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Via Reque Cortes DDP, Drueke TB, Moysés RMA. Persistent uncertainties in optimal treatment approaches of secondary hyperparathyroidism and hyperphosphatemia in patients with chronic kidney disease. Curr Osteoporos Rep 2024; 22:441-457. [PMID: 39158828 DOI: 10.1007/s11914-024-00881-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2024] [Indexed: 08/20/2024]
Abstract
PURPOSE OF REVIEW This review is a critical analysis of treatment results obtained in clinical trials conducted in patients with chronic kidney disease (CKD) and secondary hyperparathyroidism (SHPT), hyperphosphatemia, or both. RECENT FINDINGS Patients with CKD have a high mortality rate. The disorder of mineral and bone metabolism (CKD-MBD), which is commonly present in these patients, is associated with adverse outcomes, including cardiovascular events and mortality. Clinical trials aimed at improving these outcomes by modifying CKD-MBD associated factors have most often resulted in disappointing results. The complexity of CKD-MBD, where many players are closely interconnected, might explain these negative findings. We first present an historical perspective of current knowledge in the field of CKD-MBD and then examine potential flaws of past and ongoing clinical trials targeting SHPT and hyperphosphatemia respectively in patients with CKD.
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Affiliation(s)
| | - Tilman B Drueke
- Inserm Unit 1018, CESP, Hôpital Paul Brousse, Paris-Sud University (UPS) and Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University, UVSQ), Team 5, Villejuif, France
| | - Rosa Maria Affonso Moysés
- Laboratório de Fisiopatologia Renal, Faculdade de Medicina da USP, Nephrology Division, LIM 16, São Paulo, Brazil.
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Castillo RF, Pérez RG, González AL. Beneficial effects of physical exercise on the osteo-renal Klotho-FGF-23 axis in Chronic Kidney Disease: A systematic review with meta-analysis. Int J Med Sci 2024; 21:332-340. [PMID: 38169578 PMCID: PMC10758140 DOI: 10.7150/ijms.90195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/10/2023] [Indexed: 01/05/2024] Open
Abstract
The aim of this study was to investigate the efficacy of physical exercise in chronic kidney disease, describing its impact on the Klotho-FGF23 axis. PubMed, Web of Science and Scopus databases, updated to January 2023, were searched. The present study employed mean difference and a 95% confidence interval (CI) to examine the efficacy of the intervention. Heterogeneity was assessed through inconsistency statistics (I2). Out of the 299 studies identified, a total of 4 randomized controlled trials (RCTs), comprising 272 participants, met the eligibility criteria. Compared with the control group, physical exercise significantly decreased the concentrations of FGF23 (MD: -102.07 Pg/mL, 95% CI: -176.23.47, -27.91 I2= 97%, p = 0.001), and a significantly increased the concentrations of Klotho protein: (MD: 158.82 Pg/mL, 95% CI: 123.33, -194.31, I2 = 0%, p = 0.001). The results of our study indicated that the exercise has a direct relationship with Klotho-FGF23 axis. We can conclude that physical exercise in patients with CKD produces beneficial effects on the pathophysiological components related to this disease, including cardiorespiratory fitness and vascular functions. As observed, both endurance and aerobic physical exercise increase Klotho production and decrease FGF23 levels. Evidence indicates that exercise attenuates the progression of CKD, improves uremic parameters and down-regulates inflammation-related markers.
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Affiliation(s)
- Rafael Fernandez Castillo
- Instituto de Investigación Biosanitaria ibs.Granada; Faculty of Health Sciences, University of Granada, 18071 Granada, Spain
| | - Raquel García Pérez
- University of Granada. Faculty of Health Sciences, Parque Tecnológico de Ciencias de la Salud. Avd de la Ilustración 60 CP18016 Granada/Spain
| | - Antonio Liñán González
- University of Granada. Faculty of Health Sciences, Parque Tecnológico de Ciencias de la Salud. Avd de la Ilustración 60 CP18016 Granada/Spain
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Misella Hansen N, Kamper AL, Rix M, Feldt-Rasmussen B, Leipziger J, Sørensen MV, Berg P, Astrup A, Salomo L. Health effects of the New Nordic Renal Diet in patients with stage 3 and 4 chronic kidney disease, compared with habitual diet: a randomized trial. Am J Clin Nutr 2023; 118:1042-1054. [PMID: 37598748 DOI: 10.1016/j.ajcnut.2023.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) leads to an accumulation of waste products and causes adverse cardiometabolic effects. OBJECTIVES We investigated the health effects of the New Nordic Renal Diet (NNRD), a novel meal pattern reduced in phosphorus, protein, and sodium. METHODS A 26-wk randomized trial compared the NNRD with a habitual diet. The NNRD group received weekly home deliveries of food and recipes. Monthly study visits included fasting blood samples, 24-h urine samples, blood pressure, and anthropometric measurements. Intention-to-treat analysis used linear mixed-effects models. RESULTS Sixty patients, mean estimated glomerular filtration rate (eGFR) 34 mL/min/1.73 m2 and body mass index of 25-27 kg/m2, were included and 58 completed. Metabolic syndrome was present in 53% (NNRD group) and 57% (control group). The NNRD group (n = 30) reduced their 24-h urine phosphorus excretion by 19% (-153 mg; 95% confidence interval [CI]: -210, -95), control group (n = 30) (no change), between-group difference -171 mg (95% CI: -233, -109; P < 0.001). Proteinuria was reduced by 39% in the NNRD group (-0.33 g/d; 95% CI: -0.47, -0.18), control group (no change), between-group difference -0.34 g/d (95% CI: -0.52, -0.17; P < 0.001). Plasma urea was reduced by -1.5 mmol/L in the NNRD group (95% CI: -2.1, -0.9), control group (no change), between-group difference -1.4 mmol/L (95% CI: -2.0, -0.7; P < 0.001). Systolic blood pressure fell by -5.2 mmHg in the NNRD group (95% CI: -8.4, -2.1), control group (no change), between-group difference -3.9 mmHg (95% CI; -7.6, -0.2; P = 0.04). The NNRD group lost -1.7 kg (95% CI: -2.6, -0.8), control group (no change), between-group difference -2.0 kg (95% CI: -3.0, -1.0; P < 0.001). There were no effects on eGFR during the 26-wk intervention. CONCLUSION NNRD in moderate CKD reduces phosphorus excretion, proteinuria, systolic blood pressure, and weight, mainly by reducing abdominal fat. This trial was registered at clinicaltrials.gov as NCT04579315.
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Affiliation(s)
- Nikita Misella Hansen
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Anne-Lise Kamper
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Bo Feldt-Rasmussen
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Jens Leipziger
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Peder Berg
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Arne Astrup
- Department of Obesity and Nutritional Sciences, Novo Nordisk Foundation, Hellerup, Denmark
| | - Louise Salomo
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Che QC, Jia Q, Zhang XY, Sun SN, Zhang XJ, Shu Q. A prospective study of the association between serum klotho and mortality among adults with rheumatoid arthritis in the USA. Arthritis Res Ther 2023; 25:149. [PMID: 37587536 PMCID: PMC10428634 DOI: 10.1186/s13075-023-03137-0] [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: 05/04/2023] [Accepted: 08/08/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND While it is known that klotho has negative regulatory effects in a variety of diseases such as metabolic disorders and kidney disease, the specific role of klotho in rheumatoid arthritis (RA) and its effect on mortality are unclear. This study investigated the association between serum klotho levels and mortality in patients with RA. METHODS This study included 841 adults with RA from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2016 to extract the concentrations of serum klotho. The association between klotho and RA was determined using Cox regression, Kaplan-Meier (KM) curves, and restricted cubic spline (RCS) models. RESULTS A total of 841 patients with RA were included in this study, who were divided into four groups based on the quartiles of serum klotho levels (Q1, Q2, Q3, and Q4). Cox regression analysis with adjustment for covariates revealed that high levels of klotho lowered the risk of both all-cause and cardiovascular mortality compared to the Q1 group. The KM curve analysis suggested that this effect was more pronounced for all-cause mortality. The RCS-fitted Cox regression model indicated a U-shaped correlation between serum klotho levels and RA mortality. The risk of all-cause mortality increased with decreasing serum klotho levels below a threshold of 838.81 pg/mL. Subgroup analysis revealed that the protective effect of klotho was more pronounced in patients with the following characteristics: male, white ethnicity, age ≥ 60 years, body mass index < 25 kg/m2, estimated glomerular filtration rate ≥ 60 mL/ (min × 1.73 m2), and 25-hydroxyvitamin D level ≥ 50 nmol/L. CONCLUSION Serum klotho levels had a U-shaped correlation with all-cause mortality in patients with RA, indicating that maintain a certain level of serum klotho could prevent premature death.
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Affiliation(s)
- Qin-Cheng Che
- Department of Rheumatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No.107, West Culture Road, Lixia District, Jinan, 250012, China
- Department of Rheumatology, Qilu Hospital, Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Jinan, China
| | - Qian Jia
- Department of Rheumatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No.107, West Culture Road, Lixia District, Jinan, 250012, China
- Department of Rheumatology, Qilu Hospital, Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Jinan, China
| | - Xiao-Yu Zhang
- Department of Rheumatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No.107, West Culture Road, Lixia District, Jinan, 250012, China
- Department of Rheumatology, Qilu Hospital, Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Jinan, China
| | - Shu-Ning Sun
- Department of Rheumatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No.107, West Culture Road, Lixia District, Jinan, 250012, China
- Department of Rheumatology, Qilu Hospital, Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Jinan, China
| | - Xiao-Jie Zhang
- Department of Rheumatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No.107, West Culture Road, Lixia District, Jinan, 250012, China
- Department of Rheumatology, Qilu Hospital, Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Jinan, China
| | - Qiang Shu
- Department of Rheumatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No.107, West Culture Road, Lixia District, Jinan, 250012, China.
- Department of Rheumatology, Qilu Hospital, Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Jinan, China.
