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Kuhn C, Mohebbi N, Ritter A. Metabolic acidosis in chronic kidney disease: mere consequence or also culprit? Pflugers Arch 2024; 476:579-592. [PMID: 38279993 PMCID: PMC11006741 DOI: 10.1007/s00424-024-02912-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/29/2024]
Abstract
Metabolic acidosis is a frequent complication in non-transplant chronic kidney disease (CKD) and after kidney transplantation. It occurs when net endogenous acid production exceeds net acid excretion. While nephron loss with reduced ammoniagenesis is the main cause of acid retention in non-transplant CKD patients, additional pathophysiological mechanisms are likely inflicted in kidney transplant recipients. Functional tubular damage by calcineurin inhibitors seems to play a key role causing renal tubular acidosis. Notably, experimental and clinical studies over the past decades have provided evidence that metabolic acidosis may not only be a consequence of CKD but also a driver of disease. In metabolic acidosis, activation of hormonal systems and the complement system resulting in fibrosis have been described. Further studies of changes in renal metabolism will likely contribute to a deeper understanding of the pathophysiology of metabolic acidosis in CKD. While alkali supplementation in case of reduced serum bicarbonate < 22 mmol/l has been endorsed by CKD guidelines for many years to slow renal functional decline, among other considerations, beneficial effects and thresholds for treatment have lately been under intense debate. This review article discusses this topic in light of the most recent results of trials assessing the efficacy of dietary and pharmacological interventions in CKD and kidney transplant patients.
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Affiliation(s)
- Christian Kuhn
- Clinic for Nephrology and Transplantation Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | | | - Alexander Ritter
- Clinic for Nephrology and Transplantation Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
- Clinic for Nephrology, University Hospital Zurich, Zurich, Switzerland.
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Ploypetch S, Wongbandue G, Roytrakul S, Phaonakrop N, Prapaiwan N. Comparative Serum Proteome Profiling of Canine Benign Prostatic Hyperplasia before and after Castration. Animals (Basel) 2023; 13:3853. [PMID: 38136890 PMCID: PMC10740436 DOI: 10.3390/ani13243853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 11/18/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
BPH is the most prevalent prostatic condition in aging dogs. Nevertheless, clinical diagnosis and management remain inconsistent. This study employed in-solution digestion coupled with nano-liquid chromatography tandem mass spectrometry to assess serum proteome profiling of dogs with BPH and those dogs after castration. Male dogs were divided into two groups; control and BPH groups. In the BPH group, each dog was evaluated at two time points: Day 0 (BF subgroup) and Day 30 after castration (AT subgroup). In the BF subgroup, three proteins were significantly upregulated and associated with dihydrotestosterone: solute carrier family 5 member 5, tyrosine-protein kinase, and FRAT regulator of WNT signaling pathway 1. Additionally, the overexpression of polymeric immunoglobulin receptors in the BF subgroup hints at its potential as a novel protein linked to the BPH development process. Conversely, alpha-1-B glycoprotein (A1BG) displayed significant downregulation in the BF subgroup, suggesting A1BG's potential as a predictive protein for canine BPH. Finasteride was associated with increased proteins in the AT subgroup, including apolipoprotein C-I, apolipoprotein E, apolipoprotein A-II, TAO kinase 1, DnaJ homolog subfamily C member 16, PH domain and leucine-rich repeat protein phosphatase 1, neuregulin 1, and pseudopodium enriched atypical kinase 1. In conclusion, this pilot study highlighted alterations in various serum proteins in canine BPH, reflecting different pathological changes occurring in this condition. These proteins could be a source of potential non-invasive biomarkers for diagnosing this disease.
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Affiliation(s)
- Sekkarin Ploypetch
- Department of Clinical Sciences and Public Health, Faculty of Veterinary Science, Mahidol University, Nakhon Pathom 73170, Thailand; (S.P.); (G.W.)
| | - Grisnarong Wongbandue
- Department of Clinical Sciences and Public Health, Faculty of Veterinary Science, Mahidol University, Nakhon Pathom 73170, Thailand; (S.P.); (G.W.)
| | - Sittiruk Roytrakul
- Functional Proteomics Technology Laboratory, National Center for Genetic Engineering and Biotechnology, National Science and Technology Development Agency, Pathum Thani 12120, Thailand; (S.R.); (N.P.)
| | - Narumon Phaonakrop
- Functional Proteomics Technology Laboratory, National Center for Genetic Engineering and Biotechnology, National Science and Technology Development Agency, Pathum Thani 12120, Thailand; (S.R.); (N.P.)
| | - Nawarus Prapaiwan
- Department of Clinical Sciences and Public Health, Faculty of Veterinary Science, Mahidol University, Nakhon Pathom 73170, Thailand; (S.P.); (G.W.)
