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Aquino HBS, Canziani MEF, Barra ABL, Roque-da-Silva AP, Strogoff-de-Matos JP, Dalboni MA, Moyses RMA, Elias RM. PTH may predict early mortality in incident patients on hemodialysis: results from a large cohort. Int Urol Nephrol 2024:10.1007/s11255-024-04188-1. [PMID: 39222240 DOI: 10.1007/s11255-024-04188-1] [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: 04/29/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Parathyroid hormone (PTH) is merit as a risk factor for mortality in patients with chronic kidney disease in prevalent hemodialysis patients in a U shape. Most studies, however, do not focus on incident patients and those who died within the first 90 days of therapy. We evaluated PTH as a risk factor for mortality in a large cohort population in Brazil. METHODS This is an observational cohort study that included 4317 adult patients who initiated hemodialysis between July 1st, 2012 and June 30, 2017. The main outcome was all-cause mortality. Fine-gray sub-distribution hazard models were used to evaluate survival in the presence of a competing event (kidney transplant). RESULTS Median PTH levels of 252 (118, 479) pg/mL. There were 331 deaths during the first 90 days of therapy (6.7%), 430 in a 1-year follow-up (10.7%) and 1282 (32%) during the 5-year study period. Deaths according to PTH < 150, 150-600 and > 600 pg/mL corresponded to 38.1%, 33.0% and 28.5%, respectively (p < 0.001). In an adjusted model, patients who started dialysis with PTH < 150 pg/mL had a higher mortality risk within the first 90 days, but not in 1 year and 5 years after starting dialysis. Analyses in a subset of patients with a repeated PTH in 1 year (N = 1954) showed that although persistent PTH low levels (< 150 pg/mL) at 1 year were significantly associated with all-cause mortality, this result was not sustained after multiple adjustments. CONCLUSION PTH < 150 pg/mL confers a high mortality risk in the first 90 days of dialysis. If this result reflects poor nutritional conditions, it deserves further investigations.
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Affiliation(s)
- Hugo B S Aquino
- Universidade Nove de Julho (UNINOVE), Sao Paulo, (SP), Brazil
| | - Maria Eugenia F Canziani
- Departamento de Medicina, Divisão de Nefrologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ana Beatriz L Barra
- Fresenius Medical Care, Rio de Janeiro RJ, Brasil
- Departamento de Medicina, Universidade Federal Fluminense, Rio de Janeiro, Brazil
| | | | | | | | - Rosa M A Moyses
- Departamento de Medicina, Divisão de Nefrologia, Universidade de São Paulo, São Paulo, Brazil
| | - Rosilene M Elias
- Universidade Nove de Julho (UNINOVE), Sao Paulo, (SP), Brazil.
- Departamento de Medicina, Divisão de Nefrologia, Universidade de São Paulo, São Paulo, Brazil.
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Patel MJ, Emerenini C, Wang X, Bottiglieri T, Kitzman H. Metabolomic and Physiological Effects of a Cardiorenal Protective Diet Intervention in African American Adults with Chronic Kidney Disease. Metabolites 2024; 14:300. [PMID: 38921435 PMCID: PMC11205948 DOI: 10.3390/metabo14060300] [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: 04/16/2024] [Revised: 05/19/2024] [Accepted: 05/20/2024] [Indexed: 06/27/2024] Open
Abstract
Chronic kidney disease (CKD) impacts 14% of adults in the United States, and African American (AA) individuals are disproportionately affected, with more than 3 times higher risk of kidney failure as compared to White individuals. This study evaluated the effects of base-producing fruit and vegetables (FVs) on cardiorenal outcomes in AA persons with CKD and hypertension (HTN) in a low socioeconomic area. The "Cardiorenal Protective Diet" prospective randomized trial evaluated the effects of a 6-week, community-based FV intervention compared to a waitlist control (WL) in 91 AA adults (age = 58.3 ± 10.1 years, 66% female, 48% income ≤ USD 25K). Biometric and metabolomic variables were collected at baseline and 6 weeks post-intervention. The change in health outcomes for both groups was statistically insignificant (p > 0.05), though small reductions in albumin to creatinine ratio, body mass index, total cholesterol, and systolic blood pressure were observed in the FV group. Metabolomic profiling identified key markers (p < 0.05), including C3, C5, 1-Met-His, kynurenine, PC ae 38:5, and choline, indicating kidney function decline in the WL group. Overall, delivering a directed cardiorenal protective diet intervention improved cardiorenal outcomes in AA adults with CKD and HTN. Additionally, metabolomic profiling may serve as a prognostic technique for the early identification of biomarkers as indicators for worsening CKD and increased CVD risk.
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Affiliation(s)
- Meera J. Patel
- Peter J. O’Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, TX 75390, USA;
| | - Chiamaka Emerenini
- College of Natural Sciences, University of Texas at Austin, Austin, TX 78712, USA;
| | - Xuan Wang
- Center of Metabolomics, Institute of Metabolic Disease, Baylor Scott & White Research Institute, Dallas, TX 75204, USA; (X.W.); (T.B.)
| | - Teodoro Bottiglieri
- Center of Metabolomics, Institute of Metabolic Disease, Baylor Scott & White Research Institute, Dallas, TX 75204, USA; (X.W.); (T.B.)
| | - Heather Kitzman
- Peter J. O’Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, TX 75390, USA;
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Kee YK, Jeon HJ, Oh J, Cho A, Lee YK, Yoon JW, Kim H, Yoo TH, Shin DH. Fibroblast growth factor-23 and cardiovascular disease among prevalent hemodialysis patients focusing on residual kidney function. Front Endocrinol (Lausanne) 2023; 14:1099975. [PMID: 37501787 PMCID: PMC10368752 DOI: 10.3389/fendo.2023.1099975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 04/28/2023] [Indexed: 07/29/2023] Open
Abstract
Background In patients undergoing incident hemodialysis, increased fibroblast growth factor-23 (FGF-23) levels are associated with the development of cardiovascular disease (CVD), but the influence of residual kidney function (RFK) on this association is unclear. This study aimed to investigate the association between FGF-23 levels, RKF, and CVD in patients undergoing prevalent hemodialysis. Methods This cross-sectional and longitudinal observational study included 296 patients undergoing maintenance hemodialysis for at least three months who were followed up for a median of 44 months. RKF was defined as 24-h urine output >200 mL, left ventricular (LV) diastolic dysfunction as E/E' >15 on echocardiographic parameters. CVD was defined as hospitalization or emergency room visits due to cardiovascular causes, such as angina, myocardial infarction, or congestive heart failure. Results The median intact FGF-23 (iFGF-23) level was 423.8 pg/mL (interquartile range, 171-1,443). Patients with an FGF-23 level > 423.8 pg/mL significantly had a lower proportion of RKF (39.2% vs. 60.1%, P < 0.001) and a higher proportion of LV diastolic dysfunction (54. 1% vs. 29.1%, P < 0.001) than those with an iFGF-23 level ≤ 423.8 pg/mL. The odds ratio (OR) for LV diastolic dysfunction was significantly higher in patients with RFK (OR per one-unit increase in the natural log-transformed iFGF-23 levels, 1.80; 95% confidence interval [CI]: 1.11-2.93) than in patients without RKF (OR per one-unit increase in the natural log-transformed iFGF-23 levels: 1.42; 95% CI: 1.01-1.99) in multivariate analysis (p < 0.001). During the follow-up period, 55 patients experienced CVD. The hazard ratio (HR) for CVD development was also significantly higher in patients with RKF (HR per one-unit increase in the natural log-transformed iFGF-23 levels, 2.64; 95% CI: 1.29-5.40) than those without RKF (HR per one-unit increase in the natural log-transformed iFGF-23 levels: 1.44; 95% CI: 1.04-1.99) in multivariate analysis (p = 0.05). Conclusions Increased iFGF-23 levels were associated with LV diastolic dysfunction and CVD development in patients undergoing prevalent hemodialysis; however, the loss of RKF attenuated the magnitude of these associations. Therefore, in these patients, RKF strongly influenced the detrimental role of iFGF-23 in the development of CVD.
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Affiliation(s)
- Youn Kyung Kee
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, Republic of Korea
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Jung Jeon
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, Republic of Korea
| | - Jieun Oh
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, Republic of Korea
| | - Ajin Cho
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jong-Woo Yoon
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gangwon-do, Republic of Korea
| | - Hyunsuk Kim
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Gangwon-do, Republic of Korea
| | - Tae-Hyun Yoo
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Ho Shin
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, College of Medicine, Seoul, Republic of Korea
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Kendrick JB, Zhou M, Ficociello LH, Parameswaran V, Mullon C, Anger MS, Coyne DW. Serum Phosphorus and Pill Burden Among Hemodialysis Patients Prescribed Sucroferric Oxyhydroxide: One-Year Follow-Up on a Contemporary Cohort. Int J Nephrol Renovasc Dis 2022; 15:139-149. [PMID: 35431567 PMCID: PMC9012313 DOI: 10.2147/ijnrd.s353213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/19/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose In prior analyses of real-world cohorts of hemodialysis patients switched from one phosphate binder (PB) to sucroferric oxyhydroxide (SO), SO therapy has been associated with improvements in serum phosphorus (sP) and reductions in daily PB pill burden. To characterize how SO initiation patterns have changed over time, we examined the long-term effectiveness of SO in a contemporary (2018–2019) cohort. Patients and Methods Adult Fresenius Kidney Care hemodialysis patients first prescribed SO monotherapy as part of routine care between May 2018 and May 2019 (N = 1792) were followed for 1 year. All patients received a non-SO PB during a 91-day baseline period before SO prescription. Mean PB pills/day and laboratory parameters were compared before and during SO treatment. Results were divided into consecutive 91-day intervals (Q1–Q4) and analyzed using linear mixed-effects regression and Cochran’s Q test. These results were contrasted with findings from a historical (2014–2015) cohort (N = 530). Results The proportion of patients achieving sP ≤5.5 mg/dl increased after switching to SO (from 27.0% at baseline to 37.8%, 45.1%, 44.7%, and 44.0% at Q1, Q2, Q3, and Q4, respectively; P < 0.0001 for all). The mean daily PB pill burden decreased from a baseline of 7.7 to 4.4, 4.6, 4.8, and 4.9, respectively, across quarters (P < 0.0001 for all). Patients in the contemporary cohort had improved sP control (27.0% achieving sP ≤5.5 mg/dl vs 17.7%) and lower daily PB pill burden (mean 7.7 vs 8.5 pills/day) at baseline than those in the historical cohort. Overall use of active vitamin D was similar between cohorts, although higher use of oral active vitamin D (63.9% vs 15.7%) and lower use of IV active vitamin D lower (23.4% vs 74.2%) was observed in the contemporary cohort. Conclusion Despite evolving treatment patterns, switching to SO resulted in improved sP control with fewer pills per day in this contemporary hemodialysis cohort.
