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Usmani S, Ahmed N, Gnanasegaran G, Marafi F, Bani-Mustafa A, Van den Wyngaert T. Assessment of regional and total skeletal metabolism using 18F-NaF PET/CT in patients with chronic kidney disease. Ann Nucl Med 2024; 38:563-573. [PMID: 38676905 DOI: 10.1007/s12149-024-01929-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/08/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE The study aims to assess regional and total bone metabolic activity in patients with chronic kidney disease using Na[18F]F PET and correlation between semi-quantitative indices and blood parameters. METHODS Seventy-two subjects (mean age 61.8 ± 13.8 years) were included. Of these 24/72 patients had end-stage renal disease (ESRD) (GFR < 15 mL/min/1.73 m2), 38/72 had chronic kidney disease (CKD) (GFR between 60 and 15 mL/min/1.73 m2), and 10/72 were controls with normal renal function. All subjects underwent Na[18F]F PET-CT with a dose activity of 0.06 mCi/Kg. Regional and total skeletal metabolism were assessed with mean SUVs in a skeletal volume of interest (VOI), bone to soft tissue index (B/S), global SUV mean (GSUV mean) of the whole bone, and uptake in the femoral neck. RESULTS Statistically significant differences were observed in a number of 18F-NaF metrics like femoral neck metabolism in CKD and ERSD groups in comparison to control in right (P = 0.003) and left femur (P = 0.006), bone to soft tissue index in the femur (P = 0.016) and GSUV5 (P = 0.006). There is also a significant difference in SUV mean in lumbar vertebrae (L1-L4) among CKD, ESRD, and controls. There was a moderate correlation between 18F-NaF PET scan uptake and blood parameters such as ALP and PTH. Na[18F]F uptake parameters were significantly different in low versus high bone turnover state. CONCLUSIONS The assessment of total skeleton and regional metabolism and bone turnover in CKD patients is feasible with Na[18F]F PET. Na[18F]F can help to detect early changes in bone metabolism and assess the progression of bone disease in this complex condition. Quantification with Na[18F]F PET might provide better assessment of the bone turnover. The difference in Na[18F]F uptake in CKD compared to controls is likely related to a change in bone turnover which, however, requires further validation.
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Affiliation(s)
- Sharjeel Usmani
- Department of Nuclear Medicine, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, Oman.
- Hull York Medical School, Hull, UK.
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Najeeb Ahmed
- Department of Nuclear Medicine, Jack Brignall PET/CT Centre, Castle Hill Hospital, Cottingham, UK
- Hull York Medical School, Hull, UK
| | | | - Fahad Marafi
- Department of Nuclear Medicine, Jaber Al-Ahmad Molecular Imaging Center, Kuwait, Kuwait
| | | | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Hashim SM, Tuan Ismail TS, Che Soh NAA, Mat MC, Rapiah ZF, Shafii N, Kassim NK, Yaacob NM. Agreement of Parathyroid Hormone Status Measured by Intact and Biointact Parathyroid Hormone Assays among Chronic Kidney Disease Patients and Its Correlation with Bone Turnover Parameters. Malays J Med Sci 2023; 30:69-82. [PMID: 37102048 PMCID: PMC10125231 DOI: 10.21315/mjms2023.30.2.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 07/31/2022] [Indexed: 04/28/2023] Open
Abstract
Background This study aimed to determine the agreement between intact parathyroid hormone (iPTH) and biointact parathyroid hormone (bio-PTH) assays and to correlate them with bone markers. Methods This cross-sectional study included 180 patients with chronic kidney disease (CKD) stages 3b, 4 and 5D. We measured their iPTH, bio-PTH, 25-hydroxyvitaminD (25(OH)D), C-terminal telopeptide collagen (CTX), procollagen 1 intact N-terminal propeptide (P1NP), calcium, phosphate and alkaline phosphatase (ALP). Results Higher iPTH than bio-PTH concentrations were seen in CKD stages 3b, 4 and 5D (58[62] versus 55[67] pg/mL, 94[85] versus 85[76] pg/mL and 378[481] versus 252[280] pg/mL, respectively). Both PTH assays showed good agreement among all the subjects, with an intraclass correlation coefficient of 0.832 (P-value < 0.001). The Passing-Bablok showed that the equation for the bio-PTH was PTH = 0.64 iPTH + 15.80, with r = 0.99. The Bland-Altman plots showed increased bias with an increasing PTH concentration. Both PTH assays showed a high positive correlation with CTX and P1NP, a moderate correlation with phosphate, a low correlation with ALP and calcium, and a negligible correlation with phosphate and 25(OH)D. Conclusion The iPTH and bio-PTH assays were in agreement, but their bias increased with the PTH concentration. The unacceptable large bias indicates that the two assays cannot be used interchangeably. They had a variable correlation with the bone parameters.
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Affiliation(s)
- Saidah Madihah Hashim
- Chemical Pathology Unit, Hospital Raja Perempuan Zainab II, Kelantan, Malaysia
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Tuan Salwani Tuan Ismail
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Noor Azlin Azraini Che Soh
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Mahaya Che Mat
- Chemical Pathology Unit, Hospital Raja Perempuan Zainab II, Kelantan, Malaysia
| | - Zuad Firdaus Rapiah
- Nephrology Unit, Department of Medical, Hospital Raja Perempuan Zainab II, Kelantan, Malaysia
| | - Noorazliyana Shafii
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Nur Karyatee Kassim
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Najib Majdi Yaacob
- Biostatistics and Research Methodology Unit, Universiti Sains Malaysia, Kelantan, Malaysia
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Bone Disease in Chronic Kidney Disease and Kidney Transplant. Nutrients 2022; 15:nu15010167. [PMID: 36615824 PMCID: PMC9824497 DOI: 10.3390/nu15010167] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022] Open
Abstract
Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) comprises alterations in calcium, phosphorus, parathyroid hormone (PTH), Vitamin D, and fibroblast growth factor-23 (FGF-23) metabolism, abnormalities in bone turnover, mineralization, volume, linear growth or strength, and vascular calcification leading to an increase in bone fractures and vascular disease, which ultimately result in high morbidity and mortality. The bone component of CKD-MBD, referred to as renal osteodystrophy, starts early during the course of CKD as a result of the effects of progressive reduction in kidney function which modify the tight interaction between mineral, hormonal, and other biochemical mediators of cell function that ultimately lead to bone disease. In addition, other factors, such as osteoporosis not apparently dependent on the typical pathophysiologic abnormalities resulting from altered kidney function, may accompany the different varieties of renal osteodystrophy leading to an increment in the risk of bone fracture. After kidney transplantation, these bone alterations and others directly associated or not with changes in kidney function may persist, progress or transform into a different entity due to new pathogenetic mechanisms. With time, these alterations may improve or worsen depending to a large extent on the restoration of kidney function and correction of the metabolic abnormalities developed during the course of CKD. In this paper, we review the bone lesions that occur during both CKD progression and after kidney transplant and analyze the factors involved in their pathogenesis as a means to raise awareness of their complexity and interrelationship.
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Ulmer CZ, Kritmetapak K, Singh RJ, Vesper HW, Kumar R. High-Resolution Mass Spectrometry for the Measurement of PTH and PTH Fragments: Insights into PTH Physiology and Bioactivity. J Am Soc Nephrol 2022; 33:1448-1458. [PMID: 35396262 PMCID: PMC9342634 DOI: 10.1681/asn.2022010036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Full-length parathyroid hormone (PTH 1-84) is crucial for the regulation of calcium and phosphate homeostasis and bone remodeling. PTH 1-84 is metabolized into various PTH fragments, which are measured with varying levels of efficiency by PTH immunoassays. These PTH fragments, which increase in serum as CKD progresses, could potentially modulate the effects of PTH 1-84 and contribute to CKD-associated bone disorders. To obtain a true biologic representation of total PTH bioactivity, it is necessary to measure not only PTH 1-84 but also PTH fragments that are present in circulation. Traditional second-generation PTH immunoassays collectively measure PTH 1-84, PTH fragments, and post-translationally modified PTH 1-84, making it difficult to accurately predict the character of underlying renal osteodystrophy. This review highlights current advances in methods available for PTH measurement and the clinical relevance of PTH fragments in CKD. We emphasize the usefulness of mass spectrometry as a potential reference method for PTH measurement.