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Rasheed ZA, AL-Hashemi BA, Ali AA. Effects of Oral Sodium Bicarbonate Supplementation on Protein Metabolism and Inflammation in Iraqi Hemodialysis Patients: An Open-Label Randomized Controlled Trial. Int J Nephrol 2023; 2023:6657188. [PMID: 37545875 PMCID: PMC10403331 DOI: 10.1155/2023/6657188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023] Open
Abstract
Background The effect of correcting metabolic acidosis on protein metabolism in hemodialysis patients is controversial. Objectives To study the effects of oral sodium bicarbonate on protein metabolism and markers of inflammation in acidotic hemodialysis patients. Patients and Methods. An open-label randomized controlled trial was conducted at a single center. Sixty-six clinically stable adult hemodialysis patients were recruited with an average predialysis serum bicarbonate level of <22 mmol/l and a dialysate bicarbonate concentration of 35 mmol/l. Forty-nine participants have completed the study. Oral sodium bicarbonate tablets of 500 mg were given daily in the intervention group (n = 25) for 12 weeks versus the standard of care in the control group (n = 24). Outcomes compared intervention versus nonintervention in both groups at equivalent time points (0 and 3 months). The clinical data, anthropometry, dialysis adequacy, albumin, normalized protein catabolism rate, blood gas analysis, and bicarbonate were recorded at 0 and 3 months. In addition, muscle mass and handgrip strength were measured. Finally, IL-6 as a marker of inflammation was measured at randomization and three months. Results Serum bicarbonate and pH increased significantly from 17.57 ± 3.34 mmol/L to 20.69 ± 2.54 mmol/L and from 7.26 ± 0.06 to 7.34 ± 0.04, respectively (p < 0.0001). Serum albumin was significantly higher in the intervention group at three months than in the control group, 4.11 ± 0.45 vs. 3.79 ± 0.47 (p value 0.011). Serum potassium significantly decreased in the intervention group at three months compared to the control group, 5.00 ± 0.43 mEq/l vs. 5.33 ± 0.63 mEq/l (p value 0.03). Muscle strength expressed as handgrip has improved significantly in the intervention group at three months compared to the control group, 45.01 ± 19.19 vs. 33.93 ± 15.06 (p value 0.03). The IL-6 values were less in the intervention group at 3 months with a p value of 0.01. The interdialytic weight of the intervention group at three months was 2.42 ± 0.64 compared to the 2.20 ± 1.14 control group, but this did not reach statistical significance (p value of 0.4). The composite of (albumin + nPCR) at three months was achieved in 59.18% of the intervention group compared to 14.28% with a p value of 0.01. Conclusions Correcting metabolic acidosis in hemodialysis patients improved serum albumin and nPCR without hypokalemia or significant interdialytic weight gain. This was particularly evident in patients with minimal inflammation with low IL-6 values.
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Affiliation(s)
- Zina A. Rasheed
- Nephrology and Renal Transplantation Centre, Baghdad Medical City, Baghdad, Iraq
| | | | - Ala A. Ali
- Nephrology and Renal Transplantation Centre, Baghdad Medical City, Baghdad, Iraq
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Abstract
Small-scale trials in patients with chronic kidney disease (CKD) 3-5 have shown that hypobicarbonatemic metabolic acidosis promotes progression of CKD. Accordingly, the 2012 KDIGO (Kidney Disease: Improving Global Outcomes) guideline suggests base administration to patients with CKD when serum bicarbonate concentration ([HCO3ˉ]) is <22 mEq/L (~15% of non–dialysis-dependent patients with CKD). However, individuals with milder CKD largely maintain serum [HCO3ˉ] within the normal range (eubicarbonatemia) and yet can manifest hydrogen ion (H+) retention. Limited data in eubicarbonatemic patients with CKD 2 suggest that base administration ameliorates CKD progression. Furthermore, most patients with moderate and advanced CKD maintain a normal serum [HCO3ˉ], and of those, the vast majority most likely harbor masked H+ retention. The present review probes this expanded concept of metabolic acidosis of CKD: the eubicarbonatemic H+ retention or subclinical metabolic acidosis of CKD. It focuses on the high prevalence of the entity, its pathophysiologic features, its clinical course, and recent work on potential biomarkers of the condition. Further, it puts forward the urgent task of investigating definitively whether treatment with alkali of eubicarbonatemic H+ retention delays CKD progression. If proven true, such knowledge would trigger a paradigm shift in the indication for alkali therapy in CKD.
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Affiliation(s)
- Nicolaos E Madias
- Department of Medicine, Tufts University School of Medicine and Division of Nephrology, Department of Medicine, St. Elizabeth's Medical Center, Boston, MA
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George JS, Joseph R, Thomas ETA, John GP, Siby A, Nair MM. Active deprescribing program in chronic kidney disease patients undergoing haemodialysis. Nephrology (Carlton) 2021; 26:890-897. [PMID: 34240512 DOI: 10.1111/nep.13936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/20/2021] [Accepted: 07/04/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Deprescribing is gaining attention of medical community to address polypharmacy. Existing deprescribing tools were not validated in haemodialysis population. We designed this study to assess the pill burden of patients undergoing haemodialysis and to measure the outcome after implementation of an active deprescribing program. METHODS An evidence based deprescription tool was formulated. All patients who were on dialysis for 3 months or more were eligible to participate. Medication reconciliation followed by medication list evaluation for appropriateness was done for all patients. All inappropriate medications were discontinued followed by monitoring for 6 months for complications. Primary outcome was the average number of medications and pills per patient before and 12 weeks after implementation of deprescribing program. RESULTS We enrolled 150 patients to the active deprescribing program. Mean age was 60.4 ± 10.9 years. After deprescription, there were significant reduction in the number of medications from 11 (Interquartile range 8-13.25) to 8 (IQR 6-9) (p < .001) and reduction in the number of pills from 16 (IQR 12.75-21.25) to 11 (IQR 8-14.25) (p < .001). Pill burden accessed using Living with Medication Questionnaire-Visual Analogue Scale score also had a significant reduction from 7 (IQR 5-8) to 4 (IQR 3-5) (p < .001). CONCLUSION Polypharmacy is a significant problem in haemodialysis patients, which can lead to poor quality of life and health hazards due to side effects of medications. Implementation of a proactive deprescribing program can cut down polypharmacy to a significant extent.
