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Kono K, Fujii H, Watanabe K, Goto S, Nishi S. Relationship between parathyroid hormone and renin-angiotensin-aldosterone system in hemodialysis patients with secondary hyperparathyroidism. J Bone Miner Metab 2021; 39:230-236. [PMID: 32920706 DOI: 10.1007/s00774-020-01139-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Hyperparathyroidism (HPT) is associated with mortality and cardiovascular disease (CVD) in dialysis patients. However, its mechanism is still unclear. It is suspected that parathyroid hormone (PTH) is associated with the renin-angiotensin-aldosterone system (RAAS) as a possible mechanism. Thus, we examined their hormonal interaction in hemodialysis patients with secondary HPT. MATERIALS AND METHODS Seventeen hemodialysis patients with HPT were included. All patients underwent total parathyroidectomy (PTx). Serum intact PTH (iPTH), calcium and phosphate levels, plasma renin activity (PRA), and plasma aldosterone levels (ALD) were measured pre- and post-PTx. RESULTS Pre-serum iPTH tended to be correlated with pre-PRA and were significantly correlated with pre-ALD (pre-PRA: r = 0.44, p = 0.07, pre-ALD: r = 0.49, p < 0.05). With the reduction in serum iPTH after PTx, PRA and ALD significantly decreased after PTx. Additionally, the change in serum iPTH tended to be correlated with the changes in PRA and ALD (PRA; r = 0.46, p = 0.05, ALD; r = 0.45, p = 0.06). CONCLUSION Our results suggest that PTH could be interrelated with RAAS in hemodialysis patients with secondary HPT.
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Affiliation(s)
- Keiji Kono
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Hideki Fujii
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kentaro Watanabe
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Shunsuke Goto
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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Winiarska A, Filipska I, Knysak M, Stompór T. Dietary Phosphorus as a Marker of Mineral Metabolism and Progression of Diabetic Kidney Disease. Nutrients 2021; 13:789. [PMID: 33673618 PMCID: PMC7997399 DOI: 10.3390/nu13030789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 12/31/2022] Open
Abstract
Phosphorus is an essential nutrient that is critically important in the control of cell and tissue function and body homeostasis. Phosphorus excess may result in severe adverse medical consequences. The most apparent is an impact on cardiovascular (CV) disease, mainly through the ability of phosphate to change the phenotype of vascular smooth muscle cells and its contribution to pathologic vascular, valvular and other soft tissue calcification. Chronic kidney disease (CKD) is the most prevalent chronic disease manifesting with the persistent derangement of phosphate homeostasis. Diabetes and resulting diabetic kidney disease (DKD) remain the leading causes of CKD and end-stage kidney disease (ESRD) worldwide. Mineral and bone disorders of CKD (CKD-MBD), profound derangement of mineral metabolism, develop in the course of the disease and adversely impact on bone health and the CV system. In this review we aimed to discuss the data concerning CKD-MBD in patients with diabetes and to analyze the possible link between hyperphosphatemia, certain biomarkers of CKD-MBD and high dietary phosphate intake on prognosis in patients with diabetes and DKD. We also attempted to clarify if hyperphosphatemia and high phosphorus intake may impact the onset and progression of DKD. Careful analysis of the available literature brings us to the conclusion that, as for today, no clear recommendations based on the firm clinical data can be provided in terms of phosphorus intake aiming to prevent the incidence or progression of diabetic kidney disease.
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Affiliation(s)
| | | | | | - Tomasz Stompór
- Department of Nephrology, Hypertension and Internal Medicine, University of Warmia and Mazury in Olsztyn, 10561 Olsztyn, Poland; (A.W.); (I.F.); (M.K.)
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Forster CM, White CA, Turner ME, Norman PA, Ward EC, Hopman WM, Adams MA, Holden RM. Circulating Levels of Dickkopf-Related Protein 1 Decrease as Measured GFR Declines and Are Associated with PTH Levels. Am J Nephrol 2020; 51:871-880. [PMID: 33238271 DOI: 10.1159/000511658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/16/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Wnt/β-catenin pathway has been implicated in the development of adynamic bone disease in early-stage chronic kidney disease (CKD). Dickkopf-related protein 1 (DKK1) and sclerostin are antagonists of the Wnt/β-catenin pathway yet have not been widely used as clinical indicators of bone disease. This study characterized levels of DKK1, sclerostin, and other biomarkers of mineral metabolism in participants across a spectrum of inulin-measured glomerular filtration rate (GFR). METHODS GFR was measured by urinary inulin clearance (mGFR) in 90 participants. Blood samples were obtained for measurement of circulating DKK1, sclerostin, fibroblast growth factor 23 (FGF-23), parathyroid hormone (PTH), calcium, phosphate, α-klotho, and vitamin D metabolites including 25-hydroxyvitamin D3 and 1,25-dihydroxyvitamin D3. Spearman correlations and linear regressions were used where appropriate to examine the associations between measured values. RESULTS The median [IQR] age was 64 years [53.0-71.0], and the median [IQR] mGFR was 32.6 [21.7-60.6] mL/min. DKK1 decreased (r = 0.6, p < 0.001) and sclerostin increased (r = -0.4, p < 0.001) as kidney function declined, and both were associated with phosphate, PTH, FGF-23, and 1,25-dihydroxyvitamin D3 in the unadjusted analysis. After adjustment for age and mGFR, DKK1 remained significantly associated with PTH. CONCLUSION The results of this study demonstrate opposing trends in Wnt/β-catenin pathway inhibitors, DKK1 and sclerostin, as mGFR declines. Unlike sclerostin, DKK1 levels decreased significantly as mGFR declined and was independently associated with PTH. Future studies should determine whether measurement of Wnt signaling inhibitors may be useful in predicting bone histomorphometric findings and important clinical outcomes in patients with CKD.
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Affiliation(s)
- Corey M Forster
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Christine A White
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Mandy E Turner
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada
| | - Patrick A Norman
- Kingston General Health Research Institute, Kingston General Hospital, Kingston, Ontario, Canada
| | - Emilie C Ward
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada
| | - Wilma M Hopman
- Kingston General Health Research Institute, Kingston General Hospital, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Michael A Adams
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada
| | - Rachel M Holden
- Department of Biomedical and Molecular Science, Queen's University, Kingston, Ontario, Canada,
- Department of Medicine, Queen's University, Kingston, Ontario, Canada,
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Danese MD, Lubeck D, Belozeroff V, Lin TC, Desai P, Gleeson M, Martin K, Chonchol M. Real World Use and Effects of Calcimimetics in Treating Mineral and Bone Disorder in Hemodialysis Patients. Am J Nephrol 2020; 51:815-822. [PMID: 32966995 DOI: 10.1159/000510360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/21/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Calcimimetics are used to treat mineral and bone disorder by reducing parathyroid hormone (PTH), calcium (Ca), and phosphorus (Phos). The study objectives were to assess the control of PTH, Ca, and Phos over time in patients receiving cinacalcet or etelcalcetide as well as dosing and time to discontinuation for etelcalcetide. METHODS This was a retrospective cohort study using electronic medical records from small and independent dialysis centers. Adults ≥18 years of age were identified as cinacalcet or etelcalcetide users based on the first calcimimetic received in 2018 (index date). Patients were followed from the index date until parathyroidectomy, kidney transplant, death, or end of data (December 31, 2018). Analyses of mean PTH, Ca, and Phos, as well as target achievement of PTH, Ca, and Phos were conducted over a 9-month period. Discontinuation with etelcalcetide was measured with the Kaplan-Meier estimator. RESULTS There were 1,346 cinacalcet patients (mean age 60.5 years, 43.5% female, and 47.1% Black) and 1,255 etelcalcetide patients (mean age 63.4 years, 46.6% female, and 38.5% Black). At baseline, the proportions in target were similar for etelcalcetide versus cinacalcet: 36 versus 38% for PTH, 79 versus 80% for Ca, and 43 versus 44% for Phos. Overall, 40-47% of cinacalcet users and 48-62% of etelcalcetide users were observed to be in target for PTH over 9 months. The proportion in target for Phos ranged from 41 to 46% for cinacalcet and 46-51% for etelcalcetide. The proportion in target for Ca ranged from 74 to 78% for cinacalcet and 60-73% for etelcalcetide. Etelcalcetide 12-month discontinuation was 37.4%. CONCLUSION Both calcimimetics were effective in keeping PTH, Ca, and Phos levels within target. Patients receiving etelcalcetide tended to have lower laboratory values for PTH, Ca, and Phos over time, while patients receiving cinacalcet tended to be more likely to be in target for Ca over time.
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Affiliation(s)
- Mark D Danese
- Outcomes Insights, Inc., Agoura Hills, California, USA,
| | | | | | | | | | | | - Kevin Martin
- Division of Nephrology and Hypertension, Saint Louis University, St. Louis, Missouri, USA
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, USA
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Ishida H, Komaba H, Hamano N, Yamato H, Sawada K, Wada T, Nakamura M, Fukagawa M. Skeletal and mineral metabolic effects of risedronate in a rat model of high-turnover renal osteodystrophy. J Bone Miner Metab 2020; 38:501-510. [PMID: 32140785 DOI: 10.1007/s00774-020-01095-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/24/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION High-turnover bone disease is a major consequence of SHPT and may explain the high risk for fracture in patients with advanced chronic kidney disease (CKD). Bisphosphonates suppress bone turnover and improve bone strength, but their effects have not been fully characterized in advanced CKD with severe SHPT. Bisphosphonates also increase 1,25-dihydroxyvitamin D levels in normal and uremic rats, but the underlying mechanism remains to be determined. MATERIALS AND METHODS We investigated the skeletal and mineral metabolic effects of RIS, a pyridinyl bisphosphonate, in rats with severe SHPT induced by 5/6 nephrectomy plus a high phosphate diet. RESULTS Nephrectomized rats developed severe SHPT, along with hyperphosphatemia, low 1,25-dihydroxyvitamin D, and markedly increased FGF23. Moreover, these rats exhibited characteristic features of high-turnover renal osteodystrophy, including increased indices of trabecular bone turnover, decreased cortical bone thickness, inferior cortical biomechanical properties, and a prominent increase in peritrabecular fibrosis. RIS treatment increased bone volume and partially attenuated trabecular bone remodeling, cortical bone loss, and mechanical properties, whereas it produced a marked improvement in peritrabecular fibrosis along with a corresponding decrease in osteogenic gene markers. RIS treatment also suppressed the elevation of FGF23, which was associated with increased 1,25-dihydroxyvitamin D. CONCLUSIONS In a rat model of severe SHPT, treatment with RIS partially attenuated histological manifestations of high-turnover bone disease. RIS treatment also suppressed the elevation of FGF23, which may explain the increased 1,25-dihydroxyvitamin D production during the treatment.
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Affiliation(s)
- Hiroaki Ishida
- Department of Transplant Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan.
- Interactive Translational Research Center for Kidney Diseases, Tokai University School of Medicine, Isehara, Japan.
- The Institute of Medical Sciences, Tokai University, Isehara, Japan.
| | - Naoto Hamano
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Hideyuki Yamato
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Kaichiro Sawada
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Takehiko Wada
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
| | - Michio Nakamura
- Department of Transplant Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, 143 Shimo-Kasuya, Isehara, 259-1193, Japan
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Allen MR, Wallace J, McNerney E, Nyman J, Avin K, Chen N, Moe S. N-acetylcysteine (NAC), an anti-oxidant, does not improve bone mechanical properties in a rat model of progressive chronic kidney disease-mineral bone disorder. PLoS One 2020; 15:e0230379. [PMID: 32203558 PMCID: PMC7089527 DOI: 10.1371/journal.pone.0230379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/27/2020] [Indexed: 01/17/2023] Open
Abstract
Individuals with chronic kidney disease have elevated levels of oxidative stress and are at a significantly higher risk of skeletal fracture. Advanced glycation end products (AGEs), which accumulate in bone and compromise mechanical properties, are known to be driven in part by oxidative stress. The goal of this study was to study effects of N-acetylcysteine (NAC) on reducing oxidative stress and improving various bone parameters, most specifically mechanical properties, in an animal model of progressive CKD. Male Cy/+ (CKD) rats and unaffected littermates were untreated (controls) or treated with NAC (80 mg/kg, IP) from 30 to 35 weeks of age. Endpoint measures included serum biochemistries, assessments of systemic oxidative stress, bone morphology, and mechanical properties, and AGE levels in the bone. CKD rats had the expected phenotype that included low kidney function, elevated parathyroid hormone, higher cortical porosity, and compromised mechanical properties. NAC treatment had mixed effects on oxidative stress markers, significantly reducing TBARS (a measure of lipid peroxidation) while not affecting 8-OHdG (a marker of DNA oxidation) levels. AGE levels in the bone were elevated in CKD animals and were reduced with NAC although this did not translate to a benefit in bone mechanical properties. In conclusion, NAC failed to significantly improve bone architecture/geometry/mechanical properties in our rat model of progressive CKD.
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Affiliation(s)
- Matthew R. Allen
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Department of Biomedical Engineering, Indiana University—Purdue University, Indianapolis, IN, United States of America
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Roudebush VA Medical Center, Indianapolis, IN, United States of America
- * E-mail:
| | - Joseph Wallace
- Department of Biomedical Engineering, Indiana University—Purdue University, Indianapolis, IN, United States of America
| | - Erin McNerney
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Jeffry Nyman
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Keith Avin
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Neal Chen
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Sharon Moe
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Roudebush VA Medical Center, Indianapolis, IN, United States of America
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Castro BBAD, Carmo WB, Oliveira RSMF, Peters VM, Jorgetti V, Custodio MR, Sanders-Pinheiro H. Digital radiography as an alternative method in the evaluation of bone density in uremic rats. J Bras Nefrol 2020; 42:8-17. [PMID: 31419270 PMCID: PMC7213932 DOI: 10.1590/2175-8239-jbn-2019-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/24/2019] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Digital radiography (DRx) may provide a suitable alternative to investigate mineral and bone disorder (MBD) and loss of bone density (BD) in rodent models of chronic kidney disease (CKD). The objective of this study was to use DRx to evaluate BD in CKD rats, and to evaluate the correlation between DRx findings and serum MBD markers and bone histomorphometry. METHODS Uremia was induced by feeding Wistar rats an adenine-enriched diet (0.75% for 4 weeks/0.10% for 3 weeks); outcomes were compared to a control group at experimental weeks 3, 4, and 7. The following biochemical markers were measured: creatinine clearance (CrC), phosphate (P), calcium (Ca), fractional excretion of P (FeP), alkaline phosphatase (ALP), fibroblast growth factor-23 (FGF-23), and parathyroid hormone (PTH). DRx imaging was performed and histomorphometry analysis was conducted using the left femur. RESULTS As expected, at week 7, uremic rats presented with reduced CrC and higher levels of P, FeP, and ALP compared to controls. DRx confirmed the lower BD in uremic animals (0.57±0.07 vs. 0.68 ± 0.06 a.u.; p = 0.016) compared to controls at the end of week 7, when MBD was more prominent. A severe form of high-turnover bone disease accompanied these biochemical changes. BD measured on DRx correlated to P (r=-0.81; p = 0.002), ALP (r = -0.69, p = 0.01), PTH (r = -0.83, p = 0.01), OS/BS (r = -0.70; p = 0.02), and ObS/BS (r = -0.70; p = 0.02). CONCLUSION BD quantified by DRx was associated with the typical complications of MBD in CKD and showed to be viable in the evaluation of bone alterations in CKD.
