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Teh JW, Mac Gearailt C, Lappin DWP. Post-Transplant Bone Disease in Kidney Transplant Recipients: Diagnosis and Management. Int J Mol Sci 2024; 25:1859. [PMID: 38339137 PMCID: PMC10856017 DOI: 10.3390/ijms25031859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
Kidney transplantation is the preferred gold standard modality of treatment for kidney failure. Bone disease after kidney transplantation is highly prevalent in patients living with a kidney transplant and is associated with high rates of hip fractures. Fractures are associated with increased healthcare costs, morbidity and mortality. Post-transplant bone disease (PTBD) includes renal osteodystrophy, osteoporosis, osteonecrosis and bone fractures. PTBD is complex as it encompasses pre-existing chronic kidney disease-mineral bone disease and compounding factors after transplantation, including the use of immunosuppression and the development of de novo bone disease. After transplantation, the persistence of secondary and tertiary hyperparathyroidism, renal osteodystrophy, relative vitamin D deficiency and high levels of fibroblast growth factor-23 contribute to post-transplant bone disease. Risk assessment includes identifying both general risk factors and kidney-specific risk factors. Diagnosis is complex as the gold standard bone biopsy with double-tetracycline labelling to diagnose the PTBD subtype is not always readily available. Therefore, alternative diagnostic tools may be used to aid its diagnosis. Both non-pharmacological and pharmacological therapy can be employed to treat PTBD. In this review, we will discuss pathophysiology, risk assessment, diagnosis and management strategies to manage PTBD after kidney transplantation.
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Affiliation(s)
- Jia Wei Teh
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - Conall Mac Gearailt
- Department of Rheumatology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - David W. P. Lappin
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
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2
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Jørgensen HS, Evenepoel P. Persistent Hyperparathyroidism: A Reality Calling for Additional Evidence. Am J Kidney Dis 2023; 81:256-258. [PMID: 36424304 DOI: 10.1053/j.ajkd.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium.
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3
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Persistent hyperparathyroidism in long-term kidney transplantation: time to consider a less aggressive approach. Curr Opin Nephrol Hypertens 2023; 32:20-26. [PMID: 36250468 DOI: 10.1097/mnh.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Persistent hyperparathyroidism affects 50% of long-term kidney transplants with preserved allograft function. Timing, options and the optimal target for treatment remain unclear. Clinical practice guidelines recommend the same therapeutic approach as patients with chronic kidney disease. RECENT FINDINGS Mild to moderate elevation of parathyroid hormone (PTH) levels in long-term kidney transplants may not be associated with bone loss and fracture. Recent findings on bone biopsy revealed the lack of association between hypercalcaemic hyperparathyroidism with pathology of high bone turnover. Elevated PTH levels may be required to maintain normal bone volume. Nevertheless, several large observational studies have revealed the association between hypercalcemia and the elevation of PTH levels with unfavourable allograft and patient outcomes. Both calcimimetics and parathyroidectomy are effective in lowering serum calcium and PTH. A recent meta-analysis suggested parathyroidectomy may be performed safely after kidney transplantation without deterioration of allograft function. SUMMARY Treatment of persistent hyperparathyroidism is warranted in kidney transplants with hypercalcemia and markedly elevated PTH levels. A less aggressive approach should be applied to those with mild to moderate elevation. Whether treatments improve outcomes remain to be elucidated.
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Systematic Review of the Treatment of Persistent Hyperparathyroidism Following Kidney Transplantation. Biomedicines 2022; 11:biomedicines11010025. [PMID: 36672533 PMCID: PMC9855347 DOI: 10.3390/biomedicines11010025] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022] Open
Abstract
Chronic kidney disease-mineral and bone disorder is one of the complications associated with chronic kidney disease. About 10-50% of patients following kidney transplantation have persistent hyperparathyroidism. Hypercalcaemic hyperparathyroidism has a negative impact on the kidney transplant outcome; therefore, it requires treatment. The data regarding the treatment of persistent hyperparathyroidism provided in scientific publications are divergent and contradictory. Therefore, the aim of our systematic review was to evaluate the efficacy of persistent hyperparathyroidism treatment in patients following kidney transplantation. The Cochrane, PubMed, and Scopus databases were browsed independently by two authors. The search strategy included controlled vocabulary and keywords. The effectiveness of calcitriol, paricalcitol, cinacalcet, and parathyroidectomy was compared and analysed. The mean calcium and parathormone (PTH) concentrations per patient in the group of paricalcitol increased by 1.27% and decreased by 35.14% (n = 248); in the group of cinacalcet decreased by 12.09% and 32.16% (n = 368); and in the group of parathyroidectomy decreased by 19.06% and 86.49% (n = 15) at the end of the study compared to the baseline (n = 244, n = 342 and n = 15), respectively. Paricalcitol, cinacalcet, and parathyroidectomy decreased the intact PTH level. Cinacalcet and parathyroidectomy lowered calcium levels in renal transplant patients with hypercalcaemia. Conversely, paricalcitol increased the serum calcium concentration. Cinacalcet seems to be a good candidate in the treatment of post-transplant hyperparathyroidism.
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Molinari P, Alfieri CM, Mattinzoli D, Campise M, Cervesato A, Malvica S, Favi E, Messa P, Castellano G. Bone and Mineral Disorder in Renal Transplant Patients: Overview of Pathology, Clinical, and Therapeutic Aspects. Front Med (Lausanne) 2022; 9:821884. [PMID: 35360722 PMCID: PMC8960161 DOI: 10.3389/fmed.2022.821884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/08/2022] [Indexed: 12/25/2022] Open
Abstract
Renal transplantation (RTx) allows us to obtain the resolution of the uremic status but is not frequently able to solve all the metabolic complications present during end-stage renal disease. Mineral and bone disorders (MBDs) are frequent since the early stages of chronic kidney disease (CKD) and strongly influence the morbidity and mortality of patients with CKD. Some mineral metabolism (MM) alterations can persist in patients with RTx (RTx-p), as well as in the presence of complete renal function recovery. In those patients, anomalies of calcium, phosphorus, parathormone, fibroblast growth factor 23, and vitamin D such as bone and vessels are frequent and related to both pre-RTx and post-RTx specific factors. Many treatments are present for the management of post-RTx MBD. Despite that, the guidelines that can give clear directives in MBD treatment of RTx-p are still missed. For the future, to obtain an ever-greater individualisation of therapy, an increase of the evidence, the specificity of international guidelines, and more uniform management of these anomalies worldwide should be expected. In this review, the major factors related to post-renal transplant MBD (post-RTx-MBD), the main mineral metabolism biochemical anomalies, and the principal treatment for post-RTx MBD will be reported.
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Affiliation(s)
- Paolo Molinari
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Carlo Maria Alfieri
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- *Correspondence: Carlo Maria Alfieri ;
| | - Deborah Mattinzoli
- Renal Research Laboratory Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Mariarosaria Campise
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Angela Cervesato
- Department of Nephrology, Clinical and Translational Sciences, Università degli Studi della Campania L.Vanvitelli, Naples, Italy
| | - Silvia Malvica
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Evaldo Favi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of General Surgery, Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giuseppe Castellano
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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6
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Abstract
After kidney transplantation, mineral and bone disorders are associated with higher risk of fractures and consequent morbidity and mortality. Disorders of calcium and phosphorus, vitamin D deficiency, and hyperparathyroidism are also common. The epidemiology of bone disease has evolved over the past several decades due to changes in immunosuppressive regimens, mainly glucocorticoid minimization or avoidance. The assessment of bone disease in kidney transplant recipients relies on risk factor recognition and bone mineral density assessment. Several drugs have been trialed for the treatment of post-transplant mineral and bone disorders. This review will focus on the epidemiology, effect, and treatment of metabolic and skeletal derangements in the transplant recipient.
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Affiliation(s)
- Pascale Khairallah
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
| | - Thomas L. Nickolas
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York
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Asadipooya K, Abdalbary M, Ahmad Y, Kakani E, Monier-Faugere MC, El-Husseini A. Bone Quality in Chronic Kidney Disease Patients: Current Concepts and Future Directions - Part II. KIDNEY DISEASES (BASEL, SWITZERLAND) 2021; 7:359-371. [PMID: 34604343 PMCID: PMC8443940 DOI: 10.1159/000515542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 12/16/2022]
Abstract
Background Patients with chronic kidney disease (CKD) have an increased risk of osteoporotic fractures, which is due not only to low bone volume and mass but also poor microarchitecture and tissue quality. The pharmacological and nonpharmacological interventions detailed, herein, are potential approaches to improve bone health in CKD patients. Various medications build up bone mass but also affect bone tissue quality. Antiresorptive therapies strikingly reduce bone turnover; however, they can impair bone mineralization and negatively affect the ability to repair bone microdamage and cause an increase in bone brittleness. On the other hand, some osteoporosis therapies may cause a redistribution of bone structure that may improve bone strength without noticeable effect on BMD. This may explain why some drugs can affect fracture risk disproportionately to changes in BMD. Summary An accurate detection of the underlying bone abnormalities in CKD patients, including bone quantity and quality abnormalities, helps in institution of appropriate management strategies. Here in this part II, we are focusing on advancements in bone therapeutics that are anticipated to improve bone health and decrease mortality in CKD patients. Key Messages Therapeutic interventions to improve bone health can potentially advance life span. Emphasis should be given to the impact of various therapeutic interventions on bone quality.
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Affiliation(s)
- Kamyar Asadipooya
- Division of Endocrinology, University of Kentucky, Lexington, Kentucky, USA
| | - Mohamed Abdalbary
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA.,Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt
| | - Yahya Ahmad
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | - Elijah Kakani
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
| | | | - Amr El-Husseini
- Division of Nephrology & Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, USA
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8
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Cianciolo G, Cappuccilli M, Tondolo F, Gasperoni L, Zappulo F, Barbuto S, Iacovella F, Conte D, Capelli I, La Manna G. Vitamin D Effects on Bone Homeostasis and Cardiovascular System in Patients with Chronic Kidney Disease and Renal Transplant Recipients. Nutrients 2021; 13:1453. [PMID: 33922902 PMCID: PMC8145016 DOI: 10.3390/nu13051453] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/14/2021] [Accepted: 04/22/2021] [Indexed: 12/25/2022] Open
Abstract
Poor vitamin D status is common in patients with impaired renal function and represents one main component of the complex scenario of chronic kidney disease-mineral and bone disorder (CKD-MBD). Therapeutic and dietary efforts to limit the consequences of uremia-associated vitamin D deficiency are a current hot topic for researchers and clinicians in the nephrology area. Evidence indicates that the low levels of vitamin D in patients with CKD stage above 4 (GFR < 15 mL/min) have a multifactorial origin, mainly related to uremic malnutrition, namely impaired gastrointestinal absorption, dietary restrictions (low-protein and low-phosphate diets), and proteinuria. This condition is further worsened by the compromised response of CKD patients to high-dose cholecalciferol supplementation due to the defective activation of renal hydroxylation of vitamin D. Currently, the literature lacks large and interventional studies on the so-called non-calcemic activities of vitamin D and, above all, the modulation of renal and cardiovascular functions and immune response. Here, we review the current state of the art of the benefits of supplementation with native vitamin D in various clinical settings of nephrological interest: CKD, dialysis, and renal transplant, with a special focus on the effects on bone homeostasis and cardiovascular outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplantation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.C.); (M.C.); (F.T.); (L.G.); (F.Z.); (S.B.); (F.I.); (D.C.); (I.C.)
