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Forouzanmehr B, Hedayati AH, Gholami E, Hemmati MA, Maleki M, Butler AE, Jamialahmadi T, Kesharwani P, Yaribeygi H, Sahebkar A. Sodium-glucose cotransporter 2 inhibitors and renin-angiotensin-aldosterone system, possible cellular interactions and benefits. Cell Signal 2024; 122:111335. [PMID: 39117253 DOI: 10.1016/j.cellsig.2024.111335] [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: 06/23/2024] [Revised: 07/30/2024] [Accepted: 08/04/2024] [Indexed: 08/10/2024]
Abstract
Sodium glucose cotransporter 2 inhibitors (SGLT2is) are a newly developed class of anti-diabetics which exert potent hypoglycemic effects in the diabetic milieu. However, the evidence suggests that they also have extra-glycemic effects. The renin-angiotensin-aldosterone system (RAAS) is a hormonal system widely distributed in the body that is important for water and electrolyte homeostasis as well as renal and cardiovascular function. Therefore, modulating RAAS activity is a main goal in patients, notably diabetic patients, which are at higher risk of complications involving these organ systems. Some studies have suggested that SGLT2is have modulatory effects on RAAS activity in addition to their hypoglycemic effects and, thus, these drugs can be considered as promising therapeutic agents for renal and cardiovascular disorders. However, the exact molecular interactions between SGLT2 inhibition and RAAS activity are not clearly understood. Therefore, in the current study we surveyed the literature for possible molecular mechanisms by which SGLT2is modulate RAAS activity.
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Affiliation(s)
- Behina Forouzanmehr
- Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran
| | | | - Emad Gholami
- Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran
| | | | - Mina Maleki
- Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alexandra E Butler
- Research Department, Royal College of Surgeons in Ireland Bahrain, Adliya 15503, Bahrain
| | - Tannaz Jamialahmadi
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Medical Toxicology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Prashant Kesharwani
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India.
| | - Habib Yaribeygi
- Research Center of Physiology, Semnan University of Medical Sciences, Semnan, Iran.
| | - Amirhossein Sahebkar
- Center for Global Health Research, Saveetha Medical College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India; Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Applied Biomedical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
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Zillinger LS, Hustedt K, Schnepel N, Hirche F, Schmicke M, Stangl GI, Muscher-Banse AS. Effects of dietary nitrogen and/or phosphorus reduction on mineral homeostasis and regulatory mechanisms in young goats. Front Vet Sci 2024; 11:1375329. [PMID: 38799725 PMCID: PMC11117143 DOI: 10.3389/fvets.2024.1375329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction The reduction of nitrogen (N) and phosphorus (P) in ruminant feed is desirable due to costs and negative environmental impact. Ruminants are able to utilize N and P through endogenous recycling, particularly in times of scarcity. When N and/or P were reduced, changes in mineral homeostasis associated with modulation of renal calcitriol metabolism occurred. The aim of this study was to investigate the potential effects of dietary N- and/or P-reduction on the regulatory mechanisms of mineral transport in the kidney and its hormonal regulation in young goats. Results During N-reduction, calcium (Ca) and magnesium (Mg) concentrations in blood decreased, accompanied by a lower protein expression of cytochrome P450 family 27 subfamily B member 1 (CYP27B1) (p = 0.016). The P-reduced fed goats had low blood phosphate concentrations with simultaneously high Ca and Mg levels. The insulin-like growth factor 1 concentrations decreased significantly with P-reduction. Furthermore, gene expression of CYP27B1 (p < 0.001) and both gene (p = 0.025) and protein (p = 0.016) expression of the fibroblast growth factor receptor 1c isoform in the kidney were also significantly reduced during a P-reduced diet. ERK1/2 activation exhibited a trend toward reduction in P-reduced animals. Interestingly, calcitriol concentrations remained unaffected by either restriction individually, but interacted significantly with N and P (p = 0.014). Additionally, fibroblast growth factor 23 mRNA expression in bone decreased significantly with P-restriction (p < 0.001). Discussion These results shed light on the complex metabolic and regulatory responses of mineral transport of young goats to dietary N and P restriction.
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Affiliation(s)
- Luisa S. Zillinger
- Institute for Physiology and Cell Biology, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Karin Hustedt
- Institute for Physiology and Cell Biology, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Nadine Schnepel
- Institute for Physiology and Cell Biology, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Frank Hirche
- Institute of Agricultural and Nutritional Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Marion Schmicke
- Clinic for Cattle, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Gabriele I. Stangl
- Institute of Agricultural and Nutritional Science, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Alexandra S. Muscher-Banse
- Institute for Physiology and Cell Biology, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
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Ito N, Hidaka N, Kato H. The pathophysiology of hypophosphatemia. Best Pract Res Clin Endocrinol Metab 2024; 38:101851. [PMID: 38087658 DOI: 10.1016/j.beem.2023.101851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
After identification of fibroblast growth factor (FGF) 23 as the pivotal regulator of chronic serum inorganic phosphate (Pi) levels, the etiology of disorders causing hypophosphatemic rickets/osteomalacia has been clarified, and measurement of intact FGF23 serves as a potent tool for differential diagnosis of chronic hypophosphatemia. Additionally, measurement of bone-specific alkaline phosphatase (BAP) is recommended to differentiate acute and subacute hypophosphatemia from chronic hypophosphatemia. This article divides the etiology of chronic hypophosphatemia into 4 groups: A. FGF23 related, B. primary tubular dysfunction, C. disturbance of vitamin D metabolism, and D. parathyroid hormone 1 receptor (PTH1R) mediated. Each group is further divided into its inherited form and acquired form. Topics for each group are described, including "ectopic FGF23 syndrome," "alcohol consumption-induced FGF23-related hypophosphatemia," "anti-mitochondrial antibody associated hypophosphatemia," and "vitamin D-dependent rickets type 3." Finally, a flowchart for differential diagnosis of chronic hypophosphatemia is introduced.
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Affiliation(s)
- Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan; Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan.
| | - Naoko Hidaka
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan; Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan.
| | - Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan; Osteoporosis Center, The University of Tokyo Hospital, Tokyo, Japan.
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Egli-Spichtig D, Hamid AK, Arroyo EMP, Ketteler M, Wiecek A, Rosenkranz AR, Pasch A, Lorenz H, Hellmann B, Karus M, Ammer R, Rubio-Aliaga I, Wagner CA. Intact FGF23 predicts serum phosphate improvement after combined nicotinamide and phosphate binder treatment in hemodialysis patients. Clin Kidney J 2023; 16:1622-1633. [PMID: 37779856 PMCID: PMC10539220 DOI: 10.1093/ckj/sfad040] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Indexed: 10/03/2023] Open
Abstract
Background Hyperphosphatemia is associated with increased mortality and cardiovascular morbidity of end-stage kidney failure (ESKF) patients. Managing serum phosphate in ESKF patients is challenging and mostly based on limiting intestinal phosphate absorption with low phosphate diets and phosphate binders (PB). In a multi-centric, double-blinded, placebo-controlled study cohort of maintenance hemodialysis patients with hyperphosphatemia, we demonstrated the efficacy of nicotinamide modified release (NAMR) formulation treatment in addition to standard PB therapy in decreasing serum phosphate. Here we aimed to assess the relationship between phosphate, FGF23, inflammation and iron metabolism in this cohort. Methods We measured the plasma concentrations of intact fibroblast growth factor 23 (iFGF23) and selected proinflammatory cytokines at baseline and Week 12 after initiating treatment. Results We observed a strong correlation between iFGF23 and cFGF23 (C-terminal fragment plus iFGF23). We identified iFGF23 as a better predictor of changes in serum phosphate induced by NAMR and PB treatment compared with cFGF23. Recursive partitioning revealed at baseline and Week 12, that iFGF23 and cFGF23 together with T50 propensity were the most important predictors of serum phosphate, whereas intact parathyroid hormone (iPTH) played a minor role in this model. Furthermore, we found serum phosphate and iPTH as the best predictors of iFGF23 and cFGF23. Sex, age, body mass index, and markers of inflammation and iron metabolism had only a minor impact in predicting FGF23. Conclusion Lowering serum phosphate in ESKF patients may depend highly on iFGF23 which is correlated to cFGF23 levels. Serum phosphate was the most important predictor of plasma FGF23 in this ESKF cohort.
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Affiliation(s)
- Daniela Egli-Spichtig
- Institute of Physiology, University of Zurich, 8057 Zurich, Switzerland, and National Center of Competence in Research NCCR Kidney.CH
| | - Ahmad Kamal Hamid
- Institute of Physiology, University of Zurich, 8057 Zurich, Switzerland, and National Center of Competence in Research NCCR Kidney.CH
| | - Eva Maria Pastor Arroyo
- Institute of Physiology, University of Zurich, 8057 Zurich, Switzerland, and National Center of Competence in Research NCCR Kidney.CH
| | - Markus Ketteler
- Robert Bosch Hospital, Department of General Internal Medicine and Nephrology, Stuttgart, Germany
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Alexander R Rosenkranz
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Pasch
- Calciscon AG, 2503 Biel, Switzerland
- Department of Nephrology, Lindenhofspital, 3012 Bern, Switzerland
- Department of Physiology and Pathophysiology, Johannes Kepler University Linz, Linz, Austria
| | - Horst Lorenz
- Buero fuer Biometrie und Statistik, Neuberg, Germany
| | | | - Michael Karus
- MEDICE Arzneimittel Pütter GmbH & Co KG, Iserlohn, Germany
| | - Richard Ammer
- MEDICE Arzneimittel Pütter GmbH & Co KG, Iserlohn, Germany
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Münster, Germany
| | - Isabel Rubio-Aliaga
- Institute of Physiology, University of Zurich, 8057 Zurich, Switzerland, and National Center of Competence in Research NCCR Kidney.CH
| | - Carsten A Wagner
- Institute of Physiology, University of Zurich, 8057 Zurich, Switzerland, and National Center of Competence in Research NCCR Kidney.CH
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Vergaro G, Del Franco A, Aimo A, Gentile F, Castiglione V, Saponaro F, Masotti S, Prontera C, Fusari N, Emdin M, Passino C. Intact fibroblast growth factor 23 in heart failure with reduced and mildly reduced ejection fraction. BMC Cardiovasc Disord 2023; 23:433. [PMID: 37658340 PMCID: PMC10474676 DOI: 10.1186/s12872-023-03441-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 08/09/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Fibroblast growth factor-23 (FGF23) has been associated to left ventricular (LV) hypertrophy and heart failure (HF) severity. We aimed to investigate the clinical correlates and prognostic value of intact FGF23 (iFGF23) in HF patients. METHODS Patients with stable HF and left ventricular ejection fraction (LVEF) < 50% were prospectively enrolled, managed according to current recommendations and followed over time. iFGF23 was measured at baseline with a fully automated immuno-chemiluminescent assay. RESULTS We enrolled 150 patients (82% males; median age 65 years). First, second, and third iFGF23 tertiles were < 35.2 pg/mL, 35.2-50.9 pg/mL, and > 50.9 pg/mL. LVEF decreased from the first iFGF23 tertile to the third tertile (p = 0.014). N-terminal pro-B-type natriuretic peptide (NT-proBNP) increased from the first to the third tertile (p = 0.001), while peak oxygen consumption decreased (p < 0.001). Thirty-five patients (23%) experienced the primary endpoint (all-cause death or HF hospitalization at 5 years), and 26 (17%) the secondary endpoint (all-cause death at 5 years). On multivariable analysis, iFGF23 independently predicted the primary endpoint on top of age, gender and LVEF (HR 4.6 [95% CI 2.1-10.3], p < 0.001), age, gender and eGFR (HR 4.1 [95% CI 1.6-10.3], p = 0.003), as well as age, gender and NT-proBNP (HR 3.6 [95% CI 1.6-8.2], p = 0.002). iFGF23 even reclassified patient risk on top of all the 3 models, with NRI values of 0.65 (95% CI 0.30-1.01), 0.55 (95% CI 0.25-0.88), and 0.60 (95% CI 0.24-0.96), respectively (both p < 0.001). CONCLUSIONS Circulating iFGF23 is associated with disease severity and outcome in HF patients with reduced and mildly reduced ejection fraction.
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Affiliation(s)
- Giuseppe Vergaro
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, 56127, Italy.
- Health Science Interdisciplinary Center , Scuola Superiore Sant'Anna, Pisa, Italy.
| | - Annamaria Del Franco
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, 56127, Italy
- Health Science Interdisciplinary Center , Scuola Superiore Sant'Anna, Pisa, Italy
| | - Alberto Aimo
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, 56127, Italy
- Health Science Interdisciplinary Center , Scuola Superiore Sant'Anna, Pisa, Italy
| | - Francesco Gentile
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, 56127, Italy
| | - Vincenzo Castiglione
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, 56127, Italy
| | | | - Silvia Masotti
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, 56127, Italy
| | - Concetta Prontera
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, 56127, Italy
| | - Niccolò Fusari
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, 56127, Italy
| | - Michele Emdin
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, 56127, Italy
- Health Science Interdisciplinary Center , Scuola Superiore Sant'Anna, Pisa, Italy
| | - Claudio Passino
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, 56127, Italy
- Health Science Interdisciplinary Center , Scuola Superiore Sant'Anna, Pisa, Italy
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Clinkenbeard E. Fibroblast Growth Factor 23 Bone Regulation and Downstream Hormonal Activity. Calcif Tissue Int 2023; 113:4-20. [PMID: 37306735 DOI: 10.1007/s00223-023-01092-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/01/2023] [Indexed: 06/13/2023]
Abstract
Mineral homeostasis of calcium and phosphate levels is one critical component to the maintenance of bone mineral density (BMD) and strength. Diseases that disrupt calcium and phosphate balanced have highlighted not only the role these minerals play in overall bone homeostasis, but also the factors, hormones and downstream transporters, responsible for mineral metabolism. The key phosphaturic hormone elucidated from studying rare heritable disorders of hypophosphatemia is Fibroblast Growth Factor 23 (FGF23). FGF23 is predominantly secreted from bone cells in an effort to maintain phosphate balance by directly controlling renal reabsorption and indirectly affecting intestinal uptake of this mineral. Multiple factors have been shown to enhance bone mRNA expression; however, FGF23 can also undergo proteolytic cleavage to control secretion of the biologically active form of the hormone. The review focuses specifically on the regulation of FGF23 and its secretion from bone as well as its hormonal actions under physiological and disease conditions.
