseous calcification, especially vascular calcification. In this review, we discuss normal bone mineralisation, the pathophysiology of dysregulated homeostasis leading to mineralisation defects in CKD and its clinical consequences. Bone mineralisation is best assessed on bone histology and histomorphometry, but given the rarity with which this is performed, we present an overview of the tools available to clinicians to assess bone mineral density, including serum biomarkers and imaging such as dual-energy X-ray absorptiometry and peripheral quantitative computed tomography. We discuss key studies that have used these techniques, their advantages and disadvantages in childhood CKD and their relationship to biomarkers and bone histomorphometry. Finally, we present recommendations from relevant guidelines-Kidney Disease Improving Global Outcomes and the International Society of Clinical Densitometry-on the use of imaging, biomarkers and bone biopsy in assessing bone mineral density. Given low-level evidence from most paediatric studies, bone imaging and histology remain largely research tools, and current clinical management is guided by serum calcium, phosphate, PTH, vitamin D and alkaline phosphatase levels only.
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Affiliation(s)
- A.D. Lalayiannis
- Nephrology Department Great Ormond St. Hospital for Children NHS Foundation Trust and University College London Institute of Child Health, London, UK
| | - N.J. Crabtree
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - M. Fewtrell
- Nephrology Department Great Ormond St. Hospital for Children NHS Foundation Trust and University College London Institute of Child Health, London, UK
| | - L. Biassoni
- Nephrology Department Great Ormond St. Hospital for Children NHS Foundation Trust and University College London Institute of Child Health, London, UK
| | - D.V. Milford
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - C.J. Ferro
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R. Shroff
- Nephrology Department Great Ormond St. Hospital for Children NHS Foundation Trust and University College London Institute of Child Health, London, UK
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19
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Liao HW, Huang TH, Chang YH, Liou HH, Chou YH, Sue YM, Hung PH, Chang YT, Ho PC, Tsai KJ. Exercise Alleviates Osteoporosis in Rats with Mild Chronic Kidney Disease by Decreasing Sclerostin Production. Int J Mol Sci 2019; 20:ijms20082044. [PMID: 31027235 PMCID: PMC6514556 DOI: 10.3390/ijms20082044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease–mineral bone disorder (CKD–MBD), comprising mineral, hormonal, and bone metabolic imbalance, is a major CKD-related issue; it causes osteoporosis prevalence in CKD patients. Osteocyte-derived sclerostin inhibits the osteogenic Wnt/β-catenin signaling pathway; its levels rise when kidney function declines. Exercise modulates the physiological functions of osteocytes, potentially altering sclerostin production. It may aid bone and mineral electrolyte homeostasis in CKD. Mild CKD was induced in rats by partial nephrectomy. They were divided into: sham (no CKD), CKD, and CKD + exercise (8 weeks of treadmill running) groups. Micro-CT scanning demonstrated that the CKD + exercise-group rats had a higher bone mineral density (BMD) of the spine and femoral metaphysis and higher femoral trabecular bone volume than the CKD-group rats. Bone formation rates were not significantly different. The CKD + exercise-group rats had lower serum sclerostin (157.1 ± 21.1 vs 309 ± 38.1 pg/mL, p < 0.05) and CTX-1 (bone resorption marker) levels. Immunohistochemistry revealed higher tibial β-catenin concentrations in the CKD + exercise-group rats. Serum FGF-23, intact parathyroid hormone (iPTH), alkaline phosphatase (ALP), calcium, and phosphate levels showed no significant differences between these groups. Thus, exercise improves BMD and bone microstructure in mild CKD by inhibiting sclerostin production, but does not alter serum minerals.
