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Teh JW, Mac Gearailt C, Lappin DWP. Post-Transplant Bone Disease in Kidney Transplant Recipients: Diagnosis and Management. Int J Mol Sci 2024; 25:1859. [PMID: 38339137 PMCID: PMC10856017 DOI: 10.3390/ijms25031859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
Kidney transplantation is the preferred gold standard modality of treatment for kidney failure. Bone disease after kidney transplantation is highly prevalent in patients living with a kidney transplant and is associated with high rates of hip fractures. Fractures are associated with increased healthcare costs, morbidity and mortality. Post-transplant bone disease (PTBD) includes renal osteodystrophy, osteoporosis, osteonecrosis and bone fractures. PTBD is complex as it encompasses pre-existing chronic kidney disease-mineral bone disease and compounding factors after transplantation, including the use of immunosuppression and the development of de novo bone disease. After transplantation, the persistence of secondary and tertiary hyperparathyroidism, renal osteodystrophy, relative vitamin D deficiency and high levels of fibroblast growth factor-23 contribute to post-transplant bone disease. Risk assessment includes identifying both general risk factors and kidney-specific risk factors. Diagnosis is complex as the gold standard bone biopsy with double-tetracycline labelling to diagnose the PTBD subtype is not always readily available. Therefore, alternative diagnostic tools may be used to aid its diagnosis. Both non-pharmacological and pharmacological therapy can be employed to treat PTBD. In this review, we will discuss pathophysiology, risk assessment, diagnosis and management strategies to manage PTBD after kidney transplantation.
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Affiliation(s)
- Jia Wei Teh
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - Conall Mac Gearailt
- Department of Rheumatology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - David W. P. Lappin
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
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2
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Kotwal N, Bansal N, Muthukrishnan J, Verma V. Transplant endocrinology. Med J Armed Forces India 2023; 79:651-656. [PMID: 37981924 PMCID: PMC10654368 DOI: 10.1016/j.mjafi.2023.08.017] [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: 07/30/2023] [Accepted: 08/27/2023] [Indexed: 11/21/2023] Open
Abstract
Solid organ transplants and stem cell transplants are becoming more common but a significant proportion of patients are still on waiting lists, awaiting transplants. When endocrinologists treat transplant recipients who have underlying endocrine problems, which might include endocrine emergencies, there are special clinical care considerations to be aware of. The stage of the transplant (pre-transplant, early post-transplant, and chronic post-transplant) must be taken into account. Additionally, it's crucial to be knowledgeable about immunosuppressive medications, their typical adverse effects and drug interactions. The review article addresses a number of endocrine and metabolic abnormalities that are reported after transplantation.
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Affiliation(s)
- Narendra Kotwal
- Director & Commandant, Armed Forces Medical College, Pune, India
| | - Naresh Bansal
- Senior Adviser (Medicine) & Endocrinologist, Command Hospital (Southern Command), Pune, India
| | - J. Muthukrishnan
- Professor & Head, Department of Internal Medicine, Armed Forces Medical College, Pune, India
| | - Vishesh Verma
- Professor, Department of Internal Medicine, Armed Forces Medical College, Pune, India
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3
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Santoso D, Thaha M, Empitu MA, Kadariswantiningsih IN, Suryantoro SD, Haryati MR, Hertanto DM, Pramudya D, Bintoro SUY, Nasronudin N, Alsagaff MY, Susilo H, Wungu CDK, Budhiparama NC, Hogendoorn PCW. Brown Tumour in Chronic Kidney Disease: Revisiting an Old Disease with a New Perspective. Cancers (Basel) 2023; 15:4107. [PMID: 37627135 PMCID: PMC10452999 DOI: 10.3390/cancers15164107] [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: 07/14/2023] [Revised: 08/10/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
Osteitis fibrosa cystica (OFC) and Brown Tumours are two related but distinct types of bone lesions that result from the overactivity of osteoclasts and are most often associated with chronic kidney disease (CKD). Despite their potential consequences, these conditions are poorly understood because of their rare prevalence and variability in their clinical manifestation. Canonically, OFC and Brown Tumours are caused by secondary hyperparathyroidism in CKD. Recent literature showed that multiple factors, such as hyperactivation of the renin-angiotensin-aldosterone system and chronic inflammation, may also contribute to the occurrence of these diseases through osteoclast activation. Moreover, hotspot KRAS mutations were identified in these lesions, placing them in the spectrum of RAS-MAPK-driven neoplasms, which were until recently thought to be reactive lesions. Some risk factors contributed to the occurrence of OFC and Brown Tumours, such as age, gender, comorbidities, and certain medications. The diagnosis of OFC and Brown Tumours includes clinical symptoms involving chronic bone pain and laboratory findings of hyperparathyroidism. In radiological imaging, the X-ray and Computed tomography (CT) scan could show lytic or multi-lobular cystic alterations. Histologically, both lesions are characterized by clustered osteoclasts in a fibrotic hemorrhagic background. Based on the latest understanding of the mechanism of OFC, this review elaborates on the manifestation, diagnosis, and available therapies that can be leveraged to prevent the occurrence of OFC and Brown Tumours.
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Affiliation(s)
- Djoko Santoso
- Department of Internal Medicine, Dr. Soetomo Hospital, Surabaya 60286, Indonesia; (D.S.); (D.M.H.); (D.P.); (S.U.Y.B.); (N.N.)
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga Hospital, Universitas Airlangga, Surabaya 60115, Indonesia; (S.D.S.); (M.R.H.)
| | - Mochammad Thaha
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga Hospital, Universitas Airlangga, Surabaya 60115, Indonesia; (S.D.S.); (M.R.H.)
| | - Maulana A. Empitu
- Department of Anatomy, Histology, and Pharmacology, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia;
| | | | - Satriyo Dwi Suryantoro
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga Hospital, Universitas Airlangga, Surabaya 60115, Indonesia; (S.D.S.); (M.R.H.)
| | - Mutiara Rizki Haryati
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga Hospital, Universitas Airlangga, Surabaya 60115, Indonesia; (S.D.S.); (M.R.H.)
| | - Decsa Medika Hertanto
- Department of Internal Medicine, Dr. Soetomo Hospital, Surabaya 60286, Indonesia; (D.S.); (D.M.H.); (D.P.); (S.U.Y.B.); (N.N.)
| | - Dana Pramudya
- Department of Internal Medicine, Dr. Soetomo Hospital, Surabaya 60286, Indonesia; (D.S.); (D.M.H.); (D.P.); (S.U.Y.B.); (N.N.)
| | | | - Nasronudin Nasronudin
- Department of Internal Medicine, Dr. Soetomo Hospital, Surabaya 60286, Indonesia; (D.S.); (D.M.H.); (D.P.); (S.U.Y.B.); (N.N.)
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga Hospital, Universitas Airlangga, Surabaya 60115, Indonesia; (S.D.S.); (M.R.H.)
| | - Mochamad Yusuf Alsagaff
- Department of Cardiology and Vascular Medicine, Universitas Airlangga Hospital, Universitas Airlangga, Surabaya 60115, Indonesia; (M.Y.A.); (H.S.)
| | - Hendri Susilo
- Department of Cardiology and Vascular Medicine, Universitas Airlangga Hospital, Universitas Airlangga, Surabaya 60115, Indonesia; (M.Y.A.); (H.S.)
| | - Citrawati Dyah Kencono Wungu
- Department of Physiology and Medical Biochemistry, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia;
| | - Nicolaas C. Budhiparama
- Department of Orthopaedic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Pancras C. W. Hogendoorn
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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4
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Prytula A, Shroff R, Krupka K, Deschepper E, Bacchetta J, Ariceta G, Awan A, Benetti E, Büscher A, Berta L, Carraro A, Christian M, Dello Strologo L, Doerry K, Haumann S, Klaus G, Kempf C, Kranz B, Oh J, Pape L, Pohl M, Printza N, Rubik J, Schmitt CP, Shenoy M, Spartà G, Staude H, Sweeney C, Weber L, Weber S, Weitz M, Haffner D, Tönshoff B. Hyperparathyroidism Is an Independent Risk Factor for Allograft Dysfunction in Pediatric Kidney Transplantation. Kidney Int Rep 2022; 8:81-90. [PMID: 36644359 PMCID: PMC9832060 DOI: 10.1016/j.ekir.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/15/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Little is known about the consequences of deranged chronic kidney disease-mineral and bone disorder (CKD-MBD) parameters on kidney allograft function in children. We examined a relationship between these parameters over time and allograft outcome. Methods This registry study from the Cooperative European Paediatric Renal Transplant Initiative (CERTAIN) collected data at baseline, months 1, 3, 6, 9, and 12 after transplant; and every 6 months thereafter up to 5 years. Survival analysis for a composite end point of graft loss or estimated glomerular filtration rate (eGFR) ≤30 ml/min per 1.73 m2 or a ≥50% decline from eGFR at month 1 posttransplant was performed. Associations of parathyroid hormone (PTH), calcium, phosphate, and 25-hydroxyvitamin D (25(OH)D) with allograft outcome were investigated using conventional stratified Cox proportional hazards models and further verified with marginal structural models with time-varying covariates. Results We report on 1210 patients (61% boys) from 16 European countries. The composite end point was reached in 250 grafts (21%), of which 11 (4%) were allograft losses. In the conventional Cox proportional hazards models adjusted for potential confounders, only hyperparathyroidism (hazard ratio [HR], 2.94; 95% confidence interval [CI], 1.82-4.74) and hyperphosphatemia (HR, 1.94; 95% CI, 1.28-2.92) were associated with the composite end point. Marginal structural models showed similar results for hyperparathyroidism (HR, 2.74; 95% CI, 1.71-4.38), whereas hyperphosphatemia was no longer significant (HR, 1.35; 95% CI, 0.87-2.09), suggesting that its association with graft dysfunction can be ascribed to a decline in eGFR. Conclusion Hyperparathyroidism is a potential independent risk factor for allograft dysfunction in children.
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Affiliation(s)
- Agnieszka Prytula
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Ghent, Belgium
- Correspondence: Agnieszka Prytula, Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent 9000, Belgium.
| | - Rukshana Shroff
- Renal Unit, University College London Great Ormond Street Hospital, London, United Kingdom
| | - Kai Krupka
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Ellen Deschepper
- Biostatistics Unit, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Justine Bacchetta
- Reference Center for Rare Renal Diseases, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, Hospices Civils de Lyon, France
| | - Gema Ariceta
- Pediatric Nephrology. University Hospital Vall d’ Hebron, Barcelona, Spain
| | - Atif Awan
- Department of Nephrology and Transplantation, Temple Street, Dublin, Ireland
| | - Elisa Benetti
- Pediatric Nephrology, Dialysis and Transplant Unit, Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Anja Büscher
- Department of Pediatrics II, University Hospital of Essen, Essen, Germany
| | - László Berta
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Andrea Carraro
- Pediatric Nephrology, Dialysis and Transplant Unit, Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | | | - Luca Dello Strologo
- Renal Transplant Unit, Bambino Gesù Children’s Research Hospital Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Katja Doerry
- Department of Pediatric Nephrology and Transplantation, University Children’s Hospital, University Medical Center Hamburg/Eppendorf, Hamburg, Germany
| | - Sophie Haumann
- Pediatric Nephrology, Children’s and Adolescents’ Hospital, University Hospital of Cologne, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Guenter Klaus
- KfH-Pediatric Kidney Center and Department of Pediatrics, Philipps-University of Marburg, Marburg, Germany
| | - Caroline Kempf
- Department of Pediatric Gastroenterology, Nephrology and Metabolism, Charité–University Medicine Berlin, Berlin, Germany
| | | | - Jun Oh
- Department of Pediatric Nephrology and Transplantation, University Children’s Hospital, University Medical Center Hamburg/Eppendorf, Hamburg, Germany
| | - Lars Pape
- Department of Pediatrics II, University Hospital of Essen, Essen, Germany
| | - Martin Pohl
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nikoleta Printza
- Pediatric Nephrology Unit, Pediatric Department I, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| | - Jacek Rubik
- Department of Nephrology, Kidney Transplantation and Arterial Hypertension, Children’s Memorial Health Institute, Warsaw, Poland
| | - Claus Peter Schmitt
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Mohan Shenoy
- Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Giuseppina Spartà
- Department of Pediatric Nephrology, University Children’s Hospital Zurich, Zurich, Switzerland
| | | | - Clodagh Sweeney
- Department of Nephrology and Transplantation, Temple Street, Dublin, Ireland
| | - Lutz Weber
- Pediatric Nephrology, Children’s and Adolescents’ Hospital, University Hospital of Cologne, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Stefanie Weber
- KfH-Pediatric Kidney Center and Department of Pediatrics, Philipps-University of Marburg, Marburg, Germany
| | - Marcus Weitz
- Department of General Pediatrics and Hematology/Oncology, University Children’s Hospital Tuebingen, Tuebingen, Germany
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
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5
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Kamel MH, Ahmed DH, Mikhael ES, Abdalla MS, Sadek KM, ElNahid MS. Serum Phosphorus, Parathyroid Hormone, and Serum Fibroblast Growth Factor-23 in Egyptian Patients Six Months after Undergoing Living-donor Kidney Transplantation. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:353-360. [PMID: 37843136 DOI: 10.4103/1319-2442.385958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
End-stage renal disease is a major health problem with many complications. Previous studies emphasized the relationship of cardiovascular disease and mortality among these patients to dysregulated phosphate homeostasis. Even after successful renal transplantation, the risk is not eliminated. Several factors seem to interplay to regulate serum phosphorus levels after renal transplantation. Fibroblast growth factor-23 (FGF-23) is a hormone with the major function of inhibiting the reabsorption of phosphate by the renal tubules. Parathormone reduces the reabsorption of phosphate from the proximal tubule of the kidney. The aim of our study was to explore the changes that occurred in FGF-23 and intact parathyroid hormone (iPTH) levels in a cohort of Egyptian patients undergoing renal transplantation and to examine the effect of these factors on posttransplant serum phosphorus levels. The study was carried out prospectively on 37 candidates for live-donor renal transplantation. Serum levels of calcium, phosphorus, iPTH, and FGF-23 were measured before and 6 months after renal transplantation. Statistically significant differences were detected in serum calcium, phosphorus, FGF-23, and iPTH before and 6 months after transplantation (P < 0.001, P < 0.001, P < 0.001, and P < 0.001, respectively). The results also showed a statistically significant correlation between FGF-23 levels and phosphorus levels before transplantation. The interplay between FGF-23 and iPTH has an impact on posttransplant serum phosphorus levels.
