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Dufour I, Van Regemorter E, Kanaan N, Buemi A, Darius T, Mourad M, Goffin E, Jadoul M, Devresse A, Gillion V. Bridging the Gap Between CKD Management Paradigms in Transplant and Nontransplant Settings: Published Evidence, Challenges, and Perspectives. Transplantation 2024:00007890-990000000-00859. [PMID: 39198967 DOI: 10.1097/tp.0000000000005186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2024]
Abstract
Kidney transplantation (KT) is the best treatment for patients with kidney failure, associated with improved survival and quality of life compared with maintenance dialysis. However, despite constant improvements in the assessment and management of the alloimmune response, KT patients frequently demonstrate a reduced estimated glomerular filtration rate. Therefore, the usual complications of chronic kidney disease (CKD), such as anemia, hypertension, metabolic acidosis, hyperkalemia, or persistent secondary hyperparathyroidism, are highly prevalent after KT. However, their underlying mechanisms are different in the transplant setting (compared with the nontransplanted CKD population), and management recommendations are based on relatively poor-quality data. In recent years, new therapies have emerged, significantly improving kidney and cardiovascular outcomes of non-KT patients with CKD. Whether those new drugs could improve the outcomes of KT patients has largely been under investigated so far. In this review, we will address the challenges of the management of a KT patient with a reduced estimated glomerular filtration rate, cover the published evidence, and highlight the critical knowledge gaps.
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Affiliation(s)
- Inès Dufour
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Elliott Van Regemorter
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Nada Kanaan
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Antoine Buemi
- Department of Abdominal Surgery and Transplantation, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Tom Darius
- Department of Abdominal Surgery and Transplantation, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Michel Mourad
- Department of Abdominal Surgery and Transplantation, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Eric Goffin
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Michel Jadoul
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Arnaud Devresse
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
- Department of Abdominal Surgery and Transplantation, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Valentine Gillion
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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Şahin SH, Küçük O, Tütüncüler B. The relationship between anti-seizures medications and metabolic acidosis in craniotomy operations: is topiramate or zonisamide the cause of metabolic acidosis? BMC Anesthesiol 2024; 24:296. [PMID: 39192186 DOI: 10.1186/s12871-024-02677-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 08/08/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND/AIM The most commonly prescribed anti-seizures medications (ASMs) for the treatment of epilepsy are currently topiramate, zonisamide, lacosamide, carbamazepine and levetiracetam. The objective of this study was to examine the correlation between preoperative, intraoperative, and postoperative metabolic acidosis and the use of ASMs prior to craniotomy operations. MATERIALS AND METHODS This retrospective cross-sectional study evaluated patients who underwent intracranial surgery with craniotomy under general anaesthesia between May 2020 and April 2023 and used ASMs. The patients were classified into four groups based on the pharmacological mechanisms of action of the ASMs administered before intracranial surgery (Group-I, zonisamide or topiramate; Group-II, lacosamide; Group-III, carbamazepine; Group-IV, levetiracetam). Metabolic acidosis severity was defined based on base excess (BE) levels: mild (-3 to -5), moderate (-5 to -10), and severe (below - 10). The study investigated the correlation between ASMs and the severity of metabolic acidosis in preoperative, intraoperative, and postoperative blood gas measurements. RESULTS Out of 35 patients, 24 patients underwent intracranial surgery and 11 patients underwent epilepsy surgery. There were statistically significant differences in the severity of metabolic acidosis between preoperative (p < 0.001), intraoperative (p < 0.001) and postoperative (p = 0.01) groups. The preoperative mean BE of group-I was - 4.7, which was statistically lower than that of group-III (p = 0.01) and group-IV (p < 0.001). Intraoperatively and postoperatively, group-I had a mean BE of -7.5 and - 3.2, respectively, which was statistically lower than that of groups II (p = 0.007; p = 0.04), III (p = 0.002; p = 0.03), and IV (p < 0.001; p = 0.009). There was no statistically significant difference in BE between groups II, III and IV at all three time points. Group I had the lowest BE at all three time points. Intraoperative bicarbonate was administered to all patients in group I, whereas no intraoperative bicarbonate was required in the other groups. In group I, 50% of patients required postoperative intensive care. CONCLUSION The use of ASMs in patients undergoing surgery is important in terms of mortality and morbidity. Topirimat and zonisamide are ASMs that can cause preoperative, intraoperative and postoperative metabolic acidosis. Patients receiving topirimat or zonisamide are particularly susceptible to metabolic acidosis. Special care should be taken in the management of anaesthesia in patients receiving these drugs, and monitoring of the perioperative metabolic status is essential.
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Affiliation(s)
- Sevtap H Şahin
- Department of Anesthesiology and Reanimation, Faculty of Medicine, University of Trakya, Merkez, Edirne, Turkey
| | - Onur Küçük
- Department of Anesthesiology and Reanimation, Faculty of Medicine, University of Trakya, Merkez, Edirne, Turkey.
- Department of Anesthesiology and Reanimation, University of Health Sciences, Ankara Atatürk Sanatoryum Training and Research Hospital, Keçiören, Ankara, Turkey.
| | - Banu Tütüncüler
- Department of Neurosurgery, Faculty of Medicine, University of Trakya, Merkez, Edirne, Turkey
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Raphael KL. Metabolic Acidosis in CKD: Pathogenesis, Adverse Effects, and Treatment Effects. Int J Mol Sci 2024; 25:5187. [PMID: 38791238 PMCID: PMC11121226 DOI: 10.3390/ijms25105187] [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: 12/29/2023] [Revised: 04/28/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024] Open
Abstract
Metabolic acidosis is a frequent complication of chronic kidney disease and is associated with a number of adverse outcomes, including worsening kidney function, poor musculoskeletal health, cardiovascular events, and death. Mechanisms that prevent metabolic acidosis detrimentally promote further kidney damage, creating a cycle between acid accumulation and acid-mediated kidney injury. Disrupting this cycle through the provision of alkali, most commonly using sodium bicarbonate, is hypothesized to preserve kidney function while also mitigating adverse effects of excess acid on bone and muscle. However, results from clinical trials have been conflicting. There is also significant interest to determine whether sodium bicarbonate might improve patient outcomes for those who do not have overt metabolic acidosis. Such individuals are hypothesized to be experiencing acid-mediated organ damage despite having a normal serum bicarbonate concentration, a state often referred to as subclinical metabolic acidosis. Results from small- to medium-sized trials in individuals with subclinical metabolic acidosis have also been inconclusive. Well-powered clinical trials to determine the efficacy and safety of sodium bicarbonate are necessary to determine if this intervention improves patient outcomes.
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Affiliation(s)
- Kalani L. Raphael
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT 84112, USA;
- Medicine Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT 84148, USA
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Singh W, Kushwaha P. Potassium: A Frontier in Osteoporosis. Horm Metab Res 2024; 56:329-340. [PMID: 38346690 DOI: 10.1055/a-2254-8533] [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] [Indexed: 05/04/2024]
Abstract
Osteoporosis is a significant public health concern, particularly in aging populations, leading to fractures, decreased mobility, and reduced quality of life. While calcium and vitamin D have long been recognized as essential for bone health, emerging research suggests that potassium may play a crucial role in maintaining bone density and preventing osteoporosis. This manuscript explores the relationship between potassium and osteoporosis, delving into the mechanisms, epidemiological evidence, and potential therapeutic implications of potassium in bone health. Furthermore, the manuscript discusses the sources of dietary potassium, its impact on bone metabolism, and the future directions in research and clinical practice regarding potassium's role in osteoporosis management.
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Raphael KL, Katz R, Larive B, Kendrick C, Isakova T, Sprague S, Wolf M, Raj DS, Fried LF, Gassman J, Hoofnagle A, Cheung AK, Ix JH. Oral Sodium Bicarbonate and Bone Turnover in CKD: A Secondary Analysis of the BASE Pilot Trial. J Am Soc Nephrol 2024; 35:57-65. [PMID: 38170601 PMCID: PMC10786609 DOI: 10.1681/asn.0000000000000264] [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: 08/07/2023] [Accepted: 10/18/2023] [Indexed: 01/05/2024] Open
Abstract
SIGNIFICANCE STATEMENT In CKD, metabolic acidosis is commonly treated with alkali in the hope that it will improve bone health. In a post hoc analysis of the Bicarbonate Administration to Stabilize eGFR Pilot Trial, we investigated whether sodium bicarbonate affects serum levels of bone turnover markers and other hormones related to bone health in individuals with CKD who have normal to slightly reduced total CO2 (20-28 mEq/L). Sodium bicarbonate increased serum levels of α-klotho but had no significant effect on other bone health markers, including intact fibroblast growth factor-23 (iFGF-23), intact parathyroid hormone (iPTH), and bone-specific alkaline phosphatase (B-SAP). Further study is needed to determine the effect of bicarbonate administration on clinical aspects of bone health. BACKGROUND Treatment with alkali has been hypothesized to improve bone health in CKD by mitigating adverse effects of acid on bone mineral. We investigated the effect of treatment with sodium bicarbonate on bone turnover markers and other factors related to bone metabolism in CKD. METHODS This is a post hoc analysis of the Bicarbonate Administration to Stabilize eGFR Pilot Trial in which 194 individuals with CKD and serum total CO2 20-28 mEq/L were randomly assigned to placebo or one of two doses of sodium bicarbonate (0.5 or 0.8 mEq/kg lean body weight per day) for 28 weeks. The following serum measurements were performed at baseline, week 12, and week 28: B-SAP, c-telopeptide, procollagen type I intact N-terminal propeptide, iPTH, iFGF-23, soluble klotho, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and tartrate-resistant acid phosphatase 5b. The difference (sodium bicarbonate versus placebo) in mean change of each bone biomarker from baseline was determined using linear mixed models. RESULTS One hundred sixty-eight participants submitted samples for post hoc investigations. Mean eGFR was 37±10 ml/min per 1.73 m2 and mean total CO2 was 24±3 mEq/L at baseline. Sodium bicarbonate induced a dose-dependent increase in soluble klotho levels compared with placebo. There was no significant effect of treatment with either dose of sodium bicarbonate on any of the other bone biomarkers, including iFGF-23, iPTH, and B-SAP. Effects on bone biomarkers were similar in those with baseline serum total CO2 <24 mEq/L compared with those with total CO2 ≥24 mEq/L. CONCLUSIONS In this pilot trial of individuals with CKD and total CO2 20-28 mEq/L, sodium bicarbonate treatment increased serum klotho levels but did not affect other bone health markers over 28 weeks. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER ClinicalTrials.gov, NCT02521181.
