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Almeida PP, Brito ML, Thomasi B, Mafra D, Fouque D, Knauf C, Tavares-Gomes AL, Stockler-Pinto MB. Is the enteric nervous system a lost piece of the gut-kidney axis puzzle linked to chronic kidney disease? Life Sci 2024; 351:122793. [PMID: 38848938 DOI: 10.1016/j.lfs.2024.122793] [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: 02/12/2024] [Revised: 05/20/2024] [Accepted: 06/04/2024] [Indexed: 06/09/2024]
Abstract
The enteric nervous system (ENS) regulates numerous functional and immunological attributes of the gastrointestinal tract. Alterations in ENS cell function have been linked to intestinal outcomes in various metabolic, intestinal, and neurological disorders. Chronic kidney disease (CKD) is associated with a challenging intestinal environment due to gut dysbiosis, which further affects patient quality of life. Although the gut-related repercussions of CKD have been thoroughly investigated, the involvement of the ENS in this puzzle remains unclear. ENS cell dysfunction, such as glial reactivity and alterations in cholinergic signaling in the small intestine and colon, in CKD are associated with a wide range of intestinal pathways and responses in affected patients. This review discusses how the ENS is affected in CKD and how it is involved in gut-related outcomes, including intestinal permeability, inflammation, oxidative stress, and dysmotility.
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Affiliation(s)
| | - Michele Lima Brito
- Pathology Post Graduate Program, Fluminense Federal University (UFF), Niterói, RJ, Brazil
| | - Beatriz Thomasi
- Department of Physiology, Neuroscience Program, Michigan State University (MSU), East Lansing, MI, USA
| | - Denise Mafra
- Graduate Program in Biological Sciences - Physiology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Denis Fouque
- Department of Nephrology, Centre Hopitalier Lyon Sud, INSERM 1060, CENS, Université de Lyon, France
| | - Claude Knauf
- INSERM U1220 Institut de Recherche en Santé Digestive, CHU Purpan, Université Toulouse III Paul Sabatier Toulouse, Toulouse, France
| | - Ana Lúcia Tavares-Gomes
- Neurosciences Post Graduate Program, Fluminense Federal University (UFF), Niterói, RJ, Brazil
| | - Milena Barcza Stockler-Pinto
- Pathology Post Graduate Program, Fluminense Federal University (UFF), Niterói, RJ, Brazil; INSERM U1220 Institut de Recherche en Santé Digestive, CHU Purpan, Université Toulouse III Paul Sabatier Toulouse, Toulouse, France
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2
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Li C, Ng JKC, Chan GCK, Fung WWS, Lai KB, Poon PYK, Luk CCW, Chow KM, Szeto CC. Gut permeability, circulating bacterial fragments and measures of congestion in peritoneal dialysis. Clin Kidney J 2024; 17:sfae056. [PMID: 38516523 PMCID: PMC10956420 DOI: 10.1093/ckj/sfae056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Indexed: 03/23/2024] Open
Abstract
Background Limited data exist on the association between gut permeability, circulating bacterial fragment and volume overload in peritoneal dialysis (PD) patients. We measured circulating bacterial fragments, N-terminal pro B-type natriuretic peptide (NT-proBNP), calprotectin and zonulin levels, and evaluate their association with the clinical outcomes in PD patients. Methods This was a single-center prospective study on 108 consecutive incident PD patients. Plasma endotoxin and bacterial DNA, and serum NT-proBNP, calprotectin and zonulin levels were measured. Primary outcomes were technique and patient survival, secondary outcomes were hospitalization data. Results There was no significant correlation between plasma endotoxin and bacterial DNA, and serum NT-proBNP, calprotectin and zonulin levels. The Homeostatic Model Assessment for Insulin Resistance (HOMA)-2β index, which represents insulin resistance, positively correlated with plasma bacterial DNA (r = 0.421, P < .001) and calprotectin levels (r = 0.362, P = .003), while serum NT-proBNP level correlated with the severity of volume overload and residual renal function. Serum NT-proBNP level was associated with technique survival even after adjusting for confounding factors [adjusted hazard ratio (aHR) 1.030, 95% confidence interval 1.009-1.051]. NT-proBNP level was also associated with patient survival by univariate analysis, but the association became insignificant after adjusting for confounding factors (aHR 1.010, P = .073). Similarly, NT-proBNP correlated with the number of hospitalizations and duration of hospitalization by univariate analysis, but the association became insignificant after adjusting for confounding factors. Conclusion There was no correlation between markers of gut permeability, circulating bacterial fragments and measures of congestion in PD patients. Bacterial fragments levels and gut permeability are both associated with insulin resistance. Serum NT-proBNP level is associated with the severity of volume overload and technique survival. Further studies are required to delineate the mechanism of high circulating bacterial fragment levels in PD patients.
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Affiliation(s)
- Chuanlei Li
- Carol & Richard Yu Peritoneal Dialysis Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Jack Kit-Chung Ng
- Carol & Richard Yu Peritoneal Dialysis Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Gordon Chun-Kau Chan
- Carol & Richard Yu Peritoneal Dialysis Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Winston Wing-Shing Fung
- Carol & Richard Yu Peritoneal Dialysis Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Ka-Bik Lai
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Peter Yam-Kau Poon
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Cathy Choi-Wan Luk
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Kai-Ming Chow
- Carol & Richard Yu Peritoneal Dialysis Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Cheuk-Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Ray N, Park SJ, Jung H, Kim J, Korcsmaros T, Moon Y. Stress-responsive Gdf15 counteracts renointestinal toxicity via autophagic and microbiota reprogramming. Commun Biol 2023; 6:602. [PMID: 37270567 DOI: 10.1038/s42003-023-04965-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 05/22/2023] [Indexed: 06/05/2023] Open
Abstract
The integrated stress response (ISR) plays a pivotal role in the cellular stress response, primarily through global translational arrest and the upregulation of cellular adaptation-linked molecules. Growth differentiation factor 15 (Gdf15) is a potent stress-responsive biomarker of clinical inflammatory and metabolic distress in various types of diseases. Herein, we assess whether ISR-driven cellular stress contributes to pathophysiological outcomes by modulating Gdf15. Clinical transcriptome analysis demonstrates that PKR is positively associated with Gdf15 expression in patients with renal injury. Gdf15 expression is dependent on protein kinase R (PKR)-linked ISR during acute renointestinal distress in mice and genetic ablation of Gdf15 aggravates chemical-induced lesions in renal tissues and the gut barrier. An in-depth evaluation of the gut microbiota indicates that Gdf15 is associated with the abundance of mucin metabolism-linked bacteria and their enzymes. Moreover, stress-responsive Gdf15 facilitates mucin production and cellular survival via the reorganization of the autophagy regulatory network. Collectively, ISR-activated Gdf15 counteracts pathological processes via the protective reprogramming of the autophagic network and microbial community, thereby providing robust predictive biomarkers and interventions against renointestinal distress.