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Affiliation(s)
- Mai Hamed Kamel
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Dina Hesham Ahmed
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Emily Samir Mikhael
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Shehata Abdalla
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Khaled Marzouk Sadek
- Department of Internal Medicine and Nephrology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maggie Said ElNahid
- Department of Internal Medicine and Nephrology, Faculty of Medicine, Cairo University, Cairo, Egypt
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6
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Duni A, Koutlas V, Tsitouridis A, Tzalavra E, Oikonomaki T, Kitsos A, Rapsomanikis KP, Alekos J, Tatsis V, Pappas C, Mitsis M, Dounousi E. Longitudinal Assessment of Electrolyte Disorders in a Cohort of Chronic Stable Kidney Transplant Recipients. Transplant Proc 2021; 53:2786-2792. [PMID: 34690001 DOI: 10.1016/j.transproceed.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Kidney transplantation is complicated by various electrolyte disturbances with variable reported prevalence and incidence and of multifactorial pathogenesis. The aim of our study was the retrospective longitudinal assessment of the serum electrolytes in a cohort of stable kidney transplant recipients (KTRs) and the possible associated parameters, including graft function and medications. METHODS We included 93 stable KTRs under follow-up in our hospital's kidney transplant unit. Serum magnesium, calcium, phosphorus, potassium, sodium, and urine sodium levels were recorded retrospectively during 3 consecutive years. In addition, comorbidities, biochemical parameters, medications, and graft function (estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration equation and 24-hour urinary protein [uTpr]) were recorded. RESULTS Mean age at baseline was 51 ± 11 years; 64 KTRs were men (68.8%), 17 (18.3%) had diabetes, 79 (85%) had hypertension, and 11 (11.8%) had cardiovascular disease. Mean eGFR and uTpr (mg/24 h) at study initiation were 47.1 ± 13.5 mL/min/1.73 m2 and 369.4 ± 404.2 mg/24 h, respectively. Hypomagnesemia was the most common disturbance observed in 21.7% of KTRs. Patients with hypomagnesemia displayed higher parathyroid hormone levels and more frequently had diabetes. Hypophosphatemia was recorded in 9.7% of KTRs during the first year. Hyperkalemia, hypokalemia, and hypercalcemia were rare (<5%). Mean serum and urine sodium concentration remained stable during the study, whereas urinary sodium levels showed a positive correlation with uTpr (P < .05). CONCLUSIONS In our cohort of KTRs, there were no significant electrolyte disorders, either in terms of frequency or severity, with hypomagnesemia being the most prevalent disturbance. The identification of potential associated risk factors and clinical data correlations are pivotal for the development of individualized and evidence-based therapeutic approach and decisions.
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Affiliation(s)
- Anila Duni
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Vasileios Koutlas
- Department of Surgery and Kidney Transplant Unit, University Hospital of Ioannina, Ioannina, Greece
| | | | - Eirini Tzalavra
- Department of Surgery and Kidney Transplant Unit, University Hospital of Ioannina, Ioannina, Greece
| | - Theodora Oikonomaki
- Department of Nephrology, Evaggelismos General Hospital of Athens, Athens, Greece
| | - Athanasios Kitsos
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | | | - John Alekos
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Vasileios Tatsis
- Department of Surgery and Kidney Transplant Unit, University Hospital of Ioannina, Ioannina, Greece
| | - Charalampos Pappas
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Mixalis Mitsis
- Department of Surgery and Kidney Transplant Unit, University Hospital of Ioannina, Ioannina, Greece
| | - Evangelia Dounousi
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece.
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7
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Jørgensen HS, Behets G, Bammens B, Claes K, Meijers B, Naesens M, Sprangers B, Kuypers DRJ, D'Haese P, Evenepoel P. Patterns of renal osteodystrophy one year after kidney transplantation. Nephrol Dial Transplant 2021; 36:2130-2139. [PMID: 34383929 DOI: 10.1093/ndt/gfab239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Renal osteodystrophy is considered common, but is not well characterized, in contemporary kidney transplant recipients. This study reports extensively on bone phenotype by bone histomorphometry, bone densitometry, and novel bone biomarkers 1 year after kidney transplantation. METHODS A transiliac bone biopsy and dual energy x-ray absorptiometry were performed in 141 unselected kidney transplant recipients in this observational cohort study. Blood and 24 hr urine samples were collected simultaneously. RESULTS Median age was 57 ± 11 years, 71% were men, and all were of Caucasian ethnicity. Bone turnover was normal in 71% of patients, low in 26%, and high in just four cases (3%). Hyperparathyroidism with hypercalcemia was present in 13% of patients, of which one had high bone turnover. Delayed bone mineralization was detected in 16% of patients, who were characterized by hyperparathyroidism (137 vs. 53 ρg/mL), a higher fractional excretion of phosphate (40 vs. 32%), and lower levels of phosphate (2.68 vs 3.18 mg/dL) and calcidiol (29 vs. 37 ng/mL) compared to patients with normal bone mineralization. Osteoporosis was present in 15-46% of patients, with the highest prevalence at the distal skeleton. The proportion of osteoporotic patients was comparable across categories of bone turnover and mineralization. CONCLUSION The majority of kidney transplant recipients, including patients with osteoporosis, have a normal bone turnover at 1-year post-transplant. Low bone turnover is seen in a substantial subset, while high bone turnover is rare. Vitamin D deficiency and hypophosphatemia represent potential interventional targets to improve bone health post-transplant.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Geert Behets
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Bert Bammens
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Bjorn Meijers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Dirk R J Kuypers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Patrick D'Haese
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
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8
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Tantisattamo E, Ho BT, Workeneh BT. Editorial: Metabolic Changes After Kidney Transplantation. Front Med (Lausanne) 2021; 8:709644. [PMID: 34307432 PMCID: PMC8297834 DOI: 10.3389/fmed.2021.709644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 05/31/2021] [Indexed: 01/21/2023] Open
Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California, Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, Veterans Affairs Long Beach Healthcare System, Long Beach, CA, United States.,Multi-Organ Transplant Center, Section of Nephrology, Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, United States
| | - Bing T Ho
- Comprehensive Transplant Center, Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Biruh T Workeneh
- Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
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9
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van der Plas WY, Gomes Neto AW, Berger SP, Pol RA, Kruijff S, Bakker SJL, de Borst MH. Association of time-updated plasma calcium and phosphate with graft and patient outcomes after kidney transplantation. Am J Transplant 2021; 21:2437-2447. [PMID: 33331113 PMCID: PMC8359271 DOI: 10.1111/ajt.16457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/08/2020] [Accepted: 12/09/2020] [Indexed: 01/25/2023]
Abstract
Disturbances in calcium-phosphate homeostasis are common after kidney transplantation. We aimed to assess the relationship between deregulations in plasma calcium and phosphate over time and mortality and death-censored graft failure (DCGF). In this prospective cohort study, we included kidney transplant recipients with ≥2 plasma calcium and phosphate measurements. Data were analyzed using time-updated Cox regression analyses adjusted for potential confounders including time-updated kidney function. We included 2769 patients (mean age 47 ± 14 years, 42.3% female) with 138 496 plasma calcium and phosphate levels (median [IQR] 43 [31-61] measurements per patient). During follow-up of 16.3 [8.7-25.2] years, 17.2% developed DCGF and 7.9% died. Posttransplant hypercalcemia was associated with an increased risk of mortality (1.63 [1.31-2.00], p < 0.0001), but not with DCGF. Hyperphosphatemia was associated with both DCGF (2.59 [2.05-3.27], p < .0001) and mortality (3.14 [2.58-3.82], p < .0001). Only the association between hypercalcemia and mortality remained significant in sensitivity analyses censored by a simultaneous eGFR <45 mL/min/1.73 m2 . Hypocalcemia and hypophosphatemia were not consistently associated with either outcome. Posttransplant hypercalcemia, even in the presence of preserved kidney function, was associated with an increased mortality risk. Associations of hyperphosphatemia with DCGF and mortality may be driven by eGFR.
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Affiliation(s)
- Willemijn Y. van der Plas
- Department of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - António W. Gomes Neto
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Stefan P. Berger
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Robert A. Pol
- Department of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Schelto Kruijff
- Department of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Stephan J. L. Bakker
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands,TransplantLines Biobank and Cohort StudyGroningenThe Netherlands
| | - Martin H. de Borst
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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10
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Prevalence of Musculoskeletal Manifestations in Adult Kidney Transplant's Recipients: A Systematic Review. ACTA ACUST UNITED AC 2021; 57:medicina57060525. [PMID: 34071098 PMCID: PMC8224589 DOI: 10.3390/medicina57060525] [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: 04/03/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: The musculoskeletal (MSK) manifestations in the kidney transplant recipient (KTxR) could lead to decreased quality of life and increased morbidity and mortality. However, the prevalence of these MSK manifestations is still not well-recognized. This review aimed to investigate the prevalence and outcomes of MSK manifestations in KTxR in the last two decades. Materials and Methods: Research was performed in EBSCO, EMBASE, CINAHL, PubMed/MEDLINE, Cochrane, Google Scholar, PsycINFO, Scopus, Science Direct, and Web of Science electronic databases were searched during the years 2000–2020. Results: The PRISMA flow diagram revealed the search procedure and that 502 articles were retrieved from the initial search and a total of 26 articles were included for the final report in this review. Twelve studies reported bone loss, seven studies reported a bone pain syndrome (BPS) or cyclosporine-induced pain syndrome (CIPS), and seven studies reported hyperuricemia (HU) and gout. The prevalence of MSK manifestations in this review reported as follow: BPS/CIPS ranged from 0.82% to 20.7%, while bone loss ranged from 14% to 88%, and the prevalence of gout reported in three studies as 7.6%, 8.0%, and 22.37%, while HU ranged from 38% to 44.2%. Conclusions: The post-transplantation period is associated with profound MSK abnormalities of mineral metabolism and bone loss mainly caused by corticosteroid therapy, which confer an increased fracture risk. Cyclosporine (CyA) and tacrolimus were responsible for CIPS, while HU or gout was attributable to CyA. Late diagnosis or treatment of post-transplant bone disease is associated with lower quality of life among recipients
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11
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Torregrosa JV, Ferreira AC, Cucchiari D, Ferreira A. Bone Mineral Disease After Kidney Transplantation. Calcif Tissue Int 2021; 108:551-560. [PMID: 33765230 DOI: 10.1007/s00223-021-00837-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/09/2021] [Indexed: 12/18/2022]
Abstract
Chronic kidney disease-mineral bone disorder (CKD-MBD) after kidney transplantation is a mix of pre-existing disorders and new alterations. The final consequences are reflected fundamentally as abnormal mineral metabolism (hypercalcemia, hypophosphatemia) and bone alterations [high or low bone turnover disease (as fibrous osteitis or adynamic bone disease), an eventual compromise of bone mineralization, decrease bone mineral density and bone fractures]. The major cause of post-transplantation hypercalcemia is the persistence of severe secondary hyperparathyroidism, and treatment options include calcimimetics or parathyroidectomy. On turn, hypophosphatemia is caused by both the persistence of high blood levels of PTH and/or high blood levels of FGF23, with its correction being very difficult to achieve. The most frequent bone morphology alteration is low bone turnover disease, while high-turnover osteopathy decreases in frequency after transplantation. Although the pathogenic mechanisms of these abnormalities have not been fully clarified, the available evidence suggests that there are a number of factors that play a very important role, such as immunosuppressive treatment, persistently high levels of PTH, vitamin D deficiency and hypophosphatemia. Fracture risk is four-fold higher in transplanted patients compared to general population. The most relevant risk factors for fracture in the kidney transplant population are diabetes mellitus, female sex, advanced age (especially > 65 years), dialysis vintage, high PTH levels and low phosphate levels, osteoporosis, pre-transplant stress fracture and high doses or prolonged steroids therapy. Treatment alternatives for CKD-MBD after transplantation include minimization of corticosteroids, use of calcium and vitamin D supplements, antiresorptives (bisphosphonates or Denosumab) and osteoformers (synthetic parathyroid hormone). As both mineral metabolism and bone disorders lead to increased morbidity and mortality, the presence of these changes after transplantation has to be prevented (if possible), minimized, diagnosed, and treated as soon as possible.
