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Vergili JM, Proaño GV, Jimenez EY, Moloney L, Papoutsakis C, Steiber A. Academy of Nutrition and Dietetics Commentary on the Phosphorus Recommendation in the KDOQI Clinical Practice Guidelines for Nutrition in CKD: 2020 Update. J Ren Nutr 2024; 34:192-199. [PMID: 38007185 DOI: 10.1053/j.jrn.2023.11.001] [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: 11/10/2023] [Accepted: 11/15/2023] [Indexed: 11/27/2023] Open
Abstract
The Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Kidney Disease: 2020 Update recommends adjusting dietary phosphorus to maintain a serum phosphate goal for hemodialysis patients in the normal range (0.81 to 1.45 mmol/L [2.5 to 4.5 mg/dL]). This is lower than the serum phosphate goal used by many dialysis centers (0.97 to 1.78 mmol/L [3.0 and 5.5 mg/dL]). Although context and clinical judgment must always be considered when providing individualized care to patients, a guideline implementation study conducted from December 2020 to December 2022 found that, based on their documentation, registered dietitian nutritionists from two national dialysis chains are almost universally using dialysis center goals instead of the lower phosphate goal recommended by the guideline. This commentary discusses the possible barriers to implementing the Kidney Disease Outcomes Quality Initiative 2020 nutrition guideline's phosphorus recommendation and proposes a systems level approach to promote and support adoption of the recommendation. Calls to action for potential changes in clinician practices, organizational/institutional culture, and government regulations are put forth.
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Affiliation(s)
- Joyce Marcley Vergili
- Registered Dietitian, Board Certified Specialist in Renal Nutrition, Research Consultant, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, Illinois
| | - Gabriela V Proaño
- Senior Research Project Manager, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, Illinois.
| | - Elizabeth Yakes Jimenez
- Professor and Assistant Dean for Research, College of Population Health and Departments of Pediatrics and Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Lisa Moloney
- Nutrition Researcher, Level 2, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, Illinois
| | - Constantina Papoutsakis
- Senior Director, Data Science Center, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, Illinois
| | - Alison Steiber
- Chief Science Officer, Research, International, and Scientific Affairs, Academy of Nutrition and Dietetics, Chicago, Illinois
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2
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Rahman RK, Mattilda A, Iyengar A. Assessment of Dietary Phosphorus Intake and Implementation of Parental Phosphate Education in Pediatric Chronic Kidney Disease. Indian J Nephrol 2023; 33:188-194. [PMID: 37448899 PMCID: PMC10337224 DOI: 10.4103/ijn.ijn_149_21] [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: 04/07/2021] [Revised: 01/13/2022] [Accepted: 03/25/2022] [Indexed: 07/15/2023] Open
Abstract
Introduction Management of dietary phosphorus intake is a challenge in children with chronic kidney disease and is governed by regional food sources and culinary practices. The aim of this study was to evaluate dietary intake of phosphorus in these children and assess the utility of parental phosphate education for control of hyperphosphatemia. Methods This prospective study included children aged 2-18 years with CKD stages 2-5D. Phosphorus intake was assessed by 24-hour dietary recall, analyzed using food processor software, and interpreted based on dietary reference intake (DRI) and suggested dietary intake (SDI). Parents of those with hyperphosphatemia were subjected to a structured phosphate education, and serum phosphate was monitored every 2 months for 6 months. Results Seventy children were recruited (mean age 9.4 ± 3.4 years, CKD5/5D: 51% (n = 36)) with median duration of CKD being 3.8 (IQR2,6) years. In the overall cohort, 50% (35/70) had phosphorus intake exceeding DRI with no significant difference between groups [CKD 5/5D,52.7% (n = 19) vs CKD2-4 47% (n = 16), P = 0.63]. Mean daily phosphorus intake was comparable between children with and without hyperphosphatemia [908 ± 279 mg vs 814 ± 302 mg, P = 0.1]. Based on DRI, 44% of children with normal serum phosphate and 58% with hyperphosphatemia had increased dietary intake of phosphorus (P = 0.15). Based on SDI, 26% with normal serum phosphate and 94% with hyperphosphatemia had increased dietary phosphorus intake (P < 0.001). Hyperphosphatemia was observed in 51% (CKD 2-4); 33% CKD5-5D 66%, P = 0.6). Among 29 children completing 6 months of follow up, there was a significant reduction in mean serum phosphate levels (P = 0.001) which was independent of age, stage of CKD or intake of phosphate binders. At end of the study, hyperphosphatemia persisted in 34%. Conclusion Compared to DRI, dietary assessment of phosphorus intake based on SDI was significantly associated with hyperphosphatemia in children with CKD 2-5D. In the majority, repeated parental structured phosphate education over 6 months was useful in managing hyperphosphatemia.
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Affiliation(s)
- Rehna K. Rahman
- Department of Pediatric Nephrology, St. John’s Medical College Hospital, Bengaluru, Karnataka, India
| | - Annie Mattilda
- Department of Nutrition, St. John’s Research Institute, Bengaluru, Karnataka, India
| | - Arpana Iyengar
- Department of Pediatric Nephrology, St. John’s Medical College Hospital, Bengaluru, Karnataka, India
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Alvarado F, Aklilu A, Powe NR, Vart P, Delgado C. Diversity in Studies Developing Kidney Function Estimating Equations: Improving Representation, Interpretation, and Utility of Clinical Research. Am J Kidney Dis 2023; 81:1-6. [PMID: 35842013 DOI: 10.1053/j.ajkd.2022.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 05/18/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Flor Alvarado
- Section of Nephrology and Hypertension, Department of Medicine, Tulane University, New Orleans, Louisiana.
| | - Abinet Aklilu
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Neil R Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and University of California, San Francisco, California
| | - Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Cynthia Delgado
- Nephrology Section, San Francisco VA Medical Center and Division of Nephrology, University of California, San Francisco, California
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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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Czaya B, Heitman K, Campos I, Yanucil C, Kentrup D, Westbrook D, Gutierrez O, Babitt JL, Jung G, Salusky IB, Hanudel M, Faul C. Hyperphosphatemia increases inflammation to exacerbate anemia and skeletal muscle wasting independently of FGF23-FGFR4 signaling. eLife 2022; 11:74782. [PMID: 35302487 PMCID: PMC8963881 DOI: 10.7554/elife.74782] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 03/17/2022] [Indexed: 12/01/2022] Open
Abstract
Elevations in plasma phosphate concentrations (hyperphosphatemia) occur in chronic kidney disease (CKD), in certain genetic disorders, and following the intake of a phosphate-rich diet. Whether hyperphosphatemia and/or associated changes in metabolic regulators, including elevations of fibroblast growth factor 23 (FGF23) directly contribute to specific complications of CKD is uncertain. Here, we report that similar to patients with CKD, mice with adenine-induced CKD develop inflammation, anemia, and skeletal muscle wasting. These complications are also observed in mice fed high phosphate diet even without CKD. Ablation of pathologic FGF23-FGFR4 signaling did not protect mice on an increased phosphate diet or mice with adenine-induced CKD from these sequelae. However, low phosphate diet ameliorated anemia and skeletal muscle wasting in a genetic mouse model of CKD. Our mechanistic in vitro studies indicate that phosphate elevations induce inflammatory signaling and increase hepcidin expression in hepatocytes, a potential causative link between hyperphosphatemia, anemia, and skeletal muscle dysfunction. Our study suggests that high phosphate intake, as caused by the consumption of processed food, may have harmful effects irrespective of pre-existing kidney injury, supporting not only the clinical utility of treating hyperphosphatemia in CKD patients but also arguing for limiting phosphate intake in healthy individuals.
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Affiliation(s)
- Brian Czaya
- Division of Nephrology and Hypertension, Department of Medicine, The University of Alabama at BirminghamBirminghamUnited States,Department of Medicine, David Geffen School of Medicine at UCLALos AngelesUnited States
| | - Kylie Heitman
- Division of Nephrology and Hypertension, Department of Medicine, The University of Alabama at BirminghamBirminghamUnited States
| | - Isaac Campos
- Division of Nephrology and Hypertension, Department of Medicine, The University of Alabama at BirminghamBirminghamUnited States
| | - Christopher Yanucil
- Division of Nephrology and Hypertension, Department of Medicine, The University of Alabama at BirminghamBirminghamUnited States
| | - Dominik Kentrup
- Division of Nephrology and Hypertension, Department of Medicine, The University of Alabama at BirminghamBirminghamUnited States
| | - David Westbrook
- Division of Nephrology and Hypertension, Department of Medicine, The University of Alabama at BirminghamBirminghamUnited States
| | - Orlando Gutierrez
- Division of Nephrology and Hypertension, Department of Medicine, The University of Alabama at BirminghamBirminghamUnited States
| | - Jodie L Babitt
- Division of Nephrology, Program in Membrane Biology, Massachusetts General Hospital, Harvard Medical SchoolBostonUnited States
| | - Grace Jung
- Department of Medicine, David Geffen School of Medicine at UCLALos AngelesUnited States
| | - Isidro B Salusky
- Department of Pediatrics, David Geffen School of Medicine at UCLALos AngelesUnited States
| | - Mark Hanudel
- Department of Pediatrics, David Geffen School of Medicine at UCLALos AngelesUnited States
| | - Christian Faul
- Division of Nephrology and Hypertension, Department of Medicine, The University of Alabama at BirminghamBirminghamUnited States
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Mohottige D, McElroy LM, Boulware LE. A Cascade of Structural Barriers Contributing to Racial Kidney Transplant Inequities. Adv Chronic Kidney Dis 2021; 28:517-527. [PMID: 35367020 PMCID: PMC11200179 DOI: 10.1053/j.ackd.2021.10.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/17/2021] [Accepted: 10/27/2021] [Indexed: 11/11/2022]
Abstract
Stark racial disparities in access to and receipt of kidney transplantation, especially living donor and pre-emptive transplantation, have persisted despite decades of investigation and intervention. The causes of these disparities are complex, are inter-related, and result from a cascade of structural barriers to transplantation which disproportionately impact minoritized individuals and communities. Structural barriers contributing to racial transplant inequities have been acknowledged but are often not fully explored with regard to transplant equity. We describe longstanding racial disparities in transplantation, and we discuss contributing structural barriers which occur along the transplant pathway including pretransplant health care, evaluation, referral processes, and the evaluation of transplant candidates. We also consider the role of multilevel socio-contextual influences on these processes. We believe focused efforts which apply an equity lens to key transplant processes and systems are required to achieve greater structural competency and, ultimately, racial transplant equity.