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Yan J, Wang J, Chen J, Shi H, Liao X, Pan C, Liu Y, Yang X, Ren Z, Yang X. Adjusting phosphate feeding regimen according to daily rhythm increases eggshell quality via enhancing medullary bone remodeling in laying hens. J Anim Sci Biotechnol 2023; 14:17. [PMID: 36894995 PMCID: PMC9999492 DOI: 10.1186/s40104-023-00829-0] [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: 08/11/2022] [Accepted: 01/03/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Body phosphorus metabolism exhibits a circadian rhythm over the 24-h daily cycle. The egg laying behavior makes laying hens a very special model for investigating phosphorus circadian rhythms. There is lack of information about the impact of adjusting phosphate feeding regimen according to daily rhythm on the phosphorus homeostasis and bone remodeling of laying hens. METHODS AND RESULTS Two experiments were conducted. In Exp. 1, Hy-Line Brown laying hens (n = 45) were sampled according the oviposition cycle (at 0, 6, 12, and 18 h post-oviposition, and at the next oviposition, respectively; n = 9 at each time point). Diurnal rhythms of body calcium/phosphorus ingestions and excretions, serum calcium/phosphorus levels, oviduct uterus calcium transporter expressions, and medullary bone (MB) remodeling were illustrated. In Exp. 2, two diets with different phosphorus levels (0.32% and 0.14% non-phytate phosphorus (NPP), respectively) were alternately presented to the laying hens. Briefly, four phosphorus feeding regimens in total (each included 6 replicates of 5 hens): (1) fed 0.32% NPP at both 09:00 and 17:00; (2) fed 0.32% NPP at 09:00 and 0.14% NPP at 17:00; (3) fed 0.14% NPP at 09:00 and 0.32% NPP at 17:00; (4) fed 0.14% NPP at both 09:00 and 17:00. As a result, the regimen fed 0.14% NPP at 09:00 and 0.32% NPP at 17:00, which was designed to strengthen intrinsic phosphate circadian rhythms according to the findings in Exp. 1, enhanced (P < 0.05) MB remodeling (indicated by histological images, serum markers and bone mineralization gene expressions), elevated (P < 0.05) oviduct uterus calcium transportation (indicated by transient receptor potential vanilloid 6 protein expression), and subsequently increased (P < 0.05) eggshell thickness, eggshell strength, egg specific gravity and eggshell index in laying hens. CONCLUSIONS These results underscore the importance of manipulating the sequence of daily phosphorus ingestion, instead of simply controlling dietary phosphate concentrations, in modifying the bone remodeling process. Body phosphorus rhythms will need to be maintained during the daily eggshell calcification cycle.
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Affiliation(s)
- Jiakun Yan
- College of Animal Science and Technology, Northwest A&F University, Yangling, 712100, Shaanxi, China
| | - Jiajie Wang
- College of Animal Science and Technology, Northwest A&F University, Yangling, 712100, Shaanxi, China
| | - Jie Chen
- College of Animal Science and Technology, Northwest A&F University, Yangling, 712100, Shaanxi, China
| | - Hao Shi
- College of Animal Science and Technology, Northwest A&F University, Yangling, 712100, Shaanxi, China
| | - Xujie Liao
- College of Animal Science and Technology, Northwest A&F University, Yangling, 712100, Shaanxi, China
| | - Chong Pan
- College of Animal Science and Technology, Northwest A&F University, Yangling, 712100, Shaanxi, China
| | - Yanli Liu
- College of Animal Science and Technology, Northwest A&F University, Yangling, 712100, Shaanxi, China
| | - Xin Yang
- College of Animal Science and Technology, Northwest A&F University, Yangling, 712100, Shaanxi, China
| | - Zhouzheng Ren
- College of Animal Science and Technology, Northwest A&F University, Yangling, 712100, Shaanxi, China.
| | - Xiaojun Yang
- College of Animal Science and Technology, Northwest A&F University, Yangling, 712100, Shaanxi, China.
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Lioufas NM, Pascoe EM, Hawley CM, Elder GJ, Badve SV, Block GA, Johnson DW, Toussaint ND. Systematic Review and Meta-Analyses of the Effects of Phosphate-Lowering Agents in Nondialysis CKD. J Am Soc Nephrol 2022; 33:59-76. [PMID: 34645696 PMCID: PMC8763193 DOI: 10.1681/asn.2021040554] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 09/22/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Benefits of phosphate-lowering interventions on clinical outcomes in patients with CKD are unclear; systematic reviews have predominantly involved patients on dialysis. This study aimed to summarize evidence from randomized controlled trials (RCTs) concerning benefits and risks of noncalcium-based phosphate-lowering treatment in nondialysis CKD. METHODS We conducted a systematic review and meta-analyses of RCTs involving noncalcium-based phosphate-lowering therapy compared with placebo, calcium-based binders, or no study medication, in adults with CKD not on dialysis or post-transplant. RCTs had ≥3 months follow-up and outcomes included biomarkers of mineral metabolism, cardiovascular parameters, and adverse events. Outcomes were meta-analyzed using the Sidik-Jonkman method for random effects. Unstandardized mean differences were used as effect sizes for continuous outcomes with common measurement units and Hedge's g standardized mean differences (SMD) otherwise. Odds ratios were used for binary outcomes. Cochrane risk of bias and GRADE assessment determined the certainty of evidence. RESULTS In total, 20 trials involving 2498 participants (median sample size 120, median follow-up 9 months) were eligible for inclusion. Overall, risk of bias was low. Compared with placebo, noncalcium-based phosphate binders reduced serum phosphate (12 trials, weighted mean difference -0.37; 95% CI, -0.58 to -0.15 mg/dl, low certainty evidence) and urinary phosphate excretion (eight trials, SMD -0.61; 95% CI, -0.90 to -0.31, low certainty evidence), but resulted in increased constipation (nine trials, log odds ratio [OR] 0.93; 95% CI, 0.02 to 1.83, low certainty evidence) and greater vascular calcification score (three trials, SMD, 0.47; 95% CI, 0.17 to 0.77, very low certainty evidence). Data for effects of phosphate-lowering therapy on cardiovascular events (log OR, 0.51; 95% CI, -0.51 to 1.17) and death were scant. CONCLUSIONS Noncalcium-based phosphate-lowering therapy reduced serum phosphate and urinary phosphate excretion, but there was an unclear effect on clinical outcomes and intermediate cardiovascular end points. Adequately powered RCTs are required to evaluate benefits and risks of phosphate-lowering therapy on patient-centered outcomes.
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Affiliation(s)
- Nicole M. Lioufas
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia,Department of Medicine, University of Melbourne, Parkville, Australia,Department of Nephrology, Western Health, Melbourne, Australia
| | | | - Carmel M. Hawley
- Australasian Kidney Trials Network, Brisbane, Australia,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia,Translational Research Institute, Brisbane, Australia
| | - Grahame J. Elder
- School of Medicine, University of Notre Dame, Sydney, Australia,Department of Medicine, University of Sydney, Sydney, Australia,Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst, Australia,Department of Nephrology, Westmead Hospital, Sydney, Australia
| | - Sunil V. Badve
- Australasian Kidney Trials Network, Brisbane, Australia,Department of Nephrology, St. George Hospital, Sydney, Australia,Renal and Metabolic Division, the George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - David W. Johnson
- Australasian Kidney Trials Network, Brisbane, Australia,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia,Translational Research Institute, Brisbane, Australia
| | - Nigel D. Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia,Department of Medicine, University of Melbourne, Parkville, Australia
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Basutkar RS, Varghese R, Mathew NK, Sankar Indira P, Viswanathan B, Sivasankaran P. Systematic review and meta-analysis of potential pleiotropic effects of sevelamer in chronic kidney disease: Beyond phosphate control. Nephrology (Carlton) 2021; 27:337-354. [PMID: 34882904 DOI: 10.1111/nep.14011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 11/26/2022]
Abstract
Sevelamer, has been shown to have many pleiotropic actions on lipid panel, various inflammatory markers, and blood glucose levels in chronic kidney disease patients. We conducted a systematic review and meta-analysis to compare these pleiotropic effects of sevelamer to other phosphate binders used in chronic kidney disease patients. The relevant randomized controlled trials published from 1 January 2001 to 31 November 2019 on the following databases: Cochrane Central Register of Controlled Trials published in The Cochrane Library, PubMed, Scopus and Google Scholar were identified. All the included studies were independently assessed for eligibility and risk of bias. The modified data extraction form of Cochrane was used. This review included 44 studies for qualitative analysis and 28 reports for quantitative analysis. A meta-analysis of three studies (n = 180) showed that glycated haemoglobin had significantly decreased in sevelamer-treated patients (MD: 0.5%; p = <.001). Compared with calcium-based phosphate binders, sevelamer showed a significant reduction in low-density lipoprotein (MD: -19.43 mg/dL; p = <.001) and total cholesterol (MD: -19.98 mg/dL; p < .001). A significant increase in high-density lipoprotein (MD: 1.29 mg/dL; p = .05) was also prominent in sevelamer treated patients. However, we were not able to observe a significant change in other biochemical parameters such as TG, CRP, hs-CRP, FGF-23, IL-6 and albumin as, no statistically significant difference was observed.
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Affiliation(s)
- Roopa Satyanarayan Basutkar
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | - Resia Varghese
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | - Nina Kallanthanath Mathew
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | - Prithika Sankar Indira
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | | | - Ponnusankar Sivasankaran
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
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Ito K, Yokoyama K, Nakayama M, Fukagawa M, Hirakata H. Association of fibroblast growth factor 23 and α-klotho in hemodialysis patients during administration of ferric citrate hydrate: post hoc analysis of ASTRIO study. BMC Nephrol 2021; 22:374. [PMID: 34758731 PMCID: PMC8582217 DOI: 10.1186/s12882-021-02575-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/25/2021] [Indexed: 12/28/2022] Open
Abstract
Background Fibroblast growth factor-23 (FGF23) and α-klotho are associated with anemia in patients with chronic kidney disease. In this post hoc analysis of the ASTRIO study (UMIN000019176), we investigated the relationship between FGF23 and α-klotho during treatment with an iron-based phosphate binder, ferric citrate hydrate (FC), compared with non-iron-based phosphate binders in hemodialysis (HD) patients. We examined the effect of iron absorption by FC on the relationship between FGF23 and α-klotho. There have been few clinical studies evaluating these biomarkers simultaneously in HD patients. Methods The ASTRIO study was a 24-week, randomized, open-label, multicenter trial. HD patients taking non-iron-based phosphate binder(s) were randomized at a 1:1 ratio to continue other binder(s) (control group) or switch to FC (FC group). Serum phosphate (P) and hemoglobin (Hb) were maintained within 3.5–6.0 mg/dL and 10–12 g/dL, respectively. Plasma levels of intact FGF23 (i-FGF23), C-terminal FGF23 (c-FGF23), and α-klotho were measured, as were iron-related parameters. Association analyses of FGF23 and α-klotho were conducted. Results Patients were randomized to FC (n = 48) and control (n = 45) groups. Serum ferritin significantly increased from baseline to end-of-treatment (EOT) in the FC group, compared with the control group (adjusted mean difference [95% confidence interval]: 79.5 [44.7, 114.4] ng/mL; p < 0.001). The mean change from baseline to EOT in c-FGF23 was significantly different between the FC and control groups (mean ± standard deviation (SD): − 0.2 ± 0.8 loge pg/mL vs. 0.2 ± 0.8 loge pg/mL, respectively; p = 0.04). The mean change from baseline to EOT in i-FGF23 and α-klotho were not significantly different between the FC and control groups (mean ± SD: − 0.1 ± 0.8 loge pg/mL vs. 0.1 ± 0.9 loge pg/mL; p = 0.33, and 2.0 ± 91.5 pg/mL vs. − 8.9 ± 145.3; p = 0.58, respectively). However, both forms of FGF23 and α-klotho were not significantly associated with each other in both groups. Conclusions Iron absorbed via FC administration in HD patients did not influence the correlation relationship between plasma levels of FGF23 and α-klotho under the condition of serum P and Hb were maintained. Trial registration ASTRIO study (UMIN000019176, registered at UMIN Clinical Trials Registry on October 1, 2015).