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Affiliation(s)
- Josep-Vicent Torregrosa
- Nephrology & Renal Transplant Department - Hospital Clínic, Barcelona, Spain.
- Universidad de Barcelona, Barcelona, Spain.
| | - Ana Carina Ferreira
- Nephrology Department, Centro Hospitalare, Universitário de Lisboa Central, Lisbon, Portugal
- Nova Medical School, Nova University, Lisbon, Portugal
| | - David Cucchiari
- Nephrology & Renal Transplant Department - Hospital Clínic, Barcelona, Spain
| | - Aníbal Ferreira
- Nephrology Department, Centro Hospitalare, Universitário de Lisboa Central, Lisbon, Portugal
- Nova Medical School, Nova University, Lisbon, Portugal
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12
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Coban M, Okten S. The correlation between sclerostin and bone mineral density in renal transplant recipients. Nefrologia 2020; 40:506-513. [PMID: 32896441 DOI: 10.1016/j.nefro.2020.04.009] [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: 05/27/2019] [Revised: 03/02/2020] [Accepted: 04/03/2020] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Sclerostin is an anti-anabolic protein synthesized by osteocytes that may cause osteoporosis by inhibiting bone formation. The aim of our study was to investigate the correlation between sclerostin and bone mineral density (BMD) reduction in renal transplant recipients (RTRs) with more than 1 year after transplantation. MATERIAL AND METHODS This cross-sectional study was conducted on 80 patients (38 (47.5%) male/42 (52.5%) female) RTRs with a mean age of 44.68±10.39 years. Patients were compared with an age and sex-matched control group of 40 healthy individuals. BMD was measured by dual-energy X-ray absorptiometry. The levels of sclerostin were determined using enzyme-linked immunosorbent assay. RESULTS The mean sclerostin was 3.77±0.3pg/mL in patients and 3.81±0.21pg/mL in healthy individuals. The mean T score of femoral trochanter (FT) (FT-T), femoral neck (FN) (FN-T), lumbar vertebrae (L1-4) (L1-4-T) were -0.81±0.86, -1.08±1.09 and -0.8±1.2, respectively. The mean Z score of FT (FT-Z), FN (FN-Z), L1-4 (L1-4-Z) were -0.6±0.73, -0.32±0.9 and -0.54±1.13, respectively. FT-Z and L1-4-Z were lower in patients than healthy subjects (p=0.009, p=0.021 respectively). Serum creatinine (p<0.001), intact parathyroid hormone (p<0.001) were higher and phosphate (p<0.001), was lower in patients than healthy subjects. Patients with a log10 sclerostin of >3.84pg/mL had higher FT-T (p=0.040), FT-Z, FN-T (p=0.018), FN-Z (p=0.006) than those with a log10 sclerostin of ≤3.84pg/mL. There was a significant correlation between log10 sclerostin and FN-T (r=-0.296, p=0.009) and FN-Z (r=-0.269, p=0.019). In linear regression analysis, high sclerostin was found to be correlated with male gender, lower FN-T and lower FN-Z independently of other risk factors. CONCLUSION The levels of sclerostin can predict reduction of proximal femur BMD and development of mineral and bone disorder in RTRs. There was no difference in sclerostin levels between RTRs and healthy individuals.
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Affiliation(s)
- Melahat Coban
- Department of Nephrology, Ankara City Hospital, Ankara, Turkey.
| | - Sarper Okten
- Department of Radiology, Ankara City Hospital, Ankara, Turkey
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13
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Holden RM, Mustafa RA, Alexander RT, Battistella M, Bevilacqua MU, Knoll G, Mac-Way F, Reslerova M, Wald R, Acott PD, Feltmate P, Grill A, Jindal KK, Karsanji M, Kiberd BA, Mahdavi S, McCarron K, Molnar AO, Pinsk M, Rodd C, Soroka SD, Vinson AJ, Zimmerman D, Clase CM. Canadian Society of Nephrology Commentary on the Kidney Disease Improving Global Outcomes 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder. Can J Kidney Health Dis 2020; 7:2054358120944271. [PMID: 32821415 PMCID: PMC7412914 DOI: 10.1177/2054358120944271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/06/2020] [Indexed: 12/23/2022] Open
Abstract
Purpose of review: (1) To provide commentary on the 2017 update to the Kidney Disease Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD); (2) to apply the evidence-based guideline update for implementation within the Canadian health care system; (3) to provide comment on the care of children with chronic kidney disease (CKD); and (4) to identify research priorities for Canadian patients. Sources of information: The KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD. Methods: The commentary committee co-chairs selected potential members based on their knowledge of the Canadian kidney community, aiming for wide representation from relevant disciplines, academic and community centers, and different geographical regions. Key findings: We agreed with many of the recommendations in the clinical practice guideline on the diagnosis, evaluation, prevention, and treatment of CKD-MBD. However, based on the uncommon occurrence of abnormalities in calcium and phosphate and the low likelihood of severe abnormalities in parathyroid hormone (PTH), we recommend against screening and monitoring levels of calcium, phosphate, PTH, and alkaline phosphatase in adults with CKD G3. We suggest and recommend monitoring these parameters in adults with CKD G4 and G5, respectively. In children, we agree that monitoring for CKD-MBD should begin in CKD G2, but we suggest measuring ionized calcium, rather than total calcium or calcium adjusted for albumin. With regard to vitamin D, we suggest against routine screening for vitamin D deficiency in adults with CKD G3-G5 and G1T-G5T and suggest following population health recommendations for adequate vitamin D intake. We recommend that the measurement and management of bone mineral density (BMD) be according to general population guidelines in CKD G3 and G3T, but we suggest against routine BMD testing in CKD G4-G5, CKD G4T-5T, and in children with CKD. Based on insufficient data, we also recommend against routine bone biopsy in clinical practice for adults with CKD or CKD-T, or in children with CKD, although we consider it an important research tool. Limitations: The committee relied on the evidence summaries produced by KDIGO. The CSN committee did not replicate or update the systematic reviews.
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Affiliation(s)
- Rachel M Holden
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Reem A Mustafa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, USA.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - R Todd Alexander
- Department of Pediatrics and Physiology, University of Alberta, Edmonton, Canada
| | - Marisa Battistella
- University Health Network, Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
| | - Micheli U Bevilacqua
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Greg Knoll
- Division of Nephrology, The Ottawa Hospital, ON, Canada
| | - Fabrice Mac-Way
- Division of Nephrology, CHU de Québec, Hôtel-Dieu de Québec Hospital, Université Laval, Québec City, QC, Canada
| | - Martina Reslerova
- Nephrology Section, St. Boniface General Hospital, University of Manitoba, Winnipeg, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Philip D Acott
- Division of Nephrology, Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Patrick Feltmate
- Department of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Allan Grill
- Department of Family & Community Medicine, University of Toronto, ON, Canada
| | - Kailash K Jindal
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Meena Karsanji
- Professional Practice, Vancouver Coastal Health, Richmond, BC, Canada
| | - Bryce A Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sara Mahdavi
- Department of Nutritional Sciences, University of Toronto, ON, Canada.,Department of Nephrology, Scarborough Health Network, ON, Canada
| | - Kailee McCarron
- Nova Scotia Renal Program, Nova Scotia Health Authority, Halifax, Canada
| | - Amber O Molnar
- Division of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Maury Pinsk
- Division of Nephrology, Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Canada
| | - Celia Rodd
- Division of Diabetes & Endocrinology, Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Canada
| | - Steven D Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, NSHA Renal Program and Pharmacy Services, Halifax, NS, Canada
| | - Amanda J Vinson
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Deborah Zimmerman
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
| | - Catherine M Clase
- Division of Nephrology, Department of Medicine, Department of Health Research, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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14
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Chevarria J, Sexton DJ, Murray SL, Adeel CE, O'Kelly P, Williams YE, O'Seaghdha CM, Little DM, Conlon PJ. Calcium and phosphate levels after kidney transplantation and long-term patient and allograft survival. Clin Kidney J 2020; 14:1106-1113. [PMID: 33841855 PMCID: PMC8023198 DOI: 10.1093/ckj/sfaa061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 03/25/2020] [Indexed: 11/28/2022] Open
Abstract
Background Non-traditional cardiovascular risk factors, including calcium and phosphate derangement, may play a role in mortality in renal transplant. The data regarding this effect are conflicting. Our aim was to assess the impact of calcium and phosphate derangements in the first 90 days post-transplant on allograft and recipient outcomes. Methods We performed a retrospective cohort review of all-adult, first renal transplants in the Republic of Ireland between 1999 and 2015. We divided patients into tertiles based on serum phosphate and calcium levels post-transplant. We assessed their effect on death-censored graft survival and all-cause mortality. We used Stata for statistical analysis and did survival analysis and spline curves to assess the association. Results We included 1525 renal transplant recipients. Of the total, 86.3% had hypophosphataemia and 36.1% hypercalcaemia. Patients in the lowest phosphate tertile were younger, more likely female, had lower weight, more time on dialysis, received a kidney from a younger donor, had less delayed graft function and better transplant function compared with other tertiles. Patients in the highest calcium tertile were younger, more likely male, had higher body mass index, more time on dialysis and better transplant function. Adjusting for differences between groups, we were unable to show any difference in death-censored graft failure [phosphate = 1.14, 95% confidence interval (CI) 0.92–1.41; calcium = 0.98, 95% CI 0.80–1.20] or all-cause mortality (phosphate = 1.10, 95% CI 0.91–1.32; calcium = 0.96, 95% CI 0.81–1.13) based on tertiles of calcium or phosphate in the initial 90 days. Conclusions Hypophosphataemia and hypercalcaemia are common occurrences post-kidney transplant. We have identified different risk factors for these metabolic derangements. The calcium and phosphate levels exhibit no independent association with death-censored graft failure and mortality.
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Affiliation(s)
- Julio Chevarria
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Donal J Sexton
- Department of Nephrology, Trinity College Dublin, Dublin, Ireland
| | - Susan L Murray
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Chaudhry E Adeel
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Yvonne E Williams
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Conall M O'Seaghdha
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Dilly M Little
- Department of Urology and Transplant, Beaumont Hospital, Dublin, Ireland
| | - Peter J Conlon
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland.,Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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15
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Two-year retrospective study of the effect of preemptive kidney transplantation and pretransplant mineral bone factors on calcium in post-kidney transplant recipients. Clin Exp Nephrol 2020; 24:836-841. [PMID: 32342291 DOI: 10.1007/s10157-020-01895-8] [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: 01/10/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Preemptive kidney transplantation (PEKT) incidence has recently increased in Japan. The effect of PEKT and mineral bone factors before kidney transplantation (KTx) on long-term calcium (Ca) levels remains unknown. METHODS Eighty-one consecutive patients at Nagoya Daini Red Cross Hospital were included in this study (PEKT group with 41 patients and non PEKT group with 40 patients). Ca metabolism, including intact fibroblast growth factor 23 (iFGF23), were measured before KTx and intact parathyroid hormone (iPTH), and corrected Ca (cCa) were measured before KTx and 6 months (M), 12 M, and 24 M after KTx. RESULTS In PEKT group, cCa levels at 24 M were higher from the baseline level. At baseline, cCa levels had a positive correlation with iFGF23 levels (r = 0.51; p < 0.001) and a negative correlation with iPTH levels (r = 0.51; p < 0.001). The cCa difference between baseline and 24 M was 0.8 ± 0.6 mg/dL in PEKT group and 0.3 ± 0.7 mg/dL in non-PEKT group (p = 0.001). A multivariate linear regression analysis showed iFGF23 and iPTH at baseline in entire groups were useful markers on calcium levels at 24 M. However, in PEKT group, both markers were found to be not associated with Ca at 24 M, whereas in non PEKT group, iPTH was the only effective marker. CONCLUSIONS This study suggested that iFGF23 and iPTH may be useful markers of the calcium status after KTx. However, no correlation was noted in PEKT group.