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Affiliation(s)
- Candice Z. Ulmer
- Clinical Chemistry Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kittrawee Kritmetapak
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Ravinder J. Singh
- Immunochemical Core Laboratory, Mayo Clinic, Rochester, Minnesota,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Hubert W. Vesper
- Clinical Chemistry Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rajiv Kumar
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota,Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota
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Aaltonen L, Koivuviita N, Seppänen M, Burton IS, Kröger H, Löyttyniemi E, Metsärinne K. Bone Histomorphometry and 18F-Sodium Fluoride Positron Emission Tomography Imaging: Comparison Between only Bone Turnover-based and Unified TMV-based Classification of Renal Osteodystrophy. Calcif Tissue Int 2021; 109:605-614. [PMID: 34137924 PMCID: PMC8531121 DOI: 10.1007/s00223-021-00874-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/03/2021] [Indexed: 01/13/2023]
Abstract
Bone biopsy is the gold standard for characterization of renal osteodystrophy (ROD). However, the classification of the subtypes of ROD based on histomorphometric parameters is not unambiguous and the range of normal values for turnover differ in different publications. 18F-Sodium Fluoride positron emission tomography (18F-NaF PET) is a dynamic imaging technique that measures turnover. 18F-NaF PET has previously been shown to correlate with histomorphometric parameters. In this cross-sectional study, 26 patients on dialysis underwent a 18F-NaF PET and a bone biopsy. Bone turnover-based classification was assessed using Malluche's historical reference values for normal bone turnover. In unified turnover-mineralization-volume (TMV)-based classification, the whole histopathological picture was evaluated and the range for normal turnover was set accordingly. Fluoride activity was measured in the lumbar spine (L1-L4) and at the anterior iliac crest. On the basis of turnover-based classification of ROD, 12% had high turnover and 61% had low turnover bone disease. On the basis of unified TMV-based classification of ROD, 42% had high turnover/hyperparathyroid bone disease and 23% had low turnover/adynamic bone disease. When using unified TMV-based classification of ROD, 18F-NaF PET had an AUC of 0.86 to discriminate hyperparathyroid bone disease from other types of ROD and an AUC of 0.87, for discriminating adynamic bone disease. There was a disproportion between turnover-based classification and unified TMV-based classification. More research is needed to establish normal range of bone turnover in patients with CKD and to establish the role of PET imaging in ROD.
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Affiliation(s)
- Louise Aaltonen
- Department of Medicine, Kidney Center, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland.
| | - Niina Koivuviita
- Department of Medicine, Kidney Center, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Marko Seppänen
- Turku PET Centre, University of Turku, Kiinamyllynkatu 4-8, 20521, Turku, Finland
- Department of Clinical Physiology, Nuclear Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Inari S Burton
- Kuopio Musculoskeletal Research Unit (KMRU), Institute of Clinical Medicine, University of Eastern Finland, POB 1627, Kuopio, Finland
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit (KMRU), Institute of Clinical Medicine, University of Eastern Finland, POB 1627, Kuopio, Finland
- Kuopio University Hospital, Kuopio, Finland
| | - Eliisa Löyttyniemi
- Department of Biostatistics, University of Turku, Kiinamyllynkatu 10, 20014, Turku, Finland
| | - Kaj Metsärinne
- Department of Medicine, Kidney Center, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, 20521, Turku, Finland
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Jørgensen HS, Behets G, Viaene L, Bammens B, Claes K, Meijers B, Naesens M, Sprangers B, Kuypers D, D'Haese PC, Evenepoel P. Static histomorphometry allows for a diagnosis of bone turnover in renal osteodystrophy in the absence of tetracycline labels. Bone 2021; 152:116066. [PMID: 34147707 DOI: 10.1016/j.bone.2021.116066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/08/2021] [Accepted: 06/13/2021] [Indexed: 11/28/2022]
Abstract
A bone biopsy with prior tetracycline labeling is the gold standard to diagnose renal osteodystrophy. In cases of missing tetracycline labels, it is still paramount to gain clinically relevant information from the extracted bone sample, by evaluating the static histomorphometry. This study investigates the diagnostic performance of static histomorphometry for the evaluation of high and low bone turnover. Transiliac bone biopsies taken pre- or post- kidney transplantation, of sufficient quality for a full histomorphometric analysis were included (n = 205). The cohort was randomly split to provide separate exploration and validation subsets. Diagnostic performance was evaluated by area under the receiver operator characteristics curve (AUC). All histomorphometric parameters were significantly different across categories of low (24%), normal (60%), and high (16%) bone turnover, and all were significant predictors of both high and low bone turnover (AUC 0.71-0.84). Diagnostic performance was very good for high turnover, as a combination of static parameters resulted in negative and positive predictive values (NPV and PPV) of 80% and 96%, respectively. For low turnover, the combined model resulted in PPV of 71% and NPV of 82%. We conclude that in the absence of tetracycline labels, static histomorphometry provide an acceptable alternative for a diagnosis of bone turnover in renal osteodystrophy.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Geert Behets
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | | | - Bert Bammens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Bjorn Meijers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Patrick C D'Haese
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Belgium; Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium.
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Salam S, Gallagher O, Hughes D, Khwaja A, Eastell R. The role of static bone histomorphometry in diagnosing renal osteodystrophy. Bone 2021; 142:115689. [PMID: 33065356 DOI: 10.1016/j.bone.2020.115689] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/23/2020] [Accepted: 10/09/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bone biopsy is the gold standard test to diagnose renal osteodystrophy (ROD). There is a preference to perform bone biopsy during renal transplantation but tetracycline bone labelling is usually not possible. We aimed to test if histomorphometry static parameters can identify low and high bone turnover as assessed by dynamic measurement using double tetracycline labelling. METHODS 43 CKD stages 4-5D had trans-iliac bone biopsy using a 4 mm Jamshidi trephine and needle after tetracycline labelling. Quantitative histomorphometry was performed using the Bioquant Osteo histomorphometry system. Normal bone turnover was defined as bone formation rate/bone surface (BFR/BS) of 18-38 μm3/μm2/year. Static parameters of bone turnover included osteoblast surface/bone surface (Ob.S/BS, %), osteoclast surface/bone surface (Oc.S/BS, %) and erosion surface/bone surface (ES/BS, %). Receiver operating characteristics (ROC) analysis was used to evaluate diagnostic accuracy of these static parameters for low and high bone turnover (based on BFR/BS). RESULTS Median (IQR) for BFR/BS in this study was 32.12 (17.76-48.25) μm3/μm2/year. 26% of patients had low, 34% had normal and 40% had high bone turnover. The area under the ROC curve (AUC) for Ob.S/BS, Oc.S/BS and ES/BS were non-significant indicating poor accuracy for identifying low bone turnover. The AUC for Ob.S/BS was 0.697 (95% CI 0.538 to 0.827) indicating fair accuracy for identifying high bone turnover. Oc.S/BS and ES/BS had non-significant AUCs for high bone turnover. CONCLUSIONS Static histomorphometry parameters for bone turnover are unable to replace dynamic parameter in diagnosing ROD. Tetracycline bone labelling is still required.
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Affiliation(s)
- Syazrah Salam
- Sheffield Kidney Institute, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, United Kingdom; Department of Oncology and Metabolism, Mellanby Centre for Bone Research, University of Sheffield, United Kingdom.
| | - Orla Gallagher
- Department of Oncology and Metabolism, Mellanby Centre for Bone Research, University of Sheffield, United Kingdom
| | - David Hughes
- Department of Oncology and Metabolism, Mellanby Centre for Bone Research, University of Sheffield, United Kingdom; Histopathology Department, Sheffield Teaching Hospitals NHS Foundation Trust, United Kingdom
| | - Arif Khwaja
- Sheffield Kidney Institute, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, United Kingdom
| | - Richard Eastell
- Department of Oncology and Metabolism, Mellanby Centre for Bone Research, University of Sheffield, United Kingdom
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TOMŞA AM, ALEXA AL, RĂCHIŞAN AL, PICOŞ A, PICOŞ AM, CIUMĂRNEAN L. Skeletal manifestations in end-stage renal disease patients and relation to FGF23 and Klotho. BALNEO RESEARCH JOURNAL 2020. [DOI: 10.12680/balneo.2020.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Chronic kidney disease affects patients of all ages and, as it progresses, it greatly affects their lives, especially with the complications it causes. One major complication is renal osteodystrophy (ROD) which starts to develop from the early stages of the disease, but becomes most apparent in patients in need of renal replacement therapy. Diagnosing ROD in the early stages remains a challenge, which brings up the need to find novel biomarkers. Studies are focusing on the role of fibroblast growth factor 23 and Klotho in the bone and mineral homeostasis, but the results are conflicting. ROD remains a major complication in CKD patients, therefore we need to gain a better understanding from the pathophysiological point of view, in order to be able to adjust the medical therapy.