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Affiliation(s)
- Bárbara Bruna Abreu de Castro
- Núcleo de Experimentação Animal, Laboratório de Nefrologia Experimental, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
| | - Wander Barros Carmo
- Núcleo de Experimentação Animal, Laboratório de Nefrologia Experimental, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
| | | | - Vera Maria Peters
- Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
| | - Vanda Jorgetti
- Laboratório de Fisiopatologia Renal, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Melani Ribeiro Custodio
- Laboratório de Fisiopatologia Renal, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Helady Sanders-Pinheiro
- Núcleo de Experimentação Animal, Laboratório de Nefrologia Experimental, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
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Haffner D, Leifheit-Nestler M. Treatment of hyperphosphatemia: the dangers of aiming for normal PTH levels. Pediatr Nephrol 2020; 35:485-491. [PMID: 31823044 DOI: 10.1007/s00467-019-04399-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/30/2019] [Accepted: 10/14/2019] [Indexed: 12/14/2022]
Abstract
Secondary hyperparathyroidism is part of the complex of chronic kidney disease-associated mineral and bone disorders (CKD-MBD) and is linked with high bone turnover, ectopic calcification, and increased cardiovascular mortality. Therefore, measures for CKD-MBD aim at lowering PTH levels, but there is no general consensus on optimal PTH target values. This manuscript is part of a pros and cons debate for keeping PTH levels within the normal range in children with CKD, focusing on the cons. We conclude that a modest increase in PTH most likely represents an appropriate adaptive response to declining kidney function in patients with CKD stages 2-5D, due to phosphaturic effects and increasing bone resistance. There is no evidence for strictly keeping PTH levels within the normal range in CKD patients with respect to bone health and cardiovascular outcome. In addition, the potentially adverse effects of PTH-lowering measures, such as active vitamin D and calcimimetics, must be taken into account. We suggest that PTH values of 1-2 times the upper normal limit (ULN) may be acceptable in children with CKD stage 2-3, and that PTH levels of 1.7-5 times UNL may be optimal in patients with CKD stage 4-5D. However, standard care of CKD-MBD in children relies on a combination of different measures in which the observation of PTH levels is only a small part of, and trends in PTH levels rather than absolute target values should determine treatment decisions in patients with CKD as recommended by the 2017 KDIGO guidelines.
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Affiliation(s)
- Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Pediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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McAlister L, Pugh P, Greenbaum L, Haffner D, Rees L, Anderson C, Desloovere A, Nelms C, Oosterveld M, Paglialonga F, Polderman N, Qizalbash L, Renken-Terhaerdt J, Tuokkola J, Warady B, Walle JV, Shaw V, Shroff R. The dietary management of calcium and phosphate in children with CKD stages 2-5 and on dialysis-clinical practice recommendation from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2020; 35:501-518. [PMID: 31667620 PMCID: PMC6969014 DOI: 10.1007/s00467-019-04370-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/01/2019] [Accepted: 09/17/2019] [Indexed: 12/19/2022]
Abstract
In children with chronic kidney disease (CKD), optimal control of bone and mineral homeostasis is essential, not only for the prevention of debilitating skeletal complications and achieving adequate growth but also for preventing vascular calcification and cardiovascular disease. Complications of mineral bone disease (MBD) are common and contribute to the high morbidity and mortality seen in children with CKD. Although several studies describe the prevalence of abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels as well as associated clinical and radiological complications and their medical management, little is known about the dietary requirements and management of calcium (Ca) and phosphate (P) in children with CKD. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists, who develop clinical practice recommendations (CPRs) for the nutritional management of various aspects of renal disease management in children. We present CPRs for the dietary intake of Ca and P in children with CKD stages 2-5 and on dialysis (CKD2-5D), describing the common Ca- and P-containing foods, the assessment of dietary Ca and P intake, requirements for Ca and P in healthy children and necessary modifications for children with CKD2-5D, and dietary management of hypo- and hypercalcemia and hyperphosphatemia. The statements have been graded, and statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. These CPRs will be regularly audited and updated by the PRNT.
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Affiliation(s)
- Louise McAlister
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK
| | - Pearl Pugh
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Dieter Haffner
- Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Lesley Rees
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK
| | - Caroline Anderson
- Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Michiel Oosterveld
- Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Fabio Paglialonga
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - José Renken-Terhaerdt
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jetta Tuokkola
- Children's Hospital and Clinical Nutrition Unit, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | - Vanessa Shaw
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK
- University of Plymouth and University College London Institute of Child Health, London, UK
| | - Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK.
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Pendón-Ruiz de Mier MV, Rodelo-Haad C, Díaz-Tocados JM, Muñoz-Castañeda JR, Rodríguez M. Magnesium: An old player revisited in the context of CKD-MBD. Clin Chim Acta 2019; 501:53-59. [PMID: 31836501 DOI: 10.1016/j.cca.2019.11.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/27/2019] [Accepted: 11/27/2019] [Indexed: 12/18/2022]
Abstract
Chronic kidney disease (CKD) is associated with a wide number of abnormalities in mineral metabolism. Often, these alterations are the leading players in the development of comorbidities associated with CKD, which are risk factors of mortality. In this context, mineral and bone disorder associated with CKD (CKD-MBD) are highlighted, connecting bone, renal, and cardiovascular disorders. Many studies have been led to propose strategies to avoid, reduce, or slow down CKD-MBD progression using different compositions of metallic elements-based P binders such as aluminum, magnesium, or calcium. Magnesium, the aim of this review, has been used by nephrologists to treat CKD-MBD with a variable acceptation due mainly to different results on bone homeostasis. Nowadays, we have new evidence about the efficacy of magnesium supplementation on vascular calcification, renal function, and bone disorders, suggesting potential beneficial effects of Magnesium in the management of CKD-MBD.
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Affiliation(s)
- M V Pendón-Ruiz de Mier
- Maimonides Institute for Biomedical Research (IMIBIC), Cordoba, Spain; University of Cordoba, Spain; Nephrology Service, Reina Sofia University Hospital, Cordoba, Spain; Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
| | - C Rodelo-Haad
- Maimonides Institute for Biomedical Research (IMIBIC), Cordoba, Spain; University of Cordoba, Spain; Nephrology Service, Reina Sofia University Hospital, Cordoba, Spain; Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
| | - J M Díaz-Tocados
- Maimonides Institute for Biomedical Research (IMIBIC), Cordoba, Spain; University of Cordoba, Spain
| | - J R Muñoz-Castañeda
- Maimonides Institute for Biomedical Research (IMIBIC), Cordoba, Spain; University of Cordoba, Spain; Nephrology Service, Reina Sofia University Hospital, Cordoba, Spain; Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain.
| | - M Rodríguez
- Maimonides Institute for Biomedical Research (IMIBIC), Cordoba, Spain; University of Cordoba, Spain; Nephrology Service, Reina Sofia University Hospital, Cordoba, Spain; Spanish Renal Research Network (REDinREN), Institute of Health Carlos III, Madrid, Spain
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11
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Liabeuf S, McCullough K, Young EW, Pisoni R, Zee J, Reichel H, Pecoits-Filho R, Port FK, Stengel B, Csomor PA, Metzger M, Robinson B, Massy ZA. International variation in the management of mineral bone disorder in patients with chronic kidney disease: Results from CKDopps. Bone 2019; 129:115058. [PMID: 31493530 DOI: 10.1016/j.bone.2019.115058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/12/2019] [Accepted: 09/03/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Chronic kidney disease (CKD) is commonly associated with mineral and bone metabolism disorders, but these are less frequently studied in non-dialysis CKD patients than in dialysis patients. We examined and described international variation in mineral and bone disease (MBD) markers and their treatment and target levels in Stage 3-5 CKD patients. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS Prospective cohort study of 7658 adult patients with eGFR <60mL/min/1.73m2, excluding dialysis or transplant patients, participating in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) in Brazil, France, Germany, and the US. CKD-MBD laboratory markers included serum levels of phosphorus (P), calcium (Ca), intact parathyroid hormone (iPTH), and 25-hydroxyvitamin D (25-D). MBD treatment data included phosphate binders and vitamin D (nutritional and active). Nephrologist survey data were collected on target MBD marker levels. RESULTS Over two-thirds of the patients had MBD markers measured at time intervals in line with practice guidelines. P and iPTH increased and Ca decreased gradually from eGFR 60-20mL/min/1.73m2 and more sharply for eGFR<20. 25-D showed no relation to eGFR. Nephrologist survey data indicated marked variation in upper target P and iPTH levels. Among patients with P>5.5mg/dL, phosphate binder use was 14% to 43% across the four countries. Among patients with PTH >300pg/mL, use of active (calcitriol and related analogs) vitamin D was 12%-51%, and use of any (active or nutritional) vitamin D was 60%-87%. CONCLUSIONS Although monitoring of CKD-MBD laboratory markers by nephrologists in CKDopps countries is consistent with guidelines, target levels vary notably and prescription of medications to treat abnormalities in these laboratory markers is generally low in these cross-sectional analyses. While there are opportunities to increase treatment of hyperphosphatemia, hyperparathyroidism, and vitamin D deficiency in advanced CKD, the effect on longer-term complications of these conditions requires study.
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Affiliation(s)
- Sophie Liabeuf
- Pharmacology Department and Laboratory EA 7517, Amiens University Hospital, 80000 Amiens, France
| | | | - Eric W Young
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Ronald Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA; Pontifícia Universidade Católica Do Paraná, Nephrology, Do Paraná, Brazil
| | | | - Bénédicte Stengel
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, UVSQ, University Paris-Saclay, Villejuif, France
| | | | - Marie Metzger
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, UVSQ, University Paris-Saclay, Villejuif, France
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Ziad A Massy
- Centre for Research in Epidemiology and Population Health (CESP), UMRS 1018, UVSQ, University Paris-Saclay, Villejuif, France; Department of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne Billancourt/Paris, France.
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12
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Aref MW, Swallow EA, Metzger CE, Chen N, Moe SM, Allen MR. Parathyroid suppression therapy normalizes chronic kidney disease-induced elevations in cortical bone vascular perfusion: a pilot study. Osteoporos Int 2019; 30:1693-1698. [PMID: 31069439 PMCID: PMC6689147 DOI: 10.1007/s00198-019-04974-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 04/14/2019] [Indexed: 01/27/2023]
Abstract
UNLABELLED Interventions that alter PTH levels in an animal model of chronic kidney disease have effects on the perfusion of bone and bone marrow. INTRODUCTION Patients with chronic kidney disease (CKD) have accelerated bone loss, vascular calcification, and abnormal biochemistries, together contributing to an increased risk of cardiovascular disease and fracture-associated mortality. Despite evidence of vascular pathologies and dysfunction in CKD, our group has shown that cortical bone tissue perfusion is higher in a rat model of high-turnover CKD. The goal of the present study was to test the hypothesis that parathyroid hormone (PTH) suppressive interventions would normalize cortical bone vascular perfusion in the setting of CKD. METHODS In two separate experiments, 35-week-old CKD animals and their normal littermates underwent intra-cardiac fluorescent microsphere injection to assess the effect of 10 weeks of PTH suppression (Experiment 1: calcium supplementation, Experiment 2: calcimimetic treatment) on alterations in bone tissue perfusion. RESULTS In Experiment 1, CKD animals had serum blood urea nitrogen (BUN) and PTH levels significantly higher than NL (+ 182% and + 958%; p < 0.05). CKD+Ca animals had BUN levels that were similar to CKD, while PTH levels were significantly lower and comparable to NL. Both femoral cortex (+ 220%, p = 0.003) and tibial cortex (+ 336, p = 0.005) tissue perfusion were significantly higher in CKD animals when compared to NL; perfusion was normalized to those of NL in CKD+Ca animals. MicroCT analysis of the proximal tibia cortical porosity showed a trend toward higher values in CKD (+ 401%; p = 0.017) but not CKD+Ca (+ 111%; p = 0.38) compared to NL. Experiment 2, using an alternative method of PTH suppression, showed similar results as those of Experiment 1. CONCLUSIONS These data demonstrate that PTH suppression-based interventions normalize cortical bone perfusion in the setting of CKD.
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Affiliation(s)
- M W Aref
- Department of Anatomy and Cell Biology, MS 5035, Indiana University School of Medicine, 635 Barnhill Dr, Indianapolis, IN, 46202, USA
| | - E A Swallow
- Department of Anatomy and Cell Biology, MS 5035, Indiana University School of Medicine, 635 Barnhill Dr, Indianapolis, IN, 46202, USA
| | - C E Metzger
- Department of Anatomy and Cell Biology, MS 5035, Indiana University School of Medicine, 635 Barnhill Dr, Indianapolis, IN, 46202, USA
| | - N Chen
- Department of Medicine - Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - S M Moe
- Department of Medicine - Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
| | - M R Allen
- Department of Anatomy and Cell Biology, MS 5035, Indiana University School of Medicine, 635 Barnhill Dr, Indianapolis, IN, 46202, USA.
- Department of Medicine - Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA.
- Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA.
- Department of Biomedical Engineering, Indiana University Purdue University of Indianapolis, Indianapolis, IN, USA.
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13
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Canney M, Djurdjev O, Tang M, Zierold C, Blocki F, Wolf M, Levin A. GFR-Specific versus GFR-Agnostic Cutoffs for Parathyroid Hormone and Fibroblast Growth Factor-23 in Advanced Chronic Kidney Disease. Am J Nephrol 2019; 50:105-114. [PMID: 31238301 DOI: 10.1159/000501189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/17/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND In the majority of patients with advanced chronic kidney disease (CKD), values of parathyroid hormone (PTH1-84) and fibroblast growth factor 23 (FGF-23) exceed the normal reference range, potentially as an appropriate adaptation to reduced glomerular filtration rate (GFR). We tested whether GFR-specific cutoffs for PTH1-84 and FGF-23 could better identify patients with inappropriately high PTH1-84 and FGF-23 for their degree of CKD and thereby improve prognostication of clinical outcomes compared to a uniform threshold. METHODS Prospective pan-Canadian cohort of 1,812 patients with mean estimated GFR (eGFR) 28.9 mL/min/1.73 m2 followed for a median of 52 months. Repeated log-rank tests were used to identify optimal cutoffs for PTH1-84 and FGF-23 within eGFR strata (<20, 20-29 and ≥30 mL/min/1.73 m2) that maximally differentiated high- and low-risk populations for (1) cardiovascular (CV) events (fatal or nonfatal myocardial infarction, coronary revascularization, stroke, heart failure) and (2) renal events (initiation of chronic renal replacement therapy). In multivariable models, we examined the association between -GFR-specific cutoffs and outcomes and compared their added prognostic value to existing uniform thresholds. RESULTS Risk-based cutoffs for PTH1-84 and FGF-23 increased in a graded fashion with decreasing eGFR. Among patients with eGFR <20 mL/min/1.73 m2, CV risk-based cutoffs for PTH1-84 and FGF-23 were 3.4 and 5.5 times the upper limit of normal, respectively, and reclassified 31.9 and 35.1% of patients when added to a multivariable base model for CV events. In contrast, the addition of PTH1-84 and FGF-23 to the base model using uniform cutoffs failed to reclassify such patients. Similar findings were demonstrated for renal outcomes. CONCLUSION GFR-specific risk-based cutoffs for PTH1-84 and FGF-23 may facilitate more meaningful risk stratification in advanced CKD than current GFR-agnostic reference ranges derived from healthy adults. This may be most applicable in those with severely reduced GFR.
