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Martino FK, di Vico V, Basso A, Gobbi L, Stefanelli LF, Cacciapuoti M, Bettin E, Del Prete D, Scaparrotta G, Nalesso F, Calò LA. The Role of Daily Dialysate Calcium Exposure in Phosphaturic Hormones in Dialysis Patients. Life (Basel) 2024; 14:964. [PMID: 39202706 PMCID: PMC11355329 DOI: 10.3390/life14080964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 07/21/2024] [Accepted: 07/26/2024] [Indexed: 09/03/2024] Open
Abstract
Managing mineral bone disease (MBD) could reduce cardiovascular risk and improve the survival of dialysis patients. Our study focuses on the impact of calcium bath exposure in dialysis patients by comparing peritoneal dialysis patients (PD, intervention group) and hemodialysis patients (HD, control group). We assessed various factors, including calcium, phosphorus, magnesium, PTH, vitamin D 25-OH, C-terminal telopeptide (CTX), and FGF-23 levels, as well as the calcium bath six hours before the blood sample and the length of daily calcium exposure. We enrolled 40 PD and 31 HD patients with a mean age of 68.7 ± 13.6 years. Our cohort had median PTH and FGF-23 levels of 194 ng/L (Interquartile range [IQR] 130-316) and 1296 pg/mL (IQR 396-2698), respectively. We identified the length of exposure to a 1.25 mmol/L calcium bath, phosphate levels, and CTX as independent predictors of PTH (OR 0.279, p = 0.011; OR 0.277, p = 0.012; OR 0.11, p = 0.01, respectively). In contrast, independent predictors of FGF-23 were phosphate levels (OR 0.48, p < 0.001) and serum calcium levels (OR 0.25, p = 0.015), which were affected by the calcium bath. These findings suggest that managing dialysate calcium baths impacts phosphaturic hormones and could be a critical factor in optimizing CKD-MBD treatment in PD patients, sparking a new avenue of research and potential interventions.
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Affiliation(s)
- Francesca K. Martino
- Nephrology, Dialysis and Transplantation Unit, Department of Medicine (DIMED), University of Padova, 35128 Padua, Italy; (V.d.V.); (A.B.); (L.G.); (L.F.S.); (M.C.); (E.B.); (D.D.P.); (G.S.); (L.A.C.)
| | | | | | | | | | | | | | | | | | - Federico Nalesso
- Nephrology, Dialysis and Transplantation Unit, Department of Medicine (DIMED), University of Padova, 35128 Padua, Italy; (V.d.V.); (A.B.); (L.G.); (L.F.S.); (M.C.); (E.B.); (D.D.P.); (G.S.); (L.A.C.)
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An N, Zhou H, Li X, Yu X, Yang H, Zhai L, Huang Y, Yao C. Effect of low-calcium and standard-calcium dialysate on serum calcium, phosphorus and full-segment parathyroid hormone in patients on peritoneal dialysis: A retrospective observational study. Int J Artif Organs 2023; 46:539-546. [PMID: 37877542 DOI: 10.1177/03913988231206641] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
OBJECTIVE To investigate the effects of low-calcium and standard-calcium dialysate in patients with chronic kidney disease on peritoneal dialysis, and find out which dialysate has less vascular calcification effect. METHODS A total of 141 patients who had undergone peritoneal dialysis (PD) for 2 years in the PD centre from January 2012 to December 2017 were included and divided into two groups according to the calcium concentration of the PD fluid used. There were 79 cases in the low-calcium group, with a dialysate calcium concentration of 1.25 mmol/L and 62 cases in the standard-calcium group, with a dialysate calcium concentration of 1.75 mmol/L. The demographic characteristics and clinical information before initiation of PD were collected and compared between the two groups. Information on the serum calcium, phosphorus and PTH, systolic and diastolic blood pressures and the use of antihypertensive and phosphate-lowering drugs in the second year of dialysis was also collected and compared between the two groups. Vascular calcification was assessed in patients on PD treatment. RESULTS The mean serum calcium concentrations before initiation of PD in the low- and standard-calcium groups were 1.94 ± 0.27 and 1.89 ± 0.28 mmol/L, respectively. The serum calcium concentrations after PD were 2.30 ± 0.21 and 2.41 ± 0.23 mmol/L, respectively. After PD, the serum calcium concentration in both groups was significantly increased (p < 0.05). The serum calcium concentration in the low-calcium group after PD treatment was lower than that in the standard-calcium group, and the difference was statistically significant (p < 0.05). Compared with the standard-calcium group, patients in the low-calcium group had significantly higher parathyroid hormone concentrations (p < 0.05). More types of phosphate-lowering drugs were used (59.49%) in the low-calcium group than that in the standard-calcium group (35.48%; p < 0.05). The number of antihypertensive drug usage were also higher in the low-calcium group, and the difference was statistically significant (p < 0.05). As for the vascular calcification effect, the two groups have shown no statistical difference in abdominal aortic calcification rate, carotid arteriosclerosis rate and aortic arch calcification rate (p < 0.05). CONCLUSION We found that low-calcium PD fluid may increase the PTH level and the proportion of CKD patients using antihypertensive drug and phosphorus-lowering drug, but the vascular calcification effect of the low and standard calcium PD fluid needs further exploration. This paper provides new evidence for the choice of dialysate for PD, low-calcium dialysate has no outstanding advantages for long term dialysis.