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Affiliation(s)
- Anamaria Magdalena TOMŞA
- 1. “Iuliu Hatieganu” University of Medicine and Pharmacy, Department Mother and Child, 2nd Clinic of Pediatrics, Cluj-Napoca, Romania
| | - Alexandru Leonard ALEXA
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Department of Surgery, Cluj-Napoca, Romania
| | - Andreea Liana RĂCHIŞAN
- 1. “Iuliu Hatieganu” University of Medicine and Pharmacy, Department Mother and Child, 2nd Clinic of Pediatrics, Cluj-Napoca, Romania
| | - Andrei PICOŞ
- 3. “Iuliu Hatieganu” University of Medicine and Pharmacy, Department of Prosthetics, Cluj-Napoca, Romania
| | - Alina Monica PICOŞ
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Department of Oral Rehabilitation, Cluj-Napoca, Romania
| | - Lorena CIUMĂRNEAN
- 5. “Iuliu Hatieganu” University of Medicine and Pharmacy, Department of Internal Medicine, Cluj-Napoca, Romania
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Aaltonen L, Koivuviita N, Seppänen M, Tong X, Kröger H, Löyttyniemi E, Metsärinne K. Correlation between 18F-Sodium Fluoride positron emission tomography and bone histomorphometry in dialysis patients. Bone 2020; 134:115267. [PMID: 32058018 DOI: 10.1016/j.bone.2020.115267] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/03/2020] [Accepted: 02/09/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The diagnosis of renal osteodystrophy is challenging. Bone biopsy is the gold standard, but it is invasive and limited to one site of the skeleton. The ability of biomarkers to estimate the underlying bone pathology is limited. 18F-Sodium Fluoride positron emission tomography (18F-NaF PET) is a noninvasive quantitative imaging technique that allows assessment of regional bone turnover at clinically relevant sites. The hypothesis of this study was, that 18F-NaF PET correlates with bone histomorphometry in dialysis patients and could act as a noninvasive diagnostic tool in this patient group. METHODS This was a cross-sectional diagnostic test study. 26 dialysis patients with biochemical abnormalities indicating mineral and bone disorder were included. All the participants underwent a 18F-NaF PET scan and a bone biopsy. Fluoride activity in the PET scan was measured in the lumbar spine and at the anterior iliac crest. Dynamic and static histomorphometric parameters of the bone biopsy were assessed. As histomorphometric markers for bone turnover we used bone formation rate per bone surface (BFR/BS) and activation frequency per year (Ac.f). RESULTS There was a statistically significant correlation between fluoride activity in the 18F-NaF PET scan and histomorphometric parameters such as bone formation rate, activation frequency and osteoclast and osteoblast surfaces and mineralized surfaces. 18F-NaF PET's sensitivity to recognize low turnover in respect to non-low turnover was 76% and specificity 78%. Because of the small number of patients with high turnover, we were unable to demonstrate significant predictive value in this group. CONCLUSIONS A clear correlation between histomorphometric parameters and fluoride activity in the 18F-NaF PET scan was established. 18F-NaF PET may possibly be a noninvasive diagnostic tool in dialysis patients with low turnover bone disease, but further research is needed.
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Affiliation(s)
- Louise Aaltonen
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, Turku 20521, Finland.
| | - Niina Koivuviita
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, Turku 20521, Finland
| | - Marko Seppänen
- Department of Clinical Physiology, Nuclear Medicine and Turku PET Centre, University of Turku, Kiinamyllynkatu 4-8, Turku 20521, Finland
| | - Xiaoyu Tong
- Kuopio Musculoskeletal Research Unit (KMRU), Institute of Clinical Medicine, University of Eastern Finland, POB 1627, Kuopio, Finland
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit (KMRU), Institute of Clinical Medicine, University of Eastern Finland, POB 1627, Kuopio, Finland; Kuopio University Hospital, Kuopio, Finland
| | - Eliisa Löyttyniemi
- Department of Biostatistics, University of Turku, Kiinamyllynkatu 10, 20014 Turku, Finland
| | - Kaj Metsärinne
- Kidney Center, Department of Medicine, Turku University Hospital, PL 52, Kiinamyllynkatu 4-8, Turku 20521, Finland
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Affiliation(s)
- Cheryl P. Sanchez
- Pediatrics University of Wisconsin Medical School Madison, Wisconsin, USA
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11
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Smit MA, van Kinschot CMJ, van der Linden J, van Noord C, Kos S. Clinical Guidelines and PTH Measurement: Does Assay Generation Matter? Endocr Rev 2019; 40:1468-1480. [PMID: 31081903 DOI: 10.1210/er.2018-00220] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 03/08/2019] [Indexed: 11/19/2022]
Abstract
PTH is an important regulator of calcium and phosphate homeostasis and bone remodeling. It is metabolized into PTH fragments, which are measured to a different extent by PTH assays of different generations because of differences in fragments recognized and lack of assay standardization. PTH is measured in the workup of several conditions, and clinical guidelines provide recommendations concerning these measurements. This review provides an overview of the impact of differences between PTH assays, applying distinct clinical guidelines for primary and secondary hyperparathyroidism and perioperative use of PTH measurements. Guidelines deal with PTH measurement in different ways, recommending either trend monitoring, the use of a fold increase of the upper reference limit, or an absolute PTH cutoff value. For classic primary hyperparathyroidism (PHPT), the type of PTH assay used will not affect diagnosis or management because the precise concentration of PTH is less relevant. In chronic kidney disease, the guideline recommends treating secondary hyperparathyroidism above a twofold to ninefold PTH increase, which will result in different clinical decisions depending on the assay used. For patients after bariatric surgery, guidelines state absolute cutoff values for PTH, but the impact of different generation assays is unknown because direct comparison of PTH assays has never been performed. During parathyroid surgery, PTH measurements with a third-generation assay reflect treatment success more rapidly than second-generation assays. Increased awareness among clinicians regarding the complexity of PTH measurements is warranted because it can affect clinical decisions.
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Affiliation(s)
- Marjon A Smit
- Department of Clinical Chemistry, Maasstad Hospital, Rotterdam, Netherlands
| | | | | | | | - Snježana Kos
- Department of Clinical Chemistry, Maasstad Hospital, Rotterdam, Netherlands
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Chandran M, Wong J. Secondary and Tertiary Hyperparathyroidism in Chronic Kidney Disease: An Endocrine and Renal Perspective. Indian J Endocrinol Metab 2019; 23:391-399. [PMID: 31741895 PMCID: PMC6844175 DOI: 10.4103/ijem.ijem_292_19] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Secondary Hyperparathyroidism (SHP) seen as a frequent complication in Chronic Kidney Disease (CKD) has many pathogenetic peculiarities that are still incompletely defined and understood. During the long course of chronic renal failure, SHP can also transform sometimes into the hypercalcemic state characterized by quasi-autonomous production of Parathyroid Hormone from the parathyroid glands: a disorder that is termed Tertiary Hyperparathyroidism. The clinical consequences of SHP in CKD are protean, encompassing bone and mineral abnormalities but as recently identified, also several metabolic and cardiovascular problems, the most important of which is vascular calcification. There have been several advances in the therapeutic armamentarium available for the treatment of SHP, though clear demonstration of a benefit regarding major clinical outcomes with any of the new agents is still lacking. This narrative review summarizes the current understanding about this disorder and highlights some of the recent research on the subject.