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Affiliation(s)
| | - Meijiao Zhou
- Fresenius Medical Care Global Medical Office, Waltham, MA, USA
| | | | | | - Claudy Mullon
- Fresenius Medical Care Global Medical Office, Waltham, MA, USA
| | - Michael S Anger
- Fresenius Medical Care Global Medical Office, Waltham, MA, USA
- Unversity of Colorado School of Medicine, Denver, CO, USA
| | - Daniel W Coyne
- Washington University School of Medicine, St. Louis, MO, USA
- Correspondence: Daniel W Coyne, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA, Tel +1 314-362-7603, Fax +1 314-747-5213, Email
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The Influence of Dietary Interventions on Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Nutrients 2021; 13:nu13062065. [PMID: 34208727 PMCID: PMC8235119 DOI: 10.3390/nu13062065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease is a health problem whose prevalence is increasing worldwide. The kidney plays an important role in the metabolism of minerals and bone health and therefore, even at the early stages of CKD, disturbances in bone metabolism are observed. In the course of CKD, various bone turnover or mineralization disturbances can develop including adynamic hyperparathyroid, mixed renal bone disease, osteomalacia. The increased risk of fragility fractures is present at any age in these patients. Nutritional treatment of patients with advanced stages of CKD is aiming at prevention or correction of signs, symptoms of renal failure, avoidance of protein-energy wasting (PEW), delaying or prevention of the occurrence of mineral/bone disturbances, and delaying the start of dialysis. The results of studies suggest that progressive protein restriction is beneficial with the progression of renal insufficiency; however, other aspects of dietary management of CKD patients, including changes in sodium, phosphorus, and energy intake, as well as the source of protein and lipids (animal or plant origin) should also be considered carefully. Energy intake must cover patients' energy requirement, in order to enable correct metabolic adaptation in the course of protein-restricted regimens and prevent negative nitrogen balance and protein-energy wasting.
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Fuller DS, Dluzniewski PJ, Cooper K, Bradbury BD, Robinson BM, Tentori F. Combinations of mineral and bone disorder markers and risk of death and hospitalizations in the international Dialysis Outcomes and Practice Patterns Study. Clin Kidney J 2020; 13:1056-1062. [PMID: 33391749 PMCID: PMC7769536 DOI: 10.1093/ckj/sfz112] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/30/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Prior studies have developed a chronic kidney disease-mineral and bone disorder (CKD-MBD) composite score based on combinations of calcium (Ca), phosphorus (P) and parathyroid hormone (PTH) that have been shown to be associated with an increased risk of clinical outcomes in the USA. We examined this association in a contemporary, international cohort of hemodialysis patients. METHODS We studied 19 313 patients surviving ≥12 months in the Dialysis Outcomes and Practice Patterns Study Phases 3-5 (2005-15) from Europe, Canada and the USA. The CKD-MBD composite score was defined as the number of markers above target levels (P, 3.5-5.5 mg/dL; Ca, 8.4-10.2 mg/dL; PTH, 150-600 pg/mL). Using Cox models, we estimated hazard ratios (HRs) for death and a composite event (death or hospitalization), contrasting MBD 2/3 (2-3 parameters above target) with MBD 0 (all in target), adjusted for a disease risk score (DRS). RESULTS MBD 2/3 above target was observed in 10-14% of patients across regions and was associated with greater DRS-adjusted mortality {HR 1.41 [95% confidence interval (CI) 1.10-1.82]} and composite events [HR 1.23 (95% CI 1.10-1.38)] in the USA compared with MBD 0; the mortality association was stronger for patients ≥ 65 years of age [HR 1.82 (95% CI 1.28-2.58)] compared with patients <65 years of age [HR 1.11 (95% CI 0.80-1.55)]. HRs observed in Canada and Europe were generally consistent but weaker. Estimates for MBD 2/3 outside target (above or below) were slightly lower in all regions. CONCLUSIONS Simultaneous consideration of Ca, P and PTH may help in identifying patients on dialysis with a higher risk of major clinical outcomes related to CKD-MBD.
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Affiliation(s)
| | | | - Kerry Cooper
- Center for Observational Research, Amgen, Thousand Oaks, CA, USA
| | - Brian D Bradbury
- Center for Observational Research, Amgen, Thousand Oaks, CA, USA
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Francesca Tentori
- DaVita Clinical Research, Minneapolis, MN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
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Komaba H, Fuller DS, Taniguchi M, Yamamoto S, Nomura T, Zhao J, Bieber BA, Robinson BM, Pisoni RL, Fukagawa M. Fibroblast Growth Factor 23 and Mortality Among Prevalent Hemodialysis Patients in the Japan Dialysis Outcomes and Practice Patterns Study. Kidney Int Rep 2020; 5:1956-1964. [PMID: 33163716 PMCID: PMC7609896 DOI: 10.1016/j.ekir.2020.08.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/04/2020] [Accepted: 08/11/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Elevated fibroblast growth factor 23 (FGF23) levels have been strongly associated with mortality in the predialysis and incident hemodialysis populations, but few studies have examined this relationship in a large cohort of prevalent hemodialysis patients and in particular among persons with high dialysis vintage. To address this, we analyzed data from the Japan Dialysis Outcomes and Practice Patterns Study (J-DOPPS). METHODS We included 1122 prevalent hemodialysis patients from the J-DOPPS phase 5 (2012-2015) who had FGF23 measurements. We evaluated the association of FGF23 levels with all-cause mortality and cardiovascular composite outcome using Cox regression adjusted for potential confounders. RESULTS At study enrollment, median dialysis vintage was 5.8 years (interquartile range, 2.7-12.4 years) and median FGF23 level was 2113 pg/ml (interquartile range, 583-6880 pg/ml). During 3-year follow-up, 154 of the 1122 participants died. In adjusted analyses, higher FGF23 was associated with a greater hazard of death (hazard ratio per doubling of FGF23, 1.12; 95% confidence interval, 1.03-1.21); however, the association became weaker as the dialysis vintage increased and finally disappeared in the highest tertile (>9.4 years). Similar patterns of effect modification by dialysis vintage were observed for cardiovascular composite outcome and in time-dependent models. CONCLUSION Elevated FGF23 was associated with mortality and cardiovascular events in prevalent hemodialysis patients, but the association was attenuated at longer dialysis vintages. This novel finding suggests that long-term hemodialysis patients may be less susceptible to the detrimental effects of FGF23 or correlated biological processes, and additional studies are needed to gain understanding of these possibilities.
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Affiliation(s)
- Hirotaka Komaba
- Division of Nephrology, Endocrinology, and Metabolism, Tokai University School of Medicine, Isehara, Japan
- The Institute of Medical Sciences, Tokai University, Isehara, Japan
| | | | | | - Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takanobu Nomura
- Medical Affairs Department, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Brian A. Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | | | - Ronald L. Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Tokai University School of Medicine, Isehara, Japan
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Block GA, Chertow GM, Cooper K, Xing S, Fouqueray B, Halperin M, Danese MD. Fibroblast growth factor 23 as a risk factor for cardiovascular events and mortality in patients in the EVOLVE trial. Hemodial Int 2020; 25:78-85. [PMID: 33016505 DOI: 10.1111/hdi.12887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION High mortality rates in patients with chronic kidney disease-mineral and bone disorder (CKD-MBD) receiving maintenance hemodialysis are largely due to cardiovascular (CV) events. METHODS We evaluated associations between MBD parameters, fibroblast growth factor 23 (FGF23) concentrations, and clinically adjudicated CV events from the Evaluation of Cinacalcet Hydrochloride Therapy to Lower Cardiovascular Events (EVOLVE) trial. Patients enrolled in EVOLVE, who had not experienced any study endpoints between randomization and week 20 with evaluable baseline and week 20 values for key laboratory parameters (parathyroid hormone, calcium, phosphate, and FGF23), were assessed. We used adjusted Cox proportional hazards regression models to estimate relative risk of outcomes (primary composite, all-cause mortality, and CV events) based on FGF23 and MBD parameters. Laboratory values were modeled with linear terms and using natural cubic splines with two degrees of freedom. FINDINGS For the primary endpoint, patients assessed (N = 2309) were followed up over a mean duration of 3.1 years, during which 1037 CV events (497 deaths, 540 nonfatal events) occurred. Adjusted models showed an association between FGF23 and the risk of CV events. Hazard ratio per log unit of FGF23 at week 20 was 1.09 [95% CI: 1.03-1.16], and the hazard ratio per log unit change in FGF23 from week 0 to week 20 was 1.09 [95% CI: 1.00-1.17]. DISCUSSION Our data highlight FGF23 as an independent CV risk factor and potential biomarker and therapeutic target for patients with CKD-MBD receiving maintenance hemodialysis.
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Affiliation(s)
| | - Glenn M Chertow
- Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Shan Xing
- Amgen Inc., Thousand Oaks, California, USA
| | | | - Marc Halperin
- Outcomes Insights, Inc., Agoura Hills, California, USA
| | - Mark D Danese
- Outcomes Insights, Inc., Agoura Hills, California, USA
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Fibroblast growth factor 23 (FGF23) level is associated with ultrafiltration rate in patients on hemodialysis. Heart Vessels 2020; 36:414-423. [PMID: 33000285 PMCID: PMC7872991 DOI: 10.1007/s00380-020-01704-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/18/2020] [Indexed: 11/18/2022]
Abstract
Fibroblast growth factor 23 (FGF23) is a bone-derived hormone that regulates renal phosphate reabsorption and vitamin D synthesis in renal proximal tubules. High circulating FGF23 levels are associated with increased mortality in patients with chronic kidney disease and those on dialysis. Current data also suggest higher circulating levels of FGF23 are associated with cardiovascular mortality, vascular calcification, and left ventricular hypertrophy; however, evidence on the role of FGF23 in patients on dialysis is incomplete, and some of the data, especially those on cardiovascular disease (CVD), are controversial. This study aimed to evaluate factors associated with FGF23 in hemodialysis patients with or without CVD. Randomly selected 76 patients on maintenance hemodialysis at a single hemodialysis center were enrolled. After the exclusion of eight patients with extremely outlying FGF23 levels, 68 patients, including 48 males and 46 patients with a CVD history, were included in the study. The mean age was 64.4 ± 12.1 years, and the mean dialysis duration was 12.7 ± 7.1 years. Dialysis duration, time-averaged concentration of urea (TAC-urea), ultrafiltration rate (UFR), blood pressure during hemodialysis session, laboratory data, and echocardiographic parameters including interventricular septum thickness (IVST), left ventricular mass indices (LVMI), and ejection fraction were included in univariate and multivariate analyses. The median lgFGF23 levels in the overall cohort and in those with and without CVD were 2.14 (interquartile range, IQR − 0.43 to − 4.23), 2.01 (− 0.52 to 4.12), and 2.59 (0.07 to 4.32), respectively, and there was no difference between the patients with and without CVD (p = 0.14). The univariate analysis revealed that FGF23 was significantly associated with age (r = − 0.12, p < 0.01), duration of hemodialysis (r = − 0.11, p < 0.01), TAC-urea (r = 0.29, p = 0.01), UFR (r = 0.26, p = 0.04), alkaline phosphatase (ALP; r = − 0.27, p = 0.03), corrected serum calcium (cCa; r = 0.32, p < 0.01), serum phosphate (iP, r = 0.57, p < 0.01), intact parathyroid hormone (iPTH; r = 0.38, p < 0.01), IVST (r = 0.30, p = 0.01), and LVMI (r = 0.26, p = 0.04). In multivariate regression analysis, FGF23 was significantly associated with cCa (F = 25.6, p < 0.01), iP (F = 22.5, p < 0.01), iPTH (F = 19.2, p < 0.01), ALP (F = 5.34, p = 0.03), and UFR (F = 3.94, p = 0.05). In addition, the univariate analysis after the categorization of patients according to CVD indicated that FGF23 was significantly associated with cCa (r = 0.34, p = 0.02), iP (r = 0.41, p < 0.01), iPTH (r = 0.39, p = 0.01), and TAC-urea (r = 0.45, p < 0.01) in patients with CVD, whereas only IVST (r = 0.53, p = 0.04) was associated with FGF23 in those without CVD. FGF23 levels in hemodialysis patients were extremely high and associated not only with mineral bone disease-related factors but also with UFR. Additionally, dialysis efficacy might be associated with lower FGF23 levels in patients with CVD.
