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Halim A, Burney HN, Li X, Li Y, Tomkins C, Siedlecki AM, Lu TS, Kalim S, Thadhani R, Moe S, Ting SM, Zehnder D, Hiemstra TF, Lim K. FGF23 and Cardiovascular Structure and Function in Advanced Chronic Kidney Disease. Kidney360 2022; 3:1529-1541. [PMID: 36245643 PMCID: PMC9528374 DOI: 10.34067/kid.0002192022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/29/2022] [Indexed: 11/27/2022]
Abstract
Background Fibroblast growth factor 23 (FGF23) is a bone-derived phosphatonin that is elevated in chronic kidney disease (CKD) and has been implicated in the development of cardiovascular disease. It is unknown whether elevated FGF23 in CKD is associated with impaired cardiovascular functional capacity, as assessed by maximum exercise oxygen consumption (VO2Max). We sought to determine whether FGF23 is associated with cardiovascular functional capacity in patients with advanced CKD and after improvement of VO2Max by kidney transplantation. Methods We performed secondary analysis of 235 patients from the Cardiopulmonary Exercise Testing in Renal Failure and After Kidney Transplantation (CAPER) cohort, which recruited patients with stage 5 CKD who underwent kidney transplantation or were waitlisted and hypertensive controls. All patients underwent cardiopulmonary exercise testing (CPET) and echocardiography and were followed longitudinally for 1 year after study enrollment. Results Patients across FGF23 quartiles differed in BMI (P=0.004) and mean arterial pressure (P<0.001) but did not significantly differ in sex (P=0.5) or age (P=0.08) compared with patients with lower levels of FGF23. Patients with higher FGF23 levels had impaired VO2Max (Q1: 24.2±4.8 ml/min per kilogram; Q4: 18.6±5.2 ml/min per kilogram; P<0.001), greater left ventricular mass index (LVMI; P<0.001), reduced HR at peak exercise (P<0.001), and maximal workload (P<0.001). Kidney transplantation conferred a significant decline in FGF23 at 2 months (P<0.001) before improvement in VO2Max at 1 year (P=0.008). Multivariable regression modeling revealed that changes in FGF23 was significantly associated with VO2Max in advanced CKD (P<0.001) and after improvement after kidney transplantation (P=0.006). FGF23 was associated with LVMI before kidney transplantation (P=0.003), however this association was lost after adjustment for dialysis status (P=0.4). FGF23 was not associated with LVMI after kidney transplantation in all models. Conclusions FGF23 levels are associated with alterations in cardiovascular functional capacity in advanced CKD and after kidney transplantation. FGF23 is only associated with structural cardiac adaptations in advanced CKD but this was modified by dialysis status, and was not associated after kidney transplantation.
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Affiliation(s)
- Arvin Halim
- Division of Nephrology and Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Heather N. Burney
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Yang Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Claudia Tomkins
- Biochemistry Department, Kettering General Hospital NHS Foundation Trust, Kettering, United Kingdom
| | - Andrew M. Siedlecki
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tzong-shi Lu
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sahir Kalim
- Nephrology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Ravi Thadhani
- Mass General Brigham, Harvard Medical School, Massachusetts
| | - Sharon Moe
- Division of Nephrology and Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephen M.S. Ting
- Department of Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Daniel Zehnder
- Department of Nephrology and Department of Acute Medicine, North Cumbria University Hospital NHS Trust, Carlisle, United Kingdom
| | - Thomas F. Hiemstra
- School of Clinical Medicine, University of Cambridge; Clinical Trials Unit (CTU), Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Kenneth Lim
- Division of Nephrology and Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Lim K, McGregor G, Coggan AR, Lewis GD, Moe SM. Cardiovascular Functional Changes in Chronic Kidney Disease: Integrative Physiology, Pathophysiology and Applications of Cardiopulmonary Exercise Testing. Front Physiol 2020; 11:572355. [PMID: 33041870 PMCID: PMC7522507 DOI: 10.3389/fphys.2020.572355] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 08/21/2020] [Indexed: 12/24/2022] Open
Abstract
The development of cardiovascular disease during renal impairment involves striking multi-tiered, multi-dimensional complex alterations encompassing the entire oxygen transport system. Complex interactions between target organ systems involving alterations of the heart, vascular, musculoskeletal and respiratory systems occur in Chronic Kidney Disease (CKD) and collectively contribute to impairment of cardiovascular function. These systemic changes have challenged our diagnostic and therapeutic efforts, particularly given that imaging cardiac structure at rest, rather than ascertainment under the stress of exercise, may not accurately reflect the risk of premature death in CKD. The multi-systemic nature of cardiovascular disease in CKD patients provides strong rationale for an integrated approach to the assessment of cardiovascular alterations in this population. State-of-the-art cardiopulmonary exercise testing (CPET) is a powerful, dynamic technology that enables the global assessment of cardiovascular functional alterations and reflects the integrative exercise response and complex machinery that form the oxygen transport system. CPET provides a wealth of data from a single assessment with mechanistic, physiological and prognostic utility. It is an underutilized technology in the care of patients with kidney disease with the potential to help advance the field of cardio-nephrology. This article reviews the integrative physiology and pathophysiology of cardio-renal impairment, critical new insights derived from CPET technology, and contemporary evidence for potential applications of CPET technology in patients with kidney disease.
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Affiliation(s)
- Kenneth Lim
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Gordon McGregor
- Coventry University Hospital, Coventry and Warwickshire NHS Trust, Coventry, United Kingdom.,Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Andrew R Coggan
- Department of Kinesiology, Indiana University - Purdue University, Indianapolis, IN, United States
| | - Gregory D Lewis
- Division of Cardiology, The Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, United States
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