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Affiliation(s)
- Ning An
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Haishan Zhou
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Xianhui Li
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Xinyin Yu
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Haijuan Yang
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Liping Zhai
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Yuhua Huang
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Cuiwei Yao
- Department of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
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Davenport A. Differences in prevalence of reduced and low bone mineral density between lumbar spine and femoral neck in peritoneal dialysis patients using dual-energy X-ray absorptiometry (DXA). ARCH ESP UROL 2023:8968608221146867. [PMID: 36627766 DOI: 10.1177/08968608221146867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The pattern of chronic kidney disease-mineral bone disease has changed following the increase in elderly patients receiving dialysis, with escalating likelihood of osteoporosis, with associated increased fracture risk and mortality. Thus, we wished to determine the prevalence of osteoporosis in our peritoneal dialysis (PD) cohort. Lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA), and low BMD (osteoporosis) and reduced BMD (osteopenia) defined according to the World Health Organisation T scores. DXA scans from 734 patients, 57.2% male, mean age 61.0 ±16.0 years, 34.6% diabetic, with a median 8.0 (2-24) months of treatment with PD were reviewed. Fewer patients had normal BMD at the FN vs. LS (24.1 vs. 55%), and more classified as reduced (FN 55.9 vs. 34% LS) and low BMD (FN 17 vs. 11% LS), χ 2 112.2, p < 0.001. Agreement between FN and LS T scores was r = 0.36 with Spearman rank correlation, and 0.34 by Kendall's tau b, Cohen's kappa score 0.17, and Bland-Altman bias -0.37 (95% limits of agreement -1.8 to 1.08). The prevalence of reduced and low BMD was much greater when using FN T scores compared to LS, with LS T scores a mean of 0.34 higher than FN. DXA scanning at the LS can be affected by overlying vascular calcification and electron densities in the bowel, and as such we suggest that FN T scores are used to report BMD in PD patients.
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Affiliation(s)
- Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London Medical School, UK
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Chen CL, Chen NC, Wu FZ, Wu MT. Impact of denosumab on cardiovascular calcification in patients with secondary hyperparathyroidism undergoing dialysis: a pilot study. Osteoporos Int 2020; 31:1507-1516. [PMID: 32246167 DOI: 10.1007/s00198-020-05391-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/13/2020] [Indexed: 11/25/2022]
Abstract
UNLABELLED The receptor activator of nuclear factor-kappa B ligand (RANKL)/RANK/osteoprotegerin system is dysregulated in hyperparathyroid bone diseases. The introduction of denosumab preceding elective surgery as an alternative option when surgery is not possible immediately. INTRODUCTION The effects of denosumab on vascular calcification in patients with chronic renal failure and low bone mass have been a subject of interest. Therefore, this investigation aimed to determine the short-term changes in vascular calcification after denosumab treatment using a serial electrocardiography-gated computed tomography (CT) to measure coronary artery calcification (CAC) in patients with secondary hyperparathyroidism (SHPT) and low bone mass. METHODS This 6-month study enrolled patients with SHPT and low bone mass (T-score < - 2.5) owing to dialysis. The 2 groups administered denosumab at a dose of 60 mg (denosumab group), and conventional treatment (control group) had 21 patients each. All patients underwent CT scans at baseline and at the follow-up examination at 6 months to determine the bone mineral density and CAC. RESULTS The control group demonstrated a significant increase in Agatston scores (187.79 ± 72.27) (P = 0.004). However, no significant change was noted in the denosumab group (P = 0.41). In the denosumab group, only the baseline serum alkaline phosphatase levels correlated negatively with changes in the CAC score (P = 0.01); the baseline alkaline phosphatase levels were the deciding biomarkers for non-responsive CAC scores by Berry Criteria after denosumab treatment (P = 0.02). The denosumab group demonstrated significantly increased bone mineral density in the femoral neck and lumbar spine (P < 0.01). CONCLUSION The findings provide evidence that denosumab may suppress the progression of CAC and also regress osseous calcification in severe cases of high bone turnover.