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Affiliation(s)
- Erica Clinkenbeard
- Department of Medical and Molecular Genetics, School of Medicine, Indiana University, 635 Barnhill Drive MS 5023, Indianapolis, IN, 46202, USA.
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Yasuda S, Inoue K, Matsui I, Matsumoto A, Katsuma Y, Okushima H, Imai A, Sakaguchi Y, Kaimori JY, Yamamoto R, Mizui M, Isaka Y. Hepatic phosphate uptake and subsequent nerve-mediated phosphaturia are crucial for phosphate homeostasis following portal vein passage of phosphate in rats. Sci Rep 2023; 13:5794. [PMID: 37031318 PMCID: PMC10082792 DOI: 10.1038/s41598-023-32856-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/03/2023] [Indexed: 04/10/2023] Open
Abstract
Fibroblast growth factor 23, parathyroid hormone, and 1,25-dihydroxyvitamin D are critical in phosphate homeostasis. Despite these factors' importance, regulators of phosphaturia in the acute postprandial phase remain largely unknown. This study investigated the mechanism of acute phosphate regulation in the postprandial phase in rats. Duodenal administration of radiolabeled phosphate (32P) showed that 32P levels in the inferior vena cava (IVC) blood were lower than those in the portal vein (PV) blood. Serum phosphate concentration transiently increased 5 min after phosphate solution administration through IVC, while it was maintained after the administration through PV. Phosphate administration through both IVC and PV resulted in increased fractional excretion of phosphate (FEPi) at 10 min without elevation of the known circulating factors, but urinary phosphate excretion during the period was 8% of the dose. Experiments using 32P or partial hepatectomy showed that the liver was one of the phosphate reservoirs. The elevation of FEPi and suppression of sodium-phosphate cotransporter 2a in the kidney at 10 min was attenuated in rats with SCH23390, hepatic denervation, or renal denervation, thus indicating that the liver communicated with the kidney via the nervous system to promote phosphaturia. These results revealed previously unknown mechanisms for serum phosphate maintenance.
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Affiliation(s)
- Seiichi Yasuda
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Kazunori Inoue
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Isao Matsui
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan.
- Transdimensional Life Imaging Division, Institute for Open and Transdisciplinary Research Initiatives, Osaka University, 2-1 Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Ayumi Matsumoto
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yusuke Katsuma
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Hiroki Okushima
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Atsuhiro Imai
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yusuke Sakaguchi
- Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Jun-Ya Kaimori
- Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ryohei Yamamoto
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
- Health Promotion and Regulation, Department of Health Promotion Medicine, Osaka University Graduate School of Medicine, 1-17 Machikaneyamacho, Toyonaka, Osaka, 560-0043, Japan
- Health and Counseling Center, Osaka University, 1-17 Machikaneyamacho, Toyonaka, Osaka, 560-0043, Japan
| | - Masayuki Mizui
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
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Pons-Belda OD, Alonso-Álvarez MA, González-Rodríguez JD, Mantecón-Fernández L, Santos-Rodríguez F. Mineral Metabolism in Children: Interrelation between Vitamin D and FGF23. Int J Mol Sci 2023; 24:ijms24076661. [PMID: 37047636 PMCID: PMC10094813 DOI: 10.3390/ijms24076661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 03/29/2023] [Accepted: 04/01/2023] [Indexed: 04/05/2023] Open
Abstract
Fibroblast growth factor 23 (FGF23) was identified at the turn of the century as the long-sought circulating phosphatonin in human pathology. Since then, several clinical and experimental studies have investigated the metabolism of FGF23 and revealed its relevant pathogenic role in various diseases. Most of these studies have been performed in adult individuals. However, the mineral metabolism of the child is, to a large extent, different from that of the adult because, in addition to bone remodeling, the child undergoes a specific process of endochondral ossification responsible for adequate mineralization of long bones’ metaphysis and growth in height. Vitamin D metabolism is known to be deeply involved in these processes. FGF23 might have an influence on bones’ growth as well as on the high and age-dependent serum phosphate concentrations found in infancy and childhood. However, the interaction between FGF23 and vitamin D in children is largely unknown. Thus, this review focuses on the following aspects of FGF23 metabolism in the pediatric age: circulating concentrations’ reference values, as well as those of other major variables involved in mineral homeostasis, and the relationship with vitamin D metabolism in the neonatal period, in vitamin D deficiency, in chronic kidney disease (CKD) and in hypophosphatemic disorders.
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Affiliation(s)
| | | | | | | | - Fernando Santos-Rodríguez
- Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
- Department of Medicine, Faculty of Medicine, University of Oviedo, 33003 Oviedo, Spain
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Chaturvedi S, Vijayakumar TS, Job V, Mahendri NV, Salusky I, Agarwal I. A Cross-sectional Study on Fibroblast Growth Factor 23 and Other Markers of Mineral Metabolism in Healthy Children in India. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2023; 34:147-153. [PMID: 38146724 DOI: 10.4103/1319-2442.391893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
Fibroblast growth factor 23 (FGF23) plays a significant role in phosphate homeostasis but data on children are limited. We aimed to detect FGF23 levels in 107 healthy children aged 6-16 years and evaluate its correlation with markers of phosphate and calcium metabolism, and the dietary intake of calcium, phosphate, and proteins. Height, weight, and Tanner stages were measured, and dietary intake was calculated. Biochemical analyses of hemoglobin, serum calcium, phosphate, creatinine, Vitamin D, and plasma parathyroid hormone (PTH) and FGF23 levels were performed, alongside their associations with FGF23. Of the children, 65.4% were males. Their mean body mass index was 15.79 ± 2.96 for males and 16.5 ± SD 2.72 for females. The mean Vitamin D and PTH levels were 29.7 ± 1.1 ng/mL and 29.2 ± 1.2 pg/mL, respectively. The mean FGF23 levels were 159 ± 15.2 reference units (RU)/mL. The mean FGF23 levels were significantly higher in females (209.3 ± 31 RU/mL) than in males (132.3 ± 15.1 RU/mL). All biochemical parameters were within the normal range. FGF23 correlated with age, weight, and height, but not Vitamin D, PTH, or dietary calcium and phosphate. FGF23 showed a negative correlation with hemoglobin levels (r = -0.23). Since most children had a nonvegetarian diet, the FGF23 levels were not assessed in vegetarians. These observations were attributed to the rural lifestyle favoring adequate exposure to sunlight and physical activity. The increased FGF23 levels in females, the trends in urban settings, and the levels in strictly vegetarian diets need further study.
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Affiliation(s)
| | | | - Victoria Job
- Department of Clinical Biochemistry, Christian Medical College, Vellore, India
| | - N V Mahendri
- Department of Dietary, Christian Medical College, Vellore, India
| | - Isidro Salusky
- Department of Pediatric Nephrology, David Geffen School of Medicine UCLA, CA, USA
| | - Indira Agarwal
- Department of Pediatrics, Christian Medical College, Vellore, India
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10
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Burstad KM, Cladis DP, Vorland CJ, Wastney ME, Biruete A, Dominguez JM, O'Neill KD, Chen NX, Moe SM, Hill Gallant KM. Acute High Dietary Phosphorus Following Low-Phosphorus Diet Acclimation Does Not Enhance Intestinal Fractional Phosphorus Absorption in Nephrectomized Male Rats. JBMR Plus 2022; 6:e10698. [PMID: 36530183 PMCID: PMC9751657 DOI: 10.1002/jbm4.10698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/05/2022] [Accepted: 10/27/2022] [Indexed: 05/21/2024] Open
Abstract
Dietary phosphorus restriction and phosphorus binders are commonly prescribed for patients with chronic kidney disease (CKD). However, occurrences of non-adherence to these interventions are common. As low-phosphorus (LP) diets have been consistently experimentally shown in vitro to increase intestinal phosphorus absorption efficiency, a bout of non-adherence to diet or binders may cause an unintended consequence of enhanced intestinal phosphorus absorption. Thus, we aimed to determine the effect of a single bout of high-phosphorus (HP) intake after acclimation to a LP diet. Male Sprague Dawley rats with 5/6 nephrectomy (n = 36) or sham operation (n = 36) were block-randomized to 1 of 3 diets: LP (0.1% P w/w), HP (1.2%), or LP followed by acute HP (LPHP 0.1% then 1.2%). Phosphorus absorption tests were conducted using 33P radioisotope administrated by oral gavage or intravenously (iv). Although the overall two-way ANCOVA model for intestinal fractional phosphorus absorption was non-significant, exploratory comparisons showed intestinal fractional phosphorus absorption efficiency tended to be higher in rats in the LP compared with HP or LPHP groups. Rats in the HP or LPHP groups had higher plasma phosphorus compared with rats in the LP group, but the LPHP group was not different from the HP group. Gene expression of the major intestinal phosphate transporter, NaPi-2b, was lower in the jejunum of rats in the LPHP group compared with rats in the HP group but not different in the duodenum. These results demonstrate that an acute HP load after acclimation to a LP diet does not lead to enhanced intestinal fractional phosphorus absorption efficiency in 5/6 nephrectomized male rats. These data provide evidence against the notion that dietary phosphorus restriction or binder use adversely increases absorption efficiency after a single instance of dietary or binder non-adherence. However, other adverse consequences of fluctuating dietary phosphorus intake cannot be ruled out. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Kendal M Burstad
- Department of Food Science and NutritionUniversity of MinnesotaSaint PaulMNUSA
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
| | - Dennis P Cladis
- Department of Food Science and NutritionUniversity of MinnesotaSaint PaulMNUSA
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
| | - Colby J Vorland
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
- Department of Applied Health ScienceIndiana University School of Public Health‐BloomingtonBloomingtonINUSA
| | - Meryl E Wastney
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
| | - Annabel Biruete
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
- Department of Nutrition and DieteticsIndiana University‐Purdue University IndianapolisIndianapolisINUSA
| | - James M Dominguez
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
| | - Kalisha D O'Neill
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
| | - Neal X Chen
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
| | - Sharon M Moe
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
- Department of Anatomy and Cell BiologyIndiana University School of MedicineIndianapolisINUSA
- Department of MedicineRoudebush Veterans Affairs Medicine CenterIndianapolisINUSA
| | - Kathleen M Hill Gallant
- Department of Food Science and NutritionUniversity of MinnesotaSaint PaulMNUSA
- Department of Nutrition SciencePurdue UniversityWest LafayetteINUSA
- Department of Medicine‐Division of NephrologyIndiana University School of MedicineIndianapolisINUSA
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11
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Marques JVO, Moreira CA, Borba VZC. New treatments for rare bone diseases: hypophosphatemic rickets/osteomalacia. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:658-665. [PMID: 36382755 PMCID: PMC10118827 DOI: 10.20945/2359-3997000000555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Phosphorus is one of the most abundant minerals in the human body; it is required to maintain bone integrity and mineralization, in addition to other biological processes. Phosphorus is regulated by parathyroid hormone, 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], and fibroblast growth factor 23 (FGF-23) in a complex set of processes that occur in the gut, skeleton, and kidneys. Different molecular mechanisms - overproduction of FGF-23 by tumors responsible for oncogenic osteomalacia, generation of an FGF-23 mutant that is resistant to cleavage by enzymes, and impaired FGF-23 degradation due to a reduction in or loss of the PHEX gene - can lead to FGF-23-stimulating activity and the consequent waste of urinary phosphate and low levels of 1,25(OH)2D3. Conventional treatment consists of multiple daily doses of oral phosphate salts and vitamin D analogs, which may improve radiographic rickets but do not normalize growth. Complications of the conventional long-term treatment consist of hypercalcemia, hypercalciuria, nephrolithiasis, nephrocalcinosis, impaired renal function, and potentially chronic kidney disease. Recently, burosumab, an antibody against FGF-23, was approved as a novel therapy for children and adults with X-linked hypophosphatemia and patients with tumor-induced osteomalacia. Burosumab showed good performance in different trials in children and adults. It increased and sustained the serum phosphorus levels, decreased the rickets severity and pain scores, and improved mineralization. It offers a new perspective on the treatment of chronic and disabling diseases.
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12
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A review of ferric citrate clinical studies, and the rationale and design of the Ferric Citrate and Chronic Kidney Disease in Children (FIT4KiD) trial. Pediatr Nephrol 2022; 37:2547-2557. [PMID: 35237863 PMCID: PMC9437144 DOI: 10.1007/s00467-022-05492-7] [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: 11/24/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 12/01/2022]
Abstract
Pediatric chronic kidney disease (CKD) is characterized by many co-morbidities, including impaired growth and development, CKD-mineral and bone disorder, anemia, dysregulated iron metabolism, and cardiovascular disease. In pediatric CKD cohorts, higher circulating concentrations of fibroblast growth factor 23 (FGF23) are associated with some of these adverse clinical outcomes, including CKD progression and left ventricular hypertrophy. It is hypothesized that lowering FGF23 levels will reduce the risk of these events and improve clinical outcomes. Reducing FGF23 levels in CKD may be accomplished by targeting two key stimuli of FGF23 production-dietary phosphate absorption and iron deficiency. Ferric citrate is approved for use as an enteral phosphate binder and iron replacement product in adults with CKD. Clinical trials in adult CKD cohorts have also demonstrated that ferric citrate decreases circulating FGF23 concentrations. This review outlines the possible deleterious effects of excess FGF23 in CKD, summarizes data from the adult CKD clinical trials of ferric citrate, and presents the Ferric Citrate and Chronic Kidney Disease in Children (FIT4KiD) study, a randomized, placebo-controlled trial to evaluate the effects of ferric citrate on FGF23 in pediatric patients with CKD stages 3-4 (ClinicalTrials.gov Identifier NCT04741646).