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Affiliation(s)
- Mark Canney
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Mila Tang
- Nephrology Research, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Claudia Zierold
- Diasorin Inc., Scientific Affairs, Stillwater, Minnesota, USA
| | - Frank Blocki
- Diasorin Inc., Scientific Affairs, Stillwater, Minnesota, USA
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada,
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Vorland CJ, Lachcik PJ, Swallow EA, Metzger CE, Allen MR, Chen NX, Moe SM, Hill Gallant KM. Effect of ovariectomy on the progression of chronic kidney disease-mineral bone disorder (CKD-MBD) in female Cy/+ rats. Sci Rep 2019; 9:7936. [PMID: 31138895 PMCID: PMC6538713 DOI: 10.1038/s41598-019-44415-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/16/2019] [Indexed: 01/08/2023] Open
Abstract
Male Cy/+ rats have shown a relatively consistent pattern of progressive kidney disease development that displays multiple key features of late stage chronic kidney disease-mineral bone disorder (CKD-MBD), specifically the development of cortical bone porosity. However, progression of disease in female Cy/+ rats, assessed in limited studies, is more heterogeneous and to date has failed to show development of the CKD-MBD phenotype, thus limiting their use as a practical model of progressive CKD-MBD. Animal and human studies suggest that estrogen may be protective against kidney disease in addition to its established protective effect on bone. Therefore, in this study, we aimed to determine the effect of ovariectomy (OVX) on the biochemical and skeletal manifestations of CKD-MBD in Cy/+ female rats. We hypothesized that OVX would accelerate development of the biochemical and skeletal features of CKD-MBD in female Cy/+ rats, similar to those seen in male Cy/+ rats. Female Cy/+ rats underwent OVX (n = 8) or Sham (n = 8) surgery at 15 weeks of age. Blood was collected every 5 weeks post-surgery until 35 weeks of age, when the rats underwent a 4-day metabolic balance, and the tibia and final blood were collected at the time of sacrifice. OVX produced the expected changes in trabecular and cortical parameters consistent with post-menopausal disease, and negative phosphorus balance compared with Sham. However, indicators of CKD-MBD were similar between OVX and Sham (similar kidney weight, plasma blood urea nitrogen, creatinine, creatinine clearance, phosphorus, calcium, parathyroid hormone, and no cortical porosity). Contrary to our hypothesis, OVX did not produce evidence of development of the CKD-MBD phenotype in female Cy/+ rats.
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Affiliation(s)
- Colby J Vorland
- Department of Nutrition Science, Purdue University, West Lafayette, IN, 47907, USA
| | - Pamela J Lachcik
- Department of Nutrition Science, Purdue University, West Lafayette, IN, 47907, USA
| | - Elizabeth A Swallow
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
| | - Corinne E Metzger
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
| | - Matthew R Allen
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
- Roudebush Veterans Affairs Medical Center, Indianapolis, IN, 46202, USA
| | - Neal X Chen
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
| | - Sharon M Moe
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, 46202, IN, USA
- Roudebush Veterans Affairs Medical Center, Indianapolis, IN, 46202, USA
| | - Kathleen M Hill Gallant
- Department of Nutrition Science, Purdue University, West Lafayette, IN, 47907, USA.
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, 46202, IN, USA.
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15
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Pietrzyk B, Wyskida K, Ficek J, Kolonko A, Ficek R, Więcek A, Olszanecka-Glinianowicz M, Chudek J. Relationship between plasma levels of sclerostin, calcium-phosphate disturbances, established markers of bone turnover, and inflammation in haemodialysis patients. Int Urol Nephrol 2019; 51:519-526. [PMID: 30584645 PMCID: PMC6424932 DOI: 10.1007/s11255-018-2050-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/07/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Data concerning the relation between increased levels of circulating sclerostin (a physiological inhibitor of bone formation) and bone turnover in patients with chronic renal failure (CRF) are limited. Therefore, the aim of this study was to evaluate associations between plasma sclerostin levels and calcium-phosphate disturbances, markers of bone turnover as well as inflammation in haemodialysis (HD) patients. METHODS In plasma samples obtained in 150 stable HD patients (92 men) aged 40-70 years, levels of sclerostin, fibroblast growth factor (cFGF23), osteocalcin, the N-terminal propeptide of type I procollagen, C-terminal telopeptide of the alpha chain of type I collagen (β-CTx), and inflammatory markers (IL-6 and TNF-α) in addition to routine parameters (calcium, phosphorus, parathyroid hormone-iPTH, 25-OH-D, alkaline phosphatase) were measured. RESULTS Plasma sclerostin concentrations were significantly higher in HD men than women (2.61 vs. 1.88 ng/mL, p < 0.01). Patients with sclerostin levels above median were characterized by lower iPTH and IL-6, but higher cFGF23 and TNF-α (significantly only in men) concentrations. Plasma sclerostin concentration positively correlated with serum 25-OH-D (τ = 0.204), phosphorus (τ = 0.1482), and TNF-α (τ = 0.183) and inversely with iPTH (τ = - 0.255), alkaline phosphatase (τ = - 0.203), IL-6 (τ =- 0.201), and β-CTx (τ = - 0.099) levels. In multivariate regression analysis, variability of sclerostin levels was explained by sex and 25-OH-D and phosphorus levels. CONCLUSIONS Increased circulating sclerostin levels seem to reflect slower bone turnover in HD patients. Low levels of sclerostin are associated with vitamin D deficiency and good phosphates alignment.
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Affiliation(s)
- Barbara Pietrzyk
- Pathophysiology Unit, Department of Pathophysiology, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Wyskida
- Health Promotion and Obesity Management Unit, Department of Pathophysiology, Medical University of Silesia, Katowice, Poland
| | - Joanna Ficek
- Pathophysiology Unit, Department of Pathophysiology, Medical University of Silesia, Katowice, Poland
| | - Aureliusz Kolonko
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Rafał Ficek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Andrzej Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | | | - Jerzy Chudek
- Pathophysiology Unit, Department of Pathophysiology, Medical University of Silesia, Katowice, Poland.
- Department of Internal Medicine and Oncological Chemotherapy, School of Medicine in Katowice, Medical University of Silesia in Katowice, 40-752, Katowice, Poland.
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Roetker NS, Peng Y, Ashfaq A, Gilbertson DT, Wetmore JB. Adherence to Kidney Disease: Improving Global Outcomes Mineral and Bone Guidelines for Monitoring Biochemical Parameters. Am J Nephrol 2019; 49:225-232. [PMID: 30820015 DOI: 10.1159/000497477] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/21/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mineral and bone disorder (MBD) is common in patients with chronic kidney disease (CKD), and is associated with risk of fractures, cardiovascular disease, and death. Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend monitoring CKD-MBD biochemical markers, including parathyroid hormone (PTH), phosphorus, 25-hydroxyvitamin D (25D), calcium, and alkaline phosphatase (ALP), in patients with moderate-to-severe CKD. METHODS To determine guideline adherence, we used administrative claims records from the 20% sample of Medicare beneficiaries with Parts A, B, and D coverage, 2007 to 2015, and identified cohorts of patients with nondialysis stage 3, 4, or 5 CKD. Testing for biochemical markers during follow-up was defined based on laboratory procedure codes. Baseline factors associated with laboratory testing were determined using logistic regression. All analyses were performed separately by CKD stage. RESULTS A total of 640,946 stage 3, 136,278 stage 4, and 22,076 stage 5 CKD patients, 50.2-52.9% women, mean age 74.4-78.0 years, were followed for a mean of 2.5, 1.3, and 0.7 years respectively. The frequency of testing was low for PTH (35.2-48.2%), phosphorus (46.6-62.0%), and 25D (29.3-46.7%). Testing was somewhat higher for calcium (88.1-95.4%) and ALP (63.5-88.1%); most tests were features of larger panels (e.g., basic metabolic panel). Older age, most comorbid conditions, and lack of prior nephrology care were associated with lower likelihood of testing. CONCLUSIONS In fee-for-service Medicare beneficiaries, laboratory testing for CKD-MBD biochemical markers appears to be suboptimal in relation to KDIGO guidelines. Competing priories, such as management of comorbid disease and preparation for renal replacement therapy, may distract from CKD-MBD monitoring.
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Affiliation(s)
- Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA,
| | - Yi Peng
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | | | - David T Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- Division of Nephrology, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
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17
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Laster M, Soohoo M, Streja E, Elashoff R, Jernigan S, Langman CB, Norris KC, Salusky IB, Kalantar-Zadeh K. Racial-ethnic differences in chronic kidney disease-mineral bone disorder in youth on dialysis. Pediatr Nephrol 2019; 34:107-115. [PMID: 30267239 PMCID: PMC6420309 DOI: 10.1007/s00467-018-4048-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 07/02/2018] [Accepted: 08/07/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Studies in healthy pediatric populations and adults treated with dialysis demonstrate higher parathyroid hormone (PTH) and lower 25-hydroxyvitamin D levels in African-Americans. Despite these findings, African-Americans on dialysis demonstrate greater bone strength and a decreased risk of fracture compared to the Caucasian dialysis population. The presence of such differences in children and young adult dialysis patients is unknown. METHODS Differences in the markers of mineral and bone metabolism (MBM) were assessed in 661 incident dialysis patients (aged 1 month to < 21 years). Racial-ethnic differences in PTH, calcium, phosphate, and total alkaline phosphatase (AP) activity were analyzed over the first year of dialysis using multivariate linear mixed models. RESULTS African-American race predicted 23% higher serum PTH (95% CI, 4.7-41.3%) when compared to Caucasian patients, while Hispanic ethnicity predicted 17.5% higher PTH (95% CI, 2.3-38%). Upon gender stratification, the differences in PTH were magnified in African-American and Hispanic females: 38% (95% CI, 14.8-69.8%) and 28.8% (95% CI, 4.7-54.9%) higher PTH compared to Caucasian females. Despite higher PTH values, African-American females persistently demonstrated up to 10.9% lower serum AP activity (95% CI, - 20.6-- 0.7%). CONCLUSIONS There are racial-ethnic differences in the markers of MBM. Higher PTH is seen in African-American and Hispanic children and young adults on dialysis with a magnification of this difference amongst the female population. There is a need to consider how factors like race, ethnicity, and gender impact the goal-targeted treatment of MBM disorders.
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Affiliation(s)
- Marciana Laster
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA
- Division of Pediatric Nephrology, Mattel Children's Hospital at UCLA, Los Angeles, CA, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Robert Elashoff
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA
| | - Stephanie Jernigan
- Division of Pediatric Nephrology, Emory University School of Medicine, Atlanta, GA, USA
| | - Craig B Langman
- Feinberg School of Medicine, Northwestern University and the Anne and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Keith C Norris
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA
| | - Isidro B Salusky
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte, Box 951752, Los Angeles, CA, 90095-1752, USA.
- Division of Pediatric Nephrology, Mattel Children's Hospital at UCLA, Los Angeles, CA, USA.
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
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18
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胡 顺, 王 东, 张 芮, 曹 媛, 金 华, 茅 燕, 魏 玲, 任 克, 章 雪, 王 亿. [Effect of Ronghuang Granule on serum FGF23, FGFRs and Klotho in non-dialysis patients with CKD-MBD and kidney deficiency and damp-heat syndrome]. Nan Fang Yi Ke Da Xue Xue Bao 2018; 38:1427-1432. [PMID: 30613009 PMCID: PMC6744217 DOI: 10.12122/j.issn.1673-4254.2018.12.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To observe the effect of Ronghuang granule on serum fibroblast growth factor 23 (FGF23), fibroblast growth factor receptor (FGFRs) and Klotho protein levels in non-dialysis patients with chronic kidney disease-mineral and bone disorder (CKD-MBD) and kidney deficiency and damp heat syndrome. METHODS Seventy non-dialysis CKD-MBD patients with kidney deficiency and dampness-heat syndrome were randomized into control group (n=35) and treatment group (n=35). All the patients were given routine treatment combined with traditional Chinese medicine retention enema, and the patients in the treatment group received additional Ronghuang granule treatment (3 times a day). After the 12-week treatments, the patients were examined for changes of TCM syndromes. Serum levels of Ca, P, parathyroid hormone (iPTH), FGF23, FGFRs and Klotho proteins were detected before and after treatment. These parameters were also examined in 20 healthy volunteers. RESULTS Sixty-five patients completed the study, including 33 in the control group and 32 in the treatment group. The patients in the treatment group showed significantly better treatment responses than those in the control group (P < 0.05 or 0.01). At 4, 8, and 12 weeks of treatment, the patients in the treatment group had significantly lowered scores of TCM syndromes compared with the score before treatment (P < 0.05 or 0.01), while in the control group, significant reduction of the scores occurred only at 12 weeks (P < 0.05); at each of the time points, the treatment group had significantly greater reductions in the score than the control group (P < 0.01). Significant improvements in serum Ca, P and iPTH levels were observed at 4, 8, and 12 weeks in the treatment group (P < 0.05) but only at 12 weeks in the control group (P < 0.05). The patients in the control and treatment groups all showed elevated serum levels of FGF23, FGFRs and Klotho protein compared with the normal subjects (P < 0.01); FGF23, FGFRs and Klotho levels were significantly reduced in the treatment group (P < 0.05) but remained unchanged in the control group (P>0.05), showing significant differences between the two groups. CONCLUSIONS Ronghuang granule improves the clinical symptoms of non-dialysis CKD-MBD patients with kidney deficiency and dampness heat syndrome by reducing serum levels of FGF23, FGFRs and Klotho, improving calcium and phosphorus metabolism disorder, and inhibiting secondary hyperparathyroidism.
