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Kubota M, Hamasaki Y, Hashimoto J, Aoki Y, Kawamura T, Saito A, Yuasa R, Muramatsu M, Komaba H, Toyoda M, Fukagawa M, Shishido S, Sakai K. Fibroblast growth factor 23-Klotho and mineral metabolism in the first year after pediatric kidney transplantation: A single-center prospective study. Pediatr Transplant 2023; 27:e14440. [PMID: 36471536 DOI: 10.1111/petr.14440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of fibroblast growth factor 23 (FGF23) levels in mineral metabolism before and after kidney transplantation in pediatric patients is poorly understood. METHODS We prospectively evaluated 24 patients under 18 years of age (4.5 [3.3-9.8] years) who underwent living kidney transplantation between July 2016 and March 2018, and measured intact FGF23 and serum αKlotho levels, and other parameters of mineral metabolism before and after transplantation (Day 7, 1 and 4 months, and 1 year). Relationships between parameters were examined by linear analysis. RESULTS FGF23 level was 440.8 [63.4-5916.3] pg/ml pre-transplant and decreased significantly to 37.1 [16.0-71.5] pg/ml at Day 7 post-transplant (-91.6%, p < .001). Thereafter, it remained at normal levels until 1 year. αKlotho level was 785 [568-1292] pg/ml pre-transplant and remained low at Day 7 and 1 month post-transplant, with an increasing trend at 4 months. Post-transplant phosphorus levels were significantly decreased compared with pre-transplant, with a lowest level of 1.7 [1.3-2.9] mg/dl, -5.7 [-6.8, -3.8] SD at Day 4, followed by gradual recovery. Phosphorus levels and the ratio of tubular maximum phosphate reabsorption were significantly and negatively associated with pre-transplant FGF23 until 4 months of post-transplant. Pre-transplant αKlotho was negatively associated with pre-transplant FGF23 but not FGF23 or other parameters after transplantation. CONCLUSION FGF23 in pediatric kidney transplant patients decreased rapidly after transplantation and associated with post-transplant hypophosphatemia and increased phosphorus excretion. Post-transplant αKlotho was low early post-transplant but tended to increase subsequently. Post-transplant αKlotho was unaffected by pre-transplant FGF23 or other factors, suggesting pre-transplant chronic kidney disease status has no effect.
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Affiliation(s)
- Mai Kubota
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Junya Hashimoto
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Yujiro Aoki
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Takeshi Kawamura
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Akinobu Saito
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Rena Yuasa
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Masaki Muramatsu
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Masao Toyoda
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Seichiro Shishido
- Department of Pediatric Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
| | - Ken Sakai
- Department of Nephrology, Toho University, Faculty of Medicine, Tokyo, Japan
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Delucchi Á, Toro L, Alzamora R, Barrientos V, González M, Andaur R, León P, Villanueva F, Galindo M, Las Heras F, Montecino M, Moena D, Lazcano A, Pinto V, Salas P, Reyes ML, Mericq V, Michea L. Glucocorticoids Decrease Longitudinal Bone Growth in Pediatric Kidney Transplant Recipients by Stimulating the FGF23/FGFR3 Signaling Pathway. J Bone Miner Res 2019; 34:1851-1861. [PMID: 31099911 DOI: 10.1002/jbmr.3761] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 05/05/2019] [Accepted: 05/11/2019] [Indexed: 12/11/2022]
Abstract
Renal transplantation (RTx) is an effective therapy to improve clinical outcomes in pediatric patients with terminal chronic kidney disease. However, chronic immunosuppression with glucocorticoids (GCs) reduces bone growth and BMD. The mechanisms causing GC-induced growth impairment have not been fully clarified. Fibroblast growth factor 23 (FGF23) is a peptide hormone that regulates phosphate homeostasis and bone growth. In pathological conditions, FGF23 excess or abnormal FGF receptors (FGFR) activity leads to bone growth impairment. Experimental data indicate that FGF23 expression is induced by chronic GC exposure. Therefore, we hypothesize that GCs impair bone growth by increasing FGF23 expression, which has direct effects on bone growth plate. In a post hoc analysis of a multicentric randomized clinical trial of prepubertal RTx children treated with early GC withdrawal or chronic GC treatment, we observed that GC withdrawal was associated with improvement in longitudinal growth and BMD, and lower plasma FGF23 levels as compared with a chronic GC group. In prepubertal rats, GC-induced bone growth