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13
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Portales-Castillo I, Simic P. PTH, FGF-23, Klotho and Vitamin D as regulators of calcium and phosphorus: Genetics, epigenetics and beyond. Front Endocrinol (Lausanne) 2022; 13:992666. [PMID: 36246903 PMCID: PMC9558279 DOI: 10.3389/fendo.2022.992666] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022] Open
Abstract
The actions of several bone-mineral ion regulators, namely PTH, FGF23, Klotho and 1,25(OH)2 vitamin D (1,25(OH)2D), control calcium and phosphate metabolism, and each of these molecules has additional biological effects related to cell signaling, metabolism and ultimately survival. Therefore, these factors are tightly regulated at various levels - genetic, epigenetic, protein secretion and cleavage. We review the main determinants of mineral homeostasis including well-established genetic and post-translational regulators and bring attention to the epigenetic mechanisms that affect the function of PTH, FGF23/Klotho and 1,25(OH)2D. Clinically relevant epigenetic mechanisms include methylation of cytosine at CpG-rich islands, histone deacetylation and micro-RNA interference. For example, sporadic pseudohypoparathyroidism type 1B (PHP1B), a disease characterized by resistance to PTH actions due to blunted intracellular cAMP signaling at the PTH/PTHrP receptor, is associated with abnormal methylation at the GNAS locus, thereby leading to reduced expression of the stimulatory G protein α-subunit (Gsα). Post-translational regulation is critical for the function of FGF-23 and such modifications include glycosylation and phosphorylation, which regulate the cleavage of FGF-23 and hence the proportion of available FGF-23 that is biologically active. While there is extensive data on how 1,25(OH)2D and the vitamin D receptor (VDR) regulate other genes, much more needs to be learned about their regulation. Reduced VDR expression or VDR mutations are the cause of rickets and are thought to contribute to different disorders. Epigenetic changes, such as increased methylation of the VDR resulting in decreased expression are associated with several cancers and infections. Genetic and epigenetic determinants play crucial roles in the function of mineral factors and their disorders lead to different diseases related to bone and beyond.
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Affiliation(s)
- Ignacio Portales-Castillo
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Petra Simic
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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14
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Rubio-Aliaga I, Krapf R. Phosphate intake, hyperphosphatemia, and kidney function. Pflugers Arch 2022; 474:935-947. [PMID: 35511366 PMCID: PMC9338892 DOI: 10.1007/s00424-022-02691-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 12/25/2022]
Abstract
Phosphate is essential in living organisms and its blood levels are regulated by a complex network involving the kidneys, intestine, parathyroid glands, and the skeleton. The crosstalk between these organs is executed primarily by three hormones, calcitriol, parathyroid hormone, and fibroblast growth factor 23. Largely due to a higher intake of ultraprocessed foods, dietary phosphate intake has increased in the last decades. The average intake is now about twice the recommended dietary allowance. Studies investigating the side effect of chronic high dietary phosphate intake suffer from incomplete dietary phosphate assessment and, therefore, often make data interpretation difficult. Renal excretion is quickly adapted to acute and chronic phosphate intake. However, at the high ends of dietary intake, renal adaptation, even in pre-existing normal kidney function, apparently is not perfect. Experimental intervention studies suggest that chronic excess of dietary phosphate can result in sustained higher blood phosphate leading to hyperphosphatemia. Evidence exists that the price of the homeostatic response (phosphaturia in response to phosphate loading/hyperphosphatemia) is an increased risk for declining kidney function, partly due by intraluminal/tubular calcium phosphate particles that provoke renal inflammation. High dietary phosphate intake and hyperphosphatemia are progression factors for declining kidney function and are associated with higher cardiovascular disease and mortality risk. This is best established for pre-existing chronic kidney disease, but epidemiological and experimental data strongly suggest that this holds true for subjects with normal renal function as well. Here, we review the latest advances in phosphate intake and kidney function decline.
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Affiliation(s)
- Isabel Rubio-Aliaga
- Institute of Physiology, National Center of Competence in Research NCCR Kidney.CH, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.
| | - Reto Krapf
- Synlab Suisse, 6002, Lucerne, Switzerland
- Department of Medicine, University of Basel, 4056, Basel, Switzerland
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15
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Econs MJ, Selen DJ, Balza R, Zurkiya O, Kronenberg HM, Hung YP. Case 18-2022: A 29-Year-Old Woman with Recurrent Fractures. N Engl J Med 2022; 386:2316-2326. [PMID: 35704485 DOI: 10.1056/nejmcpc2107348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Michael J Econs
- From the Department of Medicine, Indiana University School of Medicine, Indianapolis (M.J.E.); and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Massachusetts General Hospital, and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Harvard Medical School - both in Boston
| | - Daryl J Selen
- From the Department of Medicine, Indiana University School of Medicine, Indianapolis (M.J.E.); and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Massachusetts General Hospital, and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Harvard Medical School - both in Boston
| | - Rene Balza
- From the Department of Medicine, Indiana University School of Medicine, Indianapolis (M.J.E.); and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Massachusetts General Hospital, and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Harvard Medical School - both in Boston
| | - Omar Zurkiya
- From the Department of Medicine, Indiana University School of Medicine, Indianapolis (M.J.E.); and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Massachusetts General Hospital, and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Harvard Medical School - both in Boston
| | - Henry M Kronenberg
- From the Department of Medicine, Indiana University School of Medicine, Indianapolis (M.J.E.); and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Massachusetts General Hospital, and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Harvard Medical School - both in Boston
| | - Yin P Hung
- From the Department of Medicine, Indiana University School of Medicine, Indianapolis (M.J.E.); and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Massachusetts General Hospital, and the Departments of Medicine (D.J.S., H.M.K.), Radiology (R.B., O.Z.), and Pathology (Y.P.H.), Harvard Medical School - both in Boston
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16
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Sharma S, Katz R, Ginsberg C, Bullen A, Vallon V, Thomson S, Moe OW, Hoofnagle AN, de Leeuw PW, Kroon AA, Houben AJHM, Ix JH. Renal Clearance of Fibroblast Growth Factor-23 (FGF23) and its Fragments in Humans. J Bone Miner Res 2022; 37:1170-1178. [PMID: 35373859 PMCID: PMC9177785 DOI: 10.1002/jbmr.4553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 03/08/2022] [Accepted: 03/28/2022] [Indexed: 11/06/2022]
Abstract
Relative abundance of fibroblast growth factor-23 (FGF23) measured by the C-terminal (cFGF23, which measures both intact FGF23 and C-terminal fragments) versus intact (iFGF23, measures only intact hormone) assays varies by kidney function in humans. Differential kidney clearance may explain this finding. We measured cFGF23 and iFGF23 in the aorta and bilateral renal veins of 162 patients with essential hypertension undergoing renal angiography. Using multivariable linear regression, we examined factors associated with aorta to renal vein reduction of FGF23 using both assays. Similar parameters and with addition of urine concentrations of cFGF23 and iFGF23 were measured in six Wistar rats. Mean ± standard deviation (SD) age was 54 ± 12 years, 54% were women, and mean creatinine clearance was 72 ± 48 mL/min/100 g. The human kidney reduced the concentrations of both cFGF23 (16% ± 12%) and iFGF23 (21% ± 16%), but reduction was higher for iFGF23. Greater kidney creatinine and PTH reductions were each independently associated with greater reductions of both cFGF23 and iFGF23. The greater kidney reduction of iFGF23 compared to cFGF23 appeared stable and consistent across the range of creatinine clearance evaluated. Kidney clearance was similar, and urine concentrations of both assays were low in the rat models, suggesting kidney metabolism of both cFGF23 and iFGF23. Renal reduction of iFGF23 is higher than that of creatinine and cFGF23. Our data suggest that FGF23 is metabolized by the kidney. However, the major cell types involved in metabolization of FGF23 requires future study. Kidney clearance of FGF23 does not explain differences in C-terminal and intact moieties across the range of kidney function. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Shilpa Sharma
- Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Nephrology Section, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Ronit Katz
- University of Washington, Seattle, WA, USA
| | - Charles Ginsberg
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Alexander Bullen
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA, USA.,Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Volker Vallon
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA, USA.,Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA.,Department of Pharmacology, University of California-San Diego, La Jolla, CA, USA
| | - Scott Thomson
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA, USA.,Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA.,Department of Pharmacology, University of California-San Diego, La Jolla, CA, USA
| | - Orson W Moe
- Charles and Jane Pak Center of Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Departments of Internal Medicine and Physiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Peter W de Leeuw
- Department of Internal Medicine and CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Abraham A Kroon
- Department of Internal Medicine and CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Alfons J H M Houben
- Department of Internal Medicine and CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Joachim H Ix
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, CA, USA.,Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA
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17
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Hanudel MR, Czaya B, Wong S, Jung G, Chua K, Qiao B, Gabayan V, Ganz T. Renoprotective effects of ferric citrate in a mouse model of chronic kidney disease. Sci Rep 2022; 12:6695. [PMID: 35461329 PMCID: PMC9035171 DOI: 10.1038/s41598-022-10842-4] [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: 01/21/2022] [Accepted: 04/06/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractIn chronic kidney disease, ferric citrate has been shown to be an effective phosphate binder and source of enteral iron; however, the effects of ferric citrate on the kidney have been less well-studied. Here, in Col4α3 knockout mice—a murine model of progressive chronic kidney disease, we evaluated the effects of five weeks of 1% ferric citrate dietary supplementation. As expected, ferric citrate lowered serum phosphate concentrations and increased serum iron levels in the Col4α3 knockout mice. Consistent with decreased enteral phosphate absorption and possibly improved iron status, ferric citrate greatly reduced circulating fibroblast growth factor 23 levels. Interestingly, ferric citrate also lessened systemic inflammation, improved kidney function, reduced albuminuria, and decreased kidney inflammation and fibrosis, suggesting renoprotective effects of ferric citrate in the setting of chronic kidney disease. The factors mediating possible ferric citrate renoprotection, the mechanisms by which they may act, and whether ferric citrate affects chronic kidney disease progression in humans deserves further study.
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18
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Ammar YA, Maharem DA, Mohamed AH, Khalil GI, Shams-Eldin RS, Dwedar FI. Fibroblast growth factor-23 rs7955866 polymorphism and risk of chronic kidney disease. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2022. [DOI: 10.1186/s43042-022-00289-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
A missense gain-of-function fibroblast growth factor-23 (FGF23) gene single nucleotide polymorphism (SNP) (rs7955866) has been associated with FGF23 hypersecretion, phosphaturia, and bone disease. Excess circulating FGF23 was linked with atherosclerosis, hypertension, initiation, and progression of chronic kidney disease (CKD).
Methods
The study included 72 CKD stage 2/3 Egyptian patients (27–71 years old, 37 females) and 26 healthy controls matching in age and sex. Repeated measures of blood pressure were used to quantify hypertension on a semiquantitative scale (grades 0 to 5). Fasting serum urea, creatinine, uric acid, total proteins, albumin, calcium, phosphorus, vitamin D3, intact parathyroid hormone (iPTH), and intact FGF23 (iFGF23) were measured. DNA extracted from peripheral blood leucocytes was used for genotyping of FGF23 rs7955866 SNP using the TaqMan SNP genotyping allelic discrimination method.
Results
Major causes of CKD were hypertension, diabetic kidney disease, and CKD of unknown etiology. There was no significant difference in minor allele (A) frequency between the studied groups (0.333 in GI and 0.308 in GII). Median (IQR) serum iFGF23 was significantly higher in GI [729.2 (531.9–972.3)] than in GII [126.1 (88.5–152.4)] pg/mL, P < 0.001. Within GI, the minor allele (A) frequency load, coded for codominant inheritance, had a significant positive correlation with both hypertension grade (r = 0.385, P = 0.001) and serum iFGF23 (r = 0.259, P = 0.028). Hypertension grade had a significant positive correlation with serum phosphorus and iFGF23.
Conclusions
For the first time in an Egyptian cohort, we report a relatively high frequency of the rs7955866 SNP. It may remain dormant or become upregulated in response to some environmental triggers, notably dietary phosphorus excess, leading to increased circulating iFGF23 with ensuing hypertension and/or renal impairment. Subjects with this SNP, particularly in the homozygous form, are at increased risk for CKD of presumably “unknown” etiology, with a tendency for early onset hypertension and increased circulating iFGF23 out of proportion with the degree of renal impairment. Large-scale population studies are needed to confirm these findings and explore the role of blockers of the renin–angiotensin–aldosterone system and sodium chloride cotransporters in mitigating hypertension associated with FGF23 excess.