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Affiliation(s)
- Kyoko Ito
- Medical Affairs Department, Torii Pharmaceutical Co. Ltd., Tokyo, Japan
| | - Keitaro Yokoyama
- Health Care Center, Harumi Toriton Clinic, The Jikei University Hospital, 1-8-8 Harumi, Chuo-ku, Tokyo, 104-0053, Japan.
| | - Masaaki Nakayama
- St. Luke's International University, St. Luke's International Hospital, Tokyo, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
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Takkavatakarn K, Wuttiputhanun T, Phannajit J, Praditpornsilpa K, Eiam-Ong S, Susantitaphong P. Effectiveness of fibroblast growth factor 23 lowering modalities in chronic kidney disease: a systematic review and meta-analysis. Int Urol Nephrol 2021; 54:309-321. [PMID: 33797709 DOI: 10.1007/s11255-021-02848-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/25/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The heightened fibroblast growth factor 23 (FGF23) level in patients with chronic kidney disease (CKD) is associated with increased cardiovascular disease and mortality. We performed a systematic review and meta-analysis to synthesize the available strategies to reduce FGF23 in CKD patients. METHODS We conducted a meta-analysis by searching the databases of MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) and single-arm studies that examined the effects of dietary phosphate restriction, phosphate binders, iron supplements, calcimimetics, parathyroidectomy, dialysis techniques, and the outcome of preservation of residual renal function (RRF) on FGF23 levels in CKD patients. Random-effects model meta-analyses were used to compute changes in the outcome of interests. RESULTS A total of 41 articles (7590 patients), comprising 36 RCTs, 5 prospective studies were included in this meta-analysis. Dietary phosphate restriction less than 800 mg per day yielded insignificant effect on FGF23 reduction. Interestingly sevelamer, lanthanum, iron-based phosphate binders, and iron supplement significantly lowered FGF23 levels. In CKD patients with secondary hyperparathyroidism, calcimimetics prescription could significantly reduce FGF23 levels, while surgical parathyroidectomy had no significant effect. In dialysis patients, preservation of RRF and hemoperfusion as well as hemodiafiltration provided a significant decrease in FGF23 levels. CONCLUSIONS The present meta-analysis demonstrated that non-calcium-based phosphate binders including sevelamer, lanthanum, and iron-based phosphate binders, iron supplements, calcimimetics, hemoperfusion, and preservation of RRF could effectively reduce FGF23 in CKD patients.
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Affiliation(s)
- Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Thunyatorn Wuttiputhanun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Jeerath Phannajit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand.
- Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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10
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Zhou C, Shi Z, Ouyang N, Ruan X. Hyperphosphatemia and Cardiovascular Disease. Front Cell Dev Biol 2021; 9:644363. [PMID: 33748139 PMCID: PMC7970112 DOI: 10.3389/fcell.2021.644363] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/08/2021] [Indexed: 12/12/2022] Open
Abstract
Hyperphosphatemia or even serum phosphate levels within the “normal laboratory range” are highly associated with increased cardiovascular disease risk and mortality in the general population and patients suffering from chronic kidney disease (CKD). As the kidney function declines, serum phosphate levels rise and subsequently induce the development of hypertension, vascular calcification, cardiac valvular calcification, atherosclerosis, left ventricular hypertrophy and myocardial fibrosis by distinct mechanisms. Therefore, phosphate is considered as a promising therapeutic target to improve the cardiovascular outcome in CKD patients. The current therapeutic strategies are based on dietary and pharmacological reduction of serum phosphate levels to prevent hyperphosphatemia in CKD patients. Large randomized clinical trials with hard endpoints are urgently needed to establish a causal relationship between phosphate excess and cardiovascular disease (CVD) and to determine if lowering serum phosphate constitutes an effective intervention for the prevention and treatment of CVD.
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Affiliation(s)
- Chao Zhou
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengyu Shi
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Nan Ouyang
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiongzhong Ruan
- John Moorhead Research Laboratory, Centre for Nephrology, University College London (UCL) Medical School, London, United Kingdom.,Centre for Lipid Research and Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Institute for Viral Hepatitis, Department of Infectious Diseases, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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11
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Scialla JJ, Kendrick J, Uribarri J, Kovesdy CP, Gutiérrez OM, Jimenez EY, Kramer HJ. State-of-the-Art Management of Hyperphosphatemia in Patients With CKD: An NKF-KDOQI Controversies Perspective. Am J Kidney Dis 2021; 77:132-141. [PMID: 32771650 PMCID: PMC8109252 DOI: 10.1053/j.ajkd.2020.05.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 05/16/2020] [Indexed: 02/07/2023]
Abstract
Phosphate binders are among the most common medications prescribed to patients with kidney failure receiving dialysis and are often used in advanced chronic kidney disease (CKD). In patients with CKD glomerular filtration rate category 3a (G3a) or worse, including those with kidney failure who are receiving dialysis, clinical practice guidelines suggest "lowering elevated phosphate levels towards the normal range" with possible strategies including dietary phosphate restriction or use of binders. Additionally, guidelines suggest restricting the use of oral elemental calcium often contained in phosphate binders. Nutrition guidelines in CKD suggest<800-1,000mg of calcium daily, whereas CKD bone and mineral disorder guidelines do not provide clear targets, but<1,500mg in maintenance dialysis patients has been previously recommended. Many different classes of phosphate binders are now available and clinical trials have not definitively demonstrated the superiority of any class of phosphate binders over another with regard to clinical outcomes. Use of phosphate binders contributes substantially to patients' pill burden and out-of-pocket costs, and many have side effects. This has led to uncertainty regarding the use and best choice of phosphate binders for patients with CKD or kidney failure. In this controversies perspective, we discuss the evidence base around binder use in CKD and kidney failure with a focus on comparisons of available binders.
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Affiliation(s)
- Julia J Scialla
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA; Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA.
| | - Jessica Kendrick
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jaime Uribarri
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Csaba P Kovesdy
- Department of Medicine, University of Tennessee Health Science Center and Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Orlando M Gutiérrez
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Elizabeth Yakes Jimenez
- Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico; Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; Nutrition Research Network, Academy of Nutrition and Dietetics, Chicago, IL
| | - Holly J Kramer
- Department of Medicine, Loyola University Chicago, Maywood, IL; Department of Public Health Sciences, Loyola University Chicago, Maywood, IL
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12
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Bacchetta J, Bernardor J, Garnier C, Naud C, Ranchin B. Hyperphosphatemia and Chronic Kidney Disease: A Major Daily Concern Both in Adults and in Children. Calcif Tissue Int 2021; 108:116-127. [PMID: 31996964 DOI: 10.1007/s00223-020-00665-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/20/2020] [Indexed: 12/19/2022]
Abstract
Hyperphosphatemia is common in chronic kidney disease (CKD). Often seen as the "silent killer" because of its dramatic effect on vascular calcifications, hyperphosphatemia explains, at least partly, the onset of the complex mineral and bone disorders associated with CKD (CKD-MBD), together with hypocalcemia and decreased 1-25(OH)2 vitamin D levels. The impact of CKD-MBD may be immediate with abnormalities of bone and mineral metabolism with secondary hyperparathyroidism and increased FGF23 levels, or delayed with poor growth, bone deformities, fractures, and vascular calcifications, leading to increased morbidity and mortality. The global management of CKD-MBD has been detailed in international guidelines for adults and children, however, with difficulties to obtain an agreement on the ideal PTH targets. The clinical management of hyperphosphatemia is a daily challenge for nephrologists and pediatric nephrologists, notably because of the phosphate overload in occidental diets that is mainly due to the phosphate "hidden" in food additives. The management begins with a dietary restriction of phosphate intake, and is followed by the use of calcium-based and non-calcium-based phosphate binders, and/or the intensification of dialysis. The objective of this review is to provide an overview of the pathophysiology of hyperphosphatemia in CKD, with a focus on its deleterious effects and a description of the clinical management of hyperphosphatemia in a more global setting of CKD-MBD.
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Affiliation(s)
- Justine Bacchetta
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France.
- Université de Lyon, Lyon, France.
- INSERM 1033 Research Unit, Lyon, France.
| | - Julie Bernardor
- Unité de Néphrologie pédiatrique, Hôpital L'Archet, CHU de Nice, Nice, France
| | - Charlotte Garnier
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
| | - Corentin Naud
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
| | - Bruno Ranchin
- Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Centre de Référence Des Maladies Rénales Rares, Centre de Référence Des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France
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13
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Neyra JA, Hu MC, Moe OW. Klotho in Clinical Nephrology: Diagnostic and Therapeutic Implications. Clin J Am Soc Nephrol 2020; 16:162-176. [PMID: 32699047 PMCID: PMC7792642 DOI: 10.2215/cjn.02840320] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
αKlotho (called Klotho here) is a membrane protein that serves as the coreceptor for the circulating hormone fibroblast growth factor 23 (FGF23). Klotho is also cleaved and released as a circulating substance originating primarily from the kidney and exerts a myriad of housekeeping functions in just about every organ. The vital role of Klotho is shown by the multiorgan failure with genetic deletion in rodents, with certain features reminiscent of human disease. The most common causes of systemic Klotho deficiency are AKI and CKD. Preclinical data on Klotho biology have advanced considerably and demonstrated its potential diagnostic and therapeutic value; however, multiple knowledge gaps exist in the regulation of Klotho expression, release, and metabolism; its target organs; and mechanisms of action. In the translational and clinical fronts, progress has been more modest. Nonetheless, Klotho has potential clinical applications in the diagnosis of AKI and CKD, in prognosis of progression and extrarenal complications, and finally, as replacement therapy for systemic Klotho deficiency. The overall effect of Klotho in clinical nephrology requires further technical advances and additional large prospective human studies.