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9
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Easty DJ, Farr CJ, Hennessy BT. New Roles for Vitamin D Superagonists: From COVID to Cancer. Front Endocrinol (Lausanne) 2021; 12:644298. [PMID: 33868174 PMCID: PMC8045760 DOI: 10.3389/fendo.2021.644298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/10/2021] [Indexed: 12/12/2022] Open
Abstract
Vitamin D is a potent steroid hormone that induces widespread changes in gene expression and controls key biological pathways. Here we review pathophysiology of vitamin D with particular reference to COVID-19 and pancreatic cancer. Utility as a therapeutic agent is limited by hypercalcemic effects and attempts to circumvent this problem have used vitamin D superagonists, with increased efficacy and reduced calcemic effect. A further caveat is that vitamin D mediates multiple diverse effects. Some of these (anti-fibrosis) are likely beneficial in patients with COVID-19 and pancreatic cancer, whereas others (reduced immunity), may be beneficial through attenuation of the cytokine storm in patients with advanced COVID-19, but detrimental in pancreatic cancer. Vitamin D superagonists represent an untapped resource for development of effective therapeutic agents. However, to be successful this approach will require agonists with high cell-tissue specificity.
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Affiliation(s)
- David J. Easty
- Department of Medical Oncology, Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - Christine J. Farr
- Department of Genetics, University of Cambridge, Cambridge, United Kingdom
| | - Bryan T. Hennessy
- Department of Molecular Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Oncology, Our Lady of Lourdes Hospital, Drogheda, Ireland
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10
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Al Jurdi A, Da Silva Martins J, Riella LV. Mineral Bone Disorders in Kidney Transplantation. Semin Nephrol 2021; 41:168-179. [PMID: 34140095 DOI: 10.1016/j.semnephrol.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Bone disease after kidney transplantation is associated with an increased risk of fractures, morbidity, and mortality. Its pathophysiology is complex, involving multiple contributors including pretransplant bone disease, immunosuppressive medications, and changes in the parathyroid-bone-kidney axis. Risk scores, bone turnover markers, and noninvasive imaging modalities are only able to partially predict the fracture risk in kidney transplant recipients. The optimal management of bone disease after kidney transplantation has not yet been established, with only a limited number of randomized clinical trials evaluating the efficacy of treatment regimens in kidney transplant recipients. This review focuses on the pathophysiology, evaluation, prevention, and treatment of post-kidney transplant mineral and bone disease as guided by recent evidence.
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Affiliation(s)
- Ayman Al Jurdi
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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11
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Mimura LAN, Fraga-Silva TFDC, de Oliveira LRC, Ishikawa LLW, Borim PA, Machado CDM, Júnior JDADCEH, da Fonseca DM, Sartori A. Preclinical Therapy with Vitamin D3 in Experimental Encephalomyelitis: Efficacy and Comparison with Paricalcitol. Int J Mol Sci 2021; 22:ijms22041914. [PMID: 33671896 PMCID: PMC7918993 DOI: 10.3390/ijms22041914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/04/2021] [Accepted: 02/07/2021] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system (CNS). MS and its animal model called experimental autoimmune encephalomyelitis (EAE) immunopathogenesis involve a plethora of immune cells whose activation releases a variety of proinflammatory mediators and free radicals. Vitamin D3 (VitD) is endowed with immunomodulatory and antioxidant properties that we demonstrated to control EAE development. However, this protective effect triggered hypercalcemia. As such, we compared the therapeutic potential of VitD and paricalcitol (Pari), which is a non-hypercalcemic vitamin D analog, to control EAE. From the seventh day on after EAE induction, mice were injected with VitD or Pari every other day. VitD, but not Pari, displayed downmodulatory ability being able to reduce the recruitment of inflammatory cells, the mRNA expression of inflammatory parameters, and demyelination at the CNS. Lower production of proinflammatory cytokines by lymph node-derived cells and IL-17 by gut explants, and reduced intestinal inflammation were detected in the EAE/VitD group compared to the EAE untreated or Pari groups. Dendritic cells (DCs) differentiated in the presence of VitD developed a more tolerogenic phenotype than in the presence of Pari. These findings suggest that VitD, but not Pari, has the potential to be used as a preventive therapy to control MS severity.
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Affiliation(s)
- Luiza Ayumi Nishiyama Mimura
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu 18618-689, Brazil; (T.F.d.C.F.-S.); (L.R.C.d.O.); (L.L.W.I.); (A.S.)
- Correspondence:
| | - Thais Fernanda de Campos Fraga-Silva
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu 18618-689, Brazil; (T.F.d.C.F.-S.); (L.R.C.d.O.); (L.L.W.I.); (A.S.)
| | - Larissa Ragozzo Cardoso de Oliveira
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu 18618-689, Brazil; (T.F.d.C.F.-S.); (L.R.C.d.O.); (L.L.W.I.); (A.S.)
| | - Larissa Lumi Watanabe Ishikawa
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu 18618-689, Brazil; (T.F.d.C.F.-S.); (L.R.C.d.O.); (L.L.W.I.); (A.S.)
| | - Patrícia Aparecida Borim
- Botucatu Medical School, Department of Tropical Diseases and Image Diagnosis, São Paulo State University (UNESP), Botucatu 18618-687, Brazil;
| | - Carla de Moraes Machado
- Department of Structural and Functional Biology, Institute of Biosciences, São Paulo State University (UNESP), Botucatu 18618-689, Brazil; (C.d.M.M.); (J.d.A.d.C.eH.J.)
| | - José de Anchieta de Castro e Horta Júnior
- Department of Structural and Functional Biology, Institute of Biosciences, São Paulo State University (UNESP), Botucatu 18618-689, Brazil; (C.d.M.M.); (J.d.A.d.C.eH.J.)
| | - Denise Morais da Fonseca
- Department of Immunology, Institute of Biomedical Sciences, University of Sao Paulo (USP), São Paulo 05508-000, Brazil;
| | - Alexandrina Sartori
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu 18618-689, Brazil; (T.F.d.C.F.-S.); (L.R.C.d.O.); (L.L.W.I.); (A.S.)
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12
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Sella S, Bonfante L, Fusaro M, Neri F, Plebani M, Zaninotto M, Aghi A, Innico G, Tripepi G, Michielin A, Prandini T, Calò LA, Giannini S. Efficacy of weekly administration of cholecalciferol on parathyroid hormone in stable kidney-transplanted patients with CKD stage 1-3. Clin Chem Lab Med 2020; 59:343-351. [PMID: 32374278 DOI: 10.1515/cclm-2020-0282] [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: 03/08/2020] [Accepted: 04/10/2020] [Indexed: 11/15/2022]
Abstract
Objectives Kidney transplant (KTx) recipients frequently have deficient or insufficient levels of serum vitamin D. Few studies have investigated the effect of cholecalciferol in these patients. We evaluated the efficacy of weekly cholecalciferol administration on parathyroid hormone (PTH) levels in stable KTx patients with chronic kidney disease stage 1-3. Methods In this retrospective cohort study, 48 stable KTx recipients (37 males, 11 females, aged 52 ± 11 years and 26 months post-transplantation) were treated weekly with oral cholecalciferol (7500-8750 IU) for 12 months and compared to 44 untreated age- and gender-matched recipients. Changes in levels of PTH, 25(OH) vitamin D (25[OH]D), serum calcium, phosphate, creatinine and estimated glomerular filtration rate (eGFR) were measured at baseline, 6 and 12 months. Results At baseline, clinical characteristics were similar between treated and untreated patients. Considering the entire cohort, 87 (94.6%) were deficient in vitamin D and 64 (69.6%) had PTH ≥130 pg/mL. Serum calcium, phosphate, creatinine and eGFR did not differ between groups over the follow-up period. However, 25(OH)D levels were significantly higher at both 6 (63.5 vs. 30.3 nmol/L, p < 0.001) and 12 months (69.4 vs. 30 nmol/L, p < 0.001) in treated vs. untreated patients, corresponding with a significant reduction in PTH at both 6 (112 vs. 161 pg/mL) and 12 months (109 vs. 154 pg/mL) in treated vs. untreated patients, respectively (p < 0.001 for both). Conclusions Weekly administration of cholecalciferol can significantly and stably reduce PTH levels, without any adverse effects on serum calcium and renal function.
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Affiliation(s)
- Stefania Sella
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Luciana Bonfante
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Padova, Italy
| | - Maria Fusaro
- National Research Council, Institute of Clinical Physiology, Pisa, Italy
| | - Flavia Neri
- Department of Surgery, Renal and Pancreas Transplant Unit, University of Padova, Padova, Italy
| | - Mario Plebani
- Department of Medicine, Laboratory Medicine Unit, University of Padova, Padova, Italy
| | - Martina Zaninotto
- Department of Medicine, Laboratory Medicine Unit, University of Padova, Padova, Italy
| | - Andrea Aghi
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Georgie Innico
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Padova, Italy
| | - Giovanni Tripepi
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, CNR, Institute of Biomedicine, Reggio Calabria, Italy
| | - Alberto Michielin
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Tancredi Prandini
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Lorenzo A Calò
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Padova, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
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13
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Bone biomarkers in de novo renal transplant recipients. Clin Chim Acta 2019; 501:179-185. [PMID: 31734147 DOI: 10.1016/j.cca.2019.10.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/24/2019] [Indexed: 12/30/2022]
Abstract
Successful kidney transplantation (partly) corrects the physiologic and metabolic abnormalities driving chronic kidney disease - mineral and bone disorders. At the same time, renal transplant recipients are exposed to immunosuppressive agents that may affect bone metabolism. Bone biomarkers have been suggested as surrogates of or adjuncts to bone biopsy and imaging techniques to assess bone health and to classify risk of bone loss and fractures. Bone biomarkers may be classified as circulating factors that affect bone metabolism (commonly referred to as bone metabolism markers) or that reflect bone cell number and/or activity (commonly referred to as bone turnover markers). A growing body of evidence shows that successful renal transplantation has a major impact on both bone metabolism and bone turnover. Analytical issues, including the cross-reactivity with fragments, complicate the interpretation of bone biomarkers, especially in the setting of a rapid changing kidney function, as is the case after successful renal transplantation. Overall, bone turnover seems to decline following renal transplantation, but inter-individual variability is substantial. Preliminary evidence indicates that bone biomarkers may be useful in guiding mineral and bone therapy in renal transplant recipients.