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Natsuki Y, Morioka T, Fukumoto S, Kakutani Y, Yamazaki Y, Ochi A, Kurajoh M, Mori K, Shoji T, Imanishi Y, Inaba M, Emoto M. Role of adiponectin in the relationship between visceral adiposity and fibroblast growth factor 23 in non-diabetic men with normal kidney function. Endocr J 2022; 69:121-129. [PMID: 34497173 DOI: 10.1507/endocrj.ej21-0185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Fibroblast growth factor 23 (FGF23) is a key regulator of phosphate metabolism. Circulating FGF23 levels are associated with obesity, metabolic syndrome, and cardiovascular disease in the general population, but the underlying mechanism remains unclear. Therefore, we aimed to determine the associations between serum FGF23 levels and visceral adiposity as well as serum adiponectin levels in 189 adults without diabetes and with normal kidney function who were selected from the MedCity21 health examination registry. The exclusion criteria included diabetes mellitus or impaired kidney function (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2). Levels of serum FGF23 and total adiponectin, and visceral fat area (VFA) on computed tomography images were measured. Serum FGF23 levels were higher and VFA was greater, whereas serum adiponectin levels were lower in men than in women. Serum FGF23 levels positively correlated with VFA in men; they remained marginally significant after adjusting for age, eGFR, and serum levels of calcium, phosphate, intact parathyroid hormone, and 1,25-dihydroxyvitamin D. Importantly, when serum adiponectin levels were included as a covariate, serum adiponectin levels comprised an independent determinant of serum FGF23 levels in men, whereas VFA did not. In conclusion, lower serum adiponectin, rather than a greater VFA, was associated with higher serum FGF23 levels in non-diabetic men with normal kidney function. These findings suggest that adiponectin plays a role in the relationship between visceral adiposity and FGF23 in men.
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Affiliation(s)
- Yuka Natsuki
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tomoaki Morioka
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Shinya Fukumoto
- Department of Premier Preventive Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Yoshinori Kakutani
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Yuko Yamazaki
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Akinobu Ochi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Masafumi Kurajoh
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Katsuhito Mori
- Department of Nephrology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tetsuo Shoji
- Department of Vascular Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Yasuo Imanishi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Masanori Emoto
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
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Sirikul W, Siri-Angkul N, Chattipakorn N, Chattipakorn SC. Fibroblast Growth Factor 23 and Osteoporosis: Evidence from Bench to Bedside. Int J Mol Sci 2022; 23:ijms23052500. [PMID: 35269640 PMCID: PMC8909928 DOI: 10.3390/ijms23052500] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 02/05/2023] Open
Abstract
Osteoporosis is a chronic debilitating disease caused by imbalanced bone remodeling processes that impair the structural integrity of bone. Over the last ten years, the association between fibroblast growth factor 23 (FGF23) and osteoporosis has been studied in both pre-clinical and clinical investigations. FGF23 is a bone-derived endocrine factor that regulates mineral homeostasis via the fibroblast growth factor receptors (FGFRs)/αKlotho complex. These receptors are expressed in kidney and the parathyroid gland. Preclinical studies have supported the link between the local actions of FGF23 on the bone remodeling processes. In addition, clinical evidence regarding the effects of FGF23 on bone mass and fragility fractures suggest potential diagnostic and prognostic applications of FGF23 in clinical contexts, particularly in elderly and patients with chronic kidney disease. However, inconsistent findings exist and there are areas of uncertainty requiring exploration. This review comprehensively summarizes and discusses preclinical and clinical reports on the roles of FGF23 on osteoporosis, with an emphasis on the local action, as opposed to the systemic action, of FGF23 on the bone. Current gaps in knowledge and future research directions are also suggested to encourage further rigorous research in this important field.
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Affiliation(s)
- Wachiranun Sirikul
- Department of Community Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Natthaphat Siri-Angkul
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (N.S.-A.); (N.C.)
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Nipon Chattipakorn
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (N.S.-A.); (N.C.)
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Siriporn C. Chattipakorn
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (N.S.-A.); (N.C.)
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai 50200, Thailand
- Correspondence: ; Tel.: +66-53-944-451; Fax: +66-53-222-844
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Endocrine Fibroblast Growth Factors in Relation to Stress Signaling. Cells 2022; 11:cells11030505. [PMID: 35159314 PMCID: PMC8834311 DOI: 10.3390/cells11030505] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/30/2022] [Accepted: 01/31/2022] [Indexed: 01/10/2023] Open
Abstract
Fibroblast growth factors (FGFs) play important roles in various growth signaling processes, including proliferation, development, and differentiation. Endocrine FGFs, i.e., atypical FGFs, including FGF15/19, FGF21, and FGF23, function as endocrine hormones that regulate energy metabolism. Nutritional status is known to regulate the expression of endocrine FGFs through nuclear hormone receptors. The increased expression of endocrine FGFs regulates energy metabolism processes, such as fatty acid metabolism and glucose metabolism. Recently, a relationship was found between the FGF19 subfamily and stress signaling during stresses such as endoplasmic reticulum stress and oxidative stress. This review focuses on endocrine FGFs and the recent progress in FGF studies in relation to stress signaling. In addition, the relevance of the stress-FGF pathway to disease and human health is discussed.
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22
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Volk C, Schmidt B, Brandsch C, Kurze T, Schlegelmilch U, Grosse I, Ulrich C, Girndt M, Stangl GI. Acute Effects of an Inorganic Phosphorus Additive on Mineral Metabolism and Cardiometabolic Risk Factors in Healthy Subjects. J Clin Endocrinol Metab 2022; 107:e852-e864. [PMID: 34448875 DOI: 10.1210/clinem/dgab635] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Hyperphosphatemia and high levels of fibroblast growth factor 23 (FGF23) are risk factors for cardiovascular events in patients with chronic kidney diseases. However, the impact of an inorganic phosphorus additive in healthy people is largely unknown. OBJECTIVE We aimed to investigate the acute effect of excessive dietary phosphorus administered as sodium dihydrogen phosphate on the postprandial levels of Pi and FGF23 and the response to food. METHODS This study was a double-blind placebo-controlled crossover study with 29 healthy male and female participants from the general community who were administered a single dose of either 700 mg phosphorus (NaH2PO4) or a sodium-adjusted placebo in combination with a test meal. Postprandial plasma levels of Pi and FGF23 were measured. RESULTS Compared with placebo, oral phosphorus increased the plasma Pi level, which remained elevated during the ensuing 8 hours (at 480 minutes: 1.31 vs 1.16 mmol/l; P < 0.001), increased urinary Pi (iAUC0-480 789 vs 95 mmol/mmol; P < 0.001), reduced tubular Pi reabsorption (iAUC0-480 -31.5 vs -6.2; P < 0.001), decreased urinary calcium (iAUC0-240 30.6 vs 53.0 mmol/mmol; P = 0.009), and stimulated the release of parathyroid hormone (iAUC0-480 2212 vs 768 ng/l; P < 0.001). However, the FGF23 levels did not change. Postprandial levels of glucose, insulin, and lipids were not substantially affected by phosphorus vs placebo. CONCLUSION An oral phosphorus load can induce elevated postprandial levels of circulating Pi for hours in healthy subjects, despite rapid homeostatic counterreactions. FGF23 levels and the postprandial response to food were not affected.
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Affiliation(s)
- Christin Volk
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Benjamin Schmidt
- Institute of Computer Science, Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Corinna Brandsch
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Tabea Kurze
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Ulf Schlegelmilch
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Ivo Grosse
- Institute of Computer Science, Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
- Competence Cluster of Cardiovascular Health and Nutrition (nutriCARD), Halle-Jena-Leipzig, Germany
- German Centre for Integrative Biodiversity Research (iDiv) Halle-Jena-Leipzig, Germany
| | - Christof Ulrich
- Department of Internal Medicine II, Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Matthias Girndt
- Department of Internal Medicine II, Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Gabriele I Stangl
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
- Institute of Computer Science, Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
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Dong B, Lv R, Wang J, Che L, Wang Z, Huai Z, Wang Y, Xu L. The Extraglycemic Effect of SGLT-2is on Mineral and Bone Metabolism and Bone Fracture. Front Endocrinol (Lausanne) 2022; 13:918350. [PMID: 35872985 PMCID: PMC9302585 DOI: 10.3389/fendo.2022.918350] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/30/2022] [Indexed: 12/02/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a risk factor for osteoporosis. The effects of T2DM and anti-diabetic agents on bone and mineral metabolism have been observed. Sodium-glucose co-transporter 2 inhibitors (SGLT-2is) promote urinary glucose excretion, reduce blood glucose level, and improve the cardiovascular and diabetic nephropathy outcomes. In this review, we focused on the extraglycemic effect and physiological regulation of SGLT-2is on bone and mineral metabolism. SGLT-2is affect the bone turnover, microarchitecture, and bone strength indirectly. Clinical evidence of a meta-analysis showed that SGLT-2is might not increase the risk of bone fracture. The effect of SGLT-2is on bone fracture is controversial, and further investigation from a real-world study is needed. Based on its significant benefit on cardiovascular and chronic kidney disease (CKD) outcomes, SGLT-2is are an outstanding choice. Bone mineral density (BMD) and fracture risk evaluation should be considered for patients with a high risk of bone fracture.
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Affiliation(s)
- Bingzi Dong
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ruolin Lv
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jun Wang
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lin Che
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhongchao Wang
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhouyang Huai
- Department of Geriatric Medicine, Yantai Yuhuangding Hospital Affiliated Hospital of Qingdao University, Yantai, China
| | - Yangang Wang
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Lili Xu, ; Yangang Wang,
| | - Lili Xu
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Lili Xu, ; Yangang Wang,
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Abstract
Osteocytes, former osteoblasts encapsulated by mineralized bone matrix, are far from being passive and metabolically inactive bone cells. Instead, osteocytes are multifunctional and dynamic cells capable of integrating hormonal and mechanical signals and transmitting them to effector cells in bone and in distant tissues. Osteocytes are a major source of molecules that regulate bone homeostasis by integrating both mechanical cues and hormonal signals that coordinate the differentiation and function of osteoclasts and osteoblasts. Osteocyte function is altered in both rare and common bone diseases, suggesting that osteocyte dysfunction is directly involved in the pathophysiology of several disorders affecting the skeleton. Advances in osteocyte biology initiated the development of novel therapeutics interfering with osteocyte-secreted molecules. Moreover, osteocytes are targets and key distributors of biological signals mediating the beneficial effects of several bone therapeutics used in the clinic. Here we review the most recent discoveries in osteocyte biology demonstrating that osteocytes regulate bone homeostasis and bone marrow fat via paracrine signaling, influence body composition and energy metabolism via endocrine signaling, and contribute to the damaging effects of diabetes mellitus and hematologic and metastatic cancers in the skeleton.
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Affiliation(s)
- Jesus Delgado-Calle
- 1Department of Physiology and Cell Biology, University of Arkansas for Medical Sciences, Little Rock, Arkansas,2Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Teresita Bellido
- 1Department of Physiology and Cell Biology, University of Arkansas for Medical Sciences, Little Rock, Arkansas,2Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas,3Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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25
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Li Y, Gu Z, Wang J, Wang Y, Chen X, Dong B. The Emerging Role of Bone-Derived Hormones in Diabetes Mellitus and Diabetic Kidney Disease. Front Endocrinol (Lausanne) 2022; 13:938830. [PMID: 35966090 PMCID: PMC9367194 DOI: 10.3389/fendo.2022.938830] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
Diabetic kidney disease (DKD) causes the greatest proportion of end-stage renal disease (ESRD)-related mortality and has become a high concern in patients with diabetes mellitus (DM). Bone is considered an endocrine organ, playing an emerging role in regulating glucose and energy metabolism. Accumulating research has proven that bone-derived hormones are involved in glucose metabolism and the pathogenesis of DM complications, especially DKD. Furthermore, these hormones are considered to be promising predictors and prospective treatment targets for DM and DKD. In this review, we focused on bone-derived hormones, including fibroblast growth factor 23, osteocalcin, sclerostin, and lipocalin 2, and summarized their role in regulating glucose metabolism and DKD.
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Affiliation(s)
- Yixuan Li
- Department of Endocrinology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zuhua Gu
- Department of Endocrinology and Nephropathy, Weihai Hospital, Weihai, China
| | - Jun Wang
- Department of Endocrinology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yangang Wang
- Department of Endocrinology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xian Chen
- Department of Clinical Laboratory, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Bingzi Dong, ; Xian Chen,
| | - Bingzi Dong
- Department of Endocrinology, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Bingzi Dong, ; Xian Chen,
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26
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Nashawi M, Ahmed MS, Amin T, Abualfoul M, Chilton R. Cardiovascular benefits from SGLT2 inhibition in type 2 diabetes mellitus patients is not impaired with phosphate flux related to pharmacotherapy. World J Cardiol 2021; 13:676-694. [PMID: 35070111 PMCID: PMC8716977 DOI: 10.4330/wjc.v13.i12.676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/02/2021] [Accepted: 11/30/2021] [Indexed: 02/06/2023] Open
Abstract
The beneficial cardiorenal outcomes of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in patients with type 2 diabetes mellitus (T2DM) have been substantiated by multiple clinical trials, resulting in increased interest in the multifarious pathways by which their mechanisms act. The principal effect of SGLT2i (-flozin drugs) can be appreciated in their ability to block the SGLT2 protein within the kidneys, inhibiting glucose reabsorption, and causing an associated osmotic diuresis. This ameliorates plasma glucose elevations and the negative cardiorenal sequelae associated with the latter. These include aberrant mitochondrial metabolism and oxidative stress burden, endothelial cell dysfunction, pernicious neurohormonal activation, and the development of inimical hemodynamics. Positive outcomes within these domains have been validated with SGLT2i administration. However, by modulating the sodium-glucose cotransporter in the proximal tubule (PT), SGLT2i consequently promotes sodium-phosphate cotransporter activity with phosphate retention. Phosphatemia, even at physiologic levels, poses a risk in cardiovascular disease burden, more so in patients with type 2 diabetes mellitus (T2DM). There also exists an association between phosphatemia and renal impairment, the latter hampering cardiovascular function through an array of physiologic roles, such as fluid regulation, hormonal tone, and neuromodulation. Moreover, increased phosphate flux is associated with an associated increase in fibroblast growth factor 23 levels, also detrimental to homeostatic cardiometabolic function. A contemporary commentary concerning this notion unifying cardiovascular outcome trial data with the translational biology of phosphate is scant within the literature. Given the apparent beneficial outcomes associated with SGLT2i administration notwithstanding negative effects of phosphatemia, we discuss in this review the effects of phosphate on the cardiometabolic status in patients with T2DM and cardiorenal disease, as well as the mechanisms by which SGLT2i counteract or overcome them to achieve their net effects. Content drawn to develop this conversation begins with proceedings in the basic sciences and works towards clinical trial data.