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Affiliation(s)
- Javier A. Neyra
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Ming Chang Hu
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Orson W. Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Physiology, University of Texas Southwestern Medical Center, Dallas, Texas
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14
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Clerin V, Saito H, Filipski KJ, Nguyen AH, Garren J, Kisucka J, Reyes M, Jüppner H. Selective pharmacological inhibition of the sodium-dependent phosphate cotransporter NPT2a promotes phosphate excretion. J Clin Invest 2020; 130:6510-6522. [PMID: 32853180 PMCID: PMC7685737 DOI: 10.1172/jci135665] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 08/20/2020] [Indexed: 12/16/2022] Open
Abstract
The sodium-phosphate cotransporter NPT2a plays a key role in the reabsorption of filtered phosphate in proximal renal tubules, thereby critically contributing to phosphate homeostasis. Inadequate urinary phosphate excretion can lead to severe hyperphosphatemia as in tumoral calcinosis and chronic kidney disease (CKD). Pharmacological inhibition of NPT2a may therefore represent an attractive approach for treating hyperphosphatemic conditions. The NPT2a-selective small-molecule inhibitor PF-06869206 was previously shown to reduce phosphate uptake in human proximal tubular cells in vitro. Here, we investigated the acute and chronic effects of the inhibitor in rodents and report that administration of PF-06869206 was well tolerated and elicited a dose-dependent increase in fractional phosphate excretion. This phosphaturic effect lowered plasma phosphate levels in WT mice and in rats with CKD due to subtotal nephrectomy. PF-06869206 had no effect on Npt2a-null mice, but promoted phosphate excretion and reduced phosphate levels in normophophatemic mice lacking Npt2c and in hyperphosphatemic mice lacking Fgf23 or Galnt3. In CKD rats, once-daily administration of PF-06869206 for 8 weeks induced an unabated acute phosphaturic and hypophosphatemic effect, but had no statistically significant effect on FGF23 or PTH levels. Selective pharmacological inhibition of NPT2a thus holds promise as a therapeutic option for genetic and acquired hyperphosphatemic disorders.
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Affiliation(s)
- Valerie Clerin
- Pfizer Inc., Worldwide Research, Development and Medical, Cambridge, Massachusetts, USA
| | | | - Kevin J. Filipski
- Pfizer Inc., Worldwide Research, Development and Medical, Cambridge, Massachusetts, USA
| | - An Hai Nguyen
- Pfizer Inc., Worldwide Research, Development and Medical, Cambridge, Massachusetts, USA
| | - Jeonifer Garren
- Pfizer Inc., Worldwide Research, Development and Medical, Cambridge, Massachusetts, USA
| | - Janka Kisucka
- Pfizer Inc., Worldwide Research, Development and Medical, Cambridge, Massachusetts, USA
| | | | - Harald Jüppner
- Endocrine Unit and
- Pediatric Nephrology Unit, Massachusetts General Hospital (MGH) and Harvard Medical School, Boston, Massachusetts, USA
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15
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Ishigami J, Taliercio JT, Feldman HI, Srivastava A, Townsend RR, Cohen DL, Horwitz EJ, Rao P, Charleston J, Fink JC, Ricardo AC, Sondheimer J, Chen TK, Wolf M, Isakova T, Appel LJ, Matsushita K. Fibroblast Growth Factor 23 and Risk of Hospitalization with Infection in Chronic Kidney Disease: The Chronic Renal Insufficiency Cohort (CRIC) Study. J Am Soc Nephrol 2020; 31:1836-1846. [PMID: 32576601 PMCID: PMC7460903 DOI: 10.1681/asn.2019101106] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 04/14/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Risk of infectious disease is increased among individuals with CKD. Fibroblast growth factor 23 (FGF23) is often elevated in CKD, and may impair immune function directly or indirectly through proinflammatory and vitamin D-suppressing pathways. Whether FGF23 is associated with risk of infection has not been evaluated in a CKD population. METHODS In 3655 participants of the Chronic Renal Insufficiency Cohort study, we evaluated the association of baseline plasma levels of C-terminal FGF23 with time to first hospitalization with major infection, defined by hospital discharge with a diagnosis code for urinary tract infection, pneumonia, cellulitis/osteomyelitis, or bacteremia/septicemia. Multivariable Cox models were used to estimate hazard ratios (HRs) and adjust for confounding. RESULTS During a median follow-up of 6.5 years, 1051 individuals (29%) were hospitalized with major infection. Multivariable Cox analysis indicated a graded increase in the risk of infection with higher levels of FGF23 (HR, 1.51; 95% CI, 1.23 to 1.85 with the highest quartile [≥235.9 RU/ml] versus lowest quartile [<95.3 RU/ml]; HR, 1.26; 95% CI, 1.18 to 1.35 per SD increment in log FGF23). The association was consistent across infection subtypes and demographic and clinical subgroups, and remained significant after additional adjustment for biomarkers of inflammation (IL-6, TNF-α, high-sensitivity C-reactive protein, fibrinogen, and albumin), and bone mineral metabolism (25-hydroxyvitamin D, phosphorus, calcium, and parathyroid hormone). The association was consistent across infection subtypes of urinary tract infection (482 cases), cellulitis/osteomyelitis (422 cases), pneumonia (399 cases), and bacteremia/septicemia (280 cases). CONCLUSIONS Among individuals with CKD, higher FGF23 levels were independently and monotonically associated with an increased risk of hospitalization with infection.
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Affiliation(s)
- Junichi Ishigami
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jonathan T Taliercio
- Department of Nephrology and Hypertension, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Harold I Feldman
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anand Srivastava
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raymond R Townsend
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debbie L Cohen
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward J Horwitz
- Division of Nephrology, MetroHealth Medical Center, Cleveland, Ohio
| | - Panduranga Rao
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Jeanne Charleston
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeffrey C Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ana C Ricardo
- Division of Nephrology, University of Illinois, Chicago, Illinois
| | - James Sondheimer
- Division of Nephrology and Hypertension, Wayne State University School of Medicine, Detroit, Michigan
| | - Teresa K Chen
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lawrence J Appel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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16
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Laville SM, Gras-Champel V, Moragny J, Metzger M, Jacquelinet C, Combe C, Fouque D, Laville M, Frimat L, Robinson BM, Stengel B, Massy ZA, Liabeuf S. Adverse Drug Reactions in Patients with CKD. Clin J Am Soc Nephrol 2020; 15:1090-1102. [PMID: 32611662 PMCID: PMC7409761 DOI: 10.2215/cjn.01030120] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/13/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Little is known about the burden of adverse drug reactions in CKD. We estimated the incidence of overall and serious adverse drug reactions and assessed the probability of causation, preventability, and factors associated with adverse drug reactions in patients seen by nephrologists. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Chronic Kidney Disease-Renal Epidemiology and Information Network cohort included 3033 outpatients (65% men) with CKD and eGFR<60 ml/min per 1.73 m2, with follow-up for 2 years. Adverse drug reactions were identified from hospitalization reports, medical records, and participant interviews and finally assessed for causality, preventability, and immediate therapeutic management by experts in pharmacology. RESULTS Median (interquartile range) age was 69 (60-76) years old; 55% had eGFR≥30 ml/min per 1.73 m2, and 45% had eGFR<30 ml/min per 1.73 m2. Participants were prescribed a median (range) of eight (five to ten) drugs. Over 2 years, 536 patients had 751 adverse drug reactions, 150 (in 125 participants) classified as serious, for rates of 14.4 (95% confidence interval, 12.6 to 16.5) and 2.7 (95% confidence interval, 1.7 to 4.3) per 100 person-years, respectively. Among the serious adverse drug reactions, 32% were considered preventable or potentially preventable; 16 caused death, directly or indirectly. Renin-angiotensin system inhibitors (15%), antithrombotic agents (14%), and diuretics (10%) were the drugs to which the most adverse drug reactions were imputed, but antithrombotic agents caused 34% of serious adverse drug reactions. The drug was discontinued in 71% of cases, at least temporarily. Adjusted hazard ratios for serious adverse drug reaction were significantly higher in patients with eGFR<30 versus ≥30 ml/min per 1.73 m2 (1.8; 95% confidence interval, 1.3 to 2.6), in those prescribed more than ten versus less than five medications (2.4; 95% confidence interval, 1.1 to 5.2), or in those with poor versus good adherence (1.6; 95% confidence interval, 1.4 to 2.4). CONCLUSIONS Adverse drug reactions are common and sometimes serious in patients with CKD. Many serious adverse drug reactions may be preventable. Some specific pharmacologic classes, particularly antithrombotic agents, are at risk of serious adverse drug reactions. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN), NCT03381950.