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Affiliation(s)
- Jyothi Susan George
- Department of Clinical Pharmacy, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Rajesh Joseph
- Department of Nephrology, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - E T Arun Thomas
- Department of Nephrology, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Geo Philip John
- Department of Nephrology, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Anu Siby
- Department of Clinical Pharmacy, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Midhun M Nair
- Department of Clinical Pharmacy, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
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Sahathevan S, Khor BH, Ng HM, Abdul Gafor AH, Mat Daud ZA, Mafra D, Karupaiah T. Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review. Nutrients 2020; 12:E3147. [PMID: 33076282 PMCID: PMC7602515 DOI: 10.3390/nu12103147] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022] Open
Abstract
Hemodialysis (HD) majorly represents the global treatment option for patients with chronic kidney disease stage 5, and, despite advances in dialysis technology, these patients face a high risk of morbidity and mortality from malnutrition. We aimed to provide a novel view that malnutrition susceptibility in the global HD community is either or both of iatrogenic and of non-iatrogenic origins. This categorization of malnutrition origin clearly describes the role of each factor in contributing to malnutrition. Low dialysis adequacy resulting in uremia and metabolic acidosis and dialysis membranes and techniques, which incur greater amino-acid losses, are identified modifiable iatrogenic factors of malnutrition. Dietary inadequacy as per suboptimal energy and protein intakes due to poor appetite status, low diet quality, high diet monotony index, and/or psychosocial and financial barriers are modifiable non-iatrogenic factors implicated in malnutrition in these patients. These factors should be included in a comprehensive nutritional assessment for malnutrition risk. Leveraging the point of origin of malnutrition in dialysis patients is crucial for healthcare practitioners to enable personalized patient care, as well as determine country-specific malnutrition treatment strategies.
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Affiliation(s)
- Sharmela Sahathevan
- Dietetics Program, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia;
| | - Ban-Hock Khor
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia; (B.-H.K.); (A.H.A.G.)
| | - Hi-Ming Ng
- School of Medicine, Faculty of Health & Medical Sciences, Taylor’s University Lakeside Campus, No 1, Jalan Taylors, Subang Jaya 47500, Malaysia;
| | - Abdul Halim Abdul Gafor
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia; (B.-H.K.); (A.H.A.G.)
| | - Zulfitri Azuan Mat Daud
- Department of Dietetics, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, UPM Serdang 43400, Malaysia;
| | - Denise Mafra
- Post Graduation Program in Medical Sciences and Post-Graduation Program in Cardiovascular Sciences, (UFF), Federal Fluminense University Niterói-Rio de Janeiro (RJ), Niterói-RJ 24033-900, Brazil;
| | - Tilakavati Karupaiah
- School of BioSciences, Faculty of Health & Medical Sciences, Taylor’s University Lakeside Campus, No 1, Jalan Taylors, Subang Jaya 47500, Malaysia
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Ritter A, Mohebbi N. Causes and Consequences of Metabolic Acidosis in Patients after Kidney Transplantation. Kidney Blood Press Res 2020; 45:792-801. [PMID: 33040055 DOI: 10.1159/000510158] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/01/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Metabolic acidosis (MA) is a common complication in kidney transplantation (KTx). It is more prevalent in KTx than in CKD, and it occurs at higher glomerular filtration rates. The pathophysiologic understanding of MA in KTx and its clinical impact has been highlighted by few recent studies. However, no guidelines exist yet for the treatment of MA after KTx. SUMMARY MA in KTx seems to share pathophysiologic mechanisms with CKD, such as impaired ammoniagenesis. Additional kidney transplant-specific factors seem to alter not only the prevalence but also the phenotype of MA, which typically shows features of renal tubular acidosis. There is evidence that calcineurin inhibitors, immunological factors, process of donation, donor characteristics, and diet may contribute to MA occurrence. According to several mainly observational studies, MA seems to play a role in disturbed bone metabolism, cardiovascular morbidity, declining graft function, and mortality. A better understanding of the pathophysiology and evidence from randomized controlled trials, in particular, are needed to clarify the role of MA and the potential benefit of alkali treatment in KTx. Alkali therapy might not only be beneficial but also cost effective and safe. Key Messages: MA seems to be associated with several negative outcomes in KTx. A deeper understanding of the pathophysiology and clinical consequences of MA in KTx is crucial. Clinical trials will have to determine the potential benefits of alkali therapy.