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Affiliation(s)
- Mouhamed Nashawi
- Department of Internal Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX 76132, United States
| | - Mahmoud S Ahmed
- Division of Medicine-Cardiology, UT Health San Antonio, San Antonio, TX 78229, United States
| | - Toka Amin
- Division of Medicine-Cardiology, UT Health San Antonio, San Antonio, TX 78229, United States
| | - Mujahed Abualfoul
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Dallas, TX 75203, United States
| | - Robert Chilton
- Department of Internal Medicine, Methodist Dallas Medical Center, Dallas, TX 75203, United States
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27
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Masajtis-Zagajewska A, Hołub T, Pęczek K, Makówka A, Nowicki M. Different Effects of Empagliflozin on Markers of Mineral-Bone Metabolism in Diabetic and Non-Diabetic Patients with Stage 3 Chronic Kidney Disease. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1352. [PMID: 34946298 PMCID: PMC8705759 DOI: 10.3390/medicina57121352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/02/2021] [Accepted: 12/08/2021] [Indexed: 02/07/2023]
Abstract
Background and objectives: Treatment with sodium-glucose co-transporter 2 (SGLT2) inhibitors decrease tubular reabsorption of phosphate, which may explain the reduction of bone mineral density and an excess of bone fractures observed in some studies with this class of drugs. Since an increased risk of bone fractures may also be a result of diabetes itself, our study aimed to compare the effect of empagliflozin on the markers of mineral-bone metabolism between diabetic (DKD) and non-diabetic (ND-CKD) patients with stage 3 chronic kidney disease (CKD). Materials and Methods: Forty-two patients with stage 3 CKD and A2 albuminuria, including 18 with DKD and 24 ND-CKD, were investigated. All subjects received 10 mg empagliflozin for 7 days. Serum calcium, phosphate, parathormone (PTH), calcitriol, bone alkaline phosphatase (BAP), FGF-23 and urine calcium, phosphate, albumin and the renal tubular maximum reabsorption rate of phosphate to the glomerular filtration rate (TmP-GFR) were measured before and after empagliflozin administration. Differences in biomarkers response to empagliflozin between DKD and ND-CKD were the main measures of outcome. Results: There was a significant increase of PTH, FGF-23 and phosphate in DKD but not in ND-CKD whereas BAP and TmP/GFR did not change in either group. The reduction of albuminuria was only significant in ND-CKD. Conclusions: The effect of SGLT2 inhibitor on serum mineral and bone markers and on albuminuria in patients with CKD may be differently modified by the presence of diabetes mellitus.
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Affiliation(s)
| | | | | | | | - Michał Nowicki
- Department of Nephrology, Hypertension and Kidney Transplantation, Medical University of Lodz, Central University Hospital, 92-213 Lodz, Poland; (A.M.-Z.); (T.H.); (K.P.); (A.M.)
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28
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Gorący I, Rębacz-Maron E, Korbecki J, Gorący J. Concentrations of Mg, Ca, Fe, Cu, Zn, P and anthropometric and biochemical parameters in adults with chronic heart failure. PeerJ 2021; 9:e12207. [PMID: 34760349 PMCID: PMC8567860 DOI: 10.7717/peerj.12207] [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: 04/15/2021] [Accepted: 09/03/2021] [Indexed: 12/13/2022] Open
Abstract
Background The study investigated the relationship between the concentrations of Mg, Ca, Fe, Cu, Zn, P and anthropometric and biochemical parameters in the blood serum of patients with heart failure (HF) and the potential influence on the development and progression of HF. Material & methods The study included 214 patients (155 men and 59 women), aged 40–87 years, presenting symptoms or signs typical of HF (according to the NYHA functional classification). Serum concentrations were determined for Mg, Ca, Fe, Cu, Zn, P, C-reactive protein (CRP), creatinine, urea, triglyceride levels (TG), total cholesterol (CH), high density protein (HDL), low density protein (LDL). The levels of macro-and microminerals were analysed using inductively coupled serum optical emission spectrometry (ICP-OES). Results Our study confirmed the role of known risk factors in the development of heart failure, including: overweight, diabetes, hypertension, high triglycerides (TG), high total cholesterol (CH), high levels of low density protein (LDL) and reduced levels of high density protein (HDL), high CRP, high creatinine. Moreover, deficient serum concentrations of Mg (47% of the studied men and 54% of the women) and Cu (in 44% of men and more than 30% of women) were observed, as well as subnormal serum Fe (2% of women) and Zn (1% of men). Elevated serum Ca was found in 50% of men and 49% of women. In 44% of the studied men and 52% of the studied women, P levels in serum were also above-average. The study revealed a significant positive correlation between serum levels of Ca and Mg, and also Ca and Cu in women. In men, serum Cu was positively correlated with Mg and Ca concentrations. In patients from group 1 (NYHA I–II), Mg content was positively correlated with Ca and Cu. In this patient group, Ca was also positively associated with Cu content in serum. In group 2 (NYHA III-IV), serum Mg concentration was significantly positively correlated with that of Cu and Ca. Conclusions Changes in the serum concentrations of macro-and microminerals may significantly affect the severity of HF in Polish patients.
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Affiliation(s)
- Iwona Gorący
- Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland
| | - Ewa Rębacz-Maron
- Institute of Biology, Department of Ecology and Anthropology, University of Szczecin, Szczecin, Poland
| | - Jan Korbecki
- Department of Histology and Embryology, Department of Human Morphology and Embryology, Wroclaw Medical University, Wrocław, Poland
| | - Jarosław Gorący
- Clinic of Cardiology, Pomeranian Medical University, Szczecin, Poland
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29
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Adhikari S, Mamlouk O, Rondon-Berrios H, Workeneh BT. Hypophosphatemia in cancer patients. Clin Kidney J 2021; 14:2304-2315. [PMID: 34754427 PMCID: PMC8572986 DOI: 10.1093/ckj/sfab078] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Indexed: 12/19/2022] Open
Abstract
Dysregulation of phosphorus homeostasis resulting in hypophosphatemia is common in cancer patients and can result in serious complications and impact outcomes. Several factors, including critical illness, nutritional status, cancer type and therapy, influence the development of hypophosphatemia. Hypophosphatemia can develop as a result of phosphaturic mesenchymal tumors or as a paraneoplastic phenomenon. The clinical presentation for hypophosphatemia varies depending on the duration and severity of the hypophosphatemia and affects several organ systems. Among other serious effects, hypophosphatemia can impair tissue oxygenation and can cause hemolysis, leukocyte and platelet dysfunction, encephalopathy, seizures, arrhythmias, cardiomyopathy, rhabdomyolysis and coma. Multiple studies have demonstrated that hypophosphatemia is an adverse prognostic marker in inpatients with increased in-hospital stay, mortality and postoperative complications. The phosphate level is homeostatically regulated and maintained in a narrow range by three main hormones: parathyroid hormone, fibroblast growth factor 23 and 1,25-dihydroxyvitaminD3. Together, these hormones regulate how the intestine, kidneys and bones traffic phosphorus. Several hematological malignancies and cancer therapies are associated with proximal tubular dysfunction (Fanconi syndrome), resulting in phosphaturia. Caution should be taken with parenteral administration of phosphate salts, because secondary complications can develop, principally due to hypocalcemia. The general approach to hypophosphatemia should target the underlying cause. Early recognition and prevention are essential and the approach to hypophosphatemia in the cancer patient, because of the nuances and complexity, should be multidisciplinary.
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Affiliation(s)
- Shreedhar Adhikari
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Omar Mamlouk
- Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Helbert Rondon-Berrios
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Biruh T Workeneh
- Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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30
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Tsai WC, Wu HY, Chiu YL, Yang JY, Pai MF, Wu YR, Lin WY, Hung KY, Chien KL, Hsu SP, Peng YS. Acute effects of dietary phosphorus intake on markers of mineral metabolism in hemodialysis patients: post hoc analysis of a randomized crossover trial. Ren Fail 2021; 43:141-148. [PMID: 33427559 PMCID: PMC7808738 DOI: 10.1080/0886022x.2020.1870138] [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] [Indexed: 11/04/2022] Open
Abstract
Background Long-term dietary phosphorus excess influences disturbances in mineral metabolism, but it is unclear how rapidly the mineral metabolism responds to short-term dietary change in dialysis populations. Methods This was a post hoc analysis of a randomized crossover trial that evaluated the short-term effects of low-phosphorus diets on mineral parameters in hemodialysis patients. Within a 9-day period, we obtained a total of 4 repeated measurements for each participant regarding dietary intake parameters, including calorie, phosphorus, and calcium intake, and markers of mineral metabolism, including phosphate, calcium, intact parathyroid hormone (iPTH), intact fibroblast growth factor 23 (iFGF23), and C-terminal fibroblast growth factor 23 (cFGF23). The correlations between dietary phosphorus intake and serum mineral parameters were assessed by using mixed-effects models. Results Thirty-four patients were analyzed. In the fully adjusted model, we found that an increase in dietary phosphorus intake of 100 mg was associated with an increase in serum phosphate of 0.3 mg/dL (95% confidence intervals [CI], 0.2–0.4, p < .001), a decrease in serum calcium of 0.06 mg/dL (95% CI, −0.11 to −0.01, p = .01), an increase in iPTH of 5.4% (95% CI, 1.4–9.3, p = .01), and an increase in iFGF23 of 5.0% (95% CI, 2.0–8.0, p = .001). Dietary phosphorus intake was not related to cFGF23. Conclusions Increased dietary phosphorus intake acutely increases serum phosphate, iPTH, and iFGF23 levels and decreases serum calcium levels, highlighting the important role of daily fluctuations of dietary habits in disturbed mineral homeostasis in hemodialysis patients.
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Affiliation(s)
- Wan-Chuan Tsai
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Center for General Education, Lee-Ming Institute of Technology, New Taipei City, Taiwan
| | - Hon-Yen Wu
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei City, Taiwan
| | - Yen-Ling Chiu
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan.,Graduate Program in Biomedical Informatics, Yuan Ze University, Taoyuan City, Taiwan
| | - Ju-Yeh Yang
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Center for General Education, Lee-Ming Institute of Technology, New Taipei City, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Mei-Fen Pai
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Yong-Ru Wu
- Dietary Department, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Wan-Yu Lin
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Kuan-Yu Hung
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Shih-Ping Hsu
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Yu-Sen Peng
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan.,Department of Applied Cosmetology, Lee-Ming Institute of Technology, New Taipei City, Taiwan.,Department of Healthcare Administration, Oriental Institute of Technology, New Taipei City, Taiwan
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Rosner MH, DeMauro Renaghan A. Disorders of Divalent Ions (Magnesium, Calcium, and Phosphorous) in Patients With Cancer. Adv Chronic Kidney Dis 2021; 28:447-459.e1. [PMID: 35190111 DOI: 10.1053/j.ackd.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/23/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022]
Abstract
Disorders of the divalent ions (magnesium, calcium, and phosphorous) are frequently encountered in patients with cancer. Of these, hypomagnesemia, hypocalcemia, hypercalcemia, and hypophosphatemia are seen most commonly. These electrolyte disturbances may be related to the underlying malignancy or due to side effects of anticancer therapy. When caused by a paraneoplastic process, these abnormalities may portend a poor prognosis. Importantly, the development of severe electrolyte derangements may be associated with symptoms that negatively impact quality of life, preclude the administration of critical chemotherapeutic agents, or lead to life-threatening complications that require hospitalization and emergent treatment. In accordance, prompt recognition and treatment of these disorders is key to improving outcomes in patients living with cancer. This review will discuss selected derangements of the divalent ions seen in this population, with a focus on paraneoplastic and therapy-associated etiologies.
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Ammar Y, Mohamed A, Khalil G, Maharem D. Accelerated Atherosclerosis in Systemic Lupus Erythematosus: Role of Fibroblast Growth Factor 23- Phosphate Axis. Int J Nephrol Renovasc Dis 2021; 14:331-347. [PMID: 34475774 PMCID: PMC8407679 DOI: 10.2147/ijnrd.s326399] [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: 06/28/2021] [Accepted: 08/05/2021] [Indexed: 01/16/2023] Open
Abstract
PURPOSE Despite management advances, accelerated atherosclerotic cardiovascular disease (ACVD) remains a major cause of morbimortality in systemic lupus erythematosus (SLE) patients; that is not fully explained by traditional risk factors. Fibroblast growth factor-23 (FGF23) is a bone-derived phosphaturic hormone with multiple klotho-dependent and independent effects, including promotion of atherosclerosis and vascular calcification, particularly in the context of chronic kidney disease. Increased circulating FGF23 was reported in SLE patients, particularly with lupus nephritis (LN); but its atherogenic role in these disorders was not explored. SUBJECTS AND METHODS Three study groups of predominantly middle-aged females were categorized by the 2012 SLE International Collaborating Clinics (SLICC) criteria as SLE (without LN), LN, or controls matching for traditional CVD risk profile. Measures of SLE activity, damage, steroid therapy, and glomerular filtration rate were calculated. Fasting blood samples were checked for serum lipid profile, anti-DNA, urea, creatinine, uric acid, proteins, albumin, calcium, phosphorus, C3, C4, CRP, vitamin-D3, intact parathyroid hormone and FGF23 (iFGF23). By carotid ultrasonography, mean common carotid artery intima-media thickness (CC-IMT), plaque score (PS) and internal carotid resistive index (ICRI) were recorded. RESULTS CC-IMT, ICRI and serum iFGF23 differed along the study groups (LN>SLE>controls). In both SLE and LN patients, serum iFGF23 had a significant positive correlation with serum phosphorus, CC-IMT and PS. On multivariate analysis, the strongest predictor of increased CC-IMT was cumulative steroid dose in SLE and serum iFGF23 in LN patients. Most significant independent predictors of increased serum iFGF23 were hyperphosphatemia in SLE and proteinuria in LN patients. CONCLUSION FGF23-phosphate axis has a key role in accelerated ACVD in SLE patients. Serum phosphorus and iFGF23 should be included in ACVD risk profile assessment of these patients. Prospective studies shall define the role of dietary and/or pharmacologic control of hyperphosphatemia and proteinuria in reducing circulating iFGF23 and ACVD in them.