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14
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Palmer SC, Chung EYM, McGregor DO, Bachmann F, Strippoli GFM. Interventions for preventing bone disease in kidney transplant recipients. Cochrane Database Syst Rev 2019; 10:CD005015. [PMID: 31637698 PMCID: PMC6803293 DOI: 10.1002/14651858.cd005015.pub4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People who have chronic kidney disease (CKD) have important changes to bone structure, strength, and metabolism. Children experience bone deformity, pain, and delayed or impaired growth. Adults experience limb and vertebral fractures, avascular necrosis, and pain. The fracture risk after kidney transplantation is four times that of the general population and is related to Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) occurring with end-stage kidney failure, steroid-induced bone loss, and persistent hyperparathyroidism after transplantation. Fractures may reduce quality of life and lead to being unable to work or contribute to community roles and responsibilities. Earlier versions of this review have found low certainty evidence for effects of treatment. This is an update of a review first published in 2005 and updated in 2007. OBJECTIVES This review update evaluates the benefits and harms of interventions for preventing bone disease following kidney transplantation. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 16 May 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA RCTs and quasi-RCTs evaluating treatments for bone disease among kidney transplant recipients of any age were eligible. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial risks of bias and extracted data. Statistical analyses were performed using random effects meta-analysis. The risk estimates were expressed as a risk ratio (RR) for dichotomous variables and mean difference (MD) for continuous outcomes together with the corresponding 95% confidence interval (CI). The primary efficacy outcome was bone fracture. The primary safety outcome was acute graft rejection. Secondary outcomes included death (all cause and cardiovascular), myocardial infarction, stroke, musculoskeletal disorders (e.g. skeletal deformity, bone pain), graft loss, nausea, hyper- or hypocalcaemia, kidney function, serum parathyroid hormone (PTH), and bone mineral density (BMD). MAIN RESULTS In this 2019 update, 65 studies (involving 3598 participants) were eligible; 45 studies contributed data to our meta-analyses (2698 participants). Treatments included bisphosphonates, vitamin D compounds, teriparatide, denosumab, cinacalcet, parathyroidectomy, and calcitonin. Median duration of follow-up was 12 months. Forty-three studies evaluated bone density or bone-related biomarkers, with more recent studies evaluating proteinuria and hyperparathyroidism. Bisphosphonate therapy was usually commenced in the perioperative transplantation period (within 3 weeks) and regardless of BMD. Risks of bias were generally high or unclear leading to lower certainty in the results. A single study reported outcomes among 60 children and adolescents. Studies were not designed to measure treatment effects on fracture, death or cardiovascular outcomes, or graft loss.Compared to placebo, bisphosphonate therapy administered over 12 months in transplant recipients may prevent fracture (RR 0.62, 95% CI 0.38 to 1.01; low certainty evidence) although the 95% CI included the possibility that bisphosphonate therapy might make little or no difference. Fracture events were principally vertebral fractures identified during routine radiographic surveillance. It was uncertain whether any other drug class decreased fracture (low or very low certainty evidence). It was uncertain whether interventions for bone disease in kidney transplantation reduce all-cause or cardiovascular death, myocardial infarction or stroke, or graft loss in very low certainty evidence. Bisphosphonate therapy may decrease acute graft rejection (RR 0.70, 95% CI 0.55 to 0.89; low certainty evidence), while it is uncertain whether any other treatment impacts graft rejection (very low certainty evidence). Bisphosphonate therapy may reduce bone pain (RR 0.20, 95% CI 0.04 to 0.93; very low certainty evidence), while it was very uncertain whether bisphosphonates prevent spinal deformity or avascular bone necrosis (very low certainty evidence). Bisphosphonates may increase to risk of hypocalcaemia (RR 5.59, 95% CI 1.00 to 31.06; low certainty evidence). It was uncertain whether vitamin D compounds had any effect on skeletal, cardiovascular, death, or transplant function outcomes (very low certainty or absence of evidence). Evidence for the benefits and harms of all other treatments was of very low certainty. Evidence for children and young adolescents was sparse. AUTHORS' CONCLUSIONS Bisphosphonate therapy may reduce fracture and bone pain after kidney transplantation, however low certainty in the evidence indicates it is possible that treatment may make little or no difference. It is uncertain whether bisphosphonate therapy or other bone treatments prevent other skeletal complications after kidney transplantation, including spinal deformity or avascular bone necrosis. The effects of bone treatment for children and adolescents after kidney transplantation are very uncertain.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Edmund YM Chung
- Royal North Shore HospitalDepartment of Medicine48 Provincial RoadSydneyNSWAustralia2070
| | - David O McGregor
- Christchurch HospitalDepartment of NephrologyPrivate Bag 4710ChristchurchNew Zealand8001
| | - Friederike Bachmann
- Charité University Medicine BerlinDepartment of Nephrology and Medical Intensive CareCharitéplatz 1BerlinGermany10117
| | - Giovanni FM Strippoli
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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15
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Abstract
Significant advances in immunosuppressive therapies have been made in renal transplantation, leading to increased allograft and patient survival. Despite improvement in overall patient survival, patients continue to require management of persistent post-transplant hyperparathyroidism. Medications that treat persistent hyperparathyroidism include vitamin D, vitamin D analogues, and calcimimetics. Medication side effects such as hypocalcemia or hypercalcemia, and adynamic bone disease, may lead to a decrease in the drugs. When medical management fails to control persistent post-transplant hyperparathyroidism, treatment is a parathyroidectomy. Surgical techniques are not uniform between centers and surgeons. Undergoing the surgery may include a subtotal technique or a technique including total parathyroid gland resection with partial heterotopic gland reimplantation. In addition, there are possible post-surgical complications. The ideal treatment for persistent post-transplant hyperparathyroidism is the treatment and prevention of the condition while patients are being managed for their late-stage chronic kidney disease and end-stage renal disease.
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Affiliation(s)
- Rowena Delos Santos
- Division of Nephrology, Washington University in St. Louis, 660 S. Euclid Ave, Campus Box 8126, St. Louis, MO, 63110, USA.
| | - Ana Rossi
- Division of Nephrology and Transplantation, Maine Medical Center, Maine Transplant Program, 19 West St., Portland, ME, 04102, USA
| | - Daniel Coyne
- Division of Nephrology, Washington University in St. Louis, 660 S. Euclid Ave, Campus Box 8126, St. Louis, MO, 63110, USA
| | - Thin Thin Maw
- Division of Nephrology and Hypertension, Keck School of Medicine of USC, 2020 Zonal Ave, IRD 806, Los Angeles, CA, 90033, USA
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16
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Abstract
PURPOSE OF REVIEW Despite metabolic improvements following kidney transplantation, transplant recipients still often suffer from complex mineral and bone disease after transplantation. RECENT FINDINGS The pathophysiology of post-transplant disease is unique, secondary to underlying pre-transplant mineral and bone disease, immunosuppression, and changing kidney function. Changes in modern immunosuppression regimens continue to alter the clinical picture. Modern management includes reducing cumulative steroid exposure and correcting the biochemical abnormalities in mineral metabolism. While bone mineral density screening appears to help predict fracture risk and anti-osteoporotic therapy appears to have a positive effect on bone mineral density, more data regarding specific treatment is necessary. Patients with mineral and bone disease after kidney transplantation require special care in order to properly manage and mitigate their mineral and bone disease. Recent changes in clinical management of transplant patients may also be changing the implications on patients' mineral and bone disease.
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Affiliation(s)
- Ariella M Altman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University HealthSystem, University of Chicago Medical School, 2650 Ridge Avenue, Evanston, IL, 60201, USA.
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17
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Zhang T, Ju H, Chen H, Wen W. Comparison of Paricalcitol and Calcitriol in Dialysis Patients With Secondary Hyperparathyroidism: A Meta-Analysis of Randomized Controlled Studies. Ther Apher Dial 2018; 23:73-79. [PMID: 30328270 DOI: 10.1111/1744-9987.12760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/30/2018] [Accepted: 09/05/2018] [Indexed: 12/24/2022]
Abstract
Paricalcitol and calcitriol are widely used for the treatment of secondary hyperparathyroidism in dialysis patients. We conducted a systematic review and meta-analysis to compare the efficacy and safety of paricalcitol and calcitriol for secondary hyperparathyroidism in dialysis patients. PubMed, EMbase, Web of Science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCT) assessing the efficacy of paricalcitol and calcitriol for secondary hyperparathyroidism in dialysis patients are included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. Meta-analysis was carried out using the random-effect model. Six randomized controlled trials are included in the meta-analysis. Overall, compared with calcitriol treatment for secondary hyperparathyroidism in dialysis patients, paricalcitol treatment has comparable ≥50% reduction of parathyroid hormone (risk ratio [RR] = 1.33; 95% CI = 0.93-1.91; P = 0.12), calcium concentration (standard mean difference [Std. MD] = -0.21; 95% CI = -0.94 to 0.52; P = 0.58), phosphate concentration (Std. MD = -0.17; 95% CI = -0.58 to 0.24; P = 0.42), calcium phosphate (Std. MD = -0.08; 95% CI = -0.49-0.34; P = 0.71), alkaline phosphatase (Std. MD = -0.21; 95% CI = -0.73-0.31; P = 0.43), hypercalcemia (RR = 1.43; 95% CI = 0.51 to 3.98; P = 0.49), adverse events (RR = 0.79; 95% CI = 0.42-1.49; P = 0.47), and serious adverse events (RR = 0.78; 95% CI = 0.47-1.30; P = 0.33). Paricalcitol and calcitriol result in similar ≥50% reduction of parathyroid hormone, calcium concentration, phosphate concentration, calcium phosphate, alkaline phosphatase, hypercalcemia, adverse events, and serious adverse events for secondary hyperparathyroidism in dialysis patients.
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Affiliation(s)
- Tong Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hongbo Ju
- Nephrology Department, Fenghua People's Hospital, Ningbo, China
| | - Haojun Chen
- Nephrology Department, Fenghua People's Hospital, Ningbo, China
| | - Wen Wen
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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18
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Ussif A, Pihlstrøm H, Pasch A, Holdaas H, Hartmann A, Smerud K, Åsberg A. Paricalcitol supplementation during the first year after kidney transplantation does not affect calcification propensity score. BMC Nephrol 2018; 19:212. [PMID: 30134956 PMCID: PMC6106758 DOI: 10.1186/s12882-018-1000-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 08/03/2018] [Indexed: 01/12/2023] Open
Abstract
Background Cardiovascular complications are common in kidney transplant patients and calcification propensity of blood, measured as T50, is associated with cardiovascular outcomes. Paricalcitol supplementation affects calcium/phosphate homeostasis and may affect calcification propensity. To assess this hypothesis we measured T50 in kidney transplant recipients participating in a randomized study comparing paricalcitol versus no treatment during the first year after kidney transplantation. Methods Stored serum samples from 76 kidney transplant recipients (paricalcitol n = 37, no treatment n = 39) were analyzed. Analyses were performed at inclusion (8 weeks after transplantation) and repeated one year after transplantation. Results There were no statistically significant differences in T50 between the paricalcitol and placebo groups, neither at baseline (p = 0.56) nor at 1 year (p = 0.61). Also, there were no significant changes in T50 over time in either group or when pooling all data (p < 0.20). In multivariate regression analysis, out of 16 potentially relevant covariates, comprising clinical and biochemical parameters, only plasma PTH and T50 at baseline were significantly correlated to T50 after one year. (p < 0.03 and p < 0.01, respectively). Conclusions Calcium propensity measured as T50 score remained unchanged with paricalcitol treatment in kidney transplant recipients, and was not changed over time during the study period of one year. Trial registration ClinicalTrials.gov, NCT01694160, registered 23 September 2012.
