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Nakayama M, Kobayashi S, Kusakabe M, Ohara M, Nakanishi K, Akizawa T, Fukagawa M. Tenapanor for peritoneal dialysis patients with hyperphosphatemia: a phase 3 trial. Clin Exp Nephrol 2024; 28:153-164. [PMID: 37910313 PMCID: PMC10808471 DOI: 10.1007/s10157-023-02406-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/10/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Tenapanor is a novel selective inhibitor of intestinal sodium/hydrogen exchanger 3 transporter. This is the first trial to assess the efficacy and safety of tenapanor in Japanese patients with hyperphosphatemia who are undergoing peritoneal dialysis. METHODS This phase 3, open-label, multicenter, single-arm clinical trial targeted patients whose serum phosphorus was within 3.5-7.0 mg/dL with phosphate binders at screening. After phosphate binder washout, tenapanor was orally administered twice-daily, stepwise from 5 to 30 mg/dose for 16 weeks. The primary endpoint, mean change in serum phosphorus level, was evaluated at week 8. The 16-week treatment period was completed with tenapanor alone, and only one phosphate binder type was allowed for combined use after the primary endpoint. RESULTS Of the 54 patients enrolled, 34 completed the study. At week 8, the primary endpoint, mean change in serum phosphorus level (last observation carried forward), was - 1.18 mg/dL (95% confidence interval: - 1.54, - 0.81 mg/dL) with tenapanor. From a baseline value of 7.65 mg/dL, serum phosphorus decreased to 6.14 and 5.44 mg/dL at weeks 8 and 16, respectively, and 46.3% and 76.5% of patients achieved serum phosphorus within 3.5-6.0 mg/dL at week 8 and week 16, respectively. The most common adverse event, diarrhea, occurred in 74.1% of patients; the severity of diarrhea was mild or moderate. Thus, the discontinuation percentage due to diarrhea was low at 5.6%. CONCLUSIONS Administration of tenapanor resulted in a sufficient reduction in serum phosphorus level at week 8 and was considered safe and tolerable. TRIAL REGISTRATION NCT04766385.
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Affiliation(s)
- Masaaki Nakayama
- Kidney Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan.
| | | | | | - Meiko Ohara
- R&D Division, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | | | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
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Hernández-Escobar D, Pajares-Chamorro N, Chatzistavrou X, Hankenson KD, Hammer ND, Boehlert CJ. Tailored Coatings for Enhanced Performance of Zinc-Magnesium Alloys in Absorbable Implants. ACS Biomater Sci Eng 2024; 10:338-354. [PMID: 38109649 DOI: 10.1021/acsbiomaterials.3c01255] [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] [Indexed: 12/20/2023]
Abstract
Absorbable metals exhibit potential for next-generation temporary medical implants, dissolving safely in the body during tissue healing and regeneration. Their commercial incorporation could substantially diminish the need for additional surgeries and complications that are tied to permanent devices. Despite extensive research on magnesium (Mg) and iron (Fe), achieving the optimal combination of mechanical properties, biocompatibility, and controlled degradation rate for absorbable implants remains a challenge. Zinc (Zn) and Zn-based alloys emerged as an attractive alternative for absorbable implants, due to favorable combination of in vivo biocompatibility and degradation behavior. Moreover, the development of suitable coatings can enhance their biological characteristics and tailor their degradation process. In this work, four different biodegradable coatings (based on zinc phosphate (ZnP), collagen (Col), and Ag-doped bioactive glass nanoparticles (AgBGNs)) were synthesized by chemical conversion, spin-coating, or a combination of both on Zn-3Mg substrates. This study assessed the impact of the coatings on in vitro degradation behavior, cytocompatibility, and antibacterial activity. The ZnP-coated samples demonstrated controlled weight loss and a decreased corrosion rate over time, maintaining a physiological pH. Extracts from the uncoated, ZnP-coated, and Col-AgBGN-coated samples showed higher cell viability with increasing concentration. Bacterial viability was significantly impaired in all coated samples, particularly in the Col-AgBGN coating. This study showcases the potential of a strategic material-coating combination to effectively tackle multiple challenges encountered in current medical implant technologies by modifying the properties of absorbable metals to tailor patient treatments.
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Affiliation(s)
- David Hernández-Escobar
- Department of Chemical Engineering and Materials Science, Michigan State University, East Lansing, Michigan 48824, United States
| | - Natalia Pajares-Chamorro
- Department of Chemical Engineering and Materials Science, Michigan State University, East Lansing, Michigan 48824, United States
| | - Xanthippi Chatzistavrou
- Department of Chemical Engineering and Materials Science, Michigan State University, East Lansing, Michigan 48824, United States
- Department of Chemical Engineering, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Kurt D Hankenson
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan 48104, United States
| | - Neal D Hammer
- Department of Microbiology and Molecular Genetics, Michigan State University, East Lansing, Michigan 48824, United States
| | - Carl J Boehlert
- Department of Chemical Engineering and Materials Science, Michigan State University, East Lansing, Michigan 48824, United States
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Laursen SH, Boel L, Brandi L, Christensen JH, Vestergaard P, Hejlesen OK. Evaluation of a phosphate kinetics model in hemodialysis therapy-Assessment of the temporal robustness of model predictions. Physiol Rep 2023; 11:e15899. [PMID: 38129113 PMCID: PMC10737683 DOI: 10.14814/phy2.15899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023] Open
Abstract
In-depth understanding of intra- and postdialytic phosphate kinetics is important to adjust treatment regimens in hemodialysis. We aimed to modify and validate a three-compartment phosphate kinetic model to individual patient data and assess the temporal robustness. Intradialytic phosphate samples were collected from the plasma and dialysate of 12 patients during two treatments (HD1 and HD2). 2-h postdialytic plasma samples were collected in four of the patients. First, the model was fitted to HD1 samples from each patient to estimate the mass transfer coefficients. Second, the best fitted model in each patient case was validated on HD2 samples. The best model fits were determined from the coefficient of determination (R2 ) values. When fitted to intradialytic samples only, the median (interquartile range) R2 values were 0.985 (0.959-0.997) and 0.992 (0.984-0.994) for HD1 and HD2, respectively. When fitted to both intra- and postdialytic samples, the results were 0.882 (0.838-0.929) and 0.963 (0.951-0.976) for HD1 and HD2, respectively. Eight patients demonstrated a higher R2 value for HD2 than for HD1. The model seems promising to predict individual plasma phosphate in hemodialysis patients. The results also show good temporal robustness of the model. Further modifications and validation on a larger sample are needed.
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Affiliation(s)
- Sisse H. Laursen
- The Danish Diabetes AcademyOdense University HospitalOdenseDenmark
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
- Department of NursingUniversity College of Northern DenmarkAalborgDenmark
- Steno Diabetes Center North JutlandAalborg University HospitalAalborgDenmark
- Clinical Nursing Research UnitAalborg University HospitalAalborgDenmark
| | - Lise Boel
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Lisbet Brandi
- Department of Cardiology, Nephrology, and Endocrinology, Nordsjællands HospitalHillerødDenmark
| | | | - Peter Vestergaard
- Steno Diabetes Center North JutlandAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of EndocrinologyAalborg University HospitalAalborgDenmark
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Laursen SH, Boel L, Brandi L, Christensen JH, Vestergaard P, Hejlesen OK. Implementation of a coagulation component into a phosphate kinetics model in haemodialysis therapy: A tool for detection of clotting problems? Exp Physiol 2023; 108:1325-1336. [PMID: 37566800 PMCID: PMC10996865 DOI: 10.1113/ep091201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023]
Abstract
A coagulation component should be considered in phosphate kinetics modelling because intradialytic coagulation of the extracorporeal circuit and dialyser might reduce phosphate removal in haemodialysis. Thus, the objective of this study was to add and evaluate coagulation as an individual linear clearance reduction component to a promising three-compartment model assuming progressive intradialytic clotting. The model was modified and validated on intradialytic plasma and dialysate phosphate samples from 12 haemodialysis patients collected during two treatments (HD1 and HD2) at a Danish hospital ward. The most suitable clearance reduction in each treatment was identified by minimizing the root mean square error (RMSE). The model simulations with and without clearance reduction were compared based on RMSE and coefficient of determination (R2 ) values. Improvements were found for 17 of the 24 model simulations when clearance reduction was added to the model. The slopes of the clearance reduction were in the range of 0.011-0.632/h. Three improvements were found to be statistically significant (|observed z value| > 1.96). A very significant correlation (R2 = 0.708) between the slopes for HD1 and HD2 was found. Adding the clearance reduction component to the model seems promising in phosphate kinetics modelling and might be explained, at least in part, by intradialytic coagulation. In future studies, the model might be developed further to serve as a potentially useful tool for the quantitative detection of clotting problems in haemodialysis. NEW FINDINGS: What is the central question of this study? The aim was to add an intradialytic coagulation component to a modified version of a promising three-compartment phosphate kinetics model. The hypothesis was that circuit and dialyser clotting can be modelled by an individual linear phosphate clearance reduction component during haemodialysis treatment. What is the main finding and its importance? Improvements were found for 17 of 24 model simulations when clearance reduction was added to the model. Thus, the kinetics model seems promising and could be a useful tool for the quantitative detection of clotting problems in haemodialysis patients.
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Affiliation(s)
- Sisse H. Laursen
- The Danish Diabetes AcademyOdense University HospitalOdenseDenmark
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
- Department of NursingUniversity College of Northern DenmarkAalborgDenmark
- Steno Diabetes Center North DenmarkAalborg University HospitalAalborgDenmark
- Clinical Nursing Research UnitAalborg University HospitalAalborgDenmark
| | - Lise Boel
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
| | - Lisbet Brandi
- Department of Cardiology, Nephrology and EndocrinologyNordsjællands HospitalHillerødDenmark
| | | | - Peter Vestergaard
- Steno Diabetes Center North DenmarkAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of EndocrinologyAalborg University HospitalAalborgDenmark
| | - Ole K. Hejlesen
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
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Kaur R, Singh R. Mechanistic insights into CKD-MBD-related vascular calcification and its clinical implications. Life Sci 2022; 311:121148. [DOI: 10.1016/j.lfs.2022.121148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/22/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
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William Whitehouse R, Ahmad G, Kirwadi A, Matthew Howard J. Imaging of Chronic Kidney Disease-Mineral and Bone Disorder. Radiol Clin North Am 2022; 60:547-559. [PMID: 35672088 DOI: 10.1016/j.rcl.2022.02.004] [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: 11/28/2022]
Abstract
The characteristic radiological appearances of metabolic bone and soft tissue diseases in chronic renal failure are described and illustrated in the context of advancing understanding of the complex metabolic changes that occur in chronic kidney disease and its management.