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Affiliation(s)
- 顺金 胡
- 安徽中医药大学 第一附属医院,安徽 合肥 230000First Affiliated Hospital, Anhui University of Chinese Medicine, Heifei 230000, China
| | - 东 王
- 安徽中医药大学 第一附属医院,安徽 合肥 230000First Affiliated Hospital, Anhui University of Chinese Medicine, Heifei 230000, China
| | - 芮 张
- 安徽中医药大学 研究生院,安徽 合肥 230000Graduate School, Anhui University of Chinese Medicine, Heifei 230000, China
| | - 媛茹 曹
- 安徽省中西医结合医院,安徽 合肥 230000Anhui Provincial Hospital of Integrated Traditional Chinese and Western Medicine Hospital, Hefei 230000, China
| | - 华 金
- 安徽中医药大学 第一附属医院,安徽 合肥 230000First Affiliated Hospital, Anhui University of Chinese Medicine, Heifei 230000, China
| | - 燕萍 茅
- 安徽中医药大学 第一附属医院,安徽 合肥 230000First Affiliated Hospital, Anhui University of Chinese Medicine, Heifei 230000, China
| | - 玲 魏
- 安徽中医药大学 第一附属医院,安徽 合肥 230000First Affiliated Hospital, Anhui University of Chinese Medicine, Heifei 230000, China
| | - 克军 任
- 安徽中医药大学 第一附属医院,安徽 合肥 230000First Affiliated Hospital, Anhui University of Chinese Medicine, Heifei 230000, China
| | - 雪莲 章
- 安徽中医药大学 第一附属医院,安徽 合肥 230000First Affiliated Hospital, Anhui University of Chinese Medicine, Heifei 230000, China
| | - 亿平 王
- 安徽中医药大学 第一附属医院,安徽 合肥 230000First Affiliated Hospital, Anhui University of Chinese Medicine, Heifei 230000, China
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Mercadal L, Tezenas du Montcel S, Chonchol MB, Debure A, Depreneuf H, Servais A, Bassilios N, Assogba U, Allouache M, Prié D. Effects of L-Carnitine on Mineral Metabolism in the Multicentre, Randomized, Double Blind, Placebo-Controlled CARNIDIAL Trial. Am J Nephrol 2018; 48:349-356. [PMID: 30408788 DOI: 10.1159/000494338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/01/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The use of L-carnitine has been proposed in haemodialysis (HD) when deficiency is present to improve anaemia resistant to erythropoietin stimulating agent, intradialytic hypotension or cardiac failure. We tested the effects of L-carnitine supplementation on parameters of chronic kidney disease-mineral bone disorder. METHODS CARNIDIAL was a randomized, double-blinded trial having included 92 incident HD subjects for a 1-year period to receive L-carnitine versus placebo. Determinant factors of C-terminal fibroblast growth factor 23 (cFGF23) and intact FGF23 were studied including Klotho level. The L-carnitine effect on mineral metabolism was analyzed between groups by mixed linear models for repeated measurements. RESULTS Klotho was below the lower limit of quantification (LLOQ) in 55% of the 163 samples. In multivariate analysis, cFGF23 was positively correlated with calcium and phosphate and was higher in subjects having Klotho > LLOQ. No correlation existed between Klotho and phosphate and phosphate was even higher in subjects having Klotho > LLOQ (p < 0.001). Both forms of FGF23 were not related to iron markers nor to IV iron dose. No L-carnitine effect was detected on parathyroid hormone (PTH) or FGF23 during the study period where PTH slightly decreased over time, whereas FGF23 increased. But calcium and phosphate increased more in the L-carnitine group. CONCLUSION L-carnitine supplementation increased calcium and phosphate plasma concentrations with no detected downregulation effect on PTH and FGF23. (Clinical Trial 00322322, May 5, 2006).
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Affiliation(s)
- Lucile Mercadal
- Department of Nephrology, Assistance Publique Hôpitaux de Paris (AP-HP), Pitié Salpêtrière Hospital, Paris, France,
| | - Sophie Tezenas du Montcel
- Sorbonne Universités, UPMC Univ Paris 06 UMR_S1136, INSERM UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles-Foix, Department of Biostatistics and Medical Informatics, Paris, France
| | - Michel B Chonchol
- University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado, USA
| | - Alain Debure
- Hemodialysis Unit, CMC Pantin, Aubervilliers, France
| | - Hélène Depreneuf
- Association pour l'Utilisation du Rein Artificiel, Paris, France
| | - Aude Servais
- Department of Nephrology, AP-HP, Necker Hospital, Paris, France
| | | | | | | | - Dominique Prié
- Department of Biology, AP-HP, Necker Hospital, Paris Descartes University, Paris, France
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Andrews ES, Perrenoud L, Nowak KL, You Z, Pasch A, Chonchol M, Kendrick J, Jalal D. Examining the effects of uric acid-lowering on markers vascular of calcification and CKD-MBD; A post-hoc analysis of a randomized clinical trial. PLoS One 2018; 13:e0205831. [PMID: 30356327 PMCID: PMC6200237 DOI: 10.1371/journal.pone.0205831] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 10/01/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD)-mineral and bone disorder (MBD) is a systemic disorder that leads to vascular calcification and accelerated atherosclerosis. Uric acid has been shown to associate with vascular calcification and with carotid intima-media thickness (CIMT) and to suppress the 1 α-hydroxylase enzyme leading to lower 1,25-dihydroxyvitamin D (1,25(OH)2D) and higher intact parathyroid hormone (iPTH) levels. We hypothesized that lowering serum uric acid would reduce CIMT, calcification propensity, and circulating markers of CKD-MBD in CKD. METHODS This is a post-hoc analysis of a randomized, double-blind study of 80 patients with stage 3 CKD and hyperuricemia who received allopurinol or placebo for 12 weeks. CIMT and T50 were measured as markers of vascular disease and serum calcification propensity, respectively. The following markers of CKD-MBD were measured: serum calcium, phosphorus, vitamin D metabolites, iPTH, and fibroblast growth factor-23 (FGF-23). Expression of extra-renal 1α-hydroxylase was evaluated in endothelial cells of study participants. FINDINGS Allopurinol successfully lowered serum uric acid levels compared to placebo with an estimate of -3.3 mg/dL (95% C.I. -4.1,-2.5; p < 0.0001). After 12 weeks, however, we found no significant change in CIMT or serum T50. There was not a significant change in vitamin D metabolites, iPTH, FGF-23, or the expression of endothelial 1α-hydroxylase. CONCLUSION These data suggest that factors other than uric acid may play a more important role in the regulation of CKD- MBD including vascular calcification and vitamin D metabolism in patients with CKD.
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Affiliation(s)
- Emily S. Andrews
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Loni Perrenoud
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Kristen L. Nowak
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Zhiying You
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Andreas Pasch
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Jessica Kendrick
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Diana Jalal
- Nephrology Division, The University of Iowa, Iowa City, IA, United States of America
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Ruospo M, Palmer SC, Natale P, Craig JC, Vecchio M, Elder GJ, Strippoli GFM. Phosphate binders for preventing and treating chronic kidney disease-mineral and bone disorder (CKD-MBD). Cochrane Database Syst Rev 2018; 8:CD006023. [PMID: 30132304 PMCID: PMC6513594 DOI: 10.1002/14651858.cd006023.pub3] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Phosphate binders are used to reduce positive phosphate balance and to lower serum phosphate levels for people with chronic kidney disease (CKD) with the aim to prevent progression of chronic kidney disease-mineral and bone disorder (CKD-MBD). This is an update of a review first published in 2011. OBJECTIVES The aim of this review was to assess the benefits and harms of phosphate binders for people with CKD with particular reference to relevant biochemical end-points, musculoskeletal and cardiovascular morbidity, hospitalisation, and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs of adults with CKD of any GFR category comparing a phosphate binder to another phosphate binder, placebo or usual care to lower serum phosphate. Outcomes included all-cause and cardiovascular death, myocardial infarction, stroke, adverse events, vascular calcification and bone fracture, and surrogates for such outcomes including serum phosphate, parathyroid hormone (PTH), and FGF23. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess evidence certainty. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised MD (SMD) for continuous outcomes. MAIN RESULTS We included 104 studies involving 13,744 adults. Sixty-nine new studies were added to this 2018 update.Most placebo or usual care controlled studies were among participants with CKD G2 to G5 not requiring dialysis (15/25 studies involving 1467 participants) while most head to head studies involved participants with CKD G5D treated with dialysis (74/81 studies involving 10,364 participants). Overall, seven studies compared sevelamer with placebo or usual care (667 participants), seven compared lanthanum to placebo or usual care (515 participants), three compared iron to placebo or usual care (422 participants), and four compared calcium to placebo or usual care (278 participants). Thirty studies compared sevelamer to calcium (5424 participants), and fourteen studies compared lanthanum to calcium (1690 participants). No study compared iron-based binders to calcium. The remaining studies evaluated comparisons between sevelamer (hydrochloride or carbonate), sevelamer plus calcium, lanthanum, iron (ferric citrate, sucroferric oxyhydroxide, stabilised polynuclear iron(III)-oxyhydroxide), calcium (acetate, ketoglutarate, carbonate), bixalomer, colestilan, magnesium (carbonate), magnesium plus calcium, aluminium hydroxide, sucralfate, the inhibitor of phosphate absorption nicotinamide, placebo, or usual care without binder. In 82 studies, treatment was evaluated among adults with CKD G5D treated with haemodialysis or peritoneal dialysis, while in 22 studies, treatment was evaluated among participants with CKD G2 to G5. The duration of study follow-up ranged from 8 weeks to 36 months (median 3.7 months). The sample size ranged from 8 to 2103 participants (median 69). The mean age ranged between 42.6 and 68.9 years.Random sequence generation and allocation concealment were low risk in 25 and 15 studies, respectively. Twenty-seven studies reported low risk methods for blinding of participants, investigators, and outcome assessors. Thirty-one studies were at low risk of attrition bias and 69 studies were at low risk of selective reporting bias.In CKD G2 to G5, compared with placebo or usual care, sevelamer, lanthanum, iron and calcium-based phosphate binders had uncertain or inestimable effects on death (all causes), cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. Sevelamer may lead to constipation (RR 6.92, CI 2.24 to 21.4; low certainty) and lanthanum (RR 2.98, CI 1.21 to 7.30, moderate certainty) and iron-based binders (RR 2.66, CI 1.15 to 6.12, moderate certainty) probably increased constipation compared with placebo or usual care. Lanthanum may result in vomiting (RR 3.72, CI 1.36 to 10.18, low certainty). Iron-based binders probably result in diarrhoea (RR 2.81, CI 1.18 to 6.68, high certainty), while the risks of other adverse events for all binders were uncertain.In CKD G5D sevelamer may lead to lower death (all causes) (RR 0.53, CI 0.30 to 0.91, low certainty) and induce less hypercalcaemia (RR 0.30, CI 0.20 to 0.43, low certainty) when compared with calcium-based binders, and has uncertain or inestimable effects on cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. The finding of lower death with sevelamer compared with calcium was present when the analysis was restricted to studies at low risk of bias (RR 0.50, CI 0.32 to 0.77). In absolute terms, sevelamer may lower risk of death (all causes) from 210 per 1000 to 105 per 1000 over a follow-up of up to 36 months, compared to calcium-based binders. Compared with calcium-based binders, lanthanum had uncertain effects with respect to all-cause or cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification and probably had reduced risks of treatment-related hypercalcaemia (RR 0.16, CI 0.06 to 0.43, low certainty). There were no head-to-head studies of iron-based binders compared with calcium. The paucity of placebo-controlled studies in CKD G5D has led to uncertainty about the effects of phosphate binders on patient-important outcomes compared with placebo.It is uncertain whether the effects of binders on clinically-relevant outcomes were different for patients who were and were not treated with dialysis in subgroup analyses. AUTHORS' CONCLUSIONS In studies of adults with CKD G5D treated with dialysis, sevelamer may lower death (all causes) compared to calcium-based binders and incur less treatment-related hypercalcaemia, while we found no clinically important benefits of any phosphate binder on cardiovascular death, myocardial infarction, stroke, fracture or coronary artery calcification. The effects of binders on patient-important outcomes compared to placebo are uncertain. In patients with CKD G2 to G5, the effects of sevelamer, lanthanum, and iron-based phosphate binders on cardiovascular, vascular calcification, and bone outcomes compared to placebo or usual care, are also uncertain and they may incur constipation, while iron-based binders may lead to diarrhoea.
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Affiliation(s)
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Patrizia Natale
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | | | - Grahame J Elder
- Westmead HospitalDepartment of Renal MedicineWestmeadNSWAustralia2145
- Garvan Institute of Medical ResearchOsteoporosis and Bone Biology DivisionDarlinghurstNSWAustralia2010
| | - Giovanni FM Strippoli
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Diaverum AcademyBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
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Mirfatahi M, Imani H, Tabibi H, Nasrollahi A, Hedayati M. Effects of Flaxseed Oil on Serum Bone Turnover Markers in Hemodialysis Patients: a Randomized Controlled Trial. Iran J Kidney Dis 2018; 12:215-222. [PMID: 30087216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/18/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Chronic kidney disease-mineral and bone disorder is a common complication in hemodialysis patients. The present study was designed to investigate the effects of flaxseed oil, a rich source of plant omega-3 fatty acid alpha-linolenic acid, on serum markers of bone formation and resorption in hemodialysis patients. MATERIALS AND METHODS In this randomized controlled trial, 34 hemodialysis patients were randomly assigned to either the flaxseed oil or the control group. The patients in the flaxseed oil group received 6 g/d of flaxseed oil for 8 weeks, whereas the control group received 6 g/d of medium chain triglycerides oil. At baseline and the end of the 8th week, 7 mL of blood was obtained from each patient after a 12- to 14-hour fast and serum concentrations of osteocalcin, osteoprotegerin, N-telopeptide, and receptor activator of nuclear factor kappa B ligand were measured. RESULTS Serum N-telopeptide concentration decreased significantly up to 17% in the flaxseed oil group at the end of week 8, as compared to baseline (P < .01), and the reduction was significant in comparison with the control group. There were no significant differences between the two groups in the mean changes of serum osteocalcin, osteoprotegerin, or receptor activator of nuclear factor kappa B ligand. CONCLUSIONS This study indicates that daily consumption of 6 g/d of flaxseed oil may reduce bone resorption in hemodialysis patients.
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Affiliation(s)
| | | | - Hadi Tabibi
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Nordholm A, Mace ML, Gravesen E, Hofman-Bang J, Morevati M, Olgaard K, Lewin E. Klotho and activin A in kidney injury: plasma Klotho is maintained in unilateral obstruction despite no upregulation of Klotho biosynthesis in the contralateral kidney. Am J Physiol Renal Physiol 2018; 314:F753-F762. [PMID: 29187373 PMCID: PMC6031917 DOI: 10.1152/ajprenal.00528.2017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/22/2017] [Accepted: 11/27/2017] [Indexed: 12/17/2022] Open
Abstract
In a new paradigm of etiology related to chronic kidney disease-mineral and bone disorder (CKD-MBD), kidney injury may cause induction of factors in the injured kidney that are released into the circulation and thereby initiate and maintain renal fibrosis and CKD-MBD. Klotho is believed to ameliorate renal fibrosis and CKD-MBD, while activin A might have detrimental effects. The unilateral ureter obstruction (UUO) model is used here to examine this concept by investigating early changes related to renal fibrosis in the obstructed kidney, untouched contralateral kidney, and vasculature which might be affected by secreted factors from the obstructed kidney, and comparing with unilateral nephrectomized controls (UNX). Obstructed kidneys showed early Klotho gene and protein depletion, whereas plasma Klotho increased in both UUO and UNX rats, indicating an altered metabolism of Klotho. Contralateral kidneys had no compensatory upregulation of Klotho and maintained normal expression of the examined fibrosis-related genes, as did remnant UNX kidneys. UUO caused upregulation of transforming growth factor-β and induction of periostin and activin A in obstructed kidneys without changes in the contralateral kidneys. Plasma activin A doubled in UUO rats after 10 days while no changes were seen in UNX rats, suggesting secretion of activin A from the obstructed kidney with potentially systemic effects on CKD-MBD. As such, increased aortic sclerostin was observed in UUO rats compared with UNX and normal controls. The present results are in line with the new paradigm and show very early vascular effects of unilateral kidney fibrosis, supporting the existence of a new kidney-vasculature axis.