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Affiliation(s)
- Dinushika Mohottige
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC; Center for Community and Population Health Improvement, Clinical and Translational Science Institute, Duke University School of Medicine, Durham, NC.
| | - Lisa M McElroy
- Division of Abdominal Transplant, Department of Surgery, Duke University School of Medicine, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - L Ebony Boulware
- Center for Community and Population Health Improvement, Clinical and Translational Science Institute, Duke University School of Medicine, Durham, NC; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
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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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A New Disease Concept in the Age of Processed Foods-Phosphorus-Burden Disease; including CKD-MBD Concrete Analysis and the Way to Solution. Nutrients 2021; 13:nu13082874. [PMID: 34445034 PMCID: PMC8399778 DOI: 10.3390/nu13082874] [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: 07/19/2021] [Revised: 08/07/2021] [Accepted: 08/19/2021] [Indexed: 01/04/2023] Open
Abstract
In 2012, the Japanese Society for Dialysis Therapy (JSDT) established the order of correction of P, corrected Ca (cCa), and whole PTH (w-PTH) in the treatment of Chronic Kidney Disease-Metabolic Bone Disorder (CKD-MBD) as P-first. However, there is no report that analyzes whether this rule is in line with reality and what the adequate rate of P is. Therefore, we analyzed the test values of our 48 patients during the year of 2019 and examined the validity of the results. The results showed that the adequate range rates were 70.8% for P, 100% for cCa, and 89.6% for w-PTH. This result is better than the JSDT Web-based Analysis of Dialysis Data Archives (WADDA) P adequacy rate of 66.2%. Although the guideline is P-first, it is often the case that we cannot reach the adequate level; therefore, healthcare professionals and patients often blame each other. We believe that this is due to the mismatch between the modern era of processed foods covered with P additives and treatment methods (P intake restriction and P-binders). The development of processed foods with P additives has brought light and darkness to mankind. The light side is freedom from starvation, and the dark side is a new condition caused by P burden: P burden disease including CKD-MBD.
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9
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Klotho and calciprotein particles as therapeutic targets against accelerated ageing. Clin Sci (Lond) 2021; 135:1915-1927. [PMID: 34374422 PMCID: PMC8355631 DOI: 10.1042/cs20201453] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 01/25/2023]
Abstract
The klotho gene, named after a Greek goddess who spins the thread of life, was identified as a putative 'ageing-suppressor' gene. Klotho-deficient mice exhibit complex ageing-like phenotypes including hypogonadism, arteriosclerosis (vascular calcification), cardiac hypertrophy, osteopenia, sarcopenia, frailty, and premature death. Klotho protein functions as the obligate co-receptor for fibroblast growth factor-23 (FGF23), a bone-derived hormone that promotes urinary phosphate excretion in response to phosphate intake. Thus, Klotho-deficient mice suffer not only from accelerated ageing but also from phosphate retention due to impaired phosphate excretion. Importantly, restoration of the phosphate balance by placing Klotho-deficient mice on low phosphate diet rescued them from premature ageing, leading us to the notion that phosphate accelerates ageing. Because the extracellular fluid is super-saturated in terms of phosphate and calcium ions, an increase in the phosphate concentration can trigger precipitation of calcium-phosphate. In the blood, calcium-phosphate precipitated upon increase in the blood phosphate concentration is adsorbed by serum protein fetuin-A to form colloidal nanoparticles called calciprotein particles (CPPs). In the urine, CPPs appear in the renal tubular fluid when FGF23 increases phosphate load excreted per nephron. CPPs can induce cell damage, ectopic calcification, and inflammatory responses. CPPs in the blood can induce arteriosclerosis and non-infectious chronic inflammation, whereas CPPs in the urine can induce renal tubular damage and interstitial inflammation/fibrosis. Thus, we propose that CPPs behave like a pathogen that accelerates ageing and should be regarded as a novel therapeutic target against age-related disorders including chronic kidney disease.
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Vázquez-Sánchez S, Poveda J, Navarro-García JA, González-Lafuente L, Rodríguez-Sánchez E, Ruilope LM, Ruiz-Hurtado G. An Overview of FGF-23 as a Novel Candidate Biomarker of Cardiovascular Risk. Front Physiol 2021; 12:632260. [PMID: 33767635 PMCID: PMC7985069 DOI: 10.3389/fphys.2021.632260] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/15/2021] [Indexed: 12/12/2022] Open
Abstract
Fibroblast growth factor-23 (FGF)-23 is a phosphaturic hormone involved in mineral bone metabolism that helps control phosphate homeostasis and reduces 1,25-dihydroxyvitamin D synthesis. Recent data have highlighted the relevant direct FGF-23 effects on the myocardium, and high plasma levels of FGF-23 have been associated with adverse cardiovascular outcomes in humans, such as heart failure and arrhythmias. Therefore, FGF-23 has emerged as a novel biomarker of cardiovascular risk in the last decade. Indeed, experimental data suggest FGF-23 as a direct mediator of cardiac hypertrophy development, cardiac fibrosis and cardiac dysfunction via specific myocardial FGF receptor (FGFR) activation. Therefore, the FGF-23/FGFR pathway might be a suitable therapeutic target for reducing the deleterious effects of FGF-23 on the cardiovascular system. More research is needed to fully understand the intracellular FGF-23-dependent mechanisms, clarify the downstream pathways and identify which could be the most appropriate targets for better therapeutic intervention. This review updates the current knowledge on both clinical and experimental studies and highlights the evidence linking FGF-23 to cardiovascular events. The aim of this review is to establish the specific role of FGF-23 in the heart, its detrimental effects on cardiac tissue and the possible new therapeutic opportunities to block these effects.
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Affiliation(s)
- Sara Vázquez-Sánchez
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jonay Poveda
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - José Alberto Navarro-García
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Laura González-Lafuente
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Elena Rodríguez-Sánchez
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Luis M. Ruilope
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
- School of Doctoral Studies and Research, European University of Madrid, Madrid, Spain
| | - Gema Ruiz-Hurtado
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
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Bacchetta J, Bernardor J, Garnier C, Naud C, Ranchin B. Hyperphosphatemia and Chronic Kidney Disease: A Major Daily Concern Both in Adults and in Children. Calcif Tissue Int 2021; 108:116-127. [PMID: 31996964 DOI: 10.1007/s00223-020-00665-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/20/2020] [Indexed: 12/19/2022]
Abstract
Hyperphosphatemia is common in chronic kidney disease (CKD). Often seen as the "silent killer" because of its dramatic effect on vascular calcifications, hyperphosphatemia explains, at least partly, the onset of the complex mineral and bone disorders associated with CKD (CKD-MBD), together with hypocalcemia and decreased 1-25(OH)2 vitamin D levels. The impact of CKD-MBD may be immediate with abnormalities of bone and mineral metabolism with secondary hyperparathyroidism and increased FGF23 levels, or delayed with poor growth, bone deformities, fractures, and vascular calcifications, leading to increased morbidity and mortality. The global management of CKD-MBD has been detailed in international guidelines for adults and children, however, with difficulties to obtain an agreement on the ideal PTH targets. The clinical management of hyperphosphatemia is a daily challenge for nephrologists and pediatric nephrologists, notably because of the phosphate overload in occidental diets that is mainly due to the phosphate "hidden" in food additives. The management begins with a dietary restriction of phosphate intake, and is followed by the use of calcium-based and non-calcium-based phosphate binders, and/or the intensification of dialysis. The objective of this review is to provide an overview of the pathophysiology of hyperphosphatemia in CKD, with a focus on its deleterious effects and a description of the clinical management of hyperphosphatemia in a more global setting of CKD-MBD.
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Affiliation(s)
- Justine Bacchetta
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France.
- Université de Lyon, Lyon, France.
- INSERM 1033 Research Unit, Lyon, France.
| | - Julie Bernardor
- Unité de Néphrologie pédiatrique, Hôpital L'Archet, CHU de Nice, Nice, France
| | - Charlotte Garnier
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
| | - Corentin Naud
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
| | - Bruno Ranchin
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
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12
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Rubio-Aliaga I. Phosphate and Kidney Healthy Aging. Kidney Blood Press Res 2020; 45:802-811. [DOI: 10.1159/000509831] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/29/2020] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> The aging population is increasing rapidly, much faster than our understanding on how to promote healthy aging free of multimorbidities. The aging kidney shows a decline in its function. Whether this decline is preventable or physiological is still debated. Main risks factors for developing CKD are aging common comorbidites, such as hypertension, diabetes, and obesity. Phosphate is vital for our organism, but it is also present in a great variety of food products as food additive and preservative. Due to the higher consumption of processed food in the last century, concern has arisen if a chronic high consumption of phosphate may be toxic impacting on healthy aging. <b><i>Summary:</i></b> Several studies show an association between higher serum phosphate levels and a higher risk of overall mortality and cardiovascular disease. Moreover, higher phosphate levels also worsen CKD progression and may contribute to renal dysfunction in healthy individuals. Acute high phosphate intake is rare but can cause acute kidney injury. Yet, the question if controlling phosphate intake may modulate serum phosphate concentrations remains unanswered, as assessment of phosphate intake is still a difficult task. Phosphate consumption estimations by dietary recalls are largely underestimated, especially in populations groups consuming high amount of processed food. <b><i>Key Message:</i></b> A healthy diet with phosphate source from food may contribute to promote healthy aging and longevity.
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13
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Using race in the estimation of glomerular filtration rates: time for a reversal? Curr Opin Nephrol Hypertens 2020; 29:227-231. [PMID: 31895163 DOI: 10.1097/mnh.0000000000000587] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Bedside estimates of renal function are essential for clinical practice in the modern era and have largely relied on serum creatinine concentrations despite the known drawbacks associated with this choice of biomarker, including the fact that creatinine clearance overestimates the glomerular filtration rate. RECENT FINDINGS Initial estimates relied primarily on equations that incorporated factors known to influence creatinine concentrations such as age, sex and anthropometric measures. More recent estimates of glomerular filtration rate have replaced the anthropometric measures with the social construct of race, suggesting that glomerular filtration rates for black individuals are higher at the same concentration of creatinine. This approach has led to large variations in the estimated differences in glomerular filtration rate between black and nonblack individuals in the United States that have not been reproducible, resulting in a plethora of population-specific formulae across the country. SUMMARY The introduction of race in estimated glomerular filtration rate equations may have potential unintended negative consequences for the very population with the greatest burden of kidney disease. These potential disadvantages underscore the need to perhaps return to the replacement of race with more objective anthropometric measures without the loss of precision.
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Saunders MR, Ricardo AC, Chen J, Anderson AH, Cedillo-Couvert EA, Fischer MJ, Hernandez-Rivera J, Hicken MT, Hsu JY, Zhang X, Hynes D, Jaar B, Kusek JW, Rao P, Feldman HI, Go AS, Lash JP. Neighborhood socioeconomic status and risk of hospitalization in patients with chronic kidney disease: A chronic renal insufficiency cohort study. Medicine (Baltimore) 2020; 99:e21028. [PMID: 32664108 PMCID: PMC7360239 DOI: 10.1097/md.0000000000021028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Patients with chronic kidney disease (CKD) experience significantly greater morbidity than the general population. The hospitalization rate for patients with CKD is significantly higher than the general population. The extent to which neighborhood-level socioeconomic status (SES) is associated with hospitalization has been less explored, both in the general population and among those with CKD.We evaluated the relationship between neighborhood SES and hospitalizations for adults with CKD participating in the Chronic Renal Insufficiency Cohort Study. Neighborhood SES quartiles were created utilizing a validated neighborhood-level SES summary measure expressed as z-scores for 6 census-derived variables. The relationship between neighborhood SES and hospitalizations was examined using Poisson regression models after adjusting for demographic characteristics, individual SES, lifestyle, and clinical factors while taking into account clustering within clinical centers and census block groups.Among 3291 participants with neighborhood SES data, mean age was 58 years, 55% were male, 41% non-Hispanic white, 49% had diabetes, and mean estimated glomerular filtration rate (eGFR) was 44 ml/min/1.73 m. In the fully adjusted model, compared to individuals in the highest SES neighborhood quartile, individuals in the lowest SES neighborhood quartile had higher risk for all-cause hospitalization (rate ratio [RR], 1.28, 95% CI, 1.09-1.51) and non-cardiovascular hospitalization (RR 1.30, 95% CI, 1.10-1.55). The association with cardiovascular hospitalization was in the same direction but not statistically significant (RR 1.21, 95% CI, 0.97-1.52).Neighborhood SES is associated with risk for hospitalization in individuals with CKD even after adjusting for individual SES, lifestyle, and clinical factors.