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Affiliation(s)
- Manju Chandran
- Department of Endocrinology, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, Singapore
| | - Jiunn Wong
- Department of Renal Medicine, Singapore General Hospital, Singapore
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Laowalert S, Khotavivattana T, Wattanachanya L, Luangjarmekorn P, Udomkarnjananun S, Katavetin P, Eiam‐Ong S, Praditpornsilpa K, Susantitaphong P. Bone turnover markers predict type of bone histomorphometry and bone mineral density in Asian chronic haemodialysis patients. Nephrology (Carlton) 2019; 25:163-171. [DOI: 10.1111/nep.13593] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/25/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Suthanit Laowalert
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Tanatorn Khotavivattana
- Center of Excellence in Natural Products Chemistry, Department of ChemistryFaculty of Science, Chulalongkorn University Bangkok Thailand
| | - Lalita Wattanachanya
- Division of Endocrinology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Pobe Luangjarmekorn
- Department of OrthopedicsChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Pisut Katavetin
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Somchai Eiam‐Ong
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
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Yang G, Ge Y, Zha X, Mao H, Wang N, Xing C. Peritoneal dialysis can alleviate the clinical course of hungry bone syndrome after parathyroidectomy in dialysis patients with secondary hyperparathyroidism. Int Urol Nephrol 2019; 51:535-542. [PMID: 30689179 DOI: 10.1007/s11255-019-02076-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/03/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE It is unclear whether clinical courses of hungry bone syndrome (HBS) after parathyroidectomy (PTX) in peritoneal dialysis (PD) and hemodialysis (HD) patients are different. The present study aimed to investigate the possible differences of postoperative hypocalcemia and hyperkalemia between PD and HD patients. METHODS We performed retrospectively 29 PD patients as the PD group and 169 HD patients as the HD group undergoing successful total PTX with autotransplantation. Calcium supplement after surgery was recorded. Higher levels of serum potassium during and immediately after surgery were recorded as K+d0. K+d3 was recorded as peak pre-dialysis serum potassium level 3 days post-surgery. RESULTS There were 157 (92.90%) patients in HD group and 22 (75.86%) patients in PD group suffered from HBS after surgery, with significant difference between the groups (P = 0.004). Patients in PD group had significantly shorter intravenous calcium supplement duration (P = 0.037) and significantly smaller intravenous calcium supplement dosage (P = 0.042) and total calcium supplement dosage during hospitalization (P = 0.012) than patients in HD group. The levels of serum K+d0 (P < 0.001) and K+d3 (P < 0.001) were both significantly lower in PD group than those in HD group. Peritoneal dialysis was one of the independent influencing factors with negative correlation for calcium supplement, serum K+d0 and serum K+d3. CONCLUSIONS Compared with HD patients, the clinical course of HBS after PTX in PD patients was alleviated. Efforts should be devoted to individual perioperative management for PD patients undergoing PTX.
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Affiliation(s)
- Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Xiaoming Zha
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu Province, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, 300# Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.
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Damasiewicz MJ, Nickolas TL. Rethinking Bone Disease in Kidney Disease. JBMR Plus 2018; 2:309-322. [PMID: 30460334 PMCID: PMC6237213 DOI: 10.1002/jbm4.10117] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/05/2018] [Accepted: 10/03/2018] [Indexed: 12/17/2022] Open
Abstract
Renal osteodystrophy (ROD) is the bone component of chronic kidney disease mineral and bone disorder (CKD-MBD). ROD affects bone quality and strength through the numerous hormonal and metabolic disturbances that occur in patients with kidney disease. Collectively these disorders in bone quality increase fracture risk in CKD patients compared with the general population. Fractures are a serious complication of kidney disease and are associated with higher morbidity and mortality compared with the general population. Furthermore, at a population level, fractures are at historically high levels in patients with end-stage kidney disease (ESKD), whereas in contrast the general population has experienced a steady decline in fracture incidence rates. Based on these findings, it is clear that a paradigm shift is needed in our approach to diagnosing and managing ROD. In clinical practice, our ability to diagnose ROD and initiate antifracture treatments is impeded by the lack of accurate noninvasive methods that identify ROD type. The past decade has seen advances in the noninvasive measurement of bone quality and strength that have been studied in kidney disease patients. Below we review the current literature pertaining to the epidemiology, pathology, diagnosis, and management of ROD. We aim to highlight the pressing need for a greater awareness of this condition and the need for the implementation of strategies that prevent fractures in kidney disease patients. Research is needed for more accurate noninvasive assessment of ROD type, clinical studies of existing osteoporosis therapies in patients across the spectrum of kidney disease, and the development of CKD-specific treatments. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
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Affiliation(s)
- Matthew J Damasiewicz
- Department of NephrologyMonash HealthClaytonAustralia
- Department of MedicineMonash UniversityClaytonAustralia
| | - Thomas L Nickolas
- Columbia University Medical CenterDepartment of MedicineDivision of NephrologyNew YorkNYUSA
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Soliman M, Hassan W, Yaseen M, Rao M, Sawaya BP, El-Husseini A. PTH assays in dialysis patients: Practical considerations. Semin Dial 2018; 32:9-14. [PMID: 30168196 DOI: 10.1111/sdi.12743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Parathyroid hormone (PTH) 1-84 is the main biologically active hormone produced by the parathyroid cells. Circulating PTH molecules include the whole PTH 1-84 along with amino (N) and carboxyl (C) terminal fragments. While PTH is the best available noninvasive biomarker to assess bone turnover in dialysis patients, the biological roles of individual circulating PTH fragments are still not completely known. The understanding that there is an enormous variation in the target specificity of currently available PTH assays for different circulating forms of PTH has led to the evolution of assays from first to second then third generation. With a reduction in kidney function, there is a preferential increase in circulating C fragments and non-PTH 1-84 forms, resulting in a decrease in the ratio of PTH 1-84/non-PTH 1-84. However, there are also substantial differences in between-assay measurements, with several fold variations in results. Targets based on multiples of the upper limit of normal (ULN) should be used rather than PTH ranges using absolute iPTH values. To date, the second-generation PTH remains the most widely used assay. Current guidelines recommend following iPTH trends rather than absolute values. Herein, we highlight problems and challenges in PTH assays/measurements and their interpretations in dialysis patients.
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Affiliation(s)
- Mohanad Soliman
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Waleed Hassan
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Maria Yaseen
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Madhumathi Rao
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - B Peter Sawaya
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
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Einbinder Y, Benchetrit S, Golan E, Zitman-Gal T. Comparison of Intact PTH and Bio-Intact PTH Assays Among Non-Dialysis Dependent Chronic Kidney Disease Patients. Ann Lab Med 2018. [PMID: 28643486 PMCID: PMC5500736 DOI: 10.3343/alm.2017.37.5.381] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The third-generation bio-intact parathyroid hormone (PTH) (1-84) assay was designed to overcome problems associated with the detection of C-terminal fragments by the second-generation intact PTH assay. The two assays have been compared primarily among dialysis populations. The present study evaluated the correlations and differences between these two PTH assays among patients with chronic kidney disease (CKD) stages 3 to 5 not yet on dialysis. METHODS Blood samples were collected from 98 patients with CKD stages 3 to 5. PTH concentrations were measured simultaneously by using the second-generation - PTH intact-STAT and third-generation bio-intact 1-84 PTH assays. Other serum biomarkers of bone mineral disorders were also assessed. CKD stage was calculated by using the CKD-Epidemiology Collaboration (EPI) formula. RESULTS Serum bio-intact PTH concentrations were strongly correlated but significantly lower than the intact PTH concentrations (r=0.963, P<0.0001). This finding was consistent among CKD stages 3 to 5. PTH concentrations by both assays (intact and bio-intact PTH) positively correlated with urea (r=0.523, r=0.504; P=0.002, respectively), phosphorus (r=0.532, r=0.521; P<0.0001, respectively) and negatively correlated with blood calcium (r=-0.435, r=-0.476; P<0.0001, respectively), 25(OH) vitamin D, (r=-0.319, r=-0.353; respectively, P<0.0001) and the estimated glomerular filtration rate (r=-0.717, r=-0.688; P<0.0001, respectively). CONCLUSIONS Among patients with CKD stages 3 to 5 not on dialysis, the bio-intact PTH assay detected significantly lower PTH concentrations compared with intact PTH assay. Additional studies that correlate the diagnosis and management of CKD mineral and bone disorders with bone histomorphometric findings are needed to determine whether bio-intact PTH assay results are better surrogate markers in these early stages of CKD.