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Affiliation(s)
| | - Tsang-Hai Huang
- Institute of Physical Education, Health and Leisure Studies, National Cheng Kung University, Tainan 704, Taiwan.
| | - Yi-Han Chang
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan.
| | - Hung-Hsiang Liou
- Division of Nephrology, Department of Medicine, Hsin-Jen Hospital, New Taipei City 242, Taiwan.
| | - Yu-Hsien Chou
- Institute of Physical Education, Health and Leisure Studies, National Cheng Kung University, Tainan 704, Taiwan.
| | - Yuh-Mou Sue
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine and Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan.
| | - Peir-Haur Hung
- Department of Internal Medicine, Ditmanson Medical Foundation Chia-yi Christian Hospital, Chia-yi City 600; Taiwan.
- Division of Applied Life Science and Health, Chia-Nan University of Pharmacy and Science, Tainan 717, Taiwan.
| | - Yu-Tzu Chang
- Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan.
| | - Pei-Chuan Ho
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan.
| | - Kuen-Jer Tsai
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan.
- Research center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan.
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N-Terminal Pro-Brain Natriuretic Peptide Predicts Long-Term Technique Failure in Patients Undergoing Peritoneal Dialysis. J Clin Med 2018; 7:jcm7120557. [PMID: 30558385 PMCID: PMC6306793 DOI: 10.3390/jcm7120557] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 12/06/2018] [Accepted: 12/13/2018] [Indexed: 12/29/2022] Open
Abstract
It is unclear whether N-terminal pro-brain type natriuretic peptide (NT-proBNP) level can be a biomarker for technique failure among long-term peritoneal dialysis (PD) patients. We prospectively included end-stage renal disease patients undergoing PD from a single center between December 2011 and December 2017. We divided the cohort into high or low NT-proBNP groups and analyzed the risk factors associated with the incidence of technique failure using Cox proportional hazard regression analysis. A total of 258 chronic PD patients (serum NT-proBNP, 582 ± 1216 ng/mL) were included. After a mean follow-up of 3.6 years, 49.6% of PD patients developed technique failure and switched to hemodialysis, while 15.5% died. Cox proportional hazard regression analyses accounting for age, gender, diabetes, renal clearance, C-reactive protein, and hydration status, showed that higher natural log transformed NT-proBNP levels (hazard ratio [HR] 1.13, p < 0.01) were predictive of an increased risk of technique failure, and were also predictive of an increased risk of mortality (HR 1.56, p < 0.01). Consequently, NT-proBNP might be an under-recognized biomarker for estimating the risk of technique failure, and regular monitoring NT-proBNP levels among PD patients may assist in their care.
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Abstract
Chronic kidney disease (CKD) is an inherently systemic disease that refers to a long-term loss of kidney function. The progression of CKD has repercussions for other organs, leading to many kinds of extrarenal complications. Intensive studies are now being undertaken to reveal the risk factors and pathophysiological mechanism of this disease. During the past 20 years, increasing evidence from clinical and basic studies has indicated that klotho, which was initially known as an anti-aging gene and is mainly expressed in the kidney, is significantly correlated with the development and progression of CKD and its complications. Here, we discuss in detail the role and pathophysiological implications of klotho in ion disorders, the inflammation response, vascular calcification, mineral bone disorders, and renal fibrosis in CKD. Based on the pathogenic mechanism of klotho deficiency and klotho decline in urine early in CKD stage 2 and even earlier in CKD stage 1, it is not difficult to understand that soluble klotho can serve as an early and sensitive marker of CKD. Moreover, the prevention of klotho decline by several mechanisms can attenuate renal injuries, retard CKD progression, ameliorate extrarenal complications, and improve renal function. In this review, we focus on the functions and pathophysiological implications of klotho in CKD and its extrarenal complications as well as its potential applications as a diagnostic and/or prognostic biomarker for CKD and as a novel treatment strategy to improve and decrease the burden of comorbidity in CKD.