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Affiliation(s)
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jinsong Chen
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Amanda H. Anderson
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Michael J. Fischer
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown VAMC, Chicago, IL
| | | | | | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Xiaoming Zhang
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Denise Hynes
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
- College of Public Health and Human Sciences, Oregon State University, and US Department of Veterans Affairs, Portland, OR
| | - Bernard Jaar
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - John W. Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Panduranga Rao
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Harold I. Feldman
- Center for Clinical Epidemiology and Biostatistics
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - James P. Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
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Bacchetta J. Treatment of hyperphosphatemia: the dangers of high PTH levels. Pediatr Nephrol 2020; 35:493-500. [PMID: 31696357 DOI: 10.1007/s00467-019-04400-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/10/2019] [Accepted: 10/14/2019] [Indexed: 12/01/2022]
Abstract
The control of secondary hyperparathyroidism (SHPT) in pediatric chronic kidney disease is of utmost importance. Even though parathyroid hormone (PTH) is an important biomarker of mineral and bone disorders associated to CKD (CKD-MBD), calcium, phosphate, alkaline phosphatase, and vitamin D are also crucial and should be assessed together. In pediatric dialysis, high PTH levels have been associated with impaired longitudinal growth, bone disease, cardiovascular comorbidities, left ventricular hypertrophy, anemia, and even mortality (when PTH levels were above 500 pg/mL, i.e., 8.3-fold the upper normal limit (UNL)). As such, high PTH levels are for sure deleterious, but too low PTH levels have also been shown to impair growth and to promote vascular calcifications because of the underlying adynamic bone. This manuscript is part of a pros and cons debate for keeping PTH levels within the normal range in pediatric CKD, focusing on the pros. High bone turnover lesions can occur at lower PTH levels than "current" guidelines would suggest; thus, PTH alone is not a good predictor of the underlying osteodystrophy. PTH results can vary locally depending on the assay. Existing guidelines for PTH targets are conflicting and based on a very little evidence. However, the 120-180 pg/mL (2- to 3-fold the UNL) range is common to most of the guidelines; it seems to be a reasonable target in children undergoing dialysis, even though it does not correspond to "normal" PTH levels. As always, the philosophy of PTH levels in pediatric dialysis may be balanced, i.e., "not too low, not too high, and keep phosphate under control."
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Affiliation(s)
- Justine Bacchetta
- Centre de Référence des Maladies Rénales Rares, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France. .,Université de Lyon, Lyon, France. .,INSERM 1033 Research Unit, Université de Lyon, Lyon, France.
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16
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Chang TI, Lim H, Park CH, Rhee CM, Kalantar-Zadeh K, Kang EW, Kang SW, Han SH. Association Between Income Disparities and Risk of Chronic Kidney Disease: A Nationwide Cohort Study of Seven Million Adults in Korea. Mayo Clin Proc 2020; 95:231-242. [PMID: 32029084 PMCID: PMC7224965 DOI: 10.1016/j.mayocp.2019.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/10/2019] [Accepted: 09/30/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To examine the association between income level and incident chronic kidney disease (CKD) in adults with normal baseline kidney function. PATIENT AND METHODS We studied the association between income level categorized into deciles and incident CKD in a national cohort comprised of 7,405,715 adults who underwent National Health Insurance Service health examinations during January 1, 2009, to December 31, 2015, with baseline estimated glomerular filtration rates (eGFRs) ≥60 mL/min/1.73 m2. Incident CKD was defined as de novo development of eGFR <60 mL/min/1.73 m2 (model 1) or ≥25% decline in eGFR from baseline values accompanied by eGFR <60 mL/min/1.73 m2 (model 2). RESULTS During a median follow-up of 4.8 years, there were 122,032 of 7,405,715 (1.65%) and 55,779 of 7,405,715 (0.75%) incident CKD events based on model 1 and 2 definitions, respectively. Compared with income levels in the sixth decile, there was an inverse association between lower income level and higher risk for CKD up to the fourth decile, above which no additional reduction (model 1) or slightly higher risk for CKD (model 2) was observed at higher income levels. The multivariable-adjusted hazard ratios from the lowest to fourth deciles were 1.30 (95% CI, 1.26-1.33), 1.16 (95% CI, 1.13-1.19), 1.07 (95% CI, 1.05-1.10), and 1.06 (95% CI, 1.03-1.09) in model 1 and 1.32 (95% CI, 1.27-1.37), 1.18 (95% CI, 1.14-1.22), 1.08 (95% CI, 1.04-1.13), and 1.05 (95% CI, 1.01-1.09) in model 2, respectively. These associations persisted across various subgroups of age, sex, and comorbidity status. CONCLUSION In this large nationwide cohort, lower income levels were associated with higher risk for incident CKD.
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Affiliation(s)
- Tae Ik Chang
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Hyunsun Lim
- Research and Analysis Team, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Cheol Ho Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange; Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA
| | - Ea Wha Kang
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Internal Medicine, College of Medicine, Severance Biomedical Science Institute, Brain Korea 21 PLUS, Yonsei University, Seoul, Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Olanbiwonnu T, Holden RM. Inorganic phosphate as a potential risk factor for chronic disease. CMAJ 2019; 190:E784-E785. [PMID: 29970366 DOI: 10.1503/cmaj.180525] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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18
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Barreto FC, Barreto DV, Massy ZA, Drüeke TB. Strategies for Phosphate Control in Patients With CKD. Kidney Int Rep 2019; 4:1043-1056. [PMID: 31440695 PMCID: PMC6698320 DOI: 10.1016/j.ekir.2019.06.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/27/2019] [Accepted: 06/03/2019] [Indexed: 02/08/2023] Open
Abstract
Hyperphosphatemia is a common complication in patients with chronic kidney disease (CKD), particularly in those requiring renal replacement therapy. The importance of controlling serum phosphate has long been recognized based on observational epidemiological studies that linked increased phosphate levels to adverse outcomes and higher mortality risk. Experimental data further supported the role of phosphate in the development of bone and cardiovascular diseases. Recent advances in our understanding of the mechanisms involved in phosphate homeostasis have made it clear that the serum phosphate concentration depends on a complex interplay among the kidneys, intestinal tract, and bone, and is tightly regulated by a complex endocrine system. Moreover, the source of dietary phosphate and the use of phosphate-based additives in industrialized foods are additional factors that are of particular importance in CKD. Not surprisingly, the management of hyperphosphatemia is difficult, and, despite a multifaceted approach, it remains unsuccessful in many patients. An additional issue is the fact that the supposedly beneficial effect of phosphate lowering on hard clinical outcomes in interventional trials is a matter of ongoing debate. In this review, we discuss currently available treatment approaches for controlling hyperphosphatemia, including dietary phosphate restriction, reduction of intestinal phosphate absorption, phosphate removal by dialysis, and management of renal osteodystrophy, with particular focus on practical challenges and limitations, and on potential benefits and harms.
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Affiliation(s)
- Fellype Carvalho Barreto
- Service of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Daniela Veit Barreto
- Service of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Ziad A Massy
- Institut National de la Santé et de la Recherche Médicale U-1018, Team 5, Centre de Recherche en Epidémiologie et Santé des Populations, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University), Paris-Sud University and Paris Saclay University, Villejuif, France.,Division of Nephrology, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne Billancourt/Paris, France
| | - Tilman B Drüeke
- Institut National de la Santé et de la Recherche Médicale U-1018, Team 5, Centre de Recherche en Epidémiologie et Santé des Populations, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University), Paris-Sud University and Paris Saclay University, Villejuif, France
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19
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Nerbass FB, Canzi ER, Araujo RDA, Corrêa D, Santos RGD, Vieira MA, Morais JG. Differences in phosphatemia and frequency of consumption of dietary sources of phosphorus in hemodialysis patients in southern and northern Brazil. J Bras Nefrol 2019. [PMCID: PMC6534029 DOI: 10.1590/2175-8239-jbn-2018-0063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Introduction: Hyperphosphatemia is associated with unfavorable outcomes, and the percentage of patients presenting with this condition in hemodialysis (HD) in kidney foundation units in the state of Santa Catarina (SC) is historically higher than that of patients in the state of Tocantins (TO). Objective: To assess the frequency of consumption of the main dietary sources of phosphorus and to compare them between the two states. Methodology: A cross-sectional study was carried out involving 123 patients, 66 of SC and 57 of TO: 52% were men, average age was 46.9 ± 15.7 years, and mean HD time 48 (57-71) months. A food frequency questionnaire (FFQ) with 33 items that are dietary sources of phosphorus was applied. A consumption score was calculated for sources of organic, inorganic, and total phosphorus, and the six-month average of phosphatemia was obtained. Results: The mean phosphatemia of SC patients was higher (6.2 ± 1.5 vs 4.7 ± 1.3 mg/dL, p <0001) than TO patients, as well as the prevalence of hyperphosphatemia (62% vs 28%; p <10001). In the total sample, the foods most frequently consumed were milk and beans. Comparing the frequency of consumption between the two states, a significant difference was found in 17 items. In TO, beef and beans were the foods most frequently consumed, and in SC, fourteen other items of the FFQ (pork, sausages, dairy products, etc.) were the most frequently consumed. Phosphatemia correlated with the frequency of consumption of inorganic phosphorus sources. Conclusion: the frequency of consumption of several items was different between the states, and this explains the differences in phosphatemia between the two regions.
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20
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Laster M, Soohoo M, Streja E, Elashoff R, Jernigan S, Langman CB, Norris KC, Salusky IB, Kalantar-Zadeh K. Racial-ethnic differences in chronic kidney disease-mineral bone disorder in youth on dialysis. Pediatr Nephrol 2019; 34:107-115. [PMID: 30267239 PMCID: PMC6420309 DOI: 10.1007/s00467-018-4048-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 07/02/2018] [Accepted: 08/07/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Studies in healthy pediatric populations and adults treated with dialysis demonstrate higher parathyroid hormone (PTH) and lower 25-hydroxyvitamin D levels in African-Americans. Despite these findings, African-Americans on dialysis demonstrate greater bone strength and a decreased risk of fracture compared to the Caucasian dialysis population. The presence of such differences in children and young adult dialysis patients is unknown. METHODS Differences in the markers of mineral and bone metabolism (MBM) were assessed in 661 incident dialysis patients (aged 1 month to < 21 years). Racial-ethnic differences in PTH, calcium, phosphate, and total alkaline phosphatase (AP) activity were analyzed over the first year of dialysis using multivariate linear mixed models. RESULTS African-American race predicted 23% higher serum PTH (95% CI, 4.7-41.3%) when compared to Caucasian patients, while Hispanic ethnicity predicted 17.5% higher PTH (95% CI, 2.3-38%). Upon gender stratification, the differences in PTH were magnified in African-American and Hispanic females: 38% (95% CI, 14.8-69.8%) and 28.8% (95% CI, 4.7-54.9%) higher PTH compared to Caucasian females. Despite higher PTH values, African-American females persistently demonstrated up to 10.9% lower serum AP activity (95% CI, - 20.6-- 0.7%). CONCLUSIONS There are racial-ethnic differences in the markers of MBM. Higher PTH is seen in African-American and Hispanic children and young adults on dialysis with a magnification of this difference amongst the female population. There is a need to consider how factors like race, ethnicity, and gender impact the goal-targeted treatment of MBM disorders.