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Affiliation(s)
- Solène M Laville
- Paris-Saclay University, Versailles Saint-Quentin-en-Yvelines University, National Institute of Health and Medical Research, Center for research in Epidemiology and Population Health (CESP), Clinical Epidemiology Team, Villejuif, France
| | | | - Julien Moragny
- Department of Clinical Pharmacology, Amiens University Hospital, Amiens, France
| | - Marie Metzger
- Paris-Saclay University, Versailles Saint-Quentin-en-Yvelines University, National Institute of Health and Medical Research, Center for research in Epidemiology and Population Health (CESP), Clinical Epidemiology Team, Villejuif, France
| | - Christian Jacquelinet
- Paris-Saclay University, Versailles Saint-Quentin-en-Yvelines University, National Institute of Health and Medical Research, Center for research in Epidemiology and Population Health (CESP), Clinical Epidemiology Team, Villejuif, France.,Renal Epidemiology and Information Network Registry, Biomedicine Agency, Saint Denis, France
| | - Christian Combe
- Department of Nephrology Transplantation Dialysis, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Inserm Unit 1026, University of Bordeaux Segalen, Bordeaux, France
| | - Denis Fouque
- Nephrology Department, Centre Hospitalier Lyon Sud, Université de Lyon, Carmen, Pierre-Bénite, France
| | - Maurice Laville
- Nephrology Department, Centre Hospitalier Lyon Sud, Université de Lyon, Carmen, Pierre-Bénite, France
| | - Luc Frimat
- Nephrology Department, Centre Hospitalier Régional Universitaire de Nancy, Vandoeuvre-lès-Nancy, France.,Lorraine University, APEMAC, Vandoeuvre-lès-Nancy, France
| | | | - Bénédicte Stengel
- Paris-Saclay University, Versailles Saint-Quentin-en-Yvelines University, National Institute of Health and Medical Research, Center for research in Epidemiology and Population Health (CESP), Clinical Epidemiology Team, Villejuif, France
| | - Ziad A Massy
- Paris-Saclay University, Versailles Saint-Quentin-en-Yvelines University, National Institute of Health and Medical Research, Center for research in Epidemiology and Population Health (CESP), Clinical Epidemiology Team, Villejuif, France.,Division of Nephrology, Ambroise Paré University Hospital, Assistance publique - Hôpitaux de Paris, Boulogne-Billancourt/Paris, France
| | - Sophie Liabeuf
- Department of Clinical Pharmacology, Amiens University Hospital, Amiens, France.,MP3CV Laboratory, EA7517, University of Picardie Jules Verne, Amiens, France
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17
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Vervloet MG. FGF23 measurement in chronic kidney disease: What is it really reflecting? Clin Chim Acta 2020; 505:160-166. [PMID: 32156608 DOI: 10.1016/j.cca.2020.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 12/20/2022]
Abstract
Fibroblast growth factor can be measured in clinical practice using ELISA, with acceptable validity. Different from many metabolites and minerals, its value can differ by a thousand-fold between individuals, largely because of differences in kidney function and dietary habits. This wide range complicates the proper interpretation of the concentration of FGF23, both in terms of the appropriateness of a given value for a given estimated GFR, and in terms of estimating the magnitude of risk for clinical events, with which FGF23 is clearly associated. In this narrative review, the impact of kidney function, exposure to phosphate from diet, and novel emerging factors that influence FGF23 concentrations are discussed. These and yet to define determinants of FGF23 question the causality of the association of FGF23 with hard (cardiovascular) endpoints, as observed in several epidemiological studies.
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Affiliation(s)
- Marc G Vervloet
- Amsterdam University Medical Center, Department of Nephrology, and Amsterdam Cardiovascular Sciences (ACS), Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
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18
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Bouma-de Krijger A, Vervloet MG. Fibroblast growth factor 23: are we ready to use it in clinical practice? J Nephrol 2020; 33:509-527. [PMID: 32130720 PMCID: PMC7220896 DOI: 10.1007/s40620-020-00715-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/15/2020] [Indexed: 12/15/2022]
Abstract
Patients with chronic kidney disease (CKD) have a greatly enhanced risk of cardiovascular morbidity and mortality. Over the past decade it has come clear that a disturbed calcium-phosphate metabolism, with Fibroblast Growth Factor-23 as a key hormone, is partly accountable for this enhanced risk. Numerous studies have been performed unravelling FGF23s actions and its association with clinical conditions. As FGF23 is strongly associated with adverse outcome it may be a promising biomarker for risk prediction or, even more important, targeting FGF23 may be a strategy to improve patient outcome. This review elaborates on the clinical usefulness of FGF23 measurement. Firstly it discusses the reliability of the FGF23 measurement. Secondly, it evaluates whether FGF23 measurement may lead to improved patient risk classification. Finally, and possibly most importantly, this review evaluates if lowering of FGF23 should be a target for therapy. For this, the review discusses the current evidence indicating that FGF23 may be in the causal pathway to cardiovascular pathology, provides an overview of strategies to lower FGF23 levels and discusses the current evidence concerning the benefit of lowering FGF23.
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Affiliation(s)
- Annet Bouma-de Krijger
- Department of Nephrology, Amsterdam Cardiovascular Science, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Marc G. Vervloet
- Department of Nephrology, Amsterdam Cardiovascular Science, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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19
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Salomo L, Rix M, Kamper AL, Thomassen JQ, Sloth JJ, Astrup A. Short-term effect of the New Nordic Renal Diet on phosphorus homoeostasis in chronic kidney disease Stages 3 and 4. Nephrol Dial Transplant 2020; 34:1691-1699. [PMID: 30590827 DOI: 10.1093/ndt/gfy366] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/29/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The New Nordic Diet is a food concept favouring organically produced food items, fruits, vegetables, whole grains and fish. We investigated the short-term effects of a modified phosphorus-reduced New Nordic Renal Diet (NNRD) in chronic kidney disease (CKD) patients on important parameters of phosphorus homoeostasis. METHODS The NNRD contained a total of 850 mg phosphorus/day. A total of 18 patients, CKD Stages 3 and 4 were studied in a randomized crossover trial comparing a 1-week control period of the habitual diet with a 1-week period of the NNRD. Data were obtained at baseline and during 1 week of dietary intervention (habitual diet versus NNRD) by collecting fasting blood samples and 24-h urine collections. The primary outcome was the difference in the change in 24-h urine phosphorus excretion from baseline to Day 7 between the NNRD and habitual diet periods. Secondary outcomes were changes in the fractional excretion of phosphorus, fibroblast growth factor 23 (FGF23) and plasma phosphate. RESULTS As compared with the habitual diet, 24-h urine phosphorus excretion was reduced in the NNRD by 313 mg/day (P < 0.001). The mean baseline phosphorus was 875 ± 346 mg/day and was decreased by 400 ± 256 mg/day in the NNRD and 87 ± 266 mg/day in the habitual diet. The 24-h urine fractional excretion of phosphorus decreased by 11% (P < 0.001) and FGF23 decreased by 30 pg/mL (P = 0.03) with the NNRD compared with the habitual diet. Plasma phosphate did not change. CONCLUSION This study demonstrates that dietary phosphorus restriction in the context of the NNRD is feasible and has positive effects on phosphorus homeostasis in CKD patients.
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Affiliation(s)
- Louise Salomo
- Department of Nephrology, University Hospital of Copenhagen, Rigshospitalet, Denmark.,Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Jesper Q Thomassen
- Department of Clinical Biochemistry, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Jens J Sloth
- National Food Institute, Technical University of Denmark, Kemitorvet, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Denmark
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20
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Ketteler M, Sprague SM, Covic AC, Rastogi A, Spinowitz B, Rakov V, Walpen S, Floege J. Effects of sucroferric oxyhydroxide and sevelamer carbonate on chronic kidney disease-mineral bone disorder parameters in dialysis patients. Nephrol Dial Transplant 2020; 34:1163-1170. [PMID: 29846719 PMCID: PMC6603395 DOI: 10.1093/ndt/gfy127] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Indexed: 12/15/2022] Open
Abstract
Background Treatment of hyperphosphataemia is the primary goal of chronic kidney disease–mineral and bone disorder (CKD-MBD) management. This post hoc analysis of a randomized, Phase 3 study evaluated the effects of 1-year treatment with the phosphate binders sucroferric oxyhydroxide or sevelamer carbonate (‘sevelamer’) on CKD-MBD indices among dialysis patients with hyperphosphataemia. Methods After a 2- to 4-week washout from previous phosphate binders, 1059 patients were randomized 2:1 to sucroferric oxyhydroxide 1.0–3.0 g/day (n = 710) or sevelamer 2.4–14.4 g/day (n = 349) for up to 24 weeks. Eligible patients enrolled in a 28-week extension. This post hoc analysis was performed for patients who completed ≥1 year of continuous treatment (n = 549). As the treatment groups showed similar CKD-MBD outcomes, the data were pooled for this analysis. Results Phosphate-binder therapy was associated with significant and sustained 30% reductions in serum phosphorus (P < 0.001). Median intact fibroblast growth factor-23 (FGF-23) also significantly decreased (P < 0.001) by 64% over 1 year. Intact parathyroid hormone decreased significantly after 24 weeks (P < 0.001), but levels returned to near baseline values by Week 52; minimal changes in serum calcium were observed. Of the bone resorption markers evaluated, tartrate-resistant acid phosphatase 5b (TRAP5b) decreased significantly (P < 0.001), whereas CTx increased transiently but returned to baseline levels by Week 52. The bone formation markers bone-specific alkaline phosphatase and osteocalcin both increased over 1 year of treatment. Conclusions Overall, 1 year of sucroferric oxyhydroxide or sevelamer treatment significantly reduced serum FGF-23, which has been associated with clinical benefit in patients with CKD. The trend towards increased bone formation marker levels indicates a beneficial effect on bone metabolism.
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Affiliation(s)
- Markus Ketteler
- Klinikum Coburg and KfH-Dialysis Center, Coburg, Germany.,School of Medicine, University of Split, Split, Croatia
| | - Stuart M Sprague
- NorthShore University Health System, University of Chicago, Pritzker School of Medicine, Evanston, IL, USA
| | - Adrian C Covic
- Gr.T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Anjay Rastogi
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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21
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Bacchetta J. Treatment of hyperphosphatemia: the dangers of high PTH levels. Pediatr Nephrol 2020; 35:493-500. [PMID: 31696357 DOI: 10.1007/s00467-019-04400-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/10/2019] [Accepted: 10/14/2019] [Indexed: 12/01/2022]
Abstract
The control of secondary hyperparathyroidism (SHPT) in pediatric chronic kidney disease is of utmost importance. Even though parathyroid hormone (PTH) is an important biomarker of mineral and bone disorders associated to CKD (CKD-MBD), calcium, phosphate, alkaline phosphatase, and vitamin D are also crucial and should be assessed together. In pediatric dialysis, high PTH levels have been associated with impaired longitudinal growth, bone disease, cardiovascular comorbidities, left ventricular hypertrophy, anemia, and even mortality (when PTH levels were above 500 pg/mL, i.e., 8.3-fold the upper normal limit (UNL)). As such, high PTH levels are for sure deleterious, but too low PTH levels have also been shown to impair growth and to promote vascular calcifications because of the underlying adynamic bone. This manuscript is part of a pros and cons debate for keeping PTH levels within the normal range in pediatric CKD, focusing on the pros. High bone turnover lesions can occur at lower PTH levels than "current" guidelines would suggest; thus, PTH alone is not a good predictor of the underlying osteodystrophy. PTH results can vary locally depending on the assay. Existing guidelines for PTH targets are conflicting and based on a very little evidence. However, the 120-180 pg/mL (2- to 3-fold the UNL) range is common to most of the guidelines; it seems to be a reasonable target in children undergoing dialysis, even though it does not correspond to "normal" PTH levels. As always, the philosophy of PTH levels in pediatric dialysis may be balanced, i.e., "not too low, not too high, and keep phosphate under control."
