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Wang M, Xiao J, Du Q, Zhang W, Zhang J, Yan Z, Luo J, Yu C, Ye Z, Chen J. Phosphorus balance calculator: an individualized tool for treatment of hyperphosphatemia in hemodialysis patients. Nephrol Dial Transplant 2024; 39:1159-1170. [PMID: 38037501 DOI: 10.1093/ndt/gfad256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Lack of evaluations of the dietary phosphorus and dialysis phosphorus removal in daily clinical practice are common obstacles to assessing phosphorus balance and controlling phosphorus in hemodialysis patients. We aimed to investigate whether individualized therapy using a phosphorus balance calculator improves phosphorus control. METHODS A randomized, open-label, multicenter, 4-week clinical trial was conducted. A total of 119 maintenance hemodialysis patients aged 18-85 years old and with serum phosphorus level >1.45 mmol/L from three university teaching hospitals in Shanghai were enrolled. Patients were randomized in a 1:1 ratio to individualized therapy (n = 60) or conventional therapy (n = 59). The primary outcome was the serum phosphorus concentration after 4-week treatment. Secondary outcomes included the serum calcium and parathyroid hormone (PTH) concentrations, changes in serum phosphorus, calcium and PTH concentrations, and the proportion of patients achieving target ranges of serum phosphorus, calcium and PTH after 4-week treatment. RESULTS Among 119 randomized participants [mean age 62 years; 68 male (57%)], 116 completed the trial. Using the phosphorus balance calculator, the individualized group achieved a better phosphorus balance state and significantly reduced serum phosphorus (1.62 ± 0.45 mmol/L versus 1.85 ± 0.45 mmol/L, P = .006), increased the proportions of patients achieving target serum phosphorus range (41% versus 18%, P = .006) and had greater adjusted mean difference in change in serum phosphorus over the 4 weeks (-0.47 versus -0.23 mmol/L, P = .010) when compared with conventional therapy. No significant changes were observed in serum calcium and PTH levels, the proportion of patients achieving target serum calcium or PTH levels, or the adjusted mean difference of serum calcium and PTH levels over the treatment period. CONCLUSION Phosphorus balance calculator was proved to improve serum phosphorus control in patients undergoing maintenance hemodialysis, offering a new tool for managing hyperphosphatemia.
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Affiliation(s)
- Mengjing Wang
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jing Xiao
- Nephrology, Huadong Hospital, Fudan University, Shanghai, China
| | - Qiuna Du
- Nephrology, Tongji Hospital, Tongji University, Shanghai, China
| | - Weichen Zhang
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiaying Zhang
- Division of Nutrition, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhenwen Yan
- Nephrology, Huadong Hospital, Fudan University, Shanghai, China
| | - Jianfeng Luo
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China
| | - Chen Yu
- Nephrology, Tongji Hospital, Tongji University, Shanghai, China
| | - Zhibin Ye
- Nephrology, Huadong Hospital, Fudan University, Shanghai, China
| | - Jing Chen
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Iannone F, Angotti E, Lucia F, Martino L, Antico GC, Galato F, Aversa I, Gallo R, Giordano C, Abatino A, Mancuso S, Carinci LG, Martucci M, Teti C, Costanzo F, Cuda G, Palmieri C. The biological variation of serum 1,25-dihydroxyvitamin D and parathyroid hormone, and plasma fibroblast growth factor 23 in healthy individuals. Clin Chim Acta 2024; 557:117863. [PMID: 38471629 DOI: 10.1016/j.cca.2024.117863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND AND AIMS Measuring 1,25-dihydroxyvitamin D (1,25(OH)2D), parathyroid hormone 1-84 (PTH 1-84) and intact FGF23 (iFGF23) is crucial for diagnosing a variety of diseases affecting bone and mineral homeostasis. Biological variability (BV) data are important for defining analytical quality specifications (APS), the usefulness of reference intervals, and the significance of variations in serial measurements in the same subject. The aim of this study was to pioneer the provision of BV estimates for 1,25(OH)2D and to improve existing BV estimates for iFGF23 and PTH 1-84. MATERIALS AND METHODS Serum and plasma-EDTA samples of sixteen healthy subjects have been collected for seven weeks and measured in duplicate by chemiluminescent immunoassay on the DiaSorin Liaison platform. After variance verification, within-subject (CVI) and between-subject (CVG) BV estimates were assessed by either standard ANOVA, or CV-ANOVA. The APSs were calculated according to the EFLM-BV-model. RESULTS We found the following CVI estimates with 95% confidence intervals:1,25(OH)2D, 22.2% (18.9-26.4); iFGF23, 16.1% (13.5-19.5); and PTH 1-84, 17.9% (14.8-21.8). The CVG were: 1,25(OH)2D, 21.2% (14.2-35.1); iFGF23, 21.1% (14.5-35.8); and PTH 1-84, 31.1% (22.1-50.8). CONCLUSIONS We report for the first time BV estimates for 1,25(OH)2D and enhance existing data about iFGF23-BV and PTH 1-84-BV through cutting-edge immunometric methods.
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Affiliation(s)
- Francesca Iannone
- Department of Clinical and Experimental Medicine, University Magna Grecia of Catanzaro, viale Europa, 88100 Catanzaro, Italy
| | - Elvira Angotti
- Laboratory of Clinical Biochemistry, AOU "Renato Dulbecco" Hospital, 88100 Catanzaro, Italy
| | - Fortunata Lucia
- Laboratory of Clinical Biochemistry, AOU "Renato Dulbecco" Hospital, 88100 Catanzaro, Italy
| | - Luisa Martino
- Laboratory of Clinical Biochemistry, AOU "Renato Dulbecco" Hospital, 88100 Catanzaro, Italy
| | - Giulio Cesare Antico
- Laboratory of Clinical Biochemistry, AOU "Renato Dulbecco" Hospital, 88100 Catanzaro, Italy
| | - Francesco Galato
- Laboratory of Clinical Biochemistry, AOU "Renato Dulbecco" Hospital, 88100 Catanzaro, Italy
| | - Ilenia Aversa
- Department of Clinical and Experimental Medicine, University Magna Grecia of Catanzaro, viale Europa, 88100 Catanzaro, Italy
| | - Raffaella Gallo
- Department of Clinical and Experimental Medicine, University Magna Grecia of Catanzaro, viale Europa, 88100 Catanzaro, Italy
| | - Caterina Giordano
- Department of Clinical and Experimental Medicine, University Magna Grecia of Catanzaro, viale Europa, 88100 Catanzaro, Italy
| | - Antonio Abatino
- Department of Clinical and Experimental Medicine, University Magna Grecia of Catanzaro, viale Europa, 88100 Catanzaro, Italy
| | - Serafina Mancuso
- Laboratory of Clinical Biochemistry, AOU "Renato Dulbecco" Hospital, 88100 Catanzaro, Italy
| | | | - Maria Martucci
- Laboratory of Clinical Biochemistry, AOU "Renato Dulbecco" Hospital, 88100 Catanzaro, Italy
| | - Consuelo Teti
- Laboratory of Clinical Biochemistry, AOU "Renato Dulbecco" Hospital, 88100 Catanzaro, Italy
| | - Francesco Costanzo
- Department of Clinical and Experimental Medicine, University Magna Grecia of Catanzaro, viale Europa, 88100 Catanzaro, Italy; Laboratory of Clinical Biochemistry, AOU "Renato Dulbecco" Hospital, 88100 Catanzaro, Italy
| | - Giovanni Cuda
- Department of Clinical and Experimental Medicine, University Magna Grecia of Catanzaro, viale Europa, 88100 Catanzaro, Italy; Laboratory of Clinical Biochemistry, AOU "Renato Dulbecco" Hospital, 88100 Catanzaro, Italy
| | - Camillo Palmieri
- Department of Clinical and Experimental Medicine, University Magna Grecia of Catanzaro, viale Europa, 88100 Catanzaro, Italy; Laboratory of Clinical Biochemistry, AOU "Renato Dulbecco" Hospital, 88100 Catanzaro, Italy.
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3
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Nyssen L, Fillet M, Cavalier E, Servais AC. Qualitative and quantitative comparison of different commercially available 1-84 parathyroid hormone proteins to the WHO international standard 95/646 using orthogonal methods. J Pharm Biomed Anal 2022; 219:114942. [PMID: 35863167 DOI: 10.1016/j.jpba.2022.114942] [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: 04/28/2022] [Revised: 07/01/2022] [Accepted: 07/12/2022] [Indexed: 11/18/2022]
Abstract
Relative quantitation methods rely on the use of reference substances to determine the content of samples. The aim of this study was to compare 1-84 parathyroid hormone (PTH) standards from different manufacturers to the WHO international standard 95/646. CE and LC with UV detection were investigated as quick and inexpensive quantitation methods, with an emphasis on selectivity between intact 1-84 PTH and its oxidized forms. Both methods were fully validated according to ICH Q2R1. Moreover, method performance was also evaluated according to guidelines defining the maximum allowable measurement uncertainty (MU) of a biological parameter from its intraindividual variation (CVI), as well as the proportion of that MU devoted to the reference material. This study highlighted the fact that some 1-84 PTH standards have a content that is actually twice as high as the one stated on the label, which was confirmed by an amino acid analysis investigation. Our approach offers a quick and inexpensive way to estimate the content of 1-84 PTH standards.
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Affiliation(s)
- Laurent Nyssen
- Department of Clinical Chemistry, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, CHU de Liège, Liège, Belgium; Laboratory for the Analysis of Medicines (LAM), Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium
| | - Marianne Fillet
- Laboratory for the Analysis of Medicines (LAM), Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, CHU de Liège, Liège, Belgium
| | - Anne-Catherine Servais
- Laboratory for the Analysis of Medicines (LAM), Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
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4
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Ding M, Zhang Q, Zhang M, Jiang X, Wang M, Ni L, Gong W, Huang B, Chen J. Phosphate Overload Stimulates Inflammatory Reaction via PiT-1 and Induces Vascular Calcification in Uremia. J Ren Nutr 2021; 32:178-188. [PMID: 34688540 DOI: 10.1053/j.jrn.2021.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/27/2021] [Accepted: 03/20/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Vascular calcification (VC) is an important risk factor for cardiovascular disease in maintenance hemodialysis (MHD) patients. Hyperphosphatemia and microinflammation statement are known major contributors to the development of VC; however, the mechanisms are unknown. The aims of this study were to explore the risk factors of VC in MHD patients and to explore whether high phosphate could increase the secretion of inflammatory cytokines via PiT-1 in monocytes. METHODS A cross-sectional study was conducted on 65 MHD patients to assess the relevance of coronary artery calcification (CAC), inflammatory factors, serum phosphate, and sodium-dependent phosphate cotransporter (NPT) mRNA expression of peripheral blood mononuclear cells (PBMCs). Multivariate logistic regression analysis was used to analyze the predictors of CAC. The calcification effects of high phosphate (HP), TNF-α, and supernatants of healthy human monocytes treated with HP were further evaluated in cultured HASMCs. RESULTS Diabetes, longer dialysis vintage, higher serum TNF-α levels, and PiT-1 mRNA expression of PBMCs) were independent risk factors of CAC in MHD patients. The mRNA levels of PiT-1 in PBMCs were positively correlated with serum phosphate, CAC scores, and Pit-2 mRNA levels of PBMCs. The expressions of TNF-α, IL-6, and PiT-1 in human monocytes were significantly increased in a dose-dependent manner after treatment with HP, which was subsequently inhibited by NPT antagonist phosphonoformic acid. Neither TNF-α alone nor supernatants of monocytes stimulated with HP promoted the expression of osteopontin and Runt-related transcription factor 2 (Runx2) or caused mineralization in human aortic smooth muscle cells, but combined with HP intervention, the calcification effects were markedly increased in human aortic smooth muscle cells and ameliorated by phosphonoformic acid treatment. CONCLUSION Hyperphosphatemia directly increased the synthesis and secretion of TNF-α by monocytes may via PiT-1 pathway, resulting in elevated systemic inflammatory response, which may further aggravate VC induced by phosphate overload in MHD patients.