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Roumeliotis S, Mallamaci F, Zoccali C. Endothelial Dysfunction in Chronic Kidney Disease, from Biology to Clinical Outcomes: A 2020 Update. J Clin Med 2020; 9:jcm9082359. [PMID: 32718053 PMCID: PMC7465707 DOI: 10.3390/jcm9082359] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 02/06/2023] Open
Abstract
The vascular endothelium is a dynamic, functionally complex organ, modulating multiple biological processes, including vascular tone and permeability, inflammatory responses, thrombosis, and angiogenesis. Endothelial dysfunction is a threat to the integrity of the vascular system, and it is pivotal in the pathogenesis of atherosclerosis and cardiovascular disease. Reduced nitric oxide (NO) bioavailability is a hallmark of chronic kidney disease (CKD), with this disturbance being almost universal in patients who reach the most advanced phase of CKD, end-stage kidney disease (ESKD). Low NO bioavailability in CKD depends on several mechanisms affecting the expression and the activity of endothelial NO synthase (eNOS). Accumulation of endogenous inhibitors of eNOS, inflammation and oxidative stress, advanced glycosylation products (AGEs), bone mineral balance disorders encompassing hyperphosphatemia, high levels of the phosphaturic hormone fibroblast growth factor 23 (FGF23), and low levels of the active form of vitamin D (1,25 vitamin D) and the anti-ageing vasculoprotective factor Klotho all impinge upon NO bioavailability and are critical to endothelial dysfunction in CKD. Wide-ranging multivariate interventions are needed to counter endothelial dysfunction in CKD, an alteration triggering arterial disease and cardiovascular complications in this high-risk population.
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Affiliation(s)
- Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, School of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Francesca Mallamaci
- CNR-IFC (National Research Council of Italy, Centre of Clinical Physiology, Clinical Epidemiology of Renal Diseases and Hypertension Unit, Reggio Cal., c/o Ospedali Riuniti, 89124 Reggio Cal, Italy;
| | - Carmine Zoccali
- CNR-IFC (National Research Council of Italy, Centre of Clinical Physiology, Clinical Epidemiology of Renal Diseases and Hypertension Unit, Reggio Cal., c/o Ospedali Riuniti, 89124 Reggio Cal, Italy;
- Correspondence: ; Tel.: +39-340-73540-62
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Effect of Sevelamer on Calciprotein Particles in Hemodialysis Patients: The Sevelamer Versus Calcium to Reduce Fetuin-A-Containing Calciprotein Particles in Dialysis (SCaRF) Randomized Controlled Trial. Kidney Int Rep 2020; 5:1432-1447. [PMID: 32954068 PMCID: PMC7486191 DOI: 10.1016/j.ekir.2020.06.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 01/03/2023] Open
Abstract
Introduction Calciprotein particles (CPPs) are potentially modifiable mediators of phosphate toxicity in patients with kidney disease. We compared the effects of calcium carbonate (CC) and the non–calcium-based phosphate binder sevelamer on CPP levels in patients undergoing hemodialysis (HD). We hypothesized that treatment with sevelamer would achieve greater reductions in amorphous calcium phosphate–containing CPP (CPP-1) and hydroxyapatite-containing CPP (CPP-2) owing to reduced calcium loading and anti-inflammatory pleiotropic effects. Methods We conducted an open-label, randomized controlled trial (RCT) in which 31 stable prevalent HD patients were allocated to receive either sevelamer hydrochloride (SH), sevelamer carbonate (SC), or CC for 24 weeks. Dual primary endpoints were the between groups differences in serum CPP-1 and CPP-2 levels at 24 weeks in SH + SC–treated versus CC-treated patients. Effects on aortic pulse wave velocity (aPWV), inflammatory cytokines (interleukin-6 and -8), and effects across individual treatment arms were also assessed. Results Serum CPP-1, but not CPP-2, levels were lower in those randomly assigned to the sevelamer (SH + SC) group compared with the CC group at 24 weeks (–70%, 95% confidence interval [CI] –90% to –15%, P = 0.02). In subgroup analysis, this effect was confined to those receiving SC (–83.4%, 95% CI –95.7% to –36.8%, P = 0.01). aPWV and interleukin-8 levels were also lower in those who received sevelamer compared with CC at 24 weeks (–2.0 m/s, 95% CI –2.9 to –1.1; –57%, 95% CI –73% to –30%, respectively, both P = 0.01). Conventional markers of mineral metabolism remained stable across all treatment groups. Discussion Compared with treatment with CC, use of sevelamer for 24 weeks was associated with lower serum CPP-1 levels and a reduction in aPWV and systemic inflammation.
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12
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Bouma-de Krijger A, Vervloet MG. Fibroblast growth factor 23: are we ready to use it in clinical practice? J Nephrol 2020; 33:509-527. [PMID: 32130720 PMCID: PMC7220896 DOI: 10.1007/s40620-020-00715-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/15/2020] [Indexed: 12/15/2022]
Abstract
Patients with chronic kidney disease (CKD) have a greatly enhanced risk of cardiovascular morbidity and mortality. Over the past decade it has come clear that a disturbed calcium-phosphate metabolism, with Fibroblast Growth Factor-23 as a key hormone, is partly accountable for this enhanced risk. Numerous studies have been performed unravelling FGF23s actions and its association with clinical conditions. As FGF23 is strongly associated with adverse outcome it may be a promising biomarker for risk prediction or, even more important, targeting FGF23 may be a strategy to improve patient outcome. This review elaborates on the clinical usefulness of FGF23 measurement. Firstly it discusses the reliability of the FGF23 measurement. Secondly, it evaluates whether FGF23 measurement may lead to improved patient risk classification. Finally, and possibly most importantly, this review evaluates if lowering of FGF23 should be a target for therapy. For this, the review discusses the current evidence indicating that FGF23 may be in the causal pathway to cardiovascular pathology, provides an overview of strategies to lower FGF23 levels and discusses the current evidence concerning the benefit of lowering FGF23.
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Affiliation(s)
- Annet Bouma-de Krijger
- Department of Nephrology, Amsterdam Cardiovascular Science, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Marc G. Vervloet
- Department of Nephrology, Amsterdam Cardiovascular Science, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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13
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Robinson-Cohen C, Shlipak M, Sarnak M, Katz R, Peralta C, Young B, Hoofnagle AN, Szklo M, Ix JH, Psaty BM, de Boer IH, Kestenbaum B, Bansal N. Impact of Race on the Association of Mineral Metabolism With Heart Failure: the Multi-Ethnic Study of Atherosclerosis. J Clin Endocrinol Metab 2020; 105:5639682. [PMID: 31760429 PMCID: PMC7064305 DOI: 10.1210/clinem/dgz218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/22/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Alterations in mineral metabolism, such as high phosphorus, high parathyroid hormone (PTH), and high fibroblast growth factor-23 (FGF-23) have been identified as potential risk factors for heart failure (HF). Important differences in the prevalence of mineral metabolism abnormalities and in the risk of HF have been reported across race and/or ethnic groups. In this study, we evaluated whether the associations of mineral metabolism markers with HF differed by race and/or ethnicity. METHODS We included participants free of cardiovascular disease from the Multi-Ethnic Study of Atherosclerosis to quantify rates of HF overall and across race and/or ethnic groups. Using Cox models, we tested associations of baseline higher phosphorus (>4 mg/dL), PTH greater than 65 pg/mL, and FGF-23 greater than 46.5 pg/mL with incident HF, and for interactions by race and/or ethnicity, adjusting for sociodemographic and cardiovascular risk factors. RESULTS Among the 6413 participants, median follow-up time was 14.9 years. The incidence rate for HF was highest for African Americans and lowest for Chinese (4.71 and 2.42 per 1000 person-years, respectively). The prevalence of elevated PTH (18.8% vs 7.4%) but not FGF-23 (23.1% vs 28.8%) was higher in African Americans vs Whites. In multivariable models, the associations of elevated PTH (hazard ratio [HR] 1.50, 95% CI: 1.13-1.99) and FGF-23 (HR 1.37, 95% CI: 1.07-1.75) with incident HF were statistically significant. However, the interactions by race and/or ethnicity were not statistically significant. CONCLUSIONS In a multiethnic population, higher PTH and FGF-23 were associated with risk of HF in African American and Hispanic individuals. There is no evidence that race and/or ethnicity modifies the association of altered mineral metabolism with risk of HF.
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Affiliation(s)
- Cassianne Robinson-Cohen
- Vanderbilt O’Brien Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Correspondence: Cassianne Robinson-Cohen, PhD, Division of Nephrology, Vanderbilt University Medical Center, 2525 W End Ave, Suite 300, Nashville, Tennessee 37203. E-mail:
| | - Michael Shlipak
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco
| | - Mark Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Ronit Katz
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Carmen Peralta
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco
- Cricket Health, Inc, San Francisco, California
| | - Bessie Young
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | | | - Moyses Szklo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joachim H Ix
- Division of Nephrology, Department of Medicine, University of California, San Diego
| | - Bruce M Psaty
- Departments of Medicine, Epidemiology, and Health Services, University of Washington, Seattle
| | - Ian H de Boer
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Bryan Kestenbaum
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle
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14
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Bouma-de Krijger A, de Roij van Zuijdewijn CLM, Nubé MJ, Grooteman MPC, Vervloet MG. Change in FGF23 concentration over time and its association with all-cause mortality in patients treated with haemodialysis or haemodiafiltration. Clin Kidney J 2020; 14:891-897. [PMID: 33777372 PMCID: PMC7986440 DOI: 10.1093/ckj/sfaa028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/26/2019] [Indexed: 12/18/2022] Open
Abstract
Background Previous studies in patients on haemodialysis (HD) have shown an association of fibroblast growth factor 23 (FGF23) with all-cause mortality. As of yet, the result of FGF23 lowering on mortality is unknown in this population. Methods FGF23 was measured in a subset of 404 patients from the Dutch CONvective TRansport STudy (CONTRAST study) [a randomized trial in prevalent dialysis patients comparing HD and haemodiafiltration (HDF) with clinical outcome] at baseline and Months 6 and 12. A substantial decline of FGF23 change over time was anticipated in patients randomized to HDF since HDF induces higher dialytic clearance of FGF23. The associations of both baseline FGF23 and 6-months change in FGF23 with all-cause mortality were analysed. In addition, the difference in FGF23 change between HD and HDF was explored. Furthermore, the role of dialysis modality in the association between FGF23 change and outcome was analysed. Results No association was observed between quartiles of baseline FGF23 and all-cause mortality. Over 6 months, FGF23 declined in patients on HDF, whereas FGF23 remained stable in patients on HD. A decrease in FGF23 was not associated with improved survival compared with a stable FGF23 concentration. However, increasing FGF23 was associated with a significantly higher mortality risk, both in crude and fully adjusted models [hazard ratio 2.01 (95% confidence interval 1.30–3.09)]. Conclusion Whereas no association between a single value of FGF23 and all-cause mortality was found, increasing FGF23 concentrations did identify patients at risk for mortality. Since lowering FGF23 did not improve outcome, this study found no argument for therapeutically lowering FGF23.