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Affiliation(s)
- Amin Ussif
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway.
| | - Hege Pihlstrøm
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway
| | | | - Hallvard Holdaas
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway
| | - Anders Hartmann
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Knut Smerud
- Smerud Medical Research International AS, Oslo, Norway
| | - Anders Åsberg
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway.,The Norwegian Renal Registry, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
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19
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Oblak M, Mlinšek G, Kandus A, Buturović-Ponikvar J, Arnol M. Paricalcitol versus placebo for reduction of proteinuria in kidney transplant recipients: a double-blind, randomized controlled trial. Transpl Int 2018; 31:1391-1404. [PMID: 30062716 DOI: 10.1111/tri.13323] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/30/2018] [Accepted: 07/26/2018] [Indexed: 12/24/2022]
Abstract
Proteinuria after kidney transplantation is accompanied by an increased risk of graft failure. In this single-center, placebo-controlled, double-blind trial we studied whether vitamin D receptor activator paricalcitol might reduce proteinuria. Patients with urinary protein-to-creatinine ratio (UPCR) ≥20 mg/mmol despite optimization of the renin angiotensin aldosterone system (RAAS) blockade were randomly assigned to receive 24 weeks' treatment with 2 μg/day paricalcitol or placebo. Primary endpoint was change in UPCR, and main secondary endpoints were change in urinary albumin-to-creatinine ratio (UACR) and 24-h proteinuria. Analysis was by intention to treat. One hundred and sixty-eight patients undergo randomization, and 83 were allocated to paricalcitol, and 85 to placebo. Compared with baseline, UPCR declined in the paricalcitol group (-39%, 95% CI -45 to -31) but not in the placebo group (21%, 95% CI 9 to 35), with a between group difference of -49% (95% CI -57 to -41; P < 0.001). UACR and 24-h proteinuria decreased only on paricalcitol therapy and significantly differed between groups at end-of-treatment (P < 0.001). Paricalcitol was well tolerated but incidence of mild hypercalcemia was higher than in placebo. In conclusion, addition of 2 μg/day paricalcitol lowers residual proteinuria in kidney transplant recipients. Long-term studies are needed to determine if the reduction in proteinuria improves transplant outcomes (ClinicalTrials.gov, number NCT01436747).
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Affiliation(s)
- Manca Oblak
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gregor Mlinšek
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Aljoša Kandus
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jadranka Buturović-Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Arnol
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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20
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Ureña-Torres PA, Vervloet M, Mazzaferro S, Oury F, Brandenburg V, Bover J, Cavalier E, Cohen-Solal M, Covic A, Drüeke TB, Hindié E, Evenepoel P, Frazão J, Goldsmith D, Kazama JJ, Cozzolino M, Massy ZA. Novel insights into parathyroid hormone: report of The Parathyroid Day in Chronic Kidney Disease. Clin Kidney J 2018; 12:269-280. [PMID: 30976408 PMCID: PMC6452197 DOI: 10.1093/ckj/sfy061] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease (CKD) is often associated with a mineral and bone disorder globally described as CKD-Mineral and Bone Disease (MBD), including renal osteodystrophy, the latter ranging from high bone turnover, as in case of secondary hyperparathyroidism (SHPT), to low bone turnover. The present article summarizes the important subjects that were covered during ‘The Parathyroid Day in Chronic Kidney Disease’ CME course organized in Paris in September 2017. It includes the latest insights on parathyroid gland growth, parathyroid hormone (PTH) synthesis, secretion and regulation by the calcium-sensing receptor, vitamin D receptor and fibroblast growth factor 23 (FGF23)–Klotho axis, as well as on parathyroid glands imaging. The skeletal action of PTH in early CKD stages to the steadily increasing activation of the often downregulated PTH receptor type 1 has been critically reviewed, emphasizing that therapeutic strategies to decrease PTH levels at these stages might not be recommended. The effects of PTH on the central nervous system, in particular cognitive functions, and on the cardiovascular system are revised, and the reliability and exchangeability of second- and third-generation PTH immunoassays discussed. The article also reviews the different circulating biomarkers used for the diagnosis and monitoring of CKD-MBD, including PTH and alkaline phosphatases isoforms. Moreover, it presents an update on the control of SHPT by vitamin D compounds, old and new calcimimetics, and parathyroidectomy. Finally, it covers the latest insights on the persistence and de novo occurrence of SHPT in renal transplant recipients.
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Affiliation(s)
- Pablo A Ureña-Torres
- Ramsay-Générale de Santé, Clinique du Landy, Department of Nephrology and Dialysis and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Marc Vervloet
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), VU University Medical Center, Amsterdam, The Netherlands
| | - Sandro Mazzaferro
- Department of Cardiovascular Respiratory Nephrologic Anaesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Franck Oury
- INEM, Centre de Mdecine Moléculaire Faculté de Médecine Paris Descartes, Sorbonne, Paris Cité Bâtiment Leriche, France
| | - Vincent Brandenburg
- Department of Cardiology, University Hospital RWTH Aachen, Pauwelsstraße, Aachen, Germany
| | - Jordi Bover
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350 Barcelona, Spain
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU Sart-Tilman, Liège, Belgium
| | - Martine Cohen-Solal
- INSERM U1132 & USPC Paris-Diderot, Department of Rheumatology, Hôpital Lariboisière, Paris, France
| | - Adrian Covic
- Department of Nephrology, University of Medicine and Pharmacy "Gr. T. Popa", Iasi, Romania
| | - Tilman B Drüeke
- Inserm Unit 1018, CESP, Team 5, Paul Brousse Hospital, Villejuif/Paris, France
| | - Elif Hindié
- Nuclear Medicine, University of Bordeaux, Haut-Lévêque Hospital, Pessac, France
| | - Pieter Evenepoel
- Department of Medicine, Division of Nephrology, University Hospital Leuven, Leuven, Belgium.,Dienst nefrologie, Universitair Ziekenhuis Gasthuisberg, Herestraat, Leuven, Belgium
| | - João Frazão
- Institute of Investigation and Innovation in Health, University of Porto, Porto, Portugal.,INEB-National Institute of Biomedical Engineer, University of Porto, Porto, Portugal.,Department of Nephrology, São João Hospital Center, Porto, Portugal.,School of Medicine of University of Porto, Porto, Portugal
| | | | - Junichiro James Kazama
- Department of Nephrology and Hypertension, Fukushima Medical University, 1 Hikarigaoka, Fukushima 960-1247, Japan
| | - Mario Cozzolino
- Renal Division, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré University Medical Center, APHP, University of Paris Ouest (UVSQ), Boulogne Billancourt/Paris, France
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21
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Ciebiera M, Włodarczyk M, Ciebiera M, Zaręba K, Łukaszuk K, Jakiel G. Vitamin D and Uterine Fibroids-Review of the Literature and Novel Concepts. Int J Mol Sci 2018; 19:E2051. [PMID: 30011902 PMCID: PMC6073230 DOI: 10.3390/ijms19072051] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/06/2018] [Accepted: 07/12/2018] [Indexed: 02/08/2023] Open
Abstract
This article provides a detailed review of current knowledge on the role of vitamin D and its receptor in the biology and management of uterine fibroids (UFs). Authors present ideas for future steps in this area. A literature search was conducted in PubMed using the following key words: "uterine fibroid" and "vitamin D". The results of the available studies, published in English from January 2002 up to April 2018, have been discussed. Vitamin D is a group of steroid compounds with a powerful impact on many parts of the human body. This vitamin is believed to regulate cell proliferation and differentiation, inhibit angiogenesis, and stimulate apoptosis. Nowadays, hypovitaminosis D is believed to be a major risk factor in the development of UFs. In many studies vitamin D appears to be a powerful factor against UFs, resulting in inhibition of tumor cell division and a significant reduction in its size, however, the exact role of this compound and its receptor in the pathophysiology of UFs is not fully understood. According to available studies, vitamin D and its analogs seem to be promising, effective, and low-cost compounds in the management of UFs and their clinical symptoms, and the anti-tumor activities of vitamin D play an important role in UF biology. The synergy between vitamin D and selected anti-UF drugs is a very interesting issue which requires further research. Further studies about the biological effect of vitamin D on UF biology are essential. Vitamin D preparations (alone or as a co-drugs) could become new tools in the fight with UFs, with the additional beneficial pleiotropic effect.
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Affiliation(s)
- Michał Ciebiera
- Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, 00-416 Warsaw, Poland.
| | - Marta Włodarczyk
- Department of Biochemistry and Pharmacogenomics, Faculty of Pharmacy with Division of Laboratory Medicine, Medical University of Warsaw, 02-097 Warsaw, Poland.
- Center for Preclinical Research, Medical University of Warsaw, 02-097 Warsaw, Poland.
| | - Magdalena Ciebiera
- Students' Scientific Association at the Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-015 Warsaw, Poland.
| | - Kornelia Zaręba
- Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, 00-416 Warsaw, Poland.
| | - Krzysztof Łukaszuk
- Department of Obstetrics and Gynecological Nursing, Faculty of Health Sciences, Medical University of Gdansk, 80-210 Gdansk, Poland.
- INVICTA Fertility and Reproductive Center, 80-172 Gdansk, Poland.
| | - Grzegorz Jakiel
- Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, 00-416 Warsaw, Poland.
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22
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Giannini S, Mazzaferro S, Minisola S, De Nicola L, Rossini M, Cozzolino M. Raising awareness on the therapeutic role of cholecalciferol in CKD: a multidisciplinary-based opinion. Endocrine 2018; 59:242-259. [PMID: 28726185 PMCID: PMC5846860 DOI: 10.1007/s12020-017-1369-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 06/27/2017] [Indexed: 12/19/2022]
Abstract
Vitamin D is recognized to play an essential role in health and disease. In kidney disease, vitamin D analogs have gained recognition for their involvement and potential therapeutic importance. Nephrologists are aware of the use of oral native vitamin D supplementation, however, uncertainty still exists with regard to the use of this treatment option in chronic kidney disease as well as clinical settings related to chronic kidney disease, where vitamin D supplementation may be an appropriate therapeutic choice. Two consecutive meetings were held in Florence in July and November 2016 comprising six experts in kidney disease (N = 3) and bone mineral metabolism (N = 3) to discuss a range of unresolved issues related to the use of cholecalciferol in chronic kidney disease. The panel focused on the following six key areas where issues relating to the use of oral vitamin D remain controversial: (1) vitamin D and parathyroid hormone levels in the general population, (2) cholecalciferol in chronic kidney disease, (3) vitamin D in cardiovascular disease, (4) vitamin D and renal bone disease, (5) vitamin D in rheumatological diseases affecting the kidney, (6) vitamin D and kidney transplantation.
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Affiliation(s)
- Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Sandro Mazzaferro
- Department of Cardiovascular Respiratory Nephrologic Anesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
| | - Luca De Nicola
- Division of Nephrology, Second University of Naples, Naples, Italy
| | - Maurizio Rossini
- Department of Medicine, Rheumatology Unit, University of Verona, Verona, Italy
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division and Laboratory of Experimental Nephrology, San Paolo Hospital, University of Milan, Milan, Italy.