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Affiliation(s)
- Kalani L. Raphael
- University of Utah Health and VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Ronit Katz
- Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington
| | | | | | - Tamara Isakova
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stuart Sprague
- Division of Nephrology & Hypertension, Northshore University Health System-University of Chicago, Evanston, Illinois
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Dominic S. Raj
- George Washington University School of Medicine, Washington, DC
| | - Linda F. Fried
- University of Pittsburgh and VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| | | | - Andy Hoofnagle
- Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington
| | - Alfred K. Cheung
- University of Utah Health and VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Joachim H. Ix
- University of California San Diego and VA San Diego Health Care System, San Diego, California
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de Rooij ENM, de Fijter JW, Le Cessie S, Hoorn EJ, Jager KJ, Chesnaye NC, Evans M, Windahl K, Caskey FJ, Torino C, Szymczak M, Drechsler C, Wanner C, Dekker FW, Hoogeveen EK. Serum Potassium and Risk of Death or Kidney Replacement Therapy in Older People With CKD Stages 4-5: Eight-Year Follow-up. Am J Kidney Dis 2023; 82:257-266.e1. [PMID: 37182596 DOI: 10.1053/j.ajkd.2023.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/02/2023] [Indexed: 05/16/2023]
Abstract
RATIONALE & OBJECTIVE Hypokalemia may accelerate kidney function decline. Both hypo- and hyperkalemia can cause sudden cardiac death. However, little is known about the relationship between serum potassium and death or the occurrence of kidney failure requiring replacement therapy (KRT). We investigated this relationship in older people with chronic kidney disease (CKD) stage 4-5. STUDY DESIGN Prospective observational cohort study. SETTING & PARTICIPANTS We followed 1,714 patients (≥65 years old) from the European Quality (EQUAL) study for 8 years from their first estimated glomerular filtration rate (eGFR)<20mL/min/1.73m2 measurement. EXPOSURE Serum potassium was measured every 3 to 6 months and categorized as≤3.5,>3.5-≤4.0,>4.0-≤4.5,>4.5-≤5.0 (reference),>5.0-≤5.5, >5.5-≤6.0, and>6.0mmol/L. OUTCOME The combined outcome death before KRT or start of KRT. ANALYTICAL APPROACH The association between categorical and continuous time-varying potassium and death or KRT start was examined using Cox proportional hazards and restricted cubic spline analyses, adjusted for age, sex, diabetes, cardiovascular disease, renin-angiotensin-aldosterone system (RAAS) inhibition, eGFR, and subjective global assessment (SGA). RESULTS At baseline, 66% of participants were men, 42% had diabetes, 47% cardiovascular disease, and 54% used RAAS inhibitors. Their mean age was 76±7 (SD) years, mean eGFR was 17±5 (SD) mL/min/1.73m2, and mean SGA was 6.0±1.0 (SD). Over 8 years, 414 (24%) died before starting KRT, and 595 (35%) started KRT. Adjusted hazard ratios for death or KRT according to the potassium categories were 1.6 (95% CI, 1.1-2.3), 1.4 (95% CI, 1.1-1.7), 1.1 (95% CI, 1.0-1.4), 1 (reference), 1.1 (95% CI, 0.9-1.4), 1.8 (95% CI, 1.4-2.3), and 2.2 (95% CI, 1.5-3.3). Hazard ratios were lowest at a potassium of about 4.9mmol/L. LIMITATIONS Shorter intervals between potassium measurements would have allowed for more precise estimations. CONCLUSIONS We observed a U-shaped relationship between serum potassium and death or KRT start among patients with incident CKD 4-5, with a nadir risk at a potassium level of 4.9mmol/L. These findings underscore the potential importance of preventing both high and low potassium in patients with CKD 4-5. PLAIN-LANGUAGE SUMMARY Abnormal potassium blood levels may increase the risk of death or kidney function decline, especially in older people with chronic kidney disease (CKD). We studied 1,714 patients aged≥65 years with advanced CKD from the European Quality (EQUAL) study and followed them for 8 years. We found that both low and high levels of potassium were associated with an increased risk of death or start of kidney replacement therapy, with the lowest risk observed at a potassium level of 4.9 mmol/L. In patients with CKD, the focus is often on preventing high blood potassium. However, this relatively high optimum potassium level stresses the potential importance of also preventing low potassium levels in older patients with advanced CKD.
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Affiliation(s)
- Esther N M de Rooij
- Department of Nephrology, Leiden University Medical Center, Leiden; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden.
| | | | - Saskia Le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam
| | - Kitty J Jager
- European Renal Association (ERA) Registry, Amsterdam UMC, University of Amsterdam, Medical Informatics, Amsterdam; Amsterdam Public Health Research Institute, Quality of Care, Amsterdam
| | - Nicholas C Chesnaye
- European Renal Association (ERA) Registry, Amsterdam UMC, University of Amsterdam, Medical Informatics, Amsterdam; Amsterdam Public Health Research Institute, Quality of Care, Amsterdam
| | - Marie Evans
- Renal Unit, Department of Clinical Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Karin Windahl
- Renal Unit, Department of Clinical Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Fergus J Caskey
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Claudia Torino
- National Research Council, Institute of Clinical Physiology, Reggio Calabria, Italy
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | | | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden
| | - Ellen K Hoogeveen
- Department of Nephrology, Leiden University Medical Center, Leiden; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden; Department of Nephrology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
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Zaki SA, Shanbag P. Metabolic Acidosis in Children: A Literature Review. EUROPEAN MEDICAL JOURNAL 2023. [DOI: 10.33590/emj/10302459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Metabolic acidosis is characterised by a primary decrease in the serum bicarbonate concentration, a secondary decrease in the arterial partial pressure of CO2, and a reduction in blood pH. Metabolic acidosis, acute or chronic, may have deleterious effects on cellular function and cause increased morbidity and mortality. A systematic review of the available literature was performed to identify data on the prevalence, manifestations, cause, outcomes, and treatment of metabolic acidosis in children. Online databases (Ovid Medline, Embase, and PubMed), commercial search engines (including Google), and chapters on metabolic acidosis in the standard textbooks of paediatrics and medicine were reviewed.
Systematic approach to acute metabolic acidosis starts with proper history taking and examination. This is followed by assessment of acid-base parameters, including pH, partial pressure of CO2, and bicarbonate concentration in arterial blood. Blood gas is needed to differentiate primary metabolic acidosis from compensated respiratory alkalosis. Once the diagnosis of a metabolic acidosis has been confirmed, serum electrolyte values are used to determine the serum anion gap. The various causes of increased and normal anion gap metabolic acidosis have been discussed in the article. The main aim of treatment in metabolic acidosis is to reverse the primary pathophysiology. In acute metabolic acidosis, sodium bicarbonate therapy is not beneficial due to potential complications and is reserved for specific situations. Base therapy is used in chronic metabolic acidosis where it ameliorates many of its untoward effects. Other modalities of treatment of metabolic acidosis include peritoneal or haemodialysis and tris-hydroxymethyl aminomethane.
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Affiliation(s)
- Syed Ahmed Zaki
- Department of Pediatrics, All India Institute of Medical Sciences, Hyderabad, India
| | - Preeti Shanbag
- Sir Jamshedjee Jeejeebhoy Group of Hospital and Grant Medical College, Mumbai, India
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Dirckx N, Zhang Q, Chu EY, Tower RJ, Li Z, Guo S, Yuan S, Khare PA, Zhang C, Verardo A, Alejandro LO, Park A, Faugere MC, Helfand SL, Somerman MJ, Riddle RC, de Cabo R, Le A, Schmidt-Rohr K, Clemens TL. A specialized metabolic pathway partitions citrate in hydroxyapatite to impact mineralization of bones and teeth. Proc Natl Acad Sci U S A 2022; 119:e2212178119. [PMID: 36322718 PMCID: PMC9659386 DOI: 10.1073/pnas.2212178119] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/17/2022] [Indexed: 11/06/2022] Open
Abstract
Citrate is a critical metabolic substrate and key regulator of energy metabolism in mammalian cells. It has been known for decades that the skeleton contains most (>85%) of the body's citrate, but the question of why and how this metabolite should be partitioned in bone has received singularly little attention. Here, we show that osteoblasts use a specialized metabolic pathway to regulate uptake, endogenous production, and the deposition of citrate into bone. Osteoblasts express high levels of the membranous Na+-dependent citrate transporter solute carrier family 13 member 5 (Slc13a5) gene. Inhibition or genetic disruption of Slc13a5 reduced osteogenic citrate uptake and disrupted mineral nodule formation. Bones from mice lacking Slc13a5 globally, or selectively in osteoblasts, showed equivalent reductions in cortical thickness, with similarly compromised mechanical strength. Surprisingly, citrate content in mineral from Slc13a5-/- osteoblasts was increased fourfold relative to controls, suggesting the engagement of compensatory mechanisms to augment endogenous citrate production. Indeed, through the coordinated functioning of the apical membrane citrate transporter SLC13A5 and a mitochondrial zinc transporter protein (ZIP1; encoded by Slc39a1), a mediator of citrate efflux from the tricarboxylic acid cycle, SLC13A5 mediates citrate entry from blood and its activity exerts homeostatic control of cytoplasmic citrate. Intriguingly, Slc13a5-deficient mice also exhibited defective tooth enamel and dentin formation, a clinical feature, which we show is recapitulated in primary teeth from children with SLC13A5 mutations. Together, our results reveal the components of an osteoblast metabolic pathway, which affects bone strength by regulating citrate deposition into mineral hydroxyapatite.