retardation correlated with increased plasma FGF23 and bone FGF23 expression. Additionally, GC treatment decreased FGFR1 expression whereas it increased FGFR3 expression in mouse tibia explants. The GC-induced bone growth impairment in tibiae explants was prevented by blockade of FGF23 receptors using either a pan-FGFR antagonist (PD173074), a C-terminal FGF23 peptide (FGF23180-205) which blocks the binding of FGF23 to the FGFR-Klotho complex or a specific FGFR3 antagonist (P3). Finally, local administration of PD173074 into the tibia growth plate ameliorated cartilage growth impairment in GC-treated rats. These results show that GC treatment partially reduces longitudinal bone growth via upregulation of FGF23 and FGFR3 expression, thus suggesting that the FGF23/Klotho/FGFR3 axis at the growth plate could be a potential therapeutic target for the management of GC-induced growth impairment in children.
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Affiliation(s)
- Ángela Delucchi
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,Division of Nephrology, Clínica Alemana de Santiago, Santiago, Chile
| | - Luis Toro
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada, Hospital Clínico Universidad de Chile, Santiago, Chile.,Clinica Las Condes, Santiago, Chile
| | - Rodrigo Alzamora
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Nucleus of Ion Channel-Associated Diseases (MiNICAD), Santiago, Chile
| | - Victor Barrientos
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Magdalena González
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Rodrigo Andaur
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Pablo León
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Francisco Villanueva
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Mario Galindo
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Institute on Immunology and Immunotherapy (MIII), Santiago, Chile
| | - Facundo Las Heras
- Clinica Las Condes, Santiago, Chile.,Department of Anatomic Pathology, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Martín Montecino
- Institute of Biomedical Sciences, Faculty of Medicine and Faculty of Life Sciences, Universidad Andrés Bello, Santiago, Chile.,FONDAP Center for Genome Regulation, Universidad Andres Bello, Santiago, Chile
| | - Daniel Moena
- Institute of Biomedical Sciences, Faculty of Medicine and Faculty of Life Sciences, Universidad Andrés Bello, Santiago, Chile.,FONDAP Center for Genome Regulation, Universidad Andres Bello, Santiago, Chile
| | - Andrea Lazcano
- Division of Nephrology, Clínica Alemana de Santiago, Santiago, Chile.,Division of Nephrology, Hospital de Niños Roberto del Río, Santiago, Chile
| | - Viola Pinto
- Clinica Las Condes, Santiago, Chile.,Pediatric Nephrology Unit, Hospital Doctor Exequiel González Cortés, Santiago, Chile
| | - Paulina Salas
- Pediatric Nephrology Unit, Hospital Doctor Exequiel González Cortés, Santiago, Chile
| | - María Loreto Reyes
- Pediatric Endocrinology Unit, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Verónica Mericq
- Clinica Las Condes, Santiago, Chile.,Institute of Maternal and Child Research, Universidad de Chile, Santiago, Chile
| | - Luis Michea
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile.,Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Institute on Immunology and Immunotherapy (MIII), Santiago, Chile
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Abstract
The last 25 years have been characterized by dramatic improvements in short-term patient and allograft survival after kidney transplantation. Long-term patient and allograft survival remains limited by cardiovascular disease and chronic allograft injury, among other factors. Cardiovascular disease remains a significant contributor to mortality in native chronic kidney disease as well as cardiovascular mortality in chronic kidney disease more than doubles that of the general population. The chronic kidney disease (CKD)-mineral bone disorder (MBD) is a syndrome recently coined to embody the biochemical, skeletal, and cardiovascular pathophysiology that results from disrupting the complex systems biology between the kidney, skeleton, and cardiovascular system in native and transplant kidney disease. The CKD-MBD is a unique kidney disease-specific syndrome containing novel cardiovascular risk factors, with an impact reaching far beyond traditional notions of renal osteodystrophy and hyperparathyroidism. This overview reviews current knowledge of the pathophysiology of the CKD-MBD, including emerging concepts surrounding the importance of circulating pathogenic factors released from the injured kidney that directly cause cardiovascular disease in native and transplant chronic kidney disease, with potential application to mechanisms of chronic allograft injury and vasculopathy.