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Affiliation(s)
- Anders Nordholm
- Nephrological Department B, Herlev Hospital, Herlev, University of Copenhagen , Copenhagen , Denmark
| | - Maria L Mace
- Nephrological Department B, Herlev Hospital, Herlev, University of Copenhagen , Copenhagen , Denmark
- Nephrological Department P, Rigshospitalet, Copenhagen , Denmark
| | - Eva Gravesen
- Nephrological Department P, Rigshospitalet, Copenhagen , Denmark
| | | | - Marya Morevati
- Nephrological Department P, Rigshospitalet, Copenhagen , Denmark
| | - Klaus Olgaard
- Nephrological Department P, Rigshospitalet, Copenhagen , Denmark
| | - Ewa Lewin
- Nephrological Department B, Herlev Hospital, Herlev, University of Copenhagen , Copenhagen , Denmark
- Nephrological Department P, Rigshospitalet, Copenhagen , Denmark
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Malhotra R, Katz R, Hoofnagle A, Bostom A, Rifkin DE, Mcbride R, Probstfield J, Block G, Ix JH. The Effect of Extended Release Niacin on Markers of Mineral Metabolism in CKD. Clin J Am Soc Nephrol 2018; 13:36-44. [PMID: 29208626 PMCID: PMC5753310 DOI: 10.2215/cjn.05440517] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 10/03/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Niacin downregulates intestinal sodium-dependent phosphate transporter 2b expression and reduces intestinal phosphate transport. Short-term studies have suggested that niacin lowers serum phosphate concentrations in patients with CKD and ESRD. However, the long-term effects of niacin on serum phosphate and other mineral markers are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Trial was a randomized, double-blind, placebo-controlled trial testing extended release niacin in persons with prevalent cardiovascular disease. We examined the effect of randomized treatment with niacin (1500 or 2000 mg) or placebo on temporal changes in markers of mineral metabolism in 352 participants with eGFR<60 ml/min per 1.73 m2 over 3 years. Changes in each marker were compared over time between the niacin and placebo arms using linear mixed effects models. RESULTS Randomization to niacin led to 0.08 mg/dl lower plasma phosphate concentrations per year of treatment compared with placebo (P<0.01) and 0.25 mg/dl lower mean phosphate 3 years after baseline (3.32 versus 3.57 mg/dl; P=0.03). In contrast, randomization to niacin was not associated with statistically significant changes in plasma intact fibroblast growth factor 23, parathyroid hormone, calcium, or vitamin D metabolites over 3 years. CONCLUSIONS The use of niacin over 3 years lowered serum phosphorous concentrations but did not affect other markers of mineral metabolism in participants with CKD.
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Affiliation(s)
- Rakesh Malhotra
- Division of Nephrology-Hypertension, Department of Medicine and
- Imperial Valley Family Care Medical Group, El Centro, California
| | - Ronit Katz
- Division of Nephrology, Department of Medicine
| | | | - Andrew Bostom
- Division of Hypertension and Kidney Diseases, Rhode Island Hospital, Providence, Rhode Island
| | - Dena E. Rifkin
- Division of Nephrology-Hypertension, Department of Medicine and
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California, San Diego, California
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California
| | | | - Jeffrey Probstfield
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
| | | | - Joachim H. Ix
- Division of Nephrology-Hypertension, Department of Medicine and
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California, San Diego, California
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California
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Yang HM, Meng XJ, Wu W, Liu YL, Zhai XJ. [Regression analysis of serum bone metabolic markers and traditional Chinese medicine syndromes in patients with CKD-MBD]. Zhongguo Zhong Yao Za Zhi 2017; 42:4027-4034. [PMID: 29243442 DOI: 10.19540/j.cnki.cjcmm.20170901.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Indexed: 06/07/2023]
Abstract
To analyze the interdependent relationship between serum bone metabolic markers and traditional Chinese medicine (TCM) syndromes in patients with chronic kidney disease (stages 3 and 4)-related mineral and bone disorder (CKD-MBD), in order to provide the objective basis for exploring the rules of TCM syndrome differentiation in patients with CKD-MBD. The retrospective survey was conducted to collect 105 cases with CKD (stages 3 and 4)-MBD. General clinical indexes, frequency of TCM syndromes and distribution of TCM syndrome type were investigated. Furthermore, serum bone metabolic markers, including calcium (Ca2+), phosphonium (P3+), intact parathyroid hormone (iPTH), alkaline phosphatase (ALP), procollagen type 1 amino-N-terminal propeptide (P1NP) and β-crosslaps (β-CTX) were analyzed, respectively. Meanwhile, bone mineral density (BMD) was assessed. And then, the multivariate regression analysis was performed for serum bone metabolic markers and TCM syndromes. The results showed that the general clinical features of the 105 patients included old age, hypertension, fracture, loss of bone mass and mild abnormalities of serum bone metabolic markers. High-frequency TCM syndromes were related to Yang deficiency in Spleen and Kidney, Qi deficiency in Spleen and Kidney and blood stasis. Moreover, Yang deficiency in Spleen and Kidney and blood stasis were found as the most frequent characteristics of the distribution of TCM syndromes type. The clinical characteristics of patients with the syndrome type of Yang deficiency in Spleen and Kidney were probably old age, increase in TCM syndrome scores and abnormalities in iPTH and P1NP. In addition, the interdependent relationship between abnormality in Ca2+ and syndromes of hair loss, tooth shake and sexual dysfunction, abnormality in P3+ and syndromes of aches in waist and knees, abnormality in iPTH and syndromes of soreness and weakness in waist and knees, lassitude, fatigue and extreme chilliness, abnormality in ALP and syndromes of loose stools, abnormality in P1NP and syndromes of fear of chills, tendency of warmth and loose stools, and abnormality in β-CTX and syndromes of chills and pain in waist and knees. In general, among the 105 cases with CKD (stages 3 and 4)-MBD were clinically characterized by mild changes in serum bone metabolic markers; And their main TCM syndrome was the deficiency in spleen and kidney. Serum bone metabolic markers with mild changes have an interdependent relationship with main TCM syndromes, and can be considered as an objective syndrome factor of TCM syndrome differentiation.
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Affiliation(s)
- Hai-Ming Yang
- Department of Traditional Chinese Medicine, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Xian-Jie Meng
- Department of Nephrology, Yancheng Hospital of Traditional Chinese Medicine, Yancheng 224001, China
| | - Wei Wu
- Department of Traditional Chinese Medicine, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Ying-Lu Liu
- Department of Traditional Chinese Medicine, Nanjing Drum Tower Hospital Clinical College of Chinese Medicine and Western Medicine, Nanjing University of Chinese Medicine, Nanjing 210008, China
| | - Xiao-Juan Zhai
- Department of Traditional Chinese Medicine, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, China
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Da Silva Martins J, Castro JH, Sainz Rueda NA, dos Reis LM, Jorgetti V, Affonso Moysés RM, Caramori JT. Renal osteodystrophy in the obesity era: Is metabolic syndrome relevant? PLoS One 2017; 12:e0180387. [PMID: 28719612 PMCID: PMC5515407 DOI: 10.1371/journal.pone.0180387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/14/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Observational studies have shown a beneficial effect of obesity on bone health; however, most of those studies were not based on bone biopsies. Metabolic syndrome (MetS) could have an effect on bone remodeling. However, there are no data on the effects of MetS in the presence of renal osteodystrophy. OBJECTIVE The aim of this study was to investigate associations between MetS and renal osteodystrophy using the bone histomorphometric turnover-mineralization-volume (TMV) classification. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS This observational cross-sectional study included 55 hemodialysis patients (28 women/27 men) who were evaluated for MetS and bone histomorphometry. Biochemical parameters included calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone (iPTH), 25-hydroxyvitamin D, free serum leptin, fibroblast growth factor 23 (FGF23), intact osteocalcin, sclerostin (Scl), glucose, insulin, and thyroid hormones. Robust models of multivariate linear regressions were used for the statistical analyses. RESULTS Females had higher iPTH levels (1,143 vs. 358, p = 0.02). Patients with normal bone volume (BV/TV) had a higher prevalence of MetS (73.6% vs. 41.7%, p = 0.02) and higher serum phosphorus, C-terminal FGF23 and insulin levels. The multivariate regression analysis showed that low-density lipoprotein cholesterol (LDL) was positively correlated with bone formation rate (BFR/BS) and negatively associated with mineralization lag time. Bone volume was negatively associated with age but positively associated with MetS. Body mass index (BMI) was not correlated with any of the bone histomorphometric parameters. CONCLUSION Our results suggest that MetS is not a risk factor for low bone volume in hemodialysis patients. Furthermore, BMI alone was not related to bone volume in this population.
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Affiliation(s)
- Janaina Da Silva Martins
- Nephrology, Department of Internal Medicine, Faculdade de Medicina Botucatu Univ. Estadual Paulista-UNESP. Botucatu, Brazil
- Department of Medicine, Universidade Estadual de Maringa, Maringa, Brazil
- * E-mail:
| | - João Henrique Castro
- Nephrology, Department of Internal Medicine, Faculdade de Medicina Botucatu Univ. Estadual Paulista-UNESP. Botucatu, Brazil
| | - Nestor A. Sainz Rueda
- Multidisciplinary Clinical Nutrition Team, Universidade Estadual de Maringa, Maringa, Brazil
| | | | - Vanda Jorgetti
- Nephrology Division, Universidade de São Paulo, São Paulo, Brazil
| | | | - Jacqueline Teixeira Caramori
- Nephrology, Department of Internal Medicine, Faculdade de Medicina Botucatu Univ. Estadual Paulista-UNESP. Botucatu, Brazil
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Wang M, Obi Y, Streja E, Rhee CM, Lau WL, Chen J, Hao C, Hamano T, Kovesdy CP, Kalantar-Zadeh K. Association of Parameters of Mineral Bone Disorder with Mortality in Patients on Hemodialysis according to Level of Residual Kidney Function. Clin J Am Soc Nephrol 2017; 12:1118-1127. [PMID: 28487345 PMCID: PMC5498357 DOI: 10.2215/cjn.11931116] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 04/04/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The relationship between mineral and bone disorders and survival according to residual kidney function status has not been previously studied in patients on hemodialysis. We hypothesized that residual kidney function, defined by renal urea clearance, modifies the association between mineral and bone disorder parameters and mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The associations of serum phosphorus, albumin-corrected calcium, intact parathyroid hormone, and alkaline phosphatase with all-cause mortality were examined across three strata (<1.5, 1.5 to <3.0, and ≥3.0 ml/min per 1.73 m2) of baseline residual renal urea clearance using Cox models adjusted for clinical characteristics and laboratory measurements in 35,114 incident hemodialysis patients from a large United States dialysis organization over the period of 2007-2011. RESULTS A total of 8102 (23%) patients died during the median follow-up of 1.3 years (interquartile range, 0.6-2.3 years). There was an incremental mortality risk across higher serum phosphorus concentrations, which was pronounced among patients with higher residual renal urea clearance (Pinteraction=0.001). Lower concentrations of serum intact parathyroid hormone were associated with higher mortality among patients with low residual renal urea clearance (i.e., <1.5 ml/min per 1.73 m2), whereas higher concentrations showed a higher mortality risk among patients with greater residual renal urea clearance (i.e., ≥1.5 ml/min per 1.73 m2; Pinteraction<0.001). Higher serum corrected total calcium and higher alkaline phosphatase concentrations consistently showed higher mortality risk (Ptrend<0.001 for both) irrespective of residual renal urea clearance strata (Pinteraction=0.34 and Pinteraction=0.53, respectively). CONCLUSIONS Residual kidney function modified the mortality risk associated with serum phosphorus and intact parathyroid hormone among incident hemodialysis patients. Future studies are needed to examine whether taking account for residual kidney function into the assessment of mortality risk associated with serum phosphorus and intact parathyroid hormone improves patient management and clinical outcomes in the hemodialysis population.
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Affiliation(s)
- Mengjing Wang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Connie M. Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Wei Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Jing Chen
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chuanming Hao
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Takayuki Hamano
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
- Department of Epidemiology, Fielding School of Public Health at University of California, Los Angeles, Los Angeles, California; and
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California
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28
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Moe SM, Wetherill L, Decker BS, Lai D, Abdalla S, Long J, Vatta M, Foroud TM, Chertow GM. Calcium-Sensing Receptor Genotype and Response to Cinacalcet in Patients Undergoing Hemodialysis. Clin J Am Soc Nephrol 2017; 12:1128-1138. [PMID: 28630081 PMCID: PMC5498355 DOI: 10.2215/cjn.11141016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/23/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES We tested the hypothesis that single nucleotide polymorphisms (SNPs) in the calcium-sensing receptor (CASR) alter the response to the calcimimetic cinacalcet. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We analyzed DNA samples in the Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events (EVOLVE) trial, a randomized trial comparing cinacalcet to placebo on a background of usual care. Of the 3883 patients randomized, 1919 (49%) consented to DNA collection, and samples from 1852 participants were genotyped for 18 CASR polymorphisms. The European ancestry (EA; n=1067) and African ancestry (AfAn; n=405) groups were assessed separately. SNPs in CASR were tested for their association with biochemical measures of mineral metabolism at baseline, percent change from baseline to 20 weeks, and risk of clinical fracture as dependent variables. RESULTS There were modest associations of CASR SNPs with increased baseline serum parathyroid hormone and bone alkaline phosphatase primarily with the minor allele in the EA group (all P≤0.03), but not in the AfAn sample. In contrast, there was a modest association of decreased baseline serum calcium and FGF23 with CASR SNPs (P=0.04) primarily with the minor allele in the AfAn but not in the EA sample. The minor allele of two SNPs was associated with decreased percent reduction in parathyroid hormone from baseline to 20 weeks in the EA population (P<0.04) and this was not altered with cinacalcet. In both EA and AfAn, the same SNP (rs9740) was associated with decreased calcium with cinacalcet treatment (EA and AfAn P≤0.03). Three SNPs in high linkage disequilibrium were associated with a higher risk of clinical fracture that was attenuated by cinacalcet treatment in the EA sample (P<0.04). CONCLUSIONS These modest associations, if validated, may provide explanations for differences in CKD-mineral bone disorder observed in EA and AfAn populations, and for differential biochemical responses to calcimimetics.