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Affiliation(s)
| | - Gulraiz Ahmad
- Department of Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Anand Kirwadi
- Department of Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - James Matthew Howard
- Department of Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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Asada T, Iwata M, Matsuzaki S, Hamakawa H, Sengan S, Noguchi T, Daimon K, Matsumura N, Shibasaki M, Tsujimoto T, Ooi K, Fukuyama H. Hypercalcemia and hyperphosphatemia associated with 25-OH vitamin D deficiency in an alcoholic patient with normal renal function. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2022. [DOI: 10.1016/j.jecr.2022.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Michigami T, Yamazaki M, Razzaque MS. Extracellular Phosphate, Inflammation and Cytotoxicity. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1362:15-25. [DOI: 10.1007/978-3-030-91623-7_3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Wung CH, Wang YH, Lee YC, Chang CW, Wu PY, Huang JC, Tsai YC, Chen SC, Chang JM, Hwang SJ. Association between Flow-Mediated Dilation and Skin Perfusion Pressure with Peripheral Artery Disease in Hemodialysis Patients. J Pers Med 2021; 11:jpm11121251. [PMID: 34945724 PMCID: PMC8708979 DOI: 10.3390/jpm11121251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/21/2022] Open
Abstract
Flow-mediated dilation (FMD) is used to noninvasively assess the health of blood vessels and it has been shown to have a similar predictive ability for cardiovascular disease to traditional risk factors. Skin perfusion pressure (SPP) refers to the blood pressure required to restore capillary or microcirculatory flow after controlled occlusion and the return of flow. SPP has been shown to be an important measurement when making clinical decisions for patients with limb ischemia and to be a predictor of the likelihood of wound healing. Peripheral artery disease is common in hemodialysis (HD) patients. However, little is known about the association between FMD or SPP and peripheral artery disease. The aim of this study was to evaluate the association between FMD and SPP with brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index (ABI) in HD patients in Taiwan, an area with a high rate of ESRD. This study was conducted at a regional hospital in southern Taiwan. ABI and baPWV values were measured using an ABI automated device. FMD and SPP were measured using ultrasound and a microvasculature blood flow monitor, respectively. Eighty patients were enrolled in this study. Compared to the patients with an ABI ≥ 0.95, those with an ABI < 0.95 had lower SPP of the feet (dorsal and plantar portions, both p < 0.001). After multivariable adjustments, low triglycerides (p = 0.033) and high calcium–phosphate product (p = 0.018) were significantly associated with low FMD. Further, low ABI (p = 0.001) and low baPWV (p = 0.036) were significantly associated with low SPP of dorsal portions. Old age (p = 0.005), low high-density lipoprotein cholesterol (p = 0.016), and low ABI (p = 0.002) were significantly associated with low SPP of plantar portions. This study demonstrated an association between FMD and SPP with peripheral artery disease in HD patients. Patients with low ABI and baPWV had a high risk of low SPP of the feet. However, there was no significant correlation between FMD and ABI or baPWV.
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Affiliation(s)
- Chih-Hsuan Wung
- Department of Post Baccalaureate Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
| | - Yu-Hsiu Wang
- Department of Nursing, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan; (Y.-H.W.); (Y.-C.L.); (C.-W.C.)
| | - Yuang-Chi Lee
- Department of Nursing, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan; (Y.-H.W.); (Y.-C.L.); (C.-W.C.)
| | - Chieh-Wei Chang
- Department of Nursing, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan; (Y.-H.W.); (Y.-C.L.); (C.-W.C.)
| | - Pei-Yu Wu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (P.-Y.W.); (J.-C.H.)
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan; (Y.-C.T.); (J.-M.C.)
| | - Jiun-Chi Huang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (P.-Y.W.); (J.-C.H.)
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan; (Y.-C.T.); (J.-M.C.)
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Yi-Chun Tsai
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan; (Y.-C.T.); (J.-M.C.)
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Szu-Chia Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (P.-Y.W.); (J.-C.H.)
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan; (Y.-C.T.); (J.-M.C.)
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Correspondence: (S.-C.C.); (S.-J.H.); Tel.: +886-7-8036783 (ext. 3440) (S.-C.C.); +886-7-3121101 (ext. 7351) (S.-J.H.); Fax: +886-7-8063346 (S.-C.C.)
| | - Jer-Ming Chang
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan; (Y.-C.T.); (J.-M.C.)
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Shang-Jyh Hwang
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan; (Y.-C.T.); (J.-M.C.)
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Correspondence: (S.-C.C.); (S.-J.H.); Tel.: +886-7-8036783 (ext. 3440) (S.-C.C.); +886-7-3121101 (ext. 7351) (S.-J.H.); Fax: +886-7-8063346 (S.-C.C.)
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Shih TY, Wu YC, Tseng SC, Chen KH, Pan CC, Lee CH. Correlation between Preoperative Serum Levels of Calcium, Phosphate, and Intact Parathyroid Hormone and Radiological Outcomes in Spinal Interbody Fusion among End-Stage Renal Disease Patients. J Clin Med 2021; 10:jcm10225447. [PMID: 34830729 PMCID: PMC8619249 DOI: 10.3390/jcm10225447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 11/29/2022] Open
Abstract
Spinal fusion surgery for end-stage renal disease (ESRD) patients is a clinical challenge. This study aimed to investigate whether postoperative radiological outcomes are related to preoperative serum calcium, phosphate, or intact parathyroid hormone (iPTH) levels in patients with ESRD who underwent spinal interbody fusion surgery. This study included 62-consecutive patients with ESRD who underwent anterior cervical discectomy and fusion (ACDF) or transforaminal lumbar interbody fusion (TLIF) surgery for symptomatic spinal disorder. The most recent preoperative serum calcium, phosphate, and iPTH levels were recorded, and the postoperative radiographic outcomes were assessed. A significant correlation was found between the occurrence of cage subsidence and higher blood phosphate, calcium–phosphate product (Ca × P), and iPTH levels in the TLIF group. The occurrence of pedicle screw loosening was related to higher blood phosphate and Ca × P product in the TLIF group. However, no correlation was found between the fusion grades and the serum levels in either the TLIF or ACDF groups. These results indicated that higher preoperative serum phosphate and Ca × P product are risk factors for both cage subsidence and screw loosening in patients with ESRD who underwent TLIF surgery. Higher iPTH levels are also a possible risk factor for cage subsidence.
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Affiliation(s)
- Ting-Yu Shih
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.S.); (Y.-C.W.); (S.-C.T.); (K.-H.C.); (C.-C.P.)
| | - Yun-Che Wu
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.S.); (Y.-C.W.); (S.-C.T.); (K.-H.C.); (C.-C.P.)
| | - Sheng-Chieh Tseng
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.S.); (Y.-C.W.); (S.-C.T.); (K.-H.C.); (C.-C.P.)
| | - Kun-Hui Chen
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.S.); (Y.-C.W.); (S.-C.T.); (K.-H.C.); (C.-C.P.)
| | - Chien-Chou Pan
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.S.); (Y.-C.W.); (S.-C.T.); (K.-H.C.); (C.-C.P.)
| | - Cheng-Hung Lee
- Department of Orthopaedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.S.); (Y.-C.W.); (S.-C.T.); (K.-H.C.); (C.-C.P.)
- Department of Food Science and Technology, Hung Kuang University, Taichung 43302, Taiwan
- College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan
- Correspondence: ; Tel.: +886-4-23592525 (ext. 5101)
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Zaki HM, Sliem HA, Ibrahim HR, Yassine IA. Silent neurological lesions detected by magnetic resonance imaging: Relationship to hyperparathyroidism among end-stage renal disease young patients on haemodialysis. Int J Clin Pract 2021; 75:e14569. [PMID: 34165847 DOI: 10.1111/ijcp.14569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/23/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND End-stage renal disease (ESRD) patients on haemodialysis (HD) suffer from several peripheral and central neurological complications. They are at high risk for developing silent neurological lesions (SNL) that may be detected accidentally by magnetic resonance imaging (MRI). Many factors are implicated in the development of neurological deficits in ESRD patients on HD. AIM OF THE WORK Evaluation of SNL in young ESRD patients by using MRI and assessing its correlation with hyperparathyroidism. METHODS The study involved 48 young ESRD patients (mean age of 19.6 ± 6 years) with HD and do not have any apparent abnormalities in the neurological examination. Laboratory investigations and conventional brain MRI were done on all. RESULTS 79.2% have SBI and 45.8% have white matter lesions. Regression analysis revealed that calcium level and duration of dialysis were independent predictor factors for the presence of silent brain MRI lesions (P = .034 & 0.045 respectively). ROC curve showed that parathyroid hormone (PTH) level >585 pg/mL, duration of dialysis >2 years, and calcium level >7.5 mg/dL predicted the presence of SNL. CONCLUSION The duration of HD and hyperparathyroidism (HPT) were independent predictors for the presence of SNL. MRI brain is considered as a mandatory affordable tool for HD patients >2 years and has HPT for early detection of SNL to help early intervention and avoid neurological complications and disabilities.
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Affiliation(s)
- Heba M Zaki
- Department of Internal Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Hamdy A Sliem
- Department of Internal Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Heba R Ibrahim
- Department of Diagnostic Radiology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Imane A Yassine
- Department of Neurology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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12
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Rodrigues FG, Ormanji MS, Heilberg IP, Bakker SJL, de Borst MH. Interplay between gut microbiota, bone health and vascular calcification in chronic kidney disease. Eur J Clin Invest 2021; 51:e13588. [PMID: 33948936 PMCID: PMC8459296 DOI: 10.1111/eci.13588] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/30/2021] [Accepted: 05/01/2021] [Indexed: 02/06/2023]
Abstract
Deregulations in gut microbiota may play a role in vascular and bone disease in chronic kidney disease (CKD). As glomerular filtration rate declines, the colon becomes more important as a site of excretion of urea and uric acid, and an increased bacterial proteolytic fermentation alters the gut microbial balance. A diet with limited amounts of fibre, as well as certain medications (eg phosphate binders, iron supplementation, antibiotics) further contribute to changes in gut microbiota composition among CKD patients. At the same time, both vascular calcification and bone disease are common in patients with advanced kidney disease. This narrative review describes emerging evidence on gut dysbiosis, vascular calcification, bone demineralization and their interrelationship termed the 'gut-bone-vascular axis' in progressive CKD. The role of diet, gut microbial metabolites (ie indoxyl sulphate, p-cresyl sulphate, trimethylamine N-oxide (TMAO) and short-chain fatty acids (SCFA)), vitamin K deficiency, inflammatory cytokines and their impact on both bone health and vascular calcification are discussed. This framework may open up novel preventive and therapeutic approaches targeting the microbiome in an attempt to improve cardiovascular and bone health in CKD.
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Affiliation(s)
- Fernanda G Rodrigues
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Nutrition Post-Graduation Program, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Milene S Ormanji
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ita P Heilberg
- Nutrition Post-Graduation Program, Universidade Federal de São Paulo, São Paulo, Brazil.,Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Stephan J L Bakker
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Martin H de Borst
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Kalantar-Zadeh K, Jafar TH, Nitsch D, Neuen BL, Perkovic V. Chronic kidney disease. Lancet 2021; 398:786-802. [PMID: 34175022 DOI: 10.1016/s0140-6736(21)00519-5] [Citation(s) in RCA: 469] [Impact Index Per Article: 156.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/11/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA, USA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA.
| | - Tazeen H Jafar
- Duke-NUS Graduate Medical School, Singapore; Department of Renal Medicine, Singapore General Hospital, Singapore; Duke Global Health Institute, Durham, NC, USA
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; United Kingdom Renal Registry, Bristol, UK; Department of Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Vlado Perkovic
- Faculty of Medicine, University of New South Wales Sydney, Sydney, NSW, Australia
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Dobenecker B, Reese S, Herbst S. Effects of dietary phosphates from organic and inorganic sources on parameters of phosphorus homeostasis in healthy adult dogs. PLoS One 2021; 16:e0246950. [PMID: 33606750 PMCID: PMC7894875 DOI: 10.1371/journal.pone.0246950] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/28/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The impact of dietary phosphorus (P) excess, especially on renal and cardiovascular health, has been investigated in several species, but little is known in dogs. OBJECTIVE The aim of this study was to examine effects of different P sources on concentration and postprandial kinetics of selected parameters of P homeostasis in dogs. METHODS Eight beagles received one control diet (P 0.5% dry matter [DM]) and three high P diets (poultry meal, NaH2PO4, and KH2PO4; P 1.7% DM) for 18d. Urine samples were collected pre- and postprandially while faeces were collected quantitatively for 5d and analysed for minerals. On day 18, blood was sampled 1h pre- and 0.5, 1, 1.5, 2, 3, 5 and 7h postprandially. RESULTS Pi (KH2PO4, NaH2PO4) but not organic P caused an increased apparent P digestibility and significantly influenced kinetics of serum FGF23, parathyroid hormone, P, CrossLaps and bonespecific alkaline phosphatase, demonstrating a disrupted calcium (Ca) and P homeostasis with potential harm for renal, cardiovascular and skeletal health. CONCLUSIONS Results of feeding Pi to dogs indicate distinct disturbances of Ca and P metabolism, in contrast to organic sources. The use of Pi in food can therefore not be considered as safe. Further research, especially on dose and long-term effects, is warranted.