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Seifert ME, Ashoor IF, Chiang ML, Chishti AS, Dietzen DJ, Gipson DS, Janjua HS, Selewski DT, Hruska KA. Fibroblast growth factor-23 and chronic allograft injury in pediatric renal transplant recipients: a Midwest Pediatric Nephrology Consortium study. Pediatr Transplant 2016; 20:378-87. [PMID: 26880121 PMCID: PMC4818682 DOI: 10.1111/petr.12682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2016] [Indexed: 11/30/2022]
Abstract
The chronic kidney disease-mineral bone disorder (CKD-MBD) produces fibroblast growth factor-23 (FGF-23) and related circulating pathogenic factors that are strongly associated with vascular injury and declining kidney function in native CKD. Similarly, chronic renal allograft injury (CRAI) is characterized by vascular injury and declining allograft function in transplant CKD. We hypothesized that circulating CKD-MBD factors could serve as non-invasive biomarkers of CRAI. We conducted a cross-sectional, multicenter case-control study. Cases (n = 31) had transplant function >20 mL/min/1.73 m(2) and biopsy-proven CRAI. Controls (n = 31) had transplant function >90 mL/min/1.73 m(2) and/or a biopsy with no detectable abnormality in the previous six months. We measured plasma CKD-MBD factors at a single time point using ELISA. Median (range) FGF23 levels were over twofold higher in CRAI vs. controls [106 (10-475) pg/mL vs. 45 (8-91) pg/mL; p < 0.001]. FGF23 levels were inversely correlated with transplant function (r(2) = -0.617, p < 0.001). Higher FGF23 levels were associated with increased odds of biopsy-proven CRAI after adjusting for transplant function, clinical, and demographic factors [OR (95% CI) 1.43 (1.23, 1.67)]. Relationships between additional CKD-MBD factors and CRAI were attenuated in multivariable models. Higher FGF23 levels were independently associated with biopsy-proven CRAI in children.
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Affiliation(s)
- Michael E. Seifert
- Department of Pediatrics, Division of Pediatric Nephrology, Southern Illinois University, Springfield, IL
,Department of Pediatrics, Washington University, St. Louis, MO
| | - Isa F. Ashoor
- Division of Nephrology, Children’s Hospital of New Orleans, New Orleans, LA
| | - Myra L. Chiang
- Department of Pediatrics, West Virginia University, Charleston, WV
| | - Aftab S. Chishti
- Division of Nephrology, Hypertension & Renal Transplantation, University of Kentucky, Lexington, KY
| | | | - Debbie S. Gipson
- Division of Nephrology, C.S. Mott Children’s Hospital and University of Michigan, Ann Arbor, MI
| | - Halima S. Janjua
- Center for Pediatric Nephrology, Cleveland Clinic Children’s Hospital and Case Western Reserve University, Cleveland, OH
| | - David T. Selewski
- Division of Nephrology, C.S. Mott Children’s Hospital and University of Michigan, Ann Arbor, MI
| | - Keith A. Hruska
- Department of Pediatrics, Washington University, St. Louis, MO
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Bonthuis M, Busutti M, van Stralen KJ, Jager KJ, Baiko S, Bakkaloğlu S, Battelino N, Gaydarova M, Gianoglio B, Parvex P, Gomes C, Heaf JG, Podracka L, Kuzmanovska D, Molchanova MS, Pankratenko TE, Papachristou F, Reusz G, Sanahuja MJ, Shroff R, Groothoff JW, Schaefer F, Verrina E. Mineral metabolism in European children living with a renal transplant: a European society for paediatric nephrology/european renal association-European dialysis and transplant association registry study. Clin J Am Soc Nephrol 2015; 10:767-75. [PMID: 25710805 DOI: 10.2215/cjn.06200614] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 01/13/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Data on mineral metabolism in pediatric renal transplant recipients largely arise from small single-center studies. In adult patients, abnormal mineral levels are related to a higher risk of graft failure. This study used data from the European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry to study the prevalence and potential determinants of mineral abnormalities, as well as the predictive value of a disturbed mineral level on graft survival in a large cohort of European pediatric renal transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study included 1237 children (0-17 years) from 10 European countries, who had serum calcium, phosphorus, and parathyroid hormone measurements from 2000 onward. Abnormalities of mineral metabolism were defined according to European guidelines on prevention and treatment of renal osteodystrophy in children on chronic renal failure. RESULTS Abnormal serum phosphorus levels were observed in 25% (14% hypophosphatemia and 11% hyperphosphatemia), altered serum calcium in 30% (19% hypocalcemia, 11% hypercalcemia), and hyperparathyroidism in 41% of the patients. A longer time since transplantation was associated with a lower risk of having mineral levels above target range. Serum phosphorus levels were inversely associated with eGFR, and levels above the recommended targets were associated with a higher risk of graft failure independently of eGFR. CONCLUSIONS Abnormalities in mineral metabolism are common after pediatric renal transplantation in Europe and are associated with graft dysfunction.