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Systemic Activation of Activin A Signaling Causes Chronic Kidney Disease-Mineral Bone Disorder. Int J Mol Sci 2018; 19:ijms19092490. [PMID: 30142896 PMCID: PMC6163495 DOI: 10.3390/ijms19092490] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 11/19/2022] Open
Abstract
The high cardiovascular mortality associated with chronic kidney disease (CKD) is caused in part by the CKD-mineral bone disorder (CKD-MBD) syndrome. The CKD-MBD consists of skeletal, vascular and cardiac pathology caused by metabolic derangements produced by kidney disease. The prevalence of osteopenia/osteoporosis resulting from the skeletal component of the CKD-MBD, renal osteodystrophy (ROD), in patients with CKD exceeds that of the general population and is a major public health concern. That CKD is associated with compromised bone health is widely accepted, yet the mechanisms underlying impaired bone metabolism in CKD are not fully understood. Therefore, clarification of the molecular mechanisms by which CKD produces ROD is of crucial significance. We have shown that activin A, a member of the transforming growth factor (TGF)-β super family, is an important positive regulator of receptor activator of nuclear factor kappa-B ligand (RANKL)-induced osteoclastogenesis with Smad-mediated signaling being crucial for inducing osteoclast development and function. Recently, we have demonstrated systemic activation of activin receptors and activin A levels in CKD mouse models, such as diabetic CKD and Alport (AL) syndrome. In these CKD mouse models, bone remodeling caused by increased osteoclast numbers and activated osteoclastic bone resorption was observed and treatment with an activin receptor ligand trap repaired CKD-induced-osteoclastic bone resorption and stimulated individual osteoblastic bone formation, irrespective of parathyroid hormone (PTH) elevation. These findings have opened a new field for exploring mechanisms of activin A-enhanced osteoclast formation and function in CKD. Activin A appears to be a strong candidate for CKD-induced high-turnover ROD. Therefore, the treatment with the decoy receptor for activin A might be a good candidate for treatment for CKD-induced osteopenia or osteoporosis, indicating that the new findings from in these studies will lead to the identification of novel therapeutic targets for CKD-related and osteopenia and osteoporosis in general. In this review, we describe the impact of CKD-induced Smad signaling in osteoclasts, osteoblasts and vascular cells in CKD.
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Kawada S, Nagasawa Y, Kawabe M, Ohyama H, Kida A, Kato-Kogoe N, Nanami M, Hasuike Y, Kuragano T, Kishimoto H, Nakasho K, Nakanishi T. Iron-induced calcification in human aortic vascular smooth muscle cells through interleukin-24 (IL-24), with/without TNF-alpha. Sci Rep 2018; 8:658. [PMID: 29330517 PMCID: PMC5766506 DOI: 10.1038/s41598-017-19092-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/20/2017] [Indexed: 12/14/2022] Open
Abstract
In CKD patients, arteriosclerotic lesions, including calcification, can occur in vascular smooth muscle cells in a process called Moenckeberg's medial arteriosclerosis. Iron overload induces several complications, including the acceleration of arteriosclerosis. However, the relationship between Moenckeberg's arteriosclerosis in vascular smooth muscle cells and iron accumulation has remained unknown. We tested the accelerated effect of iron on calcification in cultured human aortic vascular smooth muscle cells (HASMCs). After establishment of this model, we performed a microarray analysis using mRNA from early stage culture HASMCs after iron stimulation with or without TNF-alpha stimulation. The role of interleukin-24 (IL-24) was confirmed from candidate genes that might contribute to calcification. HASMCs demonstrated calcification induced by iron and TNF-alpha. Calcification of HASMCs was synergistically enhanced by stimulation with both iron and TNF-alpha. In the early phase of calcification, microarray analysis revealed up-regulation of IL-24. Stimulation of HASMCs by IL-24 instead of iron induced calcification. The anti-IL-24 antibody reversed the effect of IL-24, supporting the important role of IL-24 in HASMCs calcification. In conclusion, iron-induced calcification in vascular smooth muscle cells occurred via IL-24, IL-24 was increased during the calcification process induced by iron, and IL-24 itself caused calcification in the absence of iron.