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Affiliation(s)
- Yael Einbinder
- Department of Nephrology and Hypertension, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sydney Benchetrit
- Department of Nephrology and Hypertension, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eliezer Golan
- Department of Nephrology and Hypertension, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Zitman-Gal
- Department of Nephrology and Hypertension, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Bolasco PG, Ghezzi PM, Ferrara R, Maxia M, Pinna M, Logias F, Cogoni G, Cadinu F, Ghisu T, Contu B, Casu D, Passaghe M, Pilloni A, Ganadu M, Gazzanelli L. Effect of On-Line Hemodiafiltration with Endogenous Reinfusion (HFR) on the Calcium-Phosphorus Metabolism: Medium-Term Effects. Int J Artif Organs 2018; 29:1042-52. [PMID: 17160961 DOI: 10.1177/039139880602901104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim The purpose of the study was to examine the effect of hemodiafiltration with endogenous reinfusion (HFR) compared to hemodialysis (HD) on 28 uremic patients with secondary hyperparathyroidism (2HPT) but positively selected for good and stable control of phosphatemia in order to evaluate the independent effects of dialysis treatments on bone turnover metabolism. Methods: The study was divided into 3 periods of observation: a) HD for three months; b) HFR for three months; c) HFR for a further 3 months. We analysed the trend of: whole PTH, 1–84 PTH, 7–84 PTH, alkaline phosphatase and its bone isoenzyme, total and ionised calcium, phosphatemia, dose of phosphate binder agents, β2-microglobulin, CRP. All the variations found were evaluated through mean values ± SD, t-tests, multivariate analysis. Results We observed a deceleration in bone turnover characterized by a reduction of the total and bone alkaline phosphatase (IU/mL) from 92.3 ± 82.8 and 35.8 ± 49.8 at the end of HD to 63.4 ± 23.9 and 16.0 ± 8.7 at the end of HFR, respectively, and 1–84 PTH from 317.5 ± 264.6 pg/mL at the end of HD to 287.5 ± 258.9 pg/mL at the end of the 3rd month of HFR. β2-microglobulin was reduced from 32.9 ± 16.1 mg/L at the end of HD to 26.4 ± 8.1 mg/L already at the end of the first three months of HFR. CRP was reduced from 2.5 ± 2.6 mg/dL at the beginning of the study to 1.3 ± 1.7 mg/dL at the end of HFR. There were no differences with regard to: dialytic efficiency, nutritional status, calcemia, phosphatemia (maintained in the K-DOQI range for the entire duration of the study), also thanks to more careful use of phosphate chelating agents. Conclusion We are of the opinion that HFR - essentially thanks to the use of ultrapure endogenous infusate - induces a deceleration in bone turnover due to 2PHT. In addition, phosphate substraction in HFR is better compared to HD, thanks to the improvement of the anti-inflammatory conditions by removing the cytokines harmful to bone metabolism and excluding a priori the negative effects related to hyperphosphatemia. (Int J Artif Organs 2006; 29: 1042–52)
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Affiliation(s)
- P G Bolasco
- Territorial Nephrology and Dialysis Unit, Azienda USL n. 8, Cagliari, Italy.
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Abstract
Laboratory biochemical testing is critical to the clinical understanding of bone disorders. Patients with skeletal diseases have underlying themes in their pathophysiology that would be impossible to detect without biochemical assessment of serum and urine minerals, vitamin D, parathyroid hormone, parathyroid hormone-related peptide, and bone turnover markers. Bone disorders are caused by abnormalities in signaling pathways that affect bone formation and resorption. Therapies for common bone diseases were developed in direct response to underlying biochemical abnormalities.
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Affiliation(s)
- Chee Kian Chew
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, E-18A, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Bart L Clarke
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, E-18A, 200 1st Street Southwest, Rochester, MN 55905, USA.
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20
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Abstract
PURPOSE OF THE REVIEW Impaired bone quality contributes to the increased fracture risk in chronic kidney disease patients. Both low and high turnover bone disease may compromise bone quality. The question arises whether bone biomarkers may be additive or replace bone histormorphometry for diagnosing the extremes of bone turnover. RECENT FINDINGS Studies exploring the performance of established and emerging bone biomarkers against histomorphometric assessment of bone turnover are limited and overall yield inconclusive results as to their diagnostic utility. Bone biomarkers, although promising, currently fail to meet the needed diagnostic accuracy to replace bone histomorphometry and thus are not yet ready for clinical use. Bone biomarkers have not only several advantages, but also important limitations such as high biological variability, retention with kidney disease, preanalytical issues, and interassay variability. These important issues must be considered when developing and evaluating bone biomarkers. There is an urgent need for harmonization and standardization of available assays and additional bone biopsy studies.
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Affiliation(s)
- Pieter Evenepoel
- Department of Immunology and Microbiology, Laboratory of Nephrology, KU Leuven, 3000, Leuven, Belgium.
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, 3000, Leuven, Belgium.
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liege, CHU de Liege, 4000, Liege, Belgium
| | - Patrick C D'Haese
- Department of Biomedical Sciences, Laboratory of Pathophysiology, Antwerp University, 2610, Wilrijk, Belgium
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Abstract
PURPOSE OF REVIEW In this paper, we review the epidemiology, diagnosis, and pathogenesis of fractures and renal osteodystrophy. RECENT FINDINGS The role of bone quality in the pathogenesis of fracture susceptibility in chronic kidney disease (CKD) is beginning to be elucidated. Bone quality refers to bone material properties, such as cortical and trabecular microarchitecture, mineralization, turnover, microdamage, and collagen content and structure. Recent data has added to our understanding of the effects of CKD on alterations to bone quality, emerging data on the role of abnormal collagen structure on bone strength, the potential of non-invasive methods to inform our knowledge of bone quality, and how we can use these methods to inform strategies that protect against bone loss and fractures. However, more prospective data is required. CKD is associated with abnormal bone quality and strength which results in high fracture incidence.
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Affiliation(s)
- Erin M B McNerny
- Indiana University School of Medicine, Indianapolis, IN, USA
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, 622 West 168th Street, PH4-124, New York, NY, 10032, USA
| | - Thomas L Nickolas
- Indiana University School of Medicine, Indianapolis, IN, USA.
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, 622 West 168th Street, PH4-124, New York, NY, 10032, USA.
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Salam SN, Khwaja A, Wilkie ME. Pharmacological Management of Secondary Hyperparathyroidism in Patients with Chronic Kidney Disease. Drugs 2017; 76:841-52. [PMID: 27142279 DOI: 10.1007/s40265-016-0575-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Secondary hyperparathyroidism (SHPT) is a common complication of chronic kidney disease (CKD) and is part of the CKD-mineral bone disorder (CKD-MBD). SHPT is associated with increased risk of fracture and mortality; thus, SHPT control is recommended as kidney function declines. Effective SHPT management becomes more difficult once skeletal and cardiovascular adverse effects associated with severe SHPT have become established. However, interventional studies to lower parathyroid hormone (PTH) have so far shown inconsistent results in improving patient-centred outcomes such as mortality, cardiovascular events and fracture. Pharmacological treatment effect on PTH level is also inconsistent between pre-dialysis CKD and dialysis patients, which adds to the complexity of SHPT management. This review aims to give an overview on the pathophysiology, pharmacological and non-pharmacological treatment for SHPT in CKD including some of the limitations of current therapeutic options.
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Affiliation(s)
- S N Salam
- Sheffield Kidney Institute, Sheffield, UK
| | - A Khwaja
- Sheffield Kidney Institute, Sheffield, UK
| | - M E Wilkie
- Sheffield Kidney Institute, Sheffield, UK.
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Portillo MR, Rodríguez-Ortiz ME. Secondary Hyperparthyroidism: Pathogenesis, Diagnosis, Preventive and Therapeutic Strategies. Rev Endocr Metab Disord 2017; 18:79-95. [PMID: 28378123 DOI: 10.1007/s11154-017-9421-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Uremic secondary hyperparathyroidism is a multifactorial and complex disease often present in advanced stages of chronic kidney disease. The accumulation of phosphate, the increased FGF23 levels, the reduction in active vitamin D production, and the tendency to hypocalcemia are persistent stimuli for the development and progression of parathyroid hyperplasia with increased secretion of PTH. Parathyroid proliferation may become nodular mainly in cases of advanced hyperparathyroidism. The alterations in the regulation of mineral metabolism, the development of bone disease and extraosseous calcifications are essential components of chronic kidney disease-mineral and bone disorder and have been associated with negative outcomes. The management of hyperparathyroidism includes the correction of vitamin D deficiency and control of serum phosphorus and PTH without inducing hypercalcemia. An update of the leading therapeutic tools available for the prevention and clinical management of secondary hyperparathyroidism, its diagnosis, and the main mechanisms and factors involved in the pathogenesis of the disease will be described in this review.
