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Lucander ACK, Judd E, Cooper DKC. What is the clinical relevance of deviant serum calcium and phosphate levels after pig-to-primate kidney xenotransplantation? Xenotransplantation 2022; 29:e12785. [PMID: 36300760 PMCID: PMC10154070 DOI: 10.1111/xen.12785] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/06/2022] [Indexed: 01/15/2023]
Abstract
Experience from human renal allotransplantation informs us that disturbances in serum calcium and phosphate levels are relatively common. Post-transplant hypercalcemia is associated with an increased risk of recipient mortality, but not of graft loss or nephropathy, and post-transplant hyperphosphatemia with an increased risk of both recipient mortality and death-censored graft failure, but neither post-transplant hypocalcemia nor hypophosphatemia is associated with adverse outcome. Studies after pig-to-nonhuman primate kidney xenotransplantation have demonstrated consistent supranormal serum calcium and subnormal serum phosphate levels. If these trends in serum electrolyte levels were to occur following pig-to-human kidney xenotransplantation, the data from allotransplant studies would indicate an increased risk of recipient mortality (associated with hypercalcemia) but not of graft loss or nephropathy, and no adverse outcome from hypophosphatemia. Furthermore, some nonhuman primates are now surviving in a healthy state for longer than a year after life-supporting pig kidney transplantation, suggesting that chronic hypercalcemia and/or hypophosphatemia are not detrimental to long-term survival, and should not prevent clinical trials of pig kidney transplantation from being undertaken.
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Affiliation(s)
- Aaron C K Lucander
- Medical Scientist Training Program, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Eric Judd
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Charlestown, Massachusetts, USA
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2
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Ralston MR, Stevenson KS, Mark PB, Geddes CC. Clinical factors associated with severe hypophosphataemia after kidney transplant. BMC Nephrol 2021; 22:407. [PMID: 34886802 PMCID: PMC8656060 DOI: 10.1186/s12882-021-02624-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 11/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The mechanism by which hypophosphataemia develops following kidney transplantation remains debated, and limited research is available regarding risk factors. This study aimed to assess the association between recipient and donor variables, and the severity of post-transplantation hypophosphataemia. METHODS We performed a single-centre retrospective observational study. We assessed the association between demographic, clinical and biochemical variables and the development of hypophosphataemia. We used linear regression analysis to assess association between these variables and phosphate nadir. RESULTS 87.6% of patients developed hypophosphataemia. Patients developing hypophosphataemia were younger, had a shorter time on renal replacement therapy, were less likely to have had a parathyroidectomy or to experience delayed graft function, were more likely to have received a living donor transplant, from a younger donor. They had higher pre-transplantation calcium levels, and lower alkaline phosphatase levels. Receipt of a living donor transplant, lower donor age, not having had a parathyroidectomy, receiving a transplant during the era of tacrolimus-based immunosuppression, not having delayed graft function, higher pre-transplantation calcium, and higher pre-transplantation phosphate were associated with lower phosphate nadir by multiple linear regression. CONCLUSIONS This analysis demonstrates an association between variables relating to better graft function and hypophosphataemia. The links with biochemical measures of mineral-bone disease remain less clear.
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Affiliation(s)
- Maximilian R Ralston
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Karen S Stevenson
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Patrick B Mark
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, UK.,Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Colin C Geddes
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, UK
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3
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van der Plas WY, Gomes Neto AW, Berger SP, Pol RA, Kruijff S, Bakker SJL, de Borst MH. Association of time-updated plasma calcium and phosphate with graft and patient outcomes after kidney transplantation. Am J Transplant 2021; 21:2437-2447. [PMID: 33331113 PMCID: PMC8359271 DOI: 10.1111/ajt.16457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/08/2020] [Accepted: 12/09/2020] [Indexed: 01/25/2023]
Abstract
Disturbances in calcium-phosphate homeostasis are common after kidney transplantation. We aimed to assess the relationship between deregulations in plasma calcium and phosphate over time and mortality and death-censored graft failure (DCGF). In this prospective cohort study, we included kidney transplant recipients with ≥2 plasma calcium and phosphate measurements. Data were analyzed using time-updated Cox regression analyses adjusted for potential confounders including time-updated kidney function. We included 2769 patients (mean age 47 ± 14 years, 42.3% female) with 138 496 plasma calcium and phosphate levels (median [IQR] 43 [31-61] measurements per patient). During follow-up of 16.3 [8.7-25.2] years, 17.2% developed DCGF and 7.9% died. Posttransplant hypercalcemia was associated with an increased risk of mortality (1.63 [1.31-2.00], p < 0.0001), but not with DCGF. Hyperphosphatemia was associated with both DCGF (2.59 [2.05-3.27], p < .0001) and mortality (3.14 [2.58-3.82], p < .0001). Only the association between hypercalcemia and mortality remained significant in sensitivity analyses censored by a simultaneous eGFR <45 mL/min/1.73 m2 . Hypocalcemia and hypophosphatemia were not consistently associated with either outcome. Posttransplant hypercalcemia, even in the presence of preserved kidney function, was associated with an increased mortality risk. Associations of hyperphosphatemia with DCGF and mortality may be driven by eGFR.