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Affiliation(s)
- Sharon M. Moe
- Division of Nephrology, Department of Medicine and
- Department of Medicine, Roudebush Veterans Administration Medical Center, Indianapolis, Indiana; and
| | - Leah Wetherill
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Dongbing Lai
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Safa Abdalla
- Division of Nephrology, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Jin Long
- Division of Nephrology, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Matteo Vatta
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Tatiana M. Foroud
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford School of Medicine, Stanford, California
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29
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Sonkar SK, Bhutani M, Sonkar GK, Pandey SK, Chandra S, Bhosale V. Vitamin D levels and other biochemical parameters of mineral bone disorders and their association with diastolic dysfunction and left ventricular mass in young nondiabetic adult patients with chronic kidney disease. Saudi J Kidney Dis Transpl 2017; 28:758-763. [PMID: 28748877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with end-stage renal disease. Chronic kidney disease (CKD)-associated cardiovascular mortality is more prevalent in those with diastolic heart failure and is an early predictor, while increased left ventricular mass (LVM) is a strong independent risk factor. Hypovitaminosis D is extensively being studied as a nontraditional risk factor for CVD. The aim of the present study is to look at the association of Vitamin D and other parameters of mineral bone disorder (MBD) with diastolic dysfunction and LVM in nondiabetic young adult patients with CKD. This was a hospital-based, cross-sectional observational study. Groups I and II comprised nondiabetic predialysis CKD patients (stage 4 and 5) and healthy controls, respectively. Groups IA and IB comprised cases with and without diastolic dysfunction, respectively. Vitamin D level was measured by enhanced chemiluminescence method and intact parathyroid hormone (iPTH) by electrochemiluminescence method. Parameters for diastolic function and LVM were assessed by Doppler echocardiography, tissue Doppler imaging, and M-mode echocardiography. Vitamin D level was significantly lower in Group I as compared to Group II. Diastolic dysfunction was present in 48.8% of the cases and was significantly associated with serum phosphorus and calcium-phosphorous product, but not with Vitamin D level. A statistically significant positive correlation between LVM and iPTH was found in our study. Hyperphosphatemia and high calcium-phosphorous product can be a better early predictor of diastolic dysfunction than Vitamin D while secondary hyperpara-thyroidism with increased LVM may be a bad prognostic marker.
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MESH Headings
- Adult
- Biomarkers/blood
- Bone Remodeling
- Calcium/blood
- Case-Control Studies
- 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
- Cross-Sectional Studies
- Diastole
- Echocardiography, Doppler
- Female
- Humans
- Hypertrophy, Left Ventricular/diagnostic imaging
- Hypertrophy, Left Ventricular/etiology
- Hypertrophy, Left Ventricular/physiopathology
- Male
- Parathyroid Hormone/blood
- Phosphorus/blood
- Renal Insufficiency, Chronic/blood
- Renal Insufficiency, Chronic/complications
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/physiopathology
- Risk Factors
- Ventricular Dysfunction, Left/diagnostic imaging
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Function, Left
- Ventricular Remodeling
- Vitamin D/blood
- Vitamin D Deficiency/blood
- Vitamin D Deficiency/complications
- Vitamin D Deficiency/diagnosis
- Vitamin D Deficiency/physiopathology
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Affiliation(s)
| | - Mohit Bhutani
- Department of Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Gyanendra Kumar Sonkar
- Department of Biochemistry, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Sant Kumar Pandey
- Department of Nephrology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Sharad Chandra
- Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Vivek Bhosale
- Division of Clinical and Experimental Medicine, CSIR-Central Drug Research Institute, Lucknow, Uttar Pradesh, India
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30
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Etta PK, Sharma RK, Gupta A. Study of chronic kidney disease-mineral bone disorders in newly detected advanced renal failure patients: A Hospital-based cross-sectional study. Saudi J Kidney Dis Transpl 2017; 28:874-885. [PMID: 28748891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
We aim to evaluate the disturbances in mineral metabolism, abnormalities in bone mineral density (BMD), and extraskeletal calcification in newly detected, untreated predialysis stage 4 and 5 chronic kidney disease (CKD) patients at a tertiary care hospital in North India. This is cross-sectional observational study. A total of 95 (68 males, 27 females) newly detected patients underwent clinical evaluation, biochemical assessment [serum calcium, phosphorus, alkaline phosphatase (ALP), albumin, creatinine, intact parathyroid hormone (iPTH), 25- hydroxyvitamin D (25(OH)D)], BMD measurement (at spine, hip, and forearm) by dual-energy X-ray absorptiometry (DXA), lateral abdominal radiograph [for abdominal aortic calcification (AAC)], skeletal survey (to look for any abnormality including fractures), and echocardiography [for any cardiac valvular calcification (CVC)]. Symptoms related to CKD-mineral bone disorder were seen in 33.6% of the study patients. Prevalence of hypocalcemia, hyperphosphatemia, hyperparathyroidism, and hypovitaminosis D was 64.2%, 81.1%, 49.5%, and 89.5%, respectively. CVC was seen in 22.1% of patients on echocardiography, mostly involving the mitral valve. Patients with CVC were more likely to be males and smokers. There was no significant difference in iPTH levels between patients with or without CVC. AAC was seen in 10.5% of patients on lateral abdominal X-ray. Patients with AAC had higher levels of iPTH, phosphorus, and ALP and lower levels of calcium compared to patients without AAC. BMD by DXA showed a low bone mass in 41.05% of our patients and was more prevalent in CKD stage 5. Most of the study patients had hyperparathyroidism and low 25(OH)D levels. Our study shows that newly detected, naïve Indian CKD patients have a high prevalence of disturbances of mineral metabolism including hyperparathyroidism, Vitamin D deficiency, abnormal BMD, and valvular and vascular calcification, even before initiating dialysis.
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Affiliation(s)
- Praveen Kumar Etta
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - R K Sharma
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Gupta
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Abstract
Renal osteodystrophy is a feature of chronic kidney disease (CKD), with increasing prevalence as CKD progresses. This bone disease is responsible for major morbidity, including fractures, and a deterioration in the quality of life and its sequelae. Circulating biomarkers of renal osteodystrophy typically indicate bone turnover, but not other features of bone, like bone volume, mineralization, quality or strength. Bone turnover can be considered to be primarily a reflection of bone cell activity, in particular that of osteoblasts and osteoclasts. Since current treatments for bone disease usually target cellular activity, biomarkers are considered to be able to contribute to the decision-making for treatment and its follow-up. In CKD, one has to consider the impact of a diminished clearance of biomarkers or their altered metabolism, both potentially limiting its clinical use. Here, several aspects of the most frequently used biomarkers of bone turnover are reviewed, with an emphasis on the specific situation represented by CKD. This review is based on the overview lecture at the symposium held in Amsterdam, September 23, 2016: “The Bone In CKD”, organized by the CKD-MBD working group of ERA-EDTA.
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Affiliation(s)
- Marc G Vervloet
- Department of Nephrology and Institute of Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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32
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Kwon YE, Lee MJ, Park KS, Han SH, Yoo TH, Oh KH, Lee J, Lee KB, Chung W, Kim YH, Ahn C, Choi KH. Cystatin C is Better than Serum Creatinine for Estimating Glomerular Filtration Rate to Detect Osteopenia in Chronic Kidney Disease Patients. Yonsei Med J 2017; 58:380-387. [PMID: 28120569 PMCID: PMC5290018 DOI: 10.3349/ymj.2017.58.2.380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/30/2016] [Accepted: 09/13/2016] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Recent studies have reported that loss of bone mass is associated with renal function decline and increased fracture risks in chronic kidney disease (CKD) patients. The aim of this study was to investigate the best estimated glomerular filtration rate (eGFR) equation to detect osteopenia in CKD patients. MATERIALS AND METHODS This was a cross-sectional study, and 780 patients aged 50 years or above were classified into normal bone mass or osteopenia groups according to the -1.0 of T-scores at total hip and femur neck. Comparisons of area under the receiver operating characteristic (ROC) curves (AUC) were performed to investigate significant differences among three eGFR formulas: Modification of Diet in Renal Disease, CKD-Epidemiology Collaboration (EPI) creatinine, and CKD-EPI cystatin C (CKD-EPI-Cys). RESULTS The mean age was 61 years old and the proportion of females was 37.3%. The total hip osteopenia group showed lower CKD-EPI-Cys eGFR levels (osteopenia group, 33.3±19.0 mL/min/1.73 m²; normal group, 48.1±26.2 mL/min/1.73 m², p<0.001). In multiple logistic regression analysis, CKD-EPI-Cys eGFR was independently associated with osteopenia at the total hip (per 1 mL/min/1.73 m² increase, odds ratio 0.98, 95% confidence interval 0.97-0.99, p=0.004) after adjusting for confounding variables. ROC curve analyses indicated that CKD-EPI-Cys shows the largest AUC for osteopenia at the total hip (AUC=0.678, all p<0.01) and the femur neck (AUC=0.665, all p<0.05). CONCLUSION Decreased renal function assessed by CKD-EPI-Cys equation correlates with osteopenia better than creatinine-based methods in CKD patients, and the CKD-EPI-Cys formula might be a useful tool to assess skeletal-related event risks.
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Affiliation(s)
- Young Eun Kwon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Mi Jung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyoung Sook Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hyun Yoo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kook Hwan Oh
- Department of Internal Medicine, Seoul National University, Seoul, Korea
| | - Joongyub Lee
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea
| | - Kyu Beck Lee
- Department of Internal Medicine, Kangbuck Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wookyung Chung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yeong Hoon Kim
- Department of Nephrology, College of Medicine, Inje University, Busan, Korea
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University, Seoul, Korea
| | - Kyu Hun Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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Sekercioglu N, Angeliki Veroniki A, Thabane L, Busse JW, Akhtar-Danesh N, Iorio A, Cruz Lopes L, Guyatt GH. Effects of different phosphate lowering strategies in patients with CKD on laboratory outcomes: A systematic review and NMA. PLoS One 2017; 12:e0171028. [PMID: 28248961 PMCID: PMC5331957 DOI: 10.1371/journal.pone.0171028] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/14/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Chronic kidney disease-mineral and bone disorder (CKD-MBD), a complication of chronic kidney disease, has been linked to reduced quality and length of life. High serum phosphate levels that result from CKD-MBD require phosphate-lowering agents, also known as phosphate binders. The objective of this systematic review is to compare the effects of available phosphate binders on laboratory outcomes in patients with CKD-MBD. METHODS Data sources included MEDLINE and EMBASE from January 1996 to April 2016, and the Cochrane Register of Controlled Trials up to April 2016. Teams of two reviewers, independently and in duplicate, screened titles and abstracts and potentially eligible full text reports to determine eligibility, and subsequently abstracted data and assessed risk of bias in eligible randomized controlled trials (RCTs). Eligible trials enrolled patients with CKD-MBD and randomized them to receive calcium-based phosphate binders (delivered as calcium acetate, calcium citrate or calcium carbonate), non-calcium-based phosphate binders (NCBPB) (sevelamer hydrochloride, sevelamer carbonate, lanthanum carbonate, sucroferric oxyhydroxide and ferric citrate), phosphorus restricted diet (diet), placebo or no treatment and reported effects on serum levels of phosphate, calcium and parathyroid hormone. We performed Bayesian network meta-analyses (NMA) to calculate the effect estimates (mean differences) and 95% credible intervals for serum levels of phosphate, calcium and parathyroid hormone. We calculated direct, indirect and network meta-analysis estimates using random-effects models. We applied the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to rate the quality of evidence for each pairwise comparison. RESULTS Our search yielded 1108 citations; 71 RCTs were retrieved for full review and 16 proved eligible. Including an additional 13 studies from a previous review, 29 studies that enrolled 8335 participants proved eligible; 26 trials provided data for quantitative synthesis. Sevelamer, lanthanum, calcium, iron, diet and combinations of active treatments (calcium or sevelamer or lanthanum and combination of calcium and sevelamer) resulted in significantly lower serum phosphate as compared to placebo (moderate to very low quality of evidence). We found no statistically significant differences between active treatment categories in lowering serum phosphate. Sevelamer, lanthanum and diet resulted in lower serum calcium compared to calcium (moderate quality evidence for lanthanum and diet; low quality evidence for Sevelamer). Iron, sevelamer and calcium yielded lower parathyroid hormone levels as compared to lanthanum. Meta-regression analyses did not yield a statistically significant association between treatment effect and trial duration. DISCUSSION/CONCLUSIONS We found few differences between treatments in impact on phosphate and differences in parathyroid hormone. Relative to calcium, sevelamer, lanthanum and diet showed significant reduction in serum calcium from baseline. Treatment recommendations should be based on impact on patient-important outcomes rather than on surrogate outcomes. Systematic review registration: PROSPERO CRD-42016032945.
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Affiliation(s)
- Nigar Sekercioglu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
| | | | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics and Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Centre for Evaluation of Medicine, St Joseph's Healthcare—Hamilton, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jason W. Busse
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Noori Akhtar-Danesh
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Luciane Cruz Lopes
- Pharmaceutical Sciences Master Course, University of Sorocaba, UNISO, Sorocaba, Brazil
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Torino C, Pizzini P, Cutrupi S, Tripepi G, Mallamaci F, Thadhani R, Zoccali C. Active vitamin D treatment in CKD patients raises serum sclerostin and this effect is modified by circulating pentosidine levels. Nutr Metab Cardiovasc Dis 2017; 27:260-266. [PMID: 28017524 DOI: 10.1016/j.numecd.2016.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 11/06/2016] [Accepted: 11/14/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS 1,25(OH)2Vitamin D increases the expression of the sclerostin gene. Whether vitamin D receptor activation (VDRA) influences serum sclerostin in CKD and whether compounds interfering with VDRA like Advanced Glycosylation End Products (AGEs) may alter the sclerostin response to VDRA is unknown. METHODS AND RESULTS Eighty-eight stage G3-4 CKD patients randomly received 2 μg paricalcitol (PCT)/day (n = 44) or placebo (n = 44) for 12 weeks. Sclerostin, a major AGE compound like pentosidine, and bone mineral disorder biomarkers were measured at baseline, at 12 weeks and 2 weeks after stopping the treatments. At baseline, in the whole study population sclerostin correlated with male gender (P = 0.002), BMI (P < 0.001), waist circumference (P < 0.001), serum pentosidine (P = 0.002) and to a weaker extent, with diabetes (P = 0.04), 1,25(OH)2Vitamin D (r = 0.22, P = 0.04) and serum phosphate (r = -0.26, P = 0.01). Sclerostin increased during PCT treatment (average + 15.7 pg/ml, 95% CI: -3.0 to +34.3) but not during placebo (P = 0.03) and the PCT effect was abolished 2 weeks after stopping this drug. The increase in sclerostin levels induced by PCT was modified by prevailing pentosidine levels (P = 0.01) and was abolished by statistical adjustment for simultaneous changes in PTH but not by FGF23 changes. CONCLUSIONS VDRA by paricalcitol causes a moderate increase in serum sclerostin in CKD patients. Such an effect is abolished by adjustment for PTH, suggesting that it may serve to counter PTH suppression. The sclerostin rise by PCT is attenuated by pentosidine, an observation in keeping with in vitro studies showing that AGEs alter the functioning of the VDRA.