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Affiliation(s)
- Minwen Ding
- Division of Nephrology, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Qian Zhang
- Division of Nephrology, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Minmin Zhang
- Division of Nephrology, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xinxin Jiang
- Division of Nephrology, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Mengjing Wang
- Division of Nephrology, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Li Ni
- Division of Nephrology, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Wen Gong
- Division of Nephrology, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Bihong Huang
- Division of Nephrology, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jing Chen
- Division of Nephrology, National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China.
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5
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Kang SH, Do JY, Kim JC. Association Between Alkaline Phosphatase and Muscle Mass, Strength, or Physical Performance in Patients on Maintenance Hemodialysis. Front Med (Lausanne) 2021; 8:657957. [PMID: 34079810 PMCID: PMC8165237 DOI: 10.3389/fmed.2021.657957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 04/21/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: Alkaline phosphatase (ALP) is an indicator for checking liver or bone disorders, but recent studies have shown the possibility of an additive indicator beyond the simple mineral-bone status in dialysis patients. The aim of the study was to evaluate the ALP level and various indicators for malnutrition, physical performance, or hospitalization in patients on hemodialysis (HD). Methods: This study was an observational study (n = 84). We included all patients undergoing HD with the following criteria: age ≥ 20 years, duration of dialysis ≥ 6 months, ability to ambulate without an assistive device, ability to communicate with the interviewer, and no hospitalization within the last 3 months before enrollment. Furthermore, none of the patients had liver disease. We recommended abstinence of alcohol for ≥ 1 month for the duration of the study. The patients were divided into tertiles based on the ALP level. Muscle mass [appendicular muscle mass index using dual-energy X-ray absorptiometry (ASM/Ht2), thigh muscle area index using computed tomography (TMA/Ht2)], strength [handgrip strength (HGS)], and physical performance [gait speed (GS), sit-to-stand for 30-s test (STS30), 6-min walk test (6-MWT), or Short Physical Performance Battery test (SPPB)] were evaluated. The number of hospitalizations was also evaluated. Results: The ALP level in the low, middle, and high tertiles was 50.5 ± 7.5, 69.8 ± 5.4, and 113.3 ± 47.3 IU/l, respectively. The high tertile group showed the poorest trends in ASM/Ht2, TMA/Ht2, HGS, GS, STS30, and 6-MWT compared to the other tertile groups. Logistic regression analysis showed that the high tertile group for low HGS, low GS, or low SPPB had a higher odds ratio compared to the other tertiles. Subgroup analyses according to age, sex and diabetes mellitus showed similar trends as in the total cohort. Hospitalization-free survival rates after 300 days in the high tertile and the other tertiles were 53.8 and 77.2%, respectively (P = 0.105). Conclusion: The present study demonstrated that ALP is associated with muscle mass, strength, and physical performance in patients on maintenance HD. In addition, the trend showed better hospitalization-free survival in the low or middle tertiles than in the high tertile. ALP can be considered as a simple and useful indicator to detect malnutrition, physical performance, or hospitalization in patients on HD.
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Affiliation(s)
- Seok Hui Kang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, South Korea
| | - Jun Young Do
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu, South Korea
| | - Jun Chul Kim
- Division of Nephrology, Department of Internal Medicine, CHA Gumi Medical Center, CHA University, Gumi, South Korea
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6
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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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7
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Bottani M, Banfi G, Guerra E, Locatelli M, Aarsand AK, Coşkun A, Díaz-Garzón J, Fernandez-Calle P, Sandberg S, Ceriotti F, González-Lao E, Simon M, Carobene A. European Biological Variation Study (EuBIVAS): within- and between-subject biological variation estimates for serum biointact parathyroid hormone based on weekly samplings from 91 healthy participants. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:855. [PMID: 32793699 DOI: 10.21037/atm-19-4498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background The European Biological Variation Study (EuBIVAS) was created by the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group on Biological Variation to establish high-quality biological variation (BV) estimates for clinically important measurands. In this study, the aim was to deliver reliable BV estimates for the biointact parathyroid hormone (PTH 1-84). Methods Serum samples were obtained from a population of 91 healthy individuals (38 men, 43 pre-menopausal women, and 10 post-menopausal women; 21-69 years) from 5 European countries, with all samples stored at -80 °C prior to analysis. PTH 1-84 analysis was performed at the San Raffaele Hospital (Milan, Italy) on the Roche Cobas e801. All samples from each individual were analysed in duplicate within a single run. CV-ANOVA was applied, after analysis of variance homogeneity and outliers, to obtain BV estimates for PTH 1-84 with 95% CIs. Results The within-subject BV [CVI (95% CI)] estimates were significantly different between men and women [13.0% (12.1-14.2%) and 15.2% (14.3-16.3%), respectively], while the between-subject estimates [CVG (95% CI)] were similar (men: 26.8% (21.4-35.1%), pre-menopausal women: 27.8% (22.7-36.1%)], allowing for delivery of updated analytical performance specifications and reference change values. Conclusions Updated BV estimates for serum PTH 1-84 based on the large-scale EuBIVAS may be beneficial for the diagnosis and management of parathyroid glands and bone turnover pathologies.
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Affiliation(s)
- Michela Bottani
- IRCCS Istituto Ortopedico Galeazzi, Laboratory of Experimental Biochemistry and Molecular Biology, Milan, Italy
| | - Giuseppe Banfi
- IRCCS Istituto Ortopedico Galeazzi, Laboratory of Experimental Biochemistry and Molecular Biology, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Elena Guerra
- Laboratory Medicine, Ospedale San Raffaele, Milan, Italy
| | | | - Aasne K Aarsand
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway.,Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Abdurrahman Coşkun
- Acibadem Mehmet Ali Aydınlar University, School of Medicine, Atasehir, Istanbul, Turkey
| | - Jorge Díaz-Garzón
- Hospital Universitario La Paz, Madrid, Spain, and Quality Analytical Commission of Spanish Society of Clinical Chemistry (SEQC), Barcelona, Spain
| | - Pilar Fernandez-Calle
- Hospital Universitario La Paz, Madrid, Spain, and Quality Analytical Commission of Spanish Society of Clinical Chemistry (SEQC), Barcelona, Spain
| | - Sverre Sandberg
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway.,Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ferruccio Ceriotti
- Central Laboratory, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Margarita Simon
- Intercomarcal Laboratory Consortiums of Alt Penedès, Anoia and Garraf, Barcelona, Spain
| | - Anna Carobene
- Laboratory Medicine, Ospedale San Raffaele, Milan, Italy
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8
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Corte Z, Venta R. Biological variation of metabolic cardiovascular risk factors in haemodialysis patients and healthy individuals. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:281. [PMID: 32355725 PMCID: PMC7186598 DOI: 10.21037/atm.2020.03.26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Maintenance haemodialysis (HD) is associated with a very high cardiovascular risk and the assessment of metabolic cardiovascular risk factors is essential for an adequate diagnosis and management. The aim of the study has been to estimate the biological variation (BV) of serum lipids, calcium, inorganic phosphorus, 25-OH vitamin D, C-reactive protein and plasma intact parathyroid hormone (PTHi) and total homocysteine, to evaluate whether HD alter the homeostatic set-point of these magnitudes. Methods Blood samples were collected from 18 HD patients in steady-state conditions, one per month during 6 months, and from 11 healthy volunteers at weekly intervals over 5 weeks. BV data were derived using CV-ANOVA. Results Within-subject coefficients of variation (CVI) and derived reference change values (RCV) estimated in HD patients were significantly higher than in healthy individuals for calcium (CVI =3.8% vs. 2.3%) (RCV =12.6% vs. 7.6%), inorganic phosphorus (13.1% vs. 8.0%) (RCV =38.7% vs. 30.1%) and PTHi (20.3% vs. 11.3%) (RCV =57.5% vs. 34.0%). Conclusions For calcium, inorganic phosphorus and PTHi, RCV derived from advanced disease-specific BV data is recommended for the management of bone-mineral disturbances in HD patients. For the rest of cardiovascular risk factors, the use of RCV derived from healthy individuals could be appropriate.
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Affiliation(s)
- Zoraida Corte
- Clinical Biochemistry Service, San Agustín University Hospital, Avilés, Asturias, Spain
| | - Rafael Venta
- Clinical Biochemistry Service, San Agustín University Hospital, Avilés, Asturias, Spain.,Biochemistry and Molecular Biology Department, Oviedo University, Asturias, Spain
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9
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Smit MA, van Kinschot CMJ, van der Linden J, van Noord C, Kos S. Clinical Guidelines and PTH Measurement: Does Assay Generation Matter? Endocr Rev 2019; 40:1468-1480. [PMID: 31081903 DOI: 10.1210/er.2018-00220] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 03/08/2019] [Indexed: 11/19/2022]
Abstract
PTH is an important regulator of calcium and phosphate homeostasis and bone remodeling. It is metabolized into PTH fragments, which are measured to a different extent by PTH assays of different generations because of differences in fragments recognized and lack of assay standardization. PTH is measured in the workup of several conditions, and clinical guidelines provide recommendations concerning these measurements. This review provides an overview of the impact of differences between PTH assays, applying distinct clinical guidelines for primary and secondary hyperparathyroidism and perioperative use of PTH measurements. Guidelines deal with PTH measurement in different ways, recommending either trend monitoring, the use of a fold increase of the upper reference limit, or an absolute PTH cutoff value. For classic primary hyperparathyroidism (PHPT), the type of PTH assay used will not affect diagnosis or management because the precise concentration of PTH is less relevant. In chronic kidney disease, the guideline recommends treating secondary hyperparathyroidism above a twofold to ninefold PTH increase, which will result in different clinical decisions depending on the assay used. For patients after bariatric surgery, guidelines state absolute cutoff values for PTH, but the impact of different generation assays is unknown because direct comparison of PTH assays has never been performed. During parathyroid surgery, PTH measurements with a third-generation assay reflect treatment success more rapidly than second-generation assays. Increased awareness among clinicians regarding the complexity of PTH measurements is warranted because it can affect clinical decisions.