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16
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Oruc A, Ersoy A, Kocaeli AA, Yildiz A, Gul OO, Ertürk E, Ersoy C. Association Between Resistance to Cinacalcet and Parathyroid Gland Hyperplasia in Kidney Transplant Recipients with Persistent Hypercalcemia. Int J Organ Transplant Med 2020; 11:107-114. [PMID: 32913586 PMCID: PMC7471614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Persistent hypercalcemia and hyperparathyroidism after successful kidney transplantation can be detrimental in some recipients and should be ameliorated. OBJECTIVE To point out the concerns regarding resistance to cinacalcet in kidney transplant recipients with persistent hypercalcemia. METHODS 14 renal transplant recipients who received cinacalcet treatment because of persistent hypercalcemia were included in the study. Serum creatinine, estimated glomerular filtration rate (eGFR), calcium, phosphorus, and intact parathyroid hormone (PTH) levels at the baseline and throughout the treatment, and ultrasonography and parathyroid scintigraphy findings were recorded. RESULTS Cinacalcet treatment was initiated after a mean±SD of 20.7±19.7 months of transplantation and maintained for 16.9±7.9 months. Serum calcium levels were significantly decreased with the cinacalcet treatment. There were no significant changes in serum creatinine, eGFR, phosphorus, and PTH levels. In all participants, serum calcium levels were increased from 9.8±0.6 to 11.1±0.6 mg/dL (p<0.001) within 1 month of cessation of cinacalcet. 7 recipients with adenoma-like hyperplastic glands underwent parathyroidectomy (PTx) due to failure with cinacalcet. CONCLUSION Cinacalcet may be an appropriate treatment for a group of recipients with hypercalcemia without adenoma-like hyperplastic glands or who had a contraindication for surgery. Recipients with enlarged parathyroid gland may resist to cinacalcet-induced decrease in serum PTH, although the concomitant hypercalcemia may be corrected.
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Affiliation(s)
- A. Oruc
- Uludag University Faculty of Medicine, Department of Nephrology, Bursa, Turkey,Correspondence: Aysegul Oruc, MD, Uludag University School of Medicine, Department of Nephrology, 16059, Bursa, Turkey. ORCID: 0000-0002-0342-9692, Tel: +90-506-204-9350, E-mail:
| | - A. Ersoy
- Uludag University Faculty of Medicine, Department of Nephrology, Bursa, Turkey
| | - A. A. Kocaeli
- Uludag University Faculty of Medicine, Department of Endocrinology, Bursa, Turkey
| | - A. Yildiz
- Uludag University Faculty of Medicine, Department of Nephrology, Bursa, Turkey
| | - O. O. Gul
- Uludag University Faculty of Medicine, Department of Endocrinology, Bursa, Turkey
| | - E. Ertürk
- Uludag University Faculty of Medicine, Department of Endocrinology, Bursa, Turkey
| | - C. Ersoy
- Uludag University Faculty of Medicine, Department of Endocrinology, Bursa, Turkey
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17
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Alagoz S, Trabulus S. Long-Term Evaluation of Mineral Metabolism After Kidney Transplantation. Transplant Proc 2019; 51:2330-2333. [PMID: 31402243 DOI: 10.1016/j.transproceed.2019.01.181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 01/28/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Persistence of abnormalities in mineral metabolism is common after kidney transplantation and appears to have a negative effect on survival. We aimed to evaluate the mineral metabolism and identify risk factors for persistent hyperparathyroidism (HPT) over 10 years. METHODS We retrospectively analyzed the medical records of 176 consecutive renal transplant patients. Serum creatinine, calcium, phosphorus, and intact parathyroid hormone (iPTH) levels before and after transplantation up to the 10th year post transplantation were recorded for 11 different dates. Calcium > 10.2 mg/dL was considered hypercalcemia, phosphorus < 2.5 mg/dL was considered hypophosphatemia, and iPTH > 2.5 times the upper limit was considered HPT. RESULTS After a major fall in the first 3 months, iPTH steadily decreased over 5 years. Thereafter, it stabilized at a level of 1.5 times the upper limit. Rates of persistent HPT were 9.2% and 10.7% in the fifth and 10th years, respectively. The rate of hypercalcemia increased up to 21.7% at the ninth month, and after 10 years, it was 5.9%. The rate of hypophosphatemia peaked at 33.3% in the first month, and it was 8.9% in 10th year. Multivariate analysis revealed that calcium (P = .047) and phosphorus (P = .041) at the time of transplantation and female sex (P = .037) were independent predictors of persistent HPT in the first year. iPTH correlated significantly with kidney function and pre-transplant iPTH. CONCLUSIONS High serum levels of iPTH, calcium, and phosphorus at the time of transplantation were risk factors for persistent HPT in kidney transplant recipients, especially when renal function was suboptimal.
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Affiliation(s)
- Selma Alagoz
- Division of Nephrology, Department of Internal Medicine, University of Health Sciences, Bagcilar Training and Research Hospital, Istanbul, Turkey.
| | - Sinan Trabulus
- Division of Nephrology, Department of Internal Medicine, Istanbul University Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
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18
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Lynch Cronin I, Byrne F, Doyle R, Fraser WD, Chipchase A, Eustace JA. The Effect of Short-Term Vitamin D Supplementation on Calcium Status in Vitamin D Insufficient Renal Transplant Recipients at Risk of Hypercalcemia. J Ren Nutr 2019; 29:181-187. [DOI: 10.1053/j.jrn.2018.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/08/2018] [Accepted: 11/18/2018] [Indexed: 12/28/2022] Open
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19
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Pathogenesis and treatment of electrolyte problems post transplant. Curr Opin Pediatr 2019; 31:213-218. [PMID: 30585865 DOI: 10.1097/mop.0000000000000715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Electrolyte abnormalities posttransplant are common occurrences that can have significant short-term and long-term effects on graft outcome and patient quality of life. Understanding the pathophysiology of these electrolyte derangements can help guide management to optimize bone health and minimize cardiovascular disease. This review explores the pathogenesis of the most common postrenal transplant electrolytes abnormalities as well as current treatment options. RECENT FINDINGS Clarifications of the role of FGF-23 has improved our understanding of posttransplant bone disease in addition to the known roles of hyperparathyroidism and vitamin D. The mechanisms of renal electrolyte wasting by immunosuppressive agents give insight into potential treatment options for hyperkalemia and hypomagnesemia. SUMMARY Understanding the pathogenesis of the common electrolyte abnormalities found post renal transplant may lead to targeted treatment options that in turn may improve transplant complications. Further studies are required to evaluate the effects on long-term outcomes of renal allografts.
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20
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Pochineni V, Rondon-Berrios H. Electrolyte and Acid-Base Disorders in the Renal Transplant Recipient. Front Med (Lausanne) 2018; 5:261. [PMID: 30333977 PMCID: PMC6176109 DOI: 10.3389/fmed.2018.00261] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022] Open
Abstract
Kidney transplantation is the current treatment of choice for patients with end-stage renal disease. Innovations in transplantation and immunosuppression regimens have greatly improved the renal allograft survival. Based on recently published data from the Scientific Registry of Transplant recipients, prevalence of kidney transplants is steadily rising in the United States. Over 210,000 kidney transplant recipients were alive with a functioning graft in mid-2016, which is nearly twice as many as in 2005. While successful renal transplantation corrects most of the electrolyte and mineral abnormalities seen in advanced renal failure, the abnormalities seen in the post-transplant period are surprisingly different from those seen in chronic kidney disease. Multiple factors contribute to the high prevalence of these abnormalities that include level of allograft function, use of immunosuppressive medications and metabolic changes in the post-transplant period. Electrolyte disturbances are common in patients after renal transplantation, and several studies have tried to determine the clinical significance of these disturbances. In this manuscript we review the key aspects of the most commonly found post-transplant electrolyte abnormalities. We focus on their epidemiology, pathophysiology, clinical manifestations, and available treatment approaches.
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Affiliation(s)
- Vaishnavi Pochineni
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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21
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Vangala C, Pan J, Cotton RT, Ramanathan V. Mineral and Bone Disorders After Kidney Transplantation. Front Med (Lausanne) 2018; 5:211. [PMID: 30109232 PMCID: PMC6079303 DOI: 10.3389/fmed.2018.00211] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/09/2018] [Indexed: 12/16/2022] Open
Abstract
The risk of mineral and bone disorders among patients with chronic kidney disease is substantially elevated, owing largely to alterations in calcium, phosphorus, vitamin D, parathyroid hormone, and fibroblast growth factor 23. The interwoven relationship among these minerals and hormones results in maladaptive responses that are differentially affected by the process of kidney transplantation. Interpretation of conventional labs, imaging, and other fracture risk assessment tools are not standardized in the post-transplant setting. Post-transplant bone disease is not uniformly improved and considerable variation exists in monitoring and treatment practices. A spectrum of abnormalities such as hypophosphatemia, hypercalcemia, hyperparathyroidism, osteomalacia, osteopenia, and osteoporosis are commonly encountered in the post-transplant period. Thus, reducing fracture risk and other bone-related complications requires recognition of these abnormalities along with the risk incurred by concomitant immunosuppression use. As kidney transplant recipients continue to age, the drivers of bone disease vary throughout the post-transplant period among persistent hyperparathyroidism, de novo hyperparathyroidism, and osteoporosis. The use of anti-resorptive therapies require understanding of different options and the clinical scenarios that warrant their use. With limited studies underscoring clinical events such as fractures, expert understanding of MBD physiology, and surrogate marker interpretation is needed to determine ideal and individualized therapy.
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Affiliation(s)
- Chandan Vangala
- Division of Nephrology and Solid-Organ Transplantation, Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Jenny Pan
- Division of Nephrology and Solid-Organ Transplantation, Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Ronald T Cotton
- Division of Abdominal Transplantation, Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Venkat Ramanathan
- Division of Nephrology and Solid-Organ Transplantation, Michael E. DeBakey VA Medical Center, Houston, TX, United States
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Mascia G, Argiolas D, Carta E, Michittu MB, Piredda GB. Acute Kidney Injury Secondary to Hypercalcemia in a Kidney Transplant Patient With Pneumocystis jirovecii Pneumonia: A Case Report. Transplant Proc 2018; 51:220-222. [PMID: 30736974 DOI: 10.1016/j.transproceed.2018.04.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Persistent hyperparathyroidism is one of the main causes of hypercalcemia following kidney transplantation; differential diagnosis is required. CASE PRESENTATION We report the case of a 61-year-old kidney transplant recipient who underwent transplant in September 2016. She was admitted in March 2017 presenting with a 3-week history of asthenia, hypotension, and cough. Laboratory analysis showed acute kidney injury with hypercalcemia and elevation of inflammatory markers. She was initially treated with hydration therapy. A few days after admission she developed respiratory failure: chest computed tomography showed a ground-glass pattern. A diagnosis of Pneumocystis jirovecii was made on bronchoalveolar lavage. A subsequent graft biopsy was performed that revealed intratubular calcium deposition without signs of rejection. The patient was given trimethoprim/sulfamethoxazole, with improvement in pulmonary and renal function as well as improvement in hypercalcemia. CONCLUSIONS P jirovecii infection can trigger activation of intra-alveolar macrophages that leads to extrarenal vitamin D production with subsequent hypercalcemia. This rare event should be considered in renal transplant patients with pulmonary infection accompanied by hypercalcemia. In our case, hypercalcemia also provoked acute kidney injury.