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Affiliation(s)
- Willemijn Y. van der Plas
- Department of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - António W. Gomes Neto
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Stefan P. Berger
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Robert A. Pol
- Department of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Schelto Kruijff
- Department of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Stephan J. L. Bakker
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
- TransplantLines Biobank and Cohort StudyGroningenThe Netherlands
| | - Martin H. de Borst
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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Chevarria J, Sexton DJ, Murray SL, Adeel CE, O'Kelly P, Williams YE, O'Seaghdha CM, Little DM, Conlon PJ. Calcium and phosphate levels after kidney transplantation and long-term patient and allograft survival. Clin Kidney J 2020; 14:1106-1113. [PMID: 33841855 PMCID: PMC8023198 DOI: 10.1093/ckj/sfaa061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 03/25/2020] [Indexed: 11/28/2022] Open
Abstract
Background Non-traditional cardiovascular risk factors, including calcium and phosphate derangement, may play a role in mortality in renal transplant. The data regarding this effect are conflicting. Our aim was to assess the impact of calcium and phosphate derangements in the first 90 days post-transplant on allograft and recipient outcomes. Methods We performed a retrospective cohort review of all-adult, first renal transplants in the Republic of Ireland between 1999 and 2015. We divided patients into tertiles based on serum phosphate and calcium levels post-transplant. We assessed their effect on death-censored graft survival and all-cause mortality. We used Stata for statistical analysis and did survival analysis and spline curves to assess the association. Results We included 1525 renal transplant recipients. Of the total, 86.3% had hypophosphataemia and 36.1% hypercalcaemia. Patients in the lowest phosphate tertile were younger, more likely female, had lower weight, more time on dialysis, received a kidney from a younger donor, had less delayed graft function and better transplant function compared with other tertiles. Patients in the highest calcium tertile were younger, more likely male, had higher body mass index, more time on dialysis and better transplant function. Adjusting for differences between groups, we were unable to show any difference in death-censored graft failure [phosphate = 1.14, 95% confidence interval (CI) 0.92–1.41; calcium = 0.98, 95% CI 0.80–1.20] or all-cause mortality (phosphate = 1.10, 95% CI 0.91–1.32; calcium = 0.96, 95% CI 0.81–1.13) based on tertiles of calcium or phosphate in the initial 90 days. Conclusions Hypophosphataemia and hypercalcaemia are common occurrences post-kidney transplant. We have identified different risk factors for these metabolic derangements. The calcium and phosphate levels exhibit no independent association with death-censored graft failure and mortality.