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Affiliation(s)
- Marciana Laster
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA
- Division of Pediatric Nephrology, Mattel Children's Hospital at UCLA, Los Angeles, CA, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Robert Elashoff
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA
| | - Stephanie Jernigan
- Division of Pediatric Nephrology, Emory University School of Medicine, Atlanta, GA, USA
| | - Craig B Langman
- Feinberg School of Medicine, Northwestern University and the Anne and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Keith C Norris
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA
| | - Isidro B Salusky
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA.
- Division of Pediatric Nephrology, Mattel Children's Hospital at UCLA, Los Angeles, CA, USA.
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
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21
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Erem S, Razzaque MS. Dietary phosphate toxicity: an emerging global health concern. Histochem Cell Biol 2018; 150:711-719. [PMID: 30159784 DOI: 10.1007/s00418-018-1711-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2018] [Indexed: 12/27/2022]
Abstract
Phosphate is a common ingredient in many healthy foods but, it is also present in foods containing additives and preservatives. When found in foods, phosphate is absorbed in the intestines and filtered from the blood by the kidneys. Generally, any excess is excreted in the urine. In renal pathologies, however, such as chronic kidney disease, a reduced renal ability to excrete phosphate can result in excess accumulation in the body. This accumulation can be a catalyst for widespread damage to the cellular components, bones, and cardiovascular structures. This in turn can reduce mortality. Because of an incomplete understanding of the mechanism for phosphate homeostasis, and the multiple organ systems that can modulate it, treatment strategies designed to minimize phosphate burden are limited. The Recommended Dietary Allowance (RDA) for phosphorous is around 700 mg/day for adults, but the majority of healthy adult individuals consume far more phosphate (almost double) than the RDA. Studies suggest that low-income populations are particularly at risk for dietary phosphate overload because of the higher amounts of phosphate found in inexpensive, processed foods. Education in nutrition, as well as access to inexpensive healthy food options may reduce risks for excess consumption as well as a wide-range of disorders, ranging from cardiovascular diseases to kidney diseases to tumor formation. Pre-clinical and clinical studies suggest that dietary phosphate overload has toxic and prolonged adverse health effects. Improved regulations for reporting of phosphate concentrations on food labels are necessary so that people can make more informed choices about their diets and phosphate consumption. This is especially the case given the lack of treatments available to mitigate the short and long-term effects of dietary phosphate overload-related toxicity. Phosphate toxicity is quickly becoming a global health concern. Without measures in place to reduce dietary phosphate intake, the conditions associated with phosphate toxicity will likely to cause untold damage to the wellbeing of individuals around the world.
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Affiliation(s)
- Sarah Erem
- Department of Pathology, Saba University School of Medicine, Saba, Dutch Caribbean, The Netherlands
| | - Mohammed S Razzaque
- Department of Pathology, Saba University School of Medicine, Saba, Dutch Caribbean, The Netherlands.
- Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, USA.
- Department of Preventive and Community Dentistry, School of Dentistry, University of Rwanda College of Medicine & Health Sciences, Kigali, Rwanda.
- Department of Pathology, Lake Erie College of Osteopathic Medicine, 1858 West Grandview Boulevard, Room: B2-306, Erie, PA, 16509, USA.
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Correlation between Soluble α-Klotho and Renal Function in Patients with Chronic Kidney Disease: A Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9481475. [PMID: 30159331 PMCID: PMC6109492 DOI: 10.1155/2018/9481475] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 05/29/2018] [Accepted: 07/11/2018] [Indexed: 01/11/2023]
Abstract
Objective Over decades, numerous inconsistent studies are reported on the relationship between soluble α-Klotho and renal function in patients with chronic kidney disease (CKD). This study aims to perform a meta-analysis to figure out the correlations between soluble α-Klotho and renal function in patients with CKD. Materials and Methods We searched medical and scientific literature databases, PubMed and EMBASE (from the inception to October 2017), for publications that reported studies on associations between soluble α-Klotho and renal function in patients with CKD. Only publications in English were extracted. Summary correlation coefficient (r) values were extracted from each study, and 95% confidence intervals (CIs) were calculated. Publication bias was tested, and sensitivity and subgroup analyses were performed to investigate potential heterogeneity. Results Of 611 studies, 9 publications with 1457 patients were included into the analysis. The following data were extracted from the literature: first author, year of publication, research region, research index, sample size, average age and Pearson or Spearman correlation coefficient, study design, the αKlotho/FGF23 assays utilized, full length, or the C-terminal fragment of FGF23. The pooled r between α-Klotho and estimated glomerular filtration rate (eGFR), FGF-23 were 0.35 (95%CI, 0.23~0.46, and P<0.05), -0.10 (95%CI, -0.19~-0.01, and P<0.05) with remarkable significance, indicating moderate heterogeneity. There was no significant heterogeneity between subgroups in analyses of α-Klotho and eGFR stratified by research region, mean age, and eGFR, but heterogeneity exists in analyses of α-Klotho and FGF-23 stratified by research region. There was no significant correlation between a-klotho and Ca and PTH and PHOS. There was no evidence of publication bias with Egger's test (p=0.360) or with Begg's test (p=0.902) and the distribution of funnel plots was symmetrical in all of our analysis. Conclusions There exists a significant positive correlation between soluble α-Klotho and eGFR in patients with CKD. Also, a significant negative correlation between α-Klotho and FGF23 levels is proven. This raises hope to employ αKlotho and FGF23 as early biomarkers of CKD. However, further large prospective follow-up researches are needed to validate this hypothesis and to explore whether maintaining or elevating the Klotho level could improve renal function and complications in CKD patients.
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23
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Hernando N, Wagner CA. Mechanisms and Regulation of Intestinal Phosphate Absorption. Compr Physiol 2018; 8:1065-1090. [PMID: 29978897 DOI: 10.1002/cphy.c170024] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
States of hypo- and hyperphosphatemia have deleterious consequences including rickets/osteomalacia and renal/cardiovascular disease, respectively. Therefore, the maintenance of appropriate plasma levels of phosphate is an essential requirement for health. This control is executed by the collaborative action of intestine and kidney whose capacities to (re)absorb phosphate are regulated by a number of hormonal and metabolic factors, among them parathyroid hormone, fibroblast growth factor 23, 1,25(OH)2 vitamin D3 , and dietary phosphate. The molecular mechanisms responsible for the transepithelial transport of phosphate across enterocytes are only partially understood. Indeed, whereas renal reabsorption entirely relies on well-characterized active transport mechanisms of phosphate across the renal proximal epithelia, intestinal absorption proceeds via active and passive mechanisms, with the molecular identity of the passive component still unknown. The active absorption of phosphate depends mostly on the activity and expression of the sodium-dependent phosphate cotransporter NaPi-IIb (SLC34A2), which is highly regulated by many of the factors, mentioned earlier. Physiologically, the contribution of NaPi-IIb to the maintenance of phosphate balance appears to be mostly relevant during periods of low phosphate availability. Therefore, its role in individuals living in industrialized societies with high phosphate intake is probably less relevant. Importantly, small increases in plasma phosphate, even within normal range, associate with higher risk of cardiovascular disease. Therefore, therapeutic approaches to treat hyperphosphatemia, including dietary phosphate restriction and phosphate binders, aim at reducing intestinal absorption. Here we review the current state of research in the field. © 2017 American Physiological Society. Compr Physiol 8:1065-1090, 2018.
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Affiliation(s)
- Nati Hernando
- National Center for Competence in Research NCCR Kidney.CH, Institute of Physiology, University Zurich-Irchel, Zurich, Switzerland
| | - Carsten A Wagner
- National Center for Competence in Research NCCR Kidney.CH, Institute of Physiology, University Zurich-Irchel, Zurich, Switzerland
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Covic A, Vervloet M, Massy ZA, Torres PU, Goldsmith D, Brandenburg V, Mazzaferro S, Evenepoel P, Bover J, Apetrii M, Cozzolino M. Bone and mineral disorders in chronic kidney disease: implications for cardiovascular health and ageing in the general population. Lancet Diabetes Endocrinol 2018; 6:319-331. [PMID: 29050900 DOI: 10.1016/s2213-8587(17)30310-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 07/17/2017] [Accepted: 08/10/2017] [Indexed: 12/11/2022]
Abstract
The patient with chronic kidney disease (CKD) represents an extreme model for arteriosclerosis, vascular calcification, and bone disorders, all of which are also associated with ageing in the general population. These pathological features are also relevant to other common chronic health disorders such as diabetes, and chronic inflammatory and cardiovascular diseases. Although management and interventions for these major risk factors are now incorporated into most public health guidelines (eg, smoking cessation and control of bodyweight and blood pressure, as well as glucose and cholesterol concentrations), some residual cardiovascular risk is not reduced by implementation of these interventions. CKD should be regarded as an atypical disease in which both traditional and novel cardiovascular risk factors have effects on outcomes. But CKD can also be viewed conceptually as an accelerator of traditional cardiovascular risk factors. Findings from research into mineral bone disorder associated with CKD (CKD-MBD) could help the medical community to better understand the vascular actions of certain molecules, such as phosphates, fibroblast growth factor 23, parathyroid hormone, sclerostin, or vitamin D and their relevance to the management of different pathologies in the general population. Importantly, these components, which are recognised in nephrology, could help to explain residual risk of cardiovascular events in the general population. Thus, achieving a better understanding of CKD-MBDs could provide substantial insight into future treatments for arteriosclerosis and osteoporosis, which are strongly associated with ageing and morbidity in the general population.