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Affiliation(s)
- Navin Ray
- Laboratory of Mucosal Exposome and Biomodulation, Department of Integrative Biomedical Sciences, Pusan National University, Yangsan, Korea
| | - Seung Jun Park
- Laboratory of Mucosal Exposome and Biomodulation, Department of Integrative Biomedical Sciences, Pusan National University, Yangsan, Korea
| | - Hoyung Jung
- Laboratory of Mucosal Exposome and Biomodulation, Department of Integrative Biomedical Sciences, Pusan National University, Yangsan, Korea
| | - Juil Kim
- Laboratory of Mucosal Exposome and Biomodulation, Department of Integrative Biomedical Sciences, Pusan National University, Yangsan, Korea
| | - Tamas Korcsmaros
- Division of Digestive Diseases, Faculty of Medicine, Imperial College London, London, UK
- Earlham Institute, Norwich Research Park, Norwich, UK
- Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Yuseok Moon
- Laboratory of Mucosal Exposome and Biomodulation, Department of Integrative Biomedical Sciences, Pusan National University, Yangsan, Korea.
- Earlham Institute, Norwich Research Park, Norwich, UK.
- Graduate Program of Genomic Data Sciences, Pusan National University, Yangsan, Korea.
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Sharma S, Raman P, Deo AS. Comparative preoperative sonological assessment of gastric contents in patients with chronic kidney disease versus those with normal renal function - A prospective observational study. Indian J Anaesth 2023; 67:503-508. [PMID: 37476431 PMCID: PMC10355363 DOI: 10.4103/ija.ija_82_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 07/22/2023] Open
Abstract
Background and Aims Though the role of fasting preoperative gastric ultrasound has been validated in different patient populations, namely, obese, pregnant and diabetics, it has not been explored in patients with chronic kidney disease (CKD). This prospective, observational study compared the fasting sonological assessment of gastric contents in patients with CKD versus those with normal renal function scheduled for elective surgery. Methods After ethical approval and trial registration were obtained, preoperative gastric ultrasound was done in 115 CKD patients and 115 with normal renal function. Qualitative and quantitative assessment of residual gastric volume was done. Also, the patients were administered the Porto Alegre Dyspeptic Symptoms Questionnaire (PADYQ) to evaluate gastroparesis objectively. The researcher was not blinded to the patient groups. Data analyses were done using the Statistical Package for Social Sciences (SPSS) for Windows software (version 22.0). Results Gastric volumes exceeding 1.5 ml/kg or particulate or solid contents were found in 57 patients with CKD and 36 patients with normal renal function (P = 0.004). The PADYQ scores were 6.54 ± 8.49 for CKD and 2.15 ± 5.71 for normal renal function (P < 0.0001) groups. CKD patients had a higher age (P < 0.001), lower body mass index (P = 0.005) and higher incidence of diabetes mellitus (P < 0.001). There were no incidents of gastric aspiration. Conclusion Renal dysfunction contributes to delayed gastric emptying. PADYQ can also help identify those at high risk of gastroparesis. Combining the questionnaire and preoperative gastric ultrasound must be considered in these patients to ensure optimum safety.
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Affiliation(s)
- Sadhvi Sharma
- Department of Anaesthesiology and Critical Care, NU Hospitals, Padmanabhanagar, Bengaluru, Karnataka, India
| | - Padmalatha Raman
- Department of Anaesthesiology and Critical Care, Prakriya Hospitals, Bengaluru, Karnataka, India
| | - Alka S. Deo
- Department of Anaesthesiology and Critical Care, NU Hospitals, Padmanabhanagar, Bengaluru, Karnataka, India
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Chan GCK, Fung WWS, Szeto CC, Ng JKC. From MIA to FIFA: The vicious matrix of frailty, inflammation, fluid overload and atherosclerosis in peritoneal dialysis. Nephrology (Carlton) 2023; 28:215-226. [PMID: 36807408 DOI: 10.1111/nep.14150] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/25/2023] [Accepted: 02/14/2023] [Indexed: 02/20/2023]
Abstract
Cardiovascular disease (CVD) is a major cause of mortality and morbidity in peritoneal dialysis (PD) patients. Two decades ago, the common co-existence of malnutrition and systemic inflammation PD patients with atherosclerosis and CVD led to the proposed terminology of 'malnutrition-inflammation-atherosclerosis (MIA) syndrome'. Although the importance of malnutrition is well accepted, frailty represents a more comprehensive assessment of the physical and functional capability of the patient and encompasses the contributions of sarcopenia (a key component of malnutrition), obesity, cardiopulmonary as well as neuropsychiatric impairment. In recent years, it is also increasingly recognized that fluid overload is not only the consequence but also play an important role in the pathogenesis of CVD. Moreover, fluid overload is closely linked with the systemic inflammatory status, presumably by gut oedema, gastrointestinal epithelial barrier dysfunction and leakage of bacterial fragments to the systemic circulation. There are now a wealth of published evidence to show intricate relations between frailty, inflammation, fluid overload and atherosclerotic disease in patients with chronic kidney disease (CKD) and those on PD, a phenomenon that we propose the term 'FIFA complex'. In this system, frailty and atherosclerotic disease may be regarded as two patient-oriented outcomes, while inflammation and fluid overload are two inter-connected pathogenic processes. However, there remain limited data on how the treatment of one component affect the others. It is also important to define how treatment of fluid overload affect the systemic inflammatory status and to develop effective anti-inflammatory strategies that could alleviate atherosclerotic disease and frailty.
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Affiliation(s)
- Gordon Chun-Kau Chan
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Winston Wing-Shing Fung
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cheuk-Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jack Kit-Chung Ng
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Bertoli D, Steinkohl E, Mark EB, Brock C, Drewes AM, Frøkjaer JB. Quantification of gastric emptying with magnetic resonance imaging in healthy volunteers: A systematic review. Neurogastroenterol Motil 2022; 34:e14371. [PMID: 35340100 PMCID: PMC10078504 DOI: 10.1111/nmo.14371] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/17/2022] [Accepted: 03/14/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several magnetic resonance imaging (MRI) protocols have been used to assess gastric emptying (GE) with MRI. This systematic review summarizes the current literature on the topic. The aim was to provide an overview of the available imaging protocols and underline the items that appear most agreed upon and those that deserve further investigation. METHODS According to PRISMA guidelines, two independent reviewers conducted a systematic literature search with a pre-specified strategy in different databases. Peer-reviewed articles that utilized MRI techniques to assess GE in healthy volunteers (HVs) were included. The quality and the outcomes of the studies were reported and analyzed. KEY RESULTS The literature search yielded 30 studies (531 HVs, weighted mean age 27.4, weighted mean body mass index 23.0 kg/m2 ), T2-weighted sequences, balanced turbo field echo, and balanced gradient echo were evenly utilized, with volunteers in the supine position (74% of the studies). After overnight fasting, both liquid (56%) and mixed (44%) meals were equally utilized. Segmentation of the volumes was predominantly performed manually (63%) with a reported mean T50 ranging from 7 to 330 min. CONCLUSIONS & INFERENCES As observed in this systematic review, MRI is a flexible tool for assessing GE. Different protocols were analyzed, showing an equal capacity to assess the GE. However, many items in these protocols still require further investigation to obtain a common standard and increase this assessment quality.