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Affiliation(s)
- Britta Dobenecker
- Chair of Animal Nutrition and Dietetics, Department of Animal Science, Ludwig-Maximilians- Universität, Munich, Germany
| | - Sven Reese
- Chair of Anatomy, Histology and Embryology, Department of Animal Science, Ludwig-Maximilians- Universität, Munich, Germany
| | - Sarah Herbst
- Chair of Animal Nutrition and Dietetics, Department of Animal Science, Ludwig-Maximilians- Universität, Munich, Germany
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15
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Sprague SM. The Enigma of Vascular Calcifications. Kidney Int Rep 2020; 5:2127-2129. [PMID: 33306042 PMCID: PMC7710879 DOI: 10.1016/j.ekir.2020.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Stuart M. Sprague
- Division of Nephrology and Hypertension, NorthShore University HealthSystem, Evanston, Illinois, USA
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16
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Cai G, Keen HI, Host LV, Aitken D, Laslett LL, Winzenberg T, Wluka AE, Black D, Jones G. Once-yearly zoledronic acid and change in abdominal aortic calcification over 3 years in postmenopausal women with osteoporosis: results from the HORIZON Pivotal Fracture Trial. Osteoporos Int 2020; 31:1741-1747. [PMID: 32361951 DOI: 10.1007/s00198-020-05430-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 04/22/2020] [Indexed: 12/19/2022]
Abstract
UNLABELLED This study evaluated whether zoledronic acid (ZA) inhibited the progression of abdominal aortic calcification (AAC) over 3 years in 502 postmenopausal women with osteoporosis. AAC progressed in a similar proportion of participants in the ZA (29%) and placebo (31%) groups, suggesting no effect of ZA on AAC progression. INTRODUCTION Bisphosphonate use is associated with reduced risk of all-cause mortality and cardiovascular events. The underlying mechanisms are uncertain but may include effects on vascular calcification. This study aimed to evaluate the effect of zoledronic acid (ZA) on abdominal aortic calcification (AAC) in postmenopausal women with osteoporosis. METHODS This was a post hoc analysis of the HORIZON Pivotal Fracture Trial that included 502 postmenopausal women (mean age 72.5 years) with osteoporosis (234 received ZA and 268 placebo). AAC scores (range, 0-8) were assessed from paired spine X-rays at baseline and after 3 years. Progression of AAC was defined as any increase in AAC score. The association between change in hip and femoral neck bone mineral density and change in AAC score was also assessed. RESULTS At baseline, 292 (58.2%) participants had AAC (i.e., AAC score > 0), with AAC scores similar in the two intervention groups (median [interquartile range], 1 [0 to 2] for both; p = 0.98). Over 3 years, AAC progressed in a similar proportion of participants in both groups (ZA 29% and placebo 31%; p = 0.64). Change in bone mineral density and change in AAC score were not correlated. CONCLUSION Once-yearly zoledronic acid did not affect progression of AAC over 3 years in postmenopausal women with osteoporosis. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00049829.
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Affiliation(s)
- G Cai
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia
| | - H I Keen
- Department of Rheumatology, Fiona Stanley Hospital, Murdoch, Australia
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia
| | - L V Host
- Department of Rheumatology, Fiona Stanley Hospital, Murdoch, Australia
| | - D Aitken
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia
| | - L L Laslett
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia
| | - T Winzenberg
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia
| | - A E Wluka
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Alfred Hospital, Monash University, Melbourne, Australia
| | - D Black
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - G Jones
- Menzies Institute for Medical Research, University of Tasmania, Private Bag 23, Hobart, Tasmania, 7000, Australia.
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17
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Ting IW, Yeh HC, Huang HC, Chiang HY, Chu PL, Kuo CC. Joint Longitudinal Low Calcium High Phosphorus Trajectory Associates with Accelerated Progression, Acute Coronary Syndrome and Mortality in Chronic Kidney Disease. Sci Rep 2020; 10:9682. [PMID: 32541796 PMCID: PMC7296014 DOI: 10.1038/s41598-020-66577-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
The effects of long-term disturbance of the mineral metabolism on patients with chronic kidney disease (CKD) are unclear. We investigated whether the longitudinal Ca-P (joint calcium and phosphorus) trajectories are associated with incident end-stage renal disease (ESRD), acute coronary syndrome (ACS), and all-cause mortality in patients with CKD. We conducted a prospective cohort study by using data from a 13-year multidisciplinary pre-ESRD care registry. The final study population consisted of 4,237 CKD patients aged 20–90 years with data gathered from 2003 to 2015. Individuals’ Ca-P trajectories were defined using group-based multi-trajectory modeling into three distinct patterns: reference, moderately abnormal, and severely abnormal. Times to ESRD, ACS, and death were analyzed using multiple Cox regression. Compared with those with a “reference” Ca-P trajectory, the adjusted hazard ratios (aHRs) (95% confidence interval [CI]) for incidental ESRD were 5.92 (4.71–7.44) and 15.20 (11.85–19.50) for “moderately abnormal” and “severely abnormal” Ca-P trajectories, respectively. The corresponding aHRs for ACS were 1.94 (1.49–2.52) and 3.18 (2.30–4.39), and for all-cause mortality, they were 1.88 (1.64–2.16) and 2.46 (2.05–2.96) for “moderately abnormal” and “severely abnormal” Ca-P trajectories, respectively. For outcomes of progression to ESRD, the detrimental effects of abnormal Ca-P trajectories were more substantial in patients with CKD stage 3 than those with CKD stage 4 or 5 (p-value for interaction < 0.001). Future studies should validate reliable longitudinal cut-offs of serum phosphorus and consider the “lowering phosphorus— the lower the better, the earlier the better” approach to phosphorus control in CKD.
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Affiliation(s)
- I-Wen Ting
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Hung-Chieh Yeh
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.,Big Data Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Han-Chun Huang
- Big Data Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Hsiu-Yin Chiang
- Big Data Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Pei-Lun Chu
- Department of Internal Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei, Taiwan.,School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan
| | - Chin-Chi Kuo
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan. .,Big Data Center, China Medical University Hospital, China Medical University, Taichung, Taiwan.
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18
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Cheungpasitporn W, Thongprayoon C, Hansrivijit P, Medaura J, Chewcharat A, Bathini T, Mao MA, Erickson SB. Impact of Admission Calcium-phosphate Product on 1-year Mortality among Hospitalized Patients. Adv Biomed Res 2020; 9:14. [PMID: 32775307 PMCID: PMC7282693 DOI: 10.4103/abr.abr_249_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/12/2020] [Accepted: 02/16/2020] [Indexed: 11/04/2022] Open
Abstract
Background Calcium-phosphate product is associated with mortality among patients with end-stage kidney disease on dialysis. However, clinical evidence among hospitalized patients is limited. The objective of this study was to investigate the relationship between admission calcium-phosphate product and 1-year mortality in hospitalized patients. Materials and Methods All adult patients admitted to a tertiary referral hospital in 2009-2013 were studied. Patients who had both available serum calcium and phosphate measurement within 24 h of hospital admission were included. Admission calcium-phosphate product (calcium × phosphate) was stratified based on its distribution into six groups: <21, 21-<27, 27-<33, 33-<39, 39-<45, and ≥45 mg2/dL2. Multivariate cox proportional hazard analysis was performed to evaluate the association between admission calcium-phosphate product and 1-year mortality, using the calcium-phosphate product of 33-<39 mg2/dL2 as the reference group. Results A total of 14,772 patients were included in this study. The mean admission calcium-phosphate product was 34.4 ± 11.3 mg2/dL2. Of these patients, 3194 (22%) died within 1 year of hospital admission. In adjusted analysis, admission calcium-phosphate product of ≥45 mg2/dL2 was significantly associated with increased 1-year mortality with hazard ratio of 1.41 (95% 95% confidence interval 1.25-1.67), whereas lower admission calcium-phosphate product was not significantly associated with 1-year mortality. Conclusion Elevated calcium-phosphate product was significantly associated with increased 1-year mortality in hospitalized patients.
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Affiliation(s)
- Wisit Cheungpasitporn
- Department of Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi, USA.,Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Charat Thongprayoon
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, USA
| | - Juan Medaura
- Department of Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Api Chewcharat
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, Arizona, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL, USA
| | - Stephen B Erickson
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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19
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Muñoz-Castañeda JR, Rodelo-Haad C, Pendon-Ruiz de Mier MV, Martin-Malo A, Santamaria R, Rodriguez M. Klotho/FGF23 and Wnt Signaling as Important Players in the Comorbidities Associated with Chronic Kidney Disease. Toxins (Basel) 2020; 12:E185. [PMID: 32188018 PMCID: PMC7150840 DOI: 10.3390/toxins12030185] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/05/2020] [Accepted: 03/11/2020] [Indexed: 12/31/2022] Open
Abstract
Fibroblast Growth Factor 23 (FGF23) and Klotho play an essential role in the regulation of mineral metabolism, and both are altered as a consequence of renal failure. FGF23 increases to augment phosphaturia, which prevents phosphate accumulation at the early stages of chronic kidney disease (CKD). This effect of FGF23 requires the presence of Klotho in the renal tubules. However, Klotho expression is reduced as soon as renal function is starting to fail to generate a state of FGF23 resistance. Changes in these proteins directly affect to other mineral metabolism parameters; they may affect renal function and can produce damage in other organs such as bone, heart, or vessels. Some of the mechanisms responsible for the changes in FGF23 and Klotho levels are related to modifications in the Wnt signaling. This review examines the link between FGF23/Klotho and Wnt/β-catenin in different organs: kidney, heart, and bone. Activation of the canonical Wnt signaling produces changes in FGF23 and Klotho and vice versa; therefore, this pathway emerges as a potential therapeutic target that may help to prevent CKD-associated complications.
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Affiliation(s)
- Juan Rafael Muñoz-Castañeda
- Maimonides Institute for Biomedical Research (IMIBIC), 14005 Cordoba, Spain; (J.R.M.-C.); (C.R.-H.); (A.M.-M.); (R.S.); (M.R.)
- School of Medicine, Department of Medicine, University of Cordoba, 14005 Cordoba, Spain
- Nephrology Service, Reina Sofia University Hospital, 14005 Cordoba, Spain
- Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, 28029 Madrid, Spain
| | - Cristian Rodelo-Haad
- Maimonides Institute for Biomedical Research (IMIBIC), 14005 Cordoba, Spain; (J.R.M.-C.); (C.R.-H.); (A.M.-M.); (R.S.); (M.R.)
- School of Medicine, Department of Medicine, University of Cordoba, 14005 Cordoba, Spain
- Nephrology Service, Reina Sofia University Hospital, 14005 Cordoba, Spain
- Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, 28029 Madrid, Spain
| | - Maria Victoria Pendon-Ruiz de Mier
- Maimonides Institute for Biomedical Research (IMIBIC), 14005 Cordoba, Spain; (J.R.M.-C.); (C.R.-H.); (A.M.-M.); (R.S.); (M.R.)