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Affiliation(s)
- Marjon A Smit
- Department of Clinical Chemistry, Maasstad Hospital, Rotterdam, Netherlands
| | | | | | | | - Snježana Kos
- Department of Clinical Chemistry, Maasstad Hospital, Rotterdam, Netherlands
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10
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Ercan M, Akbulut ED, Avcı E, Yücel Ç, Oğuz EF, Turhan T, Serdar M. Determining biological variation of serum parathyroid hormone in healthy adults. Biochem Med (Zagreb) 2019; 29:030702. [PMID: 31379460 PMCID: PMC6610671 DOI: 10.11613/bm.2019.030702] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 05/24/2019] [Indexed: 11/21/2022] Open
Abstract
Introduction Measurement of parathyroid hormone (PTH) is essential in the investigation and management of calcium metabolism disorders. To assess the significance of any assay result when clinical decision making biological variation (BV) of the measurand must be taken into consideration. The aim of the present study is determining the BV parameters for serum PTH. Materials and methods Blood samples were taken at weekly intervals from 20 healthy subjects for ten weeks in this prospective BV study. Serum “intact PTH” concentrations were measured with electrochemiluminescence method. Biological variation parameters were estimated using the approach proposed by Fraser. Results The values of within-subject biological variation (CVI), between-subject biological variation (CVG), analytical variation (CVA), reference change value (RCV) and individuality index (II) for serum PTH were 21.1%, 24.9%, 3.8%, 59.4% and 0.8%, respectively. Within-subject biological variation and CVG were also determined according to gender separately; 18.5% and 24.0%; 26.2% and 18.6% for male and female, respectively. Calculated desirable precision and bias goals were < 10.6% and < 6.3%, respectively. Conclusion This study may contribute to BV data on serum PTH as it includes a sufficient number of volunteers from both genders over an acceptable period of time. We do not recommend the usage of population-based reference intervals for serum PTH concentrations. Reference change value may be helpful for the evaluation of serial serum PTH results. Nonetheless, evaluation of data according to gender is necessary when setting analytical performance specifications.
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Affiliation(s)
- Müjgan Ercan
- Faculty of Medicine, Department of Biochemistry, Harran University, Şanlıurfa, Turkey
| | - Emiş Deniz Akbulut
- Biochemistry Laboratory, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Esin Avcı
- Faculty of Medicine, Department of Biochemistry, Pamukkale University, Denizli, Turkey
| | - Çiğdem Yücel
- Biochemistry Laboratory, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Esra Fırat Oğuz
- Biochemistry Laboratory, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Turan Turhan
- Biochemistry Laboratory, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Muhittin Serdar
- Faculty of Medicine, Department of Biochemistry, Acıbadem University, İstanbul, Turkey
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11
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Barreto FC, Barreto DV, Massy ZA, Drüeke TB. Strategies for Phosphate Control in Patients With CKD. Kidney Int Rep 2019; 4:1043-1056. [PMID: 31440695 PMCID: PMC6698320 DOI: 10.1016/j.ekir.2019.06.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/27/2019] [Accepted: 06/03/2019] [Indexed: 02/08/2023] Open
Abstract
Hyperphosphatemia is a common complication in patients with chronic kidney disease (CKD), particularly in those requiring renal replacement therapy. The importance of controlling serum phosphate has long been recognized based on observational epidemiological studies that linked increased phosphate levels to adverse outcomes and higher mortality risk. Experimental data further supported the role of phosphate in the development of bone and cardiovascular diseases. Recent advances in our understanding of the mechanisms involved in phosphate homeostasis have made it clear that the serum phosphate concentration depends on a complex interplay among the kidneys, intestinal tract, and bone, and is tightly regulated by a complex endocrine system. Moreover, the source of dietary phosphate and the use of phosphate-based additives in industrialized foods are additional factors that are of particular importance in CKD. Not surprisingly, the management of hyperphosphatemia is difficult, and, despite a multifaceted approach, it remains unsuccessful in many patients. An additional issue is the fact that the supposedly beneficial effect of phosphate lowering on hard clinical outcomes in interventional trials is a matter of ongoing debate. In this review, we discuss currently available treatment approaches for controlling hyperphosphatemia, including dietary phosphate restriction, reduction of intestinal phosphate absorption, phosphate removal by dialysis, and management of renal osteodystrophy, with particular focus on practical challenges and limitations, and on potential benefits and harms.
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Affiliation(s)
- Fellype Carvalho Barreto
- Service of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Daniela Veit Barreto
- Service of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Ziad A Massy
- Institut National de la Santé et de la Recherche Médicale U-1018, Team 5, Centre de Recherche en Epidémiologie et Santé des Populations, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University), Paris-Sud University and Paris Saclay University, Villejuif, France.,Division of Nephrology, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne Billancourt/Paris, France
| | - Tilman B Drüeke
- Institut National de la Santé et de la Recherche Médicale U-1018, Team 5, Centre de Recherche en Epidémiologie et Santé des Populations, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University), Paris-Sud University and Paris Saclay University, Villejuif, France
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12
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Dupuy AM, Bargnoux AS, Morena M, Lauret E, Souberbielle JC, Cavalier E, Cristol JP. Moving from the second to the third generation Roche PTH assays: what are the consequences for clinical practice? Clin Chem Lab Med 2018; 57:244-249. [PMID: 30183664 DOI: 10.1515/cclm-2018-0300] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/06/2018] [Indexed: 11/15/2022]
Abstract
Background The determination of parathyroid hormone (PTH) is essential for exploring phosphocalcic disorders especially in patients with renal failure. At present, second or third generation PTH assays are available on the market from Roche Diagnostics as well as from others companies but the lack of standardization has complicated the interpretation. Methods We wanted to assess the clinical impact by measuring the PTH levels with the two generations concomitantly on different groups of populations including 46 healthy, 103 pre-dialyzed and 73 hemodialyzed (HD) patients. Results In healthy subjects, the PTH concentrations were not different whatever the generation used, whereas beyond 200 pg/mL, we reported an overestimation of the second generation PTH. In patients with chronic kidney disease (CKD) stage 3-5 the observed differences between the two generations increase with increasing PTH levels and decreasing glomerular filtration rate (GFR). Classification according to the kidney disease: improving global outcomes (KDIGO) revealed a high percentage of discordant results between the two generations (κ coefficient <0.20). These discrepancies are clinically relevant as PTH levels remain the cornerstone for diagnosis and treatment of the CKD-mineral and bone disorder (CKD-MBD). Conclusions The introduction of a new PTH assay generation in clinical practice should be carried out with caution.
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Affiliation(s)
- Anne Marie Dupuy
- Laboratoire de Biochimie et Hormonologie, CHU Montpellier, University Montpellier 1, Montpellier, France
| | - Anne Sophie Bargnoux
- Laboratoire de Biochimie et Hormonologie, CHU de Montpellier, PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Marion Morena
- Laboratoire de Biochimie et Hormonologie, CHU de Montpellier, PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Emilie Lauret
- Laboratoire de Biochimie et Hormonologie, CHU Montpellier, University Montpellier 1, Montpellier, France
| | - Jean Claude Souberbielle
- Service d'explorations fonctionnelles, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Université René Descartes (Paris V), Paris, France
| | - Etienne Cavalier
- Département de Chimie Clinique, CHU Liège, Université de Liège, Liège, Belgium
| | - Jean Paul Cristol
- Laboratoire de Biochimie et Hormonologie, CHU Montpellier, University Montpellier 1, 371 Avenue Doyen Gaston Giraud, Montpellier 34295, France
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13
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Sánchez-González C, Gonzalez-Casaus ML, Sellares VL, Albalate M, Torregrosa JV, Mas S, Ortiz A, Rodriguez M, Gonzalez-Parra E. Higher Proportion of Non-1-84 PTH Fragments in Peritoneal Dialysis Patients Compared to Hemodialysis Patients Using Solutions Containing 1.75 mmol/l Calcium. Front Physiol 2018; 9:1643. [PMID: 30524306 PMCID: PMC6262178 DOI: 10.3389/fphys.2018.01643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/30/2018] [Indexed: 11/13/2022] Open
Abstract
Background: The prevalence of low- turnover bone disease (LTBD) in peritoneal dialysis (PD) patients is higher than in hemodialysis (HD) patients. LTBD patients may be at risk for vascular calcification, and cardiovascular disease. Current therapy for chronic kidney disease metabolic bone disorders (CKD-MBD) is guided by biochemical parameters, as bone biopsy is not used in routine clinical care. Methods: We assessed intact PTH (iPTH: 1-84PTH plus non-1-84PTH), 1-84PTH, and the 1-84PTH/non-1-84PTH ratio in 129 hemodialysis and 73 PD prevalent patients dialyzed with solutions containing 1.75 mmol/L calcium. Results: Hemodialysis and PD patients presented similar iPTH and tCa values and prevalence of putative LTBD as defined according to KDOQI iPTH cut-off levels or 1-84 PTH levels. However, iCa accounted for a higher percentage of tCa in PD (53%) than in hemodialysis (39%) p < 0.001, and the 1-84PTH/non-1-84PTH ratio was lower in PD than in hemodialysis patients (0.44 ± 0.12) vs. (0.60 ± 0.10), p < 0.001. The prevalence of putative LTBD when using the coexistence of 1-84PTH/non-1-84PTH ratio < 1.0 and iPTH < 420 pg/m, was higher in PD than in hemodialysis patients (73 vs. 16% respectively, p < 0.001). In a multivariate logistic regression analysis, dialysis modality was the main determinant of the 1-84PTH/non-1-84PTH ratio. Conclusion: Solutions containing 1.75 mmol/L calciums are associated to a higher proportion of non-1-84PTH fragments in PD than in HD patients. Different analytical criteria result in widely different estimates of LTBD prevalence, thus impairing the ability of clinicians to optimize therapy for CKD-MBD.