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Affiliation(s)
- Alexander Ritter
- Division of Nephrology, University Hospital of Zurich, Zurich, Switzerland
| | - Nilufar Mohebbi
- Division of Nephrology, University Hospital of Zurich, Zurich, Switzerland, .,Praxis und Dialysezentrum Zürich-City, Zurich, Switzerland,
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Gojowy D, Skiba K, Bartmanska M, Kolonko A, Wiecek A, Adamczak M. Is Metabolic Acidosis a Novel Risk Factor for a Long-Term Graft Survival in Patients after Kidney Transplantation? Kidney Blood Press Res 2020; 45:702-712. [PMID: 32799205 DOI: 10.1159/000508476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/06/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Results of both experimental and clinical studies suggest that metabolic acidosis (MA) contributes to the progression of chronic kidney disease (CKD) and mortality in CKD patients. It is unknown whether the same relationship exists in kidney transplantation (KTx) patients. The aim of this observational study was to examine this relationship between MA and both mortality and renal outcomes in patients after KTx. METHODS Four hundred eighty-six (290 male; 196 female) patients aged 48 ± 12 years, at least 1 year after KTx, were analyzed. Blood HCO3- was measured, and patients were then observed over 3 years. MA was defined as the blood HCO3- concentration <22 mmol/L. The end points of survival analysis were death and initiation of dialysis therapy. In patients who did not reach the above-mentioned end points, the difference between final (after 3 years of follow-up) and initial estimated glomerular filtration rate (eGFR) was calculated. RESULTS MA was initially diagnosed in 57 (12%) patients after KTx. Three-year patient survival was 89.5% in the MA group and 97.4% in the non-MA group (p = 0.001). Three-year graft survival was 73.7% for patients with MA and 93.0% for patients without MA (p < 0.001). In patients with MA who did not reach study end points, blood bicarbonate concentration at baseline correlated positively with a change in eGFR (R = 0.48, p = 0.002, n = 36). Such a correlation was not found in patients without MA (n = 388). CONCLUSIONS (1) MA significantly increases the risk of mortality in patients after KTx. (2) The intensity of MA may be associated with progression of transplanted kidney dysfunction in KTx patients.
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Affiliation(s)
- Damian Gojowy
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Skiba
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Magdalena Bartmanska
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Aureliusz Kolonko
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Marcin Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland,
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Wesson DE, Buysse JM, Bushinsky DA. Mechanisms of Metabolic Acidosis-Induced Kidney Injury in Chronic Kidney Disease. J Am Soc Nephrol 2020; 31:469-482. [PMID: 31988269 DOI: 10.1681/asn.2019070677] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Retrospective analyses and single-center prospective studies identify chronic metabolic acidosis as an independent and modifiable risk factor for progression of CKD. In patients with CKD, untreated chronic metabolic acidosis often leads to an accelerated reduction in GFR. Mechanisms responsible for this reduction include adaptive responses that increase acid excretion but lead to a decline in kidney function. Metabolic acidosis in CKD stimulates production of intrakidney paracrine hormones including angiotensin II, aldosterone, and endothelin-1 (ET-1) that mediate the immediate benefit of increased kidney acid excretion, but their chronic upregulation promotes inflammation and fibrosis. Chronic metabolic acidosis also stimulates ammoniagenesis that increases acid excretion but also leads to ammonia-induced complement activation and deposition of C3 and C5b-9 that can cause tubule-interstitial damage, further worsening disease progression. These effects, along with acid accumulation in kidney tissue, combine to accelerate progression of kidney disease. Treatment of chronic metabolic acidosis attenuates these adaptive responses; reduces levels of angiotensin II, aldosterone, and ET-1; reduces ammoniagenesis; and diminishes inflammation and fibrosis that may lead to slowing of CKD progression.
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Affiliation(s)
- Donald E Wesson
- Baylor Scott & White Health and Wellness Center, Dallas, Texas; .,Department of Internal Medicine, Texas A&M College of Medicine, Bryan, Texas
| | | | - David A Bushinsky
- Division of Nephrology, University of Rochester School of Medicine, Rochester, New York
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Aigner C, Cejka D, Sliber C, Fraunschiel M, Sunder-Plassmann G, Gaggl M. Oral Sodium Bicarbonate Supplementation Does Not Affect Serum Calcification Propensity in Patients with Chronic Kidney Disease and Chronic Metabolic Acidosis. Kidney Blood Press Res 2019; 44:188-199. [PMID: 31067546 DOI: 10.1159/000498975] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 01/23/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death in patients with chronic kidney disease (CKD) and metabolic acidosis might accelerate vascular calcification. The T50 calcification inhibition test (T50-test) is a global functional test analyzing the overall propensity of calcification in serum, and low T50-time is associated with progressive aortic stiffening and with all-cause mortality in non-dialysis CKD, dialysis, and transplant patients. Low serum bicarbonate is associated with a short T50-time and alkali supplementation could be a simple modifier of calcification propensity. The aim of this study was to investigate the short-term effect of oral sodium bicarbonate supplementation on T50-time in CKD patients. MATERIAL AND METHODS The SoBic-study is an ongoing randomized-controlled trial in CKD-G3 and G4 patients with chronic metabolic acidosis (serum HCO3- ≤21 mmol/L), in which patients are randomized to either achieve serum HCO3- levels of 24 ± 1 mmol/L (intervention group) or 20 ± 1 mmol/L (rescue group). The effect of bicarbonate treatment on T50-time was assessed. RESULTS The study cohort consisted of 35 (14 female) patients aged 57 (±15) years, and 18 were randomized to the intervention group. The mean T50-time was 275 (± 64) min. After 4 weeks, the mean change of T50-time was 4 (±69) min in the intervention group and 18 min (±56) in the rescue group (β = -25; 95% CI: -71 to 22; p = 0.298). Moreover, change of serum bicarbonate in individual patients was not associated with change in T50-time, analyzed by regression analysis. Change of serum phosphate had a significant impact on change of T50-time (β = -145; 95% CI: -237 to -52). CONCLUSION Oral sodium bicarbonate supplementation showed no effect on T50-time in acidotic CKD patients.