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Affiliation(s)
- Julio Chevarria
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Donal J Sexton
- Department of Nephrology, Trinity College Dublin, Dublin, Ireland
| | - Susan L Murray
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Chaudhry E Adeel
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Yvonne E Williams
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Conall M O'Seaghdha
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Dilly M Little
- Department of Urology and Transplant, Beaumont Hospital, Dublin, Ireland
| | - Peter J Conlon
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland.,Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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van Londen M, Aarts BM, Deetman PE, van der Weijden J, Eisenga MF, Navis G, Bakker SJL, de Borst MH. Post-Transplant Hypophosphatemia and the Risk of Death-Censored Graft Failure and Mortality after Kidney Transplantation. Clin J Am Soc Nephrol 2017; 12:1301-1310. [PMID: 28546442 PMCID: PMC5544514 DOI: 10.2215/cjn.10270916] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 04/25/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Hypophosphatemia is common in the first year after kidney transplantation, but its clinical implications are unclear. We investigated the relationship between the severity of post-transplant hypophosphatemia and mortality or death-censored graft failure in a large cohort of renal transplant recipients with long-term follow-up. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a longitudinal cohort study in 957 renal transplant recipients who were transplanted between 1993 and 2008 at a single center. We used a large real-life dataset containing 28,178 phosphate measurements (median of 27; first to third quartiles, 23-34) serial measurements per patient) and selected the lowest intraindividual phosphate level during the first year after transplantation. The primary outcomes were all-cause mortality, cardiovascular mortality, and death-censored graft failure. RESULTS The median (interquartile range) intraindividual lowest phosphate level was 1.58 (1.30-1.95) mg/dl, and it was reached at 33 (21-51) days post-transplant. eGFR was the main correlate of the lowest serum phosphate level (model R2 =0.32). During 9 (5-12) years of follow-up, 181 (19%) patients developed graft failure, and 295 (35%) patients died, of which 94 (32%) deaths were due to cardiovascular disease. In multivariable Cox regression analysis, more severe hypophosphatemia was associated with a lower risk of death-censored graft failure (fully adjusted hazard ratio, 0.61; 95% confidence interval, 0.43 to 0.88 per 1 mg/dl lower serum phosphate) and cardiovascular mortality (fully adjusted hazard ratio, 0.37; 95% confidence interval, 0.22 to 0.62) but not noncardiovascular mortality (fully adjusted hazard ratio, 1.33; 95% confidence interval, 0.9 to 1.96) or all-cause mortality (fully adjusted hazard ratio, 1.15; 95% confidence interval, 0.81 to 1.61). CONCLUSIONS Post-transplant hypophosphatemia develops early after transplantation. These data connect post-transplant hypophosphatemia with favorable long-term graft and patient outcomes.
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Affiliation(s)
- Marco van Londen
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen and University of Groningen, Groningen, The Netherlands
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Jeon HJ, Kim YC, Park S, Kim CT, Ha J, Han DJ, Oh J, Lim CS, Jung IM, Ahn C, Kim YS, Lee JP, Kim YH. Association of Serum Phosphorus Concentration with Mortality and Graft Failure among Kidney Transplant Recipients. Clin J Am Soc Nephrol 2017; 12:653-662. [PMID: 28159828 PMCID: PMC5383385 DOI: 10.2215/cjn.07090716] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 01/03/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Hyperphosphatemia in kidney transplant recipients has been shown to predict poorer graft and patient survival. However, studies examining hypophosphatemia are scarce. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS To evaluate the association of serum phosphorus level with patient and graft survival, we performed a retrospective multicenter cohort study. Between January of 1997 and August of 2012, 2786 kidney transplant recipients (41.7±11.4 years; 59.3% men; 73.5% living donors; 26.1% with diabetes; 3.8% with prior history of cardiovascular disease) were classified into seven groups according to serum phosphorus levels 1 year after transplantation, with intervals of 0.5 mg/dl (lowest group, <2.5 mg/dl; highest group, ≥5.0 mg/dl; reference group, 3.5-3.99 mg/dl). Survival analysis was performed by defining baseline time point as 1 year after transplantation. RESULTS During median follow-up of 78.5 months, 60 patient deaths and 194 cases of graft loss occurred. In multivariate analysis, both lowest and highest serum phosphorus groups were associated with higher mortality, compared with the reference group (hazard ratio [HR], 4.82; 95% confidence interval [95% CI], 1.36 to 17.02; P=0.01; and HR, 4.24; 95% CI, 1.07 to 16.84; P=0.04, respectively). Higher death-censored graft loss was observed in the lowest and highest groups (HR, 3.32; 95% CI, 1.42 to 7.79; P=0.01; and HR, 2.93; 95% CI, 1.32 to 6.49; P=0.01, respectively), despite eGFR exhibiting no difference between the lowest group and reference group (65.4±19.3 versus 61.9±16.7 ml/min per 1.73 m2; P=0.33). Moreover, serum phosphorus showed a U-shape association with patient mortality and graft failure in restricted cubic spline curve analysis. CONCLUSIONS Serum phosphorus level 1 year after transplantation exhibits a U-shape association with death-censored graft failure and patient mortality in kidney transplant patients characterized by relatively high rate of living donor transplant and low incidence of diabetes and prior cardiovascular disease compared with Western countries.