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Affiliation(s)
| | | | | | | | | | - Sebastian Mas
- Unidad de Diálsis IIS Fundación Jiménez Díaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Alberto Ortiz
- REDINREN, Madrid, Spain
- Unidad de Diálsis IIS Fundación Jiménez Díaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mariano Rodriguez
- REDINREN, Madrid, Spain
- Nefrología y Unidad de Investigación, Hospital Universitario Reina Sofia, Córdoba, Spain
| | - Emilio Gonzalez-Parra
- REDINREN, Madrid, Spain
- Unidad de Diálsis IIS Fundación Jiménez Díaz, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
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Abstract
The prevention and treatment of fragility fractures continuously evolve. Adequate fracture care should involve treating the fracture itself and the underlying bone disease. Although effective treatments of osteoporosis are available, a large proportion of patients with fragility fractures are not prescribed antiosteoporotic medications after their injury. Recent advances in diagnostic tools, medications, and implementation of Fracture Liaison Services allow for more effective and comprehensive treatment or fragility fractures. In the Fracture Liaison Service model, a physician and physician extenders coordinate care. This includes a thorough medical and surgical history, metabolic bone disease laboratory testing, dual-energy x-ray absorptiometry screening, treatment, and long-term follow-up. Treatment options include nonpharmacologic treatment with calcium and vitamin D and antiresorptive and anabolic agents. Antiresorptive agents such as bisphosphonates and denosumab are first-line treatments for osteoporosis and anabolic agents such as teriparatide are effective in reducing bone density loss and have implications in fracture healing. In addition, new anabolic agents including antisclerostin antibodies and parathyroid hormone-related protein show promise as potential treatments to increase bone density.
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15
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Soliman M, Hassan W, Yaseen M, Rao M, Sawaya BP, El-Husseini A. PTH assays in dialysis patients: Practical considerations. Semin Dial 2018; 32:9-14. [PMID: 30168196 DOI: 10.1111/sdi.12743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Parathyroid hormone (PTH) 1-84 is the main biologically active hormone produced by the parathyroid cells. Circulating PTH molecules include the whole PTH 1-84 along with amino (N) and carboxyl (C) terminal fragments. While PTH is the best available noninvasive biomarker to assess bone turnover in dialysis patients, the biological roles of individual circulating PTH fragments are still not completely known. The understanding that there is an enormous variation in the target specificity of currently available PTH assays for different circulating forms of PTH has led to the evolution of assays from first to second then third generation. With a reduction in kidney function, there is a preferential increase in circulating C fragments and non-PTH 1-84 forms, resulting in a decrease in the ratio of PTH 1-84/non-PTH 1-84. However, there are also substantial differences in between-assay measurements, with several fold variations in results. Targets based on multiples of the upper limit of normal (ULN) should be used rather than PTH ranges using absolute iPTH values. To date, the second-generation PTH remains the most widely used assay. Current guidelines recommend following iPTH trends rather than absolute values. Herein, we highlight problems and challenges in PTH assays/measurements and their interpretations in dialysis patients.
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Affiliation(s)
- Mohanad Soliman
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Waleed Hassan
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Maria Yaseen
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Madhumathi Rao
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - B Peter Sawaya
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
| | - Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky
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16
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Bover J, Ureña P, Aguilar A, Mazzaferro S, Benito S, López-Báez V, Ramos A, daSilva I, Cozzolino M. Alkaline Phosphatases in the Complex Chronic Kidney Disease-Mineral and Bone Disorders. Calcif Tissue Int 2018; 103:111-124. [PMID: 29445837 DOI: 10.1007/s00223-018-0399-z] [Citation(s) in RCA: 28] [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: 11/29/2017] [Accepted: 01/29/2018] [Indexed: 12/16/2022]
Abstract
Alkaline phosphatases (APs) remove the phosphate (dephosphorylation) needed in multiple metabolic processes (from many molecules such as proteins, nucleotides, or pyrophosphate). Therefore, APs are important for bone mineralization but paradoxically they can also be deleterious for other processes, such as vascular calcification and the increasingly known cross-talk between bone and vessels. A proper balance between beneficial and harmful activities is further complicated in the context of chronic kidney disease (CKD). In this narrative review, we will briefly update the complexity of the enzyme, including its different isoforms such as the bone-specific alkaline phosphatase or the most recently discovered B1x. We will also analyze the correlations and potential discrepancies with parathyroid hormone and bone turnover and, most importantly, the valuable recent associations of AP's with cardiovascular disease and/or vascular calcification, and survival. Finally, a basic knowledge of the synthetic and degradation pathways of APs promises to open new therapeutic strategies for the treatment of the CKD-Mineral and Bone Disorder (CKD-MBD) in the near future, as well as for other processes such as sepsis, acute kidney injury, inflammation, endothelial dysfunction, metabolic syndrome or, in diabetes, cardiovascular complications. However, no studies have been done using APs as a primary therapeutic target for clinical outcomes, and therefore, AP's levels cannot yet be used alone as an isolated primary target in the treatment of CKD-MBD. Nonetheless, its diagnostic and prognostic potential should be underlined.
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Affiliation(s)
- Jordi Bover
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain.
| | - Pablo Ureña
- Department of Nephrology and Dialysis, Clinique du Landy and Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Armando Aguilar
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Benito
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Víctor López-Báez
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Alejandra Ramos
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Iara daSilva
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, C. Cartagena, Catalonia, 340-350, Barcelona, Spain
| | - Mario Cozzolino
- Laboratory of Experimental Nephrology, Renal Division,San Paolo Hospital, DiSS University of Milan, Milan, Italy
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Variability in measures of mineral metabolism in children on hemodialysis: impact on clinical decision-making. Pediatr Nephrol 2017; 32:2311-2318. [PMID: 28667458 DOI: 10.1007/s00467-017-3730-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/13/2017] [Accepted: 06/15/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Variability in measures of mineral metabolism has not been studied in pediatric end stage kidney disease. We sought to determine the intra-individual variability in measures of mineral metabolism in children on hemodialysis (HD) and its impact on clinical decision-making. METHODS We conducted a prospective single-center study of children (3.6-17.3 years old) on chronic HD. Serial twice weekly measures of serum calcium, phosphate and intact parathyroid hormone (PTH), as well as weekly measures of fibroblast growth factor 23 (FGF23) and vitamin D metabolites, were obtained over a 12-week period in 10 children. Samples (n = 226) were assayed in a single batch at the end of the study. RESULTS The median intra-individual coefficient of variation (CV) calculated by 4-week blocks was 5.1-6.5% for calcium, 9.5-14.9% for phosphate and 32.7-33.4% for PTH. The median overall CV for FGF23 was 44.4%. Using the first value of each block as a reference, subsequent values would dictate a discrepant management decision 33-56%, 19-28%, and 30-33% of the time for calcium, phosphate, and PTH, respectively. Adjusting for sex and age, most of the variability in phosphate and PTH was attributable to within-participant variability. For calcium, 49% of the variability was attributable to day of blood collection (Monday vs. Friday). The median (range) of an individual participant's values within clinical target ranges was 55% (26-86%) for calcium, 58% (0-96%) for phosphate, and 21% (0-64%) for PTH. CONCLUSIONS There is considerable intra-individual variability in measures of mineral metabolism that serve as surrogate markers for bone health in children on HD. Within a 4-week period, at least 20-30% of measures would dictate a discrepant decision from the referent measure of that month. These findings have important implications for clinical decision-making and underscore the need to base therapeutic decisions on trends rather than single measurements.
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Isakova T, Nickolas TL, Denburg M, Yarlagadda S, Weiner DE, Gutiérrez OM, Bansal V, Rosas SE, Nigwekar S, Yee J, Kramer H. KDOQI US Commentary on the 2017 KDIGO Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD). Am J Kidney Dis 2017; 70:737-751. [DOI: 10.1053/j.ajkd.2017.07.019] [Citation(s) in RCA: 199] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 07/29/2017] [Indexed: 12/25/2022]
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Schleck ML, Souberbielle JC, Delanaye P, Plebani M, Cavalier E. Parathormone stability in hemodialyzed patients and healthy subjects: comparison on non-centrifuged EDTA and serum samples with second- and third-generation assays. ACTA ACUST UNITED AC 2017; 55:1152-1159. [DOI: 10.1515/cclm-2016-0914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 11/22/2016] [Indexed: 11/15/2022]
Abstract
Abstract
Background:
Parathyroid hormone (PTH) stability is important. Many studies have shown divergent results between EDTA and serum, which are mainly linked to differences in protocols or cut-offs used to determine whether or not PTH remained stable. No studies have yet compared PTH stability as measured by second- and third-generation assays on the same samples in hemodialyzed patients and healthy subjects.
Methods:
Five pairs of samples (EDTA and gel tubes) were obtained in 10 hemodialyzed patients before a dialysis session and in 10 healthy subjects. One pair was centrifuged and run directly to define the “T0”. Two pairs were kept at +4°C and two pairs were kept at +25°C. They were centrifuged after 4 and 18 h. Supernatant was kept at –80°C for 1 week. All samples were measured in a single batch, on Roche Cobas and DiaSorin XL second- and third-generation PTH assays. We used three different approaches to evaluate PTH stability: Wilcoxon test, an Acceptable Change Limit (ACL) according to ISO Guide 5725-6 and a Total Change Limit (TCL) derived from the sum of biological and technical variability according to WHO.
Results:
PTH decreased in all samples. Stability of PTH was mainly dependent on the way it was evaluated. Percentages of decrease were systematically lower in EDTA vs. serum. Wilcoxon and ACL showed that PTH was no more stable after 4 h at +4°C in EDTA or serum gel tubes. None of the subjects presented a PTH decrease higher than the TCL with EDTA plasma. In serum gel tubes, PTH was unstable only when kept at 25°C for 18 h.
Conclusions:
PTH seems more stable in EDTA than in serum gel tubes but only when samples have to stay unprocessed for a long period (18 h) at room temperature (25°C), which can happen when samples are delivered from external care centers. For all the other conditions, using serum gel tubes is recommended since calcium measurement, which is necessary for a good PTH results interpretation, can be achieved on the same tube.
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Abstract
Cardiovascular disease is the main cause of early death in the settings of chronic kidney disease (CKD), type 2 diabetes mellitus (T2DM), and ageing. Cardiovascular events can be caused by an imbalance between promoters and inhibitors of mineralization, which leads to vascular calcification. This process is akin to skeletal mineralization, which is carefully regulated and in which isozymes of alkaline phosphatase (ALP) have a crucial role. Four genes encode ALP isozymes in humans. Intestinal, placental and germ cell ALPs are tissue-specific, whereas the tissue-nonspecific isozyme of ALP (TNALP) is present in several tissues, including bone, liver and kidney. TNALP has a pivotal role in bone calcification. Experimental overexpression of TNALP in the vasculature is sufficient to induce vascular calcification, cardiac hypertrophy and premature death, mimicking the cardiovascular phenotype often found in CKD and T2DM. Intestinal ALP contributes to the gut mucosal defence and intestinal and liver ALPs might contribute to the acute inflammatory response to endogenous or pathogenic stimuli. Here we review novel mechanisms that link ALP to vascular calcification, inflammation, and endothelial dysfunction in kidney and cardiovascular diseases. We also discuss new drugs that target ALP, which have the potential to improve cardiovascular outcomes without inhibiting skeletal mineralization.