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Affiliation(s)
- Annet Bouma-de Krijger
- Department of Nephrology, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Camiel L M de Roij van Zuijdewijn
- Department of Nephrology, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Menso J Nubé
- Department of Nephrology, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Muriel P C Grooteman
- Department of Nephrology, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Marc G Vervloet
- Department of Nephrology, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, The Netherlands
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15
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Waziri B, Duarte R, Naicker S. Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD): Current Perspectives. Int J Nephrol Renovasc Dis 2019; 12:263-276. [PMID: 31920363 PMCID: PMC6935280 DOI: 10.2147/ijnrd.s191156] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/13/2019] [Indexed: 02/06/2023] Open
Abstract
Despite the availability of global and regional guidelines to curtail the adverse clinical outcomes associated with chronic kidney disease–mineral and bone disorder (CKD-MBD), most CKD patients are still affected by the consequences of abnormalities of CKD-MBD. This important clinical complication of CKD continues to be studied, in order to improve the understanding and management of CKD-MBD. Some notable discoveries include the role of fibroblast growth factor 23 (FGF23) in the pathogenesis of CKD-MBD, leading to a shift from the previous well-established classic trade-off hypothesis to the updated trade-off hypothesis. More recently, there has been a shift from the treatment of CKD-MBD based on a single level of biomarkers to serial measurements of calcium, phosphate and parathyroid hormone (PTH). Furthermore, some clinical trials have emerged after the 2009 Kidney Disease-Improving Global Outcomes (KDIGO) Guidelines, leading to the 2017 KDIGO updated recommendations. Hence, this review gives an overview of the rapidly evolving trends in CKD-MBD, linking the past and current concepts of CKD-MBD.
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Affiliation(s)
- Bala Waziri
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Medicine, Ibrahim Badamasi Babangida Specialist Hospital, Minna, Nigeria
| | - Raquel Duarte
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Saraladevi Naicker
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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16
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Gardezi AI, Karim MS, Rosenberg JE, Scialla JJ, Banerjee T, Powe NR, Shafi T, Parekh RS, Yevzlin AS, Astor BC. Markers of mineral metabolism and vascular access complications: The Choices for Healthy Outcomes in Caring for ESRD (CHOICE) study. Hemodial Int 2019; 24:43-51. [PMID: 31789482 DOI: 10.1111/hdi.12798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Vascular access dysfunction is a major cause of morbidity in patients with end-stage renal disease (ESRD) on chronic hemodialysis. The effects of abnormalities in mineral metabolism on vascular access are unclear. In this study, we evaluated the association of mineral metabolites, including 25-hydroxy vitamin D (25(OH)D) and fibroblast growth factor-23 (FGF-23), with vascular access complications. METHODS We included participants from the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study who were using an arteriovenous fistula (AVF; n = 103) or arteriovenous graft (AVG; n = 116). Serum levels of 25(OH)D, FGF-23, parathyroid hormone (PTH), calcium, phosphorus, C-reactive protein (CRP) and interleukin-6 (IL-6) were assessed from stored samples. Participants were followed for up to 1 year or until a vascular access intervention or replacement. FINDINGS A total of 24 participants using an AVF and 43 participants using an AVG experienced access intervention. Those with 25(OH)D level in the lowest tertile (<11 ng/mL) had an increased risk of AVF intervention compared to those with higher 25(OH)D levels (adjusted relative hazard [aHR] = 3.28; 95% confidence interval [CI]: 1.31, 8.20). The highest tertile of FGF-23 (>3750 RU/mL) was associated with greater risk of AVF intervention (aHR = 2.56; 95% CI: 1.06, 6.18). Higher PTH was associated with higher risk of AVF intervention (aHR = 1.64 per SD of log(PTH); 95% CI: 1.02, 2.62). These associations were not observed in participants using an AVG. None of the other analytes were significantly associated with AVF or AVG intervention. DISCUSSION Low levels of 25(OH)D and high levels of FGF-23 and PTH are associated with increased risk of AVF intervention. Abnormalities in mineral metabolism are risk factors for vascular access dysfunction and potential therapeutic targets to improve outcomes.
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Affiliation(s)
- Ali I Gardezi
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Muhammad S Karim
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Joel E Rosenberg
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tanushree Banerjee
- Department of Medicine, University of California, San Francisco, California, USA
| | - Neil R Powe
- Department of Medicine, University of California, San Francisco, California, USA
| | - Tariq Shafi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rulan S Parekh
- Department of Pediatrics and Medicine, Hospital for Sick Children, University Health Network and University of Toronto, Toronto, Canada
| | | | - Brad C Astor
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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17
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Pickup L, Radhakrishnan A, Townend JN, Ferro CJ. Arterial stiffness in chronic kidney disease. Curr Opin Nephrol Hypertens 2019; 28:527-536. [DOI: 10.1097/mnh.0000000000000535] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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18
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Zhang Y, Darssan D, Pascoe EM, Johnson DW, Pi H, Dong J. Vitamin D status and mortality risk among patients on dialysis: a systematic review and meta-analysis of observational studies. Nephrol Dial Transplant 2019; 33:1742-1751. [PMID: 29481620 DOI: 10.1093/ndt/gfy016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 01/06/2018] [Indexed: 01/10/2023] Open
Abstract
Background Vitamin D deficiency is highly prevalent in patients on dialysis. Although vitamin D deficiency is closely associated with cardiovascular disease (CVD) and high mortality in the general population, the relationship between serum 25-hydroxyvitamin D [25(OH)D] and all-cause and cardiovascular mortality in dialysis patients is uncertain. We aim to explore the relationship between serum 25(OH)D levels and all-cause and cardiovascular mortality in dialysis patients. Methods This is a systematic review and meta-analysis of clinical studies among patients receiving maintenance dialysis. We did a systematic literature search in PubMed and Embase to identify studies reporting the relationship between serum 25(OH)D levels and all-cause and cardiovascular mortality in patients on dialysis. The search was last updated on 10 February 2017. Results The study included 18 moderate to high-quality cohort studies with an overall sample of 14 154 patients on dialysis. The relative risk of all-cause mortality per 10 ng/mL increase in serum 25(OH)D level was 0.78 [95% confidence interval (CI) 0.71-0.86], although there was marked heterogeneity (I2=96%, P < 0.01) that was partly explained by differences in CVD prevalence, baseline parathyroid hormone level and dialysis duration among included studies. The relative risk of cardiovascular mortality per 10 ng/mL increase in serum 25(OH)D level was 0.71 (95% CI 0.63-0.79), with substantial heterogeneity (I2=74%, P=0.004) that was largely explained by differences in study type and serum 25(OH)D measurement method. Conclusions In the present study, increased serum 25(OH)D level was significantly associated with lower all-cause mortality and lower cardiovascular mortality in dialysis patients.
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Affiliation(s)
- Yuhui Zhang
- Department of Medicine Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health; Key Laboratory of Renal Disease, Ministry of Education, Beijing, China
| | - Darsy Darssan
- Australasian Kidney Trials Network, Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia.,Department of Kidney Disease, Translational Research Institute, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Haichen Pi
- Department of Emergency Medicine, Peking University First Hospital, Beijing, China
| | - Jie Dong
- Department of Medicine Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health; Key Laboratory of Renal Disease, Ministry of Education, Beijing, China
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19
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Kendrick J, Parameswaran V, Ficociello LH, Ofsthun NJ, Davis S, Mullon C, Kossmann RJ, Kalantar-Zadeh K. One-Year Historical Cohort Study of the Phosphate Binder Sucroferric Oxyhydroxide in Patients on Maintenance Hemodialysis. J Ren Nutr 2019; 29:428-437. [PMID: 30679076 PMCID: PMC6642852 DOI: 10.1053/j.jrn.2018.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/11/2018] [Accepted: 11/20/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The high pill burden of many phosphate binders (PBs) may contribute to increased prevalence of hyperphosphatemia and poor nutritional status observed among patients undergoing maintenance hemodialysis therapy. We examined the real-world effectiveness of sucroferric oxyhydroxide (SO), a PB with low pill burden, in managing serum phosphorus in patients with prevalent hemodialysis over a 1-year period. DESIGN Historical cohort analyses of de-identified electronic medical records. SUBJECTS In-center hemodialysis patients switched from another PB to SO therapy as part of routine care with 12 months of uninterrupted SO prescriptions recorded, and documented serum phosphorus levels were eligible for inclusion. Clinical data were extracted from a pharmacy service, FreseniusRx, database and Fresenius Kidney Care clinical data warehouse. MAIN OUTCOME MEASURES Comparisons were made between the 91-day period before SO initiation (i.e., baseline) and the 4 consecutive 91-day intervals of SO treatment (Q1-Q4). Clinical measures included achievement of target phosphorus levels (≤5.5 mg/dL) and mean number of PB pills/day. RESULTS Among 530 analyzed patients, the proportion achieving target serum phosphorus levels increased by >100% 1 year after switching to SO therapy, that is, from 17.7% at baseline to 24.5%, 30.5%, 36.4%, and 36.0% at Q1 through Q4, respectively (P < .0001 for all). Reductions in serum phosphorus were observed at all follow-up timepoints (P < .0001), irrespective of baseline PB. From a mean baseline PB pill burden of 8.5 pills/day, patients experienced an average 50% pill burden reduction during SO treatment (P < .0001). Phosphorus-attuned albumin and phosphorus-attuned protein intake (normalized protein catabolic rate) improved significantly after transition to SO (P < .0001). The effectiveness of SO was evident in prespecified subgroups of interest (i.e., black/African-American patients, Hispanic/Latino patients, and women). CONCLUSION Among patients on hemodialysis, switching to SO resulted in a 2-fold greater likelihood of achieving target phosphorus levels while halving daily PB pill burden. Increases in phosphorus-attuned albumin and protein intake suggest improved nutritional status.
