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Martino FK, di Vico V, Basso A, Gobbi L, Stefanelli LF, Cacciapuoti M, Bettin E, Del Prete D, Scaparrotta G, Nalesso F, Calò LA. The Role of Daily Dialysate Calcium Exposure in Phosphaturic Hormones in Dialysis Patients. Life (Basel) 2024; 14:964. [PMID: 39202706 PMCID: PMC11355329 DOI: 10.3390/life14080964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 07/21/2024] [Accepted: 07/26/2024] [Indexed: 09/03/2024] Open
Abstract
Managing mineral bone disease (MBD) could reduce cardiovascular risk and improve the survival of dialysis patients. Our study focuses on the impact of calcium bath exposure in dialysis patients by comparing peritoneal dialysis patients (PD, intervention group) and hemodialysis patients (HD, control group). We assessed various factors, including calcium, phosphorus, magnesium, PTH, vitamin D 25-OH, C-terminal telopeptide (CTX), and FGF-23 levels, as well as the calcium bath six hours before the blood sample and the length of daily calcium exposure. We enrolled 40 PD and 31 HD patients with a mean age of 68.7 ± 13.6 years. Our cohort had median PTH and FGF-23 levels of 194 ng/L (Interquartile range [IQR] 130-316) and 1296 pg/mL (IQR 396-2698), respectively. We identified the length of exposure to a 1.25 mmol/L calcium bath, phosphate levels, and CTX as independent predictors of PTH (OR 0.279, p = 0.011; OR 0.277, p = 0.012; OR 0.11, p = 0.01, respectively). In contrast, independent predictors of FGF-23 were phosphate levels (OR 0.48, p < 0.001) and serum calcium levels (OR 0.25, p = 0.015), which were affected by the calcium bath. These findings suggest that managing dialysate calcium baths impacts phosphaturic hormones and could be a critical factor in optimizing CKD-MBD treatment in PD patients, sparking a new avenue of research and potential interventions.
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Affiliation(s)
- Francesca K. Martino
- Nephrology, Dialysis and Transplantation Unit, Department of Medicine (DIMED), University of Padova, 35128 Padua, Italy; (V.d.V.); (A.B.); (L.G.); (L.F.S.); (M.C.); (E.B.); (D.D.P.); (G.S.); (L.A.C.)
| | | | | | | | | | | | | | | | | | - Federico Nalesso
- Nephrology, Dialysis and Transplantation Unit, Department of Medicine (DIMED), University of Padova, 35128 Padua, Italy; (V.d.V.); (A.B.); (L.G.); (L.F.S.); (M.C.); (E.B.); (D.D.P.); (G.S.); (L.A.C.)
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Nitta K, Bieber B, Karaboyas A, Johnson DW, Kanjanabuch T, Kim YL, Lambie M, Hartman J, Shen JI, Naljayan M, Pecoits-Filho R, Robinson BM, Pisoni RL, Perl J, Kawanishi H. International variations in serum PTH and calcium levels and their mortality associations in peritoneal dialysis patients: Results from PDOPPS. Perit Dial Int 2024; 44:275-286. [PMID: 38501163 DOI: 10.1177/08968608241235516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Mineral bone disorder (MBD) in chronic kidney disease (CKD) is associated with high symptom burden, fractures, vascular calcification, cardiovascular disease and increased morbidity and mortality. CKD-MBD studies have been limited in peritoneal dialysis (PD) patients. Here, we describe calcium and parathyroid hormone (PTH) control, related treatments and mortality associations in PD patients. METHODS We used data from eight countries (Australia and New Zealand (A/NZ), Canada, Japan, Thailand, South Korea, United Kingdom, United States (US)) participating in the prospective cohort Peritoneal Dialysis Outcomes and Practice Patterns Study (2014-2022) among patients receiving PD for >3 months. We analysed the association of baseline PTH and albumin-adjusted calcium (calciumAlb) with all-cause mortality using Cox regression, adjusted for potential confounders, including serum phosphorus and alkaline phosphatase. RESULTS Mean age ranged from 54.6 years in South Korea to 63.5 years in Japan. PTH and serum calciumAlb were measured at baseline in 12,642 and 14,244 patients, respectively. Median PTH ranged from 161 (Japan) to 363 pg/mL (US); mean calciumAlb ranged from 9.1 (South Korea, US) to 9.8 mg/dL (A/NZ). The PTH/mortality relationship was U-shaped, with the lowest risk at PTH 300-599 pg/mL. Mortality was nearly 20% higher at serum calciumAlb 9.6+ mg/dL versus 8.4-<9.6 mg/dL. MBD therapy prescriptions varied