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Affiliation(s)
- Adrian Covic
- Department of Nephrology, Grigore T Popa University of Medicine and Pharmacy, Iasi, Romania.
| | - Marc Vervloet
- Department of Nephrology and Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, Netherlands
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré Hospital, Paris Ile de France Ouest Université, Paris, France; Inserm U1018, Université Paris-Saclay, Versailles Saint-Quentin-en-Yvelines University, Villejuif, France
| | - Pablo Ureña Torres
- Department of Nephrology and Dialysis, Ramsay-Générale de Santé, Necker Hospital, University of Paris Descartes, Paris, France
| | | | - Vincent Brandenburg
- Department of Cardiology and Intensive Care Medicine, RWTH University Hospital, Aachen, Germany
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Pieter Evenepoel
- Department of Medicine, Division of Nephrology, Dialysis and Renal Transplantation, University Hospital Leuven, Leuven, Belgium
| | - Jordi Bover
- Fundació Puigvert, IIB Sant Pau, REDinREN, Barcelona, Spain
| | - Mugurel Apetrii
- Department of Nephrology, Grigore T Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, San Paolo Hospital, University of Milan, Milan, Italy
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Cooke A. Dietary Food-Additive Phosphate and Human Health Outcomes. Compr Rev Food Sci Food Saf 2017; 16:906-1021. [PMID: 33371609 DOI: 10.1111/1541-4337.12275] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/12/2017] [Accepted: 05/17/2017] [Indexed: 01/19/2023]
Abstract
Dietary intake of phosphorus is required for human health, and dietary reference intakes for phosphorus have been established. Food-grade phosphates are used as additives to provide a wide range of technical functions in food production. Phosphates are often the most efficient ingredients to provide the required functionality in many applications, and in some cases, there are not effective and approved alternatives. However, many investigators have expressed concern about the quantities of phosphorus and food-additive phosphate present in the diets of many populations. This paper presents the outcome of an extensive review of 110 primary research articles focused on identifying evidence that substantiates or refutes associations of total dietary phosphorus and food-additive phosphate intake with health and disease in humans. The lack of conclusive evidence prevented the drawing of firm conclusions about the safety and possible risks of food-additive phosphate in the general population, which is consonant with the overall assessments of authoritative institutions who have concluded that available data are insufficient to make the required determinations. Despite the inadequacy of the evidence currently available, many of the authors of the publications reviewed for this paper expressed concerns about the quantities of phosphorus and food-additive phosphate in the diets of the populations and subpopulations they studied. At the same time, most of these authors offered only qualified conclusions and expressed themselves tentatively. In addition, authors of primary research publications, authors of review articles, and authoritative institutions have called for the conduct of further research.
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Affiliation(s)
- Allison Cooke
- Intl. Food Additives Council, 529 14th St. NW, Suite 750, Washington, DC, 20045, U.S.A
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Abstract
The discovery of fibroblast growth factor 23 (FGF23) has provided a more complete understanding of the regulation of phosphate and mineral homeostasis in health and in chronic kidney disease. It has also offered new insights into stratification of risk of cardiovascular events and death among patients with chronic kidney disease and the general population. In this review, we provide an overview of FGF23 biology and physiology, summarize clinical outcomes that have been associated with FGF23, discuss potential mechanisms for these observations and their public health implications, and explore clinical and population health interventions that aim to reduce FGF23 levels and improve public health.
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Affiliation(s)
- Lindsay R Pool
- Center for Translational Health and Metabolism, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611;
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina 27703;
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Kawate Y, Miyata H. The importance of nutritional intervention by dietitians for hyperphosphatemia in maintained hemodialysis patients. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0095-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Kim H, Yoo TH, Choi KH, Oh KH, Lee J, Kim SW, Kim TH, Sung S, Han SH. Baseline Cardiovascular Characteristics of Adult Patients with Chronic Kidney Disease from the KoreaN Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD). J Korean Med Sci 2017; 32:231-239. [PMID: 28049233 PMCID: PMC5219988 DOI: 10.3346/jkms.2017.32.2.231] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/11/2016] [Indexed: 01/17/2023] Open
Abstract
Cardiovascular disease (CVD) is the most common cause of death in patients with chronic kidney disease (CKD). We report the baseline cardiovascular characteristics of 2,238 participants by using the data of the KoreaN Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD) study. The cohort comprises 5 subcohorts according to the cause of CKD: glomerulonephritis (GN), diabetic nephropathy (DN), hypertensive nephropathy (HTN), polycystic kidney disease (PKD), and unclassified. The average estimated glomerular filtration rate (eGFR) was 50.5 ± 30.3 mL/min⁻¹/1.73 m⁻² and lowest in the DN subcohort. The overall prevalence of previous CVD was 14.4% in all patients, and was highest in the DN followed by that in the HTN subcohort. The DN subcohort had more adverse cardiovascular risk profiles (higher systolic blood pressure [SBP], and higher levels of cardiac troponin T, left ventricular mass index [LVMI], coronary calcium score, and brachial-ankle pulse wave velocity [baPWV]) than the other subcohorts. The HTN subcohort exhibited less severe cardiovascular risk profiles than the DN subcohort, but had more severe cardiovascular risk features than the GN and PKD subcohorts. All these cardiovascular risk profiles were inversely correlated with eGFR. In conclusion, this study shows that the KNOW-CKD cohort exhibits high cardiovascular burden, as other CKD cohorts in previous studies. Among the subcohorts, the DN subcohort had the highest risk for CVD. The ongoing long-term follow-up study up to 10 years will further delineate cardiovascular characteristics and outcomes of each subcohort exposed to different risk profiles.
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Affiliation(s)
- Hyoungnae Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hyun Yoo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu Hun Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kook Hwan Oh
- Department of Internal Medicine, Seoul National University, Seoul, Korea
| | - Joongyub Lee
- Medical Research Collaborating Center, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Tae Hee Kim
- Department of Internal Medicine, Inje University, Pusan Paik Hospital, Busan, Korea
| | - Suah Sung
- Department of Internal Medicine, Eulji Medical Center, Eulji University, Seoul, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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Kang E, Han M, Kim H, Park SK, Lee J, Hyun YY, Kim YS, Chung W, Kim HJ, Oh YK, Ahn C, Oh KH. Baseline General Characteristics of the Korean Chronic Kidney Disease: Report from the KoreaN Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD). J Korean Med Sci 2017; 32:221-230. [PMID: 28049232 PMCID: PMC5219987 DOI: 10.3346/jkms.2017.32.2.221] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 11/11/2016] [Indexed: 12/29/2022] Open
Abstract
The KoreaN Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD) was developed to investigate various clinical courses and risk factors for progression of Korean chronic kidney disease (CKD). The KNOW-CKD study consists of nine clinical centers in Korea, and patients aged between 20 and 75 years with CKD from stage 1 to 5 (predialysis) were recruited. At baseline, blood and urine samples were obtained and demographic data including comorbidities, drugs, quality of life, and health behaviors were collected. Estimated glomerular filtration rate (eGFR) was calculated by 4-variable Modification of Diet in Renal Disease (MDRD) equation using isotope dilution mass spectrometry (IDMS)-calibrated serum creatinine measured at a central laboratory. As a dynamic cohort, a total of 2,341 patients were enrolled during the enrollment period from 2011 until 2015, among whom 2,238 subjects were finally analyzed for baseline profiles. The mean age of the cohort was 53.7 ± 12.2 year and 61.2% were men. Mean eGFR was 50.5 ± 30.3 mL/min/1.73 m². The participants with lower eGFR had a tendency to be older, with more comorbidities, to have higher systolic blood pressure (BP) and pulse pressure, with lower income level and education attainment. The patients categorized as glomerulonephritis (GN) were 36.2% followed by diabetic nephropathy (DN, 23.2%), hypertensive nephropathy (HTN, 18.3%), polycystic kidney disease (PKD, 16.3%), and other unclassified disease (6.1%). The KNOW-CKD participants will be longitudinally followed for 10 years. The study will provide better understanding for physicians regarding clinical outcomes, especially renal and cardiovascular outcomes in CKD patients.
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Affiliation(s)
- Eunjeong Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Miyeun Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyunsuk Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sue Kyung Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Joongyub Lee
- Medical Research Collaborating Center, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Young Youl Hyun
- Division of Nephrology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Soo Kim
- Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Wookyung Chung
- Department of Internal Medicine, Gachon University, Gil Hospital, Incheon, Korea
| | - Hyo Jin Kim
- Department of Internal Medicine, Dongguk University Gyeongju Hospital, Gyeongju, Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kook Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
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Copland M, Komenda P, Weinhandl ED, McCullough PA, Morfin JA. Intensive Hemodialysis, Mineral and Bone Disorder, and Phosphate Binder Use. Am J Kidney Dis 2016; 68:S24-S32. [DOI: 10.1053/j.ajkd.2016.05.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/25/2016] [Indexed: 12/17/2022]
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Taylor JM, Oladitan L, Degnan A, Henderson S, Dai H, Warady BA. Psychosocial Factors That Create Barriers to Managing Serum Phosphorus Levels in Pediatric Dialysis Patients: A Retrospective Analysis. J Ren Nutr 2016; 26:270-5. [PMID: 26993357 DOI: 10.1053/j.jrn.2016.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/03/2016] [Accepted: 02/06/2016] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Abnormal phosphorus homeostasis is among the medley of metabolic disturbances commonly associated with chronic kidney disease. We sought to determine the psychosocial factors that create barriers to controlling serum phosphorus levels in children on dialysis and to evaluate the perceptions of children and caregivers on the ease or difficulty of following a dietary phosphorus restriction and taking phosphorus binder medications. DESIGN Single center cross-sectional study. SETTING Pediatric dialysis unit at a children's hospital. SUBJECTS Forty-eight patients on chronic hemodialysis or peritoneal dialysis (mean age: 11.03 ± 6.88 years; 69% male). MAIN OUTCOME MEASURE Serum phosphorus levels were recorded from electronic health records and converted to a mean phosphorus standard deviation score (SDS) for each individual. Mean phosphorus SDS values were compared to each independent categorical variable using an analysis of variance test, continuous variables were analyzed using linear regression, and logistic regression was used to determine odds ratios. RESULTS There was a significant relationship between age and phosphorus SDS (P < .001), with patients over 13 years of age having the highest prevalence of hyperphosphatemia (88%). Patients and caregivers who identified phosphorus levels as "controlled" had lower phosphorus SDS values compared to the other subjects (P = .003). However, of the patients and caregivers who reported that serum phosphorus levels were "controlled," 46% were hyperphosphatemic. Furthermore, 73% and 87% of patients and caregivers reported that following a phosphorus-restricted diet and taking phosphorus binders were "easy"; yet, 40% and 49% of these patients were hyperphosphatemic, respectively. CONCLUSION In the present study, elevated serum phosphorus levels were most common in adolescent dialysis patients. There also appears to be a disconnect between the perceived ease of following a phosphorus-restricted diet and taking phosphorus binders and the achievement of normal serum phosphorus levels. These data further emphasize the importance of ongoing education regarding dietary and medical management requirements.