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Affiliation(s)
- Naomi Dirckx
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Qian Zhang
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Nutrition and Health, China Agricultural University, Beijing 100193, China
| | - Emily Y. Chu
- Department of General Dentistry, Operative Division, University of Maryland School of Dentistry, Baltimore, MD 21201
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, MD 20892
| | - Robert J. Tower
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390
| | - Zhu Li
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Shenghao Guo
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD 21218
| | - Shichen Yuan
- Department of Chemistry, Brandeis University, Waltham, MA 02453
| | - Pratik A. Khare
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218
| | - Cissy Zhang
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287
| | - Angela Verardo
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205
| | - Lucy O. Alejandro
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, MD 20892
| | - Angelina Park
- Department of General Dentistry, Operative Division, University of Maryland School of Dentistry, Baltimore, MD 21201
| | | | - Stephen L. Helfand
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University, Providence, RI 02906
| | - Martha J. Somerman
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, MD 20892
| | - Ryan C. Riddle
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201
- Research and Development Service, The Baltimore Veterans Administration Medical Center, Baltimore, MD 21201
| | - Rafael de Cabo
- Translational Gerontology Branch, National Institute on Aging, NIH, Baltimore, MD 21224
| | - Anne Le
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 21218
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21231
| | | | - Thomas L. Clemens
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201
- Research and Development Service, The Baltimore Veterans Administration Medical Center, Baltimore, MD 21201
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Icard P, Simula L, Fournel L, Leroy K, Lupo A, Damotte D, Charpentier MC, Durdux C, Loi M, Schussler O, Chassagnon G, Coquerel A, Lincet H, De Pauw V, Alifano M. The strategic roles of four enzymes in the interconnection between metabolism and oncogene activation in non-small cell lung cancer: Therapeutic implications. Drug Resist Updat 2022; 63:100852. [PMID: 35849943 DOI: 10.1016/j.drup.2022.100852] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
NSCLC is the leading cause of cancer mortality and represents a major challenge in cancer therapy. Intrinsic and acquired anticancer drug resistance are promoted by hypoxia and HIF-1α. Moreover, chemoresistance is sustained by the activation of key signaling pathways (such as RAS and its well-known downstream targets PI3K/AKT and MAPK) and several mutated oncogenes (including KRAS and EGFR among others). In this review, we highlight how these oncogenic factors are interconnected with cell metabolism (aerobic glycolysis, glutaminolysis and lipid synthesis). Also, we stress the key role of four metabolic enzymes (PFK1, dimeric-PKM2, GLS1 and ACLY), which promote the activation of these oncogenic pathways in a positive feedback loop. These four tenors orchestrating the coordination of metabolism and oncogenic pathways could be key druggable targets for specific inhibition. Since PFK1 appears as the first tenor of this orchestra, its inhibition (and/or that of its main activator PFK2/PFKFB3) could be an efficacious strategy against NSCLC. Citrate is a potent physiologic inhibitor of both PFK1 and PFKFB3, and NSCLC cells seem to maintain a low citrate level to sustain aerobic glycolysis and the PFK1/PI3K/EGFR axis. Awaiting the development of specific non-toxic inhibitors of PFK1 and PFK2/PFKFB3, we propose to test strategies increasing citrate levels in NSCLC tumors to disrupt this interconnection. This could be attempted by evaluating inhibitors of the citrate-consuming enzyme ACLY and/or by direct administration of citrate at high doses. In preclinical models, this "citrate strategy" efficiently inhibits PFK1/PFK2, HIF-1α, and IGFR/PI3K/AKT axes. It also blocks tumor growth in RAS-driven lung cancer models, reversing dedifferentiation, promoting T lymphocytes tumor infiltration, and increasing sensitivity to cytotoxic drugs.
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Affiliation(s)
- Philippe Icard
- Thoracic Surgery Department, Paris Center University Hospitals, AP-HP, Paris, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, Unité de recherche BioTICLA INSERM U1086, 14000 Caen, France.
| | - Luca Simula
- Department of Infection, Immunity and Inflammation, Cochin Institute, INSERM U1016, CNRS UMR8104, Paris University, Paris 75014, France
| | - Ludovic Fournel
- Thoracic Surgery Department, Paris Center University Hospitals, AP-HP, Paris, France; INSERM UMR-S 1124, Cellular Homeostasis and Cancer, University of Paris, Paris, France
| | - Karen Leroy
- Department of Genomic Medicine and Cancers, Georges Pompidou European Hospital, APHP, Paris, France
| | - Audrey Lupo
- Pathology Department, Paris Center University Hospitals, AP-HP, Paris, France; INSERM U1138, Integrative Cancer Immunology, University of Paris, 75006 Paris, France
| | - Diane Damotte
- Pathology Department, Paris Center University Hospitals, AP-HP, Paris, France; INSERM U1138, Integrative Cancer Immunology, University of Paris, 75006 Paris, France
| | | | - Catherine Durdux
- Radiation Oncology Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Mauro Loi
- Radiotherapy Department, University of Florence, Florence, Italy
| | - Olivier Schussler
- Thoracic Surgery Department, Paris Center University Hospitals, AP-HP, Paris, France
| | | | - Antoine Coquerel
- INSERM U1075, COMETE " Mobilités: Attention, Orientation, Chronobiologie", Université Caen, France
| | - Hubert Lincet
- ISPB, Faculté de Pharmacie, Lyon, France, Université Lyon 1, Lyon, France; INSERM U1052, CNRS UMR5286, Cancer Research Center of Lyon (CRCL), France
| | - Vincent De Pauw
- Thoracic Surgery Department, Paris Center University Hospitals, AP-HP, Paris, France
| | - Marco Alifano
- Thoracic Surgery Department, Paris Center University Hospitals, AP-HP, Paris, France; INSERM U1138, Integrative Cancer Immunology, University of Paris, 75006 Paris, France
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10
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Moe OW, Maalouf NM, Sakhaee K, Lederer E. Preclinical and Clinical Evidence of Effect of Acid on Bone Health. Adv Chronic Kidney Dis 2022; 29:381-394. [PMID: 36175076 PMCID: PMC11375989 DOI: 10.1053/j.ackd.2022.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Acid can have ill effect on bone health in the absence of frank clinical acidosis but affecting the bone mioneral matrix and bone cells via complex pathways botyh ascute;y and chronically. While the reaction of bone to an acid load is conserved in evolution and is adaptive, the capacity can be overwhelmed resulting in dire consequences. The preclinical an clincl evidence of the acdi effect on bone is very convincing and the clinical evidence in both association and interventiopn studies are also quite credible, The adverse effects of acid on bone is underappreoicated, under-investigated, and the potential benefits of alkali therapy is not generrally known.
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Affiliation(s)
- Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX; Department of Physiology, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Naim M Maalouf
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Khashayar Sakhaee
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Eleanor Lederer
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX; Medical Service, VA North Texas Health Care System, Dallas, TX
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11
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Saraf SL, Derebail VK, Zhang X, Machado RF, Gordeuk VR, Lash JP, Little J. Hyperkalemia and Metabolic Acidosis Occur at a Higher eGFR in Sickle Cell Disease. KIDNEY360 2022; 3:608-614. [PMID: 35721605 DOI: 10.34067/kid.0006802021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/27/2022] [Indexed: 11/27/2022]
Abstract
Background People with sickle cell disease (SCD) have an elevated estimated glomerular filtration rate (eGFR) compared with the general population, and this may alter the usual creatinine-based eGFR cutoffs for which physiologic evidence of kidney dysfunction is apparent. This study aimed to identify eGFR thresholds for hyperkalemia and metabolic acidosis in patients with SCD. Methods This was a cross-sectional analysis of 733 patients with severe (hemoglobin SS or Sβ 0-thalassemia) SCD genotype, 238 patients with moderate (hemoglobin SC or Sβ +-thalassemia) SCD genotype, and 1333 age- and sex-matched African Americans from the National Health and Nutrition Examination Survey (NHANES). The prevalence rates of hyperkalemia and metabolic acidosis were compared by eGFR category. Cutoffs for hyperkalemia and metabolic acidosis were determined using generalized additive models. Results Hyperkalemia and metabolic acidosis were more common in those with severe SCD genotype (13% and 21%, respectively) compared with the NHANES (0.3% and 5%, respectively); the prevalence rates in the moderate SCD genotype were intermediate for hyperkalemia (3%) and metabolic acidosis (11%). The proportion of patients with hyperkalemia and metabolic acidosis progressively increased with lower eGFR category in both SCD genotype groups. The eGFR thresholds for hyperkalemia and metabolic acidosis were higher in the severe (85 and 91 ml/min per 1.73 m2, respectively) and moderate (52 and 102 ml/min per 1.73 m2, respectively) SCD genotypes compared with the NHANES (34 and 46 ml/min per 1.73 m2). Conclusions We demonstrate that hyperkalemia and metabolic acidosis are more common and occur at higher eGFR values in patients with SCD compared with age- and sex-matched African Americans, including in eGFR ranges considered to be normal. Future studies using redefined creatinine-based eGFR thresholds for abnormal kidney function may identify high-risk patients for earlier intervention strategies and referral for specialized renal care in SCD.