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Affiliation(s)
- Davide Bertoli
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Emily Steinkohl
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Esben Bolvig Mark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jens Brøndum Frøkjaer
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
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7
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Ng JKC, Than WH, Szeto CC. Obesity, Weight Gain, and Fluid Overload in Peritoneal Dialysis. FRONTIERS IN NEPHROLOGY 2022; 2:880097. [PMID: 37675033 PMCID: PMC10479638 DOI: 10.3389/fneph.2022.880097] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/02/2022] [Indexed: 09/08/2023]
Abstract
Obesity is a global epidemic that has a complicated pathogenesis as well as impact on the outcome of peritoneal dialysis (PD) patients. In this review, the prevalence of obesity in incident PD patients as well as the phenomenon of new-onset glucose intolerance after PD will be reviewed. Published literature on the effect of obesity on the survival and incidence of cardiovascular disease in PD patients will be discussed. Particular emphasis would be put on literature that compared the impact of obesity on the outcome of hemodialysis and PD, and the confounding effect of dialysis adequacy. Next, the complex concept of obesity and its relevance for PD will be explored. The focus would be put on the methods of assessment and clinical relevance of central versus general obesity, as well as visceral versus subcutaneous adipose tissue. The relation between obesity and systemic inflammation, as well as the biological role of several selected adipokines will be reviewed. The confounding effects of metabolic syndrome and insulin resistance will be discussed, followed by the prevalence and prognostic impact of weight gain during the first few years of PD. The differences between weight gain due to fluid overload and accumulation of adipose tissue will be discussed, followed by the current literature on the change in body composition after patients are put on chronic PD. The methods of body composition will be reviewed, and the clinical relevance of individual body component (fluid, fat, muscle, and bone) will be discussed. The review will conclude by highlighting current gaps of knowledge and further research directions in this area.
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Affiliation(s)
- Jack Kit-Chung Ng
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Win Hlaing Than
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Cheuk Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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Kusumi K, Kremsdorf R, Kakajiwala A, Mahan JD. Pediatric Mineral and Bone Disorder of Chronic Kidney Disease and Cardiovascular Disease. Adv Chronic Kidney Dis 2022; 29:275-282. [PMID: 36084974 DOI: 10.1053/j.ackd.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/11/2022]
Abstract
Chronic kidney disease is common and causes significant morbidity including shortened lifespans and decrease in quality of life for patients. The major cause of mortality in chronic kidney disease is cardiovascular disease. Cardiovascular disease within the chronic kidney disease population is closely tied with disordered calcium and phosphorus metabolism and driven in part by renal bone disease. The complex nature of renal, bone, and cardiovascular diseases was renamed as mineral and bone disorder of chronic kidney disease to encompass how bone disease drives vascular calcification and contributes to the development of long-term cardiovascular disease, and recent data suggest that managing bone disease well can augment and improve cardiovascular disease status. Pediatric nephrologists have additional obstacles in optimal mineral and bone disorder of chronic kidney disease management such as linear growth and skeletal maturation. In this article, we will discuss cardiovascular and bone diseases in chronic kidney disease and end-stage kidney disease patients with a focus on pediatric issues and concerns.
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Affiliation(s)
- Kirsten Kusumi
- Department of Pediatric Nephrology, Akron Children's Hospital, Akron, OH.
| | - Robin Kremsdorf
- Pediatric Nephrology and Hypertension, Hasbro Children's Hospital, Providence, RI
| | - Aadil Kakajiwala
- Departments of Pediatric Critical Care Medicine and Nephrology, Children's National Hospital, Washington, DC
| | - John D Mahan
- Division of Nephrology and Hypertension at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
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Chen YT, Kao ZK, Shih CJ, Ou SM, Yang CY, Yang AH, Lee OKS, Tarng DC. Magnesium exposure increases hip fracture risks in patients with chronic kidney disease: a population-based nested case-control study. Osteoporos Int 2022; 33:1079-1087. [PMID: 34994816 DOI: 10.1007/s00198-022-06301-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022]
Abstract
UNLABELLED This population-based study demonstrates a strong link between Mg-containing antacid exposure and hip fracture risk in nondialysis CKD and dialysis patients. As an Mg-containing antacid, MgO is also commonly used as a stool softener, which can be effortlessly replaced by other laxatives in CKD patients to maintain bone health. PURPOSE Bone fracture is a severe complication in chronic kidney disease (CKD) patients, leading to disability and reduced survival. In CKD patients, blood magnesium (Mg) concentrations are usually above the normal range due to reduced kidney excretion of Mg. The present study examines the association between Mg-containing antacid exposure and the risk of hip fracture of CKD patients. METHODS In this nationwide nested case-control study, we enrolled 44,062 CKD patients with hip fracture and 44,062 CKD matched controls, among which the mean age was 77.1 years old, and 87.9% was nondialysis CKD. RESULTS As compared to non-users, Mg-containing antacid users were significantly more likely to experience hip fracture (adjusted odds ratio (OR) 1.36, 95% CI, 1.32 to 1.41; p < 0.001). Subgroup analysis showed that such risk exists in both nondialysis CKD patients and long-term dialysis patients. In contrast, aluminum or calcium-containing-antacid use did not reveal such association. Next, we examined the influence of Mg-containing antacid dosage on hip fracture risk, the adjusted ORs in the first quartile (Q1), Q2, Q3, and Q4 were 1.20 (95% CI, 1.15 to 1.25; p < 0.001), 1.35 (95% CI, 1.30 to 1.41; p < 0.001), 1.49 (95% CI, 1.43 to 1.56; p < 0.001), and 1.54 (95% CI, 1.47 to 1.61; p < 0.001), respectively, showing that such risk exists regardless of the antacid dosage. A receiver operating characteristic curve analysis demonstrated that the best cutoff value of the exposed Mg dose to discriminate the hip fracture is 532 mEq during the follow-up period. CONCLUSION This population-based study demonstrates a strong link between Mg-containing antacid exposure and the hip fracture risk in both nondialysis CKD and dialysis patients.
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Affiliation(s)
- Y-T Chen
- Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, 10065, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan
| | - Z-K Kao
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Room 208, Shou-Ren Building, No.155, Section 2, Li-Nong Street, Beitou District, Taipei, 11221, Taiwan
| | - C-J Shih
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan
- Deran Clinic, Yilan, 26044, Taiwan
| | - S-M Ou
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 11217, Taiwan
| | - C-Y Yang
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan.
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Room 208, Shou-Ren Building, No.155, Section 2, Li-Nong Street, Beitou District, Taipei, 11221, Taiwan.
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 11217, Taiwan.
- Center for Osteoporosis Prevention and Treatment, Taipei Veterans General Hospital, Taipei, 11217, Taiwan.
- Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, 11217, Taiwan.
- Stem Cell Research Center, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan.