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Affiliation(s)
- G Mascia
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - D Argiolas
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - E Carta
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy.
| | - M B Michittu
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - G B Piredda
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
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Demir E, Karaoglan C, Yegen G, Sair B, Yazici H, Turkmen A, Sever MS. Extreme hypercalcemia in a kidney transplant recipient. CEN Case Rep 2018; 7:229-233. [PMID: 29705974 DOI: 10.1007/s13730-018-0334-1] [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: 12/26/2017] [Accepted: 04/21/2018] [Indexed: 10/17/2022] Open
Abstract
Post-transplant hypercalcemia is a major problem in renal transplant recipients, which may negatively affect both graft and patient survival. In this paper, we present a 66-year-old male kidney transplant recipient, who was admitted to our clinic with symptoms of fever, nausea, vomiting and lethargy. Laboratory data showed good renal function; however, a serum calcium level of 22.1 mg/dL. The patient was treated by isotonic saline together with furosemide and methylprednisolone. Because of treatment resistance, subcutaneous calcitonin and ibandronate were added to the treatment protocol as well. Since all these medications were not effective, hemodialysis with low-calcium (1.25 mmol/L) dialysate was applied for three consecutive days, which resulted in normalization of serum calcium. Several investigations were carried out for diagnosing the underlying etiology. Positron-emission tomography (PET)/CT revealed a strong diffuse uptake of FDG in the bones and spleen. A bone marrow biopsy showed diffuse interstitial infiltration of CD20 + neoplastic B cells and, thus, post transplant lymphoproliferative disease (PTLD) was diagnosed. Tacrolimus was switched to everolimus, mycophenolate mofetil was stopped, while treatment with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) was initiated. Despite all therapeutic interventions, the patient died of septic shock in the intensive care unit on the 10th day of emergency service admission. Importance of hemodialysis as an emergent treatment modality in extreme hypercalcemia, and unfavorable course of PTLD were underlined.
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Affiliation(s)
- Erol Demir
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Cagla Karaoglan
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Gulcin Yegen
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Betul Sair
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Halil Yazici
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aydin Turkmen
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Sukru Sever
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Laucyte-Cibulskiene A, Boreikaite E, Aucina G, Gudynaite M, Rudminiene I, Anisko S, Vareikiene L, Gumbys L, Valanciene D, Ryliskyte L, Strupas K, Rimsevicius L, Miglinas M. Usefulness of pretransplant aortic arch calcification evaluation for kidney transplant outcome prediction in one year follow-up. Ren Fail 2018; 40:201-208. [PMID: 29619867 PMCID: PMC6014335 DOI: 10.1080/0886022x.2018.1455588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Vascular calcification (VC) is linked to post-transplant cardiovascular events and hypercalcemia which may influence kidney graft function in the long term. We aimed to evaluate whether pretransplant aortic arch calcification (AoAC) can predict post-transplant cardiovascular or cerebrovascular events (CVEs), and to assess its association with post-transplant plasma calcium levels and renal function in one-year follow-up. Our single-center observational prospective study enrolled 37 kidney transplant recipients (KTR) without previous history of vascular events. Two radiologists evaluated pretransplant AoAC on chest X-ray as suggested by Ogawa et al. in 2009. Cohen’s kappa coefficient was 0.71. The mismatching results were repeatedly reviewed and resulted in consensus. Carotid-femoral (cfPWV) and carotid-radial pulse wave velocity (crPWV) was measured using applanation tonometry before and one year after transplantation. Patient clinical, biochemical data, and cardiovascular/CVE rate were monitored within 1 year. We found out that eGFR1year correlated with eGFRdischarge and calcium based on hospital discharge data (β = 0.563, p = .004 and β = 51.360, p = .026, respectively). Multivariate linear regression revealed that donor age, donor gender, and recipient eGFRdischarge (R-squared 0.65, p = .002) better predict eGFR1year than AoAC combined with recipient eGFRdischarge (R-squared 0.35, p = .006). During 1-year follow-up, four (10.81%) patients experienced cardiovascular events, which were predicted by PWV ratio (HR 7.549, p = .045), but not related to AoAC score (HR 1.044, p = .158). In conclusion, KTR without previous vascular events have quite low cardiovascular/CVE rate within 1-year follow-up. VC evaluated as AoAC on pretransplant chest X-ray together with recipient eGFRdischarge could be related to kidney function in one-year follow-up.
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Affiliation(s)
- Agne Laucyte-Cibulskiene
- a Clinic of Gastroneterology, Nephrourology and Abdominal Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
| | | | - Gediminas Aucina
- b Faculty of Medicine , Vilnius University , Vilnius , Lithuania
| | - Migle Gudynaite
- c Centre of Nephrology, Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Ilona Rudminiene
- c Centre of Nephrology, Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Sigita Anisko
- c Centre of Nephrology, Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Loreta Vareikiene
- c Centre of Nephrology, Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Liutauras Gumbys
- d Centre of Radiology and Nuclear Medicine , Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Dileta Valanciene
- b Faculty of Medicine , Vilnius University , Vilnius , Lithuania.,d Centre of Radiology and Nuclear Medicine , Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Ligita Ryliskyte
- b Faculty of Medicine , Vilnius University , Vilnius , Lithuania
| | - Kestutis Strupas
- a Clinic of Gastroneterology, Nephrourology and Abdominal Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
| | - Laurynas Rimsevicius
- a Clinic of Gastroneterology, Nephrourology and Abdominal Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
| | - Marius Miglinas
- a Clinic of Gastroneterology, Nephrourology and Abdominal Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
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25
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First investigation on microcrystalline pathologies of kidney allografts through cellular scale physicochemical techniques. CR CHIM 2016. [DOI: 10.1016/j.crci.2015.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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26
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Sharma AK, Masterson R, Holt SG, Tan SJ, Hughes PD, Chu M, Jayadeva P, Toussaint ND. Impact of cinacalcet pre-transplantation on mineral metabolism in renal transplant recipients. Nephrology (Carlton) 2016; 21:46-54. [PMID: 26072678 DOI: 10.1111/nep.12536] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2015] [Indexed: 11/30/2022]
Abstract
AIM Cinacalcet is effective in reducing parathyroid hormone (PTH) in patients on dialysis. Reports of biochemical profiles and other clinical outcomes in patients discontinuing cinacalcet at time of renal transplantation are limited. METHODS A retrospective study assessing markers of mineral metabolism, graft and patient outcomes in renal transplant recipients to determine differences in patients discontinuing cinacalcet (C+) compared with patients not treated with cinacalcet (C-) at time of transplantation. To allow for differences between groups in pre-transplant biochemical parameters, we also analysed a matched cohort of C- with C+ recipients (2:1), matched for age, calcium and PTH levels at transplantation. RESULTS Five hundred thirty-two recipients (460 C-, 72 C+), transplanted January 2006-December 2012, were analysed, mean age 48.0 ± 12.7 years and 64.3% were men. At a median 42.9 months follow up, there were 10 deaths (1.9%), 56 allograft loss (10.6%) and 5 parathyroidectomies post-transplant (0.8%). Median PTH immediately pre-transplant was higher in C+ versus C- (50.7(25.4-75.2) versus 28.3(13.9-49.7) pmol/L, P < 0.001). Twelve-month post-transplant PTH was reduced but higher in C+ (11.7(6.9-21.2) vs 7.2(4.6-11.2) pmol/L, P < 0.001). Mean calcium was higher for C+ versus C- at 12 months (2.50 ± 0.19 vs 2.43 ± 0.17 mmol/L, P < 0.001), with differences to 4 years post-transplant. No difference was seen in renal function, graft loss, post-transplant parathyroidectomy rate and mortality. In the matched cohort (144 C- vs 72 C+), similar findings were also seen. CONCLUSION Differences in mineral metabolism post-transplant are seen with cinacalcet pre-transplant compared with no cinacalcet. Transplant recipients discontinuing cinacalcet had higher post-transplant PTH and calcium although the clinical significance is unclear.
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Affiliation(s)
- Ashish K Sharma
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Rosemary Masterson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter D Hughes
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Melissa Chu
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Pavithra Jayadeva
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
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Çeltik A, Şen S, Yılmaz M, Demirci MS, Aşçı G, Tamer AF, Sarsık B, Hoşcoşkun C, Töz H, Ok E. The effect of hypercalcemia on allograft calcification after kidney transplantation. Int Urol Nephrol 2016; 48:1919-1925. [DOI: 10.1007/s11255-016-1391-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 08/02/2016] [Indexed: 11/28/2022]
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Prevalence of Hypercalcaemia in a Renal Transplant Population: A Single Centre Study. Int J Nephrol 2016; 2016:7126290. [PMID: 27493801 PMCID: PMC4963578 DOI: 10.1155/2016/7126290] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/01/2016] [Accepted: 05/29/2016] [Indexed: 11/25/2022] Open
Abstract
Introduction. Postrenal transplant bone disease is a significant problem. Factors influencing postrenal transplant bone status include high dose acute and low dose long-term steroid use, persistent hypercalcaemia, and graft failure. In this study, we aimed to determine the prevalence of hypercalcaemia and to evaluate the risk factors for postrenal transplant hypercalcaemia in long-term renal transplant patients at our centre. Methods. This is a biochemical audit in which we studied renal transplant recipients from the Central Northern Adelaide Renal Transplant Services, South Australia. Inclusion criteria include kidney transplant patients with functioning graft since 1971 and at least 3 months after transplantation at the time of analysis. Hypercalcaemia was defined as persistently elevated serum corrected calcium greater than or equal to 2.56 mmol/L for three consecutive months. Results. 679 renal transplant recipients with a functioning graft were studied and 101 were hypercalcaemic between March 2011 and June 2011 (15%). 60% of the hypercalcaemic patients were male and 40% were female, with chronic glomerulonephritis (39%) being the commonest cause of their end stage kidney disease (ESKD). Prevalence was similar in those that had haemodialysis and peritoneal dialysis pretransplantation. Hypercalcaemia in the renal transplant population was not secondary to suboptimal allograft function but secondary to pretransplantation hyperparathyroidism with persistent high parathyroid hormone (PTH) levels after transplantation. Conclusion. There is a high prevalence of hypercalcaemia (15%) in renal transplant recipients. The predominant cause for hypercalcaemia is pretransplantation hyperparathyroidism. The magnitude of pretransplantation hyperparathyroidism is the major determinant for long-term parathyroid function rather than graft function or pretransplantation duration on dialysis or mode of dialysis.
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29
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Scalea JR, Levi ST, Ally W, Brayman KL. Tacrolimus for the prevention and treatment of rejection of solid organ transplants. Expert Rev Clin Immunol 2016; 12:333-42. [PMID: 26588770 DOI: 10.1586/1744666x.2016.1123093] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Since its introduction to the antirejection armamentarium in 1994, tacrolimus has become the workhorse of transplant professionals for avoidance of solid organ transplant rejection. Not only does tacrolimus have potent immunosuppressive qualities that prevent rejection, but dosing is straight forward and it is generally well tolerated. However, in the long term, conditions such as calcineurin inhibitor nephrotoxicity can become a problem. A discussion of the compound, the pharmacokinetics, history, and current approved uses for tacrolimus is described. Indeed, tacrolimus is the most important drug for preventing transplant rejection. However, the increased appreciation for significant side effects, particularly in the long term, has led to building interest in new agents with different mechanisms of action and different metabolism.
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Affiliation(s)
- Joseph R Scalea
- a Division of Transplantation, Department of Surgery , University of Wisconsin , Madison , VA , USA
| | - Shoshana T Levi
- b School of Medicine , University of Virginia , Charlottesville , VA , USA
| | - Winston Ally
- c Department of Pharmacy Services , University of Virginia Health System , Charlottesville , VA , USA
| | - Kenneth L Brayman
- b School of Medicine , University of Virginia , Charlottesville , VA , USA
- d Division of Transplantation, Department of Surgery , University of Virginia , Charlottesville , VA , USA
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Lorenz K, Bartsch DK, Sancho JJ, Guigard S, Triponez F. Surgical management of secondary hyperparathyroidism in chronic kidney disease--a consensus report of the European Society of Endocrine Surgeons. Langenbecks Arch Surg 2015; 400:907-27. [PMID: 26429790 DOI: 10.1007/s00423-015-1344-5] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 09/18/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite advances in the medical management of secondary hyperparathyroidism due to chronic renal failure and dialysis (renal hyperparathyroidism), parathyroid surgery remains an important treatment option in the spectrum of the disease. Patients with severe and complicated renal hyperparathyroidism (HPT), refractory or intolerant to medical therapy and patients with specific requirements in prospect of or excluded from renal transplantation may require parathyroidectomy for renal hyperparathyroidism. METHODS Present standard and actual controversial issues regarding surgical treatment of patients with hyperparathyroidism due to chronic renal failure were identified, and pertinent literature was searched and reviewed. Whenever applicable, evaluation of the level of evidence concerning diagnosis and management of renal hyperparathyroidism according to standard criteria and recommendation grading were employed. Results were discussed at the 6th Workshop of the European Society of Endocrine Surgeons entitled Hyperparathyroidism due to multiple gland disease: An evidence-based perspective. RESULTS Presently, literature reveals scant data, especially, no prospective randomized studies to provide sufficient levels of evidence to substantiate recommendations for surgery in renal hyperparathyroidism. Appropriate surgical management of renal hyperparathyroidism involves standard bilateral exploration with bilateral cervical thymectomy and a spectrum of four standardized types of parathyroid resection that reveal comparable outcome results with regard to levels of evidence and recommendation. Specific patient requirements may favour one over the other procedure according to individualized demands. CONCLUSIONS Surgery for patients with renal hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves efficient control of hyperparathyroidism. The overall success rate and long-term control of renal hyperparathyroidism and optimal handling of postoperative metabolic effects also depend on the timely indication, individually suitable type of parathyroid resection and specialized endocrine surgery.