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Affiliation(s)
- Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | | | | | - Norma J Ofsthun
- Fresenius Medical Care North America, Waltham, Massachusetts
| | - Shannon Davis
- Fresenius Medical Care North America, Waltham, Massachusetts
| | - Claudy Mullon
- Fresenius Medical Care Renal Therapies Group, Waltham, Massachusetts
| | - Robert J Kossmann
- Fresenius Medical Care Renal Therapies Group, Waltham, Massachusetts
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20
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Kleine CE, Obi Y, Streja E, Hsiung JT, Park C, Holick MF, Kalantar-Zadeh K. Seasonal variation of serum 25-hydroxyvitamin D and parameters of bone and mineral disorder in dialysis patients. Bone 2019; 124:158-165. [PMID: 30858148 DOI: 10.1016/j.bone.2019.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/20/2019] [Accepted: 03/04/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Vitamin D deficiency is common among dialysis patients and may impact blood concentrations of calcium, phosphorus, intact parathyroid hormone (iPTH), and alkaline phosphatase (ALP). Seasonal variation of serum 25-hydroxyvitamin D [25(OH)D] concentrations has been well established for the general population; however, less is known about circannual variation in 25(OH)D as well as other parameters of mineral and bone disorder among dialysis patients. METHOD Based on 57,500 serum 25(OH)D measurements collected over two years from January 2009 to December 2010 among 25,025 dialysis patients, we evaluated the circannual variations in serum concentrations of 25(OH)D, calcium, phosphorus, iPTH, and ALP by a linear regression model with a cosinor function for the time period (month). We adjusted for potential confounders including case-mix variables, and ultraviolet index. RESULTS Serum 25(OH)D concentrations showed significant circannual variation and mean serum 25(OH)D was 3.2 ng/mL higher in summer than in winter. Furthermore, 25(OH)D concentration increased steadily by 1.3 ng/mL per year. While serum calcium concentrations showed statistically significant but clinically negligible seasonal variation (0.02 mg/dL in peak-trough difference), serum phosphorus did not follow such a pattern. Serum iPTH concentrations also showed a modest seasonal variation with 9% higher values in winter than in summer. Concordantly, ALP concentrations in the winter were 2% higher than in the summer time. Seasonal variation of 25(OH)D was greater in male (vs. female), African-American (vs. non-African-American), and younger (vs. older) dialysis patients. CONCLUSION Serum 25(OH)D and iPTH concentrations show seasonal variation among dialysis patients while the variation in other parameters of mineral and bone disorder was clinically irrelevant, if any. Serum 25(OH)D also showed a gradual increase over time. Clinicians and researchers should be aware of these changes when interpreting laboratory results in dialysis patients.
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Affiliation(s)
- Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA
| | - Michael F Holick
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA; Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA.
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21
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Gao S, Xu J, Zhang S, Jin J. Meta-Analysis of the Association between Fibroblast Growth Factor 23 and Mortality and Cardiovascular Events in Hemodialysis Patients. Blood Purif 2019; 47 Suppl 1:24-30. [PMID: 30699419 DOI: 10.1159/000496220] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION This study was conducted to ensure the correlation between fibroblast growth factor 23 (FGF23) and death and cardiovascular events in hemodialysis patients. METHODS We conducted a literature search of PubMed database to April 2018 for relevant articles that reported the association between FGF23 and risk of all-cause mortality and cardiovascular disease (CVD) events. The meta-analysis was performed using the Revman 5.3 software. RESULTS A total of 7 articles were included, and all reported mortality in hemodialysis patients, and 3 reported cardiovascular events in hemodialysis patients. Since the current reagent can detect C-terminal FGF23 (cFGF23) and intact-FGF23 (iFGF23), we discuss the association between cFGF23 and iFGF23 and death and cardiovascular events in hemodialysis patients. The correlation between serum iFGF23 levels and death in hemodialysis patients: high levels of iFGF23 vs. low levels of iFGF23: RR 1.14, 95% CI (1.01-1.30), p = 0.04 (I2 = 0%, p = 0.38). The correlation between serum C-terminal levels and death in hemodialysis patients: high levels of cFGF23 versus low levels of cFGF23: RR 1.39, 95% CI (1.21-1.59), p < 0.001 (I2 = 2%, p = 0.38). The correlation of serum iFGF23 levels with cardiovascular events: high levels of iFGF23 versus low levels of iFGF23: RR 1.21, 95% CI (1.13-1.30), p < 0.001 (I2 = 0%, p = 0.49). A paper has reported the association between cFGF23 and CVD events, so we did not conduct meta-analysis. CONCLUSIONS Elevated serum FGF23 levels are positively associated with all-cause mortality and cardiovascular events in hemodialysis patients, with a 14 or 39% increase in all-cause mortality and a 21% increased risk of cardiovascular events.
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Affiliation(s)
- Shaohui Gao
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jinsheng Xu
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China,
| | - Shenglei Zhang
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingjing Jin
- Departments of Nephrology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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Laster M, Soohoo M, Streja E, Elashoff R, Jernigan S, Langman CB, Norris KC, Salusky IB, Kalantar-Zadeh K. Racial-ethnic differences in chronic kidney disease-mineral bone disorder in youth on dialysis. Pediatr Nephrol 2019; 34:107-115. [PMID: 30267239 PMCID: PMC6420309 DOI: 10.1007/s00467-018-4048-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 07/02/2018] [Accepted: 08/07/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Studies in healthy pediatric populations and adults treated with dialysis demonstrate higher parathyroid hormone (PTH) and lower 25-hydroxyvitamin D levels in African-Americans. Despite these findings, African-Americans on dialysis demonstrate greater bone strength and a decreased risk of fracture compared to the Caucasian dialysis population. The presence of such differences in children and young adult dialysis patients is unknown. METHODS Differences in the markers of mineral and bone metabolism (MBM) were assessed in 661 incident dialysis patients (aged 1 month to < 21 years). Racial-ethnic differences in PTH, calcium, phosphate, and total alkaline phosphatase (AP) activity were analyzed over the first year of dialysis using multivariate linear mixed models. RESULTS African-American race predicted 23% higher serum PTH (95% CI, 4.7-41.3%) when compared to Caucasian patients, while Hispanic ethnicity predicted 17.5% higher PTH (95% CI, 2.3-38%). Upon gender stratification, the differences in PTH were magnified in African-American and Hispanic females: 38% (95% CI, 14.8-69.8%) and 28.8% (95% CI, 4.7-54.9%) higher PTH compared to Caucasian females. Despite higher PTH values, African-American females persistently demonstrated up to 10.9% lower serum AP activity (95% CI, - 20.6-- 0.7%). CONCLUSIONS There are racial-ethnic differences in the markers of MBM. Higher PTH is seen in African-American and Hispanic children and young adults on dialysis with a magnification of this difference amongst the female population. There is a need to consider how factors like race, ethnicity, and gender impact the goal-targeted treatment of MBM disorders.
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Affiliation(s)
- Marciana Laster
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA
- Division of Pediatric Nephrology, Mattel Children's Hospital at UCLA, Los Angeles, CA, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Robert Elashoff
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA
| | - Stephanie Jernigan
- Division of Pediatric Nephrology, Emory University School of Medicine, Atlanta, GA, USA
| | - Craig B Langman
- Feinberg School of Medicine, Northwestern University and the Anne and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Keith C Norris
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA
| | - Isidro B Salusky
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA.
- Division of Pediatric Nephrology, Mattel Children's Hospital at UCLA, Los Angeles, CA, USA.
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
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Melamed ML, Chonchol M, Gutiérrez OM, Kalantar-Zadeh K, Kendrick J, Norris K, Scialla JJ, Thadhani R. The Role of Vitamin D in CKD Stages 3 to 4: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2018; 72:834-845. [PMID: 30297082 PMCID: PMC6615058 DOI: 10.1053/j.ajkd.2018.06.031] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/24/2018] [Indexed: 02/07/2023]
Abstract
Deficiency of 25-hydroxyvitamin D (25[OH]D) is common in patients with chronic kidney disease stages 3 and 4 and is associated with poor outcomes. However, the evaluation and management of vitamin D deficiency in nephrology remains controversial. This article reports on the proceedings from a "controversies conference" on vitamin D in chronic kidney disease that was sponsored by the National Kidney Foundation. The report outlines the deliberations of the 3 work groups that participated in the conference. Until newer measurement methods are widely used, the panel agreed that clinicians should classify 25(OH)D "adequacy" as concentrations > 20ng/mL without evidence of counter-regulatory hormone activity (ie, elevated parathyroid hormone). The panel also agreed that 25(OH)D concentrations < 15ng/mL should be treated irrespective of parathyroid hormone level. Patients with 25(OH)D concentrations between 15 and 20ng/mL may not require treatment if there is no evidence of counter-regulatory hormone activity. The panel agreed that nutritional vitamin D (cholecalciferol, ergocalciferol, or calcifediol) should be supplemented before giving activated vitamin D compounds. The compounds need further study evaluating important outcomes that observational studies have linked to low 25(OH)D levels, such as progression to end-stage kidney disease, infections, fracture rates, hospitalizations, and all-cause mortality. We urge further research funding in this field.
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Affiliation(s)
- Michal L Melamed
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.
| | | | | | | | | | - Keith Norris
- University of California-Los Angeles, Los Angeles, CA
| | | | - Ravi Thadhani
- Massachusetts General Hospital, Boston, MA; Cedars-Sinai Medical Center, Los Angeles, CA
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Abstract
Chronic kidney disease mineral and bone disorder (MBD) encompasses changes in mineral ion and vitamin D metabolism that are widespread in the setting of chronic kidney disease and end-stage renal disease. MBD components associate with cardiovascular disease in many epidemiologic studies. Through impacts on hypertension, activation of the renin-angiotensin-aldosterone system, vascular calcification, endothelial function, and cardiac remodeling and conduction, MBD may be a direct and targetable cause of cardiovascular disease. However, assessment and treatment of MBD is rife with challenges owing to biological tensions between its many components, such as calcium and phosphorus with their regulatory hormones fibroblast growth factor 23 and parathyroid hormone; fibroblast growth factor 23 with its co-receptor klotho; and vitamin D with control of calcium and phosphorus. These complex interactions between MBD components hinder the simple translation to clinical trials, which ultimately are needed to prove the benefits of treating MBD. Deeper investigation using precision medicine tools and principles, including genomics and individualized risk assessment and therapy, may help move the field closer toward clinical applications. This review provides a high-level overview of conventional and precision epidemiology in MBD, potential mechanisms of cardiovascular disease pathogenesis, and guiding therapeutic principles for established and emerging treatments.
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Affiliation(s)
- Joseph Lunyera
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC.
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Marthi A, Donovan K, Haynes R, Wheeler DC, Baigent C, Rooney CM, Landray MJ, Moe SM, Yang J, Holland L, di Giuseppe R, Bouma-de Krijger A, Mihaylova B, Herrington WG. Fibroblast Growth Factor-23 and Risks of Cardiovascular and Noncardiovascular Diseases: A Meta-Analysis. J Am Soc Nephrol 2018; 29:2015-2027. [PMID: 29764921 PMCID: PMC6050929 DOI: 10.1681/asn.2017121334] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 03/30/2018] [Indexed: 12/20/2022] Open
Abstract
Background Fibroblast growth factor-23 (FGF-23) has been hypothesized to play a role in the increased risk of cardiovascular disease in patients with CKD.Methods We identified prospective studies reporting associations between FGF-23 concentration and risk of cardiovascular events. Maximally adjusted risk ratios (RRs) were extracted for each outcome and scaled to a comparison of the top versus bottom third of the baseline FGF-23 concentration, and the results aggregated.Results Depending on the assay used, median FGF-23 concentrations were 43-74 RU/ml and 38-47 pg/ml in 17 general population cohorts; 102-392 RU/ml in nine cohorts of patients with CKD not requiring dialysis; and 79-4212 RU/ml and 2526-5555 pg/ml in eight cohorts of patients on dialysis. Overall, comparing participants in the top and bottom FGF-23 concentration thirds, the summary RRs (95% confidence intervals [95% CIs]) were 1.33 (1.12 to 1.58) for myocardial infarction, 1.26 (1.13 to 1.41) for stroke, 1.48 (1.29 to 1.69) for heart failure, 1.42 (1.27 to 1.60) for cardiovascular mortality, and 1.70 (1.52 to 1.91) for all-cause mortality. The summary RR for noncardiovascular mortality, calculated indirectly, was 1.52 (95% CI, 1.28 to 1.79). When studies were ordered by average differences in FGF-23 concentration between the top and bottom thirds, there was no trend in RRs across the studies.Conclusions The similarly-sized associations between increased FGF-23 concentration and cardiovascular (atherosclerotic and nonatherosclerotic) and noncardiovascular outcomes, together with the absence of any exposure-response relationship, suggest that the relationship between FGF-23 and cardiovascular disease risk may be noncausal.