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Affiliation(s)
- Christof Aigner
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Daniel Cejka
- Department of Medicine III, Nephrology, Hypertension, Transplantation and Rheumatology, Ordensklinikum Linz at Krankenhaus der Elisabethinen, Linz, Austria
| | - Christopher Sliber
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria.,Department of Medicine, Sana Klinikum Offenbach, Offenbach, Germany
| | - Melanie Fraunschiel
- ITSC - IT Systems & Communications, Section IT4Science, Medical University of Vienna, Vienna, Austria
| | - Gere Sunder-Plassmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria
| | - Martina Gaggl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Vienna, Austria,
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Stancu S, Mircescu G, Mocanu A, Capusa C, Stefan G. Metabolic Acidosis of Chronic Kidney Disease and Cardiovascular Disorders. MÆDICA 2019; 13:267-272. [PMID: 30774724 DOI: 10.26574/maedica.2018.13.4.267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The burden of chronic diseases, which include both cardiovascular diseases (CVD) and chronic kidney disease (CKD), is constantly growing worldwide. Moreover, bidirectional links between kidney and heart disorders are commonly recognized and the pathogenesis of these interactions is a matter of current interest in medicine. One remarkable aspect, extensively showed by epidemiological studies, is the very high prevalence of CVD in patients with CKD, up to thirty times higher than in the general population. Since the traditional cardiovascular risk factors cannot solely account for this difference, numerous abnormalities due to the decline in glomerular filtration rate were hypothesized to be involved as non-traditional risk factors for CVD. Among them, the metabolic acidosis frequently seen in advanced CKD was studied, but conflicting results were reported. Therefore, we intend to briefly summarize the current knowledge and points of controversy regarding the possible influence of CKD-related chronic metabolic acidosis on cardiovascular diseases.
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Affiliation(s)
- Simona Stancu
- Nephrology Department, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Gabriel Mircescu
- Nephrology Department, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Andreea Mocanu
- "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Cristina Capusa
- Nephrology Department, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Gabriel Stefan
- Nephrology Department, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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Retarding progression of chronic kidney disease: use of modalities that counter acid retention. Curr Opin Nephrol Hypertens 2018; 27:94-101. [PMID: 29140821 DOI: 10.1097/mnh.0000000000000386] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Acid retention because of chronic kidney disease (CKD) increases tissue acidity and accelerates progression of CKD, whereas reduction in acid retention slows progression of CKD. Herein, we describe the mechanisms through which increased tissue acidity worsens CKD, modalities for countering acid retention and their impact on progression of CKD, and current recommendations for therapy. RECENT FINDINGS Studies in animals and humans show that increased tissue acidity raises the renal levels of endothelin, angiotensin II, aldosterone, and ammoniagenesis, thereby worsening renal fibrosis and causing progression of CKD. Measures that counter acid retention, such as providing alkali or modifying the quantity or type of dietary protein, reduce the levels of endothelin, angiotensin II, aldosterone, and ammoniagenesis, slowing progression of CKD. Alkali can be provided as NaHCO3, sodium citrate, or base in fruits and vegetables. A serum [HCO3] of 24-26 mEq/l is targeted, because higher values can be associated with adverse consequences. SUMMARY Insights into the mechanisms through which increased tissue acidity mediates progression of CKD and the beneficial impact of ameliorating positive acid balance underlie our recommendation for modalities that counter acid retention in CKD.