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Krishnasamy R, Hawley CM, Johnson DW. An update on bone imaging and markers in chronic kidney disease. Expert Rev Endocrinol Metab 2016; 11:455-466. [PMID: 30058917 DOI: 10.1080/17446651.2016.1239527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Bone disorders in chronic kidney disease (CKD) are associated with heightened risks of fractures, vascular calcification, poor quality of life and mortality compared to the general population. However, diagnosis and management of these disorders in CKD are complex and appreciably limited by current diagnostic modalities. Areas covered: Bone histomorphometry remains the gold standard for diagnosis but is not widely utilised and lacks feasibility as a monitoring tool. In practice, non-invasive imaging and biochemical markers are preferred to guide therapeutic decisions. Expert commentary: This review aims to summarize the risk factors for, and spectrum of bone disease in CKD, as well as appraise the clinical utility of dual energy X-ray densitometry, peripheral quantitative computed tomography, high-resolution peripheral quantitative computed tomography, and bone turnover markers.
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Affiliation(s)
- Rathika Krishnasamy
- a Department of Nephrology , Nambour General Hospital , Nambour , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
| | - Carmel M Hawley
- b Department of Nephrology , Princess Alexandra Hospital , Brisbane , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
- d Department of Nephrology , Translation Research Institute , Brisbane , Australia
| | - David W Johnson
- b Department of Nephrology , Princess Alexandra Hospital , Brisbane , Australia
- c School of Medicine , The University of Queensland , Brisbane , Australia
- d Department of Nephrology , Translation Research Institute , Brisbane , Australia
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Cavalier E, Plebani M, Delanaye P, Souberbielle JC. Considerations in parathyroid hormone testing. Clin Chem Lab Med 2016; 53:1913-9. [PMID: 26035114 DOI: 10.1515/cclm-2015-0314] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 05/04/2015] [Indexed: 11/15/2022]
Abstract
Parathyroid hormone (PTH) is a major player in phosphocalcic metabolism and its measurement is very important for the correct diagnosis and treatment of several diseases. PTH determination represents the paradigm of quality in laboratory medicine as many variables in the pre-, intra-, and post-analytical phases strongly affect the value of the clinical information. Analytical determination of PTH has been rendered difficult by the presence, in the circulation, of truncated fragments that can cross-react with the antibodies used for its determination. In addition, pre-analytical phase is complicated by the lack of stability of the peptide and the best sample to use for its determination remains controversial, as well as sample handling and storage. PTH secretion is also affected by circadian and seasonal rhythms and by physical exercise. Finally, from the post-analytical perspective, establishment of reliable reference ranges requires further efforts as the selection criteria for reference subjects should take into consideration new variables such as gender, race and vitamin D levels. Finally, clinical guidelines have recently revised and improved the criteria for a correct interpretation of PTH values.
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Fishbane S, Hazzan AD, Jhaveri KD, Ma L, Lacson E. Bone Parameters and Risk of Hip and Femur Fractures in Patients on Hemodialysis. Clin J Am Soc Nephrol 2016; 11:1063-1072. [PMID: 27026521 PMCID: PMC4891749 DOI: 10.2215/cjn.09280915] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 02/23/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients on hemodialysis have a high rate of hip fractures. In this study, we performed a contemporary analysis of mineral and bone parameters and their relationship to hip and femur fracture risk. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients on hemodialysis treated between 2000 and 2013 in Fresenius Medical Care North America facilities were included. Predictors were on the basis of data as of December 31 of each baseline year and time-averaged values of selected laboratory parameters and medication doses throughout the year. Four period cohorts were constructed from baseline years: 2000, 2003, 2006, and 2009. Follow-up for each cohort was ≤3 years. RESULTS The incidence of hip and femur fractures remained generally unchanged (P=0.40), except among patients who were white and >65 years of age, in whom the rate decreased significantly over the 14-year period (P<0.01). Results from combined multivariable models indicated that the lowest quartiles of time-averaged intact parathyroid hormone were independently associated with higher hip fracture risk (intact parathyroid hormone =181-272 pg/ml: hazard ratio, 1.20; 95% confidence interval [95% CI], 1.03 to 1.41 and intact parathyroid hormone <181 pg/ml: hazard ratio, 1.20; 95% CI, 1.01 to 1.44; referent third quartile, 273 to <433 pg/ml). The lowest quartile of time-averaged serum calcium was also associated with higher risk (calcium <8.7 mg/dl; hazard ratio, 1.17; 95% CI, 1.00 to 1.37) compared with the referent third quartile of 9.1 to <9.5 mg/dl. CONCLUSIONS We found an association between lower levels of intact parathyroid hormone and serum calcium and greater risk for hip and femur fractures among patients on hemodialysis. These findings support additional research toward elucidating long-term safety of treatment approaches for hyperparathyroidism in patients with ESRD.
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Affiliation(s)
- Steven Fishbane
- Department of Medicine, Division of Nephrology, Hofstra North Shore–Long Island Jewish School of Medicine, Great Neck, New York
| | - Azzour D. Hazzan
- Department of Medicine, Division of Nephrology, Hofstra North Shore–Long Island Jewish School of Medicine, Great Neck, New York
| | - Kenar D. Jhaveri
- Department of Medicine, Division of Nephrology, Hofstra North Shore–Long Island Jewish School of Medicine, Great Neck, New York
| | - Lin Ma
- Fresenius Medical Care North America, Waltham, Massachusetts; and
| | - Eduardo Lacson
- Division of Nephrology, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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Sharma AK, Masterson R, Holt SG, Toussaint ND. Emerging role of high-resolution imaging in the detection of renal osteodystrophy. Nephrology (Carlton) 2016; 21:801-11. [PMID: 27042945 DOI: 10.1111/nep.12790] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/14/2016] [Accepted: 03/25/2016] [Indexed: 12/17/2022]
Abstract
The term renal osteodystrophy refers to changes in bone morphology induced by chronic kidney disease (CKD) and represents the skeletal component of the entity 'chronic kidney disease - mineral and bone disorder'. Changes in turnover, mineralization, mass and microarchitecture impair bone quality, compromising strength and increasing susceptibility to fractures. Fractures are more common in CKD compared with the general population and result in increased morbidity and mortality. Screening for fracture risk and management of renal osteodystrophy are hindered by the complex, and still only partially understood, pathophysiology and the inadequacy of currently available diagnostic methods. Bone densitometry and bone turnover markers, although potentially helpful, have significant limitations in patients with CKD, and the 'gold standard' test of bone biopsy is infrequently performed in routine clinical practice. However, recent advances in high-resolution bone microarchitecture imaging may offer greater potential for quantification and assessment of bone structure and strength and, when used in conjunction with serum biomarkers, may allow non-invasive testing for a diagnostic virtual bone biopsy.
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Affiliation(s)
- Ashish K Sharma
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Rosemary Masterson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia. .,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia.
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Sprague SM, Bellorin-Font E, Jorgetti V, Carvalho AB, Malluche HH, Ferreira A, D’Haese PC, Drüeke TB, Du H, Manley T, Rojas E, Moe SM. Diagnostic Accuracy of Bone Turnover Markers and Bone Histology in Patients With CKD Treated by Dialysis. Am J Kidney Dis 2016; 67:559-66. [DOI: 10.1053/j.ajkd.2015.06.023] [Citation(s) in RCA: 166] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 06/15/2015] [Indexed: 11/11/2022]
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Covic A, Voroneanu L, Apetrii M. PTH and/or Bone Histology: Are We Still Waiting for a Verdict From the CKD-MBD Grand Jury? Am J Kidney Dis 2016; 67:535-8. [DOI: 10.1053/j.ajkd.2015.11.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 11/29/2015] [Indexed: 11/11/2022]
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Lamb EJ, Delaney MP. Does PTH offer additive value to ALP measurement in assessing CKD-MBD? Perit Dial Int 2015; 34:687-91. [PMID: 25520480 DOI: 10.3747/pdi.2014.00246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Edmund J Lamb
- Clinical Biochemistry, Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, CT1 3NG, UK
| | - Michael P Delaney
- Clinical Biochemistry, Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, CT1 3NG, UK
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Jean G, Granjon S, Zaoui E, Deleaval P, Hurot JM, Lorriaux C, Mayor B, Chazot C. Usefulness and feasibility of measuring ionized calcium in haemodialysis patients. Clin Kidney J 2015; 8:378-87. [PMID: 26251703 PMCID: PMC4515894 DOI: 10.1093/ckj/sfv039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/04/2015] [Indexed: 12/21/2022] Open
Abstract
Background Measuring blood calcium level is recommended in haemodialysis (HD) patients. The Kidney Disease Improving Global Outcomes position states that the measurement of ionized calcium (ICa) level is preferred, but in the clinical setting, due to technical difficulties, total calcium (tCa) level is preferred to ICa. Aim The aim of this study was to test the possibility of delayed ICa analysis using frozen serum, and so to identify the factors associated with predialysis ICa level and compare the ability of tCa and Alb-Ca to predict ICa level and finally to compare the survival rate according to the three calcium measurements. Methods All prevalent HD patients, dialysed by a native AV fistula in a 3 × 4 to 3 × 8 h schedule, had their predialysis ICa, tCa and Alb-Ca levels and usual mid-week biology recorded. Intergroup comparisons between ICa quartile were performed. Bland–Altman plots and linear regression were used to assess the differences between 30 fresh and frozen samples. Survival analyses were performed using ICa and tCa levels. Results Comparing fresh blood and frozen serum samples, linear regression (y = 0.98 + 0.02, r = 0.961) showed that the two methods were quite identical with the same mean ICa value (1.1 ± 0.1 mmol/L, P = 0.45). A total of 160 HD patients were included in the study. Hypocalcaemia, using ICa values, was highly prevalent in our population (40%) whereas hypercalcaemia was observed only in three cases (1.8%). In predicting ICa hypocalcaemia (<1.12 mmol/L, n = 64), the use of tCa was accurate in 48.4% of patients, and the use of Alb-Ca was accurate in only 17.2% of patients; tCa was not a predictive factor for hypercalcaemia (ICa > 1.32 mmol/L, n = 3); Alb-Ca value predicted hypercalcaemia in 2/3 of the patients. In predicting normocalcaemia, the use of tCa values was correct in 92.4% of patients and the use of Alb-Ca values in 88.1% of patients; only younger age (P = 0.03) and female sex (P = 0.01) were associated with higher ICa quartile. None of the three calcium measures was significantly associated with survival rate using log-rank and Cox models adjusted for age, dialysis vintage, diabetes and sex. Conclusion In the present study, we report that (1) delayed ICa measure is feasible in dialysis patients using a freezing technique, (2) hypocalcaemia is highly prevalent in HD patients and poorly predicted by Alb-Ca level, (3) the main factor associated with ICa level is sex of the individual and (4) calcaemia is not associated with survival rate using any of the three methods.