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), Hsinchu, 30010, Taiwan.
| | - A-H Yang
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Room 208, Shou-Ren Building, No.155, Section 2, Li-Nong Street, Beitou District, Taipei, 11221, Taiwan
- Department of Pathology, Taipei Veterans General Hospital, Taipei, 11217, Taiwan
| | - O K-S Lee
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Room 208, Shou-Ren Building, No.155, Section 2, Li-Nong Street, Beitou District, Taipei, 11221, Taiwan
- Stem Cell Research Center, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan
- Department of Orthopedics, China Medical University Hospital, Taichung, 40447, Taiwan
| | - D-C Tarng
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Room 208, Shou-Ren Building, No.155, Section 2, Li-Nong Street, Beitou District, Taipei, 11221, Taiwan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, 11217, Taiwan
- Center for Osteoporosis Prevention and Treatment, Taipei Veterans General Hospital, Taipei, 11217, Taiwan
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), Hsinchu, 30010, Taiwan
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Pavlova E, Gold RM, Tolbert MK, Lidbury JA. Medical conditions associated with gastroduodenal ulceration or erosion in 168 dogs: 2008-2018. J Vet Intern Med 2021; 35:2697-2704. [PMID: 34596276 PMCID: PMC8692196 DOI: 10.1111/jvim.16275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 12/17/2022] Open
Abstract
Background Many medical conditions are thought to cause gastroduodenal ulceration or erosion (GUE) in dogs. However, evidence for the association between many of these conditions and GUE in dogs is lacking. Objective To identify medical conditions associated with GUE in dogs. Animals One hundred and sixty‐eight dogs with GUE and 168 randomly selected control dogs without evidence of GUE identified on necropsy between January 2008 and September 2018. Methods Patient signalment, blood urea nitrogen (BUN) and serum creatinine concentrations, recently administered ulcerogenic drugs, as well as necropsy findings were recorded. The association between these findings and presence of GUE was assessed by univariable and multivariable analysis. Results In the final multivariable model, the following factors were associated with GUE: Nonsteroidal anti‐inflammatory drug (NSAID) administration (odds ratio [OR], 6.3; 95% confidence interval [CI], 2.3‐17.4; P = .0004), glucocorticoid administration (OR, 3.0; 95% CI, 1.5‐5.9; P = .001), gastrointestinal neoplasia (OR, 13.5; 95% CI, 1.7‐108.0; P = .01) and gastrointestinal mechanical disease (foreign bodies, gastric dilatation, and volvulus; OR, 4.8; 95% CI, 1.2‐19.7; P = .03). Additionally, working dog breeds were predisposed to GUE compared to mixed breed dogs (OR, 2.8; 95% CI, 1.1‐7.4; P = .04). Insufficient clinical data was available to either support or refute a role of other putative risk factors evaluated. Conclusion and Clinical Importance Administration of NSAID or glucocorticoid and gastrointestinal neoplasia or mechanical disease were associated with GUE in dogs. The potential predisposition of working breed dogs for GUE requires further investigation.
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Affiliation(s)
- Elena Pavlova
- Department of Small Animal Clinical Sciences, Texas A&M University College of Veterinary Medicine and Biomedical Sciences, College Station, Texas, USA
| | - Randi M Gold
- Department of Small Animal Clinical Sciences, Texas A&M University College of Veterinary Medicine and Biomedical Sciences, College Station, Texas, USA
| | - M Katherine Tolbert
- Department of Small Animal Clinical Sciences, Texas A&M University College of Veterinary Medicine and Biomedical Sciences, College Station, Texas, USA
| | - Jonathan A Lidbury
- Department of Small Animal Clinical Sciences, Texas A&M University College of Veterinary Medicine and Biomedical Sciences, College Station, Texas, USA
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11
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Elfar W, Gurjar AA, Talukder MAH, Noble M, Di Lorenzo C, Elfar J. Erythropoietin promotes functional recovery in a mouse model of postoperative ileus. Neurogastroenterol Motil 2021; 33:e14049. [PMID: 33368893 DOI: 10.1111/nmo.14049] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 07/27/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dysmotility and postoperative ileus (POI) are major clinical problems after surgical trauma and it is associated with increased intestinal inflammation and oxidative stress. Despite the high occurrence of POI following intra-abdominal surgeries, no effective treatment is currently available. Erythropoietin (EPO) is a multifunctional tissue-protective cytokine with potent anti-inflammatory and anti-oxidative properties, and it is an FDA approved medicine for clinical use. While both EPO and EPO receptors (EPOR) are widely expressed in the gut, the role of EPO in POI is largely unknown. This study was designed to explore the possible beneficial effect of EPO in a mouse model of POI. METHODS Mice were subjected to intestinal manipulation to induce standard POI and intestinal transit time was determined at 24-h post-injury with or without EPO treatment (5000 units/kg, once, IP, immediately after intestinal trauma). Intestinal samples were harvested for histological and immunohistochemical analysis. RESULTS Systemic EPO significantly improved intestinal transit time compared with control group and it was associated with significantly increased levels of tissue macrophages and reduced levels of oxidative stress. CONCLUSIONS AND INFERENCES This is the first pre-clinical study to document novel beneficial effects of EPO in gut dysmotility and our findings suggest that the beneficial effects of EPO in POI is predominantly mediated by its anti-oxidative and immunomodulatory properties.
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Affiliation(s)
- Walaa Elfar
- Division of Gastroenterology and Nutrition, Department of Pediatrics, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Anagha A Gurjar
- Department of Orthopedics and Rehabilitation, Center for Orthopedics and Translational Sciences (CORTS), The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - M A Hassan Talukder
- Department of Orthopedics and Rehabilitation, Center for Orthopedics and Translational Sciences (CORTS), The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Mark Noble
- Department of Biomedical Genetics, University of Rochester Medical Center, Rochester, New York, USA
| | - Carlo Di Lorenzo
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - John Elfar
- Department of Orthopedics and Rehabilitation, Center for Orthopedics and Translational Sciences (CORTS), The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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12
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Ikee R, Sasaki N, Yasuda T, Fukazawa S. Chronic Kidney Disease, Gut Dysbiosis, and Constipation: A Burdensome Triplet. Microorganisms 2020; 8:microorganisms8121862. [PMID: 33255763 PMCID: PMC7760012 DOI: 10.3390/microorganisms8121862] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022] Open
Abstract
Gut dysbiosis has been implicated in the progression of chronic kidney disease (CKD). Alterations in the gut environment induced by uremic toxins, the dietary restriction of fiber-rich foods, and multiple drugs may be involved in CKD-related gut dysbiosis. CKD-related gut dysbiosis is considered to be characterized by the expansion of bacterial species producing precursors of harmful uremic toxins, such as indoxyl sulfate and p-cresyl sulfate, and the contraction of species generating beneficial short-chain fatty acids, such as butyrate. Gut-derived uremic toxins cause oxidative stress and pro-inflammatory responses, whereas butyrate exerts anti-inflammatory effects and contributes to gut epithelial integrity. Gut dysbiosis is associated with the disruption of the gut epithelial barrier, which leads to the translocation of endotoxins. Research on CKD-related gut dysbiosis has mainly focused on chronic inflammation and consequent cardiovascular and renal damage. The pathogenic relationship between CKD-related gut dysbiosis and constipation has not yet been investigated in detail. Constipation is highly prevalent in CKD and affects the quality of life of these patients. Under the pathophysiological state of gut dysbiosis, altered bacterial fermentation products may play a prominent role in intestinal dysmotility. In this review, we outline the factors contributing to constipation, such as the gut microbiota and bacterial fermentation; introduce recent findings on the pathogenic link between CKD-related gut dysbiosis and constipation; and discuss potential interventions. This pathogenic link needs to be elucidated in more detail and may contribute to the development of novel treatment options not only for constipation, but also cardiovascular disease in CKD.