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Affiliation(s)
- Kerstin Lorenz
- Department of General-, Visceral-, and Vascular Surgery, Martin-Luther University of Halle-Wittenberg, Ernst-Grube-Str. 40, Halle (Saale), 06120, Germany.
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstraße 1, Marburg, 35043, Germany.
| | - Juan J Sancho
- Department of General Surgery, Endocrine Surgery Unit, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, Barcelona, 08003, Spain.
| | - Sebastien Guigard
- Department of Thoracic and Endocrine Surgery, University Hospitals of Geneva, Switzerland, Rue Gabrielle Perret-Gentil 4, 14, Geneva, 1211, Switzerland.
| | - Frederic Triponez
- Chirurgie thoracique et endocrinienne, Hôpitaux Universitaires de Genève, Rue Gabrielle Perret-Gentil 4, 14, Geneva, 1211, Switzerland.
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Barros X, Fuster D, Paschoalin R, Oppenheimer F, Rubello D, Perlaza P, Pons F, Torregrosa JV. Changes in bone mineral metabolism parameters, including FGF23, after discontinuing cinacalcet at kidney transplantation. Endocrine 2015; 49:267-73. [PMID: 25154517 DOI: 10.1007/s12020-014-0400-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 08/18/2014] [Indexed: 12/11/2022]
Abstract
Little is known about the effects of the administration of cinacalcet in dialytic patients who are scheduled for kidney transplantation, and in particular about the changes in FGF23 and other mineral metabolism parameters after surgery compared with recipients not on cinacalcet at kidney transplantation. We performed a prospective observational cohort study with recruitment of consecutive kidney transplant recipients at our institution. Patients were classified according to whether they were under treatment with cinacalcet before transplantation. Bone mineral metabolism parameters, including C-terminal FGF23, were measured at baseline, on day 15, and at 1, 3, and 6 months after transplantation. In previously cinacalcet-treated patients, cinacalcet therapy was discontinued on the day of surgery and was not restarted after transplantation. A total of 48 kidney transplant recipients, 20 on cinacalcet at surgery and 28 cinacalcet non-treated patients, completed the follow-up. Serum phosphate declined significantly in the first 15 days after transplantation with no differences between the two groups, whereas cinacalcet-treated patients showed higher FGF23 levels, although not significant. After transplantation, PTH and serum calcium were significantly higher in cinacalcet-treated patients. We conclude that patients receiving cinacalcet on dialysis presented similar serum phosphate levels but higher PTH and serum calcium levels during the initial six months after kidney transplantation than cinacalcet non-treated patients. The group previously treated with cinacalcet before transplantation showed higher FGF23 levels without significant differences, so further studies should investigate its relevance in the management of these patients.
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Affiliation(s)
- Xoana Barros
- Nephrology and Renal Transplant Department, Hospital Clinic, Barcelona, Spain
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Moiz A, Javed T, Garces J, Dornelles A, Staffeld-Coit C. Posttransplant nephrocalcinosis is associated with poor renal allograft function: a single-center experience. Ochsner J 2015; 15:25-29. [PMID: 25829877 PMCID: PMC4365843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Nephrocalcinosis, characterized by intratubular and/or parenchymal deposition of calcium phosphate and calcium oxalate crystals, is frequently seen in renal allograft biopsies; however, the clinical consequence of this histologic finding remains unknown. Kidney transplant recipients with good allograft function usually demonstrate improvement in biochemical parameters; however, persistent hyperparathyroidism remains prevalent in this population of patients. We identified renal allografts with nephrocalcinosis and evaluated the effects on renal allograft function and survival. METHODS We conducted a single-center, retrospective review of kidney allograft biopsies performed at our center from December 1, 2006 to November 30, 2012. Biopsies with nephrocalcinosis as the primary diagnosis were included in the final analysis. Biochemical parameters at the time of biopsy included serum creatinine, phosphate, calcium, intact parathyroid hormone (iPTH), 25-hydroxy vitamin D, and albumin. Serum creatinine was measured at 1, 3, 6, and 12 months after nephrocalcinosis was diagnosed. The use of calcimimetics, vitamin D analogs, active vitamin D, and bisphosphonates was also reviewed. RESULTS We identified 12 patients with nephrocalcinosis as the primary diagnosis on renal biopsy. The average age of these patients was 52.2 ± 11.9 years, and the average time since transplantation was 2.3 ± 2.7 years. The baseline serum creatinine was 1.37 ± 0.4 mg/dL before the onset of acute kidney injury (AKI). Mean iPTH and 25-hydroxy vitamin D at the time of AKI were 495.66 ± 358.9 pg/mL and 19.9 ± 13.3 ng/mL, respectively. Renal function deteriorated in all patients, and mean serum creatinine at 12-month follow up was 2.37 ± 1.3 mg/dL (P=0.028). One patient progressed to end-stage renal disease at the end of the study period. CONCLUSION The histologic finding of nephrocalcinosis is associated with poor renal allograft function. Metabolic abnormalities including hyperparathyroidism persist in renal allograft recipients despite normal allograft function and may be associated with the development of nephrocalcinosis in renal transplant recipients.
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Affiliation(s)
- Abdul Moiz
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Tariq Javed
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
| | - Jorge Garces
- Department of Nephrology, Ochsner Clinic Foundation, New Orleans, LA
| | - Adriana Dornelles
- Office of Biostatistical Support, Ochsner Clinic Foundation, New Orleans, LA
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Dewberry LC, Tata S, Graves S, Weber CJ, Sharma J. Predictors of tertiary hyperparathyroidism: Who will benefit from parathyroidectomy? Surgery 2014; 156:1631-6; discussion 1636-7. [PMID: 25456966 DOI: 10.1016/j.surg.2014.08.070] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 08/21/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Tertiary hyperparathyroidism (3°HPT) is hyperparathyroidism with hypercalcemia after renal transplantation. With unclear guidelines for parathyroidectomy (PTX), this study aims to determine which renal transplant patients develop 3°HPT and would benefit from PTX. METHODS We performed a retrospective review of patients who received a renal transplant between 1994 and 2013; 105 patients who underwent near total PTX (NTPTX) were compared with 180 renal transplant control patients who did not undergo NTPTX. RESULTS Calcium and PTH varied significantly between groups (P < .001). One year before transplant, the mean serum calcium was 9.7 ± 1.1 mg/dL in the NTPTX group versus 9.1 ± 0.9 mg/dL in the control group (P < .01). One month after transplant, the mean calcium in the NTPTX group was 10.4 ± 1.1 versus 9.4 ± 0.6 mg/dL in the control group (P < .001). One year before renal transplant, the median serum PTH level was 723 pg/mL (range, 557-919) in the NTPTX group versus 212 pg/mL (range, 160-439) in the control group (P < .01). One-month post renal transplant, the NTPTX group had a median PTH of 351 pg/mL (range, 199-497) versus 112 pg/mL (range, 73-178) pg/mL in the control group (P < .01). CONCLUSION Before and after renal transplantation, PTH and calcium levels can serve as predictors of 3°HPT.
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Affiliation(s)
- Lindel C Dewberry
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Sudha Tata
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Sharon Graves
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Collin J Weber
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Jyotirmay Sharma
- Department of Surgery, Emory University School of Medicine, Atlanta, GA.
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Torregrosa JV, Morales E, Díaz JM, Crespo J, Bravo J, Gómez G, Gentil MÁ, Rodríguez Benot A, García MR, Jiménez VL, Gutiérrez Dalmau A, Jimeno L, Sáez MJP, Romero R, Gómez Alamillo C. Cinacalcet for hypercalcaemic secondary hyperparathyroidism after renal transplantation: a multicentre, retrospective, 3-year study. Nephrology (Carlton) 2014; 19:84-93. [PMID: 24428216 DOI: 10.1111/nep.12186] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2013] [Indexed: 01/05/2023]
Abstract
AIMS Our aim was to evaluate the long-term effect of cinacalcet in patients with hypercalcaemic secondary hyperparathyroidism (SHPT) after renal transplantation (RT) in order to expand real-world data in this population. METHODS We performed a multicentre, observational, retrospective study in 17 renal transplant units from Spain. We collected data from renal recipients with hypercalcaemic (calcium >10.2 mg/dL) SHPT (intact parathyroid hormone (iPTH) > 120 pg/mL) who initiated cinacalcet in the clinical practice. RESULTS We included 193 patients with a mean (standard deviation (SD)) age of 52 (12) years, 58% men. Cinacalcet treatment was initiated at a median of 20 months after RT (median dose 30 mg/day). Mean calcium levels decreased from a mean (SD) of 11.1 (0.6) at baseline to 10.1 (0.8) at 6 months (9.0% reduction, P < 0.0001). Median iPTH was reduced by 23.0% at 6 months (P = 0.0005) and mean phosphorus levels increased by 11.1% (P < 0.0001). The effects were maintained up to 3-years. No changes were observed in renal function or anticalcineurin drug levels. Only 4.1% of patients discontinued cinacalcet due to intolerance and 1.0% due to lack of efficacy. CONCLUSIONS In renal transplant patients with hypercalcaemic SHPT, cinacalcet controlled serum calcium, iPTH and phosphorus levels up to 3 years. Tolerability was good.
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Affiliation(s)
- Jose-Vicente Torregrosa
- Nephrology Service and Renal Transplant Unit, Hospital Clínic de Barcelona, Barcelona, Spain
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Van de Cauter J, Sennesael J, Haentjens P. Long-term evolution of the mineral metabolism after renal transplantation: a prospective, single-center cohort study. Transplant Proc 2014; 43:3470-5. [PMID: 22099822 DOI: 10.1016/j.transproceed.2011.09.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Abnormalities in bone and mineral metabolism are common after renal transplantation (RT) but information on their long-term time course is scarce. OBJECTIVES (1) Evaluate the time course of biochemical parameters of bone and mineral metabolism over 60 months after RT; (2) identify predictors for persistent hyperparathyroidism (HPT). DESIGN Prospective, longitudinal, single-center cohort study. METHODS We determined serum levels (mean values ± standard deviations) of intact parathyroid hormone (iPTH), calcium (Ca), phosphorus (P), magnesium (Mg), alkaline phosphatase (APh), calcitriol, and creatinine (Cr) preoperatively as well as 6, 12, 24, 36, 48, and 60 months after cadaveric RT in 49 patients. We in addition recorded demographic, clinical, and therapeutic data. RESULTS Pretransplantation iPTH stabilized from 194.2 ± 273.5 to 71.5 ± 50.7 ng/L at 6 months. Serum Ca (9.5 ± 1.1 mg/dL) and APh (81.9 ± 42.1 U/L) did not change. Baseline serum P (5.7 ± 1.8 mg/dL) and serum Mg (2.4 ± 0.4 mg/dL) decreased to normal ranges from month 6 onward. Low baseline calcitriol (22.4 ± 21.8 pmol/L) normalized slowly by 12 months (95.4 ± 46.7 pmol/L). Stable graft function (53.2 ± 15.8 mL/min) was achieved from 6 months onward. By 60 months, 26.5% of patients had a serum Ca above 9.8 mg/dL and serum P below 2.7 mg/dL; 22.4%, an Mg below 1.7 mg/dL and 8.2%, a serum iPTH more than 2.5-fold the upper limit of normal. Upon multiple regression analyses the iPTH at 60 months was influenced by a dialysis duration ≥ 2 years (β = 0.259, P = .003), body mass index > 25 kg/m(2) (β = 0.257, P = .006), baseline iPTH (β = 0.182, P = .036), serum Cr (β = 0.268, P = .002) and Mg (β = -0.242, P = .006). CONCLUSIONS Hypercalcemia, hypophosphatemia, hypomagnesemia, and elevated iPTH persist in a subset of post-RT patients. Pretransplantation iPTH and obesity, dialysis duration, and posttransplant serum creatininemia and hypomagnesemia independently contribute to persistent HPT.