- School of Medicine, Department of Medicine, University of Cordoba, 14005 Cordoba, Spain
- Nephrology Service, Reina Sofia University Hospital, 14005 Cordoba, Spain
- Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, 28029 Madrid, Spain
| | - Alejandro Martin-Malo
- Maimonides Institute for Biomedical Research (IMIBIC), 14005 Cordoba, Spain; (J.R.M.-C.); (C.R.-H.); (A.M.-M.); (R.S.); (M.R.)
- School of Medicine, Department of Medicine, University of Cordoba, 14005 Cordoba, Spain
- Nephrology Service, Reina Sofia University Hospital, 14005 Cordoba, Spain
- Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, 28029 Madrid, Spain
| | - Rafael Santamaria
- Maimonides Institute for Biomedical Research (IMIBIC), 14005 Cordoba, Spain; (J.R.M.-C.); (C.R.-H.); (A.M.-M.); (R.S.); (M.R.)
- School of Medicine, Department of Medicine, University of Cordoba, 14005 Cordoba, Spain
- Nephrology Service, Reina Sofia University Hospital, 14005 Cordoba, Spain
- Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, 28029 Madrid, Spain
| | - Mariano Rodriguez
- Maimonides Institute for Biomedical Research (IMIBIC), 14005 Cordoba, Spain; (J.R.M.-C.); (C.R.-H.); (A.M.-M.); (R.S.); (M.R.)
- School of Medicine, Department of Medicine, University of Cordoba, 14005 Cordoba, Spain
- Nephrology Service, Reina Sofia University Hospital, 14005 Cordoba, Spain
- Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, 28029 Madrid, Spain
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20
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Arterial Medial Calcification through Enhanced small Extracellular Vesicle Release in Smooth Muscle-Specific Asah1 Gene Knockout Mice. Sci Rep 2020; 10:1645. [PMID: 32015399 PMCID: PMC6997457 DOI: 10.1038/s41598-020-58568-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 01/17/2020] [Indexed: 11/09/2022] Open
Abstract
Arterial medial calcification (AMC) involves an increased small extracellular vesicle (sEV) secretion and apatite calcium precipitation in the arterial wall. The mechanisms mediating AMC remain poorly understood. In the present study, smooth muscle-specific acid ceramidase (Ac) gene knockout mice (Asah1fl/fl/SMCre) were used to demonstrate the role of lysosomal ceramide signaling pathway in AMC. Asah1fl/fl/SMCre mice were found to have more severe AMC in both aorta and coronary arteries compared to their littermates (Asah1fl/fl/SMwt and WT/WT mice) after receiving a high dose vitamin D. These mice also had pronounced upregulation of osteopontin and RUNX2 (osteogenic markers), CD63, AnX2 (sEV markers) and ALP expression (mineralization marker) in the arterial media. In cultured coronary arterial smooth muscle cells (CASMCs) from Asah1fl/fl/SMCre mice, high dose of Pi led to a significantly increased calcium deposition, phenotypic change and sEV secretion compared to WT CASMCs, which was associated with reduced lysosome-multivesicular body (MVB) interaction. Also, GW4869, sEV release inhibitor decreased sEV secretion and calcification in these cells. Lysosomal transient receptor potential mucolipin 1 (TRPML1) channels regulating lysosome interaction with MVBs were found remarkably inhibited in Asah1fl/fl/SMCre CASMCs as shown by GCaMP3 Ca2+ imaging and Port-a-Patch patch clamping of lysosomes. Lysosomal Ac in SMCs controls sEV release by regulating lysosomal TRPML1 channel activity and lysosome-MVB interaction, which importantly contributes to phenotypic transition and AMC.
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21
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Almeida YE, Fessel MR, do Carmo LS, Jorgetti V, Farias-Silva E, Pescatore LA, Gamarra LF, Andrade MC, Simplicio-Filho A, Mangueira CLP, Rangel ÉB, Liberman M. Excessive cholecalciferol supplementation increases kidney dysfunction associated with intrarenal artery calcification in obese insulin-resistant mice. Sci Rep 2020; 10:87. [PMID: 31919470 PMCID: PMC6952360 DOI: 10.1038/s41598-019-55501-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 11/29/2019] [Indexed: 12/13/2022] Open
Abstract
Diabetes mellitus accelerates vascular calcification (VC) and increases the risk of end-stage renal disease (ESRD). Nevertheless, the impact of VC in renal disease progression in type 2 diabetes mellitus (T2DM) is poorly understood. We addressed the effect of VC and mechanisms involved in renal dysfunction in a murine model of insulin resistance and obesity (ob/ob), comparing with their healthy littermates (C57BL/6). We analyzed VC and renal function in both mouse strains after challenging them with Vitamin D3 (VitD3). Although VitD3 similarly increased serum calcium and induced bone disease in both strains, 24-hour urine volume and creatinine pronouncedly decreased only in ob/ob mice. Moreover, ob/ob increased urinary albumin/creatinine ratio (ACR), indicating kidney dysfunction. In parallel, ob/ob developed extensive intrarenal VC after VitD3. Coincidently with increased intrarenal vascular mineralization, our results demonstrated that Bone Morphogenetic Protein-2 (BMP-2) was highly expressed in these arteries exclusively in ob/ob. These data depict a greater susceptibility of ob/ob mice to develop renal disease after VitD3 in comparison to paired C57BL/6. In conclusion, this study unfolds novel mechanisms of progressive renal dysfunction in diabetes mellitus (DM) after VitD3 in vivo associated with increased intrarenal VC and highlights possible harmful effects of long-term supplementation of VitD3 in this population.
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Affiliation(s)
- Youri E Almeida
- Hospital Israelita Albert Einstein, São Paulo/SP, 01425001, Brazil
| | - Melissa R Fessel
- Hospital Israelita Albert Einstein, São Paulo/SP, 01425001, Brazil
| | | | - Vanda Jorgetti
- Department of Nephrology, Medical School, Universidade de São Paulo, São Paulo/SP, 01246000, Brazil
| | | | - Luciana Alves Pescatore
- Hospital Israelita Albert Einstein, São Paulo/SP, 01425001, Brazil
- Laboratório de Biologia Vascular, LIM-64, InCor, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo/SP, Brazil
| | - Lionel F Gamarra
- Hospital Israelita Albert Einstein, São Paulo/SP, 01425001, Brazil
| | | | | | | | - Érika B Rangel
- Hospital Israelita Albert Einstein, São Paulo/SP, 01425001, Brazil
| | - Marcel Liberman
- Hospital Israelita Albert Einstein, São Paulo/SP, 01425001, Brazil.
- Laboratório de Biologia Vascular, LIM-64, InCor, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo/SP, Brazil.
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22
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Su Y, Wang K, Gao J, Yang Y, Qin YX, Zheng Y, Zhu D. Enhanced cytocompatibility and antibacterial property of zinc phosphate coating on biodegradable zinc materials. Acta Biomater 2019; 98:174-185. [PMID: 30930304 PMCID: PMC6766429 DOI: 10.1016/j.actbio.2019.03.055] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/21/2019] [Accepted: 03/26/2019] [Indexed: 02/07/2023]
Abstract
Zinc (Zn) has recently emerged as a promising biodegradable metal thanks to its critical physiological roles and promising degradation behavior. However, cytocompatibility and antibacterial property of Zn is still suboptimal, in part, due to the excessive Zn ions released during degradation. Inspired by the calcium phosphate-based minerals in natural bone tissue, zinc phosphate (ZnP) coatings were prepared on pure Zn using a chemical conversion method in this study. The coating morphology was then optimized through controlling the pH of coating solution, resulting in a homogeneous micro-/nano-ZnP coating structure. The ZnP coating significantly increased the cell viability, adhesion, and differentiation of pre-osteoblasts and vascular endothelial cells, while significantly reduced the adhesion of the platelets and E. coli. Additionally, ZnP coating significantly reduced the Zn ion release from the bulk material during degradation process, resulting in a much lower Zn2+ concentration and pH change in the surrounding environment. The improved hemocompatibility, cytocompatibility and antibacterial performance of ZnP coated Zn biomaterials could be mainly attributed to the controlled Zn ion release and micro-/nano-scaled coating structure. Taken together, ZnP coating on Zn-based biomaterial appears to be a viable approach to enhance its biocompatibility and antibacterial property as well as to control its degradation rate. Statement of Significance Zn and its alloys are promising biodegradable implant materials for orthopedic and cardiovascular applications. However, notable cytotoxicity has been reported due to degradation products accumulated in the local environment, largely overdosed Zn2+. Thus, controlling burst Zn2+ release is the key to minimize the toxicity of Zn implants. To achieve this goal, we prepared a homogenous ZnP coating on Zn metals thanks to its easy synthesis, stable chemical property, and good biocompatibility. Results showed that ZnP not only improved the cell viability, adhesion and proliferation, but also significantly reduced the attachment of platelet and bacterial. Therefore, ZnP could be a promising approach to improve the functional performance of Zn-based implants, and potentially be applied to many other medical implants.
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Affiliation(s)
- Yingchao Su
- Department of Biomedical Engineering, University of North Texas, TX, USA
| | - Kai Wang
- Department of Biomedical Engineering, University of North Texas, TX, USA
| | - Julia Gao
- Department of Biomedical Engineering, University of North Texas, TX, USA
| | - Yong Yang
- Department of Biomedical Engineering, University of North Texas, TX, USA
| | - Yi-Xian Qin
- Department of Biomedical Engineering, Stony Brook University, New York, USA
| | - Yufeng Zheng
- Department of Materials Science and Engineering, Peking University, Beijing, China
| | - Donghui Zhu
- Department of Biomedical Engineering, University of North Texas, TX, USA.
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23
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Allen LA, Pyart RD, Holmes J, Donovan KL, Anderson RA, Phillips AO. Cardiovascular and renal outcomes following percutaneous coronary intervention in a population with renal disease: a case-control study. QJM 2019; 112:669-674. [PMID: 31161203 DOI: 10.1093/qjmed/hcz130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 05/01/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients with renal disease are less likely to undergo percutaneous coronary intervention (PCI) due to concerns about poor outcomes. AIM We describe outcomes following PCI in individuals with chronic kidney disease (CKD), as compared with matched controls with comparable CKD who did not undergo PCI. We also identified factors predictive of poor outcomes following PCI amongst patients with CKD. DESIGN Retrospective observational case-control study. METHODS Cases were individuals with CKD (stages 1-5) undergoing PCI between 2008 and 2014. Controls were age, gender and creatinine-matched individuals not requiring PCI. We compared mortality between groups using Kaplan-Meier curves and Cox regression modelling. We assessed changes in serum creatinine using Wilcoxon Rank testing. We explored the relationship between biochemical and haematological measures (baseline creatinine, calcium, phosphate, calcium-phosphate product, parathyroid hormone, white cell count, haemoglobin, platelet count, c-reactive protein and total cholesterol) and post-PCI mortality, using logistic regression. RESULTS We identified 144 cases and 144 controls. Mortality was significantly lower amongst cases compared with controls [hazard ratio 0.46 (95% confidence intervals 0.31, 0.69)]. PCI did not result in a significant change in renal function (P=0.52). Amongst cases, serum creatinine and calcium-phosphate product were predictors of mortality following PCI. CONCLUSION Cases undergoing PCI had lower mortality, and PCI was not associated with accelerated CKD progression. On this data, PCI should not be deferred as a treatment option in patients with CKD. Serum creatinine and calcium-phosphate product predict mortality following PCI in this cohort, and may be useful in risk-stratifying patients with CKD being considered for PCI.