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Affiliation(s)
- Yaser Ammar
- Internal Medicine Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Amira Mohamed
- Internal Medicine Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Gihane Khalil
- Chemical Pathology Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Dalia Maharem
- Internal Medicine Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
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van der Vaart A, Yeung S, van Dijk P, Bakker S, de Borst M. Phosphate and fibroblast growth factor 23 in diabetes. Clin Sci (Lond) 2021; 135:1669-1687. [PMID: 34283205 PMCID: PMC8302806 DOI: 10.1042/cs20201290] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/30/2021] [Accepted: 07/05/2021] [Indexed: 12/11/2022]
Abstract
Diabetes is associated with a strongly elevated risk of cardiovascular disease, which is even more pronounced in patients with diabetic nephropathy. Currently available guideline-based efforts to correct traditional risk factors are only partly able to attenuate this risk, underlining the urge to identify novel treatment targets. Emerging data point towards a role for disturbances in phosphate metabolism in diabetes. In this review, we discuss the role of phosphate and the phosphate-regulating hormone fibroblast growth factor 23 (FGF23) in diabetes. We address deregulations of phosphate metabolism in patients with diabetes, including diabetic ketoacidosis. Moreover, we discuss potential adverse consequences of these deregulations, including the role of deregulated phosphate and glucose as drivers of vascular calcification propensity. Finally, we highlight potential treatment options to correct abnormalities in phosphate and FGF23. While further studies are needed to more precisely assess their clinical impact, deregulations in phosphate and FGF23 are promising potential target in diabetes and diabetic nephropathy.
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Affiliation(s)
- Amarens van der Vaart
- Department of Medicine, Division of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen,The Netherlands
- Department of Medicine, Division of Endocrinology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stanley M.H. Yeung
- Department of Medicine, Division of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen,The Netherlands
| | - Peter R. van Dijk
- Department of Medicine, Division of Endocrinology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stephan J.L. Bakker
- Department of Medicine, Division of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen,The Netherlands
| | - Martin H. de Borst
- Department of Medicine, Division of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen,The Netherlands
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Sullivan VK, Appel LJ, Seegmiller JC, McClure ST, Rebholz CM. A Low-Sodium DASH Dietary Pattern Affects Serum Markers of Inflammation and Mineral Metabolism in Adults with Elevated Blood Pressure. J Nutr 2021; 151:3067-3074. [PMID: 34293127 PMCID: PMC8485900 DOI: 10.1093/jn/nxab236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/19/2021] [Accepted: 06/22/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The blood pressure-lowering effects of the Dietary Approaches to Stop Hypertension (DASH) dietary pattern and reduced sodium intake are well established. The effects on other biomarkers related to vascular health are of interest and might assist in explaining the effects of the DASH diet and sodium reduction. OBJECTIVES We hypothesized that a low-sodium DASH diet improves (lowers) biomarkers of inflammation [C-reactive protein (CRP) and soluble urokinase plasminogen activator receptor (suPAR)] and mineral metabolism [phosphorus and fibroblast growth factor-23 (FGF23)]. METHODS We conducted a secondary analysis of the DASH-Sodium trial using frozen serum samples. This controlled feeding study randomly assigned 412 adults (≥22 y) with elevated blood pressure (120-159/80-95 mmHg) to consume either a DASH diet or control diet. Within each arm, participants received 3 sodium levels [low (1150 mg), intermediate (2300 mg), high (3450 mg)] in random sequence, each for 30 d. To maximize contrast, samples collected at the end of the low-sodium DASH (n = 198) and high-sodium control (n = 194) diets were compared. Between-diet differences in serum CRP, suPAR, phosphorus, and FGF23 concentrations were assessed using linear regression adjusted for age, sex, race, income, education, smoking status, and BMI. RESULTS CRP concentrations did not differ between groups (P = 0.83), but suPAR was higher after the low-sodium DASH diet than the high-sodium control [geometric mean 2470 pg/mL (95% CI: 2380, 2560 pg/mL), compared with 2290 pg/mL (95% CI: 2210, 2380 pg/mL); P = 0.006]. Phosphorus was higher after the low-sodium DASH diet [geometric mean 3.50 mg/dL (95% CI: 3.43, 3.57 mg/dL)] compared with the high-sodium control diet [geometric mean 3.39 mg/dL (95% CI: 3.33, 3.46 mg/dL); P = 0.04]. FGF23 was also higher after the low-sodium DASH diet [geometric mean 35.3 pg/mL (95% CI: 33.3, 37.3 pg/mL) compared with 28.2 pg/mL (95% CI: 26.6, 29.8 pg/mL); P < 0.001]. CONCLUSIONS Contrary to our hypothesis, biomarkers of inflammation and mineral metabolism were increased or unchanged by a low-sodium DASH diet compared with a high-sodium control diet in adults with elevated blood pressure.
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Affiliation(s)
- Valerie K Sullivan
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lawrence J Appel
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jesse C Seegmiller
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Scott T McClure
- Department of Public Health, College of Arts and Sciences, Shenandoah University, Winchester, VA, USA
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Li Z, Hu M, Guo Y, Zhang L, Peng Y, Abdelrahim MEA, Jiang X. Level of phosphate diets effect on fibroblast growth factor-23 levels in chronic kidney disease subjects: A meta-analysis. Int J Clin Pract 2021; 75:e14195. [PMID: 33792113 DOI: 10.1111/ijcp.14195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/27/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND High fibroblast growth factor-23 levels increase cardiovascular disease risk in chronic kidney disease subjects. The effects of dietary phosphate levels on fibroblast growth factor-23 in chronic kidney disease subjects have conflicting results. This meta-analysis was performed to evaluate this relationship. METHODS A systematic-literature search up to July 2020 was performed and 7 studies were detected with 548 chronic kidney disease subjects at the baseline of the studies; a total of 170 of them were with lower dietary phosphate levels and 175 were higher dietary phosphate levels. They reported relationships between dietary phosphate levels and fibroblast growth factor-23 level in chronic kidney disease subjects. Mean differences (MD) with 95% confidence intervals (CIs) were calculated comparing the lower versus higher phosphate levels effect on urinary phosphate levels and fibroblast growth factor-23 level in chronic kidney disease subjects using the contentious methods with a random or fixed-effect model. RESULTS Lower dietary phosphate levels had significantly lower 24-hour urinary phosphate excretion (MD, -41.23; 95% CI, -59.95 to 22.52, P < .001), and lower intact fibroblast growth factor-23 level (MD, -25.68; 95% CI, -39.85 to -11.51, P < .001) compared with higher dietary phosphate levels in chronic kidney disease subjects. However, no significant difference was found between low and high dietary phosphate levels in C-terminal fibroblast growth factor-23 level in chronic kidney disease subjects (MD, -7.10; 95% CI, -14.29 to 0.10, P = .05). CONCLUSIONS Lower dietary phosphate levels had significantly lower 24-hour urinary phosphate excretion, intact fibroblast growth factor-23 level compared with higher dietary phosphate levels in chronic kidney disease subjects. This relationship forces us to recommend low dietary phosphate levels in chronic kidney disease subjects to decrease fibroblast growth factor-23 level to avoid any possible cardiovascular disease risk in such a subject.
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Affiliation(s)
- Zhong Li
- Nephrology Department, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Maorong Hu
- Nephrology Department, First Affiliated Hospital of Guizhou, University of Traditional Chinese Medicine, Guiyang, China
| | - Yinxue Guo
- Nephrology Department, First Affiliated Hospital of Guizhou, University of Traditional Chinese Medicine, Guiyang, China
| | - Lin Zhang
- Nephrology Department, The Fourth Hospital of Changsha (Changsha Hospital of Hunan Normal University), Changsha, China
| | - Yunhua Peng
- Nephrology Department, Dafeng People's Hospital, Yancheng, China
| | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Xin Jiang
- Department of Internal Medicine, Wuhan University Hospital, Wuhan, China
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Ito N, Prideaux M, Wijenayaka AR, Yang D, Ormsby RT, Bonewald LF, Atkins GJ. Sclerostin Directly Stimulates Osteocyte Synthesis of Fibroblast Growth Factor-23. Calcif Tissue Int 2021; 109:66-76. [PMID: 33616712 DOI: 10.1007/s00223-021-00823-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 02/05/2021] [Indexed: 12/16/2022]
Abstract
Osteocyte produced fibroblast growth factor 23 (FGF23) is the key regulator of serum phosphate (Pi) homeostasis. The interplay between parathyroid hormone (PTH), FGF23 and other proteins that regulate FGF23 production and serum Pi levels is complex and incompletely characterised. Evidence suggests that the protein product of the SOST gene, sclerostin (SCL), also a PTH target and also produced by osteocytes, plays a role in FGF23 expression, however the mechanism for this effect is unclear. Part of the problem of understanding the interplay of these mediators is the complex multi-organ system that achieves Pi homeostasis in vivo. In the current study, we sought to address this using a cell line model of the osteocyte, IDG-SW3, known to express FGF23 at both the mRNA and protein levels. In cultures of differentiated IDG-SW3 cells, both PTH1-34 and recombinant human (rh) SCL remarkably induced Fgf23 mRNA expression dose-dependently within 3 h. Both rhPTH1-34 and rhSCL also strongly induced C-terminal FGF23 protein secretion. Secreted intact FGF23 levels remained unchanged, consistent with constitutive post-translational cleavage of FGF23 in this cell model. Both rhPTH1-34 and rhSCL treatments significantly suppressed mRNA levels of Phex, Dmp1 and Enpp1 mRNA, encoding putative negative regulators of FGF23 levels, and induced Galnt3 mRNA expression, encoding N-acetylgalactosaminyl-transferase 3 (GalNAc-T3), which protects FGF23 from furin-like proprotein convertase-mediated cleavage. The effect of both rhPTH1-34 and rhSCL was antagonised by pre-treatment with the NF-κβ signalling inhibitors, BAY11 and TPCK. RhSCL also stimulated FGF23 mRNA expression in ex vivo cultures of human bone. These findings provide evidence for the direct regulation of FGF23 expression by sclerostin. Locally expressed sclerostin via the induction of FGF23 in osteocytes thus has the potential to contribute to the regulation of Pi homeostasis.
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Affiliation(s)
- Nobuaki Ito
- Biomedical Orthopaedic Research Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA, 5000, Australia
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Matthew Prideaux
- Biomedical Orthopaedic Research Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA, 5000, Australia
- School of Medicine, Indiana Center for Musculoskeletal Health, Indiana University, Indianapolis, IN, 46202, USA
| | - Asiri R Wijenayaka
- Biomedical Orthopaedic Research Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA, 5000, Australia
| | - Dongqing Yang
- Biomedical Orthopaedic Research Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA, 5000, Australia
| | - Renee T Ormsby
- Biomedical Orthopaedic Research Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA, 5000, Australia
- Brigham and Women's Hospital, Boston, MA, USA
| | - Lynda F Bonewald
- School of Medicine, Indiana Center for Musculoskeletal Health, Indiana University, Indianapolis, IN, 46202, USA
| | - Gerald J Atkins
- Biomedical Orthopaedic Research Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA, 5000, Australia.
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Rickets in Children: An Update. Biomedicines 2021; 9:biomedicines9070738. [PMID: 34199067 PMCID: PMC8301330 DOI: 10.3390/biomedicines9070738] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/15/2021] [Accepted: 06/24/2021] [Indexed: 12/16/2022] Open
Abstract
Rickets refers to a deficient mineralization of the growth plate cartilage, predominantly affecting longer bones. Despite the fact that preventive measures are available, it is still a common disease worldwide; nutritional rickets, due to vitamin D deficiency or dietary calcium inadequate intake, remains the most common form. Medical history, physical examination, radiologic features and biochemical tests are essential for diagnosis. Although recent studies suggest hypophosphatemia as the leading alteration, rickets is classically divided into two categories: calcipenic rickets and phosphopenic rickets. Knowledge of this categorization and of respective clinical and laboratory features is essential for rapid diagnosis and correct management. The aim of this review is to analyze the epidemiological, pathogenetic, clinical, and therapeutic aspects of the different forms of rickets, describing the novelties on this “long-lived” disease.