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Affiliation(s)
- Santosh L Saraf
- Department of Medicine, Division of Hematology and Oncology, University of Illinois at Chicago, Chicago, Illinois
| | - Vimal K Derebail
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Xu Zhang
- Department of Medicine, Division of Hematology and Oncology, University of Illinois at Chicago, Chicago, Illinois
| | - Roberto F Machado
- Department of Medicine, Division of Pulmonary Medicine, University of Indiana, Indianapolis, Indiana
| | - Victor R Gordeuk
- Department of Medicine, Division of Hematology and Oncology, University of Illinois at Chicago, Chicago, Illinois
| | - James P Lash
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, Illinois
| | - Jane Little
- Department of Medicine, Division of Hematology & Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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12
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Bushinsky DA, Krieger NS. Effects of Acid on Bone. Kidney Int 2022; 101:1160-1170. [DOI: 10.1016/j.kint.2022.02.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 12/11/2022]
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13
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Why may citrate sodium significantly increase the effectiveness of transarterial chemoembolization in hepatocellular carcinoma? Drug Resist Updat 2021; 59:100790. [PMID: 34924279 DOI: 10.1016/j.drup.2021.100790] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/01/2021] [Accepted: 09/04/2021] [Indexed: 02/07/2023]
Abstract
Hepatocellular carcinoma (HCC) represents the third cause of cancer death in men worldwide, and its increasing incidence can be explained by the increasing occurrence of non-alcoholic steatohepatitis (NASH). HCC prognosis is poor, as its 5-year overall survival is approximately 18 % and most cases are diagnosed at an inoperable advanced stage. Moreover, tumor sensitivity to conventional chemotherapeutics (particularly to cisplatin-based regimen), trans-arterial chemoembolization (cTACE), tyrosine kinase inhibitors, anti-angiogenic molecules and immune checkpoint inhibitors is limited. Oncogenic signaling pathways, such as HIF-1α and RAS/PI3K/AKT, may provoke drug resistance by enhancing the aerobic glycolysis ("Warburg effect") in cancer cells. Indeed, this metabolism, which promotes cancer cell development and aggressiveness, also induces extracellular acidity. In turn, this acidity promotes the protonation of drugs, hence abrogating their internalization, since they are most often weakly basic molecules. Consequently, targeting the Warburg effect in these cancer cells (which in turn would reduce the extracellular acidification) could be an effective strategy to increase the delivery of drugs into the tumor. Phosphofructokinase-1 (PFK1) and its activator PFK2 are the main regulators of glycolysis, and they also couple the enhancement of glycolysis to the activation of key signaling cascades and cell cycle progression. Therefore, targeting this "Gordian Knot" in HCC cells would be of crucial importance. Here, we suggest that this could be achieved by citrate administration at high concentration, because citrate is a physiologic inhibitor of PFK1 and PFK2. As shown in various in vitro studies, including HCC cell lines, administration of high concentrations of citrate inhibits PFK1 and PFK2 (and consequently glycolysis), decreases ATP production, counteracts HIF-1α and PI3K/AKT signaling, induces apoptosis, and sensitizes cells to cisplatin treatment. Administration of high concentrations of citrate in animal models (including Ras-driven tumours) has been shown to effectively inhibit cancer growth, reverse cell dedifferentiation, and neutralize intratumor acidity, without apparent toxicity in animal studies. Citrate may also induce a rapid secretion of pro-inflammatory cytokines by macrophages, and it could favour the destruction of cancer stem cells (CSCs) sustaining tumor recurrence. Consequently, this "citrate strategy" could improve the tumor sensitivity to current treatments of HCC by reducing the extracellular acidity, thus enhancing the delivery of chemotherapeutic drugs into the tumor. Therefore, we propose that this strategy should be explored in clinical trials, in particular to enhance cTACE effectiveness.
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14
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Jørgensen HS, Behets G, Bammens B, Claes K, Meijers B, Naesens M, Sprangers B, Kuypers DRJ, D'Haese P, Evenepoel P. Patterns of renal osteodystrophy one year after kidney transplantation. Nephrol Dial Transplant 2021; 36:2130-2139. [PMID: 34383929 DOI: 10.1093/ndt/gfab239] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Renal osteodystrophy is considered common, but is not well characterized, in contemporary kidney transplant recipients. This study reports extensively on bone phenotype by bone histomorphometry, bone densitometry, and novel bone biomarkers 1 year after kidney transplantation. METHODS A transiliac bone biopsy and dual energy x-ray absorptiometry were performed in 141 unselected kidney transplant recipients in this observational cohort study. Blood and 24 hr urine samples were collected simultaneously. RESULTS Median age was 57 ± 11 years, 71% were men, and all were of Caucasian ethnicity. Bone turnover was normal in 71% of patients, low in 26%, and high in just four cases (3%). Hyperparathyroidism with hypercalcemia was present in 13% of patients, of which one had high bone turnover. Delayed bone mineralization was detected in 16% of patients, who were characterized by hyperparathyroidism (137 vs. 53 ρg/mL), a higher fractional excretion of phosphate (40 vs. 32%), and lower levels of phosphate (2.68 vs 3.18 mg/dL) and calcidiol (29 vs. 37 ng/mL) compared to patients with normal bone mineralization. Osteoporosis was present in 15-46% of patients, with the highest prevalence at the distal skeleton. The proportion of osteoporotic patients was comparable across categories of bone turnover and mineralization. CONCLUSION The majority of kidney transplant recipients, including patients with osteoporosis, have a normal bone turnover at 1-year post-transplant. Low bone turnover is seen in a substantial subset, while high bone turnover is rare. Vitamin D deficiency and hypophosphatemia represent potential interventional targets to improve bone health post-transplant.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Geert Behets
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Bert Bammens
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Bjorn Meijers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Dirk R J Kuypers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Patrick D'Haese
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
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15
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Ando H, Eshima K, Ishida T. Neutralization of Acidic Tumor Microenvironment (TME) with Daily Oral Dosing of Sodium Potassium Citrate (K/Na Citrate) Increases Therapeutic Effect of Anti-cancer Agent in Pancreatic Cancer Xenograft Mice Model. Biol Pharm Bull 2021; 44:266-270. [PMID: 33518679 DOI: 10.1248/bpb.b20-00825] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Extracellular pH (pHe) of tumor cells is characteristic of tumor microenvironment (TME). Acidic TME impairs the responses of tumors to some anti-cancer chemotherapies. In this study, we showed that daily oral dosing of sodium potassium citrate (K/Na citrate) increased blood HCO3- concentrations, corresponding to increase of HCO3- concentrations and pHs in urine, and neutralized the tumor pHe. Neutralization of acidic TME by alkaline substance like HCO3-, an active metabolite of K/Na citrate, well potentiated the therapeutic effect of anticancer agent TS-1®, an orally active 5-fuluoro-uracil derivative, in Panc-1 pancreatic cancer-xenograft murine model. Neutralization of acidic TME by using an alkaline K/Na citrate is a smart approach for enhancement of the therapeutic effects of anticancer agents for pancreatic cancer in the end stage.
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Affiliation(s)
- Hidenori Ando
- Department of Pharmacokinetics and Biopharmaceutics, Institute of Biomedical Sciences, Tokushima University
| | | | - Tatsuhiro Ishida
- Department of Pharmacokinetics and Biopharmaceutics, Institute of Biomedical Sciences, Tokushima University
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16
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Ando H, Emam SE, Kawaguchi Y, Shimizu T, Ishima Y, Eshima K, Ishida T. Increasing Tumor Extracellular pH by an Oral Alkalinizing Agent Improves Antitumor Responses of Anti-PD-1 Antibody: Implication of Relationships between Serum Bicarbonate Concentrations, Urinary pH, and Therapeutic Outcomes. Biol Pharm Bull 2021; 44:844-852. [PMID: 34078817 DOI: 10.1248/bpb.b21-00076] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Acidic extracellular pH (pHe) is characteristic of the tumor microenvironment. Several reports suggest that increasing pHe improves the response of immune checkpoint inhibitors in murine models. To increase pHe, either sodium bicarbonate (NaHCO3) or citric acid/potassium-sodium citrate (KNa-cit) was chronically administered to mice. It is hypothesized that bicarbonate ions (HCO3-), produced from these alkalinizing agents in vivo, increased pHe in the tumor, and excess HCO3- eliminated into urine increased urinary pH values. However, there is little published information on the effect of changing serum HCO3- concentrations, urinary HCO3- concentrations and urinary pH values on the therapeutic outcomes of immunotherapy. In this study, we report that oral administration of either NaHCO3 or KNa-cit increased responses to anti-programmed cell death-1 (PD-1) antibody, an immune checkpoint inhibitor, in a murine B16 melanoma model. In addition, we report that daily oral administration of an alkalinizing agent increased blood HCO3- concentrations, corresponding to increasing the tumor pHe. Serum HCO3- concentrations also correlated with urinary HCO3- concentrations and urinary pH values. There was a clear relationship between urinary pH values and the antitumor effects of immunotherapy with anti-PD-1 antibody. Our results imply that blood HCO3- concentrations, corresponding to tumor pHe and urinary pH values, may be important factors that predict the clinical outcomes of an immunotherapeutic agent, when combined with alkalinizing agents such as NaHCO3 and KNa-cit.
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Affiliation(s)
- Hidenori Ando
- Department of Pharmacokinetics and Biopharmaceutics, Institute of Biomedical Sciences, Tokushima University
| | - Sherif E Emam
- Department of Pharmacokinetics and Biopharmaceutics, Institute of Biomedical Sciences, Tokushima University
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Zagazig University
| | - Yoshino Kawaguchi
- Department of Pharmacokinetics and Biopharmaceutics, Institute of Biomedical Sciences, Tokushima University
| | - Taro Shimizu
- Department of Pharmacokinetics and Biopharmaceutics, Institute of Biomedical Sciences, Tokushima University
| | - Yu Ishima
- Department of Pharmacokinetics and Biopharmaceutics, Institute of Biomedical Sciences, Tokushima University
| | | | - Tatsuhiro Ishida
- Department of Pharmacokinetics and Biopharmaceutics, Institute of Biomedical Sciences, Tokushima University
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17
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Wu X, Dai H, Yu S, Zhao Y, Long Y, Li W, Tu J. Magnesium Calcium Phosphate Cement Incorporating Citrate for Vascularized Bone Regeneration. ACS Biomater Sci Eng 2020; 6:6299-6308. [PMID: 33449642 DOI: 10.1021/acsbiomaterials.0c00929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The development of bioactive bone cement is still a challenge for vascularized bone regeneration. Citrate participated in multiple biological processes, such as energy metabolism, osteogenesis, and angiogenesis. However, it is difficult to obtain a thorough and comprehensive understanding on osteogenic effects of exogenous citrate from different experimental conditions and treatment methods. In this study, by using a magnesium calcium phosphate cement (MCPC) matrix, we investigated the dual effect of exogenous citrate on osteogenesis and angiogenesis. Our studies show that citrate elevates the osteogenic function of osteoblasts under low doses and the angiogenic function of vascular endothelial cells under a broader dose range. These findings furnish a new strategy for regulating angiogenesis and osteogenic differentiation by administration of citrate in MCPC, driving the development of bioactive bone repair materials.