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Affiliation(s)
- L A Allen
- Institute of Nephrology, Cardiff University School of Medicine, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - R D Pyart
- Institute of Nephrology, Cardiff University School of Medicine, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - J Holmes
- Institute of Nephrology, Cardiff University School of Medicine, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
- Welsh Renal Clinical Network, Cwm Taf University Health Board, Wales, UK
| | - K L Donovan
- Institute of Nephrology, Cardiff University School of Medicine, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - R A Anderson
- Department of Cardiology, Cardiff University School of Medicine, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - A O Phillips
- Institute of Nephrology, Cardiff University School of Medicine, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
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Thongprayoon C, Cheungpasitporn W, Mao MA, Erickson SB. Calcium‐phosphate product and its impact on mortality in hospitalized patients. Nephrology (Carlton) 2019; 25:22-28. [DOI: 10.1111/nep.13603] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of MedicineMayo Clinic Rochester Minnesota USA
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of MedicineUniversity of Mississippi Medical Center Jackson Mississippi USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Department of MedicineMayo Clinic Rochester Minnesota USA
| | - Stephen B Erickson
- Division of Nephrology and Hypertension, Department of MedicineMayo Clinic Rochester Minnesota USA
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Jahan I, Ahmed S, Islam MR, Hai ANMA, Islam MF, Bhuiyan MA, Nahar Z. Association of ORAI1 Genetic Polymorphism with Serum Calcium and Phosphorus Levels in Non-dialysis Chronic Kidney Disease Patients: A Case-control Study. Cureus 2019; 11:e4564. [PMID: 31281748 PMCID: PMC6599462 DOI: 10.7759/cureus.4564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background As chronic kidney disease (CKD) is a silent killer, it is now a global concern to find out the possible causes by genetic and biological markers. In the earlier stages of CKD, serum calcium and phosphorus levels fall down later on turned into hypercalcemia and hyperphosphatemia contributing high mortality in CKD. This study aimed to examine the serum calcium and phosphorus levels in non-dialysis CKD patients and healthy controls to find out their association with ORAI1 genetic polymorphism. Methods The present study recruited 96 non-dialysis CKD patients and 100 control subjects matched by age, gender, and body mass index (BMI). Measurement of serum calcium levels was performed with atomic absorption spectrophotometer (HITACHI, 170-30) and phosphorus levels were determined by UV VIS spectrophotometer (Analytik Jena SPEKOL 2000). PCR-RFLP technique was applied to determine the genetic polymorphism of ORAI1 (rs12313273 and rs6486795) gene. Results The mean values of serum calcium and phosphorus levels were 2.53 ± 0.50 mg/dL and 3.77 ± 0.42 mg/dL for the patient group and 3.67 ± 2.37 mg/dL and 13.66 ± 6.34 mg/dL for the control group, respectively. We observed significantly reduced serum calcium and phosphorus levels in non-dialysis CKD patients compared with control subjects (p < 0.001). No significant polymorphism of ORAI1 (rs12313273 and rs6486795) was found with declined serum calcium and phosphorus levels. Conclusions The present study suggested that there is no linear correlation between ORAI1 genetic polymorphism with serum calcium and phosphorus levels in non-dialysis CKD patients.
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Affiliation(s)
- Ishrat Jahan
- Pharmacy, University of Asia Pacific, Dhaka, BGD
| | - Salma Ahmed
- Pharmacy, University of Asia Pacific, Dhaka, BGD
| | | | | | | | | | - Zabun Nahar
- Pharmacy, University of Asia Pacific, Dhaka, BGD
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26
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Tüysüz ME, Dedemoğlu M. Calcium phosphate product level as a predictor for arteriovenous fistula re-operations in patients with chronic renal failure. Vascular 2018; 27:284-290. [DOI: 10.1177/1708538118814611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objectives There is an increased calcium phosphate product level causing the formation of calcification in the arterial wall and thus decreased quality of fistula in patients with chronic renal failure. The purpose of our study is to verify the relationship between arteriovenous fistula re-operation and high calcium phosphate product level. Methods Seventy-nine consecutive patients with chronic renal failure between April 2016 and February 2018 were included in the study. Patients having calcium phosphate product level ≥50 mg2/dl2 were defined as group 1, whereas those having <50 mg2/dl2 were defined as group 2. Primary outcome of interest was the need for re-operation during the follow-up and to determine the risk factors for re-operation. To determine independent predictors for re-operation, multivariate logistic regression model was used. Results The rates of redo and tredo operation were significantly higher in group 1 compared to group 2 ( p = 0.01 and 0.04). In multivariate analysis, phosphate (OR: 1.84, 95% CI: 1.00–3.40, p = 0.05) and triglyceride (OR: 1.01, 95% CI: 1.00–1.02, p = 0.04) levels for redo operation and calcium phosphate product level (OR: 1.11, 95% CI: 1.01–1.22, p = 0.03) for tredo operation were found to be independent predictors. Conclusions High calcium phosphate product level leads to increased risk of arteriovenous fistula re-operation by causing arterial stiffness in this patient group. Additionally, these re-operations place additional burden on morbidity and cost efficacy. Thus, we recommend keeping the calcium phosphate product level at the optimal level in these patients to avoid both the risk of arteriovenous fistula re-operation and the other cardiovascular problems.
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Affiliation(s)
- Mehmet Erin Tüysüz
- Department of Cardiovascular Surgery, Mersin City Education and Research Hospital, Turkey
| | - Mehmet Dedemoğlu
- Department of Pediatric Cardiovascular Surgery, Mersin City Education and Research Hospital, Turkey
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27
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Wang J, Zhou JJ, Robertson GR, Lee VW. Vitamin D in Vascular Calcification: A Double-Edged Sword? Nutrients 2018; 10:nu10050652. [PMID: 29786640 PMCID: PMC5986531 DOI: 10.3390/nu10050652] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 05/15/2018] [Accepted: 05/17/2018] [Indexed: 01/13/2023] Open
Abstract
Vascular calcification (VC) as a manifestation of perturbed mineral balance, is associated with aging, diabetes and kidney dysfunction, as well as poorer patient outcomes. Due to the current limited understanding of the pathophysiology of vascular calcification, the development of effective preventative and therapeutic strategies remains a significant clinical challenge. Recent evidence suggests that traditional risk factors for cardiovascular disease, such as left ventricular hypertrophy and dyslipidaemia, fail to account for clinical observations of vascular calcification. Therefore, more complex underlying processes involving physiochemical changes to mineral balance, vascular remodelling and perturbed hormonal responses such as parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF-23) are likely to contribute to VC. In particular, VC resulting from modifications to calcium, phosphate and vitamin D homeostasis has been recently elucidated. Notably, deregulation of vitamin D metabolism, dietary calcium intake and renal mineral handling are associated with imbalances in systemic calcium and phosphate levels and endothelial cell dysfunction, which can modulate both bone and soft tissue calcification. This review addresses the current understanding of VC pathophysiology, with a focus on the pathogenic role of vitamin D that has provided new insights into the mechanisms of VC.
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Affiliation(s)
- Jeffrey Wang
- Centre for Transplantation and Renal Research, Westmead Institute of Medical Research, Westmead, NSW 2145, Australia.
| | - Jimmy J Zhou
- Centre for Transplantation and Renal Research, Westmead Institute of Medical Research, Westmead, NSW 2145, Australia.
- Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW 2145, Australia.
| | | | - Vincent W Lee
- Centre for Transplantation and Renal Research, Westmead Institute of Medical Research, Westmead, NSW 2145, Australia.
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Carfagna F, Del Vecchio L, Pontoriero G, Locatelli F. Current and potential treatment options for hyperphosphatemia. Expert Opin Drug Saf 2018; 17:597-607. [PMID: 29783873 DOI: 10.1080/14740338.2018.1476487] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Hyperphosphatemia is common in late stages of chronic kidney disease and is often associated with elevated parathormone levels, abnormal bone mineralization, extra-osseous calcification, and increased risk of cardiovascular events and death. Several classes of oral phosphate binders are available to help control plasma phosphorus levels. Although effective at lowering serum phosphorus, they all have safety, tolerability, and compliance issues that need to be considered when selecting which one to use. AREAS COVERED This paper reviews the most established treatment options for hyperphosphatemia, in patients with chronic kidney disease, focusing on the new inhibitors of active phosphate absorption. EXPERT OPINION The prevention and the treatment of hyperphosphatemia is today far to be satisfactory. Nonetheless, an extending range of phosphate binders are now available. Aluminum has potentially serious toxic risks. Calcium-based binders are very effective but can lead to hypercalcemia and/or positive calcium balance and progression of cardiovascular calcification. No long-term data are available for the new calcium acetate/magnesium combination product. Lanthanum is an effective phosphate binder, and long-term effects of tissue deposition seem clinically irrelevant. Sevelamer, appear to have profiles that would lead to pleiotropic effects and reduced progression of vascular calcification, and the main adverse events seen with these agents are gastrointestinal. Iron has a powerful capability of binding phosphate, thus numerous preparations are available, both with and without significant systemic absorption of the iron component. The inhibitors of active intestinal phosphate transport, with their very selective mechanism of action and low pill burden seem the most interesting approach; however, do not seem at present to be effective alone, in reducing serum phosphorus levels.
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Affiliation(s)
- Fabio Carfagna
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
| | - Lucia Del Vecchio
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
| | - Giuseppe Pontoriero
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
| | - Francesco Locatelli
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
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29
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Cozzolino M, Gallieni M, Brancaccio D. The mechanisms of hyperphosphatemia-induced vascular calcification. Int J Artif Organs 2018; 31:1002-3. [DOI: 10.1177/039139880803101203] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extensive calcification of the arterial wall and soft tissues is a frequent feature of patients with end-stage chronic kidney disease (CKD stage 5). Hyperphosphatemia and secondary hyperparathyroidism have been extensively investigated as inducing factors in cardiovascular calcification. In fact, cardiovascular disease in renal failure is associated with bone metabolism alterations. Together with passive deposition of calcium-phosphate in extraskeletal tissues, it has recently been demonstrated that inorganic phosphate induces arterial calcification directly through a real “ossification” of the tunica media in the vasculature of CKD patients. Therefore, control of serum phosphate in CKD patients becomes crucial in preventing increases in calcium × phosphate product, secondary hyperparathyroidism, and ultimately vascular calcification.
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Affiliation(s)
- M. Cozzolino
- Renal Division and Department of Nephrology, S. Paolo Hospital, University of Milan, Milan - Italy
| | - M. Gallieni
- Renal Division and Department of Nephrology, S. Paolo Hospital, University of Milan, Milan - Italy
| | - D. Brancaccio
- Renal Division and Department of Nephrology, S. Paolo Hospital, University of Milan, Milan - Italy
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30
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Cozzolino M, Brancaccio D. Hyperphosphatemia in Dialysis Patients: The Therapeutic Role of Lanthanum Carbonate. Int J Artif Organs 2018; 30:293-300. [PMID: 17520565 DOI: 10.1177/039139880703000403] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Phosphate overload is a dramatic consequence in end-stage renal disease (ESRD) patients. Recent studies have well documented that abnormalities in mineral and bone metabolism in these patients are associated with increased cardiovascular morbidity and mortality. Elevated serum phosphate and calcium-phosphate product levels play an important role in the pathogenesis of secondary hyperparathyroidism and extra-skeletal calcification in dialysis patients. Furthermore, inorganic phosphate may cause vascular calcification directly through a real “ossification” of the tunica media in the vasculature of ESRD patients. The “classical” treatment of secondary hyperparathyroidism and hyperphosphatemia in ESRD patients consists of either calcium- or aluminum-based phosphate binders and calcitriol administration. Unfortunately, this “old generation” therapy is not free of complications. This review paper suggests that new calcium- and aluminum-free phosphate binders, such as lanthanum carbonate, can be used to treat hyperphosphatemia and secondary hyperparathyroidism in ESRD patients.