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Affiliation(s)
- Mariano Rodríguez Portillo
- Nephrology Service, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Reina Sofía University Hospital/University of Córdoba, Avda. Menéndez Pidal, S/N, 14004, Córdoba, Spain.
- REDinREN, Madrid, Spain.
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Krishnasamy R, Hawley CM, Johnson DW. An update on bone imaging and markers in chronic kidney disease. Expert Rev Endocrinol Metab 2016; 11:455-466. [PMID: 30058917 DOI: 10.1080/17446651.2016.1239527] [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] [Indexed: 10/20/2022]
Abstract
Bone disorders in chronic kidney disease (CKD) are associated with heightened risks of fractures, vascular calcification, poor quality of life and mortality compared to the general population. However, diagnosis and management of these disorders in CKD are complex and appreciably limited by current diagnostic modalities. Areas covered: Bone histomorphometry remains the gold standard for diagnosis but is not widely utilised and lacks feasibility as a monitoring tool. In practice, non-invasive imaging and biochemical markers are preferred to guide therapeutic decisions. Expert commentary: This review aims to summarize the risk factors for, and spectrum of bone disease in CKD, as well as appraise the clinical utility of dual energy X-ray densitometry, peripheral quantitative computed tomography, high-resolution peripheral quantitative computed tomography, and bone turnover markers.
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Affiliation(s)
- Rathika Krishnasamy
- a Department of Nephrology , Nambour General Hospital , Nambour , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
| | - Carmel M Hawley
- b Department of Nephrology , Princess Alexandra Hospital , Brisbane , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
- d Department of Nephrology , Translation Research Institute , Brisbane , Australia
| | - David W Johnson
- b Department of Nephrology , Princess Alexandra Hospital , Brisbane , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
- d Department of Nephrology , Translation Research Institute , Brisbane , Australia
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The role of bone biopsy for the diagnosis of renal osteodystrophy: a short overview and future perspectives. J Nephrol 2016; 29:617-26. [PMID: 27473148 DOI: 10.1007/s40620-016-0339-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/18/2016] [Indexed: 12/26/2022]
Abstract
Chronic kidney disease (CKD) patients present specific bone and mineral metabolism disturbances, which account for important morbidity and mortality. The term renal osteodystrophy, classically used for the nomination of CKD-associated bone disorder, has been limited to the histologic description of bone lesions, requiring the use of bone biopsy. Biochemical markers and imaging tools do not adequately predict the complex bone changes that are observed in renal osteodystrophy. Parathyroid hormone, which is a universally used biomarker of bone turnover in clinical practice, lacks specificity and sensitivity. Therefore, tetracycline double-labelled transiliac bone biopsy, with bone histology and histomorphometric evaluation, remains the best clinical tool to discriminate bone turnover and to evaluate the other dimensions of renal osteodystrophy. This review will focus on the value of classic bone histomorphometric analysis of trabecular bone in CKD patients and unfold new perspectives of this diagnostic tool, including cortical bone evaluation and bone tissue immunohistochemistry.
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Covic A, Voroneanu L, Apetrii M. PTH and/or Bone Histology: Are We Still Waiting for a Verdict From the CKD-MBD Grand Jury? Am J Kidney Dis 2016; 67:535-8. [DOI: 10.1053/j.ajkd.2015.11.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 11/29/2015] [Indexed: 11/11/2022]
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27
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Zand L, Kumar R. Serum Parathyroid Hormone Concentrations and Clinical Outcomes in ESRD: A Call for Targeted Clinical Trials. Semin Dial 2015; 29:184-8. [PMID: 26676210 DOI: 10.1111/sdi.12457] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Secondary hyperparathyroidism almost universally accompanies end-stage renal disease (ESRD). In some, but not all studies, elevated serum parathyroid hormone (PTH) concentrations are associated with increased fracture rates, cardiovascular disease, and mortality in ESRD. The serum concentration of PTH required for optimal bone health and reduced cardiovascular risk in such patients remains elusive. Recent clinical trials have failed to show substantial changes in morbidity and mortality following reductions of elevated serum PTH concentrations. In this review, we will assess some of the difficulties in evaluating elevated serum PTH concentrations, and their association with skeletal fractures and mortality in ESRD patients. We are of the opinion that in the context of ESRD, elevated PTH concentrations occur in conjunction with other comorbid conditions such as diabetes mellitus, malnutrition, hypertension, volume excess, preexisting heart disease, all of which have prevented establishing a precise association between elevated serum PTH concentrations and global or skeletal outcomes. Age, gender, and racial variability among groups make interpretation exceptionally difficult. Analysis of prevalent ESRD populations with secondary hyperparathyroidism should take all these factors into account. We suggest that future clinical trials which examine the usefulness of reductions in serum PTH concentrations be conducted in age, sex, and racially balanced groups, without or with minimal coexisting confounding disease. Furthermore, trials in such populations should have as their primary outcome a reduction in fractures rather than an alteration in mortality.
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Affiliation(s)
- Ladan Zand
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajiv Kumar
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota
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Babayev R, Nickolas TL. Bone Disorders in Chronic Kidney Disease: An Update in Diagnosis and Management. Semin Dial 2015; 28:645-53. [DOI: 10.1111/sdi.12423] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Revekka Babayev
- Department of Medicine; Division of Nephrology; Columbia University Medical Center; New York City New York
| | - Thomas L. Nickolas
- Department of Medicine; Division of Nephrology; Columbia University Medical Center; New York City New York
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Abstract
The fact that bone disease and kidney disease co-exist is well known. Formally, this inter-relationship is called chronic kidney disease mineral bone disorder or CKD-MBD. Traditionally, it was thought that bone played a passive role in CKD-MBD - specifically that kidney disease caused disordered mineral metabolism which resulted in bone disease and ultimately fractures. More recently however our understanding of bone function in general and the role that bone plays in CKD-MBD in particular, has changed. This chapter will briefly review epidemiology of fractures in chronic kidney disease (CKD) and the roles that imaging and measuring markers of mineral metabolism can play in assessing fracture risk. We will then review more recent data consistent with the concept MBD occurs early in the course of CKD and, via the secretion of novel molecules and/or signalling pathways, the bone can influence other organ systems.
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Affiliation(s)
- Thomas L Nickolas
- Department of Medicine, Nephrology, Columbia University Medical Center, 622 West 168th Street, PH4-124, New York, NY, 10032, USA
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Brandenburg VM, Floege J. Adynamic bone disease-bone and beyond. NDT Plus 2015; 1:135-47. [PMID: 25983860 PMCID: PMC4421169 DOI: 10.1093/ndtplus/sfn040] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2008] [Accepted: 03/18/2008] [Indexed: 11/13/2022] Open
Affiliation(s)
- Vincent M Brandenburg
- Department of Nephrology and Clinical Immunology , RWTH University Hospital Aachen , Pauwelsstrasse 30, Aachen, D-52057 , Germany
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology , RWTH University Hospital Aachen , Pauwelsstrasse 30, Aachen, D-52057 , Germany
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Saab G, Navaneethan SD, Slatopolsky E. Targeting parathyroid hormone levels in dialysis patients. Semin Dial 2014; 27:562-5. [PMID: 25040125 DOI: 10.1111/sdi.12275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Georges Saab
- MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
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Nickolas TL. The utility of circulating markers to predict bone loss across the CKD spectrum. Clin J Am Soc Nephrol 2014; 9:1160-2. [PMID: 24948141 PMCID: PMC4078951 DOI: 10.2215/cjn.04660514] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Thomas L Nickolas
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
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Abstract
PURPOSE OF REVIEW Chronic kidney disease-mineral and bone disorder (CKD-MBD) is a complex disorder of bone and mineral metabolism that results in an excess risk of fractures, cardiovascular events and mortality. The management of the bone disorder aspect of CKD-MBD may require bone biopsy to determine appropriate treatment strategies. However, it is unclear when biopsy may be necessary and whether or not state-of-the art imaging and serologic testing can supplant the bone biopsy as a tool to assist with management decisions. RECENT FINDINGS Advances in imaging methods now permit the noninvasive assessment of structural aspects of bone quality. Furthermore, common bone imaging tools, such as dual-energy X-ray absorptiometry, can be used to stratify for fracture risk. Circulating markers of bone turnover can be used to assess the risk of bone loss and fracture, but they are less useful in diagnosing the type of renal osteodystrophy. SUMMARY Although advances in imaging now permit the assessment of fracture risk more accurately in CKD patients, the assessment of the type of renal osteodystrophy remains poor without bone biopsy. The virtual bone biopsy will be possible only when we are able to noninvasively assess turnover with good accuracy. A bone biopsy is needed when the bone turnover is unclear.