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Affiliation(s)
- Justine Bacchetta
- Centre de Référence des Maladies Rénales Rares, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, Boulevard Pinel, 69677, Bron Cedex, France. .,Université de Lyon, Lyon, France. .,INSERM 1033 Research Unit, Université de Lyon, Lyon, France.
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22
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Lacroix JS, Urena-Torres P. Potentielle application de l’axe fibroblast growth factor 23-Klotho dans la maladie rénale chronique. Nephrol Ther 2020; 16:83-92. [DOI: 10.1016/j.nephro.2019.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/19/2019] [Indexed: 12/17/2022]
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23
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Floege J. Phosphate binders in chronic kidney disease: an updated narrative review of recent data. J Nephrol 2019; 33:497-508. [PMID: 31865608 DOI: 10.1007/s40620-019-00689-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/17/2019] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease (CKD) is frequently accompanied by hyperphosphatemia. High serum phosphate usually requires dietary measures, adequate dialysis prescription and/or phosphate binders. For this narrative review a PubMed searched was undertaken to identify new publications on phosphate binders that had been published between January 2015 and July 2019. The present review summarizes this most recent information on dietary measures and their problems in treating hyperphosphatemia in CKD patients, overall effects of phosphate binders on cardiovascular mortality and morbidity, adherence to phosphate binder therapy as well as new data on specific aspects of the various phosphate binders on the market: calcium-containing phosphate binders, polymeric phosphate binders (sevelamer, bixalomer, colestilan), magnesium-containing phosphate binders, lanthanum carbonate, ferric citrate, sucroferric oxyhydroxide, and new compounds in development, in particular drugs targeting intestinal phosphate transporters.
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Affiliation(s)
- Jürgen Floege
- Department of Nephrology and Clinical Immunology, University Hospital, Rheinisch Westfälische Technische Hochschule (RWTH), Pauwelsstr. 30, 52057, Aachen, Germany.
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24
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Liabeuf S, McCullough K, Young EW, Pisoni R, Zee J, Reichel H, Pecoits-Filho R, Port FK, Stengel B, Csomor PA, Metzger M, Robinson B, Massy ZA. International variation in the management of mineral bone disorder in patients with chronic kidney disease: Results from CKDopps. Bone 2019; 129:115058. [PMID: 31493530 DOI: 10.1016/j.bone.2019.115058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/12/2019] [Accepted: 09/03/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Chronic kidney disease (CKD) is commonly associated with mineral and bone metabolism disorders, but these are less frequently studied in non-dialysis CKD patients than in dialysis patients. We examined and described international variation in mineral and bone disease (MBD) markers and their treatment and target levels in Stage 3-5 CKD patients. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS Prospective cohort study of 7658 adult patients with eGFR <60mL/min/1.73m2, excluding dialysis or transplant patients, participating in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) in Brazil, France, Germany, and the US. CKD-MBD laboratory markers included serum levels of phosphorus (P), calcium (Ca), intact parathyroid hormone (iPTH), and 25-hydroxyvitamin D (25-D). MBD treatment data included phosphate binders and vitamin D (nutritional and active). Nephrologist survey data were collected on target MBD marker levels. RESULTS Over two-thirds of the patients had MBD markers measured at time intervals in line with practice guidelines. P and iPTH increased and Ca decreased gradually from eGFR 60-20mL/min/1.73m2 and more sharply for eGFR<20. 25-D showed no relation to eGFR. Nephrologist survey data indicated marked variation in upper target P and iPTH levels. Among patients with P>5.5mg/dL, phosphate binder use was 14% to 43% across the four countries. Among patients with PTH >300pg/mL, use of active (calcitriol and related analogs) vitamin D was 12%-51%, and use of any (active or nutritional) vitamin D was 60%-87%. CONCLUSIONS Although monitoring of CKD-MBD laboratory markers by nephrologists in CKDopps countries is consistent with guidelines, target levels vary notably and prescription of medications to treat abnormalities in these laboratory markers is generally low in these cross-sectional analyses. While there are opportunities to increase treatment of hyperphosphatemia, hyperparathyroidism, and vitamin D deficiency in advanced CKD, the effect on longer-term complications of these conditions requires study.
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Affiliation(s)
- Sophie Liabeuf
- Pharmacology Department and Laboratory EA 7517, Amiens University Hospital, 80000 Amiens, France
| | | | - Eric W Young
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA; Pontifícia Universidade Católica Do Paraná, Nephrology, Do Paraná, Brazil
| | | | - Bénédicte Stengel
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, UVSQ, University Paris-Saclay, Villejuif, France
| | | | - Marie Metzger
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, UVSQ, University Paris-Saclay, Villejuif, France
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Ziad A Massy
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, UVSQ, University Paris-Saclay, Villejuif, France; Department of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne Billancourt/Paris, France.
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25
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Chelluboina B, Vemuganti R. Chronic kidney disease in the pathogenesis of acute ischemic stroke. J Cereb Blood Flow Metab 2019; 39:1893-1905. [PMID: 31366298 PMCID: PMC6775591 DOI: 10.1177/0271678x19866733] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/25/2019] [Accepted: 07/03/2019] [Indexed: 12/15/2022]
Abstract
Chronic kidney disease has a graded and independent inverse impact on cerebrovascular health. Both thrombotic and hemorrhagic complications are highly prevalent in chronic kidney disease patients. Growing evidence suggests that in chronic kidney disease patients, ischemic strokes are more common than hemorrhagic strokes. Chronic kidney disease is asymptomatic until an advanced stage, but mild to moderate chronic kidney disease incites various pathogenic mechanisms such as inflammation, oxidative stress, neurohormonal imbalance, formation of uremic toxins and vascular calcification which damage the endothelium and blood vessels. Cognitive dysfunction, dementia, transient infarcts, and white matter lesions are widespread in mild to moderate chronic kidney disease patients. Uremic toxins produced after chronic kidney disease can pass through the blood-brain barrier and mediate cognitive dysfunction and neurodegeneration. Furthermore, chronic kidney disease precipitates vascular risk factors that can lead to atherosclerosis, hypertension, atrial fibrillation, and diabetes. Chronic kidney disease also exacerbates stroke pathogenesis, worsens recovery outcomes, and limits the eligibility of stroke patients to receive available stroke therapeutics. This review highlights the mechanisms involved in the advancement of chronic kidney disease and its possible association with stroke.
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Affiliation(s)
- Bharath Chelluboina
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Raghu Vemuganti
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, USA
- William S. Middleton Veterans Administration Hospital, Madison, WI, USA
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Abstract
Acute kidney injury (AKI) is associated with many of the same mineral metabolite abnormalities that are observed in chronic kidney disease. These include increased circulating levels of the osteocyte-derived, vitamin D-regulating hormone, fibroblast growth factor 23 (FGF23), and decreased renal expression of klotho, the co-receptor for FGF23. Recent data have indicated that increased FGF23 and decreased klotho levels in the blood and urine could serve as novel predictive biomarkers of incident AKI, or as novel prognostic biomarkers of adverse outcomes in patients with established AKI. In addition, because FGF23 and klotho exert numerous classic as well as off-target effects on a variety of organ systems, targeting their dysregulation in AKI may represent a unique opportunity for therapeutic intervention. We review the pathophysiology, kinetics, and regulation of FGF23 and klotho in animal and human studies of AKI, and we discuss the challenges and opportunities involved in targeting FGF23 and klotho therapeutically.
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Affiliation(s)
- Marta Christov
- Department of Medicine, New York Medical College, Valhalla, NY.
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, KY; Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
| | - Sanjeev Gupta
- Department of Medicine, New York Medical College, Valhalla, NY
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
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27
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Bennis Y, Cluet Y, Titeca-Beauport D, El Esper N, Ureña P, Bodeau S, Combe C, Dussol B, Fouque D, Choukroun G, Liabeuf S. The Effect of Sevelamer on Serum Levels of Gut-Derived Uremic Toxins: Results from In Vitro Experiments and A Multicenter, Double-Blind, Placebo-Controlled, Randomized Clinical Trial. Toxins (Basel) 2019; 11:toxins11050279. [PMID: 31109001 PMCID: PMC6563242 DOI: 10.3390/toxins11050279] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 02/07/2023] Open
Abstract
High serum levels of gut-derived uremic toxins, especially p-cresyl sulfate (pCS), indoxyl sulfate (IS) and indole acetic acid (IAA), have been linked to adverse outcomes in patients with chronic kidney disease (CKD). Sevelamer carbonate could represent an interesting option to limit the elevation of gut-derived uremic toxins. The aim of the present study was to evaluate the adsorptive effect of sevelamer carbonate on different gut-derived protein-bound uremic toxins or their precursors in vitro, and its impact on the serum levels of pCS, IS and IAA in patients with CKD stage 3b/4. For the in vitro experiments, IAA, p-cresol (precursor of pCS) and indole (precursor of IS), each at a final concentration of 1 or 10 µg/mL, were incubated in centrifugal 30 kDa filter devices with 3 or 15 mg/mL sevelamer carbonate in phosphate-buffered saline at a pH adjusted to 6 or 8. Then, samples were centrifuged and free uremic toxins in the filtrates were analyzed. As a control experiment, the adsorption of phosphate was also evaluated. Additionally, patients with stage 3b/4 CKD (defined as an eGFR between 15 and 45 mL/min per 1.73 m2) were included in a multicenter, double-blind, placebo-controlled, randomized clinical trial. The participants received either placebo or sevelamer carbonate (4.8 g) three times a day for 12 weeks. The concentrations of the toxins and their precursors were measured using a validated high-performance liquid chromatography method with a diode array detector. In vitro, regardless of the pH and concentration tested, sevelamer carbonate did not show adsorption of indole and p-cresol. Conversely, with 10 µg/mL IAA, use of a high concentration of sevelamer carbonate (15 mg/mL) resulted in a significant toxin adsorption both at pH 8 (mean reduction: 26.3 ± 3.4%) and pH 6 (mean reduction: 38.7 ± 1.7%). In patients with CKD stage 3b/4, a 12-week course of treatment with sevelamer carbonate was not associated with significant decreases in serum pCS, IS and IAA levels (median difference to baseline levels: −0.12, 0.26 and −0.06 µg/mL in the sevelamer group vs. 1.97, 0.38 and 0.05 µg/mL in the placebo group, respectively). Finally, in vitro, sevelamer carbonate was capable of chelating a gut-derived uremic toxin IAA but not p-cresol and indole, the precursors of pCS and IS in the gut. In a well-designed clinical study of patients with stage 3b/4 CKD, a 12-week course of treatment with sevelamer carbonate was not associated with significant changes in the serum concentrations of pCS, IS and IAA.