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Affiliation(s)
- Marjolein Bonthuis
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Marco Busutti
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Karlijn J van Stralen
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material.
| | - Kitty J Jager
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Sergey Baiko
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Sevcan Bakkaloğlu
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Nina Battelino
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Maria Gaydarova
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Bruno Gianoglio
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Paloma Parvex
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Clara Gomes
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - James G Heaf
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Ludmila Podracka
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Dafina Kuzmanovska
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Maria S Molchanova
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Tatiana E Pankratenko
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Fotios Papachristou
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - György Reusz
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Maria José Sanahuja
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Rukshana Shroff
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Jaap W Groothoff
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Franz Schaefer
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Enrico Verrina
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
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Sgambat K, Moudgil A. Optimization of Bone Health in Children before and after Renal Transplantation: Current Perspectives and Future Directions. Front Pediatr 2014; 2:13. [PMID: 24605319 PMCID: PMC3932433 DOI: 10.3389/fped.2014.00013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 02/11/2014] [Indexed: 11/29/2022] Open
Abstract
The accrual of healthy bone during the critical period of childhood and adolescence sets the stage for lifelong skeletal health. However, in children with chronic kidney disease (CKD), disturbances in mineral metabolism and endocrine homeostasis begin early on, leading to alterations in bone turnover, mineralization, and volume, and impairing growth. Risk factors for CKD-mineral and bone disorder (CKD-MBD) include nutritional vitamin D deficiency, secondary hyperparathyroidism, increased fibroblast growth factor 23 (FGF-23), altered growth hormone and insulin-like growth factor-1 axis, delayed puberty, malnutrition, and metabolic acidosis. After kidney transplantation, nutritional vitamin D deficiency, persistent hyperparathyroidism, tertiary FGF-23 excess, hypophosphatemia, hypomagnesemia, immunosuppressive therapy, and alteration of sex hormones continue to impair bone health and growth. As function of the renal allograft declines over time, CKD-MBD associated changes are reactivated, further impairing bone health. Strategies to optimize bone health post-transplant include healthy diet, weight-bearing exercise, correction of vitamin D deficiency and acidosis, electrolyte abnormalities, steroid avoidance, and consideration of recombinant human growth hormone therapy. Other drug therapies have been used in adult transplant recipients, but there is insufficient evidence for use in the pediatric population at the present time. Future therapies to be explored include anti-FGF-23 antibodies, FGF-23 receptor blockers, and treatments targeting the colonic microbiota by reduction of generation of bacterial toxins and adsorption of toxic end products that affect bone mineralization.
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Affiliation(s)
| | - Asha Moudgil
- Children National Medical Center, Washington, DC, USA
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