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Affiliation(s)
- Ryota Ikee
- Sapporo Nephrology Satellite Clinic, 9-2-15, Hassamu 6-jo, Nishi-ku, Sapporo 063-0826, Japan;
- Correspondence:
| | - Naomi Sasaki
- Sapporo Nephrology Clinic, 20-2-12, Nishimachikita, Nishi-ku, Sapporo 063-0061, Japan; (N.S.); (S.F.)
| | - Takuji Yasuda
- Sapporo Nephrology Satellite Clinic, 9-2-15, Hassamu 6-jo, Nishi-ku, Sapporo 063-0826, Japan;
| | - Sawako Fukazawa
- Sapporo Nephrology Clinic, 20-2-12, Nishimachikita, Nishi-ku, Sapporo 063-0061, Japan; (N.S.); (S.F.)
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13
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Schijvens AM, de Wildt SN, Schreuder MF. Pharmacokinetics in children with chronic kidney disease. Pediatr Nephrol 2020; 35:1153-1172. [PMID: 31375913 PMCID: PMC7248054 DOI: 10.1007/s00467-019-04304-9] [Citation(s) in RCA: 8] [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: 03/28/2019] [Revised: 06/26/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022]
Abstract
In children, the main causes of chronic kidney disease (CKD) are congenital diseases and glomerular disorders. CKD is associated with multiple physiological changes and may therefore influence various pharmacokinetic (PK) parameters. A well-known consequence of CKD on pharmacokinetics is a reduction in renal clearance due to a decrease in the glomerular filtration rate. The impact of renal impairment on pharmacokinetics is, however, not limited to a decreased elimination of drugs excreted by the kidney. In fact, renal dysfunction may lead to modifications in absorption, distribution, transport, and metabolism as well. Currently, insufficient evidence is available to guide dosing decisions on many commonly used drugs. Moreover, the impact of maturation on drug disposition and action should be taken into account when selecting and dosing drugs in the pediatric population. Clinicians should take PK changes into consideration when selecting and dosing drugs in pediatric CKD patients in order to avoid toxicity and increase efficiency of drugs in this population. The aim of this review is to summarize known PK changes in relation to CKD and to extrapolate available knowledge to the pediatric CKD population to provide guidance for clinical practice.
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Affiliation(s)
- Anne M Schijvens
- Radboud Institute for Molecular Life Sciences, Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children's Hospital, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Michiel F Schreuder
- Radboud Institute for Molecular Life Sciences, Department of Pediatric Nephrology, Radboud University Medical Center, Amalia Children's Hospital, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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14
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Al Hillan A, Curras-Martin D, Carson M, Gor S, Ezeume A, Gupta V, Copcaalvarez A, Beri G, Bermann M, Asif A. Capsule Endoscopy Transit Time to Duodenum: Relation to Patient Demographics. Cureus 2020; 12:e6894. [PMID: 32064217 PMCID: PMC7003722 DOI: 10.7759/cureus.6894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/05/2020] [Indexed: 12/15/2022] Open
Abstract
Background Anesthesia guidelines recommend fasting for at least two hours to minimize aspiration risk related to endoscopic procedures, and the American Society for Gastrointestinal Endoscopy (ASGE) states that the final oral preparation liquid can be administered three to eight hours before the procedure. We have observed the cancellation of endoscopy procedures if liquids were consumed within four, six, or eight hours of the start time. Objectively, documenting gastric transit time via a review of pill endoscopy data could address clinician concerns, prevent delays in patient care, and improve the rate at which our clinicians practice within national guidelines. The objective was to utilize capsule endoscopy data from our center to report the relationship between patient factors that could affect gastric transit time (GTT) and small bowel transit time (SBTT) such as chronic kidney disease (CKD), diabetes mellitus (DM), nutritional status, and obesity. Methods This retrospective review obtained data on adult pill endoscopy (PillCam™ SB 3) (Medtronic, Minneapolis MN) studies on in- and outpatients. Past medical history and laboratory data were abstracted from electronic medical records. Mean GTT and SBTT are reported in minutes + standard deviation (SD) and times were compared accounting for conditions that could prolong transit, such as diabetes mellitus or chronic kidney disease (CKD). Results One hundred and sixty-three records reviewed. Four patients were excluded as the pill did not pass out of the stomach. The mean age was 66 years, 57% were female, and 26% were evaluated for gastrointestinal (GI) bleeding. The mean GTT for all patients (n = 159) was 35 + 49 with a median of 19 minutes. There were no statistically significant differences in GTT between the following subgroups: CKD0 (n = 100) 40 + 58 versus CKD5 (n = 11) 35 + 39, albumin > 3.0 (n = 123) 37 + 53 versus albumin < 3.0 (n = 36) 27 + 30, diabetes mellitus (DM) (n = 40) 51 + 71 vs. non-DM (n = 119) 42 + 79, body mass index (BMI) > 30, or aspirin use. The SBTT results in all patients (n = 124) was 238 + 88 minutes. Similarly, there was no relation between SBTT and albumin, any CKD, CKD0 versus CKD5, DM status, or BMI. The patients with the capsule stuck in the stomach did not have any other clinical history to explain this occurrence. Conclusions This analysis of objective data regarding pill endoscopy found that the mean GTT was 44 minutes, and it was < 60 minutes for 85% of the cohort. Patient factors were not associated with longer transit times, and this is the first report to document PillCam times in relation to CKD. These data support recommendations that endoscopic procedures, in accordance with anesthesia and ASGE guidelines, can be safely conducted in the majority of patients within 60 minutes of ingesting liquids.