substantially across countries. CONCLUSIONS A large proportion of PD patients in this multi-national study have calcium and/or PTH levels in ranges associated with substantially higher mortality. These observations point to the need to substantially improve MBD management in PD to optimise patient outcomes. LAY SUMMARY Chronic kidney disease-mineral bone disorder (MBD) is a systemic condition, common in dialysis patients, that results in abnormalities in parathyroid hormone (PTH), calcium, phosphorus and vitamin D metabolism. A large proportion of peritoneal dialysis (PD) patients in this current multi-national study had calcium and/or PTH levels in ranges associated with substantially higher risks of death. Our observational study design limits our ability to determine whether these abnormal calcium and PTH levels cause more death due to possible confounding that was not accounted for in our analysis. However, our findings, along with other recent work showing 48-75% higher risk of death for the one-third of PD patients having high phosphorus levels (>5.5 mg/dL), should raise strong concerns for a greater focus on improving MBD management in PD patients.
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Affiliation(s)
- Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Shinjuku, Japan
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - David W Johnson
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Department of Kidney and Transplant Services, Princess Alexandra, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine and Center of Excellence in Kidney Metabolic Disorders and Dialysis Policy & Practice Program (DiP3), School of Global Health, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yong-Lim Kim
- School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Mark Lambie
- Medicine and Health Sciences, Keele University, Keele, UK
| | | | - Jenny I Shen
- The Lundquist Institute at Harbor-University of California, Los Angeles Medical Center, Torrance, CA, USA
| | | | | | - Bruce M Robinson
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital and the Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Hideki Kawanishi
- Akane Foundation, Tsuchiya General Hospital, Nakaku, Hiroshima, Japan
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Verschuur LC, Liefting AG, van Dam B, Penne EL, Frerichs FC. Bone Mineral Parameters in Peritoneal Dialysis Patients after Lowering Calcium Concentration in Dialysis Fluids: A Case Series in Patients Using Icodextrin. Case Rep Nephrol Dial 2023; 13:184-190. [PMID: 37946857 PMCID: PMC10631776 DOI: 10.1159/000534476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 10/01/2023] [Indexed: 11/12/2023] Open
Abstract
In patients treated with peritoneal dialysis (PD), lowering the calcium level in PD fluids results in lower serum calcium levels and higher parathyroid hormone (PTH) levels. It is hypothesized that this effect is attenuated when patients are using icodextrin 7.5% for the once-daily long dwell (containing high calcium concentration). In this case series, we included 8 stable PD patients (mean age 68 ± 13 years, 7 male), all using icodextrin 7.5% (containing 1.75 mmol/L calcium) for the once-daily long dwell. The calcium content of the PD fluids for the remaining dwells was lowered from 1.75 mmol/L to 1.25 mmol/L. Bone mineral parameters and phosphate prescription at baseline, 6 weeks after this change, and after 6 months were compared. After lowering calcium concentration of the PD fluids - except for the icodextrin 7.5% - from 1.75 mmol/L to 1.25 mmol/L, calcium levels changed from 2.32 ± 0.11 to 2.29 ± 0.12 (p = NS); intact PTH (iPTH) from 39.6 ± 28.3 to 64.9 ± 34.5 pmol/L (p = 0.045); and alkaline phosphatase from 104.13 ± 48.75 to 101.38 ± 32.39 (p = NS). After 6 months, all bone mineral parameters were similar to baseline levels; however, slightly higher calcium-based phosphate binders were prescribed. Lowering calcium content from 1.75 mmol/L to 1.25 mmol/L in PD fluids in patients on icodextrin resulted in stable calcium values, a temporal increase in iPTH and a modest increase in calcium-based phosphate binder prescription. Using icodextrin for the long once-daily dwell appears to attenuate the effects on bone mineral parameters when lowering the calcium concentration of the short dwells.