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Affiliation(s)
- Xiaopei Wu
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China.,Foshan Xianhu Laboratory of the Advanced Energy Science and Technology Guangdong Laboratory, Xianhu Hydrogen Valley, Foshan 528200, China
| | - Honglian Dai
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China.,Foshan Xianhu Laboratory of the Advanced Energy Science and Technology Guangdong Laboratory, Xianhu Hydrogen Valley, Foshan 528200, China
| | - Suchun Yu
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China
| | - Yanan Zhao
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China
| | - Yanpiao Long
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China
| | - Wenqin Li
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China
| | - Jing Tu
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China
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18
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Lalayiannis AD, Crabtree NJ, Ferro CJ, Askiti V, Mitsioni A, Biassoni L, Kaur A, Sinha MD, Wheeler DC, Duncan ND, Popoola J, Milford DV, Long J, Leonard MB, Fewtrell M, Shroff R. Routine serum biomarkers, but not dual-energy X-ray absorptiometry, correlate with cortical bone mineral density in children and young adults with chronic kidney disease. Nephrol Dial Transplant 2020; 36:1872-1881. [DOI: 10.1093/ndt/gfaa199] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Indexed: 12/18/2022] Open
Abstract
Abstract
Background. Biomarkers and dual-energy X-ray absorptiometry (DXA) are thought to be poor predictors of bone mineral density (BMD). The Kidney Disease: Improving Global Outcomes guidelines suggest using DXA if the results will affect patient management, but this has not been studied in children or young adults in whom bone mineral accretion continues to 30 years of age. We studied the clinical utility of DXA and serum biomarkers against tibial cortical BMD (CortBMD) measured by peripheral quantitative computed tomography, expressed as Z-score CortBMD, which predicts fracture risk.
Methods. This was a cross-sectional multicentre study in 26 patients with CKD4 and 5 and 77 on dialysis.
Results. Significant bone pain that hindered activities of daily living was present in 58%, and 10% had at least one low-trauma fracture. CortBMD and cortical mineral content Z-scores were lower in dialysis compared with CKD patients (P = 0.004 and P = 0.02). DXA BMD hip and lumbar spine Z-scores did not correlate with CortBMD or biomarkers. CortBMD was negatively associated with parathyroid hormone (PTH; r = −0.44, P < 0.0001) and alkaline phosphatase (ALP; r = −0.22, P = 0.03) and positively with calcium (Ca; r = 0.33, P = 0.001). At PTH <3 times upper limit of normal, none of the patients had a CortBMD below −2 SD (odds ratio 95% confidence interval 7.331 to infinity). On multivariable linear regression PTH (β = −0.43 , P < 0.0001), ALP (β = −0.36, P < 0.0001) and Ca (β = 0.21, P = 0.005) together predicted 57% of variability in CortBMD. DXA measures did not improve this model.
Conclusions. Taken together, routinely used biomarkers, PTH, ALP and Ca, but not DXA, are moderate predictors of cortical BMD. DXA is not clinically useful and should not be routinely performed in children and young adults with CKD 4–5D.
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Affiliation(s)
- Alexander D Lalayiannis
- Great Ormond St Hospital for Children NHS Foundation Trust, University College London Institute of Child Health, London, UK
| | - Nicola J Crabtree
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - Charles J Ferro
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Lorenzo Biassoni
- Great Ormond St Hospital for Children NHS Foundation Trust, University College London Institute of Child Health, London, UK
| | - Amrit Kaur
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Manish D Sinha
- Evelina Children’s Hospital, Guy’s & St Thomas' NHS Foundation Trust, London, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Neill D Duncan
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| | - Joyce Popoola
- Department of Nephrology and Transplantation, George’s University Hospital NHS Foundation Trust, London, UK
| | - David V Milford
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - Jin Long
- Stanford University, Palo Alto, CA, USA
| | | | - Mary Fewtrell
- Great Ormond St Hospital for Children NHS Foundation Trust, University College London Institute of Child Health, London, UK
| | - Rukshana Shroff
- Great Ormond St Hospital for Children NHS Foundation Trust, University College London Institute of Child Health, London, UK
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19
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Ritter A, Mohebbi N. Causes and Consequences of Metabolic Acidosis in Patients after Kidney Transplantation. Kidney Blood Press Res 2020; 45:792-801. [PMID: 33040055 DOI: 10.1159/000510158] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/01/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Metabolic acidosis (MA) is a common complication in kidney transplantation (KTx). It is more prevalent in KTx than in CKD, and it occurs at higher glomerular filtration rates. The pathophysiologic understanding of MA in KTx and its clinical impact has been highlighted by few recent studies. However, no guidelines exist yet for the treatment of MA after KTx. SUMMARY MA in KTx seems to share pathophysiologic mechanisms with CKD, such as impaired ammoniagenesis. Additional kidney transplant-specific factors seem to alter not only the prevalence but also the phenotype of MA, which typically shows features of renal tubular acidosis. There is evidence that calcineurin inhibitors, immunological factors, process of donation, donor characteristics, and diet may contribute to MA occurrence. According to several mainly observational studies, MA seems to play a role in disturbed bone metabolism, cardiovascular morbidity, declining graft function, and mortality. A better understanding of the pathophysiology and evidence from randomized controlled trials, in particular, are needed to clarify the role of MA and the potential benefit of alkali treatment in KTx. Alkali therapy might not only be beneficial but also cost effective and safe. Key Messages: MA seems to be associated with several negative outcomes in KTx. A deeper understanding of the pathophysiology and clinical consequences of MA in KTx is crucial. Clinical trials will have to determine the potential benefits of alkali therapy.
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Affiliation(s)
- Alexander Ritter
- Division of Nephrology, University Hospital of Zurich, Zurich, Switzerland
| | - Nilufar Mohebbi
- Division of Nephrology, University Hospital of Zurich, Zurich, Switzerland, .,Praxis und Dialysezentrum Zürich-City, Zurich, Switzerland,
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20
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Wu X, Dai H, Yu S, Zhao Y, Long Y, Li W, Tu J. Citrate regulates extracellular matrix mineralization during osteoblast differentiation in vitro. J Inorg Biochem 2020; 214:111269. [PMID: 33129127 DOI: 10.1016/j.jinorgbio.2020.111269] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 09/24/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
The extremely high levels of citrate in bone highlight its important role, which must be involved in some essential functional or structural role that is required for the development and maintenance of normal bone. However, biomineralization researches have emphasized the interaction between the citrate and inorganic minerals during crystallization in cell-free systems. It is difficult to obtain a thorough and comprehensive understanding from cell-free experimental conditions and treatment methods. In this study, by proposing an osteoblast mineralization experimental model, we explored the regulation of citrate on bone apatite crystal structure. Our studies show that citrate stabilizes two precursors and then inhibits their transformation into hydroxyapatite. Concomitantly, the smaller size and lower crystallinity mineral deposition emerge during citrate-mediated osteogenic mineralization. These findings may provide a new perspective for the mechanism of osteogenic mineralization and a basis for further understanding of bone metabolism.
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Affiliation(s)
- Xiaopei Wu
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China; Foshan Xianhu Laboratory of the Advanced Energy Science and Technology Guangdong Laboratory, Xianhu hydrogen Valley, Foshan 528200, China
| | - Honglian Dai
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China; Foshan Xianhu Laboratory of the Advanced Energy Science and Technology Guangdong Laboratory, Xianhu hydrogen Valley, Foshan 528200, China.
| | - Suchun Yu
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China
| | - Yanan Zhao
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China
| | - Yanpiao Long
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China
| | - Wenqin Li
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China
| | - Jing Tu
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Biomedical Materials and Engineering Research Center of Hubei Province, Wuhan University of Technology, Wuhan 430070, China
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21
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Berkmann JC, Herrera Martin AX, Ellinghaus A, Schlundt C, Schell H, Lippens E, Duda GN, Tsitsilonis S, Schmidt-Bleek K. Early pH Changes in Musculoskeletal Tissues upon Injury-Aerobic Catabolic Pathway Activity Linked to Inter-Individual Differences in Local pH. Int J Mol Sci 2020; 21:ijms21072513. [PMID: 32260421 PMCID: PMC7177603 DOI: 10.3390/ijms21072513] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 01/09/2023] Open
Abstract
Local pH is stated to acidify after bone fracture. However, the time course and degree of acidification remain unknown. Whether the acidification pattern within a fracture hematoma is applicable to adjacent muscle hematoma or is exclusive to this regenerative tissue has not been studied to date. Thus, in this study, we aimed to unravel the extent and pattern of acidification in vivo during the early phase post musculoskeletal injury. Local pH changes after fracture and muscle trauma were measured simultaneously in two pre-clinical animal models (sheep/rats) immediately after and up to 48 h post injury. The rat fracture hematoma was further analyzed histologically and metabolomically. In vivo pH measurements in bone and muscle hematoma revealed a local acidification in both animal models, yielding mean pH values in rats of 6.69 and 6.89, with pronounced intra- and inter-individual differences. The metabolomic analysis of the hematomas indicated a link between reduction in tricarboxylic acid cycle activity and pH, thus, metabolic activity within the injured tissues could be causative for the different pH values. The significant acidification within the early musculoskeletal hematoma could enable the employment of the pH for novel, sought-after treatments that allow for spatially and temporally controlled drug release.
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Affiliation(s)
- Julia C. Berkmann
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
- Berlin-Brandenburg School for Regenerative Therapies, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Aaron X. Herrera Martin
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
- Berlin-Brandenburg School for Regenerative Therapies, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Agnes Ellinghaus
- BIH Center for Regenerative Therapies, Charité–Universitätsmedizin Berlin, Berlin 10178, Germany;
| | - Claudia Schlundt
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
| | - Hanna Schell
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
| | - Evi Lippens
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
| | - Georg N. Duda
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
- BIH Center for Regenerative Therapies, Charité–Universitätsmedizin Berlin, Berlin 10178, Germany;
| | - Serafeim Tsitsilonis
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
- Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, 13357 Berlin, Germany
| | - Katharina Schmidt-Bleek
- Julius Wolff Institut, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany; (J.C.B.); (A.X.H.M.); (C.S.); (H.S.); (E.L.); (G.N.D.); (S.T.)