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Affiliation(s)
| | - Killian Donovan
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
| | - Richard Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David C Wheeler
- Centre for Nephrology, University College London, London, UK
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sharon M Moe
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jun Yang
- Global Biostatistics Science, Amgen Inc., Thousand Oaks, California
| | - Lisa Holland
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
| | - Romina di Giuseppe
- Institute of Epidemiology, Christian-Albrechts University of Kiel, Kiel, Germany
| | - Annet Bouma-de Krijger
- Department of Nephrology, Vrije Universiteit University Medical Center, Amsterdam, The Netherlands; and
| | - Borislava Mihaylova
- Health Economics Research Centre,
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - William G Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Pichler G, Haller MC, Kainz A, Wolf M, Redon J, Oberbauer R. Prognostic value of bone- and vascular-derived molecular biomarkers in hemodialysis and renal transplant patients: a systematic review and meta-analysis. Nephrol Dial Transplant 2018; 32:1566-1578. [PMID: 28025385 DOI: 10.1093/ndt/gfw387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 09/26/2016] [Indexed: 12/24/2022] Open
Abstract
Background Patients undergoing hemodialysis and kidney graft recipients are high-risk populations for cardiovascular and all-cause mortality. Fibroblast growth factor 23 (FGF23), osteoprotegerin (OPG), RANK ligand, osteopontin (OPN), Klotho protein and bone morphogenetic protein-7 (BMP-7) are bone- and vascular-derived molecular biomarkers that have been shown to be associated with cardiovascular surrogate end points; however, currently available data on the prognostic value of these biomarkers is inconsistent. The aim of the present study was to conduct a systematic review and meta-analysis in order to summarize the available evidence on the association of molecular biomarkers with mortality in individuals undergoing hemodialysis and renal transplant patients. Methods Two databases (MEDLINE and Embase) were systematically searched. Studies were eligible if the association of biomarker and mortality was reported as time-to-event data [hazard Ratio (HR)] or as effect size with a fixed time of follow-up [odds Ratio (OR)]. Abstracted HRs were converted onto a standard scale of effect and combined using a random effects model. Results From a total of 1170 studies identified in initial searches, 21 met the inclusion criteria. In hemodialysis patients, comparing the lower third with the upper third of baseline FGF23 distribution, pooled HRs (95% confidence intervals) were 1.94 (1.47, 2.56) for all-cause mortality and 2.4 (1.64, 3.51) for cardiovascular mortality. For the same comparison of baseline OPG distribution, pooled HRs were 1.8 (0.95, 3.39) for all-cause mortality and 2.53 (1.29, 4.94) for cardiovascular mortality. Reported risk estimates of RANK ligand, OPN, Klotho protein and BMP-7 were not suitable for pooling; however, only Klotho protein was significantly related to mortality. For kidney graft recipients, four studies that investigated the relationship of FGF23 and OPG with mortality were identified, all of which reported a significant association. Conclusions In hemodialysis patients, FGF23 is a predictor of all-cause and cardiovascular mortality, whereas the predictive value of OPG is restricted to cardiovascular mortality. Further studies are needed in order to gain insight into the prognostic value of these biomarkers in renal transplant recipients.
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Affiliation(s)
- Gernot Pichler
- Area of Cardiometabolic and Renal Risk, Institute for Biomedical Research INCLIVA, Valencia, Spain.,Hypertension Unit, Department of Internal Medicine, University Hospital Clínico of Valencia, Valencia, Spain.,Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Maria C Haller
- Center for Medical Statistics, Informatics and Intelligent Systems (CeMSIIS), Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria.,Department of Nephrology and Hypertension Diseases, Transplantation Medicine and Rheumatology, Krankenhaus Elisabethinen, Linz, Austria.,Methods Support Team European Renal Best Practice, Ghent University Hospital, Ghent, Belgium
| | - Alexander Kainz
- Center for Medical Statistics, Informatics and Intelligent Systems (CeMSIIS), Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria
| | - Myles Wolf
- Division of Nephrology, Department of Medicine and Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Josep Redon
- Area of Cardiometabolic and Renal Risk, Institute for Biomedical Research INCLIVA, Valencia, Spain.,CIBER Physiopathology of Obesity and Nutrition (CIBEROBN), Institute of Health Carlos III, Madrid, Spain
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
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Zhang X, Guo K, Xia F, Zhao X, Huang Z, Niu J. FGF23 C-tail improves diabetic nephropathy by attenuating renal fibrosis and inflammation. BMC Biotechnol 2018; 18:33. [PMID: 29843712 PMCID: PMC5975516 DOI: 10.1186/s12896-018-0449-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 05/18/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND High level of serum fibroblast growth factor 23 (FGF23) is implicated in the development and progression of diabetic nephropathy (DN), making it a crucial factor in the pathogenesis of DN. FGF23 is also tightly correlated with inflammation in the progression of DN. The aim of this study was to explore whether the C-terminal of FGF23 (FGF23C-tail), an antagonist that can block the FGF23 signaling pathway by competing with intact FGF23, could exhibit a therapeutic effect on DN. RESULTS Biochemical data and histological examination showed that FGF23 C-tail administration ameliorated the functional and morphological abnormalities of db/db mice with DN without changing the levels of circulating FGF23 and phosphate. Evaluation of morphology and fibrosis by Masson's trichrome staining and IHC staining of fibronectin, PCR, and western blot analysis showed that FGF23C-tail prevents diabetes-induced fibrosis in db/db mice. Importantly, FGF23C-tail decreased the levels of inflammatory cytokines in serum and renal tissues. CONCLUSION FGF23C-tail may improve diabetic nephropathy by decreasing inflammation and fibrosis in db/db mice, suggesting that blocking of FGF23 action remains an important therapeutic target for the prevention or attenuation of the progression of DN.
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Affiliation(s)
- Xiaomin Zhang
- Department of Biopharmacy, School of Pharmacy, Wenzhou Medical University, Chashan Town, Wenzhou, 325035, China
| | - Kaiwen Guo
- Department of Biopharmacy, School of Pharmacy, Wenzhou Medical University, Chashan Town, Wenzhou, 325035, China
| | - Feng Xia
- Department of Biopharmacy, School of Pharmacy, Wenzhou Medical University, Chashan Town, Wenzhou, 325035, China
| | - Xinyu Zhao
- Department of Biopharmacy, School of Pharmacy, Wenzhou Medical University, Chashan Town, Wenzhou, 325035, China
| | - Zhifeng Huang
- Department of Biopharmacy, School of Pharmacy, Wenzhou Medical University, Chashan Town, Wenzhou, 325035, China.
| | - Jianlou Niu
- Department of Biopharmacy, School of Pharmacy, Wenzhou Medical University, Chashan Town, Wenzhou, 325035, China.
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Sprague SM, Ketteler M, Covic AC, Floege J, Rakov V, Walpen S, Rastogi A. Long-term efficacy and safety of sucroferric oxyhydroxide in African American dialysis patients. Hemodial Int 2018; 22:480-491. [PMID: 29656600 DOI: 10.1111/hdi.12663] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/21/2018] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Sucroferric oxyhydroxide (SFOH) is a non-calcium, iron-based phosphate binder that demonstrated sustained serum phosphorus (sP) control, good tolerability, and lower pill burden, vs. sevelamer carbonate ("sevelamer"), in a Phase 3 study conducted in dialysis patients with hyperphosphatemia. This analysis evaluates the efficacy and safety of SFOH and sevelamer among African American (AA) patients participating in the trial. METHODS Post hoc analysis of a 24-week, Phase 3, open-label trial (NCT01324128) and its 28-week extension study (NCT01464190). Patients were randomized 2:1 to SFOH (1.0-3.0 g/day) or sevelamer (2.4-14.4 g/day) for up to 52 weeks. FINDINGS Of 549 patients who completed the Phase 3 study and extension, 100 (18.2%) AA patients were eligible for efficacy analysis (SFOH, n = 48; sevelamer, n = 52). sP concentrations decreased rapidly and comparably with both treatments by Week 8 (mean ± standard deviation change from baseline: -1.9 ± 1.9 mg/dL for SFOH and -2.2 ± 1.8 mg/dL for sevelamer). These reductions were maintained for 52 weeks (-2.1 ± 2.6 and -2.1 ± 1.6 mg/dL) and achieved with a lower mean pill burden (3.4 ± 1.4 vs. 7.6 ± 2.9 tablets/day) with SFOH vs. sevelamer. Treatment adherence rates (adherence within 70%-120% of expected medication intake) were 79.2% with SFOH and 59.6% with sevelamer. The proportion of patients reporting serious adverse events (AEs) was 27.7% with SFOH and 30.7% with sevelamer. More patients withdrew due to treatment-emergent AEs with SFOH vs. sevelamer (18.5% vs. 8.0%). The most common AEs with both treatments were gastrointestinal-related: diarrhea and discolored feces with SFOH, and nausea, vomiting, and constipation with sevelamer. DISCUSSION SFOH is an efficacious and well-tolerated treatment for hyperphosphatemia in AA dialysis patients, with a lower pill burden and an improved adherence rate vs. sevelamer. These findings were consistent with the wider US patient population and the overall study population.