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Affiliation(s)
- Youssef Bennis
- Pharmacology Department, Amiens University Hospital, 80000 Amiens, France.
- MP3CV Laboratory, EA7517, University of Picardie Jules Verne, 80000 Amiens, France.
| | - Yan Cluet
- Pharmacology Department, Amiens University Hospital, 80000 Amiens, France.
- MP3CV Laboratory, EA7517, University of Picardie Jules Verne, 80000 Amiens, France.
| | - Dimitri Titeca-Beauport
- MP3CV Laboratory, EA7517, University of Picardie Jules Verne, 80000 Amiens, France.
- Nephrology Department, Amiens University Hospital, 80000 Amiens, France.
| | - Najeh El Esper
- Nephrology Department, Amiens University Hospital, 80000 Amiens, France.
| | - Pablo Ureña
- Department of Nephrology and Dialysis, AURA Nord Saint Ouen, 93400 Saint Ouen, France.
| | - Sandra Bodeau
- Pharmacology Department, Amiens University Hospital, 80000 Amiens, France.
- MP3CV Laboratory, EA7517, University of Picardie Jules Verne, 80000 Amiens, France.
| | - Christian Combe
- Nephrology Department, Bordeaux University Hospital, 33000 Bordeaux, France.
| | - Bertrand Dussol
- Clinical Inverstigation Center, Aix Marseille University, 13354 Marseille, France.
| | - Denis Fouque
- Dept Nephrology, Université de Lyon, Hospital Lyon Sud, F-69495 Pierre-Benite, France.
| | - Gabriel Choukroun
- MP3CV Laboratory, EA7517, University of Picardie Jules Verne, 80000 Amiens, France.
- Nephrology Department, Amiens University Hospital, 80000 Amiens, France.
| | - Sophie Liabeuf
- Pharmacology Department, Amiens University Hospital, 80000 Amiens, France.
- MP3CV Laboratory, EA7517, University of Picardie Jules Verne, 80000 Amiens, France.
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28
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Ruggiero B, Trillini M, Tartaglione L, Rotondi S, Perticucci E, Tripepi R, Aparicio C, Lecchi V, Perna A, Peraro F, Villa D, Ferrari S, Cannata A, Mazzaferro S, Mallamaci F, Zoccali C, Bellasi A, Cozzolino M, Remuzzi G, Ruggenenti P, Kohan DE. Effects of Sevelamer Carbonate in Patients With CKD and Proteinuria: The ANSWER Randomized Trial. Am J Kidney Dis 2019; 74:338-350. [PMID: 31027883 DOI: 10.1053/j.ajkd.2019.01.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 01/29/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Hyperphosphatemia is associated with increased risk for chronic kidney disease (CKD) progression and reduced antiproteinuric effects of renin-angiotensin system (RAS) blockers. We investigated whether the phosphate binder sevelamer carbonate may enhance the antiproteinuric effect of RAS inhibitors in patients with CKD. STUDY DESIGN Phase 2, randomized, controlled, open-label, crossover trial. SETTING & PARTICIPANTS Between November 2013 and December 2014, we enrolled 53 patients with CKD with estimated glomerular filtration rates (eGFRs)>15mL/min/1.73m2 and residual proteinuria with protein excretion≥0.5g/24h despite maximal tolerated ramipril and/or irbesartan therapy from 2 nephrology units in Italy. INTERVENTION After stratification by serum phosphate level, ≤4 or>4mg/dL, patients were randomly assigned to 3 months of sevelamer (1,600mg thrice daily) treatment followed by 3 months without sevelamer separated by a 1-month washout period or 3 months without sevelamer followed by 3 months with sevelamer, also separated by a 1-month washout period. OUTCOMES The primary outcome was 24-hour proteinuria (n=49patients). Secondary outcomes included measured GFR (using iohexol plasma clearance), office blood pressure (BP), serum lipid levels, levels of inflammation and bone metabolism biomarkers, urinary electrolyte levels, and arterial stiffness. RESULTS Changes in proteinuria during the 3-month treatment with (from 1.36 [IQR, 0.77-2.51] to 1.36 [IQR, 0.77-2.60] g/24h) or without (from 1.36 [IQR, 0.99-2.38] to 1.48 [IQR, 0.81-2.77] g/24h) sevelamer were similar (P=0.1). Sevelamer reduced urinary phosphate excretion without affecting serum phosphate levels. Sevelamer reduced C-reactive protein (CRP), glycated hemoglobin, and total and low-density lipoprotein cholesterol levels and increased high-density lipoprotein cholesterol levels without affecting levels of office BP, measured GFR, fibroblast growth factor 23, klotho, intact parathyroid hormone, serum vitamin D, or other urinary electrolytes. Results were similar in the low- and high-phosphate groups. Sevelamer was well tolerated. Adverse events were comparable between treatment periods. One case of transient hypophosphatemia was observed during treatment with sevelamer. LIMITATIONS Short treatment duration, lower pretreatment proteinuria than expected. CONCLUSIONS 3-month sevelamer treatment did not reduce proteinuria in patients with CKD on maximal RAS blockade. Amelioration of inflammation and dyslipidemia with sevelamer treatment raises the possibility that it may confer benefit in patients with CKD beyond reduction of proteinuria. FUNDING Sanofi (Milan, Italy). TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT01968759.
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Affiliation(s)
- Barbara Ruggiero
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Matias Trillini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Lida Tartaglione
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Silverio Rotondi
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Elena Perticucci
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Rocco Tripepi
- Bianchi-Melacrino-Morelli Hospital, Nephrology Unit, Reggio Calabria, Italy
| | - Carolina Aparicio
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Veruska Lecchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco Peraro
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Davide Villa
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Silvia Ferrari
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Antonio Cannata
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Carmine Zoccali
- Bianchi-Melacrino-Morelli Hospital, Nephrology Unit, Reggio Calabria, Italy
| | - Antonio Bellasi
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST-Lariana, Como, Italy
| | | | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Italy.
| | - Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Donald E Kohan
- Division of Nephrology, University of Utah Health Sciences Center, Salt Lake City, UT
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Wheeler JA, Clinkenbeard EL. Regulation of Fibroblast Growth Factor 23 by Iron, EPO, and HIF. ACTA ACUST UNITED AC 2019; 5:8-17. [PMID: 31218207 DOI: 10.1007/s40610-019-0110-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Purpose of review Fibroblast growth factor-23 (FGF23) is the key hormone produced in bone critical for phosphate homeostasis. Elevated serum phosphorus and 1,25dihydroxyvitaminD stimulates FGF23 production to promote renal phosphate excretion and decrease 1,25dihydroxyvitaminD synthesis. Thus completing the feedback loop and suppressing FGF23. Unexpectedly, studies of common and rare heritable disorders of phosphate handling identified links between iron and FGF23 demonstrating novel regulation outside the phosphate pathway. Recent Findings Iron deficiency combined with an FGF23 cleavage mutation was found to induce the autosomal dominant hypophosphatemic rickets phenotype. Physiological responses to iron deficiency, such as erythropoietin production as well as hypoxia inducible factor activation, have been indicated in regulating FGF23. Additionally, specific iron formulations, used to treat iron deficiency, alter post-translational processing thereby shifting FGF23 protein secretion. Summary Molecular and clinical studies revealed that iron deficiency, through several mechanisms, alters FGF23 at the transcriptional and post-translational level. This review will focus upon the novel discoveries elucidated between iron, its regulators, and their influence on FGF23 bioactivity.
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Affiliation(s)
- Jonathan A Wheeler
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Erica L Clinkenbeard
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
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30
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Abstract
Chronic kidney disease mineral and bone disorder (MBD) encompasses changes in mineral ion and vitamin D metabolism that are widespread in the setting of chronic kidney disease and end-stage renal disease. MBD components associate with cardiovascular disease in many epidemiologic studies. Through impacts on hypertension, activation of the renin-angiotensin-aldosterone system, vascular calcification, endothelial function, and cardiac remodeling and conduction, MBD may be a direct and targetable cause of cardiovascular disease. However, assessment and treatment of MBD is rife with challenges owing to biological tensions between its many components, such as calcium and phosphorus with their regulatory hormones fibroblast growth factor 23 and parathyroid hormone; fibroblast growth factor 23 with its co-receptor klotho; and vitamin D with control of calcium and phosphorus. These complex interactions between MBD components hinder the simple translation to clinical trials, which ultimately are needed to prove the benefits of treating MBD. Deeper investigation using precision medicine tools and principles, including genomics and individualized risk assessment and therapy, may help move the field closer toward clinical applications. This review provides a high-level overview of conventional and precision epidemiology in MBD, potential mechanisms of cardiovascular disease pathogenesis, and guiding therapeutic principles for established and emerging treatments.
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Affiliation(s)
- Joseph Lunyera
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Medicine, Durham Veterans Affairs Medical Center, Durham, NC.