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Affiliation(s)
- Hee Jung Jeon
- Departments of Internal Medicine and
- Department of Internal Medicine, Kangdong Sacred Heart Hospital
| | | | | | | | - Jongwon Ha
- Surgery, Seoul National University College of Medicine
| | - Duck Jong Han
- Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, and
| | - Jieun Oh
- Department of Internal Medicine, Kangdong Sacred Heart Hospital
| | | | - In Mok Jung
- Surgery, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Curie Ahn
- Departments of Internal Medicine and
| | | | - Jung Pyo Lee
- Departments of Internal Medicine and
- Departments of Internal Medicine and
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, and
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Wolf M, Weir MR, Kopyt N, Mannon RB, Von Visger J, Deng H, Yue S, Vincenti F. A Prospective Cohort Study of Mineral Metabolism After Kidney Transplantation. Transplantation 2016; 100:184-93. [PMID: 26177089 PMCID: PMC4683035 DOI: 10.1097/tp.0000000000000823] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Kidney transplantation corrects or improves many complications of chronic kidney disease, but its impact on disordered mineral metabolism is incompletely understood. The prevalence of posttransplant hyperparathyroidism was 86% at 12 months (PTH >65 pg/ml) but only 40% (PTH >130 mg/dL) in the absence of cinacalcet, vitamin D sterols, or parathyroidectomy. Intact fibroblast growth factor 23 decreased rapidly to G40 pg/ml by 3 months posttransplant. Supplemental digital content is available in the text.
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Affiliation(s)
- Myles Wolf
- 1 Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. 2 Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD. 3 Lehigh Valley Hospital, Allentown, PA. 4 University of Alabama at Birmingham, Birmingham, AL. 5 The Ohio State University Medical Center, Columbus, OH. 6 Amgen Inc., Thousand Oaks, CA. 7 Kidney Transplant Service, University of California San Francisco, San Francisco, CA
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Abstract
Dysregulated phosphate metabolism is a common consequence of chronic kidney disease, and is characterized by a high circulating level of fibroblast growth factor (FGF)-23, hyperparathyroidism, and hyperphosphataemia. Kidney transplantation can elicit specific alterations to phosphate metabolism that evolve over time, ranging from severe hypophosphataemia (<0.5 mmol/l) to hyperphosphataemia (>1.50 mmol/l) and high FGF-23 levels. The majority of renal transplant recipients develop hypophosphataemia during the first 3 months after transplantation as a consequence of relatively slow adaptation of FGF-23 and parathyroid hormone levels to restored renal function, and the influence of immunosuppressive drugs. By 3-12 months after transplantation, phosphate homeostasis is at least partially restored in the majority of recipients, which is paralleled by a substantially reduced risk of cardiovascular-associated morbidity and mortality compared with the pre-transplantation setting. Many renal transplant recipients, however, exhibit persistent abnormalities in phosphate homeostasis, which is often due to multifactorial causes, and may contribute to adverse outcomes on the cardiovascular system, kidney, and bone. Dietary and pharmacologic interventions might improve phosphate homeostasis in renal transplant recipients, but additional insight into the pathophysiology of transplantation-associated abnormalities in phosphate homeostasis is needed to further optimize disease management and improve prognosis for renal transplant recipients.
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TOUSSAINT NIGELD, PEDAGOGOS EUGENIE, TAN SVENJEAN, BADVE SUNILV, HAWLEY CARMELM, PERKOVIC VLADO, ELDER GRAHAMEJ. Phosphate in early chronic kidney disease: Associations with clinical outcomes and a target to reduce cardiovascular risk. Nephrology (Carlton) 2012; 17:433-44. [DOI: 10.1111/j.1440-1797.2012.01618.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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