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23
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Cruzado JM, Lauzurica R, Pascual J, Marcen R, Moreso F, Gutierrez-Dalmau A, Andrés A, Hernández D, Torres A, Beneyto MI, Melilli E, Manonelles A, Arias M, Praga M. Paricalcitol Versus Calcifediol for Treating Hyperparathyroidism in Kidney Transplant Recipients. Kidney Int Rep 2018; 3:122-132. [PMID: 29340322 PMCID: PMC5762965 DOI: 10.1016/j.ekir.2017.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 08/23/2017] [Accepted: 08/29/2017] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Secondary hyperparathyroidism (SHPT) and vitamin D deficiency are common at kidney transplantation and are associated with some early and late complications. This study was designed to evaluate whether paricalcitol was more effective than nutritional vitamin D for controlling SHPT in de novo kidney allograft recipients. METHODS This was a 6-month, investigator-initiated, multicenter, open-label, randomized clinical trial. Patients with pretransplantation iPTH between 250 and 600 pg/ml and calcium <10 mg/dl were randomized to paricalcitol (PAR) or calcifediol (CAL). The intention-to-treat population (PAR: n = 46; CAL: n = 47) was used for the analysis. The primary endpoint was the percentage of patients with serum iPTH >110 pg/ml at 6 months. Secondary endpoints were bone mineral metabolism, renal function, and allograft protocol biopsies. RESULTS The primary outcome occurred in 19.6% of patients in the PAR group and 36.2% of patients in the CAL group (P = 0.07). However, there was a higher percentage of patients with iPTH <70 pg/ml in the PAR group than in the CAL group (63.4% vs. 37.2%; P = 0.03). No differences were observed in bone turnover biomarkers and bone mineral density. The estimated glomerular filtration rate was significantly higher in the CAL group than in the PAR group without differences in albuminuria. In protocol biopsies, interstitial fibrosis and tubular atrophy tended to be higher in the PAR group than in the CAL group (48% vs. 23.8%; P = 0.09). Both medications were well tolerated. CONCLUSION Both PAR and CAL reduced iPTH, but PAR was associated with a higher proportion of patients with iPTH <70 pg/ml. These results do not support the use of PAR to treat posttransplantation hyperparathyroidism.
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Affiliation(s)
- Josep M. Cruzado
- Nephrology Department, Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Ricardo Lauzurica
- Department of Nephrology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Roberto Marcen
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Francesc Moreso
- Hospital Universitari Vall d'Hebron, Nephrology, Barcelona, Spain
| | | | - Amado Andrés
- Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | | | - Armando Torres
- Department of Nephrology, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Edoardo Melilli
- Nephrology Department, Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Manonelles
- Nephrology Department, Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Manuel Arias
- Nephrology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
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24
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Sarno G, Nappi R, Altieri B, Tirabassi G, Muscogiuri E, Salvio G, Paschou SA, Ferrara A, Russo E, Vicedomini D, Vincenzo C, Vryonidou A, Della Casa S, Balercia G, Orio F, De Rosa P. Current evidence on vitamin D deficiency and kidney transplant: What's new? Rev Endocr Metab Disord 2017; 18:323-334. [PMID: 28281103 DOI: 10.1007/s11154-017-9418-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Kidney transplant is the treatment of choice for end-stage chronic kidney disease. Kidneys generate 1,25-dihydroxyvitamin D (calcitriol) from 25-hydroxyvitamin D (calcidiol) for circulation in the blood to regulate calcium levels. Transplant patients with low calcidiol levels have an increased risk of metabolic and endocrine problems, cardiovascular disease, type 2 diabetes mellitus, poor graft survival, bone disorders, cancer, and mortality rate. The recommended calcidiol level after transplant is at least 30 ng/mL (75 nmol/L), which could require 1000-3000 IU/d vitamin D3 to achieve. Vitamin D3 supplementation studies have found improved endothelial function and acute rejection episodes. However, since kidney function may still be impaired, raising calcidiol levels may not lead to normal calcitriol levels. Thus, supplementation with calcitriol or an analog, alfacalcidiol, is often employed. Some beneficial effects found include possible improved bone health and reduced risk of chronic allograft nephropathy and cancer.
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Affiliation(s)
- Gerardo Sarno
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy.
| | - Riccardo Nappi
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
- Nephrology and Dialisys Unit - "Santa Maria della Misericordia" Hospital, ASUIUD - Udine, Udine, Italy
| | - Barbara Altieri
- Institute of Medical Pathology, Division of Endocrinology and Metabolic Diseases, Catholic University, Rome, Italy
| | - Giacomo Tirabassi
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | | | - Gianmaria Salvio
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Stavroula A Paschou
- Division of Endocrinology and Diabetes, "Aghia Sophia" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristide Ferrara
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Enrico Russo
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Daniela Vicedomini
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Cerbone Vincenzo
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, Athens, Greece
| | - Silvia Della Casa
- Institute of Medical Pathology, Division of Endocrinology and Metabolic Diseases, Catholic University, Rome, Italy
| | - Giancarlo Balercia
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Francesco Orio
- Endocrinology, Department of Sports Science and Wellness, "Parthenope" University Naples, Naples, Italy
| | - Paride De Rosa
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
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25
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Hu X, Shang J, Yuan W, Zhang S, Jiang Y, Zhao B, Duan Y, Xiao J, Zhao Z. Effects of paricalcitol on cardiovascular outcomes and renal function in patients with chronic kidney disease : A meta-analysis. Herz 2017; 43:518-528. [PMID: 28835982 DOI: 10.1007/s00059-017-4605-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 07/16/2017] [Accepted: 07/16/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Paricalcitol, a selective activator of the vitamin D receptor (VDR), influences calcium and phosphorus homeostasis and bone metabolism. Whether paricalcitol reduces cardiovascular risk and protects renal function remains unclear. To systematically evaluate this in patients with chronic kidney disease (CKD), we conducted a meta-analysis of published randomized controlled trials (RCTs). METHODS We searched MEDLINE, Embase, the Cochrane Library, and reference lists for RCTs comparing paricalcitol with placebo in stage 2-5 CKD (including pre-dialysis and renal replacement patients). The Cochrane quality assessment method was used to evaluate study quality. Results were summarized as risk ratios (RRs) for dichotomous outcomes or mean differences (MD) for continuous outcomes. RESULTS We included 21 studies comprising 1894 patients. Compared to placebo, paricalcitol reduced the risk of cardiovascular events (RR 0.55; 95% CI 0.35-0.87; p = 0.01), but the RR of hypercalcemia associated with paricalcitol was 6.50 (95% CI 3.21-13.15; p < 0.00001). Paricalcitol cannot significantly change systolic blood pressure and cardiac structure. Although proteinuria reduction was achieved more frequently with paricalcitol (RR 1.51; 95% CI 1.25-1.82; p < 0.0001), it did not significantly reduce proteinuria level compared to placebo. Paricalcitol could not protect renal function to delay CKD progression, since it reduced the glomerular filtration rate (MD -3.15; 95% CI -4.35--1.96; p < 0.0001) and elevated serum creatinine (MD 0.93; 95% CI 0.10-0.68; p = 0.008). CONCLUSION Paricalcitol reduces the risk of cardiovascular events in CKD patients but increases the risk of hypercalcemia and cannot improve cardiac structure. Meanwhile, it cannot significantly reduce proteinuria level or protect renal function.
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Affiliation(s)
- X Hu
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China
| | - J Shang
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China
| | - W Yuan
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China
| | - S Zhang
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China
| | - Y Jiang
- Emergency Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - B Zhao
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Y Duan
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - J Xiao
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China
| | - Z Zhao
- Nephrology Hospital, The First Affiliated Hospital of Zhengzhou University, No. 1 of East Jianshe Road, 450052, Zhengzhou, Henan, China.
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26
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Donate-Correa J, Henríquez-Palop F, Martín-Núñez E, Hernández-Carballo C, Ferri C, Pérez-Delgado N, Muros-de-Fuentes M, Mora-Fernández C, Navarro-González JF. Anti-inflammatory profile of paricalcitol in kidney transplant recipients. Nefrologia 2017. [PMID: 28623033 DOI: 10.1016/j.nefro.2017.03.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Paricalcitol, a selective vitamin D receptor activator, is used to treat secondary hyperparathyroidism in kidney transplant patients. Experimental and clinical studies in non-transplant kidney disease patients have found this molecule to have anti-inflammatory properties. In this exploratory study, we evaluated the anti-inflammatory profile of paricalcitol in kidney-transplant recipients. METHODS Thirty one kidney transplant recipients with secondary hyperparathyroidism completed 3 months of treatment with oral paricalcitol (1μg/day). Serum concentrations and gene expression levels of inflammatory cytokines in peripheral blood mononuclear cells were analysed at the beginning and end of the study. RESULTS Paricalcitol significantly decreased parathyroid hormone levels with no changes in calcium and phosphorous. It also reduced serum concentrations of interleukin (IL)-6 and tumour necrosis factor-alpha (TNF-α) by 29% (P<0.05) and 9.5% (P<0.05) compared to baseline, respectively. Furthermore, gene expression levels of IL-6 and TNF-α in peripheral blood mononuclear cells decreased by 14.1% (P<0.001) and 34.1% (P<0.001), respectively. The ratios between pro-inflammatory cytokines (TNF-α and IL-6) and anti-inflammatory cytokines (IL-10), both regarding serum concentrations and gene expression, also experienced a significant reduction. CONCLUSIONS Paricalcitol administration to kidney transplant recipients has been found to have beneficial effects on inflammation, which may be associated with potential clinical benefits.
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Affiliation(s)
- Javier Donate-Correa
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España; Unidad de Investigación, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España.
| | - Fernando Henríquez-Palop
- Servicio de Nefrología, Hospital Universitario Doctor Negrín, Las Palmas de Gran Canaria, España
| | - Ernesto Martín-Núñez
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Carolina Hernández-Carballo
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Carla Ferri
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Nayra Pérez-Delgado
- Servicio de Análisis Clínicos, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Mercedes Muros-de-Fuentes
- Servicio de Análisis Clínicos, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Carmen Mora-Fernández
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Juan F Navarro-González
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España; Servicio de Nefrología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España.
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27
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Pihlstrøm HK, Gatti F, Hammarström C, Eide IA, Kasprzycka M, Wang J, Haraldsen G, Svensson MHS, Midtvedt K, Mjøen G, Dahle DO, Hartmann A, Holdaas H. Early introduction of oral paricalcitol in renal transplant recipients. An open-label randomized study. Transpl Int 2017; 30:827-840. [PMID: 28436117 DOI: 10.1111/tri.12973] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/31/2016] [Accepted: 04/18/2017] [Indexed: 02/01/2023]
Abstract
In stable renal transplant recipients with hyperparathyroidism, previous studies have indicated that vitamin D agonist treatment might have anti-proteinuric effects. Animal studies indicate possible anti-fibrotic and anti-inflammatory effects. Early introduction of paricalcitol in de novo renal transplant recipients might reduce proteinuria and prevent progressive allograft fibrosis. We performed a single-center, prospective, randomized, open-label trial investigating effects of paricalcitol 2 μg/day added to standard care. Participants were included 8 weeks after engraftment and followed for 44 weeks. Primary end point was change in spot urine albumin/creatinine ratio. Exploratory microarray analyses of kidney biopsies at study end investigated potential effects on gene expression. Secondary end points included change in glomerular filtration rate (GFR), pulse wave velocity (PWV), and endothelial function measured by peripheral arterial tonometry as reactive hyperemia index (RHI). Seventy-seven de novo transplanted kidney allograft recipients were included, 37 receiving paricalcitol. Paricalcitol treatment lowered PTH levels (P = 0.01) but did not significantly reduce albuminuria (P = 0.76), change vascular parameters (PWV; P = 0.98, RHI; P = 0.33), or influence GFR (P = 0.57). Allograft gene expression was not influenced. To summarize, in newly transplanted renal allograft recipients, paricalcitol reduced PTH and was well tolerated without negatively affecting kidney function. Paricalcitol did not significantly reduce/prevent albuminuria, improve parameters of vascular health, or influence allograft gene expression.