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Affiliation(s)
- Alsadiq Al Hillan
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | | | - Michael Carson
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Shreya Gor
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Adaeze Ezeume
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Varsha Gupta
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | | | - Gagan Beri
- Gastroenterology, Jersey Shore University Medical Center, Neptune, USA
| | - Mordechai Bermann
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Arif Asif
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
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15
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Costa-Moreira P, Vilas-Boas F, Teixeira Fraga A, Macedo G. Particular aspects of gastroenterological disorders in chronic kidney disease and end-stage renal disease patients: a clinically focused review. Scand J Gastroenterol 2020; 55:129-138. [PMID: 32027522 DOI: 10.1080/00365521.2020.1722217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Besides renal disease, gastrointestinal (GI) disorders are frequently reported in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Related gastrointestinal symptoms tend to increase as the renal disease progresses. Also, in patients with ESRD, the modality of dialysis is related to particular forms of GI disorders.The kidney can interact with the digestive organs through functional endogenous systems such as the 'kidney-colon axis' and the 'kidney-liver axis'. Digestive diseases are one of the visible manifestations of the disturbance between hemostatic, hemodynamic and immunological balance in such patients.No clear management guidelines currently exist for many of the gastrointestinal problems that accompany renal failure. This review aims to describe the particular aspects of GI diseases present in CKD/ESRD. We focus our discussion in the specificities of epidemiology, diagnosis, and prognosis of such disorders between the different segments of the digestive system.
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Affiliation(s)
- Pedro Costa-Moreira
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, Medicine Department, University of Porto, Portugal
| | - Filipe Vilas-Boas
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, Medicine Department, University of Porto, Portugal
| | | | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar e Universitário São João, Porto, Portugal.,Faculty of Medicine, Medicine Department, University of Porto, Portugal
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16
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Lambert K, Bird L, Borst AC, Fuller A, Wang Y, Rogers GB, Stanford J, Sanderson-Smith ML, Williams JG, McWhinney BC, Neale EP, Probst Y, Lonergan M. Safety and Efficacy of Using Nuts to Improve Bowel Health in Hemodialysis Patients. J Ren Nutr 2020; 30:462-469. [PMID: 32001127 DOI: 10.1053/j.jrn.2019.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 09/23/2019] [Accepted: 10/04/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Constipation is common in patients with end-stage kidney disease. Nondrug strategies to manage constipation are challenging because of dietary potassium, phosphate, and fluid restrictions. Nuts are a high-fiber food but are excluded from the diet because of the high potassium and phosphate content. The aim of this study was to examine the safety and efficacy of using nuts to improve constipation in adults undertaking hemodialysis (HD). DESIGN AND METHODS Adult patients undertaking HD were recruited to this nonrandomized, 10-week repeated measures, within-subject, pragmatic clinical trial, conducted in two HD units. The intervention consisted of consumption of 40g of raw almonds daily for four weeks, followed by a two-week washout and four-week control period. The primary safety outcome measures were change in predialysis serum potassium and phosphate levels. The primary efficacy outcome was reduction in constipation, measured using the Bristol Stool Form Scale and Palliative Care Outcome Scale (POS-S) renal symptom score. Secondary outcomes included quality of life, selected uremic toxins, cognition, gut microbiota profile, and symptom burden. RESULTS Twenty patients completed the trial (median age: 67 [interquartile range: 57.5-77.8] years, 51% male). After controlling for dialysis adequacy, anuria, dietary intake, bicarbonate, and parathyroid hormone, there were no statistically significant changes in serum potassium (P = 0.21) or phosphate (P = 0.16) associated with daily consumption of almonds. However, statistically significant improvements in constipation were seen at weeks 2, 3, 4, and 10. There were statistically significant improvements in quality of life (P = 0.030), overall symptom burden (P = 0.002), vomiting (P = 0.020), itching (P = 0.006), and skin changes (P = 0.002). CONCLUSION Daily consumption of almonds for four weeks was safe, effective, and well tolerated. Improvements in quality of life and symptom burden warrant further research to elucidate potential mechanisms. The findings support the potential reinclusion of foods such as nuts into the diet of patients who underwent HD.
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Affiliation(s)
- Kelly Lambert
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia; Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia.
| | - Luke Bird
- Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Addison C Borst
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Andrew Fuller
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Yanan Wang
- Microbiome and Host Health Programme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Geraint B Rogers
- Microbiome and Host Health Programme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Jordan Stanford
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Martina L Sanderson-Smith
- Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia; School of Chemistry and Molecular Bioscience, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Jonathan G Williams
- Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia; School of Chemistry and Molecular Bioscience, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Brett C McWhinney
- Department of Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia
| | - Elizabeth P Neale
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
| | - Yasmine Probst
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
| | - Maureen Lonergan
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia; Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
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17
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Biruete A, Hill Gallant KM, Lindemann SR, Wiese GN, Chen NX, Moe SM. Phosphate Binders and Nonphosphate Effects in the Gastrointestinal Tract. J Ren Nutr 2020; 30:4-10. [PMID: 30846238 PMCID: PMC6722023 DOI: 10.1053/j.jrn.2019.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/03/2018] [Accepted: 01/13/2019] [Indexed: 12/21/2022] Open
Abstract
Phosphate binders are commonly prescribed in patients with end-stage kidney disease to prevent and treat hyperphosphatemia. These binders are usually associated with gastrointestinal distress, may bind molecules other than phosphate, and may alter the gut microbiota, altogether having systemic effects unrelated to phosphate control. Sevelamer is the most studied of the available binders for nonphosphate-related effects including binding to bile acids, endotoxins, gut microbiota-derived metabolites, and advanced glycation end products. Other binders (calcium- and noncalcium-based binders) may bind vitamins, such as vitamin K and folic acid. Moreover, the relatively new iron-based phosphate binders may alter the gut microbiota, as some of the iron or organic ligands may be used by the gastrointestinal bacteria. The objective of this narrative review is to provide the current evidence for the nonphosphate effects of phosphate binders on gastrointestinal function, nutrient and molecule binding, and the gut microbiome.
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Affiliation(s)
- Annabel Biruete
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kathleen M Hill Gallant
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Nutrition Science, Purdue University, West Lafayette, Indiana
| | - Stephen R Lindemann
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana; Department of Food Science, Purdue University, West Lafayette, Indiana
| | - Gretchen N Wiese
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana
| | - Neal X Chen
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sharon M Moe
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana; Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana.
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18
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Taguchi K, Elias BC, Brooks CR, Ueda S, Fukami K. Uremic Toxin-Targeting as a Therapeutic Strategy for Preventing Cardiorenal Syndrome. Circ J 2019; 84:2-8. [PMID: 31827008 DOI: 10.1253/circj.cj-19-0872] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic kidney disease (CKD) is a global health problem. CKD patients are at high risk of developing cardiovascular disease (CVD), including coronary artery disease, heart failure and stroke. Several factors invoke a vicious cycle of CKD and CVD, which is referred as to "cardiorenal syndrome". Among these factors, the compounds retained through loss of renal excretion play a pathological role in causing atherosclerosis and CVD. These compounds have been broadly classified as uremic toxins because of their accumulation with declining renal function and cytotoxicity. The major uremic toxins contributing to CVD are asymmetric dimethylarginine (ADMA), advanced glycation endproducts (AGE), and trimethyl amine N-oxide (TMAO). ADMA is linked to CVD through regulation of nitric oxide, reactive oxygen species, and renal anemia. AGE not only directly accumulates in the heart and kidney, but interacts with the receptor for AGE (RAGE), leading to cell damage in CVD. TMAO correlates with a high prevalence of CVD and promotes organ fibrosis by itself. The levels of these and other uremic toxins rise with worsening CKD, inducing multiplicative damage in the heart and kidney. Therefore, a better understanding of uremic toxins has great clinical importance for preventing cardiorenal syndrome. This review highlights the molecular mechanism by which these uremic toxins are implicated in CVD and suggests the possible mutual relationship between them.