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Affiliation(s)
- Guillaume Jean
- Dialysis, NephroCare Tassin-Charcot, Sainte Foy-Les-Lyon, France
| | - Samuel Granjon
- Biochemistry Department, Laboratoire Novescia, Sainte Foy Les Lyon, Rhone Alpes, France
| | - Eric Zaoui
- Biochemistry Department, Laboratoire Novescia, Sainte Foy Les Lyon, Rhone Alpes, France
| | - Patrik Deleaval
- Dialysis, NephroCare Tassin-Charcot, Sainte Foy-Les-Lyon, France
| | - Jean-Marc Hurot
- Dialysis, NephroCare Tassin-Charcot, Sainte Foy-Les-Lyon, France
| | | | - Brice Mayor
- Dialysis, NephroCare Tassin-Charcot, Sainte Foy-Les-Lyon, France
| | - Charles Chazot
- Dialysis, NephroCare Tassin-Charcot, Sainte Foy-Les-Lyon, France
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St Peter WL, Yusuf AA, Do T, Lowe KA, Liu J, Nieman KM, Bradbury BD, Collins AJ. Parathyroid hormone change after cinacalcet initiation and one-year clinical outcome risk: a retrospective cohort study. BMC Nephrol 2015; 16:41. [PMID: 25886282 PMCID: PMC4383071 DOI: 10.1186/s12882-015-0030-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 03/11/2015] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Cinacalcet reduces parathyroid hormone (PTH) levels in patients receiving hemodialysis, but no non-experimental studies have evaluated the association between changes in PTH levels following cinacalcet initiation and clinical outcomes. We assessed whether short-term change in PTH levels after first cinacalcet prescription could serve as a surrogate marker for improvements in longer-term clinical outcomes. METHODS United States Renal Data System data were linked with data from a large dialysis organization. We created a point prevalent cohort of adult hemodialysis patients with Medicare as primary payer who initiated cinacalcet November 1, 2004-February 1, 2007, and were on cinacalcet for ≥ 40 days. We grouped patients into quartiles of PTH change after first cinacalcet prescription. We used Cox proportional hazard modeling to evaluate associations between short-term PTH change and time to first composite event (hospitalization for cardiovascular events or mortality) within 1 year. Overall models and models stratified by baseline PTH levels were adjusted for several patient-related factors. RESULTS For 2485 of 3467 included patients (72%), PTH levels decreased after first cinacalcet prescription; for 982 (28%), levels increased or were unchanged. Several characteristics differed between PTH change groups, including age and mineral-and-bone-disorder laboratory values. In adjusted models, we did not identify an association between greater short-term PTH reduction and lower composite event rates within 1 year, overall or in models stratified by baseline PTH levels. CONCLUSIONS Short-term change in PTH levels after first cinacalcet prescription does not appear to be a useful surrogate for longer-term improvements in cardiovascular or survival risk.
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Affiliation(s)
- Wendy L St Peter
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
- University of Minnesota, College of Pharmacy, Minneapolis, Minnesota.
| | - Akeem A Yusuf
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
- University of Minnesota, College of Pharmacy, Minneapolis, Minnesota.
| | - Thy Do
- Center for Observational Research, Amgen Inc., Thousand Oaks, California.
| | - Kimberly A Lowe
- Center for Observational Research, Amgen Inc., Thousand Oaks, California.
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
| | - Kimberly M Nieman
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
| | - Brian D Bradbury
- Center for Observational Research, Amgen Inc., Thousand Oaks, California.
| | - Allan J Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
- University of Minnesota, College of Pharmacy, Minneapolis, Minnesota.
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Lau WL, Kalantar-Zadeh K, Kovesdy CP, Mehrotra R. Alkaline phosphatase: Better than PTH as a marker of cardiovascular and bone disease? Hemodial Int 2014; 18:720-4. [DOI: 10.1111/hdi.12190] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Low-dose cholecalciferol supplementation and dual vitamin D therapy in haemodialysis patients. Int Urol Nephrol 2014; 47:169-76. [PMID: 25262147 DOI: 10.1007/s11255-014-0842-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 09/10/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Traditionally, secondary hyperparathyroidism (SHPT) due to low calcitriol synthesis in failing kidneys has been treated with synthetic vitamin D receptor (VDR) activators. Recently, also the importance of low native vitamin D status beyond the issue of SHPT has been recognized in these patients. The aim of this work was to evaluate the effect of cholecalciferol supplementation in haemodialysis patients with low vitamin D serum levels. Another aim was to evaluate dual vitamin D therapy (cholecalciferol supplementation plus paricalcitol) in haemodialysis patients with vitamin D deficiency and concomitant SHPT. METHODS Ninety clinically stable maintenance haemodialysis patients were included. Supervised cholecalciferol supplementation was administered due to low vitamin D status. Patients with SHPT were also treated with synthetic VDR activator. Two pre hoc subgroups for statistical analysis were formed: patients treated solely with cholecalciferol (N=34; 5,000 IU once weekly) and patients treated with a combination of cholecalciferol (identical dose, i.e. 5,000 IU/week) plus paricalcitol (N=34, median dose 10 μg/week). Follow-up visit was scheduled 15 weeks later. Serum concentrations of calcidiol (25-D), parathyroid hormone (PTH) and beta-cross laps (CTX) were assessed at baseline and at follow-up. Serum calcium, phosphate and alkaline phosphatase (ALP) were monitored monthly. Only non-calcium gastrointestinal phosphate binders were administered. Dialysate calcium was 1.5 mmol/L in all patients, and no oral calcium-containing preparations were prescribed. Depending on data distribution, parametric or nonparametric statistical methods were used for comparison within each group (i.e. baseline vs. follow-up data) as well as between groups. RESULTS In the whole group of 90 patients, mean baseline 25-D serum level was 20.3 (standard deviation 8.7) nmol/L, and it increased to 66.8 (19) nmol/L (p<0.0001) after supplementation. In both preformed subgroups, the effect of vitamin D supplementation was almost identical. In cholecalciferol monotherapy, 25-D levels increased from 18.4 (8.2) to 68.6 (21.2) and in dual vitamin D therapy from 18.4 (5.0) to 67.6 (17.7) nmol/L (both p<0.0001). In addition, both treatment modalities decreased serum PTH levels importantly: from 21.7 (interquartile range 17.3; 35.4) to 18.1 pmol/L (15.3; 24.7) in monotherapy (p=0.05) and from 38.6 (31.8; 53.3) to 33.9 pmol/L (26.1; 47.5) in dual vitamin D therapy (p=0.01). Serum calcium, phosphate, ALP and CTX did not change. We have not observed any episode of hypercalcemia in any subject during the whole period of follow-up. At baseline, slightly lower 25-D levels were observed in diabetic than in non-diabetic patients. This difference disappeared after substitution. Vitamin D status and its changes were not related to the patient's age. CONCLUSION Low 25-D levels were very common in haemodialysis patients. They were safely and effectively corrected with supervised low-dose cholecalciferol supplementation. In patients with higher baseline PTH levels, dual vitamin D therapy (cholecalciferol plus paricalcitol) was safely and effectively used.
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Filipozzi P, Ayav C, Erpelding ML, Kessler M, Brunaud L, Frimat L. Influence on quality of life from an early cinacalcet prescription for secondary hyperparathyroidism in dialysis. Pharmacoepidemiol Drug Saf 2014; 24:187-96. [DOI: 10.1002/pds.3683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 06/18/2014] [Accepted: 07/07/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Pierre Filipozzi
- Department of Nephrology, Dialysis, and Transplantation; CHU Nancy; F-54 511 Vandoeuvre-les-Nancy France
- CHU Nancy, Pôle S2R; Epidémiologie et Evaluation Cliniques; Nancy F-54 000 France
- INSERM; CIC-EC, CIC 1433; Nancy F-54 000 France
| | - Carole Ayav
- CHU Nancy, Pôle S2R; Epidémiologie et Evaluation Cliniques; Nancy F-54 000 France
- INSERM; CIC-EC, CIC 1433; Nancy F-54 000 France
- Université de Lorraine; CIC-EC, CIC 1433; Nancy F-54 000 France
| | - Marie-Line Erpelding
- CHU Nancy, Pôle S2R; Epidémiologie et Evaluation Cliniques; Nancy F-54 000 France
- INSERM; CIC-EC, CIC 1433; Nancy F-54 000 France
- Université de Lorraine; CIC-EC, CIC 1433; Nancy F-54 000 France
| | - Michèle Kessler
- Department of Nephrology, Dialysis, and Transplantation; CHU Nancy; F-54 511 Vandoeuvre-les-Nancy France
| | - Laurent Brunaud
- Department of Hepatobiliary, Digestive and Endocrine Surgery; CHU Nancy; F-54 511 Vandoeuvre-les-Nancy France
| | - Luc Frimat
- Department of Nephrology, Dialysis, and Transplantation; CHU Nancy; F-54 511 Vandoeuvre-les-Nancy France
- Université de Lorraine, Université Paris Descartes; APEMAC, EA4360; Nancy France
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Saab G, Navaneethan SD, Slatopolsky E. Targeting parathyroid hormone levels in dialysis patients. Semin Dial 2014; 27:562-5. [PMID: 25040125 DOI: 10.1111/sdi.12275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Georges Saab
- MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
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Abstract
The emergence of fibroblast growth factor 23 as a potentially modifiable risk factor in CKD has led to growing interest in its measurement as a tool to assess patient risk and target therapy. This review discusses the analytical and clinical challenges faced in translating fibroblast growth factor 23 testing into routine practice. As for other bone mineral markers, agreement between commercial fibroblast growth factor 23 assays is poor, mainly because of differences in calibration, but also, these differences reflect the variable detection of hormone fragments. Direct comparison of readout from different assays is consequently limited and likely hampers setting uniform fibroblast growth factor 23-directed targets. Efforts are needed to standardize assay output to enhance clinical use. Fibroblast growth factor 23 is robustly associated with cardiovascular and renal outcomes in patients with CKD and adds value to risk assessments based on conventional risk factors. Compared with most other mineral markers, fibroblast growth factor 23 shows better intraindividual temporal stability, with minimal diurnal and week-to-week variability, but substantial interindividual variation, maximizing discriminative power for risk stratification. Conventional therapeutic interventions for the CKD-mineral bone disorder, such as dietary phosphate restriction and use of oral phosphate binders or calcimimetics, are associated with variable efficacy at modulating circulating fibroblast growth factor 23 concentrations, like they are for other mineral metabolites. Dual therapy with dietary phosphate restriction and noncalcium-based binder use achieves the most consistent fibroblast growth factor 23-lowering effect and seems best monitored using an intact assay. Additional studies are needed to evaluate whether strategies aimed at reducing levels or antagonizing its action have beneficial effects on clinical outcomes in CKD patients. Moreover, a better understanding of the mechanisms driving fibroblast growth factor 23 elevations in CKD is needed to inform the use of therapeutic interventions targeting fibroblast growth factor 23 excess. This evidence must be forthcoming to support the use of fibroblast growth factor 23 measurement and fibroblast growth factor 23-directed therapy in the clinic.