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Affiliation(s)
- Hege Kampen Pihlstrøm
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Franscesca Gatti
- Department of Pathology, Oslo University Hospital, Oslo, Norway.,Laboratory of Immunohistochemistry and Immunopathology, K.G. Jebsen Inflammation Research Centre, University of Oslo, Oslo, Norway
| | - Clara Hammarström
- Department of Pathology, Oslo University Hospital, Oslo, Norway.,Laboratory of Immunohistochemistry and Immunopathology, K.G. Jebsen Inflammation Research Centre, University of Oslo, Oslo, Norway
| | - Ivar Anders Eide
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Department of Nephrology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Monika Kasprzycka
- Department of Pathology, Oslo University Hospital, Oslo, Norway.,Laboratory of Immunohistochemistry and Immunopathology, K.G. Jebsen Inflammation Research Centre, University of Oslo, Oslo, Norway
| | - Junbai Wang
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Guttorm Haraldsen
- Department of Pathology, Oslo University Hospital, Oslo, Norway.,Laboratory of Immunohistochemistry and Immunopathology, K.G. Jebsen Inflammation Research Centre, University of Oslo, Oslo, Norway
| | | | - Karsten Midtvedt
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Geir Mjøen
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Dag Olav Dahle
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Anders Hartmann
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hallvard Holdaas
- Department of Surgery, Inflammation Medicine and Transplantation, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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28
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Donate-Correa J, Henríquez-Palop F, Martín-Núñez E, Pérez-Delgado N, Muros-de-Fuentes M, Mora-Fernández C, Navarro-González JF. Effect of Paricalcitol on FGF-23 and Klotho in Kidney Transplant Recipients. Transplantation 2017; 100:2432-2438. [PMID: 27467536 DOI: 10.1097/tp.0000000000001339] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Paricalcitol decreases intact parathyroid hormone and the frequency of secondary hyperparathyroidism after kidney transplantation. This proof-of-concept study aimed to assess the effect of paricalcitol on fibroblast growth factor-23/KLOTHO axis in renal transplants. METHODS Twenty-nine subjects with secondary hyperparathyroidism received oral paricalcitol 1 μg/d for 3 months, and 8 patients matched by age, sex, and creatinine clearance, but with intact parathyroid hormone less than 100 pg/mL, were included as controls. RESULTS Intact parathyroid hormone decreased in paricalcitol-treated patients (P < 0.0001). Serum fibroblast growth factor-23 enhanced (P < 0.01), whereas KLOTHO concentrations showed a trend to increase (P = 0.067). KLOTHO gene expression in peripheral blood mononuclear cells increased by 45.7% in paricalcitol-treated patients (P < 0.01), without change in controls. Paricalcitol administration resulted in a median percent decrease of 56% in methylated DNA levels of KLOTHO promoter (P < 0.001). The ratio of the unmethylated/methylated KLOTHO promoter DNA did not change in controls, but it increased by 177% in paricalcitol-treated subjects (P < 0.0001). The increase in this ratio was independently associated with the change in serum KLOTHO (r = 0.55, P < 0.01) and messenger RNA expression levels (r = 0.40, P < 0.05). CONCLUSIONS Paricalcitol administration to renal transplant patients significantly reduced intact parathyroid hormone and increased fibroblast growth factor-23, with a trend to increase in serum KLOTHO. Paricalcitol-treated patients showed a decrease in the methylation of the KLOTHO promoter with an increment in the ratio of un-methyated/methylated DNA, which was associated with an increase of KLOTHO gene expression levels and serum KLOTHO concentrations. Long-term studies are needed to assess whether paricalcitol-induced increase in KLOTHO gene expression and serum concentrations may translate into beneficial clinical effects.
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Affiliation(s)
- Javier Donate-Correa
- 1 Research Unit, University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain. 2 Nephrology Service, University Hospital de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain. 3 Clinical Biochemistry Service, University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain. 4 Nephrology Service, University Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
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29
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Luo JQ, Jiang F, Song WQ, Fang WZ, Lu Q. Synthesis of paricalcitol: A novel strategy combining chemical and microbial transformations. RUSSIAN JOURNAL OF BIOORGANIC CHEMISTRY 2017. [DOI: 10.1134/s1068162017030104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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30
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CYP3A4 is a crosslink between vitamin D and calcineurin inhibitors in solid organ transplant recipients: implications for bone health. THE PHARMACOGENOMICS JOURNAL 2017; 17:481-487. [PMID: 28418012 DOI: 10.1038/tpj.2017.15] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 12/23/2016] [Accepted: 01/18/2017] [Indexed: 11/08/2022]
Abstract
The use of calcineurin inhibitors (CNIs) and vitamin D deficiency may contribute to the pathogenesis of post-transplant bone disease. CNIs and 1,25-dihydroxyvitamin D₃ (1,25(OH)2D3) are substrates of the drug-metabolizing enzyme CYP3A4. This review summarizes the indications for the use of activated vitamin D analogs in post-transplant care and the current knowledge on the impact of CNIs on bone. We searched for clinical evidence of the interaction between CNIs and 1,25(OH)2D3. We also provide an overview of the literature on the interplay between vitamin D metabolism and CYP3A4 in experimental and clinical settings and discuss its possible implications for solid organ transplant recipients. In conclusion, there is a body of evidence on the interplay between vitamin D and the drug-metabolizing enzyme CYP3A4, which may have therapeutic implications.
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31
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Ziff OJ, Penny H, Frame S, Cronin A, Goldsmith D. Impact of seasonality on the dynamics of native Vitamin D repletion in long-term renal transplant patients. Clin Kidney J 2017; 10:411-418. [PMID: 28616220 PMCID: PMC5466087 DOI: 10.1093/ckj/sfw136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 11/14/2016] [Indexed: 01/06/2023] Open
Abstract
Background: Renal transplant recipients (RTRs) are often Vitamin D (VitD) depleted as a result of both chronic kidney disease and mandated sun avoidance behaviours. Repleting VitD may be warranted, but how, and for how long, is unknown, as is the impact of seasonality on the success of repletion. We investigated the impact of seasonality on VitD status following VitD repletion in a large cohort of stable, long-term RTRs. Methods: Serum 25-hydroxyvitamin D [25(OH)D] concentrations and bone biochemistry parameters were analysed from 102 VitD repletion courses in 98 RTRs that had undergone VitD repletion. Repletion was delivered over 6 months with either 240 000 IU colecalciferol if pre-repletion serum VitD was between 20 and 50 nmol/L, or with 360 000 IU if VitD was <20 nmol/L. Twelve months post-repletion 25(OH)D and parathyroid hormone (PTH) were available for 75 patients. Results: At baseline, 25(OH)D was 20.1 ± 1.0 nmol/L, increasing to 65.4 ± 1.8 nmol/L following repletion (+7.55 nmol/L/month, P < 0.0001). Twelve months post-repletion and after no further VitD administration, 25(OH)D fell to 35.4 ± 1.8 nmol/L (14.2 ± 0.7 ng/mL; −2.50 nmol/L/month, P < 0.0001). PTH followed the opposite trend with baseline, repletion-end and post-repletion values being 144.2 ± 12.0, 109.6 ± 7.5 and 129.2 ± 11.4 ng/L, respectively. VitD repletion during the summer was associated with significantly higher at repletion-end 25(OH)D compared with any other time of year [summer 80.9 ± 4.0, autumn 64.1 ± 3.0 (P = 0.002), winter 48.9 ± 3.0 (P <0.001), spring 63.8 ± 2.5 nmol/L (P <0.001)]. There was no hypercalcaemia during repletion and renal transplant function remained stable without any evidence of allograft rejection. Conclusions: VitD repletion can safely and effectively be achieved in the majority of chronic stable RTRs using a 6-month bolus intermediate-dose schedule. Winter repletion is associated with an inadequate response in 25(OH)D; however, all patients experience a post-repletion fall towards deficiency in the absence of maintenance supplementation, irrespective of the season of repletion.
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Affiliation(s)
- Oliver J Ziff
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Institute of Cardiovascular Sciences, University College London, London, UK
| | - Hugo Penny
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sharon Frame
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Antonia Cronin
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David Goldsmith
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Carvalho C, Magalhães J, Pereira L, Simões-Silva L, Castro-Ferreira I, Frazão JM. Evolution of bone disease after kidney transplantation: A prospective histomorphometric analysis of trabecular and cortical bone. Nephrology (Carlton) 2016. [PMID: 26201946 DOI: 10.1111/nep.12570] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM Post-transplant bone disease results from multiple factors, including previous bone and mineral metabolism disturbances and effects from transplant-related medications. Bone biopsy remains the gold-standard diagnostic tool. METHODS We aimed to prospectively evaluate trabecular and cortical bone by histomorphometry after kidney transplantation. Seven patients, willing to perform follow-up bone biopsy, were included in the study. Dual-X-ray absorptiometry and trans-iliac bone biopsy were performed within the first 2 months after renal transplantation and repeated after 2-5 years of follow-up. RESULTS Follow-up biopsy revealed a significant decrease in osteoblast surface/bone surface (0.91 ± 0.81 to 0.47 ± 0.12%, P = 0.036), osteoblasts number/bone surface (0.45 (0.23, 0.94) to 0.00/mm(2) , P = 0.018) and erosion surface/bone surface (3.75 ± 2.02 to 2.22 ± 1.38%, P = 0.044). A decrease in trabecular number (3.55 (1.81, 2.89) to 1.55/mm (1.24, 2.06), P = 0.018) and increase in trabecular separation (351.65 ± 135.04 to 541.79 ± 151.91 μm, P = 0.024) in follow-up biopsy suggest loss in bone quantity. We found no significant differences in cortical analysis, except a reduction in external cortical osteonal eroded surface (5.76 (2.94, 13.97) to 3.29% (0.00, 6.67), P = 0.043). Correlations between bone histomorphometric and dual-X-ray absorptiometry parameters gave inconsistent results. CONCLUSIONS The results show a reduction in bone activity, suggesting increased risk of adynamic bone and loss of bone volume. Cortical bone seems less affected by post-transplant biological changes in the first years after kidney transplantation.
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Affiliation(s)
- Catarina Carvalho
- Nephrology and Infectiology Research and Development Group, INEB, Porto, Portugal
| | - Juliana Magalhães
- Nephrology and Infectiology Research and Development Group, INEB, Porto, Portugal
| | - Luciano Pereira
- Nephrology and Infectiology Research and Development Group, INEB, Porto, Portugal
| | - Liliana Simões-Silva
- Nephrology Research and Development Unit, Medical School, Porto University, Porto, Portugal
| | - Inês Castro-Ferreira
- Nephrology Research and Development Unit, Medical School, Porto University, Porto, Portugal
| | - João Miguel Frazão
- Nephrology and Infectiology Research and Development Group, INEB, Porto, Portugal
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Bouquegneau A, Salam S, Delanaye P, Eastell R, Khwaja A. Bone Disease after Kidney Transplantation. Clin J Am Soc Nephrol 2016; 11:1282-1296. [PMID: 26912549 PMCID: PMC4934848 DOI: 10.2215/cjn.11371015] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Bone and mineral disorders occur frequently in kidney transplant recipients and are associated with a high risk of fracture, morbidity, and mortality. There is a broad spectrum of often overlapping bone diseases seen after transplantation, including osteoporosis as well as persisting high- or low-turnover bone disease. The pathophysiology underlying bone disorders after transplantation results from a complex interplay of factors, including preexisting renal osteodystrophy and bone loss related to a variety of causes, such as immunosuppression and alterations in the parathyroid hormone-vitamin D-fibroblast growth factor 23 axis as well as changes in mineral metabolism. Management is complex, because noninvasive tools, such as imaging and bone biomarkers, do not have sufficient sensitivity and specificity to detect these abnormalities in bone structure and function, whereas bone biopsy is not a widely available diagnostic tool. In this review, we focus on recent data that highlight improvements in our understanding of the prevalence, pathophysiology, and diagnostic and therapeutic strategies of mineral and bone disorders in kidney transplant recipients.