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Bayer J, Vaghela R, Drechsler S, Osuchowski MF, Erben RG, Andrukhova O. The bone is the major source of high circulating intact fibroblast growth factor-23 in acute murine polymicrobial sepsis induced by cecum ligation puncture. PLoS One 2021; 16:e0251317. [PMID: 33989306 PMCID: PMC8121358 DOI: 10.1371/journal.pone.0251317] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 04/23/2021] [Indexed: 12/20/2022] Open
Abstract
Fibroblast growth factor-23 (FGF23), a bone-produced hormone, plays a critical role in mineral homeostasis. Human diseases associated with excessive intact circulating FGF23 (iFGF23) result in hypophosphatemia and low vitamin D hormone in patients with normal kidney function. In addition, there is accumulating evidence linking FGF23 with inflammation. Based on these studies and the frequent observation of hypophosphatemia among septic patients, we sought to elucidate further the relationship between FGF23 and mineral homeostasis in a clinically relevant murine polymicrobial sepsis model. Medium-severity sepsis was induced by cecum ligation puncture (CLP) in adult CD-1 mice of both sexes. Healthy CD-1 mice (without CLP) were used as controls. Forty-eight hours post-CLP, spontaneous urine was collected, and serum, organs and bones were sampled at necropsy. Serum iFGF23 increased ~20-fold in CLP compared to control mice. FGF23 protein concentration was increased in the bones, but not in spleen or liver of CLP mice. Despite the ~20-fold iFGF23 increase, we did not observe any significant changes in mineral homeostasis or parathyroid hormone levels in the blood of CLP animals. Urinary excretion of phosphate, calcium, and sodium remained unchanged in male CLP mice, whereas female CLP mice exhibited lower urinary calcium excretion, relative to healthy controls. In line with renal FGF23 resistance, expression of phosphate-, calcium- and sodium-transporting proteins did not show consistent changes in the kidneys of male and female CLP mice. Renal expression of the co-receptor αKlotho was downregulated in female, but not in male CLP mice. In conclusion, our data demonstrate that the dramatic, sex-independent rise in serum iFGF23 post-CLP was mainly caused by an upregulation of FGF23 secretion in the bone. Surprisingly, the upsurge in circulating iFGF23 did not alter humoral mineral homeostasis in the acutely septic mice. Hence, the biological function of elevated FGF23 in sepsis remains unclear and warrants further studies.
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Affiliation(s)
- Jessica Bayer
- Department of Biomedical Sciences, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Ravikumar Vaghela
- Department of Biomedical Sciences, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Susanne Drechsler
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA Research Center, Vienna, Austria
| | - Marcin F. Osuchowski
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA Research Center, Vienna, Austria
| | - Reinhold G. Erben
- Department of Biomedical Sciences, University of Veterinary Medicine Vienna, Vienna, Austria
- * E-mail:
| | - Olena Andrukhova
- Department of Biomedical Sciences, University of Veterinary Medicine Vienna, Vienna, Austria
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Arnold A, Dennison E, Kovacs CS, Mannstadt M, Rizzoli R, Brandi ML, Clarke B, Thakker RV. Hormonal regulation of biomineralization. Nat Rev Endocrinol 2021; 17:261-275. [PMID: 33727709 DOI: 10.1038/s41574-021-00477-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 01/31/2023]
Abstract
Biomineralization is the process by which organisms produce mineralized tissues. This crucial process makes possible the rigidity and flexibility that the skeleton needs for ambulation and protection of vital organs, and the hardness that teeth require to tear and grind food. The skeleton also serves as a source of mineral in times of short supply, and the intestines absorb and the kidneys reclaim or excrete minerals as needed. This Review focuses on physiological and pathological aspects of the hormonal regulation of biomineralization. We discuss the roles of calcium and inorganic phosphate, dietary intake of minerals and the delicate balance between activators and inhibitors of mineralization. We also highlight the importance of tight regulation of serum concentrations of calcium and phosphate, and the major regulators of biomineralization: parathyroid hormone (PTH), the vitamin D system, vitamin K, fibroblast growth factor 23 (FGF23) and phosphatase enzymes. Finally, we summarize how developmental stresses in the fetus and neonate, and in the mother during pregnancy and lactation, invoke alternative hormonal regulatory pathways to control mineral delivery, skeletal metabolism and biomineralization.
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Affiliation(s)
- Andrew Arnold
- Division of Endocrinology & Metabolism and Center for Molecular Oncology, University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Elaine Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Christopher S Kovacs
- Faculty of Medicine - Endocrinology, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - René Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Maria Luisa Brandi
- Department of Biochemical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Bart Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Rochester, MN, USA
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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Bird RP, Eskin NAM. The emerging role of phosphorus in human health. ADVANCES IN FOOD AND NUTRITION RESEARCH 2021; 96:27-88. [PMID: 34112356 DOI: 10.1016/bs.afnr.2021.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Phosphorus, an essential nutrient, performs vital functions in skeletal and non-skeletal tissues and is pivotal for energy production. The last two decades of research on the physiological importance of phosphorus have provided several novel insights about its dynamic nature as a nutrient performing functions as a phosphate ion. Phosphorous also acts as a signaling molecule and induces complex physiological responses. It is recognized that phosphorus homeostasis is critical for health. The intake of phosphorus by the general population world-wide is almost double the amount required to maintain health. This increase is attributed to the incorporation of phosphate containing food additives in processed foods purchased by consumers. Research findings assessed the impact of excessive phosphorus intake on cells' and organs' responses, and highlighted the potential pathogenic consequences. Research also identified a new class of bioactive phosphates composed of polymers of phosphate molecules varying in chain length. These polymers are involved in metabolic responses including hemostasis, brain and bone health, via complex mechanism(s) with positive or negative health effects, depending on their chain length. It is amazing, that phosphorus, a simple element, is capable of exerting multiple and powerful effects. The role of phosphorus and its polymers in the renal and cardiovascular system as well as on brain health appear to be important and promising future research directions.
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Affiliation(s)
- Ranjana P Bird
- School of Health Sciences, University of Northern British Columbia, Prince George, BC, Canada.
| | - N A Michael Eskin
- Department of Food and Human Nutritional Sciences, Faculty of Agricultural and Food Sciences, University of Manitoba, Winnipeg, MB, Canada
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Mozaffari-Rad N, Soleimani A, Akbari H, Sharifi N. The Effect of Dietary Phosphorus Restriction on Urine Protein Excretion in Patients With Proteinuria: A Randomized Controlled Trial. J Ren Nutr 2021; 32:189-198. [PMID: 33715956 DOI: 10.1053/j.jrn.2021.01.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES The present study was designed to determine the effect of dietary phosphorus restriction, independent of protein intake, on the urinary protein excretion in patients with proteinuria. METHODS Seventy-one patients with proteinuria were enrolled in a parallel randomized controlled trial study. The patients were randomly allocated to receive either a recommended phosphorus-restricted diet (n = 36) or a recommended control diet (n = 35), for 8 weeks. A diet was designed and recommended to participants in a way that both trial groups would receive the same amount of energy and protein and the only significant difference between them was the amount of phosphorus intake. The study outcomes included the changes in spot urine protein-to-creatinine ratio, the changes in serum and urine levels of phosphorus, as well as the changes in estimated glomerular filtration rate (eGFR). RESULTS The mean ± standard deviation of age, body mass index, and eGFR of the participants were 59 ± 14 years, 29 ± 5.5 kg/m2, and 56.1 ± 21.7 mL/min/1.73 m2, respectively. The amount of phosphorus intake decreased significantly in the phosphorus-restricted group compared to the control one (-709 vs. -369 mg/day; P < .001). This decrease is accompanied by a significant reduction in urine protein-to-creatinine ratio in the phosphorus-restricted group; however, this change did not reach a significant level when compared to the control one (the mean change: -75.78 vs. -55.25 mg/g; P = .539). Limiting the phosphorus intake did not change its serum and urine values as well as eGFR at the end of the trial. CONCLUSIONS Although adherence to a phosphorus-restricted diet by patients with proteinuria led to a significant decrease in urinary protein excretion, this change was not significantly different from that of the control diet. Further studies with larger sample sizes and different designs will reveal more evidence for a link between phosphorus intake and proteinuria.
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Affiliation(s)
- Negar Mozaffari-Rad
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Basic Science Research Institute, Kashan University of Medical Sciences, Kashan, Iran
| | - Alireza Soleimani
- Faculty of Medicine, Department of Internal Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Hosein Akbari
- Social Determinants of Health Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Nasrin Sharifi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Basic Science Research Institute, Kashan University of Medical Sciences, Kashan, Iran.
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Simultaneous management of disordered phosphate and iron homeostasis to correct fibroblast growth factor 23 and associated outcomes in chronic kidney disease. Curr Opin Nephrol Hypertens 2021; 29:359-366. [PMID: 32452919 DOI: 10.1097/mnh.0000000000000614] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Hyperphosphatemia, iron deficiency, and anemia are powerful stimuli of fibroblast growth factor 23 (FGF23) production and are highly prevalent complications of chronic kidney disease (CKD). In this manuscript, we put in perspective the newest insights on FGF23 regulation by iron and phosphate and their effects on CKD progression and associated outcomes. We especially focus on new studies aiming to reduce FGF23 levels, and we present new data that suggest major benefits of combined corrections of iron, phosphate, and FGF23 in CKD. RECENT FINDINGS New studies show that simultaneously correcting iron deficiency and hyperphosphatemia in CKD reduces the magnitude of FGF23 increase. Promising therapies using iron-based phosphate binders in CKD might mitigate cardiac and renal injury and improve survival. SUMMARY New strategies to lower FGF23 have emerged, and we discuss their benefits and risks in the context of CKD. Novel clinical and preclinical studies highlight the effects of phosphate restriction and iron repletion on FGF23 regulation.
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Ugrica M, Bettoni C, Bourgeois S, Daryadel A, Pastor-Arroyo EM, Gehring N, Hernando N, Wagner CA, Rubio-Aliaga I. A chronic high phosphate intake in mice is detrimental for bone health without major renal alterations. Nephrol Dial Transplant 2021; 36:gfab015. [PMID: 33515264 DOI: 10.1093/ndt/gfab015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Phosphate intake has increased in the last decades due to a higher consumption of processed foods. This higher intake is detrimental for patients with chronic kidney disease, increasing mortality and cardiovascular disease risk and accelerating kidney dysfunction. Whether a chronic high phosphate diet is also detrimental for the healthy population is still under debate. METHODS We fed healthy mature adult mice over a period of one year with either a high (1.2% w/w) or a standard (0.6% w/w) phosphate diet, and investigated the impact of a high phosphate diet on mineral homeostasis, kidney function and bone health. RESULTS The high phosphate diet increased plasma phosphate, parathyroid hormone (PTH) and calcitriol levels, with no change in fibroblast growth factor 23 levels. Urinary phosphate, calcium and ammonium excretion were increased. Measured glomerular filtration rate was apparently unaffected, while blood urea was lower and urea clearance was higher in animals fed the high phosphate diet. No change was observed in plasma creatinine levels. Blood and urinary pH were more acidic paralleled by higher bone resorption observed in animals fed a high phosphate diet. Total and cortical bone mineral density was lower in animals fed a high phosphate diet and this effect is independent of the higher PTH levels observed. CONCLUSIONS A chronic high phosphate intake did not cause major renal alterations, but affected negatively bone health, increasing bone resorption and decreasing bone mineral density.
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Affiliation(s)
- Marko Ugrica
- Institute of Physiology, University of Zurich, and National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
| | - Carla Bettoni
- Institute of Physiology, University of Zurich, and National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
| | - Soline Bourgeois
- Institute of Physiology, University of Zurich, and National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
| | - Arezoo Daryadel
- Institute of Physiology, University of Zurich, and National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
| | - Eva-Maria Pastor-Arroyo
- Institute of Physiology, University of Zurich, and National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
| | - Nicole Gehring
- Institute of Physiology, University of Zurich, and National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
| | - Nati Hernando
- Institute of Physiology, University of Zurich, and National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
| | - Carsten A Wagner
- Institute of Physiology, University of Zurich, and National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
| | - Isabel Rubio-Aliaga
- Institute of Physiology, University of Zurich, and National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
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Zhang JY, You HZ, Wang MJ, Zhang Q, Dong XY, Liu JF, Chen J. High-phosphorus diet controlled for sodium elevates blood pressure in healthy adults via volume expansion. J Clin Hypertens (Greenwich) 2021; 23:849-859. [PMID: 33486869 PMCID: PMC8678725 DOI: 10.1111/jch.14182] [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: 11/12/2020] [Revised: 12/23/2020] [Accepted: 01/03/2021] [Indexed: 01/26/2023]
Abstract
Whether increasing exposure to dietary phosphorus can lead to adverse clinical outcomes in healthy people is not clear. In this open‐label prospective cross‐over study, we are to explore the impact of various dietary phosphorus intake on mineral, sodium metabolisms and blood pressure in young healthy adults. There were 3 separate study periods of 5 days, each with a 5 days washout period between different diets interventions. Six young healthy male volunteers with normal nutrition status were recruited in Phase I Clinical Research Center and sequentially exposed to the following diets: (a) normal‐phosphorus diet (NPD): 1500 mg/d, (b) low‐phosphorus diet (LPD): 500 mg/d, (c) high‐phosphorus diet (HPD): 2300 mg/d. HPD induced a significant rise in daily average serum phosphate (1.47 ± 0.02 mmol/L [4.56 ± 0.06 mg/dl]) compared to NPD (1.34 ± 0.02 mmol/L [4.15 ± 0.06 mg/dL]) and LPD (1.17 ± 0.02 mmol/L [3.63 ± 0.06 mg/dL]) (p < .05). Daily average levels of serum parathyroid hormone and fibroblast growth factor 23 in HPD were significantly higher, and serum 1,25(OH)2D3 was remarkably lower than those in LPD. HPD induced a significant decrease in daily average serum aldosterone and an increase in daily average atrial natriuretic peptide level compared to LPD. The 24‐hour urine volume in HPD subjects was less than that in LPD subjects. HPD significantly increased daily average systolic blood pressure by 6.02 ± 1.24 mm Hg compared to NPD and by 8.58 ± 1.24mm Hg compared to LPD (p < .05). Our study provides the first evidence that 5‐day high‐phosphorus diet can induce elevation in SBP in young healthy adults, which may due to volume expansion.