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Căpuşă C, Ştefan G, Stancu S, Lipan M, Tsur LD, Mircescu G. Metabolic acidosis of chronic kidney disease and subclinical cardiovascular disease markers: Friend or foe? Medicine (Baltimore) 2017; 96:e8802. [PMID: 29381982 PMCID: PMC5708981 DOI: 10.1097/md.0000000000008802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The effect of chronic metabolic acidosis (MA) on cardiovascular disease (CVD) in the setting of chronic kidney disease (CKD) is largely unknown. Therefore, we aimed to study this relationship in nondialysis CKD patients.This cross-sectional, single-center study prospectively enrolled 95 clinically stable CKD patients (median age 61 (58, 65) years, 60% male, median eGFR 27 (22, 32) mL/min). Data on CKD etiology, CVD history, CVD traditional, and nontraditional risk factors were obtained. Also, markers of subclinical CVD were assessed: intima-media thickness (IMT), abdominal aortic calcifications (Kauppila score-AACs), cardio-ankle vascular index (CAVI), ankle-brachial index (ABI), ejection fraction, and interventricular septum thickness. Using the serum bicarbonate cutoff value of 22 mEq/L, comparisons between MA (<22 mEq/L; 43 patients) and non-MA (≥22 mEq/L; 52 patients) groups were performed.Vascular (40%), tubulointerstitial (24%), and glomerular (22%) nephropathies were the main causes of CKD. Twenty-three percent of patients had diabetes mellitus, but only 5% were considered to have diabetic nephropathy. Patients with chronic MA had lower eGFR (P < .01), higher iPTH (P = .01), higher serum phosphate (P < .01), and increased serum cholesterol (P = .04) and triglycerides (P = .01).Higher ABI (P = .04), lower IMT (P = .03), CAVI (P = .05), and AACs (P = .03) were found in patients with chronic MA.Separate binomial logistic regression models were performed using ABI (cutoff 0.9), CAVI (cutoff 9), IMT (cutoff 0.1 cm), and AACs (cutoff 1) as dependent variables. MA was used as independent variable and adjustments were made for iPTH, serum phosphate, eGFR, proteinuria, cholesterol, triglycerides, CVD score. The absence of MA was retained as an independent predictor only for the presence of AACs.In conclusion, the present study shows a potential advantageous effect of MA on vascular calcifications in predialysis CKD patients. Thus, a guideline relaxation of the serum bicarbonate target might prove to be beneficial in CKD patients at high risk of vascular calcifications. However, one should always consider the negative effects of MA. Therefore, additional research is warranted before any clear clinical recommendation.
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Affiliation(s)
- Cristina Căpuşă
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy
- “Dr Carol Davila” Teaching Hospital of Nephrology
| | - Gabriel Ştefan
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy
- “Dr Carol Davila” Teaching Hospital of Nephrology
| | - Simona Stancu
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy
- “Dr Carol Davila” Teaching Hospital of Nephrology
| | | | | | - Gabriel Mircescu
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy
- “Dr Carol Davila” Teaching Hospital of Nephrology
- Romanian Renal Registry, Bucharest, Romania
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14
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Kraut JA, Madias NE. Adverse Effects of the Metabolic Acidosis of Chronic Kidney Disease. Adv Chronic Kidney Dis 2017; 24:289-297. [PMID: 29031355 DOI: 10.1053/j.ackd.2017.06.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/27/2017] [Indexed: 01/01/2023]
Abstract
The kidney has the principal role in the maintenance of acid-base balance, and therefore, a fall in renal net acid excretion and positive H+ balance often leading to reduced serum [HCO3-] are observed in the course of CKD. This metabolic acidosis can be associated with muscle wasting, development or exacerbation of bone disease, hypoalbuminemia, increased inflammation, progression of CKD, protein malnutrition, alterations in insulin, leptin, and growth hormone, and increased mortality. Importantly, some of the adverse effects can be observed even in the absence of overt hypobicarbonatemia. Administration of base decreases muscle wasting, improves bone disease, restores responsiveness to insulin, slows progression of CKD, and possibly reduces mortality. Base is recommended when serum [HCO3-] is <22 mEq/L, but the target serum [HCO3-] remains unclear. Evidence that increments of serum [HCO3-] >26 mEq/L might be associated with worsening of cardiovascular disease adds complexity to treatment decisions. Further study of the mechanisms through which positive H+ balance in CKD contributes to its various adverse effects and the pathways involved in mediating the benefits and complications of base therapy is warranted.
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15
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Izumi Y, Inoue H, Nakayama Y, Eguchi K, Yasuoka Y, Matsuo N, Nonoguchi H, Kakizoe Y, Kuwabara T, Mukoyama M. TSS-Seq analysis of low pH-induced gene expression in intercalated cells in the renal collecting duct. PLoS One 2017; 12:e0184185. [PMID: 28859164 PMCID: PMC5578634 DOI: 10.1371/journal.pone.0184185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 08/18/2017] [Indexed: 12/24/2022] Open
Abstract
Metabolic acidosis often results from chronic kidney disease; in turn, metabolic acidosis accelerates the progression of kidney injury. The mechanisms for how acidosis facilitates kidney injury are not fully understood. To investigate whether low pH directly affects the expression of genes controlling local homeostasis in renal tubules, we performed transcription start site sequencing (TSS-Seq) using IN-IC cells, a cell line derived from rat renal collecting duct intercalated cells, with acid loading for 24 h. Peak calling identified 651 up-regulated and 128 down-regulated TSSs at pH 7.0 compared with those at pH 7.4. Among them, 424 and 38 TSSs were ≥ 1.0 and ≤ -1.0 in Log2 fold change, which were annotated to 193 up-regulated and 34 down-regulated genes, respectively. We used gene ontology analysis and manual curation to profile the up-regulated genes. The analysis revealed that many up-regulated genes are involved in renal fibrosis, implying potential molecular mechanisms induced by metabolic acidosis. To verify the activity of the ubiquitin-proteasome system (UPS), a candidate pathway activated by acidosis, we examined the expression of proteins from cells treated with a proteasome inhibitor, MG132. The expression of ubiquitinated proteins was greater at pH 7.0 than at pH 7.4, suggesting that low pH activates the UPS. The in vivo study demonstrated that acid loading increased the expression of ubiquitin proteins in the collecting duct cells in mouse kidneys. Motif analysis revealed Egr1, the mRNA expression of which was increased at low pH, as a candidate factor that possibly stimulates gene expression in response to low pH. In conclusion, metabolic acidosis can facilitate renal injury and fibrosis during kidney disease by locally activating various pathways in the renal tubules.