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Ruospo M, Palmer SC, Natale P, Craig JC, Vecchio M, Elder GJ, Strippoli GFM. Phosphate binders for preventing and treating chronic kidney disease-mineral and bone disorder (CKD-MBD). Cochrane Database Syst Rev 2018; 8:CD006023. [PMID: 30132304 PMCID: PMC6513594 DOI: 10.1002/14651858.cd006023.pub3] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Phosphate binders are used to reduce positive phosphate balance and to lower serum phosphate levels for people with chronic kidney disease (CKD) with the aim to prevent progression of chronic kidney disease-mineral and bone disorder (CKD-MBD). This is an update of a review first published in 2011. OBJECTIVES The aim of this review was to assess the benefits and harms of phosphate binders for people with CKD with particular reference to relevant biochemical end-points, musculoskeletal and cardiovascular morbidity, hospitalisation, and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2018 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 We included randomised controlled trials (RCTs) or quasi-RCTs of adults with CKD of any GFR category comparing a phosphate binder to another phosphate binder, placebo or usual care to lower serum phosphate. Outcomes included all-cause and cardiovascular death, myocardial infarction, stroke, adverse events, vascular calcification and bone fracture, and surrogates for such outcomes including serum phosphate, parathyroid hormone (PTH), and FGF23. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess evidence certainty. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised MD (SMD) for continuous outcomes. MAIN RESULTS We included 104 studies involving 13,744 adults. Sixty-nine new studies were added to this 2018 update.Most placebo or usual care controlled studies were among participants with CKD G2 to G5 not requiring dialysis (15/25 studies involving 1467 participants) while most head to head studies involved participants with CKD G5D treated with dialysis (74/81 studies involving 10,364 participants). Overall, seven studies compared sevelamer with placebo or usual care (667 participants), seven compared lanthanum to placebo or usual care (515 participants), three compared iron to placebo or usual care (422 participants), and four compared calcium to placebo or usual care (278 participants). Thirty studies compared sevelamer to calcium (5424 participants), and fourteen studies compared lanthanum to calcium (1690 participants). No study compared iron-based binders to calcium. The remaining studies evaluated comparisons between sevelamer (hydrochloride or carbonate), sevelamer plus calcium, lanthanum, iron (ferric citrate, sucroferric oxyhydroxide, stabilised polynuclear iron(III)-oxyhydroxide), calcium (acetate, ketoglutarate, carbonate), bixalomer, colestilan, magnesium (carbonate), magnesium plus calcium, aluminium hydroxide, sucralfate, the inhibitor of phosphate absorption nicotinamide, placebo, or usual care without binder. In 82 studies, treatment was evaluated among adults with CKD G5D treated with haemodialysis or peritoneal dialysis, while in 22 studies, treatment was evaluated among participants with CKD G2 to G5. The duration of study follow-up ranged from 8 weeks to 36 months (median 3.7 months). The sample size ranged from 8 to 2103 participants (median 69). The mean age ranged between 42.6 and 68.9 years.Random sequence generation and allocation concealment were low risk in 25 and 15 studies, respectively. Twenty-seven studies reported low risk methods for blinding of participants, investigators, and outcome assessors. Thirty-one studies were at low risk of attrition bias and 69 studies were at low risk of selective reporting bias.In CKD G2 to G5, compared with placebo or usual care, sevelamer, lanthanum, iron and calcium-based phosphate binders had uncertain or inestimable effects on death (all causes), cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. Sevelamer may lead to constipation (RR 6.92, CI 2.24 to 21.4; low certainty) and lanthanum (RR 2.98, CI 1.21 to 7.30, moderate certainty) and iron-based binders (RR 2.66, CI 1.15 to 6.12, moderate certainty) probably increased constipation compared with placebo or usual care. Lanthanum may result in vomiting (RR 3.72, CI 1.36 to 10.18, low certainty). Iron-based binders probably result in diarrhoea (RR 2.81, CI 1.18 to 6.68, high certainty), while the risks of other adverse events for all binders were uncertain.In CKD G5D sevelamer may lead to lower death (all causes) (RR 0.53, CI 0.30 to 0.91, low certainty) and induce less hypercalcaemia (RR 0.30, CI 0.20 to 0.43, low certainty) when compared with calcium-based binders, and has uncertain or inestimable effects on cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. The finding of lower death with sevelamer compared with calcium was present when the analysis was restricted to studies at low risk of bias (RR 0.50, CI 0.32 to 0.77). In absolute terms, sevelamer may lower risk of death (all causes) from 210 per 1000 to 105 per 1000 over a follow-up of up to 36 months, compared to calcium-based binders. Compared with calcium-based binders, lanthanum had uncertain effects with respect to all-cause or cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification and probably had reduced risks of treatment-related hypercalcaemia (RR 0.16, CI 0.06 to 0.43, low certainty). There were no head-to-head studies of iron-based binders compared with calcium. The paucity of placebo-controlled studies in CKD G5D has led to uncertainty about the effects of phosphate binders on patient-important outcomes compared with placebo.It is uncertain whether the effects of binders on clinically-relevant outcomes were different for patients who were and were not treated with dialysis in subgroup analyses. AUTHORS' CONCLUSIONS In studies of adults with CKD G5D treated with dialysis, sevelamer may lower death (all causes) compared to calcium-based binders and incur less treatment-related hypercalcaemia, while we found no clinically important benefits of any phosphate binder on cardiovascular death, myocardial infarction, stroke, fracture or coronary artery calcification. The effects of binders on patient-important outcomes compared to placebo are uncertain. In patients with CKD G2 to G5, the effects of sevelamer, lanthanum, and iron-based phosphate binders on cardiovascular, vascular calcification, and bone outcomes compared to placebo or usual care, are also uncertain and they may incur constipation, while iron-based binders may lead to diarrhoea.
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Affiliation(s)
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Patrizia Natale
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | | | - Grahame J Elder
- Westmead HospitalDepartment of Renal MedicineWestmeadNSWAustralia2145
- Garvan Institute of Medical ResearchOsteoporosis and Bone Biology DivisionDarlinghurstNSWAustralia2010
| | - Giovanni FM Strippoli
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Diaverum AcademyBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
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Vanholder R, Van Laecke S, Glorieux G, Verbeke F, Castillo-Rodriguez E, Ortiz A. Deleting Death and Dialysis: Conservative Care of Cardio-Vascular Risk and Kidney Function Loss in Chronic Kidney Disease (CKD). Toxins (Basel) 2018; 10:E237. [PMID: 29895722 PMCID: PMC6024824 DOI: 10.3390/toxins10060237] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/11/2018] [Indexed: 02/07/2023] Open
Abstract
The uremic syndrome, which is the clinical expression of chronic kidney disease (CKD), is a complex amalgam of accelerated aging and organ dysfunctions, whereby cardio-vascular disease plays a capital role. In this narrative review, we offer a summary of the current conservative (medical) treatment options for cardio-vascular and overall morbidity and mortality risk in CKD. Since the progression of CKD is also associated with a higher cardio-vascular risk, we summarize the interventions that may prevent the progression of CKD as well. We pay attention to established therapies, as well as to novel promising options. Approaches that have been considered are not limited to pharmacological approaches but take into account lifestyle measures and diet as well. We took as many randomized controlled hard endpoint outcome trials as possible into account, although observational studies and post hoc analyses were included where appropriate. We also considered health economic aspects. Based on this information, we constructed comprehensive tables summarizing the available therapeutic options and the number and kind of studies (controlled or not, contradictory outcomes or not) with regard to each approach. Our review underscores the scarcity of well-designed large controlled trials in CKD. Nevertheless, based on the controlled and observational data, a therapeutic algorithm can be developed for this complex and multifactorial condition. It is likely that interventions should be aimed at targeting several modifiable factors simultaneously.
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Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Steven Van Laecke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Francis Verbeke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | | | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain.
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Filipski KJ, Sammons MF, Bhattacharya SK, Panteleev J, Brown JA, Loria PM, Boehm M, Smith AC, Shavnya A, Conn EL, Song K, Weng Y, Facemire C, Jüppner H, Clerin V. Discovery of Orally Bioavailable Selective Inhibitors of the Sodium-Phosphate Cotransporter NaPi2a (SLC34A1). ACS Med Chem Lett 2018; 9:440-445. [PMID: 29795756 DOI: 10.1021/acsmedchemlett.8b00013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/04/2018] [Indexed: 11/30/2022] Open
Abstract
Sodium-phosphate cotransporter 2a, or NaPi2a (SLC34A1), is a solute-carrier (SLC) transporter located in the kidney proximal tubule that reabsorbs glomerular-filtered phosphate. Inhibition of NaPi2a may enhance urinary phosphate excretion and correct maladaptive mineral and hormonal derangements associated with increased cardiovascular risk in chronic kidney disease-mineral and bone disorder (CKD-MBD). To date, only nonselective NaPi inhibitors have been described. Herein, we detail the discovery of the first series of selective NaPi2a inhibitors, resulting from optimization of a high-throughput screening hit. The oral PK profile of inhibitor PF-06869206 (6f) in rodents allows for the exploration of the pharmacology of selective NaPi2a inhibition.
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Affiliation(s)
- Kevin J. Filipski
- Pfizer Worldwide Research & Development, 1 Portland Street, Cambridge, Massachusetts 02139, United States
| | - Matthew F. Sammons
- Pfizer Worldwide Research & Development, 1 Portland Street, Cambridge, Massachusetts 02139, United States
| | - Samit K. Bhattacharya
- Pfizer Worldwide Research & Development, 1 Portland Street, Cambridge, Massachusetts 02139, United States
| | - Jane Panteleev
- Pfizer Worldwide Research & Development, 558 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Janice A. Brown
- Pfizer Worldwide Research & Development, 558 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Paula M. Loria
- Pfizer Worldwide Research & Development, 558 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Markus Boehm
- Pfizer Worldwide Research & Development, 1 Portland Street, Cambridge, Massachusetts 02139, United States
| | - Aaron C. Smith
- Pfizer Worldwide Research & Development, 558 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Andre Shavnya
- Pfizer Worldwide Research & Development, 558 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Edward L. Conn
- Pfizer Worldwide Research & Development, 558 Eastern Point Road, Groton, Connecticut 06340, United States
| | - Kun Song
- Pfizer Worldwide Research & Development, 1 Portland Street, Cambridge, Massachusetts 02139, United States
| | - Yan Weng
- Pfizer Worldwide Research & Development, 1 Portland Street, Cambridge, Massachusetts 02139, United States
| | - Carie Facemire
- Pfizer Worldwide Research & Development, 1 Portland Street, Cambridge, Massachusetts 02139, United States
| | - Harald Jüppner
- Endocrine Unit and Pediatric Nephrology Unit, Thier 10, Massachusetts General Hospital and Harvard Medical School, 50 Blossom Street, Boston, Massachusetts 02114, United States
| | - Valerie Clerin
- Pfizer Worldwide Research & Development, 1 Portland Street, Cambridge, Massachusetts 02139, United States
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Mehta R, Isakova T. Continued Search for Therapies to Favorably Modify Phosphate and FGF23 Levels in CKD. Clin J Am Soc Nephrol 2017; 12:1911-1913. [PMID: 29074819 PMCID: PMC5718282 DOI: 10.2215/cjn.11011017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Rupal Mehta
- Division of Nephrology and Hypertension, Department of Medicine and
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine and
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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