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Affiliation(s)
- Sayuri Kawada
- Department of Internal Medicine, Division of Kidney and Dialysis, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan
| | - Yasuyuki Nagasawa
- Department of Internal Medicine, Division of Kidney and Dialysis, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan.
| | - Mutsuki Kawabe
- Department of Pathology, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan.,Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan
| | - Hideki Ohyama
- Department of Pathology, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan
| | - Aritoshi Kida
- Department of Internal Medicine, Division of Kidney and Dialysis, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan
| | - Nahoko Kato-Kogoe
- Department of Pathology, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan
| | - Masayoshi Nanami
- Department of Internal Medicine, Division of Kidney and Dialysis, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan
| | - Yukiko Hasuike
- Department of Internal Medicine, Division of Kidney and Dialysis, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan
| | - Takahiro Kuragano
- Department of Internal Medicine, Division of Kidney and Dialysis, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan
| | - Hiromitsu Kishimoto
- Department of Oral and Maxillofacial Surgery, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan
| | - Keiji Nakasho
- Department of Pathology, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan
| | - Takeshi Nakanishi
- Department of Internal Medicine, Division of Kidney and Dialysis, Hyogo College of Medicine, 1-1 Mukogawa-Cho, Nishinomiya, Hyogo, Japan
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Biggar P, Kim GH. Treatment of renal anemia: Erythropoiesis stimulating agents and beyond. Kidney Res Clin Pract 2017; 36:209-223. [PMID: 28904872 PMCID: PMC5592888 DOI: 10.23876/j.krcp.2017.36.3.209] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/02/2017] [Accepted: 07/12/2017] [Indexed: 12/18/2022] Open
Abstract
Anemia, complicating the course of chronic kidney disease, is a significant parameter, whether interpreted as subjective impairment or an objective prognostic marker. Renal anemia is predominantly due to relative erythropoietin (EPO) deficiency. EPO inhibits apoptosis of erythrocyte precursors. Studies using EPO substitution have shown that increasing hemoglobin (Hb) levels up to 10–11 g/dL is associated with clinical improvement. However, it has not been unequivocally proven that further intensification of erythropoiesis stimulating agent (ESA) therapy actually leads to a comprehensive benefit for the patient, especially as ESAs are potentially associated with increased cerebro-cardiovascular events. Recently, new developments offer interesting options not only via stimulating erythropoeisis but also by employing additional mechanisms. The inhibition of activin, a member of the transforming growth factor superfamily, has the potential to correct anemia by stimulating liberation of mature erythrocyte forms and also to mitigate disturbed mineral and bone metabolism as well. Hypoxia-inducible factor prolyl hydroxylase inhibitors also show pleiotropic effects, which are at the focus of present research and have the potential of reducing mortality. However, conventional ESAs offer an extensive body of safety evidence, against which the newer substances should be measured. Carbamylated EPO is devoid of Hb augmenting effects whilst exerting promising tissue protective properties. Additionally, the role of hepcidin antagonists is discussed. An innovative new hemodialysis blood tube system, reducing blood contact with air, conveys a totally different and innocuous option to improve renal anemia by reducing mechanical hemolysis.
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Affiliation(s)
- Patrick Biggar
- Department of Nephrology, Klinikum Coburg, GmbH, Coburg, Germany.,KfH Kidney Centre, Coburg, Germany
| | - Gheun-Ho Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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Mok Y, Ballew SH, Matsushita K. Prognostic Value of Chronic Kidney Disease Measures in Patients With Cardiac Disease. Circ J 2017; 81:1075-1084. [PMID: 28680012 DOI: 10.1253/circj.cj-17-0550] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic kidney disease (CKD) is considered a global public health issue. The latest international clinical guideline emphasizes characterization of CKD with both glomerular filtration rate (GFR) and albuminuria. CKD is closely related to cardiac disease and increases the risk of adverse outcomes among patients with cardiovascular disease (CVD). Indeed, numerous studies have investigated the association of CKD measures with prognosis among patients with CVD, but most of them have focused on kidney function, with limited data on albuminuria. Consequently, although there are several risk prediction tools for patients with CVD incorporating kidney function, to our knowledge, none of them include albuminuria. Moreover, the selection of the kidney function measure (e.g., serum creatinine, creatinine-based estimated GFR, or blood urea nitrogen) in these tools is heterogeneous. In this review, we will summarize these aspects, as well as the burden of CKD in patients with CVD, in the current literature. We will also discuss potential mechanisms linking CKD to secondary events and consider future research directions. Given their clinical and public health importance, for CVD we will focus on 2 representative cardiac diseases: myocardial infarction and heart failure.