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Affiliation(s)
- M Cozzolino
- Renal Division, Department of Medicine, Surgery, and Dentistry, San Paolo Hospital, University of Milan, Milan - Italy.
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31
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Choi HY, Lee CJ, Lee JE, Yang HS, Kim HY, Park HC, Kim HC, Chang HJ, Park SH, Kim BS. Loss of nighttime blood pressure dipping as a risk factor for coronary artery calcification in nondialysis chronic kidney disease. Medicine (Baltimore) 2017; 96:e7380. [PMID: 28658167 PMCID: PMC5500089 DOI: 10.1097/md.0000000000007380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Diurnal variations in blood pressure (BP) loss are closely associated with target organ damage and cardiovascular events. The quantity of coronary artery calcification (CAC) correlates with the atherosclerotic plaque burden, and an increased quantity indicates a substantially increased risk of cardiovascular events. This study investigated the nighttime diurnal variation in BP loss associated with CAC in patients with chronic kidney disease (CKD).Of the 1958 participants, we enrolled 722 participants with CKD without a history of acute coronary syndrome or symptomatic coronary artery disease. CAC was measured with computed tomography. BP was measured using 24-hour ambulatory BP monitoring. Central BP was measured using a SphygmoCor waveform analysis system.Participants with CAC had significantly higher 24-hour systolic, daytime systolic, and nighttime systolic ambulatory BP and central systolic BP. The percentage of participants with dipping loss was significantly higher among those with CAC. Multivariate logistic regression analysis indicated that dipping loss and dipping ratio were independently associated with CAC after adjusting for traditional and nontraditional cardiovascular risk factors and other BP parameters, including measurements of office-measured BP and central BP. The dipping status improved risk prediction for CAC after considering traditional risk factors and office-measured BP, using the net reclassification improvement and integrated discrimination improvement.Nighttime loss of diurnal variation in BP is an independent risk factor for CAC in CKD patients.
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Affiliation(s)
| | - Chan Joo Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul
| | - Jung Eun Lee
- Department of Internal Medicine, Yong-In Severance Hospital, Yonsei University College of Medicine, Yong-In
| | | | | | | | - Hyeon Chang Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk-Jae Chang
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul
| | - Sung-Ha Park
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul
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Activation of peroxisome proliferator-activated receptor γ inhibits vascular calcification by upregulating Klotho. Exp Ther Med 2016; 13:467-474. [PMID: 28352317 PMCID: PMC5348673 DOI: 10.3892/etm.2016.3996] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 10/24/2016] [Indexed: 12/15/2022] Open
Abstract
Cardiovascular diseases are common in patients with chronic kidney disease. One of the key symptoms is the calcification of the vascular smooth muscle cells (VSMCs), which is induced by dysregulated mineral metabolism with high circulating levels of inorganic phosphate (Pi) and calcium. Klotho, which was originally identified as an aging suppressor gene, has been shown to be associated with vascular calcification. Since Klotho was recently identified as a target for nuclear receptor peroxisome proliferator-activated receptor (PPAR) γ, the present study aimed to determine whether PPARγ regulates VSMC calcification through modulating the expression levels of Klotho. It was demonstrated that the expression of PPARγ was downregulated during Pi-induced VSMC calcification. In addition, treatment with PPARγ agonists inhibited the calcification and enhanced the expression of Klotho in VSMCs in a PPARγ-dependent manner. Of note, loss of Klotho expression by RNA interference abolished the ability of PPARγ activation to inhibit VSMC calcification. Furthermore, activation of Klotho as well as PPARγ inhibited the expression of Pi transporter 1/2 and reduced Pi influx into VSMCs. To the best of our knowledge, the present study was the first to demonstrate that PPARγ regulates VSMC calcification through activating Klotho.
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Schweighofer N, Aigelsreiter A, Trummer O, Graf-Rechberger M, Hacker N, Kniepeiss D, Wagner D, Stiegler P, Trummer C, Pieber T, Obermayer-Pietsch B, Müller H. Direct comparison of regulators of calcification between bone and vessels in humans. Bone 2016; 88:31-38. [PMID: 27108945 DOI: 10.1016/j.bone.2016.04.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/30/2015] [Accepted: 04/16/2016] [Indexed: 01/16/2023]
Abstract
Calcification is not only physiologically present in bone but is a main pathophysiological process in vasculature, favouring cardiovascular diseases. Our aim was to investigate changes in the expression of calcification regulators during vascular calcification in bone and vasculature. Levels of gene expression of osteoprotegerin (OPG), receptor activator of NF-κB ligand (RANKL), osteopontin (OPN), matrix gla protein (MGP), bone sialoprotein (BSP), SMAD6, and runt-related transcription factor 2 (RUNX2) were determined in bone, aorta, and external iliac artery tissue samples of transplant donors. Histological stages of atherosclerosis (AS) in vessels are defined as "no changes", "intima thickening", or "intima calcification". Patients' bone samples were subgrouped accordingly. We demonstrate that in vessels BSP and OPN expression significantly increased during intima thickening and decreased during intima calcification, whereas the expression of regulators of calcification did not significantly change in bone during intima thickening and intima calcification. At the stage of intima thickening, MGP, OPG, and SMAD6 expression and at stage of intima calcification only MGP expression was lower in bone than in vessel. The expression of BSP and RANKL was regulated in opposite ways in bone and vessels, whereas the expression of MGP, OC, RUNX2, and OPN was regulated in a tissue-specific manner. Our study is the first direct comparison of gene expression changes during AS progression in bone and vessels. Our results indicate that changes in the expression of regulators of calcification in the vessel wall as well as in bone occur early in the calcification process, even prior to deposition of calcium/phosphate precipitation.
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Affiliation(s)
- N Schweighofer
- Department of Internal Medicine, Divison of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - A Aigelsreiter
- Institute of Pathology, Medical University of Graz, Auenbruggerplatz 25, 8036 Graz, Austria
| | - O Trummer
- Department of Internal Medicine, Divison of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - M Graf-Rechberger
- Institute of Pathology, Medical University of Graz, Auenbruggerplatz 25, 8036 Graz, Austria
| | - N Hacker
- Department of Internal Medicine, Divison of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - D Kniepeiss
- Department of Surgery, Division of Transplantation Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - D Wagner
- Department of Surgery, Division of Transplantation Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - P Stiegler
- Department of Surgery, Division of Transplantation Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - C Trummer
- Department of Internal Medicine, Divison of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
| | - T Pieber
- Department of Internal Medicine, Divison of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; Joanneum Research Health, Elisabethstrasse 5, 8010 Graz, Austria
| | - B Obermayer-Pietsch
- Department of Internal Medicine, Divison of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria.
| | - H Müller
- Department of Surgery, Division of Transplantation Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
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Jin S, Zhu M, Yan J, Fang Y, Lu R, Zhang W, Zhang Q, Lu J, Qi C, Shao X, Zhang H, Jiang R, Ni Z. Serum sclerostin level might be a potential biomarker for arterial stiffness in prevalent hemodialysis patients. Biomark Med 2016; 10:689-99. [PMID: 27347702 DOI: 10.2217/bmm-2016-0031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AIM To explore the relationship between circulating sclerostin levels and pulse wave velocity (PWV) in prevalent hemodialysis (HD) patients. PATIENTS & METHODS 154 HD patients were enrolled and examined for serum sclerostin level, carotid-femoral pulse wave velocity (cf-PWV), abdominal artery calcification and calcaneus bone marrow density. RESULTS Serum sclerostin level was significantly elevated in patients with arterial stiffness. Univariate correlation showed serum sclerostin level significantly correlated with intact parathyroid hormone level, cf-PWV and calcaneus bone marrow density. Multiple linear regression analysis in patients with parathyroid hormone ≤300 pg/ml showed that pulse pressure, logAACs and serum sclerostin level were significant independent factors for cf-PWV. CONCLUSION Serum sclerostin level was significantly associated with PWV in prevalent HD patients without hyperparathyroidism.
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Affiliation(s)
- Shi Jin
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Mingli Zhu
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Jiayi Yan
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Yan Fang
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Renhua Lu
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Weiming Zhang
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Qi Zhang
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Jiayue Lu
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Chaojun Qi
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Xinghua Shao
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Haifen Zhang
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Rong Jiang
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
| | - Zhaohui Ni
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, PR China
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Chen P, Nagai A, Tsutsumi Y, Ashida M, Doi H, Hanawa T. Differences in the calcification of preosteoblast cultured on sputter-deposited titanium, zirconium, and gold. J Biomed Mater Res A 2015; 104:639-651. [PMID: 26488234 DOI: 10.1002/jbm.a.35598] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 10/06/2015] [Accepted: 10/20/2015] [Indexed: 11/05/2022]
Abstract
In this study, osteogenic differentiation and calcification of preosteoblast (MC3T3-E1) cultured on sputter-deposited titanium (Ti), zirconium (Zr), and gold (Au) on cover glasses were evaluated to understand the differences in bone formation ability among these three metals; these metals show the same high corrosion resistance, but Ti and Zr are covered by surface passive oxide film while Au is not covered by the oxide film. Ti and Zr promoted cellular proliferation without osteogenic differentiation. Cells cultured on Ti and Zr expressed higher levels of Runx2, Col1α1, and Akp2 at an earlier stage, which indicated faster promotion of osteogenic differentiation, as compared to those cultured on Au. Moreover, after 21 days of culture, the Bglap1 and Ifitm5 expression peaks in cells cultured on Ti and Zr were higher than those in cells cultured on Au, which indicated faster promotion of calcification. Cells cultured on Ti showed an advantage in osteogenic differentiation at an early stage, while cells on Zr showed better calcification promotion with a long-term culture. The amount of extracellular calcified deposits was in good agreement with the gene expression results. On the other hand, the intracellular calcium content of cells on Au specimens was higher than that of cells on Ti and Zr specimens. The results indicate that preosteoblasts on Ti and Zr showed faster osteogenic differentiation and calcification than those on Au, whereas Au improved the intracellular calcium content. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 104A: 639-651, 2016.
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Affiliation(s)
- Peng Chen
- Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-Ku, Tokyo, 101-0062, Japan
| | - Akiko Nagai
- Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-Ku, Tokyo, 101-0062, Japan
| | - Yusuke Tsutsumi
- Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-Ku, Tokyo, 101-0062, Japan
| | - Maki Ashida
- Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-Ku, Tokyo, 101-0062, Japan
| | - Hisashi Doi
- Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-Ku, Tokyo, 101-0062, Japan
| | - Takao Hanawa
- Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-Ku, Tokyo, 101-0062, Japan
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Barrios V, Górriz JL. Atrial fibrillation and chronic kidney disease: focus on rivaroxaban. J Comp Eff Res 2015; 4:651-64. [PMID: 26388302 DOI: 10.2217/cer.15.44] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Renal insufficiency increases the risk of stroke and bleeding in atrial fibrillation patients. Although vitamin K antagonists reduce the risk of stroke in patients with moderate renal dysfunction, this observation is less clear in patients with renal impairment. Moreover, the risk of bleeding with vitamin K antagonists increases as renal function worsens. Maintaining international normalized ratio values within therapeutic targets is more difficult in patients with renal dysfunction, and those agents may cause warfarin-related nephropathy and vascular calcification. Rivaroxaban is the only nonvitamin K oral anticoagulant with a dose specifically tested in patients with moderate renal insufficiency. Rivaroxaban is effective for the prevention of stroke in atrial fibrillation patients with moderate renal dysfunction, with a lower risk of intracranial and fatal bleeding.