- BIH Center for Regenerative Therapies, Charité–Universitätsmedizin Berlin, Berlin 10178, Germany;
- Correspondence: ; Tel.: +49-(0)30-450-659209; Fax: +49-(0)30-450-559938
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22
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Bjurulf B, Magnus P, Hallböök T, Strømme P. Potassium citrate and metabolic acidosis in children with epilepsy on the ketogenic diet: a prospective controlled study. Dev Med Child Neurol 2020; 62:57-61. [PMID: 31745987 DOI: 10.1111/dmcn.14393] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 11/29/2022]
Abstract
AIM To investigate if potassium citrate, a mild alkaline compound, can prevent metabolic acidosis in children with epilepsy treated with the ketogenic diet without reducing antiepileptic efficacy. METHOD In this prospective controlled study, we investigated the frequency of initial uncompensated metabolic acidosis in 51 participants. There were 22 participants with and 29 without potassium citrate supplementation. The ketogenic diet was used as add-on treatment to children with drug resistant epilepsy. We also estimated the proportion of participants with a greater than 50% seizure reduction after 7 months. RESULTS None of the 22 participants (15 males, seven females; median age 1y 7mo, interquartile range [IQR] 3y 3mo) with, and 10 of 29 (12 males, 17 females; median age 6y 1mo, IQR 4y 8mo) without potassium citrate developed metabolic acidosis (odds ratio=0.04, 95% CI 0.00-0.75 [p<0.01]); median pH 7.32 vs 7.24; [p<0.001]), and median bicarbonate 19.7mmol/L vs 14.0mmol/L (p<0.001). The number of seizures was reduced by more than 50% in 9 of 22 with potassium citrate and 8 of 29 participants without potassium citrate, 7 months after introducing a ketogenic diet (p=0.4). INTERPRETATION In the ketogenic diet, potassium citrate supplementation can prevent metabolic acidosis, without reducing antiepileptic efficacy. WHAT THIS PAPER ADDS Citrate supplementation prevents metabolic acidosis in children treated with a ketogenic diet. Efficacy of the ketogenic diet is not affected by supplementation with citrate. Citrate supplementation does not affect beta-hydroxybuturate concentration. Potassium citrate reduces the time needed to reach an optimal ketogenic ratio. This article is commented on by Schoeler on page 8 of this issue.
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Affiliation(s)
- Björn Bjurulf
- National Centre for Epilepsy, Oslo University Hospital, Oslo, Norway.,Department of Clinical Neurosciences for Children, Division of Pediatrics and Adolescent Medicine, Oslo University Hospital, Ullevål, Oslo, Norway.,Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Tove Hallböök
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Petter Strømme
- Department of Clinical Neurosciences for Children, Division of Pediatrics and Adolescent Medicine, Oslo University Hospital, Ullevål, Oslo, Norway.,University of Oslo, Oslo, Norway
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23
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Palmer SC, Chung EYM, McGregor DO, Bachmann F, Strippoli GFM. Interventions for preventing bone disease in kidney transplant recipients. Cochrane Database Syst Rev 2019; 10:CD005015. [PMID: 31637698 PMCID: PMC6803293 DOI: 10.1002/14651858.cd005015.pub4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People who have chronic kidney disease (CKD) have important changes to bone structure, strength, and metabolism. Children experience bone deformity, pain, and delayed or impaired growth. Adults experience limb and vertebral fractures, avascular necrosis, and pain. The fracture risk after kidney transplantation is four times that of the general population and is related to Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) occurring with end-stage kidney failure, steroid-induced bone loss, and persistent hyperparathyroidism after transplantation. Fractures may reduce quality of life and lead to being unable to work or contribute to community roles and responsibilities. Earlier versions of this review have found low certainty evidence for effects of treatment. This is an update of a review first published in 2005 and updated in 2007. OBJECTIVES This review update evaluates the benefits and harms of interventions for preventing bone disease following kidney transplantation. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 16 May 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA RCTs and quasi-RCTs evaluating treatments for bone disease among kidney transplant recipients of any age were eligible. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial risks of bias and extracted data. Statistical analyses were performed using random effects meta-analysis. The risk estimates were expressed as a risk ratio (RR) for dichotomous variables and mean difference (MD) for continuous outcomes together with the corresponding 95% confidence interval (CI). The primary efficacy outcome was bone fracture. The primary safety outcome was acute graft rejection. Secondary outcomes included death (all cause and cardiovascular), myocardial infarction, stroke, musculoskeletal disorders (e.g. skeletal deformity, bone pain), graft loss, nausea, hyper- or hypocalcaemia, kidney function, serum parathyroid hormone (PTH), and bone mineral density (BMD). MAIN RESULTS In this 2019 update, 65 studies (involving 3598 participants) were eligible; 45 studies contributed data to our meta-analyses (2698 participants). Treatments included bisphosphonates, vitamin D compounds, teriparatide, denosumab, cinacalcet, parathyroidectomy, and calcitonin. Median duration of follow-up was 12 months. Forty-three studies evaluated bone density or bone-related biomarkers, with more recent studies evaluating proteinuria and hyperparathyroidism. Bisphosphonate therapy was usually commenced in the perioperative transplantation period (within 3 weeks) and regardless of BMD. Risks of bias were generally high or unclear leading to lower certainty in the results. A single study reported outcomes among 60 children and adolescents. Studies were not designed to measure treatment effects on fracture, death or cardiovascular outcomes, or graft loss.Compared to placebo, bisphosphonate therapy administered over 12 months in transplant recipients may prevent fracture (RR 0.62, 95% CI 0.38 to 1.01; low certainty evidence) although the 95% CI included the possibility that bisphosphonate therapy might make little or no difference. Fracture events were principally vertebral fractures identified during routine radiographic surveillance. It was uncertain whether any other drug class decreased fracture (low or very low certainty evidence). It was uncertain whether interventions for bone disease in kidney transplantation reduce all-cause or cardiovascular death, myocardial infarction or stroke, or graft loss in very low certainty evidence. Bisphosphonate therapy may decrease acute graft rejection (RR 0.70, 95% CI 0.55 to 0.89; low certainty evidence), while it is uncertain whether any other treatment impacts graft rejection (very low certainty evidence). Bisphosphonate therapy may reduce bone pain (RR 0.20, 95% CI 0.04 to 0.93; very low certainty evidence), while it was very uncertain whether bisphosphonates prevent spinal deformity or avascular bone necrosis (very low certainty evidence). Bisphosphonates may increase to risk of hypocalcaemia (RR 5.59, 95% CI 1.00 to 31.06; low certainty evidence). It was uncertain whether vitamin D compounds had any effect on skeletal, cardiovascular, death, or transplant function outcomes (very low certainty or absence of evidence). Evidence for the benefits and harms of all other treatments was of very low certainty. Evidence for children and young adolescents was sparse. AUTHORS' CONCLUSIONS Bisphosphonate therapy may reduce fracture and bone pain after kidney transplantation, however low certainty in the evidence indicates it is possible that treatment may make little or no difference. It is uncertain whether bisphosphonate therapy or other bone treatments prevent other skeletal complications after kidney transplantation, including spinal deformity or avascular bone necrosis. The effects of bone treatment for children and adolescents after kidney transplantation are very uncertain.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Edmund YM Chung
- Royal North Shore HospitalDepartment of Medicine48 Provincial RoadSydneyNSWAustralia2070
| | - David O McGregor
- Christchurch HospitalDepartment of NephrologyPrivate Bag 4710ChristchurchNew Zealand8001
| | - Friederike Bachmann
- Charité University Medicine BerlinDepartment of Nephrology and Medical Intensive CareCharitéplatz 1BerlinGermany10117
| | - Giovanni FM Strippoli
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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24
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Wiegand A, Graf N, Bonani M, Frey D, Wüthrich RP, Mohebbi N. Relationship of Serum Bicarbonate Levels with 1-Year Graft Function in Kidney Transplant Recipients in Switzerland. Kidney Blood Press Res 2019; 44:1179-1188. [PMID: 31536994 DOI: 10.1159/000502527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/06/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Metabolic acidosis (MA) is common in kidney transplant recipients (KTRs). Several studies have shown that MA is involved in the progression of chronic kidney disease. However, it is unclear if there is also a relationship between serum bicarbonate and graft function after kidney transplantation (KTx). We hypothesized that low serum bicarbonate is associated with a lower estimated glomerular filtration rate (eGFR) 1 year after KTx. METHODS We performed a post hoc analysis of a single-center, open-label randomized trial in 90 KTRs and investigated the relationship of serum bicarbonate and graft function in the first year after KTx. RESULTS Prevalence of MA was high after KTx (63%) and decreased to 28% after 1 year. Bicarbonate (20.6 ± 3.0 to 22.7 ± 2.7 mmol/L) increased in the first year after transplantation whereas eGFR (53.4 ± 15.8 to 56.9 ± 18.5 mL/min/1.73 m2) did not change significantly. Higher serum bicarbonate (p = 0.029) was associated with higher eGFR in the first year after KTx. CONCLUSION Prevalence of MA is high in KTRs. In the first year after KTx, serum bicarbonate was positively correlated with eGFR, suggesting a potential role of MA in kidney graft function.
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Affiliation(s)
- Anna Wiegand
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | | | - Marco Bonani
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Diana Frey
- Division of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Rudolf P Wüthrich
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Nilufar Mohebbi
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland,
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25
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Avila-Poletti D, De Azevedo L, Iommi C, Heldal K, Musso CG. Hyperchloremic metabolic acidosis in the kidney transplant patient. Postgrad Med 2019; 131:171-175. [PMID: 30924703 DOI: 10.1080/00325481.2019.1592360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Hyperchloremic metabolic acidosis of renal origin results from a defect in renal tubular acidification mechanism, and this tubular dysfunction can consist of an altered tubular proton secretion or bicarbonate reabsorption capability. Studies have documented that all forms of renal tubular acidosis (RTA), type I to IV, are documented in kidney transplant patients. Among RTA pathophysiologic mechanisms have been described the renal mass reduction, hyperkalemia, hyperparathyroidism, graft rejection, immunologic diseases, and some drugs such as renin-angiotensin-aldosterone blockers, and calcineurin inhibitors. RTA can lead to serious complications as is the case of muscle protein catabolism, muscle protein synthesis inhibition, renal osteodystrophy, renal damage progression, and anemia promotion. RTA should be treated by suppressing its etiologic factor (if it is possible), avoiding hyperkalemia, and/or supplying bicarbonate or a precursor (citrate). In conclusion: Hyperchloremic metabolic acidosis of renal origin is a relatively frequent complication in kidney transplantation patients, which can be harmful, and should be adequately treated in order to avoid its renal and systemic adverse effects.