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Affiliation(s)
| | | | - Adrian C Covic
- 'Gr.T. Popa' University of Medicine and Pharmacy, Iasi, Romania
| | | | | | | | - Anjay Rastogi
- University of California, Los Angeles, California, USA
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Waziri B, Duarte R, Dickens C, Dix Peek T, George J, Rekhviashvili V, Paget G, Naicker S. Racial Variations in the Markers of Mineral Bone Disorders in CKD Patients in South Africa. Kidney Int Rep 2017; 3:583-591. [PMID: 29854965 PMCID: PMC5976813 DOI: 10.1016/j.ekir.2017.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 11/13/2017] [Accepted: 12/06/2017] [Indexed: 01/14/2023] Open
Abstract
Introduction Several studies showed that serum intact parathyroid hormone (PTH), phosphate, and vitamin D levels differ across races. These comparative studies were largely carried out between Caucasians and black Americans. However, little is known of the existence of these associations in an African population with chronic kidney disease (CKD). Methods This cross-sectional multicenter study involved 293 CKD patients from 3 renal units in Johannesburg, South Africa. Results The 293 CKD patients (208 blacks, 85 whites) had an overall mean age of 51.1 ± 13.6 years, and black patients were significantly younger than the white patients (48.4 ± 13.6 years vs. 57.1 ± 15.5 years; P < 0.001). Compared with whites, blacks had higher median intact PTH (498 [range: 37–1084] pg/ml vs. 274 [range: 131–595] pg/ml; P = 0.03), alkaline phosphatase (122 [range: 89–192] U/L vs. 103 [range: 74–144] U/L; p = 0.03), and mean 25 OH vitamin D3 (26.8 ± 12.7 ng/ml vs. 22.7 ± 12.2 ng/ml, P = 0.01) levels, whereas their median fibroblast growth factor (FGF) level was 23 (100 [range: 34–639] pg/ml vs. 233 [range: 80–1370] pg/ml; P = 0.002), and their mean serum phosphate (1.3 ± 0.5 vs. 1.5 ± 0.5; P = 0.001) levels were significantly lower. In multivariable analyses, black race was independently associated with increased log PTH (β = 0.488, P = 0.01) and decreased log FGF-23 (β = −0.636, P = 0.02). Similarly, blacks had a 3.08 times higher likelihood (95% confidence interval: 1.51–6.30; P = 0.002) of developing severe hyperparathyroidism than whites. Conclusion This study highlighted the existence of racial differences in the circulating markers of mineral bone disorders in an African CKD population.
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Affiliation(s)
- Bala Waziri
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Raquel Duarte
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Caroline Dickens
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Therese Dix Peek
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jaya George
- Department of Chemical Pathology, National Health Laboratory Services, University of the Witwatersrand, Johannesburg, South Africa
| | - Vakhtang Rekhviashvili
- Renal Unit, Donald Gordon Medical Center, University of the Witwatersrand, Johannesburg, South Africa
| | - Graham Paget
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Saraladevi Naicker
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Elevated serum alkaline phosphatase and cardiovascular or all-cause mortality risk in dialysis patients: A meta-analysis. Sci Rep 2017; 7:13224. [PMID: 29038525 PMCID: PMC5643374 DOI: 10.1038/s41598-017-13387-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 09/22/2017] [Indexed: 12/23/2022] Open
Abstract
Studies on serum alkaline phosphatase (ALP) and mortality risk in patients with end-stage renal disease (ESRD) undergoing dialysis have yielded conflicting results. This meta-analysis was designed to assess the association of serum ALP levels with cardiovascular or all-cause mortality risk among patients on dialysis. PubMed and Embase databases were searched until March 2017 for studies evaluating the association of serum ALP levels and cardiovascular or all-cause mortality risk in adult patients with ESRD undergoing maintenance hemodialysis or chronic peritoneal dialysis. Twelve studies enrolling 393,200 patients on dialysis were included. Compared with the reference low serum ALP category, pooled adjusted hazard risk (HR) of all-cause mortality was 1.46 (95% confidence interval [CI] 1.30–1.65) for patients on hemodialysis and 1.93 (95% CI 1.71–2.17) for peritoneal patients on dialysis. In addition, elevated serum ALP significantly increased cardiovascular mortality among patients on peritoneal dialysis (HR 2.39; 95% CI 1.23–4.65) but not in patients on hemodialysis (HR 1.08; 95% CI 0.84–1.40). Elevated serum ALP was an independent risk factor for all-cause mortality among patients on hemodialysis or peritoneal dialysis. Further well-designed prospective studies are needed to investigate the association of high serum ALP levels with cardiovascular mortality among patients on dialysis.
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Chen Q, Zhang Y, Ding D, Li D, Yang Y, Li Q, Chen X, Hu G, Ling W. Associations between serum calcium, phosphorus and mortality among patients with coronary heart disease. Eur J Nutr 2017; 57:2457-2467. [PMID: 28808770 DOI: 10.1007/s00394-017-1518-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/23/2017] [Indexed: 01/21/2023]
Abstract
PURPOSE Serum calcium and phosphorus abnormalities are associated with cardiovascular disorders in general population, but evidence among patients with established coronary heart disease (CHD) is limited and controversial. This study aimed to investigate the associations of baseline serum calcium and phosphorus levels with long-term mortality risk among patients with CHD. METHODS We conducted a prospective cohort study among 3187 patients with CHD from October 2008 and December 2011 in China. Cox proportional hazards model was used to assess the associations of serum calcium and phosphorus at baseline with the risk of death. RESULTS During follow-up (mean, 4.9 years), 295 patients died, 193 of which resulted from cardiovascular causes. Multivariable-adjusted hazard ratios (HR) for each 1 mmol/L increase in serum calcium at baseline were 0.27 (95% confidence interval (CI) 0.14-0.51) for all-cause mortality and 0.26 (95% CI 0.12-0.54) for cardiovascular mortality. Patients in the highest compared to the lowest quartile of serum calcium were at lower risk of all-cause mortality (HR, 95% CI 0.57, 0.40-0.82) and cardiovascular mortality (0.50, 0.32-0.79) (both P trend < 0.001). This inverse association between serum calcium and the risk of mortality did not change when participants were stratified by sex, age groups, level of overweight, types of CHD, and history of diabetes. We also observed a graded positive association between baseline serum phosphorus and the risks of mortality. CONCLUSIONS The present study is the first to report that lower serum calcium at baseline is associated with an increased risk of all-cause and cardiovascular mortality in a Chinese coronary heart disease cohort. Further studies are required to investigate the causal relationship and actual mechanisms.
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Affiliation(s)
- Qian Chen
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshan Road 2, Guangdong, 510080, China.,Chronic Disease Epidemiology Laboratory, Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA, 70808, USA
| | - Yuan Zhang
- Department of Cardiology, General Hospital of Guangzhou Military Command of People's Liberation Army, Guangzhou, China
| | - Ding Ding
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshan Road 2, Guangdong, 510080, China
| | - Dan Li
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshan Road 2, Guangdong, 510080, China
| | - Yunou Yang
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshan Road 2, Guangdong, 510080, China
| | - Qing Li
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshan Road 2, Guangdong, 510080, China
| | - Xuechen Chen
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshan Road 2, Guangdong, 510080, China
| | - Gang Hu
- Chronic Disease Epidemiology Laboratory, Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA, 70808, USA.
| | - Wenhua Ling
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, No. 74 Zhongshan Road 2, Guangdong, 510080, China.
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Abstract
The discovery of fibroblast growth factor 23 (FGF23) has provided a more complete understanding of the regulation of phosphate and mineral homeostasis in health and in chronic kidney disease. It has also offered new insights into stratification of risk of cardiovascular events and death among patients with chronic kidney disease and the general population. In this review, we provide an overview of FGF23 biology and physiology, summarize clinical outcomes that have been associated with FGF23, discuss potential mechanisms for these observations and their public health implications, and explore clinical and population health interventions that aim to reduce FGF23 levels and improve public health.
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Affiliation(s)
- Lindsay R Pool
- Center for Translational Health and Metabolism, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611;
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina 27703;
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Qin Z, Liu X, Song M, Zhou Q, Yu J, Zhou B, Wu Y, He Y, Huang L. Fibroblast growth factor 23 as a predictor of cardiovascular and all-cause mortality in prospective studies. Atherosclerosis 2017; 261:1-11. [PMID: 28411494 DOI: 10.1016/j.atherosclerosis.2017.03.042] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 03/03/2017] [Accepted: 03/30/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS The prognostic value of fibroblast growth factor 23 (FGF23) for mortality remains controversial. We performed a meta-analysis of cohort studies to examine the controversial relationship between FGF23 and mortality. METHODS PubMed, EMBASE, the Cochrane Library databases and reference bibliographies were searched through September 2016 to identify prospective cohort studies with relative risks (RRs) and 95% confidence intervals (CIs) for FGF23 and mortality. A random effects model was used to pool the risk estimates. A dose-response analysis of the risk for all-cause mortality associated with FGF23 was conducted using the generalized least squares trend estimation method. RESULTS Nineteen prospective cohort studies were eligible for inclusion in this meta-analysis, of which 16 reported all-cause mortality and 9 reported cardiovascular mortality. During the follow-up periods ranging from 1 to 18.6 years, 5606 deaths occurred among 22,805 participants and 2458 cardiovascular deaths occurred among 28,845 participants. Elevated FGF23 was associated with an increased risk of all-cause mortality (RR 1.68; 95% CI 1.48-1.92) and cardiovascular mortality (RR 1.68; 95% CI 1.38-2.04) with moderate heterogeneity. These associations were not markedly modified by the geographic location, follow-up length, patient predisposition, FGF23 measurement or study quality. A sensitivity analysis yielded a similar effect on the pooled risk estimate. Evidence of a nonlinear relationship between FGF23 and all-cause mortality was observed in the dose-response analysis, with the risk gradually increasing as FGF23 increased. CONCLUSIONS This meta-analysis showed that individuals with increased plasma FGF23 levels might suffer a higher risk of all-cause mortality and cardiovascular mortality.
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Affiliation(s)
- Zhexue Qin
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Xi Liu
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Mingbao Song
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Quan Zhou
- Department of Science and Education, First People's Hospital of Changde City, No. 818 Renming Road, Changde, Hunan, 415003, China
| | - Jie Yu
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Baoshang Zhou
- Department of Nephrology, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Yazhou Wu
- Department of Health Statistics, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038, China
| | - Yongming He
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China
| | - Lan Huang
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
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Abstract
Cardiovascular disease is the main cause of early death in the settings of chronic kidney disease (CKD), type 2 diabetes mellitus (T2DM), and ageing. Cardiovascular events can be caused by an imbalance between promoters and inhibitors of mineralization, which leads to vascular calcification. This process is akin to skeletal mineralization, which is carefully regulated and in which isozymes of alkaline phosphatase (ALP) have a crucial role. Four genes encode ALP isozymes in humans. Intestinal, placental and germ cell ALPs are tissue-specific, whereas the tissue-nonspecific isozyme of ALP (TNALP) is present in several tissues, including bone, liver and kidney. TNALP has a pivotal role in bone calcification. Experimental overexpression of TNALP in the vasculature is sufficient to induce vascular calcification, cardiac hypertrophy and premature death, mimicking the cardiovascular phenotype often found in CKD and T2DM. Intestinal ALP contributes to the gut mucosal defence and intestinal and liver ALPs might contribute to the acute inflammatory response to endogenous or pathogenic stimuli. Here we review novel mechanisms that link ALP to vascular calcification, inflammation, and endothelial dysfunction in kidney and cardiovascular diseases. We also discuss new drugs that target ALP, which have the potential to improve cardiovascular outcomes without inhibiting skeletal mineralization.