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Affiliation(s)
- Jacob M Taylor
- Department of Nutrition Services, Children's Mercy Hospital, Kansas City, Missouri 64108; KU Department of Dietetics & Nutrition, School of Health Professions, University of Kansas Medical Center, Kansas City, Kansas 66160.
| | - Leah Oladitan
- Department of Nutrition Services, Children's Mercy Hospital, Kansas City, Missouri 64108
| | - Angela Degnan
- Department of Social Work, Children's Mercy Hospital, Kansas City, Missouri 64108
| | - Sarah Henderson
- Department of Social Work, Children's Mercy Hospital, Kansas City, Missouri 64108
| | - Hongying Dai
- Department of Health Outcomes Research, Children's Mercy Hospital, Kansas City, Missouri 64108
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, Missouri 64108
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Gutiérrez OM, Parsa A, Isakova T, Scialla JJ, Chen J, Flack JM, Nessel LC, Gupta J, Bellovich KA, Steigerwalt S, Sondheimer JH, Wright JT, Feldman HI, Kusek JW, Lash JP, Wolf M. Genetic African Ancestry and Markers of Mineral Metabolism in CKD. Clin J Am Soc Nephrol 2016; 11:653-62. [PMID: 26912553 DOI: 10.2215/cjn.08020715] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 01/05/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Disorders of mineral metabolism are more common in African Americans with CKD than in European Americans with CKD. Previous studies have focused on the differences in mineral metabolism by self-reported race, making it difficult to delineate the importance of environmental compared with biologic factors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a cross-sectional analysis of 3013 participants of the Chronic Renal Insufficiency Cohort study with complete data, we compared markers of mineral metabolism (phosphorus, calcium, alkaline phosphatase, parathyroid hormone, fibroblast growth factor 23, and urine calcium and phosphorus excretion) in European Americans versus African Americans and separately, across quartiles of genetic African ancestry in African Americans (n=1490). RESULTS Compared with European Americans, African Americans had higher blood concentrations of phosphorus, alkaline phosphatase, fibroblast growth factor 23, and parathyroid hormone, lower 24-hour urinary excretion of calcium and phosphorus, and lower urinary fractional excretion of calcium and phosphorus at baseline (P<0.001 for all). Among African Americans, a higher percentage of African ancestry was associated with lower 24-hour urinary excretion of phosphorus (Ptrend<0.01) in unadjusted analyses. In linear regression models adjusted for socio-demographic characteristics, kidney function, serum phosphorus, and dietary phosphorus intake, higher percentage of African ancestry was significantly associated with lower 24-hour urinary phosphorus excretion (each 10% higher African ancestry was associated with 39.6 mg lower 24-hour urinary phosphorus, P<0.001) and fractional excretion of phosphorus (each 10% higher African ancestry was associated with an absolute 1.1% lower fractional excretion of phosphorus, P=0.01). CONCLUSIONS A higher percentage of African ancestry was independently associated with lower 24-hour urinary phosphorus excretion and lower fractional excretion of phosphorus among African Americans with CKD. These findings suggest that genetic variability might contribute to racial differences in urinary phosphorus excretion in CKD.
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Affiliation(s)
- Orlando M Gutiérrez
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
| | - Afshin Parsa
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Tamara Isakova
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Julia J Scialla
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Jing Chen
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - John M Flack
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Lisa C Nessel
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Jayanta Gupta
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Keith A Bellovich
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Susan Steigerwalt
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - James H Sondheimer
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Jackson T Wright
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Harold I Feldman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - John W Kusek
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - James P Lash
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Myles Wolf
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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33
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Norton J. Health Disparities in Chronic Kidney Disease. PHYSICIAN ASSISTANT CLINICS 2016. [DOI: 10.1016/j.cpha.2015.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Solbu MD, Thomson PC, Macpherson S, Findlay MD, Stevens KK, Patel RK, Padmanabhan S, Jardine AG, Mark PB. Serum phosphate and social deprivation independently predict all-cause mortality in chronic kidney disease. BMC Nephrol 2015; 16:194. [PMID: 26627078 PMCID: PMC4666082 DOI: 10.1186/s12882-015-0187-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 11/13/2015] [Indexed: 01/13/2023] Open
Abstract
Background Hyperphosphataemia is linked to cardiovascular disease and mortality in chronic kidney disease (CKD). Outcome in CKD is also affected by socioeconomic status. The objective of this study was to assess the associations between serum phosphate, multiple deprivation and outcome in CKD patients. Methods All adult patients currently not on renal replacement therapy (RRT), with first time attendance to the renal outpatient clinics in the Glasgow area between July 2010 and June 2014, were included in this prospective study. Area socioeconomic status was assessed as quintiles of the Scottish Index of Multiple Deprivation (SIMD). Outcomes were all-cause and cardiovascular mortality and commencement of RRT. Results The cohort included 2950 patients with a median (interquartile range) age 67.6 (53.6–76.9) years. Median (interquartile range) eGFR was 38.1 (26.3–63.5) ml/min/1.73 m2, mean (±standard deviation) phosphate was 1.13 (±0.24) mmol/L and 31.6 % belonged to the most deprived quintile (SIMD quintile I). During follow-up 375 patients died and 98 commenced RRT. Phosphate ≥1.50 mmol/L was associated with all-cause (hazard ratio (HR) 2.51; 95 % confidence interval (CI) 1.63-3.89) and cardiovascular (HR 5.05; 95 % CI 1.90–13.46) mortality when compared to phosphate 0.90–1.09 mmol/L in multivariable analyses. SIMD quintile I was independently associated with all-cause mortality. Phosphate did not weaken the association between deprivation index and mortality, and there was no interaction between phosphate and SIMD quintiles. Neither phosphate nor SIMD predicted commencement of RRT. Conclusions Multiple deprivation and serum phosphate were strong, independent predictors of all-cause mortality in CKD and showed no interaction. Phosphate also predicted cardiovascular mortality. The results suggest that phosphate lowering should be pursued regardless of socioeconomic status.
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Affiliation(s)
- Marit D Solbu
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK. .,Section of Nephrology, University Hospital of North Norway, N-9038, Tromsø, Norway.
| | - Peter C Thomson
- Glasgow Renal & Transplant Unit, The Queen Elizabeth University Hospital, Glasgow, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Sarah Macpherson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| | - Mark D Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK. .,Glasgow Renal & Transplant Unit, The Queen Elizabeth University Hospital, Glasgow, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Kathryn K Stevens
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK. .,Glasgow Renal & Transplant Unit, The Queen Elizabeth University Hospital, Glasgow, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Rajan K Patel
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK. .,Glasgow Renal & Transplant Unit, The Queen Elizabeth University Hospital, Glasgow, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Sandosh Padmanabhan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK. .,Glasgow Renal & Transplant Unit, The Queen Elizabeth University Hospital, Glasgow, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK. .,Glasgow Renal & Transplant Unit, The Queen Elizabeth University Hospital, Glasgow, 1345 Govan Road, Glasgow, G51 4TF, UK.
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Wolf M. Mineral (Mal)Adaptation to Kidney Disease--Young Investigator Award Address: American Society of Nephrology Kidney Week 2014. Clin J Am Soc Nephrol 2015; 10:1875-85. [PMID: 26350436 PMCID: PMC4594069 DOI: 10.2215/cjn.04430415] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In the short time since its initial discovery as the cause of rare hypophosphatemic disorders, fibroblast growth factor-23 (FGF-23) has emerged as a major regulator of mineral metabolism and critical component of the bone and mineral adaptation to CKD. However, because elevated FGF-23 levels are also a novel biomarker and possible molecular mediator of increased risks of cardiovascular disease and death in CKD, the initially adaptive response to increase FGF-23 levels to maintain neutral phosphate balance in CKD may ultimately become maladaptive. Incorporating FGF-23 into understanding the complex physiology that governs normal bone and mineral metabolism and its alterations in CKD has filled critical knowledge gaps and opened a new landscape of exciting hypotheses and novel therapeutic strategies to be tested in the continued quest to alleviate the burden of CKD.
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Affiliation(s)
- Myles Wolf
- Division of Nephrology and Hypertension, Department of Medicine, and Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Kumar VA, Tilluckdharry N, Xue H, Sidell MA. Serum Phosphorus Levels, Race, and Socioeconomic Status in Incident Hemodialysis Patients. J Ren Nutr 2015; 26:10-7. [PMID: 26316276 DOI: 10.1053/j.jrn.2015.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 06/30/2015] [Accepted: 07/09/2015] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE We sought to examine the relationship between race, socioeconomic status, and serum phosphorus levels in patients with end-stage renal disease incident to hemodialysis (HD) at a large, integrated health-care delivery system in Southern California. DESIGN Retrospective cohort study. SUBJECTS A total of 5,778 adult patients who initiated HD at our institution between January 1, 2007 and June 30, 2013. MAIN OUTCOME MEASURES Unadjusted and adjusted time-averaged serum phosphorus levels and actual phosphorus levels over time. Phosphorus levels were also analyzed by repeated measures as a continuous measure and by phosphorus category. Baseline patient covariates included age, self-reported race, gender, cause of end-stage renal disease, and Charlson comorbidity index scores. Education and income level were estimated using geocoded data. RESULTS A total of 68,372 phosphorus levels were available for 4,862 patients. Estimated annual family income fell below $40,001 in 66.1% of African Americans (AAs) and 62.7% of Hispanics compared with 43.5% of Asians and 43.7% of whites, P < .0001. Educational level fell into the highest category for whites (70.8%) compared with AA (44.8%) or Hispanic (30.5%) patients, P < .0001. Adjusted time-averaged phosphorus levels were lower among Hispanics (4.33 mg/dL, 95% confidence interval [CI] 4.27-4.40) compared with Asian (4.54 mg/dL, 95% CI 4.45-4.64, P < .001) and white patients (4.48 mg/dL, 95% CI 4.43-4.54, P < .001) but similar to AA patients. Asian patients experienced a significant increase in phosphorus levels over time (0.11 mg/dL per year, P < .0001). There were no significant effects of race, time, or race by time interactions in the unadjusted and adjusted categorical analyses of phosphorus levels. CONCLUSIONS Our findings suggest that serum phosphorus levels are similar among HD patients, irrespective of race or socioeconomic status.
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Affiliation(s)
- Victoria A Kumar
- Division of Nephrology, Department of Internal Medicine, Kaiser Permanente, Los Angeles, California.
| | - Natasha Tilluckdharry
- Division of Nephrology, Department of Internal Medicine, Kaiser Permanente, Los Angeles, California
| | - Hui Xue
- Division of Nephrology, Department of Internal Medicine, Kaiser Permanente, San Diego, California
| | - Margo A Sidell
- Department of Research and Evaluation, Kaiser Permanente, Pasadena, California
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Denker M, Boyle S, Anderson AH, Appel LJ, Chen J, Fink JC, Flack J, Go AS, Horwitz E, Hsu CY, Kusek JW, Lash JP, Navaneethan S, Ojo AO, Rahman M, Steigerwalt SP, Townsend RR, Feldman HI. Chronic Renal Insufficiency Cohort Study (CRIC): Overview and Summary of Selected Findings. Clin J Am Soc Nephrol 2015; 10:2073-83. [PMID: 26265715 DOI: 10.2215/cjn.04260415] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The Chronic Renal Insufficiency Cohort (CRIC) Study is a United States multicenter, prospective study of racially and ethnically diverse patients with CKD. Although the original aims of the study were to identify novel predictors of CKD progression and to elucidate the risk and manifestations of cardiovascular disease among nearly 4000 individuals with CKD, the CRIC Study has evolved into a national resource for investigation of a broad spectrum of CKD-related topics. The study has produced >90 published scientific articles, promoted many young investigative careers in nephrology, and fostered international collaborations focused on understanding the global burden of CKD. The third phase of the CRIC Study will complete enrollment of 1500 additional study participants in 2015 and is designed to answer questions regarding morbidity and mortality in mild-to-moderate CKD and to assess the burden of CKD in older persons. This review highlights some of the salient findings of the CRIC Study in the areas of race and ethnicity, CKD progression, CKD and cognition, and cardiovascular disease outcomes; it also outlines the ongoing and forthcoming opportunities for the global nephrology community to enhance its understanding of CKD and related complications through the study.