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Affiliation(s)
- Yejin Mok
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and Welch Center for Prevention, Epidemiology, and Clinical Research
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and Welch Center for Prevention, Epidemiology, and Clinical Research
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and Welch Center for Prevention, Epidemiology, and Clinical Research
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Abstract
PURPOSE OF REVIEW In this paper, we review the pathogenesis and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD), especially as it relates to pediatric CKD patients. RECENT FINDINGS Disordered regulation of bone and mineral metabolism in CKD may result in fractures, skeletal deformities, and poor growth, which is especially relevant for pediatric CKD patients. Moreover, CKD-MBD may result in extra-skeletal calcification and cardiovascular morbidity. Early increases in fibroblast growth factor 23 (FGF23) levels play a key, primary role in CKD-MBD pathogenesis. Therapeutic approaches in pediatric CKD-MBD aim to minimize complications to the growing skeleton and prevent extra-skeletal calcifications, mainly by addressing hyperphosphatemia and secondary hyperparathyroidism. Ongoing clinical trials are focused on assessing the benefit of FGF23 reduction in CKD. CKD-MBD is a systemic disorder that has significant clinical implications. Treatment of CKD-MBD in children requires special consideration in order to maximize growth, optimize skeletal health, and prevent cardiovascular disease.
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Affiliation(s)
- Mark R Hanudel
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, MDCC A2-383, Los Angeles, CA, 90095-1752, USA.
| | - Isidro B Salusky
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Abstract
BACKGROUND Activins A and B, members of the TGF-β superfamily, are produced as part of the physiological response to tissue damage and the resulting proinflammatory response. Given that lung allograft reperfusion results in an inflammatory response, it is likely that the activins and their binding protein follistatin will form part of the regulatory response. There is a need to document the response of these proteins to allograft reperfusion to determine if there is a role for the use of follistatin to control the biological actions of the activins because some of these are potentially damaging. METHODS Serum from 48 consecutive patients undergoing lung transplantation (LTx) was collected at 2, 6, 12, and 26 weeks post-LTx. The serum levels of activin A and B and follistatin were measured by enzyme-linked immunosorbent assay and specific radioimmunoassays and compared with clinical events. RESULTS Serum activin A and B levels were at the upper limit of the normal ranges at 2 weeks post-LTx decreasing thereafter to 12 weeks post-LTx (P < 0.05). In contrast, serum follistatin levels were unchanged between 2 and 12 weeks, with a late significant increase at 24 week post-LTx (P < 0.01). Patients with primary graft dysfunction had lower serum follistatin levels (7.7 vs 9.5 ng/mL; P = 0.04) and a higher activin A/follistatin ratio (13.1 vs 10.4; P = 0.02) at 2 weeks post-LTx. CONCLUSIONS Activin and follistatin levels vary with time form LTX and reflect a proinflammatory environment. Future studies will elucidate associations with chronic lung allograft dysfunction and the therapeutic potential of exogenous follistatin administration.