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Affiliation(s)
- Revekka Babayev
- Department of Medicine, Columbia University Medical Center, New York, New York, USA
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Lu JR, Yi Y, Tian J, Xiong CX, Wang XH, Hu J, Chen XF. Prevalence and determinants of parathyroid dysfunction in elderly patients on hemodialysis. Blood Purif 2014; 37:119-24. [PMID: 24662249 DOI: 10.1159/000357969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 12/12/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND The goal of this study was to investigate underlying factors of parathyroid dysfunction in elderly patients undergoing maintenance hemodialysis. METHODS A total of 286 patients on maintenance hemodialysis were included. Hemoglobin, serum creatinine (Scr), blood urea nitrogen (BUN), serum calcium, serum phosphorus (P), intact parathyroid hormone (iPTH), and serum albumin (Alb) were measured and analyzed both before and after dialysis. RESULTS A higher incidence of low iPTH level (<150 pg/l) was observed in the elderly group than that in the non-elderly group (55.8 vs. 36.7%, p < 0.05). Elderly patients had a shorter dialysis duration, lighter dry weight, lower concentrations of BUN, Scr, P, iPTH, Alb and standard protein nitrogen present rate (nPNA) compared to that of non-elderly group patients (p < 0.05). CONCLUSIONS Low iPTH level occurs more frequently in elderly hemodialysis patients. Furthermore, age, serum P, serum Alb and nPNA were independently associated with a low iPTH level.
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Affiliation(s)
- Jian-rao Lu
- Department of Nephrology, The 7th People's Hospital, Shanghai, China
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Deckers M, de Jongh R, Lips P, Penninx B, Milaneschi Y, Smit J, van Schoor N, Blankenstein M, Heijboer A. Prevalence of vitamin D deficiency and consequences for PTH reference values. Clin Chim Acta 2013; 426:41-5. [DOI: 10.1016/j.cca.2013.08.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/06/2013] [Accepted: 08/28/2013] [Indexed: 11/26/2022]
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Gannagé-Yared MH, Farès C, Ibrahim T, Rahal ZA, Elias M, Chelala D. Comparison between a second and a third generation parathyroid hormone assay in hemodialysis patients. Metabolism 2013; 62:1416-22. [PMID: 23769129 DOI: 10.1016/j.metabol.2013.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/15/2013] [Accepted: 05/08/2013] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Third generation parathyroid hormone (PTH) assays are new generation assays that do not recognize the PTH7-84 fragment whereas second generation assays detect both PTH1-84 and PTH7-84 fragments. Despite the excellent correlation between both assays in chronic renal failure (CRF) subjects, the mean PTH levels are typically 50% lower with the third compared to the second generation assays. The assessment of third generation PTH assays has not been extensively studied in hemodialysis subjects. The purpose of our study was to compare a third generation PTH assay to a second generation one in a population of hemodialysis subjects. MATERIALS AND METHODS 92 haemodialysis subjects (36 women and 56 men) with a mean age of 67±12.9 years were included in this study. Anthropometric and clinical parameters (Body Mass Index (BMI) and blood pressure) were measured. Second and third generation PTH assays (Cis biomedical and Diasorin respectively) were performed in each subject. In addition, the following biochemical tests were measured: 25-hydroxyvitamin D (25-(OH)D), 1,25-hydroxyvitamin D (1,25-(OH)2D), crosslaps and alkaline phosphatase. RESULTS The mean second and third generation PTHs are respectively 211±205 pg/ml and 151±164 pg/ml. The mean third generation PTH values are 28.4% lower compared to the second generation ones. Both methods are strongly correlated (r=0.923, p<0.001). This correlation persisted without any significant difference after controlling for gender, age, BMI and Blood Pressure. However, the difference between both methods increases when baseline PTH increases. Each of the second and third generation method is significantly correlated with hemodialysis duration (p<0.01), crosslaps (p<0.001), alkaline phosphatase (p<0.05), but not with age, BMI, Blood Pressure, 25-(OH)D or 1,25-(OH) 2D levels. CONCLUSION Our results show that both second and third generation PTH methods are strongly correlated in hemodialysis patients mainly when PTH values are low. However, the difference between both methods increases when PTH values are high. More research is needed to establish which method is the gold standard when PTH values are high.
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Delanaye P, Souberbielle JC, Lafage-Proust MH, Jean G, Cavalier E. Can we use circulating biomarkers to monitor bone turnover in CKD haemodialysis patients? Hypotheses and facts. Nephrol Dial Transplant 2013; 29:997-1004. [DOI: 10.1093/ndt/gft275] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Moorthi RN, Moe SM. Recent advances in the noninvasive diagnosis of renal osteodystrophy. Kidney Int 2013; 84:886-94. [PMID: 23802194 PMCID: PMC3805700 DOI: 10.1038/ki.2013.254] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/18/2013] [Accepted: 03/28/2013] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease-mineral and bone disorder (CKD-MBD) is the term used to describe a constellation of biochemical abnormalities, bone disturbances that may lead to fractures, and extraskeletal calcification in soft tissues and arteries seen in CKD. This review focuses on the noninvasive diagnosis of renal osteodystrophy, the term used exclusively to define the bone pathology associated with CKD. Transiliac bone biopsy and histomorphometry with double-labeled tetracycline or its derivatives remains the gold standard for diagnosis of renal osteodystrophy. However, histomorphometry provides a 'window' into bone only at a single point in time, and is not clinically practical for studying continuous changes in bone morphology. Furthermore, the etiology of fractures in CKD is multifactorial and not fully explained by histomorphometry findings alone. The propensity of a bone to fracture is determined by bone strength, which is affected by bone mass and bone quality; the latter is a term used to describe the structure and composition of bone. Bone quantity is traditionally assessed by dual X-ray absorptiometry (DXA) and CT-based methods. Bone quality is more difficult to assess noninvasively, but newer techniques are emerging and are described in this review. Ultimately, the optimal diagnostic strategy for renal osteodystrophy may be a combination of multiple imaging techniques and biomarkers that are specific to each gender and race in CKD, with a goal of predicting fracture risk and optimizing therapy.
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Affiliation(s)
- Ranjani N Moorthi
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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39
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Endres DB. Investigation of hypercalcemia. Clin Biochem 2012; 45:954-63. [DOI: 10.1016/j.clinbiochem.2012.04.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 04/19/2012] [Accepted: 04/26/2012] [Indexed: 02/06/2023]
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Garrett G, Sardiwal S, Lamb EJ, Goldsmith DJA. PTH--a particularly tricky hormone: why measure it at all in kidney patients? Clin J Am Soc Nephrol 2012; 8:299-312. [PMID: 22403273 DOI: 10.2215/cjn.09580911] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Plasma parathyroid hormone (PTH) concentrations are commonly measured in the context of CKD, as PTH concentration elevation is typical in this clinical context. Much has been inferred from this raised PTH concentration tendency, both about the state of skeletal integrity and health and also about the potential clinical outcomes for patients. However, we feel that reliance on PTH concentrations alone is a dangerous substitute for the search for, and use of, more precise and reliable biomarkers. In this article, we rehearse these arguments, bringing together patient-level and analytical considerations for the first time.