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Affiliation(s)
- Antoine Bouquegneau
- Department of Nephrology, Dialysis, and Transplantation, Centre Hospitalier Universitaire de Liege, Liege, Belgium
| | - Syrazah Salam
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, United Kingdom; and
| | - Pierre Delanaye
- Department of Nephrology, Dialysis, and Transplantation, Centre Hospitalier Universitaire de Liege, Liege, Belgium
| | - Richard Eastell
- Academic Unit of Bone Metabolism, Metabolic Bone Centre, Northern General Hospital, Sheffield, United Kingdom
| | - Arif Khwaja
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, United Kingdom; and
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Bonani M, Frey D, Brockmann J, Fehr T, Mueller TF, Saleh L, von Eckardstein A, Graf N, Wüthrich RP. Effect of Twice-Yearly Denosumab on Prevention of Bone Mineral Density Loss in De Novo Kidney Transplant Recipients: A Randomized Controlled Trial. Am J Transplant 2016; 16:1882-91. [PMID: 26713403 DOI: 10.1111/ajt.13692] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 12/16/2015] [Accepted: 12/17/2015] [Indexed: 01/25/2023]
Abstract
We conducted an open-label, prospective, randomized trial to assess the efficacy and safety of RANKL inhibition with denosumab to prevent the loss of bone mineral density (BMD) in the first year after kidney transplantation. Ninety kidney transplant recipients were randomized 1:1 2 weeks after surgery to receive denosumab (60 mg at baseline and 6 months) or no treatment. After 12 months, total lumbar spine areal BMD (aBMD) increased by 4.6% (95% confidence interval [CI] 3.3-5.9%) in 46 patients in the denosumab group and decreased by -0.5% (95% CI -1.8% to 0.9%) in 44 patients in the control group (between-group difference 5.1% [95% CI 3.1-7.0%], p < 0.0001). Denosumab also increased aBMD at the total hip by 1.9% (95% CI, 0.1-3.7%; p = 0.035) over that in the control group at 12 months. High-resolution peripheral quantitative computed tomography in a subgroup of 24 patients showed that denosumab increased volumetric BMD at the distal tibia and radius (all p < 0.05). Biomarkers of bone turnover (C-terminal telopeptide of type I collagen, procollagen type I N-terminal propeptide) markedly decreased with denosumab (all p < 0.0001). Episodes of cystitis and asymptomatic hypocalcemia occurred more often with denosumab, whereas graft function, rate of rejections, and incidence of opportunistic infections were similar. In conclusion, denosumab increased BMD in the first year after kidney transplantation but was associated with more frequent episodes of urinary tract infection.
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Affiliation(s)
- M Bonani
- Division of Nephrology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - D Frey
- Division of Rheumatology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - J Brockmann
- Division of Visceral and Transplantation Surgery, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - T Fehr
- Division of Nephrology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - T F Mueller
- Division of Nephrology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - L Saleh
- Institute of Clinical Chemistry, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - A von Eckardstein
- Institute of Clinical Chemistry, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - N Graf
- Graf Biostatistics, Winterthur, Switzerland
| | - R P Wüthrich
- Division of Nephrology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
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Torres A, Torregrosa V, Marcen R, Campistol JM, Arias M, Hernández D, Fernández C, Esforzado N, Paschoalin R, Pérez N, García AI, Del Amo M, Pomés J, González Rinne A, Marrero D, Pérez E, Henríquez F, Díaz JM, Silva I, López V, Perello M, Ramos D, Beneyto I, Cruzado JM, Martínez Castelao A, Bravo J, Rodríguez M, Díaz C, Crespo J, Anaya F, Rodríguez ML, Cubero JJ, Pascual P, Romero R, Andrés Belmonte A, Checa MD, Jiménez C, Escuin F, Crespo M, Mir M, Gómez G, Bayes B, González MJ, Gutiérrez A, Cuberes M, Rodríguez Benoit A, García T, Llamas F, Ortega A, Conde JL, Gómez Alamillo C. Mineral metabolism disorders, vertebral fractures and aortic calcifications in stable kidney transplant recipients: The role of gender (EMITRAL study). Nefrologia 2016; 36:255-67. [PMID: 27133898 DOI: 10.1016/j.nefro.2016.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 03/06/2016] [Accepted: 03/11/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The relationship between mineral metabolism disorders, bone fractures and vascular calcifications in kidney transplant recipients has not been established. METHOD We performed a cross-sectional study in 727 stable recipients from 28 Spanish transplant clinics. Mineral metabolism parameters, the semi-quantification of vertebral fractures and abdominal aortic calcifications were determined centrally. RESULTS Vitamin D deficiency (25OHD3<15ng/ml) was more common in female recipients at CKD-T stages I-III (29.6% vs 44.4%; p=0.003). The inverse and significant correlation between 25OHD3 and PTH was gender-specific and women exhibited a steeper slope than men (p=0.01). Vertebral fractures (VFx) with deformity grade ≥2 were observed in 15% of recipients. Factors related to VFx differed by gender; in males, age (OR 1.04; 95% CI 1.01-1.06) and CsA treatment (OR: 3.2; 95% CI: 1.6-6.3); in females, age (OR 1.07; 95% CI: 1.03-1.12) and PTH levels (OR per 100pg/ml increase: 1.27; 95% CI: 1.043-1.542). Abdominal aortic calcifications were common (67.2%) and related to classical risk factors but not to mineral metabolism parameters. CONCLUSIONS Vitamin D deficiency is more common among female kidney transplant recipients at earlier CKD-T stages, and it contributes to secondary hyperparathyroidism. Prevalent vertebral fractures are only related to high serum PTH levels in female recipients.
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Affiliation(s)
- Armando Torres
- Servicio de Nefrología, HospitalUniversitario de Canarias, CIBICAN, Universidad de La Laguna, RedInRen RD12/0021/0008-Instituto de Salud Carlos III, Tenerife, Spain.
| | - Vicens Torregrosa
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Roberto Marcen
- Servicio de Nefrología, Hospital Universitario Ramón y Cajal (RedInRen, RD12/0021/0020-Instituto de Salud Carlos III), Madrid, Spain
| | - Josep María Campistol
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Manuel Arias
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, RedInRen RD12/0021/0007-Instituto de Salud Carlos III, Santander, Spain
| | - Domingo Hernández
- Servicio de Nefrología, Hospital Regional Carlos Haya, Universidad de Málaga (IBIMA), RedInRen RD12/0021/0015-Instituto de Salud Carlos III, Málaga, Spain
| | - Constantino Fernández
- Servicio de Nefrología, Complexo Hospitalario Universitario Juan Canalejo, A Coruña , Spain
| | - Nuria Esforzado
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Raphael Paschoalin
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Nuria Pérez
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Ana Isabel García
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Montserrat Del Amo
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Jaume Pomés
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Ana González Rinne
- Servicio de Nefrología, HospitalUniversitario de Canarias, CIBICAN, Universidad de La Laguna, RedInRen RD12/0021/0008-Instituto de Salud Carlos III, Tenerife, Spain
| | - Domingo Marrero
- Servicio de Nefrología, HospitalUniversitario de Canarias, CIBICAN, Universidad de La Laguna, RedInRen RD12/0021/0008-Instituto de Salud Carlos III, Tenerife, Spain
| | - Estefanía Pérez
- Servicio de Nefrología, HospitalUniversitario de Canarias, CIBICAN, Universidad de La Laguna, RedInRen RD12/0021/0008-Instituto de Salud Carlos III, Tenerife, Spain
| | - Fernando Henríquez
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Juan Manuel Díaz
- Servicio de Nefrología, Fundació Puigvert I.U.N.A, Barcelona, Spain
| | - Irene Silva
- Servicio de Nefrología, Fundació Puigvert I.U.N.A, Barcelona, Spain
| | - Verónica López
- Servicio de Nefrología, Hospital Regional Carlos Haya, Universidad de Málaga (IBIMA), RedInRen RD12/0021/0015-Instituto de Salud Carlos III, Málaga, Spain
| | - Manuel Perello
- Servicio de Nefrología, Hospital Vall D́Hebrón, Barcelona, Spain
| | - David Ramos
- Servicio de Nefrología, Hospital Universitario La Fe, Valencia, Spain
| | - Isabel Beneyto
- Servicio de Nefrología, Hospital Universitario La Fe, Valencia, Spain
| | - José María Cruzado
- Servicio de Nefrología, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | - Juan Bravo
- Servicio de Nefrología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Minerva Rodríguez
- Servicio de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Carmen Díaz
- Servicio de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Josep Crespo
- Servicio de Nefrología, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Fernando Anaya
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Luisa Rodríguez
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan José Cubero
- Servicio de Nefrología, Hospital Regional Universitario Infanta Cristina, Badajoz, Spain
| | - Pilar Pascual
- Servicio de Nefrología, Hospital Clínico Universitario de Valladolid, Spain
| | - Rafael Romero
- Servicio de Nefrología, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - María Dolores Checa
- Servicio de Nefrología, Centro Hospitalario Universitario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain
| | - Carlos Jiménez
- Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Spain
| | - Fernando Escuin
- Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Spain
| | - Marta Crespo
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Marisa Mir
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Gonzalo Gómez
- Servicio de Nefrología, Hospital Universitario Son Dureta, Palma de Mallorca, Spain
| | - Beatriz Bayes
- Servicio de Nefrología, Hospital Universitario Germans Trias I Pujol, Barcelona, Spain
| | - María José González
- Servicio de Nefrología, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Alex Gutiérrez
- Servicio de Nefrología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Marta Cuberes
- Servicio de Nefrología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Teresa García
- Servicio de Nefrología, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Francisco Llamas
- Servicio de Nefrología, Complejo Hospitalario y Universitario de Albacete, Spain
| | - Agustín Ortega
- Servicio de Nefrología, Complejo Hospitalario y Universitario de Albacete, Spain
| | - José Luis Conde
- Servicio de Nefrología, Hospital Complejo Hospitario de Toledo, Spain
| | - Carlos Gómez Alamillo
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, RedInRen RD12/0021/0007-Instituto de Salud Carlos III, Santander, Spain
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Morrone LF, Bolasco P, Camerini C, Cianciolo G, Cupisti A, Galassi A, Mazzaferro S, Russo D, Russo L, Cozzolino M. Vitamin D in patients with chronic kidney disease: a position statement of the Working Group "Trace Elements and Mineral Metabolism" of the Italian Society of Nephrology. J Nephrol 2016; 29:305-328. [PMID: 27062486 DOI: 10.1007/s40620-016-0305-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/30/2016] [Indexed: 02/07/2023]
Abstract
In the late 1970s, calcitriol was introduced into clinical practice for the management of secondary renal hyperparathyroidism in chronic kidney disease (CKD). Since then, the use of calcifediol or other native forms of vitamin D was largely ignored until the publication of the 2009 Kidney Disease Improving Global Outcomes (KDIGO) recommendations. The guidelines suggested that measurement of circulating levels of 25(OH)D (calcifediol) and its supplementation were to be performed on the same basis as for the general population. This indication was based on the fact that the precursors of active vitamin D had provided to CKD patients considerable benefits in survival, mainly due to their pleiotropic effects on the cardiovascular system. However, despite the long-term use of various classes of vitamin D in CKD, a clear definition is still lacking concerning the most appropriate time for initiation of therapy, the best compound to prescribe (active metabolites or analogs), the proper dosage, and the most suitable duration of therapy. The aim of this position statement is to provide and critically appraise the current plentiful evidence on vitamin D in different clinical settings related to CKD, particularly focusing on outcomes, monitoring and treatment-associated risks. However, it should be taken in account that position statements are meant to provide guidance; therefore, they are not to be considered prescriptive for all patients and, importantly, they cannot replace the judgment of clinicians.