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28
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Stabley JN, Towler DA. Arterial Calcification in Diabetes Mellitus: Preclinical Models and Translational Implications. Arterioscler Thromb Vasc Biol 2017; 37:205-217. [PMID: 28062508 PMCID: PMC5480317 DOI: 10.1161/atvbaha.116.306258] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 12/12/2016] [Indexed: 02/07/2023]
Abstract
Diabetes mellitus increasingly afflicts our aging and dysmetabolic population. Type 2 diabetes mellitus and the antecedent metabolic syndrome represent the vast majority of the disease burden-increasingly prevalent in children and older adults. However, type 1 diabetes mellitus is also advancing in preadolescent children. As such, a crushing wave of cardiometabolic disease burden now faces our society. Arteriosclerotic calcification is increased in metabolic syndrome, type 2 diabetes mellitus, and type 1 diabetes mellitus-impairing conduit vessel compliance and function, thereby increasing the risk for dementia, stroke, heart attack, limb ischemia, renal insufficiency, and lower extremity amputation. Preclinical models of these dysmetabolic settings have provided insights into the pathobiology of arterial calcification. Osteochondrogenic morphogens in the BMP-Wnt signaling relay and transcriptional regulatory programs driven by Msx and Runx gene families are entrained to innate immune responses-responses activated by the dysmetabolic state-to direct arterial matrix deposition and mineralization. Recent studies implicate the endothelial-mesenchymal transition in contributing to the phenotypic drift of mineralizing vascular progenitors. In this brief overview, we discuss preclinical disease models that provide mechanistic insights-and point to challenges and opportunities to translate these insights into new therapeutic strategies for our patients afflicted with diabetes mellitus and its arteriosclerotic complications.
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MESH Headings
- Animals
- Animals, Genetically Modified
- Arteries/metabolism
- Arteries/pathology
- Atherosclerosis/etiology
- Atherosclerosis/metabolism
- Atherosclerosis/pathology
- Diabetes Mellitus, Experimental/complications
- Diabetes Mellitus, Experimental/genetics
- Diabetes Mellitus, Experimental/metabolism
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/genetics
- Diabetes Mellitus, Type 1/metabolism
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/genetics
- Diabetes Mellitus, Type 2/metabolism
- Diabetic Angiopathies/etiology
- Diabetic Angiopathies/metabolism
- Diabetic Angiopathies/pathology
- Diet, High-Fat
- Disease Models, Animal
- Female
- Genetic Predisposition to Disease
- Humans
- Hyperlipidemias/complications
- Hyperlipidemias/genetics
- Male
- Phenotype
- Plaque, Atherosclerotic
- Rats
- Signal Transduction
- Translational Research, Biomedical
- Vascular Calcification/etiology
- Vascular Calcification/metabolism
- Vascular Calcification/pathology
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Affiliation(s)
- John N Stabley
- From the Division of Endocrinology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Dwight A Towler
- From the Division of Endocrinology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX.
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29
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Hu H, Patel S, Hanisch JJ, Santana JM, Hashimoto T, Bai H, Kudze T, Foster TR, Guo J, Yatsula B, Tsui J, Dardik A. Future research directions to improve fistula maturation and reduce access failure. Semin Vasc Surg 2016; 29:153-171. [PMID: 28779782 DOI: 10.1053/j.semvascsurg.2016.08.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
With the increasing prevalence of end-stage renal disease, there is a growing need for hemodialysis. Arteriovenous fistulae (AVF) are the preferred type of vascular access for hemodialysis, but maturation and failure continue to present significant barriers to successful fistula use. AVF maturation integrates outward remodeling with vessel wall thickening in response to drastic hemodynamic changes in the setting of uremia, systemic inflammation, oxidative stress, and pre-existent vascular pathology. AVF can fail due to both failure to mature adequately to support hemodialysis and development of neointimal hyperplasia that narrows the AVF lumen, typically near the fistula anastomosis. Failure due to neointimal hyperplasia involves vascular cell activation and migration and extracellular matrix remodeling with complex interactions of growth factors, adhesion molecules, inflammatory mediators, and chemokines, all of which result in maladaptive remodeling. Different strategies have been proposed to prevent and treat AVF failure based on current understanding of the modes and pathology of access failure; these approaches range from appropriate patient selection and use of alternative surgical strategies for fistula creation, to the use of novel interventional techniques or drugs to treat failing fistulae. Effective treatments to prevent or treat AVF failure require a multidisciplinary approach involving nephrologists, vascular surgeons, and interventional radiologists, careful patient selection, and the use of tailored systemic or localized interventions to improve patient-specific outcomes. This review provides contemporary information on the underlying mechanisms of AVF maturation and failure and discusses the broad spectrum of options that can be tailored for specific therapy.