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Affiliation(s)
- Debora Avila-Poletti
- a Human Physiology Department , Instituto Universitario del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Leticia De Azevedo
- a Human Physiology Department , Instituto Universitario del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Candela Iommi
- a Human Physiology Department , Instituto Universitario del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
| | - Kristian Heldal
- b Clinic of Internal Medicine, Telemark Hospital Trust , Skien , Norway.,c Institute of Clinical Medicine, Faculty of Medicine of University of Oslo , Oslo , Norway
| | - Carlos G Musso
- a Human Physiology Department , Instituto Universitario del Hospital Italiano de Buenos Aires , Buenos Aires , Argentina
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26
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Djamali A, Singh T, Melamed ML, Stein JH, Aziz F, Parajuli S, Mohamed M, Garg N, Mandelbrot D, Wesson DE, Astor BC. Metabolic Acidosis 1 Year Following Kidney Transplantation and Subsequent Cardiovascular Events and Mortality: An Observational Cohort Study. Am J Kidney Dis 2019; 73:476-485. [PMID: 30704880 DOI: 10.1053/j.ajkd.2018.12.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 12/02/2018] [Indexed: 12/24/2022]
Abstract
RATIONALE & OBJECTIVE Recent studies suggest that metabolic acidosis is associated with mortality and graft failure in kidney transplant recipients. However, it is unknown whether serum bicarbonate (measured as total carbon dioxide [tCO2] in serum) levels predict cardiovascular events (CVEs) following kidney transplantation. STUDY DESIGN Observational cohort study. SETTINGS & PARTICIPANTS Single-center study of 2,128 kidney transplant recipients free of CVEs during the first 13.5 months following transplantation. PREDICTOR tCO2 level at 1 year posttransplantation. OUTCOMES Ischemic, arrhythmic, and heart failure CVEs and death from any cause. ANALYTICAL APPROACH Independent associations were assessed using multivariable proportional hazards regression models. Restricted cubic spline Poisson models were used to explore nonlinear associations. Linear spline proportional hazards models were used to assess associations at different tCO2 levels. RESULTS The prevalence of metabolic acidosis defined as tCO2 level < 24 mEq/L was 38.8% (n=826). There were 384 recipients with a CVE and 610 deaths during a median follow-up of 4.0 years. CVEs included 241 ischemic, 137 arrhythmic, and 150 heart failure events. tCO2 level < 20 mEq/L was associated with increased risk for CVEs (adjusted HR [aHR], 2.00; 95% CI, 1.29-3.10) compared to the reference category of tCO2 level of 24.0 to 25.9 mEq/L. This association was primarily due to ischemic CVEs (aHR, 2.28; 95% CI, 1.34-3.90). For every 1 mEq/L lower tCO2 level for those with tCO2 < 24 mEq/L, risks for all CVEs and ischemic events were 17% and 15% higher, respectively (aHR for all CVEs of 0.83 [95% CI, 0.74-0.94] and aHR for ischemic CVEs of 0.85 [95% CI, 0.74-0.99]). Notably, tCO2 level < 20 mEq/L, compared to tCO2 level of 24.0 to 25.9 mEq/L, was independently associated with all-cause mortality (aHR, 1.43; 95% CI, 1.02-2.02). For every 1-mEq/L lower tCO2 level for those with tCO2 < 24 mEq/L, there was 17% higher risk for death (aHR, 0.83; 95% CI, 0.75-0.92). LIMITATIONS Single-center observational study. CONCLUSIONS Metabolic acidosis is an independent risk factor for ischemic CVEs after kidney transplantation. It is unknown whether correction of acidosis improves outcomes in these patients.
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Affiliation(s)
- Arjang Djamali
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Tripti Singh
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michal L Melamed
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - James H Stein
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Fahad Aziz
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Maha Mohamed
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Neetika Garg
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Didier Mandelbrot
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Donald E Wesson
- Baylor Scott and White Health and Wellness Center of BSW Health, Dallas, TX
| | - Brad C Astor
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
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27
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Abstract
Metabolic acidosis is not uncommon in CKD and is linked with bone demineralization, muscle catabolism, and higher risks of CKD progression and mortality. Clinical practice guidelines recommend maintaining serum total CO2 at ≥22 mEq/L to help prevent these complications. Although a definitive trial testing whether correcting metabolic acidosis improves clinical outcomes has not been conducted, results from small, single-center studies support this notion. Furthermore, biologic plausibility supports the notion that a subset of patients with CKD have acid-mediated organ injury despite having a normal serum total CO2 and might benefit from oral alkali before overt acidosis develops. Identifying these individuals with subclinical metabolic acidosis is challenging, but recent results suggest that urinary acid excretion measurements may be helpful. The dose of alkali to provide in this setting is unknown as well. The review discusses these topics and the prevalence and risk factors of metabolic acidosis, mechanisms of acid-mediated organ injury, results from interventional studies, and potential harms of alkali therapy in CKD.
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Affiliation(s)
- Kalani L Raphael
- Veterans Affairs Salt Lake City Health Care System and Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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28
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Affiliation(s)
- Kalani L Raphael
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah; and .,Research Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Fuad S Shihab
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah; and
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29
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Park S, Kang E, Park S, Kim YC, Han SS, Ha J, Kim DK, Kim S, Park SK, Han DJ, Lim CS, Kim YS, Lee JP, Kim YH. Metabolic Acidosis and Long-Term Clinical Outcomes in Kidney Transplant Recipients. J Am Soc Nephrol 2016; 28:1886-1897. [PMID: 28031407 DOI: 10.1681/asn.2016070793] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 11/23/2016] [Indexed: 01/07/2023] Open
Abstract
Metabolic acidosis (MA), indicated by low serum total CO2 (TCO2) concentration, is a risk factor for mortality and progressive renal dysfunction in CKD. However, the long-term effects of MA on kidney transplant recipients (KTRs) are unclear. We conducted a multicenter retrospective cohort study of 2318 adult KTRs, from January 1, 1997 to March 31, 2015, to evaluate the prevalence of MA and the relationships between TCO2 concentration and clinical outcomes. The prevalence of low TCO2 concentration (<22 mmol/L) began to increase in KTRs with eGFR<60 ml/min per 1.73 m2 and ranged from approximately 30% to 70% in KTRs with eGFR<30 ml/min per 1.73 m2 Multivariable Cox proportional hazards models revealed that low TCO2 concentration 3 months after transplant associated with increased risk of graft loss (hazard ratio [HR], 1.74%; 95% confidence interval [95% CI], 1.26 to 2.42) and death-censored graft failure (DCGF) (HR, 1.66; 95% CI, 1.14 to 2.42). Cox regression models using time-varying TCO2 concentration additionally demonstrated significant associations between low TCO2 concentration and graft loss (HR, 3.48; 95% CI, 2.47 to 4.90), mortality (HR, 3.16; 95% CI, 1.77 to 5.62), and DCGF (HR, 3.17; 95% CI, 2.12 to 4.73). Marginal structural Cox models adjusted for time-varying eGFR further verified significant hazards of low TCO2 concentration for graft loss, mortality, and DCGF. In conclusion, MA was frequent in KTRs despite relatively preserved renal function and may be a significant risk factor for graft failure and patient mortality, even after adjusting for eGFR.
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Affiliation(s)
| | | | | | | | | | - Jongwon Ha
- Surgery, Seoul National University College of Medicine, Seoul, Korea
| | | | | | | | - Duck Jong Han
- Division of Kidney Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul, Korea; and
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | | | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Young Hoon Kim
- Division of Kidney Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul, Korea; and
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30
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Abstract
BACKGROUND The ideal intravenous fluid for kidney transplantation has not been defined, despite the common use of normal saline during the peri-operative period. The high chloride content of normal saline is associated with an increased risk of hyperchloraemic metabolic acidosis, which may in turn increase the risk of hyperkalaemia and delayed graft function. Balanced electrolyte solutions have a lower chloride content which may decrease this risk and avoid the need for dialysis due to hyperkalaemia in the immediate post-transplant period. Randomised controlled trials (RCTs) addressing this issue have used biochemical outcomes to compare fluids and have been underpowered to address patient-centred outcomes such as delayed graft function. OBJECTIVES To examine the effect of lower-chloride solutions versus normal saline on delayed graft function, hyperkalaemia and acid-base status in kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 26 November 2015 through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA RCTs of kidney transplant recipients that compared peri-operative intravenous lower-chloride solutions to normal saline were included. DATA COLLECTION AND ANALYSIS Two independent investigators assessed studies for eligibility and risk of bias. Data from individual studies were extracted using standardised forms and pooled according to a published protocol. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. MAIN RESULTS Six studies (477 participants) were included in the review. All participants were adult kidney transplant recipients and 70% of participants underwent live-donor kidney transplantation. The overall risk of bias was low for selection bias and unclear for remaining domains. There was no difference in the risk of delayed graft function (3 studies, 298 participants: RR 1.03, 95% CI 0.62 to 1.70) or hyperkalaemia (2 studies, 199 participants: RR 0.48, 95% CI 0.04 to 6.10) for participants who received balanced electrolyte solutions compared to normal saline. Intraoperative balanced electrolyte solutions compared to normal saline were associated with higher blood pH (3 studies, 193 participants: MD 0.07, 95% CI 0.05 to 0.09), higher serum bicarbonate (3 studies, 215 participants: MD 3.02 mEq/L, 95% CI 2.00 to 4.05) and lower serum chloride (3 studies, 215 participants: MD -9.93 mmol/L, 95% CI -19.96 to 0.11). There were four cases of graft loss in the normal saline group and one in the balanced electrolyte solution group, and four cases of acute rejection in the normal saline group compared to two cases in the balanced electrolyte solution group. AUTHORS' CONCLUSIONS Balanced electrolyte solutions are associated with less hyperchloraemic metabolic acidosis compared to normal saline, however it remains uncertain whether lower-chloride solutions lead to improved graft outcomes compared to normal saline.
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Affiliation(s)
- Susan Wan
- The University of SydneyCentral Clinical SchoolSydneyNSWAustralia2006
| | - Matthew A Roberts
- Monash UniversityEastern Health Clinical SchoolBox HillVICAustralia3128
| | - Peter Mount
- Austin HealthDepartment of Nephrology145 Studley RoadMelbourneVICAustralia3084
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DXA variations and fractures after simultaneous pancreas-renal transplantation: results of a long-term follow-up. Clin Nucl Med 2014; 40:e232-5. [PMID: 25525928 DOI: 10.1097/rlu.0000000000000643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Simultaneous pancreas-kidney transplant (SPKT) has been associated with an increased risk of fracture. We prospectively evaluated the long-term effects of SPKT on bone mineral density (BMD) and fracture risk. During 1998 to 1999, 29 participants were consecutively monitored, and 18 completed the 10-year follow-up. Laboratory blood parameters, lumbar-dorsal radiography, and DEXA were determined at baseline, 1 year, and 10 years. The medical record was reviewed for peripheral fragility fractures. The BMD revealed no changes between baseline and 1 or 10 years after SPKT. Lumbar-dorsal radiography showed 0% asymptomatic vertebral fractures at baseline and after 1 year with 16.7% at 10 years. Vertebral asymptomatic fractures were correlated with acute rejection episodes (P = 0.025). During the first year, no nonvertebral fractures were identified. At the end of the follow-up, 5 nonvertebral fractures in 4 patients were reported. Dorsal and lumbar spine fractures correlated with lumbar spine t score (r = -0.591, P =0.022) and peripheral fractures with femoral neck t score (r = -0.633, P = 0.013). Patients with SPKT did not show long-term significant loss of BMD. The incidence of vertebral fractures was low and related to steroid treatment; the incidence of peripheral fractures was higher and independent of clinical or biochemical parameters.
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32
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Kato A, Kido R, Onishi Y, Kurita N, Fukagawa M, Akizawa T, Fukuhara S. Association of serum bicarbonate with bone fractures in hemodialysis patients: the mineral and bone disorder outcomes study for Japanese CKD stage 5D patients (MBD-5D). Nephron Clin Pract 2014; 128:79-87. [PMID: 25378374 DOI: 10.1159/000365089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 06/04/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Bone fracture is often complicated in hemodialysis (HD) patients. Metabolic acidosis is related to bone disease and muscle wasting, but it is not known whether acid-base disturbance is associated with the risk of bone fractures. The aim of this study was to clarify the association of serum bicarbonate level with bone fracture in HD patients. METHODS Using a subcohort of the Mineral and Bone Disorder Outcomes Study for Japanese CKD Stage 5D Patients (MBD-5D), 890 prevalent HD patients (age: 62 years old, male: 62.8%, duration of dialysis: 8.3 years) with secondary hyperparathyroidism were studied. After measuring predialysis serum bicarbonate at a 2-day interdialytic interval, we prospectively followed them every 3 months, and examined the occurrence of any type of bone fracture or hospitalization due to fracture over a 3-year observation period. RESULTS Seventy-four bone fractures and 47 hospitalizations due to fracture were observed during the follow-up period. HD patients with serum bicarbonate <20 mmol/l had a 1.93 (95% CI 1.01-3.71)-fold higher risk for all-cause fractures than those with serum bicarbonate of 20.0-21.9 mmol/l. A higher bicarbonate level (≥22 mmol/l) was also related to an increased risk of bone fracture. A restricted cubic regression spline disclosed that the higher or the lower than 21.0 mmol/l of serum bicarbonate, the greater the risk for bone fracture. CONCLUSION Both a lower level and a higher level of predialysis bicarbonate concentration were associated with risk of bone fracture in HD patients with secondary hyperparathyroidism.
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Affiliation(s)
- Akihiko Kato
- Blood Purification Unit, Hamamatsu University Hospital, Hamamatsu, Japan
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Kawada N, Isaka Y, Rakugi H, Moriyama T. SCAD syndrome: A vicious cycle of kidney stones, CKD, and AciDosis. World J Clin Urol 2014; 3:113-118. [DOI: 10.5410/wjcu.v3.i2.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 05/23/2014] [Accepted: 06/20/2014] [Indexed: 02/06/2023] Open
Abstract
Cumulative evidence has shown that kidney stone formers are at high risk for developing end-stage renal disease (ESRD) and cardiovascular disease. The aim of this mini-review is to summarize the present knowledge about the close relationships among kidney stone formation, chronic kidney disease (CKD), and plasma and urine acidosis (SCAD). Part of the cause of the positive relationships between higher risk of developing ESRD and cardiovascular diseases in stone formers may be explained by inflammation and cell death due to the components of kidney stones. In CKD patients, acidic urine and loss of anti-crystallization factors may cause stone formation. Acidosis can promote tissue inflammation and may affect vascular tone. Correction of plasma and urine acidosis may improve renal and cardiovascular outcome of stone formers and CKD patients. More intensive and long-term interventions, which include correction of plasma and urine pH in patients with reduced renal function and correction of urine pH in patients with normal renal function, may be considered in treating patients with SCAD syndrome.
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34
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[Mineral and bone disorders in renal transplantation]. Nephrol Ther 2013; 9:461-70. [PMID: 24176653 DOI: 10.1016/j.nephro.2013.07.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 07/23/2013] [Accepted: 07/26/2013] [Indexed: 11/22/2022]
Abstract
The deregulation of bone and mineral metabolism during chronic kidney disease (CKD) is a daily challenge for physicians, its management aiming at decreasing the risk of both fractures and vascular calcifications. Renal transplantation in the context of CKD, with pre-existing renal osteodystrophy as well as nutritional impairment, chronic inflammation, hypogonadism and corticosteroids exposure, represents a major risk factor for bone impairment in the post-transplant period. The aim of this review is therefore to provide an update on the pathophysiology of mineral and bone disorders after renal transplantation.
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Arrabal-Polo MÁ, Arrabal-Martín M, Girón-Prieto MS, Orgaz-Molina J, Quesada-Charneco M, López-Ruiz A, Poyatos-Andujar A, Zuluaga-Gómez A, Arias-Santiago S. Association of severe calcium lithogenic activity and bone remodeling markers. Urology 2013; 82:16-21. [PMID: 23601442 DOI: 10.1016/j.urology.2013.02.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 01/23/2013] [Accepted: 02/20/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To establish cutoff points for markers of bone remodeling that allow for screening of patients at risk for serious lithogenic activity. MATERIALS AND METHODS We conducted a cross-sectional study with 182 patients (aged between 25 and 60 years) divided into 3 groups: group 1, 56 patients without lithiasis; group 2, 67 patients with light calcium lithiasis; and group 3, 59 patients with severe calcium lithiasis. The criteria for inclusion in and exclusion from the study were established, and light and severe lithogenic activity were defined. Metabolic variables in blood and urine, along with bone densitometry, were studied for the groups. Statistical analysis of the results and preparation of receiver operating characteristic curves to establish optimal cutoff points were performed. RESULTS The patients in group 3 showed the greatest bone mineral density loss and the highest values for markers of bone remodeling, together with increased 24-hour calciuria. Using the receiver operating characteristic curves developed and based on statistical significance (P = .0001), the following cutoff points for severe lithogenic activity, with a sensitivity between 75% and 85%, were established: β-crosslaps >0.331 ng/mL; osteocalcin >13.2 ng/mL; β-crosslaps/osteocalcin >0.024; 24-hour calciuria >306.6 mg; and fasting urine calcium/creatinine >0.105. CONCLUSION Patients with calcium lithiasis and elevated values for osteocalcin, β-crosslaps, β-crosslaps/osteocalcin, 24-hour calciuria, and fasting urine calcium/creatinine may present a high risk of severe lithogenic activity.
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Roderick P, Willis NS, Blakeley S, Jones C, Tomson C. Correction of chronic metabolic acidosis for chronic kidney disease patients. Cochrane Database Syst Rev 2007; 2007:CD001890. [PMID: 17253467 PMCID: PMC7045985 DOI: 10.1002/14651858.cd001890.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Metabolic acidosis is a feature of chronic kidney disease (CKD) due to the reduced capacity of the kidney to synthesise ammonia and excrete hydrogen ions. It has adverse consequences on protein and muscle metabolism, bone turnover and the development of renal osteodystrophy. Metabolic acidosis may be corrected by oral bicarbonate supplementation or in dialysis patients by increasing the bicarbonate concentration in dialysate fluid. OBJECTIVES To examine the benefits and harms of treating metabolic acidosis in patients with CKD, both prior to reaching end-stage renal disease (ESRD) or whilst on renal replacement therapy (RRT), with sodium bicarbonate or increasing the bicarbonate concentration of dialysate. SEARCH STRATEGY We searched CENTRAL (The Cochrane Library, issue 4 2005), Cochrane Renal Group's specialised register (October 2005), MEDLINE (1966 - October 2005) and EMBASE (1980 - October 2005). SELECTION CRITERIA Randomised controlled trials (RCTs), crossover RCTs and quasi-RCTs investigating the correction of chronic metabolic acidosis in adults or children with CKD. DATA COLLECTION AND ANALYSIS Outcomes were analysed using relative risk (RR) and weighted mean difference (MD) for continuous measures. MAIN RESULTS We identified three trials in adult dialysis patients (n = 117). There were insufficient data for most outcomes for meta-analysis. In all three trials acidosis improved in the intervention group though there was variation in achieved bicarbonate level. There was no evidence of effect on blood pressure or sodium levels. Some measures of nutritional status/protein metabolism (e.g. SGA, NP NA) were significantly improved by correction in the one trial that looked in these in detail. There was heterogeneity of the effect on serum albumin in two trials. Serum PTH fell significantly in the two trials that estimated this, there was no significant effect on calcium or phosphate though both fell after correction. Complex bone markers were assessed in one study, with some evidence for a reduction in bone turnover in those with initial high bone turnover and an increase in low turnover patients. The studies were underpowered to assess clinical outcomes, in the one study that did there was some evidence for a reduction in hospitalisation after correction. AUTHORS' CONCLUSIONS The evidence for the benefits and risks of correcting metabolic acidosis is very limited with no RCTs in pre-ESRD patients, none in children, and only three small trials in dialysis patients. These trials suggest there may be some beneficial effects on both protein and bone metabolism but the trials were underpowered to provide robust evidence.
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Affiliation(s)
- P Roderick
- University of Southampton, School of Medicine, Community Clinical Sciences, Level C, South Academic Block, Southampton General Hospital, Southampton, UK, S016 6YD.
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