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Affiliation(s)
- C-L Chen
- Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - N-C Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - F-Z Wu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Radiology, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Rd., Kaohsiung, 813, Taiwan
| | - M-T Wu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.
- Department of Radiology, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Rd., Kaohsiung, 813, Taiwan.
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Jin L, Zhou J, Shao F, Yang F. Long-term effects on PTH and mineral metabolism of 1.25 versus 1.75 mmol/L dialysate calcium in peritoneal dialysis patients: a meta-analysis. BMC Nephrol 2019; 20:213. [PMID: 31185931 PMCID: PMC6558799 DOI: 10.1186/s12882-019-1388-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/16/2019] [Indexed: 12/19/2022] Open
Abstract
Background This study aimed to compare 1.25 and 1.75 mmol/L dialysate calcium for their effects on parathyroid hormone (PTH) and mineral metabolism in peritoneal dialysis (PD). Methods The PubMed, Cochrane Library, and EmBase databases were searched from inception to October 2016. Methodological quality assessment of the included studies was performed using the risk of bias tool of the Review Manager software. The meta-analysis was carried out with the Stata12.0 software. Subgroup analysis was performed by study design [randomized controlled trial (RCT) and non-RCT]. Odds ratios or standardized mean differences were used to assess the outcome measures, including intact parathyroid hormone (i-PTH) levels, serum total calcium amounts, ionized calcium levels, phosphate concentrations, and peritonitis episodes. Results Seven studies were enrolled in the synthesized analysis, including 4 RCTs and 3 non-RCTs. All studies compared 1.25 mmol/L and 1.75 mmol/L dialysate calcium for PD. Pooled analysis revealed that 1.75 mmol/L dialysate calcium significantly reduced i-PTH levels compared with the 1.25 mmol/L dose in PD patients. However, 1.25 mmol/L dialysate calcium was superior to the 1.75 mmol/L dose in decreasing the levels of serum total calcium and ionized calcium in PD patients. No significant differences in phosphate amounts and peritonitis episodes were observed between the two groups. Conclusion These findings indicated that 1.75 mmol/L dialysate calcium is more appropriate for PD patients with secondary hyperparathyroidism. Meanwhile, 1.25 mmol/L dialysate calcium is more favorable to PD patients with secondary hypercalcemia. However, further well-designed and high-quality studies are required to validate these findings.
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Affiliation(s)
- Liqin Jin
- Nephrology Center, Beijing Luhe Hospital Capital Medical University, Beijing, 101149, China.