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Affiliation(s)
- Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Negri AL, Brandenburg VM. Calcitriol resistance in hemodialysis patients with secondary hyperparathyroidism. Int Urol Nephrol 2014; 46:1145-51. [PMID: 24384877 DOI: 10.1007/s11255-013-0637-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 12/16/2013] [Indexed: 01/06/2023]
Abstract
Nonselective vitamin D receptor activators (VDRA), such as calcitriol and alfacalcidol, have been successfully used in the treatment of secondary hyperparathyroidism (SHPT) in hemodialysis. Despite their beneficial effects on the control of serum PTH levels, their use has been limited by intolerance (development of hypercalcemia and hyperphosphatemia with consecutive cardiovascular toxicity). Apart from becoming intolerant, in 20-30 % of patients who use nonselective VDRA, serum PTH levels do not decrease appropriately despite increasing doses of these agents. These patients are considered calcitriol-resistant patients. Thus, calcitriol resistance and intolerance are two sides of the same coin: active vitamin D failure. Despite the clinical relevance of active vitamin D failure, definitions of resistance and intolerance are imprecise and have varied over time. More selective VDRA claim to produce less hypercalcemia and hyperphosphatemia and could help clinicians to overcome intolerance. Also, some studies have also shown that paricalcitol can be even useful in resistant patients. Significant limitations of iPTH as a reliable and useful clinical biomarker have been increasingly appreciated. There is evidence that intact PTH concentration must differ by 72 % between any two measurements before it can be considered a significant change. VDR polymorphisms could be involved in the development of SHPT in CKD patients. Interestingly, a higher incidence of the b allele of the VDR BsmI gene variant has been shown to be present in SHPT. The BsmI genotype can also affect the response of hemodialysis to IV calcitriol. A challenge for the future will be to establish biomarkers such as laboratory determinations or ultrasound findings that can help us to early identify those patients who will not respond appropriately to calcitriol or exhibit intolerable side effects .
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Affiliation(s)
- Armando L Negri
- Instituto de Investigaciones Metabólicas, Universidad del Salvador School of Medicine, Libertad 836 1 piso, 1012, Buenos Aires, Argentina,
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36
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Abstract
There is growing interest in the role of fibroblast growth factor 23 (FGF23) in various diseases of disordered mineral metabolism. In chronic kidney disease (CKD), where biochemical evidence of mineral disturbances is especially common, FGF23 measurement has been advocated as an early and sensitive marker for CKD-related bone disease. In this setting, FGF23 analysis may also improve the discrimination of risk of adverse renal and cardiovascular outcomes and aid targeting of those patients that are likely to benefit from interventions. Nonetheless, while the physiological relevance of FGF23 in the control of mineral metabolism is now firmly established, relatively little attention has been paid to important preanalytical and analytical aspects of FGF23 measurement that may impact on its clinical utility. Here we review these issues and discuss the suitability of FGF23 testing strategies for routine clinical practice. The current ‘state-of-the-art’ enzyme-linked immunosorbent assay methods for FGF23 measurement show poor agreement due to differences in FGF23 fragment detection, antibody specificity and calibration. Such analytical variability does not permit direct comparison of FGF23 measurements made with different assays and is likely to at least in part account for some of the inconsistencies noted between observational studies. From a clinical perspective, the lack of concordance has implications for the development of standardized reference intervals and clinical decision limits. Finally, the inherent assay-dependent biological variability of plasma FGF23 concentration can further complicate the interpretation of results and the design of FGF23-based testing protocols. Currently, it would be premature to consider incorporating FGF23 measurements into standard testing repertoires.
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Affiliation(s)
- Edward R Smith
- Department of Renal Medicine, Eastern Health Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia
| | - Lawrence P McMahon
- Department of Renal Medicine, Eastern Health Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia
| | - Stephen G Holt
- Department of Renal Medicine, Eastern Health Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Box Hill, Victoria, Australia
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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Eddington H, Hudson JE, Oliver RL, Fraser WD, Hutchison AJ, Kalra PA. Variability in parathyroid hormone assays confounds clinical practice in chronic kidney disease patients. Ann Clin Biochem 2013; 51:228-36. [PMID: 24000371 DOI: 10.1177/0004563213491236] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intact parathyroid hormone (iPTH) measurements are used to guide therapy in renal patients, but variability in results can occur depending on the assay used. This study has investigated iPTH assay variation in North West England and paired data with regional audit data to determine clinical relevance of assay variability. METHODS Thirty-seven haemodialysis patients had blood taken (EDTA plasma, and serum), and samples were processed at 17 laboratories that analyse iPTH for North West dialysis patients. Correction factors were calculated and applied to the iPTH assay results to enable direct comparisons. These correction factors were also applied to Regional Audit data to determine if iPTH assay variability explains the variation in unit performance in achieving PTH targets. RESULTS The iPTH results from the 37 patients were significantly different when either analysed by different assays and/or different laboratories (P < 0.001). The Abbott Architect method consistently produced the highest iPTH results. Of the 37 patients, between 49% and 65% would achieve the Kidney Disease: Improving Global Outcomes (KDIGO) iPTH target depending on the assay used. When results were adjusted using correction factors, 21% of the patients would require a change of management according to guidelines. Data from all haemodialysis units submitted for the regional audit were adjusted to the Roche assay and this led to a small change in achievement of KDIGO iPTH targets in individual units when compared to each other. CONCLUSIONS A combination of iPTH assay variability and diversity in clinical management leads to variation in achieving iPTH targets. Both need to be improved and/or standardized to improve patient care.
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Affiliation(s)
- Helen Eddington
- Renal Department, Manchester Academic Health Science Centre, Salford Royal Hospital, The University of Manchester, Salford, UK
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Delanaye P, Souberbielle JC, Lafage-Proust MH, Jean G, Cavalier E. Can we use circulating biomarkers to monitor bone turnover in CKD haemodialysis patients? Hypotheses and facts. Nephrol Dial Transplant 2013; 29:997-1004. [DOI: 10.1093/ndt/gft275] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Moorthi RN, Moe SM. Recent advances in the noninvasive diagnosis of renal osteodystrophy. Kidney Int 2013; 84:886-94. [PMID: 23802194 PMCID: PMC3805700 DOI: 10.1038/ki.2013.254] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/18/2013] [Accepted: 03/28/2013] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease-mineral and bone disorder (CKD-MBD) is the term used to describe a constellation of biochemical abnormalities, bone disturbances that may lead to fractures, and extraskeletal calcification in soft tissues and arteries seen in CKD. This review focuses on the noninvasive diagnosis of renal osteodystrophy, the term used exclusively to define the bone pathology associated with CKD. Transiliac bone biopsy and histomorphometry with double-labeled tetracycline or its derivatives remains the gold standard for diagnosis of renal osteodystrophy. However, histomorphometry provides a 'window' into bone only at a single point in time, and is not clinically practical for studying continuous changes in bone morphology. Furthermore, the etiology of fractures in CKD is multifactorial and not fully explained by histomorphometry findings alone. The propensity of a bone to fracture is determined by bone strength, which is affected by bone mass and bone quality; the latter is a term used to describe the structure and composition of bone. Bone quantity is traditionally assessed by dual X-ray absorptiometry (DXA) and CT-based methods. Bone quality is more difficult to assess noninvasively, but newer techniques are emerging and are described in this review. Ultimately, the optimal diagnostic strategy for renal osteodystrophy may be a combination of multiple imaging techniques and biomarkers that are specific to each gender and race in CKD, with a goal of predicting fracture risk and optimizing therapy.
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Affiliation(s)
- Ranjani N Moorthi
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Jia T, Qureshi AR, Brandenburg V, Ketteler M, Barany P, Heimburger O, Uhlin F, Magnusson P, Fernström A, Lindholm B, Stenvinkel P, Larsson TE. Determinants of fibroblast growth factor-23 and parathyroid hormone variability in dialysis patients. Am J Nephrol 2013; 37:462-71. [PMID: 23635517 DOI: 10.1159/000350537] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 03/06/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND/AIMS Treatment strategies for abnormal mineral metabolism in chronic kidney disease are largely based on achieving target ranges of biomarkers that vary considerably over time, yet determinants of their variability are poorly defined. METHODS Observational study including 162 patients of three dialysis cohorts (peritoneal dialysis, n = 78; hemodialysis, n = 49; hemodiafiltration, n = 35). Clinical and biochemical determinants of parathyroid hormone (PTH) and fibroblast growth factor-23 (FGF23) variability were analyzed in the peritoneal dialysis cohort. All cohorts were used for comparison of PTH and FGF23 intra-subject variability (intra-class correlation), and their intra-subject variability in different modes of dialysis was explored. RESULTS High PTH variability was independently associated with lower 25-hydroxyvitamin D concentration and factors of lipid and glucose metabolism, whereas high FGF23 variability was mainly associated with lower baseline serum phosphorous. These results were consistent in multivariate and sensitivity analyses. The intra-subject variability of FGF23 was lower than for PTH irrespective of dialysis mode. CONCLUSIONS Baseline vitamin D status and serum phosphorous are independent determinants of the longitudinal variation in PTH and FGF23, respectively. The clinical utility of FGF23 measurement remains unknown, yet it appears favorable based on its greater temporal stability than PTH in dialysis patients.