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Affiliation(s)
- C Torino
- CNR-IFC & Nephrology and Renal Transplantation Unit, Reggio Calabria, Italy
| | - P Pizzini
- CNR-IFC & Nephrology and Renal Transplantation Unit, Reggio Calabria, Italy
| | - S Cutrupi
- CNR-IFC & Nephrology and Renal Transplantation Unit, Reggio Calabria, Italy
| | - G Tripepi
- CNR-IFC & Nephrology and Renal Transplantation Unit, Reggio Calabria, Italy
| | - F Mallamaci
- CNR-IFC & Nephrology and Renal Transplantation Unit, Reggio Calabria, Italy
| | - R Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, USA
| | - C Zoccali
- CNR-IFC & Nephrology and Renal Transplantation Unit, Reggio Calabria, Italy.
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Li D, Zhang L, Zuo L, Jin CG, Li WG, Chen JB. Association of CKD-MBD Markers with All-Cause Mortality in Prevalent Hemodialysis Patients: A Cohort Study in Beijing. PLoS One 2017; 12:e0168537. [PMID: 28045985 PMCID: PMC5207661 DOI: 10.1371/journal.pone.0168537] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 12/03/2016] [Indexed: 02/05/2023] Open
Abstract
The relationships between all-cause mortality and serum intact parathyroid hormone (iPTH), calcium, and phosphate are fairly diverse in patients on maintenance hemodialysis according to prior studies. This study evaluated the association of chronic kidney disease-mineral and bone disorder (CKD-MBD) markers with all-cause mortality in prevalent hemodialysis patients from 2007 to 2012 in Beijing, China. A cohort, involving 8530 prevalent hemodialysis patients who had undergone a 6-70 months follow-up program (with median as 40 months) was formed. Related data was recorded from the database in 120 hemodialysis centers of Beijing Health Bureau (2007 to 2012). Information regarding baseline demographics, blood CKD-MBD markers and all-cause mortality was retrospectively reviewed. By using multivariate Cox regression model analysis, patients with a low iPTH level at baseline were found to have greater risk of mortality (<75pg/ml, HR = 1.36, 95% confidence interval (CI) 1.16-1.60) than those with a baseline iPTH level within 150-300 pg/ml. Similarly, death risk showed an increase when the baseline serum calcium presented a low level (<2.1mmol/L, HR = 1.54; 95% CI 1.37-1.74). Levels of baseline serum phosphorus were not associated with the risk of death. Similar results appeared through the baseline competing risks regression analysis. Patients with a lower level of serum iPTH or calcium are at a higher risk of all-cause mortality compared with those within the range recommended by Kidney Disease Outcome Quality Initiative (KDOQI) guidelines.
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Affiliation(s)
- Duo Li
- Department of Nephrology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ling Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Li Zuo
- Department of Nephrology, People’s hospital, Peking University, Beijing, China
| | - Cheng Gang Jin
- School of Social Development and Public Policy, Beijing Normal University
| | - Wen Ge Li
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Jin-Bor Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Pasquali M, Tartaglione L, Rotondi S. [New biomarkers of CKD-MBD]. G Ital Nefrol 2016; 33:gin/00248.3. [PMID: 28134398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Chronic kidney failure involves abnormalities of mineral metabolism, skeletal and of cardiovascular system (so called CKD - MBD) that have a major impact on the survival of renal patient. Increasingly complex pathophysiological mechanisms have been discovered in recent years with evidence of new molecules involved in the development of CKD - MBD. Besides the classical PTH / Vitamin D axis, the most recent discovery of a new FGF23 / Klotho axis has expanded knowledge on the mechanisms of mineral homeostasis but also on the more complex mechanisms of cellular aging, vascular calcification and cardiac remodeling. The importance of bone as an endocrine organ has become even more evident following the discovery of molecules such as Sclerostin (involved in the regulation of osteoblastic proliferation and differentiation) and Sibling (a family of proteins that regulate both local and systemic mineral metabolism). The ability to characterize as biomarkers of CKD - MBD for these new molecules depends on their eventual ability to express a specific pathophysiological processes, identify patients at risk, highlight the response to a therapeutic treatment and to be easily identifiable and quantifiable on biological fluids. As of today, it seems that we can recognize FGF23 as a biomarker of CKD-MBD, while the remaining molecules as still waiting for a more definite settlement.
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González-Parra E, Aceña Á, Lorenzo Ó, Tarín N, González-Casaus ML, Cristóbal C, Huelmos A, Mahíllo-Fernández I, Pello AM, Carda R, Hernández-González I, Alonso J, Rodríguez-Artalejo F, López-Bescós L, Ortiz A, Egido J, Tuñón J. Important abnormalities of bone mineral metabolism are present in patients with coronary artery disease with a mild decrease of the estimated glomerular filtration rate. J Bone Miner Metab 2016; 34:587-98. [PMID: 26298279 DOI: 10.1007/s00774-015-0706-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 07/16/2015] [Indexed: 11/29/2022]
Abstract
Chronic kidney disease (CKD)-mineral and bone disorder (MBD) is characterized by increased circulating levels of parathormone (PTH) and fibroblast growth factor 23 (FGF23), bone disease, and vascular calcification, and is associated with adverse outcomes. We studied the prevalence of mineral metabolism disorders, and the potential relationship between decreased estimated glomerular filtration rate (eGFR) and CKD-MBD in coronary artery disease patients in a cross-sectional study of 704 outpatients 7.5 ± 3.0 months after an acute coronary syndrome. The mean eGFR (CKD Epidemiology Collaboration formula) was 75.8 ± 19.1 ml/min/1.73 m(2). Our patients showed lower calcidiol plasma levels than a healthy cohort from the same geographical area. In the case of men, this finding was present despite similar creatinine levels in both groups and older age of the healthy subjects. Most patients (75.6 %) had an eGFR below 90 ml/min/1.73 m(2) (eGFR categories G2-G5), with 55.3 % of patients exhibiting values of 60-89 ml/min/1.73 m(2) (G2). PTH (r = -0.3329, p < 0.0001) and FGF23 (r = -0.3641, p < 0.0001) levels inversely correlated with eGFR, whereas calcidiol levels and serum phosphate levels did not. Overall, PTH levels were above normal in 34.9 % of patients. This proportion increased from 19.4 % in G1 category patients, to 33.7 % in G2 category patients and 56.6 % in G3-G5 category patients (p < 0.001). In multivariate analysis, eGFR and calcidiol levels were the main independent determinants of serum PTH. The mean FGF23 levels were 69.9 (54.6-96.2) relative units (RU)/ml, and 33.2 % of patients had FGF23 levels above 85.5 RU/ml (18.4 % in G1 category patients, 30.0 % in G2 category patients, and 59.2 % in G3-G5 category patients; p < 0.001). In multivariate analysis, eGFR was the main predictor of FGF23 levels. Increased phosphate levels were present in 0.7 % of the whole sample: 0 % in G1 category patients, 0.3 % in G2 category patients, and 2.8 % in G3-G5 category patients (p = 0.011). Almost 90 % of patients had calcidiol insufficiency without significant differences among the different degrees of eGFR. In conclusion, in patients with coronary artery disease there is a large prevalence of increased FGF23 and PTH levels. These findings have an independent relationship with decreased eGFR, and are evident at an eGFR of 60-89 ml/min/1.73 m(2). Then, mild decreases in eGFR must be taken in consideration by the clinician because they are associated with progressive abnormalities of mineral metabolism.
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Affiliation(s)
- Emilio González-Parra
- Division of Nephrology and Hypertension, IIS-Fundación Jiménez Díaz and Autónoma University, Madrid, Spain
| | - Álvaro Aceña
- Department of Cardiology, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | - Óscar Lorenzo
- Renal and Vascular Research Laboratory, IIS-Fundación Jiménez Díaz and Autónoma University, Madrid, Spain
| | - Nieves Tarín
- Department of Cardiology, Hospital Universitario de Móstoles, Madrid, Spain
| | | | - Carmen Cristóbal
- Department of Cardiology, Hospital de Fuenlabrada and Rey Juan Carlos University, Fuenlabrada, Spain
| | - Ana Huelmos
- Department of Cardiology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Ana María Pello
- Department of Cardiology, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | - Rocío Carda
- Department of Cardiology, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | | | - Joaquín Alonso
- Department of Cardiology, Hospital de Fuenlabrada and Rey Juan Carlos University, Fuenlabrada, Spain
| | - Fernando Rodríguez-Artalejo
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Alberto Ortiz
- Division of Nephrology and Hypertension, IIS-Fundación Jiménez Díaz and Autónoma University, Madrid, Spain
| | - Jesús Egido
- Division of Nephrology and Hypertension, IIS-Fundación Jiménez Díaz and Autónoma University, Madrid, Spain
- Renal, Vascular and Diabetes Research Laboratory, IIS-Fundación Jiménez Díaz, Autónoma University, and CIBERDEM, Madrid, Spain
| | - José Tuñón
- Department of Cardiology and Laboratory of Vascular Pathology, IIS-Fundación Jiménez Díaz and Autónoma University, 28040, Madrid, Spain.
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Melamed ML, Buttar RS, Coco M. CKD-Mineral Bone Disorder in Stage 4 and 5 CKD: What We Know Today? Adv Chronic Kidney Dis 2016; 23:262-9. [PMID: 27324680 PMCID: PMC5034723 DOI: 10.1053/j.ackd.2016.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 01/20/2016] [Accepted: 03/29/2016] [Indexed: 11/11/2022]
Abstract
Patients with CKD stages 4 and 5 experience biochemical derangements associated with CKD-mineral bone disorder. Some of the key abnormalities are hyperparathyroidism, hyperphosphatemia, hypocalcemia, and metabolic acidosis. We review the available treatments for these conditions and the evidence behind the treatments. We conclude that there is greater evidence for treating hyperphosphatemia than hyperparathyroidism. Treatment of metabolic acidosis in small clinical trials appears to be safe. We caution the reader about side effects associated with some of these treatments that differ in patients with CKD Stages 4 and 5 compared with patients on dialysis. The use of cinacalcet has been associated with hyperphosphatemia in patients with functioning kidneys. Activated vitamin D therapy has been associated with elevated creatinine levels, which may or may not be a reflection of true decrement in kidney function. Finally, the use of non-calcium-containing phosphate binders may be associated with improved clinical outcomes in patients; however, many more clinical trials are needed in this important area of medicine.
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Affiliation(s)
- Michal L Melamed
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
| | - Rupinder Singh Buttar
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Maria Coco
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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Soohoo M, Feng M, Obi Y, Streja E, Rhee CM, Lau WL, Wang J, Ravel VA, Brunelli S, Kovesdy CP, Kalantar-Zadeh K. Changes in Markers of Mineral and Bone Disorders and Mortality in Incident Hemodialysis Patients. Am J Nephrol 2016; 43:85-96. [PMID: 26950688 DOI: 10.1159/000444890] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 02/09/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Abnormalities in mineral and bone disorder (MBD) markers are common in patients with chronic kidney disease. However, previous studies have not accounted for their changes over time, and it is unclear whether these changes are associated with survival. METHODS We examined the association of change in MBD markers (serum phosphorus (Phos), albumin-corrected calcium (Ca(Alb)), intact parathyroid hormone (iPTH) and alkaline phosphatase (ALP)) during the first 6 months of hemodialysis (HD) with all-cause mortality across baseline MBD strata using survival models adjusted for clinical characteristics and laboratory measurements in 102,754 incident HD patients treated in a large dialysis organization between 2007 and 2011. RESULTS Across all MBD markers (Phos, Ca(Alb), iPTH and ALP), among patients whose baseline MBD levels were higher than the reference range, increase in MBD levels was associated with higher mortality (reference group: MBD level within reference range at baseline and no change at 6 months follow-up). Conversely, decrease in Phos and iPTH, among baseline Phos and iPTH levels lower than the reference range, respectively, were associated with higher mortality. An increase in ALP was associated with higher mortality across baseline strata of ALP ≥80 U/l. However, patients with baseline ALP <80 U/l trended towards a lower risk of mortality irrespective of the direction of change at 6 months follow-up. CONCLUSIONS There is a differential association between changes in MBD markers with mortality across varying baseline levels in HD patients. Further study is needed to determine if consideration of both baseline and longitudinal changes in the management of MBD derangements improves outcomes in this population.
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Affiliation(s)
- Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Calif., USA
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40
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Klimentová A, Ságová I, Prídavková D, Kantárová D, Makovický P, Sadloňová J, Mokáň M. [Diabetic Kidney Disease 3rd stage - laboratory markers of mineral bone disorder]. Vnitr Lek 2016; 62:442-448. [PMID: 27485841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Diabetes mellitus is the most common cause of end stage kidney disease in the developed countries. Chronic kidney disease-mineral and bone disorder (CKD-MBD) develops with deteriorating of the renal functions. Diabetic patients on hemodialysis are characterized by low bone turnover, higher prevalence of severe and progressive vascular calcification with increased cardiovascular morbidity and mortality. The main factor which causes vascular calcification in patients with diabetic kidney disease (DKD) is poor glycemic control. The recent trial findings describe an inverse correlation between intact parathyroid hormone (iPTH) serum levels and glycemic control in a group of diabetic patients on hemodialysis. AIM The objective of the proposed project is to access the difference of the laboratory markers MBD in the group of patients with 3rd stage DKD depending on glycemic control. We focused on the relationship between the glycemic compensation of diabetes (HbA1c) and iPTH serum level. PATIENTS AND METHOD Ninety one patients with 3rd stage DKD were investigated. There were 46 women (50.5 %) and 45 men (49.5 %), average age of patients was 71.2 ± 7.0 years, with creatinine level 128 ± 30 μmol/l and estimated glomerular filtration (eGF, MDRD) 0.82 ± 0.16 ml/s. There were 60 patients with better glycemic control of diabetes (HbA1c < 7 %) vs 29 patients with poorly controlled diabetes (HbA1c > 7 %). MBD markers were compared in both groups. Patients were further stratified into subgroups based on the serum level of iPTH (iPTH < 35 pg/ml vs iPTH > 35 pg/ml) and MBD markers compared. Statistical analysis was performed using and Mann-Whitney test. RESULTS We have found the statistical significance in the serum phosphate and proteinuria levels in between groups with HbA1c < 7 % vs patients with HbA1c > 7 %. Diabetics with better glycemic control had significant reduction in serum phosphate level (1.14 ± 0.20 vs 1.23 ± 0.18 mmol/l, p = 0.038) and in 24 hrs proteinuria level (0.56 ± 1.35 vs 1.30 ± 1.61 g/day, p = 0.007). In the group of presumed low bone turnover (iPTH < 35 pg/ml) we have found the trend towards increased serum calcium level (2.49 ± 0.12 vs 2.43 ± 0.10 mmol/l, p = 0.063) and increased HbA1c value (7.5 ± 1.8 vs 6.4 ± 1.6 %, p = 0.023). CONCLUSION Our results suggest the closer relationship between glycemic control of diabetes and mineral-bone disorder in earlier stages of DKD. KEY WORDS diabetes mellitus type 2 (DM2T) - chronic kidney disease (CKD) - mineral and bone disorder (MBD).