| | - Jingjing Zhou
- Nephrology Center, Beijing Luhe Hospital Capital Medical University, Beijing, 101149, China
| | - Feng Shao
- Nephrology Center, Beijing Luhe Hospital Capital Medical University, Beijing, 101149, China
| | - Fan Yang
- Nephrology Center, Beijing Luhe Hospital Capital Medical University, Beijing, 101149, China
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Heaf JG. Chronic Kidney Disease-Mineral Bone Disorder in the Elderly Peritoneal Dialysis Patient. Perit Dial Int 2016; 35:640-4. [PMID: 26702005 DOI: 10.3747/pdi.2014.00339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The purpose of this paper was to review the literature concerning the treatment of chronic kidney disease-mineral bone disorder (CKD-MBD) in the elderly peritoneal dialysis (PD) patient. RESULTS Chronic kidney disease-mineral bone disorder is a major problem in the elderly PD patient, with its associated increased fracture risk, vascular calcification, and accelerated mortality fracture risk. Peritoneal dialysis, however, bears a lower risk than hemodialysis (HD). The approach to CKD-MBD prophylaxis and treatment in the elderly PD patient is similar to other CKD patients, with some important differences. Avoidance of hypercalcemia, hyperphosphatemia, and hyperparathyroidism is important, as in other CKD groups, and is generally easier to attain. Calcium-free phosphate binders are recommended for normocalcemic and hypercalcemic patients. Normalization of vitamin D levels to > 75 nmol/L (> 30 pg/L) and low-dose active vitamin D therapy is recommended for all patients. Hyperparathryoidism is to be avoided by using active vitamin D and cinacalcet. Particular attention should be paid to treating protein malnutrition. Fracture prophylaxis (exercise, use of walkers, dwelling modifications) are important. Hypomagnesemia is common in PD and can be treated with magnesium supplements. Vitamin K deficiency is also common and has been identified as a cause of vascular calcification. Accordingly, warfarin treatment for this age group is problematic. CONCLUSION While treatment principles are similar to other dialysis patient groups, physicians should be aware of the special problems of the elderly group.
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Affiliation(s)
- James Goya Heaf
- Department of Medicine, Roskilde Hospital, University of Copenhagen, Copenhagen, Denmark
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Chen CL, Chen NC, Hsu CY, Chou KJ, Lee PT, Fang HC, Renn JH. An open-label, prospective pilot clinical study of denosumab for severe hyperparathyroidism in patients with low bone mass undergoing dialysis. J Clin Endocrinol Metab 2014; 99:2426-32. [PMID: 24670088 DOI: 10.1210/jc.2014-1154] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Denosumab is widely used for bone diseases with increased bone resorption. Its effectiveness in patients with severe secondary hyperparathyroidism on dialysis is unclear. OBJECTIVE This study aimed to evaluate the efficacy and safety of denosumab in patients with severe secondary hyperparathyroidism who are on dialysis. DESIGN This 6-month prospective, open-labeled study evaluated 12 patients (five women, seven men; mean age 53.5 ± 3.8 y). All had intact PTH (iPTH; > 1000 pg/mL), low bone mass (T-score < -1.0 SD), and bone pain and were poor surgical candidates. Serum calcium, phosphorus, alkaline phosphatase (AP), and iPTH levels were assessed at baseline and every month thereafter. Vertebral spine x-rays and bone mineral densities (BMDs) (lumbar spine and femoral neck) were assessed at the start and end of the study. All patients received denosumab (60 mg), calcitriol, phosphate binders, and dialysate calcium that were adjusted according to the biochemistry data. RESULTS The BMD increased in both the femoral neck (mean increase 23.7% ± 4.0%) and lumbar spine (17.1% ± 2.6%) after 6 months. In the first month, most patients had increased iPTH levels, which dramatically decreased from 1702.1 ± 181.9 to 518.8 ± 126.8 pg/mL by the end of the study after increasing the calcitriol dose. All patients had significant decreases in AP, calcium × phosphorus, and bone pain. Changes in femoral neck BMD correlated only with AP and iPTH levels. CONCLUSIONS Denosumab is effective in restoring bone mass and reducing bone pain in patients on dialysis with secondary hyperparathyroidism. It also allows for a more aggressive use of calcitriol to control hyperparathyroidism.
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Affiliation(s)
- Chien-Liang Chen
- Division of Nephrology (C.-L.C., C.-Y.H., K.-J.C., P.-T.L., H.-C.F.) and Department of Orthopedics (J.-H.R.), Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan; Department of Medicine (C.-L.C., C.-Y.H., K.-J.C., P.-T.L., H.-C.F.), National Yang-Ming University School of Medicine, Taipei 112, Taiwan; Department of Neurology (N.-C.C.), Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 333, Taiwan; and College of Pharmacy and Health Care (J.-H.R.), Tajen University, Pintong County 907, Taiwan
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