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Affiliation(s)
- Yuichiro Izumi
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Hideki Inoue
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Yushi Nakayama
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
- * E-mail:
| | - Koji Eguchi
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Yukiko Yasuoka
- Department of Physiology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Naomi Matsuo
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Hiroshi Nonoguchi
- Department of Internal Medicine and Education & Research Center, Kitasato University Medical Center, Kitamoto, Japan
| | - Yutaka Kakizoe
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Takashige Kuwabara
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Masashi Mukoyama
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
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Abstract
PURPOSE OF REVIEW Acid-base homeostasis is impaired in chronic kidney disease (CKD) and may contribute to disease progression. Diabetes, a major cause of CKD worldwide, may exacerbate acidosis further due to differences in acid production and excretion. Here, we review the role of abnormal acid-base homeostasis in the pathogenesis and progression of diabetes and diabetic kidney disease. RECENT FINDINGS Acidosis and dietary acid loading may contribute to the development and worsening of insulin resistance and hypertension, thereby promoting diabetes and diabetic CKD. However, although metabolic acidosis associates with progression of CKD generally, the results in diabetic CKD are mixed. Data suggests that metabolic acid production in diabetes may be higher than would be predicted based on dietary intake alone, and new observational data suggests that this higher diet-independent acid production could potentially be protective. The role of acid-base homeostasis in diabetic CKD progression is complex and must consider differences in endogenous acid production and excretion in diabetes. Ongoing observational and interventional studies in this field should consider the unique physiology of diabetes.
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Affiliation(s)
- Pascale Khairallah
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Julia J Scialla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
- Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC, USA.
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17
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Kraut JA, Madias NE. Metabolic Acidosis of CKD: An Update. Am J Kidney Dis 2015; 67:307-17. [PMID: 26477665 DOI: 10.1053/j.ajkd.2015.08.028] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 08/01/2015] [Indexed: 01/02/2023]
Abstract
The kidney has the principal role in the maintenance of acid-base balance. Therefore, a decrease in renal ammonium excretion and a positive acid balance often leading to a reduction in serum bicarbonate concentration are observed in the course of chronic kidney disease (CKD). The decrease in serum bicarbonate concentration is usually absent until glomerular filtration rate decreases to <20 to 25mL/min/1.73 m(2), although it can develop with lesser degrees of decreased kidney function. Non-anion gap acidosis, high-anion gap acidosis, or both can be found at all stages of CKD. The acidosis can be associated with muscle wasting, bone disease, hypoalbuminemia, inflammation, progression of CKD, and increased mortality. Administration of base may decrease muscle wasting, improve bone disease, and slow the progression of CKD. Base is suggested when serum bicarbonate concentration is <22 mEq/L, but the target serum bicarbonate concentration is unclear. Evidence that increments in serum bicarbonate concentration > 24 mEq/L might be associated with worsening of cardiovascular disease adds complexity to treatment decisions. Further study of the mechanisms through which metabolic acidosis contributes to the progression of CKD, as well as the pathways involved in mediating the benefits and complications of base therapy, is warranted.
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Affiliation(s)
- Jeffrey A Kraut
- Medical and Research Services, VHAGLA Healthcare System, UCLA Membrane Biology Laboratory, Los Angeles, CA; Division of Nephrology, VHAGLA Healthcare System and David Geffen School of Medicine, Los Angeles, CA.
| | - Nicolaos E Madias
- Department of Medicine, Division of Nephrology, St. Elizabeth's Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA.
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18
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Ori Y, Zingerman B, Bergman M, Bessler H, Salman H. The effect of sodium bicarbonate on cytokine secretion in CKD patients with metabolic acidosis. Biomed Pharmacother 2015; 71:98-101. [PMID: 25960222 DOI: 10.1016/j.biopha.2015.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 02/12/2015] [Indexed: 10/23/2022] Open
Abstract
The incidence of acidosis increases with the progression of chronic kidney disease (CKD). Correction of acidosis by sodium bicarbonate may slow CKD deterioration. Inflammation, which is common in CKD, may be related to acidosis. Whether the slower rate of GFR decline following the correction of acidosis is related to changes in inflammatory markers is unknown. The current study examined whether correcting CKD-acidosis affected inflammatory cytokines secretion. Thirteen patients with CKD 4-5 and acidosis were tested for cytokines secretion from peripheral-blood mononuclear cells at baseline and after one month of oral sodium bicarbonate. Following treatment with sodium bicarbonate there was no change in weight, blood pressure, serum creatinine, albumin, sodium, calcium, phosphate, PTH, hemoglobin and CRP. Serum urea decreased (134±10-116±8 mg/dl, P=0.002), potassium decreased (5.1±0.4-4.8±0.1 mequiv./l, P=0.064), pH increased (7.29±0.01-7.33±0.01, P=0.008), and serum bicarbonate increased (18.6±0.4 mequiv./l to 21.3±0.3 mequiv./l, P=0.001). The secretion of the anti-inflammatory cytokine IL-10 decreased (2.75±0.25 ng/ml to 2.29±0.21 ng/ml, P=0.041). There was no significant change in the secretion of the other pro-inflammatory and anti-inflammatory cytokines, including IL-1β, IL-2, IL-6, TNFα, IFNγ, IL-1ra. Thus, correcting acidosis in CKD with bicarbonate decreases IL-10 secretion. Its significance needs to be further investigated.