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Affiliation(s)
- Haidi Hu
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Department of Vascular and Thyroid Surgery, the First Affiliated Hospital of China Medical University, Shenyang, China; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Sandeep Patel
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT; Royal Free Hospital, University College London, London, UK
| | - Jesse J Hanisch
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Jeans M Santana
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Takuya Hashimoto
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Hualong Bai
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Tambudzai Kudze
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Trenton R Foster
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Jianming Guo
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Bogdan Yatsula
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Janice Tsui
- Royal Free Hospital, University College London, London, UK
| | - Alan Dardik
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT.
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30
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Rukov JL, Gravesen E, Mace ML, Hofman-Bang J, Vinther J, Andersen CB, Lewin E, Olgaard K. Effect of chronic uremia on the transcriptional profile of the calcified aorta analyzed by RNA sequencing. Am J Physiol Renal Physiol 2016; 310:F477-91. [PMID: 26739890 DOI: 10.1152/ajprenal.00472.2015] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 01/05/2016] [Indexed: 12/12/2022] Open
Abstract
The development of vascular calcification (VC) in chronic uremia (CU) is a tightly regulated process controlled by factors promoting and inhibiting mineralization. Next-generation high-throughput RNA sequencing (RNA-seq) is a powerful and sensitive tool for quantitative gene expression profiling and the detection of differentially expressed genes. In the present study, we, for the first time, used RNA-seq to examine rat aorta transcriptomes from CU rats compared with control rats. Severe VC was induced in CU rats, which lead to extensive changes in the transcriptional profile. Among the 10,153 genes with an expression level of >1 reads/kilobase transcript/million mapped reads, 2,663 genes were differentially expressed with 47% upregulated genes and 53% downregulated genes in uremic rats. Significantly deregulated genes were enriched for ontologies related to the extracellular matrix, response to wounding, organic substance, and ossification. The individually affected genes were of relevance to osteogenic transformation, tissue calcification, and Wnt modulation. Downregulation of the Klotho gene in uremia is believed to be involved in the development of VC, but it is debated whether the effect is caused by circulating Klotho only or if Klotho is produced locally in the vasculature. We found that Klotho was neither expressed in the normal aorta nor calcified aorta by RNA-seq. In conclusion, we demonstrated extensive changes in the transcriptional profile of the uremic calcified aorta, which were consistent with a shift in phenotype from vascular tissue toward an osteochondrocytic transcriptome profile. Moreover, neither the normal vasculature nor calcified vasculature in CU expresses Klotho.
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Affiliation(s)
- Jakob L Rukov
- Faculty of Science, Department of Biology, University of Copenhagen, Copenhagen, Denmark
| | - Eva Gravesen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Nephrological Department P, Rigshospitalet, Copenhagen, Denmark
| | - Maria L Mace
- Nephrological Department P, Rigshospitalet, Copenhagen, Denmark; Nephrological Department B, Herlev Hospital, Copenhagen, Denmark
| | | | - Jeppe Vinther
- Faculty of Science, Department of Biology, University of Copenhagen, Copenhagen, Denmark
| | | | - Ewa Lewin
- Nephrological Department P, Rigshospitalet, Copenhagen, Denmark; Nephrological Department B, Herlev Hospital, Copenhagen, Denmark
| | - Klaus Olgaard
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Nephrological Department P, Rigshospitalet, Copenhagen, Denmark;
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