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Affiliation(s)
- Matthew Denker
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Suzanne Boyle
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Amanda H Anderson
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Lawrence J Appel
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Jing Chen
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Jeffrey C Fink
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - John Flack
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Alan S Go
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Edward Horwitz
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Chi-Yuan Hsu
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - John W Kusek
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - James P Lash
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Sankar Navaneethan
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Akinlolu O Ojo
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Mahboob Rahman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Susan P Steigerwalt
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Raymond R Townsend
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Harold I Feldman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
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38
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Moore LW, Nolte JV, Gaber AO, Suki WN. Association of dietary phosphate and serum phosphorus concentration by levels of kidney function. Am J Clin Nutr 2015; 102:444-53. [PMID: 26040641 DOI: 10.3945/ajcn.114.102715] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 05/01/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The health implications of dietary phosphorus intake and the role of kidney function in managing serum phosphorus homeostasis are well studied. However, examining the source of dietary phosphorus intake and its impact on serum phosphorus has not been characterized in population studies. OBJECTIVE This study aimed to distinguish the association of food sources of organic phosphorus and inorganic phosphate additives with serum phosphorus concentration. DESIGN A cross-sectional analysis of 24-h food recall data from 7895 adult participants in the National Health and Nutrition Examination Survey 2003-2006 was performed. Phosphorus content of foods was categorized as organic or inorganic. Correlations of serum phosphorus to clinical and dietary intake variables were achieved by using multiple regression analysis. RESULTS After controlling for estimated glomerular filtration rate (eGFR), body mass index (BMI; in kg/m²), and albumin-to-creatinine ratio, a significant increase in serum phosphorus occurred with dairy foods with inorganic phosphates [parameter estimate (PE) ± SE: 0.07 ± 0.02 mg/dL, P < 0.01] or without inorganic phosphates (PE: 0.02 ± 0.01, P < 0.001) and cereals/grains with inorganic phosphates (PE: 0.005 ± 0.002, P < 0.01). Significantly higher serum phosphorus occurred when eGRF was <30 (PE: 0.24 ± 0.08, P < 0.0001), but eGFR 30-44 (PE: -0.11 ± 0.04, P < 0.01) and 45-60 (PE: -0.10 ± 0.04, P < 0.01) were associated with lower serum phosphorus; higher serum phosphorus was associated with BMI <18.5 (PE: 0.18 ± 0.05, P = 0.0009) but lower with BMI ≥35-39 (PE: -0.09 ± 0.03, P = 0.0013) or ≥40 (PE: -0.10 ± 0.03, P = 0.014). CONCLUSIONS This analysis shows that dairy products and cereals/grains having inorganic phosphate additives significantly increase serum phosphorus concentration, despite being consumed less frequently than foods without phosphate additives. It seems prudent for the Nutrient Facts Label to include phosphorus but also for food manufacturers to consider alternatives to phosphate additives.
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Affiliation(s)
| | | | | | - Wadi N Suki
- Medicine, Houston Methodist Hospital, Houston, TX
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Santoro D, Ingegnieri MT, Vita G, Lucisano S, Zuppardo C, Canale V, Savica V, Buemi M. Socio-Economic Factors, Food Habits and Phosphorus Levels in Patients on Hemodialysis. Nephrourol Mon 2015; 7:e27114. [PMID: 26539414 PMCID: PMC4628210 DOI: 10.5812/numonthly.27114] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 02/07/2015] [Accepted: 02/14/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Hyperphosphoremia is one of the most important risk factors for morbidity and mortality for chronic kidney disease (CKD) patients, and also, for the general population. Excessive dietary intake of phosphate (P) is one of the key factors. In particular, P in its inorganic form, which is contained in food additives, is more readily absorbed. Unfortunately, these food additives are mostly present in convenience so called "fast foods" (pre-cooked), soft drinks, which represent the typical food consumed by our hemodialysis (HD) population, composed by elderly people, mostly low-socio economic class, who often live alone. OBJECTIVES We performed an observational retrospective multicenter study to find any association between social, cultural and economic situation, as well as food habits, and P levels in a cohort of patients on HD. Secondarily; we also examined the association between the fast food consumption and increased P levels, as well as patient compliance for P binding products. PATIENTS AND METHODS To explore the association between socio-economic factors and serum P levels, we enrolled 100 patients on periodic HD treatment from three different units. Information on social, cultural, economic, diet habits, therapy for hyperphosphoremia and hematological and clinical parameters had been collected through specific questionnaires, administered by a physician. RESULTS Results showed serum P level was reduced in patients who live alone compared to patients in family (P = 0.04), in self-sufficient (P = 0.05) and in patients belonging to middle-upper class, versus low-class (P = 0.003). Fast foods intake correlates with increase in P serum levels (P = 0.002), whilst the same correlation was not found for cheese intake. Our data show that socio-economic status and food habits are useful predictors of P serum levels. CONCLUSIONS In conclusion, dietary counseling of patients on HD is mandatory. Interventions that consider the socio-economic situation allow delivering important messages on foods with the least amount of P and adequate protein content, and they may be a successful strategy in targeting patients at a higher risk of hyperphosphoremia.
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Affiliation(s)
- Domenico Santoro
- Department of Clinical and Experimental Medicine, AOU G MArtino University of Messina, Messina, Italy
- Corresponding author: Domenico Santoro, Department of Clinical and Experimental Medicine, AOU G MArtino University of Messina, P. O. Box: 98100, Messina, Italy. Tel/Fax: +39-0902212331, E-mail:
| | - Maria Teresa Ingegnieri
- Department of Clinical and Experimental Medicine, AOU G MArtino University of Messina, Messina, Italy
| | - Giuseppe Vita
- Department of Clinical and Experimental Medicine, AOU G MArtino University of Messina, Messina, Italy
| | - Silvia Lucisano
- Department of Clinical and Experimental Medicine, AOU G MArtino University of Messina, Messina, Italy
| | - Carmelo Zuppardo
- Department of Clinical and Experimental Medicine, AOU G MArtino University of Messina, Messina, Italy
| | - Valeria Canale
- Department of Clinical and Experimental Medicine, AOU G MArtino University of Messina, Messina, Italy
| | - Vincenzo Savica
- Department of Clinical and Experimental Medicine, AOU G MArtino University of Messina, Messina, Italy
| | - Michele Buemi
- Department of Clinical and Experimental Medicine, AOU G MArtino University of Messina, Messina, Italy
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40
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Cease AJ, Capps KA, Gates KK, McCrackin ML, Nidzgorski DA. Consumer-driven nutrient dynamics in urban environments: the stoichiometry of human diets and waste management. OIKOS 2015. [DOI: 10.1111/oik.02391] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Arianne J. Cease
- School of Sustainability, Arizona State Univ.; Tempe, AZ 85287 USA
| | - Krista A. Capps
- Dept of Wildlife, Fisheries and Conservation Biology; Univ. of Maine; Orono, ME 04473 USA
| | - Kiza K. Gates
- Oklahoma Biological Survey and the Univ. of Oklahoma; Norman, OK 73019 USA
| | | | - Daniel A. Nidzgorski
- Dept of Ecology, Evolution and Behavior; Univ. of Minnesota; Saint Paul MN 55108 USA
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41
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Kim GH. Gaps between Global Guidelines and Local Practices in CKD-MBD. Electrolyte Blood Press 2015; 12:35-40. [PMID: 25606042 PMCID: PMC4297702 DOI: 10.5049/ebp.2014.12.2.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 12/26/2014] [Indexed: 01/09/2023] Open
Abstract
The term 'chronic kidney disease-mineral bone disorder' (CKD-MBD) is a new term that, in contrast to the old term 'renal osteodystrophy', implies a systemic syndrome associated with cardiovascular morbidity and mortality. This new terminology is in line with previous studies that show elevated serum calcium, phosphorus, and parathyroid hormone (PTH) levels associated with increased cardiovascular and all-cause mortality. In order to improve outcomes in patients with CKD-MBD, many countries have developed clinical practice guidelines. Globally, the Kidney Disease Outcome Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) guidelines are the most commonly used. However, whether these global guidelines can be successfully implemented on a local level needs to be studied. Differences in medical care and social factors between countries may limit the generalizability of global guidelines. Reports from the Korean registry and the Dialysis Outcomes and Practice Patterns Study (DOPPS) suggest that many dialysis patients are not within the target ranges recommended by the KDOQI and KDIGO guidelines for serum calcium, phosphorus, and PTH, suggesting gaps between global guidelines and local practices. Clinical studies with Korean CKD-MBD patients are necessary to compare Korean practices and outcomes to those suggested by global guidelines and to determine the target serum mineral levels associated with the best local outcomes.
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Affiliation(s)
- Gheun-Ho Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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42
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Gutiérrez OM. Contextual poverty, nutrition, and chronic kidney disease. Adv Chronic Kidney Dis 2015; 22:31-8. [PMID: 25573510 DOI: 10.1053/j.ackd.2014.05.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 05/07/2014] [Accepted: 05/22/2014] [Indexed: 12/18/2022]
Abstract
Nutrition plays an important role in CKD outcomes. One of the strongest factors that affects nutrition is socioeconomic status as evidenced by the large body of epidemiologic data showing that income and education are directly associated with diet quality. Apart from individual-level markers of socioeconomic status such as income and education, contextual factors such as availability of and transportation to food outlets that provide healthy food options and the density of fast-food restaurants within particular regions markedly affect the ability of individuals to comply with nutrition recommendations. This is particularly true for nutrition guidelines most specific to individuals with CKD such as the consumption of protein, saturated fat, sodium, and phosphorus, all of which have been shown to affect CKD health and are influenced by the availability of healthy food options within individual neighborhood food environments. Because of the strong association of contextual poverty with the diet quality, any serious attempt to improve the diet of CKD patients must include a discussion of the environmental barriers that each individual faces in trying to access healthy foods, and health care providers should take account of these barriers when tailoring specific recommendations.
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43
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Galassi A, Cupisti A, Santoro A, Cozzolino M. Phosphate balance in ESRD: diet, dialysis and binders against the low evident masked pool. J Nephrol 2014; 28:415-29. [PMID: 25245472 DOI: 10.1007/s40620-014-0142-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 09/11/2014] [Indexed: 12/11/2022]
Abstract
Phosphate metabolism is crucial in the pathophysiology of secondary hyperparathyroidism and vascular calcification. High phosphate levels have been consistently associated with unfavorable outcomes in dialysis patients, but several limitations are still hampering a resolutive definition of the optimal targets of phosphate serum levels to be achieved in this cohort. Nonetheless, hyperphosphatemia is a late marker of phosphate overload in humans. Clinical nephrologists routinely counteract the positive phosphate balance in dialysis patients through nutritional counseling, stronger phosphate removal by dialysis and prescription of phosphate binders. However, the superiority against placebo of phosphate control by diet, dialysis or binders in terms of survival has never been tested in dedicated randomized controlled trials. The present review discusses this conundrum with particular emphasis on the rationale supporting the value of a simultaneous intervention against phosphate overload in dialysis patients via the improvement of dietary intakes, dialysis efficiency and an individualized choice of phosphate binders.