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Affiliation(s)
- Luigi Francesco Morrone
- Nephrology, Dialysis and Renal Transplantation Unit, University Hospital "Policlinico", Bari, Italy.
| | - Pergiorgio Bolasco
- Territorial Unit of Nephrology and Dialysis-ASL 8 of Cagliari, Cagliari, Italy
| | - Corrado Camerini
- Operative Unit of Nephrology, AO Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Giuseppe Cianciolo
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna, Italy
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Sandro Mazzaferro
- Department of Cardiovascular Respiratory Nephrologic Anesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Domenico Russo
- Department of Public Health, Unit of Nephrology and Hypertension, University of Naples Federico II, Naples, Italy
| | - Luigi Russo
- Department of Public Health, Unit of Nephrology and Hypertension, University of Naples Federico II, Naples, Italy
| | - Mario Cozzolino
- Renal Division and Laboratory of Experimental Nephrology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
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Cai P, Tang X, Qin W, Ji L, Li Z. Comparison between paricalcitol and active non-selective vitamin D receptor activator for secondary hyperparathyroidism in chronic kidney disease: a systematic review and meta-analysis of randomized controlled trials. Int Urol Nephrol 2016; 48:571-84. [PMID: 26748501 DOI: 10.1007/s11255-015-1195-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 12/19/2015] [Indexed: 02/05/2023]
Abstract
PURPOSE The goal of this systematic review is to evaluate the efficacy and safety of paricalcitol versus active non-selective vitamin D receptor activators (VDRAs) for secondary hyperparathyroidism (SHPT) management in chronic kidney disease (CKD) patients. METHODS PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), clinicaltrials.gov (inception to September 2015), and ASN Web site were searched for relevant studies. A meta-analysis of randomized controlled trials (RCTs) and quasi-RCTs that assessed the effects and adverse events of paricalcitol and active non-selective VDRA in adult CKD patients with SHPT was performed using Review Manager 5.2. RESULTS A total of 10 trials involving 734 patients were identified for this review. The quality of included trials was limited, and very few trials reported all-cause mortality or cardiovascular calcification without any differences between two groups. Compared with active non-selective VDRAs, paricalcitol showed no significant difference in both PTH reduction (MD -7.78, 95% CI -28.59-13.03, P = 0.46) and the proportion of patients who achieved the target reduction of PTH (OR 1.27, 95% CI 0.87-1.85, P = 0.22). In addition, no statistical differences were found in terms of serum calcium, episodes of hypercalcemia, serum phosphorus, calcium × phosphorus products, and bone metabolism index. CONCLUSIONS Current evidence is insufficient, showing paricalcitol is superior to active non-selective VDRAs in lowering PTH or reducing the burden of mineral loading. Further trials are required to prove the tissue-selective effect of paricalcitol and to overcome the limitation of current research.
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Affiliation(s)
- Panpan Cai
- Division of Nephrology, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Xiaohong Tang
- Division of Nephrology, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Wei Qin
- Division of Nephrology, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Ling Ji
- Division of Nephrology, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Zi Li
- Division of Nephrology, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.
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Taweesedt PT, Disthabanchong S. Mineral and bone disorder after kidney transplantation. World J Transplant 2015; 5:231-242. [PMID: 26722650 PMCID: PMC4689933 DOI: 10.5500/wjt.v5.i4.231] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/11/2015] [Accepted: 10/27/2015] [Indexed: 02/05/2023] Open
Abstract
After successful kidney transplantation, accumulated waste products and electrolytes are excreted and regulatory hormones return to normal levels. Despite the improvement in mineral metabolites and mineral regulating hormones after kidney transplantation, abnormal bone and mineral metabolism continues to present in most patients. During the first 3 mo, fibroblast growth factor-23 (FGF-23) and parathyroid hormone levels decrease rapidly in association with an increase in 1,25-dihydroxyvitamin D production. Renal phosphate excretion resumes and serum calcium, if elevated before, returns toward normal levels. FGF-23 excess during the first 3-12 mo results in exaggerated renal phosphate loss and hypophosphatemia occurs in some patients. After 1 year, FGF-23 and serum phosphate return to normal levels but persistent hyperparathyroidism remains in some patients. The progression of vascular calcification also attenuates. High dose corticosteroid and persistent hyperparathyroidism are the most important factors influencing abnormal bone and mineral metabolism in long-term kidney transplant (KT) recipients. Bone loss occurs at a highest rate during the first 6-12 mo after transplantation. Measurement of bone mineral density is recommended in patients with estimated glomerular filtration rate > 30 mL/min. The use of active vitamin D with or without bisphosphonate is effective in preventing early post-transplant bone loss. Steroid withdrawal regimen is also beneficial in preservation of bone mass in long-term. Calcimimetic is an alternative therapy to parathyroidectomy in KT recipients with persistent hyperparathyroidism. If parathyroidectomy is required, subtotal to near total parathyroidectomy is recommended. Performing parathyroidectomy during the waiting period prior to transplantation is also preferred in patients with severe hyperparathyroidism associated with hypercalcemia.
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Abstract
PURPOSE OF REVIEW Mineral and bone disorders are common problems in organ transplant recipients. Successful transplantation solves many aspects of abnormal mineral and bone metabolism, but the degree of improvement is frequently incomplete. Posttransplant bone disease can affect long-term outcomes as well as increase the likelihood of fracture. In this article, we reviewed the major posttransplant bone diseases and recent advances in treatment strategies. RECENT FINDINGS Pretransplant bone disease and immunosuppressants are important risk factors for posttransplant bone disease. Corticosteroid withdrawal may result in minimal or no protection against fractures, with increased risk for acute rejection. Vitamin D analogue and bisphosphonate are frequently used to prevent and treat posttransplant osteoporosis. Posttransplant hyperparathyroidism increases the risk for all-cause mortality and graft loss, but not major cardiovascular events. Cinacalcet was well tolerated and effectively controlled hypercalcemic hyperparathyroidism; however, it did not improve bone mineral density and discontinuation led to parathyroid hormone rebound. Six-month paricalcitol supplementation reduced parathyroid hormone levels and attenuated bone remodeling and mineral loss in case of posttransplant hyperparathyroidism. SUMMARY Posttransplant bone diseases present in various forms, including osteoporosis, hyperparathyroidism, adynamic bone disease, and osteonecrosis. Prophylactic and therapeutic approaches to both pretransplant and posttransplant periods should be considered.
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Affiliation(s)
- Hee Jung Jeon
- aDepartment of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea bDivision of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea cTransplantation Center, Seoul National University Hospital, Seoul, Republic of Korea *Hee Jung Jeon and Hyosang Kim contributed equally to the writing of this article
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Abstract
Dysregulated phosphate metabolism is a common consequence of chronic kidney disease, and is characterized by a high circulating level of fibroblast growth factor (FGF)-23, hyperparathyroidism, and hyperphosphataemia. Kidney transplantation can elicit specific alterations to phosphate metabolism that evolve over time, ranging from severe hypophosphataemia (<0.5 mmol/l) to hyperphosphataemia (>1.50 mmol/l) and high FGF-23 levels. The majority of renal transplant recipients develop hypophosphataemia during the first 3 months after transplantation as a consequence of relatively slow adaptation of FGF-23 and parathyroid hormone levels to restored renal function, and the influence of immunosuppressive drugs. By 3-12 months after transplantation, phosphate homeostasis is at least partially restored in the majority of recipients, which is paralleled by a substantially reduced risk of cardiovascular-associated morbidity and mortality compared with the pre-transplantation setting. Many renal transplant recipients, however, exhibit persistent abnormalities in phosphate homeostasis, which is often due to multifactorial causes, and may contribute to adverse outcomes on the cardiovascular system, kidney, and bone. Dietary and pharmacologic interventions might improve phosphate homeostasis in renal transplant recipients, but additional insight into the pathophysiology of transplantation-associated abnormalities in phosphate homeostasis is needed to further optimize disease management and improve prognosis for renal transplant recipients.
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Santoro D, Caccamo D, Lucisano S, Buemi M, Sebekova K, Teta D, De Nicola L. Interplay of vitamin D, erythropoiesis, and the renin-angiotensin system. BIOMED RESEARCH INTERNATIONAL 2015; 2015:145828. [PMID: 26000281 PMCID: PMC4427087 DOI: 10.1155/2015/145828] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 01/30/2015] [Accepted: 02/04/2015] [Indexed: 12/20/2022]
Abstract
For many years deficiency of vitamin D was merely identified and assimilated to the presence of bone rickets. It is now clear that suboptimal vitamin D status may be correlated with several disorders and that the expression of 1-α-hydroxylase in tissues other than the kidney is widespread and of clinical relevance. Recently, evidence has been collected to suggest that, beyond the traditional involvement in mineral metabolism, vitamin D may interact with other kidney hormones such as renin and erythropoietin. This interaction would be responsible for some of the systemic and renal effects evoked for the therapy with vitamin D. The administration of analogues of vitamin D has been associated with an improvement of anaemia and reduction in ESA requirements. Moreover, vitamin D deficiency could contribute to an inappropriately activated or unsuppressed RAS, as a mechanism for progression of CKD and/or cardiovascular disease. Experimental data on the anti-RAS and anti-inflammatory effects treatment with active vitamin D analogues suggest a therapeutic option particularly in proteinuric CKD patients. This option should be considered for those subjects that are intolerant to anti-RAS agents or, as add-on therapy, in those already treated with anti-RAS but not reaching the safe threshold level of proteinuria.
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Affiliation(s)
- Domenico Santoro
- Department of Clinical and Experimental Medicine, University of Messina, Via Faranda, 2-98123 Messina, Italy
| | - Daniela Caccamo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Italy
| | - Silvia Lucisano
- Department of Clinical and Experimental Medicine, University of Messina, Via Faranda, 2-98123 Messina, Italy
| | - Michele Buemi
- Department of Clinical and Experimental Medicine, University of Messina, Via Faranda, 2-98123 Messina, Italy
| | | | - Daniel Teta
- University Hospital (CHUV), Lausanne, Switzerland
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