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Affiliation(s)
- Ting Jia
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Sardiwal S, Magnusson P, Goldsmith DJA, Lamb EJ. Bone alkaline phosphatase in CKD-mineral bone disorder. Am J Kidney Dis 2013; 62:810-22. [PMID: 23623575 DOI: 10.1053/j.ajkd.2013.02.366] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 02/07/2013] [Indexed: 12/27/2022]
Abstract
Overall and cardiovascular mortality in patients with chronic kidney disease (CKD) is greatly increased, without obvious current effective treatments. Mineral and bone disorder (MBD) is a common manifestation of CKD and contributes to the high risk of fracture and cardiovascular mortality in these patients. Traditionally, clinical management of CKD-MBD focused on attenuation of secondary hyperparathyroidism due to impaired renal activation of vitamin D and phosphate retention, although recently, adynamic forms of renal bone disease have become more prevalent. Definitive diagnosis was based on histologic (histomorphometric) analysis of bone biopsy material supported by radiologic changes and changes in levels of surrogate laboratory markers. Of these various markers, parathyroid hormone (PTH) has been considered to be the most sensitive and currently is the most frequently used; however, the many pitfalls of measuring PTH in patients with CKD increasingly are appreciated. We propose an alternative or complementary approach using bone alkaline phosphatase (ALP), which is directly related to bone turnover, reflects bone histomorphometry, and predicts outcomes in hemodialysis patients. Here, we consider the overall merits of bone ALP as a marker of bone turnover in adults with CKD-MBD, examine published bone histomorphometric data comparing bone ALP to PTH, and discuss possible pathogenic mechanisms by which bone ALP may be linked to outcomes in patients with CKD.
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Affiliation(s)
- Sunita Sardiwal
- Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, United Kingdom
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Borai A, Livingstone C, Ferns G. Reference change values for insulin and insulin-like growth factor binding protein-1 (IGFBP-1) in individuals with varying degrees of glucose tolerance. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:274-8. [DOI: 10.3109/00365513.2013.771281] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Haffner D, Schaefer F. Searching the optimal PTH target range in children undergoing peritoneal dialysis: new insights from international cohort studies. Pediatr Nephrol 2013; 28:537-45. [PMID: 22893310 DOI: 10.1007/s00467-012-2270-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 06/26/2012] [Accepted: 07/02/2012] [Indexed: 01/27/2023]
Abstract
The treatment of the mineral and bone disorder associated with chronic kidney disease (CKD-MBD) remains a major challenge in pediatric patients. The principal aims of therapeutic measures are not only to prevent the debilitating skeletal complications and to achieve normal growth but also to preserve long-term cardiovascular health. Serum parathyroid hormone (PTH) levels are used as a surrogate parameter of bone turnover. Whereas it is generally accepted that serum calcium and phosphate levels should be kept within the range for age, current pediatric consensus guidelines differ markedly with respect to the optimal PTH target range and operate on a limited evidence base. Recently, the International Pediatric Dialysis Network (IPPN) established a global registry collecting detailed clinical and biochemical information, including data relevant to CKD-MBD in children on chronic peritoneal dialysis (PD). This review highlights the current evidence basis regarding the optimal PTH target range in pediatric CKD patients, and re-assesses the current guidelines in view of the outcome data collected by the IPPN registry. Based on a comprehensive evaluation of CKD-MBD outcome measures in this global patient cohort, a PTH target range of 1.7-3 times the upper limit of normal (i.e. 100-200 pg/ml) appears reasonable in children undergoing chronic PD.
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MESH Headings
- Adolescent
- Animals
- Biomarkers/blood
- Bone Remodeling
- Cardiovascular Diseases/blood
- Cardiovascular Diseases/diagnosis
- Cardiovascular Diseases/etiology
- Cardiovascular Diseases/physiopathology
- Cardiovascular Diseases/prevention & control
- Child
- Child, Preschool
- Chronic Kidney Disease-Mineral and Bone Disorder/blood
- Chronic Kidney Disease-Mineral and Bone Disorder/diagnosis
- Chronic Kidney Disease-Mineral and Bone Disorder/etiology
- Chronic Kidney Disease-Mineral and Bone Disorder/physiopathology
- Chronic Kidney Disease-Mineral and Bone Disorder/prevention & control
- Guideline Adherence
- Humans
- Hyperparathyroidism, Secondary/blood
- Hyperparathyroidism, Secondary/diagnosis
- Hyperparathyroidism, Secondary/etiology
- Hyperparathyroidism, Secondary/physiopathology
- Hyperparathyroidism, Secondary/prevention & control
- Infant
- Parathyroid Hormone/blood
- Peritoneal Dialysis/adverse effects
- Peritoneal Dialysis/standards
- Practice Guidelines as Topic
- Registries
- Renal Insufficiency, Chronic/blood
- Renal Insufficiency, Chronic/complications
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/physiopathology
- Renal Insufficiency, Chronic/therapy
- Treatment Outcome
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Affiliation(s)
- Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany.
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Abstract
Parathyroid hormone (PTH) is a uremic toxin with multiple systemic effects including bone disorders (renal osteodystrophy), myopathy, neurologic abnormalities, anemia, pruritus, and cardiomyopathy. Hyperparathyroidism is common in CKD and results in significant morbidity and mortality if left untreated. Clinical practice guidelines from the Kidney Disease Improving Global Outcomes initiative broadened the optimal PTH range to >2 and <9 times the upper limit of normal for the assay measured. Furthermore, the guidelines recommend following trends in PTH to determine the appropriate therapy. These guidelines overcome issues with the assay variability and help clinicians make judgments when treating individual patients. They also require frequent measurement in order to determine trends and implement appropriate treatments.
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Affiliation(s)
- Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University HealthSystem, Evanston, IL 60201, USA.
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Cavalier E, Delanaye P, Moranne O. Variability of new bone mineral metabolism markers in patients treated with maintenance hemodialysis: implications for clinical decision making. Am J Kidney Dis 2013; 61:847-8. [PMID: 23357107 DOI: 10.1053/j.ajkd.2012.12.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 12/18/2012] [Indexed: 11/11/2022]
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Hanon EA, Sturgeon CM, Lamb EJ. Sampling and storage conditions influencing the measurement of parathyroid hormone in blood samples: a systematic review. Clin Chem Lab Med 2013; 51:1925-41. [DOI: 10.1515/cclm-2013-0315] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Indexed: 01/01/2023]
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Abraham G, Kher V, Saxena S, Jayakumar M, Chafekar D, Pargaonkar P, Shetty M, Reddy YNV, Reddy YNV. Sevelamer carbonate experience in Indian end stage renal disease patients. Indian J Nephrol 2012; 22:189-92. [PMID: 23087553 PMCID: PMC3459522 DOI: 10.4103/0971-4065.98754] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This open label, multicentric, comparative clinical trial was done to compare the efficacy and tolerability of two sevelamer formulations, sevelamer carbonate, and sevelamer hydrochloride, in the treatment of hyperphosphatemia in Indian end stage renal disease (ESRD) patients. A total of 97 ESRD patients on hemodialysis, were enrolled. Patients were randomized to receive either sevelamer carbonate or sevelamer hydrochloride. All patients were evaluated every week for 6 weeks for efficacy and safety variables. Total 88 patients completed the study. After 6 weeks of therapy, there were similar reductions (P<0.0001) in mean serum phosphorus and the CaxP product both the groups. The responder rates for test and reference groups were 75%, 68.18% respectively (P=0.3474). The adverse events reported were nausea, abdominal pain/discomfort, heartburn, constipation, diarrhea, increased prothrombin time, and severe arthritis. No serious adverse events were reported. There was no significant difference between the groups for adverse events and the laboratory parameters. From the results of this multicentric, comparative, randomized clinical study on sevelamer carbonate we can recommend that sevelamer carbonate may be used as a phosphate binder in Indian chronic kidney disease patients.
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Affiliation(s)
- G Abraham
- Dialysis Unit, Tamilnad Kidney Research Foundation, Kilpauk, Chennai, India
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Smith ER, Cai MM, McMahon LP, Holt SG. Biological variability of plasma intact and C-terminal FGF23 measurements. J Clin Endocrinol Metab 2012; 97:3357-65. [PMID: 22689697 DOI: 10.1210/jc.2012-1811] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT FGF23 measurement may have a role in the management of patients with chronic kidney disease (CKD). OBJECTIVE Our objective was to study the biological variability of plasma intact FGF23 (iFGF23) and C-terminal FGF23 (cFGF23) concentrations. DESIGN Plasma samples were taken from 12 healthy adults at multiple time points on 2 consecutive days to assess diurnal variability of FGF23 concentrations. Early-morning fasting and nonfasting samples were also taken over a 6-wk period to estimate components of biological variation. Samples from 170 volunteers were used to define reference intervals. FGF23 concentrations were measured by commercial ELISA. Western blotting was used to analyze FGF23 species from the plasma of healthy adults and patients with predialysis CKD and those undergoing dialysis. PARTICIPANTS AND SETTING A total of 180 healthy adults and 18 adults with stage 3-5D CKD participated in this study at a hospital research unit. MAIN OUTCOME MEASURE Estimates were made of the biological variability of plasma FGF23 concentrations. RESULTS iFGF23, but not cFGF23, showed significant diurnal variation. cFGF23 had a significantly lower intra-individual variation than iFGF23 (8.3 vs. 18.3%) but higher inter-individual variation than iFGF23 (28.9 vs. 19.2%). Fourteen samples would be needed to estimate an individual's homeostatic set point (within 10%) for iFGF23 compared with only three samples for cFGF23. Using Western blotting, C-terminal FGF23 fragments were detected in the plasma of individuals with normal renal function and at all stages of renal disease. The percent cFGF23 was significantly higher in those without renal impairment (P < 0.001) and was positively correlated with plasma phosphate concentration in those with normal renal function. CONCLUSIONS The high intra-individual biological variability of iFGF23 may limit its clinical use as a diagnostic or management tool. Risk-related thresholds may be more appropriate for clinical decision making based on cFGF23 measurements than conventional reference intervals. FGF23 cleavage pathways may be an important natural regulatory mechanism for phosphate control.
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Affiliation(s)
- Edward R Smith
- Department of Renal Medicine, Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Level 2, 5 Arnold Street, Box Hill, 3128 Victoria, Australia.
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Cai MM, McMahon LP, Smith ER, Williams DS, Holt SG. Hyperparathyroidism in chronic kidney disease: complexities within the commonplace. Clin Med (Lond) 2012; 12:333-7. [PMID: 22930877 PMCID: PMC4952121 DOI: 10.7861/clinmedicine.12-4-333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Secondary hyperparathyroidism in patients with chronic kidney disease (CKD) is common and usually caused by associated metabolic abnormalities, in particular, hypocalcaemia and hyperphosphataemia. Nevertheless, other causes of hyperparathyroidism can exist concurrently with CKD, challenging diagnostic interpretation and therapeutic intervention. We present four cases of hyperparathyroidism in patients with CKD that highlight some of these dilemmas.
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Affiliation(s)
- Michael M Cai
- Department of Renal Medicine, Eastern Health Clinical School, Monash University, Melbourne, Australia.
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