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Affiliation(s)
- Giorgia Garrett
- East Kent Hospitals University, NHS Foundation Trust, Canterbury, Kent, United Kingdom
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41
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Komaba H, Kakuta T, Fukagawa M. Diseases of the parathyroid gland in chronic kidney disease. Clin Exp Nephrol 2011; 15:797-809. [DOI: 10.1007/s10157-011-0502-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Accepted: 07/08/2011] [Indexed: 12/31/2022]
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Gueiros JEB, Hernandes FR, Karohl C, Jorgetti V. Prevenção e tratamento do hiperparatireoidismo secundário na DRC. J Bras Nefrol 2011. [DOI: 10.1590/s0101-28002011000200013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Taniguchi M, Tanaka M, Hamano T, Nakanishi S, Fujii H, Kato H, Koiwa F, Ando R, Kimata N, Akiba T, Kono T, Yokoyama K, Shigematsu T, Kakuta T, Kazama JJ, Tominaga Y, Fukagawa M. Comparison between Whole and Intact Parathyroid Hormone Assays. Ther Apher Dial 2011; 15 Suppl 1:42-9. [DOI: 10.1111/j.1744-9987.2011.00926.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tanaka H, Komaba H, Koizumi M, Kakuta T, Fukagawa M. Novel Electrochemiluminescence Immunoassay Exclusively for Full-length Parathyroid Hormone during Treatment with Cinacalcet for Secondary Hyperparathyroidism. Ther Apher Dial 2011; 15 Suppl 1:56-61. [DOI: 10.1111/j.1744-9987.2011.00928.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Patel S, Barron JL, Mirzazedeh M, Gallagher H, Hyer S, Cantor T, Fraser WD. Changes in bone mineral parameters, vitamin D metabolites, and PTH measurements with varying chronic kidney disease stages. J Bone Miner Metab 2011; 29:71-9. [PMID: 20521154 DOI: 10.1007/s00774-010-0192-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Accepted: 04/20/2010] [Indexed: 11/27/2022]
Abstract
Vitamin D deficiency is associated with an increased risk of many diseases (skeletal and nonskeletal). Emerging data also associate high concentrations of serum parathyroid hormone (PTH) with morbidity and increased mortality in patients both with and without known chronic kidney disease (CKD). Understanding the relationship between vitamin D and PTH and the determinants of PTH is therefore important. We performed a cross-sectional study of 203 patients with varying stages of CKD randomly recruited from the Renal Unit database at our institution. Detailed case review was performed, and samples of fasting blood were taken for biochemical analyses. We measured standard biochemistry, 25-hydroxyvitamin D (25-OHD), 1,25-OHD, and three PTH measurements [1-84 PTH, total PTH, and derived N-terminal truncated, 7-84 PTH (cPTH)]. Vitamin D deficiency was high, with 86% of patients having 25-OHD levels below 30 ng/ml. Estimated glomerular filtration rate (eGFR) was not associated with 25-OHD levels, whereas 1,25-OHD was lower in those with CKD stage 5 versus stage 4, who were not treated with vitamin D metabolites (18 vs. 65 pg/ml, respectively; P < 0.05). All three PTH measurements increased with worsening eGFR, with this finding being more pronounced in those patients who were not treated with vitamin D metabolites. The slope of the regression line of cPTH on eGFR tended to be steeper, -0.90, compared to -0.81 for total PTH and -0.80 for 1-84 PTH (P = 0.06). The ratio of total PTH to cPTH did decrease significantly through the range of CKD stages (P = 0.03). The determinants of PTH were similar for all three PTH measurements, with eGFR having a strong inverse relationship, with weaker relationships for 25-OHD and ionized calcium on multivariate analyses. We confirm that there is a complex relationship between 25-OHD, eGFR, and PTH. Total PTH, 1-84 PTH, and cPTH increase with increasing CKD stages, with a relatively greater increase in cPTH, although the clinical significance of this finding remains uncertain. The three PTH measurements had similar correlations with the biochemical and clinical variables studied, suggesting that either total PTH or 1-84 PTH can be used in clinical practice when evaluating vitamin D and PTH status.
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Affiliation(s)
- Sanjeev Patel
- Department of Rheumatology, St Helier University Hospital, Wrythe Lane, Carshalton, Surrey, UK.
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Ambrus C, Almasi C, Berta K, Deak G, Marton A, Molnar MZ, Nemeth Z, Horvath C, Lakatos P, Szathmari M, Mucsi I. Bone mineral density and parathyroid function in patients on maintenance hemodialysis. Int Urol Nephrol 2010; 43:191-201. [PMID: 20091221 DOI: 10.1007/s11255-009-9702-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2009] [Accepted: 12/28/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND The relationship between parathyroid function, an important determinant of bone turnover, and bone mineral density (BMD) in patients with chronic kidney disease is not fully understood. We wanted to analyze the association between BMD and parathyroid function in hemodialysis patients in details. METHODS In a cross-sectional design, data from 270 patients (age 55 ± 15 years, 60% men, all Caucasian) on maintenance hemodialysis were analyzed. All patients underwent dual energy X-ray absorptiometry of the lumbar spine (LS), femoral neck (FN) and distal radius (DR). In addition to routine laboratory tests, blood samples were collected for iPTH, serum markers of bone metabolism (alkaline phosphatase, type I collagen crosslinked-C-telopeptide) and 25OH vitamin D. RESULTS Based on Z-scores, bone mineral density was moderately reduced only at the femoral neck in the total cohort. The average Z-score of the "low PTH" group (iPTH < 100 pg/ml) was not different from the Z-score of patients with iPTH in the "target range" (100-300 pg/ml) at any measurement site. While iPTH was negatively correlated with BMD at all measurement sites in patients with iPTH > 100 pg/ml (rho = -0.255, -0.278 and -0.251 for LS, FN and DR, respectively, P < 0.001 for all), BMD was independent of iPTH in patients with iPTH < 100 pg/ml. Furthermore, iPTH was not associated with serum markers of bone metabolism, but these markers were negatively correlated with BMD in the "low PTH" group. CONCLUSIONS Low PTH levels are not associated with low BMD in patients with end-stage kidney disease. Furthermore, bone metabolism seems to be independent of iPTH in patients with relative hypoparathyroidism likely reflecting skeletal resistance to PTH.
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Affiliation(s)
- Cs Ambrus
- 1st Department of Internal Medicine, Semmelweis University, 2/a Koranyi S. u., 1083, Budapest, Hungary
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Souberbielle JC, Cavalier E, Jean G. Interpretation of serum parathyroid hormone concentrations in dialysis patients: what do the KDIGO guidelines change for the clinical laboratory? Clin Chem Lab Med 2010; 48:769-74. [DOI: 10.1515/cclm.2010.157] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Cavalier E, Delanaye P, Hubert P, Krzesinski JM, Chapelle JP, Rozet E. Estimation of the stability of parathyroid hormone when stored at -80 degrees C for a long period. Clin J Am Soc Nephrol 2009; 4:1988-92. [PMID: 19820128 DOI: 10.2215/cjn.03970609] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Stability of parathyroid hormone (PTH) at -80 degrees C for long storage periods has never been studied. This can be of importance for the conclusions of studies where blood banks have been constituted. The study's aim was to evaluate stability of PTH when stored as serum or plasma EDTA samples at -80 degrees C. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS Samples were collected from 16 chronic hemodialysis patients using EDTA and gel-separator tubes. Plasma and serum were aliquoted; one aliquot was assayed with Elecsys and Liaison methods to determine the "baseline" values and another aliquot after 1, 3, 6, and 12 mo. The factors "method," "tubes," "subjects," and "time" were included in a mixed linear model to evaluate their effects on measured PTH values. The prediction interval methodology was used to assess where a future result could be obtained with a defined probability. RESULTS With the Liaison method, the maximum storage times with either dry or EDTA tubes were estimated to be 9 and 2 mo, respectively. With the Elecsys method, samples could be stored at least 2 yr with acceptable level of degradation. CONCLUSION PTH stability at -80 degrees C is not infinite. Maximum storage time and acceptance limits (30%) were defined, showing that with one method, samples should be stored for not more than 2 mo, whereas the other could be stored for up to 2 yr. With any PTH assay, the maximum storage time should be evaluated to ascertain that samples will keep their initial reactive profile after prolonged storage periods.
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Affiliation(s)
- Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, Domaine du Sart-Tilman, Liège, Belgium.
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50
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ZIDEHSARAI MIRIAMP, MOE SHARONM. Review article: Chronic kidney disease-mineral bone disorder: Have we got the assays right? Nephrology (Carlton) 2009; 14:374-82. [DOI: 10.1111/j.1440-1797.2009.01131.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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