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Affiliation(s)
- J Van de Cauter
- Department of Internal Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Tomei P, Zaza G, Granata S, Gatti D, Fraccarollo C, Gesualdo L, Boschiero L, Lupo A. Sclerostin and Dickkopf-1 in Post-menopausal Renal Allograft Recipients. Transplant Proc 2014; 46:2241-6. [DOI: 10.1016/j.transproceed.2014.07.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Tsujita M, Inaguma D, Goto N, Yamamoto T, Hiramitsu T, Katayama A, Takeda A, Kobayashi T, Morozumi K, Uchida K, Narumi S, Watarai Y, Tominaga Y. Beneficial effects of preemptive kidney transplantation on calcium and phosphorus disorders in early post-transplant recipients. Clin Exp Nephrol 2014; 19:319-24. [PMID: 24706030 DOI: 10.1007/s10157-014-0967-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 03/13/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recently, preemptive kidney transplantation (PKT) has increased in Japan; however, the effects of PKT on calcium (Ca) and phosphorus (Pi) metabolism are poorly understood. METHODS Thirty-two consecutive patients were enrolled in this study at Nagoya Daini Red Cross Hospital. Fifteen patients were in the PKT group and 17 patients were in the non-PKT group. Parameters of Ca and Pi metabolism, including fibroblast growth factor (FGF) 23 and intact parathyroid hormone, were measured before transplantation and 1, 3, and 24 weeks after transplantation. RESULTS FGF 23 decreased dramatically in both groups after transplantation; however, FGF 23 before transplantation and at 1 and 3 weeks after transplantation was significantly lower in the PKT group than in the non-PKT group (p < 0.05). Although iPTH levels were higher in the PKT group than in the non-PKT group before transplantation, these levels were lower in the PKT group at 24 weeks after transplantation (p < 0.05). Corrected Ca was lower at 24 weeks in the PKT group (p < 0.05), whereas Pi was lower in the non-PKT group at 1 and 3 weeks (p < 0.05), but not significantly different at 24 weeks. Multivariate linear regression analysis revealed that FGF 23 before transplantation was the strongest predictor of Ca and Pi disorders in early post-transplant recipients. CONCLUSIONS This study suggests that PKT has beneficial effects on Ca and Pi metabolism and pre-transplant FGF 23 levels are a good marker of post-transplant Ca and Pi metabolism disorders.
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Affiliation(s)
- Makoto Tsujita
- Department of the Kidney Disease Center, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 466-8650, Japan,
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Muirhead N, Zaltman JS, Gill JS, Churchill DN, Poulin-Costello M, Mann V, Cole EH. Hypercalcemia in renal transplant patients: prevalence and management in Canadian transplant practice. Clin Transplant 2013; 28:161-5. [PMID: 24329899 DOI: 10.1111/ctr.12291] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2013] [Indexed: 12/11/2022]
Abstract
Hypercalcemia, occurring in up to 25% of patients within 12 months following renal transplantation, and persistent hyperparathyroidism were evaluated following renal transplantation, by retrospective chart review of 1000 adult patients transplanted between January 1, 2003 and January 31, 2008 with at least six months follow-up. Serum calcium, parathyroid hormone, and phosphate levels were recorded at 12, 24, 36, and 48 months. Average follow-up was 766 (535) d (mean (SD); median 668 d). Majority were first transplants (85%); deceased donor 57%. Point prevalence of hypercalcemia (serum Ca(2+) > 2.6 mM) was 16.6% at month 12, 13.6% at month 24, 9.5% at month 36, and 10.1% at month 48. Point prevalence of serum parathyroid hormone (PTH) > 10 pM was 47.6% at month 12, 51.1% at month 24, 43.4% at month 36, and 39.3% at month 48. Estimated glomerular filtration rate (GFR) was maintained throughout and was not different between patients with or without hypercalcemia or elevated PTH. Cinacalcet was prescribed in 12% of patients with hypercalcemia and persistent hyperparathyroidism; parathyroidectomy was performed in 112/1000 patients, 15 post-transplant. Persistent hyperparathyroidism, often accompanied by hypercalcemia, is common following successful renal transplantation, but the lack of clear management suggests the need for further study and development of evidence-based guidelines.
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Affiliation(s)
- N Muirhead
- London Health Sciences Centre, London, ON, Canada
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Nobata H, Tominaga Y, Imai H, Uchida K. Hypocalcemia immediately after renal transplantation. Clin Transplant 2013; 27:E644-8. [PMID: 24033403 DOI: 10.1111/ctr.12221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND After renal transplantation (RTX), hypercalcemia, mainly due to persistent hyperparathyroidism, and hypophosphatemia, caused by the improved ability to excrete phosphorus in the renal tubules, are expected. However, immediately after RTX, a transient reduction in serum calcium (Ca) levels has been previously reported, the reason for which is not clear. PATIENTS AND METHODS In 21 patients receiving ABO compatible living donor kidney transplants, serum levels of Ca, phosphorus, intact parathyroid hormone (iPTH), 1,25-dihydroxyvitamin D, and tacrolimus were measured within three wk after RTX, along with urinary Ca and phosphorus excretion. The immunosuppressive regimen consisted of a three-drug combination including a glucocorticoid, a calcineurin inhibitor, and an antimetabolite agent. RESULTS Serum Ca levels declined significantly during the first post-operative week. Urinary Ca excretion increased immediately after RTX and gradually normalized. Increased urinary Ca excretion did not correlate with serum levels of iPTH and tacrolimus. CONCLUSIONS Immediately after RTX, regardless of serum iPTH and tacrolimus levels, transient increases in urinary Ca excretion and hypocalcemia were observed. Administration of glucocorticoids is one potential cause of inappropriate urinary Ca wasting.
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Affiliation(s)
- Hironobu Nobata
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Aichi Medical University School of Medicine, Nagakute, Japan
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Recovery versus persistence of disordered mineral metabolism in kidney transplant recipients. Semin Nephrol 2013; 33:191-203. [PMID: 23465505 DOI: 10.1016/j.semnephrol.2012.12.019] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In patients with end-stage renal disease, successful renal transplantation improves the quality of life and increases survival, as compared with long-term dialysis treatment. Although it long has been believed that successful kidney transplantation to a large extent solves the problem of chronic kidney disease-mineral and bone disorders (CKD-MBD), increasing evidence indicates that it only changes the phenotype of CKD-MBD. Posttransplant CKD-MBD reflects the effects of immunosuppression, previous CKD-MBD persisting after transplantation, and de novo CKD-MBD. A major and often-underestimated problem after successful renal transplantation is persistent hyperparathyroidism. Besides contributing to posttransplant hypercalcemia and hypophosphatemia, persistent hyperparathyroidism may be involved in the pathogenesis of allograft dysfunction (nephrocalcinosis), progression of vascular calcification, and bone disease (uncoupling of bone formation and bone resorption and bone mineral density loss) in renal transplant recipients. Similar to nontransplanted patients, CKD-MBD has a detrimental impact on (cardiovascular) mortality and morbidity. Additional studies urgently are needed to get more insights into the pathophysiology of posttransplant CKD-MBD. These new insights will allow for a more targeted and causal therapeutic approach.
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Onken JE, Bregman DB, Harrington RA, Morris D, Buerkert J, Hamerski D, Iftikhar H, Mangoo-Karim R, Martin ER, Martinez CO, Newman GE, Qunibi WY, Ross DL, Singh B, Smith MT, Butcher A, Koch TA, Goodnough LT. Ferric carboxymaltose in patients with iron-deficiency anemia and impaired renal function: the REPAIR-IDA trial. Nephrol Dial Transplant 2013; 29:833-42. [PMID: 23963731 DOI: 10.1093/ndt/gft251] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Iron-deficiency anemia in non-dialysis-dependent chronic kidney disease (NDD-CKD) frequently requires parenteral iron replacement, but existing therapies often require multiple administrations. We evaluated the efficacy and cardiovascular safety of ferric carboxymaltose (FCM), a non-dextran parenteral iron permitting large single-dose infusions, versus iron sucrose in patients with iron-deficiency anemia and NDD-CKD. METHODS A total of 2584 participants were randomized to two doses of FCM 750 mg in one week, or iron sucrose 200 mg administered in up to five infusions in 14 days. The primary efficacy endpoint was the mean change to highest hemoglobin from baseline to Day 56. The primary composite safety endpoint included all-cause mortality, nonfatal myocardial infarction, nonfatal stroke, unstable angina, congestive heart failure, arrhythmias and hyper- and hypotensive events. RESULTS The mean hemoglobin increase was 1.13 g/dL in the FCM group and 0.92 g/dL in the iron sucrose group (95% CI, 0.13-0.28). Similar results were observed across all subgroups, except Stage 2 CKD. More subjects in the FCM group achieved a hemoglobin increase of ≥ 1.0 g/dL between baseline and Day 56 (48.6 versus 41.0%; 95% CI, 3.6-11.6%). There was no significant difference between FCM and iron sucrose recipients with respect to the primary composite safety endpoint, including the major adverse cardiac events of death, myocardial infarction, or stroke. A significant difference in the number of protocol-defined, predominantly transient hypertensive episodes was observed in the FCM group. CONCLUSIONS Two 750-mg infusions of FCM are a safe and effective alternative to multiple lower dose iron sucrose infusions in NDD-CKD patients with iron-deficiency anemia.
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Affiliation(s)
- Jane E Onken
- Duke Clinical Research Institute, Durham, NC, USA
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Hiemstra TF, Brown AJD, Chaudhry AN, Walsh M. Association of calcium, phosphate and parathyroid hormone with renal allograft function: a retrospective cohort study. Am J Nephrol 2013; 37:339-45. [PMID: 23548209 DOI: 10.1159/000348376] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/24/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Significant variations in postoperative levels of parathyroid hormone (PTH), calcium and phosphate exist after renal transplantation, but whether they affect allograft function is unknown. We investigated the association between early post-transplant levels of PTH, calcium and phosphate and graft function. METHODS We performed a single-centre cohort study of renal transplant recipients from Addenbrooke's Hospital, Cambridge, between April 1997 and March 2007, evaluating the association between plasma calcium, phosphate and PTH 1 month after transplantation and change in epidermal growth factor receptor (eGFR) in the first 12 months after transplantation (estimated using the Modification of Diet in Renal Disease Study equation). Differences in eGFR between 26 and 52 weeks after transplantation were computed using mixed effects linear regression models for repeated measures of eGFR, while adjusting for sociodemographic and biochemical variables. RESULTS Three hundred and forty-three patients were eligible for study. The mean age (standard deviation) at transplant was 43 years (13 years). Between 30 and 90 days after transplantation, the median (25th-75th percentile) eGFR was 33 (26-50) ml/min/1.73 m(2), the mean calcium level was 2.4 (0.17) mmol/l and the mean phosphate level was 0.78 (0.23) mmol/l. There was a significant interaction between calcium and phosphate levels (p = 0.006). In patients with low levels of phosphate, higher levels of calcium were associated with declining eGFR over time. However, in patients with a high phosphate level, higher calcium was associated with improved eGFR. CONCLUSIONS Higher serum calcium in patients with low serum phosphate after transplantation is associated with a decline in graft function during the first year after transplantation. Disorders of mineral metabolism after transplant may represent an important therapeutic target to preserve allograft function.
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Affiliation(s)
- Thomas F Hiemstra
- Division of Renal Medicine, Department of Medicine, University of Cambridge, Cambridge, UK
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Withdrawal of cinacalcet at the time of renal transplantation is not a risk factor for allograft calcifications in the early posttransplantation period. Transplant Proc 2013; 44:2379-80. [PMID: 23026598 DOI: 10.1016/j.transproceed.2012.07.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Secondary hyperparathyroidism is a relevant problem in patients on dialysis. Cinacalcet in regular clinical practice increases the percentage of patients achieving treatment targets for PTH, Ca and P. We evaluated allograft calcification in serial protocol biopsies after transplantation among patients receiving Cinacalcet on dialysis but discontinued after surgery. METHODS This retrospective single-centre study included kidney allograft recipients who were receiving Cinacalcet for more than 6 months before surgery and had it withdrawn thereafter. The 46 patients including 17 women showed a mean overall age of 54 ± 30 years. Protocol graft biopsy was performed at 3 and at 12 months. Biochemical analyses at the time of biopsy included blood levels of creatinine, phosphorus, calcium, alkaline phosphatases, iPTH, and proteinuria. RESULTS Any biopsy showed nephrocalcinosis either intratubular calcifications, or in the parenchyma. There were no changes in calcemia (10.22 ± 0.7 to 10.27 ± 0.7 mg/dL), in alkaline phosphatase (259 ± 119.6 to 255 ± 122.3 mg/dL) nor in iPTH (317 ± 220.2 to 320 ± 168.8 pg/mL) between 3 and 12 months respectively. There was a slight but non-significant increase in serum phosphorus (2.79 ± 0.8 to 3.22 ± 0.9 mg/dL), serum creatinine (1.53 ± 0.6 to 1.84 ± 1.2 mg/dL) and proteinuria (528 ± 603 to 879 ± 1398 mg/24h) between 3 and 12 months respectively. CONCLUSIONS Withdrawal of Cinacalcet at the time of renal transplantation was not a risk factor for allograft calcifications in the early post-transplant period.