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Norris KC, Williams SF, Rhee CM, Nicholas SB, Kovesdy CP, Kalantar-Zadeh K, Boulware LE. Hemodialysis Disparities in African Americans: The Deeply Integrated Concept of Race in the Social Fabric of Our Society. Semin Dial 2017; 30:213-223. [PMID: 28281281 PMCID: PMC5418094 DOI: 10.1111/sdi.12589] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
End-stage renal disease (ESRD) is one of the starkest examples of racial/ethnic disparities in health. Racial/ethnic minorities are 1.5 to nearly 4 times more likely than their non-Hispanic White counterparts to require renal replacement therapy (RRT), with African Americans suffering from the highest rates of ESRD. Despite improvements over the last 25 years, substantial racial differences are persistent in dialysis quality measures such as RRT modality options, dialysis adequacy, anemia, mineral and bone disease, vascular access, and pre-ESRD care. This report will outline the current status of racial disparities in key ESRD quality measures and explore the impact of race. While the term race represents a social construct, its association with health is more complex. Multiple individual and community level social determinants of health are defined by the social positioning of race in the U.S., while biologic differences may reflect distinct epigenetic changes and linkages to ancestral geographic origins. Together, these factors conspire to influence dialysis outcomes among African Americans with ESRD.
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Affiliation(s)
- Keith C. Norris
- Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Sandra F. Williams
- Department of Integrated Medical Science, Florida Atlantic University, Florida
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
| | - Susanne B. Nicholas
- Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Csaba P. Kovesdy
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California
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High Serum Alkaline Phosphatase, Hypercalcaemia, Race, and Mortality in South African Maintenance Haemodialysis Patients. Int J Nephrol 2017; 2017:2795432. [PMID: 28168054 PMCID: PMC5266852 DOI: 10.1155/2017/2795432] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 11/12/2016] [Accepted: 12/14/2016] [Indexed: 12/30/2022] Open
Abstract
Objective. To determine the association between serum total alkaline phosphatase (TAP) and mortality in African maintenance haemodialysis patients (MHD). Patients and Methods. The study enrolled a total of 213 patients on MHD from two dialysis centers in Johannesburg between January 2009 and March 2016. Patients were categorized into a low TAP group (≤112 U/L) versus a high TAP group (>112 U/L) based on a median TAP of 112 U/L. Results. During the follow-up period of 7 years, there were 55 (25.8%) deaths. After adjusting for cofounders such as age, other markers of bone disorder, and comorbidity (diabetes mellitus), patients in the high TAP group had significantly higher risk of death compared to patients in the low TAP group (hazard ratio, 2.50; 95% CI 1.24-5.01, P = 0.01). Similarly, serum calcium >2.75 mmol/L was associated with increased risk of death compared to patients within levels of 2.10-2.37 mmol/L (HR 6.34, 95% CI 1.40-28.76; P = 0.02). The HR for death in white patients compared to black patients was 6.88; 95% CI 1.82-25.88; P = 0.004. Conclusion. High levels of serum alkaline phosphatase, hypercalcaemia, and white race are associated with increased risk of death in MHD patients.
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Fuller DS, Robinson BM. Facility Practice Variation to Help Understand the Effects of Public Policy: Insights from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin J Am Soc Nephrol 2017; 12:190-199. [PMID: 28062678 PMCID: PMC5220653 DOI: 10.2215/cjn.03930416] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Recent Centers for Medicare & Medicaid Services policies have used dialysis facility practice variation to develop public ratings and adjust payments. In the Dialysis Facility Compare star rating system (DFC SRS), facility-relative rates of performance-based clinical measures varied nearly two-fold for mortality (standardized mortality ratio; 10th/90th percentiles: 0.71, 1.34) and hospitalization (standardized hospitalization ratio; 10th/90th percentiles: 0.64, 1.37), and nearly four-fold for transfusion (standardized transfusion ratio; 10th/90th percentiles: 0.43, 1.65). Medicare claims data (from July of 2014) demonstrate that facility variation for the proportions of patients on hemodialysis hospitalized (10th/90th percentiles: 27%, 50%) and transfused (10th/90th percentiles: 3%, 17%) within 6 months that far exceeds relatively modest recent overall longitudinal trends. DFC SRS-rated facility variation is also substantial for fistula (10th/90th percentiles: 50%, 78%) and catheter use >90 days (10th/90th percentiles: 3%, 19%). By contrast, DFC SRS-rated facility distributions for adult hemodialysis Kt/V>1.2 (10th/90th percentiles: 84%, 97%) and total serum calcium >10.2 mg/dl (median, 1%; 75th/90th percentiles: 3%, 5%) are quite narrow and may be of questionable value. Likewise, variation in the US Dialysis Outcomes and Practice Patterns Study is over two-fold for facility median serum parathyroid hormone (10th/90th percentiles: 290 pg/ml, 629 pg/ml) and ferritin (10th/90th percentiles: 469 ng/ml, 1143 ng/ml) levels, and facility mean treatment time varies by 30 minutes (10th/90th percentiles: 204 minutes, 234 minutes). Rising serum parathyroid hormone and ferritin levels, and generally short dialysis treatment time, represent areas unchecked by existing policy; both overall trends and facility variation in these values may reflect unintended consequences of policy or reimbursement pressures and therefore raise concern. Additionally, outcomes in the transition period from advanced CKD to dialysis remain poor, and policy initiatives and performance accountability in this area remain insufficient. Innovative models of comprehensive care in advanced CKD and the early dialysis period which are more amenable to policy oversight are needed. In summary, facility variation is typically larger than prevailing longitudinal trends, and should not be overlooked. The combination of nationally representative observational databases (e.g., the Dialysis Outcomes and Practice Patterns Study) and ESRD registries can provide policy makers with additional tools to evaluate facility variation, develop policies, and monitor unintended effects.
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Affiliation(s)
| | - Bruce M. Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan; and
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Batra J, Buttar RS, Kaur P, Kreimerman J, Melamed ML. FGF-23 and cardiovascular disease: review of literature. Curr Opin Endocrinol Diabetes Obes 2016; 23:423-429. [PMID: 27652999 PMCID: PMC6936216 DOI: 10.1097/med.0000000000000294] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review examines associations between fibroblast growth factor 23 (FGF-23) and cardiovascular disease. RECENT FINDINGS FGF-23 is a hormone produced by osteocytes and osteoblasts that aids with phosphate excretion by the kidney and acts as a negative feedback regulator for activated vitamin D synthesis. Recent studies have found associations between elevated FGF-23 levels and a number of cardiovascular diseases, including hypertension, left ventricular hypertrophy, endothelial dysfunction, cardiovascular events and mortality. CONCLUSION Recent studies have explored the possible effects of FGF-23 on the cardiovascular system. In animal and observational human studies, there is a link between elevated FGF-23 levels and multiple cardiovascular outcomes, including hypertension, left ventricular hypertrophy and cardiovascular events and mortality. Further studies are required to evaluate whether decreasing FGF-23 levels improves cardiovascular outcomes.
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Affiliation(s)
- Jasveen Batra
- Department of Medicine/Nephrology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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The association of mineral metabolism with vascular access patency. J Vasc Access 2016; 17:392-396. [PMID: 27470251 DOI: 10.5301/jva.5000584] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Declining kidney function leads to progressively dysregulated mineral homeostasis and contributes to vascular calcification and a pro-inflammatory milieu, both of which play a critical role in loss of dialysis vascular access patency. We designed this study to examine the relationship between markers of bone and mineral metabolism, vitamin D replacement medications, and vascular access outcomes. We hypothesized that higher levels of calcium, phosphorous, parathyroid hormone (PTH), and albumin are independently associated with vascular access patency and that vitamin D supplementation is associated with lower risk of access failure. METHODOLOGY We abstracted data on 204 consecutive patients referred for angiographic evaluation of their permanent arteriovenous access over a 25-month period. We followed patients from the time of access salvage until subsequent referral for access failure. RESULTS The incidence of vascular access failure did not differ by serum phosphorus, PTH, calcium, calcium-phosphorus product or albumin level. Patients receiving any vitamin D replacement therapy, however, had a lower incidence of access failure compared to those receiving no therapy. Those receiving vitamin D3 therapy with or without paricalcitol (Zemplar, Abbot Laboratories, Abbot Park, IL) or calcitriol had an adjusted HR = 0.18 compared to those receiving no vitamin D therapy. CONCLUSIONS This study suggests a relationship between vitamin D3 usage and better vascular access patency, independent of the effect of vitamin D on PTH. Though this relationship needs more rigorous investigation prior to clinical application, the known differences in the pro- and anti-inflammatory effects of various vitamin D metabolites provide a potential mechanism for these clinical observations.
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Gadalean F, Lighezan D, Stoian D, Schiller O, Timar R, Timar B, Bob F, Donciu MD, Munteanu M, Mihaescu A, Covic A, Schiller A. The Survival of Roma Minority Patients on Chronic Hemodialysis Therapy - A Romanian Multicenter Survey. PLoS One 2016; 11:e0155271. [PMID: 27196564 PMCID: PMC4873236 DOI: 10.1371/journal.pone.0155271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/26/2016] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE The Roma minority represents the largest ethnic group in Central and South-East European countries. Data regarding the mortality in Roma hemodialysis subjects are limited. We evaluated the 3 year mortality of ESRD Roma patients treated with hemodialysis (HD). STUDY DESIGN AND SETTING Our prospective cohort study included 600 ESRD patients on HD therapy recruited from 7 HD centers, from the main geographical regions of Romania. The median age of the patients was 56 (19) years, 332 (55.3%) being males, 51 (8.5%) having Roma ethnicity. RESULTS Roma ESRD patients initiate dialysis at a younger age, 47.8 years vs. 52.3 years (P = 0.017), present higher serum albumin (P = 0.013) and higher serum phosphate levels (P = 0.021). In the Roma group, the overall 3 year mortality was higher when compared to Caucasians (33.3% vs. 24.8%). The multivariate survival analysis revealed that being of Roma ethnicity is an independent risk factor for mortality (HR = 1.74; 95% CI = 1.04-2.91; P = 0.035). CONCLUSIONS Roma patients with ESRD initiate HD therapy at a younger age as compared to Caucasians. They have a higher 3 year mortality rate and are dying at a younger age. Roma ethnicity represents an independent risk factor for mortality in our cohort.
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Affiliation(s)
- Florica Gadalean
- Department of Nephrology, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Daniel Lighezan
- Department of Internal Medicine, ‘Victor Babes’ University of Medicine and Pharmacy, Municipal Clinical Emergency Hospital, Timisoara, Romania
| | - Dana Stoian
- Department of Obstetrics and Gynecology, ‘Victor Babes’ University of Medicine and Pharmacy, Municipal Hospital, Timisoara, Romania
| | - Oana Schiller
- B Braun Avitum Dialysis Center Timisoara, Timisoara, Romania
| | - Romulus Timar
- Department of Diabetes and Metabolic Diseases, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Bogdan Timar
- Department of Medical Informatics and Biostatistics, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Flaviu Bob
- Department of Nephrology, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Mihaela Dora Donciu
- Department of Nephrology and Internal Medicine, University of Medicine “Gr. T. Popa” Iasi, Hospital “C. I. Parhon” Iasi, Iasi, Romania
| | - Mircea Munteanu
- Department of Diabetes and Metabolic Diseases, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Adelina Mihaescu
- Department of Nephrology, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
| | - Adrian Covic
- Department of Nephrology and Internal Medicine, University of Medicine “Gr. T. Popa” Iasi, Hospital “C. I. Parhon” Iasi, Iasi, Romania
| | - Adalbert Schiller
- Department of Nephrology, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
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