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Affiliation(s)
- Vivencio Barrios
- Department of Cardiology, University Hospital Ramón y Cajal, School of Medicine, Alcalá University, Madrid, Spain
| | - José Luis Górriz
- Department of Nephrology, Doctor Peset University Hospital, Department of Medicine, University of Valencia, Valencia, Spain
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An optical method for serum calcium and phosphorus level assessment during hemodialysis. Toxins (Basel) 2015; 7:719-27. [PMID: 25734785 PMCID: PMC4379520 DOI: 10.3390/toxins7030719] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/26/2015] [Accepted: 02/11/2015] [Indexed: 11/17/2022] Open
Abstract
Survival among hemodialysis patients is disturbingly low, partly because vascular calcification (VC) and cardiovascular disease are highly prevalent. Elevated serum phosphorus (P) and calcium (Ca) levels play an essential role in the formation of VC events. The purpose of the current study was to reveal optical monitoring possibilities of serum P and Ca values during dialysis. Twenty-eight patients from Tallinn (Estonia) and Linköping (Sweden) were included in the study. The serum levels of Ca and P on the basis of optical information, i.e., absorbance and fluorescence of the spent dialysate (optical method) were assessed. Obtained levels were compared in means and SD. The mean serum level of Ca was 2.54 ± 0.21 and 2.53 ± 0.19 mmol/L; P levels varied between 1.08 ± 0.51 and 1.08 ± 0.48 mmol/L, measured in the laboratory and estimated by the optical method respectively. The levels achieved were not significantly different (p = 0.5). The Bland-Altman 95% limits of agreement between the two methods varied from −0.19 to 0.19 for Ca and from −0.37 to 0.37 in the case of P. In conclusion, optical monitoring of the spent dialysate for assessing the serum levels of Ca and P during dialysis seems to be feasible and could offer valuable and continuous information to medical staff.
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Silva AP, Gundlach K, Büchel J, Jerónimo T, Fragoso A, Silva C, Guilherme P, Santos N, Faísca M, Neves P. Low Magnesium Levels and FGF-23 Dysregulation Predict Mitral Valve Calcification as well as Intima Media Thickness in Predialysis Diabetic Patients. Int J Endocrinol 2015; 2015:308190. [PMID: 26089881 PMCID: PMC4451161 DOI: 10.1155/2015/308190] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 10/15/2014] [Indexed: 01/08/2023] Open
Abstract
Background. Mitral valve calcification and intima media thickness (IMT) are common complications of chronic kidney disease (CKD) implicated with high cardiovascular mortality. Objective. To investigate the implication of magnesium and fibroblast growth factor-23 (FGF-23) levels with mitral valve calcification and IMT in CKD diabetic patients. Methods. Observational, prospective study involving 150 diabetic patients with mild to moderate CKD, divided according to Wilkins Score. Carotid-echodoppler and transthoracic echocardiography were used to assess calcification. Statistical tests used to establish comparisons between groups, to identify risk factors, and to establish cut-off points for prediction of mitral valve calcification. Results. FGF-23 values continually increased with higher values for both IMT and calcification whereas the opposite trend was observed for magnesium. FGF-23 and magnesium were found to independently predict mitral valve calcification and IMT (P < 0.05). Using Kaplan-Meier analysis, the number of deaths was higher in patients with lower magnesium levels and poorer Wilkins score. The mean cut-off value for FGF-23 was 117 RU/mL and for magnesium 1.7 mg/dL. Conclusions. Hypomagnesemia and high FGF-23 levels are independent predictors of mitral valve calcification and IMT and are risk factors for cardiovascular mortality in this population. They might be used as diagnostic/therapeutic targets in order to better manage the high cardiovascular risk in CKD patients.
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Affiliation(s)
- Ana Paula Silva
- Nephrology, Hospital de Faro, Rua Leão Penedo, 8000-386 Faro, Portugal
- *Ana Paula Silva:
| | | | - Janine Büchel
- Fresenius Medical Care Deutschland GmbH, 61352 Bad Homburg, Germany
| | - Teresa Jerónimo
- Nephrology, Hospital de Faro, Rua Leão Penedo, 8000-386 Faro, Portugal
| | - André Fragoso
- Nephrology, Hospital de Faro, Rua Leão Penedo, 8000-386 Faro, Portugal
| | - Claudia Silva
- Pathology Clinic, Hospital de Faro, 8000-386 Faro, Portugal
| | | | - Nélio Santos
- Pathology Clinic, Hospital de Faro, 8000-386 Faro, Portugal
| | - Marília Faísca
- Pharmacology, Gnostic Laboratory, 8000-386 Faro, Portugal
| | - Pedro Neves
- Nephrology, Hospital de Faro, Rua Leão Penedo, 8000-386 Faro, Portugal
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Kovacs CS. Bone development and mineral homeostasis in the fetus and neonate: roles of the calciotropic and phosphotropic hormones. Physiol Rev 2014; 94:1143-218. [PMID: 25287862 DOI: 10.1152/physrev.00014.2014] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Mineral and bone metabolism are regulated differently in utero compared with the adult. The fetal kidneys, intestines, and skeleton are not dominant sources of mineral supply for the fetus. Instead, the placenta meets the fetal need for mineral by actively transporting calcium, phosphorus, and magnesium from the maternal circulation. These minerals are maintained in the fetal circulation at higher concentrations than in the mother and normal adult, and such high levels appear necessary for the developing skeleton to accrete a normal amount of mineral by term. Parathyroid hormone (PTH) and calcitriol circulate at low concentrations in the fetal circulation. Fetal bone development and the regulation of serum minerals are critically dependent on PTH and PTH-related protein, but not vitamin D/calcitriol, fibroblast growth factor-23, calcitonin, or the sex steroids. After birth, the serum calcium falls and phosphorus rises before gradually reaching adult values over the subsequent 24-48 h. The intestines are the main source of mineral for the neonate, while the kidneys reabsorb mineral, and bone turnover contributes mineral to the circulation. This switch in the regulation of mineral homeostasis is triggered by loss of the placenta and a postnatal fall in serum calcium, and is followed in sequence by a rise in PTH and then an increase in calcitriol. Intestinal calcium absorption is initially a passive process facilitated by lactose, but later becomes active and calcitriol-dependent. However, calcitriol's role can be bypassed by increasing the calcium content of the diet, or by parenteral administration of calcium.
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Affiliation(s)
- Christopher S Kovacs
- Faculty of Medicine-Endocrinology, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
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Reddy YNV, Sundaram V, Abraham G, Nagarajan P, Reddy YNV. Optimal management of hyperphosphatemia in end-stage renal disease: an Indian perspective. Int J Nephrol Renovasc Dis 2014; 7:391-9. [PMID: 25364271 PMCID: PMC4211919 DOI: 10.2147/ijnrd.s49933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
There has been an exponential increase in the incidence of diabetes and hypertension in India in the last few decades, with a proportional increase in chronic kidney disease (CKD). Preventive health care and maintenance of asymptomatic chronic disease such as CKD are often neglected by patients until they become symptomatic with fluid retention and uremia. Management of hyperphosphatemia in CKD remains one of the challenges of nephrology in India for this reason, as it is almost completely asymptomatic but contributes to renal osteodystrophy, metastatic vascular calcification, and acceleration of cardiovascular disease. Lack of understanding of the dangers of asymptomatic hyperphosphatemia, the huge pill burden of phosphate binders, difficulty with dietary and dialysis compliance, and most importantly, the added expense of the drugs places additional road blocks in the treatment of hyperphosphatemia at a population level in developing countries like India. In this review we seek to address the contribution of hyperphosphatemia to adverse outcomes and discuss economic, cultural, and societal factors unique to the management of phosphate levels in Indian patients with advanced CKD.
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Affiliation(s)
| | - Varun Sundaram
- Department of Cardiology, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Georgi Abraham
- Department of Nephrology, Madras Medical Mission, Chennai, India
| | | | - Yuvaram NV Reddy
- Department of Nephrology, Madras Medical Mission, Chennai, India
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Holcombe H, Parry NM, Rick M, Brown DE, Albers TM, Refsal KR, Morris J, Kelly R, Marko ST. Hypervitaminosis D and Metastatic Calcification in a Colony of Inbred Strain 13 Guinea Pigs, Cavia porcellus. Vet Pathol 2014; 52:741-51. [PMID: 25281651 DOI: 10.1177/0300985814551423] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A commercial diet fed to a colony of inbred strain 13 guinea pigs for approximately 6 weeks was subsequently recalled for excessive levels of vitamin D. Twenty-one of 62 animals exhibited clinical signs, including anorexia, lethargy, and poor body condition. Nine affected and 4 clinically normal animals were euthanized for further evaluation, including serum chemistry, urinalysis, and gross and/or histopathology. Macroscopic findings included white discoloration in multiple organs in 8 animals, and microscopic evaluation confirmed multiorgan mineralization in tissues from 7 animals. Serum 25-hydroxyvitamin D levels were elevated in 10 animals. Serum inorganic phosphorus and alkaline phosphatase levels were increased in all exposed animals; however, total calcium and ionized calcium levels were not significantly higher in exposed animals than in control strain 13 guinea pigs from a different institution. The data support a diagnosis of hypervitaminosis D with metastatic calcification. Following the diet recall, the remaining guinea pigs increased their food intake and regained body condition. Diagnostic testing of 8 animals euthanized approximately 3 months after returning to a normal diet demonstrated that serum parathyroid hormone remained significantly lower, and ionized calcium and ionized magnesium were significantly higher, in recovered animals compared to controls and exposed animals. These results indicate that diagnostic tests other than serum calcium are necessary for a diagnosis of hypervitaminosis D in guinea pigs.
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Affiliation(s)
- H Holcombe
- Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - N M Parry
- Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - M Rick
- Diagnostic Center for Population and Animal Health, Michigan State University, Lansing MI, USA
| | - D E Brown
- Center for Comparative Medicine. Massachusetts General Hospital, Boston, MA, USA Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - T M Albers
- Research Models and Services, Charles River, Wilmington, MA, USA
| | - K R Refsal
- Diagnostic Center for Population and Animal Health, Michigan State University, Lansing MI, USA
| | - J Morris
- Center for Comparative Medicine. Massachusetts General Hospital, Boston, MA, USA
| | - R Kelly
- United States Army Medical Research Institute of Infectious Diseases, Fort Detrick, MD, USA
| | - S T Marko
- United States Army Medical Research Institute of Infectious Diseases, Fort Detrick, MD, USA
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Cubbon RM, Thomas CH, Drozd M, Gierula J, Jamil HA, Byrom R, Barth JH, Kearney MT, Witte KKA. Calcium, phosphate and calcium phosphate product are markers of outcome in patients with chronic heart failure. J Nephrol 2014; 28:209-15. [PMID: 24615401 DOI: 10.1007/s40620-014-0075-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 02/21/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND Serum calcium (Ca) and inorganic phosphate (Pi) concentrations and calcium-phosphate product (CPP) levels are positively associated with worse outcomes in patients with chronic kidney disease, but there are few data for Pi or Ca and none for CPP in patients with chronic heart failure (CHF). METHODS Unselected, consecutive patients with CHF (left ventricular ejection fraction, LVEF ≤45%) were enrolled in a prospective observational study for the occurrence of hospitalisation and mortality. Blood samples were collected at the time of recruitment and analysed immediately. RESULTS Patients (n = 713) were on contemporary optimal treatment and mean (standard error, SE) follow-up was 765 (18.9) days. Mean (SE) Ca was 2.29 (0.004) mmol/l. Median (interquartile range, IQR) Pi was 1.11 (0.98-1.23) mmol/l and median CPP 2.53 (2.21-2.88) mmol(2)/l(2). LVEF correlated inversely with Ca, natural log-transformed (Ln)Pi, and LnCPP. There was no difference in CPP between classes of symptom severity or diabetes status. Ca and LnCPP (but not LnPi) were associated with total mortality. Ca was significantly associated with progressive HF and non-cardiovascular death but not with sudden death. Binary logistic regression analyses showed that LnPi and LnCPP were associated with risk of hospitalisation. CONCLUSIONS Ca, Pi and CPP could be useful additional variables in determining risk in CHF patients. Further work is required to elucidate the mechanisms underlying the adverse influence and determine whether lowering phosphate levels per se in CHF patients is of benefit.