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Affiliation(s)
- Jia-Ying Zhang
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China.,Division of Nutrition, Huashan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Huai-Zhou You
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Meng-Jing Wang
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Qian Zhang
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin-Yu Dong
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jing-Fang Liu
- Division of Nutrition, Huashan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jing Chen
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
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45
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Grund A, Sinha MD, Haffner D, Leifheit-Nestler M. Fibroblast Growth Factor 23 and Left Ventricular Hypertrophy in Chronic Kidney Disease-A Pediatric Perspective. Front Pediatr 2021; 9:702719. [PMID: 34422725 PMCID: PMC8372151 DOI: 10.3389/fped.2021.702719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/05/2021] [Indexed: 12/19/2022] Open
Abstract
Cardiovascular diseases (CVD) are a hallmark in pediatric patients with chronic kidney disease (CKD) contributing to an enhanced risk of all-cause and CV morbidity and mortality in these patients. The bone-derived phosphaturic hormone fibroblast growth factor (FGF) 23 progressively rises with declining kidney function to maintain phosphate homeostasis, with up to 1,000-fold increase in patients with kidney failure requiring dialysis. FGF23 is associated with the development of left ventricular hypertrophy (LVH) and thereby accounts to be a CVD risk factor in CKD. Experimentally, FGF23 directly induces hypertrophic growth of cardiac myocytes in vitro and LVH in vivo. Further, clinical studies in adult CKD have observed cardiotoxicity associated with FGF23. Data regarding prevalence and determinants of FGF23 excess in children with CKD are limited. This review summarizes current data and discusses whether FGF23 may be a key driver of LVH in pediatric CKD.
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Affiliation(s)
- Andrea Grund
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hanover, Germany.,Paediatric Research Centre, Hannover Medical School, Hanover, Germany
| | - Manish D Sinha
- Department of Paediatric Nephrology, King's College London, Evelina London Children's Hospital, London, United Kingdom
| | - Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hanover, Germany.,Paediatric Research Centre, Hannover Medical School, Hanover, Germany
| | - Maren Leifheit-Nestler
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hanover, Germany.,Paediatric Research Centre, Hannover Medical School, Hanover, Germany
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Florenzano P, Hartley IR, Jimenez M, Roszko K, Gafni RI, Collins MT. Tumor-Induced Osteomalacia. Calcif Tissue Int 2021; 108:128-142. [PMID: 32504138 DOI: 10.1007/s00223-020-00691-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by tumoral production of fibroblast growth factor 23 (FGF23). The hallmark biochemical features include hypophosphatemia due to renal phosphate wasting, inappropriately normal or frankly low 1,25-dihydroxy-vitamin D, and inappropriately normal or elevated FGF23. TIO is caused by typically small, slow growing, benign phosphaturic mesenchymal tumors (PMTs) that are located almost anywhere in the body from the skull to the feet, in soft tissue or bone. The recent identification of fusion genes in a significant subset of PMTs has provided important insights into PMT tumorigenesis. Although management of this disease may seem straightforward, considering that complete resection of the tumor leads to its cure, locating these often-tiny tumors is frequently a challenge. For this purpose, a stepwise, systematic approach is required. It starts with thorough medical history and physical examination, followed by functional imaging, and confirmation of identified lesions by anatomical imaging. If the tumor resection is not possible, medical therapy with phosphate and active vitamin D is indicated. Novel therapeutic approaches include image-guided tumor ablation and medical treatment with the anti-FGF23 antibody burosumab or the pan-FGFR tyrosine kinase inhibitor, BGJ398/infigratinib. Great progress has been made in the diagnosis and treatment of TIO, and more is likely to come, turning this challenging, debilitating disease into a gratifying cure for patients and their providers.
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Affiliation(s)
- Pablo Florenzano
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto piso, Santiago, Chile.
| | - Iris R Hartley
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Macarena Jimenez
- Endocrinology Department, School of Medicine, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - Kelly Roszko
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.
- Skeletal Disorders and Mineral Homeostasis Section, NIDCR, NIH, 30 Convent Drive, Building 30, Room 228, MSC 4320, Bethesda, MD, 20892-4320, USA.
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Abstract
Phosphorus, a 5A element with atomic weight of 31, comprises just over 0.6% of the composition by weight of plants and animals. Three isotopes are available for studying phosphorus metabolism and kinetics. 31P is stable, whereas the radioactive isotope 33P has a half-life of 25 days and 32P has a half-life of 14 days. Phosphate ester and phosphoanhydride are common chemical linkages and phosphorus is a key element in organic molecules involved in a wide variety of essential cellular functions. These include biochemical energy transfer via adenosine triphosphate (ATP), maintenance of genetic information with nucleotides DNA and RNA, intracellular signaling via cyclic adenosine monophosphate (cAMP), and membrane structural integrity via glycerophospholipids. However, this review focuses on the metabolism of inorganic phosphorus (Pi) acting as a weak acid. Phosphoric acid has all three hydrogens attached to oxygen and is a weak diprotic acid. It has 3 pKa values: pH 2.2, pH 7.2, and pH 12.7. At physiological pH of 7.4, Pi exists as both H2PO4(-) and HPO4(2-) and acts as an extracellular fluid (ECF) buffer. Pi is the form transported across tissue compartments and cells. Measurement of Pi in biological fluids is based on its reaction with ammonium molybdate which does not measure organic phosphorus. In humans, 80% of the body phosphorus is present in the form of calcium phosphate crystals (apatite) that confer hardness to bone and teeth, and function as the major phosphorus reservoir (Fig. 1). The remainder is present in soft tissues and ECF. Dietary phosphorus, comprising both inorganic and organic forms, is digested in the upper gastrointestinal tract. Absorbed Pi is transported to and from bone, skeletal muscle and soft tissues, and kidney at rates determined by ECF Pi concentration, rate of blood flow, and activity of cell Pi transporters (Fig. 2). During growth, there is net accretion of phosphorus, and with aging, net loss of phosphorus occurs. The bone phosphorus reservoir is depleted and repleted by overall phosphorus requirement. Skeletal muscle is rich in phosphorus used in essential biochemical energy transfer. Kidney is the main regulator of ECF Pi concentration by virtue of having a tubular maximum reabsorptive capacity for Pi (TmPi) that is under close endocrine control. It is also the main excretory pathway for Pi surplus which is passed in urine. Transcellular and paracellular Pi transports are performed by a number of transport mechanisms widely distributed in tissues, and particularly important in gut, bone, and kidney. Pi transporters are regulated by a hormonal axis comprising fibroblast growth factor 23 (FGF23), parathyroid hormone (PTH), and 1,25 dihydroxy vitamin D (1,25D). Pi and calcium (Ca) metabolism are intimately interrelated, and clinically neither can be considered in isolation. Diseases of Pi metabolism affect bone as osteomalacia/rickets, soft tissues as ectopic mineralization, skeletal muscle as myopathy, and kidney as nephrocalcinosis and urinary stone formation. Fig. 1 Content of phosphorus in human adult: skeleton, soft tissue, and extracellular fluid (grams, log scale). Corresponding data for calcium are shown for comparison Fig. 2 Phosphate (Pi) transport to and from tissue compartments in mg/24 h. At a dietary phosphorus of 1400 mg, 1120 mg is absorbed in upper intestine to the ECF, 210 mg returned to intestine by endogenous secretion, resulting in 910 mg net Pi absorption and 490 mg fecal excretion. At bone, 180 mg is deposited by bone formation and 180 mg return to the ECF by bone resorption. At kidney, 5040 mg is filtered at the glomerulus and 4130 mg return to the ECF by tubular reabsorption with 910 mg excreted in the urine. In soft tissue, Pi is exchanged between ECF and cells.
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Affiliation(s)
- Munro Peacock
- Division of Endocrinology, Department of Medicine, Indiana University School of Medicine, 1120 W Michigan Street, CL365, Indianapolis, IN, 46202, USA.
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48
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Miyakawa H, Nagatani Y, Ogawa M, Nagakawa M, Sakatani A, Akabane R, Miyagawa Y, Takemura N. Fibroblast growth factor-23 as an early marker of CKD-mineral bone disorder in dogs: preliminary investigation. J Small Anim Pract 2020; 61:744-751. [PMID: 33037651 DOI: 10.1111/jsap.13244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 08/18/2020] [Accepted: 09/15/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To examine the relationship between fibroblast growth factor-23 levels, chronic kidney disease severity and mineral metabolic disorders associated to chronic kidney disease in dogs. MATERIALS AND METHODS Fifteen control and 75 chronic kidney disease dogs were retrospectively included. Serum fibroblast growth factor-23 concentration and other phosphate metabolite parameters were compared between controls and each International Renal Interest Society stage. Multiple regression analysis was performed to determine the predictors of fibroblast growth factor-23. RESULTS Serum fibroblast growth factor-23 concentrations were significantly higher in dogs with IRIS stages 2, 3 and 4 chronic kidney disease than those in dogs in control group and with stage 1 and increased along with the severity of chronic kidney disease. Compared with control dogs, serum intact parathyroid hormone significantly increased from stage 2 and serum phosphorus concentrations increased in dogs with stage 4. In dogs with stage 2, fibroblast growth factor-23 levels significantly increased in those with hyperphosphatemia compared with those with normophosphatemia. While eight of 26 (30.8%) dogs with stage 2 developed hyperparathyroidism (intact parathyroid hormone>8.5 ng/L), 19 (73.1%) dogs with stage 2 had elevated fibroblast growth factor-23 levels above the reference range (>528 pg/mL). Log creatinine, log intact parathyroid hormone and log product of total calcium and phosphorus were independent predictors of log fibroblast growth factor-23. CLINICAL SIGNIFICANCE This preliminary study suggests that canine fibroblast growth factor-23 might be involved in mineral metabolic disorders associated to chronic kidney disease in dogs, and this factor could be potentially used as an early marker for this condition.
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Affiliation(s)
- H Miyakawa
- Laboratory of Veterinary Internal Medicine II, Nippon Veterinary and Life Science University, Musashino-shi, Tokyo, 180-8602, Japan
| | - Y Nagatani
- Laboratory of Veterinary Internal Medicine II, Nippon Veterinary and Life Science University, Musashino-shi, Tokyo, 180-8602, Japan
| | - M Ogawa
- Laboratory of Veterinary Internal Medicine II, Nippon Veterinary and Life Science University, Musashino-shi, Tokyo, 180-8602, Japan
| | - M Nagakawa
- Laboratory of Veterinary Internal Medicine II, Nippon Veterinary and Life Science University, Musashino-shi, Tokyo, 180-8602, Japan
| | - A Sakatani
- Laboratory of Veterinary Internal Medicine II, Nippon Veterinary and Life Science University, Musashino-shi, Tokyo, 180-8602, Japan
| | - R Akabane
- Laboratory of Veterinary Internal Medicine II, Nippon Veterinary and Life Science University, Musashino-shi, Tokyo, 180-8602, Japan
| | - Y Miyagawa
- Laboratory of Veterinary Internal Medicine II, Nippon Veterinary and Life Science University, Musashino-shi, Tokyo, 180-8602, Japan
| | - N Takemura
- Laboratory of Veterinary Internal Medicine II, Nippon Veterinary and Life Science University, Musashino-shi, Tokyo, 180-8602, Japan
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49
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Serna J, Bergwitz C. Importance of Dietary Phosphorus for Bone Metabolism and Healthy Aging. Nutrients 2020; 12:E3001. [PMID: 33007883 PMCID: PMC7599912 DOI: 10.3390/nu12103001] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/25/2020] [Accepted: 09/26/2020] [Indexed: 12/13/2022] Open
Abstract
Inorganic phosphate (Pi) plays a critical function in many tissues of the body: for example, as part of the hydroxyapatite in the skeleton and as a substrate for ATP synthesis. Pi is the main source of dietary phosphorus. Reduced bioavailability of Pi or excessive losses in the urine causes rickets and osteomalacia. While critical for health in normal amounts, dietary phosphorus is plentiful in the Western diet and is often added to foods as a preservative. This abundance of phosphorus may reduce longevity due to metabolic changes and tissue calcifications. In this review, we examine how dietary phosphorus is absorbed in the gut, current knowledge about Pi sensing, and endocrine regulation of Pi levels. Moreover, we also examine the roles of Pi in different tissues, the consequences of low and high dietary phosphorus in these tissues, and the implications for healthy aging.
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Affiliation(s)
- Juan Serna
- Yale College, Yale University, New Haven, CT 06511, USA;
| | - Clemens Bergwitz
- Section of Endocrinology and Metabolism, Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06519, USA
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Ko GJ, Rhee CM, Kalantar-Zadeh K, Joshi S. The Effects of High-Protein Diets on Kidney Health and Longevity. J Am Soc Nephrol 2020; 31:1667-1679. [PMID: 32669325 PMCID: PMC7460905 DOI: 10.1681/asn.2020010028] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Although high-protein diets continue to be popular for weight loss and type 2 diabetes, evidence suggests that worsening renal function may occur in individuals with-and perhaps without-impaired kidney function. High dietary protein intake can cause intraglomerular hypertension, which may result in kidney hyperfiltration, glomerular injury, and proteinuria. It is possible that long-term high protein intake may lead to de novo CKD. The quality of dietary protein may also play a role in kidney health. Compared with protein from plant sources, animal protein has been associated with an increased risk of ESKD in several observational studies, including the Singapore Chinese Health Study. Potential mediators of kidney damage from animal protein include dietary acid load, phosphate content, gut microbiome dysbiosis, and resultant inflammation. In light of such findings, adopting current dietary approaches that include a high proportion of protein for weight reduction or glycemic control should be considered with care in those at high risk for kidney disease. Given the possibility of residual confounding within some observational studies and the conflicting evidence from previous trials, long-term studies including those with large sample sizes are warranted to better ascertain the effects of high protein intake on kidney health.
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Affiliation(s)
- Gang-Jee Ko
- Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, California
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, School of Medicine, University of California Irvine, Orange, California
- Department of Medicine, Long Beach Veteran Affairs Health System, Long Beach, California
- Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles, Torrance, California
| | - Shivam Joshi
- Division of General Internal Medicine, Department of Medicine, New York University School of Medicine, New York, New York
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