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Fischer JA, Binswanger U. 1,25-Dihydroxycholecalciferol in dialysed patients with clinically asymptomatic renal osteodystrophy. A controlled study. Contrib Nephrol 2015; 18:82-91. [PMID: 7353381 DOI: 10.1159/000403275] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Clinically asymptomatic patients undergoing hemodialysis and with histologically proven renal osteodystrophy were treated with 1,25-dihydroxycholecalciferol (1,25[OH]2D3) or with placebo for 9-37 weeks. Serum concentrations of total calcium were frequently increased when the ionized calcium was raised into the normal range. Serum magnesium was in the upper normal range due to the presence of magnesium in the aluminum hydroxide used to lower the hyperphosphatemia, which was difficult to control. Basal serum parathyroid hormone (PTH) levels were increased and seven times higher when measured with a radioimmunoassay recognizing mainly COOH-terminal fragments of human PTH-(1-84) (C-terminal assay) as compared to another assay measuring predominantly intact PTH-(1-84) (N-terminal assay). During treatment with 1,25 (OH)2D3, serum PTH returned towards the normal range with increasing calcium levels. Mean PTH concentrations decreased significantly by 34% (p less than 0.05) when measured with the N-terminal assay and by only 14% (p greater than 0.1) in the C-terminal assay. Serum alkaline phosphatase activity and the mineral content of the forearm estimated by photon absorptiometry remained unchanged.
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Nisbet AP, Shaw P, Taube D, Edwards S, Fogelman I, Maisey M, Mashiter G. A simple noninvasive method for assessing renal osteodystrophy. Contrib Nephrol 2015; 56:205-9. [PMID: 3111788 DOI: 10.1159/000413807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Schulz W, Baier E, Hümpfner A, Delling G. Clinical problems of renal osteopathy in patients on hemofiltration. Contrib Nephrol 2015; 32:86-91. [PMID: 7128166 DOI: 10.1159/000406909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Esposito P, Rampino T, Gregorini M, Tinelli C, De Silvestri A, Malberti F, Coppo R, Dal Canton A. Management of mineral metabolism in hemodialysis patients: discrepancy between interventions and perceived causes of failure. J Nephrol 2014; 27:689-97. [PMID: 24804853 DOI: 10.1007/s40620-014-0100-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 04/04/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mineral and bone disorders (MBD) in patients undergoing hemodialysis (HD) are a major clinical complication. Current therapeutic strategies do not attain the expected results. The Italian audit on mineral metabolism was implemented to investigate MBD management through a "patient-oriented" approach. METHODS Clinical and laboratory data pertinent to MBD from 509 prevalent adult patients on chronic HD were recorded and examined (audit), after which individual strategies were elaborated to improve MBD control. Their effectiveness was evaluated 6 months after the audit (Post-6). RESULTS The audit disclosed poor MBD control in a high percentage of patients (56 %). Low compliance to treatment was the major determinant of failure (in 43.5 % of cases). Logistic regression showed a direct correlation between high degree of compliance and the achievement of therapeutic targets, e.g. parathyroid hormone: odds ratio (OR) 2.48, p = 0.015. In contrast, a minority of the proposed interventions (14.7 %) included strategies to improve patient compliance. At Post-6, despite a significant increase in drug prescription (p < 0.05 vs. audit), the rate of successful MBD control was unchanged. CONCLUSIONS Low compliance with treatment is a major, but still neglected, cause of failure in the achievement of MBD control in HD patients.
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Affiliation(s)
- Pasquale Esposito
- Department of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico "San Matteo" and University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy.
| | - Teresa Rampino
- Department of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico "San Matteo" and University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy
| | - Marilena Gregorini
- Department of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico "San Matteo" and University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy
| | - Carmine Tinelli
- Unit of Biometry and Clinical Epidemiology, Fondazione IRCCS Policlinico "San Matteo", Pavia, Italy
| | - Annalisa De Silvestri
- Unit of Biometry and Clinical Epidemiology, Fondazione IRCCS Policlinico "San Matteo", Pavia, Italy
| | - Fabio Malberti
- Divisione di Nefrologia e Dialisi, Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Rosanna Coppo
- Nephrology, Dialysis and Transplantation Unit, City of Health and Science of Turin, Regina Margherita Children's Hospital, Turin, Italy
| | - Antonio Dal Canton
- Department of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico "San Matteo" and University of Pavia, Piazzale Golgi 19, 27100, Pavia, Italy
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Abstract
The increased awareness of the potential role played by mineral and bone disorder in the appearance of cardiovascular disease in renal patients has produced research efforts aimed at discovering possible pathogenic links. Accordingly, the diagnostic significance of the classic bone markers of mineral disorders and of the new markers in the setting of chronic kidney disease-mineral and bone disorders (CKD-MBD) needs to be re-evaluated along with increasing information. In this article we include classic markers of bone metabolism and some of the noncollagenous bone proteins that are gaining experimental and clinical significance in CKD-MBD. Among classic markers of secondary hyperparathyroidism and of renal osteodystrophy, we analyzed parathyroid hormone, alkaline phosphatase, tartrate-resistant acid phosphatase, and bone collagen-derived peptides. We underlined, for each, the relevance of parent proteins (peptides or isoforms) that affect assay methods and, eventually, the diagnostic or prognostic significance. Also, we considered their relationship with cardiovascular mortality. Among the numerous noncollagenous bone proteins, we examined matrix Gla protein (MGP), osteocalcin (OC), osteoprotegerin, and the small integrin-binding ligand N-linked glycoprotein family. For MGP and OC we report the relevant involvement with the process of calcification (MGP) and with glucose and energy metabolism (OC). Both of these proteins require vitamin K to become active and this is a specific problem in renal patients who frequently are deficient of this vitamin. Finally, recent acquisitions on the fascinating family of the small integrin-binding ligand N-linked glycoprotein proteins are recapitulated briefly to underline their potential clinical interest and their complex involvement with all aspects of CKD-MBD. Their diagnostic role in clinical practice awaits further studies.
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Affiliation(s)
- Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy.
| | - Lida Tartaglione
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Silverio Rotondi
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Jordi Bover
- Department of Nephrology, Fundaciò Puigvert, IIB Sant Pau, REDinREN, Barcelona, Spain
| | - David Goldsmith
- King's Health Partners, Academic Health Science Centre, London, United Kingdom
| | - Marzia Pasquali
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
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Bencova V, Maris K, Spustova V, Gazovic V, Straussova Z, Cernohorska B, Nemethova D. Comparison of iPTH values in serum and plasma samples depending on the time and temperature in patients with chronic kidney disease. BRATISL MED J 2014; 115:439-41. [PMID: 25077368 DOI: 10.4149/bll_2014_086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Renal osteodystrophy is a systemic disorder associated with chronic kidney disease (CKD) with abnormal values of biochemical parameters related to bone and mineral metabolism. Assessing renal osteodystrophy subtypes is especially important for diagnostic and therapeutic decision. Management of these disorders includes monitoring of homeostasis of calcium, phosphorus and parathormone (PTH). PTH is a significant regulator of mineral balance and it´s level is used as a surrogate biomarker for the type of underlying renal osteodystrophy. Worldwide, nephrologists rely on KDIGO - Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease - Mineral and Bone Disorder (CKD-MBD) to maintain PTH levels within defined narrow range of optimal values for each stage of CKD and adjust such PTH - lowering treatments as active vitamin D sterols or calcimimetics accordingly. PTH is rapidly degraded in vivo, with half life of 5 minutes and it is also unstable in blood samples. Values can differ significantly when samples are not collected in a standard way and when recommended conditions for transport and sample processing are not followed. It is also important to standardize pre-analytic conditions that may influence the variability in PTH results. The goal of the present study was to compare iPTH stability in serum and plasma samples and evaluate possible pre-analytic errors in sample collection, effect of temperature during transportat and storing prior to analysis (Tab. 1, Fig. 1, Ref. 5).
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Meng Y, Zhang H, Li Y, Li Q, Zuo L. Effects of unfractionated heparin on renal osteodystrophy and vascular calcification in chronic kidney disease rats. Bone 2014; 58:168-76. [PMID: 24145307 DOI: 10.1016/j.bone.2013.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 10/06/2013] [Accepted: 10/14/2013] [Indexed: 02/08/2023]
Abstract
Unfractionated heparin (UFH) is the most widely used anticoagulant in hemodialysis for chronic kidney disease (CKD) patients. Many studies have verified that UFH can induce bone loss in subjects with normal bone, but few have focused on its effect on renal osteodystrophy. We therefore investigated this issue in adenine-induced CKD rats. As CKD also impairs mineral metabolism systemically, we also studied the impacts of UFH on serum markers of CKD-mineral and bone disorder (CKD-MBD) and vascular calcification. We administered low and high doses of UFH (1U/g and 2U/g body weight, respectively) to CKD rats and compared them with CKD controls. At sacrifice, the serum markers of CKD-MBD did not significantly differ among the two UFH CKD groups and the CKD control group. The mean bone mineral densities (BMDs) of the total femur and a region of interest (ROI) constituted of trabecular and cortical bone were lower in the high-dose UFH (H-UFH) CKD group than in the CKD control group (P<0.05 and P<0.01, respectively). The BMD of the femoral ROI constituted of cortical bone did not differ between the H-UFH CKD group and the CKD control group. Histomorphometrical changes in the CKD rats indicated secondary hyperparathyroidism, and the femoral trabecular bone volume, but not cortical bone volume, significantly decreased with increasing UFH dose. The same decreasing trend was found in osteoblast parameters, and an increasing trend was found in osteoclast parameters; however, most differences were not significant. Moreover, no distinct statistical differences were found in the comparison of vascular calcium or phosphorus content among the CKD control group and the two UFH CKD groups. Therefore, we concluded that UFH could induce bone loss in CKD rats with secondary hyperparathyroidism, mainly by reducing the trabecular volume and had little effect on cortical bone volume. The underlying mechanism might involve inhibition of osteoblast activity and promotion of osteoclast activity by UFH. We did not find any effect of UFH on vascular calcification in CKD rats with secondary hyperparathyroidism.
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Affiliation(s)
- Yan Meng
- Renal Division, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health, Beijing, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
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Pérouse de Montclos T, Ranchin B, Leclerc AL, Bertholet-Thomas A, Belot A, Cochat P, Bacchetta J. [Online hemodiafiltration in children and hypoparathyroidism: a single-centre series of cases]. Nephrol Ther 2013; 10:35-8. [PMID: 24360980 DOI: 10.1016/j.nephro.2013.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 08/07/2013] [Accepted: 09/10/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Due to technical requirements and cost, hemodiafiltration (HDF) is not widely used in pediatrics. We have been using online HDF (oHDF) since 2009 and we observed low parathyroid hormone (PTH) levels despite the accurate management of CKD-MBD. METHODS We reviewed the medical charts and parameters of mineral metabolism assessed on a before/after session basis in the 6 children undergoing chronic oHDF in our centre. RESULTS We observed low (<80pg/mL) PTH levels in all 6 patients and very low (<45pg/mL) PTH levels in 5, two of them presenting with pathological fractures. These low PTH levels were reversed after decreasing calcium concentration to 1.25 mmol/L in the dialysate, suggesting that high-efficiency oHDF may expose children to calcium during sessions in a too important amount when using 1.5 mmol/L dialysates. Last, C-terminal FGF23 levels before sessions were relatively low (<1600RU/mL), with a 32% clearance by oHDF. CONCLUSION PTH levels should be closely monitored in pediatric oHDF and solutions with a calcium concentration of 1.25 mmol/L should be used as first line in these patients.
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Affiliation(s)
- Thomas Pérouse de Montclos
- Service de néphrologie et rhumatologie pédiatriques, centre de référence des maladies rénales rares, hôpital Femme-Mère-Enfant, groupement hospitalier Est, 69500 Bron, France.
| | - Bruno Ranchin
- Service de néphrologie et rhumatologie pédiatriques, centre de référence des maladies rénales rares, hôpital Femme-Mère-Enfant, groupement hospitalier Est, 69500 Bron, France
| | - Anne-Laure Leclerc
- Service de néphrologie et rhumatologie pédiatriques, centre de référence des maladies rénales rares, hôpital Femme-Mère-Enfant, groupement hospitalier Est, 69500 Bron, France
| | - Aurélia Bertholet-Thomas
- Service de néphrologie et rhumatologie pédiatriques, centre de référence des maladies rénales rares, hôpital Femme-Mère-Enfant, groupement hospitalier Est, 69500 Bron, France
| | - Alexandre Belot
- Service de néphrologie et rhumatologie pédiatriques, centre de référence des maladies rénales rares, hôpital Femme-Mère-Enfant, groupement hospitalier Est, 69500 Bron, France; Université de Lyon, 69008 Lyon, France
| | - Pierre Cochat
- Service de néphrologie et rhumatologie pédiatriques, centre de référence des maladies rénales rares, hôpital Femme-Mère-Enfant, groupement hospitalier Est, 69500 Bron, France; Université de Lyon, 69008 Lyon, France
| | - Justine Bacchetta
- Service de néphrologie et rhumatologie pédiatriques, centre de référence des maladies rénales rares, hôpital Femme-Mère-Enfant, groupement hospitalier Est, 69500 Bron, France; Université de Lyon, 69008 Lyon, France
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Bacchetta J, Wesseling-Perry K, Kuizon B, Pereira RC, Gales B, Wang HJ, Elashoff R, Salusky IB. The skeletal consequences of growth hormone therapy in dialyzed children: a randomized trial. Clin J Am Soc Nephrol 2013; 8:824-32. [PMID: 23559676 PMCID: PMC3641609 DOI: 10.2215/cjn.00330112] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 01/03/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVE The effects of recombinant human growth hormone on renal osteodystrophy are unknown; thus, the effects of growth hormone (GH) on bone histomorphometry were assessed in pediatric patients with ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Thirty-three patients who underwent bone biopsy between July 1994 and May 1999 were randomly assigned to therapy with or without GH. Patients were stratified by bone formation rate; all patients with high bone turnover received intraperitoneal calcitriol. Serum biochemical values were obtained monthly, and bone biopsy was repeated after 8 months. RESULTS Median patient age was 11.7 years (interquartile range [IQR], 7.6, 14.1 years); 45% of patients were male, and 52% were prepubertal. Median dialysis duration was 0.4 (IQR, 0.3, 0.8) year. Bone formation rate per bone surface increased from 15.0 (9.6, 21.8) to 154.6 (23.7, 174.3) μm(2)/μm(3) per year (P=0.05) in patients with low bone turnover treated with GH, decreased from 103.3 (57.0, 173.4) to 60.3 (20.3, 13.7) μm(2)/μm(3) per year in patients with high bone turnover receiving standard therapy (P=0.03), and was unchanged in the other two groups. Bone formation rates were higher with GH, irrespective of underlying bone histologic features (P=0.05). Parathyroid hormone did not differ between groups. GH therapy resulted in greater increases in height SD scores (estimated mean difference in change ± SD, 0.324±0.076; P<0.001), irrespective of underlying bone histologic features. CONCLUSIONS GH therapy improves height in pediatric dialysis patients, irrespective of underlying bone histologic features. Bone formation rates are higher in GH recipients, and GH therapy alters the relationship between circulating parathyroid hormone values and bone turnover.
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Affiliation(s)
| | | | | | | | | | - He-jing Wang
- Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, California, and
| | - Robert Elashoff
- Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, California, and
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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