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Affiliation(s)
- A Galassi
- Department of Medicine, Renal and Dialysis Unit, Desio Hospital, Desio, Italy,
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44
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Shi Y, Zhao Y, Liu J, Hou Y, Zhao Y. Educational intervention for metabolic bone disease in patients with chronic kidney disease: a systematic review and meta-analysis. J Ren Nutr 2014; 24:371-84. [PMID: 25193107 DOI: 10.1053/j.jrn.2014.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/02/2014] [Accepted: 06/17/2014] [Indexed: 11/11/2022] Open
Abstract
Metabolic bone disease (MBD) is a common complication of chronic kidney disease (CKD). The currently accepted international guidelines for treatment of CKD-MBD has been published, unfortunately adequate control of serum markers of disorder, especially hyperphosphatemia, is poorly achieved. Whether educational intervention is an effective way for improving CKD-MBD remains controversial. A systematic review of educational intervention versus routine care to improve patients with CKD-MBD was conducted. All randomized controlled trials (RCTs) and quasi-RCTs examining the efficacy of educational intervention to improve patients with CKD-MBD were included. We performed a comprehensive search of several databases and sources to identify eligible trials. In addition, we searched unpublished studies by tracking the SIGLE (System for Information on Grey Literature) database. Finally, 8 RCTs and 2 quasi-RCTs containing 775 participants were included in our systematic review. The result of our study revealed that the educational intervention to patients with CKD-MBD led to an improvement of the serum phosphorus and calcium by phosphate product. Educational intervention is a beneficial supplement method in improving CKD-MBD and putting off deterioration of the disease.
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Affiliation(s)
- Yuexian Shi
- School of Nursing, Tianjin Medical University, Tianjin, China; Nursing Department, Medical College Affiliated Hospital of Chinese People's Armed Police Force, Tianjin, China
| | - Yinning Zhao
- Haematology Department, the First Peoples' Hospital of Yinchuan, Ningxia Hui Autonomous Region, China
| | - Junduo Liu
- Hemodialysis Center, First Center Hospital of Tianjin, Tianjin, China
| | - Yahong Hou
- Nursing Department, Medical College Affiliated Hospital of Chinese People's Armed Police Force, Tianjin, China
| | - Yue Zhao
- School of Nursing, Tianjin Medical University, Tianjin, China.
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45
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Grams ME, Matsushita K, Sang Y, Estrella MM, Foster MC, Tin A, Kao WHL, Coresh J. Explaining the racial difference in AKI incidence. J Am Soc Nephrol 2014; 25:1834-41. [PMID: 24722442 PMCID: PMC4116065 DOI: 10.1681/asn.2013080867] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 12/23/2013] [Indexed: 12/23/2022] Open
Abstract
African Americans face higher risk of AKI than Caucasians. The extent to which this increased risk is because of differences in clinical, socioeconomic, or genetic risk factors is unknown. We evaluated 10,588 African-American and Caucasian participants in the Atherosclerosis Risk in Communities study, a community-based prospective cohort of middle-aged individuals. Participants were followed from baseline study visit (1996-1999) to first hospitalization for AKI (defined by billing code), ESRD, death, or December 31, 2010. African-American participants were slightly younger (61.7 versus 63.1 years, P<0.001), were more often women (64.5% versus 53.2%, P<0.001), and had higher baseline eGFR compared with Caucasians. Annual family income, education level, and prevalence of health insurance were lower among African Americans than Caucasians. The unadjusted incidence of hospitalized AKI was 7.4 cases per 1000 person-years among African Americans and 5.8 cases per 1000 person-years among Caucasians (P=0.002). The elevated risk of AKI among African Americans persisted after adjustment for demographics, cardiovascular risk factors, kidney markers, and time-varying number of hospitalizations (adjusted hazard ratio, 1.20; 95% confidence interval [95% CI], 1.01 to 1.43; P=0.04); however, accounting for differences in income and/or insurance by race attenuated the association (P>0.05). High-risk APOL1 variants did not associate with AKI among African Americans (demographic-adjusted hazard ratio, 1.07; 95% CI, 0.69 to 1.65; P=0.77). In summary, the higher risk of AKI among African Americans may be related to disparities in socioeconomic status.
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Affiliation(s)
- Morgan E Grams
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; andDepartments of Epidemiology and
| | | | | | - Michelle M Estrella
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | | | | | | | - Josef Coresh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; andDepartments of Epidemiology and Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
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The role of the gastrointestinal tract in phosphate homeostasis in health and chronic kidney disease. Curr Opin Nephrol Hypertens 2014; 22:481-7. [PMID: 23666413 PMCID: PMC4196778 DOI: 10.1097/mnh.0b013e3283621310] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Purpose of review For a number of years, there has been increasing interest in the concept of directly targeting intestinal phosphate transport to control hyperphosphatemia in chronic kidney disease. However, progress has been slow due to the paucity of information on the mechanisms involved in intestinal phosphate absorption. This editorial highlights the most recent developments in our understanding of this process and the role of the intestine in the maintenance of phosphate balance. Recent findings Recent studies in NaPi-IIb knockout mice have confirmed that this transport protein plays a significant role in intestinal phosphate absorption and is critical in the proposed feed-forward mechanism between the small intestine and kidney, which helps to maintain normal phosphate balance and steady-state plasma phosphate concentrations. In addition, renal failure-induced hyperphosphatemia is attenuated in NaPi-IIb knockout mice, confirming that NaPi-IIb is a suitable target in the prevention and treatment of hyperphosphatemia. Summary Recent findings suggest that consumption of processed foods containing phosphate preservatives may lead to excessive phosphate exposure (if not overload), toxicity, and cardiovascular disease in the general population, as well as in patients with declining renal function. Therefore, establishing more effective ways of targeting the intestine to limit dietary phosphate absorption could have wide-reaching health benefits.
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Shobeiri N, Adams MA, Holden RM. Phosphate: an old bone molecule but new cardiovascular risk factor. Br J Clin Pharmacol 2014; 77:39-54. [PMID: 23506202 PMCID: PMC3895346 DOI: 10.1111/bcp.12117] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 02/21/2013] [Indexed: 12/24/2022] Open
Abstract
Phosphate handling in the body is complex and involves hormones produced by the bone, the parathyroid gland and the kidneys. Phosphate is mostly found in hydroxyapatite. however recent evidence suggests that phosphate is also a signalling molecule associated with bone formation. Phosphate balance requires careful regulation of gut and kidney phosphate transporters, SLC34 transporter family, but phosphate signalling in osteoblasts and vascular smooth muscle cells is likely mediated by the SLC20 transporter family (PiT1 and PiT2). If not properly regulated, phosphate imblanace could lead to mineral disorders as well as vascular calcification. In chronic kidney disease-mineral bone disorder, hyperphosphataemia has been consistently associated with extra-osseous calcification and cardiovascular disease. This review focuses on the physiological mechanisms involved in phosphate balance and cell signalling (i.e. osteoblasts and vascular smooth muscle cells) as well as pathological consequences of hyperphosphataemia. Finally, conventional as well as new and experimental therapeutics in the treatment of hyperphosphataemia are explored.
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Affiliation(s)
- Navid Shobeiri
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
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48
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Cupisti A, Gallieni M, Rizzo MA, Caria S, Meola M, Bolasco P. Phosphate control in dialysis. Int J Nephrol Renovasc Dis 2013; 6:193-205. [PMID: 24133374 PMCID: PMC3797240 DOI: 10.2147/ijnrd.s35632] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Prevention and correction of hyperphosphatemia is a major goal of chronic kidney disease–mineral and bone disorder (CKD–MBD) management, achievable through avoidance of a positive phosphate balance. To this aim, optimal dialysis removal, careful use of phosphate binders, and dietary phosphate control are needed to optimize the control of phosphate balance in well-nourished patients on a standard three-times-a-week hemodialysis schedule. Using a mixed diffusive–convective hemodialysis tecniques, and increasing the number and/or the duration of dialysis tecniques are all measures able to enhance phosphorus (P) mass removal through dialysis. However, dialytic removal does not equal the high P intake linked to the high dietary protein requirement of dialysis patients; hence, the use of intestinal P binders is mandatory to reduce P net intestinal absorption. Unfortunately, even a large dose of P binders is able to bind approximately 200–300 mg of P on a daily basis, so it is evident that their efficacy is limited in the case of an uncontrolled dietary P load. Hence, limitation of dietary P intake is needed to reach the goal of neutral phosphate balance in dialysis, coupled to an adequate protein intake. To this aim, patients should be informed and educated to avoid foods that are naturally rich in phosphate and also processed food with P-containing preservatives. In addition, patients should preferentially choose food with a low P-to-protein ratio. For example, patients could choose egg white or protein from a vegetable source. Finally, boiling should be the preferred cooking procedure, because it induces food demineralization, including phosphate loss. The integrated approach outlined in this article should be actively adapted as a therapeutic alliance by clinicians, dieticians, and patients for an effective control of phosphate balance in dialysis patients.
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Affiliation(s)
- Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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49
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Block GA, Ix JH, Ketteler M, Martin KJ, Thadhani RI, Tonelli M, Wolf M, Jüppner H, Hruska K, Wheeler DC. Phosphate Homeostasis in CKD: Report of a Scientific Symposium Sponsored by the National Kidney Foundation. Am J Kidney Dis 2013; 62:457-73. [DOI: 10.1053/j.ajkd.2013.03.042] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 03/19/2013] [Indexed: 02/08/2023]
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50
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Cupisti A, Kalantar-Zadeh K. Management of natural and added dietary phosphorus burden in kidney disease. Semin Nephrol 2013; 33:180-90. [PMID: 23465504 DOI: 10.1016/j.semnephrol.2012.12.018] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Phosphorus retention occurs from higher dietary phosphorus intake relative to its renal excretion or dialysis removal. In the gastrointestinal tract the naturally existing organic phosphorus is only partially (∼60%) absorbable; however, this absorption varies widely and is lower for plant-based phosphorus including phytate (<40%) and higher for foods enhanced with inorganic phosphorus-containing preservatives (>80%). The latter phosphorus often remains unrecognized by patients and health care professionals, even though it is widely used in contemporary diets, in particular, low-cost foods. In a nonenhanced mixed diet, digestible phosphorus correlates closely with total protein content, making protein-rich foods a main source of natural phosphorus. Phosphorus burden is limited more appropriately in predialysis patients who are on a low-protein diet (∼0.6 g/kg/d), whereas dialysis patients who require higher protein intake (∼1.2 g/kg/d) are subject to a higher dietary phosphorus load. An effective and patient-friendly approach to reduce phosphorus intake without depriving patients of adequate proteins is to educate patients to avoid foods with high phosphorus relative to protein such as egg yolk and those with high amounts of phosphorus-based preservatives such as certain soft drinks and enhanced cheese and meat. Phosphorus rich foods should be prepared by boiling, which reduces phosphorus as well as sodium and potassium content, or by other types of cooking-induced demineralization. The dose of phosphorus-binding therapy should be adjusted separately for the amount and absorbability of phosphorus in each meal. Dietician counseling to address the emerging aspects of dietary phosphorus management is instrumental for achieving a reduction of phosphorus load.
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Affiliation(s)
- Adamasco Cupisti
- Division of Nephrology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
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