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Affiliation(s)
- Kensei Taguchi
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine.,Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Bertha C Elias
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Craig R Brooks
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center
| | - Seiji Ueda
- Division of Nephrology, Department of Internal Medicine, Juntendo University
| | - Kei Fukami
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine
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19
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Indoxyl sulfate associates with cardiovascular phenotype in children with chronic kidney disease. Pediatr Nephrol 2019; 34:2571-2582. [PMID: 31428929 DOI: 10.1007/s00467-019-04331-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 05/09/2019] [Accepted: 08/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death in children with chronic kidney disease (CKD). Serum levels of gut-derived uremic toxins increase with deterioration of kidney function and are associated with cardiac comorbidities in adult CKD patients. METHODS Indoxyl sulfate (IS) and p-cresyl sulfate (pCS) were measured by high-performance liquid chromatography in serum of children participating in the Cardiovascular Comorbidity in Children with CKD (4C) Study. Results were correlated with measurements of the carotid intima-media thickness (cIMT), central pulse wave velocity (PWV), and left ventricular mass index (LVMI) in children aged 6-17 years with initial eGFR of 10-60 ml/min per 1.73 m2. RESULTS The median serum levels of total IS and of pCS, measured in 609 patients, were 5.3 μmol/l (8.7) and 17.0 μmol/l (21.6), respectively. In a multivariable regression model, IS and pCS showed significant positive associations with urea and negative associations with eGFR and uric acid. Furthermore, positive associations of pCS with age, serum albumin, and non-Mediterranean residency and a negative association with glomerular disease were observed. By multivariable regression analysis, only IS was significantly associated with a higher cIMT SDS at baseline and progression of PWV SDS within 12 months, independent of other risk factors. CONCLUSIONS Serum levels of gut-derived uremic toxins IS and pCS correlated inversely with eGFR in children. Only IS was significantly associated with surrogate markers of cardiovascular disease in this large pediatric CKD cohort.
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20
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Chung S, Barnes JL, Astroth KS. Gastrointestinal Microbiota in Patients with Chronic Kidney Disease: A Systematic Review. Adv Nutr 2019; 10:888-901. [PMID: 31165878 PMCID: PMC6743837 DOI: 10.1093/advances/nmz028] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/02/2019] [Accepted: 02/26/2019] [Indexed: 01/08/2023] Open
Abstract
Emerging evidence suggests that gastrointestinal (GI) microbiota dysbiosis is associated with chronic kidney disease (CKD) and metabolite concentrations. The purpose of this systematic review was to evaluate and contextualize the research characterizing GI microbiota in patients with CKD. We searched for full-text, peer-reviewed, English studies in PubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Google Scholar using a combination of MeSH terms and keywords. Eleven of the 20 studies examined GI microbiota in patients with CKD, and 9 studies focused on the effect of interventions on GI microbiota or metabolites. Available data characterizing GI microbiota in patients with CKD suggest a decline in saccharolytic bacteria and an increase in fermenters of nitrogen-containing compounds, serving as a source for circulating uremic toxins. However, studies examined limited sets of predetermined microbes, which do not reflect the entire GI microbial community and its influence on host physiology. We recommend further studies examining the entire microbial community and the potential role in regulating host physiology in CKD.
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Affiliation(s)
- SeonYoon Chung
- Organizational Systems and Adult Health Department, University of Maryland School of Nursing, Baltimore, MD
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Amornphimoltham P, Yuen PST, Star RA, Leelahavanichkul A. Gut Leakage of Fungal-Derived Inflammatory Mediators: Part of a Gut-Liver-Kidney Axis in Bacterial Sepsis. Dig Dis Sci 2019; 64:2416-2428. [PMID: 30863955 DOI: 10.1007/s10620-019-05581-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/06/2019] [Indexed: 02/07/2023]
Abstract
Sepsis is a life-threatening response to systemic infection. In addition to frank gastrointestinal (GI) rupture/puncture, sepsis can also be exacerbated by translocation of pathogen-associated molecular patterns (PAMPs) from the GI tract to the systemic circulation (gut origin of sepsis). In the human gut, Gram-negative bacteria and Candida albicans are abundant, along with their major PAMP components, endotoxin (LPS) and (1 → 3)-β-D-glucan (BG). Whereas the influence of LPS in bacterial sepsis has been studied extensively, exploration of the role of BG in bacterial sepsis is limited. Post-translocation, PAMPs enter the circulation through lymphatics and the portal vein, and are detoxified and then excreted via the liver and the kidney. Sepsis-induced liver and kidney injury might therefore affect the kinetics and increase circulating PAMPs. In this article, we discuss the current knowledge of the impact of PAMPs from both gut mycobiota and microbiota, including epithelial barrier function and the "gut-liver-kidney axis," on bacterial sepsis severity.
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Affiliation(s)
| | - Peter S T Yuen
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Robert A Star
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Asada Leelahavanichkul
- Immunology Unit, Department of Microbiology, Chulalongkorn University, Bangkok, 10330, Thailand. .,Center of Excellence in Immunology and Immune-mediated Diseases, Department of Microbiology, Chulalongkorn University, Bangkok, Thailand.
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Hoad C, Clarke C, Marciani L, Graves MJ, Corsetti M. Will MRI of gastrointestinal function parallel the clinical success of cine cardiac MRI? Br J Radiol 2019; 92:20180433. [PMID: 30299989 PMCID: PMC6435057 DOI: 10.1259/bjr.20180433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/21/2018] [Accepted: 10/03/2018] [Indexed: 12/11/2022] Open
Abstract
Cine cardiac MRI is generally accepted as the "gold-standard" for functional myocardial assessment. It only took a few years after the development of commercial MRI systems for functional cardiac imaging to be developed, with electrocardiogram (ECG)-gated cine imaging first reported in 1988. The function of the gastrointestinal (GI) tract is more complex to study compared to the heart. However, the idea of having a non-invasive tool to study the GI function that also allows the concurrent assessment of different aspects of this function has become more and more attractive in the gastroenterological field. This review summarises key literature of the last 5 years to describe the current status of MRI in respect to the evaluation of GI function, highlighting the gaps and challenges and the future prospects. As the clinical application of a new technique requires that its clinical utility is confirmed by demonstration of its ability to enable clinicians to make a diagnosis and/or predict the treatment response, this review also considers whether or not this has been achieved, and how MRI has been validated against techniques currently recognised as the gold standard in clinical practice.