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Affiliation(s)
- Richard M Cubbon
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health and Therapeutics, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, LS2 9JT, UK
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Sharma VK, Dwivedi P, Dubey AK. Correlation of serum phosphate with carotid intimal-medial thickness in chronic kidney disease patients. Indian J Nephrol 2014; 24:15-9. [PMID: 24574625 PMCID: PMC3927184 DOI: 10.4103/0971-4065.125050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
While increased serum phosphate concentration is a significant risk factor for vascular calcification, it is unclear whether serum phosphate is also a risk factor for increased arterial wall thickness in chronic kidney disease (CKD) patients. Using B-mode ultrasonography, we examined carotid intimal-medial thickness (CIMT) of CKD patients and analyzed risk factors for increased IMT with regard to the effect of serum phosphate. One hundred patients were enrolled (73 patients without diabetes, 27 patients with diabetes; 57 men, 43 women; age, 46.2 ± 15.3 years). CIMT of patients with diabetes was significantly greater than that of patients without diabetes (0.78 ± 0.250 versus 0.66 ± 0.178 mm; P < 0.0001). For the group of all patients, CIMT correlated strongly and significantly with serum phosphate (r = 0.911; P < 0.001). In multiple regression analysis serum phosphate level (β = 0.356; <0.0001) was found to be a significant independent risk factor for increased CIMT, in addition to other independent risk factors, including advanced age, higher systolic blood pressure, urinary albumin and the presence of diabetes (R2 = 0.956; P < 0.00001). In conclusion, high serum phosphate level is a significant and independent factor associated with advanced arteriosclerosis in CKD patients with and without diabetes in addition to advanced age.
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Affiliation(s)
- V K Sharma
- Department of Medicine, Gandhi Medical College, Bhopal, Madhya Pradesh, India
| | - P Dwivedi
- Department of Medicine, Gandhi Medical College, Bhopal, Madhya Pradesh, India
| | - A K Dubey
- Department of Medicine, Gandhi Medical College, Bhopal, Madhya Pradesh, India
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Hsu HJ, Yen CH, Hsu KH, Wu IW, Lee CC, Hung MJ, Sun CY, Chou CC, Chen YC, Hsieh MF, Chen CY, Hsu CY, Tsai CJ, Wu MS. Factors associated with chronic musculoskeletal pain in patients with chronic kidney disease. BMC Nephrol 2014; 15:6. [PMID: 24400957 PMCID: PMC3890529 DOI: 10.1186/1471-2369-15-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Accepted: 12/18/2013] [Indexed: 11/25/2022] Open
Abstract
Background Chronic musculoskeletal (MS) pain is common in patients with chronic kidney disease (CKD) undergoing haemodialysis. However, epidemiological data for chronic MS pain and factors associated with chronic MS pain in patients with early- or late-stage CKD who are not undergoing dialysis are limited. Method A cross-sectional study to evaluate the prevalence of chronic MS pain and factors associated with chronic MS pain in patients with early- and late-stage CKD who were not undergoing dialysis, was conducted. In addition, the distribution of pain severity among patients with different stages of CKD was evaluated. Results Of the 456 CKD patients studied, 53.3% (n = 243/456) had chronic MS pain. Chronic MS pain was independently and significantly associated with hyperuricemia as co-morbidity, as well as with the calcium × phosphate product levels. In CKD patients with hyperuricemia, chronic MS pain showed a negative, independent significant association with diabetes mellitus as a co-morbidity (odds ratio: 0.413, p = 0.020). However, in the CKD patients without hyperuricemia as a co-morbidity, chronic MS pain showed an independent significant association with the calcium × phosphate product levels (odds ratio: 1.093, p = 0.027). Furthermore, stage-5 CKD patients seemed to experience more severe chronic MS pain than patients with other stages of CKD. Conclusion Chronic MS pain is common in CKD patients. Chronic MS pain was independently and significantly associated with hyperuricemia as co-morbidity, and with the calcium × phosphate product levels in early- and late-stage CKD patients who were not on dialysis.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Mai-Szu Wu
- Department of Nephrology, Chang Gung Memorial Hospital, 222, Mai-Chin Road, Keelung 20401, Taiwan.
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Iijima K, Ito Y, Son BK, Akishita M, Ouchi Y. Pravastatin and Olmesartan Synergistically Ameliorate Renal Failure-Induced Vascular Calcification. J Atheroscler Thromb 2014; 21:917-29. [DOI: 10.5551/jat.23218] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Katsuya Iijima
- Institute of Gerontology, The University of Tokyo
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo
| | - Yuki Ito
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo
| | - Bo-Kyung Son
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo
| | - Yasuyoshi Ouchi
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo
- Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital
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Azevedo-Neto RD, Gonzaga CC, Deliberador TM, Klug LG, Da Costa Oliveira L, Zielak JC, De Andrade Urban C, De Araujo MR, Giovanini AF. Fragmented Adipose Tissue Transplanted to Craniofacial Deformities Induces Bone Repair Associated with Immunoexpression of Adiponectin and Parathyroid Hormone 1-Receptor. Cleft Palate Craniofac J 2013; 50:639-47. [DOI: 10.1597/12-121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective This study analyzed the influence of autogenous white adipose tissue on bone matrix development in critical-size defects created in rabbit calvaria. Materials and Methods A 15-mm-diameter defect was created in the calvaria of 42 rabbits. Twenty-one rabbits were treated with 86 mm3 of immediate transplant of fragmented white subcutaneous adipose tissue (WSAT); the others constituted the control group (sham). The animals were euthanized at 7, 15, and 40 days postsurgery (n = 7), and the histological data were analyzed by histomorphometry and immunohistochemistry using the anti-adiponectin and parathyroid hormone 1-receptor (PTH1R) antibodies. Results The calvariae treated with fragmented WSAT demonstrated significant bone formation. These results coincided with the significant presence of immunopositivity to adiponectin and PTH1R in loci, which in turn coincided with the increase in bonelike matrix deposited both in fat tissue stroma and adipocytes' cytoplasm. In contrast, the control group revealed a small amount of bone-matrix deposition and presented scarce PTH1R expression and a lack of immunostain for adiponectin. Conclusion These results indicate that transplant of fragmented white subcutaneous adipose tissue may be an alternative to treatment of craniofacial bone deformities because adipose tissue suffers from osseous metaplasia and exhibits immunoexpression of the adiponectin and PTH1R, which are proteins associated with bone metabolism
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Zou H, Zhao X, Sun N, Zhang S, Sato T, Yu H, Chen Q, Weber HP, Dard M, Yuan Q, Lanske B. Effect of chronic kidney disease on the healing of titanium implants. Bone 2013; 56:410-5. [PMID: 23876979 PMCID: PMC3812922 DOI: 10.1016/j.bone.2013.07.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 06/29/2013] [Accepted: 07/01/2013] [Indexed: 02/05/2023]
Abstract
Chronic kidney disease (CKD) has become a worldwide public health problem. However, its effect on osseointegration of dental implants is largely unknown. The aim of this study is to investigate whether CKD impairs the quality of the osseointegration of titanium implants. Uremia was induced by 5/6 nephrectomy in mice, and serum levels of BUN, FGF23, PTH and ALP were significantly increased. For in vitro tests, bone marrow mesenchymal stem cells (BMMSCs) were obtained and cultured on titanium discs. There was no significant difference in term of expression of osteogenic marker genes including Osx, Col-1, Ocn, and Opn, as quantified by qPCR. Moreover, Alizarin Red S staining showed comparable mineralized nodules formation. Histomorphometrical analysis of experimental implants inserted in the femurs of CKD mice revealed a trend of decreased BIC ratio at 2-week healing. The strength of bone-implant integration, as measured by a push-in method, was significantly lower for the CKD group at 2 weeks, although a comparable level was reached at 4 weeks. These results demonstrated that CKD only negatively affects the osseointegration of titanium implants at the early stage.
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Affiliation(s)
- Huawei Zou
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Xuefeng Zhao
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Ningyuan Sun
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Shiwen Zhang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Tadatoshi Sato
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
| | - Haiyang Yu
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Qianming Chen
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Hans-Peter Weber
- Department of Prosthodontics and Operative Dentistry, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Michel Dard
- New York University, College of Dentistry, Department of Periodontology and Implant Dentistry, NY, USA
| | - Quan Yuan
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
- Corresponding author at: State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, 14 Third Section, Renmin Nan Road, Chengdu 610041, China. (Q. Yuan)
| | - Beate Lanske
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
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Association of serum fetuin-A and fetuin-A gene polymorphism in relation to mineral and bone disorders in patients with chronic kidney disease. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2013. [DOI: 10.1016/j.ejmhg.2013.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Evaluation of serum levels of calcium and phosphorus in uremic pruritus patients before and after narrow band ultraviolet B phototherapy. JOURNAL OF THE EGYPTIAN WOMEN’S DERMATOLOGIC SOCIETY 2013. [DOI: 10.1097/01.ewx.0000432849.47894.f9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Oral paricalcitol versus oral calcitriol in continuous ambulatory peritoneal dialysis patients with secondary hyperparathyroidism. Clin Exp Nephrol 2013; 18:507-14. [PMID: 23903802 DOI: 10.1007/s10157-013-0844-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 07/16/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Secondary hyperparathyroidism (SHPT) is common in end-stage renal disease. Our primary objective was to evaluate the efficacy of oral paricalcitol versus oral calcitriol on serum intact parathyroid hormone (iPTH) and mineral bone parameters in continuous ambulatory peritoneal dialysis (CAPD) patients with SHPT. The secondary objective was to analyze highly sensitive C-reactive protein (hsCRP) and peritoneal membrane function in both groups. METHODS This was a prospective randomized control trial. CAPD patients with SHPT were randomized to paricalcitol or calcitriol for 15 weeks. Serum intact iPTH, calcium, phosphate and alkaline phosphatase (ALP) were measured at baseline and every 3 weeks. Serum hsCRP and peritoneal membrane functions were measured at baseline and at week 15. RESULTS A total of 26 patients were enrolled and randomized-12 to paricalcitol and 14 to calcitriol. Serum iPTH reduced significantly in both groups and there was no difference in the incidence of ≥50 % reduction of iPTH between both groups. There was a significant increase in serum calcium in both groups but there were no differences in serum phosphorus across the visits. The incidence of hypercalcemia was the same in both groups. Serum calcium-phosphorus (Ca × P) product increased in the paricalcitol group but decreased in the calcitriol group. Serum ALP decreased significantly in both groups. There were also no differences in pre- and post-treatment serum hsCRP and peritoneal function test (PFT) in both groups. CONCLUSION Both oral paricalcitol and calcitriol were equally efficacious in reducing serum iPTH but were associated with significantly higher serum calcium. Serum Ca × P product increased in the paricalcitol group and decreased in the calcitriol group. Serum hsCRP level and PFT were not affected by either treatment. A larger randomized controlled trial is indicated to confirm these initial findings.
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