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Kumar V, Sinha AK, Makkar HPS, de Boeck G, Becker K. Dietary roles of non-starch polysaccharides in human nutrition: a review. Crit Rev Food Sci Nutr 2012; 52:899-935. [PMID: 22747080 DOI: 10.1080/10408398.2010.512671] [Citation(s) in RCA: 176] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Nonstarch polysaccharides (NSPs) occur naturally in many foods. The physiochemical and biological properties of these compounds correspond to dietary fiber. Nonstarch polysaccharides show various physiological effects in the small and large intestine and therefore have important health implications for humans. The remarkable properties of dietary NSPs are water dispersibility, viscosity effect, bulk, and fermentibility into short chain fatty acids (SCFAs). These features may lead to diminished risk of serious diet related diseases which are major problems in Western countries and are emerging in developing countries with greater affluence. These conditions include coronary heart disease, colo-rectal cancer, inflammatory bowel disease, breast cancer, tumor formation, mineral related abnormalities, and disordered laxation. Insoluble NSPs (cellulose and hemicellulose) are effective laxatives whereas soluble NSPs (especially mixed-link β-glucans) lower plasma cholesterol levels and help to normalize blood glucose and insulin levels, making these kinds of polysaccharides a part of dietary plans to treat cardiovascular diseases and Type 2 diabetes. Moreover, a major proportion of dietary NSPs escapes the small intestine nearly intact, and is fermented into SCFAs by commensal microflora present in the colon and cecum and promotes normal laxation. Short chain fatty acids have a number of health promoting effects and are particularly effective in promoting large bowel function. Certain NSPs through their fermented products may promote the growth of specific beneficial colonic bacteria which offer a prebiotic effect. Various modes of action of NSPs as therapeutic agent have been proposed in the present review. In addition, NSPs based films and coatings for packaging and wrapping are of commercial interest because they are compatible with several types of food products. However, much of the physiological and nutritional impact of NSPs and the mechanism involved is not fully understood and even the recommendation on the dose of different dietary NSPs intake among different age groups needs to be studied.
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Affiliation(s)
- Vikas Kumar
- Institute for Animal Production in the Tropics and Subtropics, University of Hohenheim 70599, Stuttgart, Germany
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Zhang R, Chouhan KK. Metabolic bone diseases in kidney transplant recipients. World J Nephrol 2012; 1:127-33. [PMID: 24175250 PMCID: PMC3782213 DOI: 10.5527/wjn.v1.i5.127] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Revised: 06/01/2012] [Accepted: 09/25/2012] [Indexed: 02/06/2023] Open
Abstract
Metabolic bone disease after kidney transplantation has a complex pathophysiology and heterogeneous histology. Pre-existing renal osteodystrophy may not resolve completely, but continue or evolve into a different osteodystrophy. Rapid bone loss immediately after transplant can persist, at a lower rate, for years to come. These greatly increase the risk of bone fracture and vertebral collapse. Each patient may have multiple risk factors of bone loss, such as steroids usage, hypogonadism, persistent hyperparathyroidism (HPT), poor allograft function, metabolic acidosis, hypophosphatemia, vitamin D deficiency, aging, immobility and chronic disease. Clinical management requires a comprehensive approach to address the underlying and ongoing disease processes. Successful prevention of bone loss has been shown with vitamin D, bisphosphonates, calcitonin as well as treatment of hypogonadism and HPT. Novel approach to restore the normal bone remodeling and improve the bone quality may be needed in order to effectively decrease bone fracture rate in kidney transplant recipients.
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Affiliation(s)
- Rubin Zhang
- Rubin Zhang, Kanwaljit K Chouhan, Section of Nephrology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, United States
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Fibroblast Growth Factor and Mineral Metabolism Parameters among Prevalent Kidney Transplant Patients. Int J Nephrol 2012; 2012:490623. [PMID: 22811905 PMCID: PMC3395143 DOI: 10.1155/2012/490623] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 04/23/2012] [Indexed: 12/11/2022] Open
Abstract
Background. Chronic kidney disease (CKD) related mineral bone disorders persist after kidney transplantation, but little is known about the relationship between fibroblast growth factor-23 (FGF-23) and mineral metabolism in prevalent post-transplant patients. Objectives. To examine mineral metabolism parameters and their relationship to FGF-23 and parathyroid hormone (PTH) in prevalent kidney transplant patients. Methods. Cross-sectional study of 106 kidney transplant patients enrolled November 2005–October 2009 at Tufts Medical Center (TMC), Boston. Results. The prevalence of hypophosphatemia was 34%, hypercalcemia 3%, and elevated PTH levels 66%, at a median (25th–75th percentile) duration of 12.8 (7.5–30.9) months post-transplant. Males had significantly higher levels of PTH (P = 0.04) and lower levels of serum phosphate
(P = 0.002). Serum PTH levels did not relate to eGFR, corrected calcium levels or serum phosphate. FGF-23 levels were above the reference limits in 7% of patients; higher levels were associated with higher serum phosphate and PTH levels after adjustment for transplant kidney function. Conclusion. FGF-23 is an important driver of mineral metabolism in prevalent transplant patients. Its modulatory role in mineral metabolism homeostasis may be heightened as feedback suppression of PTH is disturbed. Its role in long term cardiovascular and graft outcomes needs further study.
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Isaksson E, Sterner G. Early Development of Secondary Hyperparathyroidism following Renal Transplantation. ACTA ACUST UNITED AC 2012; 121:c68-72. [DOI: 10.1159/000342811] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 08/17/2012] [Indexed: 11/19/2022]
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Evenepoel P, Sprangers B, Lerut E, Bammens B, Claes K, Kuypers D, Meijers B, Vanrenterghem Y. Mineral metabolism in renal transplant recipients discontinuing cinacalcet at the time of transplantation: a prospective observational study. Clin Transplant 2011; 26:393-402. [PMID: 22007637 DOI: 10.1111/j.1399-0012.2011.01524.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The calcimimetic cinacalcet is approved for treating secondary hyperparathyroidism in patients with chronic kidney disease on dialysis. Biochemical profiles and clinical outcomes in patients discontinuing cinacalcet at the time of transplantation are scarce. METHODS We performed a prospective observational cohort study, including 303 incident renal transplant recipients, of whom 21 were on cinacalcet treatment at the time of transplantation. Parameters of mineral metabolism and incidence of parathyroidectomy and nephrocalcinosis in patients discontinuing cinacalcet at the time of transplantation patients ("cinacalcet +") were compared to cinacalcet-naïve patients ("cinacalcet -"). Mean follow-up was 35.6 ± 15.8 months. RESULTS At the time of transplantation, parameters of mineral metabolism were similar in both groups. Conversely, at month 3, serum ionized calcium (p = 0.0007), calcitriol (p = 0.02), biointact parathyroid hormone (p = 0.06) levels and urinary fractional excretion of phosphorus (p = 0.06) were higher, while serum phosphorus levels (p = 0.06) were lower in "cinacalcet +." Analysis based on matching at the time of initiation showed that the course of post-transplant mineral metabolism in cinacalcet-treated patients (median treatment period 12.5 months) vs. cinacalcet-naïve patients was identical. "Cinacalcet +" patients are characterized by a high-incidence proportion of both post-transplant nephrocalcinosis (45% at month 3) and parathyroidectomy (28.6%). No difference in renal function was observed between "cinacalcet +" and "cinacalcet-" patients. CONCLUSION Cinacalcet does not affect the course of secondary hyperparathyroidism in patients awaiting kidney transplantation. Biochemical profiles and a high parathyroidectomy rate suggest rebound hyperparathyroidism in renal transplant recipients discontinuing cinacalcet at the time of transplantation, which may be related to the short exposure time specific to this population. Risk/benefit studies are urgently required to define the role of continued calcimimetic treatment in renal transplant recipients and to determine the optimal treatment of secondary hyperparathyroidism in patients listed for transplantation.
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Affiliation(s)
- Pieter Evenepoel
- Division of Nephrology, Department of Medicine, University Hospitals Leuven, Leuven, Belgium.
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Teriparatide efficacy in the treatment of severe hypocalcemia after kidney transplantation in parathyroidectomized patients: a series of five case reports. Transplantation 2011; 92:316-20. [PMID: 21694663 DOI: 10.1097/tp.0b013e3182247b98] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Teriparatide is a recombinant human parathormone (PTH 1-34) currently approved for the treatment of osteoporosis with high risk of fracture. In this study, we analyze the efficacy and safety profile of teriparatide therapy in severe and prolonged hypocalcemia after kidney transplantation in patients previously submitted to parathyroidectomy. METHODS The authors report results from a series of five hemodialyzed patients (mean age: 50±15 years; three female) previously submitted to parathyroidectomy to control secondary hyperparathyroidism. All patients had developed severe refractory hypocalcemia (calcium minimum levels: 5±1.4 mg/dL) early after kidney transplantation. The effect of teriparatide in calcemia and phosphatemia levels was analyzed, and variations in calcium and vitamin D analog requirements were analyzed. Secondary effects and serum creatinine changes were also ascertained. RESULTS Teriparatide therapy was initiated 32±14 days after the development of hypocalcemia. As a result, calcemia levels increased (median±standard deviation [SD]: 6.7±0.8 vs. 8.5±0.8 mg/dL, P=0.024) allowing suspension of intravenous calcium in two patients and reduction of calcitriol doses (mean±SD: 1.1±0.38 vs. 0.55±0.27 μg/day, P=0.004). In addition, phosphatemia levels (median±SD: 5.1±1.5 vs. 3.9±0.5 mg/dL, P=0.09) and calcium carbonate requirements (mean±SD: 13.8±9.4 vs. 7.2 ±3.7 g/day, P=0.9) exhibited declining trends. No secondary effects were observed and creatinemia remained stable. CONCLUSIONS Our data strongly suggest that refractory hypocalcemia after kidney transplantation in patients with low PTH levels can be successfully treated with teriparatide. PTH analog therapy leads to faster normalization of calcemia, permits earlier suspension of intravenous calcium supplementation, and reduces calcitriol requirements.
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Evstatiev R, Marteau P, Iqbal T, Khalif IL, Stein J, Bokemeyer B, Chopey IV, Gutzwiller FS, Riopel L, Gasche C. FERGIcor, a randomized controlled trial on ferric carboxymaltose for iron deficiency anemia in inflammatory bowel disease. Gastroenterology 2011; 141:846-853.e1-2. [PMID: 21699794 DOI: 10.1053/j.gastro.2011.06.005] [Citation(s) in RCA: 235] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 05/18/2011] [Accepted: 06/03/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Iron deficiency anemia (IDA) is common in chronic diseases and intravenous iron is an effective and recommended treatment. However, dose calculations and inconvenient administration may affect compliance and efficacy. We compared the efficacy and safety of a novel fixed-dose ferric carboxymaltose regimen (FCM) with individually calculated iron sucrose (IS) doses in patients with inflammatory bowel disease (IBD) and IDA. METHODS This randomized, controlled, open-label, multicenter study included 485 patients with IDA (ferritin <100 μg/L, hemoglobin [Hb] 7-12 g/dL [female] or 7-13 g/dL [male]) and mild-to-moderate or quiescent IBD at 88 hospitals and clinics in 14 countries. Patients received either FCM in a maximum of 3 infusions of 1000 or 500 mg iron, or Ganzoni-calculated IS dosages in up to 11 infusions of 200 mg iron. Primary end point was Hb response (Hb increase ≥ 2 g/dL); secondary end points included anemia resolution and iron status normalization by week 12. RESULTS The results of 240 FCM-treated and 235 IS-treated patients were analyzed. More patients with FCM than IS achieved Hb response (150 [65.8%] vs 118 [53.6%]; 12.2% difference, P = .004) or Hb normalization (166 [72.8%] vs 136 [61.8%]; 11.0% difference, P = .015). Both treatments improved quality of life scores by week 12. Study drugs were well tolerated and drug-related adverse events were in line with drug-specific clinical experience. Deviations from scheduled total iron dosages were more frequent in the IS group. CONCLUSIONS The simpler FCM-based dosing regimen showed better efficacy and compliance, as well as a good safety profile, compared with the Ganzoni-calculated IS dose regimen.
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Affiliation(s)
- Rayko Evstatiev
- Department of Medicine 3, Division of Gastroenterology and Hepatology, Christian Doppler Laboratory for Molecular Cancer Chemoprevention, Medical University of Vienna, Vienna, Austria
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