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Affiliation(s)
| | - Christopher Clarke
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Martin John Graves
- Department of Radiology, Cambridge University Hospitals NHS Trust, Cambridge, UK
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Chironda G, Bhengu B. Barriers to management of Chronic Kidney Disease (CKD) CKD in a renal clinic in KwaZulu-Natal Province, South Africa – A qualitative study. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2019. [DOI: 10.1016/j.ijans.2019.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Personalized Approach and Precision Medicine in Supportive and End-of-Life Care for Patients With Advanced and End-Stage Kidney Disease. Semin Nephrol 2018; 38:336-345. [PMID: 30082054 DOI: 10.1016/j.semnephrol.2018.05.004] [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] [Indexed: 12/26/2022]
Abstract
Kidney supportive care requires a highly personalized approach to care. Precision medicine holds promise for a deeper understanding of the pathophysiology of symptoms and related syndromes and more precise individualization of prognosis and treatment estimates, therefore providing valuable opportunities for greater personalization of supportive care. However, the major drivers of quality of life are psychosocial, economic, lifestyle, and preference-based, and consideration of these factors and skilled communication are integral to the provision of excellent and personalized kidney supportive care. This article discusses the concepts of personalized and precision medicine in the context of kidney supportive care and highlights some opportunities and limitations within these fields.
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Szeto CC, McIntyre CW, Li PKT. Circulating Bacterial Fragments as Cardiovascular Risk Factors in CKD. J Am Soc Nephrol 2018; 29:1601-1608. [PMID: 29666156 PMCID: PMC6054355 DOI: 10.1681/asn.2018010068] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Cardiovascular disease (CVD) is a major cause of mortality and morbidity in patients with CKD. In the past decade, intestinal dysbiosis and altered gut epithelial barrier function are increasingly recognized in CKD. Uremic patients have slow intestinal transit time, impaired protein assimilation, and decreased consumption of dietary fiber. The use of multiple medications also may contribute to the proliferation of dysbiotic bacteria, which affect the barrier function of intestinal epithelium. In addition, fluid overload and uremic toxins per se directly reduce the gut barrier function. The major consequence of these alterations, the translocation of bacterial fragments from bowel lumen to systemic circulation, can lead to diverse biologic effects and probably represents an important nontraditional CVD risk factor in CKD. Among all bacterial fragments, endotoxin is the most well studied. Plasma endotoxin levels are markedly elevated in both patients with CKD and those on dialysis, and are associated with the systemic inflammatory state, accelerated atherosclerosis, and clinical CVD in patients on dialysis. Optimization of BP control and the use of ultrapure dialysate can reduce plasma endotoxin levels, with probable metabolic and cardiovascular benefits. The benefit of synbiotic therapy is not confirmed, although results from animal studies are impressive. The biologic effects and clinical relevance of other bacterial fragments, such as bacterial DNA fragments, are less well defined. Further studies are needed to delineate the pathogenic relation between circulating bacterial fragments and CVD, and to define the role of the plasma bacterial fragment level as a prognostic indicator of CKD.
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Affiliation(s)
- Cheuk-Chun Szeto
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Sha Tin, Hong Kong, China; and
| | - Christopher William McIntyre
- Division of Nephrology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Philip Kam-Tao Li
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Sha Tin, Hong Kong, China; and
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A systematic review on the efficacy and safety of PA21 versus sevelamer in dialysis patients. Int Urol Nephrol 2018; 50:905-909. [PMID: 29294216 DOI: 10.1007/s11255-017-1774-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
Abstract
AIM To evaluate the efficacy and safety of PA21 versus sevelamer in dialysis patients. METHODS We searched Medline, Embase, Science Citation Index, Cochrane Central Register of Controlled Trials, and Clinical Trial Registries for randomized controlled trials comparing PA21 and sevelamer in dialysis patients. RESULTS Four studies were included. Compared with sevelamer group, PA21 needed fewer mean daily number of tablets (WMD, - 7.97 pill; 95% CI, - 11.28 to - 4.65, p < 0.00001), developed fewer all adverse events (RR = 1.05; 95% CI, 1.00 to 1.11, p = 0.05), and developed fewer gastrointestinal adverse events (RR = 1.32; 95% CI, 1.15 to 1.53, p = 0.0001). There was no significant difference in serum phosphorus between two groups (WMD, - 0.07 mmol/L; 95% CI, - 0.15 to 0.02, p = 0.12). As for serum calcium, there was also no significant difference between two groups (WMD, 0.27 mmol/L; 95% CI, - 0.63 to 1.17, p = 0.55). CONCLUSION PA21 can effectively control serum phosphorus with lower pill burden and less side effects than sevelamer. PA21 might be another valuable choice for dialysis patients with hyperphosphatemia when patients are unable to tolerate sevelamer.
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de Andrade LS, Ramos CI, Cuppari L. The cross-talk between the kidney and the gut: implications for chronic kidney disease. ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s41110-017-0054-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Yuste C, Mérida E, Hernández E, García-Santiago A, Rodríguez Y, Muñoz T, Gómez GJ, Sevillano Á, Praga M. Gastrointestinal complications induced by sevelamer crystals. Clin Kidney J 2017; 10:539-544. [PMID: 28852493 PMCID: PMC5570024 DOI: 10.1093/ckj/sfx013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/18/2017] [Indexed: 12/13/2022] Open
Abstract
Background Sevelamer is a phosphate binder widely used in chronic kidney disease (CKD) patients. Sevelamer, as well as other resin-based binders, can crystallize leading to the formation of concretions. Sevelamer crystals (SC) have been associated with gastrointestinal (GI) mucosal injury. We describe three new cases of GI lesions associated with SC and review previously reported cases. Methods We describe three new cases of GI lesions associated with SC and review previously reported cases. Results We found 16 previously reported cases of SC-induced GI lesions. The mean patient age was 61 years (interquartile range 51.5–71.75), 62.5% were females and 10 patients were diabetic. In 13 cases, SC was found inside the GI mucosa. Six patients had history of major abdominal surgery. GI bleeding was the most common clinical symptom (n = 7), with three patients presenting with acute abdomen requiring surgical intervention. Although, SC-induced lesions were observed in all GI segments, intestine was involved in 81% of the cases. Endoscopic examination revealed mainly erosions and ulcerations (n = 7) and pseudoinflammatory polyps (n = 5). No association between sevelamer doses and the severity of GI lesions was found. However, diabetics patients seemed to develop GI lesions with smaller doses of sevelamer as compared with non-diabetic patients, in spite of their fewer GI comorbidities. Conclusions SC-induced GI lesions should be considered in CKD patients treated with sevelamer who present GI symptoms, especially lower GI bleeding, once other causes have been ruled out. Diabetics seem more prone to develop SC- associated GI lesions. Sevelamer therapy should be avoided if possible in patients with a history of major abdominal surgery or chronic constipation, because of the high risk of serious GI complications.
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Affiliation(s)
- Claudia Yuste
- Department of Nephrology, Doce de Octubre Hospital, Madrid, Spain
| | | | | | | | | | - Teresa Muñoz
- Department of Pathology, Doce de Octubre Hospital, Madrid, Spain
| | | | - Ángel Sevillano
- Department of Nephrology, Doce de Octubre Hospital, Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Doce de Octubre Hospital, Madrid, Spain
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