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Affiliation(s)
- Yaacov Ori
- Department of Nephrology and Hypertension, Rabin Medical Center-Hasharon Hospital, Petah-Tiqva, Israel; Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.
| | - Boris Zingerman
- Department of Nephrology and Hypertension, Rabin Medical Center-Hasharon Hospital, Petah-Tiqva, Israel; Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Michael Bergman
- Department of Nephrology and Hypertension, Rabin Medical Center-Hasharon Hospital, Petah-Tiqva, Israel; Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Hanna Bessler
- Laboratory for Immunology and Hematology Research, Rabin Medical Center-Hasharon Hospital, Petah-Tiqva, Israel; Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Hertzel Salman
- Department of Internal Medicine C, Rabin Medical Center-Hasharon Hospital, Petah-Tiqva, Israel; Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
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19
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Riemann A, Ihling A, Thomas J, Schneider B, Thews O, Gekle M. Acidic environment activates inflammatory programs in fibroblasts via a cAMP-MAPK pathway. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2014; 1853:299-307. [PMID: 25461841 DOI: 10.1016/j.bbamcr.2014.11.022] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 11/05/2014] [Accepted: 11/17/2014] [Indexed: 12/22/2022]
Abstract
The tissue micromilieu in disorders (inflammation, ischemia, tumor) often shows pronounced metabolic acidosis that may alter signaling and transcriptional activity in resident cells which can be of special importance for omnipresent fibroblasts. In the present study we investigated the impact of metabolic acidosis on rat fibroblasts with special emphasis on their role in inflammation by regulation of TNF-α, MCP-1, COX-2 and iNOS expression and the signaling pathways involved. Extracellular acidosis led to an enhanced expression of TNF-α, COX-2 and iNOS in parallel to an activation of p38 and ERK1/2 kinases that was not observed by sole intracellular acidosis. Accordingly, the protein amounts of TNF-α and COX-2 as well as the production of nitrate and nitrite were elevated. Acidosis-induced expression of COX-2 and iNOS depended on p38 kinase, but not on ERK1/2. In contrast acidosis-induced TNF-α expression was independent of both kinases. Although GPR4, GPR68 and GPR132 are expressed in fibroblasts, the involvement of these potential candidate pH sensors could be ruled out since no acidosis-induced elevation in intracellular cAMP or free calcium content was observed. Furthermore our data show that MAPK activation by an acidic micromilieu depends on Ser/Thr phosphatase activity, but not on the production of reactive oxygen species and is sensitive to cAMP antagonism by Rp-cAMPS. In conclusion, our results show that an acidic microenvironment induces a differential transcriptional program of pathological relevant genes in fibroblasts via the cAMP-phosphatase-MAPK pathway and thereby generates a parainflammatory situation that can result in tissue remodeling.
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Affiliation(s)
- A Riemann
- Julius-Bernstein-Institut für Physiologie, Universität Halle-Wittenberg, Germany.
| | - A Ihling
- Julius-Bernstein-Institut für Physiologie, Universität Halle-Wittenberg, Germany
| | - J Thomas
- Julius-Bernstein-Institut für Physiologie, Universität Halle-Wittenberg, Germany
| | - B Schneider
- Julius-Bernstein-Institut für Physiologie, Universität Halle-Wittenberg, Germany
| | - O Thews
- Julius-Bernstein-Institut für Physiologie, Universität Halle-Wittenberg, Germany
| | - M Gekle
- Julius-Bernstein-Institut für Physiologie, Universität Halle-Wittenberg, Germany
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Chen W, Abramowitz MK. Metabolic acidosis and the progression of chronic kidney disease. BMC Nephrol 2014; 15:55. [PMID: 24708763 PMCID: PMC4233646 DOI: 10.1186/1471-2369-15-55] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 03/31/2014] [Indexed: 11/10/2022] Open
Abstract
Metabolic acidosis is a common complication of chronic kidney disease. Accumulating evidence identifies acidosis not only as a consequence of, but as a contributor to, kidney disease progression. Several mechanistic pathways have been identified in this regard. The dietary acid load, even in the absence of overt acidosis, may have deleterious effects. Several small trials now suggest that the treatment of acidosis with oral alkali can slow the progression of kidney disease.
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Affiliation(s)
| | - Matthew K Abramowitz
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
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21
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Kraut JA, Madias NE. Association of Serum Bicarbonate With Clinical Outcomes in CKD: Could an Increase in Serum Bicarbonate Be a Double-Edged Sword? Am J Kidney Dis 2013; 62:647-9. [DOI: 10.1053/j.ajkd.2013.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 07/01/2013] [Indexed: 11/11/2022]
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