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Affiliation(s)
- Lara C Verschuur
- Department of Internal Medicine, Northwest Clinics Alkmaar, Alkmaar, The Netherlands
| | - Anouschka G Liefting
- Department of Internal Medicine, Northwest Clinics Alkmaar, Alkmaar, The Netherlands
| | - Bastiaan van Dam
- Department of Internal Medicine, Northwest Clinics Alkmaar, Alkmaar, The Netherlands
| | - Erik L Penne
- Department of Internal Medicine, Northwest Clinics Alkmaar, Alkmaar, The Netherlands
| | - Fenneke C Frerichs
- Department of Internal Medicine, Northwest Clinics Alkmaar, Alkmaar, The Netherlands
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Piraciaba MCT, Cordeiro L, Guimarães EA, Abensur H, Pereira BJ, Jorgetti V, Moysés RMA, Elias RM. A feasibility study of avoiding positive calcium balance and parathyroid hormone increase in patients on peritoneal dialysis. Bone Rep 2022; 17:101625. [PMID: 36217349 PMCID: PMC9547188 DOI: 10.1016/j.bonr.2022.101625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/05/2022] [Accepted: 09/28/2022] [Indexed: 11/28/2022] Open
Abstract
Background The effect of the dialysate calcium concentration (D[Ca]) on mineral and bone metabolism in patients on peritoneal dialysis (PD) is overlooked. D[Ca] of 1.75 mmol/L is still prescribed to many patients on PD around the world. Previous studies on the effects of reducing D[Ca] have been carried out before the incorporation of calcimimetics in clinical practice. We hypothesized that a reduction in D[Ca] is safe and without the risk of a rise in serum parathyroid hormone (PTH). Methods In this non-randomized clinical trial, the D[Ca] was reduced from 1.75 mmol/L to 1.25 mmol/L for one year in prevalent patients on PD. Demographic, clinical, and CKD-MBD-related biomarkers were evaluated at baseline, 3, 6, and 12 months of follow-up. Results 20 patients completed 1-year follow-up (56 ± 16 years, 50 % male, 25 % diabetic, 55 % with baseline parathyroid hormone – PTH >300 pg/mL). Over time, there was no significant change in calcium, phosphate, total alkaline phosphatase, 25(OH)-vitamin D or PTH, although adjustments in calcitriol and sevelamer prescription were required. After 1 year, absolute and percentual change in PTH levels were 36 (−58, 139) pg/mL, and 20 % (−28, 45) respectively. The proportion of patients with PTH > 300 pg/mL did not change during the follow-up (p = 0.173). Conclusion Knowing the risk of a positive calcium balance in patients on PD, reducing the D[Ca] concentration is a safe and valuable option, although medication adjustments are needed to detain PTH rising.
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Affiliation(s)
- Maria Clara Teixeira Piraciaba
- Department of Medicine, Division of Nephrology, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Lilian Cordeiro
- Department of Medicine, Division of Nephrology, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Erica Adelina Guimarães
- Department of Medicine, Division of Nephrology, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Hugo Abensur
- Department of Medicine, Division of Nephrology, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Benedito Jorge Pereira
- Department of Medicine, Division of Nephrology, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
- Universidade Nove de Julho (UNINOVE), Brazil
| | - Vanda Jorgetti
- Department of Medicine, Division of Nephrology, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Rosa Maria Affonso Moysés
- Department of Medicine, Division of Nephrology, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Rosilene Motta Elias
- Department of Medicine, Division of Nephrology, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
- Universidade Nove de Julho (UNINOVE), Brazil
- Corresponding author at: Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Serviço de Nefrologia, Rua Dr. Enéas de Carvalho Aguiar 255, 7° andar, São Paulo CEP 05403-000, SP, Brazil.
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Factors affecting the relationship between ionized and corrected calcium levels in peritoneal dialysis patients: a retrospective cross-sectional study. BMC Nephrol 2020; 21:370. [PMID: 32847525 PMCID: PMC7448483 DOI: 10.1186/s12882-020-02033-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 08/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic kidney disease-mineral and bone disorder (CKD-MBD) management in patients with end-stage renal disease is important owing to the risk of cardiovascular diseases. In clinical practice, we manage patients not by monitoring the levels of biologically active ionized calcium (iCa) but by monitoring total serum calcium or corrected calcium (cCa). We previously reported that iCa/cCa ratio was different between patients with hemodialysis and those with peritoneal dialysis (PD). In PD patients, several factors are expected to affect iCa/cCa ratio. Therefore, modifying the strategy to achieve better CKD-MBD management might be necessary; however, no reports have studied this to date. Therefore, we investigated the factors influencing iCa/cCa ratio in PD patients. METHODS This retrospective cross-sectional study examined background and laboratory data, including iCa, collected at routine outpatient visits. The patients were divided into the first, second, and third tertile of iCa/cCa ratio groups to compare patient background and laboratory data. Multiple regression analysis was used to investigate the factors influencing iCa/cCa ratio. We used multiple imputation to deal with missing covariate data. RESULTS In total, 169 PD patients were enrolled. In PD patients with lower iCa/cCa ratio, PD duration was longer and pH was higher. Urine volume and weekly renal Kt/V were lower in the patients with lower iCa/cCa ratio than in those with higher iCa/cCa ratio. iCa/cCa ratio and weekly renal Kt/V were directly correlated (r = 0.41, p < 0.01), and weekly renal Kt/V and pH were independent factors affecting iCa/cCa ratio (t = 2.86, p < 0.01 and t = - 5.42, p < 0.01, respectively). CONCLUSIONS iCa levels were lower in PD patients with lower residual renal function (RRF) even though their cCa levels were equal to those with maintained RRF, warranting caution in the assessment and management of CKD-MBD in PD patients.
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de Souza ABC, Arantes MF, Zatz R, Elias RM, Lopes RI, Macedo E. Influence of low free thyroxine on progression of chronic kidney disease. BMC Nephrol 2020; 21:36. [PMID: 32000713 PMCID: PMC6993384 DOI: 10.1186/s12882-019-1677-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 12/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypothyroidism is highly prevalent in patients with chronic kidney disease (CKD) and has been associated with poorer clinical outcomes, including faster decline of kidney function. However, there is no consensus whether low free thyroxin (LFT) affects the rate of estimated glomerular filtration rate (eGFR) decline and how the presence of proteinuria influences the progression of renal dysfunction in hypothyroidism. METHODS We assessed thyroid status, proteinuria, and progression of eGFR by Modification of Diet in Renal Disease equation and CKD-EPI equation in a cohort of CKD patients followed in general nephrology clinics. We estimated the association of LFT levels, and the degree of proteinuria on progression of eGFR. We adjusted for other covariables: age, gender, body mass index, diabetes, hypertension, HbA1c, uric acid, cholesterol, and triglycerides levels.. RESULTS One thousand six hundred ten patients (64 ± 15 years, 46.8% men, 25.3% diabetic) were included. At beggnining of follow up eGFR was between 45 and 60, 30-45 and 15-30 ml/min/1.73m2 in 479 (29.8%), 551(34.2%), and 580(36.0%) patients, respectively. LFT levels were available at initial evaluation in 288(17.9%) patients and 735(48.5%) had assessment of proteinuria (19.6% with LFT vs. 15.4% without LFT, p = 0.032). Median follow-up time was of 21 months, and 1223(76%) had at least 1 year of follow up. Overall, eGFR decline per month was - 0.05(- 0.26, 0.23) ml/min/1.73m2, reaching 1.7(1.3, 2.4) ml/min/1.73m2 by the end of study period. Similar results were obtained using CKD-EPI. Multivariable mixed linear analysis showed that proteinuria and age were independently associated with eGFR decline, with no effect of LFT, and no interaction between proteinuria and LFT. In patients without proteinuria, there was an improvement of eGFR despite the presence of LFT. CONCLUSIONS We confirmed a faster rate of eGFR declined in patients with proteinuria. However, despite the pathophysiological rational that hypothyroidism can lead to increased rate of CKD progression, we failed to demonstrate an association between LFT and rate of CKD progression. We conclude that the benefit of hypothyroidism treatment in CKD patients needs to be evaluate in prospective studies.
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Affiliation(s)
| | - Marcia Fernanda Arantes
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.
| | - Roberto Zatz
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Rosilene Motta Elias
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
- Universidade Nove de Julho, UNINOVE, São Paulo, Brazil
| | - Roberto Iglesias Lopes
- Urology Service Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Etienne Macedo
- Nephrology Division, Department of Medicine